Dental treatment plan for traumatic injuries in the primary and permanent dentition [14].
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Expert views are shared by international clinical experts from different medical and allied health fields. \nThis book contains an introductory chapter on the anatomical structures and physiology processes that underpin dysphagia and discusses the effects of polypharmacy and ageing on deglutition. Contemporary practices of functional assessment of swallowing and the endoscopic assessment for both oropharyngeal and esophageal dysphagia are reviewed. Both the nutritional support and decision making in oral route are described and the impact of dysphagia on carers and family when managing dysphagia. 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\r\n\tField programmable array (FPGA) is a programmable device that uses prebuilt logic blocks and routing resources to implement the system without adding additional fabrication steps. The reconfigurable system has applications in computational acceleration and prototyping application-specific integrated circuits (ASIC). The final design of ASIC or processor using FPGA will be continue reprogrammed until we have a bug-free design. The demand for FPGA is expected to increase continuously due to increased adoption of FPGA in areas of enterprise businesses as well as ASIC design because they can be dynamically reprogrammed. The optimized FPGAs are more power-efficient than running equivalent workloads on a CPU. The combination of versatility, efficiency, and performance of FPGAs make the design process more data at a lower total cost of ownership (TCO). Seeing the numerous application of FPGAs irrespective of the domain, it is necessary to understand FPGA in-depth in terms of architecture and applications.
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Other reasons of traumatic injury can be domestic abuse in adults and child abuse in children. Anterior teeth in both primary and permanent dentition are most commonly affected by dental trauma. Primary and permanent anterior teeth are not only important for esthetics but also essential for phonetics, mastication, integrity of supporting tissues, psychological and mental wellbeing [1]. Traumatic injuries are part of the growing up years and can have ever lasting wounds with scarring on the affected individuals. Dental trauma refers to injury to the oral and perioral structures i.e. teeth (enamel, dentin, pulp and cementum), gums, periodontal ligament, alveolar bone and also involves nearby soft tissues around the teeth such as the lips, tongue, etc. Traumatic dental injuries (TDI’s) are part of body injury and occur frequently in children and young adults accounting to 5% of all the bodily injuries [2]. School going children up to 25% experience dental trauma and 33% of adult’s less than 19 years of age have permanent dentition trauma [3]. Incisor teeth both in maxilla and mandible are the most commonly affected teeth with highest incidence in maxillary central incisors. A prospective study in 2017 found that among patients with maxillofacial fractures, 41.8% of them had concomitant dental injuries of two or more teeth [4]. Immediate care, appropriate diagnosis and treatment with comprehensive follow-up are essential for a favorable prognosis of the affected teeth.
Dental treatment of TDI’s is usually delayed and not given as much attention as general medical treatment. Immediate dental consultation and treatment could improve long-term prognosis of the injured teeth [5]. Timing of the dental care rendered to patient who have undergone trauma is critical in management and saving of the teeth. Dentist must have the essential knowledge regarding the management of patients with trauma especially during the emergency phase of treatment. Appropriate management of patients with dental trauma requires coordinated efforts of different specialties including general dentists, oral radiologist, pediatric dentist, periodontist, oral surgeon and endodontist. Team efforts involving these different specialists will help the patient to receive successful long term outcome.
When a subject undergoes a traumatic incident, he or she is mentally disturbed and may tend to get disoriented with time and space. The person with dental trauma will experience difficulty in maintaining daily oral hygiene and this leads to dental plaque accumulation. The neglect of oral hygiene during and after dental trauma will lead to gingivitis which if untreated may lead to periodontitis and tooth loss. Studies have also shown that Oral Health-Related Quality of Life (OHRQoL) is affected by TDI’s and it negatively impacts on the OHRQoL of children and their families [6]. It is imperative that oral hygiene standards are maintained during and post dental trauma for the long term survival of teeth with dental trauma. Twice daily brushing with soft bristled manual brush or electric toothbrush with toothpaste, interdental cleaning with dental floss or interdental brush and use of mouth rinse every day is apt to keep the teeth and mouth clean. Dentist must educate about oral hygiene maintenance and special instructions to be followed during TDI’s to patients.
The prevalence of injury and TDI’s has been observed in children and young adults of every country of the world. Different authors have reported different incidences and prevalence’s of TDI’s from many countries. A 12-year review of the literature reports that 25% of all school children experience dental trauma and 33% of adults have experienced trauma to the permanent dentition, with the majority of injuries occurring before age nineteen [7].
A study on prevalence of TDI’s conducted in India reported 59.2% of males and 40.8% of female’s experienced dental injury and they concluded that males experienced more TDI’s due to the outdoor activities [8]. Study conducted on Saudi Arabian children mention a incidence of TDI’s is 1–3% and prevalence of 20–30%, similar results were also observed in studies conducted in Europe [9, 10]. The prevalence of missing anterior teeth as a result of dental trauma is reported as 12 per 1000 children in one cross-sectional epidemiological study [11]. A 2017 prospective study found that among patients with maxillofacial fractures, 41.8% of them had concomitant dental injuries to two or more teeth [4]. The trauma prevalence in one study showed 10.13% children suffered TDI’s and only 3.37% of the children had undergone treatment for those injuries [12]. Studies have concluded that anterior teeth with increased incisal over jet and inadequate lip coverage were significant predictors for the occurrence of TDI’s [13]. Children and adolescents in the poor socio economical conditions had greater incidence of TDI’s and they had not received proper treatment for those TDI’s.
Timing of the dental care rendered to patient who have undergone trauma is critical in management and saving of the teeth. Dentist should be aware of management and treatment of patients with trauma especially during the emergency phase (Table 1). A coordinated efforts of different specialty including general dentists, pediatric dentist, periodontist, oral surgeon and endodontist is essential. Team efforts involving these different specialists will help the patient receive successful long term prognosis [15]. Avulsion of permanent teeth is one of the most serious dental injuries, prompt and correct emergency management is essential for attaining the best outcome after this injury [16].
Description | Primary dentition | Permanent dentition |
---|---|---|
Concussion/subluxation | Observe, soft foods for 1 week, dental radiograph to rule out root fracture | Observe, soft foods for 1 week, dental radiograph to rule out root fracture |
Luxation | Reposition tooth or extract, do not splint | Dental radiograph, reposition tooth, splint for 4 week |
Extrusion | Reposition tooth or extract, do not splint | Dental radiograph, reposition tooth, splint for 2 week |
Intrusion | Dental radiograph, observe and allow to re erupt, extract if alveolar plate is compromised | Dental radiograph, observe and allow to re erupt, surgical or orthodontic repositioning, root canal treatment |
Uncomplicated crown fracture | Restore tooth, smooth sharp edges, dental radiograph to rule out root fracture | Restore tooth, smooth sharp edges, radiograph to rule out root fracture |
Complicated crown fracture | Dental radiograph, pulp treatment, restore or extract tooth, observe for infection | Dental radiograph, pulp treatment, restore tooth, observe for infection, may require root canal treatment |
Root fracture | Dental radiograph, extract if root fracture is in middle or cervical third of root | Dental radiograph, splint, may require root canal treatment; if in cervical third, may need to extract |
Avulsion | Do not replant, dental radiograph to rule out intrusion if tooth is not located | Do not handle the root, replant within30 min or place in recommended transport medium (balanced salt solution, cold milk); dental radiograph, replant and splint as soon as possible; systemic antibiotics, soft diet, chlorhexidine, close follow-up |
Dental treatment plan for traumatic injuries in the primary and permanent dentition [14].
Dentist must assess the periodontal ligament (PDL) cells of the avulsed tooth, before commencing treatment: [16].
The PDL cells are most likely viable. The tooth has been replanted immediately or within a very short time (about 15 minutes) at the place of accident.
The PDL cells may be viable but compromised. The tooth has been kept in a storage medium (e.g., milk, HBSS (Save-a-Tooth or similar product), saliva, or saline, and the total extra-oral dry time has been <60 minutes).
The PDL cells are likely to be non-viable. The total extra-oral dry time has been more than 60 minutes, regardless of the tooth having been stored in a medium or not.
The treatment of TDIs patients involves five phases [2, 17, 18, 19, 20, 21, 22].
Emergency phase
Follow up phase
Restorative phase
Rehabilitation phase
Maintenance phase
When a patient with trauma arrives at the dental clinic, certain necessary actions have to be taken to start the treatment. Proper history of the etiology of the injury preferably in a structured checklist will be beneficial. The dentist can follow these steps for treating patients with dental trauma.
The dentist must thoroughly evaluate the injury to the dental and adjacent tissues. Careful extra oral and intraoral clinical examination and radiographic investigation is essential to arrive at the diagnosis of exact damage caused by the trauma.
Patient’s general health and history of systemic diseases must be collected to plan the treatment accordingly.
History of previous dental injuries and the treatment received by the patient for the current injury should be ascertained before starting the treatment protocol.
Symptoms of central nervous system injury like vomiting, nausea, confusion, blurred vision, bleeding or fluid from ear or nose, difficulty in speech, loss of consciousness, amnesia should be assessed. The patient has to be referred to a neurologist for consultation of Central Nervous System (CNS) symptoms.
Areas of pain should be re-examined properly and source, etiology and pain relief measures and medications should be prescribed accordingly.
Radiographic assessment including Orthopantomogram (OPG), Intraoral periapical radiographs (IOPA) and occlusal radiographs will aid in proper judgment about the injury and its extent. Cone beam computed tomography (CBCT) can be availed in case of serious injuries such as crown/root, root and alveolar fractures, as well as luxation injuries.
Thorough decontamination and disinfection of intraoral and extra oral wounds should be carried out, to rid of all the contaminants.
Areas of bleeding should be detected and pressure pack, cautery or suturing of the artery can be used to stop the bleeding.
Injection of Tetanus vaccine, also known as tetanus toxoid (TT) can be given to prevent spasms in the muscles.
If there is fracture of maxilla or mandible, reduction of the fracture segments should be carried out and they can be stabilized with help of arch bar wiring or plates.
Sutures can be placed in open wounds and dressing can be used over the extra oral wounds.
During the subsequent visits after three days, dentist should evaluate healing of the primary lesions and occlusion of teeth should be checked for any discrepancies. Sensitivity tests should be carried out on all teeth with trauma and the opposing teeth. Cold testing is recommended over electric pulp testing in young patients. The pulp test has to be carried out during the follow-up visits as the teeth with trauma are nonresponsive for several weeks. Dentist should help achieve complete healing of soft and hard tissue structures. Healing complications are more common in teeth with vertical fracture of teeth, trauma in supporting tissues and avulsion. Complications usually occur in the first three months and necrotic pulp was the most common complication [23].
The Restorative phase should include restoration of fractured and decayed teeth. Fractured teeth have to be carefully examined, for type and extent of the fracture and the need for endodontic and periodontal treatments. A multidisciplinary approach will improve the prognosis of the teeth. Non-surgical periodontal therapy (NSPT) including scaling, root planing, patient education and local drug delivery should be carried out, to keep the tissues in healthy state. Dentist must observe the gums for any inflammation and periodontal examination for periodontitis and check for ulcers or irritation due to prosthetic appliances.
Rehabilitation phase includes occlusal corrections with orthodontic tooth movement. Psychological counseling among children will help children to overcome and forget traumatic events of TDI’s. Patient should be educated and motivated to maintain healthy teeth, gums and periodontium for long term rehabilitation.
Maintenance phase or oral hygiene phase should be carried out during all the phases of treatment of TDI’s. Regular oral hygiene maintenance with either manual or powered toothbrush should be started in immediate follow-up phase and maintained throughout life. Brushing twice daily once early morning and once before going to bed is best advised. The interdental areas between the teeth should be kept clean with appropriate interdental cleaning aids. Mouthwashes should be routinely used to maintain the overall health of oral structures like teeth, gums, periodontium, oral mucosa and tongue.
Regular visit to the dentist for periodic checkup and examination should be followed by the patients who experienced TDI’s. Dentists must keep the patients with TDI’s on maintenance therapy for regular interaction and follow-ups.
Hirschfeld advocated tooth brushing to keep teeth and gums clean free from dental caries or periodontal diseases [24]. Cleaning of teeth and oral hygiene maintenance are carried out using toothbrushes and interdental cleaning aids. Commercially available varieties of dental products can be used to keep the mouth clean. Toothbrush with toothpaste is the most commonly employed teeth cleaning oral hygiene aid. American Dental Associations (ADA) advocates brushing of teeth twice daily, use of interdental cleaning aids regularly and oral rinse with mouthwashes every day to keep good oral health. Tooth brushing and interdental cleaning remain the mainstays of prevention of periodontal diseases. The primary approach requires individually tailored instruction for implementation of a systematic oral hygiene regimen [25].
Toothbrushes come in different designs and function.
Manual tooth brush
Powered toothbrush
Sonic, Ultrasonic and Ionic toothbrushes
Manual tooth brush with toothpaste is commonly used all over the world to clean the teeth. Manual toothbrushes come in different sizes and design and basically classified according to the diameter of the bristles as soft, medium and hard.
Different brushing techniques are used to clean the teeth by different individuals. Tooth brushes can be used with horizontal scrub, vertical scrub, vibratory, sweeping, rotatory motion or combination of them. Various researchers have recommended different brushing techniques like Bass, Charter’s, Stillman, Fone, Leonard, Hirchfeld’s, Smith-Bell and many more. Modified Bass technique also called sulcus cleansing method is advised for healthy patients with no gingival disease. Fone’s technique or circular method of brushing is advised for children as it is easy to learn. Modified Stillman’s method is recommended in patients with gingival recession for gingival massage. Charter’s method is most useful in patients with fixed prosthesis or orthodontic appliances and post periodontal surgery.
Powered toothbrush are also called electric toothbrush, they make rapid automatic bristle movements, either to and fro or rotatory-oscillation to clean the teeth. Electric brushes can be classified according to their type of action as side to side vibration, Counter oscillation, Rotation or Circular. Compared to manual toothbrushes; electric-powered ionic ones were significantly efficient in removing plaque in the premolar and molar areas [26, 27]. Powered toothbrush manufacturers do not recommend a specific brushing method, the Swiss Dental Society, in 2001 developed an instruction manual for use of electric tooth brushes. Instructions for brushes with a sweeping and/or oscillating rotary motion are as follows:
The brushes are positioned on the tooth surfaces in a 45-or 90-degree angle to the incisal plane.
Only when positioned should the brush be switched to “on.”
The mouth should be almost closed.
The brush should be moved slowly over and around each tooth for 3 to 5 seconds, making sure that the bristles clean the crevices between the teeth.
The brush head can be lifted distally and mesially into the interproximal areas to reach the interdental area; the brush always remains on a single tooth.
After a period of approximately 5 seconds, the brush is moved to the next tooth surface and repositioned [27].
Sonic tooth brushes bristles vibrate at lower frequency and ultrasonic, indicates a brush action where the bristles vibrate at ultrasonic frequencies (> 20 kHz). An ionic brush releases an electrical charge to the tooth surface which disrupts the attachment of dental plaque [28].
Interdental cleaning aids are usually dental floss, toothpick or small interdental brush and Uni-tufted brushes. The use of interdental cleaning aid depends upon the spacing between the teeth and gingival tissue in the interdental spaces. Interdental cleaning of teeth is best achieved by using interdental brushes and these brushes should therefore be the first choice in patients with open interdental spaces [29].
Several interdental cleaning aids are available for cleaning of interdental areas. The use interdental cleaning device and method can vary depending upon the type of interdental embrasure (Table 2).
Type of interdental space | Interdental cleaning device to be used |
---|---|
Narrow interdental space with intact interdental papillae | Dental floss or toothpick |
Little interdental space with slight papilla recession | Dental floss, toothpick or small interdental brush |
Wide interdental space with complete loss of interdental papilla | Interdental brush |
Wide interdental space with diastema of teeth | Uni-tufted brush or gauze strip |
Interdental space present and interdental aid to be used.
Dental floss: Dental floss is most useful in cleaning the interdental areas where the contacts between the teeth are tight and no space is present between the teeth and there is no recession of interdental papilla. Dental floss can be used by rotating around the fingers or they also can be used with a floss holder.
Toothpicks: toothpicks are used in the tight interdental areas and it can be used as normal cleaning instrument anywhere required. Toothpicks have been used to clean teeth since ages; they come in different designs and varieties.
Interproximal brushes: Miniature interproximal brushes are available and they can be used in the interdental areas with slight papillary recession. Interproximal brushes are designed like a miniature bottle cleaning brushes are used in to and fro direction in the interdental areas.
Uni-tufted brush: Uni-tufted brushes are used in wide interdental areas with open embrasure and adjacent teeth with no contact. They help in cleaning of the open contact and make them plaque free.
Water jet/piks: water jets are the instruments which spray water with pulsations and pressure. Water jets have shown to be effective in removing debris from the interdental areas in patients who avoid the use of dental floss. Mouthwashes can also be used instead of the water; this increases its action due to the anti-plaque nature of the mouthwash.
Tongue cleaners are used to clean the dorsal surface of the tongue, which harbors maximum number of microorganisms. Tongue cleaners are usually flat surfaced made up of wood or plastic to scrape the surface of the tongue.
An oral rinse help in promotion of good oral hygiene, reduce oral discomfort, provide moisture to oral tissues and reduce bad breath [1, 15]. Mouthwashes are essential to completely rid of microorganisms from all the parts of oral cavity. ADA advocates use of mouthwash for regular maintenance of oral hygiene. Many mouthwashes with different chemical formulations are available in the market. Chlorhexidine containing mouth washes are considered gold standard. Other chemicals used are Bisguanides, Hydrogen Peroxide, Sodium Hypochlorite, Salt and Herbal mouthwashes.
Rationale for the use of mouthwashes:
Antiseptics present in mouthwashes are effective against the bacteria found within dental plaque, when they are in a planktonic form; they show both bacteriostatic and bactericidal activity.
Mouthwashes have a number of advantages:
They are available without prescription.
They have a good safety record.
No significant bacterial resistance has been reported.
They require little skill and motivation on behalf of the patient.
Mouth rinses serve a variety of purposes
Antiplaque/Anti gingivitis Rinses
Therapeutic Antiseptics
Phenol products: Listerine, Chloraseptic
Chlorhexidine products: Peridex, Corsodyl
Sanguinaria products: Viadent
Cosmetic antiplaque rinses: Plax, Close-Up Anti-Plaque
Therapeutic Anti cavity Fluoride Rinses
Act+, Fluorigard+, Listermint with Fluoride.
Cosmetic Breath Freshening Mouth Rinses
Cepacol, Lavoris, Scope, Signal, Clear Choice, Rembrandt Mouth Refreshing Rinse.
Others
Topical antibiotic rinses
Enzyme rinses
Artificial saliva rinses
Rinses that control tartar
Types of mouthwashes.
First generation anti-plaque agents
Capable of reducing plaque scores by 20–50%.
Second generation anti-plaque agents
Overall plaque reduction by 70–90% and exhibit slow release properties.
Third generation anti-plaque agents
Exhibit better retentive properties over second generation agents.
Triclosan and Chlorhexidine mouthwashes have been widely used in recent times. Triclosan delays plaque maturation and inhibits formation of prostaglandin leukotrines which is a key controller of inflammation. Chlorhexidine acts against plaque and bacteria.
The primary dentition is fragile compared to the permanent dentition. The parent or the caregiver has to be delicate and gentle while brushing of teeth. It is advised to use a soft bristle brush in circular motion to clean the teeth. In the area of trauma and teeth with trauma, extra care should be given not to hurt and cause more pain and complications to the child.
In the area of injury during the healing phase, a cotton swab dipped in 0.12% chlorhexidine or antiseptic mouthwash can be used to clean the teeth and soft tissues. The cleaning of teeth and soft tissues should be carried out twice daily morning and night.
Use of mouthwashes in children is not advised as they may swallow the mouthwash instead of rinsing. In the area, where sutures are placed toothbrush usage should be avoided and gentle cleaning with a cotton swab is advised, so that the sutures do not get disturbed. After traumatic injuries of the primary dentition, most complications are associated to infection due to caries [30]. Post trauma after complete healing of the soft tissues radiographic assessment should be carried out to see any damage to the tooth buds of permanent teeth. Decidious teeth are not usually splinted to avoid disturbance to the permanent tooth buds. If splinting of deciduous teeth is carried out than the interdental areas below the splint fiber or wire should be kept clean by the use of interdental brushes in to and fro motion.
The mixed dentition is the period when maximum dental trauma cases occur. Professional oral hygiene like scaling and root planning can be rendered to the patients in this age group.
Tooth brushing with soft bristled brush with caution in the traumatic areas is advised. Dental flossing to keep the interdental areas clean and prevent inter dental plaque accumulation has to be incorporated in the oral hygiene practice. It is important to check for the trauma to the tooth buds of permanent teeth and render treatment accordingly. If the patient is accustomed to using powered toothbrush, he or she needs to be careful while brushing around teeth with dental trauma. The use of mouthwashes to reduce plaque growth helps in easy oral hygiene maintenance. If the teeth are splinted for stabilization during healing phase, use of interdental brushes such as proxa brush is advised to keep the interdental regions clean.
In the permanent dentition oral hygiene around the traumatized teeth becomes vital and post trauma care is essential for long term prognosis. The teeth with traumatic injuries may have cracks, fractures, luxation or may be replanted and this alters the natural shape and structure of the teeth. Many different oral hygiene methods have to be followed to maintain hygiene around these teeth. It is better to have supragingival prosthesis of the fractured tooth as subgingival placement of the crown margin is plaque accumulating and leads to periodontitis if not well maintained.
Oral hygiene maintenance methods have to be modified to meet the special clinical situations.
The splint should be placed on the buccal surfaces of the maxillary teeth to enable lingual access for endodontic procedures and to avoid occlusal interference [31, 32, 33, 34]. Splinting up to four months is advised in root fractures at the cervical third [13]. The use of semi rigid splint and flexible splints is more indicated than the rigid one as per The International Association of Dental Traumatology (IADT), and splinting done for long periods can cause root resorption or ankylosis of teeth [35, 36].
Care must be taken in teeth which are splinted during the healing phase. Interdental cleaning under and over the wire or fiber splint can be carried out with an interproximal brush.
Brushing must be done carefully and mouthwash should be advised to be rinsed regularly to stop the plaque growth. Interdental brush or proxa brushes are best suited for use under the wire of splints and interdental areas.
The interdental area between the teeth harbor’s plaque and it has to be cleaned with interdental aids using dental floss, interdental brushes or unitufted brushes.
Dental floss a thread like material is used to clean interdental area with tight interdental contact. The dental floss is inserted or passed between the two teeth and moved in to and fro motion to clean the interdental area below the gum papilla. Dental floss is passed between every interdental area between teeth and activated to get rid of plaque. Figure 1 shows the use of dental floss between upper right lateral incisor and canine.
The use of dental floss between upper right lateral incisor and canine.
Interdental brushes have shown to be the best in interdental cleaning. The use of interdental bushes can only be accomplished, if slight spacing is present between adjacent teeth either due to spacing or minimal gingival recession. Figure 2 shows the use of interdental brush in between two central incisors.
The use of interdental brush between two central incisors.
Unitufted or single tufted brushes are advocated in patients with spacing between teeth or severe gingival recession. Unitufted brushes are easy to use and effective in cases with big interdental space. Figure 3 shows the use of unitufted brush between the two central incisors. Figure 4 shows the use of unitufted brush on the lingual side under beneath the ligature or fiber splint.
The use of unitufted brush between two central incisors below the dental splint.
The use of unitufted brush on the lingual surface of mandibular anterior teeth below the dental splint.
Teeth with sub gingival fracture line should be observed closely and maintained plaque free otherwise, gingivitis and periodontitis can develop and jeopardize the prognosis of the tooth.
Teeth with crowns and bridges should be monitored regularly for excess cement or leakage of the cement, which can be plaque accumulating. The margins of prosthesis should be placed supra gingivally whenever possible and have to be monitored regularly for periodontal health.
Brushing on the teeth with composite build-up, inlay or onlay restoration should be carried out with caution. These teeth should not be brushed vigorously to avoid abrasion of the composite material and exposure of fracture line.
Removable dentures and any device or bite guard used by the patient should be removed and cleaned after every meal to avoid bacteria, fungi, plaque and tartar growth. The oral mucosa covered by the prosthesis, including the palate, must be cleaned at least once a day with a soft toothbrush. Mechanical cleaning of prosthesis under running water with help of denture brush should be done both on outer and inner surfaces [3].
Hold the tooth by its crown (white part). Do not touch the root (Yellow part).
Wash the teeth for ten seconds under cold tap water. Do not scrub.
Replant the tooth in the original socket in jaw.
Bite on handkerchief (to hold in position).
Refer to the dental office for fixation and antibiotics.
If the tooth cannot be replanted, place the tooth in cold milk and refer to the dental office immediately (within 20 min) [3].
The teeth that undergo TDI’s have to be maintained for a long time as there may be occurrence of complications such as pulp necrosis, root resorption and root ankylosis.
Regular follow-up and prompt treatment will improve the overall prognosis and improve the quality of life in the affected individual.
Follow up of TDI’s up to 5 years has been advocated by International Association of Dental Traumatology [37].
The research of published data suggests that there is a lack of proper knowledge on emergency dental first-aid among the parents, care givers, school authority and general public. In most of the countries worldwide, no attempt has been made by the government or other dental organizations to educate people on the management of dental trauma. TDI’s are an important general and public health issue and public awareness of its importance should be bolstered to enable equitable access for injury care. Greater emphasis on prevention and the significance of emergency care for dental injuries will reduce the financial burden of the individual and improve the quality of life [6].
Research conducted to assess the treatment and management of TDI’s have shown that the treatments provided at emergency care units are often inadequate and patients remain unsatisfied with care provided. The International Association of Dental Traumatology (IADT) has given a comprehensive guidelines management of TDI’s, which can be accessed via Internet (www.iadt-dentaltrauma.org) [38]. The IADT recently developed a core outcome set (COS) for traumatic dental injuries (TDI) in children and adults, these guidelines should be followed and, even in extreme situations, replantation of teeth should always be considered [39]. Interactive website has been introduced for clinicians (Dental Trauma Guide, www.dentaltraumaguide.org) which can be used by dentist and health care workers either via computer or smart phone during a trauma situation [40]. Mobile phone based free App was introduced by IADT (IADT ToothSOS Mobile App) to help user to take care of a dental trauma at the scene of an accident.
Dental injuries cause both periodontal and pulpal complications. The delay in dental consultation for TDI’s increases the amount of complications that develop later during the maintenance. Time lapse between the TDI’s and the date of dental consultation is a decisive element in the therapeutic choice and influences the prognosis [5]. The parents and individuals should be educated to consult a dentist immediately after trauma and take prompt treatment for the TDI’s to reduce the complications that develop at the later date.
There is need for refinement of dental curriculum for the management of TDI’s in terms of design, content, teaching methodology and long term maintenance for better prognosis of the patients with dental trauma [41].
The prevalence of TDI’s in Europe and many other continents is one in five school going children and if untreated they affect the quality of life of children. The environment of the school and action taken towards management of TDI’s is very crucial. Schools with supportive social and physical environment have fewer occurrences of TDI’s. Schools should adopt health and safety policies, improvements in the physical environment and closer supervision of children while playing will reduce the occurrence of TDI’s [42]. School teachers and physical instructors should be educated about emergency management of TDI’s and consult child specialist and dentist at the earliest to lessen post traumatic complications. Studies have pointed out that health promotion policies, safe environment at the schools, correction of predisposing risk factors of TDI’s and use of protective intraoral and extra oral devices while physical activity will lessen the financial burden caused by TDI’s [43]. Conducting health educational programs to improve the level of general knowledge about prevention and managing TDI’s at the schools is necessary [44].
Parents, Education authorities, and children involved with sports and recreation activities should be educated about the risk factors involved and management of TDI’s. Screening programs to identify children with high anatomic (incisal over jet and inadequate lip coverage) and behavioral risk for occurrence of traumatic injury and necessary corrective measures (preventive orthodontic treatment and use of Mouth guards) will help reduce the occurrence of injury among children [45]. Mounting posters, leaflets at public places along with media campaigns using television, social networking sites and internet will educate people for managing avulsed permanent teeth [1]. The teachers and school management should be educated about TDIs and emergency care and referral to dentist as schools with good physical structures and promote health activities had lesser prevalence of TDIs [46, 47].
The dentist treating TDIs must involve other specialists including Oral Radiologist, Pediatrician, Paedodontist, Endodontist, Periodontist, Prosthodontist, Orthodontist and Oral maxillofacial Surgeon. Dentist must capture good quality photographs of the TDIs and lesions and can use them to discuss the treatment protocol with specialists. Studies have proved that photographic assessment method of dental trauma was valid and reliable as compared to the oral clinical examination [48].
Dentist must be aware of different types of TDIs and its immediate treatments [49]. Dentist should educate good oral hygiene maintenance techniques to the patients suffering from TDIs. During the healing and splinting of teeth, oral hygiene cleaning with interdental brushes will help the patients.
Complications even with the best of treatment guidelines followed occur occasionally and pulp necrosis is the most observed complication [12]. Dentist must refer the patient to other specialists whenever deemed necessary. Combined efforts of different specialists will improve the prognosis of the teeth and soft tissues.
“The authors declare no conflict of interest.”
We would like to thank Dr. Reema Shah and Dr. Harshada Zagade postgraduate students in Periodontology for editing and preparation of the figures.
Traumatic Dental Injuries Oral Health-Related Quality of Life Periodontal Ligament International Association for Dental Traumatology Central Nervous System Intraoral periapical radiographs Orthopantomogram Cone beam computed tomography Tetanus Toxoid American Dental Association Non-Surgical Periodontal Therapy
Since 1962 when the first Clark’s biosensor was introduced [1], enzymatic electrochemical devices have attracted increasing attention, recently being regarded as a powerful tool for the development of emerging wearable bioelectronics [2]. Integrating enzymes with electrochemical transduction units is one of the most popular and well-built bioelectronic systems due to outstanding selectivity and natural behaviors of enzymes [2, 3, 4]. Employing enzymes, as a catalytic system, in order to substitute nonselective metal catalysts, is interesting. Because of inherent behaviors of enzymes, enzyme-based bioelectronics offers favorable operations under mild physiological conditions of pH and temperature, unlike nonenzymatic approaches [5, 6]. In addition, enzymes will usually catalyze only one particular reaction. Therefore, such enzyme specificity enables bioelectronics to operate selectively even in complex solutions, including biofluids. Recently, there is an increasing interest in transforming traditional enzymatic bioelectronics into modern wearable platforms. Wearable enzyme electronics expands appealing spectra of a variety of applicable fields, ranging from personalized healthcare, fitness, to the environment. These applications comprise of noninvasive diagnosis of biomarkers in biofluids, such as sweat, and the monitoring of the surrounding of the wearer. Besides, electron collectors can be functionalized with enzymes to develop BFCs for energy and self-powered applications. These biodevices employ enzymes to obtain electrocatalytic oxidations of biofuels, such as glucose and lactate. This aims to achieve next-generation energy autonomy for the whole wearable system. In addition to energy-harvesting purposes, BFCs can also act as self-powered electrochemical sensors. Three main applications of enzyme-based electrodes, including biosensors, biofuel cells (BFCs), and self-powered sensors, along with their relevant aspects, will be discussed (Figure 1). An enzymatic biosensor employs an enzyme, immobilized on an electrochemical transducer, to recognize and react with the target, generating a readable electrical signal (Figure 1B). A BFC energy harvester can convert chemical energy into electricity and power wearable devices (Figure 1C) [7]. A BFC can also be designed to act as a self-powered sensor by displaying power signals proportional to the target concentration (Figure 1D) [8, 9].
\n(A) Skin-worn enzyme-based electrochemical devices. The soft electrode platform is functionalized with enzymes, allowing various applications, including (B) biosensors, (C) energy-harvesting biofuel cells, and (D) self-powered biosensors.
Skin-worn enzyme-based electrochemical devices are among the most significant wearables because the skin offers the largest organ interface and unique opportunities to be accessed noninvasively [10, 11, 12, 13]. The large epidermal area also provides sweat, which contains a variety of biomarker-rich information, such as levels of glucose, lactate, hormone, urea, pH, and electrolytes. Advantageously, skin-worn electrochemical devices can be attached directly close to the location of sweat generation, enabling the fast access for monitoring or energy harvesting before the unwanted biodegradation. In addition to physical parameters obtained from existing skin-worn biodevices (such as temperature and heartbeat), chemical data is also crucial to step further to understand comprehensive insights of individual [14]. The history of sweat content analysis began many decades ago with the development of cystic fibrosis diagnosis [15]. Establishing new “lab-on-skin” electrochemical devices enables noninvasive detection of such biometrics, essential for health monitoring and early disease diagnosis. In addition, such wearable electrochemical tools are also helpful for drug testing and chemical threat screening, such as in sports [12] and in the surrounding environment [16]. Importantly, for emerging energy technologies, sweat also contains relevant biofuels, such as glucose and lactate; this is useful to BFCs as energy-harvesting and self-powered devices, which exemplify new exciting wearable autonomous bioelectronic systems.
\nAlthough researchers are battling to create new enzymatic bioelectronics, there is a continuing need for further development. Revolutionizing traditional electrodes toward wearable bioelectronics needs careful engineering to address several key challenges associated with electrochemistry, the integration of biocatalysts, mechanical stability, environment effects (e.g., O2 fluctuations), and sweat extraction. Therefore, the bulk of this chapter will focus on examples of progress in skin-worn enzymatic electrochemical devices. Key working principles and opportunities of biosensors and BFCs will be described. In addition, perspectives emphasizing on main challenges will be discussed. The outlooks of emerging wearable electrochemical technologies will also be concluded.
\nWearable enzymatic electrochemical biosensors utilize enzymes, which are functionalized in spatial contact with electrochemical transduction units. In principle, biosensors consist of electrodes and enzyme receptors, allowing the specific binding capabilities and catalytic activity to target analytes. Interfacing enzymes with electrodes will be discussed further in Section 3.3. It should be remarked that the key consideration to fabricate a successful biosensor for nonspecialist wearers is choosing highly specific biocatalysts. Enzymatic biosensors can also function continuously because enzymes are not consumed in reactions, offering an advantage for wearable sensors.
\nEnzymatic biosensors are based on numerous mechanisms. The popular mechanism relies on the conversion of the analyte as an enzymatic substrate into a product, enabling the detection by using electrochemical transducer. Another way is to monitor the analyte (e.g., a toxic compound) that acts as an enzyme inhibitor. In addition, the enzyme can be used as a labeling transducer for bioaffinity recognition. Besides, a reverse approach can be designed to detect the enzyme level. In this case, the enzyme acts as an analyte, while the substrate is immobilized on the electrode surface. When the enzyme reaches the electrode sensor, it will generate the signal, corresponding to the concentration level of the enzyme target.
\nIn recent decades, enzymatic biosensors have been proven to be modern wearables to monitor numerous analytes, such as glucose, lactate, alcohol, and organophosphate nerve agents. Among several enzymes, oxidoreductase and hydrolase, such as glucose oxidase (GOx), lactate oxidase (LOx), alcohol oxidase (AOx), and organophosphorus hydrolase, are predominant for wearable biosensing applications. A temporary tattoo with the integration of transdermal enzymatic glucose biosensor has been introduced since glucose is a key biomarker for diabetes mellitus, which still affects hundreds of millions of patients globally (Figure 2A) [17]. The iontophoretic ISF extraction system was coupled with the amperometric detection to extract the sample containing glucose. The glucose biosensor, located near the negative iontophoretic electrode, relied on GOx immobilization on the Prussian blue (PB)-carbon electrode; this PB facilitates the electroreduction of H2O2 product, generated by the GOx reaction. The amperometric reduction of H2O2 could be detected at a potential of −0.1 V versus Ag/AgCl. The iontophoresis strategy will be discussed in Section 3.5. Additionally, the tattoo-based alcohol sensor was also invented (Figure 2B). The AOx-/PB-based sensor was designed to be close to the positive iontophoretic electrode to determine ethanol in sweat induced by transdermal delivery of the pilocarpine drug [18]. Moreover, recent efforts have been made to combine these two concepts, including glucose and alcohol sensors, on a single tattoo [19]. This holds a possibility for multianalyte sweat analysis.
\nSkin-worn enzyme-based electrochemical biosensors. (A) Transdermal tattoo-based glucose sensors, coupled with reversed iontophoresis [
Skin-worn microfluidic devices can enable the continuous flow of renewed sweat over operational periods. This addresses the challenge of mixing and carry-over between new and old sweat. Figure 2C shows an example of sweat collection microfluidic devices, coupled with glucose and lactate biosensors [20]. This offers wearable effective continuous sweat sampling and flow electroanalysis.
\nFurthermore, minimally invasive microneedles for continuous glucose monitoring have been demonstrated. For example, a GOx/tetrathiafulvalene microneedlebased amperometric sensor (~1.2 mm needle height) could be used for in vivo studies [21]. The data were also validated with the finger-prick technique, indicating a promising alternative for on-skin analysis. In addition, a minimally-invasive microneedle-based potentiometric sensor for tracking β-lactam antibiotic concentrations in vivo and real time was demonstrated Figure 2C [22]. This example represents a possibility to tailor individual therapy with the optimal efficacy.
\nMoreover, reading several parameters can complete a clear picture of individual health. A fully integrated sensor array for sweat analysis was demonstrated (Figure 2E) [23]. These integrated sensors can monitor information of glucose, lactate, electrolytes (e.g., sodium and potassium ions), and temperature. The temperature sensor is also helpful to standardize the biosensing amperometric response. Furthermore, in order to apply the biosensor glucose device for health management, a transdermal closed-loop drug delivery integrated with a sweat-based glucose electrochemical sensor was demonstrated (Figure 2F) [24]. The sense-treat concept aimed to give feedback of transdermal administration of type 2 diabetes drugs in response to the glucose level. This idea represents a possible opportunity to overcome insulin overtreatment, helping patients to maintain their homeostasis.
\nBFCs are energy-conversion devices that utilize biocatalysts to convert chemical energy into electricity. For wearable electronics, the need to anatomically power sources has attracted many research groups to develop a BFC, as a “green” energy-harvesting alternative, in order to extract energy from metabolites present in biofluids, such as perspiration. Since glucose, lactate, and oxygen are present in physiological fluids, in general, a majority of wearable enzymatic BFCs rely on (1) the generation of electrons from glucose or lactate biofuels and (2) the electron reduction by oxidants (such as oxygen). Figure 1C shows a typical example of a glucose/O2 BFC. In principle, a glucose BFC uses GOx, functionalized on the bioanode, to catalyze the glucose oxidation reaction to generate electrons. After this oxidation process, these harvested electrons are driven through an external circuit to the biocathode compartment where such electrons are accepted by oxidant molecule (commonly O2) and, eventually, generate complete electrical work. In addition to Pt-based catalysts, multicopper oxidases such as laccase, bilirubin oxidase, and polyphenol oxidase are commonly used for electrocatalyzing oxygen-reduction reaction (ORR) in the BFC cathode [25].
\nEnzymatic BFCs represent an interesting alternative due to their unique advantages, such as outstanding selectivity and behaviors of enzymes. Unlike most traditional inorganic catalyst-based fuel cells, which require harsh conditions (such as acidic conditions or high temperatures ranging from 45°C to more than 100°C), the enzyme-based BFC can operate under mild conditions (20–40°C at neutral pH). Moreover, non-specific catalyst-based fuel cells require to separate anode and cathode chambers by a thin membrane. Unfortunately, this common use of separation membrane between the anode and the cathode compartments will be unsatisfactory for skin-worn miniaturized devices. Thanks to the nature of enzymes, utilizing high specificity of enzymatic catalysis can obviate this membrane requirement, facilitating the fabrication and applications [26]. In addition, enzyme-based BFCs can operate selectively in complex biofluids.
\nInterestingly, BFCs also offer opportunities to design self-powered biosensors (Figure 1D). For example, the power is proportional to the concentration of the fuel (also acting as analyte); self-powered output itself can determine the level of the target. This offers opportunities to eliminate external energy sources for powering potentiostat and signaling systems [9].
\nAn initial concept integrating enzymatic BFCs with skin-worn technologies represented an exciting way to scavenge bioenergy available in human perspiration (Figure 3A). This demonstrated the first epidermal tattoo-based BFC that converted sweat lactate biofuel and oxygen into electricity [27]. The lactate oxidation by LOx electrocatalyzation was mediated by tetrathiafulvalene on the carbon nanotube (CNT)-based anode, while electroreduction on the oxygen-reduction cathode relies on Pt black catalyst. This system facilitates mediated oxidation of lactate at −0.1 V with a peak potential of 0.14 V (versus Ag/AgCl). This low anodic onset potential indicates the efficient electron-donor-acceptor TTF/CNT. The successful on-body test displayed a power up to 70 μW cm−2. This idea was also established on fabrics and could power a light-emitting diode with an integrated DC-DC converter [28].
\nSkin-worn BFCs and self-powered sensors. (A) Epidermal tattoo-based lactate BFCs. (B) Stretchable glucose BFCs [
Mechanical stability has been the focus in the development of the next-generation of skin-worn BFCs due to the multiplex mechanical movements experienced
In addition to energy-conversion applications, BFCs can be applied further as another significant tool for wearable bioelectronics. Enzymatic BFC can serve as self-sustainable biosensors (without an extra powering device). In order to expand the spectrum of BFC applications for on-skin electroanalytical chemistry, the pioneering stretchable textile-based BFCs that can act as self-powered was demonstrated (Figure 3C) [30]. These biodevices can deliver two key functions: (1) harvesting electrical power from sweat glucose and lactate and (2) displaying signals of such metabolites. Extracted bioenergy from the wearer’s sweat can directly indicate the metabolite levels. Sock-based biodevices were successfully demonstrated on human subjects, representing a promising concept for modern wearable self-powered biosensors.
\nMaximizing the loading amount of active enzyme, mediator, and conductive materials can improve the power performance of BFCs. The high amount of such active materials can be packed by a compress. However, this strategy will affect mechanical softness. Therefore, further engineering was to fabricate island-bridge assemblies merging the high enzyme loading packed islands with stretchable serpentine bridges [34]. This combination offered a soft bioelectronic skin for harvesting a good power density of 1.2 mW cm−2. This energy was sufficient to power a Bluetooth Low Energy (BLE) radio integrated with a DC-DC converter.
\nRecently, additional efforts have been made to scavenge, improve, and store energy by hybridizing textile-based energy conversion with energy storage devices (BFCs and supercapacitors, respectively) (Figure 3E) [31]. The on-body demonstration showed that after perspiring, the supercapacitor could be charged by the BFC energy and reach a stable 0.4 V output.
\nFurthermore, a photoelectric BFC was developed to convert external light andchemical energy from wearer’s perspiration into electrical energy (Figure 3D) [32]. The anode relied on a LOx/Meldola’s blue/buckypaper electrode, while the photocathode relied on an organic polyterthiophene semiconductor, which drove a reduction reaction under illumination (wavelengths of 350 nm to over 600 nm). This system presented an attractive example of on-skin autonomous power sources and sensors.
\nAdditional efforts have been made to explore new biomedical applications of BFCs. Figure 3F shows an integrated fructose/O2 BFC patch that was conjugated with transdermal iontophoresis [33]. The current generated by the BFC was used to drive an osmotic flow from the anode to the cathode, resulting in the net ionic movement of small-molecule drug into the skin. The level of transdermal current to control the drug administration could be adjusted by connecting a thin poly(3,4-ethylenedioxythiophene)/PU resistor of a programmable resistance value.
\nYoung’s modulus of the human skin is in a range of 10–500 kPa [35, 36], while the moduli of common electronic materials, such as silicon and gold, are much higher (high GPa), indicating significant mechanical mismatch when integrating with the skin. Therefore, functionalities of non-stretchable electrodes will deteriorate after multiplex deformations commonly experienced by daily life activities. Furthermore, such rigidity and bulkiness of traditional devices also restrict the wearability and comfortability [14]. Non-compliant electrochemical devices will limit continuous long-term functions due to cracking and increasing of material resistance. This increasing of resistivity, which opposes the current flow in bioelectronics, causes poor electron communication at the enzyme-electrode interface.
\nThis major challenge of skin-integrated electronics can be addressed by exploring stretchable materials which display mechanical properties in a similar range of skin’s modulus. One approach is using polymers due to their low mechanical toughness. For example, conducting materials with high moduli can be blended with soft polydimethylsiloxane or Ecoflex materials (Young’s moduli of 0.4–3.5 MPa and 125 kPa, respectively) in order to tune the mechanical properties while keeping good electrochemical functions [37]. CNT-based materials, which are powerful for electrochemical devices [38], are used to combine with soft elastomers, such as PU and styrene-butadiene-styrene (SBS) [29, 39]. PU and SBS composites have moduli of ~700–800 kPa. As shown in Figure 3C, CNT filler (with the high-aspect ratio ∼1300) was combined with PU [30], achieving stretchable conductive electrode materials. The percolation of dispersed CNTs can facilitate the electric flow in stretchable bioelectronics. Combining the intrinsic stretchability of this engineered inks with the structural stretchability of the serpentine design allows the device to tolerate strains as high as 500% with a small effect on its electrochemical performance [29]. This concept can be expanded by adding new functionalities into electrodes. For example, platinum-decorated graphite was mixed with PU to obtain stretchable electrocatalytic materials, allowing the fabrication of stretchable electrodes for glucose biosensors [40].
\nGrowing demand of wearable technologies has stimulated the need of the development of viable energy sources. The lack of anatomically power sources becomes a key bottleneck for the progress in wearable bioelectronics. Skin-worn bioelectronics mandates the compliant and efficient energy sources to supply multitasks, including sensing and data communication. In addition to developing low-power-consuming electronic microelectronics [9, 41], there is an increasing interest in advancing bioenergy-harvesting devices. Enzymatic BFCs are attractive self-sustainable energy devices to meet this growing energy demand. For example, 0.3-V complementary metal-oxide-semiconductor (CMOS) wireless glucose or lactate biosensing systems, which consumed power of ~1.2 μW, could be powered by BFCs [9]. Nevertheless, several applications of enzymatic BFCs still have some challenges, such as low-power output. The major challenge in enzymatic BFC is faced by the electrical “wiring” of enzymes with electrodes. The difficulty of electrical wiring, referring to electron transfer, and their possible solutions will be detailed in Section 3.3.
\nCompared with traditional fuel cells, enzymatic BFCs are challenging due to their multicomponent including redox potentials of enzyme, cofactor, and mediator. This results in the typical unwanted deviation of open-circuit voltages (OCV) from their theoretical maximum values, referring to “cell voltage losses.” The redox potential for electrocatalytic oxidation at the bioanode required to be higher than that of the biocathode for reduction reaction in order to deliver a sufficient electromotive force for electron transfer between enzyme active site and mediator. The voltage difference between the formal redox potentials (E°′) of redox enzyme cofactors in the active sites, in the anode and cathode, will govern the maximum cell voltage. Parameters, including redox potential of mediator and cofactor redox potential in the enzyme, can influence the resulting potential output of BFCs. Therefore, the mediator should be carefully chosen. For example, ferrocene derivatives coimmobilized with GOx at a graphite electrode can be used for glucose sensors [42]. Nevertheless, ferrocene derivatives display high redox potentials (0.1–0.4 V versus SCE); these will cause cell voltage losses in the GOx-based BFC if they are used as anode mediators. It should be noted that the difference between the redox potentials of the enzymes wired at the anode and the cathode determines the cell voltage. An example of a successful anode mediator used in skin-worn BFCs is 1,4-naphthoquinone [30]. This quinone compound is also almost insoluble in cold water, preventing leaching during on-body operations. One challenge of using GOx on the anode is the O2 competition with a mediator, decreasing the oxidation current on the bioanode. Moreover, O2 competitive reaction on the anode can produce H2O2. This by-product can inhibit GOx activity and decrease the overall BFC performance. Therefore, catalase should be cofunctionalized to the bioanode to diminish the undesirable H2O2 [43].
\nA single-enzyme BFC can usually convert only a partial portion of biochemical energy, resulting in low current output. For instance, wearable BFCs, such as for harvesting energy from lactate sweat, commonly employ a single enzyme-based bioanode, catalyzing the oxidation of lactate to pyruvate, which only harvests two electrons. In other words, they utilize only a portion of the biofuel energy and leave most of the energy in the oxidized product. Therefore, it is interesting to harvest the total of 12 electrons in order to maximize the energy-conversion efficiency. A potential solution is to design an enzyme cascade system for complete oxidation of lactate fuel. For example, the bioinspired multienzyme catalytic cascade could complete the metabolic cycle, successfully enhancing net BFC power [44].
\nFurthermore, in order to optimize the current output, diffusion and enzyme loading should be enhanced. The engineering of specific enzyme activity and three-dimensional structure of enzymatic electrodes should be explored.
\nThe selection of enzymes is a primary subject which should be discussed. Enzymes must be selected by considering their particular reactions to target analytes or biofuels for electroanalytical monitoring and energy harvesting, respectively. One of the most predominant enzymes used to develop wearable bioelectronics is GOx from
Principles of interfacing the enzyme, such as glucose oxidase (GOx), with the electrode. Different generations of strategies (A–C: first, second, and third generations) are illustrated. (D) Reactions involving the glucose oxidase biocatalyst.
The first generation of biosensors relies on quantifying O2 generation or H2O2 depletion (Figure 4A). This leads to key drawbacks, such as low dynamic range, dependency to oxygen fluctuations, and interfering effects. For instance, for glucose amperometric sensors, the detection of H2O2 at common first-generation electrodes needs the high applied detection potential where interfering compounds existing in sweat, e.g., ascorbic acid, uric acid, and some drugs, are also electroactive. Lowering the applied potential for the detection is a strategy to minimize such electroactive interferences. One approach is to incorporate electrocatalysts in wearable electrodes, such as PB or Pt [17, 40]. This offers low-potential detection of H2O2 to mitigate interference effects.
\nFurthermore, researchers have developed two strategies to wire enzymes to the electrode interface (Figure 4B and C). These include (1) mediated electron transfer (MET) and (2) direct electron transfer (this may refer to mediatorless electron transfer between the enzyme and the electrode). Such new tactics are not only useful for enzymatic biosensors but also for enzymatic BFCs which also involve bioelectrocatalysis.
\nFirst, the MET strategy utilizes a redox mediator, acting as an electron-shuttle assistant between the enzymatic active center and the electrode. The substrate level, such as glucose, can then be monitored by the redox process of the mediator. This results in the independence of oxygen and mitigating the interfering signals due to the operation at low potentials. The first consideration in electrically wiring the enzyme with the electrode is the choice of the mediator that should be close to the redox potential of the active center of the enzyme to facilitate efficient electron communication between the enzyme and the conductive electrode surface. In particular, for enzymatic BFCs, the selection of mediators is crucial to positively control the cell voltage and enhance heterogeneous electron transfer to the order of a homogeneous transfer [50]. However, challenges of using mediators, particularly for BFCs, are their stability and deviated cell voltage. In addition, biocompatibility is highly vital for skin-worn applications. In spite of the assistance of electron shuttle by redox mediators, major concerns are their biocompatibility. One possible solution is employing nanomaterials or highly biocompatible catalysts. For example, mushroom/plant extracts could be used to obtain efficient “green” bioelectrocatalytic reactions for ethanol BFCs [51].
\nSecond, direct electron transfer is an ideal goal of electrical wiring. It can be achieved by employing nanomaterials which suggest the direct electron transfer between enzyme active site and electrode. This wiring strategy is based on the shortening of the electronic contact of the enzyme and electrode (a short distance of ~1.5 nm) where the redox center of the enzyme can be regenerated directly by the electrode [52]. Therefore, this strategy can maximize the performance of bioelectronics. The engineering needs to consider the position of the active site inside the protecting protein and the conformation of the protein in order to wire the conducting materials with the redox center. This still remains the most challenging topic.
\nSeveral variables also affect the response nature of enzyme bioelectronics. Consideration of the fundamental theory of their functions will help to improve their performances. A key well-known model of enzyme behaviors is Michaelis-Menten kinetics, \n
In addition, extra membranes can be a biocompatible barrier to address challenges from biofouling and interferents, especially when electrochemical operations are made in real matrices, samples, such as sweat. A perfluorinated sulfonated membrane (Nafion®) is an example membrane, which is also easy to drop-cast. This coating membrane can protect the enzymatic layer and also prevent anionic interferents, such as ascorbate [53].
\nShelf life and operational stabilities of enzymatic electrodes are among the most critical challenges. The enzyme and active materials, such as mediators, can also leach during operations. Extensive studies have been made to improve enzyme bioelectrodes, such as by crosslinking hydrogels in the presence of the enzyme [54, 55]. Such crosslinking can entrap the enzyme to be more stable; moreover, this way enhances the loading of the enzyme, while the three-dimensional structure can facilitate the transport of analytes or biofuels, improving bioelectrode functions. Nevertheless, crosslinking enzyme or covalent binding of the enzyme can change the conformation of the enzyme and thus affect the activity [56]. Furthermore, one alternative to stabilize the enzyme electrode is the addition of stabilizers, such as polyelectrolytes, dextrans, glycerol, polyethyleneimine, and hydrophobic oils [57, 58, 59]. For instance, hydrophobic mineral oil or silicone grease can be used to minimize enzyme denaturation [58, 59]. The pasting liquid helps to lower protein mobility, maintain conformational rigidity of enzymes, and barrier to hydronium ions from acid environments. This strategy can stabilize many enzymes, such as GOx, LOx, AOx, horseradish peroxidase, amino acid oxidase, and polyphenol oxidase.
\nIncreasing enzyme loading can also improve the performance of biocatalytic devices. Employing high surface nanomaterials is useful to enhance the surface loading of the target catalyst. A graphene-based electrode is a good example platform to offer a high enzyme loading (1.1 nmol cm−2); in addition, it offers a fast heterogeneous electron transfer rate (
Importantly, biofluids from the skin (such as sweat and extracted interstitial fluids) contain a variety of chemicals that can inhibit enzyme activity, reflecting challenges in biosensing and BFC functions in real-time on-body applications. For instance, heavy metals can be found in sweat as the body expels chemicals or balances the charges. One example is Cu2+ which has been reported as an inhibitor to deactivate the enzyme. The Cu2+ in sweat can be in a range of 1.6–16 μM [11]. 0.1 μM Cu2+ could decrease the OCV value of the glucose BFC [64]. However, this enzyme-inhibitor electrochemical behavior is analytically attractive toward the development of self-powered biosensors, such as for direct heavy metal screening or indirect cysteine monitoring. For example, cysteine prefers to bind with Cu2+ via the Cu-S bond; this superior conjugation between cysteine and Cu2+ removes metal ions from the bioanode, consequently turning on the OCV.
\nSince the O2 level in biofluids may vary, first-generation biosensors, employing O2-dependent mechanism, are subject to inaccuracy. This issue can be addressed by using fluorocarbon pasting liquids to supply internal O2 [65]. Using redox mediator as a second-generation sensor is another way to eliminate this error. Furthermore, FAD-dependent glucose dehydrogenase is an option to address O2-dependent problems due to its O2-insensitive nature, compared with GOx [49]. In addition, because of the high rate of homogeneous electron transfer rate between GOx and oxygen, GOx prefers to transfer electrons to oxygen rather than to the electrode, causing undesirable O2 competition effect [66]. Moreover, for BFCs and self-powered sensors, the commonly used ORR cathode may cause the error under anaerobic conditions. The use of Ag2O/Ag redox cathode, which does not depend on ORR, can be used to operate BFCs, mitigating the possible O2 errors [30, 67]. Note that the reduction potential of Ag2O/Ag (0.342 V vs. SHE) is close to that of O2/OH− (0.401 V vs. SHE) at pH 7. Moreover, using O2-rich cathode is another possible option to mitigate O2-deficit effects [68].
\nEach person has 2.03 million sweat glands; sweat gland densities vary broadly across the skin surface and subjects, ranging from 16 to 530 glands cm−2 [11, 13, 69]. Normally, during exercise, sweat can be secreted around 20 nL gland−1 min−1 [11]. For example, the forehead or arm can generate sweat around 3 μL cm−2 or even lower. The fluctuation of sweat rate is also related to numerous factors, such as activity intensity and hydration level. Therefore, the limited volume of sweat causes a challenge in sweat analysis and operations. This leads to the development of miniaturized skin-worn electrochemical devices that can be practical in such small dead volume. For instance, the textile-based energy-harvesting BFC requires sweat volume per area of 40 μL cm−2 to deliver steady outputs [31]. Designing a capillary chamber is a possible route for low-volume electroanalytical systems [70].
\nIn addition to a passive way to collect sweat, one strategy is an active electrical-based approach, called “iontophoresis” [71, 72]. This active strategy offers on-demand sweat generation as the device can be placed to a local skin target. There are two main approaches to extract sweat: (1) iontophoresis with pilocarpine drug and (2) reversed iontophoresis without the drug. These are attractive routes for continuous sweat analysis.
\nFirst, pilocarpine iontophoresis can be used to stimulate the sweat. In principle, a small electrical current is applied to enable the pilocarpine administration across the epidermis as illustrated in Figure 5A. For example, the tattoo-based enzymatic alcohol sensor consists of a pair of electrodes located in contact with the skin surface. Small constant current (0.2 mA cm−2) was applied through the cryogel material containing pilocarpine at the anode (positive) iontophoretic side [18]. The applied electrical force will push the pilocarpine drug, which possesses a large positive charge, to eventually enter into the skin. Such transdermal drug delivery of pilocarpine can induce the local sweat, sufficient for the subsequent electrochemical detection. In addition, interstitial fluid (ISF) located under the skin can be extracted. Without this iontophoretic strategy, it is challenging to access ISF through wearable technology.
\nElectrical-based strategies using iontophoretic electrodes to extract biofluids, including (A) pilocarpine iontophoresis and (B) reversed iontophoresis.
Second, the reversed iontophoresis without pilocarpine drug can be used to extract relevant analytes, such as glucose [17]. For instance, as presented in Figure 5B, a current (0.2 mA cm−2) is applied to extract glucose in ISF. During the reverse iontophoresis process, glucose is pulled out at the negative iontophoretic compartment. Even though glucose holds no charge, the inherent permiselective characteristic of the skin prefers to transport positive species, allowing such glucose extraction. Applying electric field on mobile electric charge can cause Coulombic force, leading to a net convective flow in the skin from the anode to cathode direction. Accordingly, dissolved analytes (e.g., glucose) are also moved toward the cathode where they can be extracted and monitored. Therefore, the glucose amperometric working electrode, adjacent to the cathodic iontophoretic side, can detect the glucose level from the extracted sample.
\nThis chapter has reviewed some examples of new trends of skin-worn enzyme-based electrochemical systems, focusing on biosensors, BFC, and self-powered sensors. The existing systems provide significant advances toward the painless and point-of-care applications and personalized electrochemical biodevices, which was not possible without such new biodevices. However, researchers still face many challenges, such as electrochemistry, electrical wiring of enzymes, enzyme behaviors, the fabrication of stretchable electrodes, O2 fluctuations in biofluids, interferences, and difficulty in sweat extraction. Moreover, the workability and reliability of biodevices can be limited due to the limited fluctuating and volume of biofluids. In order to avoid frequent recalibrations, the stability of biodevices or self-calibration systems are also important. Precise electrochemical functions for on-skin applications are still very challenging. Therefore, it is required careful attention to address all challenges in order to advance such wearable technologies.
\nAlthough main skin-worn BFCs have been driven by glucose and lactate fuels, it is interesting to explore new opportunities, such as from alcohol-based BFCs, where the bioanode can be functionalized with alcohol dehydrogenases. Future efforts may be made to expand the spectrum of current concepts. New integrated devices can be achieved by designing multifunctional sensors that can provide informative series of personalized data. This will require the incorporation of big-data analysis and Internet of things (IoT) to build up integrated networks and personalized baselines of each wearer. Big data collected from networks and individuals can then warn the user whether the body is in a healthy and equilibrium state or not. It is expected that developing new electrochemical biodevices will eventually track “fingerprints” of various pathologies and disorders. This aims toward wearable systems for early disease diagnosis. Moreover, full closed-loop concepts such as biocomputing logic gate, sensing, and therapeutic systems can also be further exploited in the integration of biosensors, BFCs, and drug delivery devices, in order to obtain both diagnostic and therapeutic applications. The next success of wearable biodevices needs the hybrid of multidiscipline, including physiological medicine, electronics, electrochemistry, bio- and nanoengineering, and computer science. These continued collaborative efforts will open fantastic opportunities for addressing current challenges and step further to create novel wearable devices and acquire comprehensive big data. Ultimately, it is expected that innovative wearable electrochemical technologies and new findings will contribute to revolutionizing diverse personalized wearables and biomedical applications.
\nThe author would like to acknowledge Hassler Bueno for proof reading.
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In 2010, he received a Ph.D. in Egyptology from the University of Basel, Switzerland.\nFrom 2012 to 2017, Dr. Pereira was a post-doctoral fellow at CHAM/FCSH – Universidade Nova de Lisboa.\nIn 2018, he became an Onassis Fellow, hosted by the Department of Mediterranean Studies, University of the Aegean, Greece. \nIn 2019, he became an auxiliary researcher at CHAM/FCSH – Universidade Nova de Lisboa. He teaches Middle Egyptian grammar, Hieratic, and disciplines regarding Egyptology, and the history of Phoenician and Greek expansion in the Mediterranean basin. \nIn 2021, he was awarded a CAARI Scholar in Residence Fellowship.",institutionString:"Universidade NOVA de Lisboa",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Universidade Nova de Lisboa",institutionURL:null,country:{name:"Portugal"}}},equalEditorTwo:null,equalEditorThree:null,productType:{id:"4",chapterContentType:"chapter",authoredCaption:"Authored by"}},{type:"book",id:"10342",title:"Ovarian Cancer",subtitle:"Updates in Tumour Biology and Therapeutics",isOpenForSubmission:!1,hash:"25a0adac7f6afa7bcd0b6daa3ef6b538",slug:"ovarian-cancer-updates-in-tumour-biology-and-therapeutics",bookSignature:"Gwo-Yaw Ho and Kate Webber",coverURL:"https://cdn.intechopen.com/books/images_new/10342.jpg",editedByType:"Edited by",editors:[{id:"297757",title:null,name:"Gwo-Yaw",middleName:null,surname:"Ho",slug:"gwo-yaw-ho",fullName:"Gwo-Yaw Ho"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10485",title:"Fibroids",subtitle:null,isOpenForSubmission:!1,hash:"64ad14b1aba83e47fb100fa63e21533e",slug:"fibroids",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/10485.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",middleName:"S",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:67,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"30747",doi:"10.5772/27200",title:"Cervical Cancer in Sub Sahara Africa",slug:"cervical-cancer-in-sub-sahara-africa",totalDownloads:8076,totalCrossrefCites:24,totalDimensionsCites:36,abstract:null,book:{id:"951",slug:"topics-on-cervical-cancer-with-an-advocacy-for-prevention",title:"Topics on Cervical Cancer With an Advocacy for Prevention",fullTitle:"Topics on Cervical Cancer With an Advocacy for Prevention"},signatures:"Atara Ntekim",authors:[{id:"69178",title:"Dr.",name:"Atara",middleName:"I",surname:"Ntekim",slug:"atara-ntekim",fullName:"Atara Ntekim"}]},{id:"43348",doi:"10.5772/55562",title:"Molecular Mechanisms of Platinum Resistance in Ovarian Cancer",slug:"molecular-mechanisms-of-platinum-resistance-in-ovarian-cancer",totalDownloads:4257,totalCrossrefCites:20,totalDimensionsCites:30,abstract:null,book:{id:"3449",slug:"ovarian-cancer-a-clinical-and-translational-update",title:"Ovarian Cancer",fullTitle:"Ovarian Cancer - A Clinical and Translational Update"},signatures:"Gonzalo Tapia and Ivan Diaz-Padilla",authors:[{id:"157073",title:"Dr.",name:"Ivan",middleName:null,surname:"Diaz-Padilla",slug:"ivan-diaz-padilla",fullName:"Ivan Diaz-Padilla"},{id:"166871",title:"Dr.",name:"Gonzalo",middleName:null,surname:"Tapia Rico",slug:"gonzalo-tapia-rico",fullName:"Gonzalo Tapia Rico"}]},{id:"37219",doi:"10.5772/47914",title:"Determining Factors of Cesarean Delivery Trends in Developing Countries: Lessons from Point G National Hospital (Bamako - Mali)",slug:"determining-factors-of-cesarean-delivery-trends-in-developing-countries-lessons-from-point-g-nat",totalDownloads:3047,totalCrossrefCites:7,totalDimensionsCites:21,abstract:null,book:{id:"952",slug:"cesarean-delivery",title:"Cesarean Delivery",fullTitle:"Cesarean Delivery"},signatures:"I. Teguete, Y. Traore, A. Sissoko, M. Y. Djire, A. Thera, T. Dolo, N. Mounkoro, M. Traore and A. Dolo",authors:[{id:"87496",title:"Dr.",name:"Ibrahima",middleName:null,surname:"Teguete",slug:"ibrahima-teguete",fullName:"Ibrahima Teguete"}]},{id:"31273",doi:"10.5772/31669",title:"Aqueous Extract of Human Placenta",slug:"aqueous-extract-of-human-placenta-as-a-therapeutic-agent",totalDownloads:5593,totalCrossrefCites:5,totalDimensionsCites:20,abstract:null,book:{id:"702",slug:"recent-advances-in-research-on-the-human-placenta",title:"Recent Advances in Research on the Human Placenta",fullTitle:"Recent Advances in Research on the Human Placenta"},signatures:"Piyali Datta Chakraborty and Debasish Bhattacharyya",authors:[{id:"88185",title:"Prof.",name:"Debasish",middleName:null,surname:"Bhattacharyya",slug:"debasish-bhattacharyya",fullName:"Debasish Bhattacharyya"},{id:"127848",title:"Dr.",name:"Piyali Datta",middleName:null,surname:"Chakraborty",slug:"piyali-datta-chakraborty",fullName:"Piyali Datta Chakraborty"}]},{id:"27121",doi:"10.5772/27439",title:"Clinical Risk Factors for Preterm Birth",slug:"clinical-risk-factors-for-preterm-birth",totalDownloads:8765,totalCrossrefCites:9,totalDimensionsCites:19,abstract:null,book:{id:"776",slug:"preterm-birth-mother-and-child",title:"Preterm Birth",fullTitle:"Preterm Birth - Mother and Child"},signatures:"Ifeoma Offiah, Keelin O’Donoghue and Louise Kenny",authors:[{id:"68552",title:"Dr.",name:"Ifeoma",middleName:null,surname:"Offiah",slug:"ifeoma-offiah",fullName:"Ifeoma Offiah"},{id:"70166",title:"Prof.",name:"Louise",middleName:null,surname:"Kenny",slug:"louise-kenny",fullName:"Louise Kenny"},{id:"74717",title:"Dr.",name:"Keelin",middleName:null,surname:"O'Donoghue",slug:"keelin-o'donoghue",fullName:"Keelin O'Donoghue"}]}],mostDownloadedChaptersLast30Days:[{id:"58219",title:"Congenital Abdominal Anomalies",slug:"congenital-abdominal-anomalies",totalDownloads:1420,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Introduction: Abdominal anomalies that appear during intrauterine life are complex due to many organs that are affected. In cases, the ultrasound appearance is a cystic image with different content and the differential diagnosis is often difficult. Body—research methods: the organs affected by abdominal congenital anomalies involve the gastrointestinal tract (stomach, duodenum, small bowel or colon, and gall bladder), the kidney and urinary tract, the peritoneal cavity (ascites), suprarenal glands, and tumors of the reproductive system (especially the ovaries). In order to identify the affected structures, it is mandatory to know the normal aspect of the abdominal content at different gestational ages. The diagnosis may be very difficult, but its accuracy is important, considering the need of further counseling the couple. In minor conditions, without chromosomal anomalies or associations, the outcome is usually good, and there are even possibilities of in utero treatment. In severe conditions, with poor outcome, the couple can choose to terminate the pregnancy, after counseling is provided. Conclusion: abdominal congenital anomalies are common findings in ultrasound screenings for anomalies in all the trimesters of pregnancy and their recognition is important for subsequent management.",book:{id:"6307",slug:"congenital-anomalies-from-the-embryo-to-the-neonate",title:"Congenital Anomalies",fullTitle:"Congenital Anomalies - From the Embryo to the Neonate"},signatures:"Ples Liana and Anca Lesnic",authors:[{id:"212333",title:"Associate Prof.",name:"Liana",middleName:null,surname:"Ples",slug:"liana-ples",fullName:"Liana Ples"}]},{id:"64417",title:"Introductory Chapter: A Comprehensive Approach to the Process of Breastfeeding",slug:"introductory-chapter-a-comprehensive-approach-to-the-process-of-breastfeeding",totalDownloads:1306,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"6191",slug:"selected-topics-in-breastfeeding",title:"Selected Topics in Breastfeeding",fullTitle:"Selected Topics in Breastfeeding"},signatures:"René Mauricio Barría P",authors:[{id:"88861",title:"Dr.",name:"R. 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The objective of this chapter is therefore to systematically search the literature and analyse the available evidence including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin. We systematically searched for meta-analysis, systematic reviews, and big studies and evaluated the evidence for each individual step.",book:{id:"6707",slug:"caesarean-section",title:"Caesarean Section",fullTitle:"Caesarean Section"},signatures:"Jan-Simon Lanowski and Constantin S. von Kaisenberg",authors:[{id:"100660",title:"Prof.",name:"Constantin",middleName:"Sylvius",surname:"Von Kaisenberg",slug:"constantin-von-kaisenberg",fullName:"Constantin Von Kaisenberg"},{id:"240353",title:"Dr.",name:"Jan-Simon",middleName:null,surname:"Lanowski",slug:"jan-simon-lanowski",fullName:"Jan-Simon Lanowski"}]},{id:"18348",title:"Anaesthetic Considerations during Laparoscopic Surgery",slug:"anaesthetic-considerations-during-laparoscopic-surgery",totalDownloads:28978,totalCrossrefCites:1,totalDimensionsCites:5,abstract:null,book:{id:"916",slug:"advanced-gynecologic-endoscopy",title:"Advanced Gynecologic Endoscopy",fullTitle:"Advanced Gynecologic Endoscopy"},signatures:"Maria F. Martín-Cancho, Diego Celdrán, Juan R. Lima, Maria S. Carrasco-Jimenez, Francisco M. Sánchez-Margallo and Jesús Usón-Gargallo",authors:[{id:"14715",title:"Prof.",name:"Francisco M.",middleName:null,surname:"Sánchez-Margallo",slug:"francisco-m.-sanchez-margallo",fullName:"Francisco M. Sánchez-Margallo"},{id:"29449",title:"Dr.",name:"Maria Fernanda",middleName:null,surname:"Martín-Cancho",slug:"maria-fernanda-martin-cancho",fullName:"Maria Fernanda Martín-Cancho"},{id:"39772",title:"Dr.",name:"Juan R.",middleName:null,surname:"Lima",slug:"juan-r.-lima",fullName:"Juan R. 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Dymond",authors:[{id:"155683",title:"Dr.",name:"Murray R.",middleName:null,surname:"Bakst",slug:"murray-r.-bakst",fullName:"Murray R. Bakst"},{id:"167852",title:"Dr.",name:"Jessica",middleName:null,surname:"Dymond",slug:"jessica-dymond",fullName:"Jessica Dymond"}]}],onlineFirstChaptersFilter:{topicId:"189",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80860",title:"From Open to Minimally Invasive: The Sacrocolpopexy",slug:"from-open-to-minimally-invasive-the-sacrocolpopexy",totalDownloads:52,totalDimensionsCites:0,doi:"10.5772/intechopen.101308",abstract:"With an increased demand for pelvic organ prolapse surgeries as the population ages, mesh-related osteomyelitis will become more prevalent. This case series enriches the paucity of data on management options for delayed osteomyelitis related to pelvic organ prolapse mesh. A literature review revealed no case reports of delayed onset osteomyelitis presenting up to a decade after colpopexy mesh placement. We present three cases of delayed osteomyelitis, their presentation, diagnosis and management at a tertiary academic referral center. Patients presented between 1 and 10 years after mesh colpopexy. Three different mesh materials were utilized during the initial procedures: Restorelle Y, Gynamesh and Gore-Tex mesh. The first case demonstrates failed expectant management with eventual surgical intervention on a medically compromised patient. The two subsequent cases describe elective complete mesh resection after several prior failed mesh revision attempts. This short case series and literature review illustrates that mesh-related osteomyelitis after a remote sacrocolpopexy carries significant morbidity. Mesh removal by means of minimally invasive surgery in the hands of an experienced surgical team utilizing DaVinci Robotic System is a good option and may lead to best patient outcomes.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Adriana Fulginiti, Frank Borao, Martin Michalewski and Robert A. Graebe"},{id:"80782",title:"Cases of Postpartum Hemorrhage and Hysterectomy in Thailand’s Northern and Northeastern Provincial Hospitals",slug:"cases-of-postpartum-hemorrhage-and-hysterectomy-in-thailand-s-northern-and-northeastern-provincial-h",totalDownloads:49,totalDimensionsCites:0,doi:"10.5772/intechopen.102948",abstract:"PPH is a major cause of maternal death. Hysterectomy is safe to treat uncontrollable PPH. However, it may not be the best option for women who want to have children. The risk score tool to detect PPH earlier is needed in low-resource cities such as Chiang Rai and Sakon Nakhon province. This study aims to perform a risk score tool to prevent PPH in the northern and northeastern hospitals in Thailand; using mixed methods, identify risk factors for PPH from 20 articles globally and in Thailand using Med Calc, and develop the tool for prediction of PPH; and tool testing and a one-year follow-up on PPH-related hysterectomy cases. Results showed that this risk score tool can detect PPH earlier, reducing the number of PPH and hysterectomy cases. This risk score tool needs to be implemented in the same situations as hospitals to save pregnant women’s lives.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Thawalsak Ratanasiri, Natakorn I. 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This chapter touches briefly on the history of this procedure, its present aspects and general advice for these women who may need a hysterectomy, and finally the direction of new developments about it.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Zouhair Odeh Amarin"},{id:"80589",title:"Perspective Chapter: Total Vaginal Hysterectomy for Unprolapsed Uterus",slug:"perspective-chapter-total-vaginal-hysterectomy-for-unprolapsed-uterus",totalDownloads:74,totalDimensionsCites:0,doi:"10.5772/intechopen.101383",abstract:"Vaginal hysterectomy was the first method to extract the uterus. Vaginal hysterectomy goes back a long way into the history of medicine. Although the first hysterectomy was carried out by Themison of Athens in the year 20 B.C., the idea of extracting the uterus through the vagina was first mentioned in 120 B.C. by Soranus of Ephesos, a distinguished obstetrician. The first elective vaginal hysterectomy was performed by J. Conrad Langenbeck in 1813. The patient was a 50-year-old multipara, who suffered from chronic pelvic pain attributed to a prolapsed uterus with a hard, bleeding tumor. The operation was carried out in challenging conditions, without anesthesia, proper instruments, or surgical assistants. Until the early 1950s, vaginal hysterectomy was the method of choice for removing the uterus. With the widespread introduction of general anesthesia and antibiotic therapy, the site of vaginal hysterectomy was taken over by abdominal hysterectomy. With the introduction of minimally invasive surgery in gynecology, vaginal hysterectomy has regained its place. Harry Reich performed the first total laparoscopic hysterectomy in 1989, being one of the most renowned vaginal surgeons, and he still claims at the beginning of the 21st century that … when the first choice of approach for hysterectomy is possible, is the vaginal route. This chapter presents the relevant anatomy from the point of view of the vaginal surgeon and the standard technique used by the author in over 5,000 vaginal hysterectomies. All intraoperative drawings and photographs are original.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Petre Bratila"},{id:"80400",title:"Laparoscopic Hysterectomy in Morbidly Obese Patients",slug:"laparoscopic-hysterectomy-in-morbidly-obese-patients",totalDownloads:43,totalDimensionsCites:0,doi:"10.5772/intechopen.101307",abstract:"The following chapter will focus on laparoscopic hysterectomy in morbidly obese patients. The discussion reviews the physiological changes associated with morbid obesity and the potential implications on pneumoperitoneum during laparoscopic surgery. Important considerations such as perioperative care and operating room setup are discussed. Additionally, obtaining abdominal access, reviewing the surgical approach, and post-operative considerations are all highlighted within this chapter.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Merima Ruhotina, Annemieke Wilcox, Shabnam Kashani and Masoud Azodi"},{id:"80238",title:"Surgical Site Infection after Hysterectomy",slug:"surgical-site-infection-after-hysterectomy",totalDownloads:117,totalDimensionsCites:0,doi:"10.5772/intechopen.101492",abstract:"Surgical site infections (SSIs) are associated with increased morbidity, mortality, and healthcare costs. SSIs are defined as an infection that occurs after surgery in the part of the body where the surgery took place. Approximately 1–4% of hysterectomies are complicated by SSIs, with higher rates reported for abdominal hysterectomy. Over the past decade, there has been an increasing number of minimally invasive hysterectomies, in conjunction with a decrease in abdominal hysterectomies. The reasons behind this trend are multifactorial but are mainly rooted in the well-documented advantages of minimally invasive surgery. Multiple studies have demonstrated a marked decrease in morbidity and mortality with minimally invasive surgeries. Specifically, evidence supports lower rates of SSIs after laparoscopic hysterectomy when compared to abdominal hysterectomy. In fact, the American College of Obstetricians and Gynecologist recommends minimally invasive approaches to hysterectomy whenever feasible. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Catherine W. Chan and Michael L. 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Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"August 12th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. 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He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:5,paginationItems:[{id:"3",title:"Bacterial Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/3.jpg",editor:{id:"205604",title:"Dr.",name:"Tomas",middleName:null,surname:"Jarzembowski",slug:"tomas-jarzembowski",fullName:"Tomas Jarzembowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKriQAG/Profile_Picture_2022-06-16T11:01:31.jpg",biography:"Tomasz Jarzembowski was born in 1968 in Gdansk, Poland. He obtained his Ph.D. degree in 2000 from the Medical University of Gdańsk (UG). After specialization in clinical microbiology in 2003, he started studying biofilm formation and antibiotic resistance at the single-cell level. In 2015, he obtained his D.Sc. degree. His later study in cooperation with experts in nephrology and immunology resulted in the designation of the new diagnostic method of UTI, patented in 2017. He is currently working at the Department of Microbiology, Medical University of Gdańsk (GUMed), Poland. Since many years, he is a member of steering committee of Gdańsk branch of Polish Society of Microbiologists, a member of ESCMID. He is also a reviewer and a member of editorial boards of a number of international journals.",institutionString:"Medical University of Gdańsk, Poland",institution:null},editorTwo:{id:"484980",title:"Dr.",name:"Katarzyna",middleName:null,surname:"Garbacz",slug:"katarzyna-garbacz",fullName:"Katarzyna Garbacz",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003St8TAQAZ/Profile_Picture_2022-07-07T09:45:16.jpg",biography:"Katarzyna Maria Garbacz, MD, is an Associate Professor at the Medical University of Gdańsk, Poland and she is head of the Department of Oral Microbiology of the Medical University of Gdańsk. She has published more than 50 scientific publications in peer-reviewed journals. She has been a project leader funded by the National Science Centre of Poland. Prof. Garbacz is a microbiologist working on applied and fundamental questions in microbial epidemiology and pathogenesis. Her research interest is in antibiotic resistance, host-pathogen interaction, and therapeutics development for staphylococcal pathogens, mainly Staphylococcus aureus, which causes hospital-acquired infections. Currently, her research is mostly focused on the study of oral pathogens, particularly Staphylococcus spp.",institutionString:"Medical University of Gdańsk, Poland",institution:null},editorThree:null,editorialBoard:[{id:"190041",title:"Dr.",name:"Jose",middleName:null,surname:"Gutierrez Fernandez",slug:"jose-gutierrez-fernandez",fullName:"Jose Gutierrez Fernandez",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"University of Granada",institutionURL:null,country:{name:"Spain"}}},{id:"156556",title:"Prof.",name:"Maria Teresa",middleName:null,surname:"Mascellino",slug:"maria-teresa-mascellino",fullName:"Maria Teresa Mascellino",profilePictureURL:"https://mts.intechopen.com/storage/users/156556/images/system/156556.jpg",institutionString:"Sapienza University",institution:{name:"Sapienza University of Rome",institutionURL:null,country:{name:"Italy"}}},{id:"164933",title:"Prof.",name:"Mónica Alexandra",middleName:null,surname:"Sousa Oleastro",slug:"monica-alexandra-sousa-oleastro",fullName:"Mónica Alexandra Sousa Oleastro",profilePictureURL:"https://mts.intechopen.com/storage/users/164933/images/system/164933.jpeg",institutionString:"National Institute of Health Dr Ricardo Jorge",institution:{name:"National Institute of Health Dr. Ricardo Jorge",institutionURL:null,country:{name:"Portugal"}}}]},{id:"4",title:"Fungal Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",editor:{id:"174134",title:"Dr.",name:"Yuping",middleName:null,surname:"Ran",slug:"yuping-ran",fullName:"Yuping Ran",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9d6QAC/Profile_Picture_1630330675373",biography:"Dr. Yuping Ran, Professor, Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China. Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. 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He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. 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He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"117248",title:"Dr.",name:"Andrew",middleName:null,surname:"Macnab",slug:"andrew-macnab",fullName:"Andrew Macnab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}}]}},subseries:{item:{id:"10",type:"subseries",title:"Animal Physiology",keywords:"Physiology, Comparative, Evolution, Biomolecules, Organ, Homeostasis, Anatomy, Pathology, Medical, Cell Division, Cell Signaling, Cell Growth, Cell Metabolism, Endocrine, Neuroscience, Cardiovascular, Development, Aging, Development",scope:"Physiology, the scientific study of functions and mechanisms of living systems, is an essential area of research in its own right, but also in relation to medicine and health sciences. The scope of this topic will range from molecular, biochemical, cellular, and physiological processes in all animal species. Work pertaining to the whole organism, organ systems, individual organs and tissues, cells, and biomolecules will be included. Medical, animal, cell, and comparative physiology and allied fields such as anatomy, histology, and pathology with physiology links will be covered in this topic. 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\r\n\tThe environment is subject to severe anthropic effects. Among them are those associated with pollution, resource extraction and overexploitation, loss of biodiversity, soil degradation, disorderly land occupation and planning, and many others. These anthropic effects could potentially be caused by any inadequate management of the environment. However, ecosystems have a resilience that makes them react to disturbances which mitigate the negative effects. It is critical to understand how ecosystems, natural and anthropized, including urban environments, respond to actions that have a negative influence and how they are managed. It is also important to establish when the limits marked by the resilience and the breaking point are achieved and when no return is possible. The main focus for the chapters is to cover the subjects such as understanding how the environment resilience works, the mechanisms involved, and how to manage them in order to improve our interactions with the environment and promote the use of adequate management practices such as those outlined in the United Nations’ Sustainable Development Goals.
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",coverUrl:"https://cdn.intechopen.com/series_topics/covers/38.jpg",keywords:"Human Activity, Pollutants, Reduced Risks, Population Growth, Waste Disposal, Remediation, Clean Environment"},{id:"41",title:"Water Science",scope:"