Salivary variables measured for caries risk assessment.
\\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:null},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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The book goes from the fundamentals up to several applications in different scientific fields. The content of the book has been classified in six sections: Classical Thermodynamics, Statistical Thermodynamics, Property Prediction in Thermodynamics, Material and Products, Non Equilibrium and Thermodynamics in Diverse Areas. The classification of the book aims to provide to the reader the facility of finding the desired topic included in the book. It is expected that this collection of chapters will contribute to the state of the art in the thermodynamics area.",isbn:null,printIsbn:"978-953-51-0779-8",pdfIsbn:"978-953-51-6241-4",doi:"10.5772/2615",price:159,priceEur:175,priceUsd:205,slug:"thermodynamics-fundamentals-and-its-application-in-science",numberOfPages:556,isOpenForSubmission:!1,isInWos:1,hash:"8a42f4f72f89572c7ad06f5e2ffe7b39",bookSignature:"Ricardo Morales-Rodriguez",publishedDate:"October 3rd 2012",coverURL:"https://cdn.intechopen.com/books/images_new/2222.jpg",numberOfDownloads:67026,numberOfWosCitations:34,numberOfCrossrefCitations:16,numberOfDimensionsCitations:38,hasAltmetrics:1,numberOfTotalCitations:88,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"December 7th 2011",dateEndSecondStepPublish:"January 11th 2012",dateEndThirdStepPublish:"April 16th 2012",dateEndFourthStepPublish:"July 15th 2012",dateEndFifthStepPublish:"August 14th 2012",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,editors:[{id:"17181",title:"Dr.",name:"Ricardo",middleName:null,surname:"Morales-Rodriguez",slug:"ricardo-morales-rodriguez",fullName:"Ricardo Morales-Rodriguez",profilePictureURL:"https://mts.intechopen.com/storage/users/17181/images/2857_n.jpg",biography:"(2012-),\nCurrent Status. Professor at Universidad Autónoma Metropolitana - Iztapalapa. México.\n\n(2009-2011),\nPost doctoral researcher. \nTitle of the Project: Integrated modelling for simulation and design of novel enzymatic processes.\nTechnical University of Denmark.\nLyngby, Denmark.\n\n(2006-2009),\nPhD (Chemical Engineering). \nTitle of the Project: Computer-Aided Multiscale Modelling for Product-Process Design.\nTechnical University of Denmark.\nLyngby, Denmark.\n\n(2003-2006),\nMSc(Chemical Engineering).\nUniversidad Autonoma Metropolitana-Iztapalapa.\nMexico City.\n\nDr. Morales-Rodriguez has submitted several papers related with product-process design, multiscale modelling, development of computer-aided tools and the synergy of diverse modelling tools for virtual product-process design.\n\nIn his PhD research, Dr. Morales-Rodriguez has developed and computer-aided modelling tool aimed to the development of new product-process employing multiscale modelling approach that is know as the \\Virtual Product-Process Design\\.\n\nDr. Morales-Rodriguez has participated in diverse conference related with computer-aided modelling tools.\n\nCurrently, Dr. Morales-Rodriguez is developing a postdoctoral research focused on the bioethanol process design for 2G biomass. 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Energy demands are continuously fulfilled by the petroleum industry. Transport lines of crude oil play an essential role in ensuring continuous supply of fuel, that is, providing flow assurance. As the maintenance cost of repairing and troubleshooting transport lines is very high, addressing issues related to flow assurance becomes critical in the petroleum industry. Crude oil consists of wax particles that are initially in the dissolved state and those get crystallized once the temperature of the pipe wall goes below certain temperature. The wax content in the crude oil is firstly in the dissolved form, and then it gets to precipitation and then gets crystallized causing accumulation across the pipe walls. This process is explained by molecular diffusion of wax particles toward the pipe wall when the temperature of the crude oil in bulk gets lower than wax appearance temperature (WAT) [1, 2, 3, 4, 5, 6, 7, 8].
\nWax deposition is a serious problem that causes reduction in the flow cross section, hence affecting flow assurance. In the subsea transport lines, the surrounding temperature drops very low which increases the crystallization, and wax deposition becomes more acute (as shown in \nFigure 1\n). With time, the crystallized wax particles get accumulated layer by layer and even can clog the pipe completely, which dramatically affect the maintenance work. Therefore, there are many methods used and studied by the industry as well research and development institutions in this direction to effectively find out the location of clog, to minimize the issue deposited wax, to remove the deposited layer of wax, and to predict the wax deposition inside the transport lines with time. All these efforts are taken to reduce wax deposition and mitigate in such a way that wax layer thickness can be predicted and addressed for maintenance once it reaches to a caution limit. Hence, predicting wax deposition can help in preventive maintenance and cost-effectiveness [9, 10, 11, 12, 13, 16].
\nSectional view of pipeline affected with acute wax deposition [14].
This book chapter will discuss methods which are used for wax clearance, prediction, and estimation. This book chapter will cover mainly four sections: introduction, wax deposition issues and solutions, wax estimation methods, and role of artificial intelligence in wax prediction. The first section introduces the basic theory behind the wax deposition as a process and explains the main factors that are affecting wax deposition. The second section discusses four different methods adopted to tackle the problems related to wax deposition. The four different methods, mechanical, thermal, chemical, and microbial methods, will be discussed highlighting general practice in the industry. Further, their advantages and limitations are added in the same section. The third section is consisting of broad discussion which includes comparison of direct and indirect measurement techniques. The direct techniques are highlighting information about the numerical wax deposition models used along with scientific measurement techniques. On the other hand, the indirect measurement techniques are discussed knowing the external probing and examining techniques that can provide information about wax layer deposition inside the pipe. Finally, the role of artificial intelligence is discussed with benefits associated with the use of mapping information and using fuzzy logic for effective wax prediction or in developing the existing wax numerical models. Lastly, a brief conclusion is provided to reflect recent literature and hot topics in this direction.
\nThe issue of wax accumulation is complex because many factors affect the wax deposition such as the wax concentration in crude oil, temperature of the surrounding, wax appearance temperature, pressure drop, viscosity of the oil, and bulk temperature of the oil. The main associated issues with wax deposition in crude oil transport lines are impact on flow assurance and a sudden clog that can lead to immediate actions of maintenance and repair. Deposited layer of wax can be observed as three sub-layers: the topmost layer is more granular and soft, the bottom layer is observed to have a strong bond with pipe wall and considered as close fitted layer, and the sandwiched layer in between the top and bottom has the mechanical impurities and high wax content. With time, the sedimented layers get hard and move from top layer stage to bottom layer stage, consequently reducing the effective flow cross section. The process of hardening of the bottom sedimented layer of wax is referred to as “aging.” Hence, it is crucial to understand that with time, the wax deposition can cause difficulty in the cleaning process [11, 12, 13, 16, 17, 18, 19, 20, 21, 22].
\nTo deal with wax deposition issues, conventionally in the industry, pigging process is used for cleaning the wax after inspecting externally or cleaning as a part of regular maintenance. In the pigging process (as shown in \nFigure 2\n), the deposited wax is scrapped by passing the pig device through the pipe such that its movement along the pipe causes its head to collect the deposited layer of wax. However, the pig device inserted has possibility to get stuck due to hard layer of wax or due to higher friction from the accumulated wax when cleaning longer distances. If the pig device gets stuck in between the pipe not near to inlet or outlet connections, then it becomes a hectic and complex issue to deal. In the following sections, common methods (mechanical, thermal, chemical, and microbial) are discussed in dealing with issues related wax deposition [16, 17, 18, 19, 20, 21, 22].
\nPigging process [15].
Mechanical removal of wax is considered as the oldest method used in the industry. This method includes the use of scrappers directly, use of scrappers in the tube, and use of “pig” device inside the pipe. Scrappers are used to scrap the tube wall and remove wax even when the well is under operation. Pipeline inspection gauge (pig) device is one of the broadly used old methods that have been used since a century in the industry [16, 17, 18, 19, 20, 21, 22].
\nBoth wax removal techniques are used for maintenance; however, they have disadvantages of plugging of perforation within the well when scrapping and when the pigging device gets stuck inside due to wax. All the mechanical methods are economical in comparison to other methods [16, 17, 18, 19, 20, 21, 22].
\nThermal methods are basically used to adhere to temperature medium or maintain temperature of crude oil for reducing wax buildup. Some of the common ways used are hot oiling or hot watering, cold flow, and surface coating. Using hot oil or hot water (temperature in range 65–105°C) pumping in the transport line, the deposited wax is melted. Using solid resin particles that are having melting point more than WAT in the oil facilitating slurry flow, the wax is prevented to deposit toward the wall. Using surface coating of thermal insulation material (like plastic), the wax inhibition is achieved shielding the drop of crude oil temperature. All these methods can be used; however, there is limitation of using hot oil or hot water depending on the heat capacity of the oil [16, 17, 18, 19, 20, 21, 22].
\nChemical methods are basically using chemical inhibitors, and these are added in the oil to reduce the wax deposition. These chemical wax inhibitors can be classified into three: detergents, dispersants, and wax crystal modifiers. Surface activators are the detergents and dispersants that sustain wax particles as suspended and dispersed such that reducing the wax particles to adhere to each other or the pipe walls or any solid surface. The surface activation agents also modify the solid surface of the pipe reducing shear and interaction of wax particles on the wall of the transport line. Other types of surfactants also modify the solubility by solubilizing nucleus and avert agglomeration of wax particles. Wax crystal modifiers are also referred to as pour point depressors because they allow the flow of oil at a minimum temperature at its own density and given conditions. Wax crystal modifiers have same structure as that of the wax particle, and they coprecipitate occupying on the crystal lattice of wax particle forming hydrocarbon chains. In this manner, they also act as encumber in the growth of wax crystals as they reduce the possibility of wax crystals to form 3D structures. All these wax inhibitors are effective but must be used before crude oil bulk temperature is above its WAT [16, 17, 18, 19, 20, 21, 22].
\nMicrobial method of treating wax is not common; however, it was found effective in few field testings. The action of bacterial culture is producing the biosurfactant which is reported to facilitate as wax inhibitor. The bacterial strains such as Actinomyces species have shown breakdown of heavy chain hydrocarbon fractions (from C15 to C20) when treating the crude oil samples. Bacterial treatment was also noticed to induce crude oil lowering the WAT of the crude oil. This makes the crude oil with less susceptible condition for wax deposition. Using microbial method is an innovative approach, but it could be used in wells to have static culture [16, 17, 18, 19, 20, 21, 22].
\nMethods discussed earlier including mechanical, thermal, chemical, and microbial methods were to reduce and clean the wax deposited inside the transport lines. Those methods served as the final solution for cleaning. However, as a part of mitigation and carrying out preventive maintenance, there is a need to have methods that can serve for estimating the wax buildup. This section is focused toward discussion of methods that can help in wax estimation. The direct measurement techniques are discussed to show the benefits associated with information process and about the numerical wax deposition models used along with scientific measurement techniques. The indirect measurement techniques are discussed to show how nondestructive testing can provide information through external probing and examining externally to know about wax layer deposition inside the pipe. Hence, this section is critically for knowing how the estimation is carried out regarding the wax layer thickness inside the crude oil transport line. Further, these are significant in avoiding sudden shutdowns due to blockage or complete closure with wax inside the pipe which can result in immediate maintenance cost [23].
\nDirect measurement techniques help in estimating the deposited wax layer thickness based on numerical assessment of deposition models as mentioned in the literature. The information about the parameters that are added to the model dependent on wax properties are measured using scientific measurement techniques. In other words, the estimation of the deposited wax layer is through wax deposition model but coupled with output obtained from scientific measurement. This section explains various wax deposition models highlighted in the literature and pointing out the most suitable model based on the assessment. In addition, different scientific measurement techniques are explained with respect to capability of each technique based on properties measured [23].
\nMathematical modeling approach is widely adopted in order to predict and monitor wax deposition either through numerical estimation directly or using software that has back-end mathematical model. In this section, some of the main highlighted wax deposition models from the literature are discussed along with respective equations. Wax deposition models are developed based on consideration of assumptions and selection of parameters. Four main models are discussed in this book chapter: film mass transfer model (FMTM), equilibrium model (EM), Matzain’s model (MM), and Venkatesan’s model (VM) [24, 25, 26, 27, 28].
\nFMTM is developed based on the mass and heat transfer assumptions considering both transfers occur independently. EM is developed based on thermodynamic equilibrium along with consideration of concentration gradient in the model unlike FMTM. MM is a modified model of EM making it more effective by including the diffusion equation as empirical correlation as well as including the factors related to shear stripping and trapped oil factors. VM is developed mainly considering shear effect with two coefficients along with quantification of mass flux in the model [23, 29, 30, 31, 32, 33, 34, 35, 36].
\nAmong these four models, MM was found to be self-sufficient due to its fitting with experimental data. Also, it was due to consideration of oil entrapment and correlation of hear stripping effect in the model. The results obtained by testing MM model are shown in \nFigure 3\n [23, 29, 30, 31, 32, 33, 34, 35, 36].
\nMatzain’s model comparison to experimental results [28].
The mathematical equations governing with respect to all these four models are mentioned below [23, 29, 30, 31, 32, 33, 34, 35, 36]:
\nwhere \n
where \n
where \n
Scientific measurement techniques are coupled to wax deposition models practically because these techniques assist in providing information that is necessarily required as inputs for providing the output which is predicting the wax deposition thickness. Most dominating measurement techniques used in the industry for obtaining properties of crude oil samples are discussed here, which include near-infrared scattering (NIR), small-angle X-ray scattering (SAXS), X-ray diffraction (XRD), controlled stress rheometer (CSR), and cross-polarized microscope (CPM) [23].
\nNIR is using the property of light scattering considered in a colloidal solution and obtains the physical properties. The near-IR range wavelength (low IR wavelength) attenuation spectra provide accurate results for obtaining WAT. The measurement deviation of ±2.5°C is observed when comparing the results obtained by CPM. This technique is effective with high-resolution results analyzed in 55 nm size window. It is also applicable if the oil sample is almost opaque to find out the WAT through delineation of radiation attenuation [37].
\nInvestigations carried out studying SAXS help in obtaining the radii of gyration. This technique can be used to study different fractions of crude oil at different operation temperatures. X-ray scattering at small angle can have issues related to low intensity. SAXS experimental results can be compared to calculations of scattering length density using chemical composition. This technique is applicable to obtain the size from radius of gyration and power law exponents providing details about physical properties of the crude oil sample [38, 39, 40, 41, 42, 43, 44, 45].
\nThis diffraction technique provides information about the crystal size of the wax by scattering in the time domain. XRD can help in understanding the wax structure capturing the wax deposition and aging. When using XRD it is important to understand that crystal size can also affect the diffraction. When the size of the crystal is below 0.1 μm, broadening of the diffraction peaks can be observed, and this broadening is as twice of the given angle. However, when the size of the crystal is above 0.1 μm, the diffraction characterizes Darwin width the same as the given angle of diffraction. XRD is suitable for characterizing crude oil samples studying the solid-solid transitions; hence, this method is effective in determining the crystal structure. But XRD has limitations in understanding the liquid-solid equilibrium, that is, identifying the crystallization from liquid to solid [46, 47, 48, 49, 50].
\nThis technique utilizes the application of controlled stress on the sample with arrangement of parallel plate to obtain the strain exerted. In this manner, steady stress and steady deformation are obtained, and measurement of viscoelastic properties of the wax sample is achieved. For measurement, it is important to make sure that two parallel plates are set properly. The difficult part in measurement is that during measurement and when applying stress, it is crucial to make sure that the top layer does not slip. Slippage can affect the results, and when the wax weight percent is above 5%, slippage can be more prevailing when taking measurement [51, 52, 53, 54, 55, 56].
\nWhen analyzing the impact of cooling on the crude oil microstructure, CPM can be used. It can help in measuring WAT because cooling rate provided to the crude oil sample can be controlled and morphology can be observed with time. CPM provides information about the wax precipitation as wax appearance can be noticed with high resolution in small-size dimensions up to 0.5 μm. The volume of the sample stored for testing is very small, and CPM is sensitive to film thickness of sample which is dependent on the concentration of the sample [57, 58, 59, 60, 61, 62, 63, 64].
\nIndirect measurements here are referred to techniques which are evaluating the wax deposition experimentally by assessing physical quantities such as volume, temperature, pressure, electric capacitance, and ultrasonic signals. Change in volume is evaluated such that the resulted difference is the volume fraction of deposited wax. Similarly, the difference in pressure is also considered accounting for deposited wax. Both methods are intrusive, hence limiting its application in the industry. Therefore, nondestructive techniques are to interest which includes techniques that use temperature sensing, electrical capacitance measurement, and ultrasonic assessment [23]. Firstly, applying the temperature-based techniques, thermal sensing utilizes the heating pulse applied externally, and its transient response can assist in real-time assessment and monitoring of wax deposition [65, 66]. The investigation by [67] collected information about wax thickness inside the transport pipeline by observing the acoustic signals after providing the heat pulse externally. Signals obtained were Fourier transformed to observe frequency domain and extract information correlating to deposited wax layer thickness. Secondly, electrical capacitance measurement widely known in the literature as electric capacitance tomography (ECT) is effective in providing high-quality images by applying complex algorithms. ECT examined on the nonmetallic transport pipe experimentally showed that online monitoring of wax deposition can be achieved. Thirdly, ultrasonic measurement technique is also applied externally, and the information provided by the decaying time of ultrasonic signals can be correlated to deposited thickness of wax. Overall, many investigations are in the direction of exploring capabilities of ECT; however, few studies focused on nondestructive testing related to temperature-based prediction and related to ultrasonic decay time measurements [68, 69, 70].
\nThe trend of research and development in the oil and gas industry is shifting toward utilization of artificial intelligence (AI) algorithms and machine learning concepts. Based on the respective operating conditions, making the systems equipped with AI can enhance the decision-making capabilities. Some of the commonly used AI algorithms are evolutionary algorithm (EA), artificial neural network (ANN), swarm intelligence (SI), and fuzzy logic (FL). More than one AI algorithm can be applied if needed. Adaptive Neural Fuzzy Inference System (ANFIS) provided information about best has condensation ratios using ANN and FL assessment helped in continuous optimization of wax deposition model [23]. Among the recent studies, the work of [71] used statistical model considering the dependent and independent variables for wax deposition prediction. The dependent variable considered is viscosity of the crude oil, whereas the independent variable considered is pressure. By plotting pressure/viscosity versus pressure plot (as shown in \nFigure 4\n), the linear boundary limits were kept, and if the actual plot goes above the upper limit, it implicates high potential of wax deposition. The ANN model was developed based on backpropagation neural network (BNN). BNN uses two loops, a forward and a backward loop. The forward loop helps in processing the information inputs to outputs, whereas the backward loop does opposite from output to input. The backward loop processes information along with the weight error correction to take as input to forward loop. In the manner, the continuous operation of forward to backward and backward to forward loops, backpropagation algorithm gets trained. Hence, BNN is also referred as learning algorithm due its adjusting weights confined in the neural network.
\nPrediction of potential to wax deposition [71].
More concise modeling is observed from work of [72] which consisted of ANN mathematical model for predicting rate of wax deposition. After observing that deposition rate of wax experimentally to be nonlinear, Kolmogorov theorem was applied; it virtually approximates nonlinear function to linear using two-layer ANN with certain error limit. The mapping structure for predicting wax deposition rate is shown below in \nFigure 5\n. The input variables (viscosity, shear stress, temperature gradient, and concentration gradient) and output variable is wax deposition rate. Comparison of the results with determined set showed that linear regression model was having correlation of 0.78, whereas ANN model had 0.97.
\nStructure of ANN model for wax deposition rate prediction [72].
The work of [73] used ANFIS model to predict thickness of deposited layer of wax considering single-phase turbulent flow. Five-layered ANFIS model was considered consisting of input variable as Reynolds number, wax concentration (%), time, temperatures (outside, inside, and pipe wall), and temperature-driven force (ratio of gradient temperature wall and outside to bulk temperature of the oil). As shown in the \nFigure 6\n, the ANIFS model has five layers, and respective equations governing output of the model are mentioned below. The first-order fuzzy logic is applied using if/then rule. Considering if “Ai\n” belongs to “x” and “Bi\n” belongs to “y,” then “fi\n” the output function can be represented with combination of the parameters (“pi\n,” “qi\n,” and “ri\n”):
\nStructure of ANFIS model for wax thickness prediction [73].
In the first-layer equation representation, the combination can be calculated as its membership degree (μ) for labels set “Ai\n” and “Bi\n”:
\nIn the second-layer equation representation, it can be shown with product of the membership degrees:
\nIn the third-layer equation representation, the calculation of the weighted ratio from each variable with respect to total weight is
\nIn the fourth layer equation representation, the adaption is achieved at this layer identifying this layer as defuzzification layer, where the learning rule is applied on this layer (i.e., minimizing the error). The summation of the weight applied with function is a resultant referring to the output layer, which is the fifth layer:
\nThe prediction of the deposited thickness of wax using this model resulted in close agreement with experimental values. The mean square error values comparing to experimental results was to three digit accuracy (0.00077034) and high value of correlation (0.9858).
\nIn brief, this chapter explores different methods used in the industry and research for predicting and monitoring wax deposition. The information discussed introduces the process of wax deposition and wax deposition models as a theoretical background. Observing the recent literature, the role of artificial intelligence is discussed which is to serve in effective and precise prediction of wax deposition. Hence, artificial intelligence for application of nondestructive data collection assessment helps in developing the wax deposition models to incorporate the updated oil sample information periodically to ensure that the wax predictions are reliable.
\nThe authors would like to acknowledge the funding support provided by United Arab Emirates under the grant numbers 31N265 and 31R168.
\nThe authors have no conflict of interest.
The authors would like to thank the United Arab Emirates University for providing necessary research facilities.
\nFrom the ancient time, dental caries has existed, even from the time when the only way to eat and drink was hunting and gathering. According to the World Health Organization, 60–90% of schoolchildren worldwide have experienced caries, with the disease being most prevalent in Asian and Latin American countries (WHO, 2008). Dental caries is a multifactor disease which appears when demineralization of the hard tissues of the teeth occurs by organic acids formed by bacteria in dental plaque through the anaerobic metabolism of sugars derived from the diet.
\nCalcium is lost from the tooth surface, and demineralization occurs only when sugars or other fermentable carbohydrates are ingested in which results fall in dental plaque pH caused by organic acids that increase the solubility of calcium hydroxyapatite in the dental hard tissues.
\nLifestyle or dental health habits are the factors that should be connected to dental diseases. Dietary and daily habits, familial and physiological well-being, socioeconomic status and lifestyle, awareness and education, and area where they live are the factors that should be taken into consideration when discussing oral health. The higher the socioeconomic status is, the more the people are exposed to the availability of junk foods and susceptible to its frequent consumption. Those from lower economic group and rural area are not as much exposed to such food habits, and they do not buy them because they are expensive for their pocket. Many adolescents fail to brush their teeth effectively and tend to consume cariogenic foods even though they have basic knowledge of dental health. Children who have caries eat snacks between meals, more than those children without dental caries do. The basic means of avoiding these primary public health measures are compiled with the use of topical fluorides and fluoridated water. When it comes to nutrition perspective, one of the main things is to have balanced diet and adherence to the dietary guidelines and the dietary reference intakes.
\nDental caries occurs due to the demineralization of enamel and dentin (the hard tissues of the teeth) by organic acids formed by bacteria in dental plaque through the anaerobic metabolism of sugars and other fermentable carbohydrates derived from the diet [1]. Organic acids increase the solubility of calcium hydroxyapatite in dental hard tissues, and demineralization process of the tooth surface occurs due to calcium loss.
\nTeeth are most susceptible to dental caries soon after they erupt, and therefore the peak ages for dental caries are 2–5 years for the deciduous dentition and early adolescence for the permanent dentition [2]. The age of adolescences is when permanent teeth begin to grow and get their full position in the dental arch. This is a crucial age for the development of several oral diseases. Dental caries, periodontal disease, and orthodontic problems such as overcrowding of the teeth or malocclusions are bringing changes and altering the facial profile and esthetic appearance.
\nCertain psychological factors like self-confidence and social outlook of the individuals can also be affected, and they can leave permanent effect on the psychology of the child if not appropriately treated.
\nNeglecting the general problems, the lack of awareness and expertise is one of the reasons that most of the children at this age face these problems. Since the treatment of dental disease is very expensive especially in low-income countries, it would exceed the available resources for health care. The large financial benefits of preventing dental diseases should be emphasized to countries where current disease levels are high [3].
\nIt is undisputable that the development of dental caries is a result of poor diet, and it has been observed in humans and animals that frequent and prolonged exposure to carbohydrates and sugars results in an appearance of dental caries. Important bacteria in the development of dental caries are Streptococcus mutans and Streptococcus sobrinus. These bacteria produce organic acids from food sugars and help bacterial colonization of the tooth surface. The bacteria attached to teeth in dental plaque, found as a thin film on the surface of the enamel, utilize mono- and disaccharides (e.g., glucose, fructose, and sucrose) to produce energy, and acid is the by-product of this metabolism.
\nConsequently, the acidity of dental plaque may decrease to a point where the demineralization of the tooth begins. Demineralization occurs at a low pH when the oral environment is undersaturated with mineral ions, relative to a tooth’s mineral content. The enamel crystal, which consists of carbonated apatite, is dissolved by organic acids (lactic and acetic) that are produced by the cellular action of plaque bacteria in the presence of dietary carbohydrates. The “white spot lesion” is the initial stage that occurs just below the enamel surface and produces a visual whitening of the tooth. At this stage of mineral loss, the lesion may not progress any further or could even regain minerals (i.e., remineralize) if the cariogenic environment diminishes. The prevention measures that can remineralize the initial carious lesion are as follows: decreasing the carbohydrate source to the bacteria, treating the tooth with fluoride, reducing the levels of cariogenic bacteria, or reducing the bacterial ability to produce acid.
\nThe initial lesion will continue to lose mineral if the procedure of disease suppression is not initiated and the acidic challenge is unabated. The progressive dissolution of enamel and loss of enamel surface structure eventually give rise to a frank carious lesion [4]. Sugary food products and their everyday consumptions exert our teeth. The reasons behind dental caries are the exposure to junk foods, colas, sweets, and other dietary products which are easy to access and abundantly available for children to consume. That is why dental caries is like a sort of non-transmittable and nonfatal sickness [5].
\nSome authors emphasize the importance of the dental biofilm and dietary sugars as essential primary etiological factors causing the appearance of the caries; moreover, one of them cannot cause caries in the absence of the other.
\nThe main direct impact of the diet is mediated through its effect on the pH of the dental biofilm. Foods high in fermentable carbohydrates (mainly sugars) cause a low biofilm pH, while foods high in proteins and fats favor a more neutral biofilm pH. High-protein foods increase the urea concentration of saliva, which can be converted by ureolytic bacteria to ammonia; this raises the biofilm pH and is associated with decreased caries risk. Dietary factors can have an indirect effect by modifying the composition and metabolic activity of dental biofilm.
\nThe major dietary factor affecting dental caries prevalence and progression is sucrose [6]. A low consumption example is from a study of the Hopewood House in Australia, conducted between 1947 and 1952. As a matter of fact, children living in this closely supervised environment consumed food that was virtually free of sugar and white flour products. Data collected from these children revealed an extremely low dental caries prevalence, compared to children attending other Australian schools [7].
\nHigh sugar consumption’s effect is best revealed from the report of the classic Vipeholm study [8]. This study examined three factors leading to these stages as follows: the timing of sugar ingestion, the effects of the frequency of sugar consumption, and finally the consistency of the sugar on dental caries rates. According to the results, the degree of the sugar’s consistency was more important than the addition of sugar to the diet and especially if it was consumed between meals, or products, which are sticky, in a form that stayed longer in the mouth such as toffees. These products have a bigger cariogenicity impact than foods that are eliminated quickly from the oral cavity. Therefore, frequent ingestion of foods such as hard candies and throat lozenges that contain fermentable carbohydrates can be extremely harmful to the teeth. The conclusions from this study, conducted a half century ago, are still well regarded today:
If sugar is taken with meals, then only a small caries increase is noted.
A marked increase in caries increment is shown if sugar is consumed as snacks between meals.
If you consume sticky candies containing sugar, then the caries activity will be at the highest form.
Caries activity may vary greatly among individuals.
By eliminating sugar-rich foods, caries activity will be declined.
The detrimental effects of sugar in causing tooth decay are shown in the two major studies of public health importance, and those are the classic Vipeholm study in Sweden and Hopewood House study in Australia. Children generally consume diets which are rich in sugar like sweets, candies, cakes, colas, etc. That is why a lot of awareness has been raised since this food has a negative effect on oral health, and that is the appearance of dental caries. Nowadays, the household food that we generally eat contains certain amounts of sugar. That is why these two studies are of huge public health importance when conducting preventive dental health programs especially in schools where the drawbacks of consuming such diet containing sugars can be addressed.
\nA direct relationship between dental caries incidence and sugar (carbohydrates) intake is indisputed. The caries will not be developed if there are no fermentable carbohydrates in the food [9].
\nFree sugars as defined by the World Health Organization present as monosaccharides and disaccharides added to food, and sugars are naturally present in honey, syrups, and fruit juices. Fermentable carbohydrates are free sugars, glucose polymers (syrups and maltodextrins), fermentable oligosaccharides, and highly refined starches. They are added to food in industrialized countries and are as acidogenic as sucrose. However, sucrose and starches today present as the main carbohydrates in modern society diet. Sucrose is the most cariogenic sugar which is a highly soluble substrate transformed into intracellular (IPS) and extracellular polysaccharides (EPS). It diffuses easily into the dental plaque accumulation and induces a lower pH [10]. Starch is a carbohydrate that can cause very small amounts of caries, unlike real sugar. It is found in fruits and vegetables and can be consumed raw or cooked. Starchy foods such as rice, potatoes, pasta, and bread have very low cariogenicity, and this is why they can cause less caries than sucrose. Starch can be sorted out to mono- and disaccharides and metabolized by bacteria, so it is retained on the teeth long enough to be hydrolyzed by salivary amylase.
\nSince the original Miller’s study, Stephan in both of his researches (1940, 1944) about the relationship between caries and sugar showed that fermentable carbohydrates can transform into acid in dental plaque. A direct relationship between caries incidence and the frequency of consumption of sweets was also presented [11], and these findings supported those of the Vipeholm study [12].
\nSucrose is freely diffusible in dental biofilm and metabolized by oral bacteria Streptococcus mutans [13]. Bacteria metabolize sucrose to soluble and insoluble extracellular polysaccharide glucan by enzyme glucosyltransferases (GTFs). Few mechanisms are involved in the role of extracellular glucans as the major caries associated factor. Glucan enables the bacteria to adhere firmly to the teeth [, 14], and in dental plaque, they contribute to the structural integrity of dental biofilms [15].
\nSeveral studies showed that the presence of insoluble glucan enhanced the demineralization potential of S. mutans. Glucan altered the diffusion properties of plaque and allowed deeper penetration of dietary carbohydrates [16, 17].
\nThere are several important and critical cariogenic factors to be considered when evaluating starch and caries relationship. They are the size and frequency of tooth exposure, the bioavailability of the starches, the microbial flora of dental plaque, the pH-lowering capacity of dental plaque, and the flow rate of saliva. Starchy foods with higher amounts of sucrose are as cariogenic as а sucrose. Some cooked and processed starches are dissolved by salivary amylase, and they release glucose and maltose metabolized by oral bacteria to acids. In Rugg-Gunn [18] study, the relationship between starches and dental caries was proved, and several conclusions were made. Rice, potatoes, bread, and cooked staple starchy foods have low cariogenicity in humans. Uncooked starch has low cariogenicity, while heat-treated starch induces lesser caries than sugars. Foods with cooked starch and higher amounts of sucrose are as cariogenic as similar quantities of sucrose.
\nFresh fruits contain various sugars and may be capable of causing caries under some conditions. They have low cariogenicity, while citrus fruits have not been associated with dental caries. Increased consumption of fresh fruit in the diet is decreasing the level of dental caries in a population [19]. Although excessive exposure to fructose may produce dental caries, fresh fruits are likely to be much less cariogenic than most sucrose-rich snack foods consumed by children. One hundred percent fruit juice has also been associated with caries, but the relationship is less clear. Children consuming more than 17 oz. 100% juice are more likely to have caries, than children consuming water or milk [20]. Conversely, in a cohort of low-income African-American children, 100% fruit juice was found to be protective of caries. The fact that 100% fruit juice contains about the same amount of sugar as the average sugar-sweetened beverages made it important to understand its role in caries [21]. Animal studies revealed that all fruits cause less caries than sucrose but dried fruits may potentially be more cariogenic since the drying process breaks down the cellular structure, releasing free sugars that tend to have a longer oral clearance.
\nFlavored drinks, especially aerated beverages like cola, have a much greater cariogenic potential due to high sugar content and regular consumption. Children are frequently offered with these drinks because of their high acceptance, low cost, and parent’s belief of being very nutritious [22]. Different campaigns and various forms of advertising by the media changed public health knowledge, and people started to become aware and understand about the bad effect of this kind of food.
\nMilk is most frequently consumed by schoolchildren. In milk а sugar named lactose is not fermented as the other sugars, so it is less cariogenic because the phosphor proteins inhibit enamel dissolution and the milk antibacterial factors may interfere with the oral microbial flora.
\nCheese can lead to protection against creating caries as it stimulates salivary flow and raises the calcium, phosphorus, and protein content of plaque.
\nThe sugar alcohols like sorbitol, mannitol, and xylitol are kind of sweeteners that are metabolized by bacteria at much slower rate than glucose or sucrose, which is not metabolized at all. According to certain clinical studies, xylitol chewing gum has the ability to reverse initial white spot lesions on teeth.
\nWhen dental decay happens there is high probability of losing a tooth. That leads to a reduced ability to eat a varied diet. It is in particular associated with a low consumption of fruits, vegetables and non-starch polysaccharides (NSP) in the persons diet [23]. NSP intakes of less than 10 g/day and fruits and vegetable intakes of less than 160 g/day have been reported in edentulous subjects. Therefore, tooth loss may impede the achievement of dietary goals related to the consumption of fruits, vegetables, and NSP. Tooth loss has also been associated with loss of enjoyment of food and confidence to socialize. So, basically, it is clear that dental diseases have a detrimental effect on the quality of life both in childhood and older age [24].
\nAn important issue for the appearance of dental caries in older children as well as infants is not only the total quantity but also the form of the carbohydrate as well as the frequency of consumption since the refined carbohydrates exert their effect in the appearance of dental caries by serving as a substrate for caries-producing streptococci, which as a small piece of it adheres to the teeth for almost an hour. In the case of sugars that are not in sticky form, a specified amount consumed at one time is likely to be less conducive to the formation of dental caries than the same amount consumed in small portions throughout the day. There is considerable evidence that between-meal snacks cause the development of dental caries. Foods that must be avoided between meals are the following: sugar, honey, corn syrup, candies, jellies, jams, sugared breakfast cereals, cookies, cakes, chewing gum, and sweetened beverages, including flavored kind of milks, carbonated drinks, sweetened fruit juices, and fruit or fruit-flavored drinks. Finally, eating frequency, particularly constant grazing or sipping of foods and beverages, is also caries promoting. In a recent study in a diverse sample of children aged 2 to 6 years, eating frequency was associated with severe early childhood caries [25].
\nReduction of dental caries can be achieved with the help of fluoride or in other words dietary fluoride drinking water, which also has rich sources. The ingested fluoride becomes incorporated into enamel during tooth formation and increases the resistance of the tooth to decay. However, the main protection from dietary fluoride is the localized intraoral effect. Fluoride promotes the remineralization of damaged enamel with resistant fluorapatite and also inhibits bacterial metabolism of sugars. As we can see, the benefits to the exposure of teeth to fluoride are therefore beneficial lifelong. It may be added to an optimum concentration of 1 mg/L as a caries preventive measure if natural water supplies are low in fluoride; Murray et al. [26] have reviewed the published data on the effect of water fluoridation on caries and have concluded that on average water fluoridation reduces dental caries by 50%. In a study of 5-year-old children, Carmichael et al. have demonstrated that water fluoridation is effective in reducing dental caries across social classes and, in terms of the number of teeth saved per child, the benefits are greatest in the lower social classes [27].
\nAccording to UK national surveys, it has been indicated that those from lower social classes have higher levels of dental diseases and poorer oral hygiene practice and are less likely to visit the dentist [28]. In these cases, dental caries is not eliminated even though the benefit of fluoride is reducing caries. Fluoride repairs the damage caused by acids produced by plaque bacteria but does not remove the cause of caries, i.e., dietary sugars. The process of prevention requires both a reduction in sugar intake as well as optimum exposure to fluoride. Very extensive and comprehensive research by the National Health Survey concluded that a preventive dentistry program is water fluoridation.
\nDietary advice by dental health professionals should be consistent and not conflict with the advices from other health professionals, based on the evidence in the various professional fields and based on the national dietary guidelines. The advices may be more readily accepted from the people when the oral healthcare professionals can make unequivocally clear that the advice benefits caries prevention. If not, the person may not understand why the dental professional interferes with his diet and not accept the advices. However, this does not dismiss the dental professional from also explaining the benefits for general health on limiting or reducing the intake of sugars. Under the premise that it benefits oral health, the dental health professional can make stronger restrictions than the general guidelines as long as they do not harm general health. Generally speaking a diet that is beneficial to both general and dental health is one that is low in free sugars, saturated fat, and salts, as well as high in fresh fruits, vegetables, nuts and seeds, and wholegrain carbohydrates with modest amounts of legumes, fish, poultry, and lean meat and plenty of fluids preferably water and milk and, thus, modest with sugar sweetened beverages [29].
\nThe teeth and oral mucosa are cleaned with the help of saliva, which is a mixed glandular secretion. Saliva by itself is consisted of three glands, and they are as follows: submandibular, sublingual, and finally the parotid. It also has hundreds of small glands inside the oral mucosa and submucosa as well as gingival cervical fluid.
\nThe maintenance of healthy teeth and oral tissues could be achieved only with the help of saliva’s presence. If there were a severe reduction of the saliva’s production, then there would be a very fast deterioration of oral health as well as the patient’s life. The results from such a condition could lead to eating difficulties like: swallowing difficulties, bad oral hygiene, dental caries that progresses very fast, mucosa’s burning sensation, difficulty in talking, wearing denture, oral infections like Candida, and ulceration of oral mucosa.
\nDry mouth is a problem, which appears in huge proportions. Xerostomia or in other words dry mouth is very common for people with Sjogren’s syndrome, as a result of radiotherapy in the head and neck in cancer treating and especially in the case of older generations when they are prescribed with drugs. The saliva’s role in oral health is huge especially taking into consideration the sicknesses that appear because of decreased quantity or quality of saliva. That is why it is very important to early diagnose and prevent this condition.
\nSaliva is considered as the most easily available diagnostic fluid for noninvasive collection and analysis because through it we can diagnose caries susceptibility, systemic, physiological, and pathological, and we can monitor the level of hormones, drugs, antibodies, microorganisms, and ions.
\nIn this research, we will try to present the main functions of saliva, the anatomy and histology of salivary glands, the physiology of saliva formation, the constituents of saliva, and the use of saliva as a diagnostic fluid, including its role in caries risk assessment.
\nSaliva has several functions which are very protective, but it has also other functions presented in Figure 1. Salivary function can be organized into five major categories that serve to maintain oral health and create an appropriate ecologic balance: (1) lubrication and protection, (2) buffering action and clearance, (3) maintenance of tooth integrity, (4) antibacterial activity, and (5) taste and digestion [30].
\nFunctions of saliva.
\nFigure 2 presents the changes in plaque pH following as a result of sucrose rinse. The graphs are named as Stephan’s curve according to the name of the scientist who was the first one who described it in 1944. By using antimony probe microelectrodes in a series of experiments, he also measured changes in plaque pH.
\nStephan’s curve illustrating the changes in plague pH over time following a sucrose rinse.
The unstimulated plaque pH in Figure 2 is approximately 6.7. After the process of sucrose rinse, the plaque pH within a few minutes is reduced to less than 5.0. When the enamel is below the critical pH 5.5, then there is demineralization of the enamel. For about 15–20 min, plaque pH stays below the critical pH and does return to normal for about 40 min. In the presence of saliva and other fluids that are supersaturated with the help of hydroxyapatite and fluorapatite, the enamel itself could be remineralized only when the plaque pH recovers to a level above the critical pH.
\nThe buffering capacity, the degree of access to saliva, the velocity of the salivary film, and the saliva’s urea content are the ones that determine the variation of the shape of Stephan’s curve among individuals and the rate of recovery of the pH plaque.
\nThe major buffer in stimulated saliva is the carbonic acid/bicarbonate system. As the bicarbonate ion concentration gets higher, also the buffering capacity of saliva increases.
\nNowadays for the study of bacteria, proteins, and genes, there are very high-level techniques where they apply saliva in order to spread out the field of oral diagnostics in the process of learning and understanding the oral diseases, systemic diseases, as well as metabolism. Saliva by itself presents an opportunity for the identification of biomarkers for the diseases like dental caries, periodontal diseases, and oral diseases, but all this should be easily done with careful collection and handling.
\nThere have been developed a series of caries risk assessment tests based on saliva’s measurements. These tests measure the capacity of salivary buffering and salivary mutans streptococci and lactobacilli. The increased risk of developing caries comes because of high levels of mutans streptococci, i.e., >105 colony-forming units (CFUs) per mL of saliva. Individuals with high levels of lactobacilli (>105 CFUs per mL saliva) are the ones who consume frequently carbohydrates, and because of that they have an increased risk of caries.
\nAs an answer to the question what is buffering capacity, one could answer that it is the host’s capability to neutralize reduction pH’s plaque constructed by acidogenic organisms. Useful caries indicators for monitoring, preventive measures, and profiling patient’s disease are the salivary tests.
\n\nTable 1 lists some salivary variables measured for caries risk assessment in dentistry, which are more used for measurement than the other types.
\nFluid/lubricant | \nIt coats hard and soft tissue. Helps to protect against mechanical, thermal, and chemical irritation and tooth wear. Assists smooth air flow, speech, and swallowing. | \n
Ion reservoir | \nSolution supersaturated with respect to tooth mineral facilitates remineralization of the teeth. Acidic proline-rich proteins and statherin in saliva inhibit spontaneous precipitation of calcium phosphate salts. | \n
Buffering action and clearance | \nHelps to neutralize plaque pH after eating, thus reducing time for demineralization. | \n
Mechanical function of cleaning the tooth surface | \nClears food and aids swallowing. | \n
Antimicrobial activity | \nSpecific (e.g., sIgA) and non-specific (e.g. lysozyme, lactoferrin, and myeloperoxidase) anti-microbial mechanisms help to control the oral microflora. | \n
Digestion | \nThe enzyme α-amylase is the most abundant salivary enzyme; it splits starchy foods into maltose, maltotriose, and dextrins. | \n
Protective remineralization (promoted by fluoride) | \nSaliva also inhibits caries by protective remineralization. This is promoted by fluoride ions in saliva. | \n
Salivary variables measured for caries risk assessment.
While either measuring unstimulated or stimulated saliva’s flow rates, we should bear in mind the conditions of saliva’s collection process. When measuring unstimulated flow, which is usually at rest, repeated measurements should be assessed during the same day as a result of circadian rhythm and also because chewing (mechanical) and citric acid (gustatory) produce different results.
\nThe best way of measuring unstimulated or stimulated saliva is using commercial kit. When it comes to buffering capacity of unstimulated saliva which is lower or stimulated saliva, they are very easily measured at the chairside. In order to do bacteriological tests as chewing dislodges the flora into the saliva, then the best way is to use paraffin wax-stimulated saliva samples. From stimulated saliva samples, you can culture mutans streptococci and lactobacilli. Their measurements could also be facilitated with the help of commercially available chairside tests. However, when it comes to fluoride, calcium, and phosphate biochemical measurement, then these must be done with the help of special laboratory facilities that are not available to practitioners.
\nAs an answer to the question what is unstimulated whole saliva, one could answer that it is the mouth’s secretion mixture with tastants or chewing in the absence of exogenous stimuli. It is composed of parotid, submandibular, and sublingual secretions as well as the minor mucous glands, but it also contains desquamated epithelial cells, gingival crevicular fluid, leucocytes (mainly from the gingival crevice), bacteria, and possibly food residues, blood, and viruses.
\nThe collection of saliva from the patient is done in that way that the patient spits out saliva in regular intervals of time without swallowing it, and there is another way when the patient keeps his or her head down and mouth just a bit open so that saliva can drip down from the mouth into a beaker during a time interval. However, one should bear in mind that when saliva is spit down, the number of desquamated epithelial cells as well as bacteria are increased. The difference between the secreted amount by the different salivary glands and the evaporated volumes is the measured flow rate. The unstimulated salivary flow rates in healthy individuals and the average value for whole saliva is about 0.3–0.4 mL/min. Patients say that they have dry mouth (xerostomia) only when saliva is almost completely absent. Objective evidence of hyposalivation is considered a flow rate of <0.1 mL/min.
\nDentists should also measure salivary flow as part of their regular examination so that when patients complain of dry mouth, they will have the tests. The usual problems are related to swallowing difficulty that often leads to individuals with very little saliva but without discomfort and others with saliva flow rates within the normal range who feel that their mouth is drowning in saliva.
\nStimulated saliva is produced in response to a mechanical, gustatory, olfactory, or pharmacological stimulus, contributing to around 40–50% of daily salivary production. Several studies of stimulated salivary flow rates have been done in healthy populations and show a wide variation among individuals. The salivary flow (SF) index is a parameter allowing stimulated and unstimulated saliva flow to be classified as normal, low, or very low (hyposalivation). In adults, normal total stimulated SF ranges 1–3 mL/min, and low ranges 0.7–1.0 mL/min, while hyposalivation is characterized by a stimulated SF <0.7 mL/min. Many factors influence the stimulated salivary flow rate which, for whole saliva, has an average maximum value of about 7 mL/min.
\nEating is a strong stimulus for the secretion of saliva by the major salivary glands. Large volumes of saliva are secreted before, during, and after eating via the gustatory-salivary reflex, masticatory-salivary reflex, olfactory-salivary reflex, and esophageal-salivary reflex. The action of chewing, in the absence of any taste, will stimulate salivation to a smaller degree than maximum gustatory stimulation with citric acid. Mastication also serves to mix the contents of the mouth, thus increasing slightly the distribution of the different types of saliva around the mouth. Mechanical stimulation of the fauces (the gag reflex) leads to increased salivation.
\nAcid is the most potent of the five basic taste stimuli, the other four being salty, bitter, sweet, and umami. A study performed with different concentrations of citric acid revealed that 5% citric acid stimulated an average maximum salivary flow rate of about 7 mL/min. The citric acid was continuously infused into the mouth, and the teeth were covered with a paraffin film to protect them against the acid. For a clinical evaluation of the residual secretory capacity in patients with hyposalivation, a 3% citric acid solution can be applied to the patient’s tongue at regular intervals so that the degree of stimulation is relatively standardized. If a gustatory stimulus is held in the mouth without movement, salivary flow decreases to nature of stimulus gland size, mechanical unilateral stimulation, gustatory vomiting, pharmacological olfaction, food intake smoking, and gag reflex.
\nDawes [31] has stimulated the flow of saliva alters its composition and noted that the rate of salivary flow increases the concentration of protein, sodium, chloride, and bicarbonate and decreases the concentration of magnesium and phosphorus. Perhaps of greatest importance is the increase in the concentration of bicarbonate, which increases progressively with the duration of stimulation. The increased concentration of bicarbonate diffuses into the plaque, neutralizes plaque acids, increases the pH of the plaque, and favors the remineralization of damaged enamel and dentin.
\nBuffer solutions are solutions that maintain an approximately constant pH when small amounts of either acid or base are added or when the solution is diluted. These solutions own the capacity of resisting changes of pH when either acids or alkalis are added to them. There are three possible buffer systems in saliva—the carbonic acid/bicarbonate system, the phosphate system, and the proteins.
\nBicarbonate is one of the most important systems in saliva, which is produced by dental plaque, and its concentration could be from less than 1 mmol/L in unstimulated parotid saliva to a very high flow rate of 60 mmol/L which is elicited by chewing gum thus having a bicarbonate concentration of about 15 mmol/L. The level of bicarbonate ions in unstimulated saliva is too low to be an effective buffer. For those who suffer from the gastroesophageal reflux disease, the bicarbonate in saliva will help them in the clearance process of acid from the esophagus.
\nThe carbonic acid/bicarbonate system is one of the components of the saliva that modifies the creation of caries. It does this by changing the environmental pH and possibly the virulence of bacteria that cause decay. Tanzer et al. [32] tasted the efficacy of a sodium bicarbonate-based dental power and paste with the addition of fluoride on dental caries and on Streptococcus sobrinus or Streptococcus mutans recoveries in rats. These authors observed that the caries reductions in these studies ranged from 42 to 50% in the rats treated with bicarbonate dentifrices when compared with rats treated with water [33, 34].
\nThe concentration of phosphate in non-stimulated saliva is about 5–6 mmol/L, compared to a level of about 1 mmol/L in plasma; there is still too little phosphate in saliva to act as a significant buffer. The pH of unstimulated saliva is less than the pK2 value of 7.2 for phosphate so that most of the phosphate is present as H2PO4\n− and cannot accept another hydrogen ion until the pH is close to 2.1, the pK1 for phosphate.
\nIn saliva’s plasma there is about one-thirtieth protein concentration as well as few amino acids with acidic or basic side chains which present an important buffering effect at the usual pH of the oral cavity.
\nWhen the bicarbonate concentration increases, the salivary pH increases too. Henderson and Hasselbalch give the equation of the relationship between the pH and the bicarbonate concentration, which is pH = pK + log[HCO3\n−]/[H2CO3], in which the pK (about 6.1) and [H2CO3] (about 1.2 mmol/L) are virtually independent of the flow rate. The latter is in equilibrium with the pCO2 which, in saliva, is about the same as that in the venous blood. If we try to measure the pH of saliva, then it is very obligative to avoid exposure of the saliva to the atmosphere because the pH will be artificially elevated and CO2 will be released. At very low flow rates, the pH of parotid saliva can be as low as 5.3, rising to 7.8 at very high flow rates. Because of the low bicarbonate concentration, patients with hyposalivation will have a low salivary buffering capacity and a low salivary pH (Figure 3).
\nThe effects of flow rate on the concentrations of some components of saliva.
The importance of salivary urea was acknowledged early in dental literature [35, 36]. The pH-raising effect of intraoral urea application was first described by Stefan [37]. This author found that in both in vivo and in vitro, urea could raise plaque pH up to pH 9 and that the addition of 40–50% urea to carbohydrates largely overcame the pH-lowering effect for up to 24 h. The value of salivary urea ranges from 2 to 6 mmol/L.
\nUrea possesses the capability to inhibit the metabolism and multiplication of bacteria in the saliva, which indirectly neutralizе the acids in the oral environment and maintain the salivary acidobasic balance due to its buffer capacity [37, 38].
\nLess aciduric oral bacteria (Streptococcus sanguinis and Streptococcus gordonii) associated with dental health have the ability for alkali generation by hydrolyzing urea or arginine to ammonia. Production of ammonia is a mechanism that influences the balance remineralization-demineralization of the tooth, maintains neutral pH in oral cavity, and prevents the appearance of a cariogenic microflora [39, 40].
\nUrea can be used as a constituent of chewing gums for neutralized acids. Imfeld [41] explored the effect of sugar-free chewing gums containing various amounts of urea on the pH recovery in dental plaque.
\nAfter rinsing the mouth with 10 or 50% (w/v) sucrose solution, the respondents chewed the gum with different content of urea (10, 20, 30 mg) for 10 min. Increased value of salivary or plaque pH was found in the first minutes of chewing, and the effect of urea continued and lasted over 10 min. The higher concentrations of urea in chewing gum resulted in a faster leveling of the pH. As a result, the highest values of pH in the examined groups were observed in cases where they were treated with chewing gum containing 30 mg urea. With the use of such chewing gum, the salivary pH value does not fall below the level which is risky for the occurrence of dental caries, and there is a positive effect of chewing on the salivary flow that also affects neutralizing the acids in saliva or plaque [42, 43]. For the purpose of demonstrating the effect it can have on unstimulated saliva, a mathematical model of the influence of salivary urea on dental plaque was constructed. Data from study indicated that urea present in unstimulated saliva has a significant effect on plaque pH by elevating and counteracting the fall of plaque pH in the fasting state. The correlation of higher salivary urea concentrations and low salivary caries activity was registered in patients with chronic renal disease. These patients, who have elevated salivary urea concentration, have a reduced incidence of dental caries [44].
\nSaliva contains a supersaturated solution of calcium and phosphate, which neutralizes acids. Some epidemiological studies have revealed that humans with relatively high Ca and P in their plaque experience correspondingly lower caries. Higher Ca concentration of plaque is associated with low caries incidence. The process of undersaturation of the saliva with respect to tooth mineral content is a result of decreasing total phosphate concentration at high flow rates which would be bad for the teeth.
\nHowever, if the flow rate increases, then the saliva’s pH increases together with the bicarbonate concentration, and therefore high pH is altered. In the proportions of four different phosphate species (H3PO4, H2PO4\n−, HPO4\n2−, and PO4\n3) together with the fall in total phosphate concentration, there is a fall in H2PO4\n− and a slight increase in HPO4\n2− but a dramatic increase in PO4\n3−, all as a result high pH. It is the PO4\n3− that is an important ionic species with respect to the solubility of tooth mineral. So, although the total level of phosphate falls with increasing flow rate, the concentration of PO4\n3− actually increases as much as 40-fold when flow rate increases from the unstimulated level to high flow rates. The three components (Ca2+, PO4\n3−, and OH−) increase with salivary flow if taking into consideration the components of the ion product determining the solubility of tooth mineral in saliva. The saliva is more effective in reducing demineralization and promoting remineralization of the teeth if the flow rate is higher as well as the potential for calculus formation.
\nIt can be concluded that tooth decay is a disease of great importance for general health. As a result, strategies to reduce the risk for dental caries are extremely important. The strategies may involve decreasing the growth or activity of bacteria especially S. mutans. To do so, people need to change their daily diet. Parents should advise children to avoid eating between meals, especially food containing carbohydrate.
\nDiet and oral microflora are connected to caries along with host factors such as salivary composition and flow.
\nDiet rich in fermentable carbohydrates is responsible for causing caries. Sucrose is one of the most cariogenic sugars, and glucose and fructose have also been shown to be less cariogenic. The cariogenic potential of carbohydrate-containing foods depends on their stickiness characteristics, frequency, and amount.
\nThe saliva with its components plays an important role in maintaining oral, especially dental, health. Saliva is a natural factor that protects against demineralization. Apart from the activity of human saliva in diluting, clearing, neutralizing, and buffering acids, it also reduces demineralization and enhances the remineralization process.
\nSaliva performs its mechanical cleaning and protective functions though several physical and biochemical mechanisms. Saliva has buffer capacity which neutralizes acids in the mouth. The carbonic acid/bicarbonate system is the most important buffer in stimulated saliva.
\nThe urea contributes to maintaining the acidobasic balance of saliva and thus affects the incidence of caries.
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She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis",institutionString:null,institution:{name:"Al Azhar University",country:{name:"Egypt"}}},{id:"113313",title:"Dr.",name:"Abdel-Aal",middleName:null,surname:"Mantawy",slug:"abdel-aal-mantawy",fullName:"Abdel-Aal Mantawy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ain Shams University",country:{name:"Egypt"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5681},{group:"region",caption:"Middle and South America",value:2,count:5161},{group:"region",caption:"Africa",value:3,count:1683},{group:"region",caption:"Asia",value:4,count:10200},{group:"region",caption:"Australia and Oceania",value:5,count:886},{group:"region",caption:"Europe",value:6,count:15610}],offset:12,limit:12,total:1683},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"8"},books:[{type:"book",id:"10454",title:"Technology in Agriculture",subtitle:null,isOpenForSubmission:!0,hash:"dcfc52d92f694b0848977a3c11c13d00",slug:null,bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",editedByType:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10502",title:"Aflatoxins",subtitle:null,isOpenForSubmission:!0,hash:"34fe61c309f2405130ede7a267cf8bd5",slug:null,bookSignature:"Dr. Lukman Bola Abdulra'uf",coverURL:"https://cdn.intechopen.com/books/images_new/10502.jpg",editedByType:null,editors:[{id:"149347",title:"Dr.",name:"Lukman",surname:"Abdulra'uf",slug:"lukman-abdulra'uf",fullName:"Lukman Abdulra'uf"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10504",title:"Crystallization",subtitle:null,isOpenForSubmission:!0,hash:"3478d05926950f475f4ad2825d340963",slug:null,bookSignature:"Dr. Youssef Ben Smida and Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10504.jpg",editedByType:null,editors:[{id:"311698",title:"Dr.",name:"Youssef",surname:"Ben Smida",slug:"youssef-ben-smida",fullName:"Youssef Ben Smida"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10552",title:"Montmorillonite",subtitle:null,isOpenForSubmission:!0,hash:"c4a279761f0bb046af95ecd32ab09e51",slug:null,bookSignature:"Prof. Faheem Uddin",coverURL:"https://cdn.intechopen.com/books/images_new/10552.jpg",editedByType:null,editors:[{id:"228107",title:"Prof.",name:"Faheem",surname:"Uddin",slug:"faheem-uddin",fullName:"Faheem Uddin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10572",title:"Advancements in Chromophore and Bio-Chromophore Research",subtitle:null,isOpenForSubmission:!0,hash:"4aca0af0356d8d31fa8621859a68db8f",slug:null,bookSignature:"Dr. Rampal Pandey",coverURL:"https://cdn.intechopen.com/books/images_new/10572.jpg",editedByType:null,editors:[{id:"338234",title:"Dr.",name:"Rampal",surname:"Pandey",slug:"rampal-pandey",fullName:"Rampal Pandey"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10581",title:"Alkaline Chemistry and Applications",subtitle:null,isOpenForSubmission:!0,hash:"4ed90bdab4a7211c13cd432aa079cd20",slug:null,bookSignature:"Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10581.jpg",editedByType:null,editors:[{id:"300527",title:"Dr.",name:"Riadh",surname:"Marzouki",slug:"riadh-marzouki",fullName:"Riadh Marzouki"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10582",title:"Chemical Vapor Deposition",subtitle:null,isOpenForSubmission:!0,hash:"f9177ff0e61198735fb86a81303259d0",slug:null,bookSignature:"Dr. Sadia Ameen, Dr. M. 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