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Language Medicina oral, patología oral y cirugía bucal. Ed inglesa. 2016. Vol. 21, no. 5
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- Haemostatic agents in apical surgery : a systematic review(2016) Clé-Ovejero, Adrià; Valmaseda Castellón, E.Blood presence in apical surgery can prevent the correct vision of the surgical field, change the physical properties of filling materials and reduce their sealing ability. To describe which are the most effective and safest haemostatic agents to control bleeding in patients undergoing apical surgery. TWe carried out a systematic review, using Medline and Cochrane Library databases, of human clinical studies published in the last 10 years. The agents that proved more effective in bleeding control were calcium sulphate (100%) and collagen plus epinephrine (92.9%) followed by ferric sulphate (60%), gauze packing (30%) and collagen (16.7%). When using aluminium chloride (Expasyl®), over 90% of the apical lesions improved, but this agent seemed to increase swelling. Epinephrine with collagen did not significantly raise either blood pressure or heart rate. Despite the use of several haemostatic materials in apical surgery, there is little evidence on their effectiveness and safety. The most effective haemostatic agents were calcium sulphate and epinephrine plus collagen. Epinephrine plus collagen did not seem to significantly raise blood pressure or heart rate during surgery. Aluminium chloride did not increase postoperative pain but could slightly increase postoperative swelling. Randomized clinical trials are needed to assess the haemostatic effectiveness and adverse effects of haemostatic materials in apical surgery.
- Bisphosphonate treatment and dental implants : a systematic review(2016) de-Freitas, Nayara-Ribeiro; Lima, Lívia-Bonjardim; de-Moura, Marcos-Boaventura; Veloso-Guedes, Cizelene-do-Carmo-Faleiros; Simamoto-Júnior, Paulo-César; de-Magalhães, DenildoTo analyze articles that studied patients submitted to diphosphonates therapy and who received dental implants before, during or after bisphosphonate (BP) treatment, compared to healthy patients, analyzing the increase of failure and loss of implants or bisphosphonate related osteonecrosis of the jaw (BRONJ) incidence. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement was used in this study. The clinical question in ?PICO? format was: In patients under bisphosphonate therapy, do dental implants placement, compared to healthy patients, increase the failure and loss of implants or bisphosphonate related osteonecrosis of the jaw incidence? PubMed/MEDLINE was searched for articles published up until April 15, 2015 using a combination of MeSH terms and their Entry terms. The search resulted in 375 articles. After selection according to the eligibility criteria, 15 studies fulfilled were included (eight retrospective, one prospective and six case series), with a total of 1339 patients analyzed, 3748 implants placed, 152 loss of implants and 78 cases of BRONJ. Due to the lack of randomized clinical trials looking at this theme, further studies with longer follow-up are needed to elucidate the remaining questions. Thus, it is wise to be careful when planning dental implant surgery in patients undergoing bisphosphonate therapy because of the risk of developing BRONJ as well as occurring failure of implant. Moreover, complete systemic condition of the patient must be also taking into considering when such procedures are performed.
- Comparison of the analgesic efficacy of oral ketorolac versus intramuscular tramadol after third molar surgery : a parallel, double-blind, randomized, placebo-controlled clinical trial(2016) Espinoza, Mario Alberto Isiordia; Pozos Guillén, Amaury de Jesús; Martínez Rider, Ricardo; Pérez Urizar, José TrinidadPreemptive analgesia is considered an alternative for treating the postsurgical pain of third molar removal. The aim of this study was to evaluate the preemptive analgesic efficacy of oral ketorolac versus intramuscular tramadol after a mandibular third molar surgery. A parallel, double-blind, randomized, placebo-controlled clinical trial was carried out. Thirty patients were randomized into two treatment groups using a series of random numbers: Group A, oral ketorolac 10 mg plus intramuscular placebo (1 mL saline solution); or Group B, oral placebo (similar tablet to oral ketorolac) plus intramuscular tramadol 50 mg diluted in 1 mL saline solution. These treatments were given 30 min before the surgery. We evaluated the time of first analgesic rescue medication, pain intensity, total analgesic consumption and adverse effects. Patients taking oral ketorolac had longer time of analgesic covering and less postoperative pain when compared with patients receiving intramuscular tramadol. According to the VAS and AUC results, this study suggests that 10 mg of oral ketorolac had superior analgesic effect than 50 mg of tramadol when administered before a mandibular third molar surgery.
- Efficacy of fentanyl transdermal patch in pain control after lower third molar surgery : a preliminary study(2016) Todorovic, Vladimir S.; Vasovic, Miroslav; Andric, Miroslav; Todorovic, Ljubomir; Kokovic, VladimirSurgical removal of impacted lower third molars is a common oral surgical procedure, generally followed by moderate to severe postoperative pain. Transdermal drug delivery as a concept offers interesting possibilities for postoperative pain control. The aim of this study was to evaluate the efficacy of transdermal system with fentanyl in relieving pain following impacted lower third molar surgery. Seventeen patients with bilateral impacted lower third molars were included in this preliminary study. For postoperative pain control, patients randomly received a fentanyl patch plus placebo tablet after the first operation and regular (placebo) patch and an analgesic, after the second operation. Analgesia was evaluated during first 24 hours postoperatively according to patients? reports about time of first pain appearance and additional analgesic consumption. Pain severity was rated using a 10 cm long visual analogue scale (VAS). Intensity of postoperative pain and postoperative analgesic consumption were significantly lower after the Fentanyl Transdermal System (FTS) was applied (p<0.05). Duration of postoperative analgesia was significantly higher with FTS when compared to control treatment (p<0.05). Based on the results of this preliminary study, transdermal system with fentanyl significantly reduced postoperative pain after third molar surgery.
- Paranasal sinuses malignancies : a 12-year review of clinical characteristics(2016) Danesh-Sani, Seyed-Amir; Sarafraz, Alireza; Chamani, Mojtaba; Derakhshandeh, HosseinInadequate epidemiologic investigations of the paranasal sinuses malignancies prompted this retrospective study with special emphasis on a major group of 111 tumors. Clinical records of 111 patients with histologically confirmed malignant tumors of the paranasal sinuses were investigated retrospectively from April 2000 to January 2012. Collection of data included demographic information, clinical manifestations, treatment plans, and histopathology of the tumor. There were 69 (62.16%) male and 42 (37.83%) female patients (male-to-female ratio of 1.6:1), with a median age of 49±12.2 years (range 21 to 88 years). A high level of occurrence was noticed in the fifth (26.3%) decade of life. The most frequent histological types were squamous cell carcinoma (43.5%) and adenoid cystic carcinoma (19%). Among clinical manifestations, nasal obstruction was the most frequent followed by diplopia, and facial swelling. Fifty three patients (47.74%) were treated with combined approach of surgery and radiation therapy. Paranasal sinuses malignancies are rare conditions with nonspecific symptoms which make early diagnosis of the lesions more challenging. The optimal therapeutic protocol for patients suffering from these tumors is still a somewhat controversial entity and requires further studies.
- Rehabilitation of the severely atrophied dentoalveolar ridge in the aesthetic region with corticocancellous grafts from the iliac crest and dental implants(2016) Lehmijoki, Miikka; Holming, Heli; Thorén, Hanna; Stoor, PatriciaThe aim of this study was to assess changes in bone volume after block bone augmentation and placement of dental implants and further evaluate the aesthetic outcome of the treatment. 9 Patients with atrophied anterior maxilla were included in this study. They received total of 21 implants. Dimensions of the alveolar ridge were measured from cone-beam computed tomography x-rays. The bone level at the implant sites was analysed from intraoral x-rays and the aesthetic outcome was assessed from clinical photographs using a pink aesthetic score (PES) scaling. The mean gained horizontal bone width at the marginal crest and 5 mm apically was accordingly 2.7mm and 5.0 mm. The mean PES rating was 9.8/14. The survival rate of. Reconstruction of the atrophied anterior maxilla with bone blocks and dental implants is a safe procedure with high survival rate and acceptable aesthetic outcome.
- Topographic characterisation of dental implants for commercial use(2016) Mendoza-Arnau, Amparo; Vallecillo Capilla, Manuel Francisco; Cabrerizo Vílchez, Miguel Angel; Rosales Leal, J. IgnacioTo characterize the surface topography of several dental implants for commercial use. Dental implants analyzed were Certain (Biomet 3i), Tissue Level (Straumann), Interna (BTI), MG-InHex (MozoGrau), SPI (Alphabio) and Hikelt (Bioner). Surface topography was ascertained using a confocal microscope with white light. Roughness parameters obtained were: Ra, Rq, Rv, Rp, Rt, Rsk and Rku. The results were analysed using single-factor ANOVA and Student-Neuman-Keuls(p<0.05) tests. Certain and Hikelt obtained the highest Ra and Rq scores, followed by Tissue Level. Interna and SPI obtained lower scores, and MG-InHex obtained the lowest score. Rv scores followed the same trend. Certain obtained the highest Rp score, followed by SPI and Hikelt, then Interna and Tissue Level. MG-InHex obtained the lowest scores. Certain obtained the highest Rt score, followed by Interna and Hikelt, then SPI and Tissue Level. The lowest scores were for MG-InHex. Rsk was negative (punctured surface) in the MG-InHex, SPI and Tissue Level systems, and positive (pointed surface) in the other systems. Rku was higher than 3 (Leptokurtic) in Tissue Level, Interna, MG-InHex and SPI, and lower than 3 (Platykurtic) in Certain and Hikelt. The type of implant determines surface topography, and there are differences in the roughness parameters of the various makes of implants for clinical use.
- Alternative method to treat oroantral communication and fistula with autogenous bone graft and platelet rich firbin(2016) Kapustecki, Micha?; Niedzielska, Iwona; Borgiel-Marek, Halina; Ró?anowski, BartoszRemoving a tooth from the jaw results in the occurrence of oroantral communication in beneficial anatomic conditions or in the case of a iatrogenic effect. Popularized treatments of the oroantral communication have numerous faults. Large bone defect eliminates the chance to introduce an implant. Purpose of this work was assessment of the usefulness of autogenous bone graft and PRF in normal bone regeneration in the site of oroantral communication. Bone regeneration in the site of oroantral communication was assessed in 20 patients. Bone defects were supplemented autogenous bone graft from mental protuberance in 14 cases and from oblique line in 6 cases. The graft was covered with a PRF membrane. In the study group in all cases closure of the oroantral communication was observed. The average width of the alveolar was 13 mm and the average height was 12.5 mm. In 3 patients an average increase of alveolar height of 1.5 mm was observed. This method may be the best option to prepare alveolar for new implant and prosthetic solutions.
- Pos?t?ve effect of platelet rich fibrin on osseointegration(2016) Öncü, Elif; Bayram, Burak; Kantarci, Alpdogan; Gülsever, Serap; Alaaddino?lu, Emine-ElifLeukocyte-platelet rich fibrin (L-PRF) is a second generation platelet concentrate clinically used to accelerate tissue healing and bone regeneration. Achieving reduced implant osseointegration time could provide immediate or early loading of implants. The aim of this study was to evaluate the L-PRF-induced osseointegration and bone-implant contact (BIC) in an experimental animal model. Twelve 4-month-old New Zealand white rabbits were used. Following general anesthesia, 3-5 mL of blood was obtained from the central artery in rabbit ear and L-PRF was prepared. Two implant cavities (5 mm long and 3 mm in diameter) were created in each tibia with a total of four cavities in each animal. Two of these cavities were selected and covered with PRF (test group). The remaining L-PRF was used to soak the implants placed into the L-PRF covered sockets. Other cavities were left as controls. In total, 48 implants were placed. Animals were sacrificed after two, three, or four weeks. Histological samples were obtained and peri-implant tissues were histomorphometrically evaluated for bone-to-implant contact and new bone formation. Histomorphometric analyses of the defects revealed that the L-PRF was detectable up to the second week. Application of L-PRF increased the rate and amount of new bone formation in the experimental group compared to the control group. Bone-to-implant contact was enhanced when the surface was pre-wetted with L-PRF (p<0.01). The results of this study demonstrated that L-PRF application may increases amount and rate of new bone formation during the early healing period and provides a faster osseointegration around implants.
- Impact of rare diseases in oral health(2016) Molina García, Ana; Castellanos Cosano, Lizett; Machuca Portillo, Guillermo; Posada de la Paz, ManuelRare diseases (RD) are those that present a lower prevalence than 5 cases per 10.000 population. The main objective of this review was to study the effect on oral health in rare diseases, while the secondary objective of the study is theme upgrade. Comparative observational case-control studies were analysed and a systematic review was conducted in PubMed. Each rare disease listed on the statistical data record of the Health Portal of the Ministry of Equality, Health and Social Policies Board of Andalusia was associated with ?oral health?. The variables studied included dental, oral mucosa and occlusion alterations, oral pathologies (caries, periodontal disease) and other alterations (mouth breathing, parafunctional habits, etc). A bias analysis of the variable caries was conducted. Six RD were selected through our inclusion and exclusion criteria (hypogammaglobulinemia, Rett syndrome, Marfan syndrome, Prader-Willi syndrome, cystic fibrosis and Cri du chat syndrome) in a total of 8 publications, of which four trials were classified as high risk of bias and one of them as medium risk. There were not trials with low risk of bias. The main statistically significant differences found by Syndrome compared to a control group were in Hypogammaglobulinemia with a greater tendency to enamel hypoplasia and dry mouth. The Rett syndrome had, as well, a greater tendency to an anterior open bite, ogival palate, bruxism, mouth breathing and tongue thrusting. Prader-Willi syndrome had a tendency of dental erosion, and Cri du chat syndrome showed a higher association to Tannerella forsythia.
- Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents(2016) Rodríguez Lozano, Francisco Javier; Oñate Sánchez, Ricardo ElíasThe clinical management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bisphosphonates and other antiresorptive agents is subject to controversy. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed guidelines for the correct management of the disorder which are revised and updated by a panel of experts. The present systematic review analyzes the different treatments currently used to treat this clinical condition, based on the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement published in 2009. An electronic Medline search was made of the PubMed database, covering the period 2006-2014. The last search date was 31 December 2014. A total of 29 articles were selected from the initial search according to the different drugs implicated in the appearance of osteonecrosis; the treatment modality used according to the stage of the disease; and the recorded success rate. It is currently still recommended that the management of MRONJ should be decided according to the stage of the disease ? conservative treatment being preferred in early stages without symptoms, while surgical management is preferred in the case of bone exposure with symptoms.
- Prevalence of the colonization of Helicobacter pylori among students of the school of dentistry, University of Granada, Spain(2016) Liébana Ureña, José; García Casas, Violeta; Liébana Cabanillas, Francisco; Arias Moliz, María TeresaThe oral cavity is a reservoir for Helicobacter pylori, and occupations that involve close contact with it, like Dentistry, could entail a higher risk of colonization. The aim of this study was to evaluate if the length of stay at the School of Dentistry of the University of Granada could influence colonization by H. pylori, and to furthermore correlate colonization by H. pylori, with the state of oral health and oral hygiene habits. The study groups were: Group 1, 35 students of Odontology in their first year of studies; Group 2, the same 35 students when they were in their fifth academic year; Group 3, 35 students from University study programs unrelated with Health and of the same age as the group 2 students. All underwent H. pylori, colonization determinations by means of the urea breath test (UBT), stool antigen test and a serological test. Also studied were the variables plaque index, gingival index and the number of times teeth were brushed per day. The Student t test was used for comparisons among the three studied groups. The Chi-squared test and Pearson correlation coefficient were used to determine any connection between colonization by H. pylori, and the variables studied. Comparisons between groups 1 and 2 and between groups 2 and 3 showed significant differences regarding colonization by H. pylori, plaque index, gingival bleeding index and tooth brushing. A positive correlation was found between being colonized by H. pylori, and having a gingival index higher than 10% and tooth brushing once a day or less, in all the studied groups. Colonization by H. pylori, among Dentistry students at the University of Granada decreased over a four-year time period at the University. Factors related with better oral health, such as a lower gingival index and more frequent tooth brushings, would explain these results.
- Current methods of sedation in dental patients : a systematic review of the literature(2016) Corcuera Flores, José Ramón; Silvestre Rangil, Javier; Cutando Soriano, Antonio; López Jiménez, JuliánThe main objective of this systematic literature review is to identify the safest and most effective sedative drugs so as to ensure successful sedation with as few complications as possible. A total of 21 studies were selected due to their rigorous study design and conduciveness to further, more exhaustive analysis. The selected studies included a total of 1,0003 patients classified as ASA I or II. Midazolam was the drug most frequently used for successful sedation in dental surgical procedures. Ketamine also proved very useful when administered intranasally, although some side effects were observed when delivered via other routes of administration. Both propofol and nitrous oxide (N2O) are also effective sedative drugs. Midazolam is the drug most commonly used to induce moderate sedation in dental surgical procedures, and it is also very safe. Other sedative drugs like ketamine, dexmedetomidine and propofol have also been proven safe and effective; however, further comparative clinical studies are needed to better demonstrate which of these are the safest and most effective.
- The role of emotions in depression and aggression(2016) Llorca Mestre, Anna; Malonda Vidal, Elisabeth; Samper García, PaulaDepression is a broad and heterogeneous diagnostic grouping, central to which is depressed mood or inability to enjoy most activities. Depressive symptoms are frequently accompanied by conduct problems stemming from anger. It is very important to know the interrelation of these emotions very well to be able to help adolescents to manage them more easily. The main aim of this article is to present the problem of interaction between negative affects (emotional instability, anger state and trait, physical and verbal aggression and depression) analyzing the different relationship through the time in spanish sample. The sample included 470 adolescents (192 boys and 225 girls) in a three-wave longitudinal study in Valencia (Spain). The mean age was 14.70 in the first wave. Structural equations modelling was employed to explore two longitudinal models. The results show differences based on sex, and that an internalised variable, like emotional instability, is relevant to prevent the appearance of depression directly in girls and also the later appearance of aggression as long as anger mediates, in both boys and girls, so the control of anger becomes an important goal to control the rest of the negative affects. This results has consequences in the preparation of all programmes that try to establish an emotional control on adolescents, as not only has to be taken into account as a direct goal the control of externalised emotions like anger, but internalised emotions like emotional instability have to be taken into account also. Furthermore, it is also made apparent that not only the punctual explosions and externalisation of anger have to be worked on, but the temperamental aspects which are the base of anger trait have to be worked on too.
- Impact of functional mandibular advancement appliances on the temporomandibular joint : a systematic review(2016) Ivorra Carbonell, Laura; Montiel Company, José María; Almerich Silla, José Manuel; Paredes Gallardo, Vanessa; Bellot Arcís, CarlosAlthough many orthodontists have no doubts about the effectiveness of functional appliances for mandibular advancement, the impact on the temporomandibular joint (TMJ) is still in dispute. The objective of this systematic review is to examine the main effects on the TMJ of using functional appliances, both in healthy patients and in patients with a pre-existing disorder. A systematic review of the literature was conducted in accordance with the PRISMA guidelines. Only systematic reviews, meta-analyses, randomized clinical trials (RCTs), case-control studies and cohort studies were included. A detailed language-independent electronic search was conducted in the Pubmed, Scopus, Cochrane Library and Embase databases. All studies published between 2000 and 2015 were included. A total of 401 articles were identified. Of these, 159 were duplicates and were excluded. On reading the title and abstract, 213 articles were excluded because they did not answer the research question, leaving a total of 29 articles. These articles were read and assessed. Following critical reading of the full text, eight articles were excluded: seven because they were considered of low quality and one because it published redundant data. As a result, 21 articles were included. After treatment with functional appliances, the condyle was found to be in a more advanced position, with remodelling of the condyle and adaptation of the morphology of the glenoid fossa. No significant adverse effects on the TMJ were observed in healthy patients and the appliances could improve joints that initially presented forward dislocation of the disk.
- Estrogen and Progesterone hormone receptor expression in oral cavity cancer(2016) Grimm, Martin; Biegner, Thorsten; Teriete, Peter; Hoefert, Sebastian; Krimmel, Michael; Munz, Adelheid; Reinert, SiegmarRecent studies have shown an increase in the incidence of oral squamous cell carcinoma (OSCC) in younger patients. The hypothesis that tumors could be hormonally induced during pregnancy or in young female patients without the well-known risk factors alcohol or tobacco abuse seems to be plausible. Estrogen Receptor alpha (ER?) and Progesterone Receptor (PR) expression were analyzed in normal oral mucosa (n=5), oral precursor lesions (simple hyperplasia, n=11; squamous intraepithelial neoplasia, SIN I-III, n=35), and OSCC specimen. OSCCs were stratified in a young female (n=7) study cohort and older patients (n=46). In the young female study cohort three patients (n=3/7) developed OSCC during or shortly after pregnancy. Breast cancer tissues were used as positive control for ER? and PR expression. ER? expression was found in four oral precursor lesions (squamous intraepithelial neoplasia, SIN I-III, n=4/35, 11%) and in five OSCC specimen (n=5/46, 11%). The five ER? positive OSCC samples were older male patients. All patients within the young female study cohort were negatively stained for both ER? and PR. ER expression could be regarded as a seldom risk factor for OSCC. PR expression seems to be not relevant for the development of OSCC.
- Alcohol abusive use increases facial trauma?(2016) Carneiro, Suzana-Célia-de-Aguiar Soares; Vasconcelos, Belmiro Cavalcanti; Matos da-Silva, Gessyca-Suielly-Melo; de-Barros-Caldas, Luciano-Cruz; Porto, Gabriela Granja; Leal, Jefferson; Catunda, IvsonTrauma is among the main death causes and morbidity in the world and is often related to the use of alcohol and its abuse has reached massive proportions, no matter if the country is developed or not, being considered as public health problem. Since there are very few randomized and prospective studies in literature about the association of facial trauma and the use of alcohol, this study aims to investigate the impact of alcohol use in facial trauma. This was a prospective and cross sectional study, involving facial trauma patients attended at Oral Maxillofacial Surgery Division of a State Hospital. Variables included patient´s profile, trauma etiology, facial region involved, type of injury and treatment and days of hospitalization. AUDIT test was applied to identify risks and damages of alcohol use and chemical dependence. Absolute distribution, uni and mutilvaried percentages were made for data evaluation. Pearson´s qui-squared and Fisher´s Exact tests were also used. One hundred patients were evaluated. The patient´s mean age was 33.50 years-old, 48% had between 17 and 29 years old, 28% had 30 to 39, and 24% 40 or more. Most of them were male (86%). The most frequent etiology was traffic accident (57%), the extraoral area was most committed (62%), the most frequent type of injury was fractures (78%) and the most affected bone was the mandible (36%). More than half of the patients (53%) had surgical treatment. 38% had their discharge from hospital right after the first attendance. The AUDIT most frequent answer was ?moderate use? (46%) and use at risk (39%). There was significant difference between the use of alcohol (AUDIT) and hematoma (0.003) and number of days of hospitalization (p=0.005). In this study it was not observed association between alcohol consumption using the AUDIT and trauma etiology, but patient victims of traffic accidents were classified as with risk in the scale. Most of the trauma were caused by traffic accidents using motorcycles and occurred in young aged men.
- Keratocystic odontogenic tumor : a biopsy service?s experience with 104 solitary, multiple and recurrent lesions(2016) Bello, Ibrahim-OlajideKeratocystic odontogenic tumor (KCOT) is a clinically significant cystic lesion of odontogenic origin. This study aimed to retrospectively review and describe the clinicopathologic features of KCOT and to objectively compare the clinical and histological features of solitary, multiple and recurrent KCOT in a Saudi Arabian population. Biopsy request forms, pathology records and archival materials (all histological slides) of 104 cases of KCOT from 75 patients were retrieved. Demographic and clinical details as well as histological evaluation were analyzed and compared between the 3 groups using chi-squared or Mann-Whitney tests of association as appropriate. Significant differences were noted in the age of presentation, location and association with impaction between multiple and solitary cases. Histologically, there was a difference in the mitotic count, presence of satellite cysts and proliferating odontogenic epithelium between solitary and multiple lesions. There was no difference between the KCOT that later recurred and solitary lesion which did not recur even when matched clinically for age, sex and location. There were differences when solitary KCOT that later recurred or recurrent KCOT were compared with multiple lesions. Multiple lesions still had more significant proliferative activity parameters than solitary recurrence-related KCOT. KCOTs in Saudi Arabians are not different from those reported from other parts of the world. Clinical and histological analyses showed multiple KCOT is different from its solitary recurrent or non-recurrent counterparts and has a higher proliferative activity than both. Clinicohistologic features alone cannot wholly explain the behavior of KCOT.
