Laser assisted periodontics: A review of the literature

Over the years, the use of the laser within health field and more particularly dentistry has been increasing and improving. The application of laser in the periodontal treatment takes part of a non-surgical and surgical approaches, is used for the decontamination of periodontal pockets due to its bactericidal effect, and the removal of granulation tissues, inflamed and diseased epithelium lining, bacterial deposits and subgingival calculus. However in spite of all the marketing surrounding, the use of laser highlighting its beneficial effect, the capacity of laser to replace the conventional treatment for chronic periodontitis is still debatable. In fact there is no evidence that any laser system adds substantial clinical value above conventional treatments of chronic periodontitis. Some studies showed a significant positive effect on clinical attachment level gain and probing depth reduction. In the other hand, several articles demonstrated no evidence of the superior effectiveness of laser therapy compared to root planing and scaling. Our aims is to review the literature on the capacity of erbium:Yttrium-aluminum-garnet and neodymium:Yttrium-aluminium-garnet laser to either replace or complete conventional mechanical/surgical periodontal treatments.

Correlation of periodontal inflamed surface area with glycated hemoglobin,interleukin-6 and lipoprotein(a)in type 2 diabetes with retinopathy

BACKGROUND The two-way relationship between periodontitis and type 2 diabetes mellitus(T2DM)is well established.Prolonged hyperglycemia contributes to increased periodontal destruction and severe periodontitis,accentuating diabetic complications.An inflammatory link exists between diabetic retinopathy(DR)and periodontitis,but the studies regarding this association and the role of lipoprotein(a)[Lp(a)]and interleukin-6(IL-6)in these conditions are scarce in the literature.AIM To determine the correlation of periodontal inflamed surface area(PISA)with glycated Hb(HbA1c),serum IL-6 and Lp(a)in T2DM subjects with retinopathy.METHODS This cross-sectional study comprised 40 T2DM subjects with DR and 40 T2DM subjects without DR.All subjects were assessed for periodontal parameters[bleeding on probing(BOP),probing pocket depth,clinical attachment loss(CAL),oral hygiene index-simplified,plaque index(PI)and PISA],and systemic parameters[HbA1c,fasting plasma glucose and postprandial plasma glucose,fasting lipid profile,serum IL-6 and serum Lp(a)].RESULTS The proportion of periodontitis in T2DM with and without DR was 47.5%and 27.5%respectively.Severity of periodontitis,CAL,PISA,IL-6 and Lp(a)were higher in T2DM with DR group compared to T2DM without DR group.Significant difference was observed in the mean percentage of sites with BOP between T2DM with DR(69%)and T2DM without DR(41%),but there was no significant difference in PI(P>0.05).HbA1c was positively correlated with CAL(r=0.351,P=0.001),and PISA(r=0.393,P≤0.001)in study subjects.A positive correlation was found between PISA and IL-6(r=0.651,P<0.0001);PISA and Lp(a)(r=0.59,P<0.001);CAL and IL-6(r=0.527,P<0.0001)and CAL and Lp(a)(r=0.631,P<0.001)among study subjects.CONCLUSION Despite both groups having poor glycemic control and comparable plaque scores,the periodontal parameters were higher in DR as compared to T2DM without DR.Since a bidirectional link exists between periodontitis and DM,the presence of DR may have contributed to the severity of periodontal destruction and periodontitis may have influenced the progression of DR.

Multifunctional role of oral bacteria in the progression of nonalcoholic fatty liver disease

Non-alcoholic fatty liver disease(NAFLD)encompasses a spectrum of liver disorders of varying severity,ultimately leading to fibrosis.This spectrum primarily consists of NAFL and non-alcoholic steatohepatitis.The pathogenesis of NAFLD is closely associated with disturbances in the gut micr-obiota and impairment of the intestinal barrier.Non-gut commensal flora,particularly bacteria,play a pivotal role in the progression of NAFLD.Notably,Porphyromonas gingivalis,a principal bacterium involved in periodontitis,is known to facilitate lipid accumulation,augment immune responses,and induce insulin resistance,thereby exacerbating fibrosis in cases of periodontitis-associated NAFLD.The influence of oral microbiota on NAFLD via the“oral-gut-liver”axis is gaining recognition,offering a novel perspective for NAFLD management through microbial imbalance correction.This review endeavors to encapsulate the intricate roles of oral bacteria in NAFLD and explore underlying mechanisms,emphasizing microbial control strategies as a viable therapeutic avenue for NAFLD.

Expert consensus on the diagnosis and therapy of endo-periodontal lesions

Endo-periodontal lesions (EPLs) involve both the periodontium and pulp tissue and have complicated etiologies and pathogenic mechanisms,including unique anatomical and microbiological characteristics and multiple contributing factors.This etiological complexity leads to difficulties in determining patient prognosis,posing great challenges in clinical practice.Furthermore,EPL-affected teeth require multidisciplinary therapy,including periodontal therapy,endodontic therapy and others,but there is still much debate about the appropriate timing of periodontal therapy and root canal therapy.By compiling the most recent findings on the etiology,pathogenesis,clinical characteristics,diagnosis,therapy,and prognosis of EPL-affected teeth,this consensus sought to support clinicians in making the best possible treatment decisions based on both biological and clinical evidence.

Unraveling brain aging through the lens of oral microbiota

The oral cavity is a complex physiological community encompassing a wide range of microorganisms.Dysbiosis of oral microbiota can lead to various oral infectious diseases,such as periodontitis and tooth decay,and even affect systemic health,including brain aging and neurodegenerative diseases.Recent studies have highlighted how oral microbes might be involved in brain aging and neurodegeneration,indicating potential avenues for intervention strategies.In this review,we summarize clinical evidence demonstrating a link between oral microbes/oral infectious diseases and brain aging/neurodegenerative diseases,and dissect potential mechanisms by which oral microbes contribute to brain aging and neurodegeneration.We also highlight advances in therapeutic development grounded in the realm of oral microbes,with the goal of advancing brain health and promoting healthy aging.

Periodontal disease:A silent factor in the development and progression of diabetic retinopathy

The global increase in the prevalence of type 2 diabetes mellitus(T2DM)and its complications presents significant challenges to public health.Recently,periodontal disease(PD)was recognized as a factor that is likely to influence the progression of T2DM and its complications due to its potential to exacerbate systemic inflammation and oxidative stress.In this editorial,we comment on the article published by Thazhe Poyil et al in the very recent issue of the World Journal of Diabetes in 2024,which investigated the correlation between PD and diabetic retinopathy(DR)in T2DM patients,with emphasis on the association between periodontal swollen surface area,glycated hemoglobin(HbA1c),interleukin-6(IL-6),and lipoprotein(a).The findings by Thazhe Poyil et al are significant as they demonstrate a strong link between PD and DR in T2DM patients.This correlation highlights the importance of addressing periodontal health in diabetes management to potentially reduce the risk and severity of DR,a complication of diabetes.The integration of periodontal evaluation and treatment into diabetes care protocols may lead to improved glycemic control and better overall outcomes for T2DM patients.A few studies have established an interconnection between PD and diabetic complication,specifically DR,in T2DM patients,which we aim to highlight in this editorial.Emphasis was placed on the different mechanisms that suggest a bidirectional relationship between PD and T2DM,where the presence of periodontal inflammation negatively influenced glycemic control and contributed to the development and progression of DR through shared inflammatory and vascular mechanisms.This article highlights the importance of collaboration amongst diabetes specialists,ophthalmologists,periodontists,and public health professionals to advance the prevention,early detection,and treatment of PD and DR.This will improve the health and quality of life of T2DM patients.Moreover,the editorial highlights the need for further research on the specific molecular and immunological mechanisms that underlie the link between periodontitis and DR,with identification of common inflammatory biomarkers and signaling pathways.This is expected to facilitate effective direction of therapeutic objectives,thereby improving the management of diabetes and its complications through integrated care that incorporates oral health.

Diagnostic value associated with the combination of saliva pepsin and microorganisms in functional heartburn and gastroesophageal reflux disease

Heartburn is a common symptom shared by both gastroesophageal reflux disease(GERD)and functional heartburn(FHB),which can make it challenging to differentiate between the two conditions.However,examining oral manifestations of GERD can be a cost-effective and readily available method to aid in this differentiation process.It may serve as a valuable tool in distinguishing GERD from FHB.

Brain abscess from oral microbiota approached by metagenomic next-generation sequencing: A case report and review of literature

BACKGROUND Brain abscess is a serious and potentially fatal disease caused primarily by microbial infection.Although progress has been made in the diagnosis and treatment of brain abscesses,the diagnostic timeliness of pathogens needs to be improved.CASE SUMMARY We report the case of a 54-year-old male with a brain abscess caused by oral bacteria.The patient recovered well after receiving a combination of metagenomic next-generation sequencing(mNGS)-assisted guided medication and surgery.CONCLUSION Therefore,mNGS may be widely applied to identify the pathogenic microor-ganisms of brain abscesses and guide precision medicine.

Meta-analysis of the association between chronic periodontitis and chronic kidney disease

BACKGROUND Many scholars have performed several clinical studies have investigated the association between chronic periodontitis(CP)and chronic kidney disease(CKD).However,there are still differences between these research results,and there is no unified conclusion.Therefore,a systematic review is required to understand this issue fully.AIM To explore the correlation between CP and CKD.METHODS Literature on the correlation between CP and CKD,as well as the clinical attachment level(CAL)and pocket probing depth(PPD)of CKD and non-CKD,were retrieved from PubMed,Embase,the Cochrane Library,and Web of Science repositories until January 2024.After the effective data were extracted,data processing and statistics were performed using Stata 12.0.RESULTS Of the 22 studies,13 were related to CP and CKD,and 9 reported CAL and PPD in patients with CKD and healthy controls.Meta-analysis of the correlation between CP and CKD revealed that CKD probability in people with CP was 1.54 times that of healthy individuals[relative risk=1.54,95%confidence interval(CI):1.40-1.70],and CP incidence in patients with CKD was 1.98 times that of healthy individuals[overall risk(OR)=1.98,95%CI:1.53-2.57].Meta-analysis of CAL and PPD evaluations between CKD patients and healthy individuals showed that CAL and PPD levels were higher in CKD patients[standard mean difference(SMD)of CAL=0.65,95%CI:0.29-1.01;SMD of PPD=0.33,95%CI:0.02-0.63].CONCLUSION A bidirectional association exists between CP and CKD.CKD risk is increased in CP patients and vice versa.Periodontal tissue or tooth loss risks increase over time in CKD patients.

Periodontitis:An often-neglected complication of diabetes

The bidirectional association between type 2 diabetes mellitus(T2DM)and periodontitis is now well established,resulting in periodontal disease being considered as the 6th major complication of diabetes mellitus(DM)after cardiovascular disease,eye disease,neuropathy,nephropathy,and peripheral vascular disease.DM can worsen the virulence and invasiveness of pathogenic oral microbial flora aggravating the local inflammation and infection in those with periodontal disease.On the other hand,the chemical and immunological mediators released into the circulation as part of periodontal inflammation worsen the systemic insulin resistance with worsening of T2DM.Periodontitis if undiagnosed or left untreated can also result in eventual tooth loss.A study by Xu et al in the World Journal of Diabetes examined the predictive factors associated with periodontitis in Chinese patients with T2DM.The prevalence of periodontitis was found to be 75.7%in this study.Based on logistic regression analysis,the predictive factors for higher risk were low tooth brushing frequency[odds ratio(OR)=4.3],high triglycerides(TG;OR=3.31),high total cholesterol(TC;OR=2.87),higher glycated hemoglobin(HbA1c;OR=2.55),and higher age(OR=1.05)while higher education level was protective(OR=0.53).However,the most influential variables were HbA1c followed by age,TC,TG,low education level,brushing frequency,and sex on the random forest model(this model showed higher sensitivity for predicting the risk).A good understanding of the predictors for periodontitis in T2DM patients is important in prevention,early detection of susceptible patients,and intervention to improve periodontal health and enable long-term glycaemic control as observed by Xu et al.

Analysis of influencing factors of anxiety and depression in patients with periodontitis

BACKGROUND Periodontitis is a chronic oral disease caused by pathogenic microorganisms that corrode tooth tissue,form periodontal pockets,absorb alveolar bone,and finally lead to tooth loss.During treatment,patients are prone to anxiety,tension,and other negative emotions,which affect their ability to face the disease and may also lead to aggravation of the original condition and affect oral health.Therefore,it is important to improve the negative psychology of patients with periodontitis to clarify the factors that may lead to negative psychological emotions.AIM To investigate the risk factors that may lead to anxiety and depression in patients with periodontitis.METHODS One hundred patients with periodontitis were selected between March 2022 and March 2023 at our hospital.All patients were assessed with the Zung Self-rating Depression Scale(SDS)(≥53 points indicate a depressive state)and Zung Selfrating Anxiety Scale(SAS)(≥50 points indicates an anxious state).In this study,patients who experienced anxiety or depression were included in the occurrence group and those without anxiety or depression were included in the nonoccurrence group.The baseline data of the two groups were compared to explore the risk factors for anxiety and depression in patients with periodontitis.RESULTS A total of 100 patients with periodontitis were included in this study.According to the SDS,38 patients(38.00%)developed depression,with an average SDS score of(68.52±5.85)points.According to the SAS,40 patients(40.00%)developed anxiety,and the average SAS score was(72.15±4.15)points.In this study,56 patients with anxiety or depression were included.Compared with the nonoccurrence group,the occurrence group had higher ages(≥60 years),lower level of hope(low level),educational level(high school or below),disease perception(poor),and sleep disorder(yes).The negative coping dimension scores of the simplified coping style questionnaire(SCSQ)and Dental Fear Scale(DFS)in the occurrence group were higher,whereas the score of the positive coping dimension of the SCSQ was significantly lower(P<0.05).There were no significant differences in the other data between the groups(P>0.05).The results of multiple logistics regression analysis showed that age(≥60 years),level of hope(low level),educational level(high school or below),disease perception(poor),sleep disorder(yes),high negative coping dimension scores of SCSQ,high score of DFS,and low positive coping dimension scores of SCSQ were all factors contributing to the anxiety and depression in patients with periodontitis(odds ratio>1,P<0.05).CONCLUSION Age,hope level,educational level,disease perception,sleep disorders,coping style,and dental fear were all associated with anxiety and depression in patients with periodontitis.

Link between periodontitis and diabetic retinopathy:Inflammatory pathways and clinical implications

The bidirectional relationship between periodontitis and type 2 diabetes mellitus has been well-established.However,the underlying molecular mechanisms remain unclear.Diabetic retinopathy(DR)is an important complication of diabetes,but there are few studies on the relationship between DR and periodontitis,especially on the intrinsic inflammatory pathway mechanism.This article reviews the latest clinical data on how diabetes promotes susceptibility to periodontitis from the epidemiological and molecular perspectives,with a special focus on the key roles of systemic inflammation and endothelial dysfunction in the interplay between DR and periodontitis.Comprehension of the intertwined pathogenesis of DR and periodontitis can better guide the development of comprehensive management strategies for glycemic control and periodontal health,with the aim of mitigating the progression of DR and enhancing overall well-being.

Microsurgical management of radicular cyst using guided tissue regeneration technique:A case report

BACKGROUND Radicular cyst is a lesion of odontogenic origin that arises from epithelial remains due to periapical periodontitis caused by inflammatory reactions generated at the apex of affected teeth with infected or necrotic pulps.The therapeutic mana gement of radicular cysts is controversial.There is only one case report of enucleation of a radicular cyst managed with microsurgery and apicoectomy,but without the use of the guided tissue regeneration(GTR)technique in the same surgical procedure.The present clinical case describes the management of a radicular cyst with microsurgical approach,performance of an apicoectomy of the tooth associated with the entity,application of GTR technique,use of a resorbable membrane of type I bovine collagen,and bovine xenograft.CASE SUMMARY A 68-year-old patient presented with a radicular cyst from an upper lateral incisor.The microsurgical management used was aimed at enucleating the chemical membrane,performing apicoectomy of the tooth along with careful and precise retrograde filling,and implementing GTR technique using a resorbable collagen membrane and bovine xenograft.The diagnosis of radicular cyst was confirmed using histopathological analysis.The patient underwent follow-up evaluations at 10 and 30 d postoperatively.At 4 months postoperative evaluation,she remained asymptomatic,and radiographs showed significant periapical healing with adequate bone formation.CONCLUSION These results suggest that microsurgical management using the GTR technique with collagen membrane and xenograft,contributes to bone regeneration.

Poor oral health was associated with higher risk of gastric cancer: Evidence from 1431677 participants

BACKGROUND In recent years,the association between oral health and the risk of gastric cancer(GC)has gradually attracted increased interest.However,in terms of GC incidence,the association between oral health and GC incidence remains contro-versial.Periodontitis is reported to increase the risk of GC.However,some studies have shown that periodontitis has no effect on the risk of GC.Therefore,the present study aimed to assess whether there is a relationship between oral health and the risk of GC.AIM To assess whether there was a relationship between oral health and the risk of GC.METHODS Five databases were searched to find eligible studies from inception to April 10,2023.Newcastle-Ottawa Scale score was used to assess the quality of included studies.The quality of cohort studies and case-control studies were evaluated separately in this study.Incidence of GC were described by odds ratio(OR)and 95%confidence interval(CI).Funnel plot was used to represent the publication bias of included studies.We performed the data analysis by StataSE 16.RESULTS A total of 1431677 patients from twelve included studies were enrolled for data analysis in this study.According to our analysis,we found that the poor oral health was associated with higher risk of GC(OR=1.15,95%CI:1.02-1.29;I2=59.47%,P=0.00<0.01).Moreover,after subgroup analysis,the outcomes showed that whether tooth loss(OR=1.12,95%CI:0.94-1.29;I2=6.01%,P>0.01),gingivitis(OR=1.19,95%CI:0.71-1.67;I2=0.00%,P>0.01),dentures(OR=1.27,95%CI:0.63-1.19;I2=68.79%,P>0.01),or tooth brushing(OR=1.25,95%CI:0.78-1.71;I2=88.87%,P>0.01)had no influence on the risk of GC.However,patients with periodontitis(OR=1.13,95%CI:1.04-1.23;I2=0.00%,P<0.01)had a higher risk of GC.CONCLUSION Patients with poor oral health,especially periodontitis,had a higher risk of GC.Patients should be concerned about their oral health.Improving oral health might reduce the risk of GC.

The Oral Health Status of Person with Special Needs in Kumasi

Background: The most prevalent non-communicable disease worldwide is oral health-related disease, with dental caries and periodontal conditions being common. Oral health status significantly impacts overall health and quality of life. Barriers to dental care affect children with special needs. This study evaluates the oral health status and treatment requirements of people with special needs. Methodology: This descriptive cross-sectional study in Kumasi, Ghana examined oral health status among people, 121 children with special needs over two months, in June-July 2022. Dental caries, periodontal changes, malocclusion, and trauma were assessed. The data was analyzed using SPSS 20.0. Results: The oral health status among people with special needs in this study was generally moderate, with a range from very good to very poor. The prevalence of dental caries was 37%, with a mean DMFT score of 2.82. Periodontal health showed unsatisfactory indicators such as mobile teeth, poor gingival health, high plaque scores, and the presence of halitosis. Conclusion: This descriptive study aimed to provide baseline data on the oral health status of special needs students in Kumasi, addressing the lack of knowledge in this area. It highlighted the importance of dental care in maintaining good oral health and overall well-being in individuals with special needs. Coordinated efforts by dental professionals are needed to provide dental health education and preventive interventions for these children.

Research Progress on the Immunomodulatory Effect of Mesenchymal Stem Cells on Chronic Periodontitis

Periodontal disease is an inflammatory and destructive disease of periodontal support tissue caused by microorganisms in dental plaque. During the development of periodontal disease, host immune regulation plays an important role, and unnecessary excessive immune regulation often exacerbates the course of chronic periodontal disease. Mesenchymal stem cells (MSCs) are adult stem cells with self replication ability and multi-directional differentiation potential. Many studies have found that MSCs have strong immunosuppressive effects on both adaptive and innate immunity. In recent years, literature has reported that MSCs are involved in the immune regulatory effect of chronic periodontal disease, inhibiting its inflammatory response and alveolar bone resorption, but the specific regulatory mechanism has not been elucidated. This article reviews the current research status of the immune regulatory effects of MSCs on chronic periodontitis.

Role of viruses in periodontitis:An extensive review of herpesviruses,human immunodeficiency virus,coronavirus-19,papillomavirus and hepatitis viruses

Periodontitis is the inflammation of the supporting structures around the dentition.Several microbial agents,mostly bacteria,have been identified as causative factors for periodontal disease.On the other hand,oral cavity is a rich reservoir for viruses since it contains a wide variety of cell types that can be targeted by viruses.Traditionally,the focus of research about the oral flora has been on bacteria because the most widespread oral diseases,like periodontitis and dental caries,are outcomes of bacterial infection.However,recently and especially after the emergence of coronavirus disease 2019,there is a growing tendency toward including viruses also into the scope of oral microbiome investigations.The global high prevalence of periodontitis and viral infections may point out to a concomitant or synergistic effect between the two.Although the exact nature of the mechanism still is not clearly understood,this could be speculated through the manipulation of the immune system by viruses;hence facilitating the furthermore colonization of the oral tissues by bacteria.This review provides an extensive and detailed update on the role of the most common viruses including herpes family(herpes simplex,varicella-zoster,Epstein-Barr,cytomegalovirus),Human papillomaviruses,Human immunodeficiency virus and severe acute respiratory syndrome coronavirus 2 in the initiation,progression and prognosis of periodontitis.

Oral Hygiene in the Presence of Orthodontic Therapy

Orthodontic treatment offers great advantages in improving facial and smile aesthetics, self-confidence and the function of the stomatognathic apparatus. The pursuit of these advantages makes use of orthodontic appliances that could be fixed or removable. However, it’s worth stating that these appliances interfere with tooth brushing, making it more difficult to brush teeth effectively. Orthodontics appliances therefore promote the accumulation of dental plaque, which results in both quantitative and qualitative changes in the oral microbiota, hence, exposing patients to several adverse effects such as White spot lesions, dental caries, periodontal pathologies and halitosis. For this reason, oral assessment of patients before, during and after treatment is necessary as well as oral hygiene instructions and motivation. Orthodontists therefore, should educate patients on oral and periodontal hygiene in order to control dental and periodontal complications. Prescriptions of plaque control materials adapted to each patient are done in order to optimize the final result and minimize unwanted complications.

Effectiveness of Oral Care in Implant Denture Restoration in Chronic Periodontitis

Objective:To explore the effect of observation of oral care in implant denture restoration of chronic periodontitis.Methods:80 patients with chronic periodontitis implant denture restoration admitted from March 2022 to March 2023 in the hospital were selected.They were randomly divided into an observation group and a control group,with 40 cases in each group.Both groups of patients received routine treatment and care.The patients in the control group used routine oral care methods to carry out oral care,the patients in the observation group carried out oral care on the basis of the control group,observation and analysis of the patients'mastery of oral knowledge,as well as the depth of the probing and the level of clinical attachment.Results:The oral knowledge mastery of the observation group was 72.31±6.98 after the nursing intervention,which was significantly higher than the score of 86.12±7.36 of the patients in the control group who used conventional oral care,and the difference was statistically significant at P<0.05;the depth of probing and the clinical attachment level of the observation group were 2.43±0.58 and 4.31±0.86 respectively,which were significantly better than those of the control group.The depth of probing and clinical attachment level scores of the observation group were 2.99±0.54 and 5.36±1.02 respectively,and P<0.05 was considered statistically significant.Conclusion:The combination of conventional treatment and oral care can effectively improve the treatment effect of implant denture prosthesis for chronic periodontitis.However,it is necessary to pay attention to the psychological counseling of the patients in the specific clinical application to ensure that the patients can actively cooperate with the clinical treatment.

Evaluation of the Effectiveness and Safety of One-Time Endodontics in the Treatment of Chronic Apical Periodontitis with Sinus Tract in Pediatric Deciduous Teeth

Objective:To observe the effectiveness and safety of one-time endodontics in the treatment of chronic apical periodontitis with sinus tract in pediatric deciduous teeth.Methods:109 cases of children with chronic apical periodontitis with sinus tract in the deciduous teeth treated in our hospital from January 2022 to December 2023 were selected and grouped by the randomized numerical table method,with 54 cases in the experimental group and 55 cases in the control group.The experimental group was treated with one-time endodontics and the control group was treated with conventional endodontics.Results:After the treatment,the total effective rate of treatment was higher in the experimental group than in the control group(P<0.05);the incidence of adverse events was lower in the experimental group than in the control group(P<0.05);the satisfaction of the children's family members was higher in the experimental group than in the control group(P<0.05);the pain duration was lower in the experimental group than in the control group(P<0.05).Conclusion:In the experimental group,children with chronic apical periodontitis with sinus tract of the deciduous teeth were given one-time endodontic treatment,and the results of its implementation were relatively good.