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In Vitro Antifungal Susceptibility of Candida Albicans Isolated from Yemeni Patients with Denture Stomatitis

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Research Article

In Vitro Antifungal Susceptibility of Candida Albicans Isolated from Yemeni Patients with Denture Stomatitis

  • Mohammed Mohammed Lutf AlKhawlani 1
  • Mohammed Mohammed Ali Al-Najhi 3,4
  • Khaled A AL-Haddad 3
  • Abdulwahab Ismail Mohamed Al-Kholani 2
  • Hassan Abdulwahab Al-Shamahy 4,5*
  • Mohammed Mohammed Ali Alsamhari 1

*Corresponding Author: Hassan A. Al-Shamahy, Department of Basic Sciences, Faculty of Dentistry, Sana’a University, Republic of Yemen.

Citation: Mohammed M. A, Mohammed A. A, Khaled A. A, Hassan A A, Mohammed M. (2022). In Vitro Antifungal Susceptibility of Candida Albicans Isolated from Yemeni Patients with Denture Stomatitis. J Dentistry and Oral Maxillofacial Surgery, 5(3); DOI: 10.31579/2643-6612/034

Copyright: © 2022, Hassan A. Al-Shamahy. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 14 May 2022 | Accepted: 30 May 2022 | Published: 13 June 2022

Keywords: Candida albicans; Candida-associated denture stomatitis (CADS); in vitro antifungal susceptibility testing (AFST); Yemen

Abstract

Background and aims: Candida-associated denture stomatitis (CADS) is a common fungal infection in people who wear dentures. The main objectives of this study were to identify the causative agents of CADS and in vitro antifungal susceptibility testing (AFST) for Candida albicans in Yemeni patients with denture stomatitis.

Methods: A total of 88 Candida spp. obtained from patients with denture stomatitis. Candida spp were identified using standard microbiological methods. The in-vitro antifungal susceptibility of Candida albicans. to fluconazole (FCZ), itraconazole (ICZ), voriconazole (VCZ), and amphotericin B (AMB) was evaluated using the E test strips. Interpretive sensitivity criteria for antifungal breakpoints were adapted from the Clinical and Laboratory Standards Institute (CLSI).

Results: Overall, C. albicans was the most commonly isolated species (

Introduction

Wearing dentures and inadequate denture hygiene, especially constantly wearing dentures rather than removing them during sleep, is another risk factor for both oral candidiasis and Candida carriage. Dentures offer a relatively acidic, moist, and anaerobic environment for the reason that the mucous membrane covered by the dentures is protected from oxygen and saliva, which prevents or limits the growth of germs. Loose and poor-fitting dentures may also cause minor mucosal trauma which is thought to increase mucosal permeability and increase the ability of C. albicans to invade tissue. Dentures may therefore become covered with biofilm and act as reservoirs of infection, resulting in persistent re-infection of the mucosa [1-4]. Candida-associated denture stomatitis (CADS) is a chronic atrophic complication of the oral cavity that mainly affects people who wear removable dentures. Some have reported that up to 65% of denture wearers have this condition to some degree. Although this condition is also known as ‘denture sore mouth”, there is rarely any pain [5]. Candida is associated with approximately 90% of denture-related stomatitis cases [6]. Numerous evidence-based studies have revealed that Candida albicans is the major causative agent of denture stomatitis (DS), goes along by Candida tropicalis,  Candida glabrata, Candida parapsilosis, Candida krusei,  or other species as Candida stellatoidea, Candida pseudotropicalis, Candida famata, Candida rugosa,  Candida geotrichium,  Candida dubliniensis, and Candida guilliermondii [1-4, 7-9]. The untimely diagnosis of pathogenic fungal agents and the detection of their susceptibility to antifungal drugs are vital to the treatment of infection and the development of preventive healthcare-associated strategies [1,2,10,11].

Management of CADS is based on a broad-choice treatment strategy [12], which consists of detecting and eradicating potential significant risk factors, avoiding systemic Candida infection, and dipping any associated inconveniences. Use of oral preparations of antimicrobial agents, such as amphotericin B (AMB), nystatin (NYS), and miconazole (MIC), and systemic drugs, such as fluconazole (FCZ), voriconazole (VCZ), posaconazole (POS), itraconazole (ICZ), and ketoconazole (KTZ), has been revealed to be efficient in the treatment of CADS [13–16]. Echinocandins, such as caspofungin (CAS), are a class of antifungal drugs that appear to be highly effective against all species of Candida, including those that are less sensitive or are resistant to FCZ and/or ICZ [15]. Nevertheless, earlier studies have described recurrence and clinical relapse of CADS after treatment [17, 18]. Obtain sufficient information about the antifungal susceptibility testing (AFST) from Candida spp. participation in CADS may aid in the selection of alternative antifungal treatments for recurrent oral candidiasis.

Despite the lack of research on dental problems in Yemen in the past, there is a growing interest in dental problems nowadays as many studies have been conducted in cases of oral bacterial and fungal infections, drug resistance, tooth decay, causes of permanent tooth extraction, chemical drugs and Oral herbal [ 1-4, 19-33]. In Yemen, there have been several studies discussing biofilm formation, sensitivity to antifungals, and isolation of Candida from the oral cavity of denture wearers and free 

dentures members, but no study has been found in determining MIC50 and MIC90 antifungal drugs for Candida albicans [1-4]. Therefore, in the current study, we identified the causative agents of CADS and an in vitro  antifungal susceptibility test (AFST) to determine the MIC in Candida albicans and the rate of resistance to 5 selected antifungal drugs among Yemeni patients with CADS.

Materials and Methods

Study site and patient selection

The patients were selected from dental clinics in Al-Thawra Hospital, Al-Jumhouri Hospital, and some private dental centers in Sana'a, Yemen. The inclusion criteria for selecting the subject were healthy individuals with no clinical signs of Candida infection and no systemic disease. In addition, individuals who smoked or were currently taking antifungals, steroids, antibiotics, or immunosuppressive drugs in the past six months were excluded.

Sample Collection Process

After examination of the oral cavity, denture samples were obtained by scraping sterile swabs across the inner surface of the denture. In a 6-month period (1st January to end of June 2020), a total of 88 clinical isolates were collected from 79 patients aged 39–76 years with DS. For patients with stomatitis caused by Candida albicans (CADS) contained 13 (21.7%) males and 47 (78.3%) females, their ages ranged between 39-74 years (Table 1). All samples were streaked on Sabouraud dextrose agar and incubated at 35°C. for 7 days. All suspected colonies were detected by CHROM Agar Candida. Candida species were identified by the color of the colonies using the color reference guide provided by the manufacturer. When color determination was unclear, fermentation assay for sucrose, maltose, glucose, lactose-galactose was performed. Candida species has also been identified by the ability to produce Chlamydia spores on glutinous rice agar [33].

CharactersNumberPercentage
Sex
Male1321.7
Female4778.3
Age groups
≤40 years23.3
41-50 years1626.7
51-60 years3558.3
>60 years711.7
Total60 100
Mean age53 years
SD9.5 years
Min39 years
Max74 years

Table 1: The age and sex distribution of patients with Candida albicans-associated denture stomatitis (CADS) at a selected dental clinic in the city of Sana'a

Antifungal susceptibility testing

The in vitro activity of the antifungal agents against each isolate was determined by E-test (HiMedia, Mumbai, India) according to the manufacturer's instructions. E-test strips for fluconazole (FCZ; 0.016 ∼ 256 μg/mL), itraconazole (ICZ; 0.002 ∼ 32 μg/mL), voriconazole (VCZ; 0.002 ∼ 32 μg/mL), and amphotericin B (AMB; 0.002 ∼ 32 μg/mL) were used [34]. Interpretive sensitivity criteria for antifungal breakpoints were adapted from the Clinical and Laboratory Standards Institute (CLSI), [35]. The breakpoints used in C. albicans are: FCZ (S=2; SDD = 4; R ≥ 8); VCZ (S ≤ 0.12; R ≥ 1), ICZ (S= 0.12; R ≥ 1) and AMB (S =2; R > 2). For quality control, C. albicans (ATCC 10231) was used as a reference strain and tested simultaneously with clinical isolates.

Results

Overall, C. albicans was the most commonly isolated species (n=60; 68.2%), followed by C. glabrata (n-9; 10.2%), C. tropicalis (n=7; 8%), and C. parapsilosis (n=3; 3.4%). 78.3% of the participants are females and only 21.7% are males. The age average ± SD for participants was 53 ± 9.5 years. Most of the subjects covered were in the age group 51-60 years (58.3%) followed by 41-50 years (26.7%). Table 3 shows, the In- vitro antifungal susceptibility of 4 antifungal agents against 60 Candida albicans isolated from Candida-associated denture stomatitis. Voriconazole had the lowest geometric mean minimum inhibitory concentration was 0.0418 ml for MIC50, and 0.957 ml for MIC90; followed by amphotericin B (AMB) in which MIC50 was 0.518 ml and for MIC90 was 1.06 ml.

Table 3: In vitro antifungal susceptibility of 4 antifungal agents against 60 Candida albicans isolated from Candida-associated denture stomatitis

MIC50 = Minimum Inhibitory Concentration required to inhibit the growth of 50% of organisms. MIC90 = Minimum Inhibitory Concentration required to inhibit the growth of 90% of organisms. MIC range is the range of the lowest and highest MIC values obtained from 60 C. albicans isolates tested. Percentage resistance is the percentage of isolates resistant to a specific antifungal drug.

Discussion

A complete denture (also known as a full denture or plate) is a removable device used when all the teeth inside the jaw are missing and need to be replaced with prosthetics. Unlike a partial denture, a full denture is created when there are no more teeth left in the arch and is therefore an exclusively tissue-reinforced prosthesis. In the current study, the mean age ± SD of the participants was 53 ± 9.5 years and ranged from 39 to 74 years. This result differs from that reported from Iran where the mean age of DS patients was 65 ± 7.5 years and the patients' ages ranged from 55 to 84 years. The younger age of Yemenis in these findings could be explained by the exposure of Yemeni patients to factors of tooth loss, such as: dental caries, periodontal disease, trauma, congenital disorders (such as ergogenesis imperfecta, hypomineralization of molar incisors) and functional impairment more than the Iranian population [36].  Dentures in the oral cavity serve as a reservoir of Candida spp. and, thus, it considered a predisposing factor for DS in denture patients, as well as a possible origin for re-infection [37]. In the current study, the dominant Candida species isolated from the mouth was Candida albicans with 58%. Other species were also isolated from the mouth; Candida glabrata from 9 patients (10.2%), Candida tropicalis from 7 patients (8%), and Candida parapsilosis isolated from 3 patients (3.4%). These results are similar to that reported by Samaranayake et al. and Lee et al. in which the most frequently identified species is C. albicans, although C. glabrata, C. guilliermondii, C. parapsilosis, C. krusei, and C. tropicalis are less commonly seen [38,39].  However, Bouquot et al. reported that C. tropicalis was the most common non-Candida albicans Candida (NCAC), followed by C. glabrata, while C. parapsilosis were rare isolated in oral colonization or as a cause of stomatitis [40].  As it is known Candida species may be able to metabolize ethanol and convert it into the carcinogen acetaldehyde, and can thus progress oral and upper gastrointestinal tract cancer.  This means that our studied individuals under risk of oral and upper gastrointestinal tract cancer. Consequently, , greater emphasis should be placed on diagnosis and treatment of oral Candida albicans infections, also on other Candida species than C. albicans as  recommended to prevent this development [41,42]. In agreement with other studies, the current research found that C. albicans, C. parapsilosis, C. tropicalis, and C. glabrata caused CADS [1, 2, 43-45] and recommended drugs in CADS patients without an underlying disease commonly includes a NYS suspension or a clotrimazole tablet. However, topical application of anazole, such as Fluconazole (FCZ or Itraconazole (ICZ), can also be used to prevent persistent or chronic fungal infections in the patients [34, 46]. Several studies reported the emergence of antifungal resistance to azoles, which has been associated with multiple episodes of recurrence [16, 47-49]. In the current study, 18.3% of C. albicans (11/60) was observed to be resistant to Fluconazole (FCZ). In contrast with the current study data, Abaci and Haliki-Uztan (2011) reported that 59.4% of C. albicans were resistant to Fluconazole (FCZ) [50].

Candida  speciesNumberPercentage
Candida albicans5158
Candida  glabrata910.2
Candida tropicalis78
Candida parapsilosis33.4
Candida albicans+ Candida glabrata55.7
Candida albicans+ Candida tropicalis44.5
Total Candida albicans6068.2
Total Candida species88100

Table 2: Distribution of different types of Candida species among Candida-associated denture stomatitis (CADS) isolated from 79 patients.

AMB, also used in the management of CADS, proved effective against Candida spp. [51]. Besides, the findings obtained in the present study were in agreement with the results of Wingeter et al.  [52] regarding the susceptibility of oral Candida strains to AMB. In the current study, 5% of C. albicans (3/60) was observed to be resistant to Amphotericin B (AMB) as AMB-resistant C. albicans isolates were reported from several previous studies [50,53]. In the current study, 11.7% of C. albicans (7/60) was observed to be resistant to Voriconazole (VCZ). However, the geometric MIC90 was 0.957ml, for C. albicans, Omran et al. (2018) in Iran previously showed that the GM-MIC90 for Voriconazole (VCZ ) were 0.25/ml for C. albicans less than our findings [36]. Several other studies also demonstrated that Voriconazole (VCZ) was strong antifungal agents against Candida spp. [36, 54-57]. Other studies have shown that ITC is useful for treating patients with DS [37, 58, 59]. Dorocka-Bobkowska and Konopka (2007) reported that AMB, FCZ, and ICZ were effective against 100%, 88.7%, and 87.3% of C. albicans and less sensitivity rates equal to 79.6%, 71.4%, and 79.6% respectively for other Candida strains [12]. Our results showed that the tested antifungal showed good efficacy for most of the isolates. However, the observed variability between some of the isolates and drug resistance highlights the need for the AFST as a monitor to administer the therapeutic procedure. 

Conclusion

In conclusion, Candida albicans was the most prevalent Candida species in Yemeni patients with CADS and was susceptible to both azoles and amphotericin B. In addition, Voriconazole could be a suitable alternative to antifungal agents currently used in the treatment of CADS, as well as in the treatment of recurrent Candidasis.

Also, the increasing rates of NCAC strains among CADS patients in Yemen should viewed as both novel and alarming. Extensive observational studies should be performed on all clinical specimens yielding significant growth of Candida spp. and the effect of resistance pattern on ICZ. As a consequence of selective pressure, emergence of drug resistance is inevitable. Therefore, future studies should focus on the emergence of drug-resistant Candida strains and their frequencies. 

Acknowledgements

The authors thank the Faculty of Dentistry, Sana'a University, Sana'a, Yemen for their generous support in providing working space and materials. 

Ethical approval 

We have obtained written consent from all cases. Consent was obtained from the participants prior to sample collection. The study proposal was evaluated and approved by the Ethics Committee of the Faculty of Medicine and Health Sciences, Sana'a University.

Conflicts of Interest

No conflict of interest associated with this work.

Author's Contribution

All authors co-wrote the article and reviewed the results. Laboratory parts and data analysis were performed by Hassan Abdelwahab Al Shamahy.

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Virginia E. Koenig

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Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

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Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

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Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

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S Munshi

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Tania Munoz

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann