Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2•72 (95% uncertainty interval [UI] 2•66–2•79) in 2000 to 2•31 (2•17–2•46) in 2019. Global annual livebirths increased from 134•5 million (131•5–137•8) in 2000 to a peak of 139•6 million (133•0–146•9) in 2016. Global livebirths then declined to 135•3 million (127•2–144•1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2•1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27•1% (95% UI 26•4–27•8) of global livebirths. Global life expectancy at birth increased from 67•2 years (95% UI 66•8–67•6) in 2000 to 73•5 years (72•8–74•3) in 2019. The total number of deaths increased from 50•7 million (49•5–51•9) in 2000 to 56•5 million (53•7–59•2) in 2019. Under-5 deaths declined from 9•6 million (9•1–10•3) in 2000 to 5•0 million (4•3–6•0) in 2019. Global population increased by 25•7%, from 6•2 billion (6•0–6•3) in 2000 to 7•7 billion (7•5–8•0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58•6 years (56•1–60•8) in 2000 to 63•5 years (60•8–66•1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. Interpretation: Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global burden of 87 risk factors in 204 countries and territories, 1990�2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. Methods: GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk�outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk�outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk�outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. Findings: The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95 uncertainty interval UI 9·51�12·1) deaths (19·2% 16·9�21·3 of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12�9·31) deaths (15·4% 14·6�16·2 of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253�350) DALYs (11·6% 10·3�13·1 of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0�9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10�24 years, alcohol use for those aged 25�49 years, and high systolic blood pressure for those aged 50�74 years and 75 years and older. Interpretation: Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Influence of the foundation substrate on the fatigue behavior of bonded glass, zirconia polycrystals, and polymer infiltrated ceramic simplified CAD-CAM restorations

© 2021 Elsevier LtdThis study evaluated the influence of distinct substrates on the mechanical fatigue behavior of adhesively cemented simplified restorations made of glass, polycrystalline or polymer infiltrated-ceramics. CAD/CAM ceramic blocks (feldspathic – FEL; lithium disilicate – LD; yttria-stabilized zirconia – YZ; and polymer-infiltrated ceramic network – PICN) were shaped into discs (n = 15, Ø = 10 mm; thickness = 1.0 mm), mimicking a simplified monolithic restoration. After, they were adhesively cemented onto different foundation substrates (epoxy resin – ER; or Ni–Cr metal alloy – MA) of the same shape (Ø = 10 mm; thickness = 2.0 mm). The assemblies were subjected to fatigue testing using a step-stress approach (200N-2800 N; step-size of 200 N; 10,000 cycles per step; 20 Hz) upon the occurrence of a radial crack or fracture. The data was submitted to two-way ANOVA (α = 0.05) to analyze differences considering ‘ceramic material’ and ‘type of substrate’ as factors. In addition, a survival analysis (Kaplan Meier with Mantel-Cox log-rank post-hoc tests; α = 0.05) was conducted to obtain the survival probability during the steps in the fatigue test. Fractographic and finite element (FEA) analyzes were also conducted. The factors ‘ceramic material’, ‘type of substrate’ and the interaction between both were verified to be statistically significant (p < .001). All evaluated ceramics presented higher fatigue failure load (FFL), cycles for failure (CFF) and survival probabilities when cemented to the metallic alloy substrate. Among the restorative materials, YZ and LD restorations presented the best fatigue behavior when adhesively cemented onto the metallic alloy substrate, while FEL obtained the lowest FFL and CFF for both substrates. The LD, PICN and YZ restorations showed similar fatigue performance considering the epoxy resin substrate. A more rigid foundation substrate improves the fatigue performance of adhesively cemented glass, polycrystalline and polymer infiltrated-ceramic simplified restorations

Polymerization shrinkage and push-out bond strength of different composite resins for sealing the screw-access hole on implant-supported crowns

Purpose: To evaluate the effect of composite resin polymerization shrinkage stress on the stress distribution in the implant-supported crown-access hole, and on the bond strength between the ceramic and composite resin. Materials and Methods: A 3D model of a ceramic crown, in which the access hole was filled with composite resin (conventional or bulk-fill), was used to evaluate the stress distribution in the access hole using finite element analysis. The contacts were considered bonded and the polymerization shrinkage was simulated based on the coefficient of linear thermal expansion of each resin. The push-out test (1 mm/min, 100 kgf) was performed on perforated lithium disilicate samples filled with conventional or bulk-fill resins to validate the stress data of the bond strength. One-way ANOVA and Tukey's test were used to analyze the bond strength data, with α set at 5%. Results: Conventional resin showed the worst stress distribution and highest displacement values, von Mises stress, maximum principal strain, maximum principal stress, and maximum shear stress vs the bulk-fill resin. Statistically significantly greater bond strength was observed for bulk-fill (13.40 ± 5.59 MPa) than the conventional resin (8.70 ± 3.02 MPa). Conclusion: Comparing both materials tested in the present study, the use of bulk-fill composite resin to seal the screw-access hole is suggested to reduce the stress concentration and increase bond strength to the ceramic crown

Survival probability, weibull characteristics, stress distribution, and fractographic analysis of polymer-infiltrated ceramic network restorations cemented on a chairside titanium base: An in vitro and in silico study

Different techniques are available to manufacture polymer-infiltrated ceramic restorations cemented on a chairside titanium base. To compare the influence of these techniques in the mechanical response, 75 implant-supported crowns were divided in three groups: CME (crown cemented on a mesostructure), a two-piece prosthetic solution consisting of a crown and hybrid abutment; MC (monolithic crown), a one-piece prosthetic solution consisting of a crown; and MP (monolithic crown with perforation), a one-piece prosthetic solution consisting of a crown with a screw access hole. All specimens were stepwise fatigued (50 N in each 20,000 cycles until 1200 N and 350,000 cycles). The failed crowns were inspected under scanning electron microscopy. The finite element method was applied to analyze mechanical behavior under 300 N axial load. Log-Rank (p = 0.17) and Wilcoxon (p = 0.11) tests revealed similar survival probability at 300 and 900 N. Higher stress concentration was observed in the crowns' emergence profiles. The MP and CME techniques showed similar survival and can be applied to manufacture an implant-supported crown. In all groups, the stress concentration associated with fractographic analysis suggests that the region of the emergence profile should always be evaluated due to the high prevalence of failures in this area

Does the prosthesis weight matter? 3D finite element analysis of a fixed implant-supported prosthesis at different weights and implant numbers

PURPOSE. This study evaluated the influence of prosthesis weight and number of implants on the bone tissue microstrain. MATERIALS AND METHODS. Fifteen (15) fixed full-arch implant-supported prosthesis designs were created using a modeling software with different numbers of implants (4, 6, or 8) and prosthesis weights (10, 15, 20, 40, or 60 g). Each solid was imported to the computer aided engineering software and tetrahedral elements formed the mesh. The material properties were assigned to each solid with isotropic and homogeneous behavior. The friction coefficient was set as 0.3 between all the metallic interfaces, 0.65 for the cortical bone-implant interface, and 0.77 for the cancellous bone-implant interface. The standard earth gravity was defined along the Z-axis and the bone was fixed. The resulting equivalent strain was assumed as failure criteria. RESULTS. The prosthesis weight was related to the bone strain. The more implants installed, the less the amount of strain generated in the bone. The most critical situation was the use of a 60 g prosthesis supported by 4 implants with the largest calculated magnitude of 39.9 mm/mm, thereby suggesting that there was no group able to induce bone remodeling simply due to the prosthesis weight. CONCLUSION. Heavier prostheses under the effect of gravity force are related to more strain being generated around the implants. Installing more implants to support the prosthesis enables attenuating the effects observed in the bone. The simulated prostheses were not able to generate harmful values of peri-implant bone strain

Fatigue resistance of simplified CAD–CAM restorations: Foundation material and ceramic thickness effects on the fatigue behavior of partially- and fully-stabilized zirconia

© 2021 The Academy of Dental MaterialsObjective: To evaluate the fatigue failure load, number of cycles until failure and survival probability of partially (PSZ) and fully-stabilized (FSZ) polycrystalline zirconia disc shaped specimens with different thicknesses adhesively cemented onto foundations with distinct elastic moduli. Methods: Disc-shaped specimens (n = 15, Ø = 10 mm; thickness = 1.0 and 0.7 mm) of CAD/CAM PSZ and FSZ blocks were adhesively cemented onto discs with different foundations (Ø = 10 mm; thickness = 2.0 mm) made from epoxy resin, composite resin or Ni–Cr metallic alloy. The cemented assemblies were subjected to fatigue testing using a step-stress approach (600−2800 N; step-size of 100 N; 10,000 cycles per step; 20 Hz) and the data was submitted to specific statistical tests (α = 0.05). Fractography and finite element (FEA) analyzes were also performed. Results: PSZ and FSZ presented higher fatigue failure load, number of cycles until failure and survival probabilities when cemented onto metallic alloy. All PSZ specimens survived the fatigue test when cemented onto Ni–Cr alloy (100% probability of survival at 2800 N; 230,000 cycles). Regardless of the foundation type, PSZ had better fatigue behavior than FSZ. For thickness, thinner PSZ restorations underperformed when bonded to softer foundations, while FSZ groups and groups bonded to metallic foundations had no statistical difference. Significance: The foundation material strongly influences the fatigue performance of PSZ and FSZ restorations, which presented mechanical behavior improvements when bonded to a metallic foundation. PSZ restorations showed better fatigue behavior than FSZ, while the ceramic thickness only influenced PSZ restorations bonded to softer foundations