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Wadhwani CPK, Hess TA, Schoenbaum TR, Wadhwani YH, Chung KH. Dentists' Perspective and Experiences Relative to the Accidental Dropping of Implant Drivers and Components Intraorally: A Survey of Practicing Clinicians. J ORAL IMPLANTOL 2024; 50:39-44. [PMID: 38579111 DOI: 10.1563/aaid-joi-d-22-00215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Ingestion or aspiration of dental implant screwdrivers or implant components is potentially life-threatening. There are no reports on the frequency at which dentists drop these devices within the mouth or which components are most problematic. There are few reports on what protective measures clinicians take, where risks exist, and how this problem is managed. A 9-part questionnaire was provided to dentists. Data collected included clinicians' roles, implant surgeons, restorative clinicians, or both-the frequency of dropping implant screwdrivers or components, items considered most problematic. Patient protection and management were also requested. Finally, questions related to how much of a problem clinicians considered this to be and if further solutions and a standardized management protocol should be developed. One hundred twelve dentists voluntarily completed the survey. Of the dentists, 54% restored, 37% restored and surgically placed, and 9% solely placed implants. Twenty-nine percent claimed never to drop components, with 56% dropping an instrument less than 10% of the time. Less than half would suggest patients seek medical advice if a screwdriver or component was accidentally dropped intraorally and was not recovered. Thirty percent never tied floss tethers to screwdrivers, and a similar percentage reported they only sometimes did so. Throat pack protection was reported 51% of the time. Ninety percent considered dropping components an issue, with screwdrivers most problematic. Aspiration or ingestion of implant screwdrivers and components is problematic, with dentists varying their use of protection devices. There is a need to standardize and implement patient protection procedures and management and develop methods to reduce the risk of these potentially life-threatening issues.
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Affiliation(s)
- Chandur P K Wadhwani
- Private practice limited to prosthodontics, Bellevue, WA, USA
- Department of Restorative Dentistry, University of Washington School of Dentistry, Seattle, WA, USA
| | - Timothy A Hess
- Department of Restorative Dentistry, University of Washington School of Dentistry, Seattle, WA, USA
- Private practice, Auburn, WA, USA
| | | | - Yasmin H Wadhwani
- Department of Neurobiology, Physiology and Behavioral Sciences, University of California, Davis, Davis, CA, USA
| | - Kwok-Hung Chung
- Department of Restorative Dentistry, University of Washington School of Dentistry, Seattle, WA, USA
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2
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Verhoeff MC, Eikenboom D, Koutris M, de Vries R, Berendse HW, van Dijk KD, Lobbezoo F. Parkinson's disease and oral health: A systematic review. Arch Oral Biol 2023; 151:105712. [PMID: 37120970 DOI: 10.1016/j.archoralbio.2023.105712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVE in patients with Parkinson's Disease (PD), oral health can be affected by motor and non-motor symptoms and/or medication use. Therefore, the aim was to systematically review the literature on oral health and associated factors of oral health in PD patients. DESIGN a literature search was performed from inception up to April 5th, 2023. Original studies that assessed oral health-related factors in PD patients and were written in English or Dutch, were included. RESULTS 11276 articles were identified, of which 43 met the inclusion criteria (quality range poor-good). A higher prevalence of dental biofilm, bleeding/gingivitis, pocket depth (≥4 mm), tooth mobility, caries, and number of decayed missing filled teeth/surfaces was found in PD patients than in controls. However, no difference between both groups was found when analysing edentulism and wearing dentures. Poor oral health of PD patients was associated with a longer disease duration, higher disease severity, and more prescribed medications. CONCLUSIONS oral health of PD patients is worse than that of healthy individuals. It is associated with the duration and severity of PD and medication use. Therefore, we advise regular appointments with oral health care professionals, with an important focus on prevention.
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Affiliation(s)
- Merel C Verhoeff
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Denise Eikenboom
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michail Koutris
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, Amsterdam, the Netherlands
| | - Henk W Berendse
- Amsterdam University Medical Centres (Amsterdam UMC), Vrije Universiteit Amsterdam, Neurology, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Karin D van Dijk
- Amsterdam University Medical Centres (Amsterdam UMC), Vrije Universiteit Amsterdam, Neurology, Amsterdam Neuroscience, Amsterdam, the Netherlands; Sleep Wake Centre, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Huh J, Lee N, Kim KY, Jung S, Cha J, Kim KD, Park W. Foreign body aspiration and ingestion in dental clinic: a seven-year retrospective study. J Dent Anesth Pain Med 2022; 22:187-195. [PMID: 35693354 PMCID: PMC9171336 DOI: 10.17245/jdapm.2022.22.3.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background This retrospective study investigated the incidence rate of accidental foreign body aspiration and ingestion according to patient sex, age, and dental department. This study aimed to verify whether the incidence rate is higher in geriatric than in younger patients and whether it is different among dental departments. Methods Accidental foreign body aspiration and ingestion cases were collected from electronic health records and the safety report system of Yonsei University Dental Hospital from January 2011 to December 2017. The collected data included patients’ age, sex, medical conditions, treatment procedures, and foreign objects that were accidentally aspirated or ingested. The incidence rate was calculated as the number of accidental foreign body aspirations and ingestions relative to the total number of patient visits. Differences depending on the patients’ sex, age, and dental department were statistically identified. Results There were 2 aspiration and 37 ingestion cases during the 7-year analysis period. The male to female incidence ratio was 2.8:1. The incidence rate increased with age and increased rapidly among those aged 80 years or older. Seven of the 37 patients with accidental foreign body ingestion had intellectual disability, Lou Gehrig’s disease, dystonia, or oral and maxillofacial cancer. The incidence rate was highest in the Predoctoral Student Clinic and the Department of Prosthodontics. The most frequently swallowed objects were fixed dental prostheses and dental implant components. Conclusion The incidence rate of accidental foreign body aspiration and ingestion differed according to patient sex, age, and dental department. Dental practitioners must identify high-risk patients and apply various methods to prevent accidental foreign body aspiration and ingestion in dental clinics. Inexperienced practitioners should be particularly careful.
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Affiliation(s)
- Jisun Huh
- Department of Dental Education, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Namkwon Lee
- Department of Advanced General Dentistry, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Ki-Yeol Kim
- Department of Dental Education, BK21 PLUS project, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Seoyeon Jung
- Department of Dental Education, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Jungyul Cha
- Department of Orthodontics, The Institute of Craniofacial Deformity, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Kee-Deog Kim
- Department of Advanced General Dentistry, Yonsei University College of Dentistry, Seoul, Republic of Korea
| | - Wonse Park
- Department of Advanced General Dentistry, Yonsei University College of Dentistry, Seoul, Republic of Korea
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Aspiration of dental items: Case report with literature review and proposed management algorithm. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:452-458. [PMID: 34687948 DOI: 10.1016/j.jormas.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 01/15/2023]
Abstract
The aim of this present study is to describe a case of a screwdriver implant aspiration removed with flexible bronchoscopy. This study reviewed the current literature and the authors also proposed an airway management algorithm in case of suspected foreign body aspiration during dental procedures. A review of English-language literature of aspiration of objects after clinical dental practice from 1984 to 2021 was performed. The bronchoscopy was the main method for dental items removal. A total of 57 cases from the literature were enrolled in this study. Aspiration of dental crown and prostheses (43.85%) followed by implant material (19.29%) and tooth (15.78%) were the main aspirated items. Prevention is the better way to avoid this type of complication. Early diagnosis facilitates the removal of foreign body and bronchoscopy is considered the treatment of choice for removal of foreign body aspiration. Also, regular professional training in basic life support is required.
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Auffret M, Meuric V, Boyer E, Bonnaure-Mallet M, Vérin M. Oral Health Disorders in Parkinson's Disease: More than Meets the Eye. JOURNAL OF PARKINSONS DISEASE 2021; 11:1507-1535. [PMID: 34250950 PMCID: PMC8609694 DOI: 10.3233/jpd-212605] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite clinical evidence of poor oral health and hygiene in Parkinson’s disease (PD) patients, the mouth is often overlooked by both patients and the medical community, who generally focus on motor or psychiatric disorders considered more burdensome. Yet, oral health is in a two-way relationship with overall health—a weakened status triggering a decline in the quality of life. Here, we aim at giving a comprehensive overview of oral health disorders in PD, while identifying their etiologies and consequences. The physical (abnormal posture, muscle tone, tremor, and dyskinesia), behavioral (cognitive and neuropsychiatric disorders), and iatrogenic patterns associated with PD have an overall detrimental effect on patients’ oral health, putting them at risk for other disorders (infections, aspiration, pain, malnutrition), reducing their quality of life and increasing their isolation (anxiety, depression, communication issues). Interdisciplinary cooperation for prevention, management and follow-up strategies need to be implemented at an early stage to maintain and improve patients’ overall comfort and condition. Recommendations for practice, including (non-)pharmacological management strategies are discussed, with an emphasis on the neurologists’ role. Of interest, the oral cavity may become a valuable tool for diagnosis and prognosis in the near future (biomarkers). This overlooked but critical issue requires further attention and interdisciplinary research.
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Affiliation(s)
- Manon Auffret
- Behavior & Basal Ganglia Research Unit (EA 4712), University of Rennes 1, Rennes, France.,Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
| | - Vincent Meuric
- INSERM, INRAE, Université de Rennes 1, CHU de Rennes, Nutrition Metabolisms and Cancer, Rennes, France
| | - Emile Boyer
- INSERM, INRAE, Université de Rennes 1, CHU de Rennes, Nutrition Metabolisms and Cancer, Rennes, France
| | - Martine Bonnaure-Mallet
- INSERM, INRAE, Université de Rennes 1, CHU de Rennes, Nutrition Metabolisms and Cancer, Rennes, France
| | - Marc Vérin
- Behavior & Basal Ganglia Research Unit (EA 4712), University of Rennes 1, Rennes, France.,Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France.,Movement Disorders Unit, Neurology Department, Pontchaillou University Hospital, Rennes, France
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Kunaparaju K, Shetty K, Jathanna V, Nath K, M R. Endoscopic retrieval of an accidentally ingested bur during a dental procedure: a case report. Patient Saf Surg 2021; 15:1. [PMID: 33402200 PMCID: PMC7786993 DOI: 10.1186/s13037-020-00273-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background Accidental ingestion of a dental bur during the dental procedure is a rare, but a potentially serious complication. Early recognition and foreign body retrieval is essential to prevent adverse patient outcomes. Case presentation A 76-year old male patient, presented to the department with a chief complaint of sensitivity in his upper right back tooth due to attrition. After assessing the pulp status, root canal therapy was planned for the tooth. During the procedure, it was noticed that the dental bur slipped out of the hand piece and the patient had accidentally ingested it. The patient was conscious and had no trouble while breathing at the time of ingestion of the bur although he had mild cough which lasted for a short duration. The dental procedure was aborted immediately and the patient was taken to the hospital for emergency care. The presence and location of the dental bur was confirmed using chest and abdominal x-rays and it was subsequently retrieved by esophagogastroduodenoscopy (EGD) procedure under general anaesthesia on the same day as a part of the emergency procedure. The analysis of this case reaffirms the importance of the use of physical barriers such as rubber dams and gauze screens as precautionary measures to prevent such incidents from occurring. Conclusion Ingestion of instruments are uncertain and hazardous complications to encounter during a dental procedure. The need for physical barrier like rubber dam is mandatory for all dental procedures. However, the dentist should be well trained to handle such medical emergencies and reassure the patient by taking them into confidence. Each incident encountered should be thoroughly documented to supply adequate guidance for treatment aspects. This would fulfil the professional responsibilities of the dentist/ clinician and may help avoid possible legal and ethical issues. This case report emphasizes on the need for the usage of physical barriers during dental procedures in order to avoid medical emergencies.
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Affiliation(s)
- Keerthana Kunaparaju
- Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Karthik Shetty
- Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vinod Jathanna
- Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kartik Nath
- Faculty of Dentistry, Department of Conservative Dentistry and Endodontics, Melaka Manipal Medical College, Manipal, India
| | - Roma M
- Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India.
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Screwdriver Aspiration During Oral Procedures: A Lesson for Dentists and Gastroenterologists. PROSTHESIS 2019. [DOI: 10.3390/prosthesis1010008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This article reports the case of a patient suffering from Alzheimer’s disease who underwent a dental procedure for the peri-implantitis of his dental implants placed some years earlier. Our aim was to describe a misinterpreted accidental foreign body aspiration and its management. Due to an involuntary movement, the patient accidentally ingested a screwdriver, so, although asymptomatic, he was taken to the hospital. Based on the radiographic interpretation, the radiologists diagnosed the presence of the object in the distal esophagus; an esophagogastroduodenoscopy was performed but the screwdriver was not found. Subsequently, a computed tomography (CT) scan was performed which placed the foreign body in the airways and it was successfully removed by bronchoscopy. Patients with dementia need additional care during dental procedures because of the increased risk of ingestion and/or aspiration. We demonstrated how important it is, even without any symptoms, the need to be vigilant in seeking out urgent care as soon as possible.
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8
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Kaka S, Lane H, Sherwin E. Dentistry and Parkinson's disease: learnings from two case reports. Br Dent J 2019; 227:30-36. [DOI: 10.1038/s41415-019-0470-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Hou R, Zhou H, Hu K, Ding Y, Yang X, Xu G, Xue P, Shan C, Jia S, Ma Y. Thorough documentation of the accidental aspiration and ingestion of foreign objects during dental procedure is necessary: review and analysis of 617 cases. Head Face Med 2016; 12:23. [PMID: 27449659 PMCID: PMC4957346 DOI: 10.1186/s13005-016-0120-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 07/12/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To review the cases of accidental aspiration and ingestion of foreign objects during dental procedure, and to emphasize the importance of thorough documentation of the accidents. METHODS A comprehensive search on (dental procedure/treatment/practice), (aspiration/inhalation), and (ingestion/swallow) was performed for all years before 1st October 2014 available. The statistic analysis was made on the variables including journals and reported year, patients' age, gender, general conditions, dental procedure and location for procedure, foreign objects, site of involvement, possible causes, anesthesia during procedure and treatment, symptoms, treatment time and treatment modality, follow-up, and so on. RESULTS A total of 617 cases reported by 45 articles from 37 kinds of journals were included and analyzed. Most reports made detailed record. While some important variables were recorded incompletely, including patient's general conditions, location for procedure, clinical experience of the involving dentists, tooth position of procedure, possible causes, and anesthesia during procedure and treatment for the accident. CONCLUSIONS Aspiration and ingestion of foreign objects are rare and risky complication during dental procedure. Each accident should have thorough documentation so as to provide enough information for the treatment and prevention.
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Affiliation(s)
- Rui Hou
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Hongzhi Zhou
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Kaijin Hu
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Yuxiang Ding
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Xia Yang
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Guangjie Xu
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Peng Xue
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Chun Shan
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Sen Jia
- />Department of Oral Surgery, State Key Laboratory of Military Stomatology & National Clinical Research Center for Oral Diseases & Shaanxi Clinical Research Center for Oral Diseases, School of Stomatology, The Fourth Military Medical University, Xi’an City, Shaanxi Province 710032 China
| | - Yuanyuan Ma
- />Department of Stomatology, Research Institute of Surgery & Daping Hospital, The Third Military Medical University, Chongqing City, 400042 China
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Abstract
Individuals with Parkinson's disease present a challenge to dental clinicians as this degenerative disease leads to problems accessing care and maintaining an adequate level of oral health. This article provides an overview of the implications of Parkinson's disease on oral health and explores the role of dental implants in the management of such patients.
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Endoscopic removal of an aspirated healing abutment and screwdriver under conscious sedation. IMPLANT DENT 2014; 23:250-2. [PMID: 24819812 DOI: 10.1097/id.0000000000000100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Aspiration of foreign bodies during dental treatment is a medical emergency that requires prompt removal. In this study, aspiration of screwdriver and healing abutment is reported with literature review. MATERIALS AND METHODS A 26-year-old male patient was referred from a local dental clinic with the suspicion of ingestion of a screwdriver and healing abutment during the second-stage surgery. The patient reported symptoms including dyspnea, cough, and foreign body sensation. On the chest radiograph, a radiopaque foreign body resembling the screwdriver and healing abutment was observed at the right mid lung. RESULTS Bronchoscopic examination using flexible cable was performed under conscious sedation, and microforceps were used to remove the instruments. Aspirated screwdriver and healing abutment were removed safely under intravenous sedation. The patient did not have any symptoms associated with lung aspiration after removal of the foreign body during follow-up periods. CONCLUSION Bronchoscopic removal is the most recommended procedure for removal of the aspirated foreign body. This can be performed under conscious sedation. Precautions, such as tethering the screwdriver, are recommended during implant procedures.
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Faggion CM. Critical appraisal of evidence supporting the placement of dental implants in patients with neurodegenerative diseases. Gerodontology 2013; 33:2-10. [DOI: 10.1111/ger.12100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Clovis Mariano Faggion
- Department of Periodontology; Faculty of Dentistry; University of Münster; Münster Germany
- Department of Oral Sciences; Faculty of Dentistry; University of Otago; Dunedin New Zealand
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