Farah Mushtaq1          BDS, FCPS
Nouman Noor2            BDS, FCPS
Nouman Anayat3        BDS, FCPS
Ahmed Yar4                 BDS, FCPS

In dental practice, discovery of a foreign body entrapment within the root canal is not uncommon. The foreign object may have
been accidently lodged due to traumatic injuries, iatrogenically during treatment or it may be a self-inflicted injury. The patient
usually reports only when he/she experiences pain with foreign object discoverable on radiographic examination. In this report,
a 20-year-old female was diagnosed with a stapler pin lodged in a permanent maxillary central incisor canal along with self
cure acrylic.
KEYWORDS: Apexification, Mineral trioxide aggregate, Stapler pin
HOW TO CITE: Mushtaq F, Noor N, Anayat N, Yar A. Self cure acrylic and stapler pin retrieval from maxillary central tooth:
Acase report. J Pak Dent Assoc 2022;31(2):106-109.
DOI: https://doi.org/10.25301/JPDA.312.107
Received: 24 July 2021, Accepted: 16 February 2022

INTRODUCTION
Foreign objects may act as a possible cause of infection. Early diagnosis and treatment becomes mandatory in such cases to avoid further complications. Thorough case history, clinical, and radiographic examinations are essential in determining the nature, size, location of the
foreign body, and the difficulty involved in its retrieval. A variety of foreign objects has been reported to be lodged in the root canals such as pencil lead,resin,needles, metal screws, beads, and pins. Grossman reported retrieval of indelible ink pencil tips, brads, toothpick, absorbent points, and tomato seed from the root canal of anterior teeth.1 Many other authors have reported the presence of, a plastic chopstick
embedded in an unerupted supernumerary tooth and hat pins, dressmaker pins, toothbrush bristles, and crayons fractured inside the root canals of the teeth.2,3 These foreign bodies inside the tooth eventually leads to infection resulting in pain, bleeding, and swelling, infection and recurrent abscess.4,5,6

CASE REPORT
A 20 year old female patient resident of Mandi Bahuddin reported to Outpatient department of Rawal Institute of Health Sciences on Ist February 2020 with the severe pain in #21.On taking detailed history patient informed that tooth #21 was operated 4 years back with root canal treatment in local dental setup at Area of Mandi Bahuddin, Pakistan. The previous operator placed wire like thing inside the tooth
and filled it with white color material, Pain along with associated swelling started few days back within the tooth,more on biting,continuous in nature in upper anterior maxillary quadrant,that radiated to upper right lip. The swelling reduced gradually in size. Patient was otherwise medically fit and well.Extra oral examination was non contributory,while during intraoral examination soft tissue mucosa overlying #21 was tender on palpation with erythemia, tooth was tender on percussion, tooth was filled with irregular rough filling material having pointed edges and was associated with plaque. On radiographic examination a vertically placed wire was found having a bend ,which was suspected to be a stapler pin or broken file at that time.After following the history and examination of the patient,she was diagnosed with apical periodontitis was diagnosed as cause. She was recalled after one week and treatment plan was discussed with the patient, Two options were given to the patient keeping in mind her financial status, First option included stepwise removal of the filling material, retrieval of the foreign object from canal, apical barrier formation of apex ,if required localized crown lengthening to achieve ferrule, obturation, endo post buildup and crown and second option included to extract the tooth and replace it with implant. Patient opted for first option, treatment cost was discussed and informed consent of patient was taken.
At the first visit, patient was explained verbally again for the steps of treatment. Localized infilteration was givenbfor #21,and small round carbide bur was used to remove restoration,During removal it was identified that the restoration was self cure acrylic which not appreciable during radiographic examination. It is a carcinogenic material which is not recommended for restoration, the buildup was removed. However, the foreign object removal from canal was quite complicated as self cure acrylic had flown with in the canal space and was hard in texture.Small tapered fissured 11 bur was used to remove the acrylic around the object,to minimize damage to the tooth structure of lateral wall of the canals and a purchase point was made in object as hook,vertical forces was given using a periodontal explorer with in this created hook and object was retrieved after few strokes. On removal it was confirmed to be the stapler pin,10mm in length, which was cured with self cure acrylic within the canal, #80 K endodontic file was placed to determine working length as radiograph was taken. Canal was prepared minimally and irrigated with 5.25% sodium hypochlorite to clean the

walls with associated pus coming out of it, there was no apical stop found, determined working length short of apex was found to be 18.5mm,canal prepared upto #80 K as shown in the (figure 1,2,3,4.) Calcium hydroxide as intracanal medicament was placed with temporary dressing and patient was recalled after 3 weeks.
At second visit temporary dressing was removed and canals were cleaned again and fractured debris remnants came out of canal on irrigation, working length was again reconfirmed. Split rubber dam isolation of tooth and single visit MTA barrier apexification was done, with apical plug of 4 mm. On subsequent day as MTA hardened as barrier, endo post was selected and inserted into canal for intraradicular retention for the foundation restoration. As shown in figure 5,6,7,8.

However it was found that tooth did not had enough available structure left that can be used to provide foundation restoration as well as ferrule for crown, so localized crown lengthening of anterior maxillary including #11, #12 ,#21, #22 was done to cater the pink gingival esthetic balance and to get enough tooth structure of #21 for restorations.
At 3rd visit after 3 months, gingival marginal healing was noted to be satisfactory, nano hybrid composite (Primedent) was used as foundation restoration and crown cutting was done with crown margins available and prepared for extra radicular retention of the crown. Crown shade A2 was selected by clinician herself and patient’s attendee.

Subsequently at 4th visit after one week, Crown was inserted with good marginal fusion and natural midline space, which patient wanted to be in there as before when she had natural #21. Patient seemed quite happy and satisfied and was recalled for follow up as shown in figure 9 and 10.

DISCUSSION
A variety of foreign objects have been reported within the canals of the patient including pencil lead, needles, metal screws, beads, and pins. Our case reported presence of stapler pin in the canal. Presence of stapler pin or any other foreign body with in the canal is usually an incidental finding, trauma or habitual psychological disorders. However, it was not the cause in our report, as the treatment was already performed by clinician or quack; who placed the stapler pin and self cure acrylic in the canal.This ,further detoriated the tooth situation which for the time being looked esthetically pleasing but proved non beneficial for the patient in the long run. Use of self cure acrylic is a common malpractice in dentistry. It is a carcinogenic and toxic material to tooth structure and mucosa itself because of presence of monomers.7
Level of difficulty of endodontic cases can be ruled out by proper history of the patient and examination, Radiographic examination played a vital role in such cases, as it gives clinicians an idea regarding the of level of obstruction present within the canal.8,9,10 In our case, level of difficulty was predicted initially as highly difficult case due to presence of foreign body within the canal, thin roots and wide apex. The factors influencing the removal of foreign objects are affected by the diameter, length and position of the obstruction within a canal and the skill of the operator. Although the technology is advanced, still the success rate for the removal of foreign objects from the pulp canals is 55- 79%.We used the tapered fissure bur to remove and retrieve the stapler pin manually, literature reported use of instrument retrieval systems, H-files, ultrasonic scaler tips too in addition to bur. However, this whole procedure should be done with minimal removal of natural tooth structure. This point is supported by McCullock too who reported that access to a foreign
object is improved by the removal of small amount of
tooth structure. According to Walvekar et al., if a foreign object is snugly bound in the canal, the object may have to be loosened first and then should be removed with minimal damage to the internal tooth.We tried to achieve the same approach in our case by first loosening and removing the stapler pin from self cure acrylic and then making a purchase point in it to remove it with rocking strokes with explorer with minimal damage to tooth. Previous cases also reported use of Stieglitz forceps to remove silver and steel points.8,9,10 For the current case calcium hydroxide was used for canal disinfection which is in agreement with few past studies. Foreign object retrieval and calcium hydroxide dressing can help eliminate chronic peri-apical infections. However few reported use of tri antibiotic paste too.10
For the current case Mineral trioxide aggregate one step apexification was used to form artificial barrier of maxillary central tooth apex. However currently calcium silicate based cements in the form of biodentine were also used by some researchers because of its potential to form mineralization zone and its less setting time of 12 min as compared to MTA. One case reported by Sharma and colloquies used
biodentine in the near past.1,11
For Intra radicular retention metallic post was used in current case. As jotkowitz and colloquies described that a ferrule of 1 mm of vertical height successfully doubled the resistance to fracture versus teeth without a ferrule, and appears to be the minimal acceptable amount of ferrule height which is required.We did localized crown lengthening of four anterior maxillary teeth to get acceptable ferrule height of #21, to get natural tooth structure for composite foundation restoration retention as well as extraradicular retention for #21 crown and symmetric gingival margins.11

CONCLUSION
Addressing and treating such problems at right time is necessary to avoid complications as well as abusive use of self cure acrylic should be reported.A step wise evidence base approach should be used to remove foreign bodies like self cure and stapler pin from the root canal to prevent infections.

DISCLAIMER
It is stated the views expressed in the submitted article are our own.

SOURCE OF SUPPORT
Study included patients data who reported to out patient department at rawal institute of health sciences.

CONFLICT OF INTEREST
We, as the authors of case report, do hereby mention that work done in this case report is exclusively our and has no conflict of interest with any author and institutions.

REFERENCES

1.Sharma V, Tanwar R, Gupta V, Mehta P. Impacted stapler pin in fractured maxillary central incisor with open apex: Advanced endodontic
management using biodentine as innovative apical matrix. Indian J Dent Res 2015;26:637-40
https://doi.org/10.4103/0970-9290.176932

2. Pereira T, Shetty S. An unusual foreign object in a tooth. Niger J Gen Pract 2018;16:30-1
https://doi.org/10.4103/NJGP.NJGP_17_17

3.Kumar D, Singh A, Agarwal N, Rizvi AA, Anand A. Esthetic and endodontic management of anterior teeth with impacted foreign objects
in the root canals: A case series. Endodontology 2016;28:50-2
https://doi.org/10.4103/0970-7212.184341

4.Khandelwal D, Kalra N, Tyagi R, Khatri A. Accidental diagnosis of a foreign body embedded in maxillary anterior tooth.
J Sci Soc 2019;46:103-5
https://doi.org/10.4103/jss.JSS_29_19

5.Yadav RK, Tikku AP, Chandra A, Rathinavel C, Shakya V, Bharti R. Endodontic management of foreign body in the root canal case series. Int J Sci Res Publ 2015;5:1 3.

6.Kariya PB, Singh S, Mallikarjuna RM, Govil S. Dental neglect leading to foreign body lodgement in pulp chamber. Adv Hum Biol
2016;6:145 8.
https://doi.org/10.4103/2321-8568.195322

7.Yadav, et al.: Dental Quacks using Autopolymerized Acrylic Resin – A risk factor for Oral Cancer.Heal talk 2016;08:37-8

8.McCullock AJ. The removal of restorations and foreign objects from root canals. Quintessence Int 1993;24:245-9

9. Walvekar SV, Al-Duwairi Y, Al-Kandari AM, Al-Quoud OA. Unusual foreign objects in the root canal. J Endod. 1995;21:526-7
https://doi.org/10.1016/S0099-2399(06)80527-3

10. Suresh K. Sachdeva et al. Stapler Pin in the Mandibular central incisor tooth: an unusual case of foreign body. Int J Dent & Oral
Heal.2016; 2:52-55.
https://doi.org/10.25141/2471-657X-2016-4.0098

11. A. Jotkowitz, N. Samet .Rethinking ferrule – a new approach to an old dilemma. Br Dent J 2010; 209: 25-33
https://doi.org/10.1038/sj.bdj.2010.580

Farah Mushtaq1             BDS, FCPS
Nouman Noor2               BDS, FCPS
Nouman Anayat3           BDS, FCPS
Ahmed Yar4                    BDS, FCPS

In dental practice, discovery of a foreign body entrapment within the root canal is not uncommon. The foreign object may have
been accidently lodged due to traumatic injuries, iatrogenically during treatment or it may be a self-inflicted injury. The patient
usually reports only when he/she experiences pain with foreign object discoverable on radiographic examination. In this report,
a 20-year-old female was diagnosed with a stapler pin lodged in a permanent maxillary central incisor canal along with self
cure acrylic.
KEYWORDS: Apexification, Mineral trioxide aggregate, Stapler pin
HOW TO CITE: Mushtaq F, Noor N, Anayat N, Yar A. Self cure acrylic and stapler pin retrieval from maxillary central tooth:
Acase report. J Pak Dent Assoc 2022;31(2):106-109.
DOI: https://doi.org/10.25301/JPDA.312.107
Received: 24 July 2021, Accepted: 16 February 2022

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Tahira Hyder          MDS Resident

OBJECTIVE: The objective of this review is to describe basic diode laser physics and to delineate the application of diode
lasers in dentistry.
REVIEW: Over the past few decades lasers have become a popular alternative to conventional methods owing to the advantages
they carry such as decreased cellular destruction and tissue swelling, minimal bleeding, enhanced visualization of surgical sites
and reduced requirement for suturing. Among the various lasers in dentistry, diode lasers are currently the most commonly used,
with applications extending from soft tissue procedures to photo-activated disinfection of periodontal pockets, endodontics and
laser-assisted tooth whitening. With its versatility and numerous benefits, small size, ease of operation and, relative and
cost-effectiveness when compared to other lasers, the diode laser is proving itself as a valuable addition to dental setups.
CONCLUSION: The diode laser provides a relatively pain-free minimally invasive technique for removal of soft tissue lesions
such as exophytic lesions and operculum, gingival depigmentation, implant exposure, biostimulation, canal disinfection in
endodontics and teeth whitening.
KEYWORDS: laser dentistry, biostimulation, oral surgery.
HOW TO CITE: Hyder T. Diode lasers in dentistry: Current and emerging applications. J Pak Dent Assoc 2022;31(2):100-105.
DOI: https://doi.org/10.25301/JPDA.312.100
Received: 14 August 2021, Accepted: 26 December 2021

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Read More

Tahira Hyder          MDS Resident

OBJECTIVE: The objective of this review is to describe basic diode laser physics and to delineate the application of diode
lasers in dentistry.
REVIEW: Over the past few decades lasers have become a popular alternative to conventional methods owing to the advantages
they carry such as decreased cellular destruction and tissue swelling, minimal bleeding, enhanced visualization of surgical sites
and reduced requirement for suturing. Among the various lasers in dentistry, diode lasers are currently the most commonly used,
with applications extending from soft tissue procedures to photo-activated disinfection of periodontal pockets, endodontics and
laser-assisted tooth whitening. With its versatility and numerous benefits, small size, ease of operation and, relative and
cost-effectiveness when compared to other lasers, the diode laser is proving itself as a valuable addition to dental setups.
CONCLUSION: The diode laser provides a relatively pain-free minimally invasive technique for removal of soft tissue lesions
such as exophytic lesions and operculum, gingival depigmentation, implant exposure, biostimulation, canal disinfection in
endodontics and teeth whitening.
KEYWORDS: laser dentistry, biostimulation, oral surgery.
HOW TO CITE: Hyder T. Diode lasers in dentistry: Current and emerging applications. J Pak Dent Assoc 2022;31(2):100-105.
DOI: https://doi.org/10.25301/JPDA.312.100
Received: 14 August 2021, Accepted: 26 December 2021

INTRODUCTION
The term LASER is an abbreviation for “Light Amplification by the Stimulated Emission of Radiation”.1 Since its introduction in dentistry in the 1960s by Maiman2 , there has been continuous research on its numerous soft and hard tissue applications. Lasers are broadly classified on basis of tissue adaptability into two types: the first type being hard lasers, such as Neodymium Yttrium Aluminum Garnet (Nd: YAG), Er:YAG and Carbon dioxide (CO2 ), which have both hard tissue and soft tissue applications, but are more costly and can potentially cause thermal injury to tooth pulp3 , while the second type are cold or soft lasers usually semiconductor diode devices, which are compact, affordable and versatile devices used for soft tissue surgical procedures and “biostimulation”.4 A second classification is based upon the physical construction of the laser (such as solid laser and gas laser) and a third one is according to the range of wavelength.

METHODOLOGY
In order to get material on the application of diode lasers in dentistry a, literature search was conducted, using Medline-PUBMED and Google Scholar search based electronic databases. Reviews of literature, clinical trials and case series that used diode laser to evaluate histologic or clinical variables were selected. “Diode laser”, “dentistry”, “oral cavity” and “oral surgery” were employed for the search strategy.

MECHANISM OF ACTION OF DIODE LASERS
Laser light is a single wavelength, monochromatic light.5 A laser essentially consists of three parts: a source of energy, lasing medium and mirrors that cause resonation. Typically an optical flexible fiber ranging from 200 to 600 µm to deliver the laser light from the laser to the target tissues. The wavelength and other properties of the laser are determined primarily by the composition of an active medium
which produces photons of energy on stimulation, and can be a gas, a crystal, or a solid-state semiconductor.6
When laser energy hits a target issue, four possible interactions occur depending on optical properties of the target tissues and the wavelength of the laser: reflection transmission, scattering, and absorption.7,8 Once the laser light is absorbed in the tissues its temperature elevates, thereby causing photochemical effects which are dependent upon the water content of the tissues. At temperature between
60°C and 100°C protein denaturation occurs; at temperature exceeding 100°C, ablation or vaporization of the water occurs and at temperatures above 200°C, the tissue lose their water content and dehydrate, resulting in burn or carbonization.
For absorption to occur, a chromophore or an absorber of light with affinity for a particular wavelength is required.9 Common chromophores in the soft tissues of the oral cavity include water, melanin and hemoglobin while those of hard tissues are typically water and hydroxyapatite.10,11 Absorption coefficients of lasers differ with respect to hard and soft tissues, thereby making the laser selection proceduredependent.8,12,13 Accordingly, dental lasers are classified as hard or soft tissue lasers, depending on their affinities.

DIODE LASERS
The diode laser has a compact and portable unit with a wide variety of clinical applications. A solid state semiconductor is made up of aluminum, gallium, arsenide, and occasionally indium converts electrical energy into light energy of approximately 810 nm to 980nm wavelength.14 These wavelength are easily absorbed by “chromophores” such as hemoglobin and melanin, while they are poorly absorbed by the hydroxyapatite and water which constitute the enamel, therefore diode lasers have no role in hard tissue application.10
A flexible optic fibre in the form of a headpiece delivers the treatment rays to the target area. The clinical approach and treatment methods dictate the selection between continuous and pulsed modes and between contact and noncontact tissues application.15 Literature suggests some advantages of the laser over conventional methodologies like scalpel, including precise soft tissue incisions, a relatively bloodless surgical field and better visualization, no requirement for suturing, good post-operative recovery period with minimal to none bleeding, swelling and reduced postsurgical pain.16
Dental lasers do carry some disadvantages. The high financial cost makes it not accessible to all dental set ups. Secondly, eye damage is a serious complication that can occur, but is prevented by the use of wavelength-specific eye wear.17 Operations of lasers also require specialized training. Additionally, laser soft tissue incision is slower than that performed with a scalpel.16

APPLICATIONS
Crown-Lengthening Laser-assisted crown-lengthening surgery has a wide variety of clinical applications such as surgical exposure of
fractured tooth or subgingival caries, correction of gummy smile in altered passive eruption cases, and access to root perforations.18 Because of its inability to remove hard tissue, diode laser assisted crown lengthening can only be performed for the treatment of type 1A altered passive eruption19 with a wide band of keratinized tissue and optimal space (approximately 1.5 mm) between the alveolar crest and
cemento-enamel junction.
When compared with conventional crown lengthening using scalpel, laser has been associated with minimal bleeding which allows improved visualization of the surgical field, with reduced post-operative pain and lower visual analogue score (VAS), thereby demonstrating laser-assisted crown lengthening as a safe and effective alternative to conventional methods.19,20

GINGIVAL DEPIGMENTATION
Gingival depigmentation is a periodontal plastic surgical procedure whereby hyper-pigmented zones of the attached gingiva are removed or reduced by various techniques including scalpel surgery, ablation with high-speed handpiece, cryosurgery, electrosurgery, and dental laser.21 Laser assisted gingival depigmentation is typically performed as a single step technique with no requirement of the use of a periodontal dressing, and is accompanied by a fast healing process with minimal pain and discomfort.22

EXPOSURE OF UNERUPTED AND PARTIALLY
ERUPTED TEETH
Diode lasers allow precise and easy excision of soft tissue over unerupted or partially erupted teeth such as the maxillary canine for the placement of a bracket or for the removal of an operculum around a partially erupted third molar, with an additional advantage over conventional scalpel surgery in sealing small blood and lymphatic vessels, thereby.23 Postoperative tissue shrinkage is reduced, resulting
in decreased scarring. In most cases the need for suturing is eliminated and healing occurs by secondary intention.24

REMOVAL OF HYPERTROPHIC TISSUE AND
BIOPSY SPECIMENS
Denture-induced fibrous hyperplasia is a benign overgrowth of soft tissue that occurs in response to a chronically ill- fitting denture. These overgrowths can be removed without the need of sutures and with good hemostasis and less post-operative pain using diode lasers. Diode laser can also be a useful treatment modality for obtaining biopsy specimens.25

FRENECTOMIES
    When the removal of a high labial frenal attachment is indicated, laser-assisted frenectomy provides a relatively painless, bloodless procedure not requiring suturing or a periodontal pack, and without the requirement of any special postoperative care. Diode lasers can also be used to remove the thick frenular band seen in ankyloglossia, in which a band of tissue extends from the bottom of the tongue’s tip
to the floor of the mouth and limits the tongue movements. The attachment of the tongue to the floor of the mouth results in difficulty in speech and deglutition, malocclusion and occasionally difficulty in performing oral hygiene, resulting in periodontal problems, thereby requiring removal of the band of tissue.

IMPLANT EXPOSURE
Studies have concluded that second-stage implant surgeries performed with diode lasers are not only efficient, safe, bloodless and painless procedures but they also linked with a faster rehabilitation phase and greater patient satisfaction.26,27
In a randomized controlled clinical trial Kholey et. al28 concluded that diode laser assisted implant exposure could be performed without the need for local anaesthesia, however it was similar to scalpel surgery in outcomes including duration of surgery, postoperative pain, healing time, and overall success rates of the implants.

PHOTOACTIVATED DISINFECTION USING
LASERS
Low-level laser energy from a diode laser is being used as a photo-activator of oxygen releasing dyes (such as tolonium chloride), which cause membrane and DNA damage to the microorganisms upon activation. Commonly referred as photoactivated disinfection (PAD), this technique has been proven in literature to effectively kill bacteria including subgingival plaque in deep periodontal pockets, which are
typically antimicrobial agents-resistant.29 Photoactivated disinfection has been demonstrated to kill Gram positive bacteria (including Methicillin resistant Staphylococcus aureus (MRSA)), Gram negative bacteria, fungi, and viruses.30,31The application of PAD is being extended to disinfection in cases of peri-mucositis and peri implantitis.32,33

WOUND HEALING AND BIOSTIMULATION
Low-level laser therapy (LLLT) is commonly referred to as “bio-stimulation”. Studies indicate that low dose of laser energy (e.g., 2 J/cm2) stimulates proliferation of fibroblasts, while high doses (e.g. 16 J/cm2) suppress it.34,35 An increase in proliferation and locomotion of fibroblasts may result in increased tensile strengths of the healed wounds.36 The effects of LLLT on proliferation and differentiation of human osteoblast cells have been investigated.37 Studies report that LLLT bio-stimulates or enhances the multiplication and differentiation of the human osteoblast-like cells during the first 72 hours after irradiation. This application indicates the use of LLLT in combination
with regenerative methods and even as stand-alone treatment for stimulation of bone repair and acceleration of the healing process.38,39

POST HERPETIC NEURALGIA AND APTHOUS
ULCERS
Low levels laser therapy has been demonstrated to reduce pain and enhance healing of aphthous ulcers and recurrent herpetic lesions.40,41 For recurrent herpes simplex labialis lesions, if photostimulation is performed during the prodromal (tingling) stage, the lesions have been shown to get arrested with acceleration of the healing time and a reduction in recurrences.42

ROOT CANAL DISINFECTION
In invitro studies diode laser irradiation has been shown to increase disinfection of deep radicular dentin.43,44 It is also associated with effective sealing of dentinal tubules and elimination of Escherichia coli and Enterococcus Faecalis45, thus increasing the efficacy of root canal treatment. For this effect, the diode laser’s optic fibre is first entered 3 mm short of the apex into the canal and gradually withdrawn, being kept in approximately 1 minute per canal.46

REMOVAL OF PERIODONTAL POCKET LINING
Diode lasers are increasingly being used as part of the laser assisted new attachment procedures (LANAP), whereby the epithelium lining the pocket is removed in an attempt to gain new attachment.47 To perform this procedure, after the completion of scaling and root planing the optical fiber is introduced into the periodontal pocket and ascending and descending movement are performed. Through the duration
of the procedure the optical fiber must be maintained parallel to the tooth root main axis, with the laser being rotated around the perimeter of each involved tooth.48

TEETH WHITENING
Laser lights activates hydrogen peroxide within the bleaching agent to yield better results compared to hydrogen peroxide activation using light-emiting-diodes (LEDs). It has been noted that the teeth bleached by the LEDs suffer a major chroma reduction and turn gray; laser irradiation however produced better chroma and less gray.49,50 Additionally, better luminosity and less sensitivity was achieved with laser activation of hydrogen peroxide.51

CONCLUSION
Over the span of the last four decades, applications of diode lasers have steadily increased across dentistry and extends from soft tissue surgical procedures (frenectomy, gingivectomy, operculectomy etc.) to biostimulation of wounds, teeth whitening gel activation, photodynamic disinfection, and improved root canal disinfection. Owing to its relatively low cost and compatible size, it is growing in popularity in dental clinics and hospitals, making it essential for dentists to know its applications and be proficient in its handling.

CONFLICT OF INTEREST
None declared

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J Lasers Med Sci. 2019;10:324-9
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5. Goldman L, Goldman B, Van-Lieu N. Current laser dentistry. Lasers Surg Med. 1987;6:559-62.
https://doi.org/10.1002/lsm.1900060616

6. Nazemisalman B, Farsadeghi M, Sokhansanj M. Types of lasers and their applications in pediatric dentistry.
J Lasers Med Sci. 2015;6:96- 101
https://doi.org/10.15171/jlms.2015.01

7. Aoki A, Mizutani K, Takasaki AA, Sasaki KM, Nagai S, Schwarz F, et al. Current status of clinical laser applications in periodontal
therapy. Gen Dent. 2008;56:674-87.

8. Carroll L, Humphreys TR. Laser-tissue interactions. Clin Dermatol. 2006;24:2-7.
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9. Sulieman M. An overview of the use of lasers in general dentist practice: Laser physics and tissue interactions. (233-4).Dent Update.
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https://doi.org/10.12968/denu.2005.32.4.228

10. Fasbinder DJ. Dental laser technology. Compend Contin Educ
Dent 2008;29:452-4, 456, 458-9.

11. Green J, Weiss A, Stern A. Lasers and radiofrequency devices in dentistry. Dent Clin North Am. 2011;55:585-97
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12. Martens LC. Laser physics and a review of laser applications in dentistry for children. Eur Arch Paediatr Dent. 2011;12:61-7.
https://doi.org/10.1007/BF03262781

13. Tracey SG. Light work. Orthod Products. 2005:88-93.

14. Weiner GP. Laser dentistry practice management. Dent Clin North Am. 2004;48:1105-26
https://doi.org/10.1016/j.cden.2004.05.001

15. Desiate A, Cantore S, Tullo D, Profeta G, Grassi FR, Ballini A. 980 nm diode lasers in oral and facial practice: current state of the
science and art. Int J Med Sci. 2009;6:358.
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16. Desiate A, Cantore S, Tullo D, Profeta G, Grassi FR, Ballini A. 980 nm diode lasers in oral and facial practice: current state of the
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17. Romanos G, Nentwig GH. Diode Laser (980 nm) in Oral and Maxillofacial Surgical Procedures: clinical observations based on
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https://doi.org/10.1089/clm.1999.17.193

18. Stabholz A, Zeltser R, Sela M, et al. The use of lasers in dentistry: principles of operation and clinical applications. Compendium of
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20. Farista, S., Kalakonda, B., Koppolu, P., Baroudi, K., Elkhatat, E. and Dhaifullah, E., 2016. Comparing laser and scalpel for soft tissue
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https://doi.org/10.5539/gjhs.v8n10p73

21. Rajesh Kumar, Garima Jain, Shrikant Vishnu Dhodapkar, Kanteshwari Iranagouda Kumathalli, Gagan Jaiswal. The comparative
evaluation of patient’s satisfaction and comfort level by diode laser and scalpel in the management of mucogingival anomalies. J Clin
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Amber Kiyani1          MS
Syed Hamza Zia3      BDS
Kanwal Sohail2         MSc
Zarnab Rizwan4        BDS
Ghina Rizwan5          BDS

OBJECTIVE: Dental anxiety can be adversely affected by pandemics like corona virus. Most patients have preferred to defer
their dental appointments and that patients generally neglect their health in epidemics. The investigation was carried out to
determine the effect of the current coronavirus pandemic on dental anxiety by comparing through and post 1st wave of pandemic
dental anxiety scores.
METHODOLOGY: A cross-sectional study was conducted on the Pakistani population using online surveys from June to
August 2020. A total of 681 participants were recruited. Standardized and validated questionnaires were used to measure dental
anxiety scores during and after the 2nd wave of pandemic. Statistical analysis was performed using SPSS version 22. Independent
t-test was used to compare dental anxiety scores through and after the 2nd wave of COVID-19. Fear of COVID-19 among the
participants was also evaluated.
RESULTS: From a total of 681 participants, 668 responses were retained in accordance to the inclusion criteria. A statistically
significant difference was obtained regarding the dental anxiety levels during and after the 2nd wave of COVID-19
(p value =0.001). However, there was no significant difference between fear of COVID-19 scale and dental anxiety scores
during COVID-19 (p value = 0.284).
CONCLUSION: The coronavirus pandemic has demonstrated an adverse effect on patient dental anxiety scores. We also noted
that the majority of the people were not willing to attend their dental appointment during this pandemic.
KEYWORDS: COVID-19, coronavirus infection, dental anxiety, fear.
HOW TO CITE: Kiyani A, Sohail K, Zia SH, Rizwan Z, Rizwan G. The Effect of fear of COVID-19 on dental anxiety levels.
J Pak Dent Assoc 2022;31(2):95-99.
DOI: https://doi.org/10.25301/JPDA.312.95
Received: 18 May 2021, Accepted: 17 January 2022

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Amber Kiyani1          MS
Syed Hamza Zia3      BDS
Kanwal Sohail2         MSc
Zarnab Rizwan4        BDS
Ghina Rizwan5          BDS

OBJECTIVE: Dental anxiety can be adversely affected by pandemics like corona virus. Most patients have preferred to defer
their dental appointments and that patients generally neglect their health in epidemics. The investigation was carried out to
determine the effect of the current coronavirus pandemic on dental anxiety by comparing through and post 1st wave of pandemic
dental anxiety scores.
METHODOLOGY: A cross-sectional study was conducted on the Pakistani population using online surveys from June to
August 2020. A total of 681 participants were recruited. Standardized and validated questionnaires were used to measure dental
anxiety scores during and after the 2nd wave of pandemic. Statistical analysis was performed using SPSS version 22. Independent
t-test was used to compare dental anxiety scores through and after the 2nd wave of COVID-19. Fear of COVID-19 among the
participants was also evaluated.
RESULTS: From a total of 681 participants, 668 responses were retained in accordance to the inclusion criteria. A statistically
significant difference was obtained regarding the dental anxiety levels during and after the 2nd wave of COVID-19
(p value =0.001). However, there was no significant difference between fear of COVID-19 scale and dental anxiety scores
during COVID-19 (p value = 0.284).
CONCLUSION: The coronavirus pandemic has demonstrated an adverse effect on patient dental anxiety scores. We also noted
that the majority of the people were not willing to attend their dental appointment during this pandemic.
KEYWORDS: COVID-19, coronavirus infection, dental anxiety, fear.
HOW TO CITE: Kiyani A, Sohail K, Zia SH, Rizwan Z, Rizwan G. The Effect of fear of COVID-19 on dental anxiety levels.
J Pak Dent Assoc 2022;31(2):95-99.
DOI: https://doi.org/10.25301/JPDA.312.95
Received: 18 May 2021, Accepted: 17 January 2022

INTRODUCTION
Dental fear or phobia that is defined as “fear related to seeking or receiving dental care” is the 5th most common cause of anxiety.1
A study has shown that approximately 80% people feel uncomfortable before any dental procedure.2 In another study conducted by the American Dental Association showed that 12% adults had dental phobia. The reasons for this dental phobia were diverse and included prior painful or unpleasant experiences, and dental fear inculcated in them by parents in childhood.3
There is also a link between general anxiety and dental phobia.4 Patients with dental phobia have significantly higher levels of psychological distress and general anxiety.5 A study demonstrated that some patients with dental anxiety may have prior psychological diagnoses; such as panic disorder, social phobia or general anxiety.6
Psychological status of a person can have an impact on an individual’s life. It is seen that coronavirus (COVID-19) has affected the psychological well-being of a person. Prior epidemics like the Middle East Respiratory Syndrome resulted in a heavy psychological impact on healthcare workers and general public by causing depression, anxiety, panic attacks, and psychotic symptoms such as functional impairments.7,8 The current pandemic of COVID-19 is expected to have similar effects on the psychological health of the general public.9-12 This psychological impact coupled with the categorization of dentists as high-risk professionals has adversely affected dental anxiety.13 This can be based on the fact that most patients have preferred to defer their dental appointments as they fear of getting infected by the dentists and that patients also tend to generally neglect their health in epidemics.14,15 Another study also established a link between the patient’s feelings in COVID-19 and willingness to attend dental appointments.16
The purpose of this study was to compare the dental anxiety during and after the 2nd wave of pandemic in the Pakistani population. It also aimed to compare the dental anxiety scores with the fear of COVID-19. In addition, it determined the willingness of the patients to attend regular appointments and precautions they find satisfactory in dental settings.

METHODOLOGY
A cross-sectional study design was used for evaluating the dental anxiety levels during and after 2ndt wave of COVID-19. This study was approved by the Ethical Research Committee of Riphah International University prior to data collection (Ref No. IIDC/IRC/2020/07/001). Data was collected from June to August 2020 and a convenience sampling technique was used. Sample size was calculated through the WHO sample size calculator. Individuals over the age of 18 who saw dentists were included in the study. Anyone who had not seen dentists was excluded.
A standard validated Modified Dental Anxiety Scale questionnaire for assessing dental phobia was used in participants after the 2nd wave.17 The same questionnaire was modified to determine dental phobia through the 2nd wave. Another validated Fear of COVID-19 Scale
questionnaire was also applied in this study.18 The final questionnaire uploaded on to Google Forms consisted of 18 questions divided into 4 sections that evaluated the anxiety level of the participants. Section 1 required demographic information like age, gender, education, occupation and information regarding dental hygiene like oral hygiene habits and how often do they visit their dentists. Section 2 evaluated
fear of COVID-19 among the participants, Section 3 assessed dental anxiety during COVID-19 and dental anxiety in patients when the pandemic settled down as in after the 1st wave of COVID-19 giving a picture of how much dental phobic they are in their regular days and also Section 4 determined information on dental appointment scheduling. The questionnaire was then shared with the general public
using social media platforms like gmail, WhatsApp and facebook.
Six hundred and eighty-one participants filled the questionnaire during the 2nd wave. Email addresses were retained to allow for the form to be sent out after the 2nd wave ended.
Data analysis was performed on the result of submitted forms using Statistical Package for Social Sciences (IBM SPSS v 22). The p-value ?0.05 was considered significant at 95% confidence interval. Descriptive analysis was obtained for the age of participants, dental anxiety scores and fear of COVID-19 scores. Percentages and frequencies were obtained for gender, education level, occupation, dental habits and
preferred precautionary measures. Independent t-test was applied to find out any statistically significant difference between the mean scores of dental anxiety levels during and after the 2nd wave of COVID-19. Another comparison was also done by comparing the mean scores of dental anxiety during COVID-19 and fear of COVID-19 scale scores by applying independent t-test.

RESULTS
Demographics
    A total of 681 participants filled in the Google Form; only 668 complete responses were returned after the 2nd wave ended. There were 156 (23.4%) males and 509 (76.2%) females. Three individuals did not specify gender. The mean age of the participants was 26.49+ 9.59 years. There were 157 (23.5%) participants with high school education, 356 (53.4%) had undergraduate degrees, and 151 (22.6%) had post-graduate degrees. One hundred and fifty-eight (23.6%) participants were associated with healthcare. These responses were retained because they also form part of the general population.

Oral Hygiene Habits
    Out of 668; 342 (51.2%) brushed their teeth twice a day, while 284 (42.5%) brushed once a day, 32 (4.8%) brushed once every 1-2 days and 10 (1.5%) brushed once a week. Three-hundred and ninety-eight (59.6%) flossed once a week/ never. There were 121 (18.1%) participants that flossed once daily, 107 (16.0%) flossed every 1-2 days while only 30 (4.5%) participants flossed twice a day. (Fig 1) From

668; 294 (44.2%) rarely visited their dentist, 53 (8%) visited every 2 years, 174 (26.2%) saw their dentist’s once a year, 82 (12.3%) went every 6 months while 62 (9.3%) went every 2-3 months.

Dental Anxiety and Fear of COVID-19
   Dental anxiety scores during and after the 2nd wave of COVID-19 were analyzed. The scores of anxiety during the COVID-19 ranged from 5 to 25 with a mean score of 14.97±5.73, while the mean anxiety score for patients after 2nd wave of COVID-19 was 10.03±4.38. A cut-off value of 19 and above indicated a highly anxious patient, we did not have this subgroup in our sample. The mean score during the COVID-19 pandemic was higher than the mean score after the 1st wave of COVID-19. The independent t-test between the two groups showed a statistically significant difference with a p-value = 0.001.
Females exhibited higher dental anxiety scores than males mean scores of 15.44±5.73 and 13.49±5.39 respectively. (p value= 0.001)
Individual scores were evaluated for fear of COVID-19 scale ranging from 5 to 25. A mean score of 14.67±4.52 was calculated. There was no statistically significant difference between fear of COVID-19 and dental anxiety scores during COVID-19 (p value = 0.284). (Table 1)

Visiting the Dentist during COVID-19
   Majority of patients; 294 (44%) were unwilling to go for routine dental appointments during COVID-19. Two hundred (29.9%) would keep their appointments, while 174 (26%) were uncertain. Three hundred and ninety-four (59%) would see the dentist only in case of an emergency (tooth pain), 54 (8.1%) would attend routine orthodontic visit/scaling polishing, 47 (7%) would schedule visits similar to before
the pandemic, while 173 (25.9%) would not see the dentist at any cost. (Fig 2) As there is an increased fear among the

participants regarding the COVID-19 infection; the participants preferred protective measures are summarized in Figure 3.

DISCUSSION
Dental anxiety can be a distressing problem for patients requiring dental care.19 It prevents regular dental visits and compromises oral health, which turn can adversely affect the patient’s quality of life.20 Dental anxiety is a consequence of numerous endogenous and exogenous factors.21 The foremost of these is a prior bad experience with a dentist; personal or narrated by people around. The second most
common reason is the fear of pain.22 Other factors include age, gender, level of education, parental anxiety and culture.19 Similarly, general anxiety affects the life of individuals by exacerbating the fear of routine occurrences.23 Given this premise, the current pandemic has synergistically affected the general anxiety of the population, this was verified through our survey as well. But we postulated that this may
have had a detrimental effect on dental anxiety as well.24-27 If this is proven true, the pandemic can have dire implications on dental economics.
Our study showed an inverse relationship between age and dental anxiety. Younger participants exhibited more anxiety than older ones. A similar trend has been reflected by Iranian and Indian studies.28,29 According to a survey carried out in India, increased dental anxiety levels were found in individuals age less than 40 years and professional workers.20 A Turkish study, however, demonstrated a higher anxiety in the older population.30
While we were unable to demonstrate a relationship between education and anxiety, prior studies have demonstrated higher anxiety levels in patients’ education (below primary).28,31 While other studies have shown that women are less anxious than men concerning dental treatment, our results have demonstrated higher dental anxiety scores in women.32 This may be attributed to higher levels of anxiety
in women through the pandemic.
We also noted that almost 44% of the patients were unwilling to go for their dental appointments. Our results were slightly higher than those published by a Brazilian study (38.3%).33 Since we recruited participants through an online survey, it is likely that our participants were better informed than the population seeking treatment at a dental facility, as in the Brazilian study.33 Majority of our participants
were willing to go to the dental clinics for only emergency treatment. However, a little over one-third were concerned about the pandemic affecting dental health.
Half of our participants claimed to have good oral hygiene habits. A little less than half were regular with their visits to the dentist in normal situation but were less likely to visit the dentist through the pandemic. This also demonstrates increased dental anxiety through the pandemic. For precautionary measures, majority of our participants thought that surgical masks, hand sanitizers/ alcohol gels,
social distancing in the waiting area and PPE were sufficient
for protecting both patients and dentists. These findings were supported by Peloso’s study.16 This implies that our participants had awareness about protective wear.

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Huma Tanvir1                              BDS, FCPS
Muhammad Haris2                     BDS, FCPS
Saroosh Ehsan3                         BDS, FCPS
Zarlashta Usman4                      BDS, FCPS
Muhammad Talha Khan5           BDS, FCPS
Zehra Ali Sultan6                        BDS, FCPS

OBJECTIVES: Root canal treatment (RCT) is performed to get rid of pain resulting from the infection in the tooth. It is a
safe procedure with high success rate. One of the main issues with root canal treatment is post-operative pain. There are many
factors which can cause pain and distress to patients.If the clinician follows the guidelines properly and use the anxiety reduction
protocol, then the procedure is not painful. RCT can be performed in multiple visits or it can be done in single visit. Present
research was conducted to compare the single visit versus multiple visits endodontic treatment in teeth with pulpal necrosis in
terms of
post-operative pain frequency.
METHODOLOGY: This study was a randomized controlled trial conducted at Department of Operative Dentistry, Fatima
Memorial Hospital, Lahore, over a period of six months. Total number of participants was 302 and the teeth were lower and
upper first and second molars with pulp necrosis and they were were equally assigned in two groups of 151with equal number
of men and women. Single visit RCT was done in Group A patients, in which the endodontic procedure was performed in one
day and multiple visit RCT was done in Group B, in which endodontic treatment was done in two or more visits.
RESULTS: In necrosed teeth single visit endodontic treatment 20.5(%) resulted in less frequent post-operative pain than in
multiple visit endodontic treatment (26.5%).
CONCLUSION: Single visit endodontic treatment is a better technique in terms of pain control as compared to multiple visit
in teeth with pulp necrosis.
KEYWORDS: Endodontics, Non-vital teeth, Post-operative pain, single visit root canal treatment, multiple visit root canal
treatment.
HOW TO CITE: Tanvir H, Haris M, Ehsan S, Usman Z, Khan MT, Sultan ZA. Comparison of post-operative pain frequency
after single visit and multiple visit root canal treatment in non-vital teeth. J Pak Dent Assoc 2022;31(2):91-94.
DOI: https://doi.org/10.25301/JPDA.312.91
Received: 11 February 2022, Accepted: 28 April 2022

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