Unilateral Protostylid on Buccal Surface of Permanent Maxillary First Molar: A Rare Finding

 

Ghazala Hassan1                         BDS

Sarah Ghafoor2                                   BDS, PhD

ABSTRACT: Human dentition either primary or permanent exhibits a number of developmental morphological variations ranging from mild alterations in tooth shape to well developed supernumerary cusp. These genetic malformations may present as an isolated finding or as a part of a syndrome. A protostylid is an uncommon anomaly which presents as a supernumerary or accessory cusp located on the mesial half of the buccal surface on the maxillary or mandibular molars which seldom pose problems to the patient. As its prevalence varies with ethnic diversity, it is a frequent object for anthropological studies. A 31 year old Pakistani female presented with a complaint of pain in right mandibular quadrant. Complete intraoral examination revealed a supernumerary cusp on the right permanent maxillary first molar as an incidental finding. No syndromic association was found.

KEY WORDS: Extra cusp; maxillary molar; morphological variations; protostylid; parastyle.

HOW TO CITE: Hassan G, Ghafoor S. Unilateral protostylid on buccal surface of  permanent maxillary first molar: a rare finding. J Pak Dent Assoc 2018;27(3):157-59.

DOI: https://doi.org/10.25301/JPDA.273.157

Received: 29 December 2017, Accepted: 19 April 2018

INTRODUCTION

Tooth development follows a series of reciprocally between the ectodermally-derived oral epithelium and neural crest cells-derived dental mesenchyme. A number of biological molecules released from these tissues maintain these reciprocal interactions. These secreted signaling molecules belong to major signaling families including Fibroblast growth factor (FGF), Transforming growth factor (TGF-β), Wingless (WNT) and Hedgehog (HH). Typically, development of placode relies on signals from all these four major families. These molecules then control various cellular events via interactions with transcription factors such as the members of Msx, Pax and Runx families.1

Developmental abnormalities affecting either deciduous or permanent dentition can exhibit in the form of changes in the crown shape, size or number of cusps or roots. These may affect one or more maxillary or mandibular teeth depending upon the magnitude of developmental disturbance. Developmental morphological variations such as gemination, fusion, taurodontism, concrescence, enamel pearl and supernumerary cusp have been reported.2

Dental traits which are not commonly seen in humans include protostylid, Entoconulid (Cusp 6) & Metaconulid (Cusp 7) on permanent molars and abnormal triangular morphology of deciduous molars have been reported.1 These anomalies are less frequent yet not uncommon. The purpose of this case report is to highlight finding of rare dental traits in human dentition as no data is available regarding such anomalies in Pakistani population.

CASE REPORT

A 31 year old female presented to the outpatient dental department of University of Health Sciences, Lahore, Pakistan in March, 2017 with the complaint of pain in right mandibular quadrant.

The patient reported with no history of any systemic illness. Complete intra-oral examination revealed poor oral hygiene status along with grossly carious right mandibular first molar. It also showed the presence of supernumerary cusp on the buccal aspect of the right maxillary first molar as an incidental finding. As a result the periodontium of the tooth was compromised and had gingival recession and bone loss with visible sub-gingival calculus and exposed root Figure 1.

Peri-apical X-ray of right maxillary first molar revealed an additional cusp over the mesio-buccal cusp. Other features include generalized inter-dental bone loss Figure 2.

The patient was not followed up. An informed consent regarding the publication of the scientific data was taken

Figure 1: Intra oral finding include supernumerary cusp on the buccal aspect of the right maxillary first molar indicated by black arrow.
Figure 2: Peri-apical X-ray of right maxillary first molar revealed an additional cusp over the mesio-buccal cusp along with a well-developed supernumerary root (Black arrow).

from the patient. An ethical approval from the Ethical Review Board of University of Health Sciences was also taken.

DISCUSSION

Elevations or a mold on the crown portion of the tooth which make up a divisional part of the occlusal surface is denoted as a cusp. Supernumerary or accessory cusps are the extra number of cusps that occur can on the surface of the tooth. Accessory cusps can occur either as dental anomalies (dens evaginatus) or as normal anatomical variations (protostylid, parastyle, and Cusp of Carabelli).3 These morphological variants manifest in low frequencies in the human populations and also represent racial and regional variations. There are no such reports published in Pakistani population regarding prevelance of these developmental anomalies.

“Paramolar Tubercle” is any stylar anomalous cusp or prominence on the outer surface of both maxillary and mandibular premolar and molars.3 It seldom poses any dental problem to the patient due to its location. In 1945, Dahlberg introduced a specific paleontological nomenclature for paramolar tubercle referring to this structure as parastyle when an extra cusp is found in the maxillary molars and as protostylid when its present in the mandibular molars.4 It is also called “Mesiobuccal edge prominencies”.

Paramolar tubercle vary with respect to size and shape. It may present as anything ranging  from a mere eminence on the outer surface, distinguished from rest of the tooth by a fossa or a groove, to a well-developed lobulated cusp, separated by a constriction and having the appearance of a fused supernumerary tooth. This lobulated structure is often found in association with a rudimentary or well-developed root.5,6 It is not always necessary that these tubercles contain pulp tissue. Root canals configuration of the tubercle range from canal connected to the other canals7 or may present as an isolated canal.8 Radiographic findings include a dentin core is covered by enamel. If tubercule is worn to point of pulpal exposure or fracture, pulpal necrosis may occur.4

The cause of supernumerary cusp formation or abberant shape is multi-factorial. However, it is believed that overactivity PAX and MSX genes in the dental lamina lead to the abnormal shape of the teeth.3 Also mutations in Eda and Edar can lead to mishappentooth. Over-expression of Eda A1 could lead to extra cusp and tooth formation. Mouse mutants of Eda (Tabby) have abnormal shape of crown .9 Para-molar tubercles provide insight into dental evolution and development.

Paramolar tubercles have long been recognized as nonmetric dental traits (NMDT) which are the structural features manifested within certain biological and geographical domains. Ethnic and racial variations may play an important role in its occurrence. The occurrence of paramolar tubercle is relatively uncommon. Though there is very little information about racial differences in the frequencies of paramolar tubercles, primarily because of their low occurrence, none the less they should not be classified as anomalous structure since they are normal morphological features of the dentition. They usually presents unilaterally in the permanent dentition. Its frequency varies different populations.  The prevalence of protostylid varies in different ethnic groups, like 18.5% in Japanese people, 37.5% in Chinese population, while 5.4 % in Colombian population.10

The paramolar tubercles are clinically relevant as they affect the treatment regimens and its related problems in many dental specialities. These superstructures are potent areas for plaque adherence as maintenance of oral hygiene in these areas is difficult and recurrence of dental caries, gingivitis, and localized periodontitis is more common. As observed in our case, the tubercle that projects from the tooth or the alveolus causes gingival regression leading to a decreased buccal alveolar bone level resulting in deterioration of the surrounding periodontal tissue. These tubercles even pose problem in the preparation of a tooth for the setting of an artificial crown.11

CONCLUSION

Protostylid or parastyle is a developmental tooth anomaly that has a rare occurance in human population. It has evident clinical implications which distinguish it markedly from teeth with normal morphological features. This manuscript encourages the dentists to report the cases of unusual morphological characteristics and to design the prevalence population studies in order to determine the NMDT’s frequency and variability among different ethnic populations. Thus, contributing to the construction of world dental anthropological data.11

ACKNOWLEDGEMENTS

We would like to acknowledge Higher Education Commission (HEC) and University of Health Sciences (UHS) library for the facility of E-library and online search of appropriate content.

Disclaimer: We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

REFERENCES

  1. Jussila M, Thesleff I. Signaling networks regulating toothorganogenesis and regeneration, and the specification of dental
  2. Turner RA, Harris EF. Maxillary second premolars with paramolartubercles. Dental Anthropology. 2004;17(3):75-8.
  3. Desai VD, Sadnani H, Kumar SM, Pratik P. Protostylid: As neverreported before! A unique case with variation. Journal of Indian Academy of Oral Medicine and Radiology. 2016;28(1):57. https://doi.org/10.4103/0972-1363.189982
  4. Dahlberg AA. The evolutionary significance of the protostylid.American journal of physical anthropology. 1950;8(1):15-26. https://doi.org/10.1002/ajpa.1330080110
  5. Friedman S, Stabholz A, Rotstein I. Endodontic management ofmolars with developmental anomalies. International endodontic journal. 1986;19(6):267-76. https://doi.org/10.1111/j.1365-2591.1986.tb00490.x
  6. Magalee R, Kramer S. The paramolar tubercle: a morphologicalanomaly with clinical considerations. The New York state dental journal. 1984;50(9):564, 6-, 6.
  7. Zidan O, El-Deeb M. Restorative and endodontic management ofan anomalous mandibular molar. Quintessence International. 1991;22(3).
  8. Baghdady MT, Pharoah MJ, Regehr G, Lam EW, Woods NN. Therole of basic sciences in diagnostic oral radiology. Journal of dental education. 2009;73(10):1187-93.
  9. Thesleff I. The genetic basis of tooth development and dental defects.American Journal of Medical Genetics Part A. 2006;140(23):2530-5. https://doi.org/10.1002/ajmg.a.31360
  10. Baby TK, Sunil S, Babu SS. Nonmetric traits of permanent posteriorteeth in Kerala population: A forensic overview. Journal of oral and maxillofacial pathology: JOMFP. 2017;21(2):301. https://doi.org/10.4103/jomfp.JOMFP_21_17
  11. Moreno S, Reyes MP, Moreno F. Cusp expression of protostylidin deciduous and permanent molars. Journal of forensic dental sciences. 2016;8(3):155. https://doi.org/10.4103/0975-1475.195108.

  1. M.Phil Student Part II, Department of Oral Biology, University of Health Sciences, Lahore, Pakistan.
  2. Assistant Professor, Department of Oral Biology, University of Health Sciences, Lahore, Pakistan.
    Corresponding author: “Dr. Sarah Ghafoor” <sarahghafoor@uhs.edu.pk>

Unilateral Protostylid on Buccal Surface of Permanent Maxillary First Molar: A Rare Finding

 

Ghazala Hassan1                         BDS

Sarah Ghafoor2                                   BDS, PhD

ABSTRACT: Human dentition either primary or permanent exhibits a number of developmental morphological variations ranging from mild alterations in tooth shape to well developed supernumerary cusp. These genetic malformations may present as an isolated finding or as a part of a syndrome. A protostylid is an uncommon anomaly which presents as a supernumerary or accessory cusp located on the mesial half of the buccal surface on the maxillary or mandibular molars which seldom pose problems to the patient. As its prevalence varies with ethnic diversity, it is a frequent object for anthropological studies. A 31 year old Pakistani female presented with a complaint of pain in right mandibular quadrant. Complete intraoral examination revealed a supernumerary cusp on the right permanent maxillary first molar as an incidental finding. No syndromic association was found.

KEY WORDS: Extra cusp; maxillary molar; morphological variations; protostylid; parastyle.

HOW TO CITE: Hassan G, Ghafoor S. Unilateral protostylid on buccal surface of  permanent maxillary first molar: a rare finding. J Pak Dent Assoc 2018;27(3):157-59.

DOI: https://doi.org/10.25301/JPDA.273.157

Received: 29 December 2017, Accepted: 19 April 2018

Polymorphous Adenocarcinoma (PAC)

Humayun Kaleem Siddiqui1                         BDS, FCPS

Ausaf Ahmed Khan2                                                   MBBS, FCPS

Sharjeel Bashir3                                              BDS

Syed Muratza Raza Kazmi4                           BDS, FCPS

ABSTRACT: Polymorphous adenocarcinoma (PAC) is almost entirely related to minor salivary glands. It is mostly found in the palatal region but on rare it was also observed in other intraoral areas. In recent studies it is observe that there is a potential for histological transformation of the lesion from low to high grade malignancy.

CASE REPORT: A 52 year old male reported to Memon Medical Institute Hospital dental OPD with growth on hard plate for 6 months and mobility of teeth. The lesion was painless with no signs of ocular involvement. Lesion was extending from premaxillary region covering whole of the hard palate to soft palate and beyond. CT scan showed heterogenous enhancing mass with calcifications probably arising from alveolar process of left upper jaw causing complete destruction of left alveolar processes with maxillary bone and hard palate. A plan for total maxillectomy was discussed with the patient and the defect to be filled with a hollow acrylic obturator. On 2 year follow-up, the patient was doning well with no signs of recurrence.

KEY WORDS:  Adenocarcinoma, Palate, Salivary glands, Tumour.

HOW TO CITE: Siddiqui HK, Khan AA, Bashir S, Kazmi SMR. Polymorphous adenocarcinoma (PAC). J Pak Dent Assoc 2018;27(3):152-56.

DOI: https://doi.org/10.25301/JPDA.273.152

Received: 05 October 2017, Accepted: 15 February 2018

INTRODUCTION

Polymorphous adenocarcinoma (PAC) is almost entirely related to minor salivary glands.1-3 In 1983, Freedman et al, described and named it lobular carcinoma on its resemblance to lobular carcinoma of the breast.2,4 On histopathology it is frequently misdiagnosed as pleomorphic adenomas, monomorphic adenomas, adenoid cystic carcinoma, malignant pleomorphic adenomas or adenocarcinoma.4,5

In 1984, Batsakis et al, introduced the term Polymorphous low grade adenocarcinoma (PLGA).6This carcinoma is mostly found in the palatal region but on rare it was also observed in other intraoral areas like upper lip, buccal mucosa, posterior tongue and retromolar trigone.5,7 It is usually found in 6th to 7th decade of life and occasioinally in adolescents.8-10 It is the second most common malignant tumor of the minor salivary gland followed by mucoepidermoid carcinoma.7 PAC is extremely infrequent in the major salivary glands.11 Recently detection of PAC has been reported in other areas instead of minor salivary glands like major salivary glands.12 The breast13, paranasal sinuses14, the skin and orbit15, vulva and vagina16, Lung lesions were also reported both as metastatic and primary lesions.8,17 Possible variant of PAC is Cribriform Adenocarcinoma of Tongue (CAT) and other Salivary Glands (CASG), but it is not clear yet whether is shows genuine entity or just unusual growth pattern in PAC.18 Histological and molecular features overlap between PAC and CASG, but CASG is a distinct tumor entity and differ from PAC by location, behavior, cytology and histologically.19 Histological and immunohistochemical features of these lesions are similar to the minor salivary gland lesions.3,12,13,16 PAC is clinically innocuous in-spite of its local infiltrative pattern and perineural and pervascular invasive features.5,20 Less than 1% of cases shows low grade malignant

potential .9,20And distant spread is rare. In recent studies it has been shown that the lesion is locally aggressive in few of cases.10,20,21 Aggressive clinical progression have been associated with various factors like inadequate excision with positive margin, repeated surgery, exposure to radiation, prolonged duration and occurrence in a young patient.10,20-22

On histopathology PAC is non-encapsulated and shows infiltrative borders. Growth pattern shows high variability that include tubular, solid, papillary, microcytic, cribriform, fascicular, single file and strand like arrangement.20,21 This morphologically different growth patterns are responsible for difficulty in diagnosis and confusion with other salivary gland tumors like pleomorphic adenoma and adenoid cystic carcinoma. In these types of cases immunohistochemical studies are indicated.23

In recent studies a potential for histological transformation of the lesion from low to high grade malignancy was observed 10,20 and the papillary cystic pattern was associated with aggressive clinical behavior.5,20-22

CASE REPORT

A 52 year old male reported to Memon Medical Institute Hospital dental OPD with growth on hard palate for 6 months and mobility of teeth. A previous biopsy showed ameloblastoma at another hospital. He was generally healthy otherwise. Extraorally the lesion was painless with no signs of ocular involvement. Paraesthesia in the division of infraorbital region was not found. All the ocular movements were in normal range with intact vision on both sides. Submandibular lymph nodes were not palpable. Intraorally a 4×3 cm swelling was noted with ulceration in the middle palate as a result of previous biopsy. The lesion was extending from premaxillary region covering whole of the hard palate to soft palate and beyond. The overlying mucosa was swollen with intact predominantly pink mucosal surface. Slight mobility of the maxillary teeth was noted. On palpation the lesion was firm to soft. There was no active discharge or bleeding. Left buccal and labial sulcus was slightly enlarged whereas right sulcus was in normal limits.

CT scan axial images showed heterogenous enhancing soft tissue mass with amorphous calcification, measuring 7.9×9.2×7.6 cm (CC x AP x Transverse), arising from alveolar processes of left upper jaw causing complete destruction of left alveolar process with maxillary bone and hard plate. The Mass was extending and occupying left maxillary sinus, nasopharynx and posterior aspect of both nasal cavities. It was extending from left cheek crossing the midline and reaching up to the medial wall of right maxillary sinus and superiorly extending into the ethmoidal sinuses. Fluid density and air was seen in right maxillary sinus could be due to obstruction by mass resulting in sinusitis. Expansion of posterior nasal cavity and nasopharynx was also noted. Mass was also abutting with both medial pterygoid plates. No abnormality was seen in the prelaryngeal space, valleculae and pyriform sinuses. The laryngeal, arytenoids and cricoids cartilages were normal. The thyroid gland showed homogenous enhancement with no focal mass. Major blood vessels of neck and both vocal cords were normal. Few subcentimeter lymphnodes were seen at submental, submandibular and right supraclavicular levels.

A plan for total maxillectomy was discussed with the patient and the defect to be filled with a hollow acrylic obturator. Under GA a Weber-Fergusson incision with infraorbital extension on left side was used to expose the tumour. A combination of sharp and blunt dissection with judicious use of periosteal elevator was used to excise the tumour with a margin of 1.5 cm overall. The tumour was removed along with the normal tissues from nasal cavity, paranasal sinuses, inferior turbinate and up to the anterior pharyngeal wall a thin sling of soft palate tissue was maintained to aid in closure and help in retention of obturator. A thin shelf of right maxillary antral wall was left with two teeth to aid in retention of the final denture. After tumour excision, a split thickness skin graft was applied to the large cavity followed by Antibiotic impregnated ribbon gauze placement and a prefabricated initial obturator was placed with circumzygomatic wires bilaterally.

Figure 1A & 1B: Pre-operative Coronal and Axial section on CT Scan

An intraoperated biopsy was sent for further confirmation. Sections examined revealed an invasive lesion composed of nest of neoplastic cell arranged in fused glands along with few areas showed cribriforming pattern of neoplastic cells. These nest and cribriform areas showed plump columnar cells with moderate atypia. At places plasmacytoid appearance of cells was also noted.

The patient was followed after two weeks with interim obturator and final obturator with maxillary teeth with the help of maxillofacial prosthodontist. On a two year follow up the patient was doing well with no signs of recurrence.

DISCUSSION

Polymorphous Adenocarcinoma (PAC) is an uncommon tumour and mostly related to minor salivary glands.1,3 It was first described in 1983 by Freedman et al, and it was named lobular carcinoma on its resemblance to lobular breast carcinoma.2,4 In 1984, Batsakis et al, introduced the term Polymorphous low grade adenocarcinoma (PLGA).6 The most preferred location for this tumour is noted to be the palatal region and minor salivary glands are involved in majority of cases3 but on rare occasion it was documented in other intra oral areas also like upper lip, buccal mucosa, posterior tongue and retromolar trigone.5,7 Patients mean age with PAC is noted

to be approximately 58 years, and male to female ratio is around 1:2.24 A study of One-sixtyfour patients of PAC with average follow up nearly 10 years, showed 97.6% of all patients treated by surgery were either alive or died without any evidence of tumour recurrence.24 From 164 patients, only 4 had evidence of tumour recurrence at the last follow up. Three died and only one was alive with a tumour.11

We describe here a case of PAC arising from minor salivary gland of the palate. The lesion was arising from alveolar process of left upper jaw causing complete destruction of left alveolar process, extending and occupying left maxillary sinus, nasopharynx and posterior aspect of both nasal cavities. From left cheek crossing the midline and reaching up to the medial wall of right maxillary sinus and superiorly extending into the ethmoidal sinuses. Expansion of posterior nasal cavity and nasopharynx was also noted. The Mass was also abutting with both medial pterigoid plates, no evidence of metastatic disease was found.

PAC is almost entirely arising from minor salivary glands and is considered to be a low grade.11 This tumours is generally slow growing.11 Previously some tumours have been reported to have variable pattern of local recurrence and metastasis.11 The extent and radiographic features of PAC were described in very few cases.11 De magalhaes et al,25 document a mandibular lesion with unusual radiographic features that resemble to a benign tumour.11 On the basis of these findings, an ameloblastoma was considered to be preferred diagnosis in that case. An intraosseous PAC of the maxilla is described by Sato et al, in this a panoramic radiographic features were more similar to a radicular cyst, but in C.T scan irregular scalloping and perforation of the cortical borders indicates a malignant lesion.11

Our case showed different radiographic features that resembled to slow growing tumour with aggressive. On C.T scan a heterogenous soft tissue mass with amorphous calcification was seen that was arising from alveolar processes of left upper jaw causing complete destruction of left alveolar processes with maxillary bone and hard palate. Mass was extending from left vestibule crossing the midline and reaching upto the medial wall of right maxillary sinus and superiorly extending into the ethmoidal sinuses. Expansion of posterior nasal cavity and nasopharynx was noted. Few sub-centimeter lymphnodes was seen at submental, submandibular and right supraclavicular levels. These all features were resembling to a low grade tumour of minor salivary gland origin.11 At some occasion these tumours could be misdiagnosed due to its varied histomorphological patterns.11

Histopathological examination of excised tumour revealed an invasive lesion composed of nest of neoplastic cell arranged in fused glands along with few areas showing cribriforming pattern of neoplastic cell. These nest and cribriform areas showed plump columnar cells with moderate atypia. At places plasmacytoid appearance of cells are also noted. Based on morphology and PAC.

In most of cases of PAC excision of the primary lesion with wide margin is recommended, but in some cases modified radical neck dissection is indicated. Recurrences may occur after a long period, so for prevention prolonged and systemic follow up is recommended.22,24,26 In majority of cases prognosis is good but mortality rate up to 12.5% was documented in a research comprising of 40 patients that are followed up for the time of ten years.21 Because of this behavior some authors suggested to remove the term “low grade” from the name.27

CONFLICT OF INTEREST

None declared.

REFERENCES

  1. Soames JV, Southam JC. Diseases of Salivary Glands. Oral Pathology. 4th ed. 2005: 218.
  2. Olusanya AA, Akadiri OA, Akinmoladun VI, et al. Polymorphous lowgrade adenocarcinoma: literature review and report of lower lip lesion with suspected lung metastasis. J maxillofac Oral Surg. 2011; 10(1): 60-63.
  3. Hannen EJ, Bulten J, Festen J, et al. Polymorphous low-grade adenocarcinoma with distant metastases and deletions on chromosome 6q23-qter and 11q23-qter: a case report. J ClinPathol. 2000; 53: 942-945. https://doi.org/10.1136/jcp.53.12.942
  4. Freedman P, Lumerman H. Lobular carcinoma of intraoral minor salivarygland origin: report of twelve cases. Oral Surg Oral Med Oral Pathol 1983; 56: 157-166. https://doi.org/10.1016/0030-4220(83)90282-7
  5. Vincent SD, Hammond HL, Finkelstein MW. Clinical and therapeuticfeatures of polymorphous low grade adenocarcinoma. Oral Surg Oral Med Oral Pathol. 1994; 77: 41-47. https://doi.org/10.1016/S0030-4220(06)80105-2
  6. Evans HL, Batsakis JG. Polymorphous low-grade adenocarcinoma ofminor salivary glands. A study of 14 cases of distinctive neoplasm. Cancer. 1984; 53: 935-942.
  7. Waldron CA, el-Mofty SK, Gnepp DR. Tumors of the intraoral minor salivary glands: a demographic and histologic study of 426 cases. Oral Surg Oral Med Oral Pathol. 1988; 66: 323-333 https://doi.org/10.1016/0030-4220(88)90240-X
  8. Lee VK, McCaughan BC, Scolyer RA. Polymorphous low-grade adenocarcinoma in the lung: a case report. Int J Surg Pathol. 2004; 12:
    287-292. https://doi.org/10.1177/106689690401200313
  9. Lengyel E, Somogyi A, Godney M, et al. Polymorphous low-grade adenocarcinoma of the nasopharynx. Case report and review of literature. Strahlenther Onkol. 2000; 176: 40-42. https://doi.org/10.1007/PL00002304
  10. Tanaka F, Wada H, Inui K, et al. Pulmonary metastasis of polymorphous low-grade adenocarcinoma of the minor salivary gland. Thorac Cardiovasc Surg. 1995; 43: 178-180. https://doi.org/10.1055/s-2007-1013795
  11. Potluri A, Prasad J, Levine S, et al. Polymorphous low-grade adenocarcinoma: a case report. Dento-maxillofacRadiol. 2013; 42:480-
    484. https://doi.org/10.1259/dmfr/14804843
  12. Yih WY, Kratochvil FJ, Stewart JC. Intraoral minor salivary gland neoplasms: review of 213 cases. J Oral Maxillofacial Surg. 2005; 63: 805- 810. https://doi.org/10.1016/j.joms.2005.02.021
  13. Asioli S, Marucci G, Ficarra G, et al. Polymorphous adenocarcinoma of the breast. Report of three cases. Virchows Arch. 2006; 448: 29-34. https://doi.org/10.1007/s00428-005-0084-2
  14. Charous DD, Cunnane MF, Rosen MR, et al. Recurrent polymorphous low-grade adenocarcinoma manifesting as a sinonasal mass: a case report. Ear Nose Throat J. 2005; 84: 354-357.
  15. Thomas KM, Cumberworth VL, McEwan J. Orbital and skin metastasis in polymorphous lowgrade adenocarcinoma of the salivary gland. J Laryngol Otol. 1995; 109: 1222-1225. https://doi.org/10.1017/S0022215100132517
  16. Young S, Leon M, Talerman A, et al. Polymorphous low-grade adenocarcinoma of the vulva and vagina: a tumor resembling adenoid cystic carcinoma. Int J Surg Pathol. 2003; 11: 43-49. https://doi.org/10.1177/106689690301100113
  17. Kyu Do Cho, Ji Han Jung, Deog Gon Cho, et al. Primary polymorphous low grade adenocarcinoma of lung treated by sleeve bronchial resection: a case report. J Korean Med Sci. 2007; 22: 373-376. https://doi.org/10.3346/jkms.2007.22.2.373
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  19. WHO classification salivary tumours: An update on Histopathology of Salivary Gland Tumors, La Spezia, Italy, Oct 18-20, 2017.
  20. Simpson RH, Pereira EM, Ribeiro AC, et al. Polymorphous low grade adenocarcinoma of the salivary glands with transformation to high-grade carcinoma. Histopathology. 2002; 41: 250-259. https://doi.org/10.1046/j.1365-2559.2002.01439.x
  21. Harry L, Evans MD, Mario A, et al. Polymorphous low-grade adenocarcinoma a study of 40 cases with long-term follow up and an evaluation of the importance of papillary areas. Am J Surg Pathol. 2000; 24: 1319-1328. https://doi.org/10.1097/00000478-200010000-00001
  22. Pelkey TJ, Mills SE. Histologic transformation of polymorphous low-grade adenocarcinoma of salivary gland. Am J Clin Pathol. 1999; 111: 785-791. https://doi.org/10.1093/ajcp/111.6.785
  23. Chaâbouni S, Ayadi L, Dhouib H, et al. Polymorphous low-grade adenocarcinoma: a palatine and a labial location. Rev Stomatol Chir Maxillofac. 2008; 109: 178-182. https://doi.org/10.1016/j.stomax.2008.04.002
  24. Castle J, Thompson L, Frommelt RA, Wenig B, Kessler H. Polymorphous low grade adenocarcinoma: a clinicopathologic study of 164 cases. Cancer 1999; 86: 207-219. https://doi.org/10.1002/(SICI)10970142(19990715)86:2<207::AID-CNCR 4>3.0.CO;2-Q
  25. de Magalhaes M, de Magalhaes R, de Araujo V, de Sousa S. Polymorphous low grade adenocarcinoma presenting an uncommon radiographic aspect. DentomaxillofacRadiol 2006; 35: 209-212. https://doi.org/10.1259/dmfr/17652888
  26. Gonzalez-Garcia R, Rodriguez-Campo FJ, et al. Polymorphous lowgrade adenocarcinoma of the palate: report of cases. Auris Nasus Larynx. 2005; 32: 275-280. https://doi.org/10.1016/j.anl.2005.03.019
  27. Speight PM, Barrett AW. Salivary gland tumors. Oral Dis. 2002; 8: 229-240. https://doi.org/10.1034/j.1601-0825.2002.02870.x

  1. Associate Professor, Oral and Maxillofacial Surgery Head of Oral and Maxillofacail Surgery Dept Baqai Dental College, Baqai Medical Univeristy Karachi, Pakistan.
  2. Consultant, ENT Surgeon Memon Medical Institute Hospital Karachi, Pakistan.
  3. Masters Candidate, Oral and Maxillofacial Surgery University of Karachi Karachi, Pakistan.
  4. Professor, Prosthodontics Fatima Jinnah Dental College Karachi, Pakistan.
    Corresponding author: “Dr. Sharjeel Bashir ” < drsharjeelbashir@yahoo.com >

Polymorphous Adenocarcinoma (PAC)

Humayun Kaleem Siddiqui1                         BDS, FCPS

Ausaf Ahmed Khan2                                                   MBBS, FCPS

Sharjeel Bashir3                                              BDS

Syed Muratza Raza Kazmi4                           BDS, FCPS

ABSTRACT: Polymorphous adenocarcinoma (PAC) is almost entirely related to minor salivary glands. It is mostly found in the palatal region but on rare it was also observed in other intraoral areas. In recent studies it is observe that there is a potential for histological transformation of the lesion from low to high grade malignancy.

CASE REPORT: A 52 year old male reported to Memon Medical Institute Hospital dental OPD with growth on hard plate for 6 months and mobility of teeth. The lesion was painless with no signs of ocular involvement. Lesion was extending from premaxillary region covering whole of the hard palate to soft palate and beyond. CT scan showed heterogenous enhancing mass with calcifications probably arising from alveolar process of left upper jaw causing complete destruction of left alveolar processes with maxillary bone and hard palate. A plan for total maxillectomy was discussed with the patient and the defect to be filled with a hollow acrylic obturator. On 2 year follow-up, the patient was doning well with no signs of recurrence.

KEY WORDS:  Adenocarcinoma, Palate, Salivary glands, Tumour.

HOW TO CITE: Siddiqui HK, Khan AA, Bashir S, Kazmi SMR. Polymorphous adenocarcinoma (PAC). J Pak Dent Assoc 2018;27(3):152-56.

DOI: https://doi.org/10.25301/JPDA.273.152

Received: 05 October 2017, Accepted: 15 February 2018

Awareness About Dental Radiography Among Dental Students

Rooha Sultan1                                          BDS

Khurram Parvez2                                                BDS, MSc

Hina Qureshi3                                          FCPS, MCPS, MBBS

 

OBJECTIVE: To assess the difference in knowledge and attitude of graduates and undergraduates towards radiological practice and hazards in dentistry.

METHODOLOGY: A cross-sectional questionnaire based study was conducted on the dental students and trainees of a public sector teaching and tertiary care institute. Questionnaire consisted of three sections of multiple choice questions including those of knowledge about dental radiography (05 questions), attitude towards dental radiography (05 questions) and practices pertinent to dental radiography (06 questions). Statistical analysis was performed using SPSS version 16.0 software. Pearson’s Chi Square test was used for the comparison of responses between the two groups at a p=value <0.05.

RESULTS: Out of total 900 participants, data of 480 participants were included in the data analysis (postgraduates= 251; undergraduates=229). Descriptive analysis shows that undergraduates had less knowledge and lack attitude and practices towards dental radiography as compared to postgraduate students with significant difference between the two groups (p <0.05).

CONCLUSION: This lack of knowledge, attitude and practices among undergraduate students (including house officers) suggest that there is a need to improve the knowledge, attitudes and practices pertinent to basic dental radiography among undergraduate students and house officers and bring it at par to that of postgraduate trainees.

KEY WORDS:  Radiography, graduates, undergraduates, protection, hazards, x-rays.

HOW TO CITE: Sultan R, Parvez K, Qureshi H. Awareness about dental radiography among dental students. J Pak Dent Assoc 2018;27(3):147-51.

DOI: https://doi.org/10.25301/JPDA.273.147

Received: 01 February 2018, Accepted: 16 April 2018

INTRODUCTION

X-rays are radiations of electromagnetic nature that produce ions on passing through matter that might pose injurious to healthy tissues. Production of free radicals or ions is alleged to have damaging effects to the human DNA by alteration and mutations.1-1 Apart from the negative effects the effectiveness of x-rays in dental imaging for diagnostic and clinical applications is far too valuable to be negated.1,4

Biological hazards associated with radiations are divided into stochastic and non-stochastic effects. Non-stochastic or deterministic effects are manifested only after a certain specified value of radiation dosage through exposure is breached while stochastic effects have no such threshold value thus may be regarded as more detrimental and difficult to manage. High consideration is required by practitioners while advising x-rays because radiations used in dentistry come under the category of stochastic effects.2,5,6 International Commission on Radiological Protection introduced its recommendations along with the ALARA principle ‘As Low As Reasonably Achievable’ in order to minimize patient as well as practitioner’s exposure to unnecessary radiations. It also emphasizes on the protection protocol consisting of the technique related precautions such as of the ideal distance between the practitioner and the radiation source, use of dosimeter, x-ray film holding technique and the use of lead barriers.2,4,5,7

The KAP study conducted in January 2017 in Bihar, India revealed a low to average result among undergraduates and graduates regarding radiation biology and protection.1 The following study was conducted so that it may help us in evaluating the level of knowledge regarding radiological practices that undergraduate and graduates dental practitioners in our set up possess.

METHODOLOGY

A cross-sectional questionnaire based study was carried out at Dow University of Health Sciences. All dental students and trainees including undergraduates, house officers and post graduate trainees enrolled in various programs of Dow University of Health Sciences (N=900) were approached. However, those who were absent on the day of data collection and those who refused to participate in this study were excluded. Any kind of missing information in the questionnaire collected by the participant also deemed that participant as excluded. The questionnaire was distributed one time only by the first author. Only 750 questionnaires in total could be distributed as per their presence and verbal consent. Questionnaire to undergraduate students were distributed in the lecture halls while house officers and trainees were approached in their respective outpatient departments during their clinical rotations. Immediately next day the questionnaires were collected back from all of them. Only 480 completely filled questionnaires were included in the study which comprised of 229 from undergraduates and 251 from graduates as per the purpose of identifying differences in the responses of the two groups.

The questionnaire used in this study was adapted from a similar previous study conducted by Eman Arnout et al.4,5 It consisted of four sections the first section categorized the samples demographically according to age, gender and qualification. The next section comprised of questions based on the knowledge of radiation hazards with multiple choice answers. Third set of questions again with multiple choice answers targeted to assess the attitude of dental students towards the technique of dental radiography. The final section of multiple choice questions was aimed at evaluating the extent of protection protocols of radiology followed by the participants.

The collected data was entered processed and analyzed through SPSS (version 16.0). Statistical significance was evaluated by the application of Pearson Chi-square test. Mean and standard deviation was calculated on the basis of age and gender of the participants and frequency percentage was calculated for the overall categorical variables. A p value of <0.05 was considered significant.

RESULT

The study participants included a total of 480 subjects consisting of 229 undergraduates with age ranging between 18years to 25years and 251 graduates with age ranging from 24years to 40years; among the two groups 115 were  males and 365 females. Tables 1.1-1.3 signify the difference in

Table 1.1 Knowledge based questions given to participants and their responses

Table 1.2 Attitude based questions given to participants and their responses

Table 1.3 Practice based questions given to participants and their responses

responses to questions on knowledge, attitude and practice of dental radiography between the two groups along with statistical values. A significant difference can be appreciated between the values of results obtained among undergraduates and graduates.

DISCUSSION

Radiation exposure may be associated with causing harm to the living cells and DNA that might result in shortening human life span this has led medical practitioners to the development of unorthodox specialized and specific radiation techniques like cone beam computed tomography (CBCT) and magnetic resonance imaging (MRI) etc.2,7 Dental radiography is not usually associated with the same kind of hazardous effects it still is essential to monitor and control its stochastic effects. This may be achieved by possessing enough knowledge of the radiation biology and adhering to the protection protocols recommended by NCRP/ICRP.2,6

The result of the present study shows the recognition of dental x-rays as being harmful with a positive response from significant number of participants, undergraduates and graduates alike. But on elaboration of x-rays being reflected from walls graduates came up with far better response than undergraduates indicating the difference in experience. This comes out as a better response compared to the study published in January 2017 conducted in India in which a very non-significant number of graduates responded positively.2 This may pertain to the fact that the current study included graduates with far greater years of experience not just interns but postgraduate trainees and participants with private practices as well. Almost half the sample size of participants claimed to recognize the radiation hazard symbol, far less in comparison to the result of study conducted in an Indian institution.6 It is worth mentioning though that there is significant difference in the sample size of both the studies also a greater proportion of graduates in the current study. NCRP/ICRP introduced the ALARA principle ‘As Low As Reasonably Achievable’ in order to monitor the amount of radiation exposure along with its own recommended radiation protection guidelines but the overall response suggested negligence in this field.4,5 There was lack of knowledge about the ALARA principle and even lesser participants from both groups were aware of the NCRP/ICRP recommendations. Similar results were reported by a study on dental students in India as well.1 Astonishingly quite nonsignificant number of participants possess the correct knowledge of the position distance rule. This rule helps in reducing the intensity and scattering effects of radiation.1,3 A study in Egypt reported better results but with far smaller sample size which consisted of very small number of undergraduate participants in comparison to the current study.4

About the attitude of practitioners towards dental x-ray techniques a mixed response was observed on being asked about the advice of multiple radiographs for diagnostic purpose. Again an average response was recorded regarding endodontic radiography. Surprisingly small number of participants agreed that conventional radiography requires more exposure than digital radiography. An Indian study reported quite a positive outcome but the participants had only recently been posted in the department of radiology while another institutional study also had comparatively better positive feedback.1,6 A dosimeter is a self-monitoring device used to measure the amount of radiation that a person is exposed to over a course of time. It is extremely useful for professionals involved in everyday radiography.1,5 The study revealed that a very non- significant number of undergraduates and graduates are aware of the use of dosimeters in dental radiography. Difference in attitude can be assessed with less than average response from undergraduates and a significant positive response from graduates in agreeing that dental radiography is not completely contraindicated in pregnant patients but to be advised with extreme caution and special precautions. A similar outcome was revealed in a study conducted on Egyptian students.4 Direct contact of dental professionals and patients with the radiation source during exposure should be minimized as much as possible. Regarding the everyday dental radiography practice a low to average outcome was revealed by the participants about their x-film holding techniques. Of even lower significance is the number of participants in both groups admitting to the use of x-film holding devices during exposure. Lead serves as one of the best radiation barriers leading to its use in lead aprons to reduce the harmful effects of exposure for professionals and patients alike.1,7 This study reveals that a very non-significant proportion of participants use lead aprons in their routine dental radiological practice. In comparison to quite a better response reported by studies conducted in India and Saudi Arabia we might take in consideration the unavailability of protective equipment to the participants of the current study.1,5 Quite a significant positive response was recorded from both groups about not advising x-rays to pregnant patients as a precautionary measure.

More studies should be conducted at other study settings not only on dental students but on practitioners as well to evaluate dental radiography practices being conducted by dentists in our region. Dental education curriculum should be investigated for what value is given to the protection protocols and techniques of dental radiography at undergraduate and post graduate study levels. Strengths/Weaknesses/Limitations of Study:

This study has a large sample size which gives us considerable amount of data for analysis and evaluation of awareness about dental radiography among dental students. Also the questionnaire used consists of precise and basic questions related to dental radiography for both undergraduate and graduate level students.

Our study was limited by the loss of a considerable amount of data due to the exclusion criteria of the study. The number of subjects in the comparative groups of undergraduates and graduates was unequal. The responses may vary depending on the learning level year or semester of an undergraduate or post graduate dental student.

RECOMMENDATIONS

Dental radiography should be an important aspect of undergraduate dental education. With due theoretical knowledge being imparted clinical practice is all the more important for the application of that knowledge and should become routine practice in teaching institutes. Continuing radiological education for graduates holds importance in refreshing their previous knowledge along with being up to date with new technology and changes in NCRP/ICRP recommendations. Seminars and workshops are the best way for graduates to share and increase their knowledge.

CONCLUSION

The results of this study show lack of knowledge regarding the biology, hazards and practice of dental radiography among the two groups. Due consideration is required to the basic knowledge and education of radiology specially at undergraduate level while the lacking at the graduate level can be dealt with repeated short courses and workshops on the subject.

CONFLICT OF INTEREST

None declared.

REFERENCES

  1. Srivastava R, Jyoti B, Jha P, Shukla A. Knowledge, attitude,perception toward radiation hazards and protection among dental undergraduate students: A study. Journal of International Oral Health. 2017; 9(2): 81. https://doi.org/10.4103/jioh.jioh_26_16
  2. Swapna LA, Koppolu P, Takarji B, Al-Maweri SA, Velpula N,Chappidi V, et al. Knowledge on Radiation Protection & Practice among Dental Students. Brit J Med Med Res 2017; 9 (7): 1-7 https://doi.org/10.9734/BJMMR/2017/30761
  3. Tejavathi Nagaraj NS, James L, Veerabasaviah BT, Goswami RD,Balraj L. An assessment of knowledge and perception of postgraduate students and interns toward radiation protection protocols: A questionnaire-based study in dental colleges. J Med Radiol Pathol Surg 2016; 3: 5-9.
  4. Arnout E. Knowledge, attitude and perception among Egyptiandental undergraduates, interns and postgraduate regard biological hazards and radiologic protection techniques: a questionnaire based cross-sectional study. Life Sci J. 2014; 11(6): 9-16.
  5. Arnout E, Jafar A. Awareness of biological hazards and radiationprotection techniques of dental imaging-A questionnaire based crosssectional study among Saudi dental students. J Dent Health Oral Disord Ther. 2014; 1(1): 1-7. https://doi.org/10.15406/jdhodt.2014.01.00008
  6. Prabhat M, Sudhakar S, Kumar BP. Knowledge, attitude andperception (KAP) of dental undergraduates and interns on radiographic protection-A questionnaire based cross-sectional study. J Adv Oral res. 2011; 2(3): 45-50.
  7. Hussein RE, Hashim NT, Awooda EM. Knowledge, Awareness And Practice of Sudanese Dentists Towards Oral Radiology And Protective Guidelines. IOSR J Dent Med Sci 2016;15(10):79-83. https://doi.org/10.9790/0853-1510047983

  1. Department of Science of Dental Materials, Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences, Karachi.
  2. Department of Science of Dental Materials, Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences, Karachi.
  3. Dr Sulaiman Al Habib Medical Group (HMG) Assuwaidi Riyadh, SA.

Corresponding author: “Dr. Rooha Sultan” < rooha.sultan@duhs.edu.pk >

Awareness About Dental Radiography Among Dental Students

Rooha Sultan1                                          BDS

Khurram Parvez2                                                BDS, MSc

Hina Qureshi3                                          FCPS, MCPS, MBBS

 

OBJECTIVE: To assess the difference in knowledge and attitude of graduates and undergraduates towards radiological practice and hazards in dentistry.

METHODOLOGY: A cross-sectional questionnaire based study was conducted on the dental students and trainees of a public sector teaching and tertiary care institute. Questionnaire consisted of three sections of multiple choice questions including those of knowledge about dental radiography (05 questions), attitude towards dental radiography (05 questions) and practices pertinent to dental radiography (06 questions). Statistical analysis was performed using SPSS version 16.0 software. Pearson’s Chi Square test was used for the comparison of responses between the two groups at a p=value <0.05.

RESULTS: Out of total 900 participants, data of 480 participants were included in the data analysis (postgraduates= 251; undergraduates=229). Descriptive analysis shows that undergraduates had less knowledge and lack attitude and practices towards dental radiography as compared to postgraduate students with significant difference between the two groups (p <0.05).

CONCLUSION: This lack of knowledge, attitude and practices among undergraduate students (including house officers) suggest that there is a need to improve the knowledge, attitudes and practices pertinent to basic dental radiography among undergraduate students and house officers and bring it at par to that of postgraduate trainees.

KEY WORDS:  Radiography, graduates, undergraduates, protection, hazards, x-rays.

HOW TO CITE: Sultan R, Parvez K, Qureshi H. Awareness about dental radiography among dental students. J Pak Dent Assoc 2018;27(3):147-51.

DOI: https://doi.org/10.25301/JPDA.273.147

Received: 01 February 2018, Accepted: 16 April 2018

Knowledge, Attitude And Stigma of Dental Students Towards Hiv/Aids Patients

Faiza Amin1                                          BDS, MDS

Kashif Aslam2                                                        BDS, MSc

Sofia Ali Syed3                                    BDS, M.Phil

Rizwan Nadim4                                    BDS, MPH

 

BACKGROUND: In most areas of the world there is a decrease of the HIV/ AIDS epidemic that can be observed from international literature. Data from the Asian region recommends increasing incidences. Understanding knowledge levels and attitudes and relate them toward willingness to treat and stigma regarding HIV/AIDS is a significant constituent to project acceptable and culturally appropriate awareness and prevention programs.

OBJECTIVES: To evaluate level of knowledge, attitudes, willingness to treat and stigma associated with HIV/AIDS of dental students and house officers of Dow Dental College.

METHODOLOGY: A cross-sectional questionnaire survey was conducted among a total of 196 dental students of 1, 2, 3, 4 professional years and house officers of 2015-2016 academic session. By using a self-administered, structured questionnaire to examine their knowledge, attitudes and behavior towards HIV/AIDS was the approach. The descriptive indices such as percentages were used to express the knowledge level among the students. Independent t test was used to evaluate the attitude and stigma of these students towards HIV/AIDS with SPSS 17.0.

RESULTS: A total of 196 questionnaires were completed and returned, with response rate of 96.5%. Overall, the knowledge of the students was adequate except first year and second year students. The attitude of the students toward people living with HIV/AIDS was positive. House officers discriminate and stigmatize most among all the students.

CONCLUSION: Despite their adequate level of knowledge majority of students have negative attitude and willingness towards treatment of patients with HIV/AIDS.

KEY WORDS: HIV/AIDS, Knowledge and attitude of dental students.

HOW TO CITE: Amin F, Aslam K, Syed SA, Nadim R. Knowledge, attitude and stigma of dental students towards hiv/aids patients. J Pak Dent Assoc 2018;27(3):140-46. DOI: https://doi.org/10.25301/JPDA.273.140.

Received: 28 February 2018, Accepted: 29 March 2018

INTRODUCTION

In this contemporary era, Human Immunodeficiency (HIV) and the Acquired Immune Deficiency Syndrome (AIDS) is a most significant public health challenge.It becomes a major health issue worldwide after recognition in 1981. By the end of 2014, approximately 1.2 million people had died from AIDS-related infections and 34.3-41.4 million people were living with HIV infection.2  In Pakistan, first case of HIV was diagnosed in 1986 and was reported in 1987.3 According to the national estimates, in Pakistan there are 102,000 people infected with HIV. In Pakistan it is now classified into concentrated phase of the epidemic because of its high prevalence.5 The mode of transmission is mainly because of  heterosexuals (52.55%) which is followed by (11.73%) blood transfusion.6 In Asia region Pakistan is among 12 countries which account for more than 90% of the infected people living with HIV.7 Globally, during last decade new HIV infections have dropped by 0.7%.  But in Pakistan the disease burden and incidence of HIV is rising at disturbing pace. In Pakistan there is a  17.6% increase in annual incidence of HIV compared to 2.2% for the rest of the world according to Global disease burden (GBD).8 The condition is becoming more poorer as there is very low coverage (5.87%) of antiretroviral treatment (ART) in Pakistani patients.9

Fear of HIV infection creates major health concerns among health care personnel. This produces a barrier to effective educational efforts about AIDS and related awareness. The consequences of this fear might lead to unwillingness to treat AIDS infected patients.10  It has been observed that health care staff are lacking in appropriately managing and counseling HIV and AIDS patients. A huge knowledge gap has been notified among health care personnel regarding diagnosis and treatment of HIV and AIDS.11

In a study conducted by Crossley Mat al12 the author found that there were lacking in the knowledge regarding transmission routes of HIV and AIDS but found  good knowledge about oral manifestations associated with HIV and AIDS. Lack of knowledge was found among Tanzanian health care workers regarding treatment procedures related to HIV and AIDS. This was result in unwillingness to provide care for HIV patients.13 In Pakistan a study conducted by Shaikh FD et al concluded in their study there is a need for further education regarding knowledge, symptoms and modes of transmission of HIV and AIDS.11 Similar findings have been reported among nurses, dentists and health care personnel in Kenya, Brazil, Singapore, South Africa and Iran.14-16 Due to the alarmingly increasing spread of HIV in the Pakistan, the present study aimed to address the suspected deficiency in the level of understanding and awareness of this disease among clinical and nonclinical dental students at the Dow University of Health Sciences.  The study was planned to assess the students’ knowledge of HIV/AIDS and its transmission and attitudes about related issues such as ethical obligations, infection control regulations, willingness to treat HIV-positive patients, fear of contracting HIV occupationally, and feelings about HIV-positive patients.

METHODOLOGY

This cross-sectional survey was conducted from August to December 2015 at Dow Dental College, Dow University of Health Sciences Karachi on all dental students who were enrolled in Dow Dental College, Dow University of Health Sciences Karachi in the academic year 2015-2016.The survey instrument was a self-administered anonymous questionnaire in the English language. The study included a convenience sample comprising dental students of all basic and clinical year (1, 2 3, 4 professional years and house officers) Permission for study was also taken from Dean of Dentistry of Dental Faculty of Dow University of Health Sciences. The purpose of the study was explained clearly and, a written consent was obtained from the students. All the questions were anonymous, participant’s voluntary took part in the study, and consent was taken from them and no incentive was given for completing the survey. The questionnaire was made up of three parts.

  1. Part I focused on the socio-demographic characteristics of the respondents, including age gender and education level. 2. Part II includes close-ended questions related to knowledge and awareness of HIV/AIDS.
  2. Part III contained questions about the attitude towards the willingness to treat HIV/AIDS patients, stigma and discrimination against HIV/AIDS patients.

The answer to each question about attitude was rated on a five point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree).

SPSS software version 17.0 was used for statistical analysis. Frequency and percentages were used to describe gender, level of education. The descriptive indices such as percentages were used to express the knowledge level among the students. Independents t test was used to assess attitude and stigma of the students and house officers regarding HIV/AIDS.

RESULTS

Out of 200 students who were sent the survey, a total of one ninety three completed the survey. Therefore the respond rate was 96.5% .These participants were from first, second, third, final professional year and house officers (Figure 1)

Knowledge of Dental Students regarding HIV/AIDS: Table 1

On question 1 (HIV is same as AIDS), majority of students have inadequate knowledge and were not aware of the fact that HIV is same as AIDS.

Regarding question 2 (saliva act as a vehicle of transmission), students from all the professional years and house officers have enough knowledge that saliva can act as vehicle of transmission.

For question 3 (needle stick injury can transmit AIDS/HIV), all the students and House officers have remarkable knowledge. Regarding question 4 (Aerosol from hand piece can cause HIV) in adequate knowledge were found among first

Table 1: Knowledge among Dental Students Regarding HIV/AIDS

students but second, third, final year students and house officers present sufficient knowledge.

For question 5 (Dental and dental auxiliary are more prone) Inadequate knowledge were found among first year and second year students.

Regarding question 6 (Treatment of HIV/AIDS require special dental clinics) insignificant knowledge were obtained from first year and second year students.

On question 7 (HIV/AIDS patient can be suspected of oral manifestations) inadequate knowledge was observed among first year and second year students.

For question 8 (Sharing a tooth brush who has HIV/AIDS can cause HIV/AIDS) all the students have the adequate knowledge that AIDS/HIV can be transmitted if a person used toothbrush of AIDS/HIV patients.

Attitude of Dental students to treat HIV/AIDS patients: Table 2

On question 1 (One can safely treat HIV patients) when first year students compared with second year, third year and final year students highly insignificant results were found among all the students.  (Independent t test were used to assess attitude of the students).

On question 2 (It is my moral responsibility to treat HIV/AIDS patient) significant differences were found among the attitude of the students of the first year when compared with the students of third year.  Second year students when compared with third year, final year and house officers, it was found that statistically significant differences were found in attitude of third year students. All these students have negative attitude towards realization that this is their moral responsibility as health care staff to treat HIV patients. On question 3 (Patients with HIV can lead normal life)

Table 2: Attitude of Dental Students to Treat HIV/AIDS Patients

among all the students only second year students and house officers have the attitude that the patient with AIDS/HIV cannot lead to normal life.

On question 4 (I will treat HIV patients for my electives) significant results were found regarding the question among students of second year when compared with third year students and third year students when compared to final year and house officers.

Stigma and Discrimination of Dental Students against HIV/AIDS patients: Table 3

On question 1 (If my colleague or assistant is HIV infected I will stop working with him or her) when stigma

Table 3: Stigma and Discrimination of Dental Students against HIV/AIDS

regarding the question is compared between first year students with the rest of professional years it was found that significant difference was observed in fourth year students and house officers When second year students were compared with other students and house officers significant differences were observed in the stigmatization of final year and house officers.

On question 2 (If a member of your family became ill with HIV, the virus that causes AIDS, would you want it to remain secret?) Highly insignificant results were obtained in this regard as only house officers among all the students were maintained the secrecy.

On question 3 (Dentists with HIV/AIDS should allowed to practice). According to house officers only in comparison with all other students that dentists should allowed to practice if he/she is suffered from AIDS/HIV.

On question 4 (Share a meal with AIDS/HIV patients) highly insignificant results were obtained in this regard as only house officers among all the students were responded that they can share meal with AIDS/HIV patients.

DISCUSSION

This study investigated dental students’ knowledge of AIDS/HIV and attitude towards infected patients and stigma to treat these infected patients. Dental and Medical workers are at high occupational risk during their professional training period for developing these infections. In this regard a survey has been conducted on dental students about different parts of knowledge and awareness of HIV/AIDS.

In our survey, excellent knowledge was observed about HIV/AIDS patients, but unfortunately this knowledge was not meaningfully related with the willingness to treat HIV/AIDS patients. In a study conducted on 174 dental students from Japan, the majority of respondents have more than average knowledge about HIV/AIDS. Regarding attitude to treat HIV-positive and negative patients 22% percent reported that they would have the same attitude toward treating both.17 Where as in this study it was found that there were no difference in the attitude of the students to treat HIV/AIDS patients from first year to final year.

During dental operation procedures it is possible to transmit HIV/AIDS.16 HIV/AIDS can be transmitted through saliva or blood contaminated instruments and equipments. It can also be transmitted by  inhalation of aerosol emitted from hand pieces.18 However, in previous studies very few students have the knowledge HIV/AIDS can transmit through inhalation of aerosol emitted from hand pieces. The results were similar with our study as majority of first year students don’t know that HIV/AIDS can be transmitted through aerosol inhalation. But their results were in contrast with results of our study as second, third final year students and house officers have the enough knowledge in this context.18,19 In one previous study, it was found that more than half of the students participants believed that there is no such route of  transmission exist.20 There is statistically significant difference in the knowledge of the participants when asked that aerosols from hand piece can cause HIV transmission among first, second and final year students. Statistically significant results were observed in the present study regarding concerns that aerosols from hand piece can cause HIV transmission. According to CDC guidelines21 dental health care personnel should position patients properly and make appropriate use of barriers e.g., surgical masks, face shields, high-volume evacuators, rubber dams and gowns. This will prevent the dentists and assistant from contact with splashes and spatter. As theses splashes and spatter creates a visible spray that is released from rotary surgical instruments and dental equipments e.g air-water syringes, handpieces and ultrasonic scalers. This spray contains mainly a large-particle spatter of blood, microorganisms, aerosol, water, debris and saliva. Saliva can be a vehicle for the transmission of AIDS/HIV. In a study conducted by Askarian M at al, some students (24.5%) agreed that saliva can be a vehicle for the transmission. However, majority of students 72.5 % declared it is possible that a CPR given to HIV/AIDS patients will might transmit the infection.14 In our study, first, second, final year students and house officers did have the sound knowledge in this context.

Mostafa Sadeghi et al22 found in their study that most of the students were aware of the major oral manifestations of AIDS: Kaposi’s sarcoma, major aphthous and oral candidiasis, which was also found in the current study.

Similar results were observed in a study conducted in Peshwar (Pakistan) by H Khan at el23 who concluded that there is a satisfactory awareness among the medical students entering into the profession. An acceptable difference was recorded among clinical, preclinical and 2 (non-clinical students) regarding their knowledge and attitude about HIV and AIDS.

Key factor in transmitting these contagious infections are contaminated needles.  In our part of the world one of the significant modes of transmitting hepatitis B and C virus is through these needles pricks.24,25 The current study analyzed that majority of the students among all the professional years (1st, 2nd, 3rd and 4rth) and house officers knew about needle safety. It is mandatory that students should be given the training  that both patient safety and  personal safety should be the priority.26,27

The results of this study found that dental students at Dow Dental College have positive attitudes towards treating HIV/AIDS patients. In this study, the general willingness to treat HIV positive patients  when first year compared with second year, third year and final year authors found that no significant difference in attitude was found among all students in comparison with the results from the study of Hu et al.28 However, our results regarding the attitude towards treating HIV/AIDS patients  were not positive in comparison with the study conducted by  Kuthy et al29 and Seacat and Inglehart.30

In the current study, there was a considerable negative attitude of the students towards AIDS and HIV positive patients. Almost about more than half of the students did not want to treat patients having HIV/AIDS as their electives. The same results were found by Brook.11 In the study conducted in Grecian schools by Merakou et al found that only a small percentage of the students (5%) stated that they would reject their friends infected with HIV/AIDS.21 Approximately half of students in our study expressed that an infected student should not be allowed to enter an ordinary school. Similarly results were reported in study conducted by Agrawal et al in India.13 These are serious issues regarding attitude towards AIDS/HIV because of lack of awareness and education and they need to be addressed. Similar results were seen in a study conducted by FD Shaikh at el11 in which researchers feel that it is essential to change the attitudes of medical students towards AIDS/HIV patients. There seems to be a high rate of anxiety and bias toward HIV-infected persons and the disease.

Statistically significant association should be observed regarding attitude towards their responsibility to treat patients having HIV/AIDS.  Prashant B Patil et al31 in their study by using  a five-point Likert scale found that students showed overall negative attitude towards HIV/AIDS patients.  Similar results were found in the current study that students have negative attitude to treat HIV/AIDS patients.  The finding differs from previous researchers, who found students having positive attitude about HIV/AIDS.22,32-34

Stigma is frequently related with human rights and discrimination.  According to Erving Goffman35  stigma is an undesirable or discrediting attribute that an individual possesses, thus reducing that individual’s status in the eyes of society. In our study when asked the participants that would they stop working with colleague if he/she had HIV/AIDS, majority of them replied affirmative to it. Parker and Aggleton et al, convincingly argue that stigma and stigmatization are central to establishing the prevailing social order as they function at the connection between power, culture, and difference.36

The current study has numerous limitations. First, in our religious culture, the investigators are limited in asking questions concerning students’ sexual beliefs and behaviors. Second, the honesty of students’ responses may be questioned due to self-report nature of the questionnaire. Third, the results of the study may not be applicable to adolescents who are not attending dental school. They only generalized to similar populations of students.

CONCLUSION

Under the limitations of the study following conclusion was drawn:  There was insufficient knowledge among first and second year students. Among third, final year students and house officer’s majority of them have sufficient knowledge regarding HIV/AIDS infection but majority of them were not willing to treat HBV/AIDS patients. Dental students appear to have a more negative attitude towards treating HIV/AIDS patients.  Refusal to treat patients with HIV was primarily associated with lack of ethical responsibility and fears related to cross-infection.

ACKNOWLEDGEMENT

The authors are grateful to Dr. Taqi Assistant Professor department of community Dentistry Dow Dental College, Dow University of Health Sciences   for his assistance in statistical Analysis.

CONFLICT OF INTEREST

None declared.

REFERENCES

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  6. Bhurgri Y. HIV/AIDS in Pakistan. JPMA. 2006;56(1):1-2.
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  12. Crossley M. An investigation of dentists’ knowledge, attitudes andpractices towards HIV+ and patients with other blood-borne viruses in South Cheshire, UK. Br Dent J. 2004;196(12):749-54. https://doi.org/10.1038/sj.bdj.4811382
  13. Marchal B, Brouwere VD, Kegels G. HIV/AIDS and the healthworkforce crisis: what are the next steps? Trop Med Int Health. 2005;10(4):300-4. https://doi.org/10.1111/j.1365-3156.2005.01397.x
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  28. Hu S-W, Lai H-R, Liao P-H. Comparing dental students’ knowledge of and attitudes toward hepatitis B virus-, hepatitis C virus-, and HIVinfected patients in Taiwan. AIDS Patient Care & STDs. 2004;18(10):587-93. https://doi.org/10.1089/apc.2004.18.587
  29. Kuthy RA, McQuistan MR, Riniker KJ, Heller KE, Qian F. Students’ comfort level in treating vulnerable populations and future willingness to treat: results prior to extramural participation. J Dent Educ 2005;69(12):1307-14.
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  1. Associate Professor/Vice Principal, Department of Dental Materials, Dow Dental      College, Dow University of Health Sciences, Karachi.
  2. Associate Professor, Department Of Prosthodontics, Dow Dental College, Dow University Of Health Sciences, Karachi
  3. Associate Professor, Department of Oral Pathology, Dow Dental College, Dow   University of Health Sciences, Karachi.
  4. Ph.D Scholar, University of Wolverhampton, U.K.

     Corresponding author: “Dr. Faiza Amin” < faiza.ameen@duhs.edu.pk >

Knowledge, Attitude And Stigma of Dental Students Towards Hiv/Aids Patients

Faiza Amin1                                          BDS, MDS

Kashif Aslam2                                                 BDS, MSc

Sofia Ali Syed3                                    BDS, M.Phil

Rizwan Nadim4                                  BDS, MPH

 

BACKGROUND: In most areas of the world there is a decrease of the HIV/ AIDS epidemic that can be observed from international literature. Data from the Asian region recommends increasing incidences. Understanding knowledge levels and attitudes and relate them toward willingness to treat and stigma regarding HIV/AIDS is a significant constituent to project acceptable and culturally appropriate awareness and prevention programs.

OBJECTIVES: To evaluate level of knowledge, attitudes, willingness to treat and stigma associated with HIV/AIDS of dental students and house officers of Dow Dental College.

METHODOLOGY: A cross-sectional questionnaire survey was conducted among a total of 196 dental students of 1, 2, 3, 4 professional years and house officers of 2015-2016 academic session. By using a self-administered, structured questionnaire to examine their knowledge, attitudes and behavior towards HIV/AIDS was the approach. The descriptive indices such as percentages were used to express the knowledge level among the students. Independent t test was used to evaluate the attitude and stigma of these students towards HIV/AIDS with SPSS 17.0.

RESULTS: A total of 196 questionnaires were completed and returned, with response rate of 96.5%. Overall, the knowledge of the students was adequate except first year and second year students. The attitude of the students toward people living with HIV/AIDS was positive. House officers discriminate and stigmatize most among all the students.

CONCLUSION: Despite their adequate level of knowledge majority of students have negative attitude and willingness towards treatment of patients with HIV/AIDS.

KEY WORDS: HIV/AIDS, Knowledge and attitude of dental students.

HOW TO CITE: Amin F, Aslam K, Syed SA, Nadim R. Knowledge, attitude and stigma of dental students towards hiv/aids patients. J Pak Dent Assoc 2018;27(3):140-46. DOI: https://doi.org/10.25301/JPDA.273.140.

Received: 28 February 2018, Accepted: 29 March 2018

Age and Gender Based Differences in Self-Assessed Reflectionin-Learning Scale

Nabiha Farasat Khan1                                          BDS, M.Phil, MPHE

Muammad Saeed2                                                                BDS

Rahila Yasmin3                                                    PhD Scholar

Arshad Kamal Butt4                                            MBBS, FCPS (Gastro, Medicine) MPHE

Ayyaz Ali Khan5                                                   BDS, MSc, PhD                                         

 

ABSTRAT: Reflection heighten students’ self-directed and life-long leaning. Gender difference probably represents significant sources of variation in learning behavior which should be detected and identified by medical educationists. This study was accomplished to “compare difference in Reflection-in-Learning Score between the gender and age of dental students in Bolan Medical College, Quetta.”

METHODOLOGY: An observational quantitative Census was carried out in all professional year dental students (n=85) of Bolan Medical College, Quetta. Data was collected during the period of 6 months (December, 2015 to May, 2016). A proforma was distributed to the participants under the supervision of principal investigator in lecture hall, time allotted to complete questionnaire was half hour; RLS was then collected, data was coded and entered in Special Package for Social Sciences version 20 for analysis. Frequency, percentage, means, median and standard deviation were computed for each RLS statement. Shapiro Wilk test was utilized to check normality of data whereas ANOVA scrutinized difference between RLS score and gender. P-value < 0.05 was considered significant.

RESULTS: Out of 85 study participants 21 (24.8%) were from 1st year, 16 (18.8%) from 2nd year, 20 (23.5%) from 3rd year and 28 (32.9%) from 4th year. Females participants were dominant (72.9%) and acquire statistically significant RLS score. (P=<0.001) Majority of the samples belong to 20-22 years age group, 14 (16.5%) were more than 23 years whereas 6 (7.1%) were below 20 years presenting no statistically significant age difference. (P=0.413).

CONCLUSION: Females participants were more reflective, whereas age doesn’t matter in RLS score.

KEY WORDS: Undergraduate Dental Students, differences, Gender, Age, Reflection-in-Learning Scale.

HOW TO CITE: Khan NF, Saeed M, Yasmin R, Butt AK, Khan AA. Age and gender based differences in self-assessed reflection-in-learning scale. J Pak Dent Assoc 2018;27(3):133-39.

DOI: https://doi.org/10.25301/JPDA.273.133

Received: 03 February 2017, Accepted: 06 March 2018

INTRODUCTION

The students of Asian origin have enhanced learning skills due to their ability to combine memorization and understanding.1,2,3 Education is a female dominant field possibly because of their devotion, keenness and single mindedness.4  Additionally competency of females at acquiring new learning strategies makes them more valuable and prominent.4

Reflection is a new and crucial component of medical education which enhances life-long learning.6,7 Reflective students are capable to mount Miller’s pyramid from cognition towards interpretation which strengthens their self-regulation, self-efficacy and builds them self-directed and life-long learners. Self-reflection accomplishes students to determine and analyze gaps in acquisition by jurisdiction of their emotions and to strengthen their performance, demonstrating positive consequences on their attitude.8,9,10,11 Reflective students get exquisite and marvelous results in their academics.12,13,14

Self-assessed, 14-item, Reflection-in-Learning Scale is a self-reported questionnaire that describes the views of student’s self-regulated learning. It has been implemented, and its effectiveness is proved in medicine and dentistry. Amal M (2010) from UK executed RLS on dental students of King Abdul Aziz University of Dentistry and concluded that there was a statistically significant association between reflective students and academic performance (P<0.001).6 Whereas Sobral DT noticed that 81% (n=83/103) of his study participants were reflective learners, exhibiting diagnostic thinking abilities.12 However controversy existed in the results finalized by an Irish investigator, Chalmers P (2011), who distinguished no progress in academic performance of 56 study participants from final year medicine.15 Devi V, an Indian researcher, pointed out the level of reflection, but she didn’t work on gender and age difference in RLS.16

Reflection-in-Learning Scale is acceptable to manipulate in the discipline of medicine and dentistry. Researchers scrutinize RLS on nurses also.17,18 Although foreign countries have carried out considerable efforts to assess reflective level of medical/dental students, but still no work has been accomplished to compare RLS score between male and

female students.12,14,15,16,17,19,20,21 Gender difference represents significant sources of variation in learning behavior of medical/dental students which should be detected and identified by medical educationists.22,23

Although, research has been carried out and reflective level assessed previously in Pakistan, but the gender difference for RLS has yet not been checked.24,25,26 We utilized this questionnaire in the current study with an aim to compare (if any) difference of RLS exists between male and female students in a government medical college in Quetta.

The rationale of applying RLS in the current study is its effectiveness in the assessment and monitoring of student learning; moreover, it also furnishes the educational feedback of the students and helps recognize requisite of learning processes which assists in better understanding of learning material.16

METHODOLOGY

It was a questionnaire based survey carried out in Bolan Medical College (BMC), Quetta, Balochistan, Pakistan on n=85 BDS students of 1st, 2nd, 3rd and 4th year. Ethical approval from administration of University of Lahore; IRB No: 03/1609, dated 26.01.2016 and Principal Bolan

Medical College (BMC), Quetta; Letter No.Admin/BMC/2016/2416/18 was taken. Data was collected during the period of December, 2015 to March, 2016. There were 95 dental student; 6 were absent whereas 4 students refused to participate in the study. Thus, a total of n=85 students were recruited for the study.

A demonstrator of dental section BMC distributed selfassessed questionnaire 14-item Reflection-in-Learning Scale (RLS) among the participants after filling the consent form.  Study was explained and they were reassured about the confidentiality of their personal information. Time allotted for filling the questionnaire was half hour after that RLS was collected. The data was entered and analyzed using SPSS (Statistical Package for Social Sciences) version 20. Frequency and percentages were given for each statement of RLS. Mean, median and standard deviation were also given for each statement. Shapiro Wilk test was used to check the normality of data. Due to the availability of data, its normal distribution and possibility to compare, ANOVA test was utilized to examine the mean difference in RLS score among male and female participants. A p-value < 0.05 was considered as significant.

RLS is formulated by a Brazilian researcher Sobral DT in 2000.12 It has proved constructive validity and good internal consistency. RLS is presented as Annexure 1.

To confirm the acceptability of questionnaire in public sector medical college, the questionnaire was applied in 20 students of 3rd year BDS to construct reliability and cognitive understanding. All of these students understand the questionnaire and its language easily; they fill it comfortably.

Students were recommended high mastery of reflective level when they encircle on Likert scale 7, competent reflective when participants encompassing option 6, they display basic/acceptable reflective when tick on scale 5, while exhibit minimally acceptable/progressing reflective degree of reflection when they encircle on scale 4, crude/emerging on scale 3 and inappropriate on 1 and 2 of Likert scale.27 For statistical purposes and its ease, the final score was further divided into 4 sub-scales representing the self-assessment question, participants scoring 14-34 were designated as limited reflective level, subjects having 35-55 score presented partial reflective level, as well as students demonstrated 56-76 score have ample level of reflection and students have maximum level of reflection when they score 77-98.6

RESULTS

Total strength of BDS students in Bolan Medical College Quetta was 95. Students gave a good response (89.47, approximately 90%) as only 6 of them refused to take part in the study while 4 were absent at the time of data collection. Out of 85/95 dental students, majority (72.9%) were females. Only 16.5% (14) participants were above the age of 23 years, whereas 7.1% were below 20 years, 76.5% (65) participants belonged to the 20-22 age group.

Comparison of Reflective-In-Learning Scale Score between Genders:

Independent sample t-test was used to compare the RLS score between male and female students. Mean RLS score of female students was significantly higher as compared to male students. Table 1 presented RLS score between genders.

*Independent t-test

Table 1: Comparison of Reflective-In-Learning Scale score between Genders.

* Significant results

Comparison of Reflective-in-Learning Scale among Age groups:

Analysis of variance (ANOVA) test was performed to compare the RLS score among the various age groups. One way ANOVA test revealed that there was no statistically significant difference in mean RLS score among them.Table 2 demonstrated RLS score among age groups.

Table 1: Comparison of Reflective-In-Learning Scale score between Genders

*One way ANOVA test

DISCUSSION

Today, women are almost proving to be in the lead in every walk of life and every profession due to their sense of responsibility, constant hard work and great determination.  This is true in medical education and field of dentistry as well as most of the study results displayed female dominance. In Pakistan, 65% of the medical students admission are females and their number is rising yearly.28 Studies that measure Reflection-in-Learning Scale of medical students in different countries including Saudi Arabia, London, U.K, Brazil, Netherland, Ireland, India, Australia, UK, Taiwan, Sweden, US and Estonia also demonstrate female dominance in the medicine.4,6,7,12,14,15,16,19,20,21,29,30

In Balochistan, which is primarily a male predominating society, it is surprising to hear that females are dominating in dentistry. The percentage of female literacy is lower in Balochistan as compared to the other parts of the country due to a bundle of varying factors including remote educational institutes, financial constraints, social problems and cultural barriers.31 However, as girls are internally motivated to acquire higher education, in Pakistan their percentage knowledge and learning becomes high in both, medicine and dentistry.31 In current study, female proportions are prominent in all 1st, 2nd, 3rd and 4th professional years of BDS where they make up a total of n=62/85 (72.9%). The results of current study agree with that of  Amal SM who confirms the predominance of  female participants.6 In his study results he reported that reflective learners present deep and organized learning approach and have better academic performance. However, in a study by Chalmers where more than half of the participants were females, (57%, 30/56) no difference in RLS score among genders was reported.15

On contrary, Sobral DT (a Brazilian researcher) investigated reflective level of 6th year medical students in 2000 and 2005.12,14 His established results demonstrate male predominance. During detecting Reflection-in-Learning Scale of clinically rotated medical students Sobral DT established no significant main effects for gender.

Previous studies conducted in Balochistan present low female literacy rate, however the current study reported contrasting result as majority of the study participants were females (72.9%) from all 4 years of BDS.32,33  This change in gender distribution in Balochistan may be due to the awareness of literacy in women or it may be due to the lack of interest in male students towards learning and struggling hard. Additionally, Boenink reported that female participants presented exceptional reflective abilities which may be due to their personality frame of mind and high level of proficiency to execute reflective scrutiny which displays their creativity, talent and particular awareness.34 ChaunYuan reporterd 2:1 female to male ratio in his study, however he did not compare gender with reflective work.19 In addition, more contrasting results are reported. Chalmers P et al did not recognize any significant difference between male and females although there were 57% female participants in her study.15 Similarly, Phan HP reported no statistical significant gender difference in a survey involving 347 study participants where 151 were women.35

An Indian researcher, Devi V, observed female predominance in her study (n=78/153), whereas 55.2% participants of Heinerichs S’s study (n=21/38) and 64.1% (n=208/324) study contributors in the research of Tricio J were females.7,16,19  Kalk K reported 95% female participants in Estonia (n=206/216). All these studies prove the women empowerment in education.16,21

Age of Participants and RLS Score

Participants of the current study were between the ages of 20-22 years. The results of current study are in accordance with the results of Chaun-Yuan study (20-22 years) and Chalmers P et al study (94% between 20-29 years).19,15

Tricio J analyzed that students above the age of 22 years and those in high grades achieve higher reflective habits.7 This is reinforced by this study as students scoring higher in academics were above the age of 20-22 and they scored

high in 14-item Reflection-in-Learning Scale. This finding may be due to the extra experience of senior students as a result of attending, facing and dealing with clinical scenarios and patients on daily basis.7

Heinerichs S reported that the mean age range of his study participants was 21.55±1.32, whereas all the participants of Devi V’s study were between the ages of 21-23.16,21 Mean age of the participants of Kalk K was

23.08 ±3.06. 4 On the other hand, Sobral did not detect any difference of reflective abilities between ages of his study participants.14 The consequences of Sobral’s research correlates with the outcomes of current study where no correlation was found between participant’s age and reflective level. The RLS score of participants, above 23 years of age, was Mean±SD 82.36±3.85. Senior participants show high scores of reflection-in-learning scale as compared to the junior ones (< 20years Mean±SD, 79.17 ±6.08). It may be due to the experience gained in clinical rotations, they have more options to discuss ill-defined situations, and can solve difficult cases along with P.Gs, senior doctors and faculty members.

Strength of the study

This study is the first of its kind to be conducted in Balochistan as well as in Pakistan. Despite of the problems students of Bolan Medical College are currently facing, they have exhibited the use of deep and organized learning strategies. Reflection-in-Learning Scale was appropriate for the assessment of the participants’ reflective abilities. Educationists, in future, should work on reflection to improve student reflective abilities.

Weaknesses of Current Study

Present study addressed only one medical college through self-assessed questionnaire to measure reflective level.

Strength of male students was low.

CONCLUSION

Females participants were more reflective, whereas age had no effect on RLS

RECOMMENDATION

To fill the gap of 1st and 2nd year student’s reflective level and enhance their effective abilities, there should be discussions on reflection, and it should be introduced into the curriculum in early clerkship in the form of reflective journal writing, log books and/or group discussion. It may help students in making better informed decisions and clinical judgments, thus improving their future practice.  In future, research should be carried out to evaluate the correlation between life performance of female students and RLS score.

ACKNOWLEDGEMENT

Authors offer regards and gratitude to all students of BDS, Bolan Medical College, Quetta for their willingness and voluntarily participation in research project.

Disclaimer

The abstract of this article is not presented or published in any conference, or published in an abstract book or any other relevant information.

CONFLICT OF INTEREST

Authors declare no conflict of interest. This project is not supported by any funding/grants.

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ANNEXURE 1 REFLECTION-IN-LEARNING SCALE (RLS)

Please answer the items below in relation to your learning experiences in dental programme. Draw a circle around the scale number closer to your usual behavior. To what extent have I: [1=Never, 2=very rarely, 3=some times, 4=when possible, 5often, 6=when required, 7= Always]


  1. Associate Professor & Head of Oral Pathology Dental Section, Bolan Medical College, Quetta.
  2. Senior Demonstrator, Department of Prosthodontics, Bolan Medical College, Quetta.
  3. Associate Dean, Riphah Academy of Research and Education Riphah, Islamabad. 4. Professor, Department of Medicine, Shakih Zayed Federal Postgraduate, Medical Institute, Lahore.
  4. Diector, Department of Institute, Shakih Zayed Federal Postgraduate, Medical Institute, Lahore.

Corresponding author: “Dr. Nabiha Farasat Khan” < nabihasaeed@hotmail.com >

Age and Gender Based Differences in Self-Assessed Reflectionin-Learning Scale

Nabiha Farasat Khan1                                          BDS, M.Phil, MPHE

Muammad Saeed2                                                                BDS

Rahila Yasmin3                                                    PhD Scholar

Arshad Kamal Butt4                                            MBBS, FCPS (Gastro, Medicine) MPHE

Ayyaz Ali Khan5                                                   BDS, MSc, PhD                                         

 

ABSTRAT: Reflection heighten students’ self-directed and life-long leaning. Gender difference probably represents significant sources of variation in learning behavior which should be detected and identified by medical educationists. This study was accomplished to “compare difference in Reflection-in-Learning Score between the gender and age of dental students in Bolan Medical College, Quetta.”

METHODOLOGY: An observational quantitative Census was carried out in all professional year dental students (n=85) of Bolan Medical College, Quetta. Data was collected during the period of 6 months (December, 2015 to May, 2016). A proforma was distributed to the participants under the supervision of principal investigator in lecture hall, time allotted to complete questionnaire was half hour; RLS was then collected, data was coded and entered in Special Package for Social Sciences version 20 for analysis. Frequency, percentage, means, median and standard deviation were computed for each RLS statement. Shapiro Wilk test was utilized to check normality of data whereas ANOVA scrutinized difference between RLS score and gender. P-value < 0.05 was considered significant.

RESULTS: Out of 85 study participants 21 (24.8%) were from 1st year, 16 (18.8%) from 2nd year, 20 (23.5%) from 3rd year and 28 (32.9%) from 4th year. Females participants were dominant (72.9%) and acquire statistically significant RLS score. (P=<0.001) Majority of the samples belong to 20-22 years age group, 14 (16.5%) were more than 23 years whereas 6 (7.1%) were below 20 years presenting no statistically significant age difference. (P=0.413).

CONCLUSION: Females participants were more reflective, whereas age doesn’t matter in RLS score.

KEY WORDS: Undergraduate Dental Students, differences, Gender, Age, Reflection-in-Learning Scale.

HOW TO CITE: Khan NF, Saeed M, Yasmin R, Butt AK, Khan AA. Age and gender based differences in self-assessed reflection-in-learning scale. J Pak Dent Assoc 2018;27(3):133-39.

DOI: https://doi.org/10.25301/JPDA.273.133

Received: 03 February 2017, Accepted: 06 March 2018