A DREEM Based Appraisal of Educational Environment at Dental Colleges: Comparing Pakistan and Turkey

Ayesha Zafar                                      BDS

Shama Asghar                                  BDS, FCPS

Muhammad Faisal Fahim                MSc

OBJECTIVE: This study was conducted to establish a baseline DREEM score for a Pakistani private dental college and a private dental college of Turkey, to compare the educational environment as perceived by the dental students’ of the two institutes and provide insight into the aspects of dental education that are in need of improvement.
METHODOLOGY: It’s a cross- sectional, questionnaire based study conducted at Bahria University Medical and Dental College, Karachi (BUMDC) and a private dental college of Istanbul, Turkey between December 2018 and March 2019. The Dundee Ready Education Environment Measure was filled out by first, second and third year undergraduate dental students at both the institutes. Ethical approval was obtained from ethical review committee of BUMDC after consent was taken from the head of the Turkish institute.
RESULTS: Global DREEM mean score of the two institutes was 116.6 ± 20.7. The overall DREEM score of Bahria University was 119.3 ±24.3 while of Turkish dental institute was 113.8±.16.1, with p-value = 0.000. Institutional DREEM depicts a student perception that is predominantly positive. In both the institutes, the perception regarding the social atmosphere (Students’ Social Self Perception) scored lowest as compared to all other domains.
CONCLUSION: Over all the educational environment at both the institutes is satisfactory however this study has highlighted a need for reforms to improve the social and teaching atmosphere. Despite the overall positive trend, the institutes have yet to achieve excellent status for educational environment. One can learn from the Turkish university in terms of how the social atmosphere can be improved, while the Turkish dental college can benefit by implementing a more student centered teaching methodology.
KEYWORDS: DREEM, Educational environment, dental students, perception, Pakistan.
HOW TO CITE: Zafar A, Asghar S, Fahim MF. A DREEM based appraisal of educational environment at dental colleges: comparing Pakistan and Turkey. J Pak Dent Assoc 2020;29(3):135-139.
DOI: https://doi.org/10.25301/JPDA.293.135
Received: 02 November 2019, Accepted: 11 May 2020

INTRODUCTION

Defined as everything that is part of the academic institute and affects the learning process, educational environment includes infrastructure, teaching methodology, attitude and behaviour of both teachers and
peers.1,2,3 Numerous studies have proven that educational environment is a major determinant of successful learning instruction.4,5,6 The atmosphere of an institute is considered a stronger predictor of academic growth as compared to prior achievement at school.3
It bears considerable consequence on the effectiveness of curriculum and hence skill, motivation and eventual success of the student.7 The acute noteworthiness of this arbitrary component of medical and dental education brought about the need to qualitatively measure it with a reproducible, universally accepted technique.8
Advances in this front led to the development of Dundee Ready Educational Environment Measure (DREEM) questionnaire by a multinational committee of medical educators in 1997.1,9,10 Further research has established it as a globally recognized and validated tool for “measuring’ the perception of learning environment of students at medical and dental institutes.11,12 Culturally nonspecific, it is an inventory of fifty components that focus on five domains of education namely learning, teaching, academic and social self-perception & atmosphere.13 It draws a holistic and comprehensive snapshot of all the domains at work within the educational institute.14 A considerable impact of this inventory is that it makes homogenized comparisons between medical and dental schools of different countries, a possibility, allowing institutes to establish a point of reference for future comparisons.15,16,17 Moreover, it may bring to light areas of concerns that might have been unintentionally left out by the educators.18,19
Bahria University Medical and Dental College (BUMDC), is located in the metropolis of Karachi. Established in 2011, the dental college follows a hybridmodular curriculum and incorporates both traditional and
latest student based teaching methodology. With a teaching history of less than a decade the college is still in its infancy and hence in constant need of rigorous introspection in order to optimize the learning environment. 2 0
Despite its validity as a successful investigative tool for evaluation of quality of teaching, only a handful of DREEM based researches have been conducted in dental colleges of Pakistan and not one international comparison has been made thus far.10
This study was conducted to establish a baseline DREEM score, to juxtapose the educational environment perception of student of the two institutes and provide insight into the aspects of dental education that are in need of improvement.

METHODOLOGY

Permission for the research was granted by the Ethical review committee of BUMDC (ERC 05/2019). It was a cross-sectional questionnaire based survey. Students who had completed one, two or three years of undergraduate dental education at Bahria University Medical and Dental College, Karachi and a private dental college located in Istanbul, Turkey were invited to take part in it between the period of December 2018 and March 2019. Final year students and house officers were excluded from the study. Sample size of 132 students from each institute was calculated, keeping the confidence interval at 95%, margin of error at 0.5%, population size of 200 and prevalence of 50%. Formula used was,

Convenience sampling technique was used. In all, 264 participants were requested to take part in the study. Participation in the study was voluntary. Data from the Turkish private dental college was collected by a faculty member who was selected under Erasmus teaching mobility program from Bahria University to deliver a lecture to dental students of the Turkish dental college. After the lecture, faculty member explicated the purpose and idea of the study, assured confidentiality and took assent before asking the students to fill the proforma. The original English DREEM inventory was translated into Turkish. Validity of the translation was evaluated with a pilot study and the participants of the pilot study were then excluded from the final study. Similarly at our institute, after explaining the purpose of the study and taking consent, 132 original English language DREEM forms were circulated. Anonymity of the process was reassured. A total of 121 students responded from Bahria University and 124 responded from the Turkish dental college.
The DREEM questionnaire was employed to measure educational environment’s perception of the participants. Based on five main domains and a total score of 200, it comprises of a 50-item inventory focused on statements related to the Educational Environment namely Students’ perceptions of learning (SPL) with 12 statements and a total sum of 48, Students’ perceptions of teachers (SPT) having 11 articles and topmost sum of 44, Students’ academic selfperceptions (SASP) with total of 8 statements and a total sum of 32, Students’ perceptions of atmosphere (SPA) comprising of 12 articles and an absolute sum of 48 and
lastly Students’ social self-perceptions (SSSP) with 7 statements and topmost sum of 28. 5- point Likert type scale was employed to collect responses ranging from strongly agree (4) to strongly disagree (0). The nine negative statements were tallied in reverse manner where strongly agree was scored 0 and strongly disagree scored 4. Incomplete questionnaires were excluded from the study. As suggested by McAleer and Roff in their DREEM inventory guide, the total DREEM score was interpreted as follows: total score of 0-50 was considered very poor, 51-100 as an environment with plenty of problems, score between 101-150 was considered more positive than negative, 151-200 as excellent. Individual statement scores < 3.5 was considered real positive, a score of 2.0-3.0 suggested that the item has room for improvement and an average score of <2.0 was considered troublesome.
The data was compiled manually into MS Office Excel Version 2010 spread sheets from both the countries and then into SPSS Version 23. For categorical variables such as nationality, frequency and percentages were presented. Continuous variables such as age and DREEM scores were presented as mean ± standard deviation (SD). To know the significance between Bahria University’s and Turkish dental college students with DREEM score independent sample ttest was applied. For comparison of different level of students with their achieved scores of DREEM inventory Fisher exact test was applied. p-value of <0.05 was considered to be statistically significant.

RESULTS

Response rate of our institute was 91.6% while that of Turkish University was 93.9%. Average age of the Pakistani students was 20.74 ± 1.24 years (18-26) and that of Turkish students was 20.61 ± 1.92 years (17-33) Table 1 mentions the Global DREEM mean score of the two institutes and the combined subscale score. The total DREEM score of our institute was 119.34 ±24.26 while of

Table 1: Overall DREEM score (mean and standard deviation) and total score of DREEM subscales. (Combined score of Pakistan and Turkey)

Turkish dental college was 113.85 ± 16.13. Overall as well as individual institutional DREEM depicts a student perception of more positive than negative (101-150). And the difference between the two institutes is statistically significant, p-value = 0.038 Subscale mean and standard deviation along with their interpretation for both the institutes is displayed in Table 2. The table also indicates the significant differences
between the two institutes.

Table 2: Mean Scores and standard deviation of different subscales and their interpretation

Individual item analysis and comparison of the DREEM inventory is presented in Table 3.

Table 3: Individual item mean scores of DREEM inventory for Pakistan and Turkey, along with their p-value

DISCUSSION

The study aimed to evaluate what differences, if any, existed between private dental college of Turkey and Pakistan in terms of educational environment as perceived by the students. For this purpose the institutes were evaluated by employing the DREEM questionnaires. It is the first time that such a study is being conducted in either of the institutes. With overall DREEM score of 119.3 ±24.3 for BUMDC and 113.8±.16.1 for the Turkish Institute there appears very little difference in the overall opinion but nonetheless, the difference is statistically significant, p-value = 0.038. Scores in the range of 100 to 150 are considered more positive than negative but with definite room for improvement, as only values above 150 are considered excellent. These values are in concurrence with findings of Khan K et al19, who reported a score of 120 for 4 dental institutes of Rawalpindi, Pakistan and also similar to results reported by Tontus O et al21 of Turkey who stated DREEM score of 107.15/200 for 11 medical faculties in Turkey. Similar scores have been reported for Saudi Arabia1, Iran3 , India23 and other countries of this region. In contrast to these, higher scores were reported by Vanghan B et al. (135.37 ±19.33) in their study9 conducted in University of Melbourne, Australia and by Hongkan W et al24 from Thailand (131.1 ±17.0).
Analysis of the subscales revealed that students of Bahria dental college rated the learning environment as the most positive aspect of their environment, suggesting that the students are generally satisfied with the hybrid curriculum, focused on incorporating student centered practices The most highly rated statements were ‘I feel I am being well prepared for my profession’ and ‘teaching time is put to good use’ which depicts that the institute is ensuring students’ satisfaction when it comes to their future performance. For the Turkish students, the atmosphere of their institute was most highly rated, showing they found the teaching environment relaxed, stress free and overall joyous. Among the highest rated statements were “the atmosphere is relaxed during lectures” and ‘I feel comfortable in class socially’. Both the institutes unanimously declared the social selfperception to be the most neglected category, indicating a need for improvement of effective support system for stressed out individuals.
Analysis of the individual items demonstrated that for the private dental college of Turkey, a shift from teacher centred to student centred approach is needed as the statements pertaining to this this category all unanimously scored less than 2. In this domain BUMDC appears to be on the right track as the students have rated this component to be the
highest among all others subscales.
According to our findings Bahria dental college needs to work on improving its control over cheating during examination as its one of the poorly rated items. Concerted efforts also need to be put into making the overall university experience enjoyable for the students as they most strongly agreed to the statement “I find the experience disappointing”
This study has provided valuable insight into students’ perception of their learning environment and how it compares with another international institute. Secondly, individual
items analysis highlighted specific problems and strengths within each of the dental colleges.
One of the inherent limitations of DREEM questionnaire is that it does not give any details about the underlying reasons for the highlighted issue nor does it suggest solutions
to the problems. Furthermore the DREEM inventory being a predetermined questionnaire might have left out certain factors that impacted our educational setups. Moreover the
sampling techniques employed for this study is voluntary participation and this may have resulted in sampling bias. The self-reporting questionnaire is likely associated with
response bias. Since this study only compared two dental colleges and its results cannot be generalized, further studies should be done in future with more number of institutes participating in order to establish a generalized score. Moreover this study can be conducted again, in the same dental college, at a later point in time to determine the effect
of any changes that the institutes may have made in their educational environment.

CONCLUSION

This study has highlighted a number of problems that are in need of attention. Both institutes need to reform their educational environment. Even though the overall scores
may be predominantly positive both the institutes have yet to achieve excellent status for all the criteria that constitute an educational environment. Bahria University can learn
from the Turkish university in terms of how the social atmosphere can be improved, while the Turkish dental college  can benefit by implementing a more student centered teaching
methodology. DREEM-based surveys are highly recommended for periodic monitoring of the educational environment.

CONFLICT OF INTEREST

None

FUNDING DISCLOSURE

No funds were availed

REFERENCES

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  19. Khan K, Sohail K, Jamil M, Durrani KO. Determining the Quality of Educational Climate Across Four Undergraduate Dental Colleges In Rawalpindi/Islamabad Using The DREEM Inventory. J Med Sci 2016;24:91-7.
  20. Bahria.edu.pk. (2020). Bahria University Medical & Dental College\ – Bahria University Official Web Portal. [online] Available at: https://bahria.edu.pk/bumdc/ [Accessed 26 Feb. 2020].
  21. Tontus O. DREEM; Dreams of the Educational Environment as Its Effect on Education Result of 11 Medical Faculties of Turkey. J Exp
    Clin Med 2010;27:104-08. https://doi.org/10.5835/jecm.omu.27.03.002
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    https://doi.org/10.1016/j.sdentj.2018.02.003
  23. Patil AA, Chaudhari VL. Students’ perception of the educational environment in medical college: a study based on DREEM questionnaire. Korean J Med Educ. 2016; 28:281-88. https://doi.org/10.3946/kjme.2016.32
  24. Hongkan W, Arora R, Muenpa R, Chamnan P. Perception of educational environment among medical students in Thailand. Int J Med Educ. 2018;9:18-23. https://doi.org/10.5116/ijme.5a4a.1eda

  1. Registrar, Department of Operative Dentistry, Bahria University Medical and Dental College, Karachi.
  2. Associate Professor, Department of Operative Dentistry, Bahria University Medical and Dental College, Karachi
  3. Reseacher, Department of Physiotherapy, Bahria University Medical and Dental College, Karachi.
    Corresponding author: “Dr. Ayesha Zafa” < ayeshazaf19@gmail.com >

A DREEM Based Appraisal of Educational Environment at Dental Colleges: Comparing Pakistan and Turkey

Ayesha Zafar                                      BDS

Shama Asghar                                  BDS, FCPS

Muhammad Faisal Fahim                MSc

OBJECTIVE: This study was conducted to establish a baseline DREEM score for a Pakistani private dental college and a private dental college of Turkey, to compare the educational environment as perceived by the dental students’ of the two institutes and provide insight into the aspects of dental education that are in need of improvement.
METHODOLOGY: It’s a cross- sectional, questionnaire based study conducted at Bahria University Medical and Dental College, Karachi (BUMDC) and a private dental college of Istanbul, Turkey between December 2018 and March 2019. The Dundee Ready Education Environment Measure was filled out by first, second and third year undergraduate dental students at both the institutes. Ethical approval was obtained from ethical review committee of BUMDC after consent was taken from the head of the Turkish institute.
RESULTS: Global DREEM mean score of the two institutes was 116.6 ± 20.7. The overall DREEM score of Bahria University was 119.3 ±24.3 while of Turkish dental institute was 113.8±.16.1, with p-value = 0.000. Institutional DREEM depicts a student perception that is predominantly positive. In both the institutes, the perception regarding the social atmosphere (Students’ Social Self Perception) scored lowest as compared to all other domains.
CONCLUSION: Over all the educational environment at both the institutes is satisfactory however this study has highlighted a need for reforms to improve the social and teaching atmosphere. Despite the overall positive trend, the institutes have yet to achieve excellent status for educational environment. One can learn from the Turkish university in terms of how the social atmosphere can be improved, while the Turkish dental college can benefit by implementing a more student centered teaching methodology.
KEYWORDS: DREEM, Educational environment, dental students, perception, Pakistan.
HOW TO CITE: Zafar A, Asghar S, Fahim MF. A DREEM based appraisal of educational environment at dental colleges: comparing Pakistan and Turkey. J Pak Dent Assoc 2020;29(3):135-139.
DOI: https://doi.org/10.25301/JPDA.293.135
Received: 02 November 2019, Accepted: 11 May 2020

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Choice of Restorative Material for Endodontically Treated Teeth in Teaching Institutions of Multan

Mehwish Rafiq                        BDS

Tahira Parveen                       BDS

Uzma Abdullah                      BDS

Jaffar Hussain Bukhari     BDS, M.Phil

OBJECTIVE: The purpose of this study was to describe the knowledge, attitude and practice for core build-up and crowning of endodontically treated teeth in teaching institutes of Multan and to assess the association of clinical experience, work place and qualification on these options.
METHODOLOGY: A cross sectional study was conducted using self-applied questionnaire with dentists working in three teaching institutes of Multan from 22nd to 28th October, 2019. The calculated sample size for the total population of 160 was 114 according to Raosoft sample size calculator by keeping the confidence level 95%. A total of 160 questionnaires were distributed. Recovered questionnaires were 148. Response rate was 92%. Information about clinical experience, work place and post-graduation qualification was collected. Data regarding preference of core build-up material, crown material, timing of restoration of endodontically treated teeth (ETT), type of post was collected. Data were analyzed by SPSS version 22, frequencies and percentage were obtained. Association between different variables was calculated using Pearson’s chi-square test.
RESULTS: Amalgam was preferred as core buildup material on the basis of strength (81%), immediate restoration of ETT was preferred by private sector participants (30%) and restoration after one week was preferred by public sector participants (45.9%). Most of the participants believed core buildup must receive endopost to have better prognosis (60%). Majority preferred prefabricated endopost (50%) over custom made post (33%). The porcelain fused to metal crown was preferred as the clinical experience of dentist increases (p=0.001).
CONCLUSION: Within the limitations of the study, it was concluded that amalgam was preferred as core buildup material, prefabricated post was preferred over custom made and PFM was material of choice for crowning.
KEYWORDS: Dental practitioners, endodontically treated tooth, post and core, restoration, survey, core build-up.
HOW TO CITE: Rafiq M, Parveen T, Abdullah U, Bukhari JH. Choice of Restorative Material for Endodontically Treated Teeth in Teaching Institutions of Multan . J Pak Dent Assoc 2020;29(3):130-134.
DOI: https://doi.org/10.25301/JPDA.293.130
Received: 26 February 2020, Accepted: 21 May 2020

INTRODUCTION

The endodontic and restorative dentistry is the study of preservation of natural tooth structure. Endodontic treatment is required for grossly carious, fractured or badly broken down vital or non-vital teeth.1
The loss of tooth structure in endodontic treatment due to caries or endodontic procedure increases the vulnerability of the tooth to fracture. The longevity of such teeth rely on the amount of tooth loss and the ability of restorative material to replace the missing tooth structure.2
It requires distinctive consideration where there is extensive loss of tooth structure. In addition, the prognosis of endodontically treated tooth (ETT) depends upon multiple criteria such as the amount of remaining tooth structure3, type of final restoration, design of the post, and type of core build-up material used.4
There is general concept that endodontic treatment failure might be due to restoration failure , therefore selection of restorative material, technique and time of restoration are significant factors.5
It is further suggested that appropriate and early permanent restoration after completion of endodontic treatment should be carried out. When temporary filling is followed by permanent restoration to seal the access cavity, there are more chances of leakage and bacterial invasion.6
There are more chances of leakage and bacterial invasion when temporary filling is followed by permanent restoration to seal the access. Endodontically treated teeth having permanent restoration are more successful as compared to temporary restoration.6-8
A core build-up is a restoration that is used to restore the coronal portion of the badly broken down tooth. As core build-up material restores large bulk of missing tooth structure and resists multidirectional chewing forces for many years, it’s compressive and tensile strength are important factors for better prognosis of ETT.9
To enable the retention of core build-up material, they are usually reinforced by pins, post and bonding system. A dental post is a material placed in the root of a structurally insufficient tooth to provide additional retention and support the coronal restoration. The post should provide this support without increasing the risk of root fracture.10
A number of dental materials have been used for core build-up.11 They are direct and indirect material namelypin retained restoration and prefabricated post or custom made post and core respectively.12 The material used as core build-up includes amalgam, glass ionomer cement, resin modified glass ionomer cement, cermet and composite resin. Composite resin is mostly used to build-up the core of the missing tooth.12 For restoration of ETT different procedures have been recommended. These treatment procedures include the use of post and core, partial or full crowns, and direct resin composite or amalgam fillings. The available post and core systems are custom made and pre-fabricated. When the coronal tooth structure is insufficient to retain a core buildup then posts are recommended. The endodontically treated tooth can be used as abutment but there were chances of fracture of those ETT that had post and were terminal abutments.13 The clinical success of ETT is significantly increased with coronal coverage.14
It has been found that ETT without coronal coverage failed six times greater than crowned teeth.15 The prognosis of posterior ETT is considerably increased with crowning, however in anterior ETT crowning has not much significance.15
To assess and understand treatment approaches for ETT restorations, surveys are important tools.12 Several survey based studies have been published regarding restoration of ETT. However, the preference and strategies of dental practitioners in teaching institutes of Multan need to be investigated. The purpose of this study was to analyze the preference, techniques.

METHODOLOGY

A cross-sectional study was performed from 22nd to 28th October, 2019 in three teaching institutes of Multan; Nishter institute of dentistry (NID), Bakhtawar Amin medical and dental college (BAMDC) and Multan medical and dental college (MMDC). Non-probability convenience sampling was done in this survey. The total population of registered dentists working in above mentioned institutions was 160. Questionnaires were distributed among them.
The number of recovered questionnaires was 148 bringing the response rate to 92.5%. The calculated sample size for the total population of 160 was 114 according to Raosoft sample size calculator by keeping the confidence level 95%. Data were collected non-specifically using a fifteenquestion survey questionnaire. Questionnaire comprised of questions regarding clinician’s demographics (designation, area of interest/expertise and clinical experience), endodontic procedure preference, choice of material for core build-up, type of post, preference ofcrowning and type of crown material preferred. The collected data were analyzed and interpreted using SPSS version 22. The association between designation of the clinicians and rest of the variables mentioned above was analyzed using Pearson’s chi-square test. A significance level of p < 0.05 and confidence level of 95% was used.

RESULTS

From the population of dentists (160) working in the targeted institutions, 148 participated in the study (n=140). The data missed was 7.5 % due to no return of the questionnaire and absence of the participants from the workplace. Among the respondents having experience greater than 10 years were 26%, those having less than10 years were 25% and less than 5 years were 97%. The working place of the participants was 54.7 % at public place, 30.4 % at private and 14.9 % were at both places.
Postgraduate participants were 31.1 % while 68.9 % were graduates. The frequencies and percentages of studied variables are shown in Table 1.

Table 1: The frequencies and percentages of studied variables

Table 2: Association of experience with crown material and buildup time with place of working

Table 3: Association of post-graduation with endo-post type and crowning ETT

There was a statistically significant association between the restoration times of ETT and work place, given in the Table 2. The participant who were in public place opted “restoration after one week” significantly more than those working at private places (p = 0.002). Majority of participants (62%) had chosen endopost in ETT and prefabricated post were preferred over custom made post (p = 0.003) given in the table 3. Most of the participants (85.6%) preferred such tooth should be crowned (p = 0.39) shown in table 3. The respondents who had more than ten years of experience (76%) preferred PFM crown (p = 0.001) given in table 2.

DISCUSSION

This survey was conducted to know the recent preferences of core build-up and crown material for ETT in teaching institutes of Multan. According to the results of this survey-based investigation, the majority of the participants preferred amalgam as core build-up material on the basis of strength. Amalgam as a core build-up material was also popular in the United Kingdom.15 This may be due to amalgam isn’t considered as health hazard in many part of the world and is cost effective.
There was significant association between the build-up time of restoration and workplace of practioners (p = 0.002). Majority of the participants working in public place preferred restoration of ETT one week after obturation followed by after one day and immediate, in a sequence. The reason behind this might be the clinical and radiographic evaluation of ETT after one week as observed in a previous study. 17 The participants working in private place preferred immediate final restoration of ETT over one day and one week. The reason behind this might be to save the time and to avoid coronal leakage leading to failure of endodontic treatment which may occur in immediate temporary restoration, supported by previous studies. 18,19
According to the results, the majority of the participant (62%) had chosen endopost in ETT and prefabricated post were preferred over custom made post, which relates with the observations of other similar studies.20,21 The association between endopost type and post-graduation was significant (p= 0.003), 67% of those who had done post-graduation preferred prefabricated post over custom made post. This
trend might be due to fact that prefabricated post are easy to use and can be completed in single visit, so its time saving procedure. Most of the participants believed that core buildup material with endopost should be used as it decreases the chance of tooth fracture. This finding was in accord with dental practitioners practicing in Sweden, Germany and the United States . 10,22-24 Regarding the crowning of ETT having core build-up, 85.6% of participants opted such tooth should be crowned.
This may be due to the fact that ETT are more prone to fracture than vital teeth and crowning increases their strength and prognosis. Findings of present study are in agreement with previous studies. 15,25,26 The choice of PFM crown increased significantly with the increase in experience (p = 0.001). The highest preference of PFM was by those who had experience more than ten years (76%). The preference of PFM might be due to the fact that it has better strength to withstand the multidirectional chewing forces especially in molars and it has long term survival. 27 PFM crowns have good mechanical properties, adequate
esthetic results, and an acceptable biological status needed for periodontal health. 27
This study revealed that amalgam was preferred as core build-up material on the basis of strength. Endo-post was preferred for ETT in order to avoid fracture28 and majority of the participants preferred PFM as crown material in ETT. Furthermore, it was observed that PFM was more popular among dentist in teaching institutes of Multan, irrespective of their post-graduation qualification and work place.

CONCLUSION

Within the limitation of this study, the following conclusion can be drawn;

  1. Amalgam was selected as core buildup on the basis of strength.
  2. Most of the participants in the present study opted restoration of ETT after one week.
  3. Endo-post was preferred by majority of the survey dentist.However, prefabricated post was preferred over custom made on the basis of ease of use and completion in single visit.
  4. For crowning of ETT, majority of practitioners irrespective of their clinical experience and post-graduation qualification believed that ETT should be crowned for better prognosis, and PFM was the material of choice for the purpose.

CONFLICT OF INTEREST

None declared

REFERENCES

  1. Maroulakos G, Nagy WW, Kontogiorgos ED. Fracture resistance of compromised endodontically treated teeth restored with bonded post and cores: An in vitro study. J Prosthet Dent. 2015;114:390-97. https://doi.org/10.1016/j.prosdent.2015.03.017
  2. Khurshid Z, Zafar M, Qasim S, Shahab S, Naseem M, AbuReqaiba A. Advances in nanotechnology for restorative dentistry. Dent Mater J. 2015;8:717-31. https://doi.org/10.3390/ma8020717
  3. Samran A, El Bahra S, Kern M. The influence of substance loss and ferrule height on the fracture resistance of endodontically treated premolars. An in vitro study. Dent Mater J. 2013;29:1280-6. https://doi.org/10.1016/j.dental.2013.10.003
  4. Abduljawad M, Samran A, Kadour J, Al-Afandi M, Ghazal M, Kern M. Effect of fiber posts on the fracture resistance of endodontically treated anterior teeth with cervical cavities: An in vitro study. J Prosthet
    Dent. 2016;116:80-4. https://doi.org/10.1016/j.prosdent.2015.12.011
  5. Habib SR, Al Rifaiy MQ, Alkunain J, Alhasan M, Albahrani J. Concepts of restoring endodontically treated teeth among dentists in Saudi Arabia. Saudi J Dent Res. 2014;5:15-20. https://doi.org/10.1016/j.ksujds.2013.08.004
  6. Chugal NM, Clive JM, Spångberg LS. Endodontic treatment outcome: effect of the permanent restoration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104:576-82.
    https://doi.org/10.1016/j.tripleo.2007.04.011
  7. Safavi KE, Dowden WE, Langeland K. Influence of delayed coronal permanent restoration on endodontic prognosis. Dent Traumatol. 1987;3:187-91.
    https://doi.org/10.1111/j.1600-9657.1987.tb00622.x
  8. Lynch C, Burke F, Ní RR, Hannigan A. The influence of coronal restoration type on the survival of endodontically treated teeth. EJPRD – Eur. J. Dent.. 2004;12:171-6.
  9. Bonilla ED, Mardirossian G, Caputo A. Fracture toughness of various core build-up materials. J Prosthodont. 2000;9:14-8. https://doi.org/10.1111/j.1532-849X.2000.00014.x
  10. Naumann M, Kiessling S, Seemann R. Treatment concepts for restoration of endodontically treated teeth: A nationwide survey of dentists in Germany. J Prosthet Dent. 2006;96:332-38. https://doi.org/10.1016/j.prosdent.2006.08.028
  11. Mangold JT, Kern M. Influence of glass-fiber posts on the fracture resistance and failure pattern of endodontically treated premolars with varying substance loss: an in vitro study. J Prosthet Dent. 2011;105:387- 93. https://doi.org/10.1016/S0022-3913(11)60080-2
  12. Cheung W. A review of the management of endodontically treated teeth: Post, core and the final restoration. J Am Dent Assoc. 2005;136:611-19. https://doi.org/10.14219/jada.archive.2005.0232
  13. Sorensen JA, Martinoff JT. Endodontically treated teeth as abutments. J Prosthet Dent. 1985;53:631-36. https://doi.org/10.1016/0022-3913(85)90008-3
  14. Nagasiri R, Chitmongkolsuk S. Long-term survival of endodontically treated molars without crown coverage: a retrospective cohort study. J Prosthet Dent. 2005;93:164-70. https://doi.org/10.1016/j.prosdent.2004.11.001
  15. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent. 2002;87:256-63. https://doi.org/10.1067/mpr.2002.122014
  16. Hussey D, Killough S. A survey of general dental practitioners’ approach to the restoration of root-filled teeth. Int Endod J. 1995;28:91- 4. https://doi.org/10.1111/j.1365-2591.1995.tb00165.x
  17. Trope M, Delano EO, Ørstavik D. Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment. J Endod. 1999;25:345-50. https://doi.org/10.1016/S0099-2399(06)81169-6
  18. Ratnakar P, Bhosgi R, Metta KK, Aggarwal K, Vinuta S, Singh N. Survey on restoration of endodontically treated anterior teeth: a questionnaire based study. J Int Oral Health. 2014;6:41.
  19. Saunders W, Saunders E. Coronal leakage as a cause of failure in root-canal therapy: a review. Dent Traumatol. 1994;10:105-08. https://doi.org/10.1111/j.1600-9657.1994.tb00533.x
  20. Naumann M, Neuhaus KW, Kölpin M, Seemann R. Why, when, and how general practitioners restore endodontically treated teeth: a representative survey in Germany. Clin Oral Investig. 2016;20:253-
    59. https://doi.org/10.1007/s00784-015-1505-5
  21. Rabi T, Rabi T. Attitudes of Palestinian Dentists toward Restoration of Endodontically Treated Teeth. Int J Prosthodont Restor Dent. 2015;5:44-50. https://doi.org/10.5005/jp-journals-10019-1128
  22. Morgano SM, Hashem AF, Fotoohi K, Rose L. A nationwide survey of contemporary philosophies and techniques of restoring endodontically treated teeth. J Prosthet Dent. 1994;72:259-67. https://doi.org/10.1016/0022-3913(94)90339-5
  23. Eckerbom M, Magnusson T. Restoring endodontically treated teeth: a survey of current opinions among board-certified prosthodontists and general dental practitioners in Sweden. Int J Prosthodont. 2001;14245-249.
  24. Sambrook R, Burrow M. A survey of Australian prosthodontists: the use of posts in endodontically treated teeth. ANZ J Surg. 2018;63:294-301. https://doi.org/10.1111/adj.12620
  25. Pratt I, Aminoshariae A, Montagnese TA, Williams KA, Khalighinejad N, Mickel A. Eight-year retrospective study of the critical time lapse between root canal completion and crown placement: its influence on the survival of endodontically treated teeth. J Endod. 2016;42:1598-603. https://doi.org/10.1016/j.joen.2016.08.006
  26. Yee K, Bhagavatula P, Stover S, Eichmiller F, Hashimoto L, MacDonald S, et al. Survival Rates of Teeth with Primary Endodontic Treatment after Core/Post and Crown Placement. J Endod. 2018;44:220-
    25. https://doi.org/10.1016/j.joen.2017.08.034
  27. Ozer F, Mante FK, Chiche G, Saleh N, Takeichi T, Blatz MB. A retrospective survey on long-term survival of posterior zirconia and porcelain-fused-to-metal crowns in private practice. Quintessence Int.
    2014;45:31-8.
  28. Saritha MK, Paul U, Keswani K, Jhamb A, Mhatre SH, Sahoo PK. Comparative evaluation of fracture resistance of different post systems. J Int Soc Prev Community Dent.2017;7:356. https://doi.org/10.4103/jispcd.JISPCD_413_17

 


  1. Demonstrator, Department of Dental Materials, Nishtar Institute of Dentistry Multan.
  2. Demonstrator, Department of Oral Biology, Nishtar Institute of Dentistry Multan.
  3. Demonstrator, Department of Oral Biology, Nishtar Institute of Dentistry Multan.
  4. Assistant Professor, Department of Dental Materials, Nishtar Institute of Dentistry Multan.
    Corresponding author: “Dr. Mehwish Rafiq ” < mehwishyasir47@gmail.com >

Choice of Restorative Material for Endodontically Treated Teeth in Teaching Institutions of Multan

Mehwish Rafiq                        BDS

Tahira Parveen                       BDS

Uzma Abdullah                      BDS

Jaffar Hussain Bukhari     BDS, M.Phil

OBJECTIVE: The purpose of this study was to describe the knowledge, attitude and practice for core build-up and crowning of endodontically treated teeth in teaching institutes of Multan and to assess the association of clinical experience, work place and qualification on these options.
METHODOLOGY: A cross sectional study was conducted using self-applied questionnaire with dentists working in three teaching institutes of Multan from 22nd to 28th October, 2019. The calculated sample size for the total population of 160 was 114 according to Raosoft sample size calculator by keeping the confidence level 95%. A total of 160 questionnaires were distributed. Recovered questionnaires were 148. Response rate was 92%. Information about clinical experience, work place and post-graduation qualification was collected. Data regarding preference of core build-up material, crown material, timing of restoration of endodontically treated teeth (ETT), type of post was collected. Data were analyzed by SPSS version 22, frequencies and percentage were obtained. Association between different variables was calculated using Pearson’s chi-square test.
RESULTS: Amalgam was preferred as core buildup material on the basis of strength (81%), immediate restoration of ETT was preferred by private sector participants (30%) and restoration after one week was preferred by public sector participants (45.9%). Most of the participants believed core buildup must receive endopost to have better prognosis (60%). Majority preferred prefabricated endopost (50%) over custom made post (33%). The porcelain fused to metal crown was preferred as the clinical experience of dentist increases (p=0.001).
CONCLUSION: Within the limitations of the study, it was concluded that amalgam was preferred as core buildup material, prefabricated post was preferred over custom made and PFM was material of choice for crowning.
KEYWORDS: Dental practitioners, endodontically treated tooth, post and core, restoration, survey, core build-up.
HOW TO CITE: Rafiq M, Parveen T, Abdullah U, Bukhari JH. Choice of Restorative Material for Endodontically Treated Teeth in Teaching Institutions of Multan . J Pak Dent Assoc 2020;29(3):130-134.
DOI: https://doi.org/10.25301/JPDA.293.130
Received: 26 February 2020, Accepted: 21 May 2020

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Effect of Interactive Teaching Methods on Removable Partial Denture Designing

Hina Zafar Raja                          BDS, FCPS, MSc

Maryam Mumtaz                        BDS

Ambreen Shabbir                      BDS, M.Phil, MHPE

Muhammad Nasir Saleem        BDS, FCPS, MSc

Asma Shakoor                           BDS, MSc, MFDSRCS(Ed)

OBJECTIVE: The aims of this study were to, (a) Assess the level of skill acquired for designing removable partial dentures through two teaching methods individually, on two courses of dental graduates. (b) Compare the level of skill of dental graduates acquired through two teaching methods for designing removable partial dentures for diverse clinical situations. Materials and
METHODOLOGY: This quasi-experimental study comprised of application of two interactive teaching methods over two courses of Dental students over a period of three years. Course I, (n=113) was assessed with a brainstorming session without a prior formal lecture. Course II (n=102) was exposed to an interactive lecture followed by a formative assessment of RPD deigning. Each participant was asked to design a removable partial denture for a clinical scenario. Assessment was based on specific satisfaction criteria. Data was analyzed descriptively and compared with student’s t test.
RESULTS: Out of all participants, 70 % of participants in course I and 63% percent from course II showed partial satisfaction. 8-15 % were able to achieve complete satisfactory scores. On comparison of two courses, mean total score in course I was 3.31 ± 1.21 and in course II mean total score was 3 ± 1.30, thus, p-value was 0.072, which was statistically insignificant.
CONCLUSION: The level of skill acquired for designing a removable partial denture through two interactive teaching methods was only partially satisfactory for most participants of both courses. The level of skill acquired from brainstorming was comparable to the skill acquired from an interactive lecture. The difference of assessment scores in both scenarios was not statistically significant.
KEYWORDS: Denture, Partial, Removable; Learning; Problem solving; Curriculum; Universities; Schools, Dental.
HOW TO CITE: Raja HZ, Mumtaz M, Shabbir A, Saleem MN, Shakoor A. Effect of interactive teaching methods on removable partial denture designing. J Pak Dent Assoc 2020;29(3):124-129.
DOI: https://doi.org/10.25301/JPDA.293.124
Received: 13 June 2020, Accepted: 17 June 2020

INTRODUCTION

Awell planned removable partial denture (RPD) restores oral functions, esthetics and imparts minimum stress to the hard and soft tissues of oral cavity.1
Poorly designed removable partial dentures may result in periodontal bone loss, caries, gingivitis, periodontal damage and stomatitis of supporting tissues.2,3,4 Acquisition of skill of partial denture design is crucial to its successful implementation during clinical practice.1
Many designs proposed in literature are without sufficient scientific evidence.5
Worldwide studies have shown disagreements over removable partial denture designs as well as lack of communication skills of dentists, pertaining to details of removable partial denture design to dental laboratories.6,7
Although digital designing of dentures is gaining popularity, but the importance of knowledge of basic principles of denture designing cannot be negated.8 Curricula of all leading universities require attainment of partial dentures designing competency for graduating dental students.9
Contemporary under-graduate prosthodontic teaching in most dental schools comprises of a non-examinable pre-clinical skill component in early years, followed by theoretical knowledge with a practical component in subsequent years. Many dental schools are not following
an equivalent pattern of teaching of removable partial dentures. This disparity is present at various levels of academic years i.e. second year10, third year or final year.
In addition, number of credit hours spent on each component of partial dentures for theory and practical teaching, varied teacher student ratio in many dental schools, reliance of students on teaching staff for denture designing8, reliance on dental technicians for partial denture construction, limited patient exposure of dental students, inability of students to perform laboratory work of their patients and non-availability of surveyors, semi-adjustable articulators within dental schools are factors that affects the skill of budding professionals.11,12 In some institutions, reduction in practical teaching is compensated by increased dependency on audiovisual aids. This may have a negative effect on achievement of adequate manual skills.12 As partial denture designing mandates sound clinical knowledge with sufficient grip on clinical dexterity, which may not be achieved with alternate means.
A Prosthodontics student must acquire knowledge thoroughly based on scientific evidence, and apply it clinically with critical thinking.13 The gradual acquisition of knowledge and skill in dentistry improves with exposure and experience. Studies have evaluated undergraduate
preclinical and final year students for teeth preparations for better adaptability of partial denture components14 and RPD designing.1 The gain of such skill is difficult to assess at preclinical years, when a student is still in a phase of acquiring basic knowledge of prosthodontics. Gradually in third year or final year levels, the interrelations of prosthodontics with other specialties like endodontics/ periodontics and skill of removable partial denture designing and construction are learnt.15 This phenomenon of gradual acquisition of skill can be explained with bloom’s taxonomy.16
Globally, there is a diversity in the preferred method of teaching in different regions. In Pakistan, limited scientific evidence is available in this regard. Studies have shown significant preference for the interactive teaching methods over didactic modes of learning.17 Teaching of partial dentures can be done through conventional teaching (elaborate lectures covering basic principles of dentures design for a specific Kennedy’s class). Interactive teaching is also recommended for partial denture designing. It may include individual or collective participation of all students and team based learning.13 Small group discussion and problem-solving based learning can aid in better
understanding of the subject. It can be achieved through brainstorming for a clinical scenario without a prior didactic teaching or designing partial dentures as an exercise taken after an interactive lecture.18 It can be hypothesized that interactive teaching done with last two methods, may result in better outcome of dental students as compared to a brainstorming session without a prior didactic lecture than teaching done with an interactive lecture followed by a mock exercise only. Effective teachers may incorporate multiple teaching methods to improve students’ competencies.19,20
The rationale of this study was to utilize diverse interactive teaching methods for improved skill of partial denture designing of dental students. The aims of this study were to, Assess the level of skill acquired for designing removable partial dentures through two teaching methods individually, over two courses of dental graduates. Compare the level of skill of dental graduates acquired through two teaching methods for designing removable partial dentures for diverse clinical situations.

METHODOLOGY

This quasi-experimental study was done individually over two courses of BDS from two Private Dental Colleges of Lahore, Pakistan over a period of three years, from 2016- 2019. The study was approved by Institutional Review Board. The data obtained was kept anonymous and all principles pertaining to data protection were strictly followed.
The description of courses and the teaching method utilized is as follows.
Course I: Removable Partial Denture designing using brainstorming: This course comprised of 113 (n=113) participants. Participants had completed four years of BDS, covering 460 credit hours for Prosthodontics. They were going through their house job. For the present study, the participants were asked to design a removable partial denture through brainstorming, over a worksheet comprising of a clinical scenario, with details of health status, magnitude and location of undercuts of primary abutments of a partial denture arch classified as Kennedy’s class 2 modification 1. Prior to this exercise, no formal traditional lecture was delivered. The RPD designs were evaluated for these components.
1. Rest
2. Indirect retainer
3. Retentive arm of the clasp assembly
4. Reciprocal arm of the clasp assembly
5. Minor connector
6. Major connector
Course II: Interactive lecture followed by individual brainstorming: This course comprised of 102 (n=102) participants. The participants had completed their theoretical and clinical rotations in preclinical and third year, covering 135 and 150 prosthodontics credit hours respectively. At the time of study, they were going through their theoretical and clinical rotations in final year. A series of three hours of traditional lectures on basic principles of removable partial denture designing of bounded and free end saddles were held. At the end of third lecture, an interactive session on concepts of removable partial denture designing took place followed by a formative assessment on worksheets.
Five different clinical situations of free end and bounded saddles were presented on different worksheets, with clinical scenarios describing magnitude and location of undercuts. Each student got only one Kennedy’s classification clinical picture and was asked about class definition, outlining of saddle areas, choice of major connector, options for means of retention, and means of support on all possible abutments.
Researchers made a key of all plausible options for each component, as given in reference text books.21,22 All the designs submitted by the students were evaluated and scored according to the same criteria as Course I. The evaluation criteria utilized was taken from a previous study.1 Out of a total score of 6, scores were classified as’Completely appropriate’ for scoring 5-6 marks, ‘Partially appropriate’ for scoring 3-4 marks, and ‘Inappropriate’ for scoring 0-2 marks. Three examiners assessed the RPD designs for each course individually. An average of their individual score was considered as a final score for that particular design. The data was entered and analyzed SPSS
version 23.0. p value was considered significant when it will be < 0.05.

RESULTS

Descriptive and frequency analysis were done for all scores in both courses to assess the level of skill acquired for designing removable partial dentures through two teaching methods individually. Course I had 113 participants (n=113). Participants were going through their house job.
They had completed 460 Prosthodontics credit hours. Course

Table 1: Total Assessment Classification Percentages of all Participants of Course I (n=113) and Course II (n=102).

II had 102 participants (n=102). They had completed 285 credit hours. Out of all participants, 92.09% were in age range of 21-25 years (Figure 1). 72 % of all participants in both courses were females

Figure 1: Age distrubution of participants of Course I (n=113) and Course II (n=102)

Figure 2: Gender distrubution of participants of Course I (n=113) and Course II (n=102)

Figure 3: Mean scores obtained within Course I (n=113) and Course II (n=102)

while 21% were males. (Figure 2) The scores of each participant were assessed according to the classification.1 70 % of participants in course I showed partially satisfaction, while 63% percent from course II showed the same grade. The difference in both courses was not statistically significant. (Table 1) However, only 8-15 % were able to achieve complete satisfactory scores.
The data obtained from each course in Student’s t test was applied to compare the level of skill of dental graduates acquired through two teaching methods for designing removable partial dentures for diverse clinical situations.
The mean total score in course I was 3.31 ± 1.21 and in course II the mean total score was 3 ± 1.30. (Figure 3) The mean total score in both courses was statistically same, thus, p-value was 0.072, which was statistically insignificant.

DISCUSSION

The use of removable partial dentures is expected to increase owing to cumulative awareness towards oral health and conservation of natural structures.3,4 Since removable partial dentures are intended to be placed and removed from the mouth on a daily basis, they are subjected to move under functional forces and other biomechanical stresses. Clinicians must design each component of the partial denture to ensure favorable distribution of these stresses.3 Inadequate planning of a removable partial denture might become the most costly way to extract a tooth. A review of the researches and surveys done on this subject brings to light the fact that a fundamental problem exists pertaining to the designing and fabrication of removable partial dentures.1,10,12,13,14
According to the results obtained in this study, the majority of dental students had partial satisfactory skills for designing of removable partial dentures. There is a myriad of reasons for this observation. According to surveys done in dental schools in different regions of the world, a few observations common to all included a lack of practical application of the theoretical principles of partial denture design by the students.4,12 However, the level of participants in these studies were diverse. A valid assessment requires accurate measurement of its subject. Hence, the academic level students may also affect the assessment scores of designing skills for RPD.
A removable partial denture can be an interim or definitive prosthesis. Its planning and designing requires careful understanding of all domains of dentistry, that might affect the prognosis of a possible abutment tooth. A preclinical, or third year student may not fully understand the inter relation of prosthodontics with other specialties.
In the present study, the participants of both courses were either going through their vocational training (Course I) or were in final year of their training, with on going clinical rotations (Course II). This implies sufficient exposure of participants to the varied clinical scenarios as evident in other studies depicting better skills of RPD designing by house officers.20
The method of teaching at under graduate level is also a factor. In this study, instead of traditional lectures, two methods of teaching were used. One was RPD designing using brainstorming without any prior formal lecture. The second was interactive teaching session followed by a mock exam. The goal of these methods was to engage the students practically and allow them to use their own critical thinking and competency level in different clinical scenarios.
According to the results obtained, there was no statistically significant difference amongst the two teaching methods (Table 1, Figure 3). According to a study conducted in the University of Florida in 2015, the traditional method of lecture based teaching is not very effective in the area of clinical knowledge.11 An improved clinical performance was observed by introducing team based learning methods in which practical involvement of students is encouraged.
Multiple teaching methods have been shown to be more effective and better accepted by students as compared to the conventional lecture based, single teaching approach.11,12 Practical courses with small group discussions, problem solving exercises, interactive sessions with videos and self- directed learning are all novel methods of teaching gaining popularity.10,12 In present study, both teaching methods for
each course were interactive, which is contrary to conventional lecturing method. In addition, the method applied on first course had no recent exposure to the basic knowledge of the subjects. Despite this, the results obtained were almost similar in all courses and all scenarios. Thus the results of the study showed null hypothesis. This observation implies that the incorporation of preferred learning style of learners may help in alleviation of extrinsic load on students and augment their learning capabilities.23,24
Such interactive teaching modalities result in better performance and participation on the students’ behalf as compared to the traditional lectures.1,11,12,13 In majority dental schools, students tend to depend on the teachers and technical staff to design and fabricate the partial dentures. This dependency is carried forwards in general dental practice in the form of complete reliance on dental technicians for partial denture design. This leads to a lack of expertise and skill in professional life.4,11 On the contrary, the students during their clinical rotations may be directed to organize a comprehensive treatment plan for a particular patient, instead of focusing on the denture part
only. This may improve their critical thinking and refine their clinical judgement.

LIMITATIONS

The limitation of this study was that participants in this study were assessed at different times of their courses. If all participants were at a similar academic level, it would improve the level of evidence. It is therefore recommended to pursue this research with introduction of other teaching methods for the same subjects to achieve a unanimous conclusion.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

ACKNOWLEDGEMENTS

We thank Dr. Asif Hanif (Director Biostatistics UnitFaculty of Allied Health Sciences) for helping with the statistics and reviewing this article. This study was not funded by any organization or institute.

CONCLUSIONS

The following conclusions were observed from this study.

  1. The level of skill acquired for designing a removable partial denture through two interactive teaching methods was partially satisfactory in most participants of both courses (63%-70%). However, only 8-15 % were able to achieve complete satisfactory scores.
  2. The level of skill acquired from brainstorming was comparable to the skill acquired from an interactive lecture. The difference of assessment scores in both scenarios was not statistically significant. The study showed null hypothesis.
  3. Globally, there is a dire need for improvement of teaching methodologies pertaining to removable partial dentures planning and designing.

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  16. Krathwohl DR, Anderson LW. A taxonomy for learning, teaching, and assessing: A revision of Bloom’s taxonomy of educational objectives: Longman; 2009.
  17. Alaagib NA, Musa OA, Saeed AM. Comparison of the effectiveness of lectures based on problems and traditional lectures in physiology teaching in Sudan. BMC Medi Educ. 2019;19:365. https://doi.org/10.1186/s12909-019-1799-0
  18. Abdulhadi Al-Samawi L, Mohammed H, editors. Multiple teaching methods to enhance removable partial learning outcome and designing skill for undergraduate dental students. a personal experience. Proceedings of INTED2014 Conference; 2014 10th-12th March; Valencia, Spain.
  19. Khalid A RK, Bashir Z, Hanif A. Learning style preferences among students of Shalamar Medical and Dental College, Pakistan. Adv
    Health Prof Educ. 2015;1:13-7.
  20. Anthony L, Latt S, Afrose T, Khaing I. Preferred Teaching Methods by Medical and Dental Students of a Private University: The Students’ Perception. 2018;Volume 6:106-11.
  21. Carr AB. Mccracken’s removable partial prosthodontics. St. louis: Elsevier mosby; 2016.
  22. Davenport JC, British Dental A. A clinical guide to removable partial denture design. London: British Dental Association; 2007.
  23. Hernandez-Torrano D, Ali S, Chan CK. First year medical students’ learning style preferences and their correlation with performance in different subjects within the medical course. BMC Med Educ. 2017;17:131. https://doi.org/10.1186/s12909-017-0965-5
  24. Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive Load Theory: implications for medical education: AMEE Guide No.
    86. Med Teach. 2014;36:371-84. https://doi.org/10.3109/0142159X.2014.889290

  1. Professor, Department of Prosthodontics, Institute of Dentistry, CMH Lahore Medical College, Lahore, Pakistan.
  2. Resident, Department of Prosthodontics, Institute of Dentistry, CMH Lahore Medical College, Lahore, Pakistan.
  3. Associate Professor, Department of Pathology, CIMS, Pakistan.
  4. Professor, Department of Operative Dentistry, Institute of Dentistry, CMH Lahore Medical College, Lahore, Pakistan.
  5. Associate Professor, Department of Community & Preventive, Institute of Dentistry, CMH Lahore Medical College, Lahore, Pakistan.
    Corresponding author: “Dr. Hina Zafar Raja” < hinazafarraja@gmail.com >

Effect of Interactive Teaching Methods on Removable Partial Denture Designing

Hina Zafar Raja                          BDS, FCPS, MSc

Maryam Mumtaz                        BDS

Ambreen Shabbir                      BDS, M.Phil, MHPE

Muhammad Nasir Saleem        BDS, FCPS, MSc

Asma Shakoor                           BDS, MSc, MFDSRCS(Ed)

OBJECTIVE: The aims of this study were to, (a) Assess the level of skill acquired for designing removable partial dentures through two teaching methods individually, on two courses of dental graduates. (b) Compare the level of skill of dental graduates acquired through two teaching methods for designing removable partial dentures for diverse clinical situations. Materials and
METHODOLOGY: This quasi-experimental study comprised of application of two interactive teaching methods over two courses of Dental students over a period of three years. Course I, (n=113) was assessed with a brainstorming session without a prior formal lecture. Course II (n=102) was exposed to an interactive lecture followed by a formative assessment of RPD deigning. Each participant was asked to design a removable partial denture for a clinical scenario. Assessment was based on specific satisfaction criteria. Data was analyzed descriptively and compared with student’s t test.
RESULTS: Out of all participants, 70 % of participants in course I and 63% percent from course II showed partial satisfaction. 8-15 % were able to achieve complete satisfactory scores. On comparison of two courses, mean total score in course I was 3.31 ± 1.21 and in course II mean total score was 3 ± 1.30, thus, p-value was 0.072, which was statistically insignificant.
CONCLUSION: The level of skill acquired for designing a removable partial denture through two interactive teaching methods was only partially satisfactory for most participants of both courses. The level of skill acquired from brainstorming was comparable to the skill acquired from an interactive lecture. The difference of assessment scores in both scenarios was not statistically significant.
KEYWORDS: Denture, Partial, Removable; Learning; Problem solving; Curriculum; Universities; Schools, Dental.
HOW TO CITE: Raja HZ, Mumtaz M, Shabbir A, Saleem MN, Shakoor A. Effect of interactive teaching methods on removable partial denture designing. J Pak Dent Assoc 2020;29(3):124-129.
DOI: https://doi.org/10.25301/JPDA.293.124
Received: 13 June 2020, Accepted: 17 June 2020

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Are Dentists Prescribing the Antibiotics in Justified Conditions? An Exploratory Study

Ahmad Liaquat                       BDS, FCPS, FFD RCSI

Mishal Fatima Jaffery             BDS

Mahwish Usman                      BDS

Tahmasub Faraz Tayyab                    BDS, FCPS

Tooba Saeed                BDS, FCPS

Ansa Naheed              MBBS

OBJECTIVE: Antibiotic prescription is a common practice among dental practitioners. Unjustified antibiotic prescription is leading to antibiotic resistance. The purpose of this survey is to analyze the most commonly prescribed antibiotics, conditions in which antibiotics are being prescribed, either the dental surgeons prescribe the antibiotics in the conditions where they are not recommended and awareness of antibiotic resistance among the dental practitioners of Lahore.
METHODOLOGY: The study aimed to identify the prevalence of unjustified prescription of antibiotics so we can take measures to teach dental students about this wrong and unjustified prescription in undergraduate studies. It was an observational crosssectional study. Among dental practitioners of Lahore, 380 were selected through a non-probability convenience sampling technique. Standardized; a previously validated questionnaire was used containing 18 questions, about the most commonly prescribed antibiotics, conditions where antibiotics are indicated, and antibiotic resistance. Data was coded in SPSS version 20.
RESULTS: It showed the studied sample of dental practitioners tends towards the over-prescription of antibiotics.
CONCLUSION: Dentists should prescribe antibiotics only according to the latest guidelines, where it is indicated. It should not be a first-line treatment modality
KEYWORDS: antibiotic resistance awareness, unjustified antibiotic prescription
HOW TO CITE: Liaquat A, Jaffary MF, Usman M, Tayyab TF, Saeed T, Naheed A . Are dentists prescribing the antibiotics in justified conditions? an exploratory study. J Pak Dent Assoc 2020;29(3):120-123.
DOI: https://doi.org/10.25301/JPDA.293.120
Received: 15 December 2019, Accepted: 28 April 2020

INTRODUCTION

Most human orofacial infections originate from odontogenic infections and prescribing antibiotics has become a ubiquitous phenomenon.1-5
Antibiotic prescription is a common practice among dental practitioners. This is leading to antibiotic resistance in our population and other health issues related to the over-prescription of antibiotics.6-8 The World Health Organization (WHO) has recognized the inappropriate, indiscriminate, and irrational use of antibiotics leading to antibiotic resistance as a global problem.2,5,7,8
Antibiotics have emerged as a boon to humanity and this advancement has led to a better quality of life along with an overall reduction in morbidity and mortality. These are chemical substances that are capable of destroying and inhibiting the growth of specific microorganisms, such as infectious bacteria and fungi. Dental infections are polymicrobial in nature. The majority of orofacial infections
require both systemic and local management.9-12 Systemic management is mostly by antibiotics, and hence, these antibiotics are pharmacotherapeutic adjuncts prescribed by dentists.1-13-15
Inappropriate, indiscriminate, and irrational use of antibiotics has led to the development of antibiotic resistance. Even more alarming is the rate at which bacteria develop resistance.16-18 Microorganisms exhibiting resistance to new drugs often are isolated soon after the drugs have been introduced. The main reason behind antibiotic resistance is due to over-prescription by the health-care personnel,
improper use by patients, and also due to the resistance developed by the bacteria.2-4,19-20 There is a significant relationship between the increase of antibiotic resistance and utilization, with higher resistance levels in bacteria isolated from areas of high antibiotic utilization.1,3 Dentists prescribe between 7% and 11% of all common antibiotics.5
As per the National Center for Disease Control and Prevention, approximately one-third of all outpatient antibiotic prescriptions are unnecessary.5
Dentistry’s contribution to antibiotic resistance is unknown. With increasing prescription of antibiotics and bacterial resistance, newer drug combinations are being introduced. Hence, keeping in the mind trend of prescribing practices in dentistry, it is required to assess the knowledge and practice among dental practitioners.1,3,5 Limited studies have assessed the antibiotic prescription pattern and knowledge regarding the development of resistance among dentists in India. Hence, the study was conducted with the objective to assess dental practitioner’s knowledge and practices regarding antibiotic prescription and development of resistance.7-10
Antimicrobial resistance has been identified as one of the greatest threats to future human health with an increasing number of resistant microbial strains reported each year across both human and animal populations in developed and developing countries.21,22 Policymakers, health organizations, and research institutes have called for tighter control over their distribution and use in society5,6 with an emphasis on front-line antibiotic prescribers and dispensers7
While efforts have been sustained over many years to promote the ‘rational use of drugs’, for example through the WHO’s International
Network on the Rational Use of Drugs program (INRUD), the scale of antibiotic use appears to be escalating.15-17 An increase in antibiotic resistance (ABR) worldwide, specifically in developing countries, necessitates the need to pay attention to antibiotics prescription and knowledge and awareness of Antibiotic Resistance among dental practitioners.1-2 In May 2015, the World Health Assembly reached an agreement to tackle the menace of Antibiotic Resistance globally, and the first objective was to increase Antibiotic Resistance awareness and understanding.3 Antibiotics are medicines formulated for treatment or prevention of bacterial infections, administered to patients based on the prescription of certified health care professionals.
In developing countries, antibiotics can be readily purchased without any control; such countries usually experience more cases of antibiotic resistance, in contrast to what occurs in western nations where tight regulations of antibiotic use are in place.4-7

METHODOLOGY

An observation study that followed a cross-sectional study design was conducted. Among dental practitioners of Lahore, 380 were selected through a non-probability convenience sampling technique. The sample size was determined using this formula.3

 

standardized, previously validated questionnaire was used containing 18 questions, about the most commonly prescribed antibiotic, conditions where antibiotics are indicated and antibiotic resistance. The questionnaire was used in English as such. Data was coded in SPSS version 20.

RESULTS

Majority dentists are prescribing antibiotics in conditions where they are not needed. Amoxicillin is commonly prescribed Antibiotic. Most dentists prefer prescribing antibiotics for 3 days. Awareness about antibiotic resistance is adequate. A considerable group of the dentist is not aware of guidelines regarding antibiotics prescription. Table-1 shows that dentists are prescribing antibiotics in conditions where they are not indicated at all. In general,

Table 1: Conditions in which antibiotics are prescribed (N=380)

more than 60% of dentists are prescribing antibiotics in conditions where they have no role.
According to the figure-1, the most commonly prescribed antibiotic is co-amoxiclav, which is a secondline drug. Whereas first-line drugs, amoxicillin is only 20.25% prescribed. The results indicate inappropriate practice among dental practitioners.
Most dentists are aware of the causes of antibiotic resistance and they claim that they take a proper history

Figure 1: Most commonly prescribed antibiotics (N=380)

Table 2: Antibiotics resistance and its factors (N=360)

Figure 2: Reasons for antibiotics prescription

about the last course of antibiotics and also advise patients to adhere to antibiotic dose regimen. Dentists claim that the most common reason for antibiotic prescription patient’s insistence and more than 60% of dentists claim that they prescribe antibiotics due to long waiting appointments and to sustain the patient until specialist treats the patient.

DISCUSSION

In our study most commonly prescribe antibiotic was Co-amoxiclav (47.75%). In a study conducted by Sapna Konde et al. in India in the sample of 100 BDS and 100 MDS, amoxicillin was the most commonly prescribed antibiotic, 86% of BDS and 70% of MDS prescribe
Amoxicillin.5
Co-amoxiclav is a second line Antibiotic according to the current guidelines7-9, a large number of dentists are prescribing it in Lahore.
Salako et al. conducted a study in Kuwait in a sample of 200 dental practitioners which shows 78.57% of dentists are prescribing antibiotics in conditions like a dry socket, pericoronitis, simple extraction, and localized intraoral swelling.16 In our study 58.25% dentists are prescribing antibiotics where they aren’t indicated.
In our study, 58.25% dentists are prescribing antibiotics where they are not indicated. According to our study, 74.47% of dentists are aware of antibiotic resistance. A study conducted in France and Scotland by D.Nathwani in a sample of 300 dentists, 95% of junior doctors and 63% of senior doctors are considerate about Antibiotic Resistance.19-20
There should be Antibiotic awareness programs. There should be our own antibiotic prescription guidelines in Pakistan. There should be strict rules about purchasing the Antibiotics in pharmacy. Antibiotics shouldn’t be over the counter sold the drug. Compliance towards the guidelines should be monitor via policy. Our relative limitations were time constraints and Initial cross-sectional non-probability convenience sampling technique was used.

CONCLUSION

Results are indicative that the studied sample of dental practitioners tends the over-prescription of antibiotics. Dentists should prescribe Antibiotics only according to the latest Guidelines, where it is indicated. It shouldn’t be first-line treatment modality.21

CONFLICT OF INTEREST

None declared

REFERENCES

  1. Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mole Biol reviews. 2010;74:417-33. https://doi.org/10.1128/MMBR.00016-10
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  4. Jain A, Bhaskar DJ, Gupta D, Yadav P, Dalai DR, Jhingala V, Garg Y, Kalra M. Drug prescription awareness among the 3 rd year and final year dental students: A cross-sectional survey. J Indian Assoc Public Health Denti. 2015;13:73 https://doi.org/10.4103/2319-5932.153598
  5. Konde S, Jairam LS, Peethambar P, Noojady SR, Kumar NC. Antibiotic overusage and resistance: A cross-sectional survey among pediatric dentists. J Indian Soci Pedodont Prevent Denti.2016;34:145. https://doi.org/10.4103/0970-4388.180444
  6. Salako NO, Rotimi VO, Adib SM, Al-Mutawa S. Pattern of antibiotic prescription in the management of oral diseases among dentists in Kuwait. J denti. 2004;32:503-09. https://doi.org/10.1016/j.jdent.2004.04.001
  7. Pulcini C, Williams F, Molinari N, Davey P, Nathwani D. Junior doctors’ knowledge and perceptions of antibiotic resistance and
    prescribing: a survey in France and Scotland. Clinical Microbiol infecti. 2011;17:80-7. https://doi.org/10.1111/j.1469-0691.2010.03179.x
  8. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28:88-96. https://doi.org/10.1111/j.1600-9657.2012.01125.x
  9. Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, Fu Y, Chen X, Cals JW, Zhang F. Knowledge, attitude and practice of antibiotics: a
    questionnaire study among 2500 Chinese students. BMC Medi Educ. 2013;13:163. https://doi.org/10.1186/1472-6920-13-163
  10. Segura-Egea JJ, Velasco-Ortega E, Torres-Lagares D, VelascoPonferrada MC, Monsalve-Guil L, Llamas-Carreras JM. Pattern of antibiotic prescription in the management of endodontic infections amongst Spanish oral surgeons. Inter Endod J.2010;43:342-50. https://doi.org/10.1111/j.1365-2591.2010.01691.x
  11. Baskaradoss JK, Alrumaih A, Alshebel A, Alfaqih A, Aleesa M, Alkhashan S, Altuwaijri M. Pattern of antibiotic prescription among
    dentists in Riyadh, Saudi Arabia. J Investigat Clini Denti. 2018:e12339. https://doi.org/10.1111/jicd.12339
  12. El-Kholey KE, Wali O, Elkomy A, Almozayen A. Pattern of Antibiotic Prescription for Oral Implant Treatment Among Dentists
    in Saudi Arabia. Implant denti. 2018;27:317. https://doi.org/10.1097/ID.0000000000000748
  13. Marra F, George D, Chong M, Sutherland S, Patrick DM. Antibiotic prescribing by dentists has increased: Why? J Am Dent Assoc.
    2016;147:320-27. https://doi.org/10.1016/j.adaj.2015.12.014
  14. Prior M, Elouafkaoui P, Elders A, Young L, Duncan EM, Newlands R, Clarkson JE, Ramsay CR. Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol. Implementa Sci. 2014;9:50. https://doi.org/10.1186/1748-5908-9-50
  15. Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C.
    Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An
    Overview. Dent Clini North Am.2018;62:279-94.
    https://doi.org/10.1016/j.cden.2017.11.007
    16. Anu V, Harshamol S, Helena T, Hannah PD, Gokila R, Manomani
    H. Paediatricians Cognizance About The Deleterious Effect Of
    Antibiotics And Dental Caries-A Preliminary Study. Int J Pharmaceutical
    Sci Res. 2018;9:708-11.
    17.Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic
    prescribing by general dentists in the United States, 2013. J Am Dent
    Assoc. 2017;148:172-8.
    https://doi.org/10.1016/j.adaj.2016.11.020
    18. Zhuo A, Labbate M, Norris JM, Gilbert GL, Ward MP, Bajorek
    BV, Degeling C, Rowbotham SJ, Dawson A, Nguyen KA, HillCawthorne GA. Opportunities and challenges to improving antibiotic
    prescribing practices through a One Health approach: results of a
    comparative survey of doctors, dentists and veterinarians in Australia.
    BMJ open. 2018;8:e020439.
    https://doi.org/10.1136/bmjopen-2017-020439
    19. Stein K, Farmer J, Singhal S, Marra F, Sutherland S, Quiñonez C.
    The use and misuse of antibiotics in dentistry: A scoping review. The
    J Am Dent Assoc. 2018;149:869-84
    https://doi.org/10.1016/j.adaj.2018.05.034
    20. Koppen L, Suda KJ, Rowan S, McGregor J, Evans CT. Dentists’
    prescribing of antibiotics and opioids to Medicare Part D beneficiaries:
    medications of high impact to public health. J Am Dent Assoc.
    2018;149:721-30.
    https://doi.org/10.1016/j.adaj.2018.04.027
    21. Suda KJ, Henschel H, Patel U, Fitzpatrick MA, Evans CT. Use of
    antibiotic prophylaxis for tooth extractions, dental implants, and
    periodontal surgical procedures. InOpen forum infectious diseases
    2018 (Vol. 5, No. 1, p. ofx250). US: Oxford University Press.
    https://doi.org/10.1093/ofid/ofx250
    22. Bird L, Landes D, Robson T, Sturrock A, Ling J. Higher antibiotic
    prescribing propensity of dentists in deprived areas and those with
    greater access to care in the North East and Cumbria, UK. Bri Dent
    J. 2018;225:517.
    https://doi.org/10.1038/sj.bdj.2018.752

  1. Assistant Professor, Department of Oral & Maxillofacial Surgery, University College of Medicine & Dentistry, University of Lahore.
  2. House officer, Department of Oral & Maxillofacial Surgery, University College of Medicine & Dentistry, University of Lahore.
  3. House officer, Department of Oral & Maxillofacial Surgery, University College of Medicine & Dentistry, University of Lahore.
  4. Assistant Professor, Department of of Oral & Maxillofacial Surgery, University College of Medicine & Dentistry, University of Lahore.
  5. Senior registrar, Department of Oral & Maxillofacial Surgery, University College of Medicine & Dentistry, University of Lahore.
  6. FCPS Resident , Department of East Medical Ward, King Edward Medical University, Lahore.
    Corresponding author: “Dr. Ahmad Liaquat” < ahmadliaquat@hotmail.com >

Are Dentists Prescribing the Antibiotics in Justified Conditions? An Exploratory Study

Ahmad Liaquat                       BDS, FCPS, FFD RCSI

Mishal Fatima Jaffery          BDS

Mahwish Usman                      BDS

Tahmasub Faraz Tayyab        BDS, FCPS

Tooba Saeed                             BDS, FCPS

Ansa Naheed                            MBBS

OBJECTIVE: Antibiotic prescription is a common practice among dental practitioners. Unjustified antibiotic prescription is leading to antibiotic resistance. The purpose of this survey is to analyze the most commonly prescribed antibiotics, conditions in which antibiotics are being prescribed, either the dental surgeons prescribe the antibiotics in the conditions where they are not recommended and awareness of antibiotic resistance among the dental practitioners of Lahore.
METHODOLOGY: The study aimed to identify the prevalence of unjustified prescription of antibiotics so we can take measures to teach dental students about this wrong and unjustified prescription in undergraduate studies. It was an observational crosssectional study. Among dental practitioners of Lahore, 380 were selected through a non-probability convenience sampling technique. Standardized; a previously validated questionnaire was used containing 18 questions, about the most commonly prescribed antibiotics, conditions where antibiotics are indicated, and antibiotic resistance. Data was coded in SPSS version 20.
RESULTS: It showed the studied sample of dental practitioners tends towards the over-prescription of antibiotics.
CONCLUSION: Dentists should prescribe antibiotics only according to the latest guidelines, where it is indicated. It should not be a first-line treatment modality
KEYWORDS: antibiotic resistance awareness, unjustified antibiotic prescription
HOW TO CITE: Liaquat A, Jaffary MF, Usman M, Tayyab TF, Saeed T, Naheed A . Are dentists prescribing the antibiotics in justified conditions? an exploratory study. J Pak Dent Assoc 2020;29(3):120-123.
DOI: https://doi.org/10.25301/JPDA.293.120
Received: 15 December 2019, Accepted: 28 April 2020

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Prevalence of Middle Mesial Canals and Isthmi in Mandibular Molars Using Cone Beam Computed Tomography

Attique ur Rehman                     BDS, FCPS

Saqib Naeem Siddique              BDS, FCPS

Saba Rehman                             BDS

Mehwish Munawar                     BDS, FCPS

Haroon Asghar Ginai                 BDS, FCPS

OBJECTIVE: The purpose of this study was to investigate the prevalence and configuration of Middle Mesial Canals (MMC) and isthmi in mandibular molars in Pakistani population using Cone Beam Computed Tomography (CBCT).
METHODOLOGY: Sixty CBCTs of patients were selected randomly from database of University College of Dentistry, Lahore. First and second permanent mandibular molars without evidence of previous endodontic treatment, full coverage restoration or root resorption were evaluated for the number of roots, canals and the presence and configuration of MMC and isthmi. The age and gender of patients were also recorded. SPSS was used for statistical analysis using chi-square test. Significance level was set at 5% (P < 0.05).
RESULTS: Out of 189 mandibular molars, MMCs were found in 9 and isthmi in 62 teeth. No statistical association was found between the presence of MMC and age, gender, side or tooth type. Significantly more isthmi were found in second molars, females and younger patients, P < 0.05.
CONCLUSION: MMC and isthmi in mesial roots of mandibular molars are not unusual findings in our population and CBCT can be a valuable tool for their detection.
KEYWORDS: Cone-Beam computed tomography, isthmus, mandibular molar, middle mesial canal, root canal therapy
HOW TO CITE: Rehman UA, Siddique SN, Rehman S, Munawar M, Ginai HA. Prevalence of middle mesial canals and isthmi in mandibular molars using cone beam computed tomography. J Pak Dent Assoc 2020;29(3):114-119.
DOI: https://doi.org/10.25301/JPDA.293.114
Received: 17 December 2019, Accepted: 27 April 2020

INTRODUCTION

Non-surgical endodontic treatment generally has a high success rate. Anatomical variations such as missed canals and isthmi are one of the main causes of endodontic treatment failure.1 Untouched areas of canals contain necrotic debris and bacterial contents, and have been
linked with the presence of apical periodontitis.2 Isthmi which are narrow ribbon like communications between canals, are difficult to completely debride by current chemomechanical preparation techniques.3 Identification and treatment of the entire endodontic space is vital for successful endodontics.
The root canal anatomy can be studied in vitro on extracted teeth using sectioning, diaphonization, plastic dye, micro CT and other techniques.4 However, the results obtained from extracted teeth may not be truly applicable on clinically restorable teeth that are to be endodontically treated. Complications like calcifications and sclerosed canals may give different results.5
In vivo methods can therefore give more representative information. Canals can be identified during treatment with the help of various aids like magnification, hand instruments, dye application, fiber-optic illumination, champagne bubble test and ultrasonics.4
Radiographs provide a non-invasive in vivo method of detecting canals and can be applied to healthy intact teeth. Conventional periapical radiographs provide limited information in two dimensions, with overlap of structures in the bucco-lingual direction. Cone beam computed tomography (CBCT) has proved to be useful for investigating complex root canal morphology as it enables visualization in all three dimensions.6
The periapical radiograph is recommended for routine preoperative endodontic evaluation. If there is a need for additional information, and benefits outweigh the risks, CBCT can be considered on an individual basis. A guideline issued jointly by American Association of Endodontics (AAE) and American Association of Oral & Maxillofacial Radiology (AAOMR) proposed that teeth with potential for extra canals such as mandibular molars should be evaluated with a limited field of view (FOV) CBCT.7
The utilization of CBCT for diagnosing complex endodontic anatomy varies geographically and with the level of qualification of dentists.8
A survey reported that when missed canals were suspected, dental practitioners ordered CBCT in only 25% of cases.8
Some studies report that the treatment plan formulated was quite different if preoperative assessment was done with CBCT as compared to when it was done without it, while other studies report insignificant influence.10,11
Mandibular molars are one of the most frequently endodontically treated teeth.12 The classical anatomy of mandibular molars is described as having two roots, one mesial and one distal. The mesial roots typically contain a mesiobuccal (MB) and a mesiolingual (ML) canal.5
At times they may have an extra canal in the middle of the two main canals, termed middle mesial canal (MMC). It was found that the unaided eye could detect only between 29% to 46% of MMC that were visible in CBCT.13
One study found that even with angled periapical radiographs, endodontists missed at least one extra canal in every 4 out of 10 teeth when further assessed by CBCT.14 In the presence of MMC and isthmus, root canal preparation and filling can be more difficult. Similarly, in surgical endodontic treatment, root end preparation and retrograde filling can be more challenging because of the complex morphology of mesial roots.15
The reported incidence of MMC in mandibular molars varies with the population being studied. Previously it was reported as between 1-15% with slightly less incidence in mandibular second molars compared to mandibular first molars.16 A recent systematic review that included 41 studies from different populations quoted a range of 0.26 to 53.8 % .5,17 There can also be a communication or ‘isthmus’
between the mesial canals. The isthmus can be present in the entire root length, or confined to some part of it. A systematic review found the average prevalence of isthmus in mesial roots be 55%.5 Very few studies report the statistics in Pakistani population. The presence of MMC in mandibular first molars was reported in only one in vitro study, and found one MMC in 30 teeth.18 Another in vitro study that
used clearing technique reported no middle mesial canal in 123 mandibular first molars.19 The presence of MMC in mandibular second molar was reported in only one case report.20 No CBCT study has been conducted in Pakistani population to our knowledge.
This study is being conducted to determine the prevalence of MMC and isthmi in mandibular first and second molars using CBCT in our population.

METHODOLOGY

It was a retrospective study conducted at the University College of Dentistry, Lahore. The Sample size was calculated to be one hundred and forty-nine teeth using OpenEpi online calculator with expected prevalence of 10.8%, confidence level of 95% and confidence limit at 5%.15 It was later increased to one hundred and eighty-nine teeth.
Sixty randomly selected medium field of view CBCT images from database of Oral & Maxillofacial Radiology departmenttaken between February 2017 and January 2019 were included in the study. All images were recorded using Planmeca ProMax 3D Max (Planmeca, Helsinki, Finland) CBCT unit, with voxel size of 200 um and exposure settings at 90 kVp and 5 mA. Images were viewed using Planmeca Romexis Viewer version 5.2.1.R on Acer Aspire E571 laptop running Microsoft Windows 10 Pro operating system with a 15-inches light emitting diode screen at 1366 x 768 pixels resolution in a dimly lit environment. Images were adjusted using the built-in tools for optimum viewing and evaluated in all 3 planes slice by slice, simultaneously by 3 assessors.
The opinion of majority observers was considered if there was any disagreement regarding the interpretation of individual CBCT images.
Permanent 1st and 2nd (either or both, whichever present) mandibular molars with no evidence of endodontic treatment or root resorption seen in CBCTs without any imaging artefact in the area of concern were included. Presence and configuration of isthmi and MMC in the mesial roots was recorded. MMC was noted when a well-defined round or oval radiolucency between the MB canal and ML canal was observed in the axial view, irrespective of the presence of an isthmus. Isthmus was noted to be present when a narrow
ribbon or fin like connection existed between the MB canal and ML canal. If MMC was located in the axial view, its configuration was further evaluated in the coronal view in the similar sequential manner, after correctly orienting the root in sagittal and axial views. Canal origin (or orifice), apical extension, and fusion with adjacent canals was also noted. MMC and isthmi were later classified according
to their start and end locations. Sex and age of patients was noted, the age was recorded in one of 4 groups; < 20, 21-40, 40-60 and > 60. Data was analyzed using Statistical Package for Social Sciences, version 24 (SPSS Inc, Chicago, IL). Chi-squared test was used to compare the presence and prevalence of MMC and isthmi, as well as their association with age and sex. Significance level was set at 5% (P < 0.05).

RESULTS

CBCTs of fifty one patients were evaluated (45% males and 55% females, mean age = 31 years). A total of one hundred and eighty-nine teeth were evaluated out of which ninety-four were mandibular first molars and ninety-five were mandibular second molars. MMC were found in nine (4.8%) teeth (Figure-1 & 2). In first molars, the prevalence

Table 1: Distribution of middle mesial canals according to molar type, side, gender and age

of MMC was 6.4%, while in second molars it was 3.2 %, P > 0.05 (Table-1). No significant difference was found when data was stratified for side, gender and age (Table-1). Isthmi were found in sixty-two (32.8%) teeth (Figure-3), with prevalence of 22.3% in first molar and 43.2% in second molar, P < 0.05 (Table-2). Significantly greater incidence of isthmi was found in younger age and in females, P < 0.05,
while there was no significant difference between the two sides (Table-2). The distribution of MMC and isthmi according to their presence in different views is listed in Table-3. The distribution of MMC and isthmi according to their start and end is listed in Table-4. The orifices of

Table 2: Distribution of isthmi according to molar type, side, gender and age

Table 3: Distribution of middle mesial canals and isthmus according to their incidence in different sections of the root

Table 4: Distribution of MM canals and isthmus according to their start and end

Table 5: Distribution of orifices of the MMCs

5 MMCs (55%) were separate, the rest were shared (45%) with ML canal (Table-5). Five MMCs fused during their course with the ML canal, two fused with MB canal and two ended blindly (Table-6). Neither any of the middle mesial canals exited from separate apical foramina, nor were observed in the roots’ apical third. Presence of isthmus in

Table 6: Course of the MMCs

Table 7: Prevalence of isthmus in apical area and number of canals according to molar type

apical area was significantly greater in second molars, P < 0.05, while the total number of canals in a tooth were found to be greater in first molars as compared to second molars, P < 0.05 (Table-7).

DISCUSSION

The incidence of MM canals was lower in present study (4.8%) compared to other CBCT studies by Tahmasbi et al. (16.4%) and Baugh eta al. (10.8%).15,21 The reported prevalence of MMC differs with the ethnicity of the studied population, geographic location and study methodology.17
Another reason for the difference could be the finer voxel size of CBCT in the other studies (76 µm in Tahmasbi et al.’s study and 160 µm in Baugh et al.’s study) compared to present study (200 µm). A retrospective in vivo study conducted by Nosrat et al. found 20% MMC in teeth treated under an operating microscope.22 On the other hand, an in vitro study by Teixeira et al. found no MMC in 50 mandibular
molars.23 Another study found 22.1% MMC in Brazilian and 14.8% in Turkish population.24 A systematic review found the overall incidence of MMC to be 2.6%.5
The incidence of MMC in Pakistani population was reported in few in vitro studies only and was 3.3% in one and 0.8% in other study.18,19 No CBCT study on Pakistani population was reported in literature to our knowledge.
Several factors have been investigated for association with the presence of MMC such as molar type, gender, side of mouth and age.17 One study found no difference in distribution of MMC in first versus second molars similar to present study.22 Other studies found greater incidence in second molars but the results were not significant.13,25 Yet another study found significantly greater number of MMC in first molars.21 No difference in the distribution of MMC based on side and gender have been reported, similar to present study.15,22 Prevalence of MMC in other studies was higher in younger patients compared to older patients.22,25 Present study could not find any significant difference based on age.
Prevalence of isthmus in present study (32.8%) is less as compared to 64.6% and 69.6% found in similar CBCT studies.15,21 A Brazilian in vitro study found 33.3% isthmus in mesial roots of mandibular first molars.23 The incidence of isthmus in mandibular molars in Pakistani population was not reported in any study. In the present study, isthmi were significantly greater in 2nd molars. A similar study found greater number of isthmi in 2nd molars but the difference was not statistically significant.21 Females had greater prevalence of isthmi, in present study, while another study reported no difference.15 Present study also found the prevalence of isthmus to be greater in younger age and no difference between the two sides, similar to another study.15
Additionally, no statistical association was found between the occurrence of an isthmus in the apical third and a MMC in the mesial root, similar to another study.15 Although results were not significant, number of canals were generally greater in present study with increasing age which may be attributed to the normal root development process.
There are several practical implications in the endodontic treatment of mandibular molars regarding MMC and isthmus. Detection of these canals might be difficult because their orifice diameter can be up to 3 times less than other canals.24
The endodontic access preparation might need modifications to facilitate the detection and negotiation of MMC. Sometimes the orifice may be concealed by the developmental groove joining the MB and ML canals.13 The course of the canal may also be complicated as it may join any one of the main canals.17 Ultrasonic troughing, magnification, and CBCT have shown to be useful for clinical detection of these canals.13 Among these, CBCT carries the risk of radiation, and therefore should be used selectively when conventional radiographs and other simple measures do not enable visualization of root anatomy.26 Ultrasonic troughing was required in 22% of teeth to negotiate MMC in a study.27 A clinical study conducted in New York, USA found MMC in 46.2% of teeth after troughing under microscope.25 Another study found that although 77% MMCs could be detected after usual endodontic access, troughing was required for accessing 15% MMCs whose orifices were 1 to 2 mm deeper than the cemento-enamel junction. The remaining 7.5% MMCs whose orifices were more than 2 mm deep were not negotiable even after troughing.27 On the other hand, MMC were found in only 6.6% teeth after conventional endodontic access, while further 39.6% teeth were found to have MMC after troughing.25 Although emphasis has been placed on the detection of MMCs, no specific preparation technique has been proposed in literature.28
Due to the common occurrence of isthmi, it has been recommended to routinely use ultrasonic agitation and other advanced irrigation techniques during preparation of mesial roots of mandibular molars. Negative pressure irrigation has been shown to achieve greater debris removal than other irrigation protocols.29 Similarly, careful attention to the detection, preparation and retrograde filling is necessary during surgical endodontics of mesial roots of mandibular molars.15
The limitations of this study are that the population studied might not be representative since it was a single center study, and the CBCT images were of limited resolution.

CONCLUSIONS

MMC and isthmi in mesial roots of mandibular molars are not unusual findings in our population. CBCT can be a valuable tool for their detection.

CONFLICT OF INTEREST

None declared

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  1. Assistant Professor, Department of Operative Dentistry, Azra Naheed Dental College, Lahore.
  2. Assistant Professor, Department of Operative Dentistry, University College of Dentistry, University of Lahore, Lahore, Pakistan.
  3. Demonstrator, Azra Naheed Dental College, Lahore.
  4. Assistant Professor, Operative Dentistry, University College of Dentistry, University of Lahore, Lahore, Pakistan.
  5. Assistant Professor, Department of Operative Dentistry, Superior University, Lahore.
    Corresponding author: “Dr. Attique ur Rehman” < attique_1@hotmail.com >

Prevalence of Middle Mesial Canals and Isthmi in Mandibular Molars Using Cone Beam Computed Tomography

Attique ur Rehman                     BDS, FCPS

Saqib Naeem Siddique              BDS, FCPS

Saba Rehman                             BDS

Mehwish Munawar                     BDS, FCPS

Haroon Asghar Ginai                 BDS, FCPS

OBJECTIVE: The purpose of this study was to investigate the prevalence and configuration of Middle Mesial Canals (MMC) and isthmi in mandibular molars in Pakistani population using Cone Beam Computed Tomography (CBCT).
METHODOLOGY: Sixty CBCTs of patients were selected randomly from database of University College of Dentistry, Lahore. First and second permanent mandibular molars without evidence of previous endodontic treatment, full coverage restoration or root resorption were evaluated for the number of roots, canals and the presence and configuration of MMC and isthmi. The age and gender of patients were also recorded. SPSS was used for statistical analysis using chi-square test. Significance level was set at 5% (P < 0.05).
RESULTS: Out of 189 mandibular molars, MMCs were found in 9 and isthmi in 62 teeth. No statistical association was found between the presence of MMC and age, gender, side or tooth type. Significantly more isthmi were found in second molars, females and younger patients, P < 0.05.
CONCLUSION: MMC and isthmi in mesial roots of mandibular molars are not unusual findings in our population and CBCT can be a valuable tool for their detection.
KEYWORDS: Cone-Beam computed tomography, isthmus, mandibular molar, middle mesial canal, root canal therapy
HOW TO CITE: Rehman UA, Siddique SN, Rehman S, Munawar M, Ginai HA. Prevalence of middle mesial canals and isthmi in mandibular molars using cone beam computed tomography. J Pak Dent Assoc 2020;29(3):114-119.
DOI: https://doi.org/10.25301/JPDA.293.114
Received: 17 December 2019, Accepted: 27 April 2020

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