Evaluation of Cross Infection Control in Dentistry; A Patients’ Perception Study

 

 

Ayesha Zafar                              BDS
Samira Adnan                            BDS, FCPS, MHPE
Naseer Ahmed                           BDS, FCPS
Maria Shakoor Abbasi              BDS, FCPS
Muhammad Adeel Ahmed        BDS, FCPS, MFDS RCSEd
Rizwan Jouhar                          BDS, FCPS
Saqib Hameed                           BDS, FCPS

 

OBJECTIVE: To assess the perception of patients visiting a dental OPD in Karachi regarding cross infection control measures
that should be taken in dental practice.
METHODOLOGY: A cross-sectional study was conducted at the OPD of Altamash Institute of Dental Medicine from January
to August 2020. A total of 546 patients aged 20-75 years of either gender coming for routine dental check-ups were included
in the study using non-probability convenience sampling. A well-structured and validated questionnaire was used to assess the
knowledge, attitude and practices of patients regarding cross infection measures that should be present in dental practices.
SPSS-25 was used to analyse the data. Descriptive statistics was used to calculate frequency and percentage of qualitative
(gender, socioeconomic and education status, knowledge attitude and practice levels of patients) and quantitative variables
(age groups). Chi-square test was used to detect the relation of patient's knowledge levels with potential factors like the age
groups, gender, socioeconomic and education status. The p-value of (< 0.05) was considered as significant.
RESULTS: Out of the total participants, 79.1% had good knowledge about cross infection control measures in dental practice.
Majority of the patients (84.6%) agreed that dentists should wear gloves during treatment, though majority were of the opinion
that a dentist can treat several patients with the same set of gloves. About 4.9% of the patients said that they ask the dentist to
wear face mask and gloves while treating them, and only 3.3% said that they ask the dentist about sterilization of instruments.
The knowledge level of patients showed variation with their education status but not with respect to socioeconomic status, age
and gender.
CONCLUSION: Although overall the patients visiting dental clinics had good perception and showed positive attitudes towards
cross infection control, the dental health practitioners need to disseminate basic technical information about the infection-control
practices required for safe dental practice to dental patients and the community at large.
KEYWORDS: cross infection, knowledge, dentist, dental patients, perception
HOW TO CITE: Zafar A, Adnan S, Ahmed N, Abbasi MS, Ahmed MA, Jouhar R, Hameed S . Evaluation of cross infection
control in dentistry; A patients’ perception study. J Pak Dent Assoc 2021;30(4):249-254.
DOI: https://doi.org/10.25301/JPDA.304.249
Received: 01 January 2021, Accepted: 15 June 2021

INTRODUCTION
 Measures for cross infection control are an essential requirement for dental clinical practice. The dental clinic is considered a potential source of spread of various infections due to the nature of the procedures undertaken.1 It is crucial to provide patient safety in terms
of cross infection by enhancing quality of care through recommended and universal steps of cross infection control.2 Dental regulatory authorities globally emphasize on the importance of proper cross infection measures as the most basic and significant part of safe dental practice.1,3 Cross infection control was significantly highlighted in the field of dentistry post discovery of HIV in the year 1980 where
six dentists were infected with HIV during dental practice.4 During dental treatment, the main reservoir for transmission of infection is blood and saliva, hence due to the nature of dental procedures, dental patients are highly prone to infectious disease transmitted through these routes.5 In addition, the transmission of infection during provision of dental care could also occur through aerosol and unsterilized
instruments or needle stick injuries.6 Cross-infection in dental practise can occur with microbes including Hepatitis B Virus (HBV), Mycobacterium tuberculosis, herpes simplex virus (HSV 1 and 2), Hepatitis C Virus (HCV), mumps, rubella, influenza, cytomegalovirus (CMV), and HIV/AIDS.6,7 Additionally, many other communicable diseases have been part of global emergence and re-emergence.8 Respiratory Syndrome-Corona Virus, and Ebola are emerging agents and a reservoir of infection during practice.9-12 Therefore, the
exposure to saliva and blood are of great concerns for the patients and the dental practitioner.13. Since dental patients are highly vulnerable to get infectious diseases during their dental treatment if cross infection measures are not practiced by their health care provider, it is essential that their perception regarding what entails cross infection control and the standards that their dental practitioner should be following are assessed. Literature shows that patients have sufficient knowledge regarding usage of face mask, gloves, and goggles
by dentist.14,15 Conversely, they have inadequate knowledge regarding the means of spread of HIV infection, Hepatitis-B, and use of autoclave.6,7 In addition, it was found that patients visiting dental clinic expect their dentist to adhere to cross infection protocols in the form of wearing gloves, masks and glasses.16 Although studies have been conducted on the knowledge, attitude and practice (KAP) of
dentists regarding cross infection control, scant literature is available for these measures assessed in patients. It is imperative to identify patient’s perceptions in this regard, which if found inaccurate could be modified with simple relevant awareness programs so they can become cognizant of the essential measure of cross infection control as well as identify and draw attention to any lapse in these when
undergoing dental treatment by a dental care provider. The perception of patients regarding cross infection control will compel the health care providers to adopt the contemporary methods and acquire latest protective equipment and barriers in their clinical setup. This will further motivate the dentist to stay updated with recent infection control guidelines. Furthermore, the patient awareness will also aid in
development of more enlightened dental practices where dentists and patients could strive together to curtail cross infection.

METHODOLOGY
This was a cross-sectional study conducted at the OPD of Altamash Institute of Dental Medicine from January, to August, 2020. The sample size was calculated using Open epi online sample size calculator by taking statistics for satisfactory knowledge as 32.5%17 margin of error as 5% and 95% confidence interval. The estimated sample size came out as 546 participants. All the patients of age 20-75 years of either gender coming for routine dental check-ups and willing to be part of the study were included. The nonprobability convenience sampling technique was used for recruiting participants. The study was approved by ethical and review board of Altamash Institute of Dental Medicine (AIDM/EC/06/2020/12).
The objective, consent statement for voluntary participations and declarations of anonymity and confidentiality was included in the questionnaire for all subjects to understand prior to their agreement. The Cronbach’s alpha statistical analysis was used to assess the internal consistency (Reliability) of the questionnaire items and a strong correlation value of (a=0.76) was recorded. Furthermore, face and content validity of items included were carried out by a group of researchers and dental specialists for accuracy and content relevance of the questionnaire. The study questionnaire was designed to evaluate the knowledge, attitude and practices of patient’s regarding cross infection control. The questionnaire was translated in the local language. The first part of the questionnaire consisted of items related to  socio-demographics, while the second part consisted of 14 questions to assess the knowledge of patients regarding cross-infection measures. Each correct response was scored as one. The score of 1-5 was labelled as poor knowledge, 6-10 as fair knowledge and 11-14 as good knowledge. The third and fourth part of questionnaire included questions regarding attitudes and practices.
The SPSS version 25 was used to analyse patient data. Descriptive statistics were performed to calculate frequency and percentage of qualitative variables (gender, socioeconomic and education status, knowledge, attitude and practice levels of patients) while mean and standard deviation was computed for quantitative variables (age groups). Chi-square test was used to detect any association of patient’s knowledge levels with potential factors like the age groups, gender, socioeconomic and education status. The p-value of < 0.05 was considered as significant.

RESULTS
The mean age of the participants was 37.29 ±13.03 years ranging from 20-70 years. Majority of them were females (n=312, 57.1%) as compared to males (n=234, 42.9%). Of the total participants, 351 (64.3%) had middle income level (50,000-70,000 PKR monthly income), 159 (29.1%) had high income level (>70,000 PKR monthly income) and 36 (6.6%) had low income level (<50,000 PKR monthly income).18 Out of 546 participants, 471(86.3%) were highly educated (education of more than primary level) and 75(13.7%) were not educated (Illiterate; who could not read or write).
The questions to assess knowledge of cross infection and infection control are given in Table 1. About 79.1% of the participants had good knowledge, 16.5% had fair knowledge and 4.4% had poor knowledge respectively.
  No statistically significant difference (p >0.05) was found between knowledge and age, gender and socio-economic level of the participants. However, majority of the educated participants had good level of knowledge as compared to the lesser educated patients and the relationship
was statistically significant (p >0.05) (Table 2).
Regarding the attitude of the participants towards infection control in dental clinics, about 89% of the patients agreed that dentists should wear goggles and 84.6% of the patients agreed that dentists should wear gloves during treatment, however 84.6% were of the opinion that a dentist can treat several patients with the same set of gloves. (Table 3).
  The self-reported practices of participants towards infection control measures in dental clinics are given in Table 4. About 4.9% of the patients said that they asked the dentist to wear face mask and gloves while treating them and only 3.3% said they asked the dentist about sterilization of instruments.
DISCUSSION 
This is the first study conducted in Karachi regarding cross-infection control perceived awareness of patients in dentistry and the results of the current study validate the findings of studies conducted in other countries. The study results affirm that majority of the dental patients had good knowledge regarding infection control, which is pivotal in the face of the current COVID-19 pandemic. The patients were also aware of the potential for transmission of TB, HCV/HBV infections during dental treatment. In a Sri Lankan study, dental patients showed same level of knowledge regarding infection control as seen in our study, and also explained their hesitation in taking dental treatment due to potential risk of transmission of diseases like HIV and HBV.18 In another research, dental patients who attended dental clinics in Saudi Arabia showed poor knowledge regarding dental infections in dentistry.17 Similarly, dental patients residing in Sudan also showed poor knowledge about HIV/AIDS.19 In a study conducted in Jordan,20 76.8% dental patients mentioned HIV transmission was through using
needles that were previously used in patients infected with AIDS.
All dentists are expected to wear gloves as per the recommendations from the Centre for Disease Control and Prevention.21 In current study, the majority of dental patients believed that the dentist should wear gloves while treating patients. This result was lower as compared to an Indian study, in which 97.7%, 93.5%, and 43.6% of the patients believed that dentist should wear gloves, face masks, and eye goggles respectively, when treating patients.22 The present findings are also in agreement with a Nigerian study23 wherein 88.8% dentists were expected to wear gloves while treating their patients and also other similar studies.24,25 However, studies conducted previously26,27 show low percentages of patients expecting dentist to wear gloves which could be because although donning gloves was recommended but was not considered necessary during dental procedures in the past, and hence dentistry was practiced without the use of gloves for every procedure. Due to current cross infection recommendations, wearing gloves for dental procedures is considered standard of care. As a result of advancement in general knowledge and global awareness programs making patients more aware of cross infection control protocols, we
see the change in the perception of patients regarding the necessity of wearing gloves by dentists while performing dental procedures
The results also showed high awareness and knowledge of patients in the local context with regards to sterilization of instruments and cross-infection control protocols cross-infection control protocols. They may be concerned that these protocols are not being followed in dental practices and hence may be hesitant in undergoing dental treatment. The results are in agreement with other studies assessing
patients’ knowledge about instrument sterilization.28 Conversely, another study demonstrated inadequate knowledge of patients regarding sterilization of dental instruments. Our study found that 85% of patients believed boiling water was a method of sterilization that can be used
in dentistry, which is alarming since the recommended methods of sterilization for critical dental instruments include autoclaving, dry heat or heat/chemical vapour under monitored conditions, and boiling is no longer considered an appropriate sterilization method.18
According to the current study results, no statistically significant difference was found between knowledge and age, gender and
socio economic level of the participants. However, majority of the educated participants had good level of knowledge as compared to lesser educated participants and the relationship was statistically significant. The results of this study validate the findings of other similar studies.16,17 Overall, the present study demonstrates a good knowledge score and a positive attitude of patients towards cross infection procedures in dentistry, however their knowledge was inadequate regarding the actual practices in this regard. This is noteworthy that despite having satisfactory knowledge and positive attitude, the patients are still hesitant to ask their dentist regarding sterilization of instruments, or wearing masks or gloves. It is essential that the patients be made aware of their rights in inquiring from the dentist about the
cross infection measures that they follow in their clinic, and if any deficiency in this regard is observed, be knowledgeable enough to draw the attention of their dental care provider to that aspect.
Some of the limitations of this study are that it only depicts the perceptions of patients presenting in one Dental OPD of Karachi. Therefore, the results from this study cannot be generalized to the whole city or country. Multicenter studies need to be conducted to include perceptions of the larger population. Also since patients living in a metropolis such as Karachi may be considered more aware of cross
infection control measures and practices, the same cannot be said for the rural areas. Literature related to identifying the reasons due to which patients are hesitant or refrain from asking their dentist about their cross infection control measures is scarce. Therefore, within the limitation of this study, it is recommended to conduct in-depth studies in this context.

CONCLUSION AND RECOMMENDATIONS
Although overall the patients visiting dental clinics had good perception and showed positive attitudes towards cross Zafar A/ Adnan S/ Ahmed N/ Abbasi MS/ Ahmed MA/ Jouhar R/ Hameed S infection control, it was found that they still need to have better basic technical information about the infection-control practices needed for safe dental practice. In this regard, patient awareness programs and seminars could be arranged by the community of dental health professionals to raise awareness in patients regarding oral health care, attending dental practices and about the essential minimal cross infection measures that should be expected and followed in a dental clinic, so that apprehensions about cross infection and contracting any disease due to dental procedures can be alleviated in the community. The same could be conducted through various media campaigns. The patients should be encouraged to question the practices of their dentist related
to cross infection control measures so the whole community can work together to prevent the spread of infection through dental practices.

FUNDING
There was no source of funding.

CONFLICT OF INTEREST
 There was no conflict of interest.

REFERENCES

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9. Abbasi MS, Ishfaq M, Ahmed N, Rahman MA, Kanwal Y, Ahmed N, Irfan AB. Awareness of Denture Cleansers and its Recognition
among Dental Professionals. J Bahria Uni Med Dental Coll. 2020;10:211-4

10. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat Novel
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11. Ahmed N, Shakoor M, Vohra F, Abduljabbar T, Mariam Q, Rehman MA. Knowledge, Awareness and Practice of Health care Professionals
amid SARS-CoV-2, Corona Virus Disease Outbreak. Pak J Med Sci. 2020; 36(COVID19-S4): S49-S56.
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12. Maqsood A, Shah R, Sarfaraz S, Irfan AB, Faisal A, Fatwani H. Healthcare workers knowledge, practices and stress level amid
COVID-19 pandemic. Pak Armed Forces Med J. 2020;70:S244-50.

13. Tada A, Watanabe M, Senpuku H. Factors influencing compliance with infection control practice in Japanese dentists. Int J Occup Environ Med. 2014;5:24-31.

14. Arif Z, Butt SA, Pirvani M, Shaikh AA, Niaz AT, Khan S. Knowledge, attitude and practice regarding infection control procedures
among dentists of Karachi. J Adv Med. 2019;30:1-7.
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15. Oberoi SS, Marya CM, Sharma N, Mohanty V, Marwah M, Oberoi A. Knowledge and attitude of Indian clinical dental students towards
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24. Yorden K. Patients’ attitudes towards the routine use of rubber gloves in a dental office. J Indiana Dent Assoc. 1985;64:25-8.

25. Burke F, Baggett F, Wilson N. Patient attitudes to the wearing of gloves by dentists. Dental Update. 1991;18:261-4.

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https://doi.org/10.1016/0030-4220(90)90379-7

Evaluation of Cross Infection Control in Dentistry; A Patients’ Perception Study

Ayesha Zafar                              BDS
Samira Adnan                            BDS, FCPS, MHPE
Naseer Ahmed                           BDS, FCPS
Maria Shakoor Abbasi              BDS, FCPS
Muhammad Adeel Ahmed        BDS, FCPS, MFDS RCSEd
Rizwan Jouhar                          BDS, FCPS
Saqib Hameed                           BDS, FCPS

 

OBJECTIVE: To assess the perception of patients visiting a dental OPD in Karachi regarding cross infection control measures
that should be taken in dental practice.
METHODOLOGY: A cross-sectional study was conducted at the OPD of Altamash Institute of Dental Medicine from January
to August 2020. A total of 546 patients aged 20-75 years of either gender coming for routine dental check-ups were included
in the study using non-probability convenience sampling. A well-structured and validated questionnaire was used to assess the
knowledge, attitude and practices of patients regarding cross infection measures that should be present in dental practices.
SPSS-25 was used to analyse the data. Descriptive statistics was used to calculate frequency and percentage of qualitative
(gender, socioeconomic and education status, knowledge attitude and practice levels of patients) and quantitative variables
(age groups). Chi-square test was used to detect the relation of patient's knowledge levels with potential factors like the age
groups, gender, socioeconomic and education status. The p-value of (< 0.05) was considered as significant.
RESULTS: Out of the total participants, 79.1% had good knowledge about cross infection control measures in dental practice.
Majority of the patients (84.6%) agreed that dentists should wear gloves during treatment, though majority were of the opinion
that a dentist can treat several patients with the same set of gloves. About 4.9% of the patients said that they ask the dentist to
wear face mask and gloves while treating them, and only 3.3% said that they ask the dentist about sterilization of instruments.
The knowledge level of patients showed variation with their education status but not with respect to socioeconomic status, age
and gender.
CONCLUSION: Although overall the patients visiting dental clinics had good perception and showed positive attitudes towards
cross infection control, the dental health practitioners need to disseminate basic technical information about the infection-control
practices required for safe dental practice to dental patients and the community at large.
KEYWORDS: cross infection, knowledge, dentist, dental patients, perception
HOW TO CITE: Zafar A, Adnan S, Ahmed N, Abbasi MS, Ahmed MA, Jouhar R, Hameed S . Evaluation of cross infection
control in dentistry; A patients’ perception study. J Pak Dent Assoc 2021;30(4):249-254.
DOI: https://doi.org/10.25301/JPDA.304.249
Received: 01 January 2021, Accepted: 15 June 2021

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Preparation and Assessment of Antimicrobial Property of Resin Based Composites Impregnated with Proanthocyanidin and Titanium Dioxide

 

 

Mumtaz ul Islam                  BDS, M.Phil
Sardar Muhammad             MBBS, DOMS, M.Phil
Fazal Ghani                         BSc, BDS, MSc, CMP, PhD, FDSRCPS (Post Humous)

 

OBJECTIVE: To synthesize three experimental resin based composites (RBCs) out of a commercial preperation (Control)
by impregnating into each a fixed weight (0.01%) of titanium dioxide (TiO2) and three different weight % (0.01, 0.02 and 0.03)
of proanthocyanidin (PA) and to compare antibacterial property, from the zones of inhibition of streptococcus mutans
(S. mutans), of the specimen restorations made in the experimental and control RBCs.
METHODOLOGY: In the first phase, Streptococcus mutans were isolated and identified from the oral cavity of patients and
identified on the basis of morphogenic appearance of colonies and confirmed through catalase test and microscopic examination.
Isolates were then incubated and cultured for sensitivity. Specimens for control and experimental RBCs were made through a
metallic mold having 2mm thickness and 5mm diameter for all the 4 groups. Specimen restorations made in the commercial
as supplied RBC acted as the control (Group A). Specimen restorations in the Group B, C, and D were made in each of the
experimental RBCs modified with 0.01% proanthocyanidin (PA) and 0.01% titanium dioxide (TiO2), 0.02% PA and 0.01% TiO2
and 0.03% PA and 0.01% TiO2. The antimicrobial property of all the specimen restorations in all the groups was evaluated by
Bauer-Kirby (Disc Diffusion) method through the formation of zones of inhibition of S. mutans colonies on blood agar plates.
Data were computed using SPSS version 21 for descriptive statistics and analyzed using one-way ANOVA with p value 0.05
taken as significant.
RESULTS: The range of the zone of inhibition for specimen RBC restorations (N= 12) containing PA and TiO2 was 0.00 for
Group A, 10-12mm for Group B, 12-14mm for Group C and 9-10mm for Group D. The mean inhibition zone for the experimental
restoration specimens was 11±2mm for Group B, 12.7±1mm for Group C and 9.7±1mm for Group D compared to no inhibition
zones (0.00 mm) with the control RBC Group A. The order of the inhibition zones from maximum to minimum was
Group C > Group B > Group D > Group A. The differences between the mean values for the control and the experimental RBC
restoration specimens were significant (p < 0.000). The specimen restorations in the Group D appeared under cured and could
impact on their mechanical properties.
CONCLUSION: Irrespective of the mentioned concentrations, impregnating PA and TiO2 rendered the RBC antimicrobial.
RBC restorations made with the experimental RBC with 0.02% PA and 0.01% TiO2 proved relatively more effective in terms
of antimicrobial effect.
KEY WORDS: dental materials, resin based dental restorations, antibacterial resin based composite, proanthocyanidin, titanium
dioxide.
HOW TO CITE: Islam MU, Muhammad S, Ghani F. Preparation and assessment of antimicrobial property of resin based
composites impregnated with proanthocyanidin and titanium dioxide. J Pak Dent Assoc 2021;30(4):243-248.
DOI: https://doi.org/10.25301/JPDA.304.243
Received: 27 January 2021, Accepted: 17 August 2021


INTRODUCTION
 The involvement of microbes in the process of dental caries is well-established due to the virulence of streptococcus mutans. 1-3 Dental resin based composites (RBCs) suffers polymerization shrinkage, have lower strength and lack antimicrobial property. These have been noted to cause failure of the RBC restoration because of fracture as well as recurrent carries at the tooth-restoration interface. 4 To address these issues, there is an ongoing research focus to produce RBCs with antimicrobial property. Antibacterial agents of bioactive nature, caries preventive additives, polymer antibiotic conjugates and quaternary ammonium salts were added in resins to elicit antimicrobial activity. 4-9
The antioxidant action and free-radical scavenging effect of Proanthocyanidin (PA) have been established when applied to a surfaces.
10 Cariogenic environment causing degradation of dentine has been prevented with PA. 11 The antibacterial action of Titanium Dioxide (TiO2) is through photo catalysis with water to release the hydroxyl radical with subsequent formation of superoxide as an antimicrobial agent. 12
Knowing the fact that there are inconsistencies in the literature regarding the antimicrobial property of RBCs, the search for making them antimicrobial is continue. 13-14 Both PA and TiO2 are naturally occurring and easily available, hence their incorporation into RBC for possible antimicrobial property of the resulting restorations justifies an investigation. When proanthocyanidin was incorporated
in adhesive agent in different concentrations ranging from 1% to 6% the antibacterial activity was same as of the control which is devoid of Proanthocyanidin. 15 Antibacterial activity of TiO2 in concentrations from 0-10% was also evaluated in orthodontic composites which provided better antibacterial activity with concentration of 10%. 16 Therefore, we have designed a comprehensive study that is looking at
the effect of adding PA and TiO2 to RBC in terms of enhancement of antimicrobial and mechanical properties. This report presents the results on the antimicrobial effect of incorporating different concentrations of PA and a fixed quantity of TiO2 in RBC and assessing their antibacterial property of specimen restorations against S. mutans isolated from the oral cavity of subjects.

METHODOLOGY
Preparation of specimen restorations:
 Group A was the control group in which no additives were added. In each group 4 specimens were prepared from a commercially available RBC, Nexcomp (Meta Biomed Co. Ltd) with 1% TiO2 which was fixed for all the experimental groups. Group B, C, & D all were test groups which have 0.01, 0.02 and 0.03% PA. Sample size was calculated according to the following values the confidence level for this study was considered as 95% while power of the study kept 80 with a response distribution 60% and margin of error kept 5% the calculated sample
size was 3 used in this pilot study.
The research protocol for the study was approved by the Board of Advanced Studies and Research (BASR) of the university (Riphah 25th meeting, dated, October, 18th, 2018) as well it was approved for publication of the research findings by the institutional review board (PRIME/IRB/ 2019-166.) The experimental work was conducted during the period of (01 May to 30 June, 2018) at the Department
of Dental Materials and Microbiology Lab, Department of Pathology, Peshawar Medical and Dental College (Pakistan). The materials used in the study including the experimental RBC are detailed in (Table 1).
Proanthocyanidin (PA) was characterized for purity using Fourier Transform Infrared Spectroscopy (FTIR) in Material Research Laboratory, Physics Department Peshawar University, Pakistan (Figure 1).

Each of the relevant weight % of PA & TiO2 were first assimilated in the resin bonding agent to facilitate easy and thorough mixing and then impregnated into a commercially available light-cure nanohybrid RBC NexcompNanohybrid Resin Composite Nexcomp contains
Bis-GMA, Bis-EMA, UDMA, TEGDMA while Meta P&Bond Adhesive contains bisphenol a Glycerolate dimethacrylate, Urethane
Dimethacrylate, Pyromellitic glyceryl dimethacrylate, 2-Hydroxy ethyl methacrylate, Ethyl alcohol (Table 1). The
 three experimental RBCs were prepared by adding in each a fixed weight % of TiO2 (0.01%) and the various weight % of the PA (0.01%, 0.02% and 0.03%) to the commercially supplied RBC. The as supplied commercial RBC acted as the control RBCs.
The specimen restorations were prepared in each of the three experimental and the control RBC using a stainless steel mold according to ISO specification No. 4049. The mold facilitated the preparation of specimens having 2 mm thickness with 5 mm diameter. Specimen restorations were made by pouring each of the RBC into the mold and cured with a light curing unit (O-Light by DTE, 5 watts, Light Intensity from 1000 to 2300 mw/cm2 ) for 20 seconds from one side. The poured resin was kept pressed under a 1mm

Assessment of antibacterial property of the specimen
restorations
 This was determined by Bauer-Kurby disc diffusion test using S. mutans from the oral cavity of patients who were negative for HbV and HcV infection. Swabs were taken from carious teeth of patients to collect S. mutans. Written consents of patients were obtained and duly signed
by witnesses. The swabs were transferred to Microbiology Department Peshawar Medical & Dental College within
confirmed through catalase negative test and finally confirmed through microscopic evaluation (Figure 3).
Colonies of S. mutans were tested for sensitivity by

DATA ANALYSIS
 Using SPSS Version 21, mean, mode and percentages for the data were computed. Data were also analyzed using one-way ANOVA to see the statistical significance of the within and between the specimen groups differences from the mean values with p value set as 0.05 considered
significant. Post hoc test is not presented due to selfexplanatory results of four groups of this pilot study.

RESULTS
The specimen restorations in the control group did not exhibit any antimicrobial property in-comparison to those in the experimental groups. Similarly, the antimicrobial property was maximum for the restoration specimens in group C. The order of antibacterial effect among the specimens in the various groups was Group C > Group B > Group D > Group A. (Table 2).
The mean size of the inhibition zone was 8.42mm for the specimens in groups B to D out of 13 mm. Maximum sizes of inhibition zones were found in two specimen restorations belonging to group C. None of the control group
DISCUSSION
 For assessing the antimicrobial property of RBC restorative materials, the method of disc diffusion has also been previously used.17 Studies on anti-microbial property of experimental RBCs have used standardized microbial strains species like ATCC3566818 , ATCC 2517519 and a different strain of S. mutans (10449) has been used for assessing the antimicrobial effect of benzalkonium incorporated RBC.20 A concern about these studies is that these have not mimicked the actual mode of action of the antimicrobial agent added to the resin. In this study strains of S. mutans collected from patient’s mouth, making the testing method relatively more relevant because virulence/activity of standard cultures is questioned and reported as of low or no bacterial activity.21
At present, a definite methodology for testing antimicrobial properties of a material is lacking. Therefore, authors preferred the easy and commonly used method for this study.22 The disc diffusion method for establishing the antimicrobial efficacy of PA to S. mutans has also been used in another study.15 Quantitative methods like plate count method, flow cytometry and quantitative polymerase chain reaction for
antimicrobial assessment are available but were not employed in the present study due to their technique sensitivity.23 Results obtained through disc diffusion method are better than other protocols.24 This was employed to verify the results obtained through direct contact test between microbial strains and the restorations and to validate the antibacterial action. Discs prepared for experimental and control RBC specimens had the same dimensions as used by other investigator.25 Furthermore, following the preparation of standardized specimen restorations and the selection of defect free specimens for testing obviated the need for using many specimens.
The incubation procedures employed for S. mutans strains were according to the Bergey’s manual of determinative microbiology.26 Due to vast discrepancy in literature for the growth medium and its yield, blood agar was used as nutrient medium for proliferation of the S. mutans colonies and their killing by the RBC specimen restorations. There is a positive correlation between genotype and phenotype evaluation of bacteria which confirms and validate the phenotypic evaluation of the
bacterium.16 The colonies obtained after incubation were identified in the present study for morphology of the colony followed by confirmation through catalase test and finally through microscopic examination (Figure 2).
The findings of the present study are in accordance with those of a previous study, in which the range of size of zones of inhibition was 9.33mm to 12.67mm for antibacterial activity of resin containing 0.25% concentration of benzalkonium chloride.20 Size of zones of inhibition always will be more than the size of discs if smaller than discs then it will be of no use and considered as no zone of inhibition.
When a drug is placed in a medium where a bacterial culture is present if that drug is of antibacterial potential it produces areas of no growth around that drug specimen these areas are zones of inhibition. The findings of the present study are more encouraging as a comparable yet better antimicrobial effect has been achieved with a small concentration of PA (0.02%). Our finding of the lack of antibacterial property in the specimen restoration made in the control RBC are supported by the finding of another study where no zones of inhibition were also observed in case of specimen restorations in the control RBC.27
In the present study, the RBC specimens in the control group exhibited no antibacterial effect as observed from no zones of inhibitions. In the present study a much lower concentration of TiO2 and PA showed comparable antibacterial activity. In the present study lower concentration of PA (0.01, 0.02 and 0.03%) were used and found effective against S. mutans.
As titanium dioxide is highly opaque material therefore its concentration in the RBC was kept 0.01% so as to avoid the problem of shade change which was confirmed through another pilot study.

LIMITATIONS OF THE STUDY
 An obvious limitation of this study may be the use of few samples and using a method for antimicrobial properties of the test RBCs restorations that does not mimic the real clinical situation in which the restorations are functioning. However, in case of in-vitro studies, using standardized dimension specimens that are defect-free, the use of few specimen restorations is justifiable. On the other side, in
the present study, the specimen RBC restorations have been subjected to relatively harsher bacterial insult than that could be expected in the oral cavity. Despite this, it was encouraging to have seen enhanced antibacterial property in case of experimental RBC restorations containing PA and TiO2.
Incorporation of additives in RBC may produce any effect on the mechanical properties which was not evaluated in current study. This aspect is being currently under investigation for the experimental RBCs used in this study. Another limitation, of this study is the addition of PA and TiO2 to the commercial RBC, which have altered the actual formulation of the commercial RBC. Therefore, it is recommended that this aspect should be kept in mind in future studies by synthesizing the experimental RBC with the mentioned additives.
effect has not been followed up over a larger duration of time and hence the sustained long term antibacterial effect of the RBC restorations cannot be predicted from the present study making observation at one time-point. It is recommended that the specimen restorations be tested repeatedly after simulated usage scenarios to give a clear picture of how much stable and long-lasting would be the observed antibacterial property as documented in this study.

CONCLUSION
 Within limitations of this study, PA and TiO2 imparted antimicrobial properties to the RBC especially PA 0.02% along with TiO2 0.01% which produced larger zones of inhibitions.

CONFLICT OF INTEREST
 None declared.

AUTHORSHIP CONTRIBUTIONS
All authors (MUI, FG, MS) contributed equally to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; All authors have given final approval and have agreed to be accountable for all the aspects of the research work and its publication. FG had accepted the responsibility as the corresponding author but after his unfortunate death MUI is now corresponding author.

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Preparation and Assessment of Antimicrobial Property of Resin Based Composites Impregnated with Proanthocyanidin and Titanium Dioxide

Mumtaz ul Islam                  BDS, M.Phil
Sardar Muhammad             MBBS, DOMS, M.Phil
Fazal Ghani                         BSc, BDS, MSc, CMP, PhD, FDSRCPS (Post Humous)

 

OBJECTIVE: To synthesize three experimental resin based composites (RBCs) out of a commercial preperation (Control)
by impregnating into each a fixed weight (0.01%) of titanium dioxide (TiO2) and three different weight % (0.01, 0.02 and 0.03)
of proanthocyanidin (PA) and to compare antibacterial property, from the zones of inhibition of streptococcus mutans
(S. mutans), of the specimen restorations made in the experimental and control RBCs.
METHODOLOGY: In the first phase, Streptococcus mutans were isolated and identified from the oral cavity of patients and
identified on the basis of morphogenic appearance of colonies and confirmed through catalase test and microscopic examination.
Isolates were then incubated and cultured for sensitivity. Specimens for control and experimental RBCs were made through a
metallic mold having 2mm thickness and 5mm diameter for all the 4 groups. Specimen restorations made in the commercial
as supplied RBC acted as the control (Group A). Specimen restorations in the Group B, C, and D were made in each of the
experimental RBCs modified with 0.01% proanthocyanidin (PA) and 0.01% titanium dioxide (TiO2), 0.02% PA and 0.01% TiO2
and 0.03% PA and 0.01% TiO2. The antimicrobial property of all the specimen restorations in all the groups was evaluated by
Bauer-Kirby (Disc Diffusion) method through the formation of zones of inhibition of S. mutans colonies on blood agar plates.
Data were computed using SPSS version 21 for descriptive statistics and analyzed using one-way ANOVA with p value 0.05
taken as significant.
RESULTS: The range of the zone of inhibition for specimen RBC restorations (N= 12) containing PA and TiO2 was 0.00 for
Group A, 10-12mm for Group B, 12-14mm for Group C and 9-10mm for Group D. The mean inhibition zone for the experimental
restoration specimens was 11±2mm for Group B, 12.7±1mm for Group C and 9.7±1mm for Group D compared to no inhibition
zones (0.00 mm) with the control RBC Group A. The order of the inhibition zones from maximum to minimum was
Group C > Group B > Group D > Group A. The differences between the mean values for the control and the experimental RBC
restoration specimens were significant (p < 0.000). The specimen restorations in the Group D appeared under cured and could
impact on their mechanical properties.
CONCLUSION: Irrespective of the mentioned concentrations, impregnating PA and TiO2 rendered the RBC antimicrobial.
RBC restorations made with the experimental RBC with 0.02% PA and 0.01% TiO2 proved relatively more effective in terms
of antimicrobial effect.
KEY WORDS: dental materials, resin based dental restorations, antibacterial resin based composite, proanthocyanidin, titanium
dioxide.
HOW TO CITE: Islam MU, Muhammad S, Ghani F. Preparation and assessment of antimicrobial property of resin based
composites impregnated with proanthocyanidin and titanium dioxide. J Pak Dent Assoc 2021;30(4):243-248.
DOI: https://doi.org/10.25301/JPDA.304.243
Received: 27 January 2021, Accepted: 17 August 2021

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Comparison of Repeated Chemical and Microwave Disinfection on Dimensional Accuracy of Gypsum Casts

Mariya Khalid                              BDS, FCPS
Mohammad Ali Chughtai           BDS, FCPS, MHPE, FFDRCSI
Sohrab Shaheed                         BDS, FCPS, FFDRCSI
Syed Nasir Shah                         BDS, FCPS

 

OBJECTIVE: The aim of this experimental study is to compare the dimensional accuracy of gypsum casts after repeated
disinfection in microwave at 900 Watts, 2450 MHz (5 minutes) and immersion in 0.5% Sodium hypochlorite (10 minutes).
Disinfecting casts is recommended to prevent cross infection but may cause dimensional changes. During fabrication of
prosthesis, a cast may get contaminated several times so there is a need of repeated disinfection.
METHODOLOGY: Sample size was 33 (11 in each group), calculated through WHO software for sample size determination
by using standard deviation of 0.16 at 95% confidence interval and 80% power of study. Impressions in irreversible hydrocolloid
were recorded of an acrylic cast fabricated for this study. The impressions were poured with die stone and were randomly
divided into 3 groups; Group I: Microwave disinfection, Group II: Immersion disinfection in 0.5% Sodium hypochlorite, Group
III: Control group. For Groups I and II, each cast was disinfected 7 times with 5 minutes interval between two disinfection
cycles, after every cycle anteroposterior and mediolateral measurements were recorded using digital Vernier caliper (accuracy
upto 0.01 mm). For group III, casts were rinsed with distilled water, dried in open air within temperature range of 28+/-2OC
for 10 mins followed by anteroposterior and mediolateral measurements. This procedure was repeated seven times for each
cast.
RESULTS: Anteroposterior and Mediolateral differences of dimensional change between and within the Group A, B and C
was calculated by One Way ANOVA. Inter/intra examiner reliability was taken into consideration at the time of study.
Mean dimensional change in the casts were insignificant through six disinfecting cycles. However, in the seventh cycle, a
significant difference (p=0.003) was observed in the anteroposterior dimension (0.03% dimensional change for Group A and
1.26 % for Group B whereas, in mediolateral dimension, dimensional change was 0.35% for Group A and 0.59% for Group B
(p=0.004). Dimensional change of >0.5% was considered as the cutoff value for casts to be considered as dimensionally accurate.
Casts disinfected through immersion disinfection did not produce dimensionally inaccurate casts in anteroposterior dimension
after third cycle and in seventh cycle in mediolateral dimension. However, result is significant only in seventh cycle. Microwave
disinfection produced dimensionally accurate casts throughout all cycles.
CONCLUSION: Microwave disinfected casts remained dimensionally stable compared to immersion disinfection.
KEYWORDS: Disinfection, microwave, immersion, dimensional stability, gypsum casts
HOW TO CITE: Khalid M, Chughtai MA, Shaheed S, Shah SN. Comparison of repeated chemical and microwave disinfection
on dimensional accuracy of gypsum casts. J Pak Dent Assoc 2021;30(4):235-242.
DOI: https://doi.org/10.25301/JPDA.304.235
Received: 13 January 2021, Accepted: 01 August 2021


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Perception of Academic Stressors Among Dental Undergraduate Students

Tayyaba Saleem            BDS, FCPS, MME
Raheela Yasmin            BDS, DCPS, MHPE, PhD
Anbreen Aziz                 BDS, MHPE
Usman Mahboob           MBBS, MPH, FHEA, DHPE, Fellow FAIMER
Ahsan Sethi                   BDS,MPH, MMEd, FHEA, MAcadMEd, FDTFEd, PhD

 

OBJECTIVE: Present study was conducted to assess the perceived academic sources of stress among undergraduate dental
students and determine its association with gender, year of study, pre-university education and accommodation. This study
was conducted in dental section, Islamabad Medical and Dental college, Islamabad from July to November 2016.
METHODOLOGY: BDS students were asked to rate their perceived stress on four point Likert scale of modified version of
Dental Environment Stress (DES) questionnaire. Descriptive statistics were applied to find the mean scores and SD on all
items. Using SPSS v.21, Kruskal Wallis test was used to compare stress levels among different undergraduate professional
years and Mann-Whitney U test was applied to determine the association and stress sources and demographic variables.
RESULTS: A total of 172/200 participants responded (86%) to the survey. Overall stress in undergraduate dental students was
in moderate range. Majority of students (93%) reported that syllabus load was either stressful or very stressful (3.53±0.64),
85% students reported lack of relaxation time as stressful or very stressful (3.42±0.86) and fear of failing was reported as
stressful or very stressful by 82.5% (3.34±0.87). When stress scores of all classes were compared third year reported more
mean stress scores than other years (2.50±0.50). Females were more stressed compared to males with mean score of (2.37±0.39),
students living at home were more stressed than hosteilites (2.38±0.38) and those with GCE A-levels had higher stress (2.40±0.38)
compared to HSC background students. Academic performance was the most stressful of the five stress domains (3.07±0.74).
CONCLUSION: Syllabus load followed by lack of time for relaxation and fear of failing were the most perceived sources
of stress. Academic performance was the most stressful of the five stress domains and third year BDS was the most stressed
class.
KEY WORDS: Dental Education; Dental Students; Psycholofical Stress, Stressor, Undergraduate,.
HOW TO CITE: Saleem T, Yasmin R, Aziz A, Mahboob U, Sethi A. Perception of academic stressors among dental undergraduate
students. J Pak Dent Assoc 2021;30(4):228-234.
DOI: https://doi.org/10.25301/JPDA.304.228
Received: 14 January 2021, Accepted: 19 June 2021

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