Analysis of Dental Practitioners Perception Towards Dental Implants

Naseer Ahmed                      BDS, FCPS

Maria Shakoor Abbasi         BDS, FCPS

Quratulain Mariam               BDS, MBA

Hanan William                      BDS

Hafsa Iftikhar                        BDS

Hamna Badar                        BDS

Adil Bin Irfan                        BDS

OBJECTIVE: To investigate the dental practitioner’s knowledge, attitude and practice towards dental implants.
METHODOLOGY: This study was carried out from May’2019 – Oct 2019. 752 dental practitioners who were currently practicing were included in the study. A well-structured questionnaire was used for data collection. SPSS-25 was used for statistical analysis. Spearman correlation was used to find the effect of gender, knowledge and attitude. The P <0.05 was considered statistically significant.
RESULTS: In this study 80.9% dental practitioners were aware of the appropriate implant material while, 57.9% had knowledge about the types. 30.3% knew about the implant surface modifications whereas 46.1% dentists were aware of possible implant placement approaches. 49.3% believed that the distance between dental implants to be 3mm and between a dental implant and natural tooth to be 1.5 mm. 76% dentists claimed that dental implants have biomechanical complications. Whereas 67.8% knew about the Branemark’s theory of osseointegration. Regarding the attitude of dental practitioners, 28.9% had received implant hands on trainings while 9% felt competent to place an implant.
CONCLUSION: This study describes that dental practitioners had an appropriate knowledge of each aspect of implantology. Moreover despite the fact majority felt that they are not competent enough to practice it. Thus, it is important that the curriculum, teaching standards, the materials and methods regarding dental implants need to be reviewed and more exposure of hands-on workshops is to be provided not only for the graduates but also the undergraduates during their clinical learning.
KEYWORDS: Dental Implants, Dentist’s opinion, Knowledge
HOW TO CITE: Ahmed N, Abbasi MS, Mariam Q, William H, Iftikhar H, Badar H, Irfan AB. Analysis of dental practitioners perception towards dental implants. J Pak Dent Assoc 2021;30(1):45-49.
DOI: https://doi.org/10.25301/JPDA.301.45
Received: 12 August 2020, Accepted: 21 November 2020

INTRODUCTION

Within the last few years, it seems that dentistry has recorded its most remarkable progress and dental implantology emerging as a contemporary and essential component of dentistry around the globe. Dental implants use the process of Osseointegration to be fixed in the jaw bone and a large number of clinical studies support their long term prognosis.1-3 Using dental implants avoids the biological complications associated with fixed partial denture that requires adjacent teeth to be prepared and serve as an abutment for the bridge, since it may lead to a long term poor prognosis.4-6 With increasing demands of the patients for implant supported prostheses, dental practitioners dealing with this
field of dentistry have to face with patients’ high expectations concerning excellent esthetics and function.7
In addition, a dental practitioner’s knowledge and attitude towards the treatment can influence the treatment planning and ultimately the oral health of an individual. The Dental practitioners play a vital role in educating the patients regarding their treatment needs, thus, it is essential for them to have an ample knowledge about dental implantology.8,9 In a study by Rathod et al in 2017, it was found that the knowledge and attitude of dental practitioners was limited, and it was concluded that the dental education programs could be
helpful to update the knowledge regarding dental implantology.10 Furthermore similar results were found by other studies including Sheth et al and Dhami et al in which general practitioners had limited knowledge and majority showed an increased desire for knowledge in the field of implants and welcomed the suggestion of introducing implantology as a separate subject in the BDS curriculum.11,12 Moreover, till now only one study evaluated the knowledge of Dental implants amongst the dental practitioner at the national level
which also showed limited knowledge and awareness about dental implants.13
To the best of authors’ knowledge there is paucity of information regarding the perception and knowledge of dental implants in dental practitioners of Pakistan. Therefore,
the present study was executed with the chief aim to assess the knowledge, attitude, and practice of dental implants among dental practitioners of Karachi, Pakistan.

METHODOLOGY

This cross-sectional study was conducted with informed consent, from May 2019 to October 2019. The study was approved by ethics and review committee of AIDM/EC/05/2019/15. Both male and female dental practitioners inclusive of all ages, who were currently practicing were included in the study. All those having a clinical postgraduate qualification were excluded. The sample size was calculated with Open-Epi software. Considering (55%)12 prevalence of knowledge amongst dental practitioners. The estimated sample size at 3% margin of error and 97% confidence interval was n = 667 dentists for considering the 30,000 population. The figure achieved was later overestimated to 800 participants, to attain maximum responses. A well-structured questionnaire comprising of knowledge and attitude based questions was distributed among the dental practitioners of different dental colleges of Karachi, Pakistan.
The questionnaire was divided into two sections. Section one included the demographic details. Section two was comprised of 15 close ended questions regarding Knowledge,
Attitude and Practices of the participants towards dental implants. The validity of the questionnaire was checked with Cronbach’s Alpha ( = 0.7). Responses were collected
through both, the hard copy and an online google form link. SPSS-25 was used for analyzing the data and descriptive analysis was performed to determine the mean, standard
deviation, frequency and percentages. Spearmen correlation test was used to find the relationship of gender with knowledge, practice and attitude level of participants. The P < 0.05 was considered statistically significant.

RESULTS

In this study, out of 800 distributed questionnaires, 752 were included. 48 questionnaires were excluded based on partially filled status and repetition of response. The total
number of dental practitioners targeted was 752 out of which 204 (27%) were males and 548 (73%) were females, with majority 717 (95.3%) belonging to age bracket of 22-31 years. 631(83.9%) were graduates, 121(16.1%) were postgraduate trainees. The results were determined, and it was found that 609 (80.9%) dental practitioners were well aware of the appropriate material (Titanium) of a dental implant. 436 (57.9%) had knowledge about all the types of implant. 421 (55.9%) of the dental practitioners were aware of the screw shaped dental implants, however only 228 (30.3%) knew about the various surface modifications, as shown in (Table I).

Table I: Responses regarding the Knowledge of Participants (n=752)

346 (46.1%) dentists were well aware of all the possible implant placement approaches. Out of all the participants, 371 (49.3%) believed the distance between two dental implants to be 3mm and distance between a dental implant and a natural tooth to be 1.5mm as presented in (Table II).

Table II: Responses regarding the Knowledge of Participants (n=752)

The Table III showing that more than 88% of the dentists said that implant supported prostheses have better aesthetic and functional efficiency though they believed that it needs
more oral hygiene maintenance. n=573 (76%) of the dentists claimed that dental implants have certain biological and technical complications. Whereas 510 (67.8%) knew about
the Branemark’s theory of osseointegration as described in (Table III).

Table III: Responses regarding the Knowledge of Participants (n=752)

Regarding the attitude of dental practitioners towards a dental implant, only 218 (28.9%) received implant hands on trainings. 223 (29%) felt competent enough to place an implant and 668 (88.8%) were the ones who attended lectures on dental implants as mentioned in (Table IV)

Table IV: Responses regarding the Attitude of Participants (n=752)

No significant relationship was found between gender with knowledge and attitude of participants regarding dental implants (rho =0.016), (p= 0.093). Though significant relationship was found between knowledge and attitude of participants regarding dental implants (rho =0.9), (p= 0.025).

DISCUSSION

Literature reveals that conventional methods like removable dentures failed to satisfy the patients, But now, with dental implants, missing teeth can be replaced with substantial, comfortable and aesthetically pleasing artificial alternatives.14-17 According to our study, 81% of dental practitioners assured that titanium is the best material which is in accordance with Parr et al, which states that titanium is extremely stable when used in human body.18 Although Titanium has been widely used in dentistry as it is biocompatible and has excellent mechanical properties, the incidence of hypersensitivity and allergic reactions is still unknown.19 Furthermore, various dental implant types, body designs and surface modifications have been reported in the literature.1,8,15,19 In this study, 57.9% had knowledge about all the types of implant. 55.9% of the dental practitioners were aware of the screw-shaped dental implants, however only 30.3% knew about the various surface modifications. Around 49.3% of the dental practitioners opted 3mm as inter-implant distance and 1.5mm as normal distance between a tooth and an implant. Whereas in a research carried out by Ramanaurkaite, A. et al, in 2018 states that the normal interimplant distance can be from 2mm to 4mm depending on the reference points.20 Similarly, Jose et. al in 2004 concluded that the average distance between two implants and the average distance between an implant and a natural tooth range from 3mm to 4mm. The research we carried out among 752 dental practitioners, only included the horizontal distance between two dental implants, unlike, the research carried out by Jose et. al, who focused not only the horizontal distance but also the vertical distance and lateral spacing.21
Taking the bio-mechanical failure of a dental implant into consideration, 76.3% of our dental practitioners reflected that an implant can surely have certain biological and technical
complications if a proper diagnosis is not made and the proper technique is not used. Similarly, in a study by Liaw, K. et al, stated that with increased use of dental implants comes an increased risk of complications, given the fact that an implantologist should be able to diagnose and recognize the complications.22 Likewise, a study done by Porter Ja, et
al, on success and failure of implant showed that, there are certain primary predictors, pre and post operatively, that lead to the failure of implant. Thus, admitting the fact that
loading a dental implant can surely have bio-mechanical complications .23 Another study focused on the complications associated with dental implants, i.e. mechanical complications (screw loosening, screw fracture, cement failure), technical complications (fracture of veneering porcelain, fracture of the framework in implant-supported fixed partial dentures) and biologic complications (adverse soft tissue reactions, sensory disturbances, progressive marginal bone loss, loss of integration).24
It was suggested by 88.2% of our respondents that the patients who received an implant should be more keen in maintaining their oral hygiene, this is in harmony with the
study carried out by Arati Sharma et al, where 58.4% candidates also felt the need to follow oral hygiene protocols by people with implants in their oral cavity.25 Assessing the knowledge on the basis of implant training received, we deduced that 29% of our candidates received hands-on trainings, whereas in a survey carried out by Vickie et al, in 2004 suggested that 86% of their respondents had received the training, revealing how the knowledge and attitude changed if implant dentistry curriculum was introduced as a predoctoral program.26 Regarding the competency to place an implant we concluded that 29.6% of our respondents felt competent enough to place an implant whereas in a study published by D. J. Schonwetter, stated that many of their respondents did not feel confident enough to place an implant because the respective field was given the least importance as a learning criteria.27 This is supported by a study conducted in various dental institutions in Pakistan regarding oral implantology education which concluded that Implant education has been introduced in most institutions during past 5-10 years only and topics such as implant prosthetics, bone regeneration and grafting are not adequately
covered in implant curriculum.28 Although majority of respondents in this study (73%) were females but there was no significant relationship found between gender with
knowledge and attitude regarding dental implants; this was in line to a cross sectional study in which no significant effect of gender could be highlighted, however male respondents predominated (54.6%). However, it has been reported that dental practitioners with implant training have an edge over those with no professional training, as it enhances the knowledge with a positive attitude and practice of dental implants.2 Since this is an era of social media and implantology is an emerging field of dentistry with widespread awareness amongst the general population, there are several aspects that need to be worked upon on part of dental professionals themselves so that better health-care services could be provided to the masses.

LIMITATIONS OF THIS STUDY

This study doesn’t provide an insight regarding awareness of the distance of a dental implant to the other vital structures in oral cavity (like maxillary sinus, inferior alveolar canal,
etc). Taking implant loading into consideration, one should be well aware of all the parameters which could lead to its success and failure. Future research with a larger sample
size could be focused on pre-treatment evaluation and predictors of success and failure to overcome the knowledge gap.

CONCLUSION

This study describes that dental practitioners had an appropriate knowledge of each aspect of implantology. Moreover despite the fact majority felt that they are not competent enough to practice it. Therefore, the curriculum, teaching standards and methods regarding dental implants need reconsideration, exposures to hands-on workshops are
necessary for the graduates and also for undergraduate students during their clinical learning

ACKNOWLEDGEMENT

The authors are grateful to research and evaluation committee Altamash Institute of Dental Medicine for support and facilitation in this study.

CONFLICT OF INTEREST

The authors declared no conflict of interest

REFERENCES

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  13. Khan MF, Khan FN, Ali I, Ahmed MR, Jawed R, Zahoor Q. Contemporary Trends Regarding Knowledge And Practices Of Dental Implants Among Dental Interns Working In Educational Institutes Of Karachi, Pakistan. J Bahria Uni Med Dental Coll: 2020;10:35-9
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  22. Liaw K, Delfini RH, Abrahams JJ. Dental Implant Complications. Semin Ultrasound CT MR. 2015;36:427-33. Epub 2015 Oct 9. PMID: 26589696 https://doi.org/10.1053/j.sult.2015.09.007
  23. Porter JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent. 2005;53:423-32.
  24. Hanif A, Qureshi S, Sheikh Z, Rashid H. Complications in implant dentistry. Eur J Dent. 2017;11:135. https://doi.org/10.4103/ejd.ejd_340_16
  25. Sharma A, Chaudhari BK, Shrestha B, Suwal P, Parajuli PK, Singh RK, Niraula SR. Knowledge and perception about dental implants among undergraduate dental students. BDJ Open. 2019:14;5:1. https://doi.org/10.1038/s41405-018-0009-1
  26. Petropoulos VC, Arbree NS, Tarnow D, Rethman M, Malmquist J, Valachovic R, Brunson WD, Alfano MC. Teaching implant dentistry in the predoctoral curriculum: a report from the ADEA Implant Workshop’s survey of deans. J Dent Educ. 2006;70:580-88. https://doi.org/10.1002/j.0022-0337.2006.70.5.tb04114.x
  27. Schönwetter DJ, Law D, Mazurat R, Sileikyte R, Nazarko O. Assessing graduating dental students’ competencies: the impact of classroom, clinic and externships learning experiences. Eur J Dent Educ. 2011;15:142-52. https://doi.org/10.1111/j.1600-0579.2010.00648.x
  28. Lone MM. A Survey on Oral Implantology Education in the Dental Colleges of Pakistan. J Pioneering Medi Sci. 2016;6.17

  1. Associate Professor, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  2. Assistant Professor, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  3. Registrar, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  4. House Surgeon, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  5. House Surgeon, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  6. House Surgeon, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
  7. Registrar, Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi 75500, Pakistan.
    Corresponding author: “Dr. Maria Shakoor Abbasi” <maria_shakoor@hotmail.com>

Analysis of Dental Practitioners Perception Towards Dental Implants

Naseer Ahmed                      BDS, FCPS

Maria Shakoor Abbasi         BDS, FCPS

Quratulain Mariam               BDS, MBA

Hanan William                      BDS

Hafsa Iftikhar                        BDS

Hamna Badar                        BDS

Adil Bin Irfan                        BDS

OBJECTIVE: To investigate the dental practitioner’s knowledge, attitude and practice towards dental implants.
METHODOLOGY: This study was carried out from May’2019 – Oct 2019. 752 dental practitioners who were currently practicing were included in the study. A well-structured questionnaire was used for data collection. SPSS-25 was used for statistical analysis. Spearman correlation was used to find the effect of gender, knowledge and attitude. The P <0.05 was considered statistically significant.
RESULTS: In this study 80.9% dental practitioners were aware of the appropriate implant material while, 57.9% had knowledge about the types. 30.3% knew about the implant surface modifications whereas 46.1% dentists were aware of possible implant placement approaches. 49.3% believed that the distance between dental implants to be 3mm and between a dental implant and natural tooth to be 1.5 mm. 76% dentists claimed that dental implants have biomechanical complications. Whereas 67.8% knew about the Branemark’s theory of osseointegration. Regarding the attitude of dental practitioners, 28.9% had received implant hands on trainings while 9% felt competent to place an implant.
CONCLUSION: This study describes that dental practitioners had an appropriate knowledge of each aspect of implantology. Moreover despite the fact majority felt that they are not competent enough to practice it. Thus, it is important that the curriculum, teaching standards, the materials and methods regarding dental implants need to be reviewed and more exposure of hands-on workshops is to be provided not only for the graduates but also the undergraduates during their clinical learning.
KEYWORDS: Dental Implants, Dentist’s opinion, Knowledge
HOW TO CITE: Ahmed N, Abbasi MS, Mariam Q, William H, Iftikhar H, Badar H, Irfan AB. Analysis of dental practitioners perception towards dental implants. J Pak Dent Assoc 2021;30(1):45-49.
DOI: https://doi.org/10.25301/JPDA.301.45
Received: 12 August 2020, Accepted: 21 November 2020
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Radiographic Employment of Mandibular Third-Molar Mineralisation to Estimate Chronological Age in a Population of Peshawar, Pakistan

Quratulain Tariq                   BDS

Mariam Ajmal Tareen         BDS

Iftikhar Uddin                        BDS

Umar Hussain                        BDS

OBJECTIVES: To determine the correlation between chronological age (CA) and mandibular third molar (MTM) development in a sample of Khyber Pakhtunkhwa (KP) population. Furthermore, to provide forensic reference data for age determination from MTM mineralisation. Finally, to derive regression formulae specific to this population to estimate age using MTM calcification stages.
METHODOLOGY: Four hundred and seventy orthopantomographs (OPGs) of patients aged between 13-26 years from the Orthodontics department archive at the main tertiary dental hospital of KP were studied for development of MTM staging using Demirjian’s method. Spearman’s Correlation was applied to determine any relationship between CA and MTM development. An Independent two-sample t-test was performed to compare third-molar development in males and females. Population-specific models was developed using quantile regression analysis.
RESULTS: A strong positive correlation was found between CA and MTM development (rs = 0.853; p- <0.001). The median quantile regression equation developed for entire sample is: Age = 8.8+ 1.4(developmental stage). Ninety-four percent of males and females at stage H were at least 18 years or older.
CONCLUSION: Mandibular third-molars can be an appropriate guide for CA estimation in the KP population. Stage H is likely to occur at 18 years of age. This may be valuable for medicolegal suits requiring CA estimation.
KEYWORDS: forensic odontology, forensic anthropology, panoramic radiographs, chronological age estimation, mandibular third-molar, Pakistan
HOW TO CITE: Tariq Q, Tareen MA, Uddin I, Hussain U. Radiographic employment of mandibular third-molar mineralisation to estimate chronological age in a population of Peshawar, Pakistan. J Pak Dent Assoc 2021;30(1):39-44.
DOI: https://doi.org/10.25301/JPDA.301.39
Received: 15 July 2020, Accepted: 11 November 2020

INTRODUCTION

Radiographic studies of skeletal and dental development have been preferentially adopted as a non-invasive method for the estimation of chronological age for both the dead and living individuals. It avoids the need for dental extraction or histological preparation of tissue.1 Dental age has persistently corresponded to specific ranges of CA, for example, the
eruption of permanent first molars is generally expected by 6-7 years of age. However, the accuracy with which age can be correlated with dentition stages is limited to the eruption
of second-molars. After which, third-molars are the only teeth developing and radiographically employable for age estimation during adolescence and early adulthood.2,3,4 Crypts of third-molars can be depicted radiographically on average as early as 8 years after birth.5
In a longitudinal study, Garn et al6 showed that third-molar development continues a further 12 years of age until the closure of root apices. Undoubtedly this lengthy period increases risk of inconsistency in its development. Third molars are known to be the most variant tooth and have the highest rate agenesis.6 Nonetheless, several studies have shown great interest in utilising third-molar for chronological age estimation focusing on its mineralisation stages.3,7 Several classifications of tooth development stages have been developed in this regard of which Demirjian’s [ANNEXURE 1] is considered the most efficacious and is extensively used because of greater observer agreement.7,8 Demirjian et al developed a maturity scoring system to determine dental age in children for universal use but it is not applicable to some populations including that of Pakistani children.9-12 The present study, however, does not use their proposed method rather it only utilises their developmental stages of the MTM. Previous studies have shown a positive correlation
between chronological age and third-molar developmental stages and have formulated population-specific regression models for age calculation. The objectives of our study were
to determine a correlation between CA and MTM development in a population of KP, north western province of Pakistan, to provide forensic reference data of CA at critical dental developmental landmarks and to develop a model specific to this populace.

METHODOLOGY

This retrospective cross-sectional analytical study was conducted at the Department of Orthodontics, Khyber College of Dentistry (KCD), Khyber Pakhtunkhwa. Panoramic radiographs of 470 orthodontic patients pertaining to the years: Jan 2016 to May 2018, were studied. The sample size was calculated using Yamane’s formula: n = N/( 1+ N(e)2 ). For projected population of KP between 13 to 26 years, N = 8468438 and a margin of error e = 0.046 the estimated sample size n = 8468438/ (1+ 8468438(0.046)2 ), n = 470 approx. Subjects who were natives of KP visiting orthodontics department at KCD and aged between 13-26 years were included. The following were excluded: any skeletal or dental pathology (impactions, anomalies, agenesis, transpositions, skeletal class II or III jaw profile, cleft lip and palate etc), any systemic developmental disturbances, previous surgery affecting the jaw or dental development and any radiographic artefacts affecting MTM region.
To carry out the study, approval was taken from the Institutional Ethical Review Committee at KCD. Data was collected by studying the developmental stages of MTMs from OPGs of both males and females aged between 13 to 26 years. Age was calculated from the date of birth stated in the patients’ files to the date on which the OPG was taken. For the developmental stage assessment Demirjian’s et al7 classification system was utilised which states 8 developmental stages (A-H). Stage 0 was applied for the presence of merely a tooth crypt. All OPGs were assessed under radiographic illuminator by two observers.
The collected data were analysed using Statistical Package for Social Sciences (SPSS) version 22. Inter-observer agreement was assessed using Cohen’s kappa statistics. Descriptive statistics like frequency, mean, standard deviation and percentage distribution of chronological ages for the eight Demirjian stages were calculated. Spearman’s correlation was used to determine if correlation exists between CA and Demirjian developmental stages of MTM. An Independent two-sample t-test was applied to examine the statistical significance of the variations observed in the ages of males and females at each stage. Quantile regression analysis was carried out using Software for Statistics and Data Science (STATA) version 12 to develop equations to estimate chronological age for the entire sample and for males and  females separately.

RESULTS

There was an almost perfect degree of agreement with Kappa value of 0.815 between the 2 observers for n=470 cases (p < 0.0001). There were 215 (45.7%) males with an average age of 17.2±3.7 years and 255 (54.3%) females with an average age of 17.6±3.7 years. The frequency of each Demirjian stage and mean age at each stage for both males and females
is given in table 1. Results from our study sample show a strong positive linear trend between CA and Demirjians development stages of both 38 and 48 (see Fig.1). Spearman rank-order correlation coefficient (rs) indicated a strong positive association between CA and developmental stages of teeth 38 (rs= 0.840) and 48(rs=0.853), which is highly statistically significant (p < 0.0001). Males showed slightly greater correlation between CA and development of both 38 (males rs=0.845; females rs=0.832) and 48 (males rs=0.862; females rs=0.840)

Figure 1: Mean plots for each developmental stage of 38 and 48.

Table 1:Mean ages of males and females at various Demirjian’s stages of teeth 38 and 48.

Further analysis was performed with data of 48 as it exhibited greater correlation with CA for both sexes than 38. Independent samples t-test showed no statistically significant differences between mean ages of males and females in any developmental stage for tooth 48. There were a negligible few individuals in whom MTM crypts were observed as late as 13 to 14 years of age. Stage A was observed on average within the 13th year. Between stages B-D, age remained relatively constant (see Fig.1). Stage D (crown completion) was predominantly observed around 14 years of age for both sexes (see Fig.2). Eighty-eight percent of females and 86% of males were at least 14 years of age at stage D (see Fig.3). Dental maturation from stage D to E occurred over a period of 1.5 years for females and 1 year for males (see Table 1). After which both males and females

Figure 2: Mean ages of males and females plotted against developmental stages

attained stages F and G at a similar period (see Fig. 2). Stage G (root-length completion) was predominantly observed after 17 years of age in both males and females. Seventy-one percent of females at stage G were >17 years and 67% of males at stage G were >17 years of age (see Fig.4). Stage H (apical closure) was obtained at 16 years of age at the earliest in both males and females. At stage H, 94% of males and 95% of females were >18 years (see Fig. 5). Through quantile regression analysis, statistical models were developed by which chronological age can be estimated using Demirjian’s developmental stages (p <0.0001):

Figure 3: Percentage of males and females in certain ages within stage D (crown completion)

Figure 4: Percentage of males and females at certain ages within stage G (root length completion)

Figure 5: Percentage of males and females at certain ages within stage H (tooth formation complete)

Entire sample:
Quantile Regression at median(17) Age = 8.8+ 1.4 (developmental stage), pseudo R2 =0.45
0.25 (14) Quantile Age = 10+ 1.0(developmental stage), pseudo R2 =0.37
0.75 (20) Quantile Age = 10+ 1.5(developmental stage), pseudo R2 =0.43
For Males:
At median(16) Age = 8.8+ 1.4 (developmental stage), pseudo R2 =0.45
0.25 (14) Quantile Age = 10+ 1.0 (developmental stage), pseudo R2 =0.37
0.75(20) Quantile Age = 10+ 1.5 (developmental stage), pseudo R2 = 0.45
For Females:
At Median(17) Age = 8.8+ 1.4 (developmental stage), pseudo R2 = 0.45
0.25 (14) Quantile Age = 7. 7+ 1.3 (developmental stage), pseudo R2 = 0.38
0.75 (20) Quantile Age = 8.6 + 1.8 (developmental stage), pseudo R2 = 0.41
McFadden’s pseudo R2 indicates goodness of fit of the aforementioned models. The larger pseudo R2 values indicate which model better predicts the outcome. When interested in predicting around the median age value17 then Quantile regression median is appropriate. Similarly, when estimating around the 0.25th quantile i.e. age value14 or around the 0.75th quantile, i.e. age value20, the Quantile regression median is also appropriate.

DISCUSSION

The results from our study show a strong positive correlation exists between MTM development and chronological age in a KP population. This is a similar finding to studies conducted on Central European13, Indian14, Iranian15, Chinese16, Japanese, South African17, Turkish18, Aboriginal-Canadians19, American3 and Brazilian20 populations.
According to Mincer, et al2 sexual dimorphism influences mineralisation of MTM: males being more advanced in development than females. Studies conducted on Turkish[18]
Indians21 and Swedish22 citizens support this. However it was observed that in Iranian females were significantly younger than their male counterparts at stage H.23 Contrary to this, there were no statistically significant differences between males and females in our study and that of a population in Brazil.20 Eighty-six percent of males and 88% of females of our population were at least 14 years of age at stage D (crown completion). This is comparable to the Turkish18, Chinese16, South African17 and Iranian15 populations (stage D was obtained on average at 14 years of age) and also close to Swedish22, American (Caucasian, Hispanic and African) populations3 in whom crown completion was attained by 15 years of age. Whereas the German, Indian and Japanese populations were much older at stage D: a mean age of 16 years, 17 years and 18 years respectively.14,17 In the present work, stage G, illustrative of root-length completion, was observed at 17 years of age with 67% of males and 71% of females being 17 years and older. A recent study on a Han population in China16 concluded that it was likely for a citizen to be over 14 at stage G. The Turkish18, Swedish22 and American (Caucasian, African and Hispanic) citizens3
were 18 years of age upon reaching stage G. Whereas the German, Japanese and South African populations reached this stage even later: at the age of twenty-one.17 Lui Y, et al16 found that stage H was obtained at a minimum age of 16 years in a population of Southern China.
The present study reports an identical finding. The likelihood of males and females of KP province being 18 years and older at stage H is 94% and 95% respectively. This is alike
to Belgian Caucasian males (96%) and females (95%) and of American (Caucasians and African) citizens (90%) and Hispanics (85%) were 18 years old upon attaining stage H.3,24 Similarly stage H was attained by 18 years of age in a Brazilian population.20 On the other hand the Japanese, German, and South African populations were all at an average age of 22 years.17 It was concluded that MTM formation may complete after 22 years of age among Iranians.23 A study on the Indian population concluded that 90% of males will reach stage H by 21 years and females by 23 years.21 Though the study sample reached crown completion stage and root-length completion stage earlier than the other ethnicities, at stage H the percentage of individuals being 18 or older was the same (>90%) for them and for Belgian Caucasian, American White and Black, and Spanish populations. Similarly there were significant differences between the Caucasian Americans and African Americans and between the German, Japanese and South African populations in the earlier stages (D-G) of development but all reached stage H at ages that were at par with each other in the respective studies.3,17 The variations in CA at earlier stages diminished towards the completion of MTM formation amongst some populations. Although currently there is no study that has utilised quantile regression to develop statistical models for CA estimation from mineralisation stages of MTM, Khan et al found quantile regression was more accurate than linear regression in estimating dental age of Pakistani children whereas Iftikhar et al developed growth charts specifically for Pakistani children using quantile regression which were more accurate than the anthropometric data proposed by World Health Organisation.21,22 There are potential limitations to this study. The present work is a single hospital-based study which may not be as representative of the general population opposed to a larger sample-based study taken from various centres of the province. Random selection of sample was limited as only those radiographs available in the archive were studied. However additional exposure for this purpose was unjustified. Follow-up radiographs of study subjects would give a greater accuracy of correlation of CA and tooth developmental stage than a retrospective study.

CONCLUSION

Developmental stages of MTM can be used as an indicator for age for Pashtun population of Pakistan. Males and females of this population do not have statistically significant variations. It is highly likely that males and females of this populace will be at least 18 years at stage H. This can be of great value in medicolegal lawsuits requiring age estimation.

RECOMMENDATIONS

Though the regression formulae closely fit the observed data, additional prediction tests may be applied for further verification of the goodness of fit of these regression models.
Studies with larger samples sizes and different tribes residing at KP should be conducted to provide additional data for forensic use.

CONFLICTS OF INTEREST STATEMENT

The authors declare no conflicts of interest in this submission

REFERENCES

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  4. Zandi M, Shokri A, Malekzadeh H, Amini P, Shafiey P. Evaluation of third molar development and its relation to chronological age: a panoramic radiographic study. Oral Maxillofac Surg, 2015; 19:183. https://doi.org/10.1007/s10006-014-0475-0
  5. Bishara SE, Andreasen SG. Third molars: a review. Am J Orthod, 1983; 83:131-37 https://doi.org/10.1016/S0002-9416(83)90298-1
  6. Garn SN, Lewis AB, Bonne B. Third molar formation and its developmental course. Angle Orthod, 1962; 32:270-79.
  7. Olze A, Bilang D, Schmidt S, Wernecke KD, Geserick G, Schmeling A. Validation of common classification systems for assessing the mineralization of third molars. Int J Legal Med, 2005; 119:22-26. https://doi.org/10.1007/s00414-004-0489-5
  8. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Ann Hum Biol, 1973; 45:211-27.
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    https://doi.org/10.1038/s41405-019-0015-y
  10. Alqadi MA, Abuaffan AH. Validity of the Demirjian and Fishman Methods for Predicting Chronological Age Amongst Yemeni Children. Sultan Qaboos Uni Med J. 2019;19:e26. https://doi.org/10.18295/squmj.2019.19.01.006
  11. Sukhia RH, Fida M, Azam SI. Dental age table for a sample of Pakistani children. Eur J Orthodo, 2012; 34:77-82. https://doi.org/10.1093/ejo/cjq161
  12. Esan TA, Yengopal V, Schepartz LA. The Demirjian versus the Willems method for dental age estimation in different populations: A meta-analysis of published studies. PloS one, 2017; 12:e0186682.
    https://doi.org/10.1371/journal.pone.0186682
  13. Hofmann E, Robold M, Proff P, Krischneck C. Age assessment based on third molar mineralisation. J Orofac Orthop, 2017; 78:97- 111. https://doi.org/10.1007/s00056-016-0063-z
  14. Priyadharshini K I, Idiculla JJ, Sivapathasundaram B, Mohanbabu V, Augustine D, Patil S. Age estimation using development of third molars in South Indian population: A radiological study. J Int Soc Prevent Communit Dent. 2015;5:32-8 https://doi.org/10.4103/2231-0762.156522
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  22. Simonsson L , Näsström Ka, Kullman L. Radiographic evaluation of third mandibular molar development as an age indicator in a Swedish population. Madridge J Dent Oral Surg. 2017; 2:31-7. https://doi.org/10.18689/mjdl-1000108
  23. Khosronejad A, Navabi M, Sakhdari S, Rakhshan V. Correlation between chronological age and third molar developmental stages in an Iranian population (Demirjian method). Dent Res J. 2017;14: 143-49.
  24. Gunst K, Mesotten K, Carbonez A, Willems G. Third molar root development in relation to chronological age: a large sample sized retrospective study. Forensic Sci Int, 2003;136:52-7. https://doi.org/10.1016/S0379-0738(03)00263-9
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    https://doi.org/10.1007/s00414-005-0530-3
  26. Sisman Y, Uysal T, Yagmur F, Ramoglu SI. Third-molar development in relation to chronologic age in Turkish children and young adults. Angle Orthodontist, 2007; 77:1040-45 https://doi.org/10.2319/101906-430.1
  27. Khan NB, Iftikhar S. Age Estimation of School Going Children of Pakistan by Number of Erupted Teeth Using Median Regression. Ann Jinnah Sindh Med Uni. 2015; 1:3-5
  28. Iftikhar S, Khan N, Siddiqui JS, Baig NA. Development of growth charts of Pakistani children using quantile regression. Cureas, 2018; 10:e2138. https://doi.org/10.7759/cureus.2138

  1. Foundation Dentist (House Officer), Department of Out-patient department, Khyber College of Dentistry, Peshawar.
  2. Foundation Dentist (House Officer), Department of Out-patient department, Khyber College of Dentistry, Peshawar.
  3. Assistant Professor, Department of Mathematics and Biostatistics, University of Agriculture Peshawar.
  4. FCPS II trainee, Department of Orthodontics, KhyberCollege of Dentistry.
    Corresponding author: “Dr. Quratulain Tariq” < qtariq03@gmail.com >

Radiographic Employment of Mandibular Third-Molar Mineralisation to Estimate Chronological Age in a Population of Peshawar, Pakistan

Quratulain Tariq                   BDS

Mariam Ajmal Tareen         BDS

Iftikhar Uddin                        BDS

Umar Hussain                        BDS

OBJECTIVES: To determine the correlation between chronological age (CA) and mandibular third molar (MTM) development in a sample of Khyber Pakhtunkhwa (KP) population. Furthermore, to provide forensic reference data for age determination from MTM mineralisation. Finally, to derive regression formulae specific to this population to estimate age using MTM calcification stages.
METHODOLOGY: Four hundred and seventy orthopantomographs (OPGs) of patients aged between 13-26 years from the Orthodontics department archive at the main tertiary dental hospital of KP were studied for development of MTM staging using Demirjian’s method. Spearman’s Correlation was applied to determine any relationship between CA and MTM development. An Independent two-sample t-test was performed to compare third-molar development in males and females. Population-specific models was developed using quantile regression analysis.
RESULTS: A strong positive correlation was found between CA and MTM development (rs = 0.853; p- <0.001). The median quantile regression equation developed for entire sample is: Age = 8.8+ 1.4(developmental stage). Ninety-four percent of males and females at stage H were at least 18 years or older.
CONCLUSION: Mandibular third-molars can be an appropriate guide for CA estimation in the KP population. Stage H is likely to occur at 18 years of age. This may be valuable for medicolegal suits requiring CA estimation.
KEYWORDS: forensic odontology, forensic anthropology, panoramic radiographs, chronological age estimation, mandibular third-molar, Pakistan
HOW TO CITE: Tariq Q, Tareen MA, Uddin I, Hussain U. Radiographic employment of mandibular third-molar mineralisation to estimate chronological age in a population of Peshawar, Pakistan. J Pak Dent Assoc 2021;30(1):39-44.
DOI: https://doi.org/10.25301/JPDA.301.39
Received: 15 July 2020, Accepted: 11 November 2020
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Oral Hygiene Maintenance Via Teledentistry in Orthodontic Patients: A Randomized Controlled Trial

Erum Behroz Khan        BDS, FCPS, C-Orth, MTFPDP, C-HPE

Mairah Shah                     BDS

S.M. Tariq Rafi                 MBBS, DLO, FCPS, FICS, FRCS

Sadia Rizwan                    BDS, FCPS

Zuhair Ahmed                  BDS

Samar Fatima                   BDS

OBJECTIVES: To determine the extent of improvement in oral hygiene via text message reminder in patients undergoing fixed orthodontic treatment.
METHODOLOGY: The participants were from 13 to 30 years of age recruited from Department of Orthodontics, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi, Pakistan. The sample comprised of 70 patients (59 female and 11 male) about to have fixed orthodontic treatment, 35 in text message group and 35 in control group. Patient’s plaque index was evaluated at baseline and after 30 days.
RESULTS: Text message group had highly significant (P < .05) plaque index score (PostPI) than control group.
CONCLUSIONS: Orthodontic patients frequently reminded to brush have better oral hygiene.
KEYWORDS: Plaque index, Text message, Oral hygiene, Orthodontics.
HOW TO CITE: Khan EB, Shah M, Rafi S.M.T, Rizwan S, Ahmed Z, Fatima S. Oral hygiene maintenance via teledentistry in orthodontic patients: A randomized controlled trial. J Pak Dent Assoc 2021;30(1):34-38.
DOI: https://doi.org/10.25301/JPDA.301.34
Received: 20 August 2019, Accepted: 23 November 2020

INTRODUCTION

Mouth cleanliness is paramount for the protection of oral health as it eliminates microbial plaque, preventing it from accumulating on teeth and gingivae. Saliva is a natural cleaning agent that removes supragingival plaque in the oral cavity. However, although such mechanisms might eradicate food debris, they do not adequately remove dental plaque. Therefore, regular personal oral hygiene is necessary to eliminate supragingival plaque.The most widely used way of actively removing plaque at home is brushing of the teeth. Research has proved that tooth brushing and other mechanical cleansing methods can reliably control plaque, if cleaning is sufficiently thorough and performed regularly.1 However, this can be challenging to the patients who have multi bracket fixed appliances that are required for the correction of orthodontic malocclusion.2 Microbial colonization of the dental and gingival tissues is a negative consequence of orthodontic treatment. Fixed orthodontic appliances inside the mouth causes qualitative and quantitative changes by altering the physicochemical state of bacterial growth. The multi bracket system encourages the development of dental plaque and hinders its elimination.3 Plaque formation in these patients is 2 to 3 times greater than levels in high plaque-forming adults without appliances.4 Numerous studies have shown oral hygiene declines after initial period of bonding in orthodontic patients as judged by plaque and gingival indices. Insufficient oral hygiene before or throughout orthodontic treatment can also lead to white spot lesions. In another study, it was demonstrated that unwanted side effects appeared at the end of the orthodontic treatment due to deteriorating oral hygiene, that led to disappointing results and early removal of appliance.5
A major side effect of fixed orthodontic treatment is appearance of caries development on the facial surface in the form of white spot lesions. Studies have shown WSL after fixed appliance therapy in 50% to 70% of patients.6 It has been proved that amount of plaque formation in orthodontic patients can be reduced by reminder therapy.7 “Tele” is a word derived from Greek meaning distance, and “mederi” is a word derived from Latin meaning “to heal”. Tele-medicine delivers healthcare across large geographic distances through information based technologies and communication system.8 Likewise communicating with orthodontic patients through the medium of information technology instead of face to face to take care of their appliance, to guide and treat them from a distance is known
as Tele- orthodontics.9 Recent developments in technology like computers and smartphones have made management of orthodontic patients by tele-dentistry more feasible.10 It has been shown that communicating with these patients through active reminders, increases their attendance on appointments, makes them take their medications on time and brings positive changes in their behavior.11
Patient’s negligence in oral health during orthodontic treatment results in plaque accumulation that can lead to undesired side effects. Patients should be frequently reminded of its importance through oral hygiene instruction’s text message. Our purpose to conduct this study is to determine the extent of improvement in oral hygiene in orthodontic patients by reminding via text message.

METHODOLOGY

This study was conducted as a randomized clinical trial, performed on 70 selected orthodontic patients, 35 in text message group and 35 in control group. The study was explained to patients or their parents and they were asked to sign informed consent forms. The sample comprised of 59 females and 11 male participants. They were from 13 to 30 years of age without any significant medical/ dental history recruited from Department of Orthodontics, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi, Pakistan. Duration of this study was 30 days. Ethical Approval was obtained (JSMU/IRB/2020/-312) Inclusion criteria: Both genders were included i.e. male and female with the age range from 13 to 30 years. Patient’s presenting with complain of mal aligned teeth, about to have
fixed orthodontic treatment, internally motivated and having good oral health. Patients with crowding in different types of malocclusions (class I, II & III). All these patients had smartphones and were able to read and write. Exclusion criteria: Patient’s with poor oral hygiene, patient’s already on fixed orthodontic treatment, diabetic patients, betel nut chewers were excluded from the study.
All the participants received standard scaling and polishing 3 to 4 weeks prior to the treatment and their periodontal health was maintained till commencement of
the treatment. These participants were then divided into two groups through sealed envelope technique i.e. principal investigator was given randomly generated treatment allocations within sealed opaque envelopes. Once a patient had consented to enter a trial an envelope was opened and the patient was then offered the allocated treatment regimen.
The control group was composed of 31 female and 4 male patients who were about to have fixed orthodontic treatment. Their plaque index was evaluated before fixed orthodontic treatment (PrePI), after the bonding they were given standardized oral hygiene instructions that included proper brushing and use of mouth wash. After 30 days their plaque index (PostPI) was reevaluated. Text message group was composed of 28 female and 7 male patients who were about to have fixed orthodontic treatment. Their plaque index was evaluated before fixed orthodontic treatment, after bonding they were given standardized oral hygiene instruction in a similar manner as the control group. They received a text message reminder once each week for 30 days. The text message stated “Keep your smile shining, keep your teeth and braces clean, don’t forget to Brush them for 2 minutes at least after every meal. See you soon.” After 30 days their plaque index was reevaluated and their results were compared and contrasted with the control group.
The plaque index was scored as described by SilnessLöe plaque index. Silness-Löe was chosen over other plaque indexes, as it assesses thickness of plaque at gingival margins rather than on its coronal extent on the tooth surface area. It is calculated on the basis of recording soft and hardened plaque deposits on following teeth: 16, 12, 24, 44, 32, 36. The buccal, lingual, mesial and distal surfaces (Four surfaces) of the each tooth were given a score between 0-3 as described in table 1. In order to calculate each tooth’s plaque index, the scores for its four surfaces were added and divided by

Table 1: Silness- Löe plaque index

four. Then all the six teeth mentioned above were summed and divided by six to calculate the index for the patient. This score was graded as described in table 2. The collected data

Table 2: Plaque index grading

was analyzed through SPSS 22, t-test was applied to compare scores of text message group with control group, keeping P value <.05.

RESULTS

All the data was analyzed using SPSS 22, the difference between the means of two groups was found by applying independent t- test. The test results were significant (P <.05) for post treatment plaque index of text message group in comparison to control group. Both groups had almost similar pretreatment plaque index, 0.67±0.17 in control group and 0.56±0.11 in text message group. There was difference in plaque index after 30 days, mean plaque index in control group was 1.18±0.31 and in text message group was 0.68±0.13 as shown in table 3. Comparison of plaque index of these two groups showed significant difference after 30 days, as discussed in table 4.

Table 3: Plaque index mean and standard deviation

Table 4: T- Test Significant results after 30 days

DISCUSSION

The principal etiologic factor behind the formation of periodontal disease and dental caries, is a very complicatedly organized form of biofilm known as dental plaque. Orthodontic treatment with fixed appliances results in plaque accumulation. It Is essential to evaluate of dental plaque regularly to maintain the cleanliness in oral cavity of individual patients who are going through fixed appliance treatment.12
Good communication with patients can be maintained through text messaging. This will make the patient believe about how much the orthodontist is involved in the patient’s treatment and how much he or she is concerned regarding health of the patient between long gaped appointments. This has been proved to be very influential in satisfying patients and encouraging a good relationship between orthodontist and patient. The influence of word of mouth, or in this case the written word, seems to be extremely useful when it serves as a medium of communication between orthodontist and their young patients.13 The current study was designed as a randomized clinical trial of 70 orthodontic patients, about to have fixed orthodontic appliance treatment. This study was carried out to check plaque index in orthodontic patients who are reminded oral hygiene instructions through text message and to compare their plaque index score with control/ conventional group. Both groups i.e. control group and text message group participated in this study for 30 days. Both groups had similar plaque index scores (95.7% rated as good) before treatment. After 30 days of treatment there

Table 5: Treatment Plaque Index Grading

wasn’t much difference in text message group’s PI (97.1% rated as good, 2.9% rated as fair) but there was a notable difference in control group’s PI (20% rated as good, 77.1% rated as fair and 2.9% as poor) as described in table 5. Comparison between the two groups shows significant difference in plaque index after 30 days of treatment with P value <.05. Limitations of the study were the small sample size and patient compliance in data collection.
In a similar study carried out in Genova, it was demonstrated that participants receiving post-treatment reassurance through communication(text message and calls) reported more compliance in oral hygiene than the control group patients.14 In 2017, in Italy a app-based approach was applied to standard maintenance of oral hygiene to improve oral health and hygiene compliance in a teenage patients group who had fixed multi bracket appliances.15 Although these methods are effective in decreasing plaque accumulation during treatment, however, text messaging is more convenient. It is has been proved that around 75% of smartphone users between the age range of 12-17 years often communicate through text messages.4 In another study conducted in Pakistan, showed decreased modified gingival index, plaque index and bleeding index after 30-60 days of orthodontic treatment in text message group and proved it successful in improving oral hygiene.5
Many studies have demonstrated that fixed orthodontic treatment’s initial months are very demanding for patients as they have to get acquainted with new manual skills for maintenance of orthodontic appliance in an appropriate hygienic condition.15 Our study’s aim is to evaluate changes in oral hygiene after one month in both groups (text message and control) on a larger population and to familiarize them to oral hygiene measures for fixed orthodontic appliance. Limitations of the study were the small sample size, limited funding and time constraint.

Table 6: Post Treatment Plaque Index Grading

CONCLUSION

  • Orthodontic patients receiving text message reminders have better oral hygiene than conventional group
  • Patients should be frequently reminded to brush and maintain their oral hygiene.

CONFLICT OF INTEREST

None declared

REFERENCES

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  12. Al-Anezi SA, Harradine NW. Quantifying plaque during orthodontic treatment: a systematic review. Angle Orthod. 2012;82:748-53. https://doi.org/10.2319/050111-312.1
  13. Brent Bowen T, Rinchuse DJ, Zullo T, DeMaria ME. The influence of text messaging on oral hygiene effectiveness. Angle Orthod. 2015;85:543-48. https://doi.org/10.2319/071514-495.1
  14. Cozzani M, Ragazzini G, Delucchi A, Mutinelli S, Barreca C, Rinchuse DJ, et al. Oral hygiene compliance in orthodontic patients: a randomized controlled study on the effects of a post-treatment communication. Prog Orthod. 2016;17:41. https://doi.org/10.1186/s40510-016-0154-9
  15. Zotti F, Dalessandri D, Salgarello S, Piancino M, Bonetti S, Visconti L, et al. Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic patients. Angle Orthod. 2016;86:101-07. https://doi.org/10.2319/010915-19.1

 


  1. Assistant Professor, Supervisor FCPS-Training Program, Department of Orthodontics, Sindh Institute of Oral Health Sciences, Karachi, Sindh, Pakistan.
  2. Fellowship of College of Physicians and Surgeons Part 2 Trainee, Department of, Sindh Institute of Oral Health Sciences, Karachi, Sindh, Pakistan.
  3. Vice Chancellor, Jinnah Sindh Medical University, Karachi, Sindh, Pakistan.
  4. Assistant Professor, Department of Orthodontics, Dr. Ishrat Ul Ibad Khan Institute of Oral Health Sciences, DUHS, Karachi, Sindh, Pakistan.
  5. Fellowship of College of Physicians and Surgeons Part 2 Trainee, Department of Orthodontics, Sindh Institute of Oral health sciences, Karachi, Sindh, Pakistan.
  6. Fellowship of College of Physicians and Surgeons Part 2 Trainee, Department of Orthodontics, Sindh Institute of Oral health sciences, Karachi, Sindh, Pakistan.
    Corresponding author: “Dr. Mairah Shah” < myrashahsyed@gmail.com >

Oral Hygiene Maintenance Via Teledentistry in Orthodontic Patients: A Randomized Controlled Trial

Erum Behroz Khan        BDS, FCPS, C-Orth, MTFPDP, C-HPE

Mairah Shah                     BDS

S.M. Tariq Rafi                 MBBS, DLO, FCPS, FICS, FRCS

Sadia Rizwan                    BDS, FCPS

Zuhair Ahmed                  BDS

Samar Fatima                   BDS

OBJECTIVES: To determine the extent of improvement in oral hygiene via text message reminder in patients undergoing fixed orthodontic treatment.
METHODOLOGY: The participants were from 13 to 30 years of age recruited from Department of Orthodontics, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi, Pakistan. The sample comprised of 70 patients (59 female and 11 male) about to have fixed orthodontic treatment, 35 in text message group and 35 in control group. Patient’s plaque index was evaluated at baseline and after 30 days.
RESULTS: Text message group had highly significant (P < .05) plaque index score (PostPI) than control group.
CONCLUSIONS: Orthodontic patients frequently reminded to brush have better oral hygiene.
KEYWORDS: Plaque index, Text message, Oral hygiene, Orthodontics.
HOW TO CITE: Khan EB, Shah M, Rafi S.M.T, Rizwan S, Ahmed Z, Fatima S. Oral hygiene maintenance via teledentistry in orthodontic patients: A randomized controlled trial. J Pak Dent Assoc 2021;30(1):34-38.
DOI: https://doi.org/10.25301/JPDA.301.34
Received: 20 August 2019, Accepted: 23 November 2020
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Association of Carcinogenic Oral Habits with Oral Squamous Cell Carcinoma

Nazish Fatima                BDS, MDS

Sidra Mohiuddin           BDS, MDS

Salim Hosein                 MBBS, DABGS

Mervyn Hosein               BDS, FDS RCSE, FDS RCS, FFD RCSI

OBJECTIVE: To determine the association among betel nut, betel quid or smoking alone, and betel quid combined with smoking in subjects reporting with oral sub mucous fibrosis, oral submucous fibrosis with malignant transformation in to cancer and oral squamous cell carcinoma.
METHODOLOGY: An analytical cross sectional, multi centric study of n = 1009 cases collected through non-probability convenience sampling. These n=1009 subjects were subdivided into four groups: group 1, who consumed areca nut only; group 2, who chewed betel quid along with areca nut; group 3, who used betel quid and smoked; and group 4, who had no chewing habits history but were smokers. These changes were further confirmed with the help of biopsy reports of the subjects with OSMFCa and OSCC. Chi square test was performed to find out association of chewing habits with the progression of disease state. Level of significance was kept at p<0.05.
RESULTS: The mean age of the sample (n=1009) were 42.79±1.31 years (range: 10-70 years). Statistically significant difference was (p<0.00) found among all four groups in terms of initiation, propagation and progression of oral squamous cell carcinoma. Furthermore, statistically insignificant difference (p=0.40) was found between group 2 and group 3 as similar number of cases (OSCC) was seen among them.
CONCLUSION: Current study concluded that patients who have combined habits of chewing betel quid with areca nut and betel quid with smoking were at highest risk of initiation and progression of oral cancer. However, smoking cigarettes alone was the weakest risk factor.
KEYWORDS: Betel quid; Areca nut; Smoking; Oral squamous cell carcinoma, Oral submucous fibrosis
HOW TO CITE: Fatima N, Mohiuddin S, Hosein S, Hosein M. Association of carcinogenic oral habits with oral squamous cell carcinoma. J Pak Dent Assoc 2021;30(1):29-33.
DOI: https://doi.org/10.25301/JPDA.301.29
Received: 07 February 2020, Accepted: 09 September 2020

INTRODUCTION

Cancer is a global burden because of its high incidence and death rates.1,2 Amongst all cancers, oral cancer is the second most common cancer reported from developing countries.3,4 Evidence has shown that cancer is proven to be a disease of multifactorial origin, associated with varying risk factors among different population sub groups.5 However, factors that are primarily considered as established risk factors are: tobacco usage ; areca nut; heavy intake of alcohol; infection with human papillomavirus; and existence of oral potentially malignant disorders Since Pakistan is a developing country where people are suffering from oral cancer are mostly belong to low socioeconomic status.6
As this high risk group of the population; in addition to oral cancer is also suffering from nutritional deficiencies such as vitamin B12, folic acid and antioxidants therefore they get easily effected by the disease.7 Many epidemiological studies have reported consumption of tobacco to be the major etiology behind oral cancer.8,9 In addition; deaths caused by tobacco hardly make headlines, but tobacco kills one person in every six seconds.10,11 Many studies within the South Asian region report the frequent exchange and/or sharing of tobacco products as a way to promote relationship ties and friendship.12,13 Furthermore, some studies have suggested that consumption of tobacco in combination with betel quid is also linked with relieving stress and / or help keep chewing workers awake because of the presence of pharmacologically active ingredients.12,14 Globally, tobacco is available in two major forms: smoked and smokeless. The common smoked form includes cigarettes, cigars, e-cigarettes and hookahs whereas the smokeless is further divided into chewing (betel quid, pan masalas, Gutka), and snuff forms (dry/moist).8 Betel quid (BQ) with tobacco and gutka (processed and packaged areca nut with added tobacco and other ingredients) are the most widely used smokeless tobacco (ST) products in the south Asian region (i.e. Pakistan, Bangladesh, India, Sri Lanka, Taiwan etc.) and are the one among four most commonly used psychoactive substances consumed by about six million people around the globe.8,12,15,16,17 Gender wise prevalence of smoking reported by WHO (2013) among Pakistani population was found to be 31.8% of men, 5.8% of women, and 19.1% of adults are currently use tobacco in one form or another. Furthermore, of these overall adult population 17.9% of men, 1% of women and 9.6% of the adults were found to be users of cigarette smoking on daily basis whereas water pipe smokers were 4.4% of men, 1% women and 2.7% were adults. On the other hand, adult’s consumption of smokeless tobacco on daily basis was found to be 10.5% men, 3.5% women and 7.1% of adults. However, among young generation 13.3% of boys, 6.6% of girls and 10.7% of all youth were consuming either tobacco in direct form or its derived products.13
Moreover, it is also reported by the World Bank that unless urgent action is taken to control the situation, the annual deaths from tobacco will rise more than 8 million by 203018 if these trends are not over looked then it will lead to an estimated 500 million people’s death associated with tobacco alone.11
There is scarcity of data in countries like Pakistan, India, and Bangladesh regarding association of OSMF, its malignant transformation and OSCC with tobacco users in forms i.e chewing & non chewing (areca nut and betel quid, betel quid and smoking) as well as combination of these habits and their association in causing oral malignancies. Furthermore, there is an utmost need to find out the synergistic effect of combination of chewing and non-chewing habits. These findings could be helpful for further evaluation of rate and progression of OSCC, and will possibly allow high authorities to allocate more resources towards prevention and management of oral cancer. Therefore, the objective of current study was to evaluate the association among betel nut, betel quid or smoking alone, and betel quid combined with smoking in subjects reporting with oral sub mucous fibrosis, oral sub mucous fibrosis with malignant transformation to oral cancer and oral squamous cell carcinoma.

METHODOLOGY

A cross sectional, multicentric study of histologically confirmed n=1009 cases of OSCC were selected and examined by the principal investigator; from both private and public tertiary care units through a non-probability convenience sampling technique. The age ranges of the subjects were 10 to 70 years of age. Selection criteria was as follow:- all those subjects who had habit of consuming betel nut, tobacco and its derivatives, were agree to be the part of study. However, subjects that were habitual eaters and came to the OPD for other dental procedures, pregnant and lactating females were excluded. Sample size was determined by WHO sample size calculator.19 Clinical details included age, gender, associated habits of eating plain or packaged areca nut alone or with its combinations in the form of betel quid (paan) with or without tobacco, naswar (moist powdered tobacco snuff), smoking tobacco etc.
Data collection was performed by subdividing the total n=1009 subjects into four groups: group 1, who consumed areca nut only; group 2, who chewed betel quid along with areca nut; group 3, who used betel quid and smoked; and group 4, who had no chewing habits history but were smokers only.
Clinical grading of OSMF was based on the classification proposed by Haider SM and Merchant AT et al.20 Clinical oral examinations was performed to detect malignant transformation related to pre-existing OSMF. These transformations were further confirmed with the help of biopsy reports of the subjects with OSMFCa and OSCC. Data were assembled and entered in SPSS version.18 Frequencies and percentages were calculated for gender and group wise chewing patterns and chi square test was performed to find out association of chewing habits with the progression of disease state. However, mean and standard deviation was calculated for quantitative. Findings were considered significant with a p-value of less than 0.05.

RESULTS

Of the total n=1009 subjects, 57.3% (n=578) were females and 42.7% (n=431) were males. The mean age of the sample (n=1009) were 42.79±1.31 years (range: 10-70 years). Moreover, 2.2% (n=22) of subjects were of ages below 25 years, 54.9% (n= 554) were within 26 to 50 years of age and about 42.1% (n= 433) were aged 51 years and above.
The subjects were divided into four groups according to usage of habits, first group was taking areca nut (AN) only, second group was taking areca nut plus betel quid (AN + BQ), third group was taking betel quid along with smoking (BQ + Smoking), while the fourth group had no chewing habit they were only smokers. Out of 1009, 21.8% (n=220) were in group 1 who were consuming AN only; 22.7% (n=229) in group 2 reported a habit of eating AN plus BQ; group 3: 32.8% (n=331) reported that they consumed BQ along with a smoking habit; while 22.7% (n=229) of the subjects in group 4 were smokers only.
Out of total n=1009 subjects, 22.5% (n= 227) were diagnosed with OSMF alone, 23.2% (n= 234) with OSMFCa while 54.3% (n=548) were diagnosed with OSCC without pre-existing OSMF. The descriptive analysis of chewing habits with the type of oral disease is described in table 1. The relationship of the type of oral habits and type of oral disease is represented in table 2.

Table 1: Descriptive analysis of oral habits and types of oral disease

Table 2: Association of oral habits and type of oral disease

DISCUSSION

In the current study we have reported the disease trend among chewers (users of areca nut, betel quid and tobacco), non-chewers (i.e smokers only) and also among subjects who had a combination habit of chewing and smoking tobacco. Furthermore, we have found that subjects who were consuming either areca nut alone or habit of tobacco smoking; reported with increased numbers of oral sub mucous fibrosis as well as malignant transformation of oral sub mucous fibrosis. On the other hand, subjects who were consuming betel quid in combination with areca nut and betel quid in combination with smoking; reported with increased numbers of oral squamous cell carcinoma. We had found statistically insignificant association among the subjects who had habit of chewing betel quid along with areca nut and chewing betel quid along with smoking with progression of oral malignant conditions i.e OSMF, OSMFCa and OSCC.
Oral carcinogenesis is a progressive, multistage process in which genetic and phenotypic molecular markers are involved in enhancing the function of several proto-oncogenes, oncogenes by deactivating tumor suppressor genes, thus causing over activity of the growth factors and its cell surface receptors, which can lead to increase messenger signaling intra-cellularly and leads to increase release of transcription
factors. Thus oncogenes alone are not responsible for causing cancer however, genes having tumor suppressor activities can result in cellular phenotypic changes and these changes are responsible for increased cell proliferation, loss of cellular cohesion, are able to infiltrate in to local tissue so they can spread to distant sites.21
In current study we have found that smoking alone is the weakest cause for developing oral cancer as compare to combination of chewing tobacco habits. This finding is similar to the studies reported by Balaram P et al and Znaor A et al from India as well as in some case control studies reported by Bundgaard T et al and Madani et al.22-25 The reason is as chewing tobacco and its product may have a stronger effect than smoking tobacco because of the direct contact of the carcinogenic substances with the oral epithelium.
In this study we have found that chewing tobacco is strongly related to develop oral cancer. This finding is in corroboration with aforementioned studies.22,23 The reason was may be the duration of keeping the chewing tobacco and its products with in the oral cavity either with or without lime. Another similar finding was reported by Muwonge et al that smokeless tobacco users were at higher risk of
developing oral cancer, along with some other oral abnormalities as compare to smokers alone.26 Moreover similar to current studies evidences have suggested that chewing betel quid with tobacco, tobacco consumed by chewing with lime, betel quid with or without
tobacco, and areca nuts are human carcinogens.27,28 However current study has reported that in addition to the carcinogenicity of these products, combination of chewing tobacco habits are more potent cause of oral cancer among Pakistani population.
It has been suggested that both dental and medical health care professionals should work together for initiation of chewing tobacco cessation awareness among high risk groups. There is also a need for designing and implementation of polices; regarding either to reduce availability or increase taxation over all kinds of tobacco products. In addition, mass media campaigns will be needed to spread awareness about the harmful effects of tobacco and its derivatives. Strategies suggested for the control of betel quid may include: elimination of carcinogenic constituents from the products as well as motivating teenagers through public education and law enforcement not to take up these habits while enhancing the intake of antioxidant containing green vegetables and beta-carotene.

CONCLUSION

Current study concluded that subjects who have combined habits of consuming betel quid with areca nut and/or betel quid with smoking were at highest risk of initiation and progression of oral cancer. However, smoking tobacco only was found the weakest risk factor for developing oral cancer.

CONFLICT OF INTEREST

None to declare

REFERENCES

  1. World Health Organization. Latest global cancer data: Cancer burden rises to 18.1 million new cases and 9.6 million cancer deaths in 2018. https://www.who.int/cancer/PRGlobocanFinal.pdf
  2. Nagai H, Kim YH. Cancer prevention from the perspective of global cancer burden patterns.J Thorac Dis.2017;9:448-51 https://doi.org/10.21037/jtd.2017.02.75
  3. Gupta N, Gupta R, Acharya AK et al.Changing trends in oral cancer-a global scenario.Nepal J Epidemiol.2016;6:613-19.
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  6. Bornigen D, Ren B, Pickard R, Li J, Ozer E, Hartmann EM et al. Alterations in oral bacterial communities are associated with risk
    factors for oral and oropharyngeal cancer. Scientific reports. 2017; 7(17686): 1-13. www.nature.com/scientific reports. https://doi.org/10.1038/s41598-017-17795-z
  7. World Health Organization. WHO Global Report: Mortality Attributable to Tobacco, WHOGeneva.2012 (http://www.who.int/tobacco/publications/surveillance/rep_mortalit y_attributable/en/, accessed 7 March 2018).
  8. Niaz K, Maqbool F, Khan F,Bahadar H, Hassan FI.Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution
    to oral cancer. Epidemiol Health. 2017; 39:1-11. https://doi.org/10.4178/epih.e2017009
  9. Kumar M, Nanavati R,Modi TG, Dobariya C. Oral cancer: Etiology and risk factors: A review.J Can Res Ther.2016;12:458-63. https://doi.org/10.4103/0973-1482.186696
  10. Mahapatra S, Kamath R, Shetty BK,Binu VS. Risk of oral cancer associated with gutka and other tobacco products: A hospital-based
    case-control study. J Cancer Res Therapeut. 2015;11:199-203 https://doi.org/10.4103/0973-1482.143332
  11. World Health Organization. The global tobacco crisis. WHO report on the global tobacco epidemic, 2008.The MPOWER package. Geneva, 2008;14-15. http://www.whi.int/tobacco/mpower/en/.
  12. Gupta B, Newell W.J. Systematic review and Meta-analysis of association of smokeless tobacco and of betel quid without tobacco
    with incidence of oral cancer in South Asia and Pacific. PLOS One. 2014;9:e113385. https://doi.org/10.1371/journal.pone.0113385
  13. World health organization. Tobacco control in Pakistan, 2015. https://www.who.int/tobacco/about/partners/bloomberg/pak/en/
  14. Anand R, Dhingra C, Prasad S, Menon I. Betel nut chewing and its deleterious effects on oral cavity. J Cancer Res Therapeut.2014;10:499-05
  15. Bile KM, Shaikh JA, Afridi HUR, Khan Y. Smokeless tobacco use in Pakistan and its association with oropharyngeal cancer. Eastern
    Mediterranean Health. 2010;16:24-30 https://doi.org/10.26719/2010.16.Supp.24
  16. Stanfill SB, Connolly GN, Zhang L, Jia LT, Henningfield JE, et al. Global surveillance of oral tobacco products: total nicotine, unionised nicotine and tobacco-specific N-nitrosamines. Tob Control.2011. 20:2. https://doi.org/10.1136/tc.2010.037465
  17. Herzog TA, Murphy KL, Little MA, Suguitan GS, Pokhrel P, et al. The betel Quid Dependence Scale: replication and extension in a Guamanian sample. Drug Alcohol Depend. 2014. 138: 154-160. https://doi.org/10.1016/j.drugalcdep.2014.02.022
  18. World Bank. Curbing the epidemic: Government and economics of tobacco control. Geneva: world Bank, 1999. https://doi.org/10.1596/0-8213-4519-2
  19. WHO sample size calculator. Available from: URL: http://www.who.int/chp/steps/resources/sampling/en.
  20. Haider SM, Merchant AT, Fikree FF, Rahbar MH. Clinical and functional staging of OSMF. Br J Oral MaxillofacSurg. 2000;38: 12-5. https://doi.org/10.1054/bjom.1999.0062
  21. 16. Jain A. Molecular pathogenesis of oral squamous cell carcinoma.In: Squamous cell carcinoma – Hallmark and treatment modalities. IntechOpen; 2019. p. 1-15. https://doi.org/10.5772/intechopen.85650
  22. Balaram P, Sridhar H, Rajkumar T, Vaccarella S, Herrero R, Nandakumar A, et al. Oral cancer in southern India: The influence of smoking, drinking, paan-chewing and oral hygiene. Int J Cancer 2002;98:440-5. https://doi.org/10.1002/ijc.10200
  23. Znaor A, Brennan P, Gajalakshmi V, Mathew A, Shanta V, Varghese C, et al. Independent and combined effects of tobacco smoking, chewing and alcohol drinking on the risk of oral, pharyngeal and esophageal cancers in Indian men. Int J Cancer 2003;105:681-6. https://doi.org/10.1002/ijc.11114
  24. Bundgaard T, Wildt J, Frydenberg M, Elbrønd O, Nielsen JE.Casecontrol study of squamous cell cancer of the oral cavity in Denmark. Cancer Causes Control 1995;6:57-67. https://doi.org/10.1007/BF00051681
  25. Madani AH, Dikshit M, Bhaduri D. Risk for oral cancer associated to smoking, smokeless and oral dip products. Indian J Public Health 2012;56:57-60. https://doi.org/10.4103/0019-557X.96977
  26. Muwonge R, Ramadas K, Sankila R, Thara S, Thomas G, Vinoda J, et al. Role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer in Trivandrum, India: a nested case-control design using incident cancer cases. Oral Oncol 2008;44:446-54. https://doi.org/10.1016/j.oraloncology.2007.06.002
  27. Sudha S, Mythili B, Balachandar V. Mixture of betel leaf, areca nut and tobacco chewing is a risk factor for cytogenetic damage in construction workers from south India. Braz J Oral Sci 2009;8: 145-48.
  28. Niaz K, Maqbool F, Khan F, et al. . Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer. Epidemiol Health. 2017;39:e2017009. https://doi.org/10.4178/epih.e2017009

  1. Associate Professor, Department of Science of Dental Materials, Ziauddin College of Dentistry, Ziauddin University.
  2. Associate Professor, Department of Community & Preventive Dentistry, Ziauddin College of Dentistry, Ziauddin University.
  3. Consultant Surgeon in Carbondale, Department of Fellow in Bariatric Surgery, Carbondale Illinois, USA.
  4. Professor, Principal and Dean of Dental Sciences, Ziauddin College of Dentistry, Ziauddin University, Karachi.
    Corresponding author: “Prof. Dr. Mervyn Hosein” < mmh5617@gmail.com >

Association of Carcinogenic Oral Habits with Oral Squamous Cell Carcinoma

Nazish Fatima                BDS, MDS

Sidra Mohiuddin           BDS, MDS

Salim Hosein                 MBBS, DABGS

Mervyn Hosein               BDS, FDS RCSE, FDS RCS, FFD RCSI

OBJECTIVE: To determine the association among betel nut, betel quid or smoking alone, and betel quid combined with smoking in subjects reporting with oral sub mucous fibrosis, oral submucous fibrosis with malignant transformation in to cancer and oral squamous cell carcinoma.
METHODOLOGY: An analytical cross sectional, multi centric study of n = 1009 cases collected through non-probability convenience sampling. These n=1009 subjects were subdivided into four groups: group 1, who consumed areca nut only; group 2, who chewed betel quid along with areca nut; group 3, who used betel quid and smoked; and group 4, who had no chewing habits history but were smokers. These changes were further confirmed with the help of biopsy reports of the subjects with OSMFCa and OSCC. Chi square test was performed to find out association of chewing habits with the progression of disease state. Level of significance was kept at p<0.05.
RESULTS: The mean age of the sample (n=1009) were 42.79±1.31 years (range: 10-70 years). Statistically significant difference was (p<0.00) found among all four groups in terms of initiation, propagation and progression of oral squamous cell carcinoma. Furthermore, statistically insignificant difference (p=0.40) was found between group 2 and group 3 as similar number of cases (OSCC) was seen among them.
CONCLUSION: Current study concluded that patients who have combined habits of chewing betel quid with areca nut and betel quid with smoking were at highest risk of initiation and progression of oral cancer. However, smoking cigarettes alone was the weakest risk factor.
KEYWORDS: Betel quid; Areca nut; Smoking; Oral squamous cell carcinoma, Oral submucous fibrosis
HOW TO CITE: Fatima N, Mohiuddin S, Hosein S, Hosein M. Association of carcinogenic oral habits with oral squamous cell carcinoma. J Pak Dent Assoc 2021;30(1):29-33.
DOI: https://doi.org/10.25301/JPDA.301.29
Received: 07 February 2020, Accepted: 09 September 2020
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Accuracy of Working Length Measured by Apex Locator and Digital Radiography

Ghulam Ishaq Khan                   BDS

Muhammad Talha Khan            BDS, FCPS

Saroosh Ehsan                          BDS, FCPS

Anam Fayyaz                             BDS, FCPS

Haider Amin Malik                     BDS, FCPS

Shafqat Hussain                         BDS, FCPS

OBJECTIVE: The objective of this study was to compare the measurements of electronic and radiographic method of working lengths calculation with actual working length of root canals. Precise working length determination is the most important part for successful root canal procedure. The most commonly used methods to determine the working length in root canal treatment are radiography and electronic apex locator.
METHODOLOGY: A cross sectional study was done over a period of 06 months in the Department of Operative Dentistry, Fatima Memorial Hospital, Lahore. Sixty patients who were recommended extraction of their premolar teeth with sixty canals were selected by convenience sampling. The Root ZX* apex locator was used to determine electronic working length exactly identifying the apical constriction. Reference points were identified and radiographic working length were determined 1mm short of radiographic apex. The teeth were extracted along with file cemented before extraction inside root canal. The actual length of the root canal was then calculated using the same files and reference point with 3.5X magnification. Pearson chisquare test was applied to compare the apex locator and digital radiographic measurement with actual working length.
RESULTS: The Root ZX® apex locator was 95% accurate to identify the apical constriction as compared 70% accuracy given by radiographs within 0.5 mm of the apex.
CONCLUSION: Electronic apex locator was more accurate as compared to digital radiography in working length determination.
KEYWORDS: Working length (WL), Electronic apex locators (EAL), Radiographic working length(RWL), Apical constriction (AC)
HOW TO CITE: Khan GI, Khan MT, Ehsan S, Fayyaz A, Malik HA, Hussain S. Accuracy of working length measured by apex locator and digital radiography. J Pak Dent Assoc 2021;30(1):24-28.
DOI: https://doi.org/10.25301/JPDA.301.24
Received: 19 October 2020, Accepted: 11 December 2020

INTRODUCTION

Root canal treatment (RCT) is the most commonly used method to treat pulpal and periapical infections. Root canal treatment is a multiple visit procedure which includes access cavity preparation, creating the patency of root canals, working length determination, pulp removal, biomechanical canal preparation, obturation and restoration of broken coronal tooth.1
Working length (WL) determination is the crucial step for root canal treatment and is described as the distance from coronal fixed point to the apical constriction of root canal space.2,3 Moreover, apical constriction (AC) is an important land mark at apical part of root canal space of tooth. Working length can be calculated by paper points, tactile sensation, conventional radiographs, digital radiographs and electronic apex locator. Working length calculation is important part of root canal procedure.
Digital radiography employs intraoral sensor in place of conventional radiographic film with added advantages of less radiation dose, good image quality, no processing time along with magnifying and storing digital image.3 On the other hand, locating apical constriction clinically and radio graphically is tough due to its variable shape and position.2 Mostly apical constriction is located 0.5 to 2.0 mm from apical foramen.3,4 The cleaning, shaping and obturation of the root canal system cannot be achieved precisely without determining accurate working length of tooth.5-8 However, there are many limitations in using digital radiography for working length calculation. The precision is mainly affected by magnification of image, radiographic analysis errors, location of apical foramen, curvature of root and two dimensional picture that is often masked by surrounding anatomic structures.9
The use of electric current to determine working length was first reported by Custer.8 According to Suzuki et al the electrical resistance between the oral mucosa and periodontal ligament was, a constant value of, 6.5 kilo ohms and this can be used to determine the accurate position of apical constriction where the canal ends at the periodontal ligament.10
In modern endodontic practice electronic apex locator is a useful device for exact position of apical constriction. Kim at al found it to be 84% accurate in determining the location of apical constriction. Acosta et al compared four different apex locators and found 81% to 89% success rate in locating apical constriction. However, there are many limitations of apex locator with regard to metallic restorations, in patients having heart pace maker, display varying and unstable reading and is expansive.11
Cianconi L.et al study compared the accuracy of three different types of electronic apex locators and digital radiography working lengths and the result was 84% accuracy with apex locator and with digital radiography 51% accuracy within ±0.5mm of apical foramen.9 In spite of modern technology and good technique, there
is still dispute of the ideal technique for measurement of WL during RCT. The apical constriction of root canal cannot be precisely determined clinically due to anatomical variations. According to some studies radiographs are more accurate while others support the apex locator. There is also enough literature showing that there is no statistical difference between the two methods.10-12 Mostly previous studies3-6 are done with conventional radiography only and most studies are in vitro. Therefore, the aim of study was to conduct a comparative in vivo study to determine the accuracy in working lengths by apex locator and digital radiography and to compare their accuracy with the actual working length after extraction so that a better modality can be selected for good clinical outcome.

METHODOLOGY

This study was approved from ethical review board of institution via letter no FMH-03-2020-IRB-751-M before the start of study. This cross sectional study was done on 60 patients of both sexes aged 20-60 years requiring extraction of their maxillary and mandibular premolar teeth for periodontal, prosthetic and/or orthodontic purposes. All teeth had fully formed apices of root. Teeth with root resorption, metallic restorations and previously RCT treated were not included in the study. The patients were selected by convenience sampling from the Operative Dentistry department of Fatima Memorial Hospital, Lahore. Sample size of 60 cases was calculated with 95% confidence, 13% margin of error and taking expected percentage of accuracy of working length measured by digital radiography i.e. 51% in teeth intended for extraction. Before starting study Informed consent was taken from all the patients. A detailed medical and dental history was documented. After giving local anaesthesia, endodontic access cavity was prepared using high speed hand piece with a number (04) and (02) round tungsten carbide bur. Coronal reference point was fixed and all pulp tissue was removed using spoon shaped excavator and barbed broaches #15 and then #20. After irrigation of the root canal, paper point was used to dry the canal. Apex locator WL (ALWL) was calculated by digital reading with manual K File No. 20 from coronal fixed point to apical constriction by using Dentaport Apex Locator (J. Morita Co, Tustin, CA). Radiographic WL (RWL) was calculated before extracting the tooth by inserting the No
20 K-file with fixed coronal reference point to 1 mm short of radiographic working length by parallel technique using periapical X-ray (Kodak Digital System). Access opening was packed with GIC, Ketac Molar Easy Mix (3M ESPE) with the files present in canals, without removing handles of files. The resident of maxillofacial surgery department was requested to extract the tooth atraumatic ally, which was later disinfected, dried and labelled. Actual working length (AWL) was calculated by longitudinal sectioning of apical 1/3 of root with a diamond tapered fissure diamond bur till the file present in the canal became visible. The distance of the file tip from fixed coronal point to anatomic apical constriction was calculated in millimetres with the help of scale and endodontic loupes (CE Dental Surgical Binocular Loupes 3.5X320mm). Actual working length was taken as gold standard to determine the accuracy of electronic apex locator and digital working length measurements.

Criteria for accuracy of determined working length i.e. the Accurate working length (AWL) for ALWL and RWL respectively:

Data analysis was completed by using SPSS version 20 for the analysis. Descriptive statistics of mean and standard deviation were computed for quantitative variables e.g. working length in millimetre and age. Frequency and percentages were calculated for gender. Accurate working length (AWL) was calculated for
radiography readings within 0.5 mm of actual working length and for apex locator readings, exactly at apical constriction. Data was stratified for age and gender to address the effect modifier. Chi-square test was used post-stratification to check the level of significance. The age group were divided into four group (g1=20-30, g2=31-40, g3=41-50, g4=51-60) for the accuracy of working length for both ALWL and RWL and to know effect of this variable on the working length determination.

RESULTS

Total 60 single rooted teeth both maxillary and mandibular premolars from 60 patients were included in the study. There were 35 (58.33%) male participants and 25 (41.67%) female participants in the study. The mean age of the patients in this study was 37.8 ± 8.55. The mean ALWL was 20.88±1.61, RWL was 21.45±1.73 and AWL was 20.87±1.57. Table 1 shows ALWL and RWL falling into the accurate category.

Table1 : Accuracy of working length by radiograph and apex locator

The results were also formulated for gender wise accuracy of both radiography and apex locator readings. Table 2 demonstrates the data. The results demonstrated no statistically significant association between age and ALWL, p=0.368, and RWL, p=0.775, respectively, when they were compared with AWL.

Table 2: Gender wise accuracy of both radiography and apex locator readings

The results were also formulated for age groups, G1=20- 30, G2=31-40, G3=41-50, G4=51-60, and accuracy of both ALWL and RWL respectively. The result p=0.446 related that there was no statistically significant association between age groups when RWL was compared with AWL. While for age and ALWL compared to AWL, p = 0.021 showed
statistically significant association. The result showed that the age of the patient had an effect on accuracy of apex locator.

DISCUSSION

Determining AWL is a crucial step in root canal treatment. The success of root canal treatment depends on accurately determining the working length. According to most dentists the apical constriction is apical end of root canal space. All the root canal preparation and obturation should be restricted to apical constriction for good long-term prognosis of treatment. Precisely locating the apical constriction is difficult because of its variable shape and position. According to most of the studies apical constriction is 0-3 mm with in radiographic apex.19
The results of this study confirmed the results of previous studies which revealed that electronic apex locator can accurately determine the apical constriction in 90% of canals.13-19 These results agree with the study of Schweiz20 who also compared radiographic and electronic working lengths and results showed 77.2% of the measured radiographic lengths within 0.5mm of the apical constriction. The results of electronic apex locator were <0.5mm of the apical constriction 98.5% of the time. However, the results of accuracy of apex locators were more reliable (95 % in this study) than the radiographic accuracy (70% in this study).
These results are alike with the results of El Ayouti who established that the radiographic working length measurements were extended in 56% of the premolars under examination.21 The results of that study showed that the use of Root ZX apex locator decreased the overestimation of working length of the premolars to 21%. This may be due to location of apical constriction laterally in 78% to 93% of the cases. The result of another study by Pineda F. et al also showed that electronic working length by apex locator were more precise in determining the apical constriction than the digital radiograph.22
The results of this study showed that if a file is placed at the radiographic apex, its tip will, in most cases, cross the apical foramen and if root canal filling is done, it will be over obturated in almost all the cases. If the file was set 1mm short of the radiographic apex the accuracy was 70% within 0.5 mm of actual working length and almost 98% within 1.0 mm actual working length. Therefore, the obturation of root canal within 2mm of radiographic apex are said to be satisfactory from clinical point of view. With the increasing age, certain physiological changes occur in root apex due to cellular cementum deposition. The successive deposition of cementum is responsible for change in root morphology in term of diameter, size and position of apical foramina and may affect the accuracy of radiography and
apex locator with respect to root apex.24-27 The RWL showed an average 70% accuracy in different age groups, meaning that there is change in position of apical constriction (AC) when the measurements were taken from root apex. These findings were inconsistent with the studies of Kuttler showing that up to 80% teeth having deviated from major apical foramina. Another study by Levy and Glatt stated that 66.4% deviation percentage of apical foramina.25 Apex locator in age groups shows 88.3% accuracy with p-value of 0.021 which was statistically significant. The reason can be due to electronic apex locator ability to precisely measure the apical constriction and working length measured by electric signal. The accuracy of radiograph mostly relies on assessment of working length with respect to root apex and position of apical foramina may vary its position with chronological age.
Therefore, the result of the study shows greater accuracy of apex locator readings when compared to accuracy of radiographic readings. The limitations of this study were that sample size was small and after extraction instead of microscope only endodontic loups and scale were used to measure the distance of the file tip from fixed coronal point to anatomic apical constriction

CONCLUSION

From clinical standpoint, the Root ZX apex locator showed 95% accuracy to determine actual working length. Radiographs showed 70% accuracy within ±0.5mm of actual working length and 98% accuracy within 1.0mm of actual working length. Within the limitations of the study it is suggested that apex locator can be a better treatment strategy for determining working length for RCT procedures. The combined use of electronic apex locator and radiographs can enhance the accuracy of working length determination and length control throughout the root canal treatment.

CONFLICT OF INTEREST

None to declare

REFERENCES

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  1. Demonstrator, Department of Operative Dentistry, Bacha Khan Dental College, Mardan.
  2. Senior Demonstrator, Department of Operative Dentistry, Fatima Memorial Hospital, Lahore.
  3. Associate Professor, Department of Operative Dentistry, Fatima Memorial Hospital, Lahore.
  4. Assistant Professor, Department of Operative Dentistry, Lahore Medical and Dental College, Lahore.
  5. Senior Demonstrator, Department of Prosthodontics, Fatima Memorial Hospital, Lahore.
  6. Assistant Professor, Department of Prosthodontics, Rehman College of Dentistry, Peshawar.
    Corresponding author: “Dr. Muhammad Talha Khan” < dr_talhakhan@hotmail.com>

Accuracy of Working Length Measured by Apex Locator and Digital Radiography

Ghulam Ishaq Khan                   BDS

Muhammad Talha Khan            BDS, FCPS

Saroosh Ehsan                          BDS, FCPS

Anam Fayyaz                             BDS, FCPS

Haider Amin Malik                     BDS, FCPS

Shafqat Hussain                         BDS, FCPS

OBJECTIVE: The objective of this study was to compare the measurements of electronic and radiographic method of working lengths calculation with actual working length of root canals. Precise working length determination is the most important part for successful root canal procedure. The most commonly used methods to determine the working length in root canal treatment are radiography and electronic apex locator.
METHODOLOGY: A cross sectional study was done over a period of 06 months in the Department of Operative Dentistry, Fatima Memorial Hospital, Lahore. Sixty patients who were recommended extraction of their premolar teeth with sixty canals were selected by convenience sampling. The Root ZX* apex locator was used to determine electronic working length exactly identifying the apical constriction. Reference points were identified and radiographic working length were determined 1mm short of radiographic apex. The teeth were extracted along with file cemented before extraction inside root canal. The actual length of the root canal was then calculated using the same files and reference point with 3.5X magnification. Pearson chisquare test was applied to compare the apex locator and digital radiographic measurement with actual working length.
RESULTS: The Root ZX® apex locator was 95% accurate to identify the apical constriction as compared 70% accuracy given by radiographs within 0.5 mm of the apex.
CONCLUSION: Electronic apex locator was more accurate as compared to digital radiography in working length determination.
KEYWORDS: Working length (WL), Electronic apex locators (EAL), Radiographic working length(RWL), Apical constriction (AC)
HOW TO CITE: Khan GI, Khan MT, Ehsan S, Fayyaz A, Malik HA, Hussain S. Accuracy of working length measured by apex locator and digital radiography. J Pak Dent Assoc 2021;30(1):24-28.
DOI: https://doi.org/10.25301/JPDA.301.24
Received: 19 October 2020, Accepted: 11 December 2020
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