Salivary Matrix Metalloproteinase (MMP)-1 as Non-Invasive Tool for The Diagnosis of Oral Squamous Cell Carcinoma (OSCC)

Sana Jafar Zaidi                BDS, M.Phil

Nabeela Riaz                     BDS, FCPS, MCPS

Asifa Iqbal                         BDS, M.Phil

Ayyaz Ali Khan                 BDS, MSc, PhD

OBJECTIVE: To determine the diagnostic accuracy of salivary MMP1 as non-invasive diagnostic biomarker of OSCC through conventional sandwich ELISA technique. Analytical cross-sectional study.
METHODOLOGY: Individuals with clinical suspicion for OSCC (IWCS-OSCC) were included in the study after fulfilling selection criteria. Saliva samples were collected from IWCS-OSCC. To confirm OSCC, the patients were referred for biopsy. After definitive diagnosis on biopsy, patients were labeled OSCC positive or OSCC negative. The colorimetric sandwich-ELISA test was performed on saliva samples to measure the level of MMP1. Data was entered in “Statistical Package for the Social Sciences (SPSS) -16” and levels of MMP1 were correlated with the biopsy status of patient (OSCC positive or OSCC negative).
RESULTS: Our sample included twice as many males as females (2.1:1) and a wide age range of 22-77years with median age of 50yrs. Of all the IWCS-OSCC 85% were OSCC +ve and 15% were OSCC-ve. Diagnostic accuracy was measured as; Area under curve (AUC) = 0.623, Sensitivity (Sn) = 50%, Specificity (Sp)= 83.3%, Positive predictive value (PPV)= 94.4%,  Negative predictive value (NPV)= 22.7%
CONCLUSION: MMP1 as detected by conventional sandwich-ELISA technique is not proven as an accurate diagnostic biomarker of OSCC.
KEY WORDS: OSCC; MMP1; IWCS-OSCC; Sandwich-ELISA
HOW TO CITE: Zaidi SJ, Riaz N, Iqbal A, Khan AA. Salivary matrix metalloproteinase (MMP)-1 as non-invasive tool for the diagnosis of oral squamous cell carcinoma (OSCC). J Pak Dent Assoc 2021;30(1):18-23.
DOI: https://doi.org/10.25301/JPDA.301.18
Received: 20 July 2020, Accepted: 01 October 2020

INTRODUCTION

OSCC is getting global attention for its increasing incidence in youngsters.1 On a universal ranking it is the 6th commonest malignancy.2 In Pakistan, it is the 2nd commonest cancer in individuals more than 15 years of age.3 In routine, approaches to diagnose OSCC include adequate clinical examination (CE) followed by histological investigation of suspicious sites but they are not efficient to diagnose OSCC at an earlier stage.4 Although, biopsy is considered as gold standard but it is a time consuming5 and site specific procedure.6
Other issue associated with incisional biopsy is increased chance of metastasis due to breakage in tissue barrier.7 In addition to it, high-risk areas with DNA mutation are not always evident on histopathology. So, these factors increase the need of more efficient diagnostic marker to prevent late and missed diagnosis of OSCC.8 Salivary detection of diseases has advantage of non-invasiveness, convenience and less discomfortness. These factors make saliva as an efficient medium for the detection of OSCC markers. Nosratzehi observed the levels of MMP1 and other MMPs in saliva of OSCC patients and came to a conclusion that further research is necessary to determine relation between MMPs and OSCC.9 MMP1 is a soluble type of interstitial collagenase responsible for the degradation of fibrillar- collagen-I, II and III.9
In 2016, salivary MMP1 was introduced in “Taiwan’s Oral Cancer Screening Program” as a part of non-invasive screening of OSCC.10 Stott-miller first time observed high levels of MMP1 proteins in saliva of OSCC patients.11 Purpose of this study was to determine diagnostic accuracy of salivary MMP1 as non-invasive diagnostic biomarker of OSCC in Pakistani population by using conventional Colorimetric MMP1 sandwich-ELISA Kit. Saliva was chosen: 1) to identify lesions with suspicion of OSCC at sites difficult to approach for biopsy and 2) to prevent incisional biopsy induced chances of metastasis 3) to avoid complications associated with medically compromised individuals where risks after surgical
intervention were high. MMP1 was chosen for its emergence as exceptionally strong biomarker to separate OSCC cases from controls in study carried out by stott-Miller.11 In current study Colorimetric MMP1 sandwich ELISA Kit was used to detect MMP1 in Pakistani population with the aim of introducing it in community for screening of OSCC
if found accurate for diagnosis.

METHODOLOGY

In this analytical cross-sectional study, IWCS-OSCC12 were selected after ethical approval by IRB, letter No.350/RC/KEMU, from Oral & Maxillofacial Surgery (OMFS) Department, Mayo Hospital, Lahore after fulfillment of selection criteria during the period of 6 months. Out of one twenty IWCS-OSCC only eighty were included in the
study by computer generated random number table, using SPSS-16 software. The patients were then referred to Oral & Maxillofacial surgeon for biopsy. Histological confirmation
via biopsy was considered as “gold standard” internationally for the confirmation of OSCC.6 So, the patients showing histopathological findings of OSCC were labelled “OSCC
positive” and the patients without histopathological findings of OSCC were labelled “OSCC negative”. Both male and female subjects of age range between 20yrs – 75yrs, visited Oral and Maxillofacial Surgery Department, Mayo Hospital, Lahore and showing clinically suspicion for OSCC, were included in study. Patients who were not willing to become part of research and showing following conditions with overexpression of MMP1 were excluded from the study.
1- Endometriosis
2- Pyogenic granuloma
3- Pyoderma gangrenosum
4- Decubitus ulcers
5- Stasis ulcers
6- Colorectal adenocarcinoma.13-15
Pyogenic granuloma was excluded on the bases of history, CE and histopathological investigation. Colorectal carcinoma was excluded on the bases of history, CE & FOBT (sensitivity
>94.1% and specificity =87.5%).16 Endometriosis was excluded in women < 40yrs of age, on the bases of history of dysmenorrhea (NPV=84.2%) but all the women with age
>40yrs were included in the study because of very low prevalence of endometriosis after 40.17,18 After informed consent, demographic data, as mentioned in “results” section of article, is collected from patients. After informed consent, patients were advised not to take food for at least 1 hour before sample collection. Unstimulated saliva was then collected by asking patients to spit into a centrifuge tube. After collection, samples were stored at 4°C for 2 hours. Samples were then centrifuged for 10 minutes at 1,300 x g in centrifuge machine and transferred into cryovials for storage at -80°C.11 Sandwich ELISA was performed on saliva samples through MMP1 sandwich-ELISA kit by using microtiter plate washer and reader machines.11,19 The ELISA protocol was followed according to the “user guide” provided along with the kit by the trained staff. All stored samples and kits were brought to room temperature before performing the ELISA. All the samples were pre-diluted to 80 folds before performing ELISA.Preparation of standards.
Fifty Microliter of standard diluent was added in each tube. Hundred Microliter of standard (1350 g/L) was Pipetted out in first-tube. From first-tube 100 l was transferred
to second-tube. Then 50 l was taken out from 2nd-tube into 3rd -tube and two more serial dilutions were prepared from 3rd-tube as below in fig-1.

Fig-1: Protocol to Prepare standard solutions

Blank well was set separately (sample & HRP-Conjugate reagent are not added in blank comparison well but other each step operation is same). Forty Microliter of sample diluent was added to testing sample well; 10 l of sample to be tested was added (sample final dilution is 5-fold) and mixed gently. Care was taken not to touch the well wall as far as possible. After covering the wells the plate was incubated at 37°C for half an hour. Thirty-fold diluted wash solution was prepared by diluting wash solution in distilled water. The adhesive strip was uncovered and liquid was discarded. Pipetted washing buffer to every well, still for 30s then drained, repeated 5 times. Then the 50 l enzyme, HRP-Conjugate reagent, was added to each well, except in the blank well. The plate was incubated at 37°C for half an hour. Again pipetted washing buffer to every well, still for 30s then drained, repeated 5 times. Then 50 l of Chromogen Solution A and 50 l of Chromogen Solution B was added to each well and light exposure was avoided for 15 minutes at 37°C. Then the reaction was
stopped by adding 50 l of “stop solution” to each well (the blue change to yellow). The plate was placed in microplate reader and absorbance (optical density/ OD) was read at 450nm after pipetting “stop Solution” within 15min. “Microsoft office Excel” was used for the calculations of ELISA test. Blank correction was done (OD of the blank well was subtracted from the OD of all wells). Then the OD values and standard concentrations were entered in Excel file. Using “graph” option, standard curve was generated  taking OD values on vertical axis and respective standard concentrations on horizontal axis as shown in fig-2. “Straight line regression” was applied on the standard-curve. By using the Linear-regression equation, y=mx+b (m= slop, x= value on x-axis, y=value on y-axis, b= intercept), “sample concentrations” of MMP1 were calculated after putting their respective OD values in equation.

Fig-2: Standard curve


Demographic profile, histopathological findings on biopsy report and, ELISA results after log-transformation using Microsoft Excel were transferred to SPSS-16. Receiver operating characteristic (roc) curve was drawn to measure the cut-off value of MMP1 Concentrations for 80 samples of IWCS-OSCC and it was observed to be 44977.78 g/l or 44977780 pg/ml (log-transformed value=7.65 pg/ml) as shown in Fig-3. These values of MMP1 concentrations above or equal to cut-off value were labeled as Positive for OSCC and the values below the cut-off value were labelled as Negative for OSCC.

Fig-3: Cutt-off value of Salivary MMp1 for edetection of OSCC

Diagnostic accuracy of salivary MMP1 was measured in terms of AUC (as shown in Fig-4), Sn, Sp, PPV and NPV. Cross-tabulation was generated between histopathological diagnosis (HD) based OSCC +ve and OSCC -ve patients and salivary diagnostic test (SDT) based OSCC +ve and

Fig-4: ROC of Salivary MMP-1

OSCC -ve patients, then the Pearson Chi-Square test was applied to find out p-Value for the association between HD and SDT.

RESULTS

Of all the IWCS-OSCC, 85% were OSCC positive and 15% were OSCC negative upon biopsy. In total 70% males and 30% females participated in research. OSCC was found to be more common in males than females with ratio of 2.3:1 Mean age of IWCS-OSCC, OSCC positive patients and OSCC negative patients was 52±13, 53±13yrs and 46±12 years respectively. For OSCC positive males, age ranged from 22yrs to 75yrs.For OSCC positive females, age ranged from 27yrs to 75yrs. Buccal mucosa was the most common site in our study while exophytic growth as the most common pattern. Most of the patients presented with stage IVa (62.2%) and WD grade (76.5%).
The observed AUC value indicates the poor diagnostic accuracy of salivary MMP1 levels in detection of OSCC as shown in table-1.

Table 1: AUC for salivary mmp1 concentration as diagnostic marker

Relationship between HD and SDT was found to be statistically significant, because p-value=0.032 is <0.05, as shown in table-2.

Table 2: cross-tabulation between histopathological diagnosis and salivary diagnostic test for OSCC.

DISCUSSION

We found sensitivity of MMP1-salivary diagnostic test as 50% & specificity as 83.3 % for the diagnosis of OSCC. These findings support the study conducted by Lallemant et al. who observed the detectable levels of salivary MMP1 mRNA in only 20% patients of Head & Neck Cancer (HNC) & 29% cases of OSCC. It was also noticed that 9 out of 10 cases of HNC showing detectable levels of salivary-mRNA, belonged to oral region as well as no any control showed detectable mRNA levels. These findings reveal lower sensitivity of this mRNA
marker in detection of OSCC but higher level of specificity upto 100% .20 Stott-Miller et al. in 2011, compared the salivary MMP1 levels of OSCC patients with the controls (while the controls were comprised of patients with non-premalignant or non-malignant lesions). He measured the cut-off value of MMP1 (log transformed) as 7.4pg/ml that was slightly lower than the cut-off value calculated by us that (log transformed value) was 7.65pg/ml.11 He noted the AUC for MMP1 as 0.845 (95% CI: 0.76-0.93). This value of AUC marks MMP1 as a good diagnostic indicator of OSCC.11 In our study, AUC was found to be 0.623 (95% Cl: 0.449-0.798) that depicts poor diagnostic accuracy of salivary MMP1 in detection of OSCC. Stott-Miller et al. used Chemiluminescent Sandwich-ELISA technique (SearchLight® multiplex sandwich-ELISA proteome array) for the quantification of salivary MMP1 while we used colorimetric ELISA technique for this purpose. Samineni et al. and Hatch et al. found Chemiluminescent technique of Sandwich ELISA as a more sensitive approach than
the colorimetric Sandwich-ELISA technique.21 So the main reason for this variation in results might be the difference in ELISA technique used for the quantitative analysis of
MMP1.
In 2020, Chang et al verified the role of salivary MMP1 in OSCC by using the new in-house technique of ELISA and found MMP1 as an efficient marker to separate OSCC patients from Non-OSCC patients. According to Chang et al, new MMP1 ELISA might be utilized as the supportive tool to detect and monitor OSCC.22 Current study showed significant association between salivary MMP1 and OSCC but the diagnostic accuracy was not adequate to use it as screening tool. One of the reason for this low diagnostic accuracy might be the conventional ELISA technique used to measure the Salivary MMP1.
In 2020, Nosratzehi et al compared means of salivary MMP1 levels in three study groups i.e. OSCC group, Oral lichen-planus group and healthy group and found no significant difference in means of salivary MMP1 levels among three groups9 that is contrary to our study showing significant association between MMP1 levels and OSCC. Current study shows the male-female ratio of OSCC as 2.1:1 that is higher than the ratio 1.4:1 presented by Minhas et al.3
This variation in both studies may be the due to the exclusion of females showing dysmenorrhea at age <40yrs to avoid inclusion of endometriosis cases in current study. On the other hand, Naseer et al. showed comparatively higher male-female ratio 3.7:1 than that of our study.23 In Pakistan where gender discrimination is obvious, females are dependent on males to seek for medical healthcare. Mostly they don’t travel alone. So, the approach to seek for oral healthcare is mostly influenced by the decision of male family members to bring them hospital for oral examination.12 Remarkably higher male-female ratio in study carried out by Naseer et al. might be the reflection of this fact and so far the reason of difference in findings of both researches.
The age we observed for OSCC patients, ranges between 22-75years. Khan et al. in 2015 found the frequency of OSCC in age-group <40yrs as 13.04%.24 We observed the frequency of this cancer in these patients as 19.1%. In our study, the prevalence of OSCC in young patients is found higher when compared with other Khan et al. Buccal-mucosa was the most common site of OSCC in current study that supports the finding of Mirza et al. showing buccal-mucosa as the most common site of OSCC in Pakistani population25 while it was also observed to be the most common site among NON-OSCC patients. Minhas et al. found tongue as the most common site in local-population of Lahore.3
The reason of this variation in results may be due to the difference in predisposing factors causing OSCC in different communities. Two recurrent cases of OSCC were noticed in
data and all showed positive SDT. This finding supports the relationship of recurrent cases with +ve SDT but this observation was not statistically significant. So, the result obtained might be by chance or the number of recurrent cases were not sufficient to depict statistically significant results. Stage, grade, site, clinical pattern, histopathological variant and age groups showed no statistically significant relationship with SDT (+ve or -ve).

CONCLUSION

As detected by colorimetric sandwich-ELISA kit, MMP1 is not proven as an accurate diagnostic biomarker of OSCC. Sensitivity (50%) of MMP1 levels is too low to be introduced as the screening tool for the detection of OSCC.

RECOMMENDATIONS

In future, latest techniques such as “Chemiluminescent sandwich-ELISA technique” or “bead-based sandwich-assay technique” with more accurate measuring potential should
be experimented to ensure the levels of salivary MMP1 in patients with or without OSCC. In addition, concomitant use of salivary MMP1 with other markers should be tested
to look for any improvement in diagnostic accuracy. Salivary MMP1 levels in different types of cancers should be tested to find out its general or specific association with cancers.

CONFLICT OF INTEREST

None to declare

REFERENCES

  1. Siddiqui IA, Khan H, Siddiqui R, Hafeez M, Dogar MR, Shahid W, et al. Oral cancer frequency at different sub sites presenting at a tertiary care hospital in karachi pakistan. Glob J Otolaryngol 2017;6:49-52. https://doi.org/10.19080/GJO.2017.06.555687
  2. Kumar M, Nanavati R, Modi TG, Dobariya C. Oral cancer: Etiology and risk factors: A review. J Cancer Res Ther. 2016;12:458-63 https://doi.org/10.4103/0973-1482.186696
  3. Minhas S, Kashif M, Altaf W, Afzal N, Nagi AH. Concomitantchemoradiotherapy-associated oral lesions in patients with oral squamous-cell carcinoma. Cancer Biol Med. 2017;14:176-82. https://doi.org/10.20892/j.issn.2095-3941.2016.0096
  4. Csosz É, Lábiscsák P, Kalló G, Márkus B, Emri M, Szabó A, et al. Proteomics investigation of OSCC-specific salivary biomarkers in a Hungarian population highlights the importance of identification of population-tailored biomarkers. PLoS One. 2017;12:e0177282. https://doi.org/10.1371/journal.pone.0177282
  5. Omar E. Current concepts and future of noninvasive procedures for diagnosing oral squamous cell carcinoma-a systematic review. Head
    Face Med. 2015;11:6. https://doi.org/10.1186/s13005-015-0063-z
  6. Vyas T. Biopsy of Oral Lesion-A Review Article. J Adv Med Dent Scie Res. 2018;6:27-35.
  7. Berwal V, Kiran S, Naik VG, Khandeparker RVS, Jain H. A review on oral mucosal biopsies with considerations on type of biopsy according to clinical diagnosis and handling of tissues. J Adv Med Dent Sci Res. 2014;2:102-07.
  8. Saxena S, Sankhla B, Sundaragiri KS, Bhargava A. A review of salivary biomarker: a tool for early oral cancer diagnosis. Adv Biomed
    Res. 2017;6:90. https://doi.org/10.4103/2277-9175.211801
  9. Nosratzehi T, Alijani E, Moodi M. Salivary MMP-1, MMP-2, MMP3 and MMP-13 levels in patients with oral lichen planus and squamous cell carcinoma. Asian Pac J Cancer Prev. 2017;18:1947-51. https://doi.org/10.1186/s13104-020-05135-w
  10. Yu J-S, Chen Y-T, Chiang W-F, Hsiao Y-C, Chu LJ, See L-C, et al. Saliva protein biomarkers to detect oral squamous cell carcinoma in a high-risk population in Taiwan. Proc Natl Acad Sci U S A. 2016;113:11549-554. https://doi.org/10.1073/pnas.1612368113
  11. Stott-Miller M, Houck JR, Lohavanichbutr P, Méndez E, Upton MP, Futran ND, et al. Tumor and salivary matrix metalloproteinase levels are strong diagnostic markers of oral squamous cell carcinoma. Cancer Epidemiol Biomarkers Prev. 2011;20:2628-36. https://doi.org/10.1158/1055-9965.EPI-11-0503
  12. Basharat S, Shaikh BT, Rashid HU, Rashid M. Health seeking behaviour, delayed presentation and its impact among oral cancer patients in Pakistan: a retrospective qualitative study. BMC Health Serv Res. 2019;19:715. https://doi.org/10.1186/s12913-019-4521-3
  13. Teixeira CR, Bonotto ML, Lima JP, Figueiredo LF, Conrado L, Frasca C. Clinical impact of the immunochemical fecal occult blood test for colorectal cancer screening in Brazil. Ann Gastroenterol. 2017;30:442-45. https://doi.org/10.20524/aog.2017.0151
  14. Jiang X-F, Ding L, Tian Y, Han N, Li Z-Q. Interaction of STAT3 and RelB modulates MMP-1 in colon cancer. Chem Biol Interact. 2018;293:94-9. https://doi.org/10.1016/j.cbi.2018.07.017
  15. Rydlova M, Holubec Jr L, Ludvikova Jr M, Kalfert D, Franeková J, Povysil C, et al. Biological activity and clinical implications of the matrix metalloproteinases. Anticancer Res. 2008;28:1389-97.
  16. Levi Z, Rozen P, Hazazi R, Vilkin A, Waked A, Maoz E, et al. A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med. 2007;146:244-55. https://doi.org/10.7326/0003-4819-146-4-200702200-00003
  17. Marasinghe JP, Senanayake H, Saravanabhava N, Arambepola C, Condous G, Greenwood P. History, pelvic examination findings and mobility of ovaries as a sonographic marker to detect pelvic adhesions with fixed ovaries. J Obstet Gynaecol Res. 2014;40:785-90. https://doi.org/10.1111/jog.12234
  18. Tahira T, Niaz A, Khalid A. Prevalence of Endometriosis in Patients with Subfertility. Ann Punjab Med Coll. 2019;13:226-28.
  19. Smriti K, Ray M, Chatterjee T, Shenoy R-P, Gadicherla S, Pentapati K-C, et al. Salivary MMP-9 as a Biomarker for the Diagnosis of Oral Potentially Malignant Disorders and Oral Squamous Cell Carcinoma. Asian Pac J Cancer Prev. 2020;21:233-38. https://doi.org/10.31557/APJCP.2020.21.1.233
  20. Lallemant B, Evrard A, Combescure C, Chapuis H, Chambon G, Raynal C, et al. Clinical relevance of nine transcriptional molecular markers for the diagnosis of head and neck squamous cell carcinoma in tissue and saliva rinse. BMC Cancer. 2009;9:370. https://doi.org/10.1186/1471-2407-9-370
  21. Kudryashova A, Mikhailova N, Borisova O. Comparison of colorimetric and chemiluminescent ELISA tests for detection of IgG antibodies to human EPO in the sera of experimental animals. Meditsinskaya Immunologiya. 2018;20:935-42. https://doi.org/10.15789/1563-0625-2018-6-935-942
  22. Chang Y-T, Chu LJ, Liu Y-C, Chen C-J, Wu S-F, Chen C-H, et al. Verification of Saliva Matrix Metalloproteinase-1 as a Strong Diagnostic Marker of Oral Cavity Cancer. Cancers. 2020;12:2273. https://doi.org/10.3390/cancers12082273
  23. Naseer R, Naz I, Mahmood MK. Frequency of delayed diagnosis of oral squamous cell carcinoma in Pakistan. Asian Pac J Cancer Prev. 2016;17:5037-40.
  24. Khan A, Khan S, Khitab U. Emerging clinical and histopathological spectrum of oral squamous cell carcinoma. J Khyber Coll Dent. 2015;5:12-5.
  25. Mirza D, Raza G, Basit A, Naqvi K, Ahmed S, Abassi ZA. Oral squamous cell carcinoma (OSCC) In Karachi city-A retrospective study. Pak Oral Dent J. 2016;36:391-94.

  1. Co-ordinator, Department of Dentistry, Institute of Advanced Dental Sciences and Research (IADSR).
  2. Head of Department, Department of Oral & Maxillofacial Surgery, Mayo Hospital, Lahore.
  3. Medical Officer, Department of Oral & Maxillofacial Surgery, Mayo Hospital, Lahore.
  4. Chairperson, Department of Dentistry, Institute of Advanced Dental Sciences and Research (IADSR).
    Corresponding author: “Dr. Sana Jafar Zaidi” < sanajaffar98@gmail.com >

Salivary Matrix Metalloproteinase (MMP)-1 as Non-Invasive Tool for The Diagnosis of Oral Squamous Cell Carcinoma (OSCC)

Sana Jafar Zaidi                BDS, M.Phil

Nabeela Riaz                     BDS, FCPS, MCPS

Asifa Iqbal                         BDS, M.Phil

Ayyaz Ali Khan                 BDS, MSc, PhD

OBJECTIVE: To determine the diagnostic accuracy of salivary MMP1 as non-invasive diagnostic biomarker of OSCC through conventional sandwich ELISA technique. Analytical cross-sectional study.
METHODOLOGY: Individuals with clinical suspicion for OSCC (IWCS-OSCC) were included in the study after fulfilling selection criteria. Saliva samples were collected from IWCS-OSCC. To confirm OSCC, the patients were referred for biopsy. After definitive diagnosis on biopsy, patients were labeled OSCC positive or OSCC negative. The colorimetric sandwich-ELISA test was performed on saliva samples to measure the level of MMP1. Data was entered in “Statistical Package for the Social Sciences (SPSS) -16” and levels of MMP1 were correlated with the biopsy status of patient (OSCC positive or OSCC negative).
RESULTS: Our sample included twice as many males as females (2.1:1) and a wide age range of 22-77years with median age of 50yrs. Of all the IWCS-OSCC 85% were OSCC +ve and 15% were OSCC-ve. Diagnostic accuracy was measured as; Area under curve (AUC) = 0.623, Sensitivity (Sn) = 50%, Specificity (Sp)= 83.3%, Positive predictive value (PPV)= 94.4%,  Negative predictive value (NPV)= 22.7%
CONCLUSION: MMP1 as detected by conventional sandwich-ELISA technique is not proven as an accurate diagnostic biomarker of OSCC.
KEY WORDS: OSCC; MMP1; IWCS-OSCC; Sandwich-ELISA
HOW TO CITE: Zaidi SJ, Riaz N, Iqbal A, Khan AA. Salivary matrix metalloproteinase (MMP)-1 as non-invasive tool for the diagnosis of oral squamous cell carcinoma (OSCC). J Pak Dent Assoc 2021;30(1):18-23.
DOI: https://doi.org/10.25301/JPDA.301.18
Received: 20 July 2020, Accepted: 01 October 2020
Download PDF

Clinical Correlation of Periodontal Disease Parameters with Crevicular Blood Glucose Levels

Quratulain Saeed                  BDS

Sarwat Memon                       BDS, FCPS

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

Sana Ikram                              BDS, M.Phil

OBJECTIVE: The purpose of the study was to assess relationship between the clinical periodontal parameters and gingival crevicular blood glucose levels and to determine the relation of severity of periodontitis with glycemic levels.
METHODOLOGY: A total number of 348 patients with chronic periodontitis participated in this cross-sectional study. After recording the number of teeth and plaque percentage, the participants were assessed for severity of periodontitis according to clinical periodontal parameters of periodontal pocket depth, gingival recession, clinical attachment loss and gingival bleeding. Gingival crevicular blood glucose was assessed via glucometers and random blood glucose levels were recorded for each patient. SPSS version 20 was used for data analysis. The correlation between periodontal parameters and glycemic levels was assessed via Pearson’s correlation coefficient. Multiple regression analysis was used to predict the association of glycemic levels with periodontal parameters. Analysis of variance was used to compare the glycemic levels in patients with mild, moderate and advance periodontitis.
RESULTS: Age, bleeding on probing and clinical attachment loss showed significant positive correlation while number of teeth showed significant negative association with crevicular blood glucose levels. Multiple regression analysis indicated that crevicular blood glucose has significant linear association with bleeding on probing and clinical attachment loss. Gingival crevicular blood glucose levels were found to be increasing with severity of periodontitis. There was significant difference (p<0.001) in mean glucose levels between mild, moderate and advanced periodontitis groups.
CONCLUSION: Clinical periodontal parameters and severity of periodontitis are strongly associated with increasing gingival crevicular blood glucose levels.
KEYWORDS: Blood glucose, inflammation, gingival bleeding, periodontitis
HOW TO CITE: Saeed Q, Memon S, Hosein M, Ikram S. Clinical correlation of periodontal disease parameters with crevicular blood glucose levels. J Pak Dent Assoc 2021;30(1):12-17.
DOI: https://doi.org/10.25301/JPDA.301.12
Received: 16 July 2020, Accepted: 19 September 2020

INTRODUCTION

Chronic Periodontitis is an inflammation of the tissues supporting the teeth, caused by a variety 76 of microorganisms, leading to periodontal ligament destruction and alveolar bone loss.1The chronic tissue damage is caused by bacterial by-products and inflammatory response produced by the host. Altered immune response
and compromised immunity also plays an important role in this destructive process.2
The major contributors to this compromised immunity are systemic diseases like diabetes mellitus, cardiovascular disorders and respiratory diseases, which are some of the known risk factors for periodontitis.3 Diabetes mellitus demonstrates a bidirectional relationship with periodontal inflammation. Past investigations suggest that periodontitis is progressively pervasive in patients with poorly controlled diabetes.4-6
Increased glycemic levels in diabetes leads to the production of advanced glycation end substances (AGEs), which compromise the capability of repair in periodontal tissues and favors periodontal inflammation.7
While chronic periodontitis negatively impacts diabetes by affecting the action of insulin and causes insulin resistance which worsens the metabolic condition.8 It has been reported that mechanical debridement of plaque and calculus in patients with periodontitis and maintaining adequate periodontal health, assists with controlling the periodontal inflammation and lowering the levels of HbA1c over the span of 6 months.9
The clinical parameters indicating chronic periodontitis include gingival bleeding while probing (Gingival crevicular blood) and clinical periodontal attachment loss of more than 3 mm.10 The diagnosis according to severity is made according to the degree of clinical attachment loss and periodontal pocket depth.11 Many studies have linked periodontal disease with diabetes but there is still not enough literature available on the relationship between clinical parameters of periodontitis and gingival crevicular blood glucose levels. Therefore, the objectives of the study were:

  1. To find the correlation between clinical periodontal attachment loss (CAL), gingival bleeding on probing, plaque percentage and tooth loss with crevicular blood glucose levels of the patients with chronic periodontitis.
  2.  To predict the association of various periodontal parameters with gingival crevicular blood glucose levels
  3. To evaluate the difference in gingival crevicular blood glucose values in mild, moderate and advanced periodontitis patients.

METHODOLOGY

The cross sectional study was conducted for the term of 6 months beginning from January 2019 to June 2019, among patients with periodontitis, visiting the department of Oral Medicine, Ziauddin Dental Hospital, Karachi. The study was accepted by Research Advocacy Committee, Ethical Review Committee and Board of Advanced Studies and Research Ziauddin University, under the reference number 0450818QPOM. Open Epi Version 3.0 was used to obtain the sample size of 348 participants, which was calculated according to 34.5% prevalence of periodontitis in Pakistan and 95% confidence interval.12 Male and female patients aged between 25 to 60 years, presenting with periodontitis (>3 mm clinical attachment loss and bleeding on probing) were included in the study, whereas, the exclusion criteria was history of hematological, cardiovascular, renal and hepatic diseases and the presence of purulent periodontal discharge.
After obtaining an informed consent and demographic details, patients were examined for number of teeth according to Federation Dentaire Internationale system of tooth numbering.13 The study included examination of 28 teeth (3rd molars were excluded). The plaque score was evaluated by running a probe through four surfaces of the teeth (buccal, lingual, mesial and distal). Percentage of sites with presence of plaque was calculated according to the O’Leary Index.14 Probing, was performed at buccal, lingual, mesial and distal areas of the teeth, to record gingival bleeding according to the Ainamo and Bay’s gingival bleeding index.15 Clinical
attachment loss (CAL) was determined by examining periodontal pocket depth at 6 sites per tooth and level of recession via UNC (University of North Carolina)
periodontal probe.16 Periodontitis was classified as mild, moderate and advanced according to the degree of clinical attachment loss and number of sites affected.11 Intra and inter operator reliability was calculated at 95% and 90% respectively.
For evaluating glycemic levels in patients with periodontitis, gentle periodontal probing was performed at the site of periodontal inflammation and random gingival
crevicular blood glucose levels were recorded by a glucometers at the site of maximum bleeding. The patients having glycemic levels between 180-200mg/dl, were
classified as pre-diabetic, whereas, glycemic levels of more than 200mg/dl indicated diabetes. The prevalence of prediabetes and diabetes among chronic periodontitis patients was calculated as: Number of patients with pre-diabetes and diabetes/Total number of patients.

STATISTICAL ANALYSIS

SPSS version 20 was used to carry out data analysis. Frequency and percentage was calculated for descriptive variables, whereas, mean and standard deviation was used for numerical data. Correlation of glycemic levels with age, number of teeth, gingival bleeding, plaque percentage and CAL was determined by Karl Pearson correlation coefficient formula. Multiple regression analysis was used to find the linear relationship of GCB glucose with periodontal disease parameters. Mean GCBG values in patients with mild, moderate and advanced periodontitis were evaluated by Analysis of variance (ANOVA) and post Hoc analysis.

RESULTS

Out of 348 patients with chronic periodontitis, 42 percent were males, while 58 percent were females. The age range of the participants was 25 to 60 years. The age
of majority of participants (61.2%) was 40 years and above, with the mean age of 43+/-10.4 years. When gingival crevicular blood glucose levels were correlated with age of the patients, a correlation(r) of 0.403 was observed with a p value of <0.001(Table 2). The prevalence of pre-diabetes and diabetes was found to be 6.6% (23 out of 348 cases) and 14.3% (50 out of 348 cases).
The average number of teeth present among the participants was 25+/-3; with a minimum number of 20 and maximum number of 28 teeth (3rd molars were not included in the examination). When number of teeth present was correlated with gingival crevicular blood glucose levels, a negative correlation was observed (Table 2).
The average percentage of plaque containing surfaces was 74% with a minimum of 34% and maximum of 100%. When plaque percentage was correlated with gingival crevicular blood glucose levels, a weak correlation was observed. While, gingival bleeding and CAL showed a strong correlation with glycemic levels (Table 1).

Table 1: Correlation of Gingival crevicular blood glucose levels with age, number of teeth, plaque percentage, clinical attachment loss and bleeding on probing

GCBG= Gingival crevicular blood glucose, CAL= Clinical attachment loss, BOP= Bleeding on probing, r= Pearson Correlation coefficient, p value= Level of Significance (taken at less than 0.05), N= Sample size

Multiple linear regression revealed significant linear association between periodontal parameters and GCB glucose value with r2 (coefficient of determination) of 0.633 at a level of significance of <0.001. Bleeding on probing and CAL were found to be significant predictors of gingival crevicular blood glucose levels, while age and plaque percentage revealed insignificant prediction values (Table 2).

Table 2: Multiple linear regression model for GCB as independent variable and periodontal disease parameters as independent variables

Multiple regression model summary: r=0.796, r2= 0.633 (p<0.001). Beta= Beta coefficient -comparison of strength of effect of independent variable on dependent variable, t= t statistic, Sig= Level of significance (taken at 0.05)

Analysis of variance (ANOVA) was used to check the difference in mean of GCB glucose values between 3 groups according to severity of periodontitis. A significant difference in mean was observed between the groups of mild, moderate and advanced periodontitis (Table 3).

Table 3: ANOVA showing difference in mean GCBG levels between groups of mild, moderate and advanced periodontitis patients

GCBG=Gingival Crevicular blood glucose, SD=Standard deviation, F= F-statistic (variation between group means/variation within group means), Sig= Level of significance (taken at 0.05)

A significant difference in mean GCB glucose values between mild, moderate and advanced periodontitis groups was found when Post Hoc Tukey’s analysis was performed (Table 4).

Table 4: Post Hoc Tukey’s analysis showing difference in mean between the mild, moderate and advanced periodontitis groups

*Mean difference is significant if p value is less than 0.05

The mean plot visualizes the variability in GCB glucose values in mild, moderate and advanced periodontitis groups (Figure1).

Figure 1

diagnosis on the basic of severity of periodontitis

DISCUSSION

Periodontitis has been known to affect about 20-50% of world’s population and has a high prevalence in developing countries, which makes it a public health concern.3 Literature suggests that there exists a strong association between periodontitis and diabetes.6,17-20 Patients with type 2 diabetes with chronic periodontitis, have 3.2 times increased mortality risk as compared to periodontally healthy individuals.3 Due to this strong association between both the diseases, it is necessary to screen blood glucose levels in periodontal patients. Therefore, in this study, we assessed GCBG (gingival crevicular blood glucose) levels via glucometers to screen chronic periodontitis patients for diabetes. According to a study carried out by Meo et al. in 2016, the prevalence of diabetes was recorded as 11.7% in Pakistan.21 Whereas, in our study, the prevalence of pre-diabetes and diabetes was found to be 21% (6.6% and 14.7%) in chronic periodontitis patients. Our study supports the concept that chronic periodontitis increases the chances of insulin resistance and promotes hyperglycemia, which is the major cause of
increased prevalence of diabetes in periodontal patients. Majority of patients included in our study were above 40 years of age. When age was correlated with gingival crevicular blood glucose levels, a moderate correlation of 0.403(r) at p value of <0.001 was observed. Based on this observation, our study suggests that glycemic levels are significantly associated with increase in age. The study by Ko et al. also reports that age and blood glucose levels are significantly correlated (r=0.114, p<0.001).22 Another study by Kalyani et al. reports that there is altered glucose metabolism with aging which leads to increased blood glucose levels.23
Dental plaque is an adherent film of microorganisms and food debris, found on the external surface of the teeth.24 In our study we found weak association between dental plaque and glycemic levels, as the plaque percentage at the dental visit depends on the personal dental hygiene of the patient and is not majorly affected by the blood glucose levels.
Gingival bleeding and clinical attachment loss are important clinical parameters of periodontitis.25 Gingival crevicular blood glucose levels demonstrated strong
correlation with bleeding on probing (r=0.760, p<0.001) and CAL(r=0.733, p<0.001) which indicates that hyperglycemia plays an important role in periodontal
inflammation and alveolar bone resorption. Our study also proves that CAL and gingival bleeding are significant predictors for glycemic levels. Alasqah et al., in their study, found similar results that CAL was significantly increased in patients with pre-diabetes and diabetes as compared to non-diabetic patients.26 The study by Oyapero et al. also support our findings.27 Kogawa et al. also reported in their study that CAL and gingival bleeding were significantly increased in patients with poorly controlled blood glucose values (p=0.05).28 The reason for increased gingival bleeding in diabetics could be an aggravated inflammatory response which develops due to high blood glucose levels in the body.6 A study by Sayeeganesh et al. also reported significant increase in gingival bleeding tendency in diabetics as
compared to non-diabetic individuals (p<0.01).29 In our study, when regression analysis was performed, periodontal parameters of bleeding on probing and clinical attachment loss where found to be significant risk indicators for increased GCBG levels (Table3), which proves that periodontitis increases the risk of hyperglycemia and leads to diabetes.
The studies conducted by Liccardo et al. and Gaurav et al. support our findings that periodontitis increases the risk of diabetes.30,31 Poor glycemic control in periodontitis leads to worsened gingival health and increase in inflammatory response, which causes increased gingival bleeding and bone resorption in periodontitis patients, leading to eventual loss of teeth. The total number of teeth showed significant negative correlation with glycemic levels, in our study,
which indicates that hyperglycemia has a significant association with tooth loss in chronic periodontitis patients (Table 2).
For evaluating the relationship of severity of periodontitis with glycemic levels, periodontitis was categorized into mild, moderate and advanced according to the criteria provided by Eke et al. and the mean GCB glucose levels of each group were compared.11 In our study, the patients with advanced periodontitis had the highest mean GCBG levels (198+/-78 mg/dl), while, the mild periodontitis patients showed the lowest GCBG values(111+/-28 mg/dl) .When the difference in mean of GCB glucose values was analyzed between the groups of patients having mild, moderate and advanced periodontitis, a highly significant difference was observed (F=65.125, p value <0.001). Post hoc Tukey’s analysis confirmed that significant difference in mean GCBG glucose was present between groups with increasing severity of periodontitis (Table 4). Through these findings, our study confirms the two-way relationship between glycemic levels and severity of clinical parameters of periodontitis and provides evidence that increase in glycemic levels increase in periodontal inflammation. The limitation of this study is that random gingival crevicular blood glucose samples were taken in our study on point and not compared with fasting blood glucose levels. Further studies are recommended to compare this screening method with conventionally used blood glucose screening procedures and for their association with periodontal disease parameters.

CONCLUSION

Through this study we conclude that clinical periodontal disease parameters and severity of periodontitis are significantly correlated with gingival crevicular blood glucose levels.

CONFLICT OF INTEREST

None

FUNDING

The study was self-funded by the researcher

DISCLAIMER

This manuscript is a component of a research study called “Clinicopathological correlation of disease severity in periodontitis with crevicular blood glucose estimation”

REFERENCES

  1. Könönen E, Gursoy M, Gursoy K. Periodontitis: A Multifaceted Disease of Tooth-Supporting Tissues. J Clin Med. 2019; 8:1135. https://doi.org/10.3390/jcm8081135
  2. Konkel JE, O’Boyle C, Krishnan S. Distal Consequences of oral inflammation. Front Immunol. 2019; 10:1403. https://doi.org/10.3389/fimmu.2019.01403
  3. Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci. 2017; 11:72-80.
  4.  Llambés F, Arias-Herrera S, Caffesse R. Relationship between diabetes and periodontal infection. World J Diabetes. 2015; 6:927-35. https://doi.org/10.4239/wjd.v6.i7.927
  5. Matthews DC. The relationship between diabetes and periodontal disease. J Can Dent Assoc. 2002; 68:161-164.
  6. Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012; 55:21-31. https://doi.org/10.1007/s00125-011-2342-y
  7. Zizzi A, Tirabassi G, Aspriello SD, Piemontese M, Rubini C, Lucarini G. Gingival advanced glycation end-products in diabetes mellitusassociated chronic periodontitis: an immunehistochemical study. J Periodontal Res. 2012; 48:293-301. https://doi.org/10.1111/jre.12007
  8. Gurav AN. Periodontitis and insulin resistance: casual or causal relationship? Diabetes Metab J. 2012; 36:404-11. https://doi.org/10.4093/dmj.2012.36.6.404
  9. Altamash M, Klinge B, Engström PE. Periodontal treatment and HbA1c levels in subjects with diabetes mellitus. J Oral Rehabil. 2016; 43:31-8.
    https://doi.org/10.1111/joor.12339
  10. Pei XY, He L, Ouyang XY. Proposing a novel, three-level definition of periodontitis using probing depth, clinical attachment loss and bleeding on probing: Analysis of a rural Chinese population. Chin J Dent Res. 2017; 20:89-96. https://doi:10.3290/j.cjdr.a38273
  11. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in United States: 2009-2010. J Dent Res. 2012; 91:914-20. https://doi.org/10.1177/0022034512457373
  12. Bokhari SAH, Sohail AM, Imran MF. Periodontal disease status and associated risk factors in patients attending a dental teaching hospital in Rawalpindi, Pakistan. J Indian Soc. 2015; 19,678-82. https://doi.org/10.4103/0972-124X.156882
  13.  Kannan D, Gurunathan D. Comparison of two systems of tooth numbering among undergraduate dental students. Indian J Dent Res. 2016; 27:378-82.
    https://doi.org/10.4103/0970-9290.191885
  14.  O’Leary TJ, Drake RB, Naylor JE. The plaque control record. J periodontal. 1972; 43:38. https://doi.org/10.1902/jop.1972.43.1.38
  15. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975; 25:229-35.
  16. Deepa R, Prakash S. Accuracy of probing attachment levels using a new computerized cemento-enamel junction probe. J Indian Soc
    Periodontol. 2012; 16:74-9. https://doi.org/10.4103/0972-124X.94609
  17. Pontes C, Flyvbjerg A, Buschard K, Holmstrup P. Relationship between Periodontitis and Diabetes: Lessons from Rodent Studies. J
    Periodontol. 2007; 78:1264-75. https://doi.org/10.1902/jop.2007.060491
  18. Pathak AK, Shakya VK, Chandra A, Goel K. Association between diabetes mellitus and periodontal status in north Indian adults. Eur J
    Gen Dent. 2013; 2:58-61. https://doi.org/10.4103/2278-9626.106815
  19. Bascones-Martíneza A, Muñoz-Corcuera M, Bascones-Ilundain J. Diabetes and periodontitis: A bidirectional relationship. Med Clin
    (Barc). 2015; 145:31-5. https://doi.org/10.1016/j.medcli.2014.07.019
  20. Kumar M, Mishra L, Mohanty R, Nayak R. Diabetes and gum disease: the diabolic duo. Diabetes Metab Syndr. 2014; 8:255-8. https://doi.org/10.1016/j.dsx.2014.09.022
  21. Meo SA, Zia I, Bukhari IA, Arain SA. Type 2 diabetes mellitus in Pakistan: Current prevalence and future forecast. J Pak Med Assoc. 2016; 66:1637-42.
  22. Ko GT, Wai HP, Tang JS. Effects of age on plasma glucose levels in non-diabetic Hong Kong Chinese. Croat Med J. 2006; 47:709-13.
  23. Kalyani RR, Egan JM. Diabetes and altered glucose metabolism with aging. Endocrinol Metab Clin North Am. 2013; 42:333-47. https://doi.org/10.1016/j.ecl.2013.02.010
  24. Seneviratne CJ, Zhang CF, Samaranayake LP. Dental plaque biofilm in oral health and disease. Chin J Dent Res. 2011; 14:87-94.
  25. Lang NP, Bartold PM. Periodontal Health. J Periodontol. 2018; 89:S9-S16. https://doi.org/10.1002/JPER.16-0517
  26. Alasqah M, Mokeem S, Alrahlah A, Al-Hamoudi N, Abduljabbar T, Akram Z. Periodontal parameters in prediabetes, type 2 diabetes mellitus, and non-diabetic patients. Braz Res. 2018; 32:e81.M https://doi.org/10.1590/1807-3107bor-2018.vol32.0081
  27. Afolabi O, Adetokunbo A, Oyinkansola S, Okeoghene A. Effect of glycemic control on periodontal disease and caries experience in diabetic patients: A pilot study. J Interdiscip Dent. 2019; 9:99-107. https://doi.org/10.4103/jid.jid_67_18
  28. Kogawa EM, Grisi CP, Falcão DP, Amorim A, Rezende B, Da Silva R. Impact of glycemic control on oral health status in type 2 diabetes individuals and its association with salivary and plasma levelsof chromogranin A. Arch Oral Biol. 2016; 62:10-9. https://doi.org/10.1016/j.archoralbio.2015.11.005
  29. Sayeeganesh N, Basker K, Manovijay B, Saranyan R, Shanmugasundaram N, Vijayakumar N. Relationship between gingival bleeding and blood glucose level: a case-control study. Int J Med Res Rev. 2015; 3:588-92. https://doi.org/10.17511/ijmrr.2015.i6.111
  30. Liccardo D, Cannavo A, Spagnuolo G, Ferrara N, Cittadini A, Rengo C. Periodontal disease: A risk factor for Diabetes and Cardiovascular Disease. Int J Mol Sci. 2019; 20:1414. https://doi.org/10.3390/ijms20061414
  31. Gurav A, Jadhav V. Periodontitis and risk of diabetes mellitus. J Diabetes. 2011; 3:21-8. https://doi.org/10.1111/j.1753-0407.2010.00098.x

 


  1. M.Phil. Trainee, Department of Oral Biology, Ziauddin College of Dentistry, Ziauddin University, Karachi, Pakistan.
  2. Associate Professor, Department of Orthodontics, Ziauddin College of Dentistry, Ziauddin University, Karachi, Pakistan
  3. Professor, Principal and Dean of Dental Sciences, Ziauddin College of Dentistry, Ziauddin University, Karachi.
  4. Assistant Professor, Department of Oral Biology, Ziauddin College of Dentistry, Ziauddin University, Karachi.
    Corresponding author: “Dr. Quratulain Saeed” < ainysaeed.aidm@gmail.com >

Clinical Correlation of Periodontal Disease Parameters with Crevicular Blood Glucose Levels

Quratulain Saeed                  BDS

Sarwat Memon                       BDS, FCPS

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

Sana Ikram                              BDS, M.Phil

OBJECTIVE: The purpose of the study was to assess relationship between the clinical periodontal parameters and gingival crevicular blood glucose levels and to determine the relation of severity of periodontitis with glycemic levels.
METHODOLOGY: A total number of 348 patients with chronic periodontitis participated in this cross-sectional study. After recording the number of teeth and plaque percentage, the participants were assessed for severity of periodontitis according to clinical periodontal parameters of periodontal pocket depth, gingival recession, clinical attachment loss and gingival bleeding. Gingival crevicular blood glucose was assessed via glucometers and random blood glucose levels were recorded for each patient. SPSS version 20 was used for data analysis. The correlation between periodontal parameters and glycemic levels was assessed via Pearson’s correlation coefficient. Multiple regression analysis was used to predict the association of glycemic levels with periodontal parameters. Analysis of variance was used to compare the glycemic levels in patients with mild, moderate and advance periodontitis.
RESULTS: Age, bleeding on probing and clinical attachment loss showed significant positive correlation while number of teeth showed significant negative association with crevicular blood glucose levels. Multiple regression analysis indicated that crevicular blood glucose has significant linear association with bleeding on probing and clinical attachment loss. Gingival crevicular blood glucose levels were found to be increasing with severity of periodontitis. There was significant difference (p<0.001) in mean glucose levels between mild, moderate and advanced periodontitis groups.
CONCLUSION: Clinical periodontal parameters and severity of periodontitis are strongly associated with increasing gingival crevicular blood glucose levels.
KEYWORDS: Blood glucose, inflammation, gingival bleeding, periodontitis
HOW TO CITE: Saeed Q, Memon S, Hosein M, Ikram S. Clinical correlation of periodontal disease parameters with crevicular blood glucose levels. J Pak Dent Assoc 2021;30(1):12-17.
DOI: https://doi.org/10.25301/JPDA.301.12
Received: 16 July 2020, Accepted: 19 September 2020
Download PDF

Endodontic Management of Acute Dental Pain Among Pregnant Patients

Salman Ashraf Khan               BDS, FRACDS

Arooj Ul Hassan                        BDS, MPH

Zunaira Iqbal                              BDS, MCPS, MPH

Mohammad Hassan                  BDS, MSc, PhD

OBJECTIVE: The purpose of this study is to reinforce the safety of non-surgical endodontic treatment in the management of acute dental pain of pulpal origin in pregnant patients in all trimesters.
METHODOLOGY: The study was conducted amongst pregnant females with acute dental pain. Pain of endodontic origin in 273 pregnant patients was managed by performing non-surgical root canal treatment. Percentages were calculated as descriptive statistics to have a comparison of preferred treatment by dentists for acute pain management during pregnancy. One Way ANOVA was used to explore the difference between treatment selection plans.
RESULTS: From the total sample of 273 participants, there was no significant difference found between the selection of endodontic treatment and Trimesters (F (2,270) = .79, p=.45) same results were obtained for the analgesics prescription during pregnancy and the trimesters during pregnancy (F (2,270) = 1.41, p=.24). On the other hand, the difference between the prescription of antibiotics during 1st, 2nd and 3rd trimesters was found which was statistically significant (F (2,270) = 12.38, p> .001). Endodontic treatment was completed on 251 (91.6%) pregnant patients to relieve the acute dental pain whereas only 22 (8.4%) patients did not undergo endodontic treatment in pregnancy. Among the cases who had endodontic treatment, 75.4% of cases were dealt with in the second trimester of pregnancy. The recommendation of antibiotics was less. In the entire data, antibiotic prescription was seen in the second trimester of pregnancy, whereas, overall, antibiotic prescription was at minimal level. Analgesic prescription was found to be (44.1%) in practice among pregnant participants during the treatment.
CONCLUSION: Non-Surgical Endodontic Treatment is a safe and reliable treatment option for the management of restorable teeth with acute pain of pulpal origin in pregnant patients. Dentists should not be reluctant in prompt invasive dental management in these patients if indicated.
KEYWORDS: pregnancy, pain, dental treatment, endodontic treatment
HOW TO CITE: Khan SA, Hassan AU, Iqbal Z, Hassan M. Endodontic management of acute dental pain among pregnant patients. J Pak Dent Assoc 2021;30(1):7-11.
DOI: https://doi.org/10.25301/JPDA.301.7
Received: 24 July 2020, Accepted: 07 December 2020

INTRODUCTION

Emergency dental treatment during pregnancy, in case of need, is frequently met with reluctance from majority of dentists in our society. Pregnancy, a physiologic state causes many changes in the patient and these changes affect the overall health of a pregnant female.1
Many changes affect physiology, i.e. anatomical changes, biochemical changes. A dentist must know about these changes before treating pregnant patients otherwise it can lead to serious complications if proper precautions are not taken. 2,3 As far as the physiology of cardiovascular system is concerned, heart rate is elevated in pregnancy4 , Supine Hypotension Syndrome5 , headache in 1st and 2nd trimester , anemia5, increased respiratory rate6, etc. Gastrointestinal changes are also very common in pregnancy.7
Changes in the hormonal level can change the growth of the gingiva which can lead to gingival hyperplasia. 8,9,10 Some common problems like tooth decay and enlarged gingiva are aggravated due to increased vomiting in first trimester due to acid attack on the tooth structure. According to American Pregnancy Association, second trimester is the ideal time to treat minor dental problems and cleaning of the teeth by a professional to treat infections. 11 Some antibiotics and analgesics can be safely prescribed by the dentist, but only as an adjunct to operative management. 12 According to the Food and Drug Administration (FDA), among five different groups (A, B, C, D and X) of medication for patients, category B is the safest to use in pregnant patients.13 It includes Penicillin and Cephalosporins group, Azithromycin, Erythromycin and Clindamycin as they do not show any harm to the developing fetus. As far as analgesics are concerned, Acetaminophen i recommended for dental treatment during pregnancy. Local anesthetic like 2% Lignocaine with 1:100,000 Adrenaline is also safe during pregnancy if needed.14
Due to the physiological and anatomical changes, oral health of the pregnant patient can worsen which is usually neglected by the patient. Studies also provide evidence that dentists tend to defer urgent dental care of pregnant patients.15 So, there is a need to educate the dental practitioners that pregnant state generally does not predispose a patient to be medically compromised. 16,17 For this reason, it is essential for dental health professionals to provide pregnant patients with appropriate and timely oral health care. 18

METHODOLOGY

Study Setting: This was an interventional study which was conducted in Operative Dentistry department, Dental Hospital, The University of Lahore after taking approval from the institutional ethical committee (UCD/ERCA/16/09).
Sample Size: This study was done by using non-probability consecutive sampling technique. The sample size of 273 patients was calculated using OpenEpi software by taking the prevalence of deferring from dental treatment of pregnant patients as 23% population proportion19, 95% Confidence Interval and 5% margin of error.
Inclusion Criteria: Pregnant female patients with an age ranging from 18 to 42 years were included as sample of the study.
Exclusion Criteria: Any pregnant patient with established co-morbidities or a history of miscarriage was not included.
Clinical Procedure: All the patients were attended and treated by a single practitioner/researcher following the same protocols to better assess the efficacy of the intervention. The patients were diagnosed by taking history and intra-oral examination including peri-apical X-ray as an investigation tool with protective measures such as thyroid collar and lead apron. A total of 273 patients were treated by non-surgical root canal treatment after acquiring informed consent. For optimal pain control, local anesthesia (Lignocaine 2% with 1:100,000 Adrenaline) was given in all patients using aspirating syringes by slow injection technique in Inferior Alveolar Nerve block (up to 2 minutes). Rubber dam isolation was used as a standard of care in all patients. Working length determination was done with the use of electronic apex locator followed by peri-apical radiograph with appropriate protection. Chemo-mechanical preparation was achieved with Sodium Hypochlorite 3% (Parcan by Septodont, Saint-Maur-des-Fossés, France) and 19% EDTA in gel form (Ethylenediaminetetraacetic acid, MD-Chelcream by Meta Biomed Co. Ltd. Chungbuk, Korea) irrigation. Pre-obturation smear layer removal was done with 17% EDTA solution (MD-Cleanse by Meta Biomed Co. Ltd. Chungbuk, Korea) Glide path was established using manual K files. Shaping of study canal was done using manual or rotary Nickel Titanium ProTaper (by Dentsply Sirona, Ballaigues, Switzerland) file systems. The canals were appropriately enlarged based on the vitality status and the initial canal size. Vital teeth were preferably treated as a
single visit endodontic procedure. In non-vital teeth, Ca(OH)2 (calcium hydroxide, Calcipex by Nippon Shika Co. Ltd., Shimonoseki, Japan) intra-canal medicament was generally placed for two weeks prior to obturation. Interim restoration given was zinc oxide based (Coltosol by Coltene, Altstätten, Switzerland) After the criteria for obturation was met, obturation was done with the cold lateral compaction technique using master gutta percha cone of the corresponding size and accessory gutta percha points using Calcium Hydroxide based sealer (Sealapex by Kerr,California, USA). Post obturation chamber cleaning and residual sealer removal was done using ethanol-soaked cotton pellets. Composite (Ceram.X SphereTEC by Dentsply Sirona, Ballaigues, Switzerland) was used as a final restorative material of choice after etching (32% phosphoric acid, Scotchbond Universal etchant by 3M ESPE, St. Paul, USA) and bonding (ESPE Single Bond Universal by 3M ESPE, St. Paul, USA)
The patients were contacted at 1 month and 3 months intervals for follow up and to identify any complications related to the treatment.

STATISTICAL ANALYSIS

Statistical analysis was performed using SPSS version 22. Percentages were calculated as descriptive statistics to have a comparison of preferred treatment by dentists for acute pain management during pregnancy. As inferential statistics, One-way ANOVA was used to get the difference between the treatment selection preferences of dentists for the management of acute dental pain during pregnancy (trimester wise).

Diagrammatical representation of the procedure followed in the study for patient induction

RESULTS

The results revealed that there was no significant difference found between the selection of endodontic treatment and Trimesters (F (2,270) = .79, p=.45) same results were obtained for the analgesics prescription during pregnancy and the trimesters during pregnancy (F (2,270) = 1.41, p=.24). On the other hand, the difference between the prescription of antibiotics during 1st, 2nd and 3rd trimesters was found which was statistically significant (F (2,270) = 12.38, p= .000) which means that the ratio of antibiotics prescription was different in 1st, 2nd and 3rd trimesters.
To get the pairwise comparison, Post Hoc, Tukey test, was performed on antibiotic prescription during pregnancy as this difference was found significant. The results revealed

Table 1: Difference between treatment selection preferences of dentists for acute dental pain management among pregnant patients
Table 2: Pairwise comparison of antibiotic prescription during pregnancy

that during 2nd trimester of pregnancy, antibiotics were prescribed to most of the patients with acute dental pain whereas no statistically significant difference was found for the prescription of antibiotics during 2nd and 3rd trimester. Contrary to this, it was found and was statistically significant that during 3rd trimester of pregnancy, the antibiotic prescription was more as compared to the antibiotic prescription during 1st trimester. The graph given below explained the dentists’ preferred endodontic treatment for acute pain management among pregnant patients as compared to the prescription of analgesics and antibiotics.

Dentists’ Treatment Selection Prefrence

DISCUSSION

Recent evidence shows that dental practitioners generally have a lack of knowledge regarding pregnant patients and are reluctant to treat these patients specially in the first trimester. According to the American Dental Association (ADA) guidelines “preventive, diagnostic and restorative dental treatment is safe throughout pregnancy”. The dentists and gynecologists both need to reinforce mutual liaison and emphasize the patient regarding timely management of acute dental pain, if needed. The dentists and the gynecologists both also need to play their role in provision of routine preventive oral healthcare to the patients.20 The American Dental Association in collaboration with the American College of Obstetricians and Gynecologists developed a consensus statement in 2012 that was reaffirmed in 2019 which emphasizes the role of dentists in treatment of oral infections as a part of healthy pregnancy.21 NonSurgical Endodontic treatment for management of acute dental pain is also considered safe and the treatment of choice where indicated. Center for Disease Control (CDC) also warns about the misuse of pain medications in pregnancy and its deleterious effects on the fetus.22 The guidelines provided by the contemporary textbooks also suggest that endodontic treatment is not a contraindication in pregnancy and the use of drugs should be in accordance with the safety and health of the patient and fetus.23 It is imperative that the dentists treat these patients promptly and explain the importance of timely care.
Maintenance of oral health is an integral part of a healthy pregnancy. During this physiological phase the female body goes through many hormonal changes which may affect the oral health. One of these changes is increased carbohydrate consumption specifically in the third trimester which can increase chances of plaque formation and dental decay.24 Increased levels of estrogen and progesterone increase the permeability of oral vessels and reduce immunocompetence during pregnancy, increasing the chances of severe oral inflammation. These changes can lead to increased caries risk and gingival enlargement which can cause pulpal and periodontal harm.25
Severe odontogenic infections in pregnancy may have dire consequences. Dental practitioners may be reluctant to treat orofacial infections invasively in pregnancy due to the false assumption of potential risk to the fetus. This also concerns to radiographic evaluation and pharmacologic therapy. It potentially leads to self medication leading to delay in optimal management, which can be very harmful for the mother and fetus and can lead to complications.26 A study conducted by Wali et al concludes that dentists have a general deficiency in knowledge regarding the management of pregnant patients and are reluctant to treat them. This study also revealed that many dentists consider treatments other than scaling and root planning to be relatively unsafe in pregnant patients. Most of the dentists were unaware of the evidence-based guidelines regarding the treatment of pregnant patients. The study recommends that dentists broaden their perspective and knowledge to provide evidencebased oral health care to the pregnant patients.27
In this study the researchers performed Non-Surgical Endodontic Treatment on more than 250 pregnant patients and followed up on their dental status and overall health for up to 3 months. All elective dental procedures should be avoided during pregnancy but if acute dental pain management like Non-Surgical Endodontics is indicated, should not be deferred. Neglect or delay in prompt treatment can lead to life threatening conditions.28 This study showed that endodontic treatment is safe in pregnancy and it should not be delayed even in the first and third trimesters.

CONCLUSION

Non-Surgical Endodontic Treatment is a safe and reliable treatment option for the management of restorable teeth with acute pain of pulpal origin in pregnant patients. Dentists should not be reluctant in prompt invasive dental management in these patients if indicated.

CONFLICT OF INTEREST

None to declare

REFERENCES

  1. Ajay G Nayak, Oral Health Considerations for the Pregnant Woman, Dental Update 2012; 39:51-54. https://doi.org/10.12968/denu.2012.39.1.51
  2. Dental Considerations in Pregnancy-A critical Review on the oral care.j clin Diagn Res 2013;7:94
  3. Adina Bosca L. Assessment of Dentists’ Knowledge Concerning the Management of Pregnant Women in the Dental Office. Biomedical J Scientific & Technical Research. 2019;15. https://doi.org/10.26717/BJSTR.2019.15.002667
  4. Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation. 2014;130:1003-08. https://doi.org/10.1161/CIRCULATIONAHA.114.009029
  5. Kurien S, Kattimani VS, Sriram RR, Sriram SK, VK PR, Bhupathi A, et al. Management of pregnant patient in dentistry. J Int Oral Health: JIOH. 2013;5:88.
  6. Costantine M. Physiologic and pharmacokinetic changes in pregnancy. Frontiers in pharmacolog. 2014;5:65. https://doi.org/10.3389/fphar.2014.00065
  7. Wald A, Van Thiel DH, Hoechstetter L, Gavaler JS, Egler KM, Verm R, et al. Effect of pregnancy on gastrointestinal transit. Dig Dis Sci. 1982;27:1015-18. https://doi.org/10.1007/BF01391748
  8. Srivastava A, Gupta KK, Srivastava S, Garg J. Massive pregnancy gingival enlargement: A rare case. J Indian Soc Periodontol. 2013;17:503-06. https://doi.org/10.4103/0972-124X.118324
  9. Boggess, K. A., Urlaub, D. M., Massey, K. E., Moos, M. K., Polinkovsky, M., Matheson, M. B., Lorenz, C. Oral hygiene practices and dental service utilization among pregnant women. J Am Dent Assoc, 2010;141:5:553-61.  https://doi.org/10.14219/jada.archive.2010.0228
  10. Pina PM, Douglass J. Practices and opinions of Connecticut general dentists regarding dental treatment during pregnancy. Gen Dent. 2011;59:e25-31.
  11. Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32:815-21. https://doi.org/10.1111/j.1600-051X.2005.00739.x
  12. Michalowicz BS, DiAngelis AJ, Novak MJ, Buchanan W, Papapanou PN, Mitchell DA, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc. 2008; 139:685-95. https://doi.org/10.14219/jada.archive.2008.0250
  13. Giglio JA, Lanni SM, Laskin DM, Giglio NW. Oral health care for the pregnant patient. J Can Dent Assoc. 2009;75:43-8. PMID: 19239743.
  14. Ouanounou A, Haas DA. Drug therapy during pregnancy: implications for dental practice. Br Dent J. 2016;220:413-7. PMID: 27103292. https://doi.org/10.1038/sj.bdj.2016.299
  15. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc 2001; 132:1009-16. https://doi.org/10.14219/jada.archive.2001.0306
  16. Pina PM, Douglass J. Practices and opinions of Connecticut general dentists regarding dental treatment during pregnancy. Gen Dent. 2011;59: e25-31.
  17. Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc. 2006;137: S7-S13. https://doi.org/10.14219/jada.archive.2006.0403
  18. Nasir A, Asghar S, Ahmed S, Rashid E, Ikram S, Moin F. Knowledge of Dentists Regarding Dental Treatment During Pregnancy in Karachi. Pak Oral Dent J. 2017;37:137-41.
  19. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008; 21:63-71. https://doi.org/10.1080/14767050701796681
  20. Oral Health Care During Pregnancy Expert Workgroup. 2012. Oral Health Care During Pregnancy: A National Consensus StatementSummary of an Expert Workgroup Meeting. Washington: National Maternal and Child Oral Health Resource Center, Georgetown University. www.cdph.ca.gov/programs/MCAHOralHealth/ Documents/MCAH-OHP-OralHealthPregnancyConsensus2011.pdf. Accessed Oct. 1, 2020.
  21. American College of Obstetricians and Gynecologists. Oral health care during pregnancy and through the life span. Committee Opinion No. 569. Obstet Gynecol. 2013;122:417-22. https://doi.org/10.1097/01.AOG.0000433007.16843.10
  22. Interrante, JD, Ailes, EC, Lind, JN, Anderka, M, Feldkamp, ML, Werler, MM, Taylor, LG, Trinidad, J, Gilboa, SM, Broussard, CS, and the National Birth Defects Prevention Study. Risk comparison for prenatal use of analgesics and selected birth defects, National Birth Defects Prevention Study 1997-2011. Ann Epidemiol. 2017 https://doi.org/10.1016/j.annepidem.2017.09.003
  23. Hargreaves, K. M., Cohen, S., & Berman, L. H. (2011). Cohen’s pathways of the pulp. St. Louis, Mo: Mosby Elsevier.
  24. Razi S, Muhammad SG, Rashid H. Dental Considerations in a Patient with Pregnancy: A Concise Review. J Pak Dent Assoc 2016;25:48-52
  25. Patil SN, Kalburgi NB, Koregol AC, Warad SB, Patil S, Ugale MS. Female sex hormones and periodontal health-awareness among gynecologists-A questionnaire survey. The Saudi Dent J. 2012;24:99- 104 https://doi.org/10.1016/j.sdentj.2011.12.001
  26. Tocaciu S, Robinson BW, Sambrook PJ. Severe odontogenic infection in pregnancy: a timely reminder. Aus Dent J. 2017;62:98-101. https://doi.org/10.1111/adj.12463
  27. Wali A, Siddiqui TM, Sarwar A, Anjum A, Rao H. Perception and understanding of dental practitioners in provision of dental treatment to pregnant women in Karachi, Pakistan. Indian J Dent Sci 2016; 8:199-204. https://doi.org/10.4103/0976-4003.196816
  28. Wazir S, Khan M, Mansoor N, Wazir A. Odontogenic fascial space infections in pregnancy-a study. Pak Oral Dent J. 2013 1;33.

  1. Assistant Professor, Head of Department, Department of Operative Dentistry, Dental Hospital University of Lahore.
  2. PhD Scholar, Assistant Professor, Head of Department, Department of Community & Preventive Dentistry, Dental Hospital University of Lahore.
  3. Registrar, Department of Operative Dentistry, Dental Hospital University of Lahore.
  4. Assistant Professor, Department of Prosthodontics, Dental Hospital University of Lahore.
    Corresponding author: “Dr. Zunaira Iqbal” < zunaira9466@gmail.com >

Endodontic Management of Acute Dental Pain Among Pregnant Patients

Salman Ashraf Khan               BDS, FRACDS

Arooj Ul Hassan                        BDS, MPH

Zunaira Iqbal                              BDS, MCPS, MPH

Mohammad Hassan                  BDS, MSc, PhD

OBJECTIVE: The purpose of this study is to reinforce the safety of non-surgical endodontic treatment in the management of acute dental pain of pulpal origin in pregnant patients in all trimesters.
METHODOLOGY: The study was conducted amongst pregnant females with acute dental pain. Pain of endodontic origin in 273 pregnant patients was managed by performing non-surgical root canal treatment. Percentages were calculated as descriptive statistics to have a comparison of preferred treatment by dentists for acute pain management during pregnancy. One Way ANOVA was used to explore the difference between treatment selection plans.
RESULTS: From the total sample of 273 participants, there was no significant difference found between the selection of endodontic treatment and Trimesters (F (2,270) = .79, p=.45) same results were obtained for the analgesics prescription during pregnancy and the trimesters during pregnancy (F (2,270) = 1.41, p=.24). On the other hand, the difference between the prescription of antibiotics during 1st, 2nd and 3rd trimesters was found which was statistically significant (F (2,270) = 12.38, p> .001). Endodontic treatment was completed on 251 (91.6%) pregnant patients to relieve the acute dental pain whereas only 22 (8.4%) patients did not undergo endodontic treatment in pregnancy. Among the cases who had endodontic treatment, 75.4% of cases were dealt with in the second trimester of pregnancy. The recommendation of antibiotics was less. In the entire data, antibiotic prescription was seen in the second trimester of pregnancy, whereas, overall, antibiotic prescription was at minimal level. Analgesic prescription was found to be (44.1%) in practice among pregnant participants during the treatment.
CONCLUSION: Non-Surgical Endodontic Treatment is a safe and reliable treatment option for the management of restorable teeth with acute pain of pulpal origin in pregnant patients. Dentists should not be reluctant in prompt invasive dental management in these patients if indicated.
KEYWORDS: pregnancy, pain, dental treatment, endodontic treatment
HOW TO CITE: Khan SA, Hassan AU, Iqbal Z, Hassan M. Endodontic management of acute dental pain among pregnant patients. J Pak Dent Assoc 2021;30(1):7-11.
DOI: https://doi.org/10.25301/JPDA.301.7
Received: 24 July 2020, Accepted: 07 December 2020
Download PDF

The Psychology of Coronavirus Fear: Are Dentists of Pakistan Suffering from Corona-Phobia?

Muhammad Mansoor Majeed                  BDS, MDS

Zohra Saleem                                            BDS

Huma Sarwar                                            BDS, MDS

Zoobia Ramzan                                        MBBS, FCPS

Syeda Naureen Iqbal                               BDS, FCPS

Meshal Muhammad Naeem                     BDS

OBJECTIVE: The objective of this study is to evaluate the level of anxiety and fear among Pakistani dentists due to COVID-19.
METHODOLOGY: Data of 386 dentists evaluated who responded to the questionnaire sent via social media. Fear of coronavirus scale (FCV-19S) was used for evaluation of fear among Pakistani dentists. Data was entered and analyzed using SPSS version 21. One way ANOVA, chi-square and independent t-test were used for statistical analysis. P-value <0.05 was considered as significant.
RESULTS: The overall mean FCV-19S score was 26.22 ± 4.907, which is on the higher end. Females showed higher fear scores as compared to males (p<0.001). A statistically significant difference between the scores of General Dental Practitioners (GDP) and specialists was also observed (p<0.001), Statistically, a significant difference was observed between all 4 age groups of dentists, young and elderly dentists demonstrating higher scores (F (3,382) = 8.618, p< 0.001).
CONCLUSION: We conclude that due to the current COVID-19 crisis, majority of the dentists of Pakistan are afraid and among them, females, GDPs, young and elderly dentists are found to be more anxious and have a greater fear of getting infected by coronavirus during COVID 19 Pandemic.
KEYWORDS: Anxiety, Fear, Pakistani, Dentist, COVID-19
HOW TO CITE: Majeed MM, Saleem Z, Sarwar H, Ramzan Z, Iqbal SN, Naeem MM. The psychology of coronavirus fear: Are dentists of pakistan suffering from corona-phobia?. J Pak Dent Assoc 2021;30(1):1-6.
DOI: https://doi.org/10.25301/JPDA.301.1
Received: 15 July 2020, Accepted: 11 November 2020

INTRODUCTION

Aviral respiratory disease that emerged in Wuhan, China by the end of 2019 that turned in to a global pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2). Coronavirus disease 19 (COVID- 19) is a highly contagious disease.1
In March 2020, the World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19) a pandemic, affecting over 110 countries and territories globally where the coronavirus illness is present.2 It can be transmitted by droplet inhalation, coughing, sneezing, and contact with the mucous membranes of the oral cavity, nasal cavity, and eye.3
Widespread outbreaks of infectious diseases, such as COVID-19, are associated with psychological distress and symptoms of mental illness.4 Infectious diseases and especially in the case of pandemic,psychological responses emerge. However, it is different in different people.5
Healthcare professionals (HCPs) are the most vulnerable group of individuals where fear, anxiety, depression and other psychological symptoms are the common problems due to the direct exposure and interaction with the patients or suspected individuals. Furthermore, studies have reported that workload, lack of protective type of equipments, isolation, and higher rate of infection among HCPs may result in anxiety and fear.6
A significant element for health care professionals is the fear that relates to COVID-19 exposure and subsequent concern of transmitting the infection to their families.7,8 A recent study conducted in China demonstrated that more than 70% of HCPs reported moderate to severe fear and 22.6% of medical staff showed mild to moderate anxiety whereas 2.9% had severe anxiety.9 Moreover, studies conducted after the outburst of the severe acute respiratory syndrome (SARS) also suggested that HCPs are at greater threat of developing anxiety, fear, depression and other psychological issues.10
Pakistan is a developing country with limited health care facilities and during the current crisis of COVID-19 many HCPs along with general public in Pakistan have lost their lives.11 This situation has created fear and anxiety among the HCPs which includes medical doctors, dental surgeons, nurses and other paramedical staff. In the current study. It is reported that dental health care professionals along with the associated staff dental nurses are at the risk of COVID-19 due to routine aerosol-generating procedures in and around the patient’s mouth.12 It has always been challenging for the staff of dental setup to maintain crossinfection control and, especially when doing selected dental procedures that produce aerosols. Due to the nature of dental care surroundings, the hazard of cross-infection is elevated among patients, dentists and their coworkers.13
To evaluate the fear among the dentists of Pakistan due to the current pandemic, we conducted this study.

METHODOLOGY

Study Design: It was an online survey-based cross-sectional study conducted in May 2020 during the period of strict lockdown as per government orders to prevent the spread
and transmission of the coronavirus. Sampling: Rao soft was used to determine the sample size. The minimum required sample size was 377 considering 50% response rate, 95% confidence interval (CI), and a 05 % margin of error. A supplementary 05 % (n=19) was added to overcome any flaws or discrepancies in the filling up of the survey form. So the final calculated sample size of 396 dentists of Pakistan was considered.
Study Population: Participants of the current study were the dentists working in different clinics, hospitals and teaching institutes of Pakistan having at least Bachelors of
Dental Surgery (BDS) degree and more than 1-year experience. Non Practicing dentists were excluded. Dentists were approached by the Principal investigator and coinvestigators through their personnel contacts as per convenience snowball technique and also recruited through a Facebook group “DENTISTS OF PAKISTAN” with over 6000 dentists.
Questionnaire Design: In the current study, we used a previously validated Fear of Corona Virus Scale (FCV-19S) with Cronbach’s alpha value of 0.82, to check the fear among the dentists of Pakistan. The FCV-19S is 7 items measured on five points Likert Scale.14 The FCV-19S is ranging between 7-35, greater the score, higher the fear.
The survey instrument for the current study was comprised of 2 sections; Demographics and FCV-19S. A pilot study was performed on dentists from different cities of Pakistan,
to furnish their views and ideas to make the current survey instrument easier and concise. After a detailed and thorough discussion with medical educationists, the current survey
instrument was finalized. The reliability coefficient of the survey instrument for the current study was computed using SPP v.21 and Cronbach’s alpha was found to be 0.807 which
is considered good.
Ethics: Ethical approval was obtained from the ethics and review committee of Altamash Institute of Dental Medicine, Karachi, Pakistan (AIDM/EC/04/2020/04).
Statistical Analysis: Data was downloaded in MS excel and afterwards transferred to SPSS V.21 for analysis. Categorical variables (Gender, Age Group, Category i.e. General Dentist
or Specialist ) were stated as frequencies and percentages and Qualitative values ( Score of FCV -19S) were calculated as mean and standard deviation. To check the significance
of demographic characteristics Chi-square test was used. Independent sample t-test was performed to access any difference in FCV-19S among genders and different
categories of dentists. Differences in mean fear among different age groups were accessed by one-way ANOVA. A p-value of less than 0.05 considered significant in all tests.

RESULTS

Total of 409 dentists participated in the current study. Due to the discrepancies in the data, analysis of 386 individuals was carried out and data of 23 participants were excluded. The analysis showed that there is a significant difference among genders (X2= 36.073, p <0.001), Age Groups (X2= 350.953, p <0.001) and between the 2 categories of dentists i.e. General Dentist and Specialists ((X2= 269.477, p <0.001). Out of 386 , females were 252 (65.3%), in the 18 to 30 age group 236 (61.7%) participants were present and 265 (68.7%) participants were general dentists.

(Table I).
In Table II the mean levels of central tendencies along

with skewness and Kurtosis of each item of FCV-19S has been reported. The total mean score of FCV-19S was 26.22 ± 4.907 which is towards the higher side (Table II).

Table II: Item properties of Fear of Coronavirus-19 Scale

We performed an independent t-test to find out the mean score among the gender for each item of FCV-19S. We analyzed that females showed higher scores of fear and the difference is highly significant. We further analyzed the difference among genders for a total score of FCV-19S. As per independent t-test, we found a significant t value (t (229.34) = -4.763, p<0.001). The analysis further revealed that males had a lower mean score (M=24.54±5.371) as compared to females (M=27.11 ±4.399). (Table III).
To analyze the statistical difference among 2 categories of dentists i.e. General Dental Practitioner (GDP) and Specialist Dentists (SD), we executed independent t-test. We evaluated that GDP showed higher scores of fear in all the 7 items of FCV-19S and the difference is highly significant (p<0.05). We further analyzed the difference between GDPs and SDs for a total score of FCV-19S. As per independent t-test, we found a significant difference (t (384) =-4.557, p<0.001). The analysis further revealed that GDP had a higher score (M=26.97 ±4.648) as compared to females (M=24.57 ± 5.077). The results show that GDP has more fear of COVID-19 as compared to the SD. (Table III).

A one-way ANOVA was performed to find out the impact of Age on fear. Participants were divided into 4 age groups: Less than 30 years old, 31 to 40, 41 to 50 and more than 51 years old. The test revealed that there were significant differences in Total Fear Score of FCV-19S for four different age groups [F (3,382) = 8.618, p< 0,001].The findings also indicate that young adults and elderly people had higher scores on the FCV-19S than middle-aged (Fig I).

Figure 1: Mean of total FCV-19S among different age group

DISCUSSION

In the current study, we observed that the mean fear score. According to FCV-19S was towards the higher side and fear is highly prevalent among the dental professionals of Pakistan. In agreement with our findings a study, conducted on HCPs, observed high fear and anxiety among the dentists as compared to medical doctors and pharmacist.8
Studies have reported that dental professionals are more prone to infections because of the aerosols generating procedures and confined environment of the dental offices.15,16 In the current study, we observed that that female dentists are more afraid of these crises and there is a significant difference in all item of FCV-19S as compared to males. This can be elucidated by the fact that women have more burden than men and they are responsible for house chores, take care of the family members and other domestic issues,17 furthermore females are more sensitive by nature. Moreover, in agreement with our findings, previous studies have also shown higher levels of anxiety among women18 and female doctors.19
Similarly, the current study expressed a higher score of fear in general dental practitioners as compared to the specialist dentist. In accordance with the finding of our study, other studies targeted physicians also showed lower levels of anxiety among the specialists as compared to nonspecialist doctors.20,21 However, an Iranian study has contradictory results.22 In our opinion, persistent jobs and salaries could be the reason of lower level of fear among the specialists, moreover their capability to buy expensive personnel protective equipments and carry forward the patients to the junior dentist may have a pivotal role. Majeed MM et al have also reported anxiety and stress among the young dentists and postgraduate dental trainees due to the closure of dental outpatient departments and dental hospitals, likewise anxiety is also reported among those dental professionals who are associated with teaching due to online classes.23
Similarly the young dentists below the age of 30 years expressed higher anxiety levels as compared to the dentists between the ages of 31 to 50 years. On the other hand dentists above 50 years of age had the highest level of anxiety among all age groups. By the current study findings, another study conducted on the general population in Pakistan reported higher fear among young individuals.24 Comorbidities and social issues could be the reason for higher FCV-19S score among the dentists above 50 years.
The observations and findings of the high level of fear in the current study are consistent with studies regarding the epidemic of SARS and MERS.25,26 Studies conducted in different parts of the world and in Pakistan about anxiety and fear among the HCPs revealed that HCPs are the most vulnerable group and because of the current COVID-19 pandemic have shown higher levels of stress, anxiety, fear, depression and other psychosomatic problems.27,28 In another study, primarily targeting the fear among dentists during the current crisis revealed that fear of being infected from the patients or colleagues, transmission of infection to family members, economic and financial insurgencies, panic and anxiety of getting quarantined, etc. are the major factors causing fear among the dentists.29-31
The probabilities of getting infected as well as transmission of the disease are highly common from the dental office. The dentist comes under the high-risk zone and the chances of the spread of infection from the handpiece, ultrasonic scalers, triple syringe, and other aerosolgenerating procedures have been reported along with the possibility of transmission of infection to the patient or dentist.32
Due to the highly contagious nature of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), professional dental organizations asked the dentist to stop performing aerosol-generating as well as elective procedures. In a few countries, dental clinics were completely closed and many dentists started giving consultancies from home.33 Due to a high level of fear among the dentists of Pakistan, it is mandatory for them to practice coping strategies and if required intervention from psychologists and psychiatrists can be obtained.
We also recommend conducting a longitudinal study facilitate identification of the prevalence of fear, anxiety, depression and other psychological issues. The strength of this study is the data was collected from all the provinces of Pakistan. There are few limitations in the current study that due to COVID-19 and lockdown we were bound to conduct online survey and results may not be generalized and may have source bias effects.

CONCLUSION

Due to the current crisis dental professionals of Pakistan are in a state of fear. To overcome such issues, government or medical and dental association should arrange sessions with the psychologist and psychiatrists. Moreover during the crisis dentist should only perform the emergency procedures following all the necessary protocols. Furthermore, policies for such pandemics should be made and implemented to prevent or to control the spread.

ACKNOWLEDGEMENTS

We acknowledge the support of the ethic and review committee of Altamash Institute of Dental Medicine, Karachi, Pakistan. We would like to thank all the respected participants for their participation and special thanks to the Professor of Psychiatry Dr. Munir Hamirani for the ideas, encouragement and support at every step of the research.

CONFLICT OF INTEREST

None

FUNDING

None

AUTHORS CONTRIBUTION

SZ: Initial draft writing, literature search, data collection and final approval of the manuscript. IN: Data collection, write up, Critical revision and final approval of the manuscript. RZ: Study Concept and design and critically revised and approved the final draft of the manuscript. SH: Data collection, write up, tables and figure and final approval of the manuscript. NMM: Data collection, statistical work and final approval of the manuscript. MMM: Conceived the study, supervised the project and is responsible for the integrity of the research. Comprehensively contributed to Data collection, statistical work, writing of the manuscript
and critically revised and approved the final draft of the manuscript.

REFERENCES

  1. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel CoronavirusInfected Pneumonia. New Eng J Med. 2020;382:1199-207. https://doi.org/10.1056/NEJMoa2001316
  2. Montemurro N. The emotional impact of COVID-19: From medical staff to common people. Brain, Behavior, Immunity. 2020;87: 23-4. https://doi.org/10.1016/j.bbi.2020.03.032
  3. Lu C-w, Liu X-f, Jia Z-f. 2019-nCoV transmission through the ocular surface must not be ignored. Lancet. 2020;395(10224): e39. https://doi.org/10.1016/S0140-6736(20)30313-5
  4. Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J psychiatry. 2020:102066. https://doi.org/10.1016/j.ajp.2020.102066
  5. Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA. Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clin Med Res. 2016;14:7-14. https://doi.org/10.3121/cmr.2016.1303
  6. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7:e14. https://doi.org/10.1016/S2215-0366(20)30047-X
  7. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID19 pandemic. J Am Assoc.2020;32:2133-4. https://doi.org/10.1001/jama.2020.5893
  8. Zohra S, Majeed MM, Sara R, Zarah S, Dinaz G, Hira T, et al.COVID-19 pandemic fear and anxiety among healthcare professionals in Pakistan. Research Square https://doiorg/1021203/rs3rs-37608/v2.
  9. Lu W, Wang H, Lin Y, Li L. Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study. Psychiatry Res. 2020:112936. https://doi.org/10.1016/j.psychres.2020.112936
  10. Wu KK, Chan SK, Ma TM. Posttraumatic stress after SARS. Emerg Infect Dis. 2005;11:1297. https://doi.org/10.3201/eid1108.041083
  11. Shabbir Hussain JM. Covid-19 infects 10,000 health staff. The Express Tribune. 2020 22nd November.
  12. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PloS one. 2017;12:e0178007. https://doi.org/10.1371/journal.pone.0178007
  13. Samaranayake LP, Peiris M. Severe acute respiratory syndrome and dentistry: a retrospective view. J Am Dent Assoc. 2004;135:1292- 302. https://doi.org/10.14219/jada.archive.2004.0405
  14. Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: Development and Initial Validation. Int J Mental Health Addict. 2020:1-9. https://doi.org/10.1007/s11469-020-00270-8
  15. Tariq R, Hamid H, Mashood S, Tariq Y, Tariq S, Asiri FYI, et al. Common misconceptions regarding COVID-19 among health care professionals: an online global cross-sectional survey. J Oral Res. 2020:36-45. https://doi.org/10.17126/joralres.2020.049
  16. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020;99:481-7.
    https://doi.org/10.1177/0022034520914246
  17. Lancet T. The gendered dimensions of COVID-19. Lancet. 2020;395:1168. https://doi.org/10.1016/S0140-6736(20)30823-0
  18. Conklin AI, Guo SX, Tam AC, Richardson CG. Gender, stressful life events and interactions with sleep: a systematic review of determinants of adiposity in young people. BMJ open. 2018;8:
    e019982. https://doi.org/10.1136/bmjopen-2017-019982
  19. Erdur B, Ergin A, Turkcuer I, Parlak I, Ergin N, Boz B. A study of depression and anxiety among doctors working in emergency units in Denizli, Turkey. Emergency Med J. 2006;23:759-63. https://doi.org/10.1136/emj.2006.035071
  20. Hasan SR, Hamid Z, Jawaid MT, Ali RK. Anxiety among doctors during COVID-19 pandemic in secondary and tertiary care hospitals. Pak J Medical Sci. 2020;36:1360.
    https://doi.org/10.12669/pjms.36.6.3113
  21. 21. Chatterjee SS, Bhattacharyya R, Bhattacharyya S, Gupta S, Das S, Banerjee BB. Attitude, practice, behavior, and mental health impact of COVID-19 on doctors. Indian J Psychia. 2020;62:257. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_333_20
  22. Taghizadeh F, Hassannia L, Moosazadeh M, Zarghami M, Taghizadeh H, Dooki AF, et al. Anxiety and Depression in Health Workers and General Population During COVID-19 Epidemic in IRAN: A Web-Based Cross-Sectional Study. medRxiv. 2020. https://doi.org/10.1101/2020.05.05.20089292
  23. Majeed MM, Durrani MS, Bashir MB, Ahmed M. COVID-19 and Dental Education in Pakistan. J Coll Physicians Surg Pak. 2020;30:S115- S7. https://doi.org/10.29271/jcpsp.2020.Supp2.115
  24. Mahmood QK, Jafree SR, Qureshi WA. The psychometric validation of FCV19S in Urdu and socio-demographic association with fear in the people of the Khyber Pakhtunkhwa (KPK) province in Pakistan. Int J Mental Health Addict. 2020:1-11. https://doi.org/10.1007/s11469-020-00371-4
  25. Lee SM, Kang WS, Cho A-R, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Comprehensive psychiatry. 2018;87:123-7. https://doi.org/10.1016/j.comppsych.2018.10.003
  26. Verma S, Mythily S, Chan Y, Deslypere J, Teo E, Chong S. PostSARS psychological morbidity and stigma among general practitioners and traditional Chinese medicine practitioners in Singapore. Ann Acad Med Singapore. 2004;33:743-8.
  27. Alwani SS, Majeed MM, Hirwani MZ, Rauf S, Saad SM, Shah SH, et al. Evaluation of Knowledge, Practices, Attitude and Anxiety of Pakistans Nurses towards COVID-19 during the Current Outbreak in Pakistan. medRxiv. 2020 https://doi.org/10.1101/2020.06.05.20123703
  28. Urooj U, Ansari A, Siraj A, Khan S, Tariq H. Expectations, Fears and Perceptions of doctors during Covid-19 Pandemic. Pak J Med Sci. 2020;36(COVID19-S4). https://doi.org/10.12669/pjms.36.COVID19-S4.2643
  29. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care. J Endod. 2020;46:584-95. https://doi.org/10.1016/j.joen.2020.03.008
  30. Ahmed N, Jouhar R, Adnan S, Ahmed MA. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic: A Dilemma for Dental Health Care Professionals. Ann Jinnah Sindh Med Uni. 2020;6:33-4. https://doi.org/10.46663/ajsmu.v6i1.33-34
  31. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat Novel Coronavirus Disease (COVID-19) outbreak. Int J Environmental Res Pub Health. 2020;17:2821. https://doi.org/10.3390/ijerph17082821
  32. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135:429-37. https://doi.org/10.14219/jada.archive.2004.0207
  33. Uddin KB. Work from home: New routines, unexplored territories, and unexpected shortcomings 2020 [Available from: https://www.geo.tv/latest/283327-work-from-home-new-routinesunexplored-territories-andunexpected-shortcomings.

  1. Assistant Professor. Department of Oral Biology, Altamash Institute of Dental Medicine, Karachi.
  2. MDS-Trainee, Department of Oral Surgery, Dow University of Health Sciences, Karachi.
  3. Lecturer, Department of Operative Dentistry, Dow University of Health Sciences, Karachi.
  4. Assistant Professor, Department of Psychiatry, Dow University of Health Sciences, Karachi.
  5. Assistant Professor, Department of Oral and Maxillofacial Surgery, Dow University of Health Sciences, Karachi.
  6. MDS Trainee and Lecturer, Department of Periodontology, Dow University of Health Sciences, Karachi.
    Corresponding author: “Dr. Muhammad Mansoor Majeed” < mmansoormajeed@gmail.com >

The Psychology of Coronavirus Fear: Are Dentists of Pakistan Suffering from Corona-Phobia?

Muhammad Mansoor Majeed                  BDS, MDS

Zohra Saleem                                            BDS

Huma Sarwar                                            BDS, MDS

Zoobia Ramzan                                        MBBS, FCPS

Syeda Naureen Iqbal                               BDS, FCPS

Meshal Muhammad Naeem                     BDS

OBJECTIVE: The objective of this study is to evaluate the level of anxiety and fear among Pakistani dentists due to COVID-19.
METHODOLOGY: Data of 386 dentists evaluated who responded to the questionnaire sent via social media. Fear of coronavirus scale (FCV-19S) was used for evaluation of fear among Pakistani dentists. Data was entered and analyzed using SPSS version 21. One way ANOVA, chi-square and independent t-test were used for statistical analysis. P-value <0.05 was considered as significant.
RESULTS: The overall mean FCV-19S score was 26.22 ± 4.907, which is on the higher end. Females showed higher fear scores as compared to males (p<0.001). A statistically significant difference between the scores of General Dental Practitioners (GDP) and specialists was also observed (p<0.001), Statistically, a significant difference was observed between all 4 age groups of dentists, young and elderly dentists demonstrating higher scores (F (3,382) = 8.618, p< 0.001).
CONCLUSION: We conclude that due to the current COVID-19 crisis, majority of the dentists of Pakistan are afraid and among them, females, GDPs, young and elderly dentists are found to be more anxious and have a greater fear of getting infected by coronavirus during COVID 19 Pandemic.
KEYWORDS: Anxiety, Fear, Pakistani, Dentist, COVID-19
HOW TO CITE: Majeed MM, Saleem Z, Sarwar H, Ramzan Z, Iqbal SN, Naeem MM. The psychology of coronavirus fear: Are dentists of pakistan suffering from corona-phobia?. J Pak Dent Assoc 2021;30(1):1-6.
DOI: https://doi.org/10.25301/JPDA.301.1
Received: 15 July 2020, Accepted: 11 November 2020
Download PDF