Restoration of Anterior Teeth Using Minimal Invasive Esthetic Techniques with Opalusture and Composite Restoration: A Clinical Technique

Farah Mushtaq                            BDS, FCPS, CHPE

Discoloration is one of the important reasons for restoration of anterior teeth in esthetic zone. Dental fluorosis is among common
discoloration. Main reason for fluorosis is that concerned person residing in area with high fluoride content in community
drinking water supply. In this case report, a 45year old male patient reported with esthetic concern due to discoloration in
anterior teeth which was in turn diagnosed to be fluorosis and eventually treated with minimal invasive techniques including
combination of microabrasion ,macroabrasion and direct composite veneers.
KEYWORDS: Fluorosis,Tooth discoloration,Enamel microabrasion,Dental veneers
HOW TO CITE: Mushtaq F. Restoration of anterior teeth using minimal invasive esthetic techniques with opalusture and
composite restoration: a clinical technique. J Pak Dent Assoc 2023;32(4):138-140.
DOI: https://doi.org/10.25301/JPDA.324.138
Received: 08 June 2023, Accepted: 21 February 2024

INTRODUCTION
Tooth discoloration is a dental condition, which effect teeth either intrinsically or extrinsically. The field of cosmetic dentistry was introduced to address such esthetics issues of the patient. There are two types of discoloration intrinsic and extrinsic. Among them fluorosis is a common reported discoloration in areas of high water fluoride content in water supply.1,2
Dental fluorosis primarily effect the anterior esthetic dental zone.Enamel opacities are created in the effected area due to decrease mineral content both in deep and superfacial areas. Basic mechanism behind this discoloration is retard activity of ameoloblast during enamel matrix formation and the enamel mineralization stages. Such discolorations are white in color in initial stages brown in severe cases,which is esthetically displeasing to patient. The frequency of these defects ranges between 8.3 and 51.6%.3,4
For correction of discoloration associated with enamel defects especially fluorosis, minimal invasive dentistry approaches were opted. It includes tooth bleaching procedures, microabrasion,macroabrasion and direct veneering techniques.5 Superfacial mild defects of fluorosis are treated with the help of microabrasion technique,which uses abrasive particles long with prophy cups on tooth surfaces. Macroabrasion involves the use of bur for removing discolored area in case of more severity. Some cases involves the hybrid technie of minimal invasive dentistry.6 In this report, we describe a patient with moderate DF who was successfully treated with a minimally invasive esthetic technique, including enamel microabrasion, macroabrasion and direct composite veneers.

CASE REPORT
45 year old male patient resident of Lahore from moderate socio economic status reported to Out patient diagnosis of Operative department Rawal Institute of Health Sciences on Ist July 2021. He complained of brown patches in his anterior maxillary teeth and wanted to improve their color and appearance. The problem was here for 10 years. Patient gave history of fall 30 years before.He started noticing change in color of the teeth with patches for 5-6 years. He underwent root canal treatment of one anterior tooth 3 years back. Medical and drug history were non contibutory. Extraoral clinical examination was normal. On intraoral examination,gingiva and soft tissue mucosa were normal. On examination of dentition there was mild staining in all anterior teeth along with brown discoloration in middle third of #11,#12,#21 with normal investigations and teeth were vital. All other teeth were normal with no obvious finding and good oral hygiene.Radiographic examination showed normal periodontal support. Occlusal examination patient showed normal bilateral class I molar occlusal relationship. Definitive diagnosis was of brown discoloration due to past trauma history of primary predecessors teeth of #11,#12,#21 (Fig 1,2).
Minimal invasive treatment option were considered as


initial modality including microabrasion with opalusture of #11,#12,#21. If the color was removed with this treatment no further treatment was planed, however if it stays than direct composite veneers options will be considered and proposed to patient. The plan was explained as a whole to the patient and informed consent was taken.
In the initial step, teeth were cleaned with pumice paste, Pre shade matching of the teeth were done ,which was found to be A3, it was done after cheek retraction. Rubber dam isolation of the concerned teeth along with flowable composite further improving the gingival seal was done (Fig 3,4,5).


Superfacial teeth layer were freshen off with bur provided in opalusture kit. Opalusture kit was used for microabrasion (Figure 6,7,8). A slurry mixture (Opalustre, Ultradent Products, Inc., South Jordan, UT, USA) was placed labialy


on brown discolored area of incisors.Then rubbed off with rubber cups,provided with in the kit.5 applications of opalusture was done.(Figure 9,10,11). Minimally macroabrasion was also performed on these teeth with water-cooled fine tapered diamond bur (no. 3195 FF; Mani Inc., Utsunomiya, Japan) (Figure 12,13). Shade was matched


again. Teeth were than restored with direct composite veneers. Teflon tape was used for protecting the adjacent teeth. Teeth were finished and polished in final step and compared with pre treatment photograph (Figure 14,15,16,17,18).

DISCUSSION
Oftenly minimal invasive dentistry procedures for esthetic improvements such as microabrasion produces satisfactory result for the patient.7 These procedures remove superficial enamel defects and hence improve esthetics. Procedure of microabrasion involves use of acid such as 18%hydrochloric acid in combination with slurry of pumice. It removes 100 µm of superfacial enamel layer. In present case lower concentration of hydrochloric acid 6.6% abrasive microparticles of silicon carbide were used. Enamel microabrasion using acidic/abrasive products is a noninvasive, conservative, and a time-saving approach which gives immediate and permanent esthetic results to patients.8
Minimal veneer preparation (0.3 mm cervical third, 0.5 mm middle third, 0.7 mm incisal third, no incisal and no interproximal reduction) was done that allows to conserve tooth structure with supragingival margins.9
In recent year ,new materials with improved mechanical and esthetic properties are introduced in the market IPS Empress Direct is a universal nano hybrid filling material for direct esthetic restorative procedures that is claimed by the manufacturers to combine the esthetic qualities of ceramics as well as convenient handling characteristics of composites providing high polishability and life-like fluorescence to the restoration.5,10,11 Present case use nano hybrid direct filling material for restoration of the concerned teeth of patient. Hence giving improve results.

CONCLUSION
Combination of minimal invasive dentistry techniques for improving teeth appearance is a good option to address cases with mild to moderate discoloration.

REFERENCES
1.Philippa Hoyle, Lyndsey Webb and Peter Nixon Severe Fluorosis Treated by Microabrasion and Composite Veneers. 2017. Dent Update 2017; 44: 93-98 https://doi.org/10.12968/denu.2017.44.2.93
2. Meireles SS, Goettems ML et.al. Dental Fluorosis Treatment Can Improve the Individuals’ OHRQoL? Results from a Randomized Clinical Trial. .Braz Dent J. 2018;29:109-116.
https://doi.org/10.1590/0103-6440201801733
3. Wang Q,Meng Q,Meng J. Minimally invasive esthetic management of dental fluorosis: a case report.J Int Med Res. 2020;48 https://doi.org/10.1177/0300060520967538
4.GencerMDG,KirziogluZ.A comparison of the effectiveness of resin infiltration and microabrasion treatments applied to developmental enamel defects in color masking. Dent Mater J. 2019;38:295-302.
https://doi.org/10.4012/dmj.2018-074
5. Nevárez-Rascón M, Molina-Frechero N et.al.Effectiveness of a microabrasion technique using 16% HCL with manual application on fluorotic teeth: A series of studies.World J Clin Cases. 2020;8:743-56.
https://doi.org/10.12998/wjcc.v8.i4.743
6. Celik EU, Yazkan B, Yildiz G, Tunac AT.Clinical performance of a combined approach for the esthetic management of fluorosed teeth: Three-year results..Niger J Clin Pract. 2017 ;20:943-951.
https://doi.org/10.4103/1119-3077.180066
7. Gaião U, Pasmadjian ACP et al. Macroabrasion and/or Partial Veneers: Techniques for the Removal of Localized White Spots..Case Rep Dent. 2022 https://doi.org/10.1155/2022/3941488
8. Hasmun N, Lawson J et.al.Change in Oral Health-Related Quality of Life Following Minimally Invasive Aesthetic Treatment for Children with Molar Incisor Hypomineralisation: A Prospective Study. Dent J (Basel) 2018;6:61.
9. Dua P, Londhe SM, Dua G, Kotwal A, Gupta S .Clinical evaluation of “componeers” and direct composite veneers using minimally invasive enamel preparation technique: In vivo study.J Indian Prosthodont Soc. 2020;20:424-430.
https://doi.org/10.4103/jips.jips_95_20
10. Shahroom NSB , Mani G , Ramakrishnan M. Interventions in management of dental fluorosis, an endemic disease: A systematic review. J Family Med Prim Care. 2019;8:3108-113.
https://doi.org/10.4103/jfmpc.jfmpc_648_19
11. Somani C, Taylor GD, Garot E, Rouas P, Lygidakis NA, Wong FSL. An update of treatment modalities in children and adolescents with teeth affected by molar incisor hypomineralisation (MIH): a systematic review. Eur Arch Paediatr Dent. 2022;23:39-64.
https://doi.org/10.1007/s40368-021-00635-0

Restoration of Anterior Teeth Using Minimal Invasive Esthetic Techniques with Opalusture and Composite Restoration: A Clinical Technique

Farah Mushtaq                       BDS, FCPS, CHPE

Discoloration is one of the important reasons for restoration of anterior teeth in esthetic zone. Dental fluorosis is among common
discoloration. Main reason for fluorosis is that concerned person residing in area with high fluoride content in community
drinking water supply. In this case report, a 45year old male patient reported with esthetic concern due to discoloration in
anterior teeth which was in turn diagnosed to be fluorosis and eventually treated with minimal invasive techniques including
combination of microabrasion ,macroabrasion and direct composite veneers.
KEYWORDS: Fluorosis,Tooth discoloration,Enamel microabrasion,Dental veneers
HOW TO CITE: Mushtaq F. Restoration of anterior teeth using minimal invasive esthetic techniques with opalusture and
composite restoration: a clinical technique. J Pak Dent Assoc 2023;32(4):138-140.
DOI: https://doi.org/10.25301/JPDA.324.138
Received: 08 June 2023, Accepted: 21 February 2024

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Predictive Role of Oral Biomarkers and Periodontal Status in Gestational Diabetes Mellitus: A Review of Literature

Aisha Wali                                     BDS, MPH, PhD
Saadia Akram                               MBBS, FCPS
Maaz Asaad                                  BDS, MDSC

Gestational Diabetes Mellitus (GDM) is a type of diabetes that occurs during pregnancy in women who did not previously have diabetes. It is characterized by high blood sugar levels that develop during pregnancy and typically resolve after childbirth.
GDM occurs when the body is unable to produce enough insulin to meet the increased demand during pregnancy or when the
body becomes resistant to the action of insulin. It can have significant implications for both the mother and the baby if not
managed properly.In Pakistan, GDM prevalence is reported to be from 4 to 10%. While Asian countries report a wide range
from 1.2 to 49.5%, largely accounting for differences in diagnostic criteria, sample size, and population source.
KEYWORDS: gestational diabetes, pregnant women, biomarkers, prevalence
HOW TO CITE: Wali A, Akram S, Asaad M. Predictive role of oral biomarkers and periodontal status in gestational diabetes
mellitus: A review of literature. J Pak Dent Assoc 2023;32(4):130-137.
DOI: https://doi.org/10.25301/JPDA.324.130
Received: 23 August 2023, Accepted: 18 January 2024

INTRODUCTION
Gestational Diabetes Mellitus (GDM) is a type of diabetes that occurs during pregnancy in women who did not previously have diabetes.1 It is characterized by high blood sugar levels that develop during pregnancy and typically resolve after childbirth. GDM occurs when the body is unable to produce enough insulin to meet the increased demand during pregnancy or when the body becomes resistant to the action of insulin. It can have significant implications for both the mother and the baby if not managed properly.2
The exact cause of GDM is not entirely understood, but it is believed to result from a combination of hormonal, genetic, and lifestyle factors. During pregnancy, certain hormones produced by the placenta, such as human placental lactogen, estrogen, and progesterone, can cause insulin resistance. This is a normal physiological response to ensure that an adequate supply of glucose is available for fetal growth and development.3,4
However, in some women, insulin resistance becomes excessive, and the pancreas may not be able to produce enough insulin to overcome it. As a result, glucose accumulates in the blood, leading to gestational diabetes.5

PREVALENCE OF GESTATIONAL DIABETES MELLITUS (GDM)
On a global scale, it is estimated that about 1 in 7 births are affected by gestational diabetes.6 However, prevalence rates have been seen to differ significantly between regions and ethnic groups. Certain ethnic groups, such as South Asian, Hispanic, African-American, and Native American women, have a higher predisposition to gestational diabetes.7 In Pakistan, the prevalence of gestational diabetes mellitus (GDM) ranges from 4% to 10%, Asian countries reported a broader range from 1.2% to 49.5%, which largely results from differences in diagnostic criteria, sample sizes, and population sources.9

GENERIC RISK FACTORS FOR GESTATIONAL DIABETES MELLITUS
The prevalence of gestational diabetes is influenced by various other factors that can increase the likelihood of developing gestational diabetes. These include: Family History: Having a family history of diabetes, especially a first-degree relative (parent or sibling) with type 2 diabetes, increases the risk of gestational diabetes.10
Maternal Age: Older Women who are older, particularly over the age of 25 or 30, have a higher risk of developing gestational diabetes.5
Body Mass Index (BMI): Women with a higher pre-pregnancy BMI, especially those who are overweight or obese, have an increased risk of gestational diabetes.11 Previous History of Gestational Diabetes: If a woman has had gestational diabetes in a previous pregnancy, she is at a higher risk of developing it again in subsequent pregnancies.12
Polycystic Ovary Syndrome (PCOS): Women with PCOS have a higher likelihood of developing gestational diabetes.13-18
Glycemic Markers: Abnormal blood glucose levels before pregnancy or early in pregnancy may indicate an increased risk of gestational diabetes.
Pregnancy with Twins or Triplets: Women carrying multiple fetuses are at a higher risk of developing gestational diabetes.19
Sedentary Lifestyle: Lack of physical activity and a sedentary lifestyle can contribute to an increased risk of gestational diabetes.20,21
Hypertension: Pre-existing high blood pressure or hypertension can be a risk factor for gestational diabetes.22

MOLECULAR BASIS OF GESTATIONAL DIABETES MELLITUS
The exact molecular basis of GDM is not fully understood, but it is believed to result from a combination of genetic and environmental factors. Some of the key molecular factors that contribute to the development of GDM include:
Insulin Resistance: Insulin resistance occurs when the body’s cells become less responsive to the effects of insulin, a hormone responsible for regulating blood sugar levels. During pregnancy, certain hormones like estrogen, progesterone, and human placental lactogen increase, leading to insulin resistance. This helps ensure that enough glucose is available for fetal development. However, in some women, insulin resistance becomes excessive, leading to high blood sugar levels and GDM.23
Beta-cell Dysfunction: Beta cells in the pancreas are responsible for producing and secreting insulin. In some cases of GDM, the beta cells may not function properly, leading to insufficient insulin production to overcome insulin resistance. This results in elevated blood glucose levels.4
Genetics: Family history and genetic factors can play a role in predisposing some women to develop GDM. Certain genetic variations may affect how the body processes glucose and insulin, increasing the risk of developing diabetes during pregnancy.24
Adipokines and Inflammation: Adipokines are signaling molecules produced by adipose tissue (fat cells). During pregnancy, the increased production of certain adipokines can lead to inflammation and interfere with insulin signaling, contributing to insulin resistance.25
Placental Hormones: The placenta, an organ that develops during pregnancy, produces various hormones that can affect glucose metabolism. Some of these hormones can promote insulin resistance and impact glucose regulation.5
Epigenetic Changes: Epigenetic modifications, which involve changes in gene expression without altering the underlying DNA sequence, can influence how certain genes related to glucose metabolism are expressed. These changes can be influenced by environmental factors, such as diet and lifestyle, and may contribute to the development of GDM.26
Oxidative Stress: Pregnancy is associated with increased oxidative stress, which occurs when there is an imbalance between reactive oxygen species (ROS) production and the body’s ability to neutralize them with antioxidants. Oxidative stress can impair insulin signaling and contribute to insulin resistance.27
GDM is a complex condition, and the interplay of these molecular factors may vary from one individual to another. Research into the molecular basis of GDM is ongoing, and a better understanding of these mechanisms may lead to improved prevention and management strategies for GDM in the future.

PREDICTIVE BIOMARKERS IN GESTATIONAL DIABETES MELLITUS
Predictive biomarkers in gestational diabetes mellitus (GDM) are biological indicators that can help identify women at risk of developing GDM during pregnancy. Early identification of these individuals allows for timely interventions and better management of the condition.28 Several potential predictive biomarkers have been studied, although more research is needed to establish their clinical utility fully. Some of the promising predictive biomarkers for GDM include:
Maternal characteristics: Certain maternal characteristics,such as age, pre-pregnancy body mass index (BMI), family history of diabetes, and previous history of GDM, can be indicative of an increased risk for developing GDM.29 Glycemic Indicators: Biomarkers related to glucose metabolism, such as fasting plasma glucose levels, oral glucose tolerance test (OGTT) results, and glycated hemoglobin (HbA1c) levels, are commonly used to diagnose GDM and can also indicate a higher risk for the condition.30
Adipokines: Adipokines are signaling molecules produced by adipose tissue (fat cells). Higher levels of certain adipokines, such as adiponectin and leptin, have been associated with insulin resistance and an increased risk of GDM.31
Insulin Sensitivity Markers: Biomarkers that reflect insulin sensitivity, such as homeostatic model assessment for insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI), can provide insights into the risk of developing GDM.32
Hormones from Placenta: The placenta produces various hormones during pregnancy, some of which can influence glucose metabolism. Biomarkers like placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1) have been studied for their association with GDM risk.33
Genetic Markers: Specific genetic variations may be associated with an increased risk of GDM. Identifying these genetic markers could help predict susceptibility to GDM in certain populations.24
Inflammatory Markers: Increased levels of inflammatory markers, such as C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-alpha), have been linked to insulin resistance and may serve as potential biomarkers for GDM risk.34
Chronic inflammation may also promote oxidative stress, which further exacerbates insulin resistance. Several inflammatory markers have been studied in relation to GDM.36
C-Reactive Protein (CRP): CRP is a protein produced by the liver in response to inflammation. Elevated levels of CRP have been associated with insulin resistance and an increased risk of GDM. High CRP levels during pregnancy may indicate a state of chronic inflammation, which can impair glucose regulation.37,38
Tumor Necrosis Factor-alpha (TNF-alpha): TNF-alpha is a pro-inflammatory cytokine that plays a role in inflammation and immune responses. Increased levels of TNF-alpha have been linked to insulin resistance and impaired glucose metabolism, potentially contributing to the pathogenesis of GDM.39,40
Interleukin-6 (IL-6): IL-6 is another pro-inflammatory cytokine that can promote insulin resistance. Higher levels of IL-6 have been associated with an increased risk of GDM.37
Interleukin-1 beta (IL-1): IL-1β is a pro-inflammatory cytokine involved in the inflammatory response. Elevated levels of IL-1β have been linked to impaired insulin secretion and glucose intolerance, which may contribute to GDM development.38
Adiponectin: Adiponectin is an adipokine with anti inflammatory properties. It plays a role in insulin sensitivity and glucose metabolism. Low levels of adiponectin have been observed in women with GDM, potentially indicating reduced insulin sensitivity.31
Leptin: Leptin is another adipokine that regulates energy balance and metabolism. Higher leptin levels have been associated with insulin resistance and an increased risk of GDM.31
It is important to note that the relationships between these inflammatory markers and GDM are complex and multifactorial. The exact mechanisms by which inflammation contributes to GDM development are still not fully understood.
Further research is needed to better understand the role of inflammatory markers in GDM and their potential as targets for therapeutic interventions or predictive tools for identifying women at risk of developing GDM.

PREDICTIVE ROLE OF INFLAMMATORY MARKERS IN GDM
The predictive role of inflammatory markers in gestational diabetes mellitus (GDM) has been a subject of research to identify potential risk factors and develop early detection methods for the condition.
While inflammatory biomarkers show promise, they are not yet routinely used for predicting GDM in clinical practice. Further research and validation studies are necessary to establish their accuracy and reliability. GDM prediction is a complex process, and a combination of biomarkers and clinical risk factors will provide reliable prediction models in the future.

ELEVATED INFLAMMATORY MARKERS FROM SOURCES OTHER THAN PREGNANCY
Inflammation is the body’s natural response to infection, injury, or other stimuli. While inflammation is a normal and essential part of the immune response, chronic or excessive inflammation can be harmful and is associated with various health conditions. Elevated inflammatory markers can result from various sources other than pregnancy.
It is important to note that elevated inflammatory markers are not specific to any one condition or source. They are general indicators of inflammation in the body and may require further evaluation to determine the underlying cause. Additionally, while inflammation is a part of the body’s defense mechanism, chronic inflammation can contribute to the development and progression of various diseases.41
Conditions like rheumatoid arthritis, lupus, inflammatory bowel disease (IBD), and multiple sclerosis involve the immune system attacking the body’s tissues, leading to chronic inflammation and elevated inflammatory markers.42
Excess body fat, particularly in the abdominal region, is associated with increased production of inflammatory cytokines and adipokines, leading to chronic low-grade inflammation. Smoking and exposure to tobacco smoke can cause inflammation in the respiratory system and increase inflammatory markers in the bloodstream.
Prolonged stress can lead to the release of stress hormones, which can promote inflammation and elevate inflammatory markers. A diet high in processed foods, saturated fats, and refined sugars can promote inflammation, while a diet rich in fruits, vegetables, and healthy fats can have anti-inflammatory effects.
Trauma or injuries to the body can lead to local inflammation as part of the healing process. Conditions such as type 2 diabetes, cardiovascular disease, and chronic kidney disease are associated with chronic inflammation and elevated inflammatory markers. Exposure to pollutants, chemicals, or allergens can trigger an inflammatory response. Most importantly bacterial, viral, or fungal infections can trigger an immune response, leading to elevated inflammatory markers such as C-reactive protein (CRP), white blood cell count (WBC), and pro-inflammatory cytokines. These among others include common oral diseases which affect almost half of the world’s population.39

ELEVATED INFLAMMATORY MARKERS IN ORAL AND PERIODONTAL DISEASES
Elevated inflammatory markers have been observed in various oral diseases, especially in chronic inflammatory conditions like periodontal disease. Periodontal disease is a common oral condition characterized by inflammation and infection of the tissues surrounding and supporting the teeth.
The inflammatory markers raised in periodontal disease include C-Reactive Protein (CRP). Tumor Necrosis Factor alpha (TNF-alpha), Interleukin-6 (IL-6), Interleukin-1 beta (IL-1β), and Matrix Metalloproteinases (MMPs).43
MMPs are enzymes that contribute to the breakdown of connective tissue in the periodontium. Their elevated levels are associated with tissue destruction in periodontal disease. Other acute-phase proteins, such as fibrinogen, haptoglobin, and serum amyloid A, may also be elevated in response to periodontal inflammation.43
It is important to note that while elevated inflammatory markers are commonly observed in periodontal disease, they are not specific to this condition. Other oral diseases, such as dental abscesses, oral infections, and oral cancers, may also result in increased inflammatory markers.43
Inflammatory markers released in response to periodontal disease can not only affect the local tissues in the oral cavity but also enter the bloodstream and potentially contribute to systemic inflammation. Chronic inflammation in the body is associated with an increased risk of various health conditions, including cardiovascular disease, rheumatoid arthritis, diabetes, and GDM among others.44,45

POTENTIAL CONTRIBUTION OF PERIODONTAL DISEASE IN ELEVATION OF INFLAMMATORY MARKERS IN GDM
There is evidence to suggest that oral diseases, particularly periodontal disease, may contribute to the elevation of inflammatory markers in gestational diabetes mellitus (GDM). This potential contribution of oral diseases, especially periodontal disease, in the elevation of inflammatory markers in GDM, can be explained through several mechanisms:
Chronic Inflammation: Periodontal disease is characterized by chronic inflammation of the gums and surrounding tissues due to the presence of dental plaque and bacteria. This chronic inflammation leads to the release of pro-inflammatory cytokines, such as interleukin-1 beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha), in the periodontal tissues.46
Bacterial Products: The bacteria present in dental plaque can release toxic byproducts and endotoxins that further stimulate the inflammatory response. These bacterial products can enter the bloodstream and contribute to systemic inflammation, potentially impacting glucose metabolism and insulin resistance.46
Immune System Activation: The body’s immune response to the bacterial invasion in periodontal disease involves the activation of immune cells, such as neutrophils and macrophages. These immune cells release inflammatory mediators, which can circulate in the blood and contribute to systemic inflammation.46
Endothelial Dysfunction: Chronic inflammation associated with periodontal disease can lead to endothelial dysfunction, impairing the function of blood vessel walls. This dysfunction may promote inflammation and insulin resistance, contributing to GDM.46
Oxidative Stress: Periodontal disease is associated with increased oxidative stress in the oral cavity. Oxidative stress can trigger the release of inflammatory cytokines and contribute to systemic inflammation.27
Immune-Mediated Mechanism: Inflammatory mediators from periodontal disease can activate immune-mediated pathways that impact glucose metabolism and insulin sensitivity.
It is noteworthy that while research has shown associations between periodontal disease and inflammatory markers in GDM, not all women with periodontal disease will develop GDM, and other factors also contribute to the development of GDM. GDM is a complex condition influenced by genetic, hormonal, and lifestyle factors. Therefore, further research is needed to fully understand the role of periodontal disease in the inflammatory response and its impact on GDM development.47

THE COMMONALITY OF INFLAMMATORY MARKERS RELATED TO GDM AND PERIODONTAL DISEASES
Inflammatory markers related to gestational diabetes mellitus (GDM) and periodontal diseases share some commonalities due to the inflammatory processes involved in both conditions. Both GDM and periodontal diseases are characterized by chronic inflammation, and as a result, there is an overlap in the inflammatory markers that may be elevated in both conditions.
Elevated levels of Tumor Necrosis Factor-alpha (TNF-alpha), Interleukin-6 (IL-6), Interleukin-1 beta (IL-1β), and Matrix Metalloproteinases (MMPs) are seen in both GDM and periodontal diseases. Some adipokines, such as adiponectin and leptin, are associated with insulin resistance and inflammation, and their levels may be altered in both GDM and periodontal diseases. While these inflammatory markers are commonly observed in both GDM and periodontal diseases, it’s important to note that the specific patterns and levels of these markers may vary between individuals and disease severity. Additionally, while there is evidence suggesting an association between periodontal disease and GDM, more research is needed to fully understand the underlying mechanisms and potential causality between these two conditions.48

CORRELATION BETWEEN PERIODONTAL DISEASE AND GESTATIONAL DIABETES
Some studies have found an association between periodontal disease and gestational diabetes. Pregnant women with periodontal disease may have an increased risk of developing gestational diabetes compared to those without periodontal disease. Both periodontal disease and gestational diabetes involve inflammation. It is hypothesized that the chronic inflammation caused by periodontal disease may contribute to insulin resistance and impaired glucose metabolism, increasing the risk of gestational diabetes.
Hormonal changes during pregnancy can affect oral health, making pregnant women more susceptible to periodontal disease. Conversely, periodontal disease may also impact hormonal regulation, potentially influencing the development of gestational diabetes.
Hormonal changes during pregnancy can affect oral health, making pregnant women more susceptible to periodontal disease. Conversely, periodontal disease may also impact hormonal regulation, potentially influencing the development of gestational diabetes.
Periodontal disease and gestational diabetes share common risk factors, such as obesity, poor oral hygiene, smoking, and a history of diabetes. These shared risk factors may contribute to the observed correlation between the two conditions.49
While studies have found associations between periodontal disease and gestational diabetes, the exact nature of the relationship is still being investigated. The evidence suggests that addressing periodontal disease during pregnancy may help reduce the risk of gestational diabetes and improve overall maternal and fetal health. However, further research is needed to establish a causal relationship and determine the precise mechanisms linking the two conditions.
Periodontal Status as a Predictor of Gestational Diabetes Research suggests that periodontal status may serve as a potential predictor for gestational diabetes. Several studies have explored the association between periodontal disease and the risk of developing gestational diabetes, with some findings indicating that the presence and severity of periodontal disease may increase the likelihood of developing gestational diabetes. Periodontal status has been proposed as a potential screening tool to identify women at higher risk of developing gestational diabetes. Some studies suggest that the presence of periodontal disease can be an independent predictor for gestational diabetes, regardless of other risk factors such as age, BMI, and previous history of gestational diabetes.
Chronic inflammation associated with periodontal disease may contribute to insulin resistance, a key factor in the development of gestational diabetes. It is hypothesized that the inflammatory mediators released during periodontal disease can impact insulin sensitivity and glucose metabolism, increasing the risk of gestational diabetes.50
Interventions targeting periodontal health during pregnancy have shown promising results in reducing the risk of gestational diabetes. Treating periodontal disease through dental procedures such as scaling and root planning or providing oral hygiene education and support has been associated with a lower incidence of gestational diabetes. Whilst there is evidence supporting the relationship between periodontal status and gestational diabetes, further research is necessary to establish a definitive cause-and-effect relationship and determine the clinical implications of using periodontal status as a predictor for gestational diabetes.51

CONFLICT OF INTEREST
None declared

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32. Paracha AI, Haroon ZH, Aamir M, Bibi A. Diagnostic Accuracy of Markers of Insulin Resistance (HOMA-IR) and Insulin Sensitivity (QUICKI) in Gestational Diabetes. J Coll Physicians Surg Pak 2021; 31:1015-1019.
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33. Dali-Youcef N, Mecili M, Ricci R, Andrès E. Metabolic inflammation: connecting obesity and insulin resistance. Ann Med. 2013;45:242-53. https://doi.org/10.3109/07853890.2012.705015
34. Ozgu-Erdinc AS, Yilmaz S, Yeral MI, Seckin KD, Erkaya S, Danisman AN. Prediction of gestational diabetes mellitus in the first trimester: comparison of C-reactive protein, fasting plasma glucose, insulin and insulin sensitivity indices. J Matern Fetal Neonatal Med. 2015;28:1957-62. https://doi.org/10.3109/14767058.2014.973397
35. Kinneret, Tenenbaum-Gavish., Adi, Sharabi-Nov., Dana, Binyamin., Holger, Jon, Møller., David, Danon., Lihi, Rothman., Eran, Hadar., Ana, Idelson., Ida, Vogel., Omry, Koren., Kypros, H., Nicolaides., Henning, Grønbæk., Hamutal, Meiri. First trimester biomarkers for prediction of gestational diabetes mellitus. Placenta, (2020).
https://doi.org/10.1016/j.placenta.2020.08.020
36. Lungile, Khambule., Jaya, A., George. The Role of Inflammation in the Development of GDM and the Use of Markers of Inflammation in GDM Screening. Advances in Experimental Medicine and Biology, (2019).;1134:217-242.
https://doi.org/10.1007/978-3-030-12668-1_12
37. Fasshauer M., Blüher M., Stumvoll M. Adipokines in gestational diabetes. Lancet Diabetes Endocrinol. 2014; 2:488-499.
https://doi.org/10.1016/S2213-8587(13)70176-1
38. Corbett JA, Sweetland MA, Wang JL, et al. Nitric oxide mediates cytokine-induced inhibition of insulin secretion by human islets of Langerhans. Proc Natl Acad Sci U S A 1993;90:1731-5.
https://doi.org/10.1073/pnas.90.5.1731
39. Abell SK, De Courten B, Boyle JA, Teede HJ. Inflammatory and Other Biomarkers: Role in Pathophysiology and Prediction of Gestational Diabetes Mellitus. Int J Mol Sci. 2015;16:13442-73.
https://doi.org/10.3390/ijms160613442
40. Rodrigo N, Glastras SJ. The Emerging Role of Biomarkers in the Diagnosis of Gestational Diabetes Mellitus. J Clin Med. 2018;7:120. https://doi.org/10.3390/jcm7060120
41. Pahwa R, Goyal A, Jialal I. Chronic Inflammation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493173/
42. Camila, Medeiros, Costa., Matheus, Augusto, Teixeira, Dos, Santos., Andrei, Pereira, Pernambuco., Andrei, Pereira, Pernambuco. Elevated levels of inflammatory markers in women with rheumatoid arthritis. J Immunoassay Immunochemistry 2019; 40:540-554.
https://doi.org/10.1080/15321819.2019.1649695
43. Martínez-García M, Hernández-Lemus E. Periodontal Inflammation and Systemic Diseases: An Overview. Front Physiol. 2021; 12:709438. https://doi.org/10.3389/fphys.2021.709438
44. Ansar W, Ghosh S. Inflammation and Inflammatory Diseases, Markers, and Mediators: Role of CRP in Some Inflammatory Diseases. Biology of C Reactive Protein in Health and Disease. 2016:67-107.
https://doi.org/10.1007/978-81-322-2680-2_4
a45. Kalburgi V, Sravya L, Warad S, Vijayalaxmi K, Sejal P, Hazeil Dj. Role of systemic markers in periodontal diseases: a possible inflammatory burden and risk factor for cardiovascular diseases? Ann Med Health Sci Res. 2014;4:388-92.
https://doi.org/10.4103/2141-9248.133465
46. Abariga SA, Whitcomb BW. Periodontitis and gestational diabetes mellitus: a systematic review and meta-analysis of observational studies. BMC Pregnancy Childbirth. 2016;16:344.
https://doi.org/10.1186/s12884-016-1145-z
47. Roozbeh Khosravi, Khady Ka, Ting Huang, Saeed Khalili, Bich Hong Nguyen, Belinda Nicolau, Simon D. Tran, “Tumor Necrosis Factor-a and Interleukin-6: Potential Interorgan Inflammatory Mediators Contributing to Destructive Periodontal Disease in Obesity or Metabolic Syndrome”, Mediators of Inflammation. 2013, Article ID 728987. https://doi.org/10.1155/2013/728987
48. Armitage GC. Bi-directional relationship between pregnancy and periodontal disease. Periodontol 2000. 2000; 2013(61): 160- 176. https://doi.org/10.1111/j.1600-0757.2011.00396.x
49. de Araujo S, Figueiredo C, Gonçalves Carvalho Rosalem C, et al. Systemic alterations and their oral manifestations in pregnant women: immune, endocrine, and other changes. J Obstet Gynaecol Res. 2017; 43: 16- 22.
https://doi.org/10.1111/jog.13150
50. Damante CA, Foratori GA Junior, de Oliveira Cunha P, Negrato CA, Sales-Peres SHC, Zangrando MSR, Sant’Ana ACP. Association among gestational diabetes mellitus, periodontitis and prematurity: a cross-sectional study. Arch Endocrinol Metab.2022;8:66:58-67.
51. Böhme Kristensen C, Ide M, Forbes A, Asimakopoulou K. Psychologically informed oral health interventions in pregnancy and type 2 diabetes: a scoping review protocol. BMJ Open. 2022;12: e062591.
https://doi.org/10.1136/bmjopen-2022-062591

Predictive Role of Oral Biomarkers and Periodontal Status in Gestational Diabetes Mellitus: A Review of Literature

Aisha Wali                                BDS, MPH, PhD
Saadia Akram                           MBBS, FCPS
Maaz Asaad                              BDS, MDSC

Gestational Diabetes Mellitus (GDM) is a type of diabetes that occurs during pregnancy in women who did not previously have diabetes. It is characterized by high blood sugar levels that develop during pregnancy and typically resolve after childbirth.
GDM occurs when the body is unable to produce enough insulin to meet the increased demand during pregnancy or when the
body becomes resistant to the action of insulin. It can have significant implications for both the mother and the baby if not
managed properly.In Pakistan, GDM prevalence is reported to be from 4 to 10%. While Asian countries report a wide range
from 1.2 to 49.5%, largely accounting for differences in diagnostic criteria, sample size, and population source.
KEYWORDS: gestational diabetes, pregnant women, biomarkers, prevalence
HOW TO CITE: Wali A, Akram S, Asaad M. Predictive role of oral biomarkers and periodontal status in gestational diabetes
mellitus: A review of literature. J Pak Dent Assoc 2023;32(4):130-137.
DOI: https://doi.org/10.25301/JPDA.324.130
Received: 23 August 2023, Accepted: 18 January 2024

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Expectations of Patients Receiving Orthodontic Treatment from Saidu College of Dentistry Swat: A Cross Sectional Study

Erum Behroz Khan                                  BDS, FCPS, CHPE, MTFPDP                                                                              Asad Ullah                                                BDS
Imran Ullah                                               BDS
Muhammad Zaheen                                 BDS

 OBJECTIVE: The aim of this study was to assess the anticipations of orthodontic treatment held by both patients and parents.
This would enable the provision of optimal services for expectations that are rational, while also facilitating discussions or
guidance for expectations that are impractical. One of the key goals of healthcare systems today is to meet patient expectations.
The declaration of a patient’s desires is significant because healthcare providers frequently undervalue their need for treatment.
When a clinician is aware of patient demands, they are better equipped to meet the patient’s realistic expectations while explaining
the least possibility to fulfil arbitrary expectations, thus results in more rewarding therapeutic interventions.
METHODOLOGY: The data collection process involved the utilization of a non-randomized sampling technique, specifically
selecting 300 participants as determined through Epi info using a structured form. The study focused on recruiting new patients
who exhibited internal motivation, along with anatomical or morphological issues related to their teeth or jaws. A prior history
of orthodontic treatment was an exclusion criterion. Participants with craniofacial syndromes or malformations, as well as those
dealing with mental or psychological health conditions, were excluded from the research.
RESULTS: In total, 300 individuals were examined, with 170 females and 130 males. Improvement in facial appearance was
the most popular reason for seeking orthodontic treatment (180 patients out of 300), although other functions like mastication,
better oral health and communication were mentioned by 120 patients. 70% (210) had a thought, since they would receive
treatment, they would be more accepted by society and thus improve their social standing, while the remaining 30% (90) thought
that it would have no difference.
CONCLUSION: Essentially, expectations from orthodontic interventions among patients are quite uniform, although males
generally display more practical perceptions regarding treatment duration and the initial appointment. However, when it comes
to dietary and beverage restrictions during orthodontic treatment, patient expectations differ from those held by their parents.
KEYWORDS: Patient expectations, orthodontics, Evaluate.
HOW TO CITE: Khan EB, Ullah A, Ullah I, Zaheen M. Expectations of Patients Receiving Orthodontic Treatment from Saidu
College of Dentistry Swat: A Cross Sectional Study. J Pak Dent Assoc 2023;32(4):126-129.
DOI: https://doi.org/10.25301/JPDA.324.126
Received: 03 November 2023, Accepted: 21 February 2024

INTRODUCTION
A crucial goal of advanced healthcare systems is to fulfill patient expectations.1 The articulation of a patient’s desires from orthodontic treatment is of considerable significance, as healthcare providers often underestimate the extent of their treatment needs.2 When a clinician possesses knowledge of a patient’s requirements, chances become optimal that they would address the patient’s rational expectations and initiate open discussions concerning idealistic hopes thereby fostering more productive therapeutic dialogues.3 The comprehension of oral health care necessities, patient contentment towards treatment and the overall perception of healthcare system, all hinge on the evaluation of patients’ expectations.4 Discrepancies between patient anticipations towards delivered services are associated with diminished satisfaction.5
The primary objectives of orthodontic treatment should focus upon achieving favorable treatment outcomes, ensuring patient satisfaction while sustaining reasonable costs.6 To achieve this aim, it is critical to use patient surveys, interviews and professional clinical evaluations to meticulously assess and thus document the quality of care.7 Patients with unrealistically high expectations may not be satisfied with even the best care, while those with unrealistically low expectations might be content with subpar care.8 Focusing on the psychological aspects of adult patients, several studies demonstrate that these individuals are more conscious of their malocclusion, leading to extremely high expectations for the outcomes of their therapy.9 It is essential for orthodontists to research and understand the expectations, challenges, and motivations of this expanding population to provide more effective treatment that addresses their concerns.10
Despite the increased popularity, adult orthodontic treatment is not a recent development. Originally mentioned by Pierre Fauchard, who wrote the first book on scientific dentistry, “Le Chirurgien Dentiste,”11 published in 1723, it has been a part of dental care provision for over centuries. In a study involving 200 adult patients aimed to determine the factors that initially led them to reject the idea of receiving orthodontic treatment. Researchers identified factors with the greatest to lowest prevalence, including a lengthy treatment period, discomfort from wearing orthodontic equipment, rejection of the brackets’ unattractive appearance, worries about pain and anxiety over being disappointed with the treatment’s outcome.12
Due to the availability of limited national research data over the expectations of patients before and after orthodontic treatment, we expect this study would be remarkable and would highlight the underlying factors providing valuable insights for orthodontists to better comprehend what patients expect while choosing for years long orthodontic treatment.

METHODOLOGY
This cross-sectional study was conducted at the Orthodontics Department of Saidu College of Dentistry, Swat, from June 19, 2023, to August 17, 2023, following approval from the Ethics Review Board (ERB) with the reference number 71-ERB/023. A non-randomized sampling technique was employed to collect the required data, specifically for 300 participants determined using Epi info on a structured performa.13 New patients who were internally motivated, had anatomical or morphological problems with their teeth or jaws and had never received orthodontic treatment before were included in the study. However, patients with craniofacial syndromes or malformations, as well as those who were mentally or psychologically unwell, were excluded from the research. A self-designed study questionnaire was developed after performing a detailed literature search. Content of questionnaire was validated by other field expert who was not part of this study. Moreover, a pilot study was performed on 30 patients to see the applicability of questionnaire on targeted population. Study questionnaire evaluated only participants’ expectation and did not use a specific scale so cronbach alpha was not calculated as a reliability measure. After doing the pilot, the questionnaire was finalized.
Data were entered and analyzed using SPSS version 24.0. Descriptive statistics were computed, including the mean age and the male-to-female ratio of the patients. A p-value of < 0.05 was considered significant.

RESULTS

Among 300 individuals (170-female and 130-male), Improvement in facial appearance was the most popular reason for seeking orthodontic treatment (180/300), although other functions like mastication, better oral health and communication were also mentioned by 120 patients (Table 1).


Additionally, questions on the patient’s awareness of the oral issue and desire for orthodontic treatment were posed. The results are shown in table 2.


Table 3 listed the patient expectations for orthodontic therapy, only 12 patients anticipated that receiving orthodontic treatment would enhance their quality of life. The majority of them believed that by enhancing their dental health and looks, they could get more social acceptance in the future.


While 70% (210) thought that they would receive treatment, they would be more accepted by society and thus would improve their social standing, while the remaining 30% (90) thought that it made no difference.
The results of the second portion of the questionnaire showed that the majority of patients thought that either the treatment’s results met or, at the very least, exceeded their expectations, only 3% (09) people thought the effort was too great compared to the result, but no one expressed complete dissatisfaction (Table 4).


80% (240) of the patients said that their loved ones had given them encouragement or were thrilled with the treatment’s results. The remaining 20% (60) individuals reported no specific response from those close to them (Table 5).


DISCUSSION
The high response rate in our study suggests that patients generally held a positive outlook and were willing to cooperate. Notably, a previous study indicated that both children and parents exhibited similar expectations for orthodontic treatment,14 reinforcing the importance of understanding the perspectives of both groups. In our cohort, a significant portion of patients and parents did not have specific expectations regarding orthodontic therapy. Interestingly, the anticipation of having an orthodontic appliance placed at the first appointment was lower among parents compared to participants.
However, common expectations included foreseeing pain, discomfort and challenges in speaking, chewing, and maintaining oral hygiene with fixed orthodontic appliances, aligning with findings reported by Miao et al. Moreover, male participants expressed significantly greater expectations of dietary restrictions during orthodontic treatment compared to their female counterparts. This discrepancy may be attributed to a general tendency for men to be less attentive to such constraints.
Strunga et al. review to assess the precision and efficiency of current AI-based systems in comparison to traditional methods for diagnosing, evaluating the progress of patients’ treatment and monitoring stability during follow-up.15 The researchers conducted a thorough investigation utilizing various online databases and identified diagnostic software and dental monitoring software as the most extensively researched programs in contemporary orthodontics. The former, specifically, demonstrates high accuracy in identifying anatomical landmarks crucial for cephalometric analysis. On the other hand, the latter empowers orthodontists to comprehensively monitor each patient, specify desired outcomes, track progress and provide early warnings regarding potential changes in pre-existing pathology. Despite these advancements, there exists limited evidence to evaluate the stability of treatment outcomes and the detection of thus contributing little to aid in patient’s expectation fulfilment. In summary, the study asserts that AI serves as an effective tool for managing orthodontic treatment, spanning from diagnosis to retention, thereby benefiting both patients and clinicians. Patients appreciate the user-friendly nature of the software and perceive improved care, while clinicians can expedite diagnoses, assess compliance and promptly identify issues such as damage to braces or aligners. The review highlights the potential of AI to enhance the overall orthodontic treatment experience for both patients and clinicians involved. Surprisingly, participants did not anticipate public opposition to wearing fixed orthodontic appliances, suggesting a normalization of orthodontic treatment within the community. Remarkably, orthodontic patients held high expectations for achieving straighter teeth and an enhanced smile, with a greater emphasis on the former. This aligns with previous research by Strunga and Bauss, revealing that patients prioritize the alignment of teeth over achieving a great smile.
Interestingly, male participants exhibited higher expectations of having to wear headgear throughout orthodontic treatment compared to their female counterparts. This finding, coupled with their anticipation of greater discomfort and dietary restrictions, suggests that male participants harbored more unfavorable expectations regarding orthodontic treatment. These nuanced insights into patient expectations contribute valuable information for orthodontic practitioners in tailoring treatment plans and addressing potential concerns.

CONCLUSION
Patients tend to have similar expectations when it comes to orthodontic care, but males often demonstrate a higher level of realism regarding treatment duration and the initial appointment. However, there is a contrast in patient expectations compared to their parents’ beliefs, particularly in terms of dietary and beverage restrictions associated with orthodontic treatment.

ACKNOWLEDGEMENT

None

DISCLAIMER

None

CONFLICT OF INTEREST

None to declare

FUNDING DISCLOSURE

None to declare

REFERENCES
1. Bauss O, Vassis S. Prevalence of bullying in orthodontic patients and its impact on the desire for orthodontic therapy, treatment motivation, and expectations of treatment. J Orofacial Orthopedics/Fortschritte der Kieferorthopadie. 2023;84(2).
https://doi.org/10.1007/s00056-021-00343-w
2. Geoghegan F, Birjandi AA, Machado Xavier G, DiBiase AT. Motivation, expectations and understanding of patients and their parents seeking orthodontic treatment in specialist practice. Journal of orthodontics. 2019;46:46-50.
https://doi.org/10.1177/1465312518820330
3. Obilade OA, Da Costa OO, Sanu OO. Patient/parent expectations of orthodontic treatment. Int Orthodontics. 2017;15:82-102. https://doi.org/10.1016/j.ortho.2016.12.005
4. Chiang YC, Wu F, Ko SH. Effective Patient-Dentist Communication with a Simulation System for Orthodontics. InHealthcare 2023. (Vol 11, No. 10, p. 1433). MDPI.
https://doi.org/10.3390/healthcare11101433
5. Hardwick LJ, Sayers MS, Newton JT. Patient’s expectations of lingual orthodontic treatment: a qualitative study. J Orthodontics. 2017;44:21-7. https://doi.org/10.1080/14653125.2017.1281868
6. Pistoni TR, de la Cruz Pérez J, Sánchez IN. Influence of social media on the esthetic perception of the lip profile of orthodontic patients. Heliyon. 2023.
7. Geoghegan F, Birjandi AA, Machado Xavier G, DiBiase AT. Motivation, expectations and understanding of patients and their parents seeking orthodontic treatment in specialist practice. J Orthodontics. 2019;46:46-50.
https://doi.org/10.1177/1465312518820330
8. Sayers MS, Cunningham SJ, Newton JT. How do you identify the patient with ‘high expectations’ of orthodontic treatment: an empirical approach. J Orthodontics. 2020;47:289-93.
https://doi.org/10.1177/1465312520939970
9. Mirzaie M, NaghibiSistani MM, Miar A, RahmariKamel M. Evaluation of expectation of patients and their parents from orthodontic treatment in babol in 2016-2017. Caspian J Dent Res. 2018;7:49-57.
10. Moresca R. Orthodontic treatment time: can it be shortened?. Dent Press J Orthodontics. 2018;23:90-105.
https://doi.org/10.1590/2177-6709.23.6.090-105.sar
11. Khan RS, Horrocks EN. A study of adult orthodontic patients and their treatment. British journal of orthodontics. 2019;18:183-94. https://doi.org/10.1179/bjo.18.3.183
12. Sayers MS, Newton JT. Patients’ expectations of orthodontic treatment: Part 2-findings from a questionnaire survey. J Orthodontics. 2007;34:25-35. https://doi.org/10.1179/146531207225021888
13. Wafaie K, Rizk MZ, Basyouni ME, Daniel B, Mohammed H. Tele orthodontics and sensor-based technologies: a systematic review of interventions that monitor and improve compliance of orthodontic patients. European J Orthodontics. 2023:cjad004.
https://doi.org/10.1093/ejo/cjad004
14. Miao Z, Zhang H, Han Y, Wang L, Wang S. Orthodontic care in orthodontic patients during the COVID-2019 pandemic: emergency, emergency response and orthodontic treatment preference. BMC Oral Health. 2023;23:364.
https://doi.org/10.1186/s12903-023-03066-z
15. Strunga M, Urban R, Surovková J, Thurzo A. Artificial intelligence systems assisting in the assessment of the course and retention of orthodontic treatment. InHealthcare 2023. (Vol. 11, No. 5, p. 683). MDPI.
https://doi.org/10.3390/healthcare11050683

Expectations of Patients Receiving Orthodontic Treatment from Saidu College of Dentistry Swat: A Cross Sectional Study

Erum Behroz Khan                        BDS, FCPS, CHPE, MTFPDP                                                                                            Asad Ullah                                      BDS
Imran Ullah                                     BDS
Muhammad Zaheen                       BDS

 OBJECTIVE: The aim of this study was to assess the anticipations of orthodontic treatment held by both patients and parents.
This would enable the provision of optimal services for expectations that are rational, while also facilitating discussions or
guidance for expectations that are impractical. One of the key goals of healthcare systems today is to meet patient expectations.
The declaration of a patient’s desires is significant because healthcare providers frequently undervalue their need for treatment.
When a clinician is aware of patient demands, they are better equipped to meet the patient’s realistic expectations while explaining
the least possibility to fulfil arbitrary expectations, thus results in more rewarding therapeutic interventions.
METHODOLOGY: The data collection process involved the utilization of a non-randomized sampling technique, specifically
selecting 300 participants as determined through Epi info using a structured form. The study focused on recruiting new patients
who exhibited internal motivation, along with anatomical or morphological issues related to their teeth or jaws. A prior history
of orthodontic treatment was an exclusion criterion. Participants with craniofacial syndromes or malformations, as well as those
dealing with mental or psychological health conditions, were excluded from the research.
RESULTS: In total, 300 individuals were examined, with 170 females and 130 males. Improvement in facial appearance was
the most popular reason for seeking orthodontic treatment (180 patients out of 300), although other functions like mastication,
better oral health and communication were mentioned by 120 patients. 70% (210) had a thought, since they would receive
treatment, they would be more accepted by society and thus improve their social standing, while the remaining 30% (90) thought
that it would have no difference.
CONCLUSION: Essentially, expectations from orthodontic interventions among patients are quite uniform, although males
generally display more practical perceptions regarding treatment duration and the initial appointment. However, when it comes
to dietary and beverage restrictions during orthodontic treatment, patient expectations differ from those held by their parents.
KEYWORDS: Patient expectations, orthodontics, Evaluate.
HOW TO CITE: Khan EB, Ullah A, Ullah I, Zaheen M. Expectations of Patients Receiving Orthodontic Treatment from Saidu
College of Dentistry Swat: A Cross Sectional Study. J Pak Dent Assoc 2023;32(4):126-129.
DOI: https://doi.org/10.25301/JPDA.324.126
Received: 03 November 2023, Accepted: 21 February 2024

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Evaluation of Awareness and Preparedness for Medical Emergencies among Dental Practitioners in Twin Cities of Punjab: A Cross-sectional Study

Fatima Khattak                                   BDS, FCPS                                                                                                                      Syed Zuhair Mehdi                             BDS, MCPS, DHPE
Arooba Mehmood                               BDS
Wajeeha Amer                                     BDS
Kanza Murtaza                                    BDS
Alishba Iftekhar                                  BDS

OBJECTIVE: The purpose of this study was to evaluate the awareness of medical emergencies among dental practitioners,
to assess the degree of expertise and readiness of dental professionals to handle medical crises in their dental practices and to
ascertain if medical emergency medications are offered in dental offices.
METHODOLOGY: A prospective study including 208 practitioners were given access to the survey through Google Form,
along with information on the study and a consent form .The questionnaire consisted of demographic details, years of experience,
and specialty of practitioners and 20 closed-ended questions with 10 assessing knowledge and rest evaluating the competence
and preparedness to handle medical emergencies.
An emergency whether medical or dental is a serious, acute, and unexpected event that requires a quick and timely intervention.
Since some diseases and their treatments increase the likelihood of a medical emergency during dental treatment. The most
often encountered medical emergencies in a dental office are vasovagal syncope, angina pectoris, hypoglycemia, and hypertensive
crisis. One of the mainstays of prevention of medical emergencies is by taking a thorough and detailed history, and vital signs
monitoring and modifying the treatment plan.
RESULTS: A response rate of 96% was achieved by including all 200 of the study’s 450 dental professionals. Just 69% of the
participants had emergency kits on hand, even though roughly 77.5% of the dentists in the study felt confident in their ability
to handle emergencies in the dental office.
CONCLUSION: In this study, dental professionals demonstrated a moderate level of understanding in medical situations, and
many of them have low to moderate perceived competency in managing medical emergencies. Every dental clinic should have
well-communicated emergency protocols in place that should be updated periodically.
KEYWORDS: Medical emergency, Dental Practitioner, Emergency kit, BLS, Dental Clinics
HOW TO CITE: Khattak F, Mehdi SZ, Mehmood A, Amer W, Murtaza K, Iftekhar A. Evaluation of awareness and preparedness for
medical emergencies among dental practitioners in twin cities of Punjab: A cross-sectional study. J Pak Dent Assoc2023;32(4):120-125.
DOI: https://doi.org/10.25301/JPDA.324.120
Received: 12 September 2023, Accepted: 18 January 2024
INTRODUCTION

In the present age, the avoidance of unintended or unexpected harm to patients during the provision of health care has become a priority in dental practice.1 An emergency whether medical or dental is a serious, acute, and unexpected event that requires a quick and timely intervention. Some diseases and their treatments increase the likelihood of a medical emergency during dental treatment.2 According to various studies medical emergencies are faced by most dentist once every year.3
Health-related conditions might cause medical emergency, which can make dental treatment more difficult. About one in twenty general dentists will have to deal with cardiopulmonary rehabilitation at some point in their career, according to a study done in France.4 The dental clinics has a disproportionate amount of medical emergencies, and the professionals there are required to be skilled in managing the same.5
One of the studies conducted in Saudi Arabia6 found that only 4% of the applicants knew the correct management for some numerous emergency conditions & 50.5% of applicants were unable to handle the emergency condition in one of the studies in India.7
A review of the literature reveals that elderly patients with co-morbidities are regarded as having a higher risk of medical emergencies during a variety of dental treatments.8 These medical emergencies most commonly occur during or after local anesthesia administration, mainly during tooth extraction.4 Such emergencies occur more frequently in dental offices due to increased levels of anxiety and stress.9
In addition various other reasons such as inadequate pain management, advanced age, prolonged procedures such as multiple implant insertion, invasive operations, and adverse reactions to medicine or anesthesia can also be one of the few reasons that can precipitate emergency situation in a dental setting.10
Compared to medical clinics, the frequency of medical emergencies in dental clinics is over 5.8 times higher.11 90% of the medical emergrncies are deemed mild, while 8% are highly dangerous and life threatning.12
The most often encountered medical emergencies in a dental office are vasovagal syncope, angina pectoris, hypoglycemia, and hypertensive crisis. One of the mainstay of prevention of medical emergencies is by taking a thorough and detailed history,vital signs monitoring and modifying the treatment plan.13
Few dentists are equipped to handle emergency and urgent episodes that occur in the outpatient department because they lack the necessary expertise. These episodes tend to be impulsive and don’t always follow predictable patterns.3 Each emergency requires a correct diagnosis to be made for effective and safe management.14
When treating medical emergencies, dentists should be knowledgeable about the warning signs, symptoms, diagnosis, and strategies to work with emergency physicians. Insufficient training and an incapacity to handle medical emergencies might lead to disastrous consequences and possibly legal action.15 It is the responsibility of dental professionals to recognize medical emergencies when they occur and to be skilled enough in providing the best care possible.16
Despite having completed an official, approved medical emergency training curriculum as part of their undergraduate and graduate degrees, dentists worldwide nevertheless find it difficult to manage similar situations in dental clinic.5
The dental team must be constantly aware of the nature of these emergencies, be prepared for them, and know how to handle them properly because they put patient’s lives and health in danger and cause emotional stress for the dentists handling them. These emergencies are unpredictable, need to be handled right away.16
There are limited local studies on the general dentist knowledge about emergencies. The results of which indicate the dentist’s knowledge and readiness to be insufficient in this matter.3
The purpose of this study is to evaluate the awareness of medical emergencies among dental practitioners, to ascertain if medical emergency medications are offered in dental offices and to assess the degree of expertise and readiness of dental professionals to handle medical crises in their dental practices.

METHADOLOGY
From June 2022 and September 2022, cross-sectional research was carried out at private dental clinics of twin cities of Punjab.With a predicted population percentage of 50%, a degree of confidence of 95%, margin of error 5%, a research power of 80%, and a population size of 450 dental clinics, the minimum necessary sample size was 208 using the WHO sample size calculator. The IRB of Dental College HITEC-IMS (Dental/HITEC/IRB/30) approved the study and gave it its ethical approval. Before having them fill out the questionnaire, research participants gave their consent. The information was gathered via a self-administered questionnaire. The questionnaire was adapted, with a few changes, from a research of a similar nature conducted in the Kingdom of Saudi Arabia1 by S. AlQahtani. In order to verify the language interpretation, a pilot research with sixteen dental professionals evaluated the face validity of the questionnaire. To capture a variety of viewpoints and experiences, participants with diverse dental specialties (e.g., oral surgeons, orthodontists, general dentists, etc.) were included. Every participant was an assistant professor or higher in title. The questionnaire was filled out by hand by each participant, who also offered comments on the question’s language and clarity. The participants understood the questions without any confusion. Before distributing the questionnaire to the whole sample, the questionnaire was then amended in light of the feedback from the pilot-study participants who were not the part of the main study. The questionnaire’s internal consistency and reliability was checked via Cronbach reliability test and found to be acceptable (coefficient of reliability = 0.7).
About 208 practitioners were then given access to the survey through Google Forms, along with information on the study and a consent form, and 200 full responses were gathered. The questionnaire consisted of demographic details, years of experience, and specialty of practitioners and 20 close ended questions with 10 assessing knowledge and rest evaluating the competence and preparedness to handle ME (level of training, types of emergency drugs and equipment available).
The data were analyzed by Statistical Package for Social Sciences (IBM SPSS version 26.0). Using descriptive statistics, the sample characteristics were assessed. Categorical variables were reported using counts and percentages. Chi-square test was used to compare the categorical variables and assess significant associations. The p value < 0.05 was considered statistically significant.

RESULTS
A response rate of 96% was achieved by including all 200 of the study’s 450 dental professionals. The majority (49%) of study participants were under 30 years old, and 59% of them were female. The majority of participants (69.5%) had a BDS qualification. Summary of demographic characteristics is given in Table 1.


According to the study’s findings 57.5% of the practitioners asked about a patient’s medical history, including any allergies or medication use. Before starting any therapy, only 40% of them took signed informed consent by the patient, around half of them 52.5% took the patient’s vital signs. Around 73.5% reported they are competent enough to treat a pregnant patients while 97% of the practitioners knew how to record BP and blood glucose level. Detailed responses to the knowledge and preparedness questionnaire are given in Table 2.
A significant portion of the participants (83%) knew about CPR and 64% reported to be BLS certified. Just 69% of the participants had emergency kits on hand and roughly 77.5% of the dentists in the study felt confident in their ability to handle emergencies in the dental office. 64.5% participants were confident about administering injections intramuscularly and through intravenous route. Oral glucose,


saline, adrenaline, aspirin, steroids, avil, and diazepam were the most often found emergency medications in emergency kits as reported by the participants of our study shown in figure 1. Most common medical emergency is vasovagal syncope according to current study as shown in figure 2. In term of gender, there was a significant association found with taking consent from patient prior treatment, trained to deal with pregnant patients and BLS certified. Females were


more likely to take consent of patients prior to treatment as compared to males (61.0% vs 42.7%, p=0.011).Females were more likely to be trained to treat and handle pregnant patients at clinics as compared to males (84.7% vs 58.5%, p<0.001) and more females were BLS certified as compared to males (72.0% vs 52.4%, p=0.005).


In terms of qualification, there was a significant association found with awareness about medical emergencies, having and operating oxygen cylinders, confident to give injections and BLS certified. Higher the qualification, more awareness about medical emergencies was found (p=0.001), more likely to have oxygen cylinder at clinics (p<0.001), more awareness regarding operating it (p=0.002), more confident to give IM and IV injections (p=0.035), and more likely to be BLS certified (p=0.006).
In terms of years of experience, there were significant associations found with consulting primary physician for medically compromised patients, having oxygen cylinder at clinic, repositioning chair during medical emergencies and BLS certification. Participants with more than 1 year of experience were more likely to consult with primary physician as compared to those with less experience (p=0.023), more likely to have oxygen cylinder at clinic (p=0.001), more likely to have readjusted chair position during emergencies (p=0.002), and having BLS certification (p=0.030)

DISCUSSION

Emergencies do not happen as frequently in a general practice, but when they do, they can be fatal. By identifying “at-risk” individuals and then giving them the proper care, the possibility of an adverse occurrence can be significantly reduced. Recognizing that any dental patient might encounter a medical emergency while undergoing treatment is a crucial first step.4 The major goal of the current study was to determine if dentists ask about important first steps such as medical history and drug allergy history and record patient’s vital signs, which might give an indication of the likelihood that a medical emergency would arise in the dental office. In the current study total 200 dental practitioners were assessed regarding medical emergencies related awareness and preparedness. Among those 200 participants 82 were males 41% and 118 were females which makes 59%. Study by Gupta et al5 showed 294 females and 207 were males out of 501 participants.
In another study17 29.4% were males and 70.6% females make up the study population. In term of gender, there was a significant association found with taking consent from patient prior treatment, and with training to deal with pregnant patients and more females were BLS certified as compared to males.
According to the findings of the current study, only 57.5% of practitioners complete out proformas and document patient history in their record. This is significantly lower than the findings of a Saudi studies by Al Qahtani et al.4 , Al-Sebaei et al.18 and Egyptian study by Hussain et al.16 who discovered that 87%, 92% and 91.17% of participants questioned about the patient’s medical history. Just a little more chair time is needed for this. Hence before beginning any therapy, proformas must be given to the patient and correctly filled out forms must be obtained. This allows for the necessary safety measures to be taken to avoid the occurrence of such emergency scenarios.6
In our study 52.5% of practitioners noted vital signs. This is higher than a study conducted in Egypt16 where only 41.82% obtained the vital signs of patients and also higher than a study4 done in Saudia where 38% took it during the first visit only and 50% never took it. Conversely study by Verma et al.19 reported about 83.06% record vital signs which is significantly higher than our study. Monitoring vital signs play a critical role in providing indicators, such as elevated temperature induced such by a sickness within the body and increased pulse and respiration caused by stress and fear of treatment. Prior to starting therapy, patients should undergo routine vital sign monitoring as well as a full medical history review and physical examination at the time of admission. The medical histories should also be updated at each visit.4 Every patient who is considered to be medically complicated at the time of intake should seek consultation with the patient’s doctor.6
Treatment success and patient compliance are directly impacted by the dental clinician’s level of confidence in managing medical emergencies. Nevertheless, the type of the medical emergency condition also has a role in the outcome.5 Our study’s data showed that 77.5% of dentists were confident in their ability to handle any emergency situation in their dental office. This is in line with several studies conducted by Al-Iryani et al.20, Seemala Jyotsna et al.21 ,Gupta et al.5 ,Stafuzza et al.22 which reported significantly higher positive response rates of 82%, 61%, 69.9% %, 66% respectively. This is in contrast to other studies10,13,16,23 where only 46.67%, 49.7%, 48.57 %,43.8%, were confident in dealing with medical emergency themselves.
About 68.5% dentists have faced medical emergencies in our study. This is in accordance with an Italian study in which 65.2%24 practitioners encountered at least one emergency event during their professional life. In the current study vasovagal syncope was the most frequent medical emergency encountered by the practitioners followed by hypoglycemia. Vasovagal attack was likewise the most common medical emergency faced by Saudi4, Polish2, Italian24, USA25, Jordan13and Dutch1 dentists.
About 69% of the dental practitioners of our study had emergency kit availability in their dental office. This can be related to dentist’s interest in being ready for medical emergencies. The current conclusion, however, is a substantially larger percentage compared to the results of a studies conducted by Hussein et al.16 (49.35%) and Al Ghanam et al.13 (37.8%). This could be because of a variety of factors, including a lack of training in their use, an underestimation of their importance, the high cost of the equipment and a lack of laws and regulations requiring the provision of life-saving equipment in dental offices in these studies. But our reported percentage is lower than findings of the studies done in India19 and Saudia5 where 82.72% and 85% had emergency kit available at their clinic.
Only 39.5% participants of our study had an oxygen cylinder at their clinic and they have the skills to confidently operate it while majority (60.5%) do not have it in their clinics. This is in line with a study done in Polish dentists2 where only 41% practitioners have oxygen source at their clinics but much higher percentage than a Jordanian study13 where only 9.4% dentists had oxygen supply at their clinics.
According to the data we gathered for our study, the majority of respondents felt comfortable administering intramuscular and intravenous injections (64.5%). This is in accordance with an Iranian study26 where level of confidence was 72%. This confidence was as low as 16%, 30.9%, 27.9%, 34%, 6.6% for intramuscular and intravenous injections in other studies9,17,26 compared to the current study.
Amiri et al.1 suggested that dental clinics stock six critical medications. These are aspirin, nitroglycerin, albuterol/salbutamol, antihistamine, oxygen, and epinephrine. Oral glucose (78.5%) normal saline (71%) adrenaline (62.5%) were the most readily available emergency medication in our study .These findings are consistent with those of Hussein et al.16 Gupta et al.5, Al Qahtani et al.4 Al Ghanam et al.13
In our study 64.5% practitioners were BLS certified and. 35.5% participants were not certified and so not aware of importance of basic life support. This is in accordance with a studies conducted by Tarmidzi et al.17 Sudeep et al.23 while much lower than findings of an Indian27 and Saudi4 study where 94.4% and 100% dental practitioners had knowledge regarding how to perform basic life support and first-aid and all of them had current BLS certification. Our findings indicates that emphasis on BLS training in our region needs to be updated and improved. In order to create a large number of basic life support responders, it is crucial to implement basic life support programs throughout the country.
The dentist is ultimately in charge of effectively handling an emergency scenario in the dental clinic. Lack of training and the incapacity to handle medical crises can have disastrous results and occasionally even legal action.2 Hence, legislation and regulations governing the supply and periodic updating of emergency medical kits are urgently needed.
The key limitations of the study are its cross-sectional design and self-reporting, which make it difficult to assess in-depth the factors causing participant differences. Another limitation is that it was only conducted at private dental offices in twin cities which may limit the applicability of the findings to all dental practitioners in Pakistan working in tertiary care hospitals.

CONCLUSION AND RECOMMENDATIONS
In this study, dental professionals demonstrated a moderate level of understanding in medical situations, and many of them have low to moderate perceived competency and preparedness in managing medical emergencies. After graduation, dentists should be encouraged to attend lectures and workshops biannually for effective management strategies. The preparedness of all practicing dentists when tragic emergency situations arise can be ensured by a standardized national guidelines from governing bodies that covers all the typical medical emergencies in dental settings.

CONFLICTS OF INTEREST

Nil.

ACKNOWLEDGEMENT

Nil.

REFERENCES
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11. Gopinathan PA, Alammari FS, Alsulaim SA, Alotaibi FG, Alanazi AM, Khammash AW,et al. Assessment of Knowledge, Attitude, and Practices of Cardiovascular Medical Emergencies Among Dental Students: An Institutional-Based Cross-Sectional Study. Cureus. 2023;15(11).
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12. Sopka S, Biermann H, Druener S, Skorning M, Knops A, Fitzner C,et al. Practical skills training influences knowledge and attitude of dental students towards emergency medical care. Eur J Dent Educ.2012;16:179 86.
https://doi.org/10.1111/j.1600-0579.2012.00740.x
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14. Greenwood M, G. Meechan J. Management of specific medical emergencies in dental practice. Bri Dent J. 2023;235:789-95.
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15. Obata K, Naito H, Yakushiji H, Obara T, Ono K, Nojima T,et al. Incidence and characteristics of medical emergencies related to dental treatment: a retrospective single-center study. Acute Medi Surg. 2021;8:e651.
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16. Hussein H, Abdelbaqy MA, Ibrahim AA, Farid S, Ibrahim S. Awareness of medical emergencies among dental practitioners in three Egyptian dental schools: A cross-sectional study. Braz Dent Sci. 2021;24(4).
https://doi.org/10.14295/bds.2021.v24i4.2621
17. Tarmidzi NA, Ramli NM, Amran N, Norazmi HN, Arifin NS. Knowledge, Attitude and Perception of Private Dental Practitioners Towards Medical Emergencies in Klang Valley, Malaysia. J Int Dent Medi Res.2022;15:649 55
18. Al-Sebaei MO, Alkayyal MA, Alsulimani AH, Alsulaimani OS, Habib WT. The preparedness of private dental offices and polyclinics for medical emergencies: a survey in Western Saudi Arabia. Saudi Medi J. 2015;36:335.
https://doi.org/10.15537/smj.2015.3.10047
19. Varma LS, Pratap KV, Padma TM, Kalyan VS, Vineela P. Evaluation of preparedness for medical emergencies among dental practitioners in Khammam town: A cross-sectional study. J Ind Assoc Public Health Dent. 2015;13:422-8.
https://doi.org/10.4103/2319-5932.171178
20. Al-Iryani GM, Ali FM, Alnami NH, Almashhur SK, Adawi MA, Tairy AA. Knowledge and preparedness of dental practitioners on management of medical emergencies in Jazan province. Open Access Macedonian J Med Sci. 2018;6:402-405.
https://doi.org/10.3889/oamjms.2018.072
21. Jyotsna S, Murali R, Shamala A, Yalamalli M, Ramachandran A, Rebello EC. Knowledge, attitude and practice related to management of medical emergencies in the dental office among dental practitioners in chikkaballapur district, Karnataka. Int J Drug Res Dent Sci. 2021.9;3:46-53.
22. Stafuzza TC, Carrara CF, Oliveira FV, Santos CF, Oliveira TM. Evaluation of the dentists’ knowledge on medical urgency and emergency. Braz Oral Res. 2014.18;28:1-5.
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23. Sudeep C, Sequeira PS, Jain J, Jain V, Maliyil M. Awareness of basic life support among students and teaching faculty in a dental college in Coorg, Karnataka. Int Dent J Students Res. 2013;2:04-21
24. Varoni EM, Rigoni M, Lodi G, Sardella A, Muti P, Vitello A,et al. Medical emergencies in dental practice: A nationwide web-based survey of Italian dentists. Heliyon. 2023;9(3).
https://doi.org/10.1016/j.heliyon.2023.e13910
25. Sorenson AD, Marusko RM, Kennedy KS. Medical emergencies in the dental school setting. J Dent Educ. 2021;85:1223-7.
https://doi.org/10.1002/jdd.12590
26. Azad A, Talattof Z, Deilami Z, Zahed M, Karimi A. Knowledge and attitude of general dentists regarding common emergencies in dental offices: A cross-sectional study in Shiraz, Iran. Ind J Dent Res. 2018;29:551-5.
https://doi.org/10.4103/ijdr.IJDR_587_16
27. Gupta H, Bhaskar DJ, Kaur N, Sharma V, Bhalla M, Hans R. Knowledge, attitude, and practices among dental practitioners and postgraduate students on the preparedness of medical emergencies in Mathura City. J Ind Assoc Public Health Dent. 2018;16:318-21.

Evaluation of Awareness and Preparedness for Medical Emergencies among Dental Practitioners in Twin Cities of Punjab: A Cross-sectional Study

Fatima Khattak                                    BDS, FCPS                                                                                                                Syed Zuhair Mehdi                               BDS, MCPS, DHPE
Arooba Mehmood                                BDS
Wajeeha Amer                                      BDS
Kanza Murtaza                                     BDS
Alishba Iftekhar                                   BDS

OBJECTIVE: The purpose of this study was to evaluate the awareness of medical emergencies among dental practitioners,
to assess the degree of expertise and readiness of dental professionals to handle medical crises in their dental practices and to
ascertain if medical emergency medications are offered in dental offices.
METHODOLOGY: A prospective study including 208 practitioners were given access to the survey through Google Form,
along with information on the study and a consent form .The questionnaire consisted of demographic details, years of experience,
and specialty of practitioners and 20 closed-ended questions with 10 assessing knowledge and rest evaluating the competence
and preparedness to handle medical emergencies.
An emergency whether medical or dental is a serious, acute, and unexpected event that requires a quick and timely intervention.
Since some diseases and their treatments increase the likelihood of a medical emergency during dental treatment. The most
often encountered medical emergencies in a dental office are vasovagal syncope, angina pectoris, hypoglycemia, and hypertensive
crisis. One of the mainstays of prevention of medical emergencies is by taking a thorough and detailed history, and vital signs
monitoring and modifying the treatment plan.
RESULTS: A response rate of 96% was achieved by including all 200 of the study’s 450 dental professionals. Just 69% of the
participants had emergency kits on hand, even though roughly 77.5% of the dentists in the study felt confident in their ability
to handle emergencies in the dental office.
CONCLUSION: In this study, dental professionals demonstrated a moderate level of understanding in medical situations, and
many of them have low to moderate perceived competency in managing medical emergencies. Every dental clinic should have
well-communicated emergency protocols in place that should be updated periodically.
KEYWORDS: Medical emergency, Dental Practitioner, Emergency kit, BLS, Dental Clinics
HOW TO CITE: Khattak F, Mehdi SZ, Mehmood A, Amer W, Murtaza K, Iftekhar A. Evaluation of awareness and preparedness for
medical emergencies among dental practitioners in twin cities of Punjab: A cross-sectional study. J Pak Dent Assoc2023;32(4):120-125.
DOI: https://doi.org/10.25301/JPDA.324.120
Received: 12 September 2023, Accepted: 18 January 2024

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Pamphlet or a Lecture, which Method is more Effective in Educating Children about Proper Ways of Tooth Brushing? Quasi-Experimental Study

Humaira Naureen Amir              BDS, MSc
Abeeha Batool Zaidi                   BDS, MSPH
Sidra Mohiuddin                         BDS, MDS
Syeda Nadia Firdous                  BDS, MPH

 OBJECTIVE: To compare the effect of educating proper tooth brushing techniques via lecture or pamphlet on the reduction
of dental plaque score among 12-year-old schoolchildren from subset Karachi.
METHODOLOGY: A quasi-experimental study was performed from September to December 2021 in three underprivileged
Karachi schools. After ethical approval schools were selected based on convenience sampling. Subjects were selected by random
sampling and were divided into groups A, B, and C. The children of groups A&B (lecture& pamphlet) were taught tooth brushing
as per American dental association criteria. The Plaque score at baseline was recorded. Group A was educated using a lecture
with a live demonstration of brushing using models and charts. Group B was given Pamphlets, that had both text and illustrations,
containing pictures of brushing techniques. Group C had no interventioni.e. a control group. The dental plaque score was
calculated using the Loe and Silness scale. The Plaque score was measured at baseline (0), after one month, and after three
months.
RESULT: At baseline mean, the mean plaque score was 1.381±0.636, at 1-monthfollow-up 1.161±0.562, and at 3 months
follow-up 1.065±0.658. There was a significant decline in mean plaque score in group A(lecture) followed by Group B(Pamphlet)
after three months of intervention. No difference was seen in the control group.
CONCLUSION: The study concluded that health education programs promote oral hygiene among school-going children as
a significant improvement in mean plaque score reported from baselines to 3 months follow-up.
KEYWORDS: Toothbrushing Technique, Dental Plaque, Lecture, intervention, Pamphlet.
HOW TO CITE: Amir HN, Zaidi AB, Mohiuddin S, Firdous SN. Pamphlet or a lecture, which method is more effective in
educating children about proper ways of tooth brushing? quasi-experimental study. J Pak Dent Assoc 2023;32(4):114-119.
DOI: https://doi.org/10.25301/JPDA.324.114
Received: 28 September 2022, Accepted: 17 January 2024

 

INTRODUCTION

Oral health is a key factor in overall health and the quality of one’s life. Oral diseases include dental caries, periodontal disease, oral cancer, oral symptoms of HIV, or-dental trauma, cleft lip and palate, and noma.1 Oral infections, such as dental caries and periodontal disease, has globally a destructive impact on oral health situation. Treatment of dental problems is likely to exceed the available resources in low-income countries.
Good dental health is an important element of sustaining a high quality of life.2
Oral diseases are on the rise in emerging countries owing to rapid changes in diet, nutrition, and lifestyles. Poor oral hygiene contributes to the formation of dental plaque, which has a significant impact on oral health. This is the precursor to dental caries and periodontal disease, which can lead to tooth loss if not treated appropriately.3
Dental plaque is considered the possible causative agent of major dental diseases such as caries and periodontal disease. An essential element in a preventive dental program is a well-organized plaque control program. The core of this preventive regimen including the mechanical and chemical plaque control measures is comprehensive home oral hygiene.4
The removal of dental plaque from the tooth surface is essential for the prevention of oral illnesses such as dental caries and periodontitis. As a result, disruption of plaque formation regularly is critical for reducing and controlling plaque-related oral illnesses.3 Assuming that toothbrushing is an important aspect of an effective plaque management program, good oral hygiene would be determined by the effectiveness of the specific method and the simplicity with which the procedure is performed.4
For plaque accumulation, tooth brushing is considered the simplest applicable mechanically preventive measure. Effective and regular plaque control measures ensure good periodontal as well as dental health.5-6
Poor oral hygiene results due to microbial plaque aggregation on the teeth and oral structure further damaging the tooth in form of dental caries, gingivitis, and periodontal disease.7 Effective plaque control not only depends on the toothbrush type but also on the proper toothbrushing technique.8
Schools are the ideal place to assess and teach children’s oral health knowledge and practice because this is when lifelong beliefs and critical abilities are formed. Teachers and parents have an essential role in improving children’s dental health. Regular, low-cost interventions such as school based health education have also been found to be effective in the short run.9
Although schools serve as a foundation for shaping children’s behavior, it is vital to improve their dental health habits through school dental health education.10 Overall positive and acceptable oral health behaviors can be achieved effectively with the support of school-based health education programs using simple and cost-effective strategy to reach and teach them.11 It has been claimed that instruction in tooth brushing techniques is particularly beneficial in improving oral hygiene and that dentists should also consider the patients’ physical dexterity.12
School management teams must take an active role in educating students and reviewing their oral health status regularly. It is important to emphasize how dental health can affect overall health and how oral health measures can aid in the prevention of systemic disorders. To create a solid and supportive structure surrounding the children, regular feedback from parents to instructors and vice versa is required. The key to the future’s overall development is to educate the children.13 Oral illnesses should be avoided before they arise, and simple oral hygiene procedures like brushing and flossing every day will help.2 Short-term oral health initiatives and health education can enhance oral hygiene and boost children’s health. Coordination efforts between school personnel, parents, and health specialists should be increased to produce long-term benefits.14
A previous study reported that educational intervention involve four meetings about oral hygiene in which the researcher educates the students about the prevention of diseases which are caused by poor oral hygiene, and appropriate way of tooth brushing had led to the improvement in dental/oral health.15 The improvement by educational intervention and by proper techniques of tooth brushing was seen among school going children.7,14,15,16
There is a scarcity of data regarding interventional methods to assess oral hygiene of school children therefore, this current study will be fruitful in assessing the effect of proper tooth brushing techniques that will be taught via lectures and pamphlets among school children for the reduction of dental plaque. Therefore, the objective of the current study was to compare the effect of educating proper tooth brushing techniques via lecture or pamphlet on the reduction of dental plaque scores among 12-year-old schoolchildren from subset Karachi.

METHODOLOGY
The Quasi-experimental study was conducted for 4 months from September to December 2021. The study was conducted after approval from the ethical review committee of Altamash Institute of Dental Medicine (AIDM) Karachi. The sample size of n=42 per group was estimated by using the WHO calculator for sample size calculator by keeping a 95% confidence level. The mean plaque index (PI) for educating proper brushing techniques via lecture was 0.89 with a standard deviation of 0.40 as suggested by (Javad Ramezaninia et al,.2018).7 The level of significance was 0.05, power of the test was 80%. Added 20% attrition rate or loss to follow-up n=42 per group was 50.4 rounded off to n=56. For the selection of study subjects, sixth-grade students were approached and screened for inclusion and exclusion criteria and they were selected by a simple random sampling method. The Principal investigator used the lottery method to select 56 chits and the selected study subjects were later enrolled in the study. On the paper chit, students’ class roll numbers were listed. All study subjects from three schools were chosen using the simple random sampling selection approach and three groups A, B, and C were formed, one from each school. Group A and B were interventional or experimental groups and Group C was the control group. After school selection is written permission from each school administration was taken.
The main data collection tools werethe oral examination kit, performa,and,Silness and Loeplaqueindex, a performa was filled by the investigator containing data like age, gender,socioeconomic status, and parents’ education. The Plaque score at baseline (T0) was recorded. After the baseline assessment, the study subjects of the Group A&B (lecture & pamphlet) were taught the Bass tooth brushing technique as per American dental association criteria (Place your toothbrush at a 45-degree angle on your gums then gently move it back and forth, brush outer inner and chewing surfaces of your teeth). Both groups Group A was educated using a lecture for about 10 minutes with a live demonstration of brushing using models and charts, both were taught in English and Urdu. Group B was given Pamphlets, that had both text and illustrations, containing pictures of brushing techniques. Group C had no intervention. The plaque scores were assessed after one month (T1) and three months (T2) from the baseline assessment.
The data was entered in SPSS version 22.0 mean and SD was calculated for quantitative variables. The normality of the data was checked via the Shapiro-Wilk test. The data was non-parametric therefore Kruskal Wallis test was applied.Friedman test was used for the analysis of multiple observations i.ebaseline,1 month 3-month, and among all 3 groups. For further sub-group analysis,Wilcoxon signed rank test was used. The level of significance was p <0.05.

RESULTS
Table1 showed the frequency distribution of Plaque scores at different visits and it was seen that out of a total of 168 study participants 91(54.2%) had 0.1-0.9 mm,63(37.5%) had 1-1.9mm and only 9(5.4%) had 0mm Plaque score at baseline (T0). At one month of follow-up (T1), 117(69.6%) had a plaque score of 0.1-0.9 mm whereas


13(8%) had a 0 mm plaque score this value is 3% greater compared to the Baseline. At three-month follow-up (T2)101(60.1%) had a plaque score 0-1 and 29(17.3%) had a plaque score of 0mm hence this value is 12% greater compared to baseline (5.4%). Moreover, at baseline 5(3%) had a plaque score of 2-3mm whereas after three months follow up it decreased to 2(1.2%).
Table 2 shows Mean±SD of Plaque Score among Group A, B, and C, and a statistically significant decline in mean plaque score was reported only in Group A (lecture) from 1.48±0.603 to 0.732±0.486 followed by Group B (Pamphlet) 1±0.572 to 0.88±0.541after three months of intervention. 1.66±0.549 to 1.60±0.596 shows that no difference was seen


in the control group.The Wilcoxon signed-rank test for further analysis shows a statistically significant difference (p-value <0.05) among all the observations recorded in the lecture group.
Table 3 shows a Pairwise comparison of plaque scores among study groups and it was seen that for baseline plaque scores there is statistically a significant difference between Group A(Lecture) and Group B (Pamphlet) as well as between-group B (Pamphlet) and Group C (Control) showing p-value <0.05 each, whereas no significant difference between Group A (Lecture) and group C (Control) was found (p=0.312)


For the Plaque score at one month follow up there is statistically a significant difference between Group A (Lecture) and Group C (Control) as well as for group B (Pamphlet) and Group C (Control) showing p=<0.05 each. Furthermore, no statistically significant difference between Group A (Lecture) and B (Pamphlet) was seen (p=1.0).
For Plaque score at three months follow up a statistically significant difference between Group A (Lecture) and Group C (Control) as well as for group B (Pamphlet) and Group C (Control) was found; showing a p-value <0.05 each whereas no statistically significant difference between Group A (Lecture) and B (Pamphlet) was reported (p=0.709)

DISCUSSION
This study found that a school-based, simple-to-organize, low-cost educational intervention can help 12-year-old students improve their oral hygiene. The individuals were picked at random and had similar background characteristics, such as similar age ranges and socioeconomic positions, as well as being from the same city school areas. The effectiveness of a dental health program was investigated in this study, and it was discovered that children who received the program had much lower mean Plaque index scores. Any combination of learning experiences aimed at encouraging behaviors that are better for one’s well-being is referred to as health education. People, families, organizations, and communities may be responsible for these actions or behaviors. As a result, health education may encompass educational initiatives for all people. Correct information or understanding about health does not always lead to optimal health behavior, as has been documented in dentistry and other professions. Nonetheless, the knowledge could be used to provide correct information about health and healthcare technologies to populations, allowing people to take action to protect their health. The main goal of intervention strategies is to shift personal behavior from health-harming to health-promoting.14 This has traditionally been accomplished through the provision of information, education, and counseling.17 Overall health promotion is vital, but oral health promotion is the most significant; it primarily aims to prevent mouth illness through health education. Oral health care should be provided to all children, not just those in primary school. Many forms of health education programs are planned to enhance the oral health status of children and to create good oral health knowledge, attitude, attitudes, and healthy behaviors. In available literature, it is stated that tooth brushing, food, nutrition activities, and dental flossing are all part of oral health education.17 The goal of oral care education and well-designed interventions is to raise schoolchildren’s awareness of oral health, which can lead to changes in oral health behavior and improved oral health. Oral health and everyday oral hygiene are intertwined, and neglecting oral hygiene leads to diseases such as dental caries, gingivitis, and a variety of others. On the other hand, numerous lifestyle choices such as eating too much, consuming sugary drinks, smoking cigarettes, and drinking alcohol have an impact on oral health, however oral health promotion techniques are promoting preventive intervention. As a result, it is possible to control all of these behaviors in school settings to improve the physical environment and provide oral health education through school policy.15
Similar to our study a previous study by Javad Ramanzania et al, in 2018 also reported the same findings at two months follow-up. In their study, a decline in PI was reported in the lecture group followed by the Pamphlet group.7 Dental/Oral health education results in improvement of oral hygiene in the school settings in which different methods were implemented.16 However, while different dental/oral health education approaches were compared, Yazdani et al,. found leaflets method more successful than videotapes and that a culturally relevant film showed an improvement in oral hygiene among Nigerian youngsters.18
Writing, audio-visual, and spoken methods are the three basic types of learning approaches.7 The authors employed a pamphlet and a lecture as two of the three main modalities of dental/oral health education. The pamphlet, could not adequately convey the content and the intricacies of practical instruction. Verbal education/Lectures using a dental model required fewer specialist equipment and facilities and allowed youngsters to see how to brush more carefully. The lecture approach is advantageous since it allows many students to learn at the same time. The lecture technique is simple to use, convenient, and widely adopted, with a specified teaching plan, location, time, and flexibility.19 Contradictory findings in plaque index were observed by Cehyan D et al., from baseline.11 Education with regular proper brushing adoption proved significant for reducing plaque accumulation for preschool children from baseline to 1st and 2nd follow up visits but later at 6th month follow up it matches baseline, hence Plaque index again rises.11
Our study found that out of a total of 168 study participants only 9(5.4%) had a 0mm Plaque score at the start of the study. Later at one month of follow-up after baseline 13(8%) had a 0 mm plaque score this value is 3% greater compared to the baseline score. Moreover, at three months follow up after baseline 29(17.3%) had a plaque score of 0m hence this value is 12% greater compared to baseline (5.4%). At baseline 5(3%) had a plaque score of 2-3mm whereas after three months follow up it decreased to 2(1.2%). Alike our study a reduction in stage 1 plaque was reported from 75.5 % to 66.5% post-intervention.20 Another study found that the experimental group’s overall oral hygiene showed a 54.58% improvement, while the control group showed no improvement. Compared to the control group(4.56%) the mean plaque score was improved by 57.67% in experimental group.21 After six months, there was a pattern for the control group to brush less frequently and accumulate more dental plaque. Compared to the control group, the intervention group’s members showed better oral health knowledge, behaviour, and hygiene. A single school-based programme for oral health education can help 12-year-old students learn more about oral health and stop their short-term hygiene and behaviour from declining.22 The reason for the similarity between our study and previous literature could be the same age group 12 years old encountered in both national and international studies.7,14,15,16,20,21,22 Another study observed reduction in plaque accumulation in both the 9-year student and teacher groups. It was discovered that both OHE programmes improved oral health and plaque control knowledge and behavior irrespective of age differences among group. Moreover similarities of social and cultural norms prevailing in the society may lead to a better understanding of oral health education.23 Programs in schools that promote oral health have shown promising results, particularly when they involve parents, teachers, and students.24 School-based interventions can be effective in reducing the burden of oral disease among primary school children. Further research is required to provide evidence of effectiveness of primary school-based interventions to improve oral health.25
The limitation of the study was the lack of parents and teachers with selected subjects as they both also play an important part in oral health promotion and the development of habits among children. Secondly, the researcher used a combination method of education i.e. lecture along with demonstration therefore, we are not sure that the change in dental plaque scores was due to which educational activity. Thirdly, we have not seen any improvements in the pamphlets group, the reason might be lack of motivation to study them at home though we had given them to the subjects so they can take them to their home.
It is recommended that schools and institutes should encourage health promotion strategies such as behavior change approaches in early childhood by incorporating oral health messages in the school curriculum and teachers do emphasize to school children about tooth brushing twice a day every day. Also, to check oral hygiene as a part of their dental checkup once in six months.

CONCLUSION
Our study concluded that a significant reduction in meanplaque score was recorded from baseline to one month and three months follow-up in the lecture group. Oral hygiene instructions through lecture was an effective strategy for reducing plaque sores. However, the pamphlet group did not show any significant improvement in plaque scores.

ETHICS APPROVAL
Ethical approval was obtained before study initiation by the institutional review board (Ref#AIDM/RDR/10/2021/03). All procedures performed in studies involving human participants were in accordance with the ethical standards of the Helsinki declaration.

DISCLAIMER
None
CONFLICT OF INTEREST
None
SOURCE OF FUNDING
None
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Pamphlet or a Lecture, which Method is more Effective in Educating Children about Proper Ways of Tooth Brushing? Quasi-Experimental Study

Humaira Naureen Amir                   BDS, MSc
Abeeha Batool Zaidi                       BDS, MSPH
Sidra Mohiuddin                             BDS, MDS
Syeda Nadia Firdous                      BDS, MPH

 OBJECTIVE: To compare the effect of educating proper tooth brushing techniques via lecture or pamphlet on the reduction
of dental plaque score among 12-year-old schoolchildren from subset Karachi.
METHODOLOGY: A quasi-experimental study was performed from September to December 2021 in three underprivileged
Karachi schools. After ethical approval schools were selected based on convenience sampling. Subjects were selected by random
sampling and were divided into groups A, B, and C. The children of groups A&B (lecture& pamphlet) were taught tooth brushing
as per American dental association criteria. The Plaque score at baseline was recorded. Group A was educated using a lecture
with a live demonstration of brushing using models and charts. Group B was given Pamphlets, that had both text and illustrations,
containing pictures of brushing techniques. Group C had no interventioni.e. a control group. The dental plaque score was
calculated using the Loe and Silness scale. The Plaque score was measured at baseline (0), after one month, and after three
months.
RESULT: At baseline mean, the mean plaque score was 1.381±0.636, at 1-monthfollow-up 1.161±0.562, and at 3 months
follow-up 1.065±0.658. There was a significant decline in mean plaque score in group A(lecture) followed by Group B(Pamphlet)
after three months of intervention. No difference was seen in the control group.
CONCLUSION: The study concluded that health education programs promote oral hygiene among school-going children as
a significant improvement in mean plaque score reported from baselines to 3 months follow-up.
KEYWORDS: Toothbrushing Technique, Dental Plaque, Lecture, intervention, Pamphlet.
HOW TO CITE: Amir HN, Zaidi AB, Mohiuddin S, Firdous SN. Pamphlet or a lecture, which method is more effective in
educating children about proper ways of tooth brushing? quasi-experimental study. J Pak Dent Assoc 2023;32(4):114-119.
DOI: https://doi.org/10.25301/JPDA.324.114
Received: 28 September 2022, Accepted: 17 January 2024

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