Status Of Oral Health Education In Pakistan: Recommendations, Future Directions & Strategy


Shahjahan Katpar1                                BDS, MCPS, FCPS

Farhan Saeed Vakani2                         BDS, FCPS


Updated, standardized and in-vogue Oral Health Education System, Clinical Skill development, Research culture and subsequent delivery of Oral Health Care targeted for patients & the growing society needs, forms the solid foundation Pillars for any progressive, globally dynamic and active Dental Institute. We feel that, this scenario at present is greatly underdeveloped in Pakistan and since our Oral Health Education is changing and positively evolving, it is therefore being addressed via this guest editorial. In addition, this situation should also be on our National priority to attain International standards. Related to our national agenda in our humble perspective, the major 7/seven Oral Health Education related issue domains faced by us are as under:

  1. Shortage of highly Qualified Dental Faculty at respective Institutes & overall Underdeveloped Positive and Supportive Working Environment.
  2. Non-Existing Qualified Dental Educationists in our country, in comparison to Medical Educationists to address our own Professional & Educational needs.
  3. Hyposkillia: presence of overall underdeveloped Clinical Skill Competence of fresh Oral Health Graduates, similarly seen in Medical Graduates & its associated reasons, as defined by Fred 1.
  4. Code of Conduct regarding Check n balance to establish new Oral Health Institutes in terms of: infrastructure, Qualified Dental Faculty – their strength, associated Clinical facilities and overall Quality of education.
  5. Absence of Associated General Dental Hospital based Clinical support, as per PMDC criteria (esp. OMFS Ward facilities in Private Sector) in terms of Equipment, infrastructure & overall Quality.
  6. Absence & promotion of Research Culture and Faculty incentives at Oral Health Institutes.

Absence of Future Directions/ Vision & Strategy related to Promotion of Oral Heath Profession Education at a National Level to meet International standards.

This academic document reflects its pioneer roles: to increase national pool of editorials related to dental education, present an update on problem domains & challenges faced by our current National Dental Education/ Profession and share related suggestions to move forward and attain related International standards. Unlike the Medical Profession and its Education System, which has better & firmer roots in our country mainly due to the greater number of Postgraduate Professionals, Medical Educationists and respective greater Research output, in comparison, our evolving Oral health Profession n Education is nascent and now has started to acknowledge & document its shortcomings. Regarding the same, we would like to contribute academically, share our humble contribution and also support similar positive work addressed earlier by our Medical colleagues. Biggs has nicely addressed in a nutshell, the overall issues related to Postgraduate Medical Education & Training in Pakistan. Similarly, we also need to address at length, our Oral Health Profession n Education related National issues with suitable solutions 2. This editorial is a template for others to share their academic contributions to promote Oral Health Profession/ Education & we also hope that, this editorial will stimulate other educationists & serve its role as a Change Agent at a national level.

Via this guest editorial as our perspective, we would also like to suggest & promote the term Oral Health Physician in comparison to the general term used, Dental Surgeon. This is so, as we feel that, our Professional diagnosis cum management spectrum and related education domain is much larger & deeper than is generally thought. As it’s a known fact, that, neglecting oral health care can not only become life threatening, but can also lead to death for any Medically Compromised Patient. Oral Health is an integral part of General health and now the Patients management domain consists of not only Oral Health Physician but is must include Medical and other related Specialists, and work as a “Team” for the larger interest of our patients. This philosophy of Team Work also applies to our Medical Colleagues not to forget us, as Oral Health Physicians for the same reasons. Furthermore, we hope that this term of Oral Health Physician would be internationally in-vogue and is more suitable to represent our highly skill dominated, manual, scientific & artistic Profession.

Time has come that, Action in terms of Positive Academic Support at Undergraduate & also Postgraduate levels should be taken by all related National stake holders to attain International standards for our existing oral health scenario 3. Our nascent Dental Educationists should not only address the concerns of our Student’s and Patients and above stated National Agenda domains, but should also make efforts to implement the following 10 recommendations given as under to move forward. In addition, we also need to identify other unexplored areas related to our dynamic skill oriented Profession, to steer away and improve our existing and budding Oral Health Profession/ Educational and local needs. We call these as, “the 10/ ten Commandment Recommendations” and these, as our humble perspective should be addressed throughout Pakistan & are shared as under:


  1. Perform Paradigm Shift of our present Education/teaching towards Student Centered 3.
  2. Address on priority, Shortage of Highly Qualified Dental Faculty & not to compromise on absence of dental hospital based facilities for clinical & research work 3,4 .
  3. Revive & practice in our Oral health academics, change our hidden Curriculum and teach the nonacademic attributes of hard work, honesty, self pride, Ethics, accountability etc as off shoots of Professionalism 1.
  4. Give due importance to regular extracurricular & sports activities with provision of respective facilities as a part of Intellectual Wellness domain 5,6.
  5. Start regular Dental Faculty Development Programs – as a part of continuous dental education (CDE) Program 6.
  6. Create an active learning environment, promote & document research culture where: learners learning styles, poor communication skills & spoken accents etc as a part of communication skill are addressed Professionally 5,7,8.
  7. Introduce, Promote and document Feedback Culture amongst students, patients & faculty in our academics
    with provision of financial incentives for documenting Research leading to Faculty growth 5,6.
  8. Introduce PBL & other related modes of information transfer in our existing curriculum to encourage development of lateral thinking & not to forget to address, Hyposkillia 1,8,9.
  9. Emphasize & appoint qualified Career Councilors at respective Institutes, to meet the mushrooming needs for our Profession, respective Specialties and country 4,6.
  10. Give due importance and incorporate in our existing curriculum, Ergonomics related to Oral Health
    Profession and associated Health Hazards for all concerned.

We strongly feel that above stated 10 commandment recommendations & remaining other academic areas which are not addressed in this editorial can positively be achieved with a positive attitude and as a collaborative team effort. To attain this, all the associated academic Institutional Stake holders & respective Government stake holders need to provide moral support, show a positive will n attitude, give a free hand to welcome the dynamic Y-generation Oral Health Change Agents of Pakistan & adopt a respective open heart n door Policy 2,4,5. In addition, this progressive
journey towards excellence for our existing Oral health Profession in this IT savvy & competitive print media era, simply cannot be achieved, without developing new Undergraduate subjects/Programs and this needs to be done in Phases. This as Phase 1 includes: open forum discussions/ debates and brain storming sessions to introduce the subjects of: Behavioral Sciences, Research Methodology-Biostatistics, Geriatric Dentistry & Forensic Odontology. In Phase 2 respective Senior Faculty at least Associate Professors needs to be identified and in Phase 3: Faculty be trained via faculty development Programs and for this giant progressive step we need support from our Medical Fraternity. In this regard, we should be ready to face hardships & resistance, as to bring a change & change our traditional mind sets is an uphill task which can only be done via team work. Therefore, patience and a Positive will to take action and get due support from our own Peers, Medical Fraternity, bureaucracy & PMDC/ HEC is indeed needed to obtain our desired objectives in the larger national interest for all and to do this, Conferences/ symposiums should be conducted 2,3.
We agree with Amin, Kamran and all others who support the idea for the need to change our Oral Health/Dental Curriculum at PMDC level and it goes without saying that, we can learn greatly from our neighbors’ like: Malaysia, Turkey, Saudi Arabia and Iran who have changed and greatly progressed in their Oral Health Professions n Education in all its domains 3,4,5. Our curriculum needs to be re-visited & updated to meet the international trends and also for our evolving Oral Health Professional needs and to do so, we must incorporate respective Dental Educationists along with all others concerned and form a dynamic “hybrid titanium coated nano- particle Composite team to meet these challenges & find solutions” 2,5.


This progressive uphill task of excellence cannot be achieved alone in a day and Our Oral Health Fraternity has to join hands with our Medical Fraternity to attain the desired national objectives. We also hope to see, proper representation from all Provincial Public and Private Sector Oral Health Academicians to obtain the desired outcome. Being optimists for our Undergraduate and also Postgraduate levels, our future is bright, as time has now finally come in Pakistan to request all leading Health related National Stake holders to identify & solve in their true spirit “all grey areas” related to our respective Academics & Professions. Hyposkiliia and its associated pitfalls need to be explored in depth, so that our oral health graduates are able to perform independently basic dental procedures with ease. By addressing these and meeting the global demands the process of International recognition for our Postgraduate Oral Health/ Dental Programs can also be accelerated 2,3. Furthermore, as advocated by Fouad, we also need to establish n promote Complement Culture at our academics 4 . PMDC/HEC and the other National level Policy makers need to redefine our national goals, develop new programs and play their active, supportive and positive regulatory
roles at National Level. In addition, let’s just not forget one of the most important basic pillars for growth: the Financial Support. We also need to prioritize our National Health Policy and also make efforts for National Oral Health Policy and handsomely augment our national budget and demonstrate a positive will from all stake holders for the overall progress, growth & development of our existing Oral Health Profession n Education system in Pakistan. Therefore, similar to Medical Education time has come to take initiative & organize an exclusive National Conference on Dental Education to discuss the same. The enlightened first lady of USA, Eleanor Roosevelt once said, that, “the future belongs to those, who believe in the beauty of their dreams”. Oral Health Profession or Dental Profession is a dynamic, demanding and a skill oriented Profession which has seen numerous phases and being optimist & dreamers like E. Roosevelt, we hope that by addressing above stated national 10 commandment recommendations, we can start our bumpy journey towards progress n attain excellence. This will finally lead to firm footing and permit positive academic growth and culture for our existing Oral Health Profession and Education in Pakistan and subsequently also pave room for attaining international status in the next decade in all basic and clinical oral health related areas. Nevertheless, a billion dollar Question still remains, as change agents, can we change our existing Oral Health Education in Pakistan to meet the global demands in the next decade? Our answer is yes, as “where there is a will, there is always a way”.


  1. Herbert L. Fred: (Guest Editorial) Hyposkillia; Deficiency of Clinical Skills: Texas Heart Institute J; November 2005; 32:255-257.
  2. John SG Biggs: Postgraduate Medical Training in Pakistan: Observations & Recommendations (Special Report); JCPSP; 2008;18:58-63.
  3. Amin M, Ahmad B (Editorial). Dental Education in Pakistan: Current Trends and Practices; JCPSP; 2010; 20: 497-498.
  4. Salama FS. Leading the young Saudi Generation Y Dentists in the 21st Century (Editorial): Saudi Dent J. 2013;25: 95-96.
  5. Ali K, Raja M, Watson G, Coombes L, Heffernan E. The Dental School Learning Milieu: Students’ Perceptions at Five Academic Dental Institutions in Pakistan. J Dent Educ 2012;76:486-494.
  6. Khalid T. Faculty Perceptions about Roles & Functions of Department of Medical Education. J Coll Physician Surg Pak 2013;23:56-61.
  7. Jessee SA, O’Neill PN, Dosch RO. Matching Student Personality Types & Learning Preferences to Teaching Methodologies. J Dent Educ 2006; 70:644-65.
  8. Shukar I, Zainab R, Rana M. Learning Styles of Postgraduate & Undergraduate Medical Students; J Coll Physician Surg Pak.2013;23:25-30.
  9. Tayyeb R. Effectiveness of Problem Based Learning as an Instructional Tool for acquisition of Content Knowledge & Promotion of Critical Thinking among Medical Students. J Coll Physician Surg Pak 2013;23:42-46

Nasal Symmetry Achieved By Nasoalveolar Molding In Cleft Lip And Palate Patients- A Literature Review

Aiyesha Wahaj1                                BDS

Imtiaz Ahmed2                                BDS, FCPS, M.ORTHRCS

Gul-e-Erum3                                     BDS, FCPS, M.ORTHRCS


OBJECTIVE: To review the significance of Nasoalveolar Molding in achieving Nasal Symmetry in Cleft lip and Palate patients before Lip repair.

METHODOLOGY: A Data search was performed based on available electronic data base, hand search articles and books since 1994-2010. This included Cochrane data base, medline, pubmed, research journals, and papers. The total of nearly 900 articles were found related to naso alveolar molding among which filtered results showed with 302 randomized control trials. Inclusion criteria included both unilateral and bilateral cleft lip and palate cases who had presurgical nasoalveolar molding with nasal stents ; prior to primary lip repair ,whilst the exclusion criteria was syndromic patients, ,interrupted treatment timings, more than six months of age, immunocompromised, autoimmune diseases ,previous history of lip or nasal surgery before nasoalveolar molding for any reasons. Overall 28 studies met the basic inclusion criteria.

RESULTS: Nasal symmetry is preferably well acheived by Nasoalveolar Molding.

KEY WORDS: Unilateral Cleft lip Palate, Bilateral Cleft lip Palate, Nasoalveolar Molding, Rhinoplasty, Gingivoperiostoplasty, Cheiloplasty.

HOW TO CITE: Wahaj A, Ahmed I, Erum G. Nasal Symmetry Achieved By Nasoalveolar Molding In Cleft Lip
And Palate Patients- A Literature Review. J PAk Dent Assoc. 2014;23(1):05-10


Presurgical infant orthopedics has been used as an evident mode of treatment from early centuries. Through Hofman et al, Desault, Hullihan, Brophy, Mcneil, Matsuo and Grayson modifications are being made in order to correct the cleft alveolar arch. All aims were to reduce the alveolar cleft width along with nasal symmetry. Nasal symmetry reflects the proportionate relationship among nasal alar base width, columellar length and nasal tip; steps being taken to improve the cleft region along with maintaining harmonious nasal morphology to enhance facial esthetics. Previously the only way for achieving nasal symmetry was by surgical means but with the advent of nasoalveolar molding before surgery, it significantly enhances the result of surgeries and reduces the side effects of early surgeries.
It was started from simple bonnet band, then silicon tubes with further advancement of molding acrylic plates. Intraoral acrylic molding plate was later constructed with added nasal stents covered with soft lining to reduce the alveolar gap with nasal symmetry. Although the technique is the extension of previous methodologies where silicon tubes was used to mold the nostrils1.
All the above studies were conducted to achieve midfacial region symmetry of which nasal anatomy and morphology is the basic component along with alveolar arch width and gap reduction. Sequential molding of Nasoalveolar region helps to prevent early side effects prior to lip surgery and hence gaining maximum benefits of lip surgery and later the Periogingivoplasty. Correction of cleft lip and palate with concomitant nasal symmetry in order to establish physiological oronasal functionality is necessary for good facial growth. Therefore the primary aim of this review was to gather the results obtained by using nasoalveolar molding and how they all accounted to be a part of nasal symmetry.


A Data search was performed based on available electronic data base, hand search articles and books since1994-2010. This included Cochrane data base, Medline, pubmed, research journals, and papers. The total of nearly 900 articles were found related to naso alveolar molding among which filtered results showed 302 randomized control trials.
The search strategy was based on PICO including search terms such as, unilateral and bilateral cleft, infant orthopedic treatment, nasoalveolar molding, acrylic plate with nasal stents and nasal symmetry. The Inclusion criteria included both unilateral and bilateral cleft lip and palate cases who had presurgical nasoalveolar molding, with nasal stents for nasal molding, prior to primary lip repair, whilst the exclusion criteria was syndromic patients, interrupted treatment timings, more than six months of age, immunocompromised, autoimmune diseases, and previous history of lip or nasal surgery before nasoalveolar molding for any reasons.
Overall 28 studies met the basic inclusion criteria. The Randomized trials filtered during study period were emphasizing more on surgical means, their sample size was not consistent, and highlighting surgical outcomes more as compared to orthodontic follow up. Further most of them were mentioning the word not detail randomization only their name suffix.



Cleft lip palate is a multivariant deformity which presents with distinct characteristics both phenotypically and genotypically. The unilateral cleft lip and palate presents as a wide nasal base and cleft at upper lip segments .The affected lower lateral nasal cartilage is displaced laterally and inferiorly which results in a depressed nasal dome with the appearance of an increased asymmetric alar rim, an oblique columella and an over hanging nostril apex. If there is a cleft of palate, the nasal septum will deviate to the non cleft side with an associated shift of nasal base and tip. While the bilateral cleft lip palate presents morphologically with procumbent or rotated premaxilla, increase alar base width and the lip segments2,3,4 the prolabium and columella appears to be deficient because of nasal tip flattening and lack of prominence. Also lower lateral alar cartilages are flared and concave. Normally they should be convex.
Previously the primary method of achieving nasal symmetry was by surgical means. Nasal molding presurgically reduced significantly the significant side effects of early surgeries like scarring, midfacial retrusion etc. This was started from simple bonnet band, silicon tubes and later molding acrylic plates. Intraoral acrylic molding plate was later constructed with added nasal stents covered with soft lining to reduce the alveolar gap with nasal symmetry. The stent is made up of .036 guage round stainless steel wire shaped bilobed form. Soft denture lining material is used to avoid nasal mucosal injury. The stent and the acrylic plates are secured by elastic loops over a retention arm extending from the anterior flange of the plate. The position of retention arm is40° down from the horizontal plane to achieve proper activation and to increase stabilization of acrylic tray5,6,7.Assembly and position of stents differs and may vary from patient to patient. Generally in unilateral clefts there is one retention arm with stent but in case with bilateral cleft there are two retention arms with two nasal stents8,9,10.Thus the nasolabial junction continues to be lifted and projected forward. This also uplifts the nostril apex and ultimatly defining the top of columella11,12,13.
Various analyses were done in which the differences were being measured and compared in order to describe symmetry along with concomittent correction achieved. Later presurgical and postsurgical comparisons were made amongst them. This included : Height of nostril, Nostril width , Columella angle on cleft side ,Nasal tip projections, Nasal tip symmetry, Alar rim symmetry measured between alar base noncleft side with respective
to cleft side, Columellar base width and symmetry with respective to noncleft side or alar base cleft side, Length of columella and Width of alveolar cleft. The above measurements were discussed in studies shown below in table 1; all the following discussed studies showed various parametric measurements for determining nasal symmetry after nasoalveolar molding. Descriptive studies enlightened that the maxillary alveolar segment molding simultaneously support and hold the deformed nasal cartilage which sequentially corrects the central nasal tip projection and cause lengthening of deficient columella 2,24,25 it has been shown that the Slight over correction of alar base on the cleft
side obtained by using pressure exerted by the nasal stent maintains nasoalveolar molding results 26,27,28. Cleft lip repair is often performed at approximately 3 months of age when the risk of anaesthesia related complications diminishes. This may be delayed however if the patient is undergoing presurgical nasoalveolar molding. At end of naso alveolar molding various measurements have been taken to identify the differences .Three dimensional studies showed effects related to facial forms with percentage distribution. Overall face form improved with columella29%, labial tubercle51% ,lower lip29%, lateral aspect of face19%, tip of nose25%and laterally to columella directly below nares29% Uppernose81%, alardome5%, columellaheight30%, lateral wall of nostril30%. Cleft side alar curvature showed large decrease in size80% 5,6.
Research evaluation also enumerates the combined surgical procedures and comprehensively illustrated their results achieved. Nasal symmetry is subsequently achieved by primary cheiloplasty. Technique is performed by using methods as Triangular flap method, Rotational Advancement flap method or Hotz plate. Kim et al evaluated and discussed the effects of nasoalveolar molding and cheiloplasty 16. Closure of cleft gap during alveolar molding was usually due to backward banding of whole part of greater segment. They addressed nasal deformity in both unilateral and bilateral clefts primarily by combined cheilorhinoplasty performed by open methods approach with delicately repositioning of lower alar rim cartilage 17,18. To improve nasal tip, nasal height / width and the post operative nasal form after nasoalveolar molding; lip repair methods using Cronin’s Triangular flap method results in significant improvement 19.All these studies were aimed to achieved nasal symmetry post surgically. Nasoalveolar molding was the primary method to achieve approximate positioning and symmetry.
Evaluation in studies of bilateral cleft lip and palate showed that nasoalveolar molding significantly cause improvement in columellar lengthening and hence decreased the chances of later nasal surgeries. Lee and Sato Yuki et al emphasized the nasoalveolar molding as esthetically beneficial and discussed the role in decreasing later surgical need 20,23.Columella length showed relapse in bilateral cleft because of differential growth pattern between the columella and rest of nose in first and second post-operative years. This was reported and found to be 1.9mm. According to growth evaluation data, columella started to increase in length in third year post operatively whereas the rest of nasal growth was significantly increased in height year by year. In a preliminary study conducted by Betty et al shows that in Unilateral cleft lip and palate cases relapse in nostril width and height is10% and 29% respectively and angle of columella [5%] at 1year of age 14.
Deirdre, Maull, Grayson et al elaborated in their three dimensional study on nasal morphology by digital surface scanning which pertains presurgical nasoalveolar molding to be significant and increases nasal symmetry 15.
Nasoalveolar Molding was started before the age of six weeks and correction was done till age of 3 or 4 months at which time the primary lip surgery and nasal surgery is performed. This associated with increase in symmetry and was reported to be maintained up to early childhood. In this context the mean symmetry index was significant to be p<0.05. Detailed considerate analysis with measurements reflect that the nasal symmetry achieved by various methods reveal better results in both unilateral and bilateral cleft lip palate cases. Presurgical orthopaedics brings better maxillary correction.
Levy et al discussed the complications with the nasoalveolar molding procedure. Broken appointments and Removal by Tongue is reported variably among which tissue irritation and removal by tongue is the predominant factor. These are collectively overwhelming conditions but subsequently found to be out weighted by the benefits achieved later 21. Further Pfeifer et al in his study compared the cost analysis and predictabily found that Nasoalveolar Molding have subsequently reduced the need of later surgeries 22.fig1 showing percentage distribution graph:

Fig 1: Graph showing percentage distribution of complications


Unilateral and Bilateral Cleft lip and palate have different morphology. Nasoalveolar molding is a presurgical treatment used to improve the surgical repair for both Unilateral and Bilateral Cleft lip and palate cases. Surgical repair alone cannot correct the multiple problems encountered with the deformities that results from cleft of the lip and palate. Nasal symmetry is preferably well achieved by Nasoalveolar Molding presurgically in all the above reviewed studies and showed to be beneficial. An acrylic orthopedic appliance with nasal stents is made to approximate the cleft and mold the nose, and hence, reducing the amount of surgical correction required during treatment. This method symmetrically molds tissues prior to surgery which included closed approximation of alveolar gap, nostril shape and width improvement. Also nasal tip projection with columellar lengthening and alar rim symmetry helps to improve over all nasal symmetry.


All the above discussed studies concomitantly have Limitations as more objective statistical analysis is required to predict three dimensional shape changes; also adult groups serving control are not of the same age group. Further there is no Long term data available with adequate follow up times related to surgical maneuvers or detailing. Randomized trials and systemic reviews are needed. Currently research studies show inconsistent sample size, and highlighting surgical outcomes more as compared to orthodontic follow up.


  1. Grayson BH, Cutting CB. Presurgical Nasoalveolar Orthopedic Molding in Primary Correction of the Nose, Lip, and Alveolus of Infants Born With Unilateral and Bilateral Clefts. The Cleft Palate-Craniofac J.2001;38:193-198.
  2. Suri S, Thompson BD. A Modified Muscle-Activated Maxillary Orthopedic Appliance for Presurgical Nasoalveolar Molding in Infants with Unilateral Cleft Lip and Palate. The Cleft Palate-Craniofac J:2004;41(3):225-229.
  3. Jaeger M, Braga-Silva J, Gehlen D, Sato Y, Zuker R, Fisher D. Correction of the Alveolar Gap and Nostril Deformity by Presurgical Passive Orthodontia in the Unilateral Cleft Lip. Annals of Plastic Surgery.2007;59:489-494.
  4. Uzel A, Alparslan ZN. Long-term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review. The Cleft PalateCraniofac J In-Press.
  5. Campbell A, Costello BJ, Ruiz RL. Cleft Lip and Palate Surgery: An Update of Clinical Outcomes for Primary Repair. Oral and Maxillofacial Surgery Clinics.2010;20:43-58.
  6. Pedro etal. Role of the Craniofacial Orthodontist on the Craniofacial and Cleft Lip and Palate Team.Semin in Orthod.2009;15:225-243.
  7. Grayson BH and Shetye PR. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Indian J Plast Surg.2009;42:s56-s61.
  8. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH. Nasoalveolar Molding Improves Long-Term Nasal Symmetry in Complete Unilateral Cleft Lip-Cleft Palate Patients. Plast Reconstr Surg J.2009;123:1002-6.
  9. Liou EJ, Subramanian M, Chen PK, Huang CS. The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study. Plast Reconstr Surg J.2004;14:p858-64.
  10. Spengler AL, Chavarria C, Teichgraeber JF, Gateno J, Xia JJ. Presurgical Nasoalveolar Molding Therapy for the Treatment of Bilateral Cleft Lip and Palate: A Preliminary Study Cleft Palate-Craniofac J.2006;43 :321- 28.
  11. Singh GD, Levy-Bercowski D, Yáñez MA, Santiago PE. Three-dimensional facial morphology following surgical repair of unilateral cleft lip and palate in patients after nasoalveolar molding .PE Santiago Orthodontics & Craniofacial Research.2007;10: 161-66.
  12. Suri S. Design features and simple methods of incorporating nasal stents in presurgical nasoalveolar molding appliances. J Craniofac Surg. 2009;20:1889-94.
  13. Singh GD, Levy-Bercowski D, Santiago PE. ThreeDimensional Nasal Changes Following Nasoalveolar Molding in Patients with Unilateral Cleft Lip and Palate: Geometric Morphometric. The Cleft Palate-Craniofac J. 2005;42:403-409.
  14. Pai BC, Ko EW, Huang CS, Liou EJ. Symmetry of the Nose after Presurgical Nasoalveolar Molding in Infants with Unilateral Cleft Lip and Palate: A Preliminary Study the Cleft Palate-Craniofac J.2005; 42 :658-663.
  15. Maull DJ, Grayson BH, Cutting CB, Brecht LL, Bookstein FL, Khorrambadi D, Webb JA, Hurwitz DJ. Long-Term Effects of Nasoalveolar Molding on ThreeDimensional Nasal Shape in Unilateral Clefts.Cleft palate-Craniofac J.1999;36:391-97.
  16. Kim etal. Effect of presurgical nasoalveolar molding (PNAM) appliance and cheiloplasty on alveolar molding of complete unilateral cleft lip and palate patients.Korean J orthod.2003; 33:234-245.
  17. Thomas C. Primary rhinoplasty by open approach with repair of bilateral complete cleft lip. J Craniofacial Surg.2009;20:1715-8.
  18. Thomas C. Primary rhinoplasty by open approach with repair of unilateral complete cleft lip. J Craniofac Surg.2009;20:1711-4.
  19. Nakamura N, Sasaguri M, Nozoe E, Nishihara K, Hasegawa H, Nakamura S.Postoperative Nasal Forms after Presurgical Nasoalveolar Molding Followed by Medial-Upward Advancement of Nasolabial Components with Vestibular Expansion for Children with Unilateral Complete Cleft Lip and Palate.Cleft palate-Craniofac J.2009;67:2222-2231.
  20. Lee CT, Garfinkle JS, Warren SM, Brecht LE, Cutting CB, Grayson BH. Nasoalveolar Molding Improves Appearance of Children with Bilateral Cleft Lip-Cleft Palate. Plastic & Reconstr Surg J:2008;122:1131-37.
  21. Levy-Bercowski D, Abreu A, DeLeon E, Looney S, Stockstill J, Weiler M, Santiago PE. Complications and solutions in presurgical nasoalveolar molding therapy. Cleft Palate-Craniofac J.2009;46:521-8.
  22. Pfeifer TM, Grayson BH, Cutting CB. Nasoalveolar Molding and Gingivoperiosteoplasty Versus Alveolar Bone Graft: An Outcome Analysis of Costs in the Treatment of Unilateral Cleft Alveolus. Cleft PalateCraniofac J.2002;39:26-9.
  23. Sato Yuki etal. The Effects of Nasoalveolar Molding for Cleft Lip and Palate .Japanese Journal of Plastic & Reconstr Surg J.2005;48:255-62.
  24. Keçik D, Enacar A. Effects of Nasoalveolar Molding Therapy on Nasal and Alveolar Morphology in Unilateral Cleft Lip and Palate. Journal of Craniofac Surg.2009;20 (6):2075-2080.
  25. Mitsuyoshi I, Masahiko W, Masayuki F. Simple modified preoperative nasoalveolar molding in infants with unilateral cleft lip and palate. Br J of Oral and Maxillofac Surg.2004;42:578-580.
  26. Vachiramon AT, Groper JN, Gamer S. A rapid solution to align the severely malpositioned premaxilla in bilateral cleft lip and palate patients.Cleft Palate Cranio fac J.2008;45:229-31.
  27. Millard DR Jr. Embryonic rationale for the primary correction of classical congenital clefts of the lip and palate. Ann R Coll Surg Engl.1994;76:150-160.
  28. Deng XH, Zhai JY, Jiang J, Li F, Pei X, Wang HT. A clinical study of presurgical nasoalveolar molding in infants with complete cleft lip and palate. Chinese Journal of Stomatology.2005;40:144-6.

  1. Post Graduate Fellowship Residency completed. Orthodontics Department .Dr.Ishratul-Ebad Khan Institute Of Oral Health Sciences-Dow University Of Health Sciences. Karachi-Pakistan.
  2. Head Of Department and Associate Professor. Orthodontics Department. Dr.Ishratul-Ebad Khan Institute Of Oral Health Sciences-Dow University Of health Sciences. Karachi-Pakistan.
  3. Associate Professor. Orthodontics Department . Dr.Ishrat-ul-Ebad Khan Institute Of Oral Health Sciences-Dow University Of health Sciences. Karachi-Pakistan.
    Corresponding author: “Dr. Aiyesha Wahaj” < >

Myofacial Pain Dysfunction Syndrome (MPDS)

Syed Abrar Ali1                                  BDS, FCPS

Mehmood Hussain2                        BDS, FCPS

Kashif Naqvi3                                     BDS, FDSRCS

Muhammad Moin Khan4              BDS

OBJECTIVE: Facial pain is considered to be one of the most common chronic head and neck pain seen in routine dental practice1, 2. Myofacial pain dysfunction syndrome is much more frequent finding within the larger chronic pain umbrella of head and neck pain3, 4. The purpose of this study was to observe factors associated with myofacial dysfunction syndrome in patients attending the operative department of Hamdard University Dental Hospital.

METHODOLOGY: One hundred and five patients with Myofacial pain dysfunction syndrome were examined. The factors that were recorded were: age, gender, marital status, masticatory muscle tenderness, presence of joint sounds, parafunctional habits, neck pain, headache, and stress related to domestic issues, and history of poor sleep pattern.

RESULTS: One hundred and five patients were studied, and out of them 89 were females and 16 males. The selected subjects were between 19 to 70 years. Stressful life style and tenderness of temporalis muscle were frequent finding.

CONCLUSION: Domestic stresses are closely associated with patients suffering from MPDS patients. Patients present with a myriad of sign and symptoms of varying intensity. Proper history and examination are very important to make a proper diagnosis. Counseling the patients on how to cope with stresses should be an integral part in managing these patients along with pharmacotherapy where indicated.

KEY WORDS: Myofacial pain dysfunction syndrome, Stress, Mastication.

HOW TO CITE: Ali SA, Hussain M, Hassan A, Moeen. Myofacial Pain Dysfunction Syndrome (MPDS). J Pak Dent Assoc 2014;23(1):15-18


One of the most common forms of temporomandibular joint (TMJ) disorders is myofacial pain dysfunction syndrome. Pathology in masticatory apparatus can lead to pain and poor function of TMJ1-4. It is not uncommon that patient suffering from myofacial pain dysfunction syndrome (MPDS) consult dentist for tooth ache 5, 6. MPDS is usually associated with joint pain, pain in muscle of mastications, limited mouth opening and deviation of jaw. Other symptoms that are commonly seen are headaches, ear ache and fracture of teeth7, 8.
Occlusal disharmony and psychosocial variable also have been shown to play an aggravating role in MPDS8, 9. Current management of MPDS now also takes into account the psychological aspects of this disorder8.
There is however still an ongoing debate regarding the primary cause of the problem.


This descriptive cross sectional study was carried out on out-patients attending department of operative dentistry at Hamdard University Dental Hospital, Karachi.
All patients referred were labeled as suspected MPDS by the filter clinic, which serves as the first port-of-call for all new patients. The study was conducted over a period of one calendar year between 1st June 2012 and 31st 2013.


Patient with complain of pain in TMJ and Preauricular area, clicking sound, limited mouth opening and associated pain in muscles of mastication were selected by the filter clinic and referred to the Operative department for thorough evaluation of MPDS 8, 9.
One hundred and five patients with MPDS were included and the following variables were evaluated

  1. Involvement of individual masticatory muscle
  2. Stressful life style
  3. Limited mouth opening (Helkimo Index)
  4. TMJ pain
  5. Pain in neck muscles
  6. Jaw deviation.
  7. Habits such as bruxism and clenching

Examination of muscle of mastication and neck muscles by digital palpation is a well accepted method 10. In normal circumstances the muscle is not tender to touch. In this method we use middle figure, index figure and thumb in continuous method. Also tissues around the muscle should be pressed by fingers rotationally. Patients were also questioned about stresses related to financial and domestic issues 10.
According to Helkimo Index, incisor edges gap is measured when the patient open the mouth widely. The mouth opening is labeled as “slight limitation” if it is between 30 to 39 mm and called “severe limitation” if it is less than 30 mm. It is considered to be within normal limits if it is 40 mm or more. Jaw deviation was described as deviation on any side in this study. Deviation means that during mouth opening, jaw deviates to one side and it returns to its normal position while closing. The patient was asked about pain in and around TMJ and pre-auricular area.
The patients were also questioned regarding parafunctional habits particularly in stressful episode of life.


One hundred and five patients (105) were studied consisting of 89 (85%) females and 16 males. The age range was between 19 and 70 years; the majority fell between 20 to 40 years old. 97 subjects out of 105 (92%) were married. It was observed that housewives constituted the majority, comprising 78 out of 105 (74%) of the patients.

The data is shown in table 1

Table 1: Frequency of variables related to myofascial pain dysfunction syndrome.


It was observe that housewives constitute the bulk of the MPDS patients in the current study. This may be because of the morning timing of dental hospital; this timing tends to suit house wife who constitute the bulk of the 105 patients. Moreover a female patient also seems to have an early help-seeking behavior.15 Result of the study shows that stress is a contributing factor in the MPDS patients. Positive history of stressful lifestyle was almost equally present in both the genders (100% in males, vs. 96% in females). In our patriarchal society, females can be under additional domestic stress, and this may be an added stratum of stress in the female patients. The contribution of domestic stress on MPDS in our society need to be further explored.
In the current study, the mean age of subjects was 37 years whereas in the studies done by other investigators such as Honarmand, Madani, De Boever and Altinday, they were 32.4, 26.67, 33.5 and 31.3 respectively 9,11,16,17.
Thus, the most common age of presentation of this syndrome is between 2nd and 4th decade, by this might be because of also validates this finding.18.19.This might be due to great increase in responsibilities and stresses both on male and female after their marriages, especially in a joint family setting, which is more of a norm in our culture.
Madland, Carlsson and Rollman also confirm that patients with MPDS show decreased tolerance in coping with daily problems; have increase in anger; excessive and forceful muscular contraction. The increases the pain episode in these patients also contribute to their psychological liability 20-22.
A study conducted by Madani, Darbandi, Yap and Deoliveira 11-14 concluded that MPDS is more common in females. This may be because female are more sensitive to pain, and psychological and domestic stresses, which may result in seeking help earlier, whereas the male counterpart tend to delay seeking help till pain intensity becomes unmanageable 23.24.

In our study the most common muscle involved was temporalis (87.6 %), and this is in contrary to study by, Darbandi which shows the most common muscle involvement was lateral pterygoid muscle (82.68%) . This may be because of common complaint of headache in female patients in our population. It has been shown that headache in females in our population are frequently associated with depression and migraine23, 24 and this should be excluded in patient with MPDS.
Limited mouth opening was observed in 63% of patients whereas Madani and Darbandi have reported 26% and 40.38%, respectively. These differences may well be due to the involvement of temporalis muscle in our study population or the result of difference in number of samples and measuring factors 11, 12.
In our study, 70 % of the patients reported to have bruxism, whereas the scales reported by Honarmand, were 45.6%, 38% and 68.9% respectively 9. In MFPD syndrome brusixm and clenching are common findings. Muscle contraction for longer episode during clenching prevents adequate blood supply to the muscle and results in accumulation of CO2 and painful metabolic products in muscle, which finally leads to pain, fatigue and muscular spasm 15.
Headache, ear ache and neck pain is also very common finding in these patients 12. In our current study, headache was more common than ear ache and neck pain.


The patient with MPDS present with a myriad of sign and symptoms which may be persistent or episodic. There is a significant background of a variety of stresses, like social, economical, domestic and security issues, particularly in reference of the current volatile law and order situation of the Country in general, and Karachi city in particular. The treating clinician needs to be aware of the psychological aspects of MPDS, and should be able to explore this factor in order to provide a more holistic care and where applicable psychiatric referral should be sought.


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  1. Asstt Professor & Head Operative Department. Hamdard University Dental Hospital. Hamdard College of medicine and Dentistry. Hamdard university Karachi.
  2. Asstt professor & Head Prosthodontics department. Hamdard University Dental Hospital. Hamdard College of medicine and Dentistry. Hamdard university Karachi.
  3. Associate Professor Department of oral Surgery. Hamdard University Dental Hospital. Hamdard College of medicine and Dentistry. Hamdard university Karachi.
  4. Lecturer, Prosthodontic Department. Hamdard University Dental Hospital. Hamdard College of medicine and Dentistry. Hamdard university Karachi.
    Corresponding author: “Dr. Syed Abrar Ali” < >

Is There A Difference In Operative Dentistry Services Offered By Teaching Versus Non-Teaching Dentists In Karachi?


Farhan Raza Khan1                           BDS, MSc, MCPS, FCPS

Sadia Mahmud2                                 MSc, MS, PhD

Munawar Rahman3                          BDS, MCPS, DDS

OBJECTIVEthe clinicians in teaching institutions and private practices of Karachi and to compare the preferences of dental material and technique selection by the two groups.

METHODOLOGY: It was a cross sectional study conducted at dental departments of academic institutions and selected dental practices in different parts of Karachi. The sample comprised of 71 subjects in the teaching while 97 subjects in the non-teaching group. Stratified random sampling was carried out. Data were obtained using a structured, self-administered questionnaire comprising of 10 questions. Chi square test of independence was used to asses, if pattern of services are different between the two groups. Kappa statistic was applied to assess the reliability of the information.

RESULTS: The response rate in teaching group was 94.67% (71 out of 75) while in the practitioners group it was 44.1% (97 out of 220). The reliability of the information obtained in this study is considered as acceptable to good (Kappa value 0.53 to 0.72). There are significant differences between the groups regarding choice of restorations for cavities. The preferences regarding the use of Rubber Dam, Inlay-Onlay preparations, Gold crowns, Dentine pins, Amalgam Bonding, use of Retraction Cords, use of Bleaching Agents for teeth whitening and Porcelain Veneers were significantly different between the groups. All of these services are provided by a greater number of teaching dentists than the private practitioners.

CONCLUSIONS: There are statistically significant difference in the preferences, selection of dental materials and pattern of dental services provided by the teaching dentists as compared to the private practitioners.

HOW TO CITE: Khan FA, Mahmud S, Rahman M. Is There A Difference In Operative Dentistry

Services Offered By Teaching Versus Non-teaching Dentists In Karachi?. J Pak Dent Assoc 2014;23(1):30-35


The city of Karachi has an estimated population of 20 million individuals. Although, the number of private dental practitioners are on a rise but still yet to cater for the population needs. To some extent, the vacuum of dental care has been filled up by the academic dental centers. The academic practices are the undergraduate and the post graduate dental institutions of the city. It’s interesting to note that there are nearly 12 such institutions with over 800 active dental operatories in this city providing dental care to thousands of individuals on annual basis. Thus, it can safely be assumed that there are two strata of dental care provision in Karachi: the private dental clinics and the dental colleges/ hospital. We hypothesized that the provision of Operative Dentistry services varies with type of the
clinical setup as the clinicians in private practice are subjected to the pressure of time and cost effectiveness.The academic dentists on the other hand, have an additional responsibility of teaching and training the young breed of dentists. This may affect their clinical volumes of quality of service. With the backdrop, it’s imperative to explore the status dental care provision in the city.


To compare the pattern of Operative Dentistry services offered by the teaching and non teaching dentists in Karachi, Pakistan.


  1. Teaching dentist: Dentists employed in academic institutions as faculty members, fellows or post graduate students were labeled as teaching group.
  2. Private Practitioners: Dentists who were not associated with any academic institution and are full time practitioners were considered in this group.
  3. Pattern of Operative Dentistry service: clinical decision making, preferences of restorative materials and selection of techniques in dental conservation.


It was a cross sectional study conducted at seven undergraduate and five post graduate dental institutions and their attached clinical settings in Karachi and selected private Dental Practices in different parts of Karachi.
Inclusion Criteria: Dentists who were registered with Pakistan Medical & Dental Council (PMDC) and have at least completed one year internship after graduation and are engaged in practice, teaching or both.

Exclusion Criteria: Dentists who are not active in practice or retired were excluded. Sampling technique: The names and contact information of the practitioners were obtained from the Office of the Pakistan Dental Association Karachi division (last updated in 2007). There are about 250 dentists in the academic settings and 750 in private settings. Stratified random sampling was done to select the study subjects, considering the academic and private practice settings as two distinct strata. Sample size: We calculated the sample size to test if there is a significant difference in the proportion of dentists using GIC (Glass ionomers based restorations) for primary teeth at 5% significance level and 80% power. We assumed (using our clinical judgment and experience) that in teaching group 70% and in the nonteaching group 50% dentists may use GIC. The sample size turned out to be 67 in teaching group, while in non-teaching group 201. To adjust for refusal, we inflated the sample size by 10% to get the sample of 75 in the teaching and 220 subjects in the non-teaching group.

Ethical Approval: The study protocol was approved by the Aga Khan University ethical Review Committee (Ref # 573-Sur/ERC-06). The informed consent of the participants was taken.

Data Collection Tool: A structured, self-administered questionnaire (written in English) regarding preferences, selection of materials and techniques used in providing

Operative Dentistry. The questionnaire had three parts:

  • First part dealt with Demographics (independent variables)
  • Second part had 28 questions on Operative Dentistry practice (response variables).

Data Collection Method: Questionnaires were given to the study population by hand. A reminder via telephone was made in case of no response after 2 weeks. A second reminder after four weeks of distribution was made to collect the maximum number of questionnaires. To ascertain the information reliability, we repeated 3 (10%) questions at the end of the of the study questionnaire.
Data Analysis: SPSS 19.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. From the demographic section, means and standard deviations of the quantitative variables and proportions for the categorical variables were determined. The response variables in the study are about the preferences in material and clinical technique selection. These responses are measured on nominal or ordinal scale.

Independent samples t test was applied to compare continuous variables such as age and experience of the participants. Chi Square test (or Fisher’s exact test) was applied to test if clinical preferences and pattern of services are different between dentists in academic settings than those in private practices. Mann-Whitney U test was applied to compare the two groups for ordinal scale responses. P-value less than 0.01 were considered as statistically significant. Kappa statistics was applied to assess the agreement between the initial responses and the repeated questions.


The total number of participants in our study was 168 out of which 71 (42.3%) participants were teaching dentists while 97 (57.7%) were private practitioners. Around 30 (out of 70) in the teaching and 40 (out of 97) in the non-teaching group were females. The response rate in the teaching group was 94.6% (71 out of 75) while in the practitioners group, it was 44.1% (97 out 220). Both groups were comparable with respect to the age (p-value 0.1) and professional experience (p-value 0.07). Teaching and non teaching dentists have statistically significant differences regarding their interest in clinical specialties (p-value 0.003).
Both groups stated that amalgam is their material of choice for Class I and Class II restoration in molars and premolars. However, both preferred composite in premolars Class I preparation. In class V teaching dentists selected composite while most practitioners preferred Glass ionomer (p<0.001)
Use of rubber dam was scarce, inlays and onlays were infrequently done by the both groups. Private practitioners were more inclined towards dentine pins and gold crowns placement while teaching dentists.

Table 1: Descriptive Statistics and Comparison of Age and Experience of Participants in the Two Groups (n=168)

Independent samples t test was applied to compare the two arithmetic means.

Table 2: Specialty of Interest according to Group Status (n=168)

Chi Square (Fisher’s Exact test) of proportions at 0.05 level of significance

Table 3: Comparison of dentists regarding directly placed restorations (n=168)

Chi Square test (or Fisher’s Exact test) were applied. Level of significance was set at 0.01

Table 4: Comparison regarding Operative Dentistry Clinical Procedures (n=168)

Mann-Whitney U test was applied to see the difference between the two groups for ordinal responses. Level of significance was set at 0.01

Table 5: Comparison of Teaching and Non -Teaching dentists, Reasons for Not Employing Clinical Procedures

Chi Square test (or Fisher’s Exact test where needed) were applied. Level of significance was set at 0.01. T refers to teaching group while P is the practice group.

Table 6: Comparison of Teaching and Non-Teaching dentists regarding Crowns (n=168).

Chi Square test (or Fisher’s Exact test where needed) were applied. Level of significance was set at 0.01.

reported frequent use of amalgam bonding, retraction cords and topical anesthetic administration (p<0.001) The reliability of the information obtained in our study ranged between acceptable to good (65-72%).


Although the participants in both the study groups were similar in age and professional experience (table 1) but their clinical interests were highly variable. Both the teaching and non-teaching dentists selected general dentistry, operative dentistry and Endodontics as their areas of interest. Pediatric Dentistry and Periodontics were found to be the least attracted fields. The probable reason of clinician not inclined towards these specialties is lack of training centers and faculty in these areas 1, 2.
There were significant differences between the two study groups for their decision making for direct restoration in Class I and II cavity preparations. Private practitioners were mainly confined to amalgam as the preferred material but selected composite resins as the alternatives. Amalgam remained the preferred restorative for academic dentists but their choice of alternatives was broad. In addition to composites, they did select GIC and RMGIC too. Similarly, major differences were seen in Class V scenario as well. Our results were in agreement with Burke

It’s a high time for teaching and non-teaching dentist to engage themselves in a life long commitment of continuing education to predictably meet the point of care and to routinely carry out good-quality dentistry.


This study involves both strata (academic institutions and as well as private practices) thus, it provides the
information from the two sides. The relatively poor response rate from the practitioner group (97 out of 201 or 48.25%) appears bad but upon exploring into the causes of this low response rate, it’s obvious that busy practitioners are not interested in completing questionnaires during business hours. A response rate of 26.3% was recorded by Haj -Ali 14 in USA, Mjor 15 had response rate of 51% while Forss 16 received a response rate of 53.6% from dentists in similar studies. This suggests that it’s not uncommon for practicing dentists to give low response rate. In this context, our response rate of 44.1% does not appear that bad. Since the information of non responding practitioners was not available, so we could not explore any further in this direction.
However, this non-response bias has the potential to affect the study results.
In comparison to practitioners, the teaching dentists showed an excellent compliance (94%) in responding to the questionnaires probably because they are familiar to research activities and therefore, more complacent and open in participation.


There are significant differences between the teaching and practitioner groups regarding operative
dentistry. The use of rubber dam, gold crowns, amalgam adhesives and retraction cord were not satisfactory for both the groups.


Emphasis should be given on Operative Dentistry at an undergraduate curriculum. A system of revalidating the dental practice license on completing required numbers of CME should made a mandatory requirement.


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  1. Assistant Professor, Operative Dentistry Aga Khan University, Karachi, Pakistan.
  2. Associate Professor, CHS Aga Khan University, Karachi, Pakistan.
  3. Senior Lecturer, Operative Dentistry Aga Khan University, Karachi, Pakistan.

Corresponding author: “Dr. Farhan Raza Khan”

Email:  Mobile: +92 3052225117


The sequence of authors of the article titled “Copy denture, Existing dentures Replacing Techique Geriatric patiant. J Pak Dent Assoc 2013” was incorrect. The correct sequence and therefore correct citation is as follows: Habib SR, Vohra FA. Copy denture, Existing dentures Replacing Techique Geriatric patiant. J Pak Dent Assoc 2013Because of a production error, in article titled “Almas AK, Almas K. Miswak

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Comparative Review Of Various Flowable Composites


Zeeshan Qamar1                             BDS, MSc

Tayyaba Fatima2                           BDS

Flowable composites are of low viscosity and a modification of small particle-filled and hybrid composites. They have reduced filler load and modified resin monomers which provide a consistency that allows the material to flow readily. They have better adaptability to cavity walls thus preventing microleakge.

HOW TO CITE: Qamar Z, Fatima T. Comparative Review Of Various Flowable Composites. J Pak Dent Assoc 2014; 23(1):11-14


Restorative dentistry is going through a dynamic transition towards adhesive dentistry. A class of resin-composite systems known as ‘flowable composites’ has become an essential part of the restorative process since their introduction in the mid-nineties. These materials were developed in response to a demand from the clinicians for easy handling. They are characterized by having less filler load and greater portion of diluent monomers. Designed to be less viscous, and so the flowable composites offer a better adaptation to internal walls of the cavity, easier insertion and greater elasticity. Flowability of these materials allows them to be dispensed through injectable dispensers and simplifies easy placement procedures.


Present day dental composites exhibit excellent aesthetics. Thus, due to this increasing demand, this has leaded to significant developments in terms of bond strength, adequate working time, shorter curing time and ease of use1. By the end of twentieth century, lowviscosity resin composite, generally known as flowable composites, were introduced amongst the variety of commercial commodities for restorative dentistry2. These flowable composites show two desirable clinical handling characteristics that were not present in composites until very recently. Firstly the material does not stick to the instruments, so the material can be easily filled in the cavity and secondly fluid injectability1.

Flowable composites were formed by keeping the same particle sizes of traditional hybrid composites, and by decreasing the filler content thus permitting increased resin to reduce the viscosity of the mixture1.


Wide ranges of flowable composite with different percentage of fillers (50%-70%/wt) are available and can be classified into low, medium or high viscosity3. Flowable composites are similar to traditional resin based fissure sealants. According to Sebastein, (2012) the former are said to have better mechanical and physical properties thus have been suggested to be used as pits and fissure sealants4. Lower filler loading results in greater polymerization shrinkage and lower mechanical properties compared to other hybrid composites5. Flowable composite also have low modulus of elasticity and their viscosity ranges from low to medium3,5. This suggests that these materials modulus of elasticity in 24 hours ranges from 2.8-6.0 GPa and thus they are not able to withstand the occlusal forces when used in bulk6. By decreasing the proportion of filler, flowable composites can easily adapt small cavity preparations. However their wear resistance is of major clinical concern as good wear resistance depends on increased filler load7. Complex viscosities of flowable composites decrease with increasing shear rate, showing a non-Newtonian behavior.4Flowable composites consist of less filler loading and the filler morphology is spherical due to which there is less shrinkage-strain values4. Their shrinkage-strain values at 23oC are 2.61-6.25%, and at 37oC range between 3.88-6.56%8. But in some flowable composite the spherical shaped filler particles have an advantage as they allow increased filler loading and enhance the fracture toughness value4. According to some in vitro studies flowable composites decrease restoration microleakage and the occurrence of voids9-11. This is mainly due to their ability to adapt well to the cavity walls and their stress-absorbing ability6. Flowable composites, as concluded in the study of Attar et al, (2003) have approximately 50% of the rigidity (elastic modulus) of the regular composites and approximately 80% of the flexural strength6.

In this article we will discuss the following flowable dental composites.


Flowable composites were brought on the market in the mid-nineties and have proven to be serviceable in a wide variety of clinical conditions.The company Kerr (Kerr, Corp, U.S.A) has developed Vertise TM flow as it’s first self adhering light cure flowable composite for direct restorations. Its formulation incorporated ‘optibond’ adhesion technology which eliminates the processes of, in no specific order; bonding, rinsing, priming and etching (Kerr, 2011).

This belongs to the 7th generation of dental composites as mentioned in table1, in which the triple mechanism

Table 1: Classification of dental adhesives. i.e. etchant, primer and adhesive are mixed together into one syringe. The glycerol-phosphate-di-methacrylate

Figure 1:  GPDM bonding in VertiseTM FLow (Kerr, 2011)

(GPDM introduced by Buonocore et al, 1956) between phosphate functional groups of GPDM monomer and calcium ions of enamel and dentine creates the bonding mechanism with the tooth structure where a chemical bonding is then attained as shown in Figure 112,13.Its composition includes GPDM and HEMA in the resin matrix and pre-polymerized barium glass filler, colloidal silica and ytterbium fluoride as filler constituents.

This material offers high bond strength, high mechanical strength and other physical attributes when compared to other traditional flowable composites3. It has multiple clinical implications and is available in nine different shades. It is a biocompatible and radiopaque product and bonds well to enamel, dentine, porcelain, metals, amalgams and composite3.


Grandio flow is a nano-hybrid flowable type of composite. When compared to general hybrid-resin, it has the highest filler load4. Its resin to filler ratio is 1:6.7 (VOCO, Grandio Flow). Filler morphology of Grandio under the SEM showed higher irregular shaped particles4. Fillers present in this material are two-thirds inorganic

fillers and the resin part consist of Bis-GMA, TEGDMA and HEDMA.

Grandio flow offers various outstanding physical properties along with its less polymerization shrinkage that is 1.57%. Its properties include good wettability, high compressive and transverse strength, less cytotoxity and good abrasion resistance15. Moreover, the nanoparticles create a network effect within the matrix that increases tensile strength, wear resistance and good flow properties16. Vickers hardness test by the Durimet gave the result of 59.9VHN, which was higher than the Premise flowable.


Premise flowable composite (Kerr, Corp, U.S.A) is a medium viscosity, light cured, nano-hybrid composite. This material is used after the application of ‘optibond/FL’ or ‘optibond solo plus’ in the cavity. The material also poses a unique property of releasing fluoride and radiopacity. It contains more regular spherically shaped filler particles. The percentage of filler content by weight in Premise flowable is 72.5%4. Premise flowable contains the trimodal filler system and resin part consists of ethoxylated bis-phenol-A-dimethacrylate.

Premise flowable composite is based on the trimodal technology, which comprises pre-polymerised filler (it is a of blend low shrinkage resin, barium glass and 0.02 micron filler-), point-4 filler and 0.02 micron filler. Due to this technology, this material shows; less shrinkage, optimal handling, good polish, durability, good mechanical strength and good wear resistance compared to other flowable composites.


Hydroxyethyl methacrylate (HEMA) Figure 2 is a hydrogel; it is hydrophilic in nature and potentially biocompatible. Thus it’s of great interest in the field of Hydrophobic End

Figure 2: Chemical structure of Hydroxyethyl methacrylate

biomaterial sciences and manufacturing soft contact lenses17. Hydrogels being hydrophilic polymers, absorb 10-20% water, being a thousand times more than their dry weight. They are chemically stable, may degrade and finally breakdown and disintegrate17. The elasticity of these hydrogels can be improved by altering their structure and by adding cross-linking agents18,19. Most commonly used cross-linking agent is ethylene glycol dimethacrylate20.

The nature of water in the hydrogel can determine the permeation of nutrients in and out of the gel. Hoffman described water absorption by HEMA as follows: A dry hydrogel starts to absorb water; this first water enters the matrix and hydrates the matrix with the most polar (hydrophilic group) resulting in ‘primary bound water’17. These polar groups, after being hydrated swell and expose hydrophobic groups; these also interact with molecules of water leading to ‘secondary bound water’ (hydrophobically bound water). Total bound water is formed by the combination of primary and secondary bound waters. Equilibrium is reached when further swelling is opposed by covalent/physical cross-links, leading to an elastic network of retraction forces. This additional water that is imbibed becomes saturated and is called the ‘free’ or ‘bulk water’. It is this free water that occupies the gaps between network chains and voids17. Thus HEMA being one of the important components of Vertise flow has made this material a subject to study.


The composites chosen for this study are marketed in the UK as low viscosity, self-adhering composites, suitable for pits and fissure sealants, repair of marginal defects, liners in deep cavities, class-v restoration and paediatric dentistry.

The company Kerr has formulated a self-adhering, low viscosity nano-hybrid composite known as Vertise TM Flow. It includes the Optibond technology and eliminates the steps of etching/priming/bonding. The bonding mechanism of this material with the tooth structure is a chemical bond achieved via the GPDM phosphate functional groups and calcium ions of the enamel and dentine. According to the company’s, this material offers high bond strength, high mechanical strength and other physical attributes comparable to other traditional flowable composites. Vertise TM Flow is a biocompatible and radiopaque material and bonds well to different substrates including enamel, dentine, porcelain, metals, amalgam and composite.

Vertise TM Flow has been a subject of this study here due to its composition containing HEMA and low filler loading (compared with Grandio Flow and Premise Flow). HEMA is a hydrophilic monomer which absorbs water and could potentially decrease the properties of the material21.

The other materials used in the study were Grandio Flow and Premise Flow. Both these are low viscosity flowable composites. The difference between them and Vertise TM Flow is that they do not contain HEMA. These are nano-hybrid composites, and their filler content by weight is 72.5% in Premise Flow and 80.2% in Grandio Flow. They both have good physical and mechanical properties but PF has an added advantage of releasing fluoride and having a higher radiopacity than Grandio Flow. These materials are in used in this study for comparisons purposes.


Flowable composites are of low viscosity and a modification of small particle-filled and hybrid composites. They have reduced filler load and modified resin monomers which provide a consistency that allows the material to flow readily. They have better adaptability to cavity walls thus preventing microleakge.


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  4. Beuna S, Bailly C, Devaux J, Leloupa G. Physical, mechanical and rheological characterization of resinbasedpit and fissuresealants compared to flowableres in composites. Dent Mater. 2012; 28:349-359.
  5. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives. Dent Mater. 1999;15: 128-137.
  6. Attar N, Tam LE, McComb D. Flow, strength, stiffness and radiopacity of flowable resin composites. J Canadian Dent Assoc. 2003; 69:516-521.
  7. Clelland NL, Pagnotto MP, Kerby RE, Seghi RR. Relative wear of flowable and highly filled composite. J Prosth Dent. 2005;93:153-157.
  8. Baroudi K, Silikas N, Watts DC. Time-dependent visco-elastic creep and recovery of flowable composites. European J Oral Sci. 2007;115:517-521.
  9. Payne JH. The marginal seal of class II restorations: flowable composite resin compared to injectable glass ionomer. J ClinPediatr Dent 1999; 23:123-130.
  10. Ferdianakis K. Microleakage reduction from newer esthetic restorative materials in permanent molars. J Clin Pediatr Dent 1998;22:221-229.
  11. Malmstrom H, Schlueter M, Roach T, Moss ME. Effect of thickness of flowable resins on marginal leakage in class II composite restorations, Oper Dent. 2002;27:373-380.
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  16. Sideridou ID, Karabela MM, VouvoudiECh. Physical properties of current dental nanohybrid and nanofill lightcured resin composites. Dent Mater. 2011;26: 599-607.
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  1. Head of the Oral Biology Department Ziauddin University Karachi, Pakistan.
  2. Department of Oral Biology University of Malaya Kuala lumpur, Malaysia.

Corresponding author: “Dr. Zeeshan Qamar” < >

Association Of Dental Caries And Parents Knowledge Of Oral Health, A Cross-Sectional Survey Of Schools Of Karachi, Pakistan


Mohammad Ali Leghari1                             BDS, MSPH

Farzeen Tanwir2                                            Post-Doc, PhD, MPhil, C.Orth, BDS

Humera Ali3                                                    BDS


OBJECTIVE: To evaluate the association of oral health knowledge of parents in relation to dental caries of their children.

METHODOLOGY: This cross sectional study was undertaken in Malir Town, Karachi. Oral examination of 399 school going children enrolled in local private schools was carried out to assess their dental caries status. A Selfadministered questionnaire was used to gauge oral health knowledge of parents.

RESULTS: Study sample comprised of 49% boys and 51% girls. The prevalence of dental caries was 70 % with a mean DMFT score of 1.4. was significantly higher among girls compared to boys. The dental caries increased as the age increased from 12 year age to 15 year. Parents were aware that regular visits to dentist can prevent dental caries but there were large numbers of parents who visited dentist when there was the pain in teeth.

CONCLUSION: The current study found that female students had relatively higher odds of dental caries than compare to males. Parent’s knowledge of oral hygiene had effect on their children oral health. Oral health programmes should be performed in future for the oral health care awareness for both children and their parents.

KEY WORDS:  Dental caries, socio economic status, parents dental knowledge. DMFT

HOW TO CITE: Leghari MA, Tanwir F, Ali H. Association of dental caries and parents knowledge of oral health, A cross-sectional survey of Private Schools. J PAk Dent Assoc. 2014;23(1):19-24.


The distribution of dental caries has changed dramatically in last few decades shifting its base from developed countries to developing countries. Dental diseases are the most expensive to treat and rank fourth in developed countries1. Dental caries that is left untreated can affect children’s quality of life, as untreated caries cause discomfort, pain, dental sepsis and as a result loss of school days2.

The prevalence of dental caries in developing countries has been attributed to less number of preventive programs in the community and in schools, lack of water fluoridation; in-efficient oral health care arrangements and consumption of refine carbohydrates. The higher number of dental caries in developing countries is mainly attributed to urbanization and socioeconomic factors3.

Good oral hygiene is imperative factor prevention of dental caries. There is little known of the oral health knowledge of the school going children in developing countries3. Recently, it has been reported that the dental health status of the children is affected by dietary habits and the social class of their family and the maternal education4, 5, 6,7.AL-Hosani reported low caries prevalence in children of parents having high education level and better socio-economic status8.

Federal surveys report of US Surgeon General’s workshop, “Children and Oral Health,” found that there were disparities in the oral health of the children and the access to dental clinic for treatment for dental cavities and there were 60 % more untreated dental diseases compared to high income group9.Factors like parents low education, unemployment and low income are also associated with the poor health and chronic diseases10.

The study of Tickle et al.11 conducted on children who were registered to general dental clinic in north of London, stated that children belonging to poor environment experience higher dental caries, and are less likely visit to dental clinics Moreover, children who visit dental clinics more often have lower incidence of dental disease although they score higher for treatment done.

There is scarcity of data on oral health knowledge amongst parents and its association with dental health status of their children. The last nationwide survey was done in 2004 in different cities of Pakistan, since than no major project has been undertaken12.

The main objective of this study was to find out the prevalence of dental caries in school going children aged 12 -15 in relation with the oral health knowledge of their parents. The results of this study could be used for evaluating health services and planning oral health related programs in Malir district.


An analytical Cross sectional study for the assessment of dental caries was conducted in school going children aged 12-15 years in Malir town, Karachi. A sample size of 380 was calculated based on previous prevalence study done by A.A khan in Lahore 13 and following formula  was used for the calculation of the study sample size14. A standard Error of 5%, a confidence interval level of 95% and an Expected prevalence of 55% was used. There are seven Union councils in Malir town, two schools from each union council were selected by convenience sampling, and from each school 28 children were selected by simple random sampling Sample size was increased from 380 to 392 due to the extra examination of the participants to prevent the dropout during the study. The head masters of selected schools were contacted and their consent was obtained for participation in the study.

Malir town is considered a low socio-economical area of Karachi, although there is no data available that specify standardized socioeconomic status of the different towns of Karachi. For clinical dental examination, specifications recommended by “World Health Organization (Oral Health Survey Basic Methods, Geneva 1997) for Oral health surveys”15 were used as at this age, all permanent teeth have had erupted.

The study tools comprised of self structured, close ended questions adopted from articles and research studies of similar design, and was modified accordingly to assess parental oral health knowledge. These questionnaires were translated into Urdu language for the ease of understanding of the respondents. Urdu is the national and official language of Pakistan 16 and majority of the population of Pakistan understands it. The questionnaires for parents were handed over to the children who carried it to their home for their parents. Those questionnaires were filled by parents and children brought them back to the school and were collected from the school, the next day.

Basic oral examination instruments namely mouth mirror, dental explorers CPI probes and a dental lamp were sterilized for the detection of dental caries following strict cross infection control protocol. Oral examination was done by single operator to detect the presence of dental caries, missing (extracted or congenital) and filled teeth. All 28 permanent teeth were examined excluding the 3rd molars.

Description of frequencies and proportions of discrete variables and mean (SD) for continuous variables were presented for dental caries of children. T-test was applied for differences of mean for categorical variable. Univariate and multivariable logistic regression analysis was applied to check the association of parent’s knowledge with dental caries. The DMFT variable and completed questionnaires were then entered in STATA version 11 for statistical analysis.


The response rate of parents was 38% (n=150) therefore the information on parent’s oral health knowledge is limited to 150 participants. Of the 150 students examined, 73 (49%) were boys and 77(51) girls. The frequency of age distribution was 15(10%) 12 year age, 36(24%) 13 year age, 39(26%) 14 year age, 60(40%) 15 year age.

The overall mean DMFT score was 1.4 (.10), scores of dt, mt and ft components were 1.17(.09), .05(.02) and .15(.03) respectfully. The mean DMFT in boys was 1.06 and in girls it was 1.45. The DMFT value by age stratification showed that DMFT value was 1.33 in 12year and 13-years old and 1.41 and 1.45 in 14- and 15years old children respectively. The study showed that as the age of the children increased from 12 to 15 years the DMFT value was also increased (see table 1).

Student’s distribution according to father education was categories into less than 10 year education consists of (33)22% students, 11-12 year education (74)49% and education greater than 12 year was (43) 29%. On the other hand student’s distribution by mother’s education

Table 1: Mean DMFT (SD), D-T, M-T, and F-T and frequencies of DMFT by age and sex.

Notes: DMFT= decayed, missing, and filled teeth; DT = decayed  teeth; MT = missing teeth by caries; FT = filled, *p-value <0.05 was (59) 39 %, (74) 49% and (17) 12% according to lower, middle and higher education categories.

Family income was categories according to income less than 15000 Rs and income greater than 15000 Rs and there were 47(31%) and (103) 69% students respectfully.

The independent variables included student’s gender, student’s age, parent’s level of education, income and knowledge of parents and dependent variable was prevalence of dental caries. The variables were categories into socioeconomic status, child variables and oral hygiene knowledge. It was observed that odds of dental caries was less in female students as compare to male although the results were not significant p value was greater than .05. The odds of dental caries were also increased with increasing age of the child, parent’s education level and household income, however the results were insignificant.

In response to the question asked from the parents regarding the knowledge of plaque, 80(53.3%) said that

plaque was the remaining of the food particles that sticks to the teeth, 49(32.7%) considered plaque and stains as synonymous, while 21(14%) did not know what plaque was.

As for the effect of plaque on teeth, 62(41%) parents considered plaque as a cause of dental caries,40(26.7%) considered it a cause of bleeding gums, 33(22%) responded that plaque discolours the teeth whereas 15(10%) did not have any knowledge about the oral effects of plaque. Regarding factors leading to dental caries, 38(2%) stated bacteria, 37(24%) chose sweets, 22(14.67%) stated sugar, while 23(15.3%) highlighted frequent snacking as a causative factor whereas 23 (15.3%) did not have any knowledge concerning factors leading to dental caries presented in table 2.

It has also been observed that 139(92.6%) parents used tooth-brush and toothpaste devices for the cleaning of their children’s teeth whereas 11(7.3%) used Miswak tool for the cleaning of their teeth. While, 97(65%) used fluoridated toothpaste and the other remaining 53(35%)

Table 2: Mean (SD), proportion of children with dental caries in relation to oral knowledge of parents.

*Correct answer

did not use a fluoride toothpaste. T-test for variable regarding knowledge of fluoride and mean DMFT in children presented in table 3.

When asked from the parents if brushing teeth prevents caries, 114(76 %) answered ‘Yes’ as a response. The odds of dental caries was 2.29 times more in children in those parents who said that fluoride had no effect on protection from dental.

The odds of dental caries were higher in children not using fluoridated toothpastes. The odds of dental caries in children were higher (OR= 2.3, p value= .034) if their parents answered that fluoride doesn’t prevent dental caries.

Multivariable logistic regression analysis. After adjusting for other variable the odds ratio of dental caries was statistically significant for father education and children’s gender. Boys were significantly more protective

Table 3: Parental knowledge of fluoride with mean DMFT of their children

Table 4: Univariate and multivariable logistic regression model to calculate OR for children’s characteristics effect on dental caries (N=150).

for been free from dental caries. The OR of dental caries increased while father’s education increased. The OR of dental caries was 3.34 for children with father’s high education compared to children with fathers who have low education (table 4).Those parents who didn’t use fluoride tooth paste the odds of dental caries was 3 times higher than those who used fluoride toothpaste (P=0.009, Table 3). The knowledge of parents about fluoride was significantly associated with occurrence of dental caries and those who didn’t know about this fact had 1.82 times higher odds to get dental caries compared to those who knew (P=0.028, Table 4).


The mean DMFT index score was 1.4 and was smaller than the previous national health survey of Pakistan (NHSP 2004) which was 1.6 12 .The prevalence of dental caries was 70% which was almost similar to the study that was carry out in Kenya17 but was higher from oral health survey that was done in 2004 where it was 50%12. Eating habits between meals and after meals was the same for boys and girls and the results showed the similarity to the study that was done in school going children in U.A.E 8.

High income parents who do not have proper oral hygiene knowledge have higher odds of occurrence of dental diseases in their children. The combination of high income and poor parental education is a new risk factor which needs further investigation. Same phenomenon was also seen in children in Abu Dhabi where the students had the high dental caries status in high income families8.

There were disparities of knowledge of oral health in girls and boys and the results were similar in study done in Japan18.The study reveals that girls had more knowledge and were more oral health conscious as compared to boys but the mean DMFT score was greater than boys.  This is more likely due to the socioeconomic status, and girls were from the families where there were no gender differences with regard to priorities for attainment of education between girls and boys. National health survey in Hungary also found out the gender difference in dental caries experience and in the increase of prevalence of caries and as age increases which is the same as our study19.

The DMFT index score increased as the father and mother education increased from lower to intermediate but it decreased in the parents with higher education. The mothers of the children with higher education had lower DMFT index score as compare to the other intermediate and lower education groups. Previous studies also reported similar DMFT in different education groups 20. But there were contrasting results regarding association the DMFT score with high level of income. Children belonging to higher household income had high DMFT score, and On the other hand, high income also related to the higher decayed, missed teeth surprisingly there were also higher numbers of fillings present on their children teeth with high level of income. It reflects that consumption of sugar and cariogenic food was increasing as the income increases and causing more teeth decay to occur as well as perception of visiting to dental clinic increases for the restorative treatment. There was no significant relationship seen in parent’s socio demographic characteristics with the mean DMFT of their children. There was less numbers of participants in the study and there was less power to reject the null hypothesis.

It has been seen that children belonging to families with high socio economic status had a higher DMFT, score and had more fillings presents on their teeth as compared to their counter parts from low socio economic status group. The poor status was not the factors for the occurrence of dental diseases but it was the high income that led the disease to occur and drove them towards dental clinic for dental filling treatment. These results were dissimilar and contradictory from the study done in USA21.  In response to the question about the effect of fluoride on teeth, 46% of the parents said that it cleans and helps in whitening of teeth. Similar wrong perceptions were reported in another study (Kingdom of Saudi Arabia)22.

Even though the sample size was very low, the current study has a great potential to be used as a pilot study23 in future research projects in Pakistan. The descriptive results can have important policy implications and that is the major contribution of the current study in future plans of oral health programs among school children in Karachi. Parents were aware that regular visits to dentist can prevent dental caries but there were large numbers of parents who visited dentist when there was the pain on teeth. There were some parents who said that they prefer to visit physicians for dental consultation.

In Pakistan there was not very much work done on national level for the evaluation of oral diseases in school going children, the last survey done in 2004 in different cities of Pakistan. There was not any study carry out on this topic and publish in local or international journals. This is the first study that focuses on both children and parents knowledge variables with relation to the dental caries in Karachi, Pakistan. This study can be baseline or reference study for the conduct of further studies in future in Pakistan.

For parents there were some variable which had significant effect of oral hygiene to their children dental caries. The role of mother particularly those who are educated with advanced education should not be neglected and have important role in taking care of oral hygiene of their children.


The prevalence of DMFT was higher in girls than compare to boys and the results were statistically significant. The DMFT status of the study population increases as the age of the students increases. Parents had moderate amount of knowledge regarding fluoride and also had some effect on their children’s dental caries status. Rinsing the mouth after taking the food and the use of fluoride containing toothpaste was protective against the cariogenic activity.


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  1. Senior lecturer, Community dentistry Department. Baqai dental college. Baqai Medical University.Karachi.Pakistan
  2. Director of Post graduate Studies and Research, Associate Professor and HOD, Department of Periodontology. Ziauddin University. Karachi. Pakistan 3. Lecturer,Department of Periodontology Ziauddin University Karachi. Pakistan

Corresponding author: “Mohammad Ali Leghari”

Email: Cell# 03212141488

Assessment Of Post-Obturation Pain: Single Vs Two Visits Root Canal Treatment


Muhammad Atif Saleem1                                 BDS, FCPS

Abu Bakar Sheikh2                                            BDS,FCPS

Muhammad Athar Khan3                              MBBS, MCPS, DCPS-HCSM, DCPS-HPE, MBA, PGD-Statistics

Sadaf Atifi4                                                          BDS

OBJECTIVE: The objectives of this study was to evaluate the severity of post-obturation pain following single visit and two visit root canal treatment using VAS (Visual Analogue Scale)and to determine the correlation between pre-obturation and post-obturation pain.

METHODOLOGY: This was a Quasi Experimental study that was conducted in the Operative Dentistry Department of Altamash Institute of Dental Medicine was done in duration of six months. Sixty patients were selected. After access preparation, working length was determined by Periapical radiograph. Canal preparation was done by StepBack technique using K-files and obturation was done by lateral condensation of gutta percha. In two visit group, canal preparation was completed in first visit and obturation was carried out at a later date. Data analysis was performed through SPSS version-13.0. Repeated measure analysis of variance (ANOVA), Chi-square  and Pearson’s correlation (r) were used with p-value <0.05 considered as significant.

RESULTS: After postoperative 4 hours, the mean VAS in single root canal visit group was 4.7±2.96 and 2.8±1.73 in two root canal visit group. The mean VAS score of two visits for postobturation pain after 12 and 24 hours was less in as compared to one visit treatment. Data showed direct correlation in pre-operative pain and post-obturation pain in both groups.

CONCLUSION: No advantage was observed when one-visit and  two-visit root canal treatment were compared regarding post-obturation pain in the initial 4 hours, but two-visit root canal treatment showed better results in terms of post-obturation pain after 12 and 24 hours. Though the present study reported favourable results in two- visit root canal treatment regarding post-obturation pain.

KEY WORDS: One visit endodontic treatment, , Pre-operative pain, Post-obturation pain, Two visit endodontic treatment, Visual Analogue Scale.

HOW TO CITE: Saleem MA, Sheikh AB, Khan MA, Atif S. Assessment Of Post-obturation Pain: Single Vs Two Visits Root Canal Treatment. J Pak Dent Assoc 2014;23(1):25-29


dontogenic pain is a primary reason for a patient to seek conventional endodontic treatment. Root canal treatment or endodontic treatment is a common procedure in dentistry. Pain and discomfort are often associated with root canal treatment. When the treatment itself appears to initiate the onset of pain and/or swelling, the result can be very distressing to both the patient and the operator1,1.

The general population generally regards root canal treatment as a painful and unpleasant experience. Usually, the root canal treatment relieves the pain symptoms; however pain may persist for a few days following the treatment. Postobturation pain after nonsurgical root canal treatment has been reported to range from approximately 3% to more than 50%3,2.

Some authors  concluded in their study that there was no difference in the post-operative pain between patients treated in one-visit and patients treated in two appointments. The majority of patients in both groups reported no pain or only minimal pain within 24 to 48 hours of treatment 5-9.

While some researchers presented a higher incidence of postobturation pain following single visit root canal treatment. Oginni & Udoye reported  higher incidences for post-obturation pain and flare-ups following the single visit procedures, this study also showed that  teeth with vital pulps reported the lowest frequency of postobturation pain (48.8%), while those with non-vital pulps were found to have the highest frequency of postobturation pain (50.3%)10. Other studies presented higher incidence of postobturation pain following two visit root canal treatment 11- 14.

Certain preoperative and operative factors are associated with pain after endodontic treatment. Patients experiencing severe preoperative pain have an increased incidence of moderate to severe post-endodontic pain when compared to those having no pain prior to

conventional endodontic treatment15,16,17.  The prevalence of postobturation pain is also significantly affected by the vitality status of tooth18 and number of appointments, gender, tooth type, size of periapical lesion bacteriologic status, tooth position, and type of filling material showed no effect on post-obturation pain19. But the operator may induce postobturation pain by exuding instruments, debris, paper points, filling materials, or chemicals paste the root apex into the periapical tissues20.Postoperative pain was significantly associated with the obturation technique used during root canal treatment.21

The objective of this study were to determine rate and severity of postobturation pain using VAS (visual analogue scale)22 and to evaluate the relationship between pre-obturation and post-obturation pain when performing root canal treatment in single visit compare to treatment in two visits.


Study was conducted with prior approval of the hospital ethical committee of Altamsah Institute of Dental Medicine. Patients requiring endodontic treatment were included in the study. Verbal informed consent was taken from the patients. History, clinical examination and radiographic investigation were done. Patients requiring single visit treatment were included in Group 1(N=30) and patients received two visit treatments in group 2(N=30). For each tooth treated, a recorded data including pulp vitality status, the presence or absence of preoperative pain and degree of postobturation pain at 6, 12 and 24 hours respectively were recorded by using a visual analogue scale (VAS).The patient were given the VAS form, along with a stamped, addressed envelope for return of the form after 24 hours. Patients were contacted by telephone at 4, 12 hours and again after 24 hrs to remind those to complete the VAS form.

The standard procedure for both groups at the first appointment included local anesthesia, rubber dam isolation, caries excavation, and standard access preparation. The working length was determined radiographically from a coronal reference to a distance 1 mm short of the radiographic apex. The root canals were cleaned and shaped using the step-back technique, hand files, and Gates-Glidden drills (Dentsply/Maillefer, Ballaigues, Switzerland). The teeth were then randomly assigned to two groups as follows: group 1, single-visit therapy each root canal was dried with paper points, then filled with gutta-percha points sealed with Sealapex root canal sealer (Sybron Endo, CA, USA) using the lateral condensation technique. Group 2, multi-visit therapy the teeth were prepared as in group 1, but were not obturated. Chemomechanical preparation was completed in the first visit using the same technique for all cases. A sterile cotton pellet was placed in the pulp chamber, and the access cavity was sealed with Provis Temporary Restoration( Favodent, Karlsruhe, Germany). One week later, the teeth were obturated as in group 1. Data analysis was performed through SPSS

(Statistical package for social sciences) version-17.0. Quantitative response variables like age, pain score (VAS) were presented by Mean ± Standard deviation and frequencies and percentages were computed for presentation of qualitative response variables like gender, tooth status and presenting complaint. Repeated measure analysis of variance (ANOVA), Pearson’s correlation (r) and Chi-square test was applied to compare these variables between two groups. Statistical significance was taken at p < 0.05.


Out of 60 patients who underwent root canal, 32 (53.3%) were males and 28 (46.7%) females (M: F=1.1: 1). The mean age of patients in single visit group was 31.9+ 12.4 years and in two  vist group was 30.5 +8.7 (p= 0.591).  Out of 30 patients of single root canal visit, 19 (63%) had vital and 11 (37%) had necrotic tooth status while in 30 patients of two visits root canal , 22 (73.3%) had vital and 8 (26.7%) had necrotic tooth status (p=0.405). Pain was the commonest presenting compliant in the groups of single and two root canal visits respectively 56.7% and 70%, followed by food packing 26.7% and 10%, sensitivity 10% and 10% and prosthetic

6.7% and 10%(p=0.408).

The mean preoperative pain score (VAS) in the patients who underwent in the group of single root canal visit group was 2.03 +1.27. While in the group of two visit root canal was 1.97 +1.09( p=.829). After postoperative 6 hours, the mean VAS in single root canal visit group was 1.97±1.12 and 1.20±0.71 in two root canal visit group. The attenuation in pain score after 6 hours was statistically significant in the groups of single and two root canal visits (p=0.003).

After postoperative 12 hours, the mean VAS in single root canal visit group was 1.40±1.07 and 1.03±0.66 in two root canal visit group. The attenuation in pain score after 12 hours was statistically insignificant in the groups of single and two root canal visits (p=0.117). After postoperative 24 hours, the mean VAS in single root canal visit group was 1.0±0.98 and 0.60±0.77 in two root canal visit group(p=0.085).

Statistically  insignificant attenuation in postoperative pain after 12 and 24 hours was observed in both groups however the mean VAS of the group of two root canal visits remained less than that of single root canal visits group after 12 and 24 hours.

In single root canal visit group, correlation was weak positive r=0.222 and statistically insignificant (p=0.239) while in two visits root canal group, correlation was strong positive i.e. r=0.803 and also significant (p=0.001).

Table :1 Comparison of Pre and Post Operative Pain between Visit 1 and 2


Debate is still ongoing among researcher and clinician concerning the effectiveness of an appointment versus  multiple appointment endodontic treatment in term of post obturation pain.

Although it was found that there was no advantage for one visit or two visit root canal treatment regarding post obturation pain in initial 6 hours , but two visit root canal treatment shoed better result in term of post obturation pain after 12 and 24 hours. According to Figini L et al found patients undergoing a single visit may experience slightly higher frequency of post obturation pain and are significantly more likely to take pain killers 23. Unlike Jalil Modaresi et al found low incidence of post obturation pain in single visit endodontic treatment as compare to two visit endodontic treatment 24. This has been supported by Albashaireh ZS et al also found a significantly higher incidence of postobturation pain was found in the multiple-visit group than in the single-visit group within 24 h of obturation 25.

Previous studies have shown that there is a strong positive correlation between pre-operative and postobturation pain 26. Oginni and Udoye10  in their study found that for both single and multiple visit procedures, there were statistically significant correlations between pre-operative and post-obturation pain.The present study also supports this correlation, in both the single and multiple visit groups there were statistically significant correlation between pre-operative and post-obturation pain.

The limitations of this study was that VAS had been used to measure the levels of  pain since there is no objective method for measuring pain, as the pain experience is very subjective and is dependent on so many factors. Therefore the ability to generalize the results is weak. However, a careful case selection and adherence to the basic principles of endodontic treatment will reduce the incidence of post-obturation pain and thus enhance a successful outcome.

And also in this study since the age, gender, pulp vitality and presenting complain  had been equally distributed in both the groups hence the effect of these factors on postobturation pain had not been identified so  the influence of these factors on post obturation pain can be identified in future studies.

Hence the hypothesis of this study was not supported by the results of this study but single visit endodontic therapy has been shown to be a safe and effective alternative to multiple visit treatment, especially in communities where patients default after the first appointment at which pain is relieved.


Although no advantage was observed when one-visit and  two-visit root canal treatment were compared regarding post-obturation pain in the initial 6 hours, but two-visit root canal treatment showed better results in terms of post-obturation pain after 12 and 24 hours. Though the present study reported favourable results in two- visit root canal treatment regarding post-obturation pain. However, single visit endodontic therapy has been shown to be a safe and effective alternative to two visit treatment, especially in communities where patients default after the first appointment at which pain is relieved.


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  1. Assistant Professor Operative Dentistry, Karachi Medical & Dental College.
  2. Assistant Professor Operative Dentistry, Fatima Jinnah Dental College
  3. Department of Medical Education King Saud bin Abdulaziz University of Health Sciences Riyadh, Kingdom of Saudi Arabia
  4. Dental Officer , Karachi Medical & Dental College
    Corresponding author: “Dr. Muhammad Atif Saleem”
    Email: Cell# 0092-3002271820