Abubakar Sheikh¹                                                            BDS, FCPS

Muhammad Atif Saleem Agwan²                               BDS, FCPS

Muhammad Amin³                                                         BDS, FCPS

Muhammad Athar Khan⁴                                            BDS, FCPS 

Ismail Sheikh⁵                                                                 BDS, FDS RCPS

Syed Imran Shah⁶                                                          BDS, FCPS 

INTRODUCTION

Root Canal Treatment is generally considered to be a painful process¹, but with proper techniques and strategies pain can be managed effectively. Optimal pain management includes both pharmacological and non-pharmacological treatment strategies². Pain management strategies start from preoperative pain control which includes accurate diagnosis and anxiety reduction followed by intra-operative pain control which can be covered by effective local anesthetic and operative techniques. Finally postoperatively pain can be managed by different pharmacologic agents².

Both pulpotomy and pulpectomy can relieve or reduce patient’s pain regardless of whether any medication is prescribed. They reduce tissue levels of inflammatory mediators and the elevated interstitial tissue pressure that stimulate peripheral terminals of nociceptors³. Clinical trials often demonstrate a significant and substantial

reduction in pain by 24 hours to 36 hours after pulpectomy⁴. Postoperative pain following root canal treatment can occur in the range of 16 to 48.5 per cent of cases, and these symptoms can last for several hours and even up to several days (23)⁵. Earlier studies conducted on postoperative endodontic pain have also shown that there can be moderate to severe pain varying from 15% to 25% (24, 25)^6,7.

Ibuprofen and other nonselective NSAIDs inhibit both cytoprotective COX-1 enzymes and inflammatory COX2 enzymes. Consequently, the use of these agents is associated with possible damage of the gastrointestinal tract causing gastric erosions, ulcers and bleeding. Studies exhibit that COX-2-selective inhibitors are almost equally effective in controlling pain compared to NSAIDs with the additional benefit of having decreased side effects such as GI ulceration, inhibition of platelet aggregation, or increased bleeding time. Therefore, COX-2-selective inhibitors can be recommended for controlling post endodontic pain⁸.

Selective COX-2 inhibitors have been tested in some studies previously. In one study Celecoxib was found to have a slower onset of action when compared to ibuprofen⁷. Barden et al. found that a single dose of oral celecoxib, 200 mg, is quite effective for controlling postoperative pain and its efficacy is equivalent to aspirin 600-650 mg and paracetamol 1000mg⁹. In a study by Malmstrom et al., rofecoxib and celecoxib were compared to ibuprofen in patients who had undergone  third molar extraction. They concluded that pain control of rofecoxib was equivalent to ibuprofen, but celecoxib showed decreased analgesic efficacy compared to both the drugs¹⁰.

Few clinical trials have been carried in dentistry to compare nonselective NSAIDs with COX-2 inhibitors. At the national level, there is hardly any such clinical trial especially in dentistry. This study was conducted with the purpose of providing dental practitioners with an option of prescribing a drug with reduced adverse effects for the management of post endodontic pain. The objective of this study was to compare the efficacy of ibuprofen and celecoxib in controlling post endodontic pain using VAS (Visual Analogue Scale).

METHODOLOGY

A quasi experimental study was conducted in the operative dentistry department, Altamash Institute of Dental Medicine, Karachi. One hundred patients requiring endodontic treatment and meeting inclusion and exclusion criteria were included in the study.

The inclusion and exclusion criteria were following:

INCLUSION CRITERIA

1. Patients requiring root canal treatment for pain of endodontic origin.
2. Patient reports spontaneous pain of at least 3 (0-10) in the visual analogue scale.
3. Patient reads and understands questionnaires.
4. Patient provides informed consent.

EXCLUSION CRITERIA

1. Younger than 15 years or older than 65 years.
2. Analgesic intake within last 12 h.
3. History of allergy to NSAIDs or local anesthetics. 4. History of gastrointestinal disorders, active asthma, decreased renal function, decreased hepatic function, hemorrhagic disorders, or poorly controlled diabetes mellitus.
4. Current use of drugs contraindicated with NSAIDs.
5. Pregnant or nursing.

Informed consent was taken from the included patients. Purpose and procedure, risks and benefits were explained to the patient. The clinical examination included a percussion test, a cold test, periodontal probing, mobility assessment and palpation. Provisional pulpal and periradicular diagnosis were determined after clinical and radiographic examination. Pulpal diagnosis was either Irreversible pulpitis or Necrosis. Periradicular diagnosis was made as Normal, Acute periradicular periodontitis, Chronic periradicular periodontitis and Acute alveolar abscess.

The included patients were allocated into two groups by using convenience sampling. Patients in Group A(N=50) were administered ibuprofen (Brufen 400mg t.d.s) and those in Group B(N=50)  were administered celecoxib (Celbex 200mg b.i.d) for two days. Pain intensity was measured using a visual analogue scale before treatment and at 4, 8, 12, 24 and 48 hours after only the canal preparation visit on a proforma. First dose of the drug was administered before root canal preparation visit; remaining medication and pain proforma were explained to the patient and given along. They were asked to record their pre and post treatment pain on the proforma. The proforma containing VAS scores was collected from patients at the second visit when the canals were obturated.

Root canal treatment was performed in two visits. During first visit, local anaesthetic was administered; tooth was isolated under rubber dam and access obtained. Cleaning and shaping was done in the following manner: The canals were negotiated with k files #10, #15, #20 and till file #25 reaching 0.5-1.0 mm of estimated working length, which was determined radiographically. Gates Glidden burs #2-4 were used for coronal flaring. Sodium

1. Assistant Professor Operative Dentistry Fatima Jinnah Dental College.
2. Assistant Professor Operative Dentistry Karachi Medical and Dental College & Abbassi Shaheed Hospital.      < dratifagwan@yahoo.com >
3. Assistant Professor & Consultant, Department of Operative Dentistry, Dental section, Dow International Medical College; DUHS, Karachi.
4. Research Unit, Department of Medical Education King Saud bin Abdulaziz University Riyadh, Kingdom of Saudi Arabia.< matharm@yahoo.com >
5. Professor, Department of Operative Dentistry, Altamash Institute of Dental Medicine, Karachi.
6. Assistant Professor, Department of Operative Dentistry Women Medical College, Abbotabad.< Imranshah_78@hotmail.com >

Corresponding author: “Dr Abubakar Sheikh ” < dr_abubakar@hotmail.com >

Khurram Parvez Sardar¹                   BDS, MPH

Rida Fatima Khan²                               BDS

Kunal Kumar³                                         BDS

Abeeha Batool Zaidi⁴                          BDS              

INTRODUCTION

Work related musculoskeletal pain is a common reason for chronic pain and disability throughout the world.  The incidence of work related musculoskeletal pain is quiet high in dental professionals¹.

As dentists have a restricted narrow space to deal with therefore to attain proper visibility they carelessly bend in wrong working positions. Primarily the pain may not be as severe but if the dentists practice the same routine, this can convert it into a problematic musculoskeletal problem, working in inadequate postures often affects muscular, skeletal, peripheral and nervous system^2,3. Discomfort, disability and continuous pain in different body parts are the major symptoms that lead to ill health^1,2. The incidence of work related musculoskeletal pain is quiet high in dental professionals^1,4-10. However if appropriate working guidelines are provided to these dentists at a younger age, severe disability can be avoided.^11-13.

The risk factors associated with these conditions include prolonged stiff postures, monotonous inaccurate actions, inadequate light, inherent tendency, anxiety, tension, body conditions, and old age¹. Various researchers have reported on the causes of musculoskeletal issues among dental professionals. Madaan and Diaz-Caballero reported that the major cause of musculoskeletal pain was incorrect working postures and uncomfortable positions^1,14. We therefore conducted a study to assess the frequency of Musculoskeletal Pain among dental students (third year, fourth year and house officers) of Dow University of Oral Health And Sciences, Karachi.

METHODOLOGY

A cross sectional study investigating the incidence of musculoskeletal pain was conducted at Dow University of Health Sciences. The duration of study was two weeks. A convenience sampling method was used for this study. Two hundred and ninety (290) dental students filled the questionnaire out of 320 dental students and house officers posted in clinical OPD’s.

Modification of Standard Nordic questionnaire was used. It consisted of 14 simple questions divided in to 4 parts. The first part consisted of demographic details while the second part was comprised of sites of pain. The third part consisted of questions regarding the presence characteristics of pain (Duration, Onset, Intensity, Aggravating and relieving factors) in the last part there were questions assessing the knowledge regarding proper positions and postures and its interference with their clinical performance. SPSS version 16 was used to analyze the data collected. Descriptive statistics was used to report frequency and percentages Chi-square test, was used to compared the presences of musculoskeletal pain and the categorical data, with level of significance less than/ equal to 0.05 considered as significant. To generate charts and figures Microsoft Office Excel 2010 was used.

RESULTS

A total of 290 (90.6%) participants out of 320 initially contacted completed the questionnaire. Majority of the respondents were females (80%). (Table no.1) Majority of the respondents (n=221, 76.2%). reported experiencing some sort of musculoskeletal discomfort. Because of more operating hours and lengthy dental practice, house officers tend to have greater percentage of musculoskeletal pain (n=76, 83.51%). (Table no.2) Question concerning the appearance of musculoskeletal

Table no.1: Details of number of Participant.

Table no.2: Incidence of Musculoskeletal pain.

Table no.3: Details of clinical practice.

Table no.4: Statistical analysis: Chi-square test applied between presences of musculoskeletal pain and the following Variables.

pain in the last 1 year was included in the study and it was reported that the maximum number of dental students (n=76, 26.3%) experience it within 1-3 months and (73, 25.2%) experience it within 0-1week. (Figure no.1). The respondents reported back (32.1%) and neck (32.4%) region to be most commonly involved site. (Figure no.2). Two thirty-nine (82.4%) participants had knowledge about correct postures while performing the dental procedure while only thirty-seven (12.8%) participants reported operating according to the standard criteria of working postures and positions. Majority of respondents reported working with both direct and indirect vision (56.9%). (Table no.3)

Chi square test revealed a significant association between presences of musculoskeletal pain, pain-related variables and the locations of pain (p<0.05). We also found an insignificant association between operating postures and position of practitioner and the presences of musculoskeletal pain. (p=0.10).(Table no.4)

DISCUSSION

A high percentage of musculoskeletal pain among dental professionals has been reported in published literature^4-11. Greater use of heavy forces, working for long hours in the same uncomfortable position and constant posture are the prime factors responsible for musculoskeletal pain^7,9,15. It has been reported that the musculoskeletal pain is also responsible for keeping the dentist away from his duty and possible early retirement^2,3. Unfortunately the occurrence of musculoskeletal disorders especially among dental students has  been under reported. Hence the Incidence of work-related musculoskeletal pain among dental students was the prime purpose of our study. Madaan reported 81% musculoskeletal pain among dental students¹. Another study by Diaz-Caballero reported 80% of dental students attending clinical practice had muscular pain¹⁴. Our results are in agreement with these

Figure no.1: Duration of musculoskeletal pain.

Figure no.2: Sites of musculoskeletal pain involved.

*Does not total 100%, because of multiple responses. two studies.

Duration of pain is a significant part of this study and question regarding the duration of pain in the last 12 months was also included .A study was conducted in which it was found that the pain not necessarily develops after long clinical exposure, it can also develop in a short training period ,this study was conducted by Mellis M. (2004)¹⁵. Similarly in our study, musculoskeletal pain developed within one week of time in (n=73,26.3%) dental students and within 1-3 months is(n=76,76.2%).

It is normally seen that the percentage of musculoskeletal pain in published literature is high among female dentist as compare to male dentist, for example in a study conducted by Lindfors (2013)⁵ showed high chances of musculoskeletal pain among female dental  practitioners, these results are similar to ours. However, our results should be interpreted with caution since majority of our study participants were females which can introduce a systematic bias.

We found back (32.1%) and neck (32.4%) region as most frequently reported affected region. Similar observations were made by Kierklo A¹⁶, Shrestha BP¹⁷ and Dayakar MM⁸.

Kanteshwari K¹⁸ reported that less than 50% were aware of the correct working posture in their study while 70% had musculoskeletal pain. Our results are in partial agreement with this study since the awareness of our participants was better, however the occurrence of reported pain was similar in both studies. However, a conclusion of better awareness of our study participants cannot be made from this questionnaire based study. The majority of dental students in this study (n=253, 87.2%) reported using a posture of their convenience. Whereas 71(24.5%) participants reported that they bend themselves for an easy vision, hence the use of mouth mirror was also reported only by 54 (18.6%) out 29 participants. However, it was also seen that 165 (56.9%) participants work by both direct and indirect vision method hence bend themselves sometimes. It has been reported in a previous study that dentists who use a mouth mirror suffered less pain then those who were working on patient without much use of mouth mirror^19-20.

A study conducted by Dayakar MM (2013)⁸ reported that dental professionals from the beginning of their practice can lower the load of muscular pain by functioning in a proper manner .There is no doubt that dental schools should concentrate more on students correct working posture from the starting of their clinical rotations. Dental students tend to have a less clinical working time but still they have reported high level of musculoskeletal pain even after a shorter engaging period clinically. In order to reduce this problem, the dental students should be taught and trained about correct working posture so that chronic painful conditions and possible early retirements can be avoided. The results of our study must be interpreted with caution due to limitations of our study.

CONCLUSION

Under of the limitations of the study conducted, a high incidence of work-related musculoskeletal pain was reported among dental students of Dow University of Health sciences. It was also found that majority of respondents in this study have a good knowledge regarding correct posture and positions of working.

REFERRENCES

1. Madaan V, ChaudhariA:Prevalence and risk factors associated with musculoskeletal pain among students of MSM Dental College: A cross sectional survey. J ContemDent 2012; 2:22-27.
2. A, KedjaruneU. and. Smith D.R:Occupational health problems in modern dentistry: a review J Ind Health 2007;45:611-621.
3. C.,Stathi I.C. and CharizaniF :Prevalence of musculoskeletal disorders in dentists.BMC Musculoskeletal Disorders2004;5:1-8.
4. DhanyaMuralidharan, NusrathFareed, Shanthi M. Musculoskeletal Disorders among Dental Practitioners:Does It Affect Practice?.Epid Research Int  2013;Article (716897):1-6
5. Lindfors P, Von thiele U and LundbergU:Work characteristics and upper extremity disorders in female dental health workers .J Occup Health 2006;48:192-197.
6. Hayes M. J, SmithD. R. and Cockrell D.: Prevalence and correlates of musculoskeletal disorders among Australian dental hygiene students .Int J Dent Hyg 2009;7:176-181.
7. Morse T, Bruneau H, and DussetschlegerJ: Musculoskeletal disorders of the neck and shoulder in the dental professions.Work 2010;35:419-429.
8. Dayakar MM, Sachin Gupta, George Philip, Prakash Pai : Prevalence of musculoskeletal disorder among dental practitioners .ASL Muscuskel Dis 2013;1:22-25.
9. Pandis N, Pandis BD, Pandis V, EliadesT :Occupational hazards in orthodontics: A review of risks and associated pathology. Am J Orthod Dentofacial Orthop 2007;132:280-292.
10. SabahatUllah Khan Tareen, YasirKhattak, Shakeelur-Rehman : Ergonomics Related Disorder among Dentists in Peshwawer-A Questionnaire survey . J Khyber Coll Dent 2013;3:24-29.
11. Maj John D. Childs ;Knowledge in Managing Musculoskeletal Conditions and EducationalPreparation  of Physical Therapists in the Uniformed Services .Military Medicine 2007;172:440-445.
12. Patel Harshid L, MarwadiMehul R, RupaniMihir, Patel Piyanka :PrevelanceAnd Associated Factors of Back Pain Among Dentists In South Gujarat .Nat J Med Research 2012;2:229-231
13. MontakarnChaikumarn :Differences In Dentists Working postures :(JOSE) 2005;11:441-449.
14. Diaz-Caballero AJ, Gómez-Palencia IP, DíazCárdenas S: Ergonomic factors that cause the presence of pain muscle in students of dentistry .Med Oral Patol Oral Cir Bucal 2010;15:e906-911
15. MellisM ,Abou-AtmeYs ,Cottognol,Pittau R :Upper Body musculoskeletal symptoms in Sardinian dental Students .J Can Dent Assoc 2004;70:306-310
16. Kierklo A, Kobus A, Jaworska M, Botulinski B :Work-related musculoskeletal disorder among dentist; a questionnaire survey, Anb Argic Environ Med 2011; 18:79-84
17. Shrestha BP, Singh GK,  Niraula SR ;Work Related Complaints among Dentists .J Nepal Med Assoc 2008;47(170):77-81.
18. Kanteshwari K, Sridhar R, Mishra AK: Correlation of awareness and practice of working postures with prevalence of musculoskeletal disorders among dental professionals. Gen Dent 2011;59:476-483.
19. Kumar VK, Kumar SP, Baliga MR. Prevalence of work-related musculoskeletal complaints among dentists in India: .A national cross-sectional survey. Indian J Dent Res 2013;24:428-438
20. Gupta S. Ergonomic applications to dental practice. Indian J Dent Res 2011;22:816-822.

1. Assistant Professor MDS Supervisor &MDS Subject Coordinator Department of Science of Dental Materials Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.
2. Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.  < princess.ridafatima@gmail.com >
3. Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.  < kunal551@hotmail.com >
4. Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.  < zaidi.abeeha@gmail.com >

Corresponding author: “Dr Khurram Parvez Sardar ”< dr_khurramparvez@hotmail.com >

Fahad Iqbal¹                                          BDS, MPH

Shehzad Fahad²                                   BDS

Jawad Iqbal³                                         M Phil

INTRODUCTION

ental plaque affects more than 80% of the human population, making it the most infectious disease present in humans^[1]. Studies suggest that poor oral health can cause gastric cancer, stomach ulcers cardiovascular disease,^[2]-[3] osteomyelitis⁴, discitis^5-6, meningitis⁷, bacteremia^8-9 and endocarditis of both prosthetic¹⁰ and native valve¹¹. Poor oral hygiene can lead to periodontal disease and dental caries⁽¹²⁾. Dental plaque initiates the oral diseases when microbes grow with the passage of time forming a bio-film by bacteria growing jointly with the human salivary glycol proteins and polysaccharides¹³. Oral biofilms form a precise pattern with a vastly intricate organization of bacterial growth^14-15.

In a study carried out in Nigeria, it was found that 90% of teachers had poor knowledge of causing factors of dental diseases¹⁶. In Pakistan, oral health is given less importance. In a study carried out by Vakani F, Basaria

N, et al in Karachi, it was found that the mean of DMFT was 1.27 which shows poor oral hygiene practices¹⁷ and this leads to a situation that there is a huge gap left in oral diseases treatment i.e. 90% of lesions never get treated. Oral hygiene is also related to socioeconomic and literacy level of the population¹⁸. The attitude, knowledge and practice regarding oral hygiene have a defining role in maintaining one’s oral health. Regional KAP studies portray a rather dismal picture¹⁹.

The aim of this study was to evaluate oral health knowledge, attitude and practice of 6th grade students in Mardan city.

METHODOLOGY

A total of 80, 6^th grade students of two Government Schools in Mardan city, Khyber Pukhtunkhwa were included. It is cross-sectional study and the sample size was eighty; comprising of forty boys and forty girls. Consent was taken from principals of the respective schools as well as students. Anonymity was ensured

throughout. Questionnaires were distributed in classes and 40 minutes were given to the students for filling it up with the permission of the Principal. The questionnaire was collected on the spot after it was filled by the students.

The questionnaire comprised of 26 close-end questionnaires. The language of questionnaires was Urdu and was translated into English for the purpose of evaluation. The participants’ knowledge of oral health was evaluated through questions regarding the importance of brushing, awareness of tooth paste means of cleaning and protections of teeth, knowledge about the relationship between tooth disease and general health, understanding of the causes of tooth disease, reasons behind bleeding gums, and tooth decay. To judge the practices of the participants regarding oral health question about their previous day brushing schedule was asked and for their attitude in oral health their visit to a dentist was enquired.

The importance of dental visits was evaluated through the frequency of the visits and the reason for it (tooth pain, decay). The participants were asked about their frequency of brushing. To understand their social milieu and financial condition, questions were asked if they were taught oral health measures in schools, curriculum, or by Masjid teachers, whereas their financial situations was evaluated through questions about their family’s ownership of any vehicle and education of their parents.

STATISTICAL ANALYSIS

The data was subsequently analyzed employing the (SPSS) statistical package in social sciences version 16.

RESULTS

Sixty percent of the student’s parents had no education on oral health. Students speaking Pashto were 93. 8%. A question regarding transport facility shows that 26.2% students have no vehicle in their house which shows they are lower middle class and 35% have motor cycle which shows that respondents belong to middle class family. The socio economic status was assessed in terms of having personal transport facility.

Oral Health Attitude Related Questions and Their Responses:

This survey has shown that 96.2% consider it necessary to brush their teeth, 56.2% respondents said that they used brush and 38.8% used Miswak for tooth cleaning.  For protecting their teeth, 57.5% used tooth paste for teeth protection. Sixty five percent said that tooth disease and general health has a relation.

Oral Health Knowledge Related Questions and Their Responses:

To a question regarding knowledge about hepatitis, 90% answered “No” whereas, 67.5% did not know as to whether it can be caused by unqualified dental intervention.

About their source of information about oral health practices 58% got it from their parents while three percent learned it from dentists. Eighty two and half percent use words or rephrase the sentence said that their teacher told them about tooth cleaning and protection. Eighty five percent said that their books contained information about tooth cleaning and protection. Fifty one percent respondents said that their Masjid teacher told them about tooth cleaning and protection. Eighty one percent respondents knew that sugar is cause of tooth decay. Oral Health Practice Related Questions and Their Responses:

Seventy five percent never visited a dentist, whereas 18% did not consider it important, 12% answered that they were not going to dentist because they self-medicate. In the study population, 58% of the respondents brushed their teeth once daily.

DISCUSSION

This study evaluated oral health attitudes, knowledge and practice of 6th grade students in two schools of rural Mardan, Khyber Pukhtunkhwa. All of the respondents belonged to rural Mardan. Sixty percent of parents of the respondents had no education at all. This study shows that 92.2 percent of the respondents considered brushing necessary which shows a high level of awareness. Besides that, 56.2% used Brush for tooth cleaning which is considerably lower than the statistics of research done by Manoj Humagain in rural Nepal where all the respondents used tooth brush and paste while brushing⁽²⁰⁾. It was reported that individuals who do not brush their teeth have higher number of microbes in their oral cavity²¹. It has also been found that 38.8% did brushing twice which is almost equal to the statistics of the study

carried out by Arun Kumar Prasad²², whereas 21.2% did brushing more than twice a day, which is similar to the study done in Burkina Faso, Africa by V, Poul E.P.²³. Miswak has a high content of fluoride²⁴ though in some microbes which can cause caries and plaque are resistant to its effects²⁵. Majority of the respondents were unaware of the effects of oral health on overall health. Similar results were seen in the study done by Arigbede AO, Ogunrinde TJ.²⁶. About 75 percent of the participants did not visit/consulted a dentist whereas only 15 percent of the participants visited a dentist only when they had toothaches, 46 percent had ‘no time’ to visit a dentist . If we compare this result with that of Arun Kumar Prasad’s we  find that attitude towards visiting dentist was still lower (36.7%)²¹ but comparatively much better than this paper’s findings where 75% did not visited a dentist.

This study was conducted keeping in view resources and time constraints other than small sample size. Limited resources included financial constraints as no financial support was provided for conducting this study which eventually leads to a restricted number of sample size. Further, the sample was selected through a non-random method constraining the external validity/generalizability of the study. Other such and related studies are required with a better sample size.

CONCLUSION

The knowledge, attitude and practices of our study population were poor.

RECOMMENDATIONS

It is recommended that:

1. Such studies shall be arranged on national level to accumulate a general database which will later help in policy making related to oral health of general population.
2. School-based health centers shall be established which will be responsible for providing oral and dental health services. Such bodies will enhance awareness of oral health on a very grass-root level which will apparently improve knowledge, attitude and practices.

REFERENCES

1. Petersen P. Continuous improvement of oral health in the 21st century: The approach of the WHO Global Oral health Programme. Chin J Stomatol. 2004;15-39.
2. Wu T, Trevisan M, Genco R, Dorn J, Falkner K, Sempos C. Periodontal disease and risk of cerebrovascular disease: the first national health and nutritional examination survey and its follow-up study. Arch Int Med. 2000; 160:2749–2755.
3. Watabe K, Nishi M, Miyake H, Hirata K. Lifestyleand gastric cancer: a case-control study. Oncol Rep. 1998; 5:1191-1194.

4. Singh N, Yu V. Osteomyelitis due to Veillonella parvula: case report and review. Clin Infect Dis 1992 ;14:361-363
5. Wren M. Anaerobic cocci of clinical importance. British Journal of Biomedical Sciences. 1996;53:294301.
6. Isner-Horobeti M, Lecocq J, Dupeyron A, De Martino S, Froehlig P, Vautravers P. Veillonella discitis: a case report. Joint Bone and Spine. 2006;73:113-115
7. Bhatti M, Frank M. Veillonella parvula Meningitis: Case Report and Review of Veillonella Infections. Clinical Infectious Diseases. 2000;839-840.
8. Fisher R, Denison M. Veillonella parvula bacteraemia without an underlying source. Journal of Clinical Microbiology. 1996; 34:3235-3236.
9. Strach M, Siedlar M, Kowalczyk ZM, Grodzicki T. Sepsis caused by Veillonella parvula infection in a 17 year old patient with X-linked agammaglubulinemia. J Clin Microbiology. 2006;2655-2656.
10. Boo T, Cryan B, O’Donnell A, Fahy G. Prosthetic valve endocarditis caused by Veillonella purvula. J Infect. 2005;50:81-83.
11. Oh S, Havlen P, Hussain N. A case of polymicrobial endocarditis caused by anaerobic organism in an injection drug user. Journal of General Internal Medicine. 2005; 20(10).
12. Marsh P. Microbiology of Dental Plaque and Their Role in Oral Health and Caries. Dental clinNorth Am. 2010; 54:441-454
13. Marsh P. Dental Plaque as a Biofilm and a Microbial Community-Implications for Health and Disease. BMC Oral Health. 2006:15;6 Suppl 1:S14.
14. Kolenbrander P. Oral Microbial Communities: Biofilm, Interactions, and Genetic Systems. Annu Rev Microbiology. 2000; 54:413-437.
15. Zijnge V, Leeuwen B, Degener J, Abbas F, Thurnheer T, Gmur R. Oral Biofilm Architecture on Natural Teeth. PLoS One. 2010;5:e9321.
16. Ehizele A, Chiwuzie J, Ofili A. Oral Health Knowledge, Attitude, Practices among Nigerian Primary School Teachers. Int J Dent Hyg. 2001;4:569–591.
17. Vakani F, Basaria N, Katpar S. Oral Hygiene KAP Assessment and DMFT Scoring among Children Aged 11-12 Years in an Urban School of Karachi. J Coll Physicians Surg Pak. 2011;21:223-226
18. Ernesto S, Francisco C, Paula FR. Oral Health Knowledge, Attitudes, and Practices in 12-year old Children. Med Oral Patol Oral Cir Bucal. 2007;12:614620.
19. Aslam M. Oral Health in Pakistan A SituationAnalysis. Dental Aid. 2005.
20. Humagain DM. Evaluation of Knowledge, Attitudeand Practice (KAP) About Oral Health Among Secondary Level Students of Rural Nepal – A Questionnaire Study. Rural Nepal 2011;36-45.
21. Al-Ahmad A, Roth D, Wolkewitz M, WeidmannAl-Ahmad M, Follo M, Ratka-Kruger P, et al. Change in diet and oral hygiene over an 8 week period: effects on oral health and oral biofilm. Clini Oral Invest. 2009; 14.
22. Arun Kumar Prasad P, Shankar S, Sowmya J, Priya Oral Health Knowledge, Attitude, Practice of School Students. JIADS. 2010; 1(1).
23. Benoît Varenne PEPO. Oral health behaviour of children and adults in urban and rural areas of Burkina Faso, Africa. International Dental Journal. 2006; 56.
24. Wu C, Darout I, Skaug N. Chewing Sticks: Timeless natural toothbrushes for oral cleansing. J Periodontal Res. 2001; 36.
25. Bowden G, Odlum O, Nolette N, Hamilton R.Microbial populations growing in the presence of flouride at low ph isolated from dental plaque of children living in an area with flouridated water. Infection and Immunity. 1982:255-262
26. Arigbede A, Ogunrinde T, Okoje V. HIV/AIDS andClinical Dentistry: Assessment of Knowledge and Attitude of Patients Attending a University Dental Centre. Niger J Med. 2011:90–95

1. Private practice/Research study coordinator Save the Children, Khyber Pakhtoonkhwa, Pakistan.
2. Private practice, District Swat, Khyber Pakhtoonkhwa Pakistan.
3. Lecturer AWKUM, Mardan, Pakistan.

Corresponding author: “Dr Fahad Iqbal” < doc.fahadiqbal@gmail.com >

Farhan Raza Khan                           BDS, MSc, MCPS, FCPS

Ethics is a discipline that is concerned with the morality and philosophy of goodness. The roots of ethics are derived from the religious writings. Bioethics is the philosophical study of ethical considerations related to health sciences including, biology, biotechnology, nursing, medicine and dentistry. The contemporary field of bioethics has emerged as a distinct academic discipline in 1960s¹.

Dentistry is a dynamic and ever changing discipline. The knowledge base in dentistry is increasing on an enormous pace. Accessibility of information technology, availability of educational resources and introduction of evidence based practice has changed the face of the discipline. In past, too many patients considered dentists as dental mechanics whose business is confined to moving, removing, restoring or replacing teeth². Although, some phases of dentistry are still mechanically driven and undoubtedly dentists are the individuals with finest digital dexterity but the contemporary dental professional has now evolved into an oral physician, a health advocate, a researcher and an educator. This evolution is mainly attributed to the discovery of association of dental diseases with systemic health.

In order to serve as useful members of society and to serve their role as an expert in the management and prevention dental disorders, the dentists in their formative years should be exposed to the concepts of ethics. An individual can gain cognitive knowledge and can develop motor skills but it’s the inculcation of right attitudes that defines his personality. Although, introduction of dental ethics in the dental curriculum is the need of this hour but just delivery of few lectures won’t make a difference.

Students learn by observation so they need role models in the form of their college teachers who are champion of ethics. Unfortunately, the state of affairs is presently not favorable. Dental teachers do deliver lectures and carry out demonstration in their academic institutions but only a small number actually practice dentistry there. Thus, students have limited opportunity to learn right sets of attitudes such as professionalism, time management, honesty, devotion and respect of patient’s confidentiality etc. from their mentors. This translates into producing dental graduates who are knowledgeable and enthusiastic about improving their skills but are ethically immature and thus likely to fail when encountered with ethical challenges. Additional limitation is the relative lack of formal training in ethics of the teachers themselves. Another dimension is ethical conduct of dental research. There is a tremendous rise in the number of dentist carrying out research. The reason behind this phenomenon may be a requirement fulfillment of an advanced degree, a prerequisite for institutional promotion or for professional recognition. The net result is that there are dentists who are initiating research without receiving its fundamental training. The undergraduate curriculum in Pakistan should make way to accommodate topics such as risk-benefit balance, informed consent process, identification of vulnerable participants, patients right of confidentiality, data safety monitoring, research participant recruitment procedures, conflict of interest etc. These can only happen if there are adequate numbers of faculty who are formally trained in clinical research and actually active in conducting research in their academic institution. The firsthand experience of learning research at undergraduate level will be a milestone in the development of future generation of dentists.

Lastly, it’s the responsibility of the leadership of dental institutions, Pakistan Medical and Dental Council and other stakeholders to mandatorily formulate institutional ethical review committees (ERC) that can oversee the matters related to ethics in research. Absence of an ERC would increase the risk for patients treated and subsequently used as research subjects in such institutions. Similarly, investigators will be vulnerable too as there would be no check points where quality of their protocol and execution of their research activity is monitored. Students will suffer the most; as they would learn the incorrect ethical practices and would likely to continue with those. For example plagiarism, students and residents can easily slip down into the beautiful

bobby trap of plagiarism. Most peer review processes can readily detect the copy paste approach and can result in professional defame of the authors. The due accountability of such incidents requires an ERC to be functional. Needless, to say that primary aim of an ERC is to prevent research misconduct rather than to penalize the persons who indulge in such acts.

The next challenge for the dental curriculum designers in Pakistan is how to inculcate rapidly evolving subjects (such as dental implantology) and accommodate teaching of ethics and training of research in the existing four years’ curriculum. It’s probably a high time for the dental fraternity to upgrade to a five year BDS curriculum where aforementioned subjects can be instilled into the teaching of the next generation of dental care providers.

REFERENCES

1. http://www.ich.org/LOB/media/MEDIA482.pdf
2. Eliades T. Research Methods in Orthodontics. Springer, Heidelberg, 2013

1. Assistant Professor & Director Operative Dentistry Residency Program Aga Khan University, Stadium Road, 74800 Karachi, PAKISTAN

Corresponding author: “Dr Farhan Raza Khan” < farhan.raza@aku.edu >

Yawar Ali Abidi¹                                   BDS, FCPS

Sameer Quraeshi²                               BDS, MSc

Syed Ahmed Omer³                            BDS, MSc,

Murtaza Raza Kazmi⁴                        BDS, FCPS

Saqib Rashid⁵                                       BDS, MSc, FCPS 

INTRODUCTION

To fulfill the esthetic demands of patient toothcolored restorative materials have been widely used in dentistry¹. Different type of dental composite resins are available in the dental market and they are classified according to shape, size and distribution of fillers². Nowadays Nanocomposite is widely used in clinical practice. Nanocomposite contains filler size ranging from 0.01-0.04mm³. It has many advantages such as increase mechanical properties, high wear resistance and low polymerization shrinkage⁴. Despite these advantages some problems still remain and one of them is color stability which is the ability of material to be able to retain its original color⁵. Dental composite resin content has been reported as being critical to color stability and leads to discoloration⁵. Discoloration of esthetic restorative material is caused by several intrinsic and extrinsic factors. Intrinsic stain is due to alteration of the resin matrix itself ⁶, However, extrinsic factors include staining by exogenous sources such as tea, coffee, beverages and mouth rinses. These agents cause discoloration by absorption and adsorption of colorants⁷.

Color evaluation can be done by visual method or by instrumental methods. In visual method an observer assesses the color change of the sample against white background, while in instrumental method devices such as Spectrophotometer, Calorimeters and computerized image analysis are used⁸.

The spectrophotometer measures wave lengths of transmitted light of specimen⁹. This instrument uses the (CIE) L*a*b* color system. This system consists of the following Parameters: L*, which refers to luminosity (white to black); a*, which refers to the red-green color axis and b*, which refers to yellow-blue axis⁹. Even though there are a number of studies on evaluating the staining power of commonly used products in daily life such as tea, coffee, soft drinks, chlorhexidine containing mouth rinses¹, but no reports were found with regards to staining power of different lipsticks which is commonly used by female patients and is available with different fixers in market. There are a few clinical and in vitro studies which reported that these lipsticks have capability to causes alterations in color of composite resins¹⁴. Thus, there is great need to find the staining capability of lipsticks with common and ultra fixers and also considering the contact time with esthetic dental materials.

This study estimates superficial color alteration of composite resin stained with two different types of lipsticks (one with common fixer and the other with ultra fixer) at different time intervals, immediately, 1 hour and 24 hours after curing.

The hypotheses tested were:

• The composite resin shows color alteration when stained with lipstick;
• The composite resin shows color alteration when stained 24 hour after polymerization.
• Lipstick with ultra fixer show more color alterationof composite then lipstick with regular fixer.

METHODOLOGY

PREPRATION OF SPECIMEN

In this study, 90 specimens of nanocomposite FiltekTM Z350 XT shade A3 (3M ESPE, St.Paul, MN, USA) were made using poly tetra fluoroethylene mold (10mm in diameter and 2mm of thickness). All materials were prepared according to manufacturers’ instructions (Table I). Composite resin was placed in one increment in mold

Table I: The detail of materials  used in this study

and overfilled, to avoid air bubbles and inclusion mold covered with mylar strips and compressed with glass slides on the upper and lower surface. Samples were light cured at the distance of 1 mm for 40 seconds on each side with LED curing lamp Mectron (Intensity 1000mw/cm2 starlight pro-led curing lamp, Italy). After curing glass slide and mylar strips were removed. The discs were polished with coarse, medium, fine and ultra fine Discs (Sof-Lex Pop-On; 3M ESPE, St. Paul, MN, USA). After preparation discs were divided in 9 groups (n=10) according to time interval between curing and contact with both lipsticks.

Two same color lipsticks represented pigmenting agents. One lipstick had common fixer and other had ultra fixer.

COLOR ANALYSIS

Color measurement were performed with a spectrophotometer (Data color; SF 600; Plus-CT; USA, Efroze Textile mills F.B.Area, Karachi) using CIE L*a*b*(Comission International l´Eclairage) system. The analyzed color parameters were the values for L*, a* and b*. Where L* is the luminosity, a* represent the color variation between green-red and b* represent the color variation between blue-yellow. DE is the total color variation. The total color variation was calculated according to following equation.

DE*ab = [(DL*)² + (Da*)²+ (Db*)²]¹/²

The spectrophotometer was calibrated before each color analysis session of discs in accordance with manufacturer’s instruction.

For color analysis each discs was placed inside the central orifice of the white, opaque Teflon matrix. A mortise device was placed on the white Teflon, which was positioned over the disc to standardize the contact of the tip from the spectrophotometer to disc surface at 90^o angle.

STAINING PROCEDURE

Study group divided according to time interval between curing and staining with lipstick and type of fixer in the lipstick detail of groups given in table II

For the groups (G1, G4 and G7) at 0 hours after curing discs surfaces were cleaned and dry with absorbent paper. Base line colors of the discs were recorded (average of 3 readings).

G1 was not stained. G4 was stained with common fixer lipstick only single coat in one direction is applied. G7 was stained with ultra fixer lipstick in a same manner like G4. These discs were then kept in dry conditions for 1 hour, after which the excess lipstick was removed with absorbent paper. Then the final color readings of the discs were taken (average of 3 readings).

For the groups (G2, G5 and G8) same procedure is repeated after 1 hour of curing. Discs were stored in artificial saliva at 37^oC. For the groups (G1, G4 and G7) same procedure is repeated after 24 hour.

STATISTICAL ANALYASIS

Statistical analysis was computed with Statistical Package for Social Sciences (SPSS) software, version 16.00 (SPSS Inc, USA). Descriptive analysis was executed in the form of mean and standard deviation for change in color. ?E values were tested for significant difference at (0.05 level of significance) using two-way ANOVA with repeated measurement and Tukey’s Honestly Significant Difference (HSD) for multiple comparisons.

RESULTS

Means and SD are  shown in table II

There was no statistically significant difference between the control group and group stained with common fixer lipstick (p>0.05), but there was statistically significant difference between the group stained with common fixer

Table II Mean and standard deviation

lipstick and group stained with ultra fixer lipstick (p<0.05). Statistically significant difference was also seen between

control group and group stained with ultra fixer lipstick. The composite resin showed more color change with both lipsticks as compare to control group.

With respect to time period there were statistically significant differences seen between all the groups at three different time periods (p<0.05). Statistically significant differences were seen at 0 hour, 1 hour and 24 hour.

DISCUSSION

There are a number of methods used for color determination of teeth and tooth color restorative material in dentistry. It is broadly categorized in two categories, instrumental and visual means⁹. Variability of results in colour determination among different observer is due to many factors including the observed object and position of observed object relative to observer, color distinctiveness of illuminate metamerism, perception of observer¹⁰. For this reason instrument measurement has been suggested, because it reduces subjective elucidation of visual color comparison, therefore, spectrophotometers and colorimeters are more extensively used today¹¹. Due to these facts, the current study used the instrumental technique with a spectrophotometer recording the color values with the CIE (Comission International l´Eclairage) L* a*b* system. This system has the capability to find out the color change value DE.

In 1989 Johnston and Kao recommend that value of DE < 3.3 was not visually perceptible so change in color in this range is esthetically acceptable. However, DE >3.3 gives clinically visual perception of color change and is deemed esthetically unacceptible¹².

The present study observed that, composite resin discs treated with ultra fixer lipsticks showed high staining index as compared to control groups and groups that were treated with common fixer, it proved our first hypothesis. These values are clinically unacceptable (DE>3.3) results are in agreement with result reported by Douglas et al¹³. Moreover, composite resin discs in control group show little color change at different time intervals, it might be caused by dehydration of composite resin or it is the continuation of cure. This change in color was considered as normal and esthetically acceptable, our results are in accordance with Avilmar et al which concluded that values of DE were much lower in control group and visually acceptable¹⁴. However, staining caused by both lipsticks was probably due to hydrophilic nature of matrix and increase vulnerability of water sorption in polymer¹⁵. As a result of this, composite resins absorbs coloring pigments in lipstick which results in discoloration. According to Ferracane et al⁹ composite resin show high absorption initially only but our results are not in agreement with it because discoloration of composite was high even at 24 hour after curing similar to color change in initial hours so the second hypothesis of present study was also accepted. Composite resins showed higher color change with ultra fixer lipstick at three different times (0 hr,1 hr and 24hrs) as compared to lipstick with common fixer, this also confirms the third hypothesis of present study.

There is necessity of more studies on staining power of different kind of lipsticks. Similar studies have reported

the effect of commonly utilized drinks such as tea, coffee, red wine and different mouth washes^17-20. We used only one brand of composite resin in our study,  therefore the results cannot be generalized. Also, only single brand of lipstick was used. Future studies addressing these limitations are recommended. Other clinical variables such as the frequency of reapplication of lipstick and the action of the tongue in terms of cleaning the stained resin restoration surface should be further analyzed. The results of our study must be interpreted with caution due to above mentioned limitation. It is recommended to instruct female patients to avoid the use of lipsticks for at least first 24 hours of composite resin based restoration on anterior teeth.

CONCLUSIONS

Groups with ultra fixer caused greater staining than other groups, so lipstick wearers should be warned to avoid the use of lipsticks with ultra fixers after receiving composite restoration in anterior teeth for at least 24 hours.

REFERENCE

1. 1. Cigdem C , Bulem Y, Selim E, Kivanc Y. Effects of Mouth Rinses on Color Stability of Resin Composites. Eur J Dent 2008;2:247-253
   2. Lutz F, Phillips RW. A classification and evaluation of composite resin systems. J Prosthet Dent 1983;50:480488.
   3. Moszner N, Klapdohr S. Nanotechnology for dental composites. Int J Nanotechnology 2004;1:130-156.
   4. Terry DA. Direct applications of a nanocomposite resin system: Part 1-The evolution of contemporary composite materials. Pract Proced Aesthet Dent 2004;16:417-42.
   5. Narendra P, Pragati K. Color stability: An importantphysical property of esthetic restorative materials: A review .Int J Clin Dent Sci.2010;1(1);81-84.
   6. Um CM, Ruyter IE. Staining of resin-based veneering materials with coffee and tea. Quint International 1991;22:377-386.
   7. Noie F, O’Keefe KL, Powers JM. Color stability of resin cements after accelerated ageing. Int J Prosthodont 1995;8:51-55.
   8. Ishikawa-Nagai S, Ishibashi K, Tsuruta O, Weber HP. Reproducibility of tooth color gradation using a computer color matching technique applied to ceramic restorations.J Prosthet Dent. 2005;93:129-137.
   9. Powers JM, Sakaguchi RL. Craig’s restorative dental materials. 12th ed. London: Mosby; 2006.
   10. Khokhar A, Razzoog M, Yaman P. Colour stability of restorative resins. Quintessence Int 1991;22:733-737.
   11. Yannikakis SA, AJ, Polyzois GL,Caroni C.Color stability of provisional resin restorative materials.J Prosthet Dent 1998;80:533-539.
   12. Johnston WM, Kao EC. Assessment of appearance match by visual observation and clinical colorimetry. J Dent Res. 1989;68:819-822.
   13. Douglas RD, Steinhauer TJ, Wee AG. Intraoral determination of the tolerance of dentists for perceptibility and acceptability ofshade mismatch. J Prosthet Dent. 2007;97:200-208
   14. Avilmar PG, Lecticia BJ, Luciana D, Paula M,Andre M. Effect of lipstick on composite resin color at different application times. J Appl Oral Sci. 2010;18:566-571.
   15. Van Noort R. Introduction to dental materials. 2nd ed. London: Mosby Wolfe; 1994.
   16. Ferracane JL. Hygroscopic and hydrolytic effects in dental polymer networks. Dent Mater. 2006;22:211-222.
   17. Fontes ST, Fernández MR, Moura CM, Meireles SS. Color stability of  a d composite effect ofdifferent immersion media.  Appl Oral Sci. 2009;17:388-391.
   18. Samra AP, Pereira SK, Delgado LC, Borges CP. Color stability evaluation of aesthetic restorative materials. Braz Oral Res. 2008;22:205-210
   19. Yazici AR, Celik C, Dayangaç, B, Ozgünaltay G. The effect of curing units and staining solutions on the color stability of resin composites. Oper Dent. 2007;32:616622.
   20. Guler A, Yilmaz F, Kulunk T,Guler E, Kurt S. Effects of different drinks on stainabilty of resin composite provisional restorative materials. J Prosthet Dent 2005;94:118-124.
       

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       1. Associate Professor & Head Department of Operative Dentistry Dr. Ishrat ul Ibad Khan Istitute of Oral Health Sciences, Dow University of Health Sciences.

       2.Assistant Professor, Department of Prosthodontics Fatima Jinnah Dental College and Hospital.    Email: escue3@gmail.com

       3.Assistant Professor & Head Department of Science of Dental Materials Bahria University Medical & Dental College.

       4.Assistant Professor, Head Department of Prosthodontics Fatima Jinnah Dental College and Hospital.

       5.Professor, Head Department of Operative Dentistry Fatima Jinnah Dental College and Hospital.

Corresponding author: “Dr Yawar Ali Abidi ” < yawar_aliabidi@hotmail.com >

Mowaffaq Al Absi¹                                    BDS, MDS

Fayez Hussain Niazi²                              BDS, MDS

Mustafa Naseem³                                     BDS, MDS

^{Zahid Iqbal4}                                               BDS, MDS

Faheem Khiyani⁵                                     BDS, MDS

INTRODUCTION

The relationship between pain and dentistry is frequently portrayed in popular culture as synonymous with situations to be avoided. In fact, poorly controlled dental pain and related anxiety contribute to postponed or cancelled appointments^[1],[2]. Dental fear is a major reason given for avoiding dental visits^[3]. Effective control of dental pain improves patient comfort, facilitates the delivery of oral care, decreases anxiety, and may even improve oral health. The aim of root canal treatment is to eliminate bacteria from the canal system in order to create an environment favorable for healing. Current preparation techniques along with disinfectants or medicaments may disrupt the intra-canal microbial environment. However, numerous studies have shown that it is impossible to achieve a bacteria free root canal consistently^1-[4]. Hence, there is concern over the consequences of the presence of the remaining microorganisms in the canal.

It is generally believed that the remaining bacteria can be either eradicated or prevented from recolonizing the root canal system through an inter-appointment medicament such as calcium hydroxide^2,5. However, it has been demonstrated that calcium hydroxide consistently fails to sterilize root canals and may even allow regrowth in some cases^3,4,6. The presence of cultivable microorganisms at the time of obturation has been reported to impair healing after root canal therapy ⁷. Certain factors such as preoperative pain² use of intra-canal medications^5,6 and tooth localization  may predispose the development of inter and post appointment pain. Mechanical instrumentation is the core method for bacterial reduction in the infected root canal. Various treatment regimens for the relief of pain during endodontic therapy, includes pre-medication relief of occlusion, establishment of drainage, intra-canal and systemic medications. Preparation of root canal systems includes both enlargement and shaping of the complex endodontic space together with its disinfection. A variety of instruments and techniques have been developed and described for this critical stage of root canal treatment. The advantages of conventional   hand instrumentation from crown to apex with early coronal flaring include less risk of inoculation of endodontic pathogens in the periradicular tissues, enhanced penetration of irrigant into the root canal system, less extrusion of irrigant solution and furthermore there is less likelihood for a change in the working length measurement during preparation, greater tactile awareness and reduced coronal binding of instruments. On the other hand the step-back technique creates a smoother flow and a tapered preparation from apical to coronal direction. Our study is comparing the inter-appointment pain in vital single rooted teeth by using two classical techniques used for root canal preparation. These techniques are crowndown or step-down and apical step-back. The frequency of pain will be assessed by employing visual analogue pain scale to compare the two groups⁸. Knowledge on the causes and the mechanisms behind inter-appointment pain is very important for the practitioner to manage this undesirable condition. Inter-appointment emergency, proper diagnosis and active treatment is required for the clinician to overcome the problem.  It is therefore important to carry out a study, which can help us in improving our knowledge and skills regarding the precise diagnosis as well as the management of inter-appointment pain. Previous local studies are limited in this regard.

METHODOLOGY

Patients were selected from out-door patients coming to operative dentistry department of Liaquat University of Medical and Health Sciences, Jamshoro.

After taking the inclusion and exclusion criteria into consideration, detailed history were taken and all necessary investigations were done. Pre-operatively, the tooth could not always be accurately diagnosed as vital or non vital by history taking, clinical and radiographic examination and vitality testing, therefore the gold standards of diagnosis was a presence of bleeding from the pulp chamber and the root canals determined by direct observation after access opening, Cases with non vital pulp were selected in this study.

Two standardized peri-apical radiographs were taken during the treatment, as follows:

• Pre-treatment.
• Working length determination with files in situ. Local Anesthesia has been administered and rubber dam applied for isolation. Adequate coronal access into the pulp chamber was made in order to provide easy access of endodontic instruments to all the walls of the root canals.

This was achieved by using high speed hand piece with a number 2 round bur and tapered fissure bur (Alpha Dental Diamond burs USA Certified ISO 9002) for both crown down and step back technique groups. To achieve the working length we used a distance of 1 to 2mm short of the apex to limit our canal preparations and obturation. According to the size of the image of the tooth on the preoperative radiograph, a file was inserted into each root canal so that it would reach approximately within 2mm of the   radiographic apex.

From instrument tip to stopper, this length was measured when in the canal the stopper was rested against a reference point. A working length radiograph was subsequently obtained. Correct working length was obtained by observing the distance between tip of the file and radiographic apex.

Canals have been instrumented using a crown-down in the first group by first flaring the coronal third of each tooth with gates gladden bur No (2-4) (Dentsply, Millefer, Switzerland) while middle and apical third was prepared by hand files  (Kerr, Romulus, Mich.) along with irrigant using 5.2% sodium hypochlorite solution and step-back technique in the second group by conventional handfiles on apical and middle third and then the coronal third of each tooth were flared with gates gladden bur No (24) (Dentsply, Millefer, Switzerland) along with irrigant using 5.2% sodium hypochlorite solution.  The canals dried and the teeth were temporized by temporary filling material cavit (provis, Favodent karl Huber GmbH, Germany) and patient were recalled for next appointment to complete the root canal procedure, in case of severe pain, symptomatic treatment were given.

The patients were assigned into group A or B by envelope method. Group A had their root canals prepared by crown down and group B by step-back. The patients were telephonically accessed to record the pain after 24 hours and 48 hours after the initial treatment. The data were collected on the Performa.

Data were collected and entered in SPSS version 10 for windows. Mean ± SD were presented for age of the patient and VAS. Male to Female ratio were presented for gender distribution. Chi-squared test were used to compare VAS between the two groups. A p-value of <0.05 was considered as statistically significant.

RESULTS

A total of 60 patients required endodontic treatment with vital teeth were included in this study and canals were instrumented using a crown-down and step-back technique. Subjects were equally divided into two groups by using envelope method, for group A, root canals prepared by crown down and group B by step-back. The average age of the patients was 32.83 ± 9.23 years (30.45 to 35.22). The average age of the patients was significantly high in group A than group B (40.50 ± 5.51 vs. 25.17 ± 4.64 p=0.0001). Out of 60 patients, 22(36.7%) were male and 38(63.3%) were female.  Proportion of gender was not significant between groups (p=1.00). Regarding maxillary and mandibular tooth location thirty three (55%) maxillary teeth were treated and 27(45%) mandibular teeth were treated.

Comparison of inter appointment pain at 24 hrs and 48 hrs between groups are presented in table 1 . Inter appointment pain at 24 hrs was found in 35% (21/60) patients. In group A (crown down technique), inter appointment pain was only in 23.3% (7/30) patients and in group B (step back technique) in 46.7% (14/30) patients. Rate of inter appointment pain was high in group B than group A but it is not statistically significant (chi-square =3.59; p=0.058). In the other word inter appointment pain was 2.87 times more likely in step back technique (group B) than crown down technique (OR=2.87; 95%CI: 0.95 to 8.69).

At 48 hours, inter appointment pain was observed in 40% (24/60) patients.  In group A inter appointment pain was in 40% (12/30) patients and in group B in 40% (12/30) patients. Rate of inter appointment pain was not

TABLE 1

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS

statistically significant between the group at 48 hours (chi-square =0.0001; p=1.00). In the other word odd ratio is 1 (OR=1.00) its mean pain was equally likely in both groups (OR=1; 95%CI: 0.35 to 2.81).

Comparisons of inter appointment pain at 24 hrs and 48 hrs between groups after stratification of gender, age groups and location were presented in table 2 and 3. Gender and age groups were not effect on pain between groups. In Maxillary teeth, pain was significantly high

TABLE 2

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS AT 24 HOURS AFTER CONTROLLING GENDER, AGE AND LOCATION OF TEETH

TABLE 3

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS AT 48 HOURS AFTER CONTROLLING GENDER, AGE AND LOCATION OF TEETH

in step back technique than crown back technique (fisher’s exact test; p=0.04) at 24hours. In mandibular teeth, pain was significant at 24hour while at 48hours it was not significant.

DISCUSSION

Inter appointment pain was and remains one of the most common problems in endodontic treatment procedure although these in most cases do not last long, but could be a source of embarrassment to the dentist and annoying for the patient. Some studies investigating inter appointment pain have reported an incidence of moderate to severe pain in the range of 15% to 25% ^7-9. Studies also have reported frequencies of inter appointment emergencies ranging from 1.4% to 16% ¹. While in our study discomfort to mild inter appointment pain noted from 35%to 46.7%. In this study the frequency of inter appointment pain has been assessed by visual analogue pain scale to compare crown-down and stepback techniques¹⁰. Knowledge on the etiological factors and the mechanisms behind inter appointment pain is very importance for the practitioner to properly prevent or manage this undesirable condition. One of this etiological factor is the preparation techniques and their effect on the amount of the debris being extruded through the apical foramina which plays very important role in the frequency of inter and post operative pain. In this study we have found that after the preparation with crown-down and step-back techniques, the rate of inter appointment pain was high in group B (step-back) than group A (crown-down) but it is not statistically significant. Although the rate of the inter appointment pain was high after using step-back technique and that could be due to the amount of the debris pushed beyond the apex or the technique was not able to produce 100% environment free of microorganism it was not enough to bring the result to the significant level. In comparative study between both technique by the quantitative assessment of canal debris forced periapically   instrumentation Ruiz-Hubard EE,et al¹¹ concluded that step-back technique reported to produce more debris

apically than crowndown. Ferraz CC, et al¹² also have found in their study that apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques were more in step-back as it compare with crown-down technique.

Reddy S, Hicks L¹³ also they have concluded in their study that crown-down extruded less debris after comparing the debris extruded from the apical constriction using two hand and two rotary instrumentation techniques.

It is well understood that the pain has direct relation with status of the pulp pre operatively and the sign/symptoms. In   our study the criteria we have taken were included only Non vital cases and we have found that the inter appointment pain was presented in 35% of the cases within the first 24 hrs and 40 % within 48 hrs but in both it was not significant  and the intensity of the pain was noticed to vary from degree of discomfort to mild  pain and that does not require any analgesic, it was also observed  that the pain disappeared slowly and gradually by the end of the root canal procedure.Walton& Fouad et al¹⁴ have found that the frequency of flare-ups or interappointment pain in necrotic pulp cases were significantly high as compare with to vital cases. Naidoff also has discuss briefly how necrotic pulp plays role in the development of antibodies-antigens reaction which lead to cascade of complement system and inflammatory reaction resulting in flare-up or inter appointment pain¹⁵. So many studies have founded that the incidence of flare-up is more with non vital pulp as it compare with vital.

As the age of the patients is concern in this study we have found that there is no relation between the age of the patients and the inter appointment pain which means that there was no statistically significant differences observed in different age groups in this study. Eleazer PD, Eleazer KR and Matusow also concluded that there is no significant relationships for inter appointment flareups with age³. Several studies also have failed to find any relation between ages and inter appointment pain Walton R, and Fouad A¹⁴. In their study have found no relation between flare-up and age of the patients   Imura N and Zolo M¹⁶ have  also concluded the same result. Toosy¹⁷ who treated necrotic teeth and found no difference in flare-ups rate of age groups except in those patients who were above 50 year. Kane ¹⁸ has found no relationship between

post obturation pain and age. The reason could be due to a coronal transportation of the radiographic apex because of secondary cementum deposition with advancing age. This would result in an error of working length determination which could lead to extrusion of debris and inter or post preparation pain. After all in the current study and the above discussed studies we have concluded that there is no scientific evidence indicating that age is risk factor in the development of inter appointment pain.

As far as the relation of the pain to gender is concerned, In this study, we have found no relation between the gender and inter appointment pain which meant that there is no significant relation between gender and inter appointment pain and the reason may be due to the small sample size of patients being assessed  in our study. However several studies have shown significant relationship where larger sample size of patients were examined 4,19,20.

Morse et al²¹, Mulhern et al²², Albashaireh and Alnegrish 2 had similar results that we have found in our study but Fox et al²³ and Genet et al²⁰ concluded that the incidence of flare-up in females are more as compare to males.

Although it’s hard to believe that women suffer from psychomatic illness but physicians believe that their pain is directed by their emotional status²⁴. Also the biological differences between genders explain the high incidence of pain in female as it compare to male²⁵. The reasons maybe due to difference in pelvic and reproductive organs which may provide an additional portal of entry of infection in females leading to possible local and distant hyperalgesia²⁶. And the fluctuation in female hormonal levels, which may be associated with changing in the levels of serotonin and nor-adrenaline, causing increase in pain during the menstrual period^27,28. Our study has concluded that gender difference and females’ predominance in the frequency of inter appointment pain is more but it is not statistically significant. In this study the frequency of inter appointment pain is more in the mandibular as it compare to maxillary teeth. In mandibular teeth pain was significant at 24 hour while at 48 hours it was not significant.

Kane¹⁸ found no correlation of post obturation pain with tooth type and that totally opposite to the result that we have concluded which similar to the result of Walton14, Toosy¹⁷, Fox²³, Mollar²⁹ and Barnett³⁰ There is possible explanations    for more pain in mandibular teeth as it compare to the maxillary teeth and that is the cortical thicker plate of the mandible which may cause accumulation of exudates, causes more pressure as compared to maxilla.

CONCLUSION

The result of this study shows no significant difference in inter-appointment pain between crown-down preparation technique and step-back technique.

LEGENDS

Table I: comparison of inter appointment pain at 24 & 48 hrs between groups.

Table II: comparison of inter appointment pain between groups at 24 hours after controlling gender, age and location of teeth.

Table III: comparison of inter appointment pain between groups at 48 hours after controlling gender, age and location of teeth.

REFERENCES

1. Siqueira JF Jr, Rocas IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, Abad EC. Incidence of post operative pain after intracanal procedures based on an antimicrobial Strategy. J Endod 2002; 28:457-460.
2. Albashaireh ZS, Alnegrish AS. Post obturation pain after single- and multiple-visit endodontic therapy. A prospective study. J Dent 1998; 26:227-232.
3. Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod 1998; 24:614-616.
4. Trope M. Relation of intra-canal medicaments to endodontic flare-ups. Endod dent tarumatol 1990;6:226-229
5. Abott PV. Medicaments: aids to success in endodontics part 1. A review of literature. Aust Dent J 1990;35:438-448.
6. Tayfun A, Ali  CT . Interappointment Emergencies in teeth with necrotic pulps. J Endod 2002; 28:375-377. 7. Clem W: Post-treatment endodontic pain, J Am Dent Assoc, 1970; 81:1166–1670.
7. Harrison J, Baumgartner J, and Svec T: Incidence of pain associated with clinical factors during and after root canal therapy. 1. Interappointment pain, J Endod 1983;9:384–387.
8. O’Keef E: Pain in endodontic therapy: preliminary study, J Endod 1976;2: 315-319.
9. Chapman HR, Kirby-Turner N. Visual/verbal analogue scales: Examples of brief assessment methods to aid management of child and adult patients in clinical practice. Br Dent J 2002; 193: 447-450.
10. Breivik EK, Barkvoll P, Skovlund E. Combining diclofenac with acetaminophen or acetaminophen-codeine after oral surgery: a randomized, double-blind singledose study. Clin Pharmacol Ther 1999; 66: 625-635.
11. Hargreaves KM, Keiser K. Development of new pain management strategies. J Dent Educ 2002: 66: 113- 121. 13. Reddy S, Hicks L. Apical extrusion of debris using two hand and two rotary instrumentation techniques. J Endod 1998;24:180-183.
12. Walton R, Fouad A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod 1992;18:172-177.
13. Naidorf IJ. Endodontic flare ups : Bacteriological and immunological mechanisms. J Endod, 1985;11: 462 – 464.
14. Imura N, Zuolo M. Factors associated with endodontic flare-ups: a prospective study. Int Endod J 1995;28:261-265.
15. Toosy A. Flare-up rate in pulply necrotic molar in one visit versus two visit endodontic treatment. Dessertation;2002.
16. Kane AW, Sarr M, Faye B, Toure B, Ba A. incidence of post operative pain in single session root canal therapy (study in black Senegalese apropos of 96 cases). Dakar Med 1999; 44:114-118.
17. Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias TS. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod 1988: 14: 261-266.
18. Genet JM, Hart AA, Wesselink PR, Thoden van Velzen SK. Preoperative and operative factors associated with pain after the first endodontic visit. Int Endod J 1987;20:53-64.
19. Morse DR, Furst ML, Belott RM, Lefkowitz RD, Spritzer IB, Sideman BH. Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial on efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions. Oral Surg Oral Med Oral Pathol 1987; 64:96-109.
20. Mulhern JM, Patterson SS, Newton CW, Ringel AM. Incidence of postoperative pain after one-appointment endodontic treatment of asymptomatic pulpal necrosis in single rooted-teeth. J Endod 1982;8:370-375. 23. Fox J et al. Incidence of pain following one visit endodontic treatment. Oral Surg 1970;30:123-125. 24. Colemeco S, Becker LA, Simpson M. sex bias in the assessment of patient’s complaints. J Fam Pract 1983; 16:1117-1121.
21. Fillingim RB, Maixner W. Gender difference in the responses to noxious stimuli. Pain Forum 1995; 4:209221.
22. Berkley KJ. Sex differences in pain. Behaviour and Brain Science 1997; 20:371-380.
23. Marcus DA. Interrelationships of neuro-chemicals, estrogen, and recurring headache. Pain 1995; 26:129139.
24. Dao TTT, Knight K, Ton-That V. Modulation of myofascial pain patterns by oral contraceptives: a preliminary reports. J Dent Res 1997; 76:148.
25. Mollar A, Fabricus L, Dahin G, Ohman A, Heyden G. Influence on periapical tissues of indigious oral bacteria and necrotic pulp tissues in monkeys. Scand J Dent Res 1981; 89:475-484.
26. Barnett F, Tronstad L. The incidence of flare-ups following endodontic treatment. J Dent Res 1989; 68:1253.

1. Operative Dentistry, Senior Registrar, Operative Dentistry Department, Isra Dental Collage, Isra University
2. Operative Dentistry, Assistant Professor, Oral Biology Dept Ziauddin College of Dentistry, Pakistan
3. Dental Public Health, Senior Lecturer Community and Preventive Dentistry Ziauddin College of Dentistry, Pakistan
4. Assistant Professor, Operative dentistry dept, Isra Dental College, Isra University.
5. Dental Public Health, Assistant Professor Dept of Community and Preventive Dentistry Ziauddin College of Dentistry, Pakistan

Corresponding author: “Dr Mustafa Naseem ” < mustafanasim@hotmail.com >

Nitin Agarwal¹                                    MDS

Devleena Bhowmick²                      MDS

Abhishek Sinha³                                MDS

Anuj Mishra⁴                                      MDS

Sudhir Shukla⁵                                  MDS

Devika Singh²                                    MDS

INTRODUCTION

sthetics has become an important aspect of dental practice & clinicians now accept the challenge to fulfil the esthetic and functional demands of the patients. Achievement of acceptable gingival appearance with biologic and functional stability has gained importance over the years. The gingival color plays a pivotal role in every perception of esthetics and it varies among different individuals which ranges from pale pink color to deep bluish purple hue depending upon on the vascular supply of gingiva, epithelial thickness, degree of keratinization & presence of pigmented cells¹.

Oral pigmentation is the discolouration of mucosa or gingiva. It could be due to physiological or pathological conditions. Gingiva is most common site of pigmentation in oral cavity. Frequent reason of gingival pigmentation is excessive deposition of melanin by melanocyte in the situated in the suprabasal and basal layers of epithelium². It has been seen that the prevalence of melanin pigmentation amongst different populations has been reported to vary between 0% to 89% in relation to the ethnic factors and smoking habits³. After birth, melanin occurs as early as 3 hrs in the oral tissues and in few cases the only sign of pigmentation is on body⁴. Gingival hyperpigmentation, often referred to as racial gingival pigmentation which is seen as a genetic trait in all the ethnicities which is  frequently observed in Africans, East Asians and Hispanics^5-7.

Depigmentation of gingiva is a perioplastic surgical treatment where gingival melanin pigmentation is completely removed and reduced by number of techniques. Technique selection is always based on clinical proficiency and choice of individual. A) Procedures required at removing the pigmented portion:

1. Surgical Scalpel Technique⁸
2. Cryosurgery⁹
3. Electrosurgery¹⁰
4. Lasers
   1. Nd: YAG (Neodium: Aluminium-Yttrium- Garnet) Laser¹¹
   2. Er: YAG (Erbium: Aluminium-Yttrium-Garnet) Laser¹²
   3. CO2 Laser¹³
   4. Diode Laser¹⁴
5. Diamond Burs¹⁵
6. Chemicals (90 % Phenol and 95 % Alcohol) B) Procedures required for covering the pigmented gingiva with grafts from lesser pigmented areas a. Free Gingival Grafts¹⁶
7. Acellular Dermal Matrix Allograft

Laser depigmentation is increasingly becoming popular as the preferred treatment modality for gingival hyperpigmentation. Laser offers many advantages over conventional surgery including less bleeding and less post operative pain¹⁷. Diode laser has been introduced in dentistry few years back. It is a semiconductor solid state laser that has a combination of Arsenide, Gallium & other various elements such as Aluminium, Indium to convert electrical energy into form of light energy ranging from 800 nm to 980 nm.  The present clinical case represents gingival depigmentation using a semiconductor diode laser.

CLINICAL CASE

A female patient aged 23 years old came to Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India in Department of Oral Medicine and Radiology with the chief complaint of dark Gums (Fig.1) and the   treatment for the same. History was carefully recorded and no evidence of tobacco consumption, any systemic condition and drug use was found. Extraoral and Intraoral examination did not suggest any evidence of abnormality. The patient had fair oral hygiene levels with good plaque control. Hyperpigmented gingiva was observed on   labial aspect of  mandibular and maxillary arches. Based on these findings, a provisional diagnosis of Gingival Hyper

Figure 1: Properative View

Melanin Pigmentation was established and deepithelisation extending from canine to canine was planned using a diode laser.

TREATMENT

The patient was given oral hygiene instructions and oral prophylaxis was completed. Topical local anaesthetic spray (Lignocaine, 10 %) was used. Laser specific protective eyewares were used by the operator, assistant and the patient. Doctor Smile SIMPLER Diode Laser by Lambda SpA, Vicenza, Italy operating at 980 nm with standard handpiece was used for gingival depigmentation. Laser was set at 2.0 watt in medium pulse mode. (Fig. 2)  Laser depigmentation started from

Figure 2: Diode Laser

mucogingival junction towards interdental papilla and free gingiva in a very light brushing strokes and tip was kept in motion throughout the procedure¹⁸. (Fig.3) Remnants of tissue were taken out using a gauze which was sterilized and moistened with saline. The entire procedure was repeated until desired epithelial thickness got removed. The maxillary and mandibular arch

Figure 3: During Surgery

depigmentation was carried out in a single visit. The patient was kept under observation at intervals of 7 days, 15 days, 3 months, 6 months and 1 year (Fig.4

Figure 4: Immediately after surgery

to Fig.7). In the first 15 days of follow up no post operative pain, haemorrhage, infection or scarring at any of the site was observed and the healing was uneventful.

Figure 5: After 7days of surgery

Post treatment, the patient was routinely recalled after 3 months, 6 months and 1 year follow up. Satisfactory results were seen amongst the patients with no recurrence of regimentation.

Figure 6: After 3 months

Figure 6: After 1 year

DISCUSSION

There is a great variation in the gingival colour of a healthy individual depending upon gingival vascularisation, thickness, keratinisation and pigmentation along with other factors including genetic factors and racial background. Melanin pigmentation is very common cause for gingival hyperpigmentation which is synthesized by melanin producing cells i.e. melanocytes situated in suprabasal and basal layers of epithelium by hydroxylation of tyrosine to melanin. Melanin hyperpigmentation can also result due to tobacco use, presence of any systemic condition (Endocrine disturbances, Peutz-Jeghers Syndrome, Malignant Melanoma Hemachromatosis, Albright’s Syndrome, etc) as well as drug use (Anti Malarial Agents, Tricyclic Antidepressants etc)

Though the presence or absence of melanin in the gingival tissue has no role to play in any disease activity, some researchers however suggest the protective action of melanin by acting as sink for free radicals generated by respiratory burst of phagocytes during bacterial lysis¹⁹.

Although medical problems are not seen, but smile with display of black gums makes the appearance very unesthetic. Various techniques have been employed to manage this condition with the sole aim to remove the basal epithelial layer containing melanin pigments and melanocytes. The technique required is based on proficiency of clinician and individual’s choice.

Scalpel technique is the oldest and popular technique of depigmentation but it causes unpleasant bleeding and requires 7-10 days periodontal dressing⁸. Cryosurgery often results in considerable swelling along with more destruction of soft tissue. The penetration depth  and optimal duration can’t be controlled if freezing unknown⁹. Electrosurgical depigmentation requires continued electrode application on  tissues resulting in greater chances of thermal damage to underlying periosteum and bone¹⁰. Depithilisation of gingiva by dental bur abrasion is quick and effective technique but causes unpleasant bleeding during the procedure and requires a periodontal dressing for 7-10 days. Chemical agents used to destroy the basal cells are harmful to oral tissues and repigmentation soon develops. Gingivectomy with free gingival graft is more invasive and unnecessarily creates a second surgical site¹⁶. Gingival depigmentation by LASER (Light

Amplification by Stimulated Emission of Radiation) is a recent addition to this list. Various types of lasers have been tried with encouraging results^11-13. The Semiconductor Diode Laser debuted in mid 1990’s and has gained considerable use in the field of dentistry with the latest systems having dimensions comparable to a that of standard dental handpiece.

Diode laser operates at near infrared (NIR) wavelengths (800 nm to 980 nm) are highly absorbed by haemoglobin, melanin and other pigments and are ideally suited for soft tissue procedures. Diode laser like its predecessors interacts with tissue in one of the four ways – Transmission, Reflection, Scatter and Absorption. This absorptive interaction results in conversion of laser energy into thermal energy causing physical changes in the target tissue – Photothermolysis.

Although healing of laser wound is slower than scalpel wound, laser offers many advantages over conventional surgery:²⁰

1. Bloodless and dry surgery
2. Instant surgical site sterilization
3. Lesser bacteremia
4. Lesser mechanical trauma
5. Minimum post operative scaring and swelling
6. Minimal post operative pain

Although initial result of depigmentation procedure is very motivating, but chances of  repigmentation is common problem. The large variation in time lag before repigmentation could be related to the technique used and race of the patient. Though the mechanism of repigmentation has been not fully understood, theories suggest migration of melanocytes which are active from adjacent pigmented tissues into the areas treated or activation of melanocytes left during surgery¹⁸.

CONCLUSION

Smile is the mirror of self confidence and joy. The great comedian, Charlie Chaplin stated, “You’ll find that life is still worthwhile, if you just smile”. However, a perfect smile is not just about shape, position and colour of teeth but also the gingiva supporting the teeth. Gingival melanin pigmentation has become an important concern for majority   number of patients. Different methods for depigmentation have been documented with comparable results. However, choice of procedure is based on preference of an individual, expertise clinicians and affordability of a patient. Diode laser depigmentation is relatively safe, minimally invasive, convenient and effective treatment modality. The procedure is almost bloodless, painless and sterile with better patient compliance and satisfaction. In  present clinical case, evidence of repigmentation was not observed even after one year of follow up.

REFERENCES

1. Dummet CO, Barens G. Pigmentation of the oral tissues: A review of literature. J Periodontol. 1967; 39; 369-378
2. Dummet CO. Over view of normal pigmentations. J Indiana dent assoc. 1980;59: 13-18
3. Lagdive S, Doshi Y, Marawar PP. Management of Gingival Hyperpigmentation using surgical blade and diode laser therapy: A comparative study. J Oral Laser Application 2009; 9: 41-47
4. Dummet CO. Physiologic pigmentation of the oral and cutaneous tissues in the Negro. J Dent Res 1946; 25: 421-432
5. Dummet CO, Barens G. Oromucosal pigmentation: An updated literary review. J Periodontol 1971; 42: 726-736
6. Dummet CO. Clinical observations on pigmented variations in healthy oral tissues of the Negro. J Dent Res 1945; 24: 7-13
7. Dummet CO. Oral Tissue Color Changes (I). Quintessence Int. 1979 Nov; 10: 39-45
8.  Ginwalla TM, Gomes BC, Varma BR. Surgical removal of gingival pigmentation. J Indian Dent Assoc 1966; 38: 147-150
9. Tal H, Landsberg J, Kozlovsky A. Cryosurgical depigmentation of the gingival pigmentation: A case report. J Clin Periodontol 1987; 14: 614-617
10. Gnanasekhar JD, Al-Duwairi YS. Electrosurgery in dentistry. Quintessence Int. 1998; 29: 649-654
11. Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingival hyperpigmentation for esthetic purposes by Nd: YAG laser: Report of 4 cases. J Periodontol 2000; 71: 315-321
12. Tal H, Oegiesser D, Tal M. Gingival depigmentation by Erbium: YAG laser: clinical observation and patient responses. J Periodontol 2003; 74: 1660-1667
13. Nakamura Y, Hossain M, Hirayama K, Matsumoto K. A clinical study on the removal of gingival melanin pigmentation with the CO2 laser. Lasers Surg Med 1999;25:140-147
14. Yousuf A, Hossain M, Nakamura Y, Yamada
15. Y,Kinoshita J, Matsumoto K. Removal of gingival melanin pigmentation with the semiconductor diode laser: A case report. J Clin Laser Med Surg 2000;18:263-266
16. Putter OH, Ouellet D, Putter A, Vilaboa D, VilaboaB, Fernandez M. A non-traumatic technique for removing melanotic pigmentation lesions from the gingiva: Gingiabrasion. Dent Today 1994;13:58-60
17. Tamizi M, Taheri M. Treatment of severe physiological gingival pigmentation with free gingival autograft. Quintessence Int. 1996;27:555-558
18. Mathews MA, Diode Lasers: A versatile clinical tool (a technical and clinical review). Intl J Laser Dent 2011; 4: 2341-2346
19. Ozbayrak S, Dumlu A, Ercalik – Yalcinkaya S. Treatment of of melanin pigmented gingiva and oral mucosa with CO2 Laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2000; 90: 14-15
20. Barrett AW, Scully C. Human oral mucosal melanocytes: a review. J Oral Pathol Med 1994; 23: 97-103.
21. Wigdor et al. Lasers in surgery and medicine 1995; 16:103-133.

1. MDS & Professor in the Department Of Oral Medicine & Radiology, Sardar Patel Post Graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.
2. MDS 2^nd Year Post Graduate student in the Department Of Oral Medicine & Radiology, Sardar Patel Post Graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.
3. MDS & Reader in the Department of Oral Medicine & Radiology, Sardar Patel Post graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.
4. MDS 3^rd Year Post Graduate student in the Department Of Oral Medicine & Radiology,Sardar Patel Post Graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.
5. MDS 3^rd Year Post Graduate student, Department Of Oral Medicine & Radiology,Sardar Patel Post Graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.
6. MDS 2^nd Year Post Graduate student, Department Of Oral Medicine & Radiology,Sardar Patel Post Graduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India.Corresponding author: “Dr Nitin Agarwal, Professor & Head Of Dept of  Oral Medicine & Radiology” < nitinmds@yahoo.com >

Asma Naz¹                                               

Syed Akhtar Hussain Bokhari²                               

Agha Mohammad Suhail³

Mian Farrukh Imran⁴

Syed Ameer Hamza⁵

INTRODUCTION

Depression and anxiety are known to be risk factors that cause a range of diseases and conditions¹. Dental fear has been suggested as a conditioned reaction to previous negative dental experiences and unpleasant dentist contacts². Anxiety of dental treatment is an insurmountable factor that may lead to irregular dental attendance behavior, and avoidance of care and is associated with poor oral health.

High dental anxiety is inversely related to oral health¹. Higher numbers of decayed teeth, lower numbers of filled teeth and higher counts of missing teeth are associated with high dental anxiety^{3, 4}.

Dental anxiety has been reported to lead to avoidance behavior and cause delay in regular or necessary dental treatment⁵ and this also negatively affects dental health⁶. The prevalence and consequences of dental anxiety have been explored and its impact on dental health status has been reported previously⁷. There is psychosocial impact

of dental anxiety on daily livelihood and physiological, cognitive, behavioral, health, and social impacts of dental anxiety have been identified⁸. An association between dental anxiety / fear with gender and age has been observed^2,9. No data on dental anxiety has been reported from Pakistan. This study was conducted to explore the status of dental anxiety among patients attending a periodontal clinic and to assess its association with  demographic variables of age and gender, education, income, occupation and residential location.

METHODOLOGY

Patients attending the Periodontology department of Margalla College of Dentistry Hospital, Rawalpindi, Pakistan were invited to participate in the study. All patients, who gave a verbal consent, were recruited by convenient sampling technique over a period of one month (1st-30th June 2013). A structured questionnaire was prepared to record demographic variables. Dental anxiety was measured using the Corah’s Dental Anxiety Scale (DAS) [10], which consisted of 5 items covering ‘relaxed, a little uneasy, tense, anxious, and very anxious’.

Responses were recorded against four questions: 1) if you had to go to the Dentist tomorrow, how would you feel about it?; 2) When you are waiting in the Dentist’s office for your turn, how do you feel?; 3) When the dentist’s gets his drill ready to begin working, how do you feel?; 4) when the dentist gets his instruments ready to scrap your teeth around the gums, how do you feel? Demographic variables of age, gender, education, income, occupation and residential location of the respondents were assessed. The response for the 4 questions were compared among genders and agegroups (>/<34 years) and Chi-squire test was applied for statistical significance that was set at p<0.050. Stepwise linear regression

with backward elimination method was applied to observe the association of dental scales as dependant variables with all the demographic variables as independent variables. Data was analyzed using SPSS version 16. Ethical approval of the study was obtained from dental college research review committee.

RESULTS

Two hundred patients were recruited during the one month period. Demographic variables showed that females were higher in number than the males (%). Mean age of the patients was 39.2±15.0 years. The mean age was 41.1±15.9 years for the males and 37.8±14.2 years for the females. 58% participants were <34 years old, while 44% subjects were in lowest income

group (Rs. 5000/-), 41% were in service and 84.5% subjects from urban location. (Table 1)

Sixty one percent of the males and 37% of the females selected the response uneasy to Q1 (having to visit the dentist). For the same question 48% subjects of the higher age group felt uneasy. This difference was found to be statistically significant (p=0.014) among genders while it was statistically insignificant (p=0.715) among the age groups. No statistically significant differences were found among the genders and different age groups with regards to Q2 and 3. Statistically significant differences were found among genders (p= 0.004) for the patients’ response to teeth scraping for the anxious category and insignificant among the age groups (p=0.080) (Table 2). Dental anxiety scale questions were also analyzed for their statistical association with demographic variables of occupation, education, income and location; however no association was observed (p>0.130) (data not shown). Stepwise linear regression

DISCUSSION

The results of this study showed that highest percentage of patients did have anxiety level of uneasy. The anxiety score for the four questions was significantly higher in females as congruent with another study¹¹ however there was an insignificant difference between different age groups¹¹. Moderate to severe anxiety regarding dental treatment was observed in 25% of the patients in Brazil, and the degree of anxiety was higher among females, over the age of 20 years;¹² this corresponds with our findings of anxious to severe anxious status of periodontal patients. A regional study by Malvania et al. (2011) has reported that 46% of the participants were anxious about dental procedures and females were significantly more anxious as compared to males¹³. In that study, subjects from villages significantly showed higher anxiety levels to those living in city. These findings are not concordant with those of our study.

Different age groups did not show statistically significant difference when compared for dental anxiety levels¹¹. In the current study, subjects of age group >34 years revealed high anxiety scores which disagree with what was reported by another study that reported higher anxiety scores for the subjects aged 20 years and below ¹⁴.  However our results were similar to the results reported by Stabholz et al. (1999) who reported that anxiety of higher level among subjects in the age group 35-44 years¹⁵. High dental anxiety is associated with irregular dental care with large odds ratios (ORs)¹.  As compared to males, females have higher dental anxiety that is also observed in the current study but females also exhibit better compliance with dental visits; have better oral hygiene².

The reported observation that higher anxiety levels are associated with low level of education as compared to individuals with higher level of education; the probable explanation for this trend may be that higher education provides the individual with better tools to cope with stressful situations like anxiety. Less educated patients had high anxiety scores⁹ and in another study gender, education and fear were reported significant predictors of dental anxiety that create hindrance in seeking dental care for the presenting complaint,¹⁶ but this aspect was not explored in the current study.

Regression analysis of the data of this study revealed a significant association of ‘anxiety’ with gender and age. An association between Corah’s Dental Anxiety Scale (DAS) scores and decayed, missing, and filled surfaces (DMFS) status in young men with relatively low level of dental caries has been observed¹⁷.

Dental anxiety has also shown association with impact of oral health related quality of life (OHQoL) in a study in Britain, higher scores of dental anxiety were observed among those with worst OHQoL¹⁸; however we have not observed QoL in our study. Therefore, it is suggested that dentists should help patients to establish a realistic expectation of pain and minimize fear-related dental avoidance in order to reduce the irregular utilization behaviors by patients². Treatment of fearful dental patients is recognized as a professional stressor and requires an understanding by the dentist of patience, empathy, and skill in behavior management^{19, 20}. Dental anxiety plays a negative role in a person’s oral health and interferes with effective dental interventions. That is why dental fear and poor dental utilization behaviors reinforce each other². This study augments observations of other epidemiological studies on dental anxiety and demographic variables^21-24.

CONCLUSION

Dental anxiety is prevalent among majority of study participants and showed a significant association with female gender, but no relationship was noted with the age-groups in this study sample. No association was observed between DAS and demographic variables of education, income, occupation and location in regression analysis (also by all the used tests).

REFERENCES

1. Boman UW, Wennstrom A, Stenman U, Hakeberg Oral health-related quality of life, sense of coherence and dental anxiety: an epidemiological cross-sectional study of middle-aged women. BMC Oral Health 2012,12:14-18
2. Meng X, Heft MW, Bradley MM, Lang PJ. Effect of fear on dental utilization behaviors and oral health outcome. Community Dent Oral Epidemiol 2007; 35:292301
3. Ha¨gglin C, Berggren U, Hakeberg M, Ahlqwist M. Dental anxiety among middle-aged and elderly women in Sweden. A study of oral state, utilization of dental services and concomitant factors. Gerodontology 1996;13:25-34.
4. Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol 2003;31:116-121
5. Schuurs AHB, Duivenvoorden HJ, Thoden van Velzen SK, Verhage F. Three factors predicting irregular versus regular dental attendance: a model fitting to empirical data. Community Dent Oral Epidemiol 1980;8:413-419.
6. Berggren U, Meynert G. Dental fear and avoidance: causes, symptoms, and consequences. J Am Dent Assoc 1984;109:247-251.
7. Ng SKS, Stouthard MEA, Leung WK. Validation of a Chinese version of Dental Anxiety Inventory. Community Dent Oral Epidemiol 2005;33:107-114.
8. Cohen SM, Fiske J, Newton JT. The impact of dental anxiety on daily living Br Dent J 2000;189:385-390
9. Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. J Oral Rehabil 2008;35:259-267.
10. Kumar S, Bhargav P, Patel A, Bhati M, Balasubramanyam G, Duraiswamy P and Kulkarni S. Does dental anxiety influence oral health-related quality of life? Observations from a cross-sectional study among adults in Udaipur district, India. J Oral Sci 2009;51:245254
11. Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci 2011;53:341-348
12. Carvalho RW, Falcão PG, Campos GJ, Bastos Ade S, Pereira JC, Pereira MA, et al. Anxiety regarding dental treatment: prevalence and predictors among Brazilians. Cien Saude Colet. 2012;17:1915-1922.
13. Malvania EA, Ajithkrishnan CG. Prevalence and sociodemographic correlates of dental anxiety among a group of adult patients attending a dental institution in Vadodara city, Gujrat, India. Indian J Dent Res 2011;22:179-180
14. . Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patient undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6:91-98.
15. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental procedures. Int Dent J 1999;49:90-94
16. Ekanayake L, Dhamawardena D. Dental anxiety in patients seeking care at the university dental hospital in Srilanka. Community Dent Health 2003;20:112-116.
17. Cohen ME. Dental anxiety and DMFS status: association within a US naval population versus differences between groups. Community Dent Oral Epidemiol 1985;13:75-78.
18. McGrath CM, Bedi R. The association between dental anxiety and oral health-related quality of life in Britain.
    Community Dent Oral Epidemiol 2004;32:67-72.
19. O’Shea RM, Corah NL, Ayer WA. Sources of dentists’ stress. J Am Dent Assoc 1984;109:48-51.
20. Corah NL, O’Shea RM, Ayer WA. Dentists’ management of patients’ fear and anxiety. J Am Dent Assoc 1985;110:734-736.
21. Nicolas E, Collado V, Faulks D, Bullier B, Hennequin M. A national cross-sectional survey of dental anxiety in the French adult population. BMC Oral Health 2007; 7: 12-19
22. Enkling N, Marwinski G, Jaehren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Investig 2006;10: 84-91.
23. Woodmansey KF. The prevalence of dental anxiety in patients of a university dental clinic. J Am Coll Health 2005;54:59-61.
24. Fredrikson M, Annas P, Fischer H, Wik G. Gender and age differences in the prevalence of specific fears and phobias. Behav Res Ther 1996;34:33-39.

1. Associate Professor Margalla College of Dentistry, Rawalpindi
2. Professor University Medical & Dental College, Faisalabad <pdplhr@yahoo.com >
3. Associate Professor University Medical & Dental College, Faisalabad <draghasuhail@hotmail.com>
4. Associate Professor University Medical & Dental College, Faisalabad < mian40100pk@yahoo.com >
5. House Officer University College of Dentistry, Lahore <syedameerhamza@yahoo.com>
   Corresponding author: “Prof Dr S Akhtar Hussain Bokhari ” <pdplhr@yahoo.com>

Uzma Shahbaz¹                                               BDS, FCPS

Fauzia Quadir²                                               BDS, FCPS

Tasleem Hosein³                                           BDS, FDSRCS

INTRODUCTION

here are many developmental defects which have genetic source. Some of them affect almost all the teeth in a more or less equal manner by altering the configuration and form of enamel. Amelogenesis imperfecta (AI) represents one such group, which may be related to structural or organic changes occurring somewhere else in the body. According to the populations studied, its incidence fluctuates from 1:700 to 1:14,000. The presentation of the defected enamel may be hypoplastic, hypomineralised or both resulting in sensitive, discolored dentition which is susceptible to breakdown. AI may occur alone or may be linked with other conditions. It can be of autosomal dominant, autosomal recessive, sex-linked or sporadic type¹. Amelogenesis imperfecta (non-syndromic form) has been found to be caused due to mutations in certain genes such as AMELX, MMP20, KLK-4 and ENAM.

These genes provide instructions for the synthesis of certain proteins that are responsible for normal tooth development including the normal enamel synthesis, which is a hard, calcium-rich protective outer layer of the teeth. Alteration in any of these genes changes the structure of these proteins interfering with their function and therefore prevents the genes from making any protein at all. As a result, the tooth enamel produced is unusually soft, thin and discolored and damages very easily.

Amelogenesis imperfecta can also be acquired in an autosomal recessive pattern resulting usually from mutations in the ENAM or MMP20 gene. In this type, mutation occurs in two copies of the gene in each cell. AI is mostly inherited in an autosomal dominant pattern which results due to an alteration in the ENAM gene. In this type, mutation in even one copy of the gene in each cell is enough to cause the disorder. Few other types of AI may result due to mutation in certain new genes or in individuals with no previous family history of this condition^[1],[2].

AI causes a lot of clinical problems including teeth that are very sensitive due to defective enamel. There is a loss of occlusal vertical dimension and dysfunction with compromised aesthetics. A timely treatment of these defects results in a positive psychological impact on the patient because of improved esthetics and function⁴.

Aberrations are seen in tooth number, crown morphology, pulp-dentine tissue, and in the eruption process. Gingival conditions and oral hygiene of such patients is usually poor, with calculus being found frequently. Patients may suffer from malocclusions⁵.

Amelogenesis imperfecta may also present in the hypoplastic form, in which the enamel may be pitted, rough, or with irregular vertical ridges of normal and defective enamel. There is as inadequate depth of the enamel seen in this type of AI, resulting in a lack of interproximal contacts⁶. Current case report presents restorative management of a case of type 1 AI.

CLINICAL REPORT

A 17 year old female patient was referred to the Prosthodontics department, Fatima Jinnah Dental Hospital, Karachi, for the replacement of missing anterior teeth. The girl was worried about the appearance of her teeth and wanted an immediate replacement. The girl was later referred to the Operative department because of the general appearance of her remaining permanent anterior teeth which lacked the normal form and thickness of enamel.

The clinical examination showed hypoplastic 13, 21, 22, 23, 31, 32, 33, 41, 42, 43 and all four permanent first molars. Affected teeth were thin, small teeth with rough and pitted enamel surface. Crown size was smaller than the normal with lack of proximal contact and anterior open bite affecting the upper and lower anterior teeth along with first permanent molars. Second molars and premolars however, were spared. The teeth no. 11 and 12 were missing and exhibited a significant loss of horizontal and vertical bone volume (Fig no 1 to Fig no 5). According to the patient the missing teeth

Fig no 1 Preoperative view from fornt

never erupted. The oral hygiene of the patient was poor with hyperemic and edematous gingiva. Medical history and extra oral examination was non-contributory. A working diagnosis of Autosomal Recessive Rough

Fig no 2 Preoperative view from left lateral side

Fig no 3 Preoperative view from right lateral side

Fig no 4 Occlusal view (upper arch)

Hypoplastic AI was made. Radiograph examination revealed periapical infection in tooth no 31.

An ideal treatment plan that included orthodontic repositioning of teeth to more favourable location

Fig no 5 Occlusal view (lower arch) followed by

ceramic veneer on anterior teeth and lithium disilicate crowns on first permanent molar, placement of implants and guided bone regeneration to replace congenitally missing right central and lateral incosors was turned down by patient owing to financial constraints and lack of time. Our alternate and cost effective treatment plan accepted by the patient included improvement in oral hygiene, direct composite restorations, full coverage metal crowns for the affected teeth and a removable partial denture for missing teeth.

Oral hygiene instructions, scaling, and root planning were done to improve her periodontal status. Two weeks later, the gingival edema and hyperemic appearance of gingiva resolved and bleeding on probing returned to normal.

All permanent first molars were prepared to receive full metal crowns, impression was performed with polyvinyl siloxane putty and light body (3M ESPE)  in a single step technique using stock trays. The preps were temporized with self cure acrylic crowns. 5 days later full metal crowns were cemented on all the first molars using a type 1 GIC cement (GC-Gold label) (Fig no 6 & 7). Composite veneers were done on all the affected

Fig no 6 Metal crowns on mandibular molars anterior

upper and lower teeth using Ceram X mono composite (Dentsply) shade M1 without any preparation.

Fig no 7 Metal crowns on maxillary molars

No attempt was made to close the proximal gaps between the teeth as there was not much tooth structure to support such restoration. The idea was to strengthen the remaining tooth structure, improve esthetics and to protect the teeth from further damage.

Upper and lower jaw impressions were taken with alginate for the fabrication of a partial denture for missing teeth 11 and 12. A wax trial was done to check for shape and color of the teeth. The acrylic partial denture was inserted and appropriate occlusal adjustment was done (Fig 8,9,10 & 11).

Fig no 8 Postoperative view (right lateral)

Fig no 9 Postoperative view (left lateral)

Fig no 10 Post operative view (occlusal)

Fig no 11 Postoperative frontal view

Fig no 12 Lips at rest showing a natural appearance of restored dentition

The patient was given instructions on cleaning of interproximal areas and partial denture. The patient was reexamined after 1 week. The patient was recalled for follow-up visits at 3 and at 6 months. No issues were noticed during this period related to her esthetics or function.

DISCUSSION

The presented clinical situation was rare and required use of treatment to protect and strengthen the affected teeth as well as improve esthetics and restore function. The patient was looking for a cost effective solution of her esthetic problem and replacement of missing teeth. She was not aware of the compromised structure of her first permanent molars and hypoplastic anterior teeth and therefore acceptance of treatment for those teeth required her understanding and cooperation. The approach to this situation was made by discussing the treatment options along with material available for veneering her anterior teeth for giving her esthetic results, with the patient and parents.

In cases of hypoplastic  AI, the enamel is properly mineralized, but its amount is deficient. The fine enamel surface is thin, hard, and rough due to presence of ridges and grooves. The teeth have crowns tapering downwards with deficient contact points. A thin border of radiopaque enamel is seen on radiographs with very low cuspal

height or entirely absent cusps of the teeth^(7,8). Clinically and radiographically,  our case was harmonious with rough pattern hypoplastic type AI.

Many other dental and skeletal developmental defects may be accompanied with AI, such as taurodontism, root resorption, attrition, dens in dente, pulp stones, tooth impaction, anterior open bite and agenesis of teeth. The eruption of the teeth may be delayed in such cases and sometimes teeth may not be formed entirely. In our case, missing teeth, disturbed eruption, anterior open bite were present⁹.

The gingiva of our patient was hyperemic and edematous. Until now, 40 papers have been published reporting the gingival conditions of patients with AI, and 28 of them had edematous and hyperemic gingivae⁽⁹⁾. This condition is perhaps contributed by mouth breathing and reluctance to brush because of sensitive teeth^(8,9). Along with poor oral hygiene, these factors adversely affect the prognosis of the prosthetic treatment^(1,8). The oral health of our patient was maintained after conventional periodontal therapy.

The management of amelogenesis imperfect usually involves direct and/or indirect restorations. Contemporary treatment modalities comprising of adhesive restorative techniques, overdentures, fixed partial dentures, full porcelain crowns, porcelain fused-to metal crowns and inlay/onlay restorations have been reported in literature^(10-18).

Full porcelain restorations are becoming increasingly popular, because of their improved esthetics, excellent biocompatibility and improved physical properties.

The recent advances in dentin bonding have revolutionized the field of esthetic dentistry. The practitioners can now predictably restore the function and esthetics to quite a satisfactory level^(10,17,18). However, the main disadvantages of laminate veneers have been identified as marginal adaptation and bonding problems (16).

In the present case, full- metal restorations on posterior first molars were preferred to redouble the mechanical durability, recover strength and protect the residual dentin. The porcelain laminate veneers were our first option to improve the esthetic outcome, but were refused by our patient due to financial constraints. Patient reported her comfort with the restorative treatment on her followup visits.

CONCULSION

In conclusion, AI is a severe disorder affecting the patient’s quality of life with relation to their oral health and may have serious psychological impact on them. From this point of view, people with AI need extensive treatment. While planning the treatment, several factors must be taken into account like patient’s age, their affordability, pattern and the nature of AI. Moreover, although rare, some dental anomalies may accompany the AI cases. In these cases, multidisciplinary approach is important for treatment success. In the present case, the patient tolerated the use of partial denture and restorations well at  routine follow ups.

REFERENCES

1. Peter JM Crawford, Michael Aldred and Agnes BlochZupan. Amelogenesis imperfect. Orphanet J Rare Diseases 2007, 2:17-27
2. Simmer JP, Hu JC . “Dental enamel formation and its impact on clinical dentistry”. J Dent Educ 2001 65 : 896-905
3. Aldred MJ, Savarirayan R, Crawford PJ .”Amelogenesis imperfecta: a classification and catalogue for the 21st century”. Oral Dis  2003 9: 19-23.
4. Santos MCLG, Line SRP. The genetics of amelogenesis imperfecta: a review of the literature. J Appl Oral Sci 2005;13:212-217.
5. Sven Poulsen, Hans Gjørup, Dorte Haubek, Gro Haukali, Hanne Hintze, Henrik Løvschall and Marie Errboe. Amelogenesis imperfecta – a systematic literature review of associated dental and oro-facial abnormalities and their impact on patients. Acta Odontologica, 2008;66: 193-199
6. Carlos F. Salinas. Developmental anomalies of the oral cavity: the relationship between oral health and genetic disorders, part II. (Developmental Anomalies. The free library.
7. Neville BW, Douglass DD, Allen CM, Bouquot JE. Abnormalities of teeth. In: Oral and Maxillofacial Pathology. 2nd ed.. Pennsylvania:Elsevier;2004. 89-94
8. Bailleul-Forestier I, Molla M, Verloes A, Berdal A. The genetic basis of inherited anomalies of the teeth. Part 1: clinical and molecular aspects of non-syndromic dental disorders. Eur J Med Genet 2008;51:273-291
9. Poulsen S, Gjqrup H, Haubek D, Haukali G, Hintze H, Lqvschall H, et al.. Amelogenesis imperfecta – a systematic literature review of associated dental and orofacial abnormalities and their impact on patients. Acta Odontol Scand 2008;66:193-199
10. Gökçe K, Canpolat C, Özel E. Restoring function and esthetics in a patient with amelogenesis imperfecta: a case report. J Contemp Dent Pract 2007;8:90-101.
11. Siadat H, Alikashi M, Mirfazaelian A. Rehabilitation of a patient with amelogenesis imperfect using allceramic crowns: a clinical report. J Prosthet Dent 2007;98:85-88.
12. Toksavul S, Ulusoy M, Türkün M, Kümbüloglu Ö. Amelogenesis imperfecta: the multidisciplinary approach: a case report. Quintessence Int 2004;35:11-14.
13. Sadighpour L, Geraminapah F, Nikzad S. Fixed rehabilitation of an ACP PDI class III patient with amelogenesis imperfecta. J Prosthodont 2009;18:64-70.
14. Kostoulas I, Kourtis S, Andritsakis D, Doukoudakis A. Functional and esthetic rehabilitation in amelogenesis imperfecta: a case report. Quintessence Int 2005;36:329338.
15. Ozturk N, Sari Z, Ozturk B. An interdisciplinary approach for restoring function and esthetics in a patient with amelogenesis imperfecta and malocclusion: a clinical report. J Prosthet Dent 2004;92:112-115.
16. Christensen GJ. Porcelain-fused-to-metal versus nonmetal crowns. J Am Dent Assoc 1999;130:409-411.
17. Sengün A, Özer F. Restorating function and aestehetics in a patient with amelogenesis imperfect: a case report. Quintessence Int 2002;33:199-204.
18. Sari T, Usumez A. Restoring function and esthetics in a patient with amelogenesis imperfecta: a clinical report. J Prosthet Dent 2003;90:522-525.

1. Assistant Professor Department of Operative Dentistry Fatima Jinnah Dental College, Karachi.
2. Assistant Professor Department of Operative Dentistry Dow Dental College, Karachi.
3. Professor and Dean Fatima Jinnah Dental College, Karachi. < hosein.tasleem@gmail.com >

Corresponding author: “Dr Fauzia Qadir” < fzb80@hotmail.com >

Mowaffaq Al Absi¹                                              BDS, MSc

Fayez Hussain Niazi²                                        BDS, MSc

Mustafa Naseem³                                               BDS, MSc

Zahid Iqbal⁴                                                         BDS, FCPS

Faheem Khiyani⁵                                                BDS, MSc

INTRODUCTION

The relationship between pain and dentistry is frequently portrayed in popular culture as synonymous with situations to be avoided. In fact, poorly controlled dental pain and related anxiety contribute to postponed or cancelled appointments^[1],[2]. Dental fear is a major reason given for avoiding dental visits^[3]. Effective control of dental pain improves patient comfort, facilitates the delivery of oral care, decreases anxiety, and may even improve oral health. The aim of root canal treatment is to eliminate bacteria from the canal system in order to create an environment favorable for healing. Current preparation techniques along with disinfectants or medicaments may disrupt the intra-canal microbial environment. However, numerous studies have shown that it is impossible to achieve a bacteria free root canal consistently^1-[4]. Hence, there is concern over the consequences of the presence of the remaining microorganisms in the canal.

It is generally believed that the remaining bacteria can be either eradicated or prevented from recolonizing the root canal system through an inter-appointment medicament such as calcium hydroxide^2,5. However, it has been demonstrated that calcium hydroxide consistently fails to sterilize root canals and may even allow regrowth in some cases^3,4,6. The presence of cultivable microorganisms at the time of obturation has been reported to impair healing after root canal therapy ⁷. Certain factors such as preoperative pain² use of intra-canal medications^5,6 and tooth localization  may predispose the development of inter and post appointment pain. Mechanical instrumentation is the core method for bacterial reduction in the infected root canal. Various treatment regimens for the relief of pain during endodontic therapy, includes pre-medication relief of occlusion, establishment of drainage, intra-canal and systemic medications. Preparation of root canal systems includes both enlargement and shaping of the complex endodontic space together with its disinfection. A variety of instruments and techniques have been developed and described for this critical stage of root canal treatment. The advantages of conventional   hand instrumentation from crown to apex with early coronal flaring include less risk of inoculation of endodontic pathogens in the periradicular tissues, enhanced penetration of irrigant into the root canal system, less extrusion of irrigant solution and furthermore there is less likelihood for a change in the working length measurement during preparation, greater tactile awareness and reduced coronal binding of instruments. On the other hand the step-back technique creates a smoother flow and a tapered preparation from apical to coronal direction. Our study is comparing the inter-appointment pain in vital single rooted teeth by using two classical techniques used for root canal preparation. These techniques are crowndown or step-down and apical step-back. The frequency of pain will be assessed by employing visual analogue pain scale to compare the two groups⁸. Knowledge on the causes and the mechanisms behind inter-appointment pain is very important for the practitioner to manage this undesirable condition. Inter-appointment emergency, proper diagnosis and active treatment is required for the clinician to overcome the problem.  It is therefore important to carry out a study, which can help us in improving our knowledge and skills regarding the precise diagnosis as well as the management of inter-appointment pain. Previous local studies are limited in this regard.

METHODOLOGY

Patients were selected from out-door patients coming to operative dentistry department of Liaquat University of Medical and Health Sciences, Jamshoro.

After taking the inclusion and exclusion criteria into consideration, detailed history were taken and all necessary investigations were done. Pre-operatively, the tooth could not always be accurately diagnosed as vital or non vital by history taking, clinical and radiographic examination and vitality testing, therefore the gold standards of diagnosis was a presence of bleeding from the pulp chamber and the root canals determined by direct observation after access opening, Cases with non vital pulp were selected in this study.

Two standardized peri-apical radiographs were taken during the treatment, as follows:

• Pre-treatment.
• Working length determination with files in situ. Local Anesthesia has been administered and rubber dam applied for isolation. Adequate coronal access into the pulp chamber was made in order to provide easy access of endodontic instruments to all the walls of the root canals.

This was achieved by using high speed hand piece with a number 2 round bur and tapered fissure bur (Alpha Dental Diamond burs USA Certified ISO 9002) for both crown down and step back technique groups. To achieve the working length we used a distance of 1 to 2mm short of the apex to limit our canal preparations and obturation. According to the size of the image of the tooth on the preoperative radiograph, a file was inserted into each root canal so that it would reach approximately within 2mm of the   radiographic apex.

From instrument tip to stopper, this length was measured when in the canal the stopper was rested against a reference point. A working length radiograph was subsequently obtained. Correct working length was obtained by observing the distance between tip of the file and radiographic apex.

Canals have been instrumented using a crown-down in the first group by first flaring the coronal third of each tooth with gates gladden bur No (2-4) (Dentsply, Millefer, Switzerland) while middle and apical third was prepared by hand files  (Kerr, Romulus, Mich.) along with irrigant using 5.2% sodium hypochlorite solution and step-back technique in the second group by conventional handfiles on apical and middle third and then the coronal third of each tooth were flared with gates gladden bur No (24) (Dentsply, Millefer, Switzerland) along with irrigant using 5.2% sodium hypochlorite solution.  The canals dried and the teeth were temporized by temporary filling material cavit (provis, Favodent karl Huber GmbH, Germany) and patient were recalled for next appointment to complete the root canal procedure, in case of severe pain, symptomatic treatment were given.

The patients were assigned into group A or B by envelope method. Group A had their root canals prepared by crown down and group B by step-back. The patients were telephonically accessed to record the pain after 24 hours and 48 hours after the initial treatment. The data were collected on the Performa.

Data were collected and entered in SPSS version 10 for windows. Mean ± SD were presented for age of the patient and VAS. Male to Female ratio were presented for gender distribution. Chi-squared test were used to compare VAS between the two groups. A p-value of <0.05 was considered as statistically significant.

RESULTS

A total of 60 patients required endodontic treatment with vital teeth were included in this study and canals were instrumented using a crown-down and step-back technique. Subjects were equally divided into two groups by using envelope method, for group A, root canals prepared by crown down and group B by step-back. The average age of the patients was 32.83 ± 9.23 years (30.45 to 35.22). The average age of the patients was significantly high in group A than group B (40.50 ± 5.51 vs. 25.17 ± 4.64 p=0.0001). Out of 60 patients, 22(36.7%) were male and 38(63.3%) were female.  Proportion of gender was not significant between groups (p=1.00). Regarding maxillary and mandibular tooth location thirty three (55%) maxillary teeth were treated and 27(45%) mandibular teeth were treated.

Comparison of inter appointment pain at 24 hrs and 48 hrs between groups are presented in table 1 . Inter appointment pain at 24 hrs was found in 35% (21/60) patients. In group A (crown down technique), inter appointment pain was only in 23.3% (7/30) patients and in group B (step back technique) in 46.7% (14/30) patients. Rate of inter appointment pain was high in group B than group A but it is not statistically significant (chi-square =3.59; p=0.058). In the other word inter appointment pain was 2.87 times more likely in step back technique (group B) than crown down technique (OR=2.87; 95%CI: 0.95 to 8.69).

At 48 hours, inter appointment pain was observed in 40% (24/60) patients.  In group A inter appointment pain was in 40% (12/30) patients and in group B in 40% (12/30) patients. Rate of inter appointment pain was not

TABLE 1

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS

statistically significant between the group at 48 hours (chi-square =0.0001; p=1.00). In the other word odd ratio is 1 (OR=1.00) its mean pain was equally likely in both groups (OR=1; 95%CI: 0.35 to 2.81).

Comparisons of inter appointment pain at 24 hrs and 48 hrs between groups after stratification of gender, age groups and location were presented in table 2 and 3. Gender and age groups were not effect on pain between groups. In Maxillary teeth, pain was significantly high

TABLE 2

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS AT 24 HOURS AFTER CONTROLLING GENDER, AGE AND LOCATION OF TEETH

TABLE 3

COMPARISON OF INTER APPOINTMENT PAIN BETWEEN GROUPS AT 48 HOURS AFTER CONTROLLING GENDER, AGE AND LOCATION OF TEETH

in step back technique than crown back technique (fisher’s exact test; p=0.04) at 24hours. In mandibular teeth, pain was significant at 24hour while at 48hours it was not significant.

DISCUSSION

Inter appointment pain was and remains one of the most common problems in endodontic treatment procedure although these in most cases do not last long, but could be a source of embarrassment to the dentist and annoying for the patient. Some studies investigating inter appointment pain have reported an incidence of moderate to severe pain in the range of 15% to 25% ^7-9. Studies also have reported frequencies of inter appointment emergencies ranging from 1.4% to 16% ¹. While in our study discomfort to mild inter appointment pain noted from 35%to 46.7%. In this study the frequency of inter appointment pain has been assessed by visual analogue pain scale to compare crown-down and stepback techniques¹⁰. Knowledge on the etiological factors and the mechanisms behind inter appointment pain is very importance for the practitioner to properly prevent or manage this undesirable condition. One of this etiological factor is the preparation techniques and their effect on the amount of the debris being extruded through the apical foramina which plays very important role in the frequency of inter and post operative pain. In this study we have found that after the preparation with crown-down and step-back techniques, the rate of inter appointment pain was high in group B (step-back) than group A (crown-down) but it is not statistically significant. Although the rate of the inter appointment pain was high after using step-back technique and that could be due to the amount of the debris pushed beyond the apex or the technique was not able to produce 100% environment free of microorganism it was not enough to bring the result to the significant level. In comparative study between both technique by the quantitative assessment of canal debris forced periapically   instrumentation Ruiz-Hubard EE,et al¹¹ concluded that step-back technique reported to produce more debris apically than crowndown. Ferraz CC, et al¹² also have found in their study that apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques were more in step-back as it compare with crown-down technique.

Reddy S, Hicks L¹³ also they have concluded in their study that crown-down extruded less debris after comparing the debris extruded from the apical constriction using two hand and two rotary instrumentation techniques.

It is well understood that the pain has direct relation with status of the pulp pre operatively and the sign/symptoms. In   our study the criteria we have taken were included only Non vital cases and we have found that the inter appointment pain was presented in 35% of the cases within the first 24 hrs and 40 % within 48 hrs but in both it was not significant  and the intensity of the pain was noticed to vary from degree of discomfort to mild  pain and that does not require any analgesic, it was also observed  that the pain disappeared slowly and gradually by the end of the root canal procedure.Walton& Fouad et al¹⁴ have found that the frequency of flare-ups or interappointment pain in necrotic pulp cases were significantly high as compare with to vital cases. Naidoff also has discuss briefly how necrotic pulp plays role in the development of antibodies-antigens reaction which lead to cascade of complement system and inflammatory reaction resulting in flare-up or inter appointment pain¹⁵. So many studies have founded that the incidence of flare-up is more with non vital pulp as it compare with vital.

As the age of the patients is concern in this study we have found that there is no relation between the age of the patients and the inter appointment pain which means that there was no statistically significant differences observed in different age groups in this study. Eleazer PD, Eleazer KR and Matusow also concluded that there is no significant relationships for inter appointment flareups with age³. Several studies also have failed to find any relation between ages and inter appointment pain Walton R, and Fouad A¹⁴. In their study have found no relation between flare-up and age of the patients   Imura N and Zolo M¹⁶ have  also concluded the same result. Toosy¹⁷ who treated necrotic teeth and found no difference in flare-ups rate of age groups except in those patients who were above 50 year. Kane ¹⁸ has found no relationship between post obturation pain and age. The reason could be due to a coronal transportation of the radiographic apex because of secondary cementum deposition with advancing age. This would result in an error of working length determination which could lead to extrusion of debris and inter or post preparation pain. After all in the current study and the above discussed studies we have concluded that there is no scientific evidence indicating that age is risk factor in the development of inter appointment pain.

As far as the relation of the pain to gender is concerned, In this study, we have found no relation between the gender and inter appointment pain which meant that there is no significant relation between gender and inter appointment pain and the reason may be due to the small sample size of patients being assessed  in our study. However several studies have shown significant relationship where larger sample size of patients were examined 4,19,20.

Morse et al²¹, Mulhern et al²², Albashaireh and Alnegrish 2 had similar results that we have found in our study but Fox et al²³ and Genet et al²⁰ concluded that the incidence of flare-up in females are more as compare to males.

Although it’s hard to believe that women suffer from psychomatic illness but physicians believe that their pain is directed by their emotional status²⁴. Also the biological differences between genders explain the high incidence of pain in female as it compare to male²⁵. The reasons maybe due to difference in pelvic and reproductive organs which may provide an additional portal of entry of infection in females leading to possible local and distant hyperalgesia²⁶. And the fluctuation in female hormonal levels, which may be associated with changing in the levels of serotonin and nor-adrenaline, causing increase in pain during the menstrual period^27,28. Our study has concluded that gender difference and females’ predominance in the frequency of inter appointment pain is more but it is not statistically significant. In this study the frequency of inter appointment pain is more in the mandibular as it compare to maxillary teeth. In mandibular teeth pain was significant at 24 hour while at 48 hours it was not significant.

Kane¹⁸ found no correlation of post obturation pain with tooth type and that totally opposite to the result that we have concluded which similar to the result of Walton14, Toosy¹⁷, Fox²³, Mollar²⁹ and Barnett³⁰ There is possible explanations    for more pain in mandibular teeth as it compare to the maxillary teeth and that is the cortical thicker plate of the mandible which may cause accumulation of exudates, causes more pressure as compared to maxilla.

CONCLUSION

The result of this study shows no significant difference in inter-appointment pain between crown-down preparation technique and step-back technique.

LEGENDS

Table I: comparison of inter appointment pain at 24 & 48 hrs between groups.

Table II: comparison of inter appointment pain between groups at 24 hours after controlling gender, age and location of teeth.

Table III: comparison of inter appointment pain between groups at 48 hours after controlling gender, age and location of teeth.

REFERENCES

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2. Albashaireh ZS, Alnegrish AS. Post obturation pain after single- and multiple-visit endodontic therapy. A prospective study. J Dent 1998; 26:227-232.
3. Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod 1998; 24:614-616.
4. Trope M. Relation of intra-canal medicaments to endodontic flare-ups. Endod dent tarumatol 1990;6:226-229
5. Abott PV. Medicaments: aids to success in endodontics part 1. A review of literature. Aust Dent J 1990;35:438-448.
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1. Operative Dentistry, Senior Registrar, Operative Dentistry Department, Isra Dental Collage, Isra University
2. Operative Dentistry, Assistant Professor, Oral Biology Dept Ziauddin College of Dentistry, Pakistan
3. Dental Public Health, Senior Lecturer Community and Preventive Dentistry Ziauddin College of Dentistry, Pakistan.
4. Assistant Professor, Operative dentistry dept, Isra Dental College, Isra University. 5. Dental Public Health, Assistant Professor Dept of Community and Preventive Dentistry Ziauddin College of Dentistry, Pakistan

Corresponding author: “Dr Mustafa Naseem ” < mustafanasim@hotmail.com >