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Vol. 25 No. 01 Jan-Mar 2016 Archives - JPDA

Amlodipine-Associated Gingival Hyperplasia: A Case Report and Review of Literature



Amara Butt1                     BDS
Kanwal Sohail2                BDS, M.Phil
Amber Kiyani3                 BDS, MS, FAAOMP, Dip-ABOMP



Gingival overgrowth can be adverse reaction of calcium channel blockers. Although nifedipine is commonly associated with
this process, some case reports have also implicated amlodipine as a possible etiology. Here we present a case of a 59-yearold Pakistani female who developed gingival hyperplasia secondary to amlodipine use. We believe that the knowledge about
amlodipine-associated gingival hyperplasia is necessary for dentists, so they can accurately diagnose this condition and provide
appropriate management.
KEYWORDS: Drug-induced gingival overgrowth (DIGO), gingival hyperplasia, amlodipine
HOW TO CITE: Butt A, Sohail K, Kiyani A. Amlodipine-associated gingival hyperplasia: A case report and review of literature.
J Pak Dent Assoc 2022;31(1):55-58.
Received: 10 February 2021, Accepted: 23 August 2021

Gingival overgrowth is hereditary or acquired enlargement of attached gingiva.1 It results from increased proliferative activity of fibroblasts that cause accumulation of extracellular matrix and collagen in gingival connective tissue. While hereditary gingival hyperplasia may be seen in association with multiple syndromes and conditions, acquired is attributed to chronic trauma, granulomatous diseases, nutritional deficiencies, endocrine problems, neoplastic diseases and medications.2 There are several medications that have been implicated as a direct cause of gingival overgrowth. The common ones include anticonvulsants, cyclosporin, antibiotics, oral contraceptives and calcium channel blockers.1
Calcium channel blockers are a class of antihypertensives.
Although little is known about the exact mechanism by which they cause gingival overgrowth, there are a couple of
explanations available in the literature. The first explanation claims that calcium channel blockers decrease folic acid
uptake by cells, thus retarding aldosterone synthesis and increasing adrenocorticotropic hormone activity. This interferes with collagenase synthesis leading to build up of collagen in gingival tissues. The second theory claims that build of drug concentration in the gingival crevicular fluid causes inflammation in the gingival tissues. The release of
inflammatory cytokines in the gingiva leads to excessive collagen deposition.3
The most calcium channel block linked to gingival hyperplasia is nifedipine.4,5 Since amlodipine has an identical mechanism of action to nifedipine, it is commonly used as a replacement drug to nifedipine when adverse effects like
tachycardia, facial flushing and gingival overgrowth arise. However, the literature now documents a correlation between gingival overgrowth and amlodipine.6-8
Here we present a case of a 59-year-old Pakistani female who developed medication-related gingival overgrowth. Our patient was taking amlodipine among other antihypertensives. Since amlodipine is commonly prescribed antihypertensive medication, our case is a good reminder for dentists to consider amlodipine as a potential cause for gingival hyperplasia.

A 59-year-old female was seen in the Oral Medicine clinics at Riphah International University with a complaint
of bleeding gums, halitosis and gingival enlargement for over one month. Her medical history was positive for unstable hypertension and a prior episode of myocardial infarction. She was currently taking telmisartan 80mg, metoprolol 100mg, aspirin 75mg, amlodipine 5mg, valsartan 50 mg, atorvastatin 10mg and alprazolam 0.5mg. She has been on this medication for almost 3 years.
On clinical examination gingival hyperplasia was identified. While the attached gingiva of both jaws was involved, it was more pronounced in the anterior region (Figure 1). The most affected area was mandibular lingual region. The hyperplasia was accompanied by heavy calculus deposits, periodontal pocketing and bleeding on probing. There was intrinsic staining noted on the anterior maxillary teeth.
We discussed the condition with the patient and explained potential causes of gingival hyperplasia. Following exclusion of other causes of gingival enlargement, a diagnosis of medication-associated gingival overgrowth was made. The patient was referred to the Periodontology department for oral hygiene prophylaxis (scaling and polishing of teeth). We also wrote a letter to patient’s physician recommending discontinuation of amlodipine.
Following the plaque and calculus removal, the patient was prescribed chlorhexidine rinse and antibiotics for week. She then saw her physician who updated her medications but persisted with use of both amlodipine and
metoprolol. The cardiologist did modify the treatment plan after numerous attempts from us to get in touch with him.
On follow up the patient no longer had complaints of halitosis and gingival bleeding. However, some degree of gingival hyperplasia still persisted (Figure 2). Our patient was offered gingivectomy to get rid of the extra tissue, but she refused. She remains on follow up and gets her calculus and plaque deposits removed through instrumentation regularly.

An increasing number of drugs are involved in causing gingival hyperplasia. The common drugs involved in causing
this are calcium channel blockers, anticonvulsants, immunosuppressants and -blockers. Since our patient was
using a medicine implicated in gingival overgrowth; amlodipine, drug-associated gingival overgrowth remained
the only option in our differential diagnosis. Drug-induced gingival overgrowth shows a female predilection, women
between the ages of 45 to 60-years are mostly affected.7,9 Our patient was also female between the favored age group.
Amlodipine is classified as a dihydropyridine in the category of calcium channel blockers. FDA has approved
amlodipine for managing hypertension and coronary artery diseases. It reduces hypertension by blocking the voltage
gated L-Type channels. This prevents activation and phosphorylation of myosin, contraction of vascular smooth muscle, and increase in blood pressure. The same mechanism of action also prevents the precipitation of angina.10
Like all medications, amlodipine is associated with some adverse effects. These include pulmonary and peripheral edema, heart failure, dizziness, headaches, nausea and abdominal pain. In the head and neck region, amlodipine is
associated with gingival overgrowth, taste alterations (dysgeusia), total loss of taste sensations (ageusia) and smell
disturbances (dysosmia).11 The mechanism of gingival overgrowth is a consequence of changes in size of cell, division of cells, increased matrix production, angiogenesis in gingiva and altered phenotype of fibroblasts. This coupled with reduced metalloproteinase production causes enlargement of gingival tissues.12 The enlargement of the gingiva can sometimes become more likely if other medications like metoprolol, a common -blocker, is being used. A study has shown that over 25% of patients using both amlodipine and metoprolol were more
likely to develop gingival overgrowth.13 Our patient was using both medications at the time of presentation.
Amlodipine-associated gingival hyperplasia presents as generalized painless swelling of the gingiva. Prominent
involvement of interdental papillae initiating soon after drug consumption is usually seen.14 The hyperplasia can range from localized bead-like enlargements of interdental papillae to pronounced gingival overgrowth. Both arches are commonly involved. The anterior gingiva is more prominently involved.15 The overgrowth is firm to hard on palpation. Loss of scalloped margins, gingival bleeding and erythema due to inflammation may also occur. Bleeding on probing may be a rare finding. Mobility and eventual loss of teeth is noted in chronic cases. Since only dentate areas demonstrate gingival hyperplasia, loss of teeth often results in resolution of overgrowth. Patients see dentists due to esthetic or functional concerns.15,16 While most of these features were noted in our patient, there was also a complaint of halitosis.
Diagnosis of drug induced gingival enlargement made based on thorough dental and medical histories, clinical presentation and histology, where appropriate. Evaluation and complete record of location, nature and extent of involvement, probing depth, presence of plaque or calculus needs to be made. Other causes of gingival overgrowth like chronic trauma, granulomatous diseases, nutritional deficiencies, endocrine problems, and neoplastic diseases
need to be ruled out.2 Common serology investigations including complete blood picture, glucose tolerance test and
renal function tests can rule out leukemia, infection, diabetes and renal failure. Pregnancy tests may be needed for women in child-bearing age. Histopathology of the enlarged tissues shows proliferation of fibroblasts and collagen. The collagen is often thick and ropy in appearance and streaming vertically. The surface oral epithelium may exhibit hyperkeratosis, acanthosis and elongated rete-ridges. Sprinkling of chronic inflammatory cells may be seen.17 Absence of multinucleated giant cells or neoplastic cells also helps in establishing definitive diagnosis.2
Management of drug-associated gingival overgrowth requires discontinuation of the offending agent and surgical
excision of excess tissue. Recurrence is a frequent problem, especially in cases when the medication cannot be stopped.18 Non-surgical intervention includes scaling and root planning along with irrigation of all subgingival pockets with 1% chlorhexidine. This gets rid of harmful organisms and prevent secondary inflammation. Oral hygiene instructions are strongly recommended.19 It was difficult for us to proceed with management due to reluctance of the cardiologist in switching medications. It took us several phone calls and 2 letters before the medications were discontinued. Our patient refused any invasive procedures, she chose to undergo scaling and polishing was given a chlorhexidine mouthwash. We believe that this is the reason why her hyperplastic tissue persisted on the 3 months follow up.
In conclusion, we discuss a case of gingival overgrowth associated with a common antihypertensive medication;
amlodipine. We believe that this knowledge is necessary for dentists so they can correctly identify medication-associated gingival hyperplasia and appropriately manage this condition by coordinating with the patient’s physician.

None declared

1. Tungare S, Paranjpe AG. Drug Induced Gingival Overgrowth (DIGO). StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020.

2. Agrawal AA. Gingival enlargements: Differential diagnosis and review of literature. World J Clin Cases. 2015;3:779-88.

3. Brown RS, Arany PR. Mechanism of drug-induced gingival overgrowth revisited: a unifying hypothesis. Oral Dis. 2015;21:e51- 61.

4. Madi M, Shetty SR, Babu SG, Achalli S. Amlodipine-induced Gingival Hyperplasia – A Case Report and Review. West Indian Med J. 2015;64:279-82.

5. Mohan RP, Rastogi K, Bhushan R, Verma S. Phenytoin-induced gingival enlargement: a dental awakening for patients with epilepsy. BMJ Case Rep. 2013;2013.

6. Sharma S, Sharma A. Amlodipine-induced gingival enlargement– a clinical report. Compend Contin Educ Dent. 2012;33:e78-82.

7. Tomar LR, Aggarwal A. Missing diagnosis: gingival hypertrophy due to amlodipine. Indian Heart
J. 2015;67:491-2.

8. Carty O, Walsh E, Abdelsalem A, MaCarthy D. Case report: druginduced gingival overgrowth associated with the use of a calcium channel blocker (amlodipine). J Ir Dent Assoc. 2015;61:248-51.

9. Krishnamoorthy KM, Nair K. Gingival overgrowth due to amlodipine.Indian Heart J. 2016;68:431.

10. PubChem. PubChem Compound Summary for CID 2162, Amlodipine. Bethesda (MD): National Library of Medicine (US), National Center for Biotechnology Information; 2004

11. Schiffman SS. Influence of medications on taste and smell. World Journal of Otorhinolaryngology – Head and Neck Surgery. 2018;4:84- 91.

12. Brown R, Arany P. Mechanism of Drug-Induced Gingival Overgrowth Revisited: A Unifying Hypothesis. Oral diseases. 2014;21.

13. Gopal S, Joseph R, Santhosh VC, Kumar VV, Joseph S, Shete AR. Prevalence of gingival overgrowth induced by antihypertensive drugs: A hospital-based study. J Indian Soc Periodontol. 2015;19:308-11.

14. Livada R, Shiloah J. Calcium channel blocker-induced gingival enlargement. J Hum Hypertens. 2014;28:10-4.

15. Lafzi A, Farahani RM, Shoja MA. Amlodipine-induced gingival hyperplasia. Med Oral Patol Oral Cir Bucal. 2006;11:E480-2.

16. Joshi S, Bansal S. A rare case report of amlodipine-induced gingival enlargement and review of its pathogenesis. Case Rep Dent. 2013;2013:138248.

17. Akca A, Ortakoglu K, Pikdöken L, Deveci S. Histopathological Evaluation of Five Unusual Gingival Enlargement Cases. Military medicine. 2005;170:986-90.

18. Zoheir N, Hughes FJ. The Management of Drug-Influenced Gingival Enlargement. Prim Dent J. 2020;8:34-9.

19. Pundir AJ, Pundir S, Yeltiwar RK, Farista S, Gopinath V, Srinivas TS. Treatment of drug-induced gingival overgrowth by full-mouth disinfection: A non-surgical approach. J Indian Soc Periodontol. 2014;18:311-5.

Xerostomia Diagnosis – A Narrative Review



Ayesha Khalid1            BDS
Savaiz Elahi2                BDS
Arsha Qurban3             BDS
Saira Atif 4                    BDS, BSc, M.Phil



Xerostomia can be defined as a feeling of dryness of mouth, which may or may not be accompanied with reduced salivary
secretions. Xerostomia may result in localized and systemic disturbances within the body. The overall global prevalence of
xerostomia is 22% with wide variation among different countries due to difference in target population. This review presents
the recent literature on the diagnostic methodologies that are present in recent times through subjective and objective corridors.
The most commonly used subjective methods for the xerostomia diagnosis include: Fox questionnaire, Visual Analogue Scale
(VAS), Xerostomia Inventory (XI), and Shortened Xerostomia Inventory (SXI). Objective xerostomia diagnostic tools include
salivary flow rate assessment. Aside from this, there are numerous radiographical modalities that can be used especially in
diagnosing salivary gland disorders or radiation exposure due to oncological treatments which can also provide the added
information to diagnose or monitor xerostomia. These radiographic tools include computer tomography (CT), scintigraphy,
sialography, magnetic resonance imaging (MRI), and ultrasonography. Different combination of tools gives a better xerostomia
assessment, selection of which also depends on the age and health condition of the patient.
KEYWORDS: flow rate; hyposalivation; diagnosis; oral dryness; salivary gland dysfunction
HOW TO CITE: Khalid A, Elahi S, Qurban A, Atif S. Xerostomia diagnosis - A narrative review. J Pak Dent Assoc 2022;31(1):
Received: 30 April 2021, Accepted: 16 November 2021

Whole saliva is a vital oral fluid that helps in preservation of healthy oral tissues. 1 Disturbances in the salivary flow rate may affect oral health, which can directly impact the quality of life of the individual.2 Less saliva in oral cavity may lead to caries, frequent oral ulcers and blisters, oral malodor, periodontal problems, difficulties in swallowing and speech. One such consequence is xerostomia. Xerostomia is defined as feeling of mouth dryness3 which may or may not be accompanied with hyposalivation. Hence, may be classified as subjective and objective xerostomia. Xerostomia from objective hyposalivation has been termed as true xerostomia, whereas subjective oral dryness despite normal salivaryn  function has been referred as pseudo xerostomia.3 Additionally, the terms “xerostomia” and “salivary gland hypofunction” have been used for the same phenomenon but in reality are separate entities.4
This solidifies the pseudo element of the condition because not all patients exhibit a pathological salivary gland dysfunction.3 Owing to its subjective trait, xerostomia poses difficulty in better understanding of its nature. The overall global prevalence of xerostomia is 22% with wide variation among different countries due to difference in target population.5 In developed countries such as Australia, xerostomia prevalence is reported to be 13%6 , whereas, in Iran, the prevalence is about 8%.7 In Pakistan, limited studies have been reported on prevalence
of xerostomia in general population. In a study conducted on Pakistani army soldiers with hepatitis C, the reported
prevalence was 70%.8 Xerostomia predisposition in females and especially among the geriatrics is well reported.7
An array of systemic diseases can be affiliated with hyposalivation. Autoimmune diseases encompassing: Sjogren syndrome, Systemic lupus erythematosus (SLE), AIDS, Parkinson’s disease, rheumatoid arthritis, and hepatitis
C virus (HCV) infection play a significant part in altering salivary glands functions.3 Moreover, hormonal, psychogenic, and neurologic diseases such as anxiety, depression, schizophrenia, bipolar disorders, also have abrief or irretrievable impact on the salivary flow rate of the
patients.9 Xerogenic drugs or chemicals such as tricyclic antidepressants, antihistamines, diuretics, antihypertensive drugs, decongestants etc. also have a potential of lowering salivary flow or causing dry mouth in individuals.3
Furthermore, hyposalivation is one of the most commonly reported and detrimental side effect occurring in 95% of
the patients that undergo radiotherapy in the region of the head and neck.10
Xerostomia can cause dental caries, frequent fungal and bacterial infections, oral ulcerations and halitosis1 , taste disturbances, difficulty in eating, swallowing and speaking9 , atrophic mucosa11, burning mouth, and difficulty in retention of dentures.3 All of which may result in malnutrition.12 Wide ranges of clinical features present a serious impediment in its diagnosis and treatment. To date no standard diagnostic protocol is present for xerostomia.13

Subjective diagnosis of xerostomia
Comprehensive history taking plays an important role in the diagnosis of a disease even before performing any
physical examinations and tests.14 Evaluation and diagnosis of xerostomia requires detailed questioning about past medical history, practice of polypharmacy, altered taste, and difficulty in any of these: eating, swallowing, chewing,
and wearing dentures.3 Multiple questionnaires are framed to identify and assess the rate of xerostomia. As xerostomia needs to be understood from patient’s perspective, a patientreported outcome measure (PROM) is essential to evaluate xerostomia.

1. Fox’s questionnaire Fox questionnaire was first introduced in 1987 and  comprises 9 items pertaining to experience of oral dryness. Four of the items in the questionnaire indicates a direct correspondence to reduced salivary flow and if the patients respond positively to any one of these four questions, they are identified as xerostomic patients.15 The purpose of this questionnaire is to identify presence of reduced saliva secretion, difficulty during swallowing, and the necessity to take sips of water with dry food.16 For patients who are
non-compliant in terms of saliva collection for salivary flow rate assessment, this questionnaire plays a vital role in the evaluation of the symptoms;16 however, questionnaire results might not draw a parallel with the salivary flow rate effectively,17 as xerostomia may exist in the absence of hyposalivation and vice versa.18

2. Xerostomia Inventory (XI)
The Xerostomia Inventory (XI) is one of the extensively used and validated PROM, introduced by Thomson et al.
in 199919. This consists of 11-items which are to be answered and then graded from 1 to 5: 1 being ‘never’ while 5 being ‘very often’. The score ranges from 11 to 55, a higher score represents poor quality of life.20 XI was introduced to better understand and record the severity of xerostomia in individuals.19 XI covers two separate aspects one being the experience of xerostomia felt by individuals and second one involving the consequences of the disease.19

3. Shortened Xerostomia Inventory (SXI)
For greater convenience a shortened 5-item PROM, SXI was endorsed in 2011 by Thomson et al.18 The need to
shorten the XI was essential as some of the questions appeared to be redundant and unnecessary i.e. those
associated to facial skin, nose and eyes.21 In SXI, 5 of the 11 items used are answered by choosing one of the three
response option: 1 ‘never’, 2 ‘occasionally’, and 3 ‘often’.  XI focuses on recording the experiences felt by individuals having a dry mouth while the behavioral consequences of oral dryness are not included in the questionnaire.18 SXI is
a valid and reliable instrument for assessment of xerostomia and has been widely used in epidemiological and clinical studies in conjunction with objective assessment of xerostomia.21 The use of SXI is popular in many parts of
the world and is validated in Dutch, Portuguese, English, Chinese and Japanese.22

4. Quality of Life Questionnaire Head and Neck
The European Organization for Research and Treatment of Cancer has approved a valuable questionnaire specifically related to head and neck cancers/radiation therapy; Quality of Life Questionnaire Head and Neck (QLQ-H&N35). Related to xerostomia, this questionnaire has 4-item scales for assessing swallowing and single-item scales for presence of dryness of mouth and sticky/thick saliva. Scores may range from zero to 100.23 This questionnaire serves as a valuable instrument for the assessment of quality of life of head and neck cancer patients before, during, and after radiation therapy.24

5. Visual Analogue Scale (VAS)
VAS was introduced as a reliable tool for clinical diagnosis of xerostomia and comprised of 8-items. This
scale involves examination for two key aspects for salivary production: (i) Dryness of oral mucosa and (ii) functional
incompetence due to dryness; and two universal components regarding the mouth dryness. Results have shown that VAS can be used in monitoring changes or improvements in salivary flow rate and can be effectively used as a  continuous evaluation instrument for patients suffering from salivary gland dysfunctions. Nearly all the components of VAS have proven to be reliable; however, when compared with objective salivary flow rate of normal individuals, they show poor to moderate validity.25

Objective diagnosis of xerostomia
The unstimulated salivary flow rate ranges from 0.3- 0.5 ml/min and flow rate below 0.1 ml/min is considered
hyposalivation26 indicating a functional loss of salivary glands.27 When the salivary flow rate is less than the fluid
absorption and evaporation rate in the oral cavity, it is referred to as objective hyposalivation.28 Objective salivary
flow rate is best measured by collecting saliva from the three major salivary glands namely: Parotid, submandibular,
and sublingual salivary glands. Different tools and techniques  are used in practice for accurate collection of saliva from individual glands: Carlson-Crittenden collector or modified Lashley cup is used for collecting glandular saliva from the Stensen’s duct of the parotid gland, and Wolff collector is used for collecting saliva from the ducts of submandibular and sublingual glands.29 The term resting or unstimulated saliva is used when any stimulus either external or pharmacological are not used for the collection of saliva. Methods such as spitting and passive drooling are commonly used for the collection of unstimulated saliva. When a stimulus, in the form of a mechanical or gustatory such as chewing gum or citrus, are used for saliva acceleration and collection, it is termed as stimulated saliva.30 Rate for both the stimulated and unstimulated saliva can be assessed; pH value of the saliva is lower in the unstimulated than in the stimulated saliva.31 Significant differences are observed for both stimulated and unstimulated salivary flow rates during the day time and evening.32

Radiographically diagnosing xerostomia
Radiographic methods can also be of aid when it comes  to diagnosing xerostomia i.e. sialography, scintigraphy,
ultrasound (US), MRI, CT, and (18) F-FDG positron emission tomography (PET);33 which may be useful in
situations in which salivary glands function are affected by some underlying disease or radiation therapy.

1. Sialography
Sialography is considered as a valuable and reliable exam, centred on cannulation of main salivary ducts and
injecting an iodinated contrast medium, which henceforth allows radiographic imaging of the entire anatomy of the
main salivary glands. The shortcoming of this method is its invasiveness and exposure to the radiation.34 It detects changes in the course of salivary gland ducts and thus is helpful in diagnosing patients with a chief complaint of
mouth dryness.35 Sialography is a non-aggressive procedure and can be a painless method if handled accurately;36
however, breach in ductal arrangement, hostile reactions to contrast agent, and instigation of some clinically dormant infections might pose as a complication.33 Sialography serves as an effective diagnostic tool to check for the severity of xerostomia.37

2. Ultrasonography
Recently, sialography has been replaced by highresolution ultrasound for the detection of salivary stones, also known as sialolithiasis.33 Ultrasound is widely gaining acceptance as a diagnostic tool for the evaluation of salivary
glands in diseases such as xerostomia. Some of the advantages of this technique are that it is a noninvasive
procedure, cost-effective, and safe without exposure to ionizing radiation.38 Ultrasound is a simple and reliable method, but has its limitations when exploring mild parenchymal variations, and can only detect obvious variations.39 Moreover, American-European Consensus Group (AECG) guidelines have declined to include ultrasound as an accepted imaging modality in the diagnosis of xerostomia associated with Sjögrens syndrome.40 For this imaging technique to come under authentication, it still needs further multicentric studies.38

3. Scintigraphy
Scintigraphy is one of the most frequently used methods for the evaluation of salivary gland function in various
diseases: Sjögren’s syndrome, xerostomia, and radiation therapy for head and neck cancers.41 This technique not only aids in the interpretation of both salivary accumulation and release but is also used for the quantitative analysis.42 99m Technetium pertechnetate are radionuclides that are intravenously injected and are taken up by the salivary glands and eventually secreted. Extent of functional acinar tissue depends on the degree of uptake and secretion into the oral cavity.43 Scintigraphy is a reliable and an effective method to study the progression and severity of xerostomia and salivary gland functions.44 Scintigraphy results are based on Schall’s classification,
which is widely considered the standard method of evaluation, showing salivary gland function that is
categorized into four grades corresponding to the uptake and activity of the gland after injecting the radionuclide (Grade 1 being normal and grade 4 showing a total lack of function or uptake).45 A drawback of this technique is
chances of any errors due to the misinterpretation by the evaluator as it is an observer dependent process.46

4. MRI
MRI detects any salivary gland anomaly due to its
ability to visualize and detect water-containing structures.43
These masses result in the obstruction of salivary flow. MRI
reveals the minor details of the anatomy of glands, which
aids in
better understanding of xerostomia diagnosis.47

5. [18F] fluorodeoxyglucose-labelled positron emission
tomography-CT (FDG-PET-CT) biomarkers
FDG-PET-CT imaging delivers efficient evidence about
the metabolic activity of tissue especially in head and neck
cancer patients. Xerostomia caused by radiation exposure
is a subsequent side effect of head and neck cancer which
can best be diagnosed using PET biomarkers.48
11C-methionine PET-CT unveils the metabolic clearance
of 11C-methionine whenever there is an augmented amount
of radiation dose; hence, this serves as an important
biomarker that correlates with salivary flow rate.49

There are numerous methods used to identify and
monitor xerostomia, largely depending on the underlying
medical condition. These methods may be used alone or in
combination, such as using both subjective and objective
tools, which may help the clinician to approach xerostomia
holistically. Different combination of tools gives a better
xerostomia assessment, selection of which also depends on
the age and health condition of the patient.

None declared

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2. Jeganathan S, Carey H, Purnomo J. Impact of xerostomia on oral health and quality of life among adults infected with HIV-1. Spec Care Dentist. 2012;32(4):130-5.

3. Millsop JW, Wang EA, Fazel N. Etiology, evaluation, and management of xerostomia. Clin Dermatol. 2017;35:468-76.

4. Ying Joanna ND, Thomson WM. Dry mouth – An overview. Singapore Dent J. 2015;36:12-7.

5. Agostini BA, Cericato GO, Silveira ERd, Nascimento GG, Costa FdS, Thomson WM, et al. How common is dry mouth? Systematic review and meta-regression analysis of prevalence estimates. Braz Dent J. 2018;29:606-18.

6. Jamieson LM, Thomson WM. Xerostomia: Its prevalence and associations in the adult australian population. Aust Dent J. 2020;65(S1):S67-S70.

7. Ghapanchi J, Rezazadeh F, Fakhraee E, Zamani A. Prevalence of xerostomia in patients referred to Shiraz dental school, Shiraz, Iran during 2006-2013. Iran J Public Health. 2016;45:1665-6.

8. Azhar J. Clinical evaluation of xerostomia in patients infected with chronic hepatitis c virus. PODJ. 2018;34.

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10. Chambers MS, Rosenthal DI, Weber RS. Radiation-induced xerostomia. Head & neck. 2007;29:58-63.

11. Shirzaiy M, Bagheri F. Prevalence of xerostomia and its related factors in patients referred to zahedan dental school in iran. Dent Exp Clin J. 2016;2.

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18. Thomson WM, van der Putten GJ, de Baat C, Ikebe K, Matsuda K, Enoki K, et al. Shortening the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:322-7.


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22. Thomson WM. Subjective aspects of dry mouth. In: Carpenter G, editor. Dry mouth: A clinical guide on causes, effects and treatments. Berlin, Heidelberg: Springer Berlin Heidelberg; 2015. p. 103-15.

23. Hohenberger R, Baumann I, Plinkert PK, Brinster R, Krisam J,nAffolter A, et al. Validating the Xerostomia Inventory in a radiationinduced xerostomia population in German language. Oral Dis. 2019;25:1744-50.

24. Bjordal K, Hammerlid E, Ahlner-Elmqvist M, Graeff A, Boysen M, Evensen J, et al. Quality of life in head and neck cancer patients:nValidation of the european organization for research and treatmentnof cancer quality of life questionnaire-H&N35. J Clin Oncol. 1999;17:1008-19.

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29. Navazesh M, Kumar SKS. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc. 2008;139:35S-40S.

30. Muddugangadhar BC, Sangur R, Rudraprasad IV, Nandeeshwar DB, Kumar BHD. A clinical study to compare between resting and stimulated whole salivary flow rate and pH before and after complete denture placement in different age groups. J Indian Prosthodont Soc. 2015;15:356-66.

31. Forcella L, Filippi C, Waltimo T, Filippi A. Measurement of unstimulated salivary flow rate in healthy children aged 6 to 15 years. Swiss Dent J. 2018;128:962-7.

32. Kawanishi N, Hoshi N, Masahiro S, Enomoto A, Ota S, Kaneko M, et al. Effects of inter-day and intra-day variation on salivary metabolomic profiles. Clin Chim Acta. 2019;489:41-8.

33. Afzelius P, Nielsen MY, Ewertsen C, Bloch KP. Imaging of the major salivary glands. Clin Physiol Funct Imaging. 2016;36:1-10.

34. Zablotskyy O, Tomczyk M, Blochowiak K. Current recommendations for treatment and diagnosing of xerostomia in sjögren’s syndrome. Eur J Clin Exp Med. 2020;17:356-63.

35. Tanaka T, Ono K, Ansai T, Yoshioka I, Habu M, Tomoyose tT, et al. Dynamic magnetic resonance sialography for patients with xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:115-23.

36. Hasson O. Modern sialography for screening of salivary gland obstruction. J Oral Maxillofac Surg. 2010;68:276-80.

37. Wada A, Uchida N, Yokokawa M, Yoshizako T, Kitagaki H. Radiation-induced xerostomia: Objective evaluation of salivary gland injury using mr sialography. Am J Neuroradiol. 2009;30:53-8.

38. Martire MV, Santiago ML, Cazenave T, Gutierrez M. Latest advances in ultrasound assessment of salivary glands in sjögren syndrome. J Clin Rheumatol. 2018;24:218-23.

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Self Medication among Dental Patients Visiting Tertiary Care Hospital, During COVID-19



Numrah Shakeel Malik1            BDS
Muhammad Umair2                   BDS, MCPS, ACMED
Iqraa Shakeel Malik3                 BDS, M.Phil



OBJECTIVE: The aim of this study was to evaluate trends in self-medication practices among dental patients during the period
of lockdown. Self-medication or using drugs without prescription of a doctor is a common practice round the world since a
long time. During lockdown due to COVID-19 pandemic all the dental facilities were either closed or were only offering
emergency-treatments, therefore lack of services led general population to the practice of self-medication. This should be taken
in account for the health and safety of patients.
METHODOLOGY: A quantitative cross-sectional study was conducted among the dental OPD patients visiting a tertiary care
hospital post COVID-19 lockdown, from 20th September,2020 to 5th December 2020. Sample size was 451 and study participants
were selected by convenient sampling technique.
RESULTS: A total of 389 out of 451 patients self-medicated (383 females and 68 males). Most common reason was tooth ache
(56.8%) followed by sensitivity of teeth (37.5%) and dental trauma (3.8%) was the least common reason. Hence, Pain relievers
(68.5%) were used by most of the patients followed by antibiotics (35.5%). Prevalence was higher in patients of low socioeconomic
status. Most of the patients thought self-medication practice to be acceptable.
CONCLUSION: It was distressing that Self-medication practices among dental patients showed a remarkable increase during
period of COVID-19 Pandemic as most of them had practiced self-medication, most commonly for relief from toothache. This
issue, being a sensitive one needs to be given required consideration.
KEYWORDS: Self-medication, COVID-19, pandemic, Dental OPD, Pain relievers, Tooth ache.
HOW TO CITE: Malik NS, Umair M, Malik IS. Self Medication among dental patients visiting tertiary care hospital, during
COVID-19. J Pak Dent Assoc 2022;31(1):43-48.
Received: 05 May 2021, Accepted: 02 November 2021

WHO defines self-medication as “the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms”.1 Consuming one or more drugs without prescription of the doctor either for treating their symptoms or self-diagnosis is termed as self-medication. Self-medication is a noteworthy concern globally, affecting both developed and developing countries especially economically.2 In current times, COVID-19 has been declared as a global public health emergency by World Health
Organization.3 Self-medication practices among dental patients, showed a remarkable increase during period of
COVID-19 Pandemic lockdown due to lack of services to general population by dental facilities, due to fear among
patients to visit hospitals where the risk of spread of virus is perceived to be high, travel restrictions, COVID SOPs of
physical distancing set up by the government of Pakistan in response to this pandemic and spread of misinformation
through social media.4,5,6 Changes among societies in rules regarding access to dental services for elective procedure are seen, as only emergency procedures are being done and many private clinics were shut down during lockdown. According to literature, pandemic is influencing self-medication behaviours among the patients7
and dangerous side effects and shortage of drugs for the people who actually need them are the consequence of such behaviors.8
Even death has been reported from different parts of the world among the people who had self-medicated with
medicines that shouldn’t have been taken without prescription of a physician.9 There has been increase in self-medication even among health care professionals during pandemic from 36.2% to 60.4% in Kenya.10 In Poland during the lockdown, 40% of respondents had taken prescription drugs without any medical consultation.7 In Nepal, 62.6% dental patients self-medicated and toothache was the most common reason (60.8%) for that. (11) In India,78.6% adolescents self-medicated in 2019 before pandemic.12
A variety of self-prescribed and Over-The-Counter (OTC) drugs, either alone or in combination with other drugs are being used for recreational purposes.13 According to study in Tanzania; 58% contributors admitted that they
self-medicated and more than 90% of them reported to go to the pharmacy for care when they fall sick instead of going to a physician.14 According to a research conducted in Islamabad and Rawalpindi commonly known as twin cities of Pakistan, 71.4% self-medicated, painkiller being the most common medication used.15
A wide range of researches on the use of drugs without prescription has been done in medical field and before the
COVID-19 lockdown but there is dearth of research on dental patients in the period of lockdown due to pandemic.
Rationale of this study is to find its prevalence, factors, sources and change in the patterns during the lock down period of COVID-19 among Dental patients, also the correlation between socioeconomic status, education and self-medication visiting a tertiary care hospital; Fauji Foundation Hospital Rawalpindi, Pakistan.

This cross-sectional study was conducted from 20th September,2020 to 5th December 2020 among patients
reporting to dental OPD of a tertiary care hospital of Rawalpindi post lock down. All the patients reporting in
dental OPD (Out Patients) of all ages were included regardless of their presenting complaint and co-morbidities. Ward patients (In patients) that came for dental consultation were excluded from this study. Prior to the commencement of the study, a written ethical approval under letter no: FF/FUMC/215-39/Phy/20 from the ethical society of Foundation University Medical College Islamabad and informed consent from patients participating in the study was obtained. The setting of this study was Dental OPD (Oral Medicine and diagnostic department) of Fauji Foundation Hospital, Rawalpindi, Pakistan.
Data collection was done via face-to-face interviews using self-structured questioner from patients visiting dental
OPD and consenting for the study. Self-structured questionnaire (Cronbach alpha 0.736) was used in this study.
The questionnaire was piloted on 49 participants who were excluded from the final study. Self-medication was explained in the beginning of questionnaire. Questionnaire was divided into three sections; first section containing six questions to gather data pertaining to demographic profile of respondents (mentioning names was optional to respect patient’s privacy). Second part containing sixteen questions about self-medication, it’s reasons and sources leading to selfmedication and third part comprised of three questions related to perception regarding self-medication.
Collected Data was entered and analyzed by using Statistical Package Programme for Social Science (SPSS)
version 21.0. Data was analysed and summarized using descriptive and inferential statistics, and later presented in
tables, percentages, graphs.

Out of 451 patients who participated in the study 185 were of age group 41-60. Among these patients, 86.5%
patients self-medicated. (Figure 1) There were 383 (84.9%) females, 68 (15.1%) males who responded to the questioner
Among the participants 40.1% patients had only primary education, 29.3 % patients had secondary education, 18%
patients had attended college, 9.5% patients were undergraduates and only 3.1% did postgraduation. Most of
the patients presenting in OPD belonged to middle socioeconomic status i.e., 47 %. Among these patients who
self-medicated during the period of lockdown females were more as compared to males. (Figure 2) Toothache (56.8%) being the most common reason, followed by sensitivity of teeth (37.5%), gum bleeding (22.2%), tooth mobility (11.3%), mouth ulcers (4.4%) and trauma (3.8%) being the least common reason. (Table 1) Most common medication used

during this period of lockdown without the prescription of any physician were Pain relievers (68.5%) then antibiotics
(35.5%), 18.6% didn’t even know what type of medication they are taking and few used steroids (6.5%). (Table 2) Tablets (67.4%) were the most common source of medication used by the participant’s, Medicated toothpastes were used by 36.4% patients, 35.5% took medication as capsules, 21.7% used gels and 18.8% used medicated mouthwash.
Many of the patient’s, around 68.5% said that their symptoms were relieved by medication, (Table 3) but a few (6%)
encountered adverse reactions from the medication they took and many (18%) were not sure if they encountered any
because of the medication they consumed. (Table 4) Most of the patients (74.7%) had a view that self-medication is
acceptable, only few (10%) think it as unacceptable. Some patients, around 15.3% patients even find it good.
(Figure 3) An inverse relation is seen between level of education and self-medication practices. Less educated people mostly with only primary schooling self-medicated the most. Similarly, socio economic status also has inverse relation with this malpractice. More self-medication is done by patients with lower income. (Table 5).

This study specifically conducted after lockdown of COVID-19 was lifted by Government of Pakistan to investigate the prevalence of self-medication, the leading factors, sources of self-medication, association of educational
and socioeconomic status of patients with self-medication and the perception of general public regarding self-medication. COVID-19 pandemic was declared to be a global health emergency as the disease spread exponentially around the globe.
Coronaviruses characterise a heterogeneous clusters of single-strand large RNA viruses that are widely scattered
among mammals and birds. Virus is grouped in a family of Coronaviridae. It spreads through direct or indirect contact.16 To avoid this spread governments all around the world implemented lockdowns and “stay at home” policies. Self-medication was being practiced before this pandemic as well but has increased remarkably from 71.4% according to a study conducted in similar settings in 2016 i.e before COVID-19 to 86.2% after COVID-19.15 Prevalence of selfmedication is considerably high in all parts of the world. During the lockdown in Poland 40% of respondents had taken prescription medications without any medical consultation.2 In a study conducted in Nepal 62.6% dental patients practiced self-medication.11 A similar prevalence of 82% among undergraduate students, who admitted that they had practiced self-medication in a private university in Nigeria was reported.17 A study conducted in India revealed 78.6 % adolescents practiced self-medication.12 According to study in Tanzania; 58% contributors acknowledged that they self-medicated and 90% or even more of them admitted that they visit a pharmacy for care if they feel sick rather than going to a doctor/physician.
The results of this study show that females practiced self-medication more as compared to the males which is
contrary to study conducted in 2016 at twin cities of Pakistan but similar to a study conducted in Brazil,17 Nigeria; where among females it was 88.2% and 70.5% in males11 and a meta-analysis conducted from world wide data also suggests the same.18 Use of unprescribed drugs is more common in
people with low socioeconomic status. Our results are agreeing with the statistics of a study conducted in Sindh,
Pakistan which states that the commonest reason behind self-medication remained economic reasons i.e.,88.0%.19 In a systemic analysis done 2017, the lowest numbers of prevalent cases of oral diseases were observed in highincome countries and the highest prevalence lower-middleincome countries.20 Hence, self-medication might follow the same trend as it can be a reason for self-medication. Similar findings of another review highlighted prevalence ranging from 81% to 93%, which is considerably high and its association with the gender of participants, education level and their incomes (monthly).21
Pain relievers were the most commonly used drugs among dental patients in this study; 68.5% followed by
antibiotics 35.5% similar to the results of a study in which analgesics being most common (58%), followed by antipyretics and antibiotics were reported among people.22 Around 1 in 16 older adults participating in an awareness survey in Arizona reported self-medication with nonprescribed antibiotics.23 Another community-based study held in Jordon shows 40.4% participants used an antibiotic without any prescription in the preceding month.24
In 1980s self-medication became popular when WHO (World Health Organization) permitted some prescription
medication to be sold without any physician’s prescription over the counter to reduce burden upon Health Care Workers. This step was taken for the ease and benefit of health care professionals but misuse of this has proven many unwanted effects; it can lead to many problems including wrong or late diagnosis of disease especially malignant or fatal diseases which get masked, addiction or dependance upon drugs, over/under dosage of drugs and the global rise of MultiDrug Resistant pathogens, these practices dearth clinical evaluation from a medical/dental professional hence causing enormous adverse effects.25
Results of present study show that the most common symptom for which a patient seeks medication is toothache
(56.8%) followed by sensitivity of teeth (37.5%) then gum bleeding (22.2%), tooth mobility (11.3%), mouth ulcers (4.4) and least commonly used as medication after trauma (3.8%) which is in agreement with a study in Malaysia showing majority of the participants (79.1%) experienced symptom of toothache during the past one month and 95.6% of the participants took pain relievers for it by themselves.26
This study result proves that the most common medication used during the period of lockdown were Pain relievers (68.5%) in form of tablets which is quite higher percentage than a study of Malaysia which reports around more than a quarter i.e.29.4% participants practiced self-medication with pain relievers or analgesics and also in agreement with study of Reema Dograa and Anjana Goyal conducted in India stating that patients commonly used medication are analgesic anti-inflammatory drugs( paracetamol, diclofenac, aspirin, naproxen and ibuprofen)27 Antibiotics (35.5%) used in capsule form by dental patients were lesser than pain relievers but not unremarkable and it has increased considerably from 10% calculated in a study of twin cities, Pakistan conducted before COVID-19 and the use of medicated toothpastes increased from 35.8% to 36.4%. It is still lesser than prevalence of self-medication of antibiotics (34%) among dental patients visiting University of Buenos Aires, Argentina,28 45% among the university students (non-medical) of Punjab, Pakistan, who used antibiotics without consulting doctor in the past six months29 and lesser than and 41.9% among patients with Respiratory symptoms presenting to a hospital in Cameroon, Africa.30 Surprisingly in this study, 18.6% didn’t even know what type of medication they are
taking and few used steroids (6.5%). According to results of this study, 18% patients were not sure that their drug
reactions or adverse effects were due to medication they used and only 6% noted the adverse effects by the drugs
they used, which is still higher than percentage of reactions due to self-medication in French hospitals (1.72%).31 Sadly, most of the patients (74.7% among 451 responders) thought self-medication is acceptable only few (10.%) agreed that it is unacceptable. Around 15.3% patients even find it as a good practice. This perception shows that this malpractice of self-medication needs urgent and firm actions by the policy makers and health care authorities.

1) The practice of self-medication is still not given enough consideration, especially in lower to middle income
countries like Pakistan.
2) Self-medication practices strongly existed among the dental patient during covid 19 and these practices have
shown a remarkable increase during the period of lockdown due to lack of services.
3) However, this generates the need to equip all the patients regarding the harmful effects of self-medication to stop such practices in society at large scale.

There must also be regulation and implementation of laws which limit the sale and purchase of prescription drugs
lacking a written validated prescription by a licensed dental practitioner. During such periods of pandemics an alternative method such as teleconsultations should be setup so that medications be prescribed by a professional health care worker. Furthermore, health care organizations should also execute public awareness programs for spreading awareness regarding self-medication and patient’s safety.

None to declare

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2. Noone J, Blanchette CM. The value of self-medication: summary of existing evidence. J Med Econ.

3. Ward MP, Li X, Tian K. Novel coronavirus 2019, an emerging public health emergency. Transbound Emerg Dis. 2020;67:469-70.

4. Blenkinsopp A, Bradley C. Over the Counter Drugs: Patients, society, and the increase in self medication. BMJ. 1996;312(7031):629- 32. 5. Malik M, Tahir MJ, Jabbar R, Ahmed A, Hussain R. Self-medication
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6. Erku DA, Belachew SA, Abrha S, Sinnollareddy M, Thomas J, Steadman KJ, et al. When fear and misinformation go viral: Pharmacists’ role in deterring medication misinformation during the ‘infodemic’ surrounding COVID-19. Res Social Adm Pharm. 2021;17:1954-63.

7. Makowska M, Boguszewki R, Nowakowski M, Podkowinska M. Self-Medication-Related Behaviors and Poland’s COVID-19 Lockdown. Int J Environ Res Public Health. 2020;17:8344.

8. Mallhi TH, Khan YH, Alotaibi NH, Alzarea AI, Alanazi AS, Qasim S, et al. Drug repurposing for COVID-19: a potential threat of selfmedication and controlling measures. Postgrad Med J. 2020:postgradmedj-2020-138447.

9. Alia E, Grant-Kels JM. Does hydroxychloroquine combat COVID19? A timeline of evidence. J Am Acad Dermatol. 2020;83:e33-e4.

10. Onchonga D, Omwoyo J, Nyamamba D. Assessing the prevalence of self-medication among healthcare workers before and during the 2019 SARS-CoV-2 (COVID-19) pandemic in Kenya. Saudi Pharm J. 2020;28:1149-54. 47

11. Bhattarai R, Khanal S, Shrestha S. Prevalence of Self-medication Practices for Oral Health Problems among Dental Patients in a dental college: A Descriptive Cross-sectional Study. JNMA J Nepal Med
Assoc. 2020;58(224):209-13.

12. Mathias EG, D’Souza A, Prabhu S. Self-Medication Practices among the Adolescent Population of South Karnataka, India. J Environ Public Health. 2020;2020:9021819-.

13. Chiappini S, Schifano F. What about “Pharming”? Issues Regarding the Misuse of Prescription and Over-the-Counter Drugs. Brain Sci. 2020;10:736.

14. Horumpende PG, Said SH, Mazuguni FS, Antony ML, Kumburu HH, Sonda TB, et al. Prevalence, determinants and knowledge of antibacterial self-medication: A cross sectional study in North-eastern
Tanzania. PLoS One. 2018;13:e0206623-e.

15. Durrani OK, Malik IS, Khan K, Zahoor S, Khurshid A, Mukhtar H, et al. self medication among dental patients visiting a tertiary care dental hospital. PODJ. 2016;36(4).

16. Galbadage T, Peterson BM, Gunasekera RS. Does COVID-19 Spread Through Droplets Alone? Public Health Front. 2020;8:163-.

17. Arrais PS, Fernandes ME, Pizzol TD, Ramos LR, Mengue SS, Luiza VL, et al. Prevalence of self-medication in Brazil and associated factors. Rev Saude Publica. 2016;50(suppl 2):13s.

18. Behzadifar M, Behzadifar M, Aryankhesal A, Ravaghi H, BaradaranHR, Sajadi HS, et al. Prevalence of self-medication in university students: systematic review and meta-analysis. East Mediterr Health J. 2020;26:846-57.

19. Bilal M, Haseeb A, Khan MH, Arshad MH, Ladak AA, Niazi SK, et al. Self-Medication with Antibiotics among People Dwelling in Rural Areas of Sindh. J Clin Diagn Res : JCDR. 2016;10:Oc08-13.

20. Jamhour A, El-Kheir A, Salameh P, Hanna PA, Mansour H. Antibiotic knowledge and self-medication practices in a developing country: A cross-sectional study. Am J Infect Control. 2017;45:384- 8.

21. Torres NF, Chibi B, Middleton LE, Solomon VP, MashambaThompson TP. Evidence of factors influencing self-medication with antibiotics in low and middle-income countries: a systematic scoping review. Public health. 2019;168:92-101.

22. Arora H, Singh A, Pathak RK, Goel S, editors. Extent and pattern of self medication use among adult residents of a jurisdiction in north, IJPSR, 2017; Vol. 8: 2205-2212.

23. Roberts EP, Roberts BS, Burns A, Goodlet KJ, Chapman A, Cyphers R, et al. Prevalence and dental professional awareness of antibiotic self-medication among older adults: Implications for dental education. J Dent Educ. 2020;84:1126-35.

24. Nusair MB, Al-Azzam S. The prevalence and patterns of selfmedication with antibiotics in Jordan: A community-based study. Int J Clin Pract 2021;75:e13665.

25. Alghanim S. Self-medication practice among patients in a public health care system. East Mediterr Health J. 2011;17:409-16.

26. Mittal P, Chan OY, Kanneppady SK, Verma RK, Hasan SS. Association between beliefs about medicines and self-medication with analgesics among patients with dental pain. PLoS One. 2018;13:e0201776-e.

27. Doomra R, Goyal A. NSAIDs and self-medication: A serious concern. J Family Med Prim Care. 2020;9:2183-5.

28. Stolbizer F, Roscher DF, Andrada MM, Faes L, Arias C, Siragusa C, et al. Self-medication in patients seeking care in a dental emergency service.AOL. 2018;31:117-21.

29. Gillani AH, Ji W, Hussain W, Imran A, Chang J, Yang C, et al. Antibiotic Self-Medication among Non-Medical University Students in Punjab, Pakistan: A Cross-Sectional Survey. Int J Environ Res Public Health. 2017;14:1152.

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Correlation of Education Level with Severity of Gingivitis and Plaque Score



Hina Mahmood1                 BDS, MDS
Faizana Wasiq Khan2        BDS
Manal Raouf 3                    BDS



OBJECTIVE: The objective of this study was to find the correlation of educational level with severity of gingivitis and plaque
score of patients reporting to the OPD of periodontology department.
METHODOLOGY: Cross sectional study was conducted at Islamabad Dental Hospital from May 2018 to May 2019. A total
of 376 patients diagnosed with gingivitis were selected using convenience sampling technique. For correlation, participants
were equally divided into four educational groups categorized as illiterate, primary, secondary and tertiary. Informed consent
was taken from the participants and information regarding socio demographic data and education level was recorded. Oral
examinations included visible plaque index (VPI) by Ainamo & Bay and for severity of gingivitis, modified gingival index
(MGI) by Lobene and Weatherford was used. Severity of gingivitis was categorized into mild, moderate and severe. Visible
plaque score was calculated as percentage on the basis of presence or absence of plaque which was divided into two categories
having plaque score < 30 and plaque score > 30. Correlation was calculated by Spearman's correlation test with statistical
significance < 0.01 at 95% confidence interval.
RESULTS: Results revealed that moderate gingivitis was most prevalent among all four education groups. Highest percentage
of severe gingivitis was observed for illiterate subjects 42(50%) whereas highest percentage of mild gingivitis was observed
for subjects with tertiary education 23(65.7%). For subjects with primary and secondary education moderate gingivitis was
most prevalent with 72(28%). Correlation of education with severity of gingivitis and plaque score was statistically significant
(p-value < 0.01) when spearman's correlation test was applied indicating that as the education level increased severity of
gingivitis and plaque score decreased.
CONCLUSION: Hence it was concluded that low educational status is moderately correlated with poor oral hygiene and high
prevalence of moderate to severe gingivitis making it necessary for the community service programs to inculcate oral health
care workshops in early years of school and to the communities where higher education is far reached.
KEYWORDS: Severity of gingivitis, plaque score, education level
HOW TO CITE: Mahmood H, Khan FW, Raouf M. Correlation of education level with severity of gingivitis and plaque score.
J Pak Dent Assoc 2022;31(1):38-42.
Received: 08 July 2021, Accepted: 16 November 2021

Oral health is an integral component of general health, negligence in it can lead to a variety of dental problems.1 Dental professionals counsel their patients for oral health care and regular oral hygiene maintenance. Oral hygiene is the practice of keeping the oral cavity clean and healthy. Oral health status is greatly influenced by oral hygiene habits which include tooth brushing, use of oral hygiene aids, proper dietary practice and routine dental visits.1
It prevents plaque buildup, calculus and stain formation on teeth.2 Plaque biofilm is a complex community of multiple microorganisms found on a tooth surface. It has been established through clinical studies and microbiological analysis that plaque has a major role in initiation and progression of gingival inflammation as well
as other oral diseases.3 This inflammation remain unresolved as long as this microbial biofilm of plaque is present.4
General and oral health are both affected by the social determinants which include education, poverty, gender and
sustainability as stated by Human Development Index report 2020.5 These determinants have an impact on oral hygiene practices.2 Educational status is an important indicator of the awareness and behavior of the people for oral health.6 Educated individuals tend to have more knowledge about oral diseases, their prevention and are more likely to attend preventive or follow-up visits. They have better oral health status than those individuals who have lower education levels.1 They also comply better with oral health care regimens.6 A study conducted on elderly population of Nigeria reported high scores of plaque index among the individuals with primary education.2 Longitudinal study with span of 32 years found association of education level with brushing habits and revealed high plaque scores among the individuals with low educational levels.7 Gingivitis has been defined as the reversible plaque induced inflammation of the gingiva without detectable bone loss or clinical attachment loss. Clinically it presents as
erythematous, sore, swollen and bleeding gums.8 It effects more than 75% of the population worldwide and is the second most common oral disease.4 Presence of dental plaque is strongly associated with the presence of gingival
inflammation.3 A study conducted among Saudi adult population showed that males who presented with excessive plaque accumulation showed more severe signs of gingival inflammation.4
Education level has a significant association with severity of gingivitis.9 A study conducted on adult male population in Nigeria reported higher prevalence of gingivitis among the participants with low educational level.10
Literature indicates a weak link of education status with oral hygiene and gingivitis, however direct correlation of
education status with plaque score and severity of gingivitis is still lacking. The present study was designed to find
correlation of plaque scores and severity of gingivitis in patients with different education levels reporting to
periodontology department at Islamabad Dental Hospital. To find correlation participants of groups were equally
distributed. A base line data from this study will help in identifying the current oral health status of local population
belonging to different education levels.

This cross-sectional study was conducted at the Periodontology department of Islamabad Dental Hospital
(IDH) from May 2018 to May 2019, after the approval from Institutional Review Board (IRB) (Ref# IMDC/DS/IRB/118). The sample size was calculated to be 91 per group with absolute precision of 0.1 and anticipated proportion for gingivitis as 0.62 at 95% confidence level. Therefore, the minimum total sample size was 364 which was inflated to 384 to manage any incorrect or insufficient data. Out of these 8 were excluded (2 from each group) due to incomplete information. The final sample included 376 patients (94 per group). Since there was no such study reporting the correlation of education level with severity of gingivitis therefore prevalence of gingivitis was used for sample size calculation. The study population included systemically healthy patients (excluding those who were diabetic, immunocompromised, receiving psychological treatment, suffering from metabolic disorders etc.) of age 23 and above, presenting with symptoms of gingivitis. Patients with compromised hand dexterity and those who have received scaling within last one month were also not included in the study.
After taking informed consent, socio demographic data and complete medical history was recorded. Intraoral examination was conducted for plaque and gingival scores. Participants were equally recruited into four educational
groups having 94 patients in each group. Educational groups were categorized as illiterate (no formal education), primary (grade 1-8), secondary (grade 9-12) and tertiary (with bachelor’s, master’s and doctoral degrees).
Each group was evaluated on basis of visible plaque index (VPI) and modified gingival index (MGI). Clinical
examination was carried out by two trained examiners. Interexaminer reliability for both the indices was calculated on 30 patients which was 80% for plaque index and 75% for modified gingival index. Absence (0) or presence (1) of
dental plaque was visually assessed according to Ainamo and Bay index and percentage was calculated. Educational
group was further divided into two subgroups for plaque index i.e., plaque < 30 % and > 30%. Modified Löe -Silness
index was used for assessment of gingival status. Four surfaces (Disto-buccal, mid buccal, mesio-buccal and lingual)
were scored for each tooth except for third molars. For MGI index each educational group was further divided into three subgroups (mild, moderate and severe gingival inflammation) having scores of (0.1 -1.0), (1.1-2.0) and (2.1-3.0)
respectively.11 Percentages of mild, moderate and severe periodontitis were calculated for each group and spearman’s correlation test was applied to find out the relation of education level with plaque score and severity of gingivitis. Spearman’s correlation test was also applied to find the relation between VPI score and MGI score. P-value of <0.01 was considered significant at 95% confidence interval.

Study sample consisted of 376 patients out of which 186 (49.5%) were females and 190 (50.5%) were males. Individuals of age 23 and above were included since the average age of graduation in Pakistan is 23 yrs. Majority
of males 53 (28.5%) had tertiary education, 52 (28%) were uneducated, while 56 (29.5%) females were educated till primary and 51 (27.4%) had secondary education. Regarding the severity of gingivitis, majority of females 136 (73.1%) had moderate inflammation. Higher percentage of males 46 (24.7%) showed severe gingival inflammation as compared to females 38 (20%). More males (58.1%) presented with VPI score > 30 as compared to females (54.7%).
Table 1 shows the frequency of gingivitis by severity in groups of different education levels. Over all moderate
gingivitis was most prevalent. The illiterate group presented with the highest percentage 42 (44.6%) of severe gingivitis and lowest percentage 7 (7.4%) was observed in tertiary group. Similarly, highest percentage 23 (24.4%) of mild gingivitis was observed in tertiary group whereas primary and secondary groups presented with highest percentage 72(28%) of moderate gingivitia.
A Spearman’s correlation of -0.2 (p-value<0.001) was observed for plaque score and -0.3 (p-value<0.001) was
observed for gingival index which is a fair correlation and implies that as the education level increased gingival and
plaque scores decreased.
The Spearman’s correlation between plaque score and gingival index also demonstrated a moderate, positive correlation (= 0.5, p-value< 0.001) which indicates that greater score of VPI corresponds to greater value of MGI score.

Education plays a pivotal role in positive behavioral changes. In Pakistan as majority of the individuals belong
to primary education status,12 it is therefore, extremely important to inculcate dental health education in early years.
Education level has an impact on oral hygiene status.13 Present study concluded that lower level of education is
moderately co-related to poor oral hygiene with coefficient of -0.2 and a good relation was observed between poor oral hygiene and higher scores of gingival inflammation with coefficient of 0.5. Reports have shown that the participants with primary education and VPI > 30% presented with moderate gingival inflammation.14 A study carried out on Swiss Army recruits reported that individuals who completed 9 years of education presented with a mean plaque score of (1.41), whereas the university students merely showed a mean plaque score of (1.26) and the difference was statistically significant.15 Another study conducted on elderly reported that higher percentage of individuals who attended high school presented with acceptable plaque index as compared to those who didn’t attend high school.16 Lower educational status has been associated with lack of oral hygiene awareness resulting in higher levels of dental plaque, a primary etiological factor for development of gingival diseases.10,11
Gingival inflammation is a reversible condition and appropriate plaque control methods and professional dental
care can prevent disease progression.14 The results of present study also revealed higher scores of plaque among male subjects which coincide with the results of adults in Latin
America showing males with greater percentage of supragingival plaque sites than females.17 Ericsson JS et al
also reported that females had significantly lower level of dental plaque (41%) than males (53%).18
With regard to severity, moderate gingival inflammation (68.35%) was the most predominant type observed. Results of the current study are in agreement with those of previous reports that have documented high prevalence of moderate levels of disease.19 Regarding gender, men had higher MGI scores compared to women. According to international studies males presented with significantly higher frequency of severe gingivitis than did women.20,21 However, results of a cross sectional study revealed no statistical differences between genders when considering gingival inflammation which could be due to the overall low mean MGI score (1.2) for both groups.22
This study also reported a higher prevalence of gingivitis in individuals with low educational attainment with a moderate correlation of -0.3 which was statistically significant having p value of < 0.001. Some of the literature supports the present results, underscoring the relation of low education level with severe gingival inflammation.9,23,24
Most of the confounders in this study were controlled and all the educational groups had equal number of
participants, which is the strength of this study. Silness-Löe plaque index and gingival index was not used which can
give us a better assessment of quantity of plaque buildup and gingival inflammation respectively. Brushing habits should also have been analyzed which could have given a clearer picture.

It was concluded that participants belonging to low educational status presented with higher scores of plaque
and gingival index. Individuals with tertiary education presented with lower levels of plaque score and increased
prevalence of mild to moderate gingivitis. Females presented with better oral hygiene and gingival status than males.
Nearly two-third of the participants presented with moderate gingival inflammation.

Under the light of the current results, it is prudent that the community based programs should include not only
dental education but also oral hygiene related workshops in early school years. It is necessary to increase the capacity
of these programs to the far reached areas where education level is low.

None declared

1. Bonfim Mde L, Mattos FF, Ferreira e Ferreira E, Campos AC, Vargas AM. Social determinants of health and periodontal disease in Brazilian adults: a cross-sectional study. BMC Oral Health. 2013;13:22.

2. Braimoh O, Soroye M. Oral hygiene status of elderly population in Port Harcourt, Rivers State, Nigeria. African J Medical and Health Sciences. 2017;16:109-14.

3. Sreenivasan PK, Prasad KV. Distribution of dental plaque and gingivitis within the dental arches. J Int Med Res. 2017;45:1585-96.

4. Idrees MM, Azzeghaiby SN, Hammad MM, ., Kujan OB. Prevalence and severity of plaque-induced gingivitis in a Saudi adult population. .35:1373-7. Saudi Med J. 2014;35:1373-7.

5. Conceição P, Jacob Assa, Cecilia Calderon, Fernanda Pavez Esbry, Ricardo Fuentes, Yu-Chieh Hsu, et al. The Next Frontier: Human development and the anthropocene. United Nations; 2020.

6. Kapoor D, Gill S, Singh A, Kaur I, Kapoor P. Oral hygiene awareness and practice amongst patients visiting the Department of Periodontology at a Dental College and Hospital in North India. Indian J Dent. 2014;5:64-8.

7. Broadbent JM, Thomson WM, Boyens JV, Poulton R. Dental plaque and oral health during the first 32 years of life. J Am Dent Assoc. 2011;142:415-26.

8. Chrysanthakopoulos NA. Prevalence of gingivitis and associated factors in 13-16-year-old adolescents in Greece. European J Gen Dent. 2016;40:58-64.

9. Sreenivasan PK, Prasad KVV, Javali SB. Oral health practices and prevalence of dental plaque and gingivitis among Indian adults. Clin Exp Dent Res. 2016;2:6-17.

10. Umoh AO, Azodo CC. Prevalence of gingivitis and periodontitis in an adult male population in Nigeria. ;9:65-9. Niger J Basic Clin Sci. 2012;9:65=9.

11. Carvajal P, Gomez M, Gomes S, Costa R, Toledo A, Solanes F, et al. Prevalence, severity, and risk indicators of gingival inflammation in a multi-center study on South American adults: a cross sectional study. J Appl Oral Sci. 2016;24:524-34.

12. Shah D, Khan MI, Yaseen M, Kakli MB, Piracha ZF, Zia MA, et al. Pakistan Education Statistics 2017-18: NEMIS-AEPAM; 2021.

13. Umoh AO, Azodo CC. Association between periodontal Status, oral Hygiene status and tooth wear among adult male population in Benin city, Nigeria. Ann Med Health Sci Res. 2013;3:149-54.

14. Elias-Boneta AR, Toro MJ, Rivas-Tumanyan S, Rajendra-Santosh AB, Brache M, Collins CJ. Prevalence, Severity, and Risk Factors of Gingival Inflammation in Caribbean Adults: A Multi-City, CrossSectional Study. P R Health Sci J. 2018;37:115-23.

15. Rothlisberger B, Kuonen P, Salvi GE, Gerber J, Pjetursson BE, Attstrom R, et al. Periodontal conditions in Swiss army recruits: a comparative study between the years 1985, 1996 and 2006. J Clin Periodontol. 2007;34:860-6.

16. Lacerda TeSP. Factors Associated With the Presence of Dental Plaque in an Urban Cohort of Elderly (Epidoso). MOJ Gerontology & Geriatrics. 2017;1:68-72.

17. Oppermann RV, Haas AN, Rosing CK, Susin C. Epidemiology of periodontal diseases in adults from Latin America. Periodontol 2000. 2015;67:13-33.

18. Ericsson JS, Ostberg AL, Wennstrom JL, Abrahamsson KH. Oral health-related perceptions, attitudes, and behavior in relation to oral hygiene conditions in an adolescent population. Eur J Oral Sci.2012;120:335-41.

19. Murillo G, Vargas MA, Castillo J, Serrano JJ, Ramirez GM. Prevalence and severity of plaque-induced gingivitis in three Latin American cities: Mexico City-Mexico, Great Metropolitan Area-Costa Rica and Bogota-Colombia. Odovtos. Int J Dent Sc. 2018;20:91-102.

20. Mostafa B, El-Refai I. Prevalence of Plaque-Induced Gingivitis in a Sample of the Adult Egyptian Population. Open Access Maced J Med Sci. 2018;6:554-8.

21. Elias-Boneta AR, Encarnacion A, Rivas-Tumanyan S, BerriosOuslan BC, Garcia-Godoy B, Murillo M, et al. Prevalence of Gingivitis in a Group of 35- to 70-Year-Olds Residing in Puerto Rico. P R Health Sci J. 2017;36:140-5.

22. Jordan RA, Lucaciu A, Fotouhi K, Markovic L, Gaengler P, Zimmer S. Pilot pathfinder survey of oral hygiene and periodontal conditions in the rural population of The Gambia (West Africa). Int J Dent Hyg.

23. Australian Research Centre for Population Oral Health TUoASA. Periodontal diseases in the Australian adult population. Aust Dent J. 2009;54:390-3.

24. Ababneh KT, Abu Hwaij ZM, Khader YS. Prevalence and risk indicators of gingivitis and periodontitis in a multi-centre study in North Jordan: a cross sectional study. BMC Oral Health. 2012;12:1.

Assessment of Precautionary Measures Medical Students & Doctors Practiced at Eid-ul-Adha during COVID-19



Usama Saeed1
Javaria Saeed2
Nabiha Farasat Khan3            BSc, M.Phil, MHPE, CME
Muhammad Saeed4                BDS



OBJECTIVE: To analyze the precautionary measures that medical students and clinicians practiced during Eid-ul-Adha' 2020."
METHODOLOGY: An online cross-sectional survey was conducted on medical students and doctors/clinicians/faculty in
Balochistan, where the questionnaire (10 items) was posted on google platforms after Eid-ul-Adha between 10th to 31st
December 2020. Inclusion criteria consisted of first to third year medical students and clinicians whereas fourth and final year,
house officers and postgraduate students were excluded. Pilot study demonstrated reliability of questionnaire Cronbach's alpha
0.624. SPSS version 23 was used for analysis.
RESULTS: In current study majority (n=82/126) of the study participants were males, more than half of them were medical
students (n=73/126). Eighty percent (80%) participants (n=66/82) offered Eid's congregational prayer in masjids, 11/82 prayed
at home only five (n=5/82) of them didn't perform prayer at all; majority (64%) of them practiced SOPs at the time of prayer
in Masjid. In family gatherings, 73% followed all precautionary measures whereas 10% avoided SOP's. At the time of ritual
livestock sacrifice, 62% participants followed whereas only 10% didn't follow to any precautions. During meat distribution,
68.5% study participants practiced all precautionary measures and just 2.7% did not follow SOP's during meat distribution.
No significant difference was found between medical students and doctors in practicing precautionary measures, except during
meat distribution (p-0.009).
CONCLUSION: Medical students and doctors practiced precautionary measures well. However, statistically significant relation
was found between medical students and doctors praying in masjids and maintaining a safe distance in Eid gatherings during
this pandemic.
KEYWORDS: COVID-19, Eid-ul-Adha, Precautionary Measures, Medical Students, Doctors.
HOW TO CITE: Saeed U, Saeed J, Khan NF, Saeed M. Assessment of precautionary measures medical students & doctors
practiced at Eid-ul-Adha during COVID-19. J Pak Dent Assoc 2022;31(1):32-37.
Received: 13 June 2021, Accepted: 01 Ocotber 2021

Eid-ul-Adha, one out of the two Islamic festivals, is celebrated with great zeal and enthusiasm annually on 10th of Dul-Al-Hajj, the last month of Islamic Calendar. Muslims gather with their families and friends to pray, sacrifice animals and distribute meat to the needy and destitute in order to please Allah Almighty. This Islamic celebration holds a symbolic value as well; it honors the willingness of Ibrahim (AS) to sacrifice his son, Ismael (AS), as an act of obedience to Allah’s command. 1 However, amid COVID-19 pandemic having already affected around 16 million individuals worldwide in the month of July’2020 and a further risk of its spread, social gatherings. 2 This
Eid-ul-Adha in August’2020 was considered problematic due to the overcrowding of people amongst the hustle and
bustle of the great event; animal transportation from rural to urban areas for sale, Eid Congregational Prayer, sacrifice in public areas and/or during social gatherings in amusement parks, restaurants, picnic points or homes.
3 All Muslims including Pakistanis celebrated Eid-Ul-Adha during the first week of August’2020 in this pandemic. Muslims sacrificed animals including goats, cows, sheep and camels. Eid celebration and sacrifices made it quite challenging for the Ministry of Health not only in Pakistan but also in the entire Muslim world to control the situation, as the chances of a drastic rise of COVID-19 infection were very high.3,4 COVID-19 is a viral infection, primarily affecting the respiratory system, transmitted directly or indirectly when a healthy person contacts the saliva, respiratory secretions or respiratory droplets of an infected individual.5 The index case was first recognized in China’s Wuhan city in December’20195 , and was declared a Global Health Emergency in January’2020 by WHO due to its worldwide spread and regulations were asked to be administered.6 The SOPs advised by health care workers included wearing face mask and gloves, physical and social isolation, washing hands for 20sec with soap, monitoring and controlling religious and social gatherings. During Eid-ul-Adha, animal sacrifice was also confined to specific areas with strict regulations to contain the disease transmission.2,3,7
Pakistan is a low-middle income country with a population of 207.8 million, predominantly Muslim population of over 95% residing in five different provinces i.e. Gilgit-Baltistan, Punjab, Sindh, Khyber Pakhtunkhwa (KPK), and Baluchistan.8 To overcome the consequences of COVID-19, the government had opted smart lockdown to arrest risk of infection spread towards individuals, families and communities. To promote and encourage adoption of key measures to prevent and minimize the spread of the infection, government officials directed the observation of SOPs. The commitment of Pakistanis to these control measures was a key factor in deciding the fate of battle against COVID-19.9 The purpose of this survey was to analyze precautionary measures adopted during social and religious practices by medical students and doctors during COVID-19 pandemic during Eid al Adha’2020.

After taking IRB from Bolan University of Medical and Health Sciences Quetta (No.00009/BUMHS/IRB/2020),
quantitative survey was designed and conducted on previous research reports and WHO guidelines for COVID-19.2
Due to pandemic, it was difficult to conduct a community-based survey and collect data so we opted for online Google platform survey. On-line questionnaire included gender, qualification, occupation and designation for background information of the participants and to analyze practice of precautionary measures among 126 medical students of four medical colleges (Makran Medical College in Turbat, Jahalawan Medical College in Khuzdar, Loralai Medical College in Loralai and Bolan Medical College in Quetta) and doctors of Balochistan during Eid-ul-Adha in this pandemic. As the newly inaugurated medical colleges of Makran, Jhalawan and Loralai comprise only three batches each, with neither house job nor post-graduation started so far, we included just first to third year medical students from Bolan Medical College to correspond data with that of the other three medical colleges. Data was collected during 10th to 20th December 2020.
After completing conceptualization of this survey, two medical educationists tested the face and content validity
of the instrument. The approved version of the instrument had 10 items only and had two parts. The first part contained questions related to the demographic information of the participants such as gender, occupation, designation and qualification (in case of clinicians/physicians) while the second part consisted of questions affiliated to precautionary measures including wearing face masks and gloves, keeping a distance of 6-feet, washing hands with soap for 20 sec and avoid touching the face with unwashed hands to prevent virus entry into mouth or nose. Participants were asked to answer in yes and no.
Prior to its official release, pilot testing was done on a small group of people having same characteristics as the
study group through a messaging and voice-over service, WhatsApp to check if the questions were clear and
unambiguous. Questionnaire was acceptable as its reliability was Cronbach’s alpha 6.24%. After this pilot survey, the
questionnaire was distributed to participants through internet into WhatsApp groups of author We used purposive and snowball sampling to recruit participants. The valid response rate was 90% after excluding invalid responses. Informed consent was obtained from all respondents. A brief introduction to the study was provided in the questionnaire on study objectives, questionnaire filling duration, as well as the names and contact information of the investigators. Participation in the survey was voluntary. All respondents were informed that they were free to continue or quit at any time, and the submission of the questionnaire would be regarded as consent to participate.
Second part of the questionnaire consists of six questions that assisted in assessing precautionary measures medical students and doctors were practicing during this pandemic in Eid-ul-Adha. One of these questions have two options: “yes”, and “no”. Whereas others have practiced-based questions focused on the attitude toward COVID-19 and Eid prayers, which precautionary measures did participants practice during family gatherings questions related to precautionary measures participants practice during sacrifice and during meat distribution including wear facemask and gloves, wash hands before and after sacrifice, make a distance of 6-feet, didn’t touch face with unwashed hands

The data was analyzed by using SPSS version 23. Frequency and percentage were given for gender, occupation
and responses pertaining to precautionary measures practices overall during Eid-ul-Adha. Chi-square was used to
determine the association of occupation and precautionary measures practiced overall during Eid-ul-Adha. A p-value
< 0.05 was taken as significant.

    One hundred and fifty participants from Makran Medical College, Jahalawan Medical College, Loralai Medical
College and Bolan Medical College across Balochistan responded to our research questionnaire. After scrutiny,
completed questionnaires (n = 126) were included in the study.
Out of 126 participants, majority (65.1%, n=82/126) were males whereas 58% (n=73/126) were medical students. Table 1 demonstrates demographic details. Table 2 presents details about the male participant’s response about precautionary measures during performing prayer, family gathering, practiced on SOP’s advised by local health authorities, observing sacrifice of the animal/s and meat distribution to neighbors and family members. Correlation
between occupations and precautionary measures practiced while meat distribution to family and friends is displayed in Table 3.

Overall results of participants following precautionary measures in COVID-19 pandemic were satisfactory. Almost
half of them followed all the precautionary measures in all items; giving an average of 73% during social gatherings,
64% during Eid-ul-Adha Prayers at Masjid, 62% during sacrifice while 68% during meat distribution. In comparison
with the results of other studies in which medical students and doctors demonstrated an overall better response towards SOPs, Hayat I from Punjab detected 81.22%6 while 92% students from Soltan’s study in Egypt practiced precautionary measures to avoid COVID-19 infection.10 The highest ratio (95%) was observed among study participants of Noreen et al research paper.11 In case of washing hands time and again, illiterate background and lack of childhood training serve as contributing factors to its low score.12 Basically majority of the population in Balochistan faces poverty13 which may be a cause of why participants (especially medical students) did not follow the precaution of wearing face masks and gloves attentively (average result 18%); whereas ignorance adds to this point as well. The result of participants maintaining a distance of 6 feet is poor as well; this may be due to the fact that this region of Pakistan has a tradition of shaking hands as well embracing each other especially on Eid Festivals; the younger ones even have to kiss the hands of the elderly as a sign of respect. These cultural norms not observed by any member create social stigma in society.
Medical students demonstrated interest to participate in the current study. More than half (58%) population of our research work (n=73/126) were medical students, remaining 42.1% (n=53/82) were doctors, 18/126 were Assistant  Professors, eight Associate Professors and nine Professors. Remaining 18 participants were also doctors but they were serving on administrative posts (MS, DHO, and registrar). We observed very low percentage of professors who participated in the study, which authenticates their busy schedule and short time for extra clinical activities. On the other hand only 49.7% Lebanese Physicians practiced precautionary measures.
During sacrifice, 42.7% (n=35/82) participants seems to have practiced precautionary measures, 23.2% (n=19/82)
avoided touching their face with unwashed hands, 21% (n=17/82) wore facemasks, whereas 12.2% (n=10/82) maintained a distance of 6feet. During meat distribution, 37.8% (n=31/82) practiced all precautionary measures, 22% (n=18/82) washed their hands with soap for 20sec before and after meat distribution, 17.1% (n=14/82) did not touch their face with unwashed hands, whereas only 7.3% (n=6/82) wore masks, whereas 9.8% participants (n=8/82) did not follow precautionary measures. Athough not on Eid-ul-Adha but other studies carried out on COVID-19 discuss percentage of participants on the basis of gender who wash their hands regularly. A study consisted of 1257 study samples out of which 632 (90.3%) females washed their hands in comparison 85.6% males for 20sec with soap.6
Only 8.2% of our study participants washed their hands for 20 sec during social gathering, however 31% (n=16/52) medical students washed their hands before and after meat distribution. When comparing practices of precautionary measures among undergraduates, majority of the study participants of Hayat K, Khasawneh et al, Soltan and Noreen K washed their hands regularly for 20 sec with resulting percentages of 87%, 88.1%, 90% and 91% respectively.9-11,15 This observation points towards the lazy nature, lack of time and/or non-serious attitude of medical students of Balochistan towards COVID-19.
Possibly the reasons responsible in maintaining low mortality in doctors and medical students would be performing prayers in home. As we found a statistically significant association when we compared Eid-ul-Adha prayer in masjid and /or in home among medical students and doctors (p-0.003). Medical students exhibited lack of time and extra burden of their studies that hinder all sorts of physical activities, and deficit social interactions that in-turn impeded them for performing prayers.16 When comparing responses there was no significant difference between medical students and doctors in wearing facemask, gloves, washing hands for 20 seconds and touching the face, statistically significant difference was observed between occupation of study participants and meat distribution after sacrifice (p-0.09). It may also be worth mentioning that despite of being blamed of fundamentalism, majority of the population in this region willingly reduced the religious rituals to a bare minimum level.17,18,19,20,21 Strict adherence to local, cultural and religious practices which include ablution almost five times in a day, use of face covering by the adult females and maintaining social distances as between genders at gatherings and educational institutions may have been the major contributory factors.22-24,25,26,27
Majority (80.5%, n=66/82) participants of current study offered Eid prayers in masjids; 39% wore facemasks (n=32/66), 22% (n=18/66) observed sufficient gap between namazis in masjid whereas 21% (n=17/66) follow all
precautionary measures. As they all were educated, they were aware of the severity and complications associated with COVID-19, so majority of the medical students and doctors practiced precautionary measures.
Balochistan is primarily a male predominating society and this aspect is confirmed in our study as 65% (n=82/126) study participants were males.28 Though various components work as contributing factors in low female literacy rate in Balochistan as compared to the other parts of the country including remote educational institutes, financial constraints, social problems and cultural barriers.28,29 However, in the current research work, the percentage of females was low as they offer prayers at home, and/or sacrifice ritual and
meat distribution during Eid-ul-Adha is related to men. In contrast, studies conducted by Hayat I, Hayat K, Soltan ,
Dhahri et al and Noreen K during this pandemic related to the adaptation of hygienic and precautionary measures
demonstrated female predominance (73.77%, 55. 7%, 61.1%, 65.9%, 71.4% respectively)6,9,11,30 and were not linked to a specific event.
This type of study had not been conducted before so the author was unable to discuss and compare results of current study with others research work.

Medical students were keener to participate in online surveys and knew about their practices during this pandemic.
Doctors, being more mature, practice precautionary measures carefully and strictly to avoid any infection. This is the first ever study to analyze medical students and doctors about the precautionary measures they practice. It was a small-scale study. To assess the perceptions, attitude and knowledge it should be done on a larger scale
among medical students and doctors. As it was an online survey, there is a chance of questionnaire bias. There may
be sampling bias, as survey may be restricted to those participants who were more active on social media. However
to reduce sampling bias, questionnaire was distributed to different online channels to improve its visibility among
respondents. There may also be response bias, which the respondents consciously or subconsciously did. As still, no
work was done on this forum to check and analyze which precautionary measures medical students and doctors were practicing, so it was impossible to compare our results with any other survey or study.

Doctors demonstrate more responsible behavior towards precautionary measures advised by healthcare workers as
compared to medical students.

Author offers her thanks to all volunteer participants of
this online survey.

Usama Saeed and Javaria Saeed: data collection (students), literature search
Muhammad Saeed: data collection (doctors), analysis
Nabiha Farasat Khan: manuscript writing, methodology
Attia Bari: review and final approval of manuscript



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23. Sibli SA. Cleanliness in Islam: Exploring Through COVID- 19 Pandemic Precautions and Concerns. SSRN Electron J. 2020;preprint a:15.

24. Ashraf H, Faraz A, Raihan M, Kalra S. Fighting pandemics: Inspiration from Islam. J Pak Med Assoc. 2020;70(5):S153-6.

25. Jia R, Ayling K, Chalder T, Massey A, Broadbent E, Coupland C, et al. Mental health in the UK during the COVID-19 pandemic: crosssectional analyses from a community cohort study. BMJ Open. 2020;10:e040620.

26. Aiyer A, Surani S, Ratnani I, Surani S. Mental Health Impact of COVID-19 on Healthcare Workers in the USA?: A Cross-Sectional Web-Based Survey. 2020;1-8.

27. Arshad MS, Hussain I, Nafees M, Majeed A, Imran I, Saeed H, et al. Assessing the Impact of COVID-19 on the Mental Health of Healthcare Workers in Three Metropolitan Cities of Pakistan. Psychol Res Behav Manag [Internet]. 2020 Nov 20 [cited 2021 Feb 10];Volume 13:1047-55. Available from: impact-of-covid-19-on-the-mental-health-of-healthcare-wo-peerreviewed-article-PRBM

28. Bashir K, Tobwal, Usman KUBSS. Social and Cultural Barrier to female Education in Balochistan?; an Assessment study with focus on district Pishin. Balochistan Rev. 2019;XXXIV:163-72.

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Perception of Smile Attractiveness Associated with Buccal Corridor Space Among Orthodontists and Laypersons Visiting de’ Montmorency College of Dentistry in Lahore, Pakistan



Hareem Sultan1              BDS, FCPS
Muhammad Ilyas2          BDS, FCPS
Asmi Shaheen3              BDS, FCPS, M.Phil
Afsheen Ghani4             BDS, DCPS-HCSM, MSc



OBJECTIVE: To determine the frequency based on the acceptance of absent, presence or excessive buccal corridor space
that maybe required for a smile to be apprehended as attractive among orthodontists and laypersons visiting de' Montmorency
College of Dentistry in Lahore, Pakistan.
METHODOLOGY: A descriptive cross sectional design was conducted to assess the perception of smile attractiveness among
orthodontists and laypersons visiting de' Montmorency College of Dentistry in Lahore, Pakistan from July 2019 to January
2020. Both male and female participants with age ranging between 25 - 50 years were included in the study. Each participant
was shown 6 digitally altered images of a female patient after which they were asked to rate whether the portrayed smile among
the images was acceptable or not. All the collected information was entered and analyzed using the SPSS version 20.0 software.
RESULTS: A combined total of 220 participants (110 Orthodontist and 110 Laypersons) who met the inclusion and exclusion
criteria were registered in this study. Among the orthodontists the mean age was 28.58±5.96 years and for the layperson was
23.38 ± 2.96 years. The mean total score for orthodontists was 33.28±7.08 and for layperson was 33.50±7.29. A statistically
insignificant difference was found between the two study groups when stratified according to gender, however a significant
difference was seen upon stratifying on acceptance of smile i.e. p-value = < 0.005
CONCLUSION: Both orthodontists and layperson do perceive that the buccal corridor space does have an impact on smile
attractiveness and its acceptance.
KEYWORDS: Esthetics, Dental*, Orthodontists, Perception, Smiling*.
HOW TO CITE: Sultan H, Ilyas M, Shaheen A, Ghani A. Perception of smile attractiveness associated with buccal corridor
space among orthodontists and laypersons visiting de’ Montmorency College of Dentistry in Lahore, Pakistan. J Pak Dent
Assoc 2022;31(1):27-31.
Received: 10 March 2021, Accepted: 04 October 2021

 Since ancient times smile in its own entity has been the most basic and oldest medium for human communication. A smile tends to amplify a person’s facial expression and beauty by enhancing features thus overall affecting human beings’ qualities and virtues of one’s personality.1 On the other hand, its impact is not only associated directly to dental esthetics; in fact a pleasant smile is linked – beyond the boundaries of just appearance of teeth
and gums – it is the amalgamation with not only structural beauty but also with the harmonious balance between the
lips and teeth and their combination into the facial configuration.1
Multiple studies have demonstrated that people formulate assumptions based on physical appearance, and then use these assumptions to judge that person in regards to intelligence level, employability, and relationships, among
other traits. Alley and Hildebrant suggest that the face is the most important contributor to physical attractiveness, and subsequently has a major influence on social interactions and an individual’s development.1
The perception of smile esthetics is subjective and is influenced by personal experiences and social environment.
However, smile is anatomically assessed on certain components or parameters i.e. smile arc, buccal corridor space which refers to dark space (negative space) visible during smile formation between corners of mouth and buccal
surfaces of maxillary teeth, midline diastema, tooth with gingival display, centerlines, and axial inclination of teeth.3
In this study,we assessed how the presence and absence of buccal corridor influenced the perceived acceptance of smile attractiveness among dental healthcare professionals i.e Orthodontists and laypersons.
Wider smiles were more favored by laypersons than small and narrow smiles. According to a study by Parekh et
al 4,80.1% of laypersons found absent buccal corridor acceptable; 82.3% of laypersons found ideal buccal corridor
acceptable; 71.9% of laypersons found excessive buccal corridor acceptable. The study also indicated that amongst
Orthodontists, 83.8% found absent buccal corridor acceptable; 82.8% found ideal and 71.3% found excessive buccal corridor acceptable, respectively.The conclusion of this study was that there is no clinical difference between orthodontic andlaypersons raters for smile attractiveness.4 Another study performed by Roden Johnson and a few other studies also found no difference among rater groups.5-8
Our study will be the first of its kind to be carried out among the Pakistani population and will immensely help in
determining and comparing perception of laypersons and Orthodontists regarding one of the most important aspects of smile esthetics. It will assist Orthodontists in achieving esthetically pleasing treatment outcomes which are acceptable to their patients (mostly laypersons) who have the right to decision making in their treatment and who ultimately have to be satisfied.

A descriptive cross – sectional study design was selected for this study. Non-probability consecutive sampling technique was used to enroll the .participants. Both male and female between the ages 25 – 50 years were included from de’ Montmorency College of Dentistry from July 2019 to January 2020.
These participants were then divided into two groups i.e. Orthodontists and laypersons. All laypersons had received a minimum of twelve years of education with no previous orthodontic treatment and belonging to professions other than dentistry were included in the study. The orthodontists were selected based on the criteria of having minimum 5 years of experience in their respective field.
We estimated a sample size of 220 cases keeping confidence level at 95% along with a margin of error of 6%
and considering expected percentage of acceptance of excessive buccal corridor space i.e. 71.3% (least among all) half of the sample size that would be orthodontists and other half as laypersons. Individuals who did not give consent or
were unable to answer correctly either due to visual imparity or mental disability were excluded from the study.
Data was collected by using a self – structured questionnaire and included well-edited colored photographs
of a female individual of age range 20-28 years on a photographic paper, with good exposure taken from a digital
camera showing bilaterally symmetrically aligned teeth and esthetic lips on close up was shown to each participant. The photograph was digitally manipulated using (Photoshop 7.0 Adobe) software, which is a valid technique
to manipulate photographs to create ideally aligned teeth and esthetic lips. The original photograph had no buccal
corridor space; digital modification was then applied to enhance the dark space gradually by 5% thereby increasing
the dark space from 0 to 25% to produce a total set of six images. There were 2 separate images with absent buccal
corridors, 1 image of ideal and 3 images of excessive buccal corridors.
All the participants were then asked to designate if the portrayed smile was according to their acceptable standards or not. Each image was assigned a score based on the Likert scale i.e. from 1 to 10 where 1 represented the least attractiveness and 10 being the most attractive. Informed consent was acquired from all participants prior to data collection along with the approval from the hospital’s ethical committee. All the data was entered and analyzed using STATA version 15.0 Quantitative variables like age were reported as mean and standard deviation while qualitative variables such as gender and acceptance of absent, ideal and excessive buccal corridors was reported as frequency and percentages. Data was later stratified for smile acceptability and gender to address effect modifiers. Inferential statistics was calculated using independent t test along with stratification, with p-value<0.005 to be considered statistically significant.

A total number of 220 participants i.e. 110 orthodontists and 110 laypersons were included in the study. Out of which, 44 (20%) were males and 176 (80%) were females. Among the orthodontist 24 were males and 86 were females and among the laypersons 20 comprised of males and 90 of females.
The mean (SD) age for the orthodontic group was 28.58 ± 5.96 and for layman group was 23.38 ± 2.96. The minimum and maximum score values were 14 & 52 respectively and the mean (SD) score was 33.55±7.63.
The total mean (SD) score for both study groups along with their respective p-value is given in Table 1.
orthodontist group for image A was 5.40 ± 1.69, for image B was 5.73 ± 1.95, for image C was 5.70 ± 1.81, for image
D was 4.74 ± 2.01, for image E was 4.40 ± 2.16 and for image F was 7.26 ± 2.16 respectively.
The mean (SD) score among the layperson group for image A was 5.75 ± 1.91, for image B was 5.89 ± 1.86, for
image C was 5.4 ± 1.81, for image D was 4.69 ± 2.00, for image E was 4.50 ± 2.44 and for image F was 7.3 ± 2.19
The two study groups were then stratified on the basis of gender and the total mean score for male participants was
33.48 ± 6.144 while for the females was 33.38 ± 6.681. An insignificant p-value of 0.931 was noted along with an
insignificant confidence interval of -2.282, 2.089.
Upon stratifying both the groups on the basis of smile acceptance it was seen that those participants who answered “No”, the total mean score among the group was 25.93 ± 3.964 and for those participants, who responded “Yes”, the total mean score was 36.74 ± 4.371.
A statistical significant difference of < 0.005 was seen between the two study groups with a confidence interval –
12.039, -9.595. Table 2

“Smile is our business card” —- a popular quote which signifies importance of physical appearance on our day to
day lives. Physical attraction is a multifaceted concept and can be defined differently depending on cultural norms and individual subjective preferences.8
In this age and era an individual’s outlook plays a huge role in their sustenance and well – being and for this reason the pre – perceived concept of physical attractiveness greatly influences and creates potential biases in terms of social decision – making. Because of this attitude people often tend to pursue social acceptance by means of improving facial harmony and thus overall appearance using different orthodontics and orthognathic surgery treatment modalities for altering or modifying a person’s facial features.9,10
The main objective of this study was to understand how smile attractiveness is affected by buccal corridor space as
perceived by dental health professional i.e. Orthodontists
and laypersons.
In this study insignificant difference was seen between the two study groups based on gender which demonstrated
similar findings to another study conducted in Indonesia in 2015 in which dental health professionals were asked to
assess smile esthetics based on gingival display.11 Both male and female participants provided similar results. However,
this study also suggested that as compared to males, females tend to pay more attention towards maintaining an esthetically pleasing smile and this in turn directly influences their confidence and self – consciousness level.
Another study by Amjad Al Taki and Amina Guidoum12 concluded that healthcare professionals belonging to the
dental community, and laypersons had similar preferences regarding trends among both genders; laypersons had a more tolerable attitude towards profiles with bi-maxillary retrusion. On the other hand, when smile acceptability was estimated we observed that both groups preferred more visible buccal corridor space and that it made the smile more pleasant. Our findings coincide with another study conducted in India, in which the presence or absence of buccal corridor space on smile esthetics was assessed among not only laypersons and orthodontists but also among prosthodontists.13 The dental health professionals were able to better apprehend the appearance of black spaces at the corner of the mouth which according to their opinion made the smile more pleasing as compared to laypersons.
Similarly, in a study by Kokich et al. found all participants which included (laypersons, dentists and orthodontists) all had various levels of observations when it came to smile characteristics and that laypersons were the most accommodating and were the least criticizing among the participant groups.14 Another study carried out in India in a medical institute also displayed similar results where orthodontists and prosthodontists perceived smile based on buccal corridor space differently from laypersons who on contrary could not appreciate the significance of buccal  corridor space in assessing smile attractiveness.15
Our results are however reciprocal to Parekh SM et al4who depicted that both laypersons and orthodontists
preferred smiles with smile arc that runs parallel to the lower lip and the amount of visible buccal corridors are minimal. The attractiveness ratings were found to be the lowest among smiles with flat smile arcs and excessive buccal corridors. Presences of flattened smile arc have seen to overcome the undesirable effects of excessive buccal corridors on attractiveness ratings.
Another study by Loi et al used a single digital photograph and altered the buccal corridor digitally in 5% increments ranging from 0 to 25 %. Their results also showed that both orthodontist and laypersons preferred broad smiles with less buccal corridors.16 Other aspects that have been seen to influence perception of smile attractiveness, is the facial type of individuals based on their ethnicity. A study by Nimbalkar et al16were able to evaluate that statistical difference was seen with individuals with long and short faces as compared to normal faces. Our study was assessed using photographs of a single person this makes it one of the strengths.
Age has also been seen to be a factor that determines the criteria for smile attractiveness. A study was also done
based on the position and amount of gingiva visible around the maxillary central incisors along with the incisal edge of these teeth. The absence and presence of a black triangle between the maxillary central incisors also contributed to
the level of acceptability of the smile.18
These findings can be due to a lot of reasons for instance, a study by Rabia Bilal19 demonstrated that there was no
significant difference in the perceptions of smile between laypersons and orthodontists. However, laypersons mean
scoring was significantly higher in few photographs. The preference for various smile attributes showed variation
between the groups.
Orthodontists rated smile arc while laypersons rated incisal show as the most preferred attribute. Other studies
have also shown that orthodontists are more critical when it comes to a gummy smile compared with laypeople. It is
seen that orthodontists observe and treat patients based on their theoretically achieved knowledge i.e. with a more
academic perspective however a layperson has a more subjective view and therefore analyzes according to it.20-22
Our future recommendation would be to perform repeated testing in order to estimate the reliability of the study along with consideration to the facial type and age of the participants, so that a broader overview of smile attractiveness can be achieved.

There is a significant difference in the perceived notion of the acceptability of a person’s smile related to the amount
of buccal corridor space visible by both dental health professionals and laypersons. It is evident that physical appearance has a huge impact on a person’s psychological behavior. Facial symmetry and types along with the amount of visible buccal corridor space also have a significant association that would make a smile attractive. And though orthodontist assesses the perfect smile based on certain assumptions such as the anatomy of the jaw, angulations of teeth and the amount of gums visible among other factors; it is necessary to consider what a
layperson interprets as a beautiful smile.

The authors declare that there is no Conflict of interest.

1. Tikku T, Khanna R, Maurya R, Ahmad N. Role of buccal corridor in smile esthetics and its correlation with underlying skeletal and dental structures. Indian Journal of Dental Research. 2012;23:187.

2. Alley TR, Hildebrandt KA. Determinants and consequences of facial aesthetics: TR Alley (Ed.), Social and applied aspects of perceiving faces1988.

3. Badran SA, Mustafa M. Perception of Smile Attractiveness by Laypeople-influence of Profession and Treatment Experience. 2014.

4. Parekh SM, Fields HW, Beck M, Rosenstiel S. Attractiveness of variations in the smile arc and buccal corridor space as judged by orthodontists and laymen. The Angle orthodontist. 2006;76:557-63.

5. Roden-Johnson D, Gallerano R, English J. The effects of buccal corridor spaces and arch form on smile esthetics. American Journal of Orthodontics and Dentofacial Orthopedics. 2005;127:343-50.

6. Ritter DE, Gandini Jr LG, Pinto AS, Locks A. Esthetic influence of negative space in the buccal corridor during smiling. The Angle orthodontist. 2006;76:198-203.

7. Gracco A, Cozzani M, D’Elia L, Manfrini M, Peverada C, Siciliani G. The smile buccal corridors: aesthetic value for dentists and laypersons. Prog Orthod. 2006;7:56-65.

8. Peck H, Peck S. A concept of facial esthetics. The Angle Orthodontist. 1970;40:284-317.

9. Vargo J, Gladwin M, Ngan P. Association between ratings of facial attractivess and patients’ motivation for orthognathic surgery. Orthodontics & craniofacial research. 2003;6:63-71.

10. Johnston C, Hunt O, Burden D, Stevenson M, Hepper P. Selfperception of dentofacial attractiveness among patients requiring orthognathic surgery. The Angle Orthodontist. 2010;80:361-6.

11. Sijabat YJ, Christnawati C, Karunia D. Contrasting perceptions of male and female dental students regarding smile aesthetics based on their gingival display. Dental Journal (MajalahKedokteran Gigi). 2018;51:200-4.

12. Al Taki A, Guidoum A. Facial profile preferences, self-awareness and perception among groups of people in the United Arab Emirates. Journal of orthodontic science. 2014;3:55.

13. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthodontics and Dentofacial Orthopedics. 1993;103:299-312.

14. Kokich VG, editor. Esthetics: the orthodontic-periodontic restorative connection. Seminars in orthodontics; 1996: Elsevier.

15. Pisulkar, Sweta K., et al. “Perception of buccal corridor space on smile aesthetics among specialty dentist and layperson.” Journal of International Society of Preventive & Community Dentistry 9.5 (2019): 499.

16. Loi H, Kang S, Shimomura T, Kim S-s, Park S-b, Son W-s, et al. Effects of buccal corridors on smile esthetics in Japanese and Korean orthodontists and orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics. 2012;142:459-65.

17. Nimbalkar S, Oh YY, Mok RY, Tioh JY, Yew KJ, Patil PG. Smile attractiveness related to buccal corridor space in 3 different facial types: A perception of 3 ethnic groups of Malaysians. J prosthetic dentistry. 2018 Aug 1;120:252-6.

18. Shimogaki SK. Position of the lips and facial profile: preferences of orthodontists versus lay people. 2007.
19. Bilal R. A comparative analysis of smile perception between orthodontists and laypersons. Pak Oral & Dental J. 2015;35.

20. Pisulkar SK, Agrawal R, Belkhode V, Nimonkar S, Borle A, Godbole SR. Perception of buccal corridor space on smile aesthetics among specialty dentist and layperson. J International Society of Preventive & Community Dentistry. 2019;9:499.

21. Reid B. Perceptions of facial attractiveness: Outcomes of orthognathic surgery: The University of Alabama at Birmingham; 2015.

22. Sriphadungporn C, Chamnannidiadha N. Perception of smile esthetics by laypeople of different ages. Progress in orthodontics. 2017;18:8.

Frequency of Kennedy Classification of Partially Dentate Arches and their Association with different Sociodemographic Factors



Aleshba Saba Khan1              BDS, FCPS
Abdul Mueed Zaigham2         BDS, FCPS
Fizza Tahir3                             BDS
Najeeb Ullah4                          BDS
Aleeza Sana5                           BDS
Asma Shakoor6                       BDS, MSc, MFDS RCS



OBJECTIVE: This study aims to find frequencies of different Kennedy's classes in partially dentate arches and determine
association of tooth loss with Sociodemographic variables.
METHODOLOGY: A cross sectional study was done with a sample size of 335 individuals. All individuals were examined
using diagnostic kit and data recorded on proforma according to Kuppuswamy's socio-economic scale.
RESULTS: Mean age was 46 years with SD ± 1.22 with 189 female and 146 males. Kennedy's class III was most common
pattern in both arches. Tooth loss is more in illiterate people showing significant correlation with education in both arches. Low
income or unemployment shows significant correlation with tooth loss in maxillary arch.
CONCLUSION: Socioeconomic status like education, income and occupation has an impact on frequency of tooth loss.
KEYWORDS: Partially dentate arch, Sociodemographic factors, Education and tooth loss, Income, occupation and tooth loss
HOW TO CITE: Khan AS, Zaigham AM, Tahir F, Ullah N, Sana A, Shakoor A. Frequency of kennedy classification of partially
dentate arches and their association with different sociodemographic factors. J Pak Dent Assoc 2022;31(1):16-20.
Received: 31 May 2021, Accepted: 23 September 2021

Teeth are the most fundamental component of stomatognathic system.1 Preserving maximum number of teeth during life is one of the prime objective of oral health.2 Tooth loss can be considered as a measure of the severity of oral diseases experienced by an individual or a population.2,3 Loss of teeth disturbs the functional harmony of the remaining dentition and might cause teeth to drift, tilt or widen the contact areas, wedging of food, occlusal instability, bone resorption, reduction in vertical dimension or temporomandibular dysfunction.1,3 This will further deteriorate the condition and affect quality of life by affecting of choice of food and masticatory efficiency.1,2
Partially dentate arch is the one in which at least one or more teeth are missing.4 Literature shows multiple factors involved in etiology of tooth loss like attitudinal factors, individual’s approach towards dental health, cost of treatment, access to and use of dental services, limitation of dental services, variation among available treatment options, systemic conditions, senility and socio-demographic factors.2,5 Various other reasons of tooth loss include caries, periodontal problems, traumatic injuries, impactions, supernumerary teeth, orthodontic extractions, neoplastic and cystic
As per literature, there is a decline in trend of complete denture wearers and an increase in number of partial denture wearers which reflects improving clinical trends and successful preventive measures.5,7 It also depicts an increase in awareness among population regarding significance of maintaining oral hygiene and retention of natural dentition.5 A simple estimation of the proportion of Partially dentate persons is a rough estimate of the prevalence of dental diseases and the success or failure of dental care.8 This forms a background for the assessment of treatment needs.9
Conservative treatment options used to treat partially dentate arches, such as dental implants also happen to be
the most expensive.7 This continues to limit their availability to lower socioeconomic groups in whom the highest rates of tooth loss occur.7 It should not be a surprise then that conventional removable prosthodontic treatment modalities continue to outnumber implant tooth replacements in general practice and remain a versatile, cost effective, and reversible treatment method for partially dentate patients at any age.7
Several studies have analyzed the correlation between partially dentate arches and its influencing factors like age
and gender but very limited studies are available locally to give information about correlation of education, occupation and income with frequency of partially dentate arches.1,3,5,10
This study will provide an insight into role of socio demographic factors in tooth loss that would help the
practitioners in addressing the relative management needs of patients. This will create awareness amongst population for maintenance and retention of natural teeth by identifying the factors of significant influence. The rationale of this study is to find frequencies of differential Kennedy’s classes in partially dentate subjects and to see its relationship with education, occupation and income.

The objectives of this study are to:
. Find frequencies of different Kennedy’s classes in partially edentulous subjects.
. Determine its association with sociodemographic variables like education, occupation and income

Across sectional study was conducted at outpatient department (OPD), Institute of Dentistry (IOD), CMH Lahore
Medical College over a period of six months. Approval was taken from ethical committee of the Institute of Dentistry,
CMH Lahore Medical College Reference no.7/ERC/CMHLMC. A sample size of 335 subjects was selected by non-probability, consecutive sampling technique. Sample was estimated using least frequency of mandible Kennedy’s class- IV i.e. 2%.11 95% confidence level and 3% margin of error was used while calculating the sample. Subjects having wisdom tooth as only missing tooth or missing 2nd molar that will not be replaced, congenitally missing teeth, edentulous patients or patients who are physically and mentally challenged or house wives were excluded from the study. Partially dentate patients or the patients having at least one missing tooth within the age range of 20 to 70 years were included.
After taking an informed consent, all required data was taken from participants and recorded. All subjects meeting
the inclusion criteria requirements were examined intra orally according to European Global Oral Health Indicators
Development12 using diagnostic kit and information was recorded on patient proforma formulated according to Kuppuswamy’s socio-economic status scale.13 Kennedy’s classification system was used for classifying arches.
Modification areas were not included in the study to simplify the analysis.
The recorded data for education, income and occupation was further categorized into 3 sub-groups for each category. The sub groups for education level were; A (illiterate), B (Primary education till intermediate) and C (Graduate or above). The sub categorization for occupation level included; A (unemployed or unskilled worker), B (semi skilled, skilled, clerk) and C (semiprofessional or professional). For categorization of income, the scale comprised of 7 scores (1,2,3,4,6,10 and 12), the data was recorded according to Kuppuswamy’s scale13 after converting Indian rupee into Pakistani rupee and then data was divided in to 3 categories; Group A included income under scores 1 to 3 i.e. <Rs.2688 to 13456, Group B included income falling under scores 4,6,and 10 i.e. Rs 13457 to 53843 and Group C included income under score 12 that is Rs.53844 and above.
All collected data was entered and analyzed using SPSS version 23. Frequency and percentages are used for categorical data like occupation, social class and Kennedy’s class I, II, III, IV. Chi-square test was applied to see association of Kennedy’s class with social class and occupation post stratification. Data was stratified for socioeconomic status and occupation. P-value < 0.05 was considered as statistically significant.

The study included a total of 335 patients who were inquired and examined to determine frequencies of differential Kennedy’s classes in partially dentate subjects and their association with different socio-demographic profiles. Mean age was 46 years with SD ± 1.22. Kennedy class III was most common pattern (Figure 1). 146(43.6%) patients were male while 189(56.4%) patients were females.
Stratification of common patterns of acquired partially dentate arches with reference to education in both maxilla
and mandible are given in table no 1.
Class I pattern is seen more in illiterate population  in both maxilla and mandible and Class III is most common
pattern seen in both arches as the education level is increased (as shown in table 1). P value was less than

0.05 showing significant results.
Stratification of common patterns of acquired partially dentate arches with reference to occupation in both maxilla
and mandible are given in table no 2.
Unemployed individuals were found to have more trend of missing teeth as compared to working/earning people.
Class I, II and III patterns were higher in unemployed or unskilled workers when compared to professionals in both
maxillary and Mandibular arch as shown in table 2. P value for maxilla was less than 0.05 and for Mandibular arch
Stratification of common patterns of acquired partially dentate arches with reference to income in both maxilla and mandible are given in table no 3.
There was increase in incidence of tooth loss in people with low income. Class I, II and III were common patterns
in individuals with low income as compared to people earning more in both maxillary and mandibular arch as shown in table 3. p value for maxilla was less than 0.05 and for mandible it was 0.097.

of missing teeth by patient is sought to restore and maintain a perfect balance of form and function.5
There are multiple factors influencing the prevalence of tooth loss that include education, occupation, financial status, oral hygiene maintenance and life style.3 The study included individuals from semi-rural population.
Education is one of the significant factors associated with knowledge about dental problem and its management.4,14 The patients are normally unknowledgeable about the oral health care measures and have a poor attitude towards management of dental problems.14
On observing the correlation of partially dentate arches with education, results were significant for both arches. Class I pattern is seen more in illiterate or minimally educated population in both maxilla and mandible and Class III is most common pattern seen in both arches as the education level is increased. Similar trends have been reported in other studies as well.1,4,15 The reason for this may be that esthetic consciousness is increased and focus is more on hygiene as education level and awareness about oral hygiene increases.1,4 More understanding of oral hygiene practice and utilization of facilities to maintain or improve oral health condition also
comes as part of learning.1,4,5
A study reported that 57.5% people reported with partially dentate arch were having medium level of education whereas 42.5% of the individuals with missing teeth were well educated.10 Results of the same study show 64.5% of
employed population reporting to clinic for replacement whereas only 10.3% of unemployed population demanded
replacement of missing teeth.10 Kennedy’s class I was the most common type of partially dentate arches in upper and lower jaws (52.4%), preceding by class-III (33%), class-II in 12.8% and class IV being least common (1.6%).10 A local study reported that 49.5% cases were from primary to intermediate educational level, 40.8% were uneducated,
while only 9.6% were graduate.5 According to income level, 72.0% were presented with income level below half million Pakistani Rupees per year, 26.1% were presented with income level between fifty thousand to one lac rupees per year and only 1.8% cases were presented with income of more than one lac Pakistani Rupees per year.5
The lack of awareness due to low educational level and unmotivated people result in poor oral hygiene and higher
prevalence of tooth loss thus, multiple saddle areas.5,14,15 Less educated people lack awareness about dental health care and importance of teeth.1,5,16 Such individuals do not visit the dentist for sake of regular checkups and present to the clinic only when in state of severe pain.16 This can be better described as a curative rather than a prophylactic approach involving emergency dental health care, with removal of teeth being the treatment rendered for the decayed teeth.15,16
The study showed increase tooth loss in people with low income or unemployed individuals. This finding is in
conformance with many other studies which state that complete or partially dentate arches were less in people with
better family income and employment status.1,2,4,5,16
According to results of this study, professional or employed people as well as people with income greater than
Rupees 20,000 were found to have less prevalence of tooth loss which was in accordance with other studies also.5,16,17 People with better employment status are more concerned about their esthetics and seek dental care for preservation or restoration of teeth.17 The trend seen from the results of this study show that the socio economic status directly influences the restoration or extraction of teeth and replacement of missing teeth as seen in this as well as other studies.17 The results for income and occupation factors were significant for maxillary arch which might be due to the fact that esthetic concerns are more for maxillary teeth as compared to the teeth in mandibular arch.18
People of lower social classes i.e. unemployed or people with income lower than Rupees 10,000 tend to show
inconsiderable value for health in general and dental health in particular.17 They give little or no importance for
preservation of their teeth for the entire life and consider tooth removal over restoration.19 Also, the individuals with
lower income could not afford the treatment procedures that would have saved their ailing tooth, so might opt for removal instead of preservation.5 Thus, most of the patients attending belong to the low socioeconomic background therefore prefer extraction over restorative treatment as they are unable to take frequent leaves from work, afford transportation fares, and treatment cost to save the ailing teeth.1,5
This study was conducted in an institute based setting and included patients reporting to that institute only. In
future, it can be conducted on greater sample size to better correlate and analyze the effect of sociodemographic variables. Further studies can be conducted by limiting the age range of the study population to young adults. Also, the strategies should be devised to enhance education level of the population apart from creating awareness about
maintenance of oral hygiene. Also, the access to the basic dental treatment should be made easier or covered up in
health insurance.

Our study concludes that there is a significant association between the Kennedy’s class and sociodemographic factors. Class I pattern was more common in illiterate people and class III was seen to be common in educated people. Therefore, prevalence of tooth loss was more in uneducated individuals. Unemployed or unskilled workers were found to have high prevalence of missing teeth. There was increase frequency of tooth loss in people with low income. Thus socio economic status is associated with of tooth loss.

Strategies should be devised to enhance education level of the population apart from creating awareness about
maintenance of oral hygiene. Also, the access to the basic dental treatment should be made easier or covered up in
health insurance.

All researchers have no conflict of interest related to
this study.


1. Goutham GB, Shrivastava N, Mathew S, Alani MM, Reba PB, Bulusu A. Sociodemographic Factors and Partial Edentulism: An Exploratory Study. Int J Oral Care & Res. 2016;4:276-79.

2. Vadavadagi SV, Srinivasa H, Goutham GB, Hajira N, Lahari M, Reddy GP. Partial edentulism and its association with socio-demographic variables among subjects attending dental teaching institutions, India. J Int Oral Health: JIOH. 2015;7(Suppl 2):60.

3. Shubita M. Evaluation of partial edentulism based on Kennedy’s classification and its relation with age and gender. Pak Oral Dent J. 2015;35(4).

4. Nirupama R, Shetty M, Prasad DK. Partial edentulousness and its correlation to the educational status of the population in the southwest coastal region of India. Int Dent Medi J Advanced Res. 2017;3:1-4.

5. Ali HI, Memon MR, Shaikh G, Memon H, Samejo I. Edentulism in relation to sociodemographic status of patients. Pakistan Oral & Dental J. 2019;39(1).

6. Kaphle B, Shrestha A, Bhagat T, Shrestha D, Bhandari S, Jha U. Partial edentulism and its correlation with educational status: a hospitalbased study. J Karnali Academy of Health Sciences. 2020;3:95-101.

7. Campbell SD, Cooper L, Craddock H, Hyde TP, Nattress B, Pavitt SH, Seymour DW. Removable partial dentures: The clinical need for innovation. J Prosthetic Dentistry. 2017;118:273-80.

8. Pengpid S, Peltzer K. The prevalence of edentulism and their related factors in Indonesia, BMC Oral Health. 2018;18:1-9.

9. Nayyer M, Khan DA, Gul H, Aslam A, Khan NB, Aslam F. Patterns of partial edentulism according to kennedy’s classification-a cross sectional study. Pak Armed Forces Medi J. 2020 Jan 27;70 (Suppl-1):S87-90.

10. Tudorici T, Feier R, Balcos C, Forna N. Socio-demographic factors and the partial edentulism in the adult population from iasi, romania. Romanian J Oral Rehabilitation. 2017;9:68-72.

11. Rashid R. Waseem-ul-Ayoub. Partial edentulism and its association with age and gender-A research article. Int J Engineering Sci Com. 2017;7:14883-86.

12. Ottolenghi L, Bourgeois DM. Health Surveillance in Europe 2008, European Global Oral Health Indicators Development Project: Europe. 2008.

13. Kumar BR, Dudala SR, Rao A. Kuppuswamy’s socio-economic status scale-a revision of economic parameter for 2012. Int J Res Dev Health. 2013;1:2-4.

14. Matsuyama Y, Jürges H, Listl S. The causal effect of education on tooth loss: evidence from United Kingdom schooling reforms. American J Epidemiology. 2019;188:87-95.

15. Rodriguez FR, Paganoni N, Weiger R, Walter C. Lower educational level is a risk factor for tooth loss-Analysis of a Swiss population (KREBS Project). Oral Health Prev Dent. 2017;15:139-45.

16. Nakahori N, Sekine M, Yamada M, Tatsuse T, Kido H, Suzuki M. Socioeconomic status and remaining teeth in Japan: results from the Toyama dementia survey. BMC public health. 2019;19:1-9.

17. Kim YH, Han K, Vu D, Cho KH, Lee SH. Number of remaining teeth and its association with socioeconomic status in South Korean adults: Data from the Korean National Health and Nutrition Examination Survey 2012-2013. PLoS One. 2018;13:e0196594.

18. Almutairy A, Mohan M. Prevalence of partial edentulism among young Saudi women of Qassim and their perception of early tooth loss. Int J Dent Res. 2017;5:172-6.

19. Mõttus R, Starr JM, Deary IJ. Predicting tooth loss in older age: Interplay between personality and socioeconomic status. Health Psychology. 2013;32:223.

Attitude and Practice of General Dental Practitioners and other Dental Specialties towards Pediatric Dentistry in Pakistan



Abul Khair Zalan1               MDS
Sakina Qazi3                        MCPS
Nabeel Zahid2                      BDS, MFDS RCSEd, M endo RCSEd
Abdul Haq4                          FCPS
Zainab Memon5                   BDS
Miraat Anser6                      BDS



OBJECTIVE: Pediatric patients have high unmet treatment needs in Pakistan. There are only a handful of pediatric dentists
in Pakistan. Thus, the dental services to child patients have to be dependent on general dentists and other dental specialists.
The aim of this study was to assess the attitude and practice of the dentists towards clinical pediatric dentistry in Pakistan.
METHODOLOGY: A cross-sectional, questionnaire-based study was conducted among the dentists in Pakistan.
RESULTS: A total of 372 dentists participated in the study. These included 122 (32.8%) males and 250 (67.2%) females. The
majority of the participants (n = 272, 73.1%) were between the ages of 25 to 35 years. As compared to other dentists, a
significantly greater number of general dentists (p < 0.008) had received any training in the behavioral management of children.
Operative dentists reported practicing more of the various procedures in child patients (pit and fissure sealants, stainless steel
crowns, pulpectomies, fluoride varnishes, pulpotomies and restorations), as compared to the other dentists. Even though the
operative dentists performed more of these procedures, more than 50% of them still did not frequently perform any of the
procedures. A total of 244 (65.6%) dentists wanted to attend pediatric dentistry courses, if available.
CONCLUSION: There is a major gap in the needs and availability of pediatric dentistry services. More training needs to be
conducted at both the undergraduate and postgraduate levels in pediatric dentistry.
KEYWORDS: Pediatric dentistry, general dentists, other dental specialists, attitude and practices.
HOW TO CITE: Zalan AK, Zahid N, Qazi S, Haq A, Memon Z, Anser M. Attitude and practice of general dental practitioners
and other dental specialties towards pediatric dentistry in Pakistan. J Pak Dent Assoc 2022;31(1):11-15.
Received: 15 January 2021, Accepted: 08 September 2021

ediatric patients are reported to have high unmet dental needs.1 Although the prevalence of dental caries among children has dramatically seen a downwards trend in the developed countries, the prevalence remains high in many developing countries.2 Moreover, in developing countries like Pakistan the dental caries prevalence has not seen much of a decline.3 However, there are no dental surveys available at a national level.
Pediatric dentistry is a specialty that provides dental care to children from infancy till adolescence including those
with special care needs. Pediatric dentists also serve as a source of preventive dental education for the parents. Pediatric dentists treat the children in the best way possible by building a positive relation with the child, gaining their confidence and by helping them develop an overall positive dental attitude.4 Although, most pediatric dental patients are referred to pediatric dentists; general dental practitioners and dentists from other dental specialties frequently encounter young patients. The greatest challenge generally faced by these dentists while performing any dental procedure on children is achieving the cooperation of the these patients.5 Fear and anxiety invoked in children as a result of a previous traumatic experience in a dental clinic may make it difficult for the dentist to manage the child. It also makes the child more likely to avoid dental care in the future.6 The dental treatment provided to pediatric patients is often left incomplete either due to an uncooperative behavior of the child or the lack of knowledge, skills and attitude of the dentist.
      To carry out a dental treatment safely and effectively, it is often necessary to modify the child’s behavior.7
Each child exhibits a wide range of intellectual, physical, social and emotional attributes accompanied by a range of temperaments and attitudes.8 Therefore, it is imperative for a dentist to have an extensive range of behavior guidance strategies to cater the needs of each child, in addition to having the tolerance and flexibility in the implementation of these strategies.9 Moreover, the support clinical staff should be welcoming and friendly while making sure the communication carried out with the child is age-specific.10 Establishing effective communication, reducing fear and anxiety, delivering quality dental service and building a trustworthy relationship between the dentist, child and the parents inculcates a positive attitude in the child towards dental health.7
Training in pediatric dentistry at undergraduate and postgraduate level shapes the attitudes and professional
behavior of dentists in terms of treatment of pediatric patients.11 The choice of treatment modalities for involved
teeth in children differs between general dentists, postgraduate residents and consultants of various dental specialties when compared to pediatric dentists. Knowledge and skills in pediatric dental care is a much needed but frequently neglected area in dentistry in Pakistan. The general dentists should be encouraged to update and improve their skills and attitudes in dealing with young dental patients. This can be achieved by reading relevant literature, watching video presentations or by attending continuing education programs in pediatric dentistry.12
There is a scarcity of literature investigating the attitude and practice of pediatric dentistry by general dental
practitioners, postgraduate residents and consultants from different dental specialties in Pakistan. Therefore, the aim of this study was to determine the attitudes and practices of general dentists, postgraduate residents and consultants of various other dental specialties towards treatment of pediatric dental patients.

This was a cross-sectional study, conducted in Pakistan from September 2020 to November 2020, after obtaining
approval from ethical review board (ERB/SZABMU/755). A sample size of 372 was selected using WHO calculator.
An online form was distributed to more than 400 dentists fulfilling the inclusion criteria. Upon attaining the required sample size of 372 participants, data were entered into a computer for analysis. The questionnaire assessed the attitude and practices of pediatric dentistry among dentists from different specialties. Self-administered pre-validated questionnaires was derived from questions used in previous studies. Different dentists in various cities across Pakistan were approached using convenience sampling. Practicing dentists who treat children having a clinical experience of three or more years were included in our study. Those with less than three years of clinical experience were excluded from the study. Consent form was signed before filling the form and identity of the participants were kept confidential by keeping the collected data in a password protected file on the principal investigator’s personal computer. Only the principal investigator had access to the data file.
A total of 13 items for practice and four items for attitude were included in the questionnaire. All data were entered and analyzed using SPSS v 25.0. Frequencies and percentages were derived for different responses, gender and age groups. The frequency distributions between different dentists’ categories were compared using Chi-squared tests. In case where at least one expected frequency was less than five, Fisher’s exact test using Monte Carlo method was used. A p-value of less than 0.05 was considered to be significant.

A total of 372 dentists participated in this study. These included 122 (32.8%) males and 250 (67.2%) females. A
total of 89 (23.9%) of the participants were less than 25 years old. This age group primarily comprises of house officers. Moreover, 272 (73.1%) were between 25 and 35 years old. This group consists represents postgraduate trainees, young general practitioners or early career specialists. Finally, only 11 (3.0%) were above 35 years of age. This age group represents consultants/specialists and experienced general practitioners.
There were 207 general dentists; 83 dentists were specialists in Operative dentistry; 38 were Orthodontists or
Prosthodontists; while 44 were Oral and Maxillofacial surgeons. Since the Orthodontists and Prosthodontists in this
study were small in number, they were categorized into one group for the purpose of data analysis.
The frequency distribution of responses by the dentists from different specialties for the 13 items pertaining to the practice of pediatric dentistry are presented in Table #1. Except for the variable “number of pediatric patients treated
per week,” significant differences were observed between the different specialties regarding responses for the rest of
the variables. A greater number of general dentists had received training in the behavioural management of children
(n = 84, 40.6%), as compared to the other specialties. A
The frequency distribution of responses by the dentists from different specialties for the four items pertaining to the attitude related to pediatric dentistry have are presented in Table #2. A significantly greater proportion of oral and maxillofacial surgeons performed treatments under physical restraints, if a child patient showed tantrums and exhibited uncooperative behaviour (n = 29, 65.9%), as compared to other specialties. No significant difference (p>.05) in any of the other attitude-related items was reported between the specialties
Greater proportion of general dentists frequently performed pulpotomies in primary teeth as compared to other specialties (n = 35, 42,2%). Oral and maxillofacial surgeons reported frequently managing the greatest proportion of trauma patients (n = 34, 77.3%), as compared to the other specialties. A significantly greater proportion of orthodontists reported frequently practicing interceptive orthodontists (n = 11, 28.9%), as compared to other specialties. Out of the 334 dentists who were not orthodontists, only 30 (8.9%) dentists practiced interceptive orthodontics. For all other items, a significantly greater proportion of specialists in operative dentistry performed the various procedures, as compared to other specialties.

This study assessed the attitude and practice towards pediatric dentistry by general dentists, operative dentists,
prosthodontists/orthodontists and oral & maxillofacial surgeons. Operative dentists reported to be treating the greatest number of child patients regularly. Overall, only one in every four (25.3%) dentists reported treating child patients regularly. This ratio is quite alarming as it suggests that majority of the child patients are left untreated due to the lack of willingness/training of the dentists to treat them.
A similar trend was prevalent ( IN) different procedures performed on the child patients. Operative dentists reported to be more frequently performing the following procedures,as compared to other dentists: stainless steel crowns, pit and fissure sealants, fluoride varnish application, pulpectomies in primary teeth, and restorations in primary teeth. However, these frequencies are still low. Stainless steel crowns are the restorative method of choice in multi-surface lesions in primary molars. If the majority of the dentists in this study have never placed these crowns, the quality of dental health care services provided to the child population can only be expected to be poor. A great majority of the dentists do not frequently perform a procedure as basic as placing a pit and fissure sealant. Similarly, 90% of the dentists do not frequently provide preventive services such as topical fluoride application. About half of the dentists do not even frequently place simple restorations in primary teeth. All these figures suggest the dire
lack of services provided to the pediatric population of Pakistan .
Interestingly, only 25.3% of the dentists regularly treat child patients. Among operative dentists, 37.3% treat child patients regularly, which is still a low figure. Moreover, only about 36.7% of the dentists frequently perform pulpotomies in primary teeth. Also, only 19.8% of the general dentists frequently performed the routine treatment of pediatric patients. A study conducted in Karachi reported only 38% dental surgeons provide dental treatment to children.7 Similarly, a study by Thomas et al reported 46% general dentists and consultants from different dental specialties aside from pediatric dentists from Chennai, India to be apprehensive in providing healthcare to child patients,13 whereas around 79% general dentists from Kerala5 and 85% dental surgeons from Saudi Arabia were reported to treat pediatric patients on a routine basis.14 These statistics vary widely between different countries and regions and reflect the tendency among dentists to generally avoid treating child patients. While it has serious implications regarding the unmet dental needs of pediatric dental patients, it also reflects on adequacy of training in the subject of pediatric dentistry at the undergraduate level.
A very low proportion of the dentists treats pediatric patients with special care needs. A study by Aras and Dogan reported 63% of the general dentists performing incorrect or incomplete treatment and, in some cases, avoiding the treatment of young patients and patients with special care needs owing to the insufficient knowledge and training.11 A study conducted in Saudi Arabia by Halawani et al reported that around 57% of the dentists treat children with special needs.14 According to Dao et al, there is a direct relationship between education in dental care for patients with special care needs and the willingness of dentists to treat such patients as those who receive sufficient undergraduate education on the subject are more well prepared to treat children with special care needs.15 Lack of training in behavioural management techniques coupled with the lack of confidence to treat these patients are possible reasons for not treating these patients.16 Many dentists simply refer these patients to other dentists or to be treated under general anesthesia.8,17 A study conducted by McQuistan et al has shown that almost 50% of general dentists referred children younger than 3 years to pediatric dentists.18
The percentage of operative dentists (14.5%) and general dentists (13.5%) using rubber dam in children was greater than the other dentists. An overall alarming 88.4% of the dentists do not use rubber dam in children. This indicates towards extremely low usage of rubber dam in children by the dentists in our study. Roshan et al reported that 9% of dentists in the UK routinely used rubber dams in their patients and only 5% dentists used them in children.19 It is alarming that such a large number of dentists do not use proper isolation in children despite the advantages of its use. Lack of cooperation among child dental patients is a highly probable reason for dentists avoiding the use of rubber dam among
pediatric patients.20 Most pediatric patients can be effectively managed by implementing the basic behavior guidance techniques.7 In our study, overall, only 34.4% of the dentists had received any training in the behavior management of children. Behavior management in children is the most common reason dentists reject endodontic treatment in primary teeth.21 This implies a greater need for training the dentists in the behaviour management of children.
Orthodontists more frequently practiced interceptive orthodontics than other dentists. This is because of their specialty. Also, oral and maxillofacial surgeons managed dental trauma in children more frequently than other
specialties. This is also because dental surgeons generally manage trauma cases. Among the other dentists, overall only 15.9% dentists frequently managed dental trauma in child patients.
Oral and maxillofacial surgeons were more likely to treat patients using physical restraints than other specialties. This is possibly because children are most uncooperative during dental extractions than any other procedure, and oral surgeons usually perform extractions.
The majority of the dentists reported to have tried treating uncooperative children. A great majority of the participants (94.6%) were likely to attend a Continuing Dental Education (CDE) program in pediatric dentistry, if offered one. This shows that dentists generally do try to deal with pediatric patients. However, due to lack of training and expertise in managing these patients, they often fail to provide successful treatment and end up referring these patients, or even avoiding them. A study by Mathews et al. reported that around 43% dentists believed one of the barriers faced by them in treating child patients was the lack of undergraduate pediatric dentistry
This study has the limitation of recruiting a small sample size. Many of the sub-groups had a small representation. Nevertheless, the study has provided an insight into attitude and practices of general dentists and other dental specialists regarding children’s dentistry. There is a dire lack of pediatric dentistry training programs in Pakistan. Currently, there is only one MDS degree program in pediatric dentistry available in the whole of Pakistan. With a population of more than 220 million people where more than 35% of the population is
under the age of 15 years, a large proportion of the Pakistani population is currently being deprived of dental health care services. Pediatric dentistry needs to be incorporated in the undergraduate dental curriculum as an independent examinable subject. Also, CDE programs need to be organized. As evident in our study, dentists are quite keen on getting training in the basics of pediatric dentistry. However, due to lack of any such courses they are deprived of this training. Finally, more postgraduate programs need to be introduced all over Pakistan.

None declared


1. Kundu H, Patthi B, Singla A, Jankiram C, Jain S, Singh K. Dental Caries Scenario Among 5, 12 and 15-Year-old Children in India- A Retrospective Analysis. J Clin Diagn Res. 2015;9:Ze01-5.

2. Teshome A, Muche A, Girma B. Prevalence of Dental Caries and Associated Factors in East Africa, 2000-2020: Systematic Review and Meta-Analysis. Front Public Health. 2021;9:645091.

3. Taqi M, Razak IA, Ab-Murat N. Comparing dental caries status using Modified International Caries Detection and Assessment System (ICDAS) and World Health Organization (WHO) indices among school children of Bhakkar, Pakistan. J Pak Med Assoc. 2019;69:950-954.

4. Acharya S. Knowledge and attitude of general and specialist dentist in pediatric dentistry: A pilot study in Odisha, India. Indian J Dent Res. 2019;30:170-174.

5. Mathews S, Khosla E, James AR, Thenumkal E. Attitude of general dental practitioners towards child patients. Age. 2015;8(37):55.

6. Adair SM, Schafer TE, Rockman RA, Waller JL. Survey of behavior management teaching in predoctoral pediatric dentistry programs. Ped Dentistry. 2004;26:143-150.

7. Wali A, Siddiqui TM, Khan R, Batool K. Knowledge, attitude, and practices of dental surgeons in managing child patients. Int J Cli Ped Dentistry. 2016;9:372.

8. Foley J. Management of carious primary molar teeth by UK postgraduates in paediatric dentistry. Eur Arc Pae Dent. 2010;11:294- 297.

9. Al-Jobair AM, Al-Mutairi MA. Saudi dental students’ perceptions of pediatric behavior guidance techniques. BMC Med Educ. 2015;15):120.

10. Gupta A, Marya CM, Bhatia HP, Dahiya V. Behaviour management of an anxious child. Stomatologija. 2014;16(1):3-6.

11. Aras A, Dogan MS. Attitude of general dental practitioners to pediatric patients and preventive dentistry. SRM J Res Dent Sci. 2019;10:178.

12. Sheller B. Challenges of managing child behavior in the 21st century dental setting.
Ped Dentistry. 2004;26:111-113.

13. Thomas A, Moses J, Rangeeth B, Inbanathan J. Attitude of general dentist in providing dental healthcare to children-isolating the challenges. Int J Ped Rehabilit. 2017;2:19.

14. Halawany HS, Al-Fadda SAA, Al-Saeed BHK, Al-Homaied MA. The Attitude of Private Dental Practitioners Towards Treatment and Management of Children in Riyadh, Saudi Arabia. The Attitude of Private Dental Practitioners Towards Treatment and Management of Children in Riyadh, Saudi Arabia. J Pak Dent
Assoc. 2011;20: 245-49.

15. Dao LP, Zwetchkenbaum S, Inglehart MR. General dentists and special needs patients: does dental education matter? J Dent Educ. 2005;69:1107-115.

16. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. The J Am Den Assoc. 2003;134:1630-640.

17. Foley J. A pan-European comparison of the management of carious primary molar teeth by postgraduates in paediatric dentistry. Eur Arc Pae Dent. 2012;13:41-46.

18. McQuistan MR, Kuthy RA, Damiano PC, Ward MM. General dentists’ referral of children younger than age 3 to pediatric dentists. Ped Dentis. 2005;27:277-283.

19. Roshan D, Curzon M, Fairpo C. Changes in dentists’ attitudes and practice in paediatric dentistry. Eur J Pae Dent. 2003;4:21-27.

20. Duggal MS, Curzon M, Fayle S, Toynba K, Robertson A. Restorative Techniques in Paediatric Dentistry: An Illustrated Guide to the Restoration of Extensive Carious Primary Teeth. CRC Press; 2002.

21. Karthikeson P, Vignesh R. Knowledge and attitude of general dentists
and dentists of other specialties toward endodontic treatment of primary
teeth. Dru Inv Today. 2019;11(6)

Radiographic Location of Mental Foramen in Dentate Adults Visiting Dental Hospitals of Peshawar



Shamayem Safdar1             BDS, M.Phil
Momena Rashid2                BDS, M.Phil
Sadia Hassan Khan3          BDS, M.Phil
Faiza Ijaz4                            BDS, M.Phil
Syed Amjad Shah5             BDS, FCPS, FDSRCPS
Zudia Riaz6                         BDS, M.Phil



OBJECTIVES: To determine the location of mental foramen in panoramic radiographs of dentate adults in local population
of Khyber Pakhtunkhwa visiting the Peshawar dental hospital, Khyber college of dentistry and Sardar begum dental hospital,
METHODOLOGY: A cross-sectional study was conducted in outpatient department of three dental hospitals of Peshawar
from November 2018 to April 2019. A total of 280 subjects (140 males, 140 females) were included that fulfilled the inclusion
criteria. Subjects underwent the standard OPG procedure. JPEG file format of OPG images were analyzed by Adobe Photoshop
software 2008 version to analyze the location of mental foramen.
RESULTS: The mental foramen was located in class I, 0 cases (0%), class II, 11 cases (2%), class III, 295 cases (53%), class
IV, 245 cases (44%) and class V, 9 cases (1%).
CONCLUSION: The most common location of mental foramen in local population of Khyber Pakhtunkhwa was between
mandibular 1st and 2nd premolar (Class III).
KEYWORDS: Mental foramen, Panoramic radiograph, Adobe Photoshop software
HOW TO CITE: Safdar S, Rashid M, Khan SH, Ijaz F, Shah SA, Riaz Z. Radiographic location of mental foramen in dentate
adults visiting dental hospitals of Peshawar. J Pak Dent Assoc 2022;31(1):5-10.
Received: 24 February 2021, Accepted: 08 September 2021

andible is the largest and strongest bone in the human skull. It contains the teeth which is called as mandibular teeth. It consists of different part i.e., the curved part known as angle of the mandible, the horizontal part is the body of the mandible and the two perpendicular portions are the rami of the mandible. The ramus is united with the end of the body by nearly at right angle.1
The mandibular osteogenesis exists in the fibrous membrane which extent over the superior surface of the Meckel’s cartilage. With this cartilage, two cartilaginous bars of both right and left side of the mandibular arch are
For the development of the mandible, Meckel’s cartilage has a main role and at the intersection between proximal
and middle third it is closely related with the mandibular nerve also. The lingual and inferior dental nerve are the branches of the mandibular nerve. It branches off at the junction between proximal and middle third.3 On the inner surface of the cartilage, a nerve i.e., lingual nerve moves anteriorly, although the inferior alveolar nerve is present
laterally to its superior margins and it passes parallel anteriorly and terminates into two branches i.e., the mental branch and incisive branch.4
Information about the location of the mental foramen is important for many reasons. In the information aids in the administration of local anesthetic and also for any surgical procedures in this region like implant placement, mandibular osteotomies, management of mandibular fractures, management of mental neuralgia, forensic analysis, surgical extractions of mandibular premolars, endodontic treatments & for periapical surgery etc.5
For clinical and diagnostic procedures, the accurate identification of mental foramen is important. The location
of the mental foramen can be predicted visually6 , by palpation7 , topography8 , and via both conventional and digital radiographic.9,10,11,12,13,14 Panoramic radiograph is widely used for dental procedures, which helps in the initial evaluation, diagnosis, treatment planning and monitoring the efficacy of treatment.15
The most common position of mental foramen in Pakistani subjects according to study by Shah et al., 2017 in Rawalpindi and Punjabi et al., 2010 in Karachi was directly inferior to long axis of 2nd premolar.16,17 They used digital panoramic radiographs for location of mental foramen. There was no significant difference between genders of different ages according to their study.
The limitations of this study are the limited age group and findings of the study are not evenly generalized to our
population of Peshawar. Therefore, it is suggested that large cohort/ case control study should be done in our population. The aim of the study was to determine the location of mental foramen in three dental hospitals of Peshawar. The data from this study will be useful in location of mental foramen for administrating the local anesthesia for mental block, for implant placement, in endodontic treatment, and for any surgical procedures in mandibular premolar region.

The cross-sectional study was conducted in Out Patient department (OPD) of Peshawar Dental Hospital, Khyber
College of Dentistry and Sardar Begum Dental Hospital. Sample size was calculated with the help of Currie et al, 2015 by using G power v. The study group comprised of 280 patients. Both male and female gender were included, out of which 140 were males and 140 were females who required panoramic radiographs for their various dental treatments. The age range was 21-40 years. This age group was selected because premolars are fully erupted, the anatomy is preserved in this age; there is no or little attrition. As premolars erupt in 10-12 years but some time there is variation in eruption of teeth. Root completion is about 14-15 years but as there is variation in eruption, if there is delayed eruption then there will be delayed root completion, so that’s why 21-40 years of age group was selected.
The inclusion criteria are as follows: 1) Mental foramen clearly visible on both side of the mandible as seen in OPG. 2) Presence of fully erupted mandibular teeth between right mandibular 2nd premolar to left mandibular 2nd premolar. The exclusion criteria are as follows: 1) Cyst or tumor in the mandibular region. 2) History of fracture in
mandible. 3) History of an orthodontic treatment. 4) Pregnant women, physical/ mental handicapped, prisoners and other vulnerable population. 5) Missing Premolars. 6) Crowding of premolars.
Informed consent was taken from all the patients included in the study. The data of the patients were recorded on a specially designed Proforma. The standardization of the radiographs was ensured so that image parameters were set to 64-70 kv and 8-10 mA and exposure time 10-12 sec. ALARA (As Low as Reasonably Achievable) principle was
applied for reducing radiation exposure.
The analysis of the soft copy of the images of OPG was done in Adobe Photoshop 8 CS Software version 2008 by
drawing a longitudinal line joining the cusp tip and root apex of mandibular 1st and 2nd premolar. After evaluation of each panoramic radiograph, the location of mental foramen were reported on the basis of gender and symmetry (or) asymmetry. The data of the mental foramen location was recorded in the data sheets and observations was entered and analyzed using the computer program (SPSS, version 22, SPSS Corp, Chicago IL, USA). Descriptive statistics in the form of mean and standard deviation for the age and percentage relating to location of mental foramen were done.

Two hundred eighty panoramic radiographs taken for the diagnostic purposes and full filling the inclusion criteria were obtained from the OPD of three dental colleges i.e., Peshawar Dental Hospital, Khyber College of Dentistry and Sardar Begum Dental Hospital. The sample consists of equal numbers of males and females i.e., 140 males and 140 females. The mean age was 30.61 ± 5.933 (SD) (range of 21-40 years). On the basis of whole study group, the most common location of mental foramen was Class III (between the cusp tip and root apex of mandibular 1st and 2nd premolar) in 53% of cases and 2nd most common location was Class IV (directly below the cusp tip and root apex of 2nd premolar) i.e., in 44% of cases. No number of cases were found in Class I (mesial to cusp tip and root apex of mandibular 1st premolar) (Table 1) (Fig: 1).
In relation to the gender, the most frequent location in males was Class IV (directly below the cusp tip and root
apex of 2nd premolar) on right side in 51.4% cases and on left side it was Class III (between the cusp tip and root apex of 1st and 2nd premolar in 53.6% of cases. The 2nd most common location of mental foramen in males on right side was Class III (between the mandibular 1st and 2nd premolar) i.e., 45.7% and on left side, it was Class IV (directly inferior to cusp tip and root apex of mandibular 2nd premolar)
(38.6%). The least common location of mental foramen was Class V (distal to the cusp tip and root apex of mandibular 2nd premolar) on both right and left side (2.9% & 1.4%). Only 6.4% cases were found in Class II (directly inferior to cusp tip and root apex of mandibular 1st premolar) on left
side (Table 2) (Fig: 2).
In females, the most frequent location of mental foramen was Class III (between the cusp tip and root apex of 1st and 2nd premolar) on both right (52.9%) and left (56.4%) side. The 2nd most common location of mental foramen was Class IV (directly inferior to cusp tip and root apex of mandibular 2nd premolar) on both right and left side (45.7% and 41.1%).
1.4% cases were found in Class II (directly inferior to cusp tip and root apex of mandibular 1st premolar) on left side
of mandible in females. The least common location was
Class V (distal to the cusp tip and root apex of mandibular 2nd premolar) on both right and left side (1.4% & 0.7%).
Only 1.4% cases were found in Class II (directly inferior to cusp tip and root apex of mandibular 1st premolar) on left
side of mandible (Table 3) (Figure 3).
In both genders, no Class I (mesial to cusp tip and root apex of right mandibular 1st premolar) location was found.
(Table 2, 3) (Fig: 2, 3).
In relation to sides of the jaw, 49.1% of cases were found between the cusp tip and root apex of mandibular 1st and
2nd premolar (Class III) on right side and 55% cases on left side and 2nd most common location was directly inferior to cusp tip and root apex of mandibular 2nd premolar (Class IV) i.e., 48.6% on right side and 40% cases on left side. No number of cases were found on mesial to cusp tip
and root apex of right and left mandibular 1st premolar (Class I) and also on right side of mandible 0% cases were
found on directly inferior to cusp tip and root apex of mandibular 1st premolar (Class II). The least common location was distal to cusp tip and root apex of mandibular 2nd premolar (Class V) on both right and left side (2.1% & 1.1%) and 2nd most least common location was directly inferior to cusp tip and root apex of mandibular 1st premolar (Class II) on left side (3.9%) (Table: 4).

    This study determined if gender, age and side of the jaw was an important variable for the location of mental foramen. The adult dentate adults visiting Out-Patient Department of Peshawar Dental College, Khyber College of Dentistry and Sardar Begum Dental hospital. The age group of 21-40 years were selected. The time interval for the study was 6-12 months. The location of mental foramen was done using soft images of subjects OPGs using Adobe Photoshop 8 CS, version 2008.
According to the current study, the overall frequency of position of mental foramen was class III (between the cusp tip and root apex of mandibular 1st and 2nd premolar) in the radiographs of the recruited patients. According to study group it was found to be 53% (295 out of 560 both sides of Mandibular premolars teeth of both genders). According to the sides of the jaw (right and left sides) i.e., 49.1% and 55% respectively. The location of mental foramen with respect to gender on both sides (Males= 45.7% on right side and 53.6% on left side, Females= 52.9% on right side and 56.4% on left side) (Table 5.1, 5.2, 5.3, 5.4) (Fig 5.1, 5.2, 5.3). These finding are in close proximity to Abed et al (2016) who observed a prevalence rate of mental foramen position in a hospital-based population of Jeddah, Saudi Arabia18 was 57.89% of patients (total sample size of 950 panoramic radiographs). In 2015, another study conducted in 600 Iraqi patients’ panoramic radiographs by Al-Shayyab19 found out a frequency of 48.6% which in agreement to this study. In a study by Gungor et al (2006), the overall frequency of location of mental foramen was reported to be 71.5%.20 He carried out the study on selected Turkish population with a sample size of 361 panoramic radiographs. Currie et al., conducted a study on UK based population in 2015 of patients with an age group between 18-30 years showed a higher frequency of mental foramen location in both premolars’ crown (51%) and apex (76%) taking as reference point.9
Contrary to the results of this study, in 2003 by Ngeow in Malay population, 2010 by Singh in India and 2013 by
Afkhami in Iranian population reported the most common location was Class IV i.e., directly inferior to mandibular
2nd premolar (69.2%, 68.8% and 67% respectively). According to this study, on the basis of whole sample size (44%), sides (R= 48.6% and L= 40%) and gender on both right and left side (Males = 51.4%, 38.6%, Females = 45.7%, 41.4%) (Table 5.1, 5.2, 5.3, 5.4) (Fig 5.1, 5.2, 5.3). The results of right side of males only agrees with Ngeow et al., 2003, Singh et al., 2010 and the Afkhami et al., 2013.21,22,25
In the current study the Class II (directly inferior to the apex of mandibular 1st premolar) position of mental foramen was 2% of the whole sample population, according to sides 0% on right side and 3.9% on left side and with respect to gender of both right and left side was (Males = 0%, 6.4% Females = 0%, 1.4%) respectively. Our studies agree with Punjabi et al.,2010 (4.5% out of 1000 patients), Al-Shayyab et al., 2015 (2.6% of whole sample population i.e., 518 panoramic radiographs, and according to gender on both right and left side males= 1.6%, 2.7% and females= 2.3% and 3.85% respectively) and Abed et al., 2016 (0.21% out of 950 radiographs).17,18,19
Similarly, in this study Class V (MF distal to 2nd premolar) is the least common position i.e., 1% of the whole
sample population, 2.1% on right side and 1.1% on left side out of 280 panoramic radiographs and 2.9% on right side
and 1.4% on left side of males and 1.4% on right side and 0.7% on left side of females. These findings are in
concordance with those of Abed et al., (2016) (0.1%), Al-Shayyab et al., (2015) 4.9% out of 518 radiographs, 5.8%
on right side and 6.6% on left side of males’ mandible and 4.2% on right side and 2.7% on left side of females’
mandible.18,19 These findings are in contradiction to the discoveries of study done in 1998 by Mbajiorgu et al., in Zimbabwean population who observed most of their cases in Class V.24
In this study no number of cases were found in Class I (anterior to mandibular 1st premolar) which is in agreement with the study done in Iraqi population by Al-Shayyab et al 2015, in Saudi Population by Abed et al.,2016, in Karachi by Punjabi et al.,2010, Ngeow et al., 2003 and in India by Singh et al., 2010.17,18,19,22,25 (Table 5.1, 5.2, 5.3, 5.4) (Fig 5.1, 5.2, 5.3).
The variation in the frequencies of position of mental foramen among various studies may be because of the participation of different populations who displayed different frequency rates.

The most common location of mental foramen was found to be between mandibular 1st and 2nd premolar in relation to cusp tip and root apex (Class III) with respect to age, gender and side of the arch, closely followed by
Class IV presence.

I am deeply grateful to Eng. Muhammad Umer Ali for his support, Dr. Momena Rasheed and Dr. Sadia Hassan
Khan for sharing their pearls of wisdom Prof. Dr. Syed Amjad Shah for proof reading and critical analysis. Dr. Faiza
Ijaz and Dr. Zudia Riaz who moderated this paper and, in that line improved the manuscript significantly

None declared


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Modification of Existing Fixed Metallo-ceramic Screw Retained Implant Prostheses to Improve the Esthetics: A Case Report


Sheikh Bilal Badar1               BDS
Farhan Raza Khan2               BDS, MS, MCPS, FCPS


The esthetic outcome of an edentulous partial restored with dental implants depends on several anatomic and technical factors. One factor is the correct inclination of implants and /or final restorations. With implants it is possible to achieve a more esthetic outcome even after delivery of final prosthesis. This report describes an edentulous patient who was unhappy with her maxillary implant supported screw retained reconstruction. Her esthetic demand was satisfied by delivery of a new metalloceramic prosthesis with correct inclination of anterior teeth.


Dental implant, prosthodontics, Esthetics.


Badar SB, Khan FR. Modification of Existing Fixed Metallo-ceramic Screw Retained Implant Prostheses to Improve the Esthetics: A Case Report. J Pak Dent Assoc 2016; 25(1):38-40.
Receive: Accepted:


The success in implant dentistry in esthetic zone is determined by the inconspicuous results obtained with the final prosthesis1. This can be achieved with quite certainty in partially edentulous patients by obtaining direction from the adjacent dentition and manipulating the soft tissue for better emergence profile2. However, obtaining better outcome is troublesome in completely edentulous patients in which pattern of alveolar bone loss in particular affects inter arch relationship and other associated morphological changes. Thus, final prosthesis not only warrants restoration of missing teeth but also additional support for the lips to compensate for the severe hard and soft tissue loss. This can be achieved with the appropriate planning, placement and inclination of implants according to the planned prosthesis but this is not always true as position and inclination of implants might differ due to various surgical and anatomical factors resulting in reevaluation of the planned prosthesis after implant placement3. At times, the decision for final prosthesis needs to be reconsidered even after delivery of the final prosthesis; this is due to differences in outcome and expectations.

Case Report

A 54 years old diabetic female with upper and lower fixed-fixed implant supported prosthesis presented to the dental clinic in Aga Khan University with the complain that appearance of her teeth gave her an older look and she felt as if her upper lip had sunken inside. Upon detailed clinical and radiological examination, it was seen that the patient had full mouth upper and lower implant supported screw retained porcelain fused to metal prosthesis (Fig. 1). Prostheses were supported with four implants in each arch and fabricated in mutually protected occlusion with class 1 incisal relationship. The profile view of the patient showed orthognathic profile with straight relationship between upper and lower jaw but the patient was concerned about the straight profile and was seemed to be engrossed in having a convex profile with more protruded upper jaw. Since the prosthesis was screw retained it could easily be removed and replaced with the desired prosthesis. The patient was more anxious about her appearance and wanted to have procumbent upper lip, this was further confirmed by patient’s previous photographic record that showed protruded upper anterior teeth. So, the replacement of both upper and lower prostheses was advised with the suitable prostheses bulkier enough to provide additional support to soft tissues. After detailed discussion and explanation, she opted for this treatment option.

Case Management

Before initiating, the procedure was discussed again with the patient and informed consent was taken. Alginate impressions were taken before dismantling the prostheses to form a vacuum form stent. Prior to the formation of stent, minor alterations were made on the gypsum cast which was then used to form vacuum form suction down stent in the inoffice laboratory. Upper and lower prostheses were removed by unscrewing abutment screws which were then replaced with Zimmer dental temporary plastic abutments (Fig. 2). Earlier fabricated vacuum form stent was then placed in mouth and marked for openings for plastic abutment screw. Block out material was placed in cylinders of plastic abutments to prevent temporary crown material from covering the screw channel. Lubricating material was placed on gingiva to prevent the impact of setting temperature, temporary crown and bridge (bis-acryl composite INTEGRITY Dentsply Caulk, Milford, DE, USA) material was poured in the stent and was seated in the patient’s mouth. Once the material was in rubbery stage, excess material was carved away and when the provisional material was fully set, it was taken out by removing screws from the plastic abutments. Minor discrepancies left were filled with addition of temporary material and provisional bridges thus formed were carefully trimmed for excess material. Occlusion was adjusted and both upper and lower provisional bridges were then polished and placed in patient’s mouth (Fig. 3). Since marginal fit for PFM bridges were appropriate, it was planned to use the same metal framework and new ceramic work over it. Bisque trial was done for both bridges in which adjustment of occlusion and esthetic improvements were carried out to increase the pout of lips by adding more ceramic on the cervical area of front teeth and by increasing the over jet (Fig. 4). Incisal show was also increased thus giving the patient her desired esthetics. When the patient is fully satisfied with the esthetics the final prosthesis were delivered to the patient (Fig. 5).


This case report outlines a comprehensive treatment philosophy that can be used to enhance the esthetic results for patients who are not pleased with their previous treatment outcome. Clinical guidelines for esthetic outcomes are questionable as esthetics is a subjective perception that varies among different individuals and even cultures4,5. This should be kept in mind while planning for smile makeover. The goal of the treatment should not be the provision of ideal occlusion and appearance in terms of dental professionals but also the appearance that is acceptable for the patient6.

Thus, interaction among dentist, dental technician and importantly patients is essential for suitable end result7. Diagnostic wax up, photographs and other digital resources should be used to show the outcome of treatment to the patient before proceeding towards the final treatment. It will enable the patient to make expectations accordingly.

In our case, we were fortunate that the final implant supported prostheses were screw retained that enabled us to completely retrieve the prosthesis. We made necessary changes on temporary bridges as needed by the patient and after patient’s full acceptance to the esthetic outcome we, then, transferred the desired esthetics to the final PFM prosthesis.


Option for screw retained implant prosthesis should be employed in cases with questionable esthetics so that relevant changes can be made according to the patient’s desire and treatment plans should be more directed by the patient.


  1. Mitrani R, Adolfi D, Tacher S. Adjacent implant-supported restorations in the esthetic zone: understanding the biology. Journal of esthetic and restorative dentistry : official publication of the American Academy of Esthetic Dentistry [et al]. 2005; 17(4): 211-22; discussion 22-3.
  2. Levin BP, Rubinstein S, Rose LF. Advanced Esthetic Management of Dental Implants: Surgical and Restorative Considerations to Improve Outcomes. Journal of esthetic and restorative dentistry : official publication of the American Academy of Esthetic Dentistry [et al]. 2015; 27(4): 224-30.
  3. Kourtis S, Kokkinos K, Roussou V. Predicting the final result in implant-supported fixed restorations for completely edentulous patients. Journal of esthetic and restorative dentistry : official publication of the American Academy of Esthetic Dentistry [et al]. 2014; 26(1): 40-7.
  4. Machado AW. 10 commandments of smile esthetics. Dental press journal of orthodontics. 2014; 19(4): 136-57.
  5. Sukhia RH, Khan M, Fida M, Shaikh A, Azam SI. Esthetic preferences for facial soft tissue profiles. International journal of orthodontics. 2011; 22(3): 17-23.
  6. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics : current principles & techniques. St. Louis: Elsevier Mosby; 2005.
  7. Camilotti V, Zambonato C, Bosquiroli V, Busato PdMR, da ROSA AC, Mendonça MJ. Planning the esthetic smile: a case report. Revista de Odontologia da UNESP. 2011; 40(3): 148-53

    1 Resident, Operative Dentistry, Aga Khan University Hospital, Karachi, Pakistan
    2 Consultant, Operative Dentistry, Aga Khan University Hospital, Karachi, Pakistan
    * Corresponding author: “Dr. Farhan Raza Khan” < >