Vol. 25 No. 02 Apr-Jun 2016

Muhammad Salman Rashid1 – BDS
Irfan Ali2 – BDS, FCPS
Zia Ur Rahman Khan3 – BDS, MFDS RCPSG
Sharjeel Bashir4 – BDS
Syed Mahmood Haider5 – BDS, MSc, FFDRCSI, FDSRCS
Nabeel Haider6 – BDS, MFDS RCSEd
Muhammad Aqeel Aslam7 – BDS, MFDS RCSEd
Abdul Hadi Bashir8 – Pharm-D

INTRODUCTION

The main aim of oral hygiene practices is to prevent diseases of oral hard and soft tissues. Tooth brushing, use of fluoridated toothepaste and flossing play a major role in prevention of oral health related disorders1, 5.

Oral diseases are clearly related to behavior, and during past two decades the prevalence of dental caries and periodontal disease has decreased with improvements in oral hygiene and a decrease in the consumption of sugar products1 . Irrespective of this improvement it is important to know about the attitudes of oral care providers of the future. While the improvements in the oral health status may also reflected in the attitudes of dental students towards oral hygiene. On the contrary, studies show a lack of positive attitude of dental students. A study reported a higher frequency of brushing and dental visits of dental students when compared to dental hygiene students2 . A similar study from China reported an improvement in the oral health related attitude of dental students from first to final year, while contrasting results were reported for medical studetns3 .

A study from Nigeria reported overall unsatisfactory oral hygiene of dental students7 . While a study from Japan suggested that majority of study participants started smoking after joining the university8 .

Another study also reported poor attitudes of dental, medical and paramedical students.4. This seems to be an alarming situation since the health care providers of the future seems oblivious of the importance of a healthy mouth. Since a similar local study could not be found in the literature, therefore the aim of this study was to compare the oral health attitude amongst medical and dental students of various medical and dental institutes of Karachi.

METHODOLOGY

A cross-sectional questionnaire based study was conducted at various dental and medical institutes of Karachi over a period of 6 months (April – September 2009). The study was reviewed and approved by the Ethical Committee of Karachi Medical and Dental College (KMDC). All the undergraduates were included in the study, while Post-graduates, house officers, senior house officers were excluded. Informed consent was taken from each student before questionnaire distribution. The questionnaire was circulated amongst 1100 students of public and private sector medical and dental institutes of the city enlisted in Table 1. The questionnaire was self-administered consisting of 15 questions related to oral health attitude were distributed. It is filled by total 1100 students of respective institutes. Students were requested to fill the questionnaire without any discussion with other classmates. They took an average of 5 minutes to complete the questionnaire. The data collected was analyzed with statistical package for social science (SPSS) version 14 using Chi Square test of associations. A p value of less than 0.05 was considered statically significant.

RESULTS

Table 2 displays the basic information about our study respondents.

Table 3 gives details of oral hygiene practices. It revels that medical students are more frequent with tooth brushing (92.7%) than dental students (87%), while dental students have more accurate brushing technique (64%) than medical students (25%) (p= 0.001). Other adjuncts like mouthwash, miswak or dandasa were more frequently practiced by dental students (49%) for better oral health maintaining than medical students (27%) (p = 0.001).

Medical students are less aware of dental visit (57%) and have more complained of bleeding gums (20%) than dental students (68% and 14% respectively). The result also reveals that females are more frequent with brushing (91%) and aware of dental visits (64.2%) than males (90.4% and 53% respectively) (p= 0.001). Fig. (1) presents graphically oral
health attitude variables. Pre-Clinical students brush (92%) their teeth more regularly than clinical students (88.1%), while the clinical students had better knowledge of correct brushing technique (62%) and were more likely to utilize other adjuncts (44%) (p = 0.001). Dental visits were seen more frequent in clinical students (75%) as compared to pre-clinical students. Similarly clinical students reported higher frequency of smoking (9.9%) habit while pre-clinical students had less smoking habits (4.3%) (p= 0.001). The pre-clinical students had more frequent bleeding gums (20.5%) and tooth sensitivity (15.8%) while they are less frequent with pan(3.3%) and betel nut chewing (9.4%) in comparison with the clinical students (5.1% and 9.5% respectively) (p = 0.001). Significantly more clinical students (14.3%) complained of bad breath than pre-clinical students (7.3%) (p = 0.001).

DISCUSSION

According to a WHO report, the disease pattern is ever changing and it may be related to an individual’s lifestyle and attitudes. 6. These attitudes become engraved in one’s personality at an early age. Regardless, the health professional students are expected to have a reasonable self -hygiene and a more favorable attitude towards personal well been as compared to other 10.

This study revealed a higher percentage of students (92% of medical and 87% of dental students) brushed as compared to a similar study conducted in Islamabad which reported only 72.6% dental students brushed their teeth 1. Kaira et al. in a study on nursing student reported 70% of the respondents
brushed their teeth19. 1,20. Mumtaz et al. in a study of oral health knowledge and attitude among dental and pharmacy students revealed 46% use of mouthwash which is similar to our results1, 11.

Under the influence of knowledge and attitude of oral health, the present study showed about 3.7% dental students were found to be indulged in smoking which was 2.5 times less than medical students. This was much lesser than national statistic of 34%21, and as well as current statistic of smoking amongst dentist in Pakistan which was 20.1%22. At students level of awareness about 4.7% of students have been reported in utilization of half packet of cigarettes as they know smoking has hazardous impact on general body health (1, 12). Females were found to be more aware of correct brushing technique (40.2%) in our study. These results are similar to a study from Nigeria Okeigbemen et al., who revealed about 33% of females reported using the correct way of brushing in comparison to males (21%) 7. In term of visits to dentists females (64.2%) reported more interest as they may be motivated by a higher demand for better aestthetics. The clinical students reported more interest to learn the correct way of brushing (62%) than pre-clinical students (30.5%), and about 11 % of clinical students brush their teeth before going to bed while 5 % of pre-clinical students reported this habit. These results are similar toa recent report7.

It is clear from the study that medical students in particular should be given more knowledge of oral health behavior and pre-clinical students should have to be guided so that they can know correct oral health behavior and attitude. Measures should be taken so that students may have better insight about oral health. Steps should be taken to minimize the use of tobacco and betel nuts among students because they are the source of motivation of oral health to their patients, friends and family. Other studies have also shown that there is in general much work to do in improving dental health knowledge even amongst dental hygiene students, dental students, and other university students14-18.

CONCLUSIONS

Within the limitations of this study Medical students (5.7%) more aware of oral hygiene as compared to dental students (p=0.001). In relation of hygiene females had better dental health than males and they visit 11.2% more frequently to visit dentist as compared to males. In summary, clinical students have more knowledge than pre- clinical students regarding dental hygiene. Medical students, female gender and students in clinical rotations had better attitude towards own oral health and hygiene.

AUTHORS’ CONTRIBUTION

Dr. Muhammad Salman Rashid gives the main research proposal and intervention to this research.
Dr. Irfan Ali helped out in manuscript writing.
Dr. Zia Ur Rahman Khan took part in methodology.
Dr. Sharjeel Bashir wrote discussion and conclusion and reviewed the article.
Dr. Syed Mahmood Haider reviewed the article.
Dr. Nabeel Hafeez helped in data collection.
Dr. Muhammad Aqeel Aslam helped in data collection and data entry.
Dr. Abdul Hadi Bashir helped in data collection, data entry and statistical analysis.

DISCLOSURE

Declared none.

ACKNOWLEDGMENTS

We would like to thanks the students of the following institutes:
 Karachi Medical & Dental College,
 Fatima Jinnah Dental College
 Jinnah Medical & Dental College
 Altamash Dental Institute,
 Liaquat College of Medicine & Dentistry,
 Aga Khan University
 Dr. Isharat-ul-Ibad Institute of Oral & Health Sciences
 Sindh medical college
 Dow University of Medical & Health Sciences
 Hamdard University

REFRENCES

1. 1.  Mumtaz R, Attaullah, Khan A. A Comparative evaluation of oral health knowledge, attitudes and practices of dental and pharmacy students of Riphah international university. Pak Oral Dent J 2009; 29:(1) 137-140
   2. AL –Wahdani, A.M, AL –Omiri, M.K, Kawamura, M: Differences in self reported oral health behavior between
      dental students and dental technology/ dental hygiene students in Jordan. Oral Sci 2004; 46: 191-97
   3. Rong, W. S. Wang, W. J. Yip, H. K.: Attitudes of dental and medical students in their first and final years of undergraduate study to oral health behavior. Eur J Dent Edu 2006;10:(3) 178-81
   4. Usman S, Bhat S, Sargod SS. Oral health knowledge and behavior of clinical medical, dental and paramedical students in Mangalore. J Oral Health Comm Dent. 2007; 1: 46-48
   5. Lang, W., Farghaly, MM., Ronis, DL. The relationship of preventive dental behaviors to periodontal health status. J Clin Periodontol 1994; 21(3):194-98.
   6. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003 Dec 1;31(s1):3-24.
   7. Okeigbemen S, Ohre R: Self- reported oral health behavior and perceived treatment needs of dental students in Benin city, Nigeria. Pak Oral Dent J 2007; 27(2): 229- 232.
   8. Furukawa S, Tokunaga R, Abe S, Shinada K , Kawaguchi Y: Dental students , smoking behaviour and their attitudes towards smoking. Kokubyo Gakkai Zasshi . J Somatological Society Japan 2005; 72 (3): 201-208.
   9. Kumar S, Kriplani D, Shah V, Tadakamadla J, Tibdewal H, Duraiswamy P, Kulkarni S. Oral health attitudes and behaviour as predisposing factor for dental caries experience among health professional and other professional college students of India. Oral Health & Prevent Dent. 2010; 1: 8(2).
   10. 10. Stypułkowska J, Łyszczarz R, Wichliński J, Pawłowska K, Solska-Kuczerek A. Oral health state in dentistry students of medical college, Jagiellonian University in Cracow . Pregl Lek . 2003; 60 suppl 6: 122-05.
   11. Duckworth RM, Horary C, Huntingkon E, Mehta V: Effects of flossing and rinsing with a fluoridated mouthwash after brushing with a fluoridated toothpaste on salivary fluoride clearance. Caries Res 2009; 43: 387-390.
   12. Doll R, Hill AB: Smoking and carcinoma of the lung a preliminary report. Br Med J .1950; 2: 237-48.
   13. Dabroska E, Lethoko M, Roszkowska JW, Lethoko M, Sadowski J: Effect of chlorohexidine mouthwash on Cathepsin C activity in human saliva. Adv. Med Sci 2005; 51: 96-99.
   14. Wynder EL, Graham EA: Tobacco smoking is a possible risk factor in broncogenic carcinoma . J Am MedAssoc. 1950; 143: 329-36.
   15. Kim K-J, Komabayashi T, Moon S-E,Goo K-M, Okada M ,Kawamura M: Oral health attitudes / behaviour and gingival self- care level of Korean dental hygiene students, J Oral Sci 2002; 43: 49-53.
   16. Kawamura M, Honkala E, Widtrom E, Komabayashi T: Cross-cultural differences of self reported oral health behavior in Japanese and Finnish dental students. Int Dent J 2000; 50: 46-50.
   17. Murtomma H, Turtola L, Rytomma I: Dental health practice among Finnish university students. Proc Fin Dent Soc 1989; 80: 155-161.
   18. Astrom AN, Masalu JR: Oral health behavior patterns among Tanzanian university students. BMC Oral Health 2001; 01: 01-12.
   19. Kaira LS, Srivastava V, Giri P, Chopra D. Oral healthrelated knowledge, attitude and practice among nursing students of Rohilkhand Medical College and Hospital. J Orofac Res. 2012 25; 2:20-3.
   20. ADA, American Dental Association www.ada.org accessed on 5th August 2008.
   21. Nishter S, Mirza Z, Mohamud KB, Latif E, Ahmed A, Jafarey NA. Tobacco Control: National action Plan for NCD Prevention, Control, and Health Promotion in Pakistan. J Pak Med Assoc 2004; 54(suppl 3): S9-S13.
   22. Mumtaz, R., Khan, A.A., Moeen, F., Noor, N., Humayun, S. Role of Pakistani Dentists in Tobacco Cessation. Int Dent J 2008; 58(6): 356-62.

1. Operative Dentistry, De Montmorency Collage of Dentistry, Lahore, Pakistan
2. Assistant Professor Oral and Maxillofacial Surgery Dept, Bhitai Dental and Medical College, Mirpurkhas, Pakistan 3. Assistant Professor, Department of Oral Medicine, Fatima Jinnah Dental College, Karachi, Pakistan
4. M.S Oral Surgery, Abbasi Shaheed Hospital, University of Karachi, Karachi, Pakistan
5. Professor, Head of Oral and Maxillofacial Surgery and Vice Principal of Karachi Medical & Dental College, Karachi, Pakistan
6. Senior Registrar Oral and Maxillofacial Surgery Dept., Muhammad Bin Qasim Medical and Dental College, Karachi, Pakistan
7. Assistant Professor, Department of Oral Medicine, Bhitai Dental and Medical College, Mirpurkhas, Pakistan

8. Federal Urdu University, Karachi, Pakistan
Corresponding author: “Dr. Sharjeel Bashir” < drsharjeelbashir@yahoo.com >

Muhammad Salman Rashid1 – BDS
Irfan Ali2 – BDS, FCPS
Zia Ur Rahman Khan3 – BDS, MFDS RCPSG
Sharjeel Bashir4 – BDS
Syed Mahmood Haider5 – BDS, MSc, FFDRCSI, FDSRCS
Nabeel Haider6 – BDS, MFDS RCSEd
Muhammad Aqeel Aslam7 – BDS, MFDS RCSEd
Abdul Hadi Bashir8 – Pharm-D

Shoaib Razi1                                              BDS
Samia Ghulam Muhammad^{2                 MBBS
Haroon Rashid3                                              BDS, MDSC}

INTRODUCTION

The changes that occur in a pregnant female are due to an increase in maternal and fetal requirements for the growth of the fetus and the preparation of the mother for deliver. Several systemic, as well as local physiologic changes in a pregnant woman occur at the time of pregnancy a substantial rise in secretion of estrogen and progesterone is seen by up-to 10 and 30 folds respectively. Also about 45% of females have gestational diabetes because pregnant women are unable to produce sufficient amounts of insulin to overcome the antagonistic action of estrogen and progesterone1,2. These hormonal changes affect most of the organ systems and oral cavity is not exempted from it. Within the oral cavity, bacterial flora changes with the change in hormone levels and these changes support the occurrence of pyogenic granulomas and disease process in periodontium3. A Pregnant woman requires various levels of dental support throughout this time and the dentists therefore must understand the requirement of the pregnant patient and improvise the treatment plan and should not perform those procedures which could require multiple dental radiographs and medications which could be harmful to the fetus unless it is an acute infection and cannot be deferred4,5.

CHANGES TO THE ORAL CAVITY DURING PREGNANCY

Gingivitis and pregnancy associated hyperplasia are the common mucosal changes observed. Pyogenic granulomas and changes in the saliva have been reported and are related to the elevated levels of estrogen causing an increase in the formation and permeability of blood capillaries. This increase leads to accumulation of inflammatory factors6. Pregnancy actually aggravates pre-existing diseases rather than causing it. A characteristic lesion of periodontium that appears is pregnancy epulis, a type of pyogenic granuloma which is characterized by a dark red, swollen and smooth gingival which bleeds easily7,8. Due to an increase in salivary estrogen levels, the proliferation and desquamation of the oral mucosal cells provide a suitable environment for bacterial growth which also predisposes the pregnant woman to dental caries9 . It has been theorized that the endotoxins from periodontal inflammation are risk factors and cause a stimulation of the production of cytokines and prostaglandins (IL-1β, IL-6, and TNF-α) 10. Such pro-inflammatory mediators could cross the placenta barrier and may induce fetal toxicity that can result in preterm delivery and low-birth-weight11. Chemical mediators of maternal periodontitis have also been reported as a strong risk factor of preterm low birth weight and improving periodontal health before or during pregnancy may prevent or reduce the occurrences of adverse pregnancy outcomes and therefore, reduce the maternal and perinatal morbidity and mortality but such cause to effect is yet to be proven as no such relationship has been established between periodontal disease and preterm low birth weight12.

RADIOGRAPHY AND CHAIR POSITIONING

It is advisable that during the first trimester, oral health status is assessed and the patient is informed about the changes which they might encounter during the pregnancy. Guidance about the management of these changes should also be outlines, if they take place. Patients must be educated and the dental treatment if possible, should be restricted to prophylaxis and emergency treatment where possible. Dental radiography is considered safe during pregnancy if protective measures have been provided such as thyroid collar, Lead apron and use of high speed E films. No fetal abnormalities have been reported to x-ray radiation values 5-10 cGy and a complete set of full mouth radiographs results in only 8 × 10–4 cGy13,14. The greatest risk to the fetus of teratogenicity and death, is during the first 10 days after the conception. Spontaneous abortions have been reported in the literature during first trimester when dental treatment were received by the patient15,16. Organogenesis is completed by the end of first trimester and the second trimester is reported to be the safest time to carry out minor elective dental treatment, but dental emergencies such as acute pain and infections should be addressed at any stage of pregnancy to avoid patient discomfort. Treatment that are time consuming and require any elective surgical intervention must be postponed until delivery has taken place17.

Dental chair position should be controlled and monitored while working because when uterus expands it lies right over dorsal aorta and vena cava. There is a chance that these may get compressed when patient is in supine position leading to decreases in cardiac output, venous return and uteroplacental blood flow. An Aotrocaval compression leads to supine hypotensive syndrome which is clinically characterized by weakness, lightheadedness, restlessness, sweating, pallor and tinnitus. Such condition is managed by having the patient turn on her left side and placing a pillow to elevate her right hip and buttock by about 15°. During the second month of the third trimester, strict pre-cautions should be taken procedures should be deferred where possible.

The rest of the period of the third trimester is safe for elective dental procedures that do not require surgical intervention. Protocols for dental radiography are the same as for first trimester and peri-apical and bitewing radiographs can be taken with protection protocols15,18.

PRESCRIBING MEDICATIONS TO PREGNANT PATIENTS

During pregnancy the serum plasma concentration is reduced, there is higher lipid solubility and low plasma half-life thus, the prescribed drugs are easily absorbed, distributed and cleared from the system as compared to a non-pregnant individual. These factors increases the transfer of drugs from mother to fetus via placenta which can culminate and cause potential miscarriage, low birth weight, neonatal toxicity and teratogenicity which intensifies the chances of morbidity and mortality of the unborn child19-22. FDA has classified drugs on basis of risk to mother-fetus during pregnancy into various categories (Table 1).

Antibiotics

When prescribing antibiotics to a gestational woman, amoxicillin and penicillin V are the safest and the most common drugs and are classified as class B. Tetracycline and Doxycycline are categorized class D because of their side effects on teeth and bone development. Arthopathy and congenital cartilage defects are found in animals with use of Ciprofloxacin but there are not sufficient evidence among human studies thus categorized as class C23 (Table 2).

Analgesics

Paracetamol (Acetaminophen) is a relative safer drug for pain management of a pregnant patient as compared to Aspirin and has no negative effects reported so far but prolong use of acetaminophen with narcotics have shown neonatal respiratory depression24. There is a risk with the use of acetaminophen of livers toxicity in adults and dosage should not exceed more than 4gm/day. Most of the analgesics which are prescribed to normal adults are categorized as class C for pregnant patients however there use is not absolutely contraindicated as there are no studies reflecting that they effect fetus but use of Class C drugs should be of short duration. Ibuprofen has been associated with fetal ductus arteriosus and inhibition of labor in third trimester thus categorized as class D but for first and second trimester its categorized as class B25 (Table 2).

Local Anesthetics and Vasoconstrictor

Local anesthetic agents can be used and Lidocane 2%, Prilocane and Etidocane are classified by FDA as safe anesthetic agents but there use should be monitored and should not exceed maximum recommended dose. Mepivicane 3%, Procaine and Articane can be used with caution with the consent of obstetrician and should be avoided if any alternate is available26-28. Epinephrine is a class C drug, theoretically if injected intravenously it might impede uteroplacental blood flow, which can be avoided by slowly injecting local anesthesia using aspirating needle and limiting to a minimum dose required (Table 2).

RESTORATIVE CONSIDERATIONS

ADA, FDA and WHO have classified amalgam restorations to be safe for pregnant patients requiring cavity restorations even though the dental community is uncertain about the use of dental amalgam. It has mercury which is a metal alloy, consisting of 50% of organic mercury. Dental amalgam fillings release mercury vapors (a form of inorganic mercury) in the oral cavity especially during chewing. As a result, mercury could cross the placental barrier through blood circulation. However; no such evidence has been found or is yet to be reported that it is harmful during the pregnancy and many concerns can be effectively managed with the application of dental rubber dam during restorative procedures29. Composite resins and glass ionomer cements can also be used for treatment however; bisphenol-A, a component found in composite resins, has reportedly caused endocrine disruptions in animals30,31.

Procedures which require gingivectomy should be done with caution and could raise a concern for a dentist while treating the patient as it may lead to bacteremia. Studies do not provide sufficient evidence to support the concern but pregnant patients may be given prophylactic antibiotic coverage if there is risk of developing infective endocarditis32. In a controlled clinical trial, 1806 women were randomized to receive scaling and root planning. Those patients who were assigned to get delayed periodontal treatment until after birth showed a worsening of their periodontal status over the course of pregnancy. However; no significant correlation could be established between groups who had birth complications in relation to periodontal infection and the treatment provided for the disease. Nevertheless periodontal therapy should be provided either antenatal or during a safe pregnancy period and should be restricted to supra gingival scaling and polishing where possible33.

CONCLUSIONS

It is important that a Dentist-Obstetrician-Patient interface is well established while formulating a treatment plan for pregnant patients so that the chances of complications can be significantly reduced for a better outcome. It is necessary that health professionals collaborate to ensure that such patients receive thorough oral health assessment, intervention as well as oral health education. The dentist must gain basic understanding of the physiological changes and influences that may occur during pregnancy with the use of certain medications and dental radiography. Oral and maxillofacial surgeons may be consulted in case there is an emergency involving trauma and severe dental infections. Active treatment should be focused toward improving the maternal oral and general health while minimizing the fetal risk.

DISCLOSURE

None declared.

REFERENCES

1. Tracy M, Dellinger H. Mark Livingston. Pregnancy: Physiological changes and considerations for dental patients. Dent Clin N Am. 2006; 50: 677-97.
2. Clark SL, Cotton DB, Lee W, Bishop C, Hill T, Southwick J. Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 1989; 161: 1439-42.
3. Mabie WC, Di Sessa TG, Crocker LG. A longitudinal study of cardiac output in normal human pregnancy. Am J Obstet Gynecol 1994; 170:849-56.
4. Turner M, Aziz SR. Management of the pregnant oral and maxillofacial surgery patient. J Oral Maxillofac Surg.
   2002; 60:1479-88.
5. Suresh L, Radfar L. Pregnancy and lactation. Oral Surg Oral Med Oral Pathol. Oral Radiol Endod. 2004; 97: 672- 82.
6. Soory M. Hormonal factors in periodontal disease. Dent Update. 2000; 27:380-83.
7. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60:257-64.
8. Laskaris G. Color Atlas of Oral Diseases. Athens:Litsas; 1998. p. 502-504.
9. Kurien S, Kattimani VS, Sriram RR, Sriram SK, Rao VKP, Bhupathi A, Bodduru RR, Patil NN. Management of Pregnant Patient in Dentistry. J Int Oral Health 2013; 5:88- 97.
10. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective study. J Am Dent Assoc. 2001; 132: 875-80. [PubMed]
11. Yeo BK, Lim LP, Paquette DW, Williams RC. Periodontal disease – the emergence of a risk for systemic conditions: Pre-term low birth weight. Ann Acad Med Singapore. 2005; 34: 111-16.
12. Parihar AS, Katoch V, Rajguru SA, Rajpoot N, Singh P, Wakhle S. Periodontal Disease: A Possible Risk-Factor for Adverse Pregnancy Outcome,J Int Oral Health. 2015; 7:137-42.
13. National Council on Radiation Protection and Measurements. Recommendations on limits for exposure to ionizing radiation. Bethesda, Md. NCRP, 1987. NCRP report no. 91.
14. Katz VL. Prenatal care. In: Scott JR, Gibbs RS, Karlan BY, Haney AF, editors. Danforth’s obstetrics and gynecology. 9th ed. Philadelphia: Lippincott, Williams and Wilkins; 2003. p. 1-20.
15. Thornburg KL, Jacobson SL, Giraud GD, Morton MJ. Hemodynamic changes in pregnancy. Semin Perinatol 2000; 24:11-4.
16. ADA Council of Scientific Affairs. An update on radiographic practices: information and recommendations. J Am Dent Assoc. 2001; 132: 234-38
17. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 7th ed. St. Louis: CV Mosby; 2008. p. 268-278, 456
18. Singh M. The pregnant dental patient. J Mass Dent Soc. 2012; 60:32-34.
19. Hashim R. Self reported oral health, oral hygiene habits and dental service utilization among pregnant women in United Arab Emirates. Int J Dent Hyg. 2012; 10:142-46.
20. Patcas R, Schmidlin PR, Zimmermann R, Gnoinski W. Dental care in pregnancy. Schweiz Monatsschr Zahnmed. 2012; 122:729-39.
21. Chaveli Lopez B, Sarrion Perez MG, Jimenez Soriano Y. Dental considerations in pregnancy and menopause. J Clin Exp Dent. 2011;3(2):e135-44.
22. Achtari MD, Georgakopoulou EA, Afentoulide N Dental care throughout pregnancy: what a dentist must know. Oral Health Dent Manag. 2012 Dec; 11:169-76.
23. Giglio JA, Lanni SM, Laskin DM, Giglio NW: Oral health care for the pregnant patient. J Can Dent Assoc. 2009; 75:43-48.
24. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 7th ed. St. Louis: CV Mosby; 2008. p. 268–278, 456.
25. Organization of teratology Information Specialists. Ibuprofen and pregnancy. Available: www.otispregnancy.org/pdf/Ibuprofen.pdf (accessed 2008 Nov 10)
26. US Food and Drug Administration. Labeling and prescription drug advertising: Content and format for labeling for human prescription drugs.
27. Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc. 2002; 68:546-551.
28. Yagiela JA. Local anesthetics. In: Dionne RA, Phero JC, Becker DE, editors. Management of Pain and Anxiety Control in the Dental Office. Philadelphia, PA: WB Saunders; 2002. p. 78-96.
29. Bates MN, Fawcett J, Garrett N, Cutress T, Kjellstrom T. Health effects of dental amalgam exposure: a retrospective cohort study. Int J Epidemiol. 2004; 33:894-902.
30. Olea N, Pulgar R, Perez P, Olea-Serrano F, Rivas A, Novillo-Fertrell A, et al. Estrogenicity of resin-based composites and sealants used in dentistry. Environ Health Perspect. 1996; 104:298-305.
31. Megan K. Kloetzel, MD, MPH, Colleen E. Huebner, PhD, MPH, and Peter Milgrom, DDS Referrals for Dental Care During Pregnancy. J Midwifery Womens Health. 2011 Mar; 56:110–117.
32. New York State Department of Health (NYSDH). Oral Health Care During Pregnancy and Early Childhood. Practice Guidelines. New York, NY: NYSDH; 2006. Available from: http://www.health.state.ny.us/ publications/0824.pdf
33. Offenbacher S, Beck JD, Jared HL, Mauriello SM, Mendoza LC, Couper DJ, et al. Effects of periodontal therapy on rate of preterm delivery. A randomized controlled trial. Obstet Gynecol. 2009; 114: 551-9.

1. Division of Prosthodontics, Faculty of Dentistry, Ziauddin University, Karachi, Pakistan.
2. Department of Gynecology & Obstetrics, Lady Dufferin Hospital, Karachi, Pakistan.
3. Division of Prosthodontics, Faculty of Dentistry, Ziauddin University, Karachi, Pakistan.
Corresponding author: “Dr. Haroon Rashid” < drh.rashid@hotmail.com >

Shoaib Razi1                                              BDS
Samia Ghulam Muhammad^{2                 MBBS
Haroon Rashid3                                              BDS, MDSC}

Farhan Raza Khan1               BDS, MCPS, MS, FCPS

Syed Sheeraz Hussain2        BDS, MCPS, DCPS, FCPS

In Pakistan, there are few regulatory bodies that govern the education and training of health care providers at different levels. These include Pakistan Medical & Dental Council (PMDC), Higher Education Commission (HEC) and College of Physicians & Surgeons of Pakistan (CPSP). There are other authorities which regulate the provision of health care services to patients visiting public and private hospital. These include service monitoring wing of PMDC, ministry of health at federal and provincial levels and health department at local government level.

An important development that has recently been observed in provinces of Punjab and Khyber Pakhtoon Khwa (KPK) is the development of Provincial Health Care Commission (PHC). This is a new player in the game of Pakistan’s health care scenario. The main objective of forming provincial health commission in these two provinces was to fill the vacuum in the existing system of health care provision.

Traditionally, the mandate of PMDC was to regulate the undergraduate medical and dental education, register the physicians and dentists as the sole statutory body and ensure patient safety and rights. However, the volume of work at PMDC for overseeing curriculum and standards of teaching and training at over 98 medical and dental institutions across Pakistan is overwhelming.1 Moreover, monitoring a huge number of 185,000 medical practitioners and 17,000 dental practitioners is a mammoth task in itself.

The above responsibilities has made PMDC so engaged that it has left with no manpower to oversee the quality of care offered at various health care facilities especially medical & dental colleges and their affiliated hospitals. Although, PMDC does have a formal system in place to resolve the complaints against medical or dental practitioners where it explore the nature of a complaint by a person or body charging the practitioner with infamous conduct in any professional respect or professional negligence etc. But in reality, the tortuous procedures make it difficult to investigate the incidents and penalize the guilty. The existing system is biased towards quality of care assessment and ignores the quality of care assurance.

Following is the mandate of the newly formed PHC:

1) Regulation of health care service through registration and licensing of the health care “establishments” (this is important as PMDC focuses at standards of teaching along with registration and licensing of individual health care providers but not the establishments where health care is actually given).

2) Development of standards for different categories of health care establishment. Like hospitals and medical practitioner’s clinic, a dental surgery clinic is a health care establishment too.

3) Management of Complaint of both patients and health care establishments.

4) Eradication of quackery.

Since, PHC has been established with an act of the parliament thus, it has the legal power to exercise its mandate. It’s obvious that the jurisdiction of PHC is not confined to public and private hospitals but it extends to all medical and dental clinics, NGO run clinics, trust hospitals, charitable hospitals, health camps, nursing homes, laboratories, diagnostic centers, homeopaths office, Hakeem’s’ matab, physiotherapy centers and acupuncture facilities in Pakistan. In other words, Pakistan Nursing Council (PNC) and PMDC will now focus on the education, training and practice of the health care personnel while PHC will oversee the patient care and organizational management of the health care premises. Presence of PHC in two provinces has created a disparity in the country. Absence of such body in Sindh and Baluchistan is a big question mark. There is no authority in the entire province of Sindh that can oversee the quality of care offered at the dental practices. The most neglected strata are the subjects who get dental treatment done at dental college hospital. The student and trainee dentists develop their skills by working on these patients. Although, this learning of skills is supposedly a supervised activity but with limited number of specialists faculty in dental disciplines, the most part of service is largely unsupervised. If a PHC is established in Sindh, a proper authority for surveillance, check and balance would be available which can protect dental patients’ right.

The implication of PHC has a great significance on the dental practice in the future. All dentists should ensure that they maintain a validated practice license with PMDC and get their clinic registered with PHC. This will actually provide a legal immunity to the dentist against prosecution, should a legal suit arises. Moreover, accreditation with PHC will provide legitimacy to the dentist for the fee he/she charges for delineated procedures. However, as dental professionals, we all need to work on the organizational management of our clinics especially in the areas of quality improvement, facility management and safety, information management system, infection control, patients’ rights/ education and overall care of the patients.

REFERENCE

1. http://www.pmdc.org.pk/Statistics/tabid/103/Default.aspx

1. Operative Dentistry, Aga Khan University & Hospital, Karachi, Pakistan
2. Orthodontics, Karachi Medical & Dental College, Pakistan
Corresponding author: “Dr. Farhan Raza Khan” < farhan.raza@aku.edu >

Hafsa Khalid Mahida1               BDS

After healthcare delivery, the ultimate outcome of all our clinical endeavors is the documentation of our work in writing. This may be through researches, case-studies and various other forms of manuscripts. Hence preparing a future doctor for this responsibility is necessary especially in the era of evidence-based practice. For someone embarking on the journey of scientific scripture, a great way to begin medical writing is by writing letters to the editor in scientific journals1 .Thereare numerous reasons as to why this is beneficial.

THE ENGLISH DILEMMA

Scientific writing is predominantly in the English language, a second language to a lot countries including ours2. Given the disparity in the systems of basic education not all medical professionals are proficient in English. Scientific writing thus comes as a struggle to most practitioners of our region. It becomes somewhat problematic when they script their research articles thus creating a writing-inertia. Since letters-to-theeditor are the easiest in the hierarchy of non-research publications, they are a good way to practice3. There is more margin of trial and error. One gets to develop the habit of writing and the more you do it, the more you learn.

LEARNING SCIENTIFIC WRITING

The beginner of scientific writing struggles with brevity and referencing or setting a scientific tone in the article. Each of this is something they develop as they frequently write letters.

Most journals provide guidelines in terms of word limits and number of references one can use in the letters. The author conforming to these for writing a relatively simple publication such as letters shall benefit in the long run when doing so for far more demanding manuscripts.

JOURNAL ORIENTATION

A student who develops the habit of writing letters to the editor gradually adopts regular literature review. It familiarizes them with journals and their requirements5. Letters to editor are written in journals to either comment on a recent publication by the journal or discuss a scientific issue. Corresponding with journals to get a letter published prepares the newer writer for more complex publication processes in the future.

DEVELOPING SCIENTIFIC OPINION

A stark contrast between a quality research publication and an average one is the sense of opinion in scientific writing. Indeed this is an art. When a student picks up a scientific journal to read and some courage to comment on what they read or to highlight something that could become worthreading, they are actually developing the art of scientific opinion. Hence, letter-writing could produce quality opinionated-writers in the medical sciences.

CHERISHING ACKNOWLEDGEMENT

Though seemingly-minor, letters-to-the-editor are a publication. It does wonders to one’s self-esteem to find a work published under their name in a journal, especially if one is an undergraduate student. It helps one gain the needed confidence to write more and write well.

CONCLUSION AND SUMMARY

The Journal of Pakistan Dental Association’s efforts to reintroduce letters in their current issues is commendable. Though letters do not hold weightage as far PMDC credits goes but they should not be underestimated. Letters to the Editor would be a stepping stone towards medical writing that should be encouraged especially by undergraduate educationists in dentistry.

REFERENCES

1. Qureshi AZ. Stepwise and simple guide to medical writing and research for beginners. J Pak Med Assoc.2015; 65: 1139-42.
2. Netzel R, Perez-Iratxeta C, Bork P, Andrade MA. The way we write. EMBO Reports. 2003; 4: 446-451.
3. George S, Moreira K. Publishing non-research papers as a trainee: a recipe for beginners. Singapore Med J 2009; 50:756.
4. Jadhav S, Bavdekar SB. Letter to Editor: Keeping the Dialogue Going. J Assoc Physicians India.2015; 63.
5. Clouet HD. Letters to the editor: more than just 1,000 words. Revistamedica de Chile. 2014; 142: 677-8.

Lecturer, Department of Dental Materials, Ziauddin College of Dentistry, Karachi, Pakistan.
< mahida.hafsa@gmail.com >

Zohaib Khurshid1                    BDS, MRes
Shariq Najeeb2                        BDS, MSc
Rabia Sanam Khan3               BDS, MSc
Muhammad Sohail Zafar4        BDS, MSc, PhD

INTRODUCTION

Omic science brings a new discipline in medical and dental sciences by viewing the molecules that make up a cell, tissue or an organism1 . The term “salivaomics” was coined in 2008 to reflect the rapid development of knowledge about the various “omics” constituents of saliva2 . Omic science has a number of applications not only to understanding of normal physiology but also pathology of various diseases. This technology detected biological samples on different levels such as genomics (genes), transcriptomics (mRNA), proteomics (proteins) and metabolomics (metabolites)3,4. Over the last decades, omic sciences is playing an essential role in the field of dentistry5 . The accessibility of five diagnostic alphabets i.e. proteins, mRNAs, miRNAs, metabolic compounds and microbes has proposed significant advantages. This is due to the fact that the disease states may escort detectable changes in one, but not in all dimensions6 . On the basis of the biomolecules from human saliva, the term “Salivaomics” was introduced7 . The human saliva contains many hormones, enzymes, proteins, peptides, growth factors, microbes, and antimicrobial peptides which help in defense as well as diagnosis of oral and systematic diseases8-10. The saliva biofluid can be collected non-invasively without the need of expertise required for blood sampling. In addition, other key benefits such as, cost effectiveness, ease of handling, disposal and transportability, minimal risk of cross contamination, patient’s comfortibility, better patient’s compliance, screening of large populations and no cultural or religious issues are in credit of saliva biofluid sampling11. By the great effort of researchers from University of California, Los Angeles (UCLA), USA a SKB (Salivaomics Knowledge Base) was introduced. This platform is web-based, data repository, management system to support human salivary proteomics, transcriptomics, miRNAs, metabolomics and microbiome research. This web-based platform provides salivaomics studies and data to clinicians or researchers for the exploration of systematic biology and pathology of human saliva12. Denny et al. compiled consortium of three research groups on the human saliva proteins collected from the ductal secretions and identified 1166 proteins. This study opened a window for the future analysis of salivary samples from individuals with oral and systemic diseases. with the goal of identifying biomarkers with diagnostic and/or prognostic value for these conditions; another possibility is the discovery of therapeutic targets13. By omic sciences, novel methods have been identified for the developments of drugs similar to human defence system. Many researchers reported oral salivary peptides carpeted on material surfaces for inhibiting microbes and activation of growth factors14-16. Synthetic peptides from natural salivary proteins reduced the demineralization of enamel17. Combination of emerging biotechnologies and salivary diagnostics, saliva has been gradually unveiled as a valuable medical analytes and biomarkers for different diseases including cancer, autoimmune diseases, viral diseases, bacterial diseases, cardiovascular diseases, and Human Immuno Virus (HIV). Amongst, the cancer detection is the most attractive area due to involvement of vital human tissues such as breast cancer, pancreatic cancer18 lung cancer19 and ovarian cancer20. Existing markers for the salivary detection include that of myocardial infarction21 and efforts are already in placefor new markers of Sjögren’s syndrome22. This has translated the saliva-based diagnostics from the simple oral cavity to the whole physiological system. Currently, saliva-based diagnostics is on the cutting edge of diagnostic technologies2 in dentistry that is very helpful in the early diagnosis, maintenance of disease, drug control and designing of new natural drugs. It may be considered by the clinicians during clinical decisions making and predicting post treatment outcomes in the near future.

REFERENCES

1.  Horgan RP, Kenny LC. ‘Omic’ technologies: genomics, transcriptomics, proteomics and metabolomics. Obstet Gynecol. 2011;13:189–195.
2. Koneru S, Tanikonda R. Salivaomics – A promising future in early diagnosis of dental diseases. Dent Res J.2014;11:11-15.
3. Latterich M, Abramovitz M, Leyland-Jones B. Proteomics: New technologies and clinical applications. Eur J Cancer. 2008;44:2737-2741.
4. Dame ZT, Aziat F, Mandal R, Krishnamurthy R, Bouatra S, Borzouie S, et al., The human saliva metabolome, Metabolomics. 2015;11:1864-1883.
5. Khurshid ZM, Zohaib S, Najeeb S, Proteomics Advancements in Dentistry. 2016;18: 2015-2016. doi:10.1111/jre.12244.13.
6. Wong DTW, Salivaomics. J Am Dent Assoc. 2012;143: 19S-24S.
7. Ai J, Smith B, Wong DT. Saliva Ontology: an ontologybased framework for a Salivaomics Knowledge Base., BMC Bioinformatics. 2010;11:302.
8. Khurshid Z, Zohaib S, Najeeb S, Zafar M, Rehman R, Rehman I. Advances of Proteomic Sciences in Dentistry. Int J Mol Sci. 2016;17: 728.
9. Khurshid Z, Najeeb S, Mali M, Moin SF, Raza SQ, Zohaib S, et al., Histatin peptides: Pharmacological functions and its applications in dentistry. Saudi Pharm J. (2016).
10. Khurshid Z, Naseem M, Sheikh Z, Najeeb S, Shahab S, Zafar MS. Oral antimicrobial peptides: Types and role in the oral cavity. Saudi Pharm J. (2015).
11. Khurshid Z, Zohaib S, Najeeb S, Zafar M, Slowey P, Almas K. Human Saliva Collection Devices for Proteomics: An Update. Int J Mol Sci. 2016;17:846.
12. Zhang Y, Sun J, Lin C.-C, Abemayor E, Wang MB, Wong DTW. The emerging landscape of salivary diagnostics.
    Periodontology 2000. 2016;70:38-52.
13. Denny P, Hagen FK, Hardt M, Liao L, Yan W, Arellanno M, et al., The proteomes of human parotid and submandibular/sublingual gland salivas collected as the ductal secretions. J Proteome Res. 2008;7:1994-2006.
14. Zhou L, Lai Y, Huang W, Huang S, Xu Z, Chen J, et al., Biofunctionalization of microgroove titanium surfaces with an antimicrobial peptide to enhance their bactericidal activity and cytocompatibility, Colloids Surf B Biointerfaces. 2015;128:552-560.
15. Yoshinari M, Matsuzaka K, Inoue T. Surface modification by cold-plasma technique for dental implants-Biofunctionalization with binding pharmaceuticals. Jpn Dent Sci Rev. 2011;47:89-101.
16. Yoshinari M, Kato T, Matsuzaka K, Hayakawa T, Shiba K. Prevention of biofilm formation on titanium surfaces modified with conjugated molecules comprised of antimicrobial and titanium-binding peptides. Biofouling. 2010;26:103-110.
17. Kosoric J, Williams RAD, Hector MP, Anderson P, A synthetic peptide based on a natural salivary protein reduces demineralisation in model systems for dental caries and erosion. Int J Pept Res Ther. 2007;13:497 503.
18. Zhang L, Farrell JJ, Zhou H, Elashoff D, Akin D, Park NH, et al., Salivary Transcriptomic Biomarkers for Detection of Resectable Pancreatic Cancer. Gastroenterology. 2010;138.
19.  Xiao H, Zhang L, Zhou H, Lee JM, Garon EB, Wong DTW. Proteomic analysis of human saliva from lung cancer patients using two-dimensional difference gel electrophoresis and mass spectrometry. Mol Cell Proteomics. 2012;11: M111.012112.
20. Lee Y.-H, Kim JH, Zhou H, Kim BW, Wong DT, Salivary transcriptomic biomarkers for detection of ovarian cancer: for serous papillary adenocarcinoma. J Mol Med. 2012;90:427-434.
21. Floriano PN, Christodoulides N, Miller CS, Ebersole JL, Spertus J, Rose BG, et al., Use of saliva-based nanobiochip tests for acute myocardial infarction at the point of care: A feasibility study. Clin Chem. 2009;55:1530-1538.
22. Hu S, Gao K, Pollard R, Arellano-Garcia M, Zhou H, Zhang L, et al., Preclinical validation of salivary biomarkers for primary Sjögren’s syndrome. Arthritis Care Res. 2010;62:1633-1638.

1. Department of Prosthodontics and Implantology, School of Dentistry, King Faisal University, Al-Hofuf 31982, Saudi Arabia
2. Department of Restorative Dental Sciences, Al Farabi Colleges, Riyadh 11313, Saudi Arabia
3. Department of Oral Pathology, College of Dentistry, Baqai University, Karachi, Pakistan.
4. Department of Restorative Dentistry, College of Dentistry, Taibah University, Madina Munawwarrah 41311, Saudi Arabia Corresponding author: “Dr. Zohaib Khurshid” < drzohaibkhurshid@gmail.com >