Vol. 25 No. 03 Jul-Sep 2016

Maham Muneeb Lone1             BDS
Farhan Raza Khan2                   BDS, MS, FCPS

INTRODUCTION

When the maxillary posterior teeth have been extracted for an extended period of time, very minimum bone is left in the upper posterior region for the placement of implants.1 This is the result of pneumatization of the maxillary sinus and simultaneous bone loss in the edentulous area because of disuse atrophy.2 In such cases, patients can be given the choice of replacement of missing teeth by a removable cast partial denture or a bridge (given abutment teeth for adequate support of the prosthesis is present). If implant supported prosthesis is the preferred treatment option at that site then sinus lift with bone augmentation becomes mandatory. 3, 4 Various techniques have been advocated in the literature for maxillary sinus elevation and bone augmentation.5 The two most predictable techniques used for gaining vertical height of the maxillary alveolar bone are the sinus intrusion osteotomy (crestal approach) and the window technique (lateral approach).6

The following case report describes a conservative way of elevating the maxillary sinus from lateral approach using conventional instruments and subsequent full mouth rehabilitation of a patient.

CASE PRESENTATION

A 39 year old male presented to the dental clinics of Aga Khan University Hospital, Karachi with the primary complaint of poor esthetics of his upper front teeth and requested replacement of his dislodged fillings. He expressed his interest in getting a fixed solution for replacement of his missing teeth. The patient these complaints for the past 3-4 years but had been deferring treatment because of the time constraints. The patient had already undergone extensive dental treatment over the past few years but was not satisfied with the quality of previous treatment.

Extra-oral examination revealed no obvious swelling or asymmetry. Intraoral clinical examination revealed calculus deposits and staining. Surveyed crowns were present on # 13 and # 17 as the patient had previously been provided with a cast partial denture for the missing teeth in the upper arch. Multiple broken fillings and recurrent carious lesions in the upper dentition were also observed (Fig. 1a-e). Radiographically, complete pneumatization of the right maxillary sinus was observed with only about 2 mm of residual ridge seen on the panoramic radiograph (Fig. 6a). Tooth # 36 was diagnosed as having post treatment periapical disease and advised for extraction. Multiple teeth with carious lesions were advised root canal treatments; followed by replacement of faulty crown and bridge work. As the patient expressed his interest in receiving a fixed prosthetic solution for missing teeth in the right upper arch; implant supported fixed partial denture was recommended as the best treatment option along with sinus elevation and bone augmentation in that area.

After discussing the treatment plan thoroughly with the patient and obtaining the written informed consent, treatment was initiated. The treatment was divided into 3 phases. Phase I included Maxillary sinus elevation with bone augmentation in the right upper quadrant. Phase II included endodontic treatments of multiple teeth, restoration of carious teeth, followed by replacement of faulty crown and bridge work. Phase III included placement of implant supported prosthesis in the right upper quadrant three months after phase I, and the final prosthesis delivery three months after implant placement. Impressions were made with alginate for obtaining study casts and to form vacuum formed stents to help in fabrication of temporary fixed prosthesis once faulty crown and bridge work was removed. In the first visit, full mouth scaling and polishing was done.

In phase I; sinus elevation was planned. The patient was advised to rinse with 0.2% Chlorhexidine gluconate solution. After adequate local anesthesia was achieved by giving posterior and middle superior alveolar nerve block, and palatal infiltration local anesthetic (Lidocaine with 1:100,000 epinephrine), a full thickness mucoperiosteal flap was raised in the right upper quadrant using a no. 15 surgical blade at the mid alveolar crest. Relieving incisions were given mesial to # 13 and distal to # 17 (Fig. 2a). Bone trephination was done using a round bur on the lateral aspect of the alveolar ridge at # 14-16 area to form a bony window in a manner that mesial, inferior and distal part of the bone is separate while superior part of bone window forms a flap that was infractured and pushed into the sinus space by rotation (Fig. 2b). The bone was tapped gently with an osteotome so that it was still attached at its cervical part and rotated medially. This medially rotated bone served as part of the the new sinus floor (Fig. 2c). The Schneiderian membrane was then gently elevated with the help of flat plastic instrument, mucoperiosteal elevator and convex side of the bone curette. Care was exercised to avoid any tearing of the delicate Schneiderian membrane. Bio-mend extend resorbable collagen membrane (Zimmer Dental, USA) was cut into desired shape, sharp corners trimmed, manipulated and placed at the roof of the newly formed bony cavity so that the collagen rests on the infractured and medially rotated buccal bone (Fig. 2d). This was done to prevent any bone particles extravagating into the elevated sinus; if any inadvertent perforation of membrane had occurred. Around 2.0 grams of allogenic cortical and cancellous mix of demineralized freeze dried bone (Rocky Mountain, USA) was gently packed into the space created (Fig. 2e). Another Bio-mend membrane was then placed on the lateral bony window to cover the bone graft. The flap was then sutured back using 3/0 vicryl in simple interrupted fashion (Fig. 2f). The patient was advised soft diet and advised to refrain from blowing his nose and in case of coughing to keep his mouth open. This was followed by prescription of 1 gram Augmentin (Amoxicillin and Clavulanic Acid), 100 mg Ansaid (Flurbiprofen) supplemented with 1000 mg Panadol (Paracetamol), twice daily, for 6 days. An antiallergy (Cetrizine) was also prescribed for one week.

At two weeks post-operative follow-up healing was satisfactory. Then all indicated teeth were removed, endodontic treatment completed, and fixed restorations were placed to complete stage 2 of the treatment plan. The definitive prostheses were cemented with Glass Ionomer based adhesive (Fig. 3 a-e). Oral hygiene instructions were reinforced, dietary counseling was done and the patient recalled after 3 months.

At three month follow-up, placement of implants in # 14 and # 16 was planned. Radiograph showed adequate bone volume for fixture placement (Fig. 6b). After raising the flap under local anesthetic and drilling the appropriate osteotomy sites, Zimmer tapered screw vent (TSV) implant of 3.7 x 11.5 mm dimension were placed in area of # 14 whereas a Zimmer TSV Implant of dimensions 4.7 x 11.5 mm was placed in the area of # 16. After confirming primary stability of the implants (>30Nm), corresponding healing abutments were placed. Closure of the flap was done by using 3/0 vicryl in simple interrupted manner (Fig. 4 a-d). The patient was given postoperative instructions to minimize any risk of bleeding and was advised soft diet for a week. This was followed by 6 days prescription of antibiotics and analgesics as advised earlier.

After three months of implant placement, their osseointegration was confirmed radiographically as well as clinically using torque resistance test. Impressions were made using poly vinyl siloxane impression material (light and heavy body) for final prosthesis fabrication. Metal trial of the cement retained implant supported fixed partial denture was done, and the necessary adjustments was made in the casting. On subsequent visit, after ensuring proper fit and proximal contact of the bisque ceramic bridge, the bridge was glazed and cemented using Glass Ionomer based adhesive. Oral hygiene instructions were reinforced and the patient was advised regular follow up visits.

At a routine follow up visit at 18 months, the patient had no active complaints and was maintaining a good oral hygiene. No new carious lesions were observed (Fig. 5a-e). Panoramic radiograph revealed no new active disease and implants serving well with crestal bone loss within normal limits (Fig. 6 c). Dietary counselling and oral hygiene instructions were reinforced. A yearly follow up was advised for maintenance.

DISCUSSION

This case report describes the full mouth rehabilitation of a patient who had multiple operative, endodontic and prosthetic complaints. Correct sequencing of the treatment plan was important to decrease the overall treatment time, alleviate the patient’s chief complaints and provide a stable, disease free dentition before prosthetic rehabilitation was carried out. To minimize the high caries risk of the patient as evident by patient’s dietary history and recurrent decay, dietary counseling and oral hygiene instructions were reinforced at each appointment. Regular follow ups were also advised to monitor patient compliance to instructions.

Patient’s demand for a fixed prosthesis necessitated implant supported prosthesis in the right upper quadrant as fixed tooth supported prosthesis was not possible because of a long edentulous span. The patient was not inclined towards a removable solution either. Thus, implants were the only choice but lack of bone volume owing to bone resorption and pneumatization of maxillary sinus made it extremely challenging.

Pneumatization of the maxillary sinus is a well-documented physiological process when the maxillary posterior teeth have been lost for a long time. This coupled with maxillary residual ridge resorption results in limited bone available for implant placement. In such cases, sinus elevation has been one of the most predictable treatment options for bone augmentation and subsequent implant placement for replacement of missing teeth. The lateral window technique for sinus elevation and vertical ridge augmentation is indicated when the residual ridge is less than 4 mm.6 Bone is augmented from a lateral window created in the maxilla for subsequent bone regeneration and implant placement. Piezoelectric instruments have been advocated in literature to carry out this sinus elevation but their high cost, availability and technique sensitivity precludes their use in the routine dental practices. In the present case, we utilized simple instruments that are commonly available in any dental surgery. These include high speed diamond burs, hand instruments such as flat plastic composite instrument, a regular periosteal elevator, osteotome, chisel and mallet and yet got satisfactory results. A randomized control trial by Barone et al.7 found no statistically significant difference in the clinical parameters of sinus floor elevation when comparing piezoelectric device with conventional diamond rotary burs; as used in the present case.

A systematic review conducted by Esposito et al.8 reported that the type of instruments (rotary, piezoelectric or hand malleting) used for sinus elevation had no effect on the implant survival rate placed in that area. The infracture, rather than complete removal of the buccal bone gave a firm surface to apply gentle pressure to the overlying sinus membrane to lift it, decreasing the chances of membrane perforation and subsequent complications associated along with it. It also provided a scaffold onto which demineralized freeze dried bone (an allograft) could be placed to fill in the bony defect present. Placement of membrane over the lateral window after sinus lift and bone grafting has been associated with a significantly higher implant success rate in a number of studies. 9-12 In the present case, we used a resorbable collagen membrane as used by the previous mentioned studies to provide a barrier against epithelial ingrowth and enhance bone regeneration in that area.

The present case report reiterates the importance of comprehensive treatment planning when dealing with multiple dental problems. The role of prevention of further disease by patient education at each follow up visit remains one of the most important factors in the success any treatment provided to the patient.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Misch CE. Maxillary sinus augmentation for endosteal implants: organized alternative treatment plans. Int J Oral Implantol. 1987; 4: 49-58.
2. Liang XH, Kim Y-M, Cho I-H. Residual bone height measured by panoramic radiography in older edentulous Korean patients. J Adv Prosthodont. 2014; 6: 53-9.
3. Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic. Eur J Oral Implantol. 2010; 3: 7-26.
4. Beretta M, Cicciu M, Bramanti E, Maiorana C. Schneider membrane elevation in presence of sinus septa: anatomic features and surgical management. Int J Dent. 2012; 2012: 1-6.
5. Raja SV. Management of the posterior maxilla with sinus lift: review of techniques. J Oral Maxillofac Surg. 2009; 67: 1730-4.
6. Stern A, Green J. Sinus Lift Procedures: An Overview of Current Techniques. Dent Clin North Am. 2012; 56:219-33.
7. Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone E, Covani U. Osteotomy and membrane elevation during the maxillary sinus augmentation procedure. A comparative study: piezoelectric device vs. conventional rotative instruments. Clin Oral Implants Res. 2008; 19: 511-5.
8. Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev. 2014; 5: CD008397.
9. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol. 2003;
   8: 328-43.
10. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodontics Restorative Dent. 2000; 20(2): 117-25.
11. Tawil G, Mawla M. Sinus floor elevation using a bovine bone mineral (Bio-Oss) with or without the concomitant use of a bilayered collagen barrier (Bio-Gide): a clinical report of immediate and delayed implant placement. Int J Oral Maxillofac Implants. 2001; 16(5): 713-21.
12. Froum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho SC. Sinus floor elevation using anorganic bovine bone matrix (OsteoGraf/N) with and without autogenous
    bone: a clinical, histologic, radiographic, and histomorphometric analysis–Part 2 of an ongoing prospective study. Int J Periodontics Restorative Dent. 1998; 18(6): 528-43.

1. Chief Resident, Operative Dentistry, Aga Khan University, Karachi, Pakistan
2. Assistant Professor, Operative Dentistry, Aga Khan University, Karachi, Pakistan
Corresponding author: < farhan.raza@aku.edu >

Maham Muneeb Lone1             BDS
Farhan Raza Khan2                   BDS, MS, FCPS

Mohammed Ayedh Al-qahtani                 BDS

INTRODUCTION

In normal teeth, the clinical crown heights are favourable and the pulps are covered by a volume of enamel and dentine that could accommodate tooth reduction for indirect restorations. The axial walls of the preparation offer good retention and resistance form while sufficient dentine is available to give the preparation mechanical strength1 . However, if less than 2 mm of sound, opposing parallel walls are remaining after occlusal and axial reduction; it is considered a short clinical crown2 .When damage to the dentition has been significant and restoration is necessary, the reduced clinical crown height and the lack of inter-occlusal space make the treatment more challenging. For indirect restoration to be acceptable both aesthetically and biologically, clinical crown height should be dimensionally adequate. Crown retention and resistance form is highly affected by crown length, total occlusal convergence degree, and axial surface area. Other features can also increase the retention and resistance form by adding boxes, grooves, or pins. Thorough clinical examination and comprehensive treatment planning with proper sequencing of therapy is needed to overcome the complications presented by restoring a short clinical crown. Many clinicians try to overcome these complications by placing the preparation margin sub-gingival which encroaches upon the biologic width and jeopardize the periodontal health. Before any attempt has been made to restore a tooth, the restorability of such tooth should be established,3 which include:

1) Consideration of the arch position of the tooth.

2) Strategic value of the tooth.

3) Periodontal considerations.

4) Crown-to-root ratio.

5) Endodontic treatment feasibility.

6) Esthetics4 .

In most cases, tooth preparation can left an adequate space for provision of acceptable aesthetic and functional restoration without affecting the retention and resistance form. Unfortunately, there are some cases where interocclusal space is limited even after tooth preparations. Example of such cases include; extensive localized or generalized tooth surface loss (caries and non-carious), missing tooth/teeth with over-erupted antagonist, genetic variation in tooth form, iatrogenic dentistry (excess tooth reduction, large endodontic access openings), trauma and eruption disharmony (insufficient passive eruption, mesially tipped teeth).

A PubMed and Google scholar search of English language papers was conducted up to March 2016 using the terms: short clinical crown, surgical crown lengthening, forced eruption, Deliberate axial tooth movement, Dahl appliance, Anterior bite plane, alveoloplasty and gingivectomy. In addition hand searching of the reference list of the original and review studies was performed as the initial relevant papers were limited. After final selection, studies that fulfilled the selection criteria were processed for data extraction. Due to limited numbers of papers found the pattern of the present review was customized to primarily summarize the pertinent information.

A number of strategies can be used to create space for localized and generalized toothwear problems. These may be broadly divided into conformative and reorganized strategies, which can help in restoring toothwear cases successfully.

A. Conformative Approach

Where the existing position of mandibular closure is maintained during restoration of the effected teeth. This is an acceptable way of treatment if we can provide aesthetic, functional restorations for localized tootwear without compromising retention and resistance form of the preparations or undertaking destructive preparation; in which the space can be created by the following methods:

1-Reducing the Teeth in the Same Arch or the Opposing Arch

This approach is appropriate when there is nearly adequate tooth tissue to allow for conventional preparation, however inter occlusal space is lacking.Using this approach is limited to mild to moderate loss of the tooth tissue where the preparation will end by a short crown height, which can be compensated by additional preparation features for auxiliary retention (grooves, slots and boxes) and maintaining of preparation height5. This method also utilizesmild preparation of the opposing tooth/teeth (enameloplasty procedure) in order to create space for the final restoration without further reduction on the tooth to be restored. However, further reduction might be needed for the opposing tooth to create the desired space, which requires a new restoration of the opposing tooth. Other ways of utilizing this method is by using restorations, which require less tooth reduction like full gold restorations, or avoiding non-functional cusp reduction in cases with steep canine guidance. In addition, with the availability of the adhesively retained restorations (heated gold, dentin-bonded restoration) teeth with short clinical crown height can be restored to the existing occlusion.

2- Surgical Crown Lengthening

One way of exposing more tooth structure prior to tooth preparation is by surgical crown lengthening (SCL). Thereby occlusal or incisal reduction will create space for restorative procedure of moderately damaged teeth. The procedure generally involves apical repositioning of the gingival tissues following removal of crestal alveolar bone. The aim is to provide increased tooth tissue for a longer, more retentive crown preparation and preservation of the biological width with pleasant aesthetic results6-7. The healing period needed for the stabilization of the soft and hard tissues after crown lengthening procedures ideally takes 3 months for an anterior teeth and6-8 weeks for posterior teeth. A potential difficulty with the final restoration of anterior teeth that have been surgically crown lengthened is poor aesthetics related to the dark triangular spaces interproximally. This is a consequence of the tapering form of the roots resulting in an increase in size of the embrasures interdentally8. Additionally, localized crown lengthening of a single tooth or several teeth can leave a poor final appearance due to the differential levels of the gingival marginal tissues after surgery9. Furthermore, there are certain situations where surgical crown lengthening is difficult to do e.g. high muscle insertion, narrow interdental bone area and in molars teeth with short trunk10,11. Commonly, surgical crown lengthening procedures are considered as adjunctive treatment in management of extensively damaged teeth with lack of space in both conformative and re-organized approach. Options to treat the case in conformative approach also include devitalization of the tooth with root filling and placing a post and core followed by tooth preparation to create space for final restoration with or without surgical crown lengthening. However, many clinicians consider the tooth to be weakened due to aggressive nature of post and core procedures, considering it as the last and unfavourable option of managing short clinical crowns with space loss. It is noteworthy that patients in need of SCL should be screened for systemic disorders and are suitable to perform SCL. In addition, poor plaque control may also compromise the healing process after the surgery12.

B. Re-Organized Approach

This may be defined as a management approach, which involves an alteration in position of closure of maxilla and mandible. Using this method, adequate amount of space for indirect restoration for generalized toothwearcan be achieved through treatment modalities, including increasing the vertical dimension, increasing the overjet, relative axial tooth movement and orthodontics.

1-Alteration of the Position of the Mandibular Closure

This method usually indicated when there is a need to restore anterior teeth in a dentition with intact posterior teeth. In cases of localized anterior tooth loss with no room for placing restoration on the affected teeth, alteration in mandibular position can provide critically required space. The method involves creation of a new inter-cuspal position (ICP) distal to the habitual ICP at the same existing occluso-vertical dimension (OVD), resulting in more room for providing an acceptable restorations. However, the feasibility of undertaking such procedure depends on the degree of space available between ICP and retruded axis position (RAP), commonly known as slide) The amount of translation between the two positions is initially assessed on diagnostic casts. Occlusal adjustment are initially rehearsed on the casts and further applied intra-orally to produce the new ICP position. This method is considered to be conservative; therefore in some cases the space created is not enough to accommodate the restoration.

2- Increasing the Vertical Dimension of Occlusion (VDO)

Traditionally the method of creating space to accommodate thickness of desired restoration was by increasing the vertical dimension of occlusion. This is generally indicated when other options are offer limited gains and is considered as the last option for space creation. For example, in cases with generalised tooth surface loss, lack of posterior stability accompanied with anterior tooth surface loss, requires space creation for posterior reconstruction. Increasing the VDO not only provides desirable space for restorations but also allows an opportunity to manage the occlusal plane. The ability of the patient to accept the new VDO is debatable. Some believed that dentition restored in an increased VDO beyond the established rest position of the mandible might be prone to failure13. However, more studieshave shown and clinical experiences has indicated that moderate increases in the vertical dimension of occlusion are well tolerated by patients, provided that a stable position of mandibular closure with anterior guidance during lateral excursion is achieved14. Also Tall green et al., stated that, the rest facial height re-establishes itself in line with the new face height15. However, disadvantages of this approach involve; obligation to restore large number of teeth, with demanding compliance for the patient and commitment from the operator with regards to cost and time. In addition, difficulty to establishing occlusal stability with anterior guidance and increased amount of anterior overjet leaving unstable incisal contact, are possible complications.

3. Relative Axial Tooth Movement (RATM)

The method was originally described by Dhal et al.16.He used removable bite-planes to intrude worn anterior teeth needing restoration, leaving the remaining teeth erupting farther without having to restore them. Simply reversing the action of dento-alveolar compensation in toothwear cases 17. The ratio of eruption versus intrusion varies among individuals, with eruption of posteriors predominating in young age group. The predictability and patient compliance have been increased through using fixed casting, composite restorations (as intermediate or definitive treatment) and even with cemented definitive restorations high in occlusion (Fig. 1).

Long-term studies by Dahl et al. 18-19 have shown RATM to have high success rates and it is also been well tolerated by patients. However, it is noteworthy to mention that, some of the posterior teeth may fail to establish complete occlusal contact due to slow or limited tooth movement. Dahl’s technique can also be used effectively in localised anterior tooth surface loss. It is also reported that RATM can be useful in creating space to restore single tooth in the posterior segment 13-20.

4. Conventional Orthodontic Option

Conventional orthodontic treatment in the pre-restorative treatment phase allows the relationship between the teeth to be altered, facilitating restorative treatment. The common orthodontic methods to create inter-occlusal space include either overbite reduction or in selected cases mandibular incisal retraction. Overbite reduction can be achieved by upper and lower incisor proclination, upper and lower anterior intrusion or premolar and molar extrusion (in children and young adult due to remaining growth). The choice of removable, fixed appliances or combination mainly depends on type of the tooth movement (removable for tipping and fixed in cases where bodily movement required). Usually this approach is considered when there are other features of malocclusion such as crowding, spacing so the creation of interocclusal space forms a part of the overall treatment. However, localized orthodontics treatment can be considered to create space mesiodistaly and inter-occlusally11.

CONCLUSION

In most cases, a combination of approaches is employed to address the problem of space and tooth surface loss. However, in all instance, it is important to perform a thorough clinical, radiological and occlusal (mounted models) examination. As well as determining a stable RAP position should be established before planning the definitive restorations with re-organized approach. This requires a utilization of an occlusal splint. Keep in mind the primary goal is to determine how we are to achieve space for restorative material with only a minimum of tooth reduction.

REFERENCES

1. Potts RG, Shillingburg HT Jr, Duncanson MG Jr. Retention & resistance of preparation for cast restorations. J Prosthet Dent. 1980; 43: 303-8.
2. Seol HW, Koak JY, Kim SK, Heo SJ. Full mouth rehabilitation of partially and fully edentulous patient with crown lengthening procedure: a case report. J Adv Prosthodont. 2010; 2: 50-3.
3. Rosenberg ES, Garber DA, Evian Cl. Tooth lengthening procedures. Compend Contin Edu Dent. 1980; 1: 161- 72.
4. Davarpanah M, Jansen CE, Vidjak FM, Etienne D, Kebir M, Martinez H. Restorative and periodontal considerations of short clinical crowns. Int J Periodontics Restorative Dent. 1998; 18: 424-33.
5. Heithersay GS. Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg Oral Med Oral Pathol. 1973; 36: 404-15.
6. Wilson RD, Maynard G. Intracrevicular restorative dentistry. Int J Periodontics Restorative Dent. 1981; 1: 34-49.
7. Maynard JG Jr, Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol. 1979; 50: 170-4.
8. Kay HB. Esthetic considerations in the definite periodontal prosthetic management of the maxillary anterior segment. Int J Periodontics Restorative Dent. 1982; 2: 44-59.
9. Yeh S, Andreana S. Crown lengthening: basic principles, indications, techniques and clinical case reports. N Y State Dent J. 2004; 70: 30-6.
10. Rosenberg ES, Cho SC, Garber DA. Crown lengthening revisited. Compend Contin Edu Dent. 1999; 20: 527-32.
11. Kohlavi D, Stern N. Crown lengthening procedure. Part II. Treatment planning and surgical considerations. CompendContinEduc Gen Dent. 1983: 4: 413-9.
12. Dibart S. Capri, D, Kachoug I, van Dyke T, Nuun ME. Crown lengthening in mandibular molars: A 5 year retrospective radiographic analysis. J Periodontol. 2003; 74: 815-21.
13. Setchell DJ. Tooth surface loss: Conventional crown and bridgework. Br Dent J 187, 68 – 74 (1999)
14. Dahl B L, Krogstad O. The effect of a partial biteraising splint on the inclination of upper and lower front teeth. Acta Odontol Scand 1983; 41: 311-4
15. Tallgren A., Lang BR, Walker GF, Ash M. Roentgen cephalometric analysis of ridge resorption and changes in jaw and occlusal relationships in immediate complete denture wearers. J Oral Rehabil 1980; 7: 77-94
16. Dahl B L, Krogstad O, Karlsen K. An alternative treatment of cases with advanced localised attrition. J Oral Rehabil 1975; 2: 209-14
17. Berry D C, Poole D F G. Attrition: Possible mechanisms of compensation. J Oral Rehabil 1976; 3: 201-6
18. Dahl B L, Krogstad O. Long-term observations of an increased occlusal face height obtained by a combined orthodontic/prosthetic approach. J Oral Rehabil 1985; 12: 173-6.
19. Dahl B L, Krogstad O. The effect of a partial bite raising splint on the occlusal face height. An x-ray cephalometric study in human adults. Acta Odontol Scand 1982; 40: 17-24
20. Gough M B, Setchell D J. A retrospective study of 50 treatments using an appliance to produce localised occlusal space by relative axial tooth movement. Br
    Dent J 1999; 187: 134-9.

Department of Prosthetic Dental Science, College Of Dentistry, King Saud University. Riyadh, Saudi Arabia
Corresponding author: < drm212@hotmail.com >

Mohammed Ayedh Al-qahtani                 BDS

Anwar Ali1                     –                      BDS, FDSRCS
Khurram Parvez Sardar2            –          BDS, MDS
Saqif Nasir3                         –                       BDS
Syeda Maliha Wakar4                 –           BDS

INTRODUCTION

Forensic dentistry is a contemporary along with emanating division of forensic medicine. Forensic odontology is the recognition discipline based upon the revealing of  inimitable characteristics exists in each individual’s dental structures. According to the Federation Dentaire Internationale (FDI), forensic dentistry deals with the appropriate conduct and assessment of dental verification and with the accurate conclusion and management of dental findings1 .

The broadly recognized classification of forensic dentistry is supported on the main fields of activity i.e. civil, criminal and research by Avon2 . The civil field deals with mass disasters such as airline accidents, earthquakes or train accidents which involve identification of the victims in complex stages of corporeal destruction. The criminal field deals with the identification of persons from their dental remains alone in cases of homicide, rape or suicide through bite mark analysis, palatal rugoscopy and cheiloscopy. Finally, the research field is palatal rugoscopy and cheiloscopy. Finally, the research field is acted to forensic odontology training for medical and dental professionals. In recent times, the author has introduced a latest effective categorization for forensic dentistry which shows dependency up on the association of different dental specialties with forensic dentistry3.
Forensic Odontologist delve in identifying unknown human remains, victim’s identification in mass disaster, assessing sex of skeletal remain, age estimation of both living and deceased analysis, evaluation of cases of violence such as adolescent, conjugal partner and family and recognition of bite marks at crime scenes.

Teeth have the capability to endure decomposition and tolerate intense changes in temperature, due to which dental validation assessment and evaluation is amongst the most reliable and consistent way of identification4. It can be conquered by evaluating characteristics of an unidentified entity (post-mortem dental records) with an identified entity (ante-mortem dental records).

Despite of the fact that forensic dentistry is one of the establishing modern field of dentistry in all over the world but in Pakistan, this subject is included as a topic in oral and maxillofacial surgery with five didactics lectures as showed on the website of Pakistan Medical and Dental Council (PM&DC). PM&DC is the dictatorial body in Pakistan regarding the medical and dental education. Regulations given by PM&DC are followed by the universities; awarding BDS degrees in Pakistan5. With the introduction of forensic odontology in the undergraduate curriculum, its teaching to undergraduate students is now necessary6.

METHODOLOGY

This hospital based cross sectional research was performed at DOW University of Health Sciences through a structured questionnaire7. SPSS 16 version was used for statistical analysis. Descriptive statistics was used to report frequency and percentages. Former to the collection of data; a concise introduction was given to all the participants about this study as well as the related information of the research and the informed consent was obtained from the subjects recruited for this study.

The research included 200 participants, among which were dental house officers and postgraduate trainees. In order to assess the knowledge, attitude and practice on forensic odontology, this structured questionnaire consists of eighteen (18) variables having multiple choice options, from which the participants chose answer nearer to their own verdict, which includes socio-demographic distinctiveness, comprising age, gender, experience and designation. The questionnaire was divided into three components, in which first section was on demographic profile of study population, second section was on knowledge and last section was on practice and attitude evaluation.

RESULT

A total of 200 questionnaires were circulated amongst dental professionals, 184 were completely filled and included in the analysis. Sociodemographic details are shown in Table 1.

The result showed that the identification of child abuse was mainly made by monitoring behavioral changes of child (54.3%), physical injuries (29.3%) followed by scars (10.9%) while 5.4% practitioners didn’t know how to identify a child behavior. Age estimation was done by dental age (66.3%) and chronological age (27.2%) by examining the teeth, 6.5% respondents did not know how to examine the teeth. 65.2 % knew that they can present dental evidence in court , while 18.5% denied and 15.2% did not know if they can present any evidence in court or not.

84.8% respondents agreed that there present knowledge regarding forensic odontology is not adequate while 15.2% were contented with their knowledge. The accurate and absolute way to recognize a person was DNA comparison (54.3%) followed by fingerprints (29.3%), visual identification (8.7%), serological comparison (2.2%) while 5.4% did not know the accurate method. 59.8% were aware of bite mark of teeth, 54 % had no awareness how to identify bite mark. Regarding the age and gender identification of deceased, 52.2% respondents said that they can identify age and gender by erupted teeth examination, while 17.4% by DNA examination of tooth, 15.2% by jaw examination and 15.2% didn’t know how to identify. (Table 2) 87% respondents agreed that dental records are useful in identifying the deceased and crime suspect, 6.5% didn’t find it useful while 6.5% didn’t know whether maintaining records are useful for crime suspect or not .69.9% sustained their dental records, of which only 17.4% maintained dental records for more than 3 years while 53.3% maintained for less than 3 years.

83.7% participants had no formal training in the field of forensic odontology, while only 16.3% participants had studied forensic odontology (Table 3).

DISCUSSION

Recognition of persons who are sufferers of criminal acts, assassinating analysis, mass victims or missing people can be done by the aid of dental records2 .The verification of a deceased individuality is essential for several reasons. It is imperative in bringing closure to the immediate family members when catastrophic and unanticipated actions occur4.

The officially authorized settlements of domains where a deceased record is required is a further motive4. For issuance of death certificate, a confirmation of individuality is required4. It is due to these causes, dental identification acquires a prime liability for detecting remains when changes in postmortem occurs, damage to traumatic tissue occurs or not having fingerprint verifications which invalidate the use of visual or fingerprinted2.

The comparison of dental substantiation is one of the most unfailing and consistent approaches of detection because the teeth can tolerate intense changes in temperature, and have the capability to endure decomposition4. However, the condition of an individual’s teeth varies during his life and the information of decayed, missing and filled teeth can be assessed and compared at any fixed instance8,9.

The application of dental records for identification appears in dispersed situations throughout documented history even in archaic forms in pre-historic times. According to the ancient testimony of the Bible, Adam was persuaded by Eve to put a ‘bite mark’ on the apple. This was the first reported evidence of bite mark in the history of mankind10. General Zia-ul-Haq, the late president of Pakistan, died due to explosion in a plane smash, in the year 1988. Mr. Rajiv Gandhi , the late Indian Prime Minister, was executed in a terrorist attack in 1991. They both were recognized from their dentition11.
According to the World Health Organization (WHO), the aggression is a main and emergent civil health dilemma across the planet12. Fracture of anterior teeth or alveolar bone, lacerations to the frenum or mucosa either labial or buccal, contusions to the lips, face and neck are the injuries due to violence in the oro-facial region. There are certain characteristics of non accidental injuries which facilitate in their identification13.

Comparison of dental records (ante-mortem with postmortem) for detection, there are three categories to inspect which include the teeth, periodontal tissue, and anatomical features14.

The dental tissues and dental restorations are resistant in nature , due to which the changes caused by ecological extremes such as temperature and decomposition , make them the most appropriate source of DNA, which will be of an immense aid to recognize a person15. The logical assertion concerning bite mark examination is stemmed from the actuality that the dentition of human being is not indistinguishable from individual to individual. Bite marks are as definite to an individual as DNA or fingerprint study; similarly, no two individuals will have the accurate identical dentition in regards to contour, dimension and arrangement of teeth16. Human bite marks are depicted as an elliptical or spherical wound that records the exact uniqueness of the teeth17. The success of identification depends on the accessibility and accuracy of these records. Unfortunately, due to dentists’ negligence of maintaining proper records, resulting in uncertainty, creates dental recognition impossible9.

CONCLUSION

This study divulges that there was a lack of knowledge and awareness of forensic odontology amongst the participants and very few of them have awareness regarding forensic odontology. It can be enhanced by instigating forensic dentistry as subject in dental curriculum at both undergraduates and postgraduates levels. Formal training should be offered in forensic odontology in all dental institutes and to upgrade the knowledge of graduates and post graduates, periodic CDE Program, conferences and workshops should be arranged.

Action, in terms of Positive Academic Support at all levels needs to be taken by all leading stake holders, in order to upgrade our current dental education & Profession, to meet our society & International standard. This is only possible by providing a positive & supportive learning environment for the new dental graduates to foster “Critical thinking & their development as Academic Leaders, to train them to think & act out of the box18.

AUTHORS’ CONTRIBUTION

Article has been revised and rechecked by Anwar Ali and Khurram Parvez Sardar. Article writing, data collection, result compiling has been done by Syeda Maliha Wakar and Saqif Nasir.

REFERENCES

1. Shamim T, Ipe Varughese V, Shameena PM, Sudha S. Forensic odontology-a new perspective. Med Leg Update Int J. 2006; 6:1-4.
2. Avon SL. Forensic odontology: the roles and responsibilities of the dentist. J Can Dent Assoc. 2004; 70: 453-8.
3. Shamim T. A new working classification proposed for forensic odontology. Journal of the College of Physicians and Surgeons–Pakistan: J Coll Physicians Surg Pak. 2011; 21:59.
4. Senn DR, Stimson PG, editors. Forensic dentistry. CRC Press; 2010 Jan 25.
5. Zeeshan M, Khalid B, Siddiqi M, Jabeen N, Israr M, Ehsan MT, Rahman F. Awareness and compliance about forensic dentistry among dental professionals of twin cities of Rawalpindi-Islamabad: a questionnaire based study. Pak Oral Dent J. 2014 1;34(2).
6. Zeeshan M, Khalid B, Siddiqi M, Jabeen N, Israr M, Ehsan MT, Rahman F. Awareness and compliance about forensic dentistry among dental professionals of twincities of Rawalpindi-Islamabad: a questionnaire based study. Pak Oral Dent J. 2014 1; 34(2).
7. Nagarajappa R, Mehta M, Shukla N, Tuteja JS, Bhalla A. Awareness of Forensic Odontology among Dental Practitioners in Kanpur City, India: A Kap Study. J Dent Res Updates. 2014; 1: 6-12.
8. Avon SL. Forensic odontology: the roles and responsibilities of the dentist. J Can Dent Assoc. 2004; 70: 453-8.
9. Spitz WU, Spitz DJ. Spitz and Fisher’s medicolegal investigation of death: guidelines for the application of pathology to crime investigation. Charles C Thomas Publisher; 2006.
10. Zeeshan M, KHALID B, Siddiqi M, Jabeen N, Israr M, EHSAN MT, Rahman F. Awareness and compliance about forensic dentistry among dental professionals of twin cities of Rawalpindi-Islamabad: a questionnaire based study. Pak Oral Dent J. 2014; 1:34(2).
11. Shamim T. Forensic Odontology. J Coll Physicians Surg Pak, 2012; 22: 240-245.
12. World Health Organization. Prevention of violence: a public health priority. Forty Ninth World Health Assernbl, WHA 49.25.[Online] Available at: http://www.who. int/violence_in jury _prevention/resources/publications/en/WHA 49 25 _eng. pdf [Accessed 30 March 20 12]. 1996.
13. Mok JY. Non-accidental injury in children—an update. Injury.2008;39(9):978-85.
14. Mok JY. Non-accidental injury in children—an update. Injury. 2008 30; 39:978-85.
15. Schwartz EA, Mieszerski L, Kobilinsky L, McNally L, Schwartz TR. Characterization of deoxyribonucleic acid (DNA) obtained from teeth subjected to various
    environmental conditions. J Forensic Sci. 1991 1;36:979-90.
16. Wright FD, Dailey JC. Human bite marks in forensic dentistry. Dent Clin North Am. 2001;45: 365-97.
17. Dhingra R, Munjal D. Role of Odontology in Forensic Medicine: An Update. Ind J Forensic Med Toxicol. 2013 1;7: 227.
18. Katpur S, Kalhoro F, Hassan G, Dal AQ. Bird’s Eye on LMC Dental Graduates Academic Contributory Role to Enhance Undergraduate Dental Education and Vision for Pakistan: A Commentary. J Liaqat Uni Med Health Sci, 2014; 13: 41-44.

1. Professor, Department of Oral and Maxillofacial Surgery, Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan
2. Assistant Professor, Department of Science of Dental Materials, Dr.Ishrat-ulEbad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan
3. House Officer, Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan
4. House Officer, Dr.Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan
Corresponding author: < dr_khurramparvez@hotmail.com >

Anwar Ali1                     –                      BDS, FDSRCS
Khurram Parvez Sardar2            –          BDS, MDS
Saqif Nasir3                         –                       BDS
Syeda Maliha Wakar4                 –           BDS

Noura A. AL-Essa1                         BDS

INTRODUCTION

Epilepsy is a chronic disorder of the brain that affects people worldwide. It is characterized by recurrent seizures, which are brief episodes of involuntary movements that may involve a part of the body or the entire body, sometimes accompanied by loss of consciousness and controlof bowel or bladder function. This condition considered as one of the most common neurological disorders effecting humans, but full understanding of development of this disease is still incomplete1-4.

Worldwide, About 50 million people are lived with epilepsy1 which affects 4 -10 per 1000 people. Unfortunately, there is deficiency in epidemiologic data from Arab countries. In Saudi Arabia, the prevalence rate of epilepsy had been  reported to be 6.54 per 1000 persons5 . The prevalence of epilepsy is different if compared from country to country, but it found to be higher in rural areas and poor countries.6 Low- and middle-income countries showed between 7-14 per 1000 people had epilepsy1 .

In many parts of the world, people with epilepsy and their families suffer from stigma and discrimination. This stigma in many countries can impact on the quality of life for people with this disorder and their families.1 Less understanding of this condition and the cultural influences can affect people’s perceptions and attitudes toward this disease. Several studies had reported that educated individuals had better knowledge and less negative attitudes regarding epilepsy.7-10 University students especially health care students probably considered as an educated people in the society. Thus, it is important to have enough knowledge for the future health care professionals about epilepsy and to improve their attitude toward people with this disease.

Several studies were conducted about the knowledge and attitude toward epilepsy among different groups of society, but there are no published studies that were conducted among university dental students in related to epilepsy knowledge in Saudi Arabia. The aim of this study is to investigate the knowledge and attitudes toward epilepsy among university dental students at King Saud University in Riyadh, Saudi Arabia and to evaluate the degree to which university dental students were aware of the nature, causes, and some of the treatment options for common and important diseases such as epilepsy.

METHODS

The study was conducted at King Saud university dental college. Approval was obtained from the College of Dentistry Research Center at King Saud University.

Attending the clinics and treating patients are started from the third year studying at this college, so only third, fourth and fifth (final year) year students who were dealing with patients were included. Informed consents were obtained from all the students and only who were willing to participate were included in this survey. The total number of the students was three hundred sixty three representing the three levels, one hundred thirty two students in the third year, one hundred thirty two students in the fourth year and ninety nine students in the fifth year. A self-administered two-page questionnaire was in English language and consisted of questions on awareness, knowledge about the causes and treatment options, attitudes toward persons with epilepsy and the students’ information sources regarding this disease. Students were required to answer ‘‘Yes’’, ‘‘No’’ or ‘‘Don’t know’’.

The questions were utilized and modified from questionnaires used in other published surveys4,11,12. The dental students were given the questionnaires in the classrooms and asked to fill it out without discussing it with any colleague. Answering the questionnaire took between 5 to 10 minutes. No private information were requested as names or contact numbers.

A pilot questionnaire was conducted for twenty students to evaluate the ease of reading clarity of the wording and understanding of the questions as it was necessary to check the students’ perception and interpretation of the questions, few modifications were introduced accordingly. The students who participated in the pilot study were not included in the final sample.

All returned questionnaires were entered and analyzed using SPSS 20.0. Frequencies and percentages were obtained and the Chi-square test was applied to assess the associations between variables. The level of statistical significance was set at P<0.05.

RESULTS

A total of three hundred and three (303) students were answered the questionnaires with a response rate of 83.4%. 156 (51.5%) were males and 147 (48.5%) were females, from third (103), fourth (106) and fifth (94) dental students at King Saud university.

Majority of the students98.3 % had heard or read about epilepsy and 9.2% of the students had a history of epileptic seizures. In addition 32.7% of the participants knew people who are suffering from epilepsy with no significant difference in different academic level or gender P>0.05. It was found that 37.3% of the study group had seen people having epileptic seizures in front of them with significantly males more than females P=0.000 (Table 1).

Table (2) reflects the knowledge of the students regarding the causes of epilepsy. Majority of the students 72.6% believed that Accidents or head trauma can cause epilepsy followed by brain tumors 70.6% with significant difference in different academic level P= 0.000, while 55.1%, 53.8% of the students reported that it is caused by genetic and certain drugs respectively.

The most reported treatment option was the use of medications 84.5% with statistically significant different between the students’ level and gender (P=0.014, 0.023 respectively). Approximately two-third of the students thought that it can be treated by Holy Quran 64% (statistically significant between males and females P=0.015). About 46.9% of the students believed that the drug therapy is seldom effective in controlling seizures with significant difference in different academic level and gender P<0.05. In the other hand only 32.3% knew that antiepileptic drugs can produce babies malformations of epileptic mothers and 46.2% of the students were recognized about the fact of epilepsy drugs had advanced over the last 10 years (Table 3).

Most of the students 92.4%defined epilepsy as convulsion or a shaking while the others defined it as loss of consciousness 72.9%, episode of behavioral change 63.4% or period of memory disturbance 57.4% all of these definitions had significant difference between 3rd,4th and 5th year students (Table 4). The most reported source of students’ information was university teaching 88.8% followed by internet 66.7% and the least sources of information were books or magazines 33.7% and newspaper 17.8%, Figure 1. Table (5) shows the Students’ knowledge and perception of children and adult with epilepsy. From the total sample, 7.3%

thought that the children with epilepsy should be isolated from other children and these children should be restricted from participation in sports 17.8%,only 10.9% of the students thought that these children should not eat candies with significant difference P<0.05between the previous thoughts of the students and different academic level. 13.9% of the study sample reported that the children with epilepsy should attend schools for people with disabilities.

Few students believed that people with epilepsy should not get married 7.6% or having children 5.9%. Approximately half of the participants 42.9% agreed that people with epilepsy can drive with statically significant more males agreed on that than females P=0.000 (Table 5).

Students’ attitudes toward people with epilepsy are shown in Table (6). Of the study group 88.8% will allow their children to play with a child with epilepsy and 89.1% are willing to go to a public place with a person with epilepsy. Approximately half of the study group is willing to employ a person with epilepsy in a clerical job 56.8%. Only one-third of the students 33.7% agreed to marry a person with epilepsy it was noticed that more males had better attitude to marry person with epilepsy than females p=0.000.

DISCUSSION

As the importance of the dentists in the community and dealing with different kinds of patients who may have different kinds of diseases one of them could be epilepsy which considered as the most common chronic neurological disorder1 and it had a high prevalence in Saudi Arabia.5 Previously published study approved dissimilarities in providing dental care for different patients with epilepsy 13 this is could be attributed to less understanding of this condition, so knowledge, attitude and perception about this disease were investigated among dental students.

First and second year dental students are classified as preclinical years and had no contacts with patients, so they were not included in this survey. The college’s curriculum includes topics about pathophysiology of epilepsy and managements of medically compromised patients including epilepsy started from third year in this college based on that only 3rd, 4th and 5th dental students were included in this study.

The results of this study reflect a favorable awareness and knowledge about epilepsy among dental students. The university teaching was the main source for the students’ knowledge 88.8%. More than two-third of the students recognized that brain tumors, accidents or head trauma can cause epilepsy. It was reported that traumatic brain injuries considered as the most common cause of acquired epilepsy.14About half of the students knew that the inherited diseases and Stroke can lead to epilepsy. The most reported treatment option was the use of medications 84.5%. It was reported that 70% of epileptic patients were controlled by antiepileptic drugs.14Majority of the students 92.4% were able to define epilepsy as convulsion or a shaking as a sign of the disease. In the present study 32.7% of the participants knew people suffering from epilepsy which considered to be high if compared to what was reported in Malaysia (6.3%).15 also it was reported that in a study conducted for Saudi university students 60% knew people with epilepsy.16 The explanation for that is the high prevalence of epilepsy in Saudi Arabia 6.54 per 1000 persons.5 Majority of dental students had positive attitudes toward people with epilepsy only 7.3% of the students thought that the children with epilepsy should be isolated from other children and 13.9% of the study sample agreed on the children with epilepsy should attend schools for people with disability. 88.8% of the students will allow their children to play with a child with epilepsy which means they had better attitudes if compared to dental student of Jordan (61.4%)17 or dentist in Pakistan (76.7%)18In the present study few students believed that people with epilepsy should not get married 7.6% or having children 5.9% while 44.4%, 89.9% of Jordanian dental students and dentists from Pakistan respectively believed that people with epilepsy should not have children.17,18 A study from Korea reported that knowledge was the important factor affecting the attitude toward epilepsy.19 In the present study 98.3% had knew about epilepsy that will rise to better attitude toward the children with epilepsy. About half of the study group are willing to employ a person with epilepsy in a clerical job 56.8% this result reflects the low level of knowledge in Saudi Arabia. That percentage could be attributed to the concerns of dental students about safety for these people rather than the work itself. Only onethird of the students 33.7% agreed to marry a person with epilepsy, this attitude was comparable with what was observed in Saudi Arabia 24% 16, United Arab Emirates 32% 20 Greece 34% 21 and Kuwait 28.3%. 22 These findings reflect the believes of the people that epilepsy is an inherited disease, in the present study about half of the students reported epilepsy as inherited disease 51.2%. Although the results of the present survey provided information about dental students’ knowledge and attitudes in case of epilepsy; increasing the sample number by including students in private sectors and other governmental sectors could help to have valuable knowledge among Saudi dental students.

CONCLUSION

The findings of this study indicate a favorable awareness and knowledge about epilepsy among dental students. They had some negative attitude toward people with epilepsy. Based on that education about the disease needs to be improved through enhancing more information about the disease at school and university teaching, so people will understand more about epilepsy and will have better attitude toward people having this disease.

ACKNOWLEDGEMENT

The author would like to thank the students for their participation to complete the research process. The research was registered at the college of Dentistry Research Center (FR 0268), King Saud University, Riyadh, Saudi Arabia.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. World Health Organization Epilepsy fact sheet: World Health Organization (2015)
2. Chang BS, Lowenstein DH. “Epilepsy”. N Engl J Med. 2003; 349: 1257-66.
3. Leonardi M, Ustun TB. The global burden of epilepsy. Epilepsia. 2002; 43: 21-5.
4. Benamer HD, Grosset DG. A systematic review of the epidemiology of epilepsy in Arab countries. Epilepsia. 2009; 50: 2301-4.
5. Al Rajeh S, Awada A, Bademosi O, Ogunniyi A. The prevalence of epilepsy and other seizure disorders in an Arab population: a community-based study. Seizure. 2001; 10: 410-4
6. Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Estimation of the burden of active and lifetime epilepsy: a meta-analytic approach. Epilepsia. 2010; 51: 883-90.
7. Pandian JD, Santosh D, Kumar TS, Sarma PS, Radhakrishnan K. High school students’ knowledge, attitude, and practice with respect to epilepsy in Kerala, southern India. Epilepsy Behav. 2006; 9: 492-7.
8. Mirnics Z, Czikora G, Zavecz T, Halasz P. Changes in public attitudes toward epilepsy in Hungary: results of surveys conducted in 1994 and 2000. Epilepsia. 2001; 42: 86-93.
9. Pupillo E, Vitelli E, Messina P, Beghi E. Knowledge and attitudes towards epilepsy in Zambia: a questionnaire survey. Epilepsy Behav. 2014; 34: 42-6.
10. Jacoby A, Gorry J, Gamble C, Baker GA. Public knowledge, private grief: a study of public attitudes to epilepsy in the United Kingdom and implications for stigma. Epilepsia. 2004; 45: 1405-15.
11. Young GB, Derry P, Hutchinson I, John V, Matijevic S, Parrent L, et al. An epilepsy questionnaire study of knowledge and attitudes in Canadian college students. Epilepsia. 2002; 43: 652-8.
12. Obeid T, Abulaban A, Al-Ghatani F, Al-Malki AR, AlGhamdi A. Possession by ‘Jinn’ as a cause of epilepsy (Saraa): a study from Saudi Arabia. Seizure. 2012; 21: 245-9.
13. Károlyházy K, Kovács E, Kivovics P, Fejérdy P, Arányi Z. Dental status and oral health of patients with epilepsy: an epidemiologic study. Epilepsia. 2003; 44: 1103-8.
14. Epilepsy in the WHO Eastern Mediterranean Region: World Health Organization (2010)
15. AbRahman AF. Awareness and knowledge of epilepsy among students in a Malaysian university. Seizure. 2005; 14: 593-6.
16. Alaqeel A, SabbaghAJ.Epilepsy; what do Saudi’s living in Riyadh know?. Seizure. 2013; 22: 205-9.
17. Hassona YM, Mahmoud AA, Ryalat SM, Sawair FA. Dental students’ knowledge and attitudes toward patients with epilepsy. Epilepsy Behav. 2014; 36: 2-5.
18. Khan M. Ahad B, Khan T, Mufti A, Khan T. knowledge of dentists about epilepsy and their attitude toward dental treatment of epileptic patients: a survey of dentists in peshawer-Pakistan. Pak Oral Dent J. 2015; 35: 356-60
19. Lee SA, Yim SB, Rho YI, Chu M, Park HM, Lee GH, et al. Factors contributing to Korean teachers’ attitudes toward students with epilepsy. Epilepsy Behav. 2011; 20: 378-81.
20. Bener A, Al-Marzooqi FH, Sztriha L. Public awareness and attitudes towards epilepsy in the United Arab Emirates. Seizure. 1998; 7: 219-22.
21. Diamantopoulos N, Kaleyias J, Tzoufi M, Kotsalis C. A survey of public aware- ness, understanding, and attitudes toward epilepsy in Greece. Epilepsia. 2006; 47: 2154-64.
22. Awad A, Sarkhoo F. Public knowledge and attitudes toward epilepsy in Kuwait. Epilepsia. 2008; 49: 564-72.

Department of Pediatric Dentistry and Orthodontics, Dental College, King Saud University, Riyadh 11362, KSA
Corresponding author: “Dr. Noura A. AL-Essa” < Dr.nnn@hotmail.com >

Noura A. AL-Essa1                         BDS

Muhammad Amin1          –          BDS
Muhammad Amanullaha2          –          M.Sc, PhD
Anwar Muneer Tarar3          –                BDS,

INTRODUCTION

Oral diseases such as dental caries and periodontal disease are prevalent all over the world1 . According to W.H.O.3 report, 60 to 90 % school children and 100% adults have been affected by dental caries and 20 % have periodontal disease worldwide. In Pakistan, the people residing in rural areas are at a disadvantage with respect to their oral health mainly because of shortage of oral health care facilities and lack of awareness resulting from poor literacy4 . According to W.H.O.3 , it was  reported that 18% population of Pakistan has some form of periodontal problems and out of these 31% has periodontitis5 . Albandar et al.6 studied some risk factors of periodontal disease and tooth loss in adults. They observed that age, gender, current smoker status and number of years of smoking are the significant risk factors of tooth loss. Treasure et al.7 studied associated factors of tooth loss among in UK adults. They found that age, social status of household head, education, and marital status are the associated factors of tooth loss. Khan et al.4 studied the effect of awareness, attitudes, practices and other factors on dental diseases. They reported that use of sweet and smoking are the significant factors for dental diseases. Eke et al.8 studied the prevalence of periodontitis disease in adult population of United States of America. They reported that 64% adults (age 65 and above) have moderate and severe periodontitis. Brothwell et al.9 studied the factors associated with of visiting a dentist among older population of s in Canadian population. They find that education, relative support, use of health services, residence and income are the significant factors for visiting dental clinics. Khalifa et al.10 studied the tooth loss factors in Sudanese adults. They found that that age, gender, ethnic group, education, tobacco use, periodontal conditions and tooth wear are the significant factors of tooth loss.
From the literature we observed that most studies in Pakistan have considered the dental diseases of children. There was no study on dental diseases among adults ever conducted in Multan, Pakistan., Pakistan. Therefore, our purpose is to determine the prevalence and the risk factors of dental diseases among dental patients at visiting teaching institution of Multan.

METHODOLOGY

A survey on the risk factors of caries and periodontal disease was carried out at Dental Hospital, Multan, Pakistan. Different questions were asked to the patients at the face to face interview during diagnosis at outpatient’s patients department from March, 2014 to August, 2014.A total 499 patients were examined in the Dental Hospital, in this period. In present study, the variables of interest are bleeding gums, dental caries and periodontal disease. Following risk factors were explored: gender, age, diseases duration, education level, income level, profession, smoking, family history, use of pan, and tooth paste habit. For the data analysis, Statgraphics, Centurion XVI (USA) software was used. Frequency and percentages of dental diseases were computed. The Chi-square test was used to determine the association of the mentioned risk factors with the dental diseases.

RESULTS

The distribution of dental diseases and their risk factors are shown in Table 1. Factors such such as duration of dental disease, family history of dental disease, smoking and use of pan turned out to be significantly associated with the presence of caries, bleeding gums and dental disease among adults visiting dental hospital, Multan, Pakistan.

DISCUSSION

The association between the different types of dental diseases with family history indicated that there are 8.47%, 11.20% and 24.59% patients in bleeding gums, caries and periodontal diseases category whose family members have or have had dental diseases. The results show that family history has a significant effect on dental diseases (p-value = 0.02).

The association between the dental diseases and disease duration showed that there are 12.88%, 14.24%and 48.49% patients in the bleeding gums, caries and periodontal disease category. This means that there are 75.62% patients having diseases duration fewer than 500 days. In the light of these results, it is obvious that there are just 0.20% patients with duration of diseases over 3000 days. The disease duration has significant effect on presence of dental diseases (p-value <0.01).

On studying the association between dental disease and education, we observed that bleeding gums, caries and periodontal diseases are 6.01%, 4.37% and 15.30% respectively among illiterate subjects… There are 37.30% patients who have college education who presented with bleeding gums, caries and periodontal dental disease. However, the results showed that education has no significant association with dental diseases (p-value = 0.13).

Similarly, we noticed that that income level has no statistically significant effect on the development of dental diseases (p-value = 0.39).

There were 3.28%, 3.01% and 4.37% dental patients who did not use pan but presented with bleeding gums, caries and periodontal disease respectively. Whereas, there are 18.03%, 16.12% and55.19% subjects in bleeding gums, caries and periodontal disease category who were regular pan chewers.. Use of pan had a marginally significant association with dental disease (p-value = 0.04).

Another factor which may cause the dental diseases is the smoking. There were 47(12.84%), 59(16.12%) and 187 (51.09%) smokers subjects who reported bleeding gums, caries and periodontal problems respectively. It is evident that there are more smoking is associated with dental disease (p-value <0.001).

The relationship between the age of the patient (p-value = 0.55) and use of tooth paste (p-value = 0.17) did not turned out to be related with development of dental disease.

Parveen et al.11 studied the status of oral health and oral hygiene practices at Nishtar Institute of Dentistry, Multan. They reported that the oral health status of the majority of the patients was very poor. Similar studies were done by Nasir et al. in Islamabad12, Ali et al. 13 at Lahore, Umer et al.14 at Sargodha, Anwar et al. 15 at Peshawar and Shaikh et al.16 at Larkana. Mutamuliza et al.17 studied the risk factors of periodontal disease of adults in Rwanda. They have found that age, education level, occupation, tooth brushing, dental office attendance, diabetes, smoking status are the significant factors of periodontal disease. Baranwal et al.18 studied the patterns of dental caries of adults in Uttar Pradesh, India. They reported that mostly dental caries problems occurred in patients with age less than 30 years.

LIMITATIONS

Limitations of this research include:

• Results are only generalizable to the subjects visiting in the Nishter Dental Hospital. Only limited risk factors were taken into account for analysis. Other factors such as eating habits, carbohydrate intake, physical disability, life styles etc. may also be associated with dental diseases.

RECOMMENDATIONS

Awareness about the dental diseases is necessary for better oral health. Better education and taking precautions may help to reduce the dental diseases prevalence.

CONCLUSION

It was observed that family history of dental diseases, disease duration, smoking and use of pan using are the significant factors for .caries and periodontal disease among adults visiting dental hospital, Multan, Pakistan.

AUTHORS CONTRIBUTION

Muhammad Amin conceived the study, did planning, questionnaire development, data analysis, and interpreted the results. Muhammad Amanullah supervised the research and did proof reading of manuscript. Anwar Muneer Tarar collected the data and wrote the manuscript under the guidance of Muhammad Amanullah.

CONFLICT OF INTEREST

We have no conflict of interest.

REFERENCES

1. Nazir R, Hussain A, Kaleem M. Oral health status and malocclusion in flood affected and internally displaced children in Pakistan. Pak Oral Dent J. 2012; 32: 110-4.
2. Iqbal F. Prevalence of oral and dental diseases among domestic employees working in sector f-7 Islamabad. Pak Oral Dent J. 2011;31(1): 137-40.
3. http://www.who.int/mediacentre/factsheets/fs318/en/
4. Khan F, Ayub A, Kibria, Z. Knowledge, attitude and practice about the oral health among the general population of Peshawar. J Dow Uni Health Sci 2013; 7: 117-21.
5. Bokhari SA, Suhail AM, Malik AR, Imran MF. Periodontal disease status and associated risk factors in patients attending a Dental Teaching Hospital in Rawalpindi, Pakistan. J Indian Soc Periodontol 2015; 19: 678-82.
6. Albandar JM, Streckfus CF, Adesanya MR, Winn DN. Cigar, pipe and cigarette smoking as risk factors for periodontal disease and tooth loss. J Periodontol. 2000; 71: 1874-81.
7. Treasure E, Kelly M, Nuttall N, Nunn J, Bradnock G, White D. Factors associated with oral health: a multivariate analysis of results from the 1998 adult dental health survey. Br Dent J. 2001; 190: 60-8.
8. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012; 91: 914-20.
9. Brothwell DJ, Jay M, Schonwetter DJ. Dental service utilization by independently dwelling older adults in Manitoba, Canada. J Can Dent Assoc. 2008; 74: 161- 161f.
10. Khalifa N, Allen PF, Abu-bakr NH, Abdel-Rahman ME, Abdelghafar KO. A Survey of oral health in a Sudanese population. BMC Oral Health 2012; 12: 5.
11. Parveen N, Ahmad B, Bari A, Butt A. Oral dental health: Awareness and practices. J Uni Med Dent Coll 2011; 2: 5-10.
12. Nasir N, Ali S, Hayat Y, Bashir U. Oral health status of patients visiting Islamic International Dental Hospital. Ann. Pak. Inst. Med. Sci. 2012; 8: 27-30.
13.  Ali S, Bhatti M, Syed A, Chaudhry A, Iqbal Z. Prevalence of dental caries among 5 – 14 years old locality school children of Lahore. Pak Oral Dent J 2012; 32: 279-83.
14. Umer MF, Farooq U, Shabbir A, Zofeen S, Mujtaba H, Tahir M. Prevalence and associated factors of dental caries, gingivitis, and calculus deposits in school children of Sargodha district, Pakistan. J Ayub Med Coll Abbottabad 2016; 28: 152-6.
15. Anwar S, Rehman K, Khan M, Afridi, R. Body mass index and dental caries. J Khyber Coll Dent 2013; 3: 30- 3.
16. Shaikh MA, Rajput F, Khatoon S, Shaikh MA. . Prevalence of dental caries in BiBi Aseefa dental College, Larkana Areas. Pak Oral Dent J 2014; 34: 131- 4.
17. Mutamuliza J, Rwema F, Rulisa S, Ntaganira J. Prevalence and associated risk factors of periodontal disease among adults attending dental department in Rwanda Military Hospital (Rwanda): a cross sectional study. Dent Open J. 2015; 2: 105-11.
18. Baranwal HC, Pandiar D, Singh TB. Pattern of dental carries among adults purvanchal region of Utter Pradesh, India. Int J Sci Res 2015; 4: 323-6.

1. Department of Statistics, Bahauddin Zakariya University, Multan, Pakistan
2. Professor, Department of Statistics, Bahauddin Zakariya University, Multan, Pakistan
3. Department of Statistics, Bahauddin Zakariya University, Multan, Pakistan
Corresponding author: “Muhammad Amin” < ma_amin15@yahoo.com >

Muhammad Amin1          –          BDS
Muhammad Amanullaha2          –          M.Sc, PhD
Anwar Muneer Tarar3          –                BDS,