Management of Edentulous Maxilla with Sagittal -Transverse Deficiency Presenting with Repeated Implant Failures: A Case Report

Muhammad Hasan Hameed1 BDS
Farhan Raza Khan2 BDS, MS, MCPS, FCPS

ABSTRACT:

Occlusion is an important factor which determines the long term success in dental implantology. Ignoring the occlusion at the treatment planning can lead to poor clinical outcomes. The present report shows a case of an elderly lady presenting with edentulous maxilla which has experienced repeated failure of implants and prostheses. The patient had a deficient maxilla in sagittal and transverse planes. Previous dentists were unable to provide a predictable fixed prosthesis to the patient resulting in patient frustration. However, at the university dental center, the authors took the occlusion into account that not only yielded a functional and esthetic outcome with implant prosthesis but resulted in a satisfied patient as well.

KEYWORDS: Dental implant, prosthetics, failure, edentulous maxilla.

HOW TO CITE: Hameed MH, Khan FR. Management of Edentulous Maxilla with Sagittal-Transverse Deficiency Presenting with Repeated Implant Failures: A Case Report. J Pak Dent Assoc 2017; 26(2): 94-97.

Received: 5 January 2017, Accepted: 7 June 2017

INTRODUCTION

Dental implant based rehabilitation of the edentulous maxilla is a restorative challenge1. Number of variables influence the aesthetic and functional outcomes of the prosthesis. Long term prognosis of implants in the maxilla is less predictable than that of the mandible2 Maxillary bone resorption after tooth extraction is more pronounced (both in horizontal and vertical dimensions) than in mandible2. Moreover; pneumatization of maxillary sinus leaves little bone for subsequent implant placement3. Differential loss of alveolar bone on the facial aspect of maxilla results not only in a cross bite but unwanted occlusal interferences in the subsequent definitive prosthesis2,4. This creates mechanical stresses on the dental implants and the associated prostheses4.

Implant failure is believed to occur as a consequence of multifactorial process. Various causative factors include surgical trauma, peri-implantitis, smoking, poor bone quantity and/or quality, lack of primary stability, immediate loading. The most important factor that is usually overlooked is occlusal trauma and overloading5,6.

Occlusion is one of the important factors that determine the long term success of implant-supported prostheses4. If occlusion is not taken into account during the treatment planning, marginal bone loss continues to occur which leads to poor treatment outcome and implant failure5. Long-term survival and stability of implants requires consideration of proper occlusal scheme and implant-protected occlusion which improves the force distribution. This helps to minimize masticatory overload on bone-implant interfaces especially when occlusal interferences are present4,5.

The present case report highlights the importance of implant protected occlusion which must be considered during full mouth rehabilitation of edentulous maxilla with implant supported prostheses.

CASE REPORT

A 64-year old, hypertensive female presented to the dental clinic at Aga Khan University Hospital with the primary complaint of dislodged metallo-ceramic bridge and exfoliated dental implants. She reported that she had four dental implants placed by a GDP in her upper jaw a year back; the implants started to feel mobile and gradually not only the bridge but two of the implants get dislodged from the upper arch and now she is tooth less in the upper arch for over three months.


Fig. (1). Pre-operative clinical and radiographic image.

According to the patient, this was not the first time she had any implant or bridge failed. Her first experience of implant failure was a couple of years back when her upper prosthesis came out with the implants.

She was concerned with the repeated failures and was quite frustrated with the previous dental work. However, getting a removable complete denture was not acceptable for her and she still wanted a fixed solution.

Upon detailed clinical examination, it was seen that the patient had edentulous upper arch and an intact mandibular dentition with fixed metallo-ceramic bridge on #35-37 and a metal crown on #47 (Fig. 1). On radiographic examination, two implants were present in positions of #14 and 16. Patient had class III incisal relationship and a prognathic profile.

The primary challenge in this case was to explore the reasons of repeated failures. We speculate that the most probable explanation for repeated failures in this case was a transversely deficient maxilla & cross bite in the prosthesis leading to unwanted occlusal interference.

After thorough discussion and counseling, we decided to provide her with implants and bridges. There were following challenges in this plan:

1. Placement of implants in maxilla that is deficient in sagittal and transverse planes

2. Arranging teeth in correct bite versus cross bite or edge to edge relationship

3. Unknown identity of the two retained implants and hence design of the definitive prosthesis

4. What should be surgical protocol and the interim prosthesis?

CASE MANAGEMENT

After thorough discussion of the management option, informed consent was taken for implants and bridge. We decided to place four new implants and utilize the existing two fixtures so that the definitive prosthesis is supported by six implants. We made a complete denture first and used that as an interim prosthesis (after a little modification) till the time osseo-integration of the newly placed implants is achieved. Her history of repeated failures warranted consideration on the occlusal scheme. We planned an edge to edge bite and avoided posterior cross bite and occlusal interference in the definitive bridge.

As she already had two integrated implants placed at the position of #14 and #16, the sites favorable for our implants were position of # 11, 21, 23 and 25. Under local anesthesia, full thickness flap was raised from right to left molar to molar region, with relieving incision at midline frenum. A non-submerged surgical protocol was followed and four Zimmer TSV implants 3.7mmX11.5mm were placed with primary stability. Corresponding healing abutments were placed on four new and two old implants (the Zimmer healing abutments were fortunately found to be compatible with her old implants). Incision closed with 3-0 vicryl in simple interrupted fashion.

At two weeks follow-up, we modified the pre-made maxillary complete denture to accommodate and passively house the healing abutments. The denture was delivered and home care instructions including hygiene given to the patient. Following the healing phase after 3 months of implant placement, the patient was called in for her definitive prosthetic phase. At this visit, final polysiloxane putty wash impression was obtained after placing fixture mount transfer abutments (Fig. 2). At subsequent visits, metal casting and bisque trials were done, adjustment made as per the occlusion and esthetic requirements (Fig. 3).


Fig. (2). Appearance of permanent abutments and metal casting trial of the implant prosthesis.


Fig. (3). Post-operative clinical and radiographic image.

Patient was kept on edge to edge occlusion in order to avoid interferences and premature occlusal contacts. After the patient was fully satisfied with the esthetics, the final prosthesis was delivered to the patient. Patient was monitored on follow-up visits annually. She was pleased with the success of the therapy. To date, there are no detectable clinical or radiographic changes around the implants, and no prosthetic complications have occurred. The patient is scheduled for annual follow- ups to maintain hygiene and periodontal prophylaxis.

DISCUSSION

This case report delineates a comprehensive treatment planning that can be considered while restoring the edentulous constricted maxilla with implant supported fixed prosthesis. Patients with constricted edentulous maxillae pose multiple challenges because the occlusion of these patients falls into cross bite which could result in occlusal interferences and overloading of implant leading to failure4,7. Occlusal overload results in crestal bone loss, thus increasing the anaerobic sulcus depth and predisposes the fixture towards progressive peri-implantitis and eventual loss of implant8,9.

Several animal studies have proved that excessive lateral forces from premature occlusal contact can cause excessive marginal bone loss or even osseointegration failure10,11. Therefore, in this case, we speculated that occlusal overload from excessive lateral forces acted as one of the factors causing previous implant failures. We managed the case according to the principles of Misch and Bidez12,13 who proposed implant-protected occlusion by reducing the occlusal forces on implant prostheses to protect the implants. They suggested that the mechanical stresses on implant can be minimized by adding the number of implants (six or eight instead four or five) or by splinting the implant together to increase the surface of support8,12,13. To compensate for the increased magnitude of a force, we increased the surface area of fixtures by increasing the number of implants in the arch and eliminated occlusal interferences on implants keeping the basic principles of implant occlusion which include:

1. Anterior guidance whenever possible,
2. Bilateral stability in centric (habitual) occlusion,
3. Wide freedom in centric (habitual) occlusion,
4. Evenly distributed occlusal contacts and forces,
5. No interferences between the retruded position and centric (habitual) position, and
6. Even lateral excursive movements without working and non-working interferences

In our case, we were fortunate that our implant system abutments were compatible with previously placed implants of dissimilar implant systems which helped us in restoring patient’s normal occlusion.

CONCLUSIONS

Edentulous maxilla that is deficient in sagittal and transverse planes poses a challenge for implant based prosthetic rehabilitation. Comprehensive and precise evaluation of the patients’ needs, followed by appropriate treatment planning provides the restorative dentist with the platform to meet patient expectations. Occlusion is a determining factor for the long term implant success. It must be factored into the treatment planning to obtain a gratifying experience for both the dentist and the patient.

Footnotes

1. Resident, Operative Dentistry, Aga Khan University, Stadium Road, Karachi, Pakistan

2. Assistant Professor, Dentistry, Aga Khan University, Stadium Road, Karachi, Pakistan
Corresponding author: “Dr. Farhan Raza Khan”
<farhan.raza@aku.edu>

REFERENCES

1. Bosse LP, Taylor TD. Problems associated with implant rehabilitation of the edentulous maxilla. Dent Clin North Am 1998; 42: 117-27.

2. Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J 2006; 201: 261-79; quiz 304.

3. Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior maxilla: implants with sinus grafting. J Oral Maxillofac Surg 2009; 67: 867-71.

4. Chen YY, Kuan CL, Wang YB. Implant occlusion: biomechanical considerations for implant-supported prostheses. J Dent Sci 2008; 3: 65-74.

5. Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early implant bone loss: myth or science? J Periodontol 2002; 73: 322-33.

6. Chee W, Jivraj S. Failures in implant dentistry. Br Dent J 2007; 202: 123-9.

7. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000; 11 Suppl 1: 156-8.

8. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Clin Oral Implants Res 2005; 16: 26-35.

9. Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: their prevention, diagnosis and treatment. Clin Oral Implants Res 2000; 11 Suppl 1: 146-55.

10. Miyata T, Kobayashi Y, Araki H, Ohto T, Shin K. The influence of controlled occlusal overload on peri-implant tissue. Part 3: A histologic study in monkeys. Int J Oral Maxillofac Implants 2000; 15: 425-31.

11. Isidor F. Loss of osseointegration caused by occlusal load of oral implants. A clinical and radiographic study in monkeys. Clin Oral Implants Res 1996; 7: 143-52.

12. Misch CE, Bidez MW. Implant-protected occlusion. Pract Periodontics Aesthet Dent 1995; 7: 25-9.

13. Misch CE, Bidez MW. Implant-protected occlusion: a biomechanical rationale. Compendium 1994; 15: 1330-2.

Use of Mineral Trioxide Aggregate for Non-Surgical Repair of a Furcal Perforation

Abdul Hakeem Qureshi1
Muhammad Rameez2
Haroon Rashid3

ABSTRACT:

The case report sheds light upon a non-surgical repair of a furcation defect. A 57-year old female reported for examination of tooth no. 46. The presenting complains included mild to moderate pain with small localized swelling and discharge from lingual aspect of tooth. Clinical examination revealed a discharging sinus with moderate inflammation at gingival margin on lingual aspect, with negative percussion. A diagnosis of chronic peri-radicular abscess of the tooth was made and the defect was repaired by using Mineral Trioxide Aggregate (MTA). The clinical sign and symptoms resolved after treatment within a week period.

KEYWORDS: Furcal perforation, Furcation defect, Mineral trioxide aggregate, Non-surgical repair.

HOW TO CITE: Qureshi AH, Rameez M, Rashid H. Use of Mineral Trioxide Aggregate for Non-Surgical Repair of a Furcal Perforation. J Pak Dent Assoc 2017; 26(2): 90-93.

Received: 20 January 2017, Accepted: 25 May 2017

INTRODUCTION

Perforations in Endodontics are defined as the artificial communications of the root canal system to supporting tissues of teeth or to the oral cavity [1]. Where left untreated, the perforations which are closer to the epithelial attachments, the crestal bone and those which are on the floor of pulp chamber have poor prognosis. Such perforations may causes persistent infections which may be intra-radicular or extra-radicular in nature1. The perforations, both intra and extra-radicular have been regarded as very serious complications in clinical dentistry. From a historical perspective, these perforations were one of the commonest causes of tooth extractions in the majority of cases2. These defects, which could occur due to a pathological or mechanical reasons, often require a creative approach for their management.

A number of materials such as the dental amalgam, intermediate restorative material (IRM), zinc-oxide eugenol cement, glass-ionomer cement and mineral trioxide aggregate (MTA) have been shown to have been used for repair of such perforations3. MTA was introduced by Torabinejad et al.4 and has been recommended as a material of choice for the repair of root canal perforations. It has been proven using different leakage approaches such as fluid filtration technique, dye-leakage model, and bacterial leakage model that the sealing ability of MTA is better as compared to many other sealing materials5. MTA has excellent anti-microbial properties, a high pH, and excellent biocompatibility, promotes cementum growth and formation of bone, which leads to periodontal ligament regeneration around the site of injury and infection6.

The current case report sheds light upon the use of MTA for the repair of a perforation which occurred in the furcation area of a molar tooth in a private dental practice.

CASE REPORT

A 57-year old female presented at the dental practice complain of mild pain and discomfort in her tooth no. 46 with no relevant medical history. Root canal therapy had been performed on the same tooth around 2 months ago. Clinical examination revealed a discharging sinus with moderate inflammation at gingival margin on lingual and buccal aspects of the tooth (Figs. 1, 2). Percussion was negative while palpation on lingual aspect was slightly positive. The peri-apical radiograph revealed a mild furcal radiolucency with a root canal filling which was considered as appropriate (Fig. 3). A diagnosis of chronic peri-radicular abscess of the tooth was made due to presence of lateral perforation and a decision of perforation repair using an MTA was taken.


Fig. (1).


Fig. (2).


Fig. (3).

Local anaesthesia was administered and rubber dam was placed to isolate the tooth. After isolation, the coronal restoration was removed by using small round-end diamond bur using a high speed air-turbine hand-piece. A round end carbide bur with a slow-speed hand-piece was used for restoration removal near the floor of the pulp chamber. After complete removal of restoration and removal of some of the gutta-percha (GP), fresh bleeding was noticed (Fig. 4). The pulp chamber was cleaned and the source of bleeding was found to be present at the lateral aspect of pulp chamber and the mesio-lingual canal of the tooth. The chamber was cleaned with 3% Sodium Hypochlorite and the coronal 1/3rd of the root end filling of the mesio-lingual (ML) canal was removed. The bleeding from the defect increased with a little more flow. The depth of the canal was measured and canal was washed and irrigated using 3% Sodium Hypochlorite. ProRoot MTA (Dentsply, Tulsa) was mixed with distilled water to a wet sand consistency as per manufacturer’s recommendations. The mixed material was placed in the canal and the pulp chamber in increments. After filling the canal completely a thin layer of MTA was also placed on the lingual wall and floor to seal the defect completely (Fig. 5). A wet cotton pellet was kept on the freshly placed MTA for 24 hours and the tooth was sealed with Cavit (3M ESPE).


Fig. (4).

The next day, the temporary restoration was removed and a bonded resin restoration was placed. Patient was recalled after one week and then at two weeks. The treatment was considered successful as all the clinical signs and symptoms had subsided (Fig. 6). Patient has been advised to revisit the dental practice, after six months for further follow-up after which the definitive crown will be placed.


Fig. (5).


Fig. (6).

DISCUSSION

Accidental perforations of the root canal system are considered to be major complications in dentistry which may occur while performing non-surgical endodontic therapy. These complications may result in formation of granulation tissues and ultimate loss of the tooth. However, these can be managed successfully using surgical and non-surgical methods, depending upon particular characteristics of the case7.

The prognosis is usually good if the condition is treated with a suitable material with good sealing ability and biocompatibility. Perforations can be treated with different materials and it is recommended that the material which is being used for repairs is non-toxic, non-resorbable, radio-opaque, bacteriostatic or bactericidal and should provide complete seal from micro leakages8. MTA has all the required characteristics for many clinical applications i.e. as a material for obturation in tooth with open apex, for root end filling, direct pulp coverage, radicular resorption and perforation. Its suitability for managing all of these problems can be attributed to its biocompability, its low solubility, its low induction of inflammation, its capacity for creating a seal between pulpal chamber and periodontal tissues and its repair capacity4. The last of these features can be helpful due to antimicrobial properties and high pH 12.5 of MTA, which promote growth of cementum and formation of bone, which in turn allow regeneration of periodontal ligament around site of defect9.

The prognosis of lesions involving furcation also depends on the size, shape, location and period of contamination. To decrease the chances of infection, studies have revealed that best time for repair of perforation is immediately after occurrence10. The size of perforation has an important role in prognosis. Smaller the size of perforation, better will be the prognosis as smaller perforations may be easier to repair and a better seal could be achieved11. Those perforations which are closer to crestal bone and the epithelial attachment are more prone to bacterial contamination from the oral environment12. Furthermore, the apical migration of attachment may cause periodontal pockets and there may be continuous ingression of irritants from pocket, leading to subsequent failures13.

FOOTNOTES

1. Faculty of Dentistry, Division of Conservative Dentistry, Ziauddin University, Karachi, Pakistan

2. Faculty of Dentistry, Division of Prosthodontics, Ziauddin University, Karachi, Pakistan

3. Faculty of Dentistry, Division of Prosthodontics, Ziauddin University, Karachi, Pakistan
Corresponding author: “Dr. Haroon Rashid”
<drh.rashid@hotmail.com>

REFERENCES

1. Tsesis I, Fuss Z. Diagnosis and Treatment of accidental Root Perforations. Endodontic Topics 2006; 13: 95-107.

2. Kvinnsland I, Oswald RJ, Halse A, Gronningsaeter AG. A clinical and roentgenological study of 55 cases of root perforation. Int Endod J 1989; 22: 75-84.

3. Bains R, Bains VK, Loomba K, Verma K, Nasir A. Management of pulpal floor perforation and grade II Furcation involvement using mineral trioxide aggregate and platelet rich fibrin: A clinical report. Contemp Clin Dent 2012; 3(Suppl 2): S223-S227.

4. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999; 25(3): 197-205.

5. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review–Part I: chemical, physical, and antibacterial properties. J Endod 2010; 36(1): 16-27.

6. Ayala S. Repair of Furcal Perforation with Mineral Trioxide Aggregate: Long- Term Follow-Up of 2 Cases. JCDA • www.cda-adc.ca/jcda • October 2008, Vol. 74, No. 8.

7. Abou-Rass M, Frank AL, Glick DH. The anticurvature filing method to prepare the curved root canal. J Am Dent Assoc 1980; 101: 792-794.

8. Sakkir N, Ahamed K, Nair MG, Joseph S, Christalin R. Management of Dilacerated and S-shaped Root Canals – An Endodontist’s Challenge. J Clin Diagn Res 2014; 8(6): 22-24.

9. Savitha Adiga Ida Ataide. Non Surgical approach for Strip perforation repair using Mineral Trioxide Aggregate. J Conserv Dent 2010; 13(2): 97-101.

10. Sinai IH. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc 1977; 95: 90-95.

11. Eleftheriadis GI, Lambrianidis TP. Technical quality of root canal treatment and detection of iatrogenic errors in an undergraduate dental clinic. Int Endod J 2005; 38: 725-734.

12. Gutmann JL, Harrison JW. Surgical Endodontics. Boston, MA: Blackwell Scientific Publications 1991; p. 409.

13. Fuss Z, Tsesis I, Lin S. Root resorption – diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol 2003; 19: 175-182.

Peri-Implant Soft Tissue Esthetics; A Journey from Implant Placement to Permanent Restoration

Fahad Umer1 BDS, FCPS, FICOI, CAGS U-PENN
Samira Adnan2 BDS, FCPS
Muhammad Rizwan Nazeer3 BDS

ABSTRACT:

Restorations placed in the anterior part of the mouth present a unique challenge in terms of reproducing the lost soft tissue. This aspect is particularly pronounced in case of avulsed central incisors. Since ‘black triangles’ have been displayed in patients where the anterior teeth are replaced by implants, particular attention needs to be paid to achieve the desired soft tissue profile. This case-report explains the restoration of upper central and lateral incisors of a patient, where the central incisor was avulsed and lateral incisor fractured. The process of replacing the central incisor with an immediate implant, followed by slowly and gradually modifying the peri-implant soft tissue, leading up to transferring the modified soft tissue profile through a specialized impression technique, has been described in detail.

KEYWORDS: Facial aesthetics, black triangle, upper central incisor, screw retained implant, cement retained implant special impression technique.

HOW TO CITE: Umer F Adnan S, Nazeer MR. Peri-Implant Soft Tissue Esthetics; A Journey from Implant Placement to Permanent Restoration. J Pak Dent Assoc 2017; 26(2): 83-89.

Received: 8 December 2016, Accepted: 15 March 2017

Introduction

Restoring aesthetics in the anterior part of the mouth after trauma is a challenging endeavor. There are multitude of reasons ascribed to failure of restorations in the anterior region of the mouth, but most are essentially esthetic concerns1. One of the ideal methods to replace a lost permanent incisor is the placement of an implant. But replacing the missing tooth with an implant does not automatically achieve ideal aesthetics for the anterior teeth2. The infamous ‘black triangle’ has widely been reported in patients rehabilitated with dental implants3. According to the patient’s soft tissue profile, the soft tissue surrounding the implant has to be modified over a period of time in order to achieve the desired soft tissue architecture4. This calls for an interim restoration of such dimensions and quality that sculpts and supports the soft tissue, while 
maintaining acceptable aesthetics and without causing any trauma to the soft tissue5. This case-report explains the restoration of upper central and lateral incisors of a patient, where the central incisor was avulsed and lateral incisor fractured. The process of replacing the missing central incisor with an immediate implant, followed by the gradual modification of the peri-implant soft tissue, and then transferring the modified soft tissue profile through a specialized impression technique, has been described in this case report.

Case Report

A 42 year old female patient came to our Dental Clinic, having suffered from dental trauma one day before (Fig. 1). On clinical examination, it was seen that the patient had an avulsed upper left central incisor and coronal fracture (Ellis class III) of upper left lateral incisor with visible pulp exposure (Fig. 2). A periapical radiograph of the upper left anterior segment showed complete absence of upper left central incisor (Fig. 3). As the retrieved tooth was kept dry and its re-implantation wound have ultimately lead to ankylosis and related complications, it was planned to place an immediate implant for replacement of 21 along with root canal treatment on the 22. After explaining the treatment plan to the patient and obtaining their consent, the patient’s treatment was commenced.


Fig. (1). Avulsed upper left central and fractured portion of left lateral incisor.


Fig. (2). A clinical picture showing an avulsed central incisor and an ellis type III fracture of left lateral incisor.


Fig. (3). Initial periapical radiograph showing an empty socket and fractured lateral incisor.

Local anesthesia (1.7 ml of 2 % Xylestine 1:80,000) was administered and osteotomy was started. The final drill was 3.2mm width with a length of 12.5mm. Afterwards, a 3.8mm width and 10.5 mm length implant was placed in the osteotomy site (Fig. 4). The primary stability was of 30 Ncm was achieved. The implant had 3.5mm platform (Biohorizons tapered internal hex laser lok). Healing abutment (Bio-horizons 3.5mm width) was placed at the same appointment (Fig. 5). Meanwhile, root canal treatment was completed on 22. The tooth was prepared as to receive a PFM crown. Since the torque on the implant replacing the central incisor was less than 45N/cm2, screw retained temporary crown could not be fabricated at that time. A temporary crown was made for 22, to which a crown for the missing 21 was cantilevered. The temporary restoration was cemented with temporary cement.


Fig. (4). Periapical radiograph showing implant placement at avusled side (#21).


Fig. (5). Clinical picture after healing collar placement.

At follow-up visit after two weeks, the patient was assessed for any uneventful healing.

At the next appointment which was after three months, a peri-apical radiograph revealed an integrated implant with absence of any pathology. After exposure, the implant exhibited secondary stability and hence, a healing abutment with regular emergence 5mm height (TP3HA5L) was placed. At the next appointment after three weeks, it was decided to place a lab fabricated screw retained temporary crown to improve soft tissue profile.

Consequently, an impression was done with a laser-lok Biohorizons titanium abutment (PYTTH) using addition silicon (Fig. 6). All parameters for an esthetic restoration, like smile line, lip line, lip position, and facial profile were recorded. At the subsequent appointment, the screw-retained temporary was placed and hand tightened (Fig. 7).


Fig. (6). Laser lok Biohorizons titanium abutment placement for final putty impression.


Fig. (7). The screw-retained temporary was placed and hand tightened.

After two weeks, composite restoration was added only at the gingival margins of the temporary restoration, gradually modifying the restoration and gently sculpting the soft tissue in that area. Consequently, after three months, both the clinician and patient were satisfied with the gingival esthetics (Fig. 8). Next, the impression was taken to transfer the peri-implant soft tissue profile to the permanent restoration. This involved the removing the temporary crown, (Fig. 9) then attaching an implant analogue to it (Fig. 10).


Fig. (8). Frontal view after 3 months follow up. Note the improvement in gingival aesthetics.


Fig. (9). Removal of abutment crown for sterlization.


Fig. (10). Connecting implant analogue to temporary crown.


Fig. (11). Assembly for recording the free gingival margin.



Fig. (12).
The surrounding space around the abutment was filled using light cured flowable composite.


Fig. (13). Permanent abutment with the collar of composite mimicking the soft tissue profile around the implant was removed.


Fig. (14). The assembly was then placed inside the patient’s mouth while confirming the facial and lingual orientation.


Fig. (15). The picking of modified permanent abutment in the impression.


Fig. (16). Soft tissue aesthetics after removal of temporary crown.

This assembly was then stabilized and plaster was poured around it, making sure that the gingival tissue, from the implant collar till the free gingival margin, was adequately recorded (Fig. 11). Once the plaster was set, the temporary crown was removed from the implant analogue and the permanent abutment was attached. The surrounding space around the abutment was filled using light cured flowable composite, (Fig. 12). The composite was cured and the permanent abutment with the collar of composite mimicking the soft tissue profile around the implant was removed (Fig. 13). This assembly was then placed inside the patient’s mouth while confirming the facial and lingual orientation (Fig. 14). The impression was taken with modified permanent abutment picked up in the impression (Fig. 15), the implant analogue was attached to it and dental stone (Plaster Neelkanth stone) poured. Once the plaster was set, the composite around the abutment was removed. The temporary crowns were replaced in the patient’s mouth and patient recalled after one week. In the meantime, the permanent crowns were fabricated in the laboratory, with external contours following the soft tissue profile of the patient developed over time. In the next appointment, the temporary restorations were removed (Fig. 16), and the permanent crowns were cemented (Figs. 17, 18). The patient was satisfied with the appearance of the final restorations and a follow-up radiograph and cone beam CT scan (Carestream CS 93000 Gallileo) done six months after delivery of the crown showed adequate healing and no signs of peri-implant disease and an intact labial plate of bone (Figs. 19, 20).


Fig. (17). Soft tissue appearance after final crown cementation.


Fig. (18). Final crown in place.


Fig. (19). Periapical radiograph after crown Cementation.


Fig. (20). Six months follow up CT scan showing intact labial plate of bone.

Discussion

Re-establishing aesthetics after trauma in the anterior region of the mouth is a challenge, especially in cases of avulsion. A viable option for replacement of such a tooth is immediate implant placement. Our patient was a healthy individual with adequate amount of bone, which made her an ideal candidate for immediate implant placement6.

The goal was to preserve the gingival tissue architecture with the help of well-made temporary restoration, until the time the implant had osseointegrated7. Although primary stability was achieved but was less than 30Ncm and therefore a screw-retained temporary crown could not be placed. This resulted in loss of the pre-existing gingival architecture of the patient, which had to be re-established with the help of customized temporary crown. The disadvantage of using a wider implant in the anterior maxillary region is the potential to damage the thin labial plate of bone, which can result in compromised aesthetics. In this case, the osteotomy site for the implant was intentionally prepared palatally in order to preserve the labial plate of bone and prevent any esthetic dilemma8.

One of the complications of implant placement in the anterior region of the mouth is labial bone dehiscence or fenestration9. Careful and atraumatic implant placement is one way of ensuring the integrity of the buccal cortical plate. In our patient, the buccal bone was intact and of adequate thickness, and hence was demonstrated to be preserved in the follow-up radiographs and CT scan.

Placing an implant in the socket immediately after extraction helps preserve the dimensions of the alveolar socket as well as the profile of the soft tissue10.

Temporary restorations placed after implant insertion play an essential role in maintaining the esthetics until the implant osseo-integrates11. The temporary restoration that was provided to the patient initially did not provide optimum contouring of the soft tissue. Hence, the screw retained temporary restoration was contoured and altered over a period of three months, allowing the surrounding tissue to mould and mature and providing time for the implant to osseo-integrate. The temporary restorations were previously modified using self-cure acrylic but this practice has been discontinued due to concerns with uncured resin deep in soft tissue surrounding the implant causing trauma12. Instead, composite is used now as it can added incrementally, has better handling properties and is tissue-friendly.

The effort exercised in maintaining the architecture of the peri-implant gingival tissues is paid off only if it is successfully translated into the permanent restoration. The most basic method includes removing the temporary restoration and obtaining an implant level impression13. There can be some issues in this technique as depending on the depth of the implant placement, the impression material may not completely record the entire soft tissue profile of the peri-implant region. Other methods include the use of the temporary restoration, as was followed in our patient. Modifications for this particular technique are using putty instead of plaster to be applied around the temporary crown, 14 or using an impression coping instead of the permanent abutment while applying flowable composite to modify it for use in final impression. These techniques have the advantage that the patient does not have to remain without the temporary crown for a longer period of time14.

Conclusion

Immediate implant placement is an ideal form of tooth replacement in a patient meeting the clinical criteria for this treatment modality. A careful placement technique and well-designed temporary restorations can help achieve ideal aesthetics with implants in the anterior region of the mouth.

DiscLOSURE

None of the authors had any financial interest in the companies whose products have mentioned in this case report.

Footnotes

1. Assistant Professor and Consultant, Operative Dentistry, The Aga Khan University and Hospital, Karachi, Pakistan.

2. Assistant Professor, Operative Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi, Pakistan.

3. FCPS-II Resident Operative Dentistry, The Aga Khan University Hospital, Karachi, Pakistan
Corresponding author: “Dr. Samira Adnan”
<nnmst@hotmail.com>

References

1. Palacci P, Nowzari H. Soft tissue enhancement around dental implants. Periodontology 2000. 2008; 47(1): 113-32.

2. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004; 19(Suppl): 30-42.

3. Jivraj S, Chee W. Treatment planning of implants in the aesthetic zone. British dental journal. 2006; 201(2): 77-89.

4. Azer SS. A Simplified Technique for Creating a Customized Gingival Emergence Profile for Implant†Supported Crowns. Journal of Prosthodontics.19(6): 497-501.

5. Cho S, Shetty S, Froum S, Elian N, Tarnow D. Fixed and removable provisional options for patients undergoing implant treatment. COMPENDIUM-NEWTOWN-. 2007; 28(11): 604.

6. Schwartz-Arad D, Chaushu G. Placement of implants into fresh extraction sites: 4 to 7 years retrospective evaluation of 95 immediate implants. Journal of periodontology. 1997; 68(11): 1110-6.

7. Greenstein G, Cavallaro J, Tarnow DP. Immediate dental implant placement: technique, part I. Dent Today.33(1): 98-100.

8. Palmer RM, Palmer PJ, Baker P. Immediate and early replacement implants and restorations. SADJ: journal of the South African Dental Association= tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging. 2008; 63(2): 074-9.

9. Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. Journal of Oral Rehabilitation. 2008; 35(s1): 33-43.

10. Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. The International journal of periodontics & restorative dentistry. 1989; 9(5): 332.

11. Bichacho N, Landsberg CJ. A modified surgical/prosthetic approach for an optimal single implantsupported crown. Part II. The cervical contouring concept. Practical periodontics and aesthetic dentistry: PPAD. 1994; 6(4): 35-41; quiz.

12. Alani A, Corson M. Soft tissue manipulation for single implant restorations. British dental journal.211(9): 411-6.

13. den Hartog L, Raghoebar GM, Stellingsma K, Meijer HJA. Immediate loading and customized restoration of a single implant in the maxillary esthetic zone: a clinical report. The Journal of prosthetic dentistry. 2009; 102(4): 211-5.

14. Barzilay I. A Mo di fied Im p ression Technique for Ac curate Registration of Peri-implant Soft Tissues. J Can Dent Assoc. 2003; 69(2): 80-3.

BDS Curriculum: Neglected Sibling

Khadija Iqbal1 MBBS, FCPS
Samra Asif2 Third year BDS
Ibad-ur-Rehman3 First year MBBS

ABSTRACT:

The medical educationists are emphasizing on the implementation of skills based curriculum which covers the oral health in a broader and global scale. Keeping in mind these things this study was conducted to know opinion of medical students regarding modern educational reforms and the present curriculum taught in their medical colleges.

Methodology: This survey was done in medical colleges with four year program in dentistry in Rawalpindi and Islamabad. A four-question survey about the format and characteristics of the dental curriculum was circulated among the 200 dental graduates graduating in the year 2014 belonging to different dental colleges in Rawalpindi and Islamabad. The respondents expressed their answers in yes or no. Respondents indicated the name of their school and answered survey questions. Descriptive statistics including percentage distribution for each response were used. Responses were recorded separately for all the four years.

Results: In response to the question about integration between oral diseases with systemic disease, almost all agreed that their curriculum is disjointed in first and second year. 40% of the students told that some integration is created in third and 30% agreed that the integration is there in fourth year. 20% said that the basic sciences were taught with clinical context in first and second year and was not done in third and fourth year. Exposure of dental students to community and public health services was around 20% in third year and 30% in fourth year. PBL and case based discussions are not used in the dental colleges in all years.

Conclusions: The dental curriculum in Pakistan needs to cover a much broader spectrum of diseases as well as patients. Linking the curriculum with modern tools like PBL can improve dental education. The link between the basic and clinical teaching and incorporation of community health can lead to marked shift in educational approach of the medical students.

KEYWORDS: M.B.B.S, dentistry, undergraduate, curriculum.

HOW TO CITE: Iqbal K, Asif S, Rehman IU. BDS Curriculum: Neglected Sibling. J Pak Dent Assoc 2017; 26(2): 79-82.

Received: 8 February 2017, Accepted: 5 May 2017

Introduction

A lot of debate is going on worldwide about the competency of medical graduates1. The M.B.B.S curriculum is undergoing reforms in this context to improve the quality of medical education and more focus is now on the skill component2. Whether we are successful or not but attempts are going on for improvements and innovations3. Dentistry is a linked field with medicine which deals with a large number of patients and dental disease also form a major factors troubling the lives of patients. In our country this field is almost totally
 neglected when the curricular reforms are taking place4. In western world the field of dentistry is growing like a modern industry but in our country it is treated like a second class degree5. The current curriculum debate in Pakistan is mostly revolving around arguments on shuffling various topics from one subject to another. It totally ignores the importance of our social demographics6. We do teach Implants to our under-graduates, but we forget that Implants is only minor percentage of the market needs. The designing of curriculum needs to know the patients for which the curriculum is designed. In our country the dental patients are the two extremes the paediatric and geriatric but the curriculum never focuses these two age groups7. In Pakistan, there is no dearth of experienced professionals and academicians, who have the global exposure to upgrade our curriculum and enable faster access to global developments8. In India the Paediatric and preventive dentistry is taught in clinical years which makes the students aware about the prevalence and treatment of paediatric dentistry9. The patients of dentistry are increasing day by day and they need specialist doctors to fulfil their needs. Many researchers have proposed a model for dental education that can built critical thinking in dental graduates and also create professionalism as well10. Oral health is a critical component of human health needs evidence-based approach to clinical decision making which built on integrative understanding of basic and applied science11. In Harward School of dentistry integrated clinical practice of dental care for adults occurs in the in clinical and preclinical years12. Research skills are developed with opportunities to become involved in faculty research projects as well as in the conduct of community health projects. PBL in the final year, provides an opportunity to experience and learn from different clinical contexts13. In many countries a six year BDS programme has been introduced14. After the publication of the Flexner report, Gies worked to trigger significant change in dental education at the time. He emphasized the importance of stronger scholarship in biomedical and clinical sciences but many of Gies’s recommendations did not gain popularity15. The American Dental Education Association (ADEA) developed programs and initiatives to support the reform of dental education16.

Table 1. Table Showing the Response of Students Regarding Different Factors Showing Integration of Dental with Systemic Health.

The present curriculum of B.D.S approved by the P.M.D.C is not according to the modern concepts of dentistry. Pakistan needs a paradigm shift towards research oriented and clinical based scientific methodologies with emphasized training on medical jurisprudence and human consumer rights as well17. Case based teaching and PBL incorporation can lead to improvement in competencies of medical graduates18. The oral health is a spectrum of diseases that needs a thinking mind to cure the disease19. The designing of the curriculum should be based on skills but to covers the oral health in a broader and global scale. Keeping in mind these things this study was conducted to know opinion of medical students regarding modern educational reforms and the present curriculum taught in their medical colleges.

Subjects and Method

This survey was done in medical colleges with four year programme in dentistry in Rawalpindi and Islamabad. A four-question survey about the format and characteristics of the dental curriculum was circulated among the 200 dental graduates graduating in the year 2014 belonging to different dental colleges in Rawalpindi and Islamabad. The respondents expressed their answers in yes or no. Respondents indicated the name of their school and answered survey questions. Descriptive statistics including percentage distribution for each response were used. Responses were recorded separately for all the four years.

Results

In response to the question about integration between oral diseases with systemic disease, almost all agreed that their curriculum is disjointed in first and second year. 40% of the students told that some integration is done in third and 30% agreed that the integration is there in fourth year. 20% said that the basic sciences were taught in clinical context. Contextual learning was done in first and second year and was not done in third and fourth year. Exposure of dental students to community and public health services was around 20% in third year and 30% in fourth year. PBL and case based discussions are not used in the dental colleges in all years (Table 1).

Discussion

Field of dentistry is not only linked to the oral cavity but it is a whole spectrum which needs to be revealed. The dentist is not the man needed to extract the toot or treat the tooth ache but he should be trained to diagnose the associated disease with oral pathology. 40% of the students told that some integration is done in third and 30% agreed that it is there in the fourth year. The content taught in a disintegrated manner does not help the student in contextual learning. Development of a good curriculum reflects objectivity so as to ensure learning to an extent which can make students critical thinkers and also identify their learning needs21. The dental curriculum in Pakistan has not yet achieved this level and we have not addressed basic problems of dental patients. The stress on oral hygiene through media campaigns has created awareness in patients and reduction in caries is expected but cases still exist in the adult population22. This means that although the awareness is there the diagnosis and care required to treat and correlate with major systemic diseases is still lacking. Oral diseases are not a localized infection but these show link with systemic like diabetes mellitus and cardiovascular diseases. The link is so great that the fetal heart disease might be seen along with tooth abnormalities. Tooth discoloration may be related to drug interactions23. Morbidity and mortality from oral and pharyngeal cancer is significantly high so the need exists to explore the complications of these diseases in context with the oral pathology24. Epidemiologists have shown that until we have standardized, comprehensive programs to screen for oral cancer, patients will continue to get diagnosed far too late when the metastasis has taken place. Association of human papilloma virus with oral cancer dental hygiene oral cancer exams must be performed by the dental hygienists25.

The dental curriculum is overloaded with marginally important content which should be replaced with essential clinical knowledge. In addition, the curriculum is poorly integrated. The clinical problems are not used to teach the content making it difficult for the students to apply the knowledge of basic sciences on the patient19. The disjointed and overcrowded content does not create the research environment required to improve the patient care. 40% of the students in third and 30% in fourth year agreed that integration between basic and clinical sciences is done (Table 1).

Community dentistry needs to be revived in our country. The increasing use of tobacco and smoking is a major threat for oral cancers26. Awareness has to create regarding dental hygiene so as to reduce the risk of these diseases. In a study done selected oral epithelial lesions were evaluated by oral brush biopsy with a computer-assisted method of analysis and results showed this tool can help identify precancers and potentially curable cancers27. Exposure of dental students to community and public health services was around 20% in third year and 30% in fourth year. Population-based surveys indicate that cancer screening and tobacco cessation advice are underutilized in the dental practice.

All over the world many medical school utilize PBL for dental education like Harvard, Connecticut, and the University of British Columbia28. In Pakistan PBL and case based discussions are not used in the dental colleges as a priority29. Many recommendations have been made which suggest that the training of a dental practitioner for the twenty first century will require substantial integration of basic medical knowledge with the clinical aspects. This can be done with the incorporation of PBL30. It is felt that dentally related biomedical cases suitable for a PBL program have not been developed and this educational approach has not been utilized in Pakistan as yet.

Conclusion

The dental curriculum in Pakistan needs to cover a much broader spectrum of diseases as well as patients. Linking the curriculum with modern tools like PBL can improve dental education. The link between the basic and clinical teaching and incorporation of community health can lead to marked shift in educational approach of the medical students.

Footnotes

1. Professor Anatomy, Al Nafees Medical College, Isra University

2. Margalla Institute of health sciences, UHS, Lahore

3. Shifa College of Medicine, Shifa Tameere Millat University
Corresponding author: “Dr. Khadija Iqbal”
<Khadijaiqbal1972@gmail.com>

References

1. McHarg J, Kay EJ. The anatomy of a new dental curriculum. Br Dent J 2008; 204: 635-8.

2. Hazmi MA, Tekian AS, el-Mahdy S, Lambourne A. Performance of men and woman students at King Saud University, Riyadh: 10-year retrospective study. Med Educ 1967; 21: 358-61.

3. Patel J, Fox K, Grieveson B, Youngson CC. Undergraduate training as preparation for vocational training in England: a survey of vocational dental practitioners’ and their trainers ‘views. Br Dent J 2006; 9-15.

4. Ryding HA, Murphy HJ. Assessing outcomes of curricular change: a view from program graduates. J Dent Educ 2001; 65: 422-6.

5. Gerrow JD, Murphy HJ, Boyd MA. Competencies for the beginning dental practitioner in Canada: a validity survey. J Dent Educ 2006; 70: 1076-80.

6. Department of Health. Oral health survey 2001. HongKong: Dental Service Head Office, Department of Health 2002: 37-60.

7. Ventä I, Lindqvist C, Ylipaavalniemi P. Malpractice claims for permanent nerve injuries related to third molar removals. Acta Odontol Scand 1998; 56: 193-6.

8. Wiseman M. The role of the dentist in recognizing elder abuse. J Can Dent Assoc 2008; 74: 715-20.

9. Hendricson WD. Changes in educational methodologies in predoctoral dental education: finding the perfect intersection. J Dent Educ 2012; 76: 118-41.

10. Nadershahi NA. Assessment of case-based integrated learning as part of dental curriculum reform. Ed.D. dissertation, University of the Pacific, 2011. Google Scholar.

11. Haden NK, Beemsterboer PL, Weaver RG, Valachovic RW. An update on future dental school faculty. J Dent Educ 2000; 64: 657-73.

12. Featherstone JDB. The science and practice of caries prevention. J Amer Dent Assoc 2000; 131: 887-99.

13. Wolsky SL, McNamara JA. Orthodontic services provided by general dentists. Amer J Ortho Dentofac Orthpaed 1996; 110: 211-6.

14. Sanders AE, Lushington K. Sources of stress for Australian dental students. J Dent Educ 1999; 63: 688-97. Question of the Month. J Amer Dent Assoc 1996; 27: 1300.

15. Clareboets, V. Sivarajasingam, I. G. Smoking cessation advice: knowledge, attitude and practice among clinical dental studentsBDJ; 2010: 4-10.

16. M. McGurk, S. E. Scott.The reality of identifying early oral cancer in the general dental practice, BDJ, 2010; 8: 347-349.

17. Schilling K, Ginn DS, Mickelson P, et al. Integration of information-seeking skills and activities into a problembased curriculum. Bull Med Lib Assoc 1995; 83: 176-83.

18. Regehr G, Martin J, Hutchinson C, et al. The effect of tutors’ content expertise on student learning, group process and participant satisfaction in a problem-based learning curriculum. Teach Learn Med 1995; 7: 225-32.

19. Koh G C-H, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008; 178: 34-41.

20. Winning T, Townsend G. Problem-based learning in dental education: what’s the evidence for and against and is it worth the effort? Aust Dent J 2007; 52: 2-9.

21. Pyle MA, Goldberg JS. Engineering curriculum change at a private midwest school of dental medicine: a faculty innovation. J Dent Educ 2008; 72: 288-98.

22. Iacopino AM. The influence of “new science” on dental education: current concepts, trends, and models for the future. J Dent Educ 2007; 71: 450-62.

23. Ryder MI, Sargent P, Perry D. Evolution and revolution: the curriculum reform process at UCSF. J Dent Educ 2008; 72: 1516-30.

24. Edelstein BL. Evidence-based dental care for children and the age 1 dental visit. Pediatric Annals 1998; 27: 569-74.

25. Offenbacher S, Beck JD. Periodontitis: a potential risk factor for spontaneous preterm birth. Compend Cont Educ Dent 1998; 19: 40-5.

26. McDerra EJC, Pollard MA, Curzon MEJ. The dental status of asthmatic British school children. Pediatr Dent 1998; 20: 281-7.

27. Morse Z, Nakahara S. English language education in Japanese dental schools. Eur J Dent Educ 2001; 5: 168-172.

28. 9. Rodis OMM, Matsumura S, Kariya N. Undergraduate dental English education in Japanese dental schools. J Dent Educ 2013; 77: 656-663.

29. Barrows HS. The essentials of problem-based learning. J Dent Educ 1998; 62: 630-3.

30. Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in preclinical medical education: 22 years of outcome research. Med Teach 2010; 32: 28-35.

Effects on Alkaline Phosphatase Level in Crevicular Fluid Produced by Rapid Palatal Expansion with Hyrax Expander

Ahmad Shamim1 BDS
Waheed-ul-Hamid2 BDS, MS, MOrth, MCPS
Muhammad Ilyas3 BDS, FCPS
Samina Qadir4 BDS, MDS
Ushna Ahmad5 BDS


ABSTRACT:

Introduction: Rapid maxillary expansion (RME) is a dramatic and preferred procedure having a history of over 100 years. When a transverse maxillary Arch is diagnosed it is corrected by doing RME. Although several studies have been done in last four decades on gingival crevicular fluid, no data have been reported on the repeatability of gingival crevicular fluid collection and then following its quantification procedure. The objectives of this study were to examine the changes in alkaline phosphatase (ALP) activities in gingival crevicular fluid (GCF) during rapid palatal expansion and in retention period by hyrax, and to explore the relationship between these changes and periodontal tissue remodeling.Methodology: Seventeen patients with age between 9-14 years were selected according to inclusion and exclusion criteria. Periodontal parameters, including probing depth, were recorded at 3 months after RME. Furthermore, the GCF ALP activity was measured at the buccal and palatal sites.Results: Periodontal parameters were generally similar between the Testing and Control sites during the study, with the exception that probing depth underwent a slight increase at the Testing sites. It was observed that at baseline, the GCF ALP activity was similar between the buccal and Control sites; however, at 3 months of retention period a significantly greater enzymatic activity was seen at the Testing sites.

Conclusion: The results of our study concluded that in the retention phase of RME, there is reported increase in GCF ALP activity even at the end of 3 months of retention period with no clinically significant tissue inflammation. This increase in GCF ALP activity demands a longer period of retention phase may be up to 6 months of duration.

KEYWORDS: Gingival Crevicular Fluid, Alkaline Phosphatase, Rapid Palatal Expansion, Bone Remodeling, Hyrax Expander.

HOW TO CITE: Shamim A, Waheed-ul-Hamid, Ilyas M, Qadir S, Ahmad U. Effects on Alkaline Phosphatase Level in Crevicular Fluid Produced by Rapid Palatal Expansion with Hyrax Expander. J Pak Dent Assoc 2017; 26(2): 72-78.

Received: 27 April 2017, Accepted: 8 June 2017

INTRODUCTION

Rapid maxillary expansion (RME) is a dramatic and preferred procedure having a history of over 100 years1. The concept of orthopedic maxillary expansion was first described by Angell in a case report2. The normal trans palatal width of maxilla ranges from 35mm to 39mm and it suggests a bony palatal base of adequate size to accommodate a permanent dentition of average size3. Expansion of the bony palatal base and width of dental arch allows us to have more space for the alignment of the crowded permanent dentition4. The expansion appliances commonly produces orthopedic forces in the range of 3 to 10 pounds5. Transverse maxillary constriction can be caused by various etiological factors including genetics, environmental and functional factors. The examples of different kind of maxillary expansion devices are Haas, Hyrax, Minnie expander, Cap Splints and recently developed acrylic bonded Rapid maxillary expander6. Expansion in skeletally mature patient can produce unwanted effects like lateral tipping of posterior teeth, extrusion of teeth, periodontal membrane compression, buccal root resorption, alveolar bone bending, fenestration of the buccal cortex, palatal tissue necrosis, inability to open the midpalatal suture, pain, and instability of the expansion. The factors that limit maxillary expansion in skeletally mature patients are numerous. These factors are related to changes with increasing age in the osseous articulations of the maxilla with the adjoining bones7. Gingival crevicular fluid (GCF) proves to be an exudate and the constituents present in it are derivative of microbial dental plaque, inflammatory cells present in it, host tissue, and serum. Different constituents present in the GCF gives information about diseases of periodontium and they have been proved as a diagnostic indicator of any damage to the tissues but few studies have paid attention on the aspect that the constituents of GCF give information about remodeling of bone also8,9. Alkaline phosphatase (ALP) is a hydrolase enzyme and its activity has been evident in bone-forming cells, and any change in the enzyme seen in serum and bone have been used as indicator for assessing metabolism of bone in a number of diseases. Acid and enzyme alkaline phosphatase in GCF of humans have been interrelated with the movement of teeth during the treatment of orthodontics and entire time period of appliance which is present in the mouth8,10-12. Higher alkaline phosphatase activities are associated with active bone formation13.

In orthodontics, exact timing of treatment plays an important role in the results of orthopedic treatment of dental and skeletal defects in growing patients. There are special maturational methods present which assess the skeletal maturity of the growing patients and they are based on radiographs like analysis of hand and wrist and the maturation of cervical vertebrae (CVM) method. These days other possibilities in the form of biochemical markers are obtainable and our patients can be benefitted from avoidance to unnecessary radiographic exposure. These agents are mainly involved in the growth of bone and its remodeling14. In GCF the first enzyme which was identified is ALP and it is essential for bone mineralization. In orthodontics the activity of GCF and ALP has been suggested as a diagnostic support12,15,16.

Therefore this study is designed to examine the changes in activities of ALP in GCF during rapid palatal expansion and in retention period to explore the relationship between these changes and periodontal tissue remodeling. Hence aiding in correct timing for the treatment of skeletal problems as well as to reduce or increase the retention phase.

METHODOLOGY

This study was conducted in the department of Orthodontics de’Montmorency college of Dentistry, Lahore and the ELISA of collected samples was done at University of Health Sciences, Lahore. The sample size was 17 patients and duration of study was 01 year. Patients were selected according to the Inclusion criteria. Patients with narrow maxilla that required palatal expansion, with good oral hygiene and periodontal status age between 9 to 14 years of either gender were selected. The exclusion criteria were Patients with compromised periodontal status, having any systemic disease like arthritis, diabetes, on antibiotic or NSAIDS therapy or those who refused to give consent. Patient’s dental and medical history was obtained from patients and their parents before the commencement of study. Complete oral prophylaxis of the patients were made necessary with strict oral hygiene instructions and rinsing of mouth twice (twelve hourly) daily with 0.5 ounces of 0.2% chlorhexidine gluconate was started 1 week prior to the study and it was advised not to stop it as long the study continued. After taking the impression study cast was made and an appliance (bonded Hyrax expander) was fabricated and cemented in to the patient maxilla. One day before cementing appliance GCF was collected from the lingual and buccal sides of lower arch using paper strips and it was taken as control group. The gingiva was massaged to activate the GCF formation before the sample collection. The patient was advised to gargle strongly with a glass of sterile water to cleanse the oral cavity. The teeth was isolated by using a self-retaining retractor, use of suction and cotton rolls. The paper points were placed in the gingival crevice lingually and buccally to obtain GCF. In case of insufficient sample, the collection of GCF sample was repeated frequently like twice or three times until sufficient sample obtained. After the insertion of expander the expansion was done by activating the expander and it was .25 turn in the morning and .25 turn in the evening. GCF sample was taken with same technique after insertion of appliance on day 1, day 14, and day 21 and 3 months after active phase of expansion stopped subsequently. In the control group the collection of GCF was also taken on the same days. An upper occlusal x-ray was done after 1 week to confirm whether expansion has started or not. ALP level was measured in mmol/L by ELISA technique.

Statistical Analysis

The collected data was entered and analyzed by using SPSS (Statistical Package for Social Sciences)version 20. The mean level of activity of enzyme alkaline phosphatase was calculated and the standard deviation of the mean values of the enzyme at the four sites was determined. Multivariant ANOVA analysis was applied to calculate any significance of enzyme activity among the predetermined 4 sites. A P-value ≤ 0.05 was considered as statistical significant.

RESULTS

Out of 17 patients, 11 (64.71%) were males and 6 (35.29%) were females. The mean age of patient was 12.35±1.57 and maximum number of patients was observed at age of 12 and 14 years. The descriptive statistics of alkaline phosphatase levels are shown in Table. A one-way analysis of variance (ANOVA) was used to analyze the mean of alkaline phosphatase levels among five groups (Day 0, Day 1, Day 14, Day 21 and Day 03 months). There was a statistically significant difference (P < 0.05) in mean alkaline phosphatase levels in all five groups as shown in Table. The mean plot shows that mean alkaline phosphatase level increases from day 0 to day 90 (Fig. 1).

The assumption of homogeneity of variance was violated therefore Welch and Brown-Forsythe test were used (P < 0.05) The mean difference of mean alkaline phosphatase level between day 1 and day 0 groups is 14.824±0.95 with a significant difference of P < 0.05. The mean alkaline phosphatase level between day 14 and day 0 groups is 16.29±1.56 with a significant difference of P < 0.05. The mean difference of mean alkaline phosphatase level between day 14 and day 1 groups is 1.471±1.50 which is not significant (P > 0.05).

A statistically significant difference (P< 0.05) was observed between day 21 and day 0, day 21 and day 1, day 21 and day 14 groups with mean difference of 24.47±1.65, 9.64±1.59, 8.17±2.01 respectively. A statistically significant difference (P< 0.05) was also observed between day 90 and day 0, day 90 and day 1, day 90 and day 14, day 90 and day 21 groups with mean difference of 37.824±2.30, 23±2.26,21.529±2.58, 13.353±2.63 respectively.

Table 1. Descriptive Statistics of Alkaline Phosphatase Levels

Table 2. One-Way Anova

Post Hoc concludes that among five groups (day 0, day 1, day 14, day 21 and day 90), the mean alkaline phosphatase level are statistically significant in day 1 group vs day 0 group, day 14 group vs day 0 group, day 21 group vs day 0 group, day 21 vs day 1, day 21 vs day 14. A significant difference (P<0.05) was observed when day 90 was compared with day 0, day 1, day 14 and day 21 groups while no significant difference was seen between day 14 and day 1 groups (P > 0.05).


Fig. (1). Mean plot of alkaline phosphatase levels.

DISCUSSION

Constricted maxilla is one of the common reasons of the anomalous dentition. This anomaly may be due to different factors like genetics, environmental and functional factors17,18.
It can be corrected by expansion of the palate and the most preferred method among growing patients is Rapid Maxillary Expansion6. The RME can be achieved with different methods which includes use of haas expander, Minnie expander, Cap splints, Niti expanders. In the study we used the bonded hyrax expander6.

Normally the RME is done in growing patients but if the subject is skeletally mature then expansion is done through surgically assisted RME19. The normal width of the maxilla is around 35mm to 39mm approximately which accommodates the dentition of average size3,4. The patients which we selected for our study were evaluated and diagnosed with constricted maxilla before the commencement of the treatment. To assess the width of the maxilla we can use different methods like x-rays and cast analysis but these days bio markers are providing new options and they are considered as diagnostic markers of different anomalies like bone diseases or periodontal diseases in mouth. The advantages of biomarkers are by checking their values we may keep our patients away from extra radiographic exposures, and they signify certain agents that are concerned mainly in bone growth and remodeling14.

Alkaline phosphatase is an enzyme which is easily detectable and it is used as a symbol of bone metabolism in numerous diseases8,12. As increased levels of ALP are associated with bone formation so these levels can play vital function in the onset of exact treatment timings of orthopedic intervention. Alteration of alkaline phosphatase levels in gingival crevicular fluid is also an indicator of bone remodeling while orthodontic tooth movement12,20.

In the present study, the alkaline phosphatase levels were calculated at different times from zero hour to 21 days and then on 3 months after the active phase of expansion was over on day 21. At the experiment side, the alkaline phosphatase level reaches peak on the 14th day after placement/activation of orthodontic appliance. This finding matches with the earlier study21,22. It is detected that there is a decline in the level of alkaline phosphatase on the 21st day in the experiment side which matches with the present study. This may be due to the reply of periodontium in response to the orthodontic force delivery over time20.

Table 3. Multiple Comparisons Games-Howell

*The mean difference is significant at the 0.05 level. There has been a single study available on humans which checked the action of ALP and GCF related with RME treatment and it did not mainly checked the tension sites and it mentioned a time period of only 28 days follow up, but showed the bone turnover markedly longer21. The ALP is a enzyme which is involved mainly in bone mineralization through the process of hydrolyzing inorganic pyrophosphate23, and the rate of bone formation is widely associated with it24. Alkaline phosphatase is an activity of bone formation cells i.e. Osteoblasts.

Alteration of alkaline phosphatase levels in gingival crevicular fluid is also an indicator of bone remodeling while orthodontic tooth movement20,12. In the present study, the alkaline phosphatase levels were calculated at different times from zero hour to 21 days. At the experiment side, the alkaline phosphatase level reaches peak on the 14th day after placement/activation of orthodontic appliance. This finding matches with the previous study21,22. Batra and colleagues also detected a decline in the level of alkaline phosphatase on the 21st day in the experiment side which matches with the present study20. This may be due to the reply of periodontium in response to the orthodontic force delivery over time. Keeling and colleagues in a study, showed that alkaline phosphatase is also an indicator of bone remodeling while orthodontic tooth movement25.

It is important to mention here that the results showed that GCF and ALP activity noted at the end of 3 months of retention period was still raised as we compare it with the 21 days of activation which showed a decline in their level. This raised level has suggested us that we should increase the retention period to more than 3 months may be up to 6 months after the removal of appliance. The results indicated that the formation of alveolar bone is still active even after the retention phase was over. This suggested that these results are comparable with other studies which have been reported earlier and even though with RME we obtain mainly the skeletal effects especially in the prepubertal phase of growth, but still we obtain dentoalveolar effects too26.

Although other studies reported that when the orthodontic treatment commences the chances of increased gingival swelling and plaque build up is a normal phenomenon27, so it may be a cause of increased ALP level but good hygiene of oral cavity measures during the treatment of orthodontics can decrease in plaque buildup and swelling of the gums28.

Moreover, we can avoid major biases by doing some split mouth protocol studies that effect the GCF and ALP levels during some systemic and local metabolic conditions.

The clinical significance of the results of our study shows that even at 3 months post RME the formation of alveolar bone at the tension sites of the teeth which are supported is still alive which needs to extend retention period up to 6 months so that proper bone formation and mineralization of these sites takes place with very less chances of relapse. As after the 3 months of retention period chances of relapse are very much high even after the use of retention appliance (Transpalatal arch with extended arms) and for patients it is not feasible to wear the appliance for the second time after the relapse of expansion.

Recently a study has been done by some researchers who recommended that as the bone formation and mineralization actively goes on even at 6 months so the retention period after the expansion of maxilla may be increased from 3 months to 6 months for proper formation of bone to avoid relapse29. In our study, we checked the levels of GCF and ALP till 3 months after RME to assess formation of alveolar bone at the pressure sites of teeth which are supported. As at base line the GCF and ALP activity was alike at both testing and control sites but as the expansion started it raised significantly especially at day 14. This activity decreased around day 21 but the results showed that GCF and ALP levels were significantly increased even at the end of 3 months of retention period and no marked tissue inflammation was seen. This enhances the support for an increase in retention period may be up to 6 months so that a very negligible chance of relapse may be noted.

CONCLUSIONS

The results of our study concluded that in the retention phase of RME, there is detection of increase in GCF ALP activity even at the end of 3 months of retention period with no clinically significant tissue inflammation. This increase in GCF ALP activity demands a longer period of retention phase may be up to 6 months of duration.

Footnotes

1. Department of Orthodontics, de,Montmorency College of Dentistry, Lahore, Pakistan

2. Principal/ Head of Orthodontic Department, de,Montmorency College of Dentistry, Lahore

3-4. Assistant Professors, Department of Orthodontics, de,Montmorency College of Dentistry, Lahore, Pakistan

5. Clinical Observer, Department of Orthodontics, de,Montmorency College of Dentistry, Lahore, Pakistan
Corresponding Author: “Dr Ahmad Shamim”
<shamimahmad335@gmail.com>

REFERENCES

1. Lamparski, DG, Rinchuse DJ, Close JM. Comparison of skeletal and dental changes between 2 point and 4 point rapid palatal expanders. Am J Orthod Dento fac Orthop 2003; 123: 321-28.

2. Angell EH. Treatment of irregularity of the permanent or adult teeth. Dent Cosmos 1860; 1: 540-44, 599-600.

3. Saeed MQ, Naeem S, Zaigham AM. A Comparison of the effects of rapid maxillary expansion screw height (deep vsshallow ) on the dentoalveolar structures in maxillary constricted patients. Biomedica 2004; 20: 90-95.

4. Saeed MQ, Naeem S, Zaigham AM. A Comparison of the effects of rapid maxillary expansion screw height (deep vsshallow ) on the dentoalveolar structures in maxillary constricted patients. Biomedica 2004; 20: 90-95.

5. Saeed MQ, Qazi H, Ahmad F, Zaigham AM. Effects of anterior maxillary expansion. A postero-anterior cephalometric evaluation J Pak Dent Assoc. 2009; 18: 102-6.

6. Wendling LK, James A, McNamara JA, Franchi, L, Baccetti, T. Prospective study of the short-term treatment effects of the acrylic-splint rapid maxillary expander combined with the lower Schwarz appliance. Angle Orthod, 2004; 75: 7-14.

7. Suria L, Tanejab P. Surgically assisted rapid palatal expansion: A literature review. Am J Orthod Dentofacial Orthop 2008; 133: 290-302.

8. Perinetti G, Paolantonio M., Attilio MD, Archivio DD, Tripodi D, Femminella B, Festa F, Spoto G. Alkaline phosphatase activity in gingival crevicular fluid during human orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2002; 122: 548-56.

9. Lamster IB. The host response in gingival crevicular fluid: potential applications in periodontitis clinical trials. J Periodontol 1992; 63: 1117-23.

10. Delmas PD. Clinical use of biochemical markers of bone remodeling in osteoporosis. Bone 1992; 13: 17-21.

11. Farley JR., Hall SL, Ritchie C, Herring S, Orcutt C, Miller BE. Quantification of skeletal alkaline phosphatase isoenzyme in canine serum. J Bone Miner Res 1992; 7: 779-92.

12. Insoft M, King GJ, Keeling SD. The measurement of acid and alkaline phosphatase in gingival crevicular fluid during orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1996; 109: 287-96.

13. Mishina Y, Starbuck MW, Gentile MA, Fukuda T, Kasparcova V, Seedor JG, Hanks MC, Amling M, Pinero GJ, Harada SI, Behringer RR. Bone morphogenetic protein type IA receptor signaling regulates postnatal osteoblast function and bone remodeling. J Biol Chem 2009; 279: 27560-66.

14. Perinetti G, Baccetti, T, Contardo L, Di Lenarda R. Gingival crevicular fluid alkaline phosphatase activity as a non‐invasive biomarker of skeletal maturation. Orthod craniofac res 2001; 14: 44-50.

15. Rodan GA. Introduction to bone biology. Bone 1992; 13: S3-S6.

16. Perinetti G, Paolantonio M, D’Attilio M, D’Archivio D, Tripodi D, Femminella B, Festa F, Spoto G. Alkaline phosphatase activity in gingival crevicular fluid during human orthodontic tooth movement. Am J Orthod Dentofac Orthop 2002; 122: 548-56.

17. Duruk C, Sokucu O, Sezer H, Canbaye E. Evaluation of nasal airway resistance during rapid maxillary expansion using acoustic rhinometry. Eur J Orthod 2004; 26: 397-401.

18. Ozbek M, Memikoglu T, Altug-Atac A, Lowe A. Stability of maxillary expansion and tongue posture. Angle Orthod. 2009; 79: 214-9.

19. Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture. Angle orthod 1965; 35: 200-17.

20. Batra P, Kharbanda OP, Duggal R, Singh N, Parkash H. Alkaline phosphatase activity in gingival crevicular fluid during canine retraction. Orthod Craniofac Res 2006; 9: 44-51.

21. Wei FL, Wang CL, Liu DX, Guo J, Ke HF, Guo XX. Changes of aspartate aminotransferase and alkaline phosphatase activities in gingival crevicular fluid during rapid palatal expansion. Shanghai kou qiang yi xue= Shanghai J stomatol 2007; 16: 168-71.

22. D’Attilio M, Filippi MR, Femminella B, Festa F, Tecco S. The influence of an experimentally-induced malocclusion on vertebral alignment in rats: a controlled pilot study. Cranio 2005; 23: 119-29.

23. Robison R Soames KM. The possible significance of hexosephosphoric esters in ossification: Part II. The phosphoric esterase of ossifying cartilage. Biochem J 1924; 18: 740.

24. Christenson RH. Biochemical markers of bone metabolism: an overview. Clin biochem 1997; 30: 573-93.

25. Keeling SD, King GJ, McCoy EA, Valdez M. Serum and alveolar bone phosphatase changes reflect bone turnover during orthodontic tooth movement. Am J Orthod Dentofac Orthop. 1993; 103: 320-26.

26. Lagravere MO, Major PW, Flores-Mir C. Long-term skeletal changes with rapid maxillary expansion: a systematic review. Angle orthod. 2005; 75: 1046-52.

27. Trossello VK, Gianelly AA. Orthodontic treatment and periodontal status. J periodontal. 1979; 50: 665-671.

28. Lundström F, Hamp SE, Nyman S. Systematic plaque control in children undergoing long-term orthodontic treatment. Euro J Orthod. 1980; 2: 27-39.

29. Perinetti G, D’Apuzzo F, Contardo L, Primozic J, Rupel K, Perillo L. Gingival crevicular fluid alkaline phosphate activity during the retention phase of maxillary expansion in prepubertal subjects. A split-mouth longitudinal study. Am J Orthod Dentofac Orthop. 2015; 148: 90-96.

Tobacco Use and its Association with Gingivitis among Dental Students of Dow Dental College

Hina Toufique1 BDS
Nighat Nisar2 MBBS, MPH, FCPS
Sohail Saadat3 BDS, MDS

 

ABSTRACT:

Background: In developing world, tobacco use among doctors and dentists is a major issue. The doctors and dentists are considered as advocates of health and responsible for providing guidance to the population. However, smoking among health professionals especially dentists has been linked with many oral health issues including gingivitis.

Objective: To determine the association of tobacco use with gingivitis among dental students of Dow Dental College, Karachi, Pakistan.

Methodology: This cross-sectional study was conducted among 150 dental students of Dow Dental College, Karachi, Pakistan. Participants were asked to fill a self administered questionnaire containing questions regarding smoking habits, knowledge related to hazards of smoking and socio-demographic characteristics. The questions related to smoking were adopted from the National Adult Tobacco Survey (NATS) by Centre for Disease Control (CDC). The participants were examined for the presence of gingivitis using Gingival Index by the principal investigator. The examination was done with patient on dental chair in out-patient department of Dow Dental College.

 

Results: The frequency of smoking was 92 (61%) among dental students of Dow Dental College. Similarly the frequency of smokeless tobacco use was present in 30 (20%) of individuals. The mean age of the students was 21.52 ±1.51 years. Mean age of initiation of smoking was 16.88 ± 4.01 years. Gingival index score was significantly higher among smokers 1.25± 0.91 as compared to non-smokers0.39 ± 0.63 (p-value<0.001)

Conclusion: This study found high frequency of smoking among dental students and the gingival index score was higher among smokers as compared to non-smokers.

KEYWORDS: Tobacco, Smoking, Gingivitis, Dental Students, Gingival Index.

HOW TO CITE: Toufique H, Nisar N, Saadat S. Tobacco Use and its Association with Gingivitis among Dental Students of Dow Dental College. J Pak Dent Assoc 2017; 26(2): 67-71

Received: 8 May 2017, Accepted: 3 June 2017

INTRODUCTION

The devastating results of tobacco use on wellbeing and health have been very frequently reported. Various studies have affirmed the strong quantitative relationship between smoking and numerous illnesses, for example, coronary arteries blockage, lung tumours, bladder malignancies, emphysema, vascular
 disorders and neonatal morbidity1-3. In the developing part of the world, smoking is quite common and prevalent among doctors1,4.

Smoking among doctors and dentists is problematic in two ways as doctors are the in charge of providing health guidance to general population and responsible for the future health and wellbeing of their nation, their behaviour of tobacco use can have adverse impacts on general population’s behaviour5.

The prevalence of tobacco use is high in Pakistan and the trend of smoking was found similar to other developing countries6. It is estimated that 36% of men and 9% of women use some form of tobacco on a regular basis. The mean age of onset for cigarette smoking in Pakistan is 18 years for males and 24 years for females. Inspite of more knowledge about its harmful effects cigarette smoking is widespread among the medical students around the world7.

It has been well established that younger the age of smoking onset, higher the dependence on smoking and more difficult it becomes to quit8,9. The Pakistani young medical and dental students who start smoking under peer pressure or social gatherings have less chances of quitting smoking and therefore not only harm their own lives but also set a bad example for their patients. A study conducted in 1993 among medical students of the Aga Khan University, Karachi, showed that 11% of the medical students were smokers (males 17%, females 4%10.

Another study conducted in Karachi reported that the prevalence of smoking was 14.4% among medical and dental students2. A study from a private medical college reported that the prevalence of smoking among male students was 26% and female students was 1.7%7. Among medical and dental students who smoke cigarettes, gingivitis is one of the earliest findings4. In a study conducted in Saudi Arabian dental students, smoking was prevalent among 13% of the students and 10% of them suffered from poor oral hygiene, gingivitis and other oral health disorders4.

This study is conducted to determine frequency of tobacco use either in the form of smoking or in its chewing smokeless form, among dental students and its association with gingivitis among dental students of Dow dental college of Karachi, Pakistan.

OBJECTIVE

To determine the association of tobacco use (both smoked and smokeless) with gingivitis among dental students of Dow Dental College, Karachi, Pakistan.

METHODOLOGY

A cross-sectional study was conducted and 150 students of Dow Dental College were enrolled in the study by using convenience sampling. The sample size was calculated using online sample size calculator for frequency of tobacco use among medical students in Karachi as 14.4% reported by Khan et al.2, with margin of error at 6% and confidence level at 95%, it was calculated to be 132. After taking the consent the student were asked to fill a self administered questionnaire containing questions regarding smoking habits, and socio-demographic characteristics. The questions related to smoking was adopted from the National Adult Tobacco Survey (NATS) by Centre for Disease Control (CDC)11. The students were examined for the presence of gingivitis using Gingival Index by the principal investigator. The examination was done with patient on dental chair in the out-patient department of Dow Dental College.

The data were entered and analysed by using SPSS version 20. Frequency of smokers and non smokers were calculated and presence of gingivitis was calculated by using gingival index. The chi-square test was applied to determine association of smoking and gingivitis. The P-value of ≤0.05 was considered statistically significant.

RESULTS

The frequency of smoking was found 92 (61%) among dental students of Dow Dental College. The mean age of the students was21.52 ±1.51 years. Mean age of initiation of smoking was 16.88 ± 4.01 years. Fifty eight percent of smokers smoked daily and 75 % were males.

Table 1. Socio-Demographic Factors of Dental Students

No statistically significant difference was found when ages of male and female smokers were compared.

Majority of dental students smoked less than 10 cigarettes per day whereas 19% smoked more than 20 cigarettes per day. Further details of number of cigarettes consumed by dental students are shown in Table 3.

Table 2. Tobacco Use among Different Dental Students

Table 3. Number of Cigarettes Smoked by Dental Students

Table 4. Tobacco Use and Gingival Index Scores

Table 4 shows the mean GI score comparisons between smokers and non-smokers. There was a statistically significant higher GI scores among smokers compared to non-smokers.

DISCUSSION

This study found a high frequency of smoking among dental college students. It was more common among males as compared to females. The students who smoke had more regular dental checkups compared to those who didn’t smoke.. There was a statistically significant difference between the total GI score among those who smoke and those who didn’t. Other forms of tobacco use, such as smokeless tobacco were also found to be associated with smoking. These trends were more common among males.

We found similar results as reported by a study conducted in Saudi Arabia4. The high prevalence of tobacco use, both smoked and smokeless, among dental students in a dental college of Karachi reflects a number of reasons. Smoking is started at a younger age among Pakistani adolescents, before their admission to medical or dental colleges hence a good proportion of these students enter medical and dental colleges already using tobacco. Secondly the once in dental colleges and acquiring the knowledge regarding hazards to tobacco use, majority of the students don’t quit its use reflecting the level of addiction and tobacco dependence.

The effect of smoking on the presence of gingivitis is reported by several studies12-14. The dental students have knowledge of oral hygiene and hazards of smoking, in spite of this fact this study found a high frequency of smokers among dental students.

The probable mechanism of causation might include decrease in blood flow to gingival tissue due to damaged blood vessels15. Furthermore, the tar in the cigarette smoke causes plaque to accumulate which increases the chances of periodontitis16.

CONCLUSION

This study found high frequency of smoking among dental students and the gingival index score was higher among smokers as compared to non-smokers.

Recommendations

This situation is alarming as for students of dental health sciences, these students should be considered advocate of smoking cessation programs and role models for the community. It is recommended that health education programs should be implemented for the control and prevention of smoking and related dental hazards due to smoking.

Footnotes

1. Lecturer / MDS Trainee, Department of Community Dentisry, Dow Dental College, Dow University of Health Sciences, Karachi, Pakistan.

2. Professor and Head of Community Medicine, Dean School of Public Health, Dow University of Health Sciences, Karachi, Pakistan.

3. Assistant Professor, Dow International College, Dow University of Health Sciences, Karachi, Pakistan.

Corresponding author: “Dr. Hina Toufique”
<dr.hina95@yahoo.com>

REFERENCES

1. Xiang H, Wang Z, Stallones L, Yu S, Gimbel HW, Yang P. Cigarette smoking among medical college students in Wuhan, People’s Republic of China. Preventive medicine. 1999;29:210-5.

2. Khan F, Husain S, Laeeq A, Awais A, Hussain S, Khan J. Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan. 2005.

3. Azab M, Khabour OF, Alzoubi KH, Anabtawi MM, Quttina M, Khader Y, et al. Exposure of pregnant women to waterpipe and cigarette smoke. Nicotine & Tobacco Research. 2013;15:231-7.

4. Almas K, Al-Hawish A, Al-Khamis W. Oral hygiene practices, smoking habit, and self-perceived oral malodor among dental students. J Contemp Dent Pract. 2003;4:77-90.

5. Kaplan RM, Fang Z, Morgan G. Providers’ advice concerning smoking cessation: Evidence from the Medical Expenditures Panel Survey. Prev Med. 2016;91:32-6.

6. Smith D, Leggat P. An international review of tobacco smoking among medical students. Journal of postgraduate medicine. 2007;53:55.

7. Omair A, Kazmi T, Alam S. Smoking prevalence and awareness about tobacco related diseases among medical students of Ziauddin Medical University. JPMA. 2002;52(389).

8. Grant BF. Age at smoking onset and its association with alcohol consumption and DSM-IV alcohol abuse and dependence: results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of substance abuse. 1998;10:59-73.

9. Khuder SA, Dayal HH, Mutgi AB. Age at smoking onset and its effect on smoking cessation. Addictive behaviors. 1999;24:673-7.

10. Hussain SF, Moid I, Khan JA. Attitudes of Asian medical students towards smoking. Thorax. 1995;50:996-7.

11. King BA, Dube SR, Tynan MA. Current tobacco use among adults in the United States: findings from the National Adult Tobacco Survey. American journal of public health. 2012;102:e93-e100.

12. Al-Bayaty FH, Baharuddin N, Abdulla MA, Ali HM, Arkilla MB, ALBayaty MF. The influence of cigarette smoking on gingival bleeding and serum concentrations of haptoglobin and alpha 1-antitrypsin. BioMed research international. 2013;2013.

13. Alexander A. The relationship between tobacco smoking calculus and plaque accumulation and gingivitis. Dental health. 1969;9:6-9.

14. Allam E, Zhang W, Zheng C, Gregory RL, Windsor LJ. Smoking and oral health. Cigarette Smoke Toxicity: Linking Individual Chemicals to Human Diseases. 2011:257-80.

15. Müller HP, Stadermann S, Heinecke A. Longitudinal association between plaque and gingival bleeding in smokers and non-smokers. Journal of clinical periodontology. 2002;29:287-94.

16. Naderi NJ, Semyari H, Elahinia Z. The Impact of Smoking on Gingiva: a Histopathological Study. Iranian journal of pathology. 2015;10:214.

Assessment of the Facial Profile: The Correlation between Various Cephalometric Analyses and the Soft Tissue Angle of Convexity

Maheen Ahmed1 BDS
Attiya Shaikh2 BDS, FCPS(Ortho), FDS RCSEd (UK), MOrth RCSEd (UK)
Mubassar Fida3 BDS, MCPS & FCPS (Orthodontics), MCPS (Periodontology),
MCPS (Community Dentistry), PGD HIMS

ABSTRACT:

Introduction: The study was designed to identify skeletal analyses that best correlate with the parameter used to assess facial soft tissue profile. This may result in a soft tissue oriented approach for the diagnosis of the underlying sagittal skeletal discrepancy, which may subsequently lead to the development of a treatment plan that may give better soft tissue outcome.

Methodology: A sample of 198 subjects (99 males and 99 females; mean age = 23.6 ± 4.6 years) was uniformly divided into Class I, II and III sagittal groups on the basis of soft tissue angle of convexity. Various sagittal parameters including ANB angle, AB plane angle, Downs angle of convexity, Wits appraisal, Beta angle and W angle were assessed on pretreatment lateral cephalograms. Correlation between various skeletal analyses and the soft tissue angle of convexity was determined using Spearman’s correlation.

Results: The ANB angle showed the highest correlation with the soft tissue angle of convexity (r = 0.907), whereas W angle showed the least correlation (r = 0.744). Amongst the sagittal groups, no significant correlation was present in Class I group. Downs angle of convexity showed a moderate positive correlation in Class II (r = 0.514) and Class III (r = 0.533) sagittal groups with the soft tissue parameter.

Conclusion: ANB angle and Downs angle of convexity were found to be reliable skeletal indicators in assessing the facial soft tissue profile. Hence, the number of cephalometric analyses for evaluating the sagittal skeletal jaw discrepancy may be limited to fewer analyses of higher diagnostic performance, which are more reliably related to the overlying facial pattern.

KEYWORDS: Soft tissue, Cephalometry, Sagittal dimension.

HOW TO CITE: Ahmed M, Shaikh A, Fida M. Assessment of the Facial Profile: The Correlation between Various Cephalometric Analyses and the Soft Tissue Angle of Convexity. J Pak Dent Assoc 2017; 26(2): 59-66.

Received: 10 February 2017, Accepted: 9 June 2017

Introduction

The perception of facial esthetics varies according to the genetic, age, gender, cultural norms and environmental factors1. Despite variations in standards, people tend to prefer faces that are balanced2. Hence for adequate esthetics, a face should be proportionate in all three dimensions i.e. sagittal, vertical and transverse. Variations in growth are common and may have certain clinical implications. A variation in sagittal growth may result in a convex or a concave profile. It can be either due to discrepancy in hard or soft tissues that form the face. A sagittal maxillary excess or mandibular deficiency may result in a convex profile with excessive overjet, and incompetent lips. In contrast, a sagittal maxillary deficiency or mandibular excess may lead to a prognathic profile and an anterior crossbite.

After standardization of the cephalogram by Broadbent3, skeletal analysis was preferred over soft tissue facial profile as treatment planning during that era was dictated by the Angle’s paradigm4. However, the relationship between the facial profile and the underlying skeletal structures was found to be inconsistent in different sagittal facial patterns5. Additionally ,utilization of only skeletal parameters may result in unesthetic soft tissue appearance6. Therefore, currently the process of treatment planning now aims at achieving adequate facial esthetics and a functional occlusion7.

The assessment of anteroposterior skeletal discrepancy has been made simpler with the introduction of lateral cephalometry. Various analyses have also been proposed for diagnosing the sagittal discrepancies. Downs8 described the AB plane angle, as a mean to assess the antero-posterior dysplasia followed by the Downs angle of convexity. In 1953, Riedel9 introduced the famous ANB angle which was popularized by Steiner10. Studies have indicated that the ANB angle varies with position of Nasion and vertical growth pattern11,12. To overcome this, Jacobson12 proposed the Wits appraisal using the occlusal plane as the reference plane. Later the Wits appraisal was deemed unreliable due to variations in the occlusal plane13. Hence, several parameters have been and are still being introduced to overcome the shortcomings of existing parameters for accurate diagnosis of sagittal discrepancies. Recently Beta angle and W angle have been proposed to measure the antero-posterior jaw dysplasia14,15. Apart from the errors in the landmark identification, variations may occur due to racial and ethnic differences16.

The goals of an orthodontic treatment are established by the soft tissues that form the face7. These not only determine the facial esthetics but also define the limitations of the treatment17. To date only few studies assessed the correlation of various skeletal and soft tissue parameters for the evaluation of anteroposterior facial pattern18-20. Moreover during orthodontic diagnosis, certain cases present with varied readings and a specific sagittal pattern is difficult to determine. This study aimed to identify skeletal parameters that more closely correlate with the analyses use to evaluate the facial soft tissue profile. This may lead to an accurate diagnosis and an efficient treatment plan. Moreover, a clinician may save time by the utilizing only those parameters that more closely represent the facial soft tissue pattern.

Methodology

The data was collected retrospectively from the dental records of patients visiting our clinics. Keeping α = 0.05, using the correlation value (r) = 0.119 between Down’s angle of convexity and soft tissue angle of convexity as reported by Raman et al.,19 power of study (β) was kept at 90 %. The total sample size was calculated to be 178. This number was increased by around 10% to obtain the sample size of 198 subjects. Subjects aged 18-35 years having clear and good quality radiographs with normodivergent growth pattern were included. The sample comprised of equal number of males and females. Subjects with any growth problems, trauma or orthodontic treatment were excluded. As growth may affect the size of skeletal and soft tissue structures hence only adult subjects were included in the study21. Further only normodivergent subjects based on FMA, SN-GoGn and PFH-TAFH were included as variations in vertical growth pattern may affect the sagittal parameters11.

The sample was equally divided into Class I, II and III groups based on soft tissue angle of convexity (G’Sn/SnPog’) as follows:22

Class I: G’Sn/SnPog’ > 17° [Males – 33; Females – 33]
Class II: G’Sn/SnPog’ = 8° – 16° [Males – 33; Females – 33]
Class III: G’Sn/SnPog’ < 7° [Males – 33; Females – 33]

Cephalograms were traced manually on acetate paper with 0.5 mm lead pencil by the principal investigator. The specific landmarks and planes for evaluating the sagittal skeletal and soft tissue growth pattern were identified (Fig. 1). The various skeletal parameters and soft tissue angle of convexity were determined on the lateral cephalogram with the help of a millimeter ruler and protractor, respectively.

Skeletal Parameters: (Figs. 2 and 3)

1. ANB Angle: The angle formed by point A, Nasion and point B (normal range = 0° to 4º)10
2. Wits Appraisal: The linear distance between AO and BO (perpendicular drawn from point A and B on to functional occlusal plane) (normal range = -1mm to +1mm)12
3. AB plane Angle: The angle formed by AB plane and N-pog line (normal range = 9° to 0°)8
4. Beta Angle: The angle formed by A-CB and AB line (normal range = 27° to 35°)14
5. W Angle: The angle between the perpendicular line from point M to S-G line and the M-G line (normal range = 51° to 55°)15
6. Downs angle of convexity: The angle between N-point A and point A-Pog (normal range = -8.5° to 10°)8


Fig. (1). Cephalometric landmarks and the occlusal plane.

1. Soft tissue glabella (G’): The most anterior point in midsagittal plane of the forehead
2. Subnasale (Sn): The point at which the columella merges with upper lip
3. Soft tissue pogonion (Pog’): The most anterior point on the soft tissue chin
4. Sella (S): The center of sella turcia cavity
5. Hard tissue nasion(N): The most anterior point on the frontonasal suture
6. A-point (A): The deepest point on the concavity at the anterior surface of the maxilla
7. B-point (B): The deepest point on the concavity at the anterior surface of the mandibular symphysis
8. Hard Tissue pogonion(Pog): The most anterior point on bony chin
9. Condylion(C): The center of the condyler head of the mandible
10. M-point (M): The center of premaxilla
11. G-point (G): The center of mandibular symphysis
12. Occlusal Plane(OP): The maximum intercuspation of posterior teeth

Soft tissue angle of convexity: The angle formed by G’-Sn and Sn-Pog’ (normal range = 8° to 16°)22 (Fig. 3)

To rule out the measurement error, thirty cephalograms were randomly selected, retraced and remeasured by the principal investigator to assess the intra-examiner reliability. The results showed a high correlation (Table 1).

Data were analyzed using SPSS for Windows (version 20.0, SPSS Inc. Chicago). Baseline information on demographics was analyzed using descriptive statistics. A Shapiro Wilk test was performed for all the variables which indicated a non-normal distribution of the data. A Mann-Whitney U test was performed to check for gender dimorphism. A Kruskal Wallis test was used to compare the age among the three sagittal groups. To evaluate the skeletal parameter that best conformed to the soft tissue facial profile, the correlation of various sagittal skeletal analyses with the soft tissue angle of convexity was determined using the Spearman’s correlation. A p-value of < 0.05 was taken as statistically significant.

Results

The means of each parameter between genders were compared using Mann-Whitney U test. The results showed no statistically significant difference between the two groups (Table 2). The mean age amongst the three sagittal groups was compared using the Kruskal Wallis test. The results showed insignificant differences (Table 3).

Spearman’s correlation showed a significant correlation between skeletal parameters and the soft tissue angle of convexity. Amongst the skeletal parameters, ANB angle showed the highest correlation with the soft tissue angle of convexity (r = 0.907, p < 0.01) (Table 4).


Fig. (2). Cephalometric parameters.
1. ANB angle: The angle formed by point A, nasion and point B (normal range = 0° to 4º)

2. Wits appraisal: The linear distance between AO and BO (perpendicular drawn from point A and B on to functional occlusal plane) (normal range = -1mm to +1mm)

3. AB plane angle: The angle formed by AB plane and N-pog line (normal range = 9° to 0°)


Fig. (3). Cephalometric parameters.

1. Beta angle: The angle formed by A-CB and AB line (normal range = 27° to 35°)

2. W angle: The angle between the perpendicular line from point M to S-G line and the M-G line (normal range = 51° to 55°)

3. Downs angle of convexity: The angle between N-point A and point A-Pog (normal range = -8.5° to 10°)

4. Soft tissue angle of convexity: The angle formed by G’-Sn and Sn-Pog’ (normal range = 8° to 16°)

Table 1. Assessment of Measurement Error

ICC: Intraclass Correlation Coefficient.

Table 2. Comparison of Means and Standard Deviations of Different Parameters between Males and Females

N = 198; SD – Standard Deviation
*p < 0.05; ** p < 0.01
Mann – Whitney U test

Table 3. Comparison of Mean Age Amongst the Three Sagittal Groups

N = 198; SD – Standard Deviation
p < 0.05 ; Kruskal Wallis test

Table 4. Correlation of Skeletal Analyses to Soft Tissue Angle of Convexity

N = 198; Spearman’s Correlation; correlation = r
† Weak Correlation (± 0.01 < r < ± 0.5); †† Moderate Correlation (± 0.5 < r < ± 0.8); ††† Strong Correlation (± 0.8 < r < ± 1) *p < 0.05; ** p < 0.01

Table 5. Correlation of Skeletal Analyses to Soft Tissue Angle of Convexity in Class I, II and III Sagittal Groups

N = 198; Spearman’s Correlation; correlation = r
† Weak Correlation (± 0.01 < r < ± 0.5); †† Moderate Correlation (± 0.5 < r < ± 0.8); ††† Strong Correlation (± 0.8 < r < ± 1)
*p < 0.05; ** p < 0.01

Correlation between skeletal analyses and the soft tissue parameter was also determined for each sagittal class. Amongst the sagittal groups, no significant correlation was present in Class I sagittal groups. Downs angle of convexity showed a moderate positive correlation in Class II (r = 0.514, p < 0.01) and Class III (r = 0.533, p < 0.01) sagittal groups with the soft tissue angle of convexity (Table 5).

Discussion

To achieve adequate esthetics, assessment of facial soft tissues is mandatory, so that the treatment goals may be oriented towards improving facial appearance17. As the skeletal structure forms the backbone of the overlying facial soft tissues, therefore their significance cannot be denied. Hence, the current study aimed to determine the skeletal parameter that correlates best with the soft tissue angle of convexity. This may concise the orthodontic diagnosis to minimal analyses based on the overlying facial soft tissues.

Facial soft tissues can be assessed by multiple methods. Previously, anthropometry and photographs were used as the diagnostic aids. With the advent of lateral cephalometry, soft tissue analysis became more precise as the soft tissue thickness and their relationship to the underlying skeletal structure can be accurately determined. A multitude of cephalometric methods have been described in literature for the evaluation of facial soft tissues. In addition to the analysis of individual structures such as the lip and nose, measurements describing the facial profile have also been proposed. These include jaw profile field, H-line and the soft tissue angle of convexity22-26. There are many variations of soft tissue angle of convexity described in the literature28-31. The variant of soft tissue angle of convexity utilizing the glabella (G’) is said to remain stable with age, as this is minimally affected by soft tissue growth29-31. Hence, this parameter was used to evaluate the soft tissue profile in the current study.

In the current study, the sample was divided into Class I, Class II and Class III groups on the basis of soft tissue angle of convexity. The comparison of various skeletal parameters showed no statistically significant difference between males and females in different skeletal parameters. This is in concordance with another study conducted by Susilowati20.

Multiple studies have reported the correlation between various skeletal analyses18,19. In contrast, only few studies have reported the correlation between the sagittal skeletal analyses and soft tissue angle of convexity19,20. In our study, since no significant difference was present between males and females, the subjects were not stratified on the basis of gender. Downs angle of convexity showed a strong positive correlation with the soft tissue parameter. Susilowati20 in his study correlated Downs angle of convexity and soft tissue angle of convexity. He reported a moderate positive correlation between the Down’s angle of convexity and the soft tissue angle of convexity in males and females. The variations in results might be due to differences in ethnicity, sample size, and exclusion of gender-based stratification in our study.

Correlation was also determined for each sagittal class separately. In our study, no statistically significant correlation was present between skeletal and soft tissue angle of convexity in Class I subjects. A moderate positive correlation was present between Downs angle of convexity and the soft tissue angle of convexity in Class II and Class III groups. Our results are in concordance with another study conducted by Raman et al.19.

It is worth mentioning here that the aforementioned studies correlated only Downs angle of convexity with the soft tissue parameter, where as in our study we correlated a total of six parameters with the soft tissue angle of convexity to validate their diagnostic accuracy in assessing the facial soft tissue profile.

Conclusion

All the sagittal skeletal analyses used in this study showed a significant correlation to the soft tissue angle of convexity. However, based on the higher values of correlation, ANB angle and Downs angle of convexity may be preferred to assess the sagittal skeletal pattern of an individual in soft tissue based diagnosis and treatment planning. This may facilitate the diagnosis and treatment of different sagittal malocclusion with a soft tissue oriented approach.

ACKNOLEDGEMENT

The authors would like to thank Dr. Waqar Jeelani (Assistant Professor and Head of Department, University Medical and Dental College, Faisalabad) for his assistance in statistical analysis.

Footnotes

1. Resident Orthodontics, Section of Dentistry, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.

2. Assistant Professor, Liaquat College of Medicine and Dentistry, Karachi, Pakistan.

3. Consultant Orthodontist/Associate Professor, Program Director Orthodontics Residency Program, Section of Dentistry, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.
Corresponding author: “Dr. Maheen Ahmed”
<a_maheen01@hotmail.com>

References

1. Jefferson Y. Facial Beauty-establishing a universal standard. Int J Orthod 2004; 15: 9-21.

2. Farhad B. Naini FB, Moss JP, Gill DS. The enigma of facial beauty: Esthetics, proportions, deformity and controversy. Am J Orthod Dentofacial Orthop 2006; 130: 277-82.

3. Broadbent H. A new x-ray technique and its application to orthodontia. Angle Orthod 1931; 1: 45-66.

4. Ackerman JL. Orthodontics: art, science or transcience? Angle Orthod 1974; 44: 243-50.

5. Jeelani W, Fida M, Shaikh A. Facial soft tissue thickness among three skeletal classes in adult Pakistani subjects. J Forensic Sci [Internet] 2015 Aug 11 [cited 2015 Sep 11]. Available from: http: //onlinelibrary.wiley.com/journal/10.1111/(ISSN)1556-4029/ early view [Epub ahead of print].

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

7. Ackerman JL, Proffit WR, Sarver DM. The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning. Clin Orthod Res 1999; 2: 49-52.

8. Downs WB. Variations in facial relationships: their significance in treatment and prognosis. Am J Orthod 1948; 34: 812-40.

9. Riedel RA. The relation of maxillary structures to cranium in malocclusion and in normal occlusion. Angle Orthod 1952; 22: 142-5.

10. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953 Oct; 39: 720-55.

11. Freeman RS. Adjusting ANB angles to reflect the effect of maxillary position. Angle Orthod 1981; 51: 162-71.

12. Jacobson A. The Wits appraisal of jaw disharmony. Am J Orthod 1975; 67: 125-38.

13. Haynes S, Chau MNY. The reproducibility and repeatability of the Wits analysis. Am J Orthod Dentofacial Orthop 1995; 107: 640-7.

14. Baik CY, Ververidou M. A new approach of assessing sagittal discrepancies: The Beta angle. Am J Orthod Dentofacial Orthop 2004; 126: 100-5.

15. Bhad WA, Subash N, Umal HD. A new approach of assessing sagittal dysplasia: The W angle. Eur J Orthod 2013; 35: 66-70.

16. Kavitha L, Karthik K. Comparison of cephalometric norms of Caucasians and non-caucasians: a forensic aid in ethnic determination. J Forensic Dent Sci 2012; 4: 53-5.

17. Ackerman JL, Proffit WR. Soft tissue limitations in orthodontics: treatment planning guidelines. Angle Orthod 1997; 67: 327-36.

18. Gul-e-Erum, Fida M. A comparison of cephalometric analyses for assessing sagittal jaw relationship. J Coll Physicians Surg Pak 2008; 18: 679-83.

19. Raman A, Shashikala KV, Padmini MN. Skeletal malocclusion and soft tissue angle of convexity: Do soft tissues camouflage underlying skeletal malocclusion? J Orofacial Health Sci 2011; 2: 6-11.

20. Susilowati. Correlation between soft tissue and skeletal profile of Deutero-malay Indonesians. Pak Orthod J 2009; 1: 40-3.

21. Subtelny JD. A longitudinal study of soft tissue facial structures and their profile characteristics, defined in relation to underlying skeletal structures. Am J Orthod 1959; 45: 481-507.

22. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod 1967; 53: 262-84.

23. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning: Part II. Am J Orthod 1984; 85: 279-93.

24. Subtelny JD, Rochester NY. A longitudinal study of soft tissue facial structures and their profile characteristics defined in relation to underlying skeletal structures. Am J Orthod 1959; 45: 481-507.

25. Muzj E. Biometric correlations among organs of the facial profile. Am J Orthod 1956; 42 : 827-57.

26. Burstone CJ. The integumental profile. Am J Orthod 1958; 44: 1- 25.

27. Pelton WJ, Elsasser WA. Studies of dentofacial morphology. IV. Profile changes among 6829 white individuals according to age and sex. Angle Orthod 1955; 25: 199- 207.

28. Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-tissue profile changes: a study of three analyses. Am J Orthod 1985; 88: 209-23.

29. Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft tissue profile changes from 5 to 45 years of age. Am J Orthod Dentofacial Orthop 1998; 114: 698-706.

30. Sharma P, Arora A, Valiathan A. Age changes of jaws and soft tissue profile. The Scientific World Journal 2014 Nov 20. doi: 10.1155/2014/301501.

31. Obaidi HA, Abdul-Qadir MY. Facial soft tissue convexity changes. Al-Rafidain Dent J 2007; 7: 88-95.

Assessment of Dental Anxiety Levels among Students of Medical and Dental Sciences

Ambrina Qureshi1 BDS, MPhil
Naghma Azad2 BDS, MCPS
Dur-e-Sameen3 MBBS, MPhil
Maham Baqai4 BDS

ABSTRACT:

Objective: This study was designed to look in the subjective ratings of dental anxiety levels among health care students (both dental and medical students) of a public sector University hospital and explore the difference in terms of their age, gender and their health related field of study.

Methodology: A cross sectional study was conducted on medical and dental students of Dow University of Health Sciences, Karachi (n=315). Dental anxiety level of the study participants was evaluated by using Modified Dental Anxiety Scale (MDAS).

Results: Two hundred (n=200) participants completed the questionnaire with 63.5% response rate. Out of the total 59% belonged to dental whereas 41% belonged to medical field. Only 3% of the total was observed to have mean anxiety score of < 5. On the other hand majority (90%) suffered from slight-to-fair anxiety and only 7% were observed as dental phobic (extreme anxiety). Statistically significant differences (p <0.05) in ranked mean anxiety scores were observed according to gender, age group and field of study differences respectively.

Conclusion: It was concluded from the present study that female dental students of age group ≤ 21 years scored higher dental anxiety scores than medical male counter group of same age group. Particularly females were found to be more fearful of local anesthesia injection.

KEYWORDS: Dental Anxiety, Medical students, Dental students.

HOW TO CITE: Qureshi A, Azad N, Dur-e-Sameen, Baqai M. Assessment of Dental Anxiety Levels among Students of Medical and Dental Sciences. J Pak Dent Assoc 2017; 26(2): 54-58

Received: 1 May 2017, Accepted: 15 June 2017

INTRODUCTION

Although ‘dental anxiety’ and ‘dental phobia’ are the terms interchangeably used, but based on their population based prevalence it must be noted that 
there may be a difference between the two terms. Researchers have found that dental anxiety is more prevalent (20%) among general population than dental phobia (5%)1. When it comes to any kind of advice in terms of dental problems being followed by the patient, it becomes the worst barrier for the dental care professionals. By definition dental anxiety is known as fear of visiting a dentist for any sort of dental procedures; whereas phobia is an extreme level of fear or anxiety. The presence of elevated levels of such an anxiety or fear amongst patients brings about negativity towards dental treatment that could be accomplished efficaciously otherwise. In fact dental anxiety is a major factor responsible for posing a major threat to oral health and due to this the patient can suffer from multiple serious complications like, septicemia, osteomyelitis of face and sinusitis2.

The most nerve-wracking situation in tackling an anxious patient might occur if confronted by a health care student. A recent local study using Depression-Anxiety-Stress Scale (DASS-21) found that dental students and that too females are found to be considered as more panicky, touchy and nervous as compared to male dental students 3. Although DASS-21 is more commonly used by oral health researchers due to its ability to assess wide spectrum of anxiety, yet Corah Dental Anxiety and its modified version Modified Dental Anxiety Scale (MDAS) has been observed to be more inclusive, more valid and consistent, with much simpler and stable responding system among University level students4.

What so ever the dentists may experience in their practice while confronted by an anxious patient, yet very little is known about the level of anxiety among health care students when they confront a dental visit themselves. Adequacy of knowledge about the dental procedures may exacerbate anxiety making health care students more cautious about their own dental treatment. Hence this study was conducted to report self-responded assessments of dental anxiety levels among health care students (both dental and medical students) of a public sector University hospital and explore the difference in terms of their age, gender and their health related field of study.

METHODOLOGY

All medical and dental students of Dow University of Health Sciences were aimed to be approached and MDAS questionnaire was distributed to be filled by them. This included five items with simplified 5-point scale responding system ranging from “not anxious” to “extremely anxious”. The five multiple-choice items were:

“If you went to your dentist for treatment tomorrow, how would you feel?”
“If you were sitting in the waiting room, how would you feel?”
“If you were about to have a tooth drilled, how would you feel?”
“If you were about to have your teeth scaled and polished, how would you feel?”
“If you were about to have a local anesthetic injection in your gum, how would you feel?”

The responses of all five items were added up to project a sum of dental anxiety scores, where score 6-18 indicated slight-to-fairly anxious and score of 19-25 indicated extremely anxious or possibly dental phobia.

The students were clarified about the questions used in study tool prior distribution. Only five hundred questionnaires could be conveniently distributed and participants were asked to return back on the same day. Data was entered and analyzed using statistical software Stata 11.0. Descriptive statistics included means (standard deviation) of participants’ age and frequency distribution for their gender and health field the students belonged to. Overall prevalence of dental anxiety and dental phobia were also calculated. Inter-group comparisons were analyzed using Mann Whitney Test as none of the grouping variables (gender (male/female), age (≤ 21/ >21 years) and field of study (dental students/ medical) fulfilled the normality assumption. Statistical significance was assessed on the probability values of p <0.05 and confidence interval of 95%.

RESULTS

Despite of aiming at all medical and dental students to be approached, only 315 were easily accessible and were recruited. Two hundred (n=200) participants returned their questionnaire without any missing information; rest either did not return or were incompletely filled giving the reason that they have never visited a dentist for any kind of treatment. Hence information of only 200 questionnaires was entered as final data considering 63.5% response rate. Out of the total students included 59% belonged to dental field of study whereas 41% belonged to medical field. Gender-vice distribution was 68% females and 32% males. The mean age of participants was 21.57 years (minimum=18 years, maximum=25 years).

The overall prevalence of anxiety categories in relation to gender and field of study is displayed as Graph 1, with an overall mean anxiety score of 12.08 (minimum=5, maximum=21). Only 3% of the total was observed to have mean anxiety score of < 5. On the other hand majority (90%) suffered from slight to fairly anxious group and only 7% were observed as dental phobic (extreme anxiety). Statistically significant differences (p <0.05) in ranked mean anxiety scores were observed according to gender, age group and field of study differences respectively as can be seen in Table 1.

DISCUSSION

The current study aimed at not only assessing the prevalence of anxiety among medical and dental students but also aimed at observing any difference in the anxiety level in terms of gender, age and field of study of the target participants. The study found that majority of students despite of gender, age and field of their study suffered from a range of slight-to-fair anxiety level. Moreover, 7% of these students were also found to suffer from dental phobia; which is almost the same as globally found among general population, that is 5% 1. It is worth mentioning that similar studies conducted to assess dental anxiety have different cut-off values for dental anxiety levels, depending upon the number of questions included. Some studies considered anxiety cut-off score of 15 where above 15 considered as high 5-7 or even severe anxiety level 8, 9 and others considered 19 and above as high and severely high10, 11.


Graph 1: Prevalence of Anxiety Categories according to Field of Study and Gender of Students (n=200).

Table 1: Difference in Ranked Mean Anxiety Scores According to Grouping Variables

Grouping Variables
n= 200Mean Rankp-value (2-tailed)
GenderMale6488.010.036*
Female136106.38
Age≤ 21 years96108.640.055
>21 years10492.99
Field of StudyMBBS Students8289.210.021*
BDS Students118108.34

*Statistical significance p < 0.05. When closely observed female BDS students were found more prevalent as compared to male MBBS students to be suffering both from anxiety as well as dental phobia. Similar result was reported in other study 9. This finding was unlike to that reported in a similar study where medical students reported dental anxiety with mean score >15 12. Likewise, another similar study found dental students less anxious than medical and pharmacy students 5. Self-reported anxiety level among female BDS students were found to be fairly raised for the two pertinent questions, that is related to “ tooth drilled” and “local anesthetic injection” The reason that BDS students were observed with raised dental anxiety score could be probably due to their exposure to prior knowledge regarding how these two procedures are routinely performed. The lack of knowledge about dentistry among medical students might be the reason for lower anxiety scores as they do not know sufficiently about the procedures performed in dentistry. Female gender found with increased dental anxiety was in compliance with other similar cross-sectional 8 and longitudinal studies 12. The reason suggested by one of these studies was neuroticism; similar to what an earlier study on the same study group was conducted to identify anxiety spectrum factors through factor analysis, attributing these females as more “touchy”, “panicky” and “nervous” than males3. Females related to health care studies are generally found to be more tensed13.

The reason for considering age 21 years as a cut-off to assess its relationship with dental anxiety in this study was because usually medical and dental students are either in their final year of studies or have already cleared their final year. The result of this study showed that students of age 21 years and below were found with higher anxiety score as compared to those belong to age group > 21 years. However, this difference was slightly significant which may be attributed to a chance finding. Although this finding was similar to what found in other studies, where fresher and sophomores were found more anxious than senior students11, 14

The differences in all variables were noticeably large and of statistical significance, except for that attributed to age where marginal difference was observed. However, the results must be critically considered in terms of significant differences observed between groups related to mean ranked dental anxiety scores or individual items score of anxiety scale which probably could be misrepresentative and possibly reflect a difference by chance and not of an actual clinical significance. This could be attributed to small sample size and did not represent the general population, probably compromising the power of the study.

CONCLUSION

It was concluded from the present study that female dental students of age group ≤ 21 years scored higher dental anxiety scores than medical male counter group of same age group. Particularly females were found to be more fearful of local anesthesia injection.

RECOMMENDATIONS

Although the results based on absolute statistical significance must be inferred with care, still it is suggested that dental anxiety and dental phobia may have an adverse effect ones quality of life. Hence appropriate measures must be taken to alleviate the obstacles related to the factors that may be related to the determinants of dental anxiety and fear. Dentists must be trained particularly in communicating and psychologically managing15, 16 their patients prior any therapy no matter he/she is treating his/her dentist fellow or a dental student. Dentists must understand that patient is after all a patient no matter he/ she belongs to a health related field or not.

ACKNOWLEDGEMENT

We appreciate the time and effort put in by the students of Dow University of Health Sciences to participate in this study.

FINANCIAL INTEREST

None.

CONFLICT OF INTEREST

None.

AUTHORS’ CONTRIBUTION

Complete manuscript writing was performed by the first author (AQ); however the research idea was conceived by fourth author (MB). Data was collected and recorded by last three authors (NA, DS and MB). Statistical analysis was performed by the first author (AQ). All authors approved the final version and agreed to be responsible for accuracy of results and integrity of the research.

Footnotes

1. Professor and Head, Department of Community Dentistry, Dr. Ishrat Ul Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan.

2. Assistant Professor, Department of Oral Medicine/ Oral Diagnosis, Dr. Ishrat-Ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan.

3. Assistant Professor, Department of Pathology, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan.

4. Lecturer, Sir Syed College of Medical Sciences, Karachi, Pakistan.
Corresponding author: “Dr. Ambrina Qureshi”
<ambrina.qureshi@duhs.edu.pk>

REFERENCES

1. Wide BU, Carlsson V, Westin M, Hakeberg M. Psychological treatment of dental anxiety among adults: a systematic review. Eur J Oral Sci 2013; 121: 225–234.

2. Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci 2011; 53 (3):341–348.

3. Qureshi A, Haider MM, Khan R. Exploring Gender Distribution in Anxiety Spectrum through Factor Analysis among Dental Students. J Pak Dent Assoc 2016; 25 (03): 87-92.

4. Shaikh MA, Kamal A. Over Dental Anxiety Problems Among University Students: Perspective from Pakistan. J Col Phy Surg Pak 2011; 21(4): 237-238.

5. Hantash R O Abu, Younis M H Abu, Aker M M. Dental anxiety and fear among medical field students at Al Quds University. Br J Med Med Res 2014; 4(12): 2312-2321.

6. Donka G. Kirova. Dental anxiety among dental students. JAMAB-Annual Proceeding (Scientific Papers) 2011; 17(2): 137-139.

7. Al-Omari WM, Al-Omiri MK. Dental anxiety among university students and its correlation with their field of study. J Appl Oral Sci 2009.

8. Sghaireen MG, Zwiri AMA, Alzoubi IA, Qodceith SM, Al-Omiri MK. Anxiety due to dental treatment and procedures among university students and its correlation with their gender and field of study. Int J Dent 2013. Article ID 647436, 5 pages. doi:10.1155/2013/647436.

9. Hakim H, Razak IA. Dental Fear among Medical and Dental Undergraduates. Sc World J 2014; Article ID 747508, 5 pages. doi:10.1155/2014/747508.

10. Gunjal S, Pateel DGS, Parkar S. Dental Anxiety among Medical and Paramedical Undergraduate Students of Malaysia. Int J Dent 2017; 2017:4762576. doi:10.1155/2017/4762576.

11. Storjord HP, Teodorsen MM, Bergdahl J, Wynn R, Johnsen J-AK. Dental anxiety: a comparison of students of dentistry, biology, and psychology. J Multi Health 2014; 7:413-418. doi:10.2147/JMDH.S69178.

12. Peretz B, Mann J. Dental anxiety among Israeli dental students: A four-year longitudinal study. Eur J Dent Edu 2000; 4(3): 133-137.

13. Fontes de Oliva CE, Vieira Rocha MM, Rodrigues de Santos AT, Vieira de Melo E, Martins LAN, Andrade TM. Common mental disorders and associated factors among final-year healthcare students. Revista da Associacao Medica Brasileira [Internet] 2014; 60( 6 ): 525-530.

14. Ali S, Farooq I, Khan SQ, Moheet IA, Al-Jandan BA, Al-Khalifa KS. Self-reported anxiety of dental procedures among dental students and its relation to gender and level of education. J Taib Univ Med Sc 2015; 10(4): 449-453.

15. Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Aust Dent J 2013; 58(4):390–407. [PubMed]

16. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosm Invest Dent 2016; 8:35-50. doi:10.2147/CCIDE.S63626.

The Association between Burnout and Job Satisfaction among Dental Undergraduates and Faculty

Shatha Subhi ALHarthi1 BDS, MSc
Monika Maya Wahi2 MPH, CPH

ABSTRACT:

Background: This study aimed to determine levels of burnout and job satisfaction in dental students and faculty, and to examine any association between them.

Methodology: A total of 31 students and 17 faculty at a Saudi Arabian dental college completed an online survey including demographics, the Maslach Burnout Inventory to measure burnout, and the Dentist Satisfaction Survey to measure job satisfaction. Descriptive statistics and correlations were calculated.

Results: Both students and faculty were moderately to highly burned out, with students significantly more burned out than faculty. Faculty were neutral on job satisfaction, but students were dissatisfied with level of personal time. In all participants, burnout was statistically significantly negatively inversely correlated with job satisfaction.

Conclusions: Burnout and job satisfaction were found to be strongly inversely correlated, and this may lead to staff turnover among faculty, as well as stress-related health and academic problems among students.

Practical Implications. This workplace should explore limiting clinical and academic obligations for its staff and students to allow them more personal time in hopes of reducing burnout levels and increasing job satisfaction.

KEYWORDS: Burnout, Emotional Fatigue, Management, Medical Staff

HOW TO CITE: ALHarthi SS, Wahi MM. The Association between Burnout and Job Satisfaction among Dental Undergraduates and Faculty. J Pak Dent Assoc 2017; 26(2): 46-53

Received: 22 December 2016, Accepted: 24 March 2017

Introduction

Burnout describes a process beginning with high and sustained levels of stress resulting in feelings of irritability, fatigue, detachment and cynicism1. Burnout in healthcare providers has been implicated as a cause of many negative outcomes, including patient safety compromises1, provider health problems2, and provider turnover2. “Burnout is associated with a lower effectiveness at work …”, reduced “… job satisfaction … “ and “… commitment to the job or the organization”2. It has also been found to be associated with intention to leave one’s job2. Therefore, burnout in healthcare providers can be a concern for healthcare management, because the providers who suffer burnout may try to leave their positions due to low job satisfaction.

Burnout has been documented among dentists. Robert Baran3 did a survey of 202 practicing dentists in the United States (US) and used the Maslach Burnout Inventory (MBI-HSS), which measures three subscales of burnout4. Baran found that on average, dentists were moderately burned out on two of the three subscales3,5. Hoseini and colleagues6 more recently used the MBI-HSS to measure burnout in 38 dentists from Birjand, Iran, and found the “frequency of exhaustion, intense depersonalization, and intense feeling of being unsuccessful was 21.1%, 81.6%, and 100%, respectively”. Al-Mobeeriek and Al-Mobeeriek7 used the Arabic version of the MBI-HSS to measure burnout in 370 academic and non-academic dentists in the Kingdom of Saudi Arabia (KSA), and found that over a fourth of general dentists were suffering from high levels of emotional exhaustion.

Burnout has been seen in dental trainees as well. A systematic review of studies of stress in dental students found that they experience considerable amounts of stress, mainly due to the demanding nature of the training, and the results of the studies suggest that there are adverse effects of elevated stress on students’ health and well-being8. Studies of dental students at various stages of training and in various settings have found that they are burned out or experiencing an elevated level of stress. A 2014 study of second-year, fourth-year, and fifth-year dental students in Spain found that 43.1% of second-year students were burned out and 50.9% of fourth-year students were burned out, but only 25.6% of fifth-year students are burned out9. A German study also found that dental students were on average moderately burned out10.

As described before, burnout reduces a healthcare provider’s commitment to his or her organization, and can increase his or her intention to leave the job2. In a study of job satisfaction among Korean dentists, researchers found that mean overall job satisfaction was only 3.2 out of 5, and patient relations, perception of income, personal time, staff, and specialty training, which can influence burnout, were important work environment factors influencing job satisfaction11. A similar result was found in a study of Egyptian dentists, where mean job satisfaction was 3.24 out of 512, and in Saudi dental assistants, where the mean job satisfaction was 3.86 out of 5.0013. In both studies, perception of income and patient relations were major factors influencing job satisfaction12,13.

Although dental trainees have not begun their careers as professional independent dentists, they generally complete their training in the same environment with professional faculty, and take on independent responsibility for a patient load. For this reason, dental trainees could be surveyed for their “job satisfaction”, as they are completing the same tasks as career dentists, although under very intense supervision. Evidence to support the concept of undergraduate or graduate level dentists actually having a “job” and therefore being able to have “job satisfaction” could be seen by reading into the results of a study on postgraduate dentists who essentially were experiencing the same high level of stress as career dentists14.

Setting can be an important influence on job satisfaction. Specifically, public sector dentists have been studied to better understand why they may choose to leave the public sector. In an Australian study, “gradual frustration because of poor remuneration and lack of professional autonomy”, which are components of job satisfaction, were significant reasons that dentists were leaving the public sector15. In a study of academic staff at a Saudi university, only 63.7% said they were satisfied with their jobs16.

It is likely that dental students and faculty who are burned out also have a low job satisfaction. However, no studies could be identified that attempted to correlate levels of burnout in dental students and faculty with levels of job satisfaction. Baran’s3 study of dentists in the US measured both burnout and job satisfaction, but did not attempt to relate the two, instead relating these measures to measures of personality type. Therefore, how burnout and job satisfaction are related in dental students and faculty is unknown.

At Princess Nourah Bint Abdulrahman University College of Dentistry PNU-COD, pre-doctoral students (“undergraduates”) are considered fourth-year and fifth-year students. These students are all from Saudi Arabia, with between 30 and 40 students in each class. There are approximately 40 full-time faculty members who have clinical responsibilities from Saudi Arabia and other countries; these members fall into the following hierarchical position categories: Lecturer, Assistant Professor, Associate Professor, and Professor. General Practitioners (GPs) are also on the workforce, but they do not have any teaching responsibilities, and only have clinical responsibilities.

Although studies of dental students and faculty have been undertaken to research burnout, studies generally do not include measures of burnout in both faculty and dental students, so it is not possible to compare levels between faculty and students. Further, no studies to date have examined levels of burnout and job satisfaction both dental students and faculty, and their potential associations. The aim of the present study is to measure the level of burnout and job satisfaction experienced by dental students and faculty at PNU-COD and to examine if there is an association between burnout and job satisfaction.

Methods

Participants and Setting

The survey was conducted among faculty and students at PNU-COD. For the faculty, to qualify for the survey, they needed to be working full-time at PNU-COD, hold clinical responsibilities at PNU-COD, be age 18 or over, and understand written English, as the survey was in English. Students qualified if they were age 18 or over, understood written English, and were enrolled at PNU-COD as a fourth- or fifth-year student at the time of the survey. This study was reviewed by the Ethics Research Board (ERB) at Princess Nourah Bint Abdulrahman University College of Dentistry. The ERB found that due to the anonymity of the survey, the study was exempt from oversight by the ERB. Because it was exempt from oversight, the ERB could not grant approval nor require informed consent. Due to the anonymity of those completing the survey, although consent language was present on the first page of the survey, no

Table 1. MBI-HSS Scoring Rules

MBI SubscaleLow-Level BurnoutModerate BurnoutHigh-Level Burnout
Emotional Exhaustion (EE)17 or less18 through 2930 or greater
Depersonalization (DP)5 or less6 through 1112 or greater
Personal Achievement (PA)40 or greater34 through 3933 or less

documentation of informed consent was obtained. The research has been conducted in full accordance with the World Medical Association Declaration of Helsinki.

Development and Administration of Survey

Two different versions of the surveys were developed: one for faculty, and one for students. Both included the 22-question MBI-HSS17, where respondents rate statements as to how often the respondent feels the statement is true: Never, a few times per year, once a month, a few times per month, once a week, a few times per week, or every day. These entries are associated with numbers, and subscales are scored through sums. The MBI-HSS produces three subscales: Emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). The MBI-HSS is considered high-quality and is the main instrument currently used to measure burnout1,6,10,18. The scoring rules for these subscales are presented in Table 1. Please note that higher EE and DP scores indicate higher burnout, and lower PA score indicates higher burnout.

The survey also included the questions from the 29-question Dentist Satisfaction Survey (DSS)19, which has been found to be a high-quality instrument and has been used in studies cited in the introduction to measure job satisfaction in dentists12,13. Respondents are asked to rate statements on the scale of strongly disagree, disagree, neutral, agree, or strongly agree. This survey produces an overall score, as well as these subscales: Overall job satisfaction (O), perception of income (PI), personal time (PET), professional time (PRT), staff (S), patient relations (PR), delivery of care (DC). Subscales are scored by taking a mean. Table 2 lists the scoring rules for the DSS; the higher the score, the more satisfied the respondent. Please note that the PI subscale was not included in the student survey as the students were not making any income.

In addition, the student survey asked for age, status (fourth- or fifth-year), and typical work hours (4 hours or less or more than four hours). The faculty survey asked for age, department (Preventive, Clinical, Basic or Other), faculty level (Lecturer, Assistant Professor, Associate Professor, and Professor), highest level of education (Bachelor’s degree, Master’s degree, Doctoral degree or other), and typical work hours (4 hours or less, 4 to 8 hours, and more than 8 hours).

The survey was administered online through SurveyMonkey20. A link was sent to each student and faculty

Table 2. DSS Scoring Rules

DSS-29 SubscaleDissatisfiedNeutralSatisfied
All questions (overall score)
Overall Job Satisfaction (O)
Perception of Income (PI)*
Personal Time (PET)Mean of 1.0 - 2.5 on indicated questionsMean of > 2.5 -< 3.5 on indicated questionsMean of 3.5 - 5.0 on indicated questions
Professional Time (PRT)
Staff (S)
Patient Relations (PR)
Delivery of Care (DC)

*Not measured in students.

e-mail address for them to complete the survey. Several reminder e-mails were sent. Data collection took place November 22 through December 31, 2016.

Data Analysis Approach

Using R21, faculty and student scores were developed for the subscales of the MBI-HSS and the DSS. Using the scoring rules in Tables 1 and 2, mean subscales were classified as low, moderate, or high for the MBI-HSS subscales, and dissatisfied, neutral, and satisfied for the DSS subscales. To determine if faculty scores on subscales were statistically significantly different from student scores on

Table 3. Faculty and Student Demographics

Faculty
n, %
Students
n, %
Total Surveys17, 100%31, 100%
Age Group
<180, 0%0, 0%
18-303, 18%31, 100%
31-408, 47%0, 0%
41-503, 18%0, 0%
51-602, 12%0, 0%
61+1, 6%0, 0%
Department*
Preventive1, 6%
Clinical7, 41%
Basic6, 35%
Other3, 18%
Faculty LevelStudent Status
Lecturer4, 24%Fourth-year21, 68%
Assistant Professor8, 47%Fifth-year10, 32%
Associate Professor2, 12%
Professor3, 18%
Faculty Highest Level of Education*
Bachelor's Degree0, 0%
Master's Degree5, 29%
Doctoral Degree12, 71%
Other0, 0%
Faculty Typical Work HoursStudent Typical Work Hours
4 hours or less0, 0%4 hours or less1, 3%
4 to 8 hours9, 53%More than 4 hours30, 97%
More than 8 hours8, 47%

*Not applicable for students.

Table 4. MBI-HSS and DSS Results

MBI-HSS ResultsStudent (mean)Student LevelFaculty (mean)Faculty Levelp-value**
Emotional Exhaustion28.45Moderate19.24Moderate0.003
Depersonalization17.48High11.82High0.026
Personal Achievement33.45Moderate38.24Moderate0.015
DSS Results
Overall3.03Neutral3.35Neutral0.035
Overall Job Satisfaction3.24Neutral3.63Satisfied0.767
Personal Income*NANA3.18NeutralNA
Personal Time1.89Dissatisfied2.51Neutral0.039
Professional Time2.70Neutral2.80Neutral0.247
Staff2.67Neutral3.14Neutral0.036
Patient Relations3.78Satisfied4.16Satisfied0.036
Delivery of Care3.67Satisfied3.69Satisfied0.920

*Personal Income questions were not asked of students.

**p-value from independent t-tests between students and faculty.

subscales, independent t-tests were used, and alpha set at 0.05. To assess the correlation between MBI-HSS subscales and DSS subscales, Pearson correlation coefficients were developed.

Results

The survey was sent to 65 students and 37 full-time faculty. A total of 31 student and 17 faculty surveys were available for analysis (response rate 48% and 49%, respectively).
Table 3 presents the demographics for the faculty and students who completed the surveys. All of the students were between 18 and 30 years old, while faculty covered all age ranges. The largest representation of faculty was from the clinical department (n=7, 41%) and the second largest was from the basic department (n=6, 35%). Most of the faculty who completed the surveys were Assistant Professors (n=8, 47%), and most of the students who completed the survey were fourth-years (n=21, 68%). Almost three-fourths of the faculty completing the survey had a doctoral degree (n=12, 71%), and slightly less than half reported working more than 8 hours per day (n=8, 47%). For students, 97% (n=31) said they work more than 4 hours per day.

Table 4 presents the results for both students and faculty for subscales of both the MBI-HSS and the DSS. In terms of burnout, both faculty and students were on average moderately burned out on the EE and PA subscales, and highly burned out on the DP subscale. Even so, students were on the higher end of the same scale as faculty, such that their raw scores were statistically significantly higher for EE, and DP, and statistically significantly lower for PA (p = 0.0030, 0.0261, and 0.0150 respectively).

In terms of DSS overall score and subscales, students measured as satisfied on only two scales, PR and DC. With PR, they were still significantly less satisfied compared to faculty (p = 0.0356), but their high satisfaction with DC was not statistically significantly different from faculty (p = 0.9202). With respect to S, both students and faculty were neutral, but faculty were statistically significantly more satisfied with respect to raw score (p = 0.0360). Students and faculty were equally neutral with respect to PRT (p = 0.2472), but with respect to PET, students were dissatisfied, while faculty were significantly higher, scoring in the neural category (p = 0.0392). Faculty were neutral with respect to PI, and for O, faculty were classified as satisfied on average, while students were only neutral; however, this difference was not statistically significant (p = 0.7667). For the overall DSS score, both students and faculty were neutral on average, but faculty scored statistically significantly higher (p = 0.0345). PI was not measured in students, but in faculty, it was found to be neutral on average.

Although faculty overall were not as burned out as students, and had higher satisfaction than students, a clear association was seen between higher burnout and lower job satisfaction, especially when correlating the overall DSS score with the EE subscale from the MBI-HSS, as seen in the scatter plot shown in Fig. (1). There was a strong, inverse correlation of -0.73 (p <0.0001) between the DSS and EE scores in both faculty and students.

Fig. (1). Heat Map Showing Correlations Between DSS and MBI-HSS Subscales in Faculty and Students. Note: EE = emotional exhaustion, DP = depersonalization, PA = personal achievement, DSS = overall DSS score, O = overall job satisfaction, PET = personal time, PRT = professional time, S = staff, PR = patient relations, DC = delivery of care.

Fig. (2) shows a heat map of all the subscales and their correlations. The top two rows represent the EE and DP subscales from the MBI-HSS. The red coloring across these rows indicates strong inverse correlations with the DSS subscales, indicating a strong inverse correlation between burnout and job satisfaction. All the DSS scales were moderately to highly positively correlated with each other, as shown by the blue color on the figure.

Discussion

The results showed that the both the faculty and students at PNU-COD appeared to be moderately to highly burned out, and to have neutral to low job satisfaction. Though both faculty and students appeared to be experiencing burnout and lack of job satisfaction, students were significantly more burned out and significantly less satisfied than the faculty. In addition, there was also a strong inverse correlation between burnout levels and job satisfaction in both the students and the faculty.


Fig. (2). Scatter Plot of Overall Dentist Satisfaction Score and Emotional Exhaustion Subscale in Faculty and Students.

The findings about burnout and job satisfaction in the faculty measured in the study are relatively consistent in with the literature. They echoed the findings from the survey of KSA academic and non-academic dentists by Al-Mobeeriek and Al-Mobeeriek7 in terms of burnout, and also mirrored findings of low job satisfaction in academic dentists in KSA from another study16.

Our study also showed, however, that these items were inversely correlated, suggesting that burnout could be leading to a high turnover rate in staff. As PNU-COD is a young college, founded in 2011, it is still growing, and along the way has experienced intermittent staff shortages. PNU-COD has unique hiring challenges. It is located in Riyadh, Saudi Arabia, and consistent with local norms, it maintains an all-female staff serving only female clientele. Finding workers who are female, qualified, and able to commit time to this profession can be challenging, although the female educated healthcare workforce in Saudi Arabia is continuing to expand. These challenges could elevate workplace stress, which could backfire by increasing burnout, leading staff to quit and escalating turnover rates, thus exacerbating the problem.

We also found a high level of burnout in students in our study, which was consistent with the findings from the studies in Spain and Germany described earlier9,10. Our finding of neutral to low job satisfaction in students, however, was novel. As with the burnout, scores on most of the job satisfaction subscales were statistically significantly lower for students compared to faculty, and they were especially dissatisfied with the amount of personal time they had. While burnout and low job satisfaction in faculty might lead to turnover, there are likely worse consequences for this combination in students. In the Spanish study, the prevalence of suicidal ideation jumped almost statistically significantly between third-year and fourth-year den【|】al students9. It is especially alarming to see these results in an environment that is geared toward developing the student intellectually, not breaking her down. Unlike the faculty member, who can quit one job and get another, the student taking leave from a dental studies program due invokes consequences that are much more serious and can forever impact the trajectory of the student’s careers.

In reflection on the results from this study, PNU-COD will be encouraged to explore limiting the clinical or didactic obligations for both students and faculty in an effort to expand their amount of personal time, as students specifically expressed dissatisfaction with the amount of personal time available. Allowing faculty and students to have more personal time will allow them to engage in non-work activities which can hopefully alleviate their feelings of burnout. If policy changes are implemented, after some time, the PNU-COD could survey their faculty and students again to determine if the intervention has had a positive impact.

Conclusion

In conclusion, our study found that burnout was moderate to high and job satisfaction neutral to low in both faculty and dental students at PNU-COD. Even so, students experienced significantly higher burnout and lower job satisfaction, and were specifically dissatisfied with their amount of personal time. Burnout and job satisfaction were found to be strongly inversely correlated, and this may lead to staff turnover among faculty, as well as stress-related health and academic problems among students. PNU-COD should explore limiting clinical and academic obligations for its staff and students to allow them more personal time in hopes this intervention will help reduce burnout levels and increase job satisfaction. After implementing this intervention, the faculty and students could be surveyed again to assess the impact of the increase in personal time on burnout and job satisfaction.

Acknowledgement

The authors would like to acknowledge the staff of the Deanship of Scientific Research at Princess Nourah Bint Abdulrahman University for their help with survey administration.

Authors Contribution

We attest that both authors made substantial contribution to the conception and design of the study. The original study was Dr. AlHarthi’s idea, and she contacted Ms. Wahi to assist with study design, data collection plans, and statistical analysis. Dr. ALHarthi collected the data, and worked with Ms. Wahi to analyze and interpret it. Together, Dr. ALHarthi and Ms. Wahi drafted the paper, and both gave final approval on the version being submitted.

Conflict of Interest

The authors declare no conflicts of interest. This study did not receive financial support. Study data are de-identified and can be accessed by contacting the corresponding author. Both authors confirm the integrity and accuracy of data analysis.

Research was conducted at:

College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia

Abstract poster presentation at the American Dental Education Association meeting, May 8-9, 2017, London, England.

Footnotes

1. Assistant Professor of Periodontology, Department of Periodontology, College of Dentistry, Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia.

2. Lecturer, General Education Department, Laboure College, Milton, Massachusetts, and Vasanta Health Science, Boston, Massachusetts, United States of America.

Corresponding author: “Ms. Monika M. Wahi”
< mwahi@vasantahealth.com >

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Burnout among Undergraduate Dental Students at a Public Academic Institution in Lahore, Pakistan

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Burnout among Undergraduate Dental Students at a Public Academic Institution in Karachi, Pakistan

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Burnout among Undergraduate Dental Students at a Public Academic Institution in Lahore, Pakistan