Vol. 26 No. 03 Jul-Sep 2017

Samira Adnan¹                      BDS, FCPS

INTRODUCTION

Root canal morphology of a tooth may vary according to gender and ethnicity of a population.¹ For a successful outcome, it is important that a clinician is able to identify aberrant or unusual root canal anatomy before or during endodontic treatment.² Failure to identify such variants may result in procedure related complications such canal perforation, ledge formation, and/or apical zipping, which ultimately contribute to treatment failures.³ A mandibular second molar usually erupts at the age of 12-13 years.⁴ It most often requires endodontic treatment due to distal surface caries which occur due mesial angulated mandibular third molar.⁵

The most frequent root canal configuration reported for mandibular second molar is the presence of two roots with three to four canals. The mesial root usually has two canals while the distal root may have one or two canals.² However, the total number of canals in mandibular second molar may vary from one to six canals.⁶ The other most common variant reported for mandibular second molar is the presence of a C- shaped canal. The formation of such an atypical anatomy is due to the failure of HERS (Hertwig’s epithelial root sheath) to merge on either lingual or buccal surface of mandibular second molar. Multiple types of C shaped canal has been reported and more than one type may coexist with a tooth at different depths making an endodontic procedure more challenging.⁷ Silva et al. reported that the frequency of C shaped canal in mandibular second molar is 8%.⁸ However its prevalence may vary according to different ethnic groups.⁸

Another rare variant reported for mandibular second molar is the occurrence of middle mesial canal, which is present in a developmental groove in between mesiobuccal and mesiolingual orifice. It is most commonly reported for mandibular first molars upto 15% ⁹ and is rarely reported for mandibular second molars. Caliskan et al. reported that middle mesial canal is present 2% of mandibular second molars.¹⁰

This case report accounts the presence and management of a middle mesial canal in the mandibular second molar.

CASE PRESENTATION

A 38-year-old man presented with the history of intense pain associated with sensitivity since three days in the lower right jaw with spontaneous pain. The pain was localized and relieved temporarily on taking analgesics. His medical history was unremarkable.

On extra oral examination, limited mouth opening of approximately 18mm was recorded. TMJ examination revealed no tenderness, crepitus or any deviation on opening or closing. Intra oral examination revealeda deep temporary restoration in # 47 along with impacted mesio-angular third molar. The initial periapical radiograph showed a dislodged temporary restoration and the cavity which was encroaching the pulp in # 47 as shown in Fig. (1). There was evidence of alveolar bone loss on distal aspect of right mandibular second molar. Diagnosis of irreversible pulpitis in # 47 was made secondary to the deep distal carious lesion encroaching the pulp.

TREATMENT

The ideal treatment plan was extraction of right mandibular third molar followed by endodontic treatment and full coverage indirect restoration on mandibular right second molar due to extensive tooth structure loss secondary to caries. The treatment plan was discussed with the patient and pros and cons of the procedure were thoroughly explained. The patient was not willing for the extraction and wanted endodontic treatment first. After obtaining an informed consent the treatment was initiated. The tooth left mandibular second molar was anesthetized using block anesthesia with 2% lidocaine with 1:80 000 epinephrine (Xylestesin-A) and isolated with rubber dam.

After removing all the temporary restoration with ultrasonic scaler (sonic scaler tip #1 universal, American Distance Education Consortium (ADEC), USA), the access opening was prepared. The pulp chamber was then cleaned and clinical examination was performed with a DG-16 endodontic explorer which disclosed three distinct canal orifices in the mesial root, and one canal in the distal root as shown in Fig. (2).

Working lengths were estimated with an apex locator (Root ZX, J. Morita Corp, Tustin,California, USA) and periapical radiographs. The middle mesial canal joined apically with the mesiobuccal canal as shown in Fig. (3). Cleaning and shaping was performed using the crown-down technique, all canals were prepared upto F1 with ProTaper Universal Rotary NiTi files (Dentsply) and lubricant used was RC-Prep (Hawe Neos Dental, Bioggio, Switzerland).  No intracanal medicament was placed. The access opening was sealed with MD-Temp (Hydraulic Temporary Restorative material, Meta Biomed). Patient was recalled after a week. On follow-up visit all canals were dried with paper points and then obturation was performed using cold lateral condensation technique. The clinical image of access opening after obturation is shown in Fig. (4) and the post- obturation periapical radiograph confirmed root canal filling upto the completed length in all four canals (Fig. 5). Patient was recalled after one week for extraction of third molar and later on, after two weeks for a full coverage restoration.

DISCUSSION

The usual root canal configuration of mandibular second molar is the presence of two canals in the mesial root and one or two canals in the distal root.In another case report the author reported three canals in the mesial root in which the middle mesial canal was joining apically with the mesiolingual canal. ⁹However in our case middle mesial canal was joining with mesiobuccal canal. In another case report middle mesial canal was found associated with extra buccal root (Radix paramolaris).¹¹ In our case on a two dimensional periapical radiograph only one mesial root can be appreciated. A three dimensional cone beam computed tomographic scan could be done to check the presence of any additional root in the third dimension. ¹²

For complete debridement of the root canal space, every effort should be made to visualize the complete chamber floor and additional aids used for orifice location whenever any variable root canal anatomy is suspected. Any additional canal, if missed, serves as substrate for bacterial inoculation, with chances of endodontic flare-up or post treatment disease, enforcing both health as well as financial burden on the patient.^{1, 7, 8}

Various aids that help in locating root canal orifices include radiographs with various angulations, troughing the groove with ultrasonic instrument, staining with methylene blue, using dental loupes under illumination or using an endodontic microscope for increased visibility and enhanced lightening.With the advent of cone beam computed radiography (CBCT) , the probability of finding and treating an extra canal have greatly improved which ultimately increases the chances of success in difficult cases. ¹³

CONCLUSION

In the present case report, all canals including middle mesial canal were identified, debrided and obturated upto length. The patient was asymptomatic after the procedure, accounting for successful endodontic treatment. For endodontic treatment, it is very important the all canals should be located and thoroughly instrumented. The clinician should keep the presence of aberrant anatomy under consideration during any endodontic treatment, even if the occurrence of such variation is rare. A clinician should be vigilant and use additional aids for canal negotiation, whenever an additional or aberrant canal anatomy is suspected.

REFERENCES

1. Nur BG, Ok E, Altunsoy M, Aglarci OS, Colak M, Gungor E. Evaluation of the root and canal morphology of mandibular permanent molars in a south-eastern Turkish population using cone-beam computed tomography. Eur J Dent. 2014; 8(2):
2. Al‐Qudah A, Awawdeh L. Root and canal morphology of mandibular first and second molar teeth in a Jordanian population. Int Endod J. 2009; 42: 775-84.
3. Garg AK, Tewari RK, Kumar A, Hashmi SH, Agrawal N, Mishra SK. Prevalence of three-rooted mandibular permanent first molars among the Indian Population. J Endod. 2010; 36(8): 1302-6
4. Khan N. Eruption time of permanent teeth in Pakistani children. Iran J Public Health. 2011; 40(4): )
5. McArdle LW, Renton TF. Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of the third molar? Br J Oral Maxillofac Surg. 2006; 44(1): 42-5.)
6. Gutmann JL, Fan B. Tooth Morphology, Isolation, and Access. in: Cohen S, Hargraves KM (Eds.) Pathways of the Pulp. 11thed. Mosby Elsevier, St Louis; 2016: 199
7. Min Y, Fan B, Cheung GS, Gutmann JL, Fan M. C-shaped canal system in mandibular second molars Part III: The morphology of the pulp chamber floor. J Endod. 2006; 32(12): 1155-9.
8. Silva EJ, Nejaim Y, Silva AV, Haiter-Neto F, Cohenca N. Evaluation of root canal configuration of mandibular molars in a Brazilian population by using cone-beam computed tomography: an in vivo study. J Endod. 2013; 39(7): 849-52
9. Paul B, Dube K. Identification and Endodontic Management of Middle Mesial Canal in Mandibular Second Molar Using Cone Beam Computed Tomography. Case Rep Dent. 2015; 2015:
10. Çalişkan MK, Pehlivan Y, Sepetçioğlu F, Türkün M, Tuncer SŞ. Root canal morphology of human permanent teeth in a Turkish population. J Endod. 1995; 21(4): 200-4
11. Ragavendran N, Bhat GT, Hegde MN. Mandibular second molar with 3 mesial canals and a radix paramolaris. J Pharm Bioallied Sci. 2014; 6: S182
12. Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J. 2007; 40(10): 818-30
13. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone-beam computed tomography to identify root canal systems in vitro. J Endod. 2008; 34: 87-9.

Assistant Professor, Operative Dentistry, Jinnah Sindh Medical University, Karachi, Pakistan

Corresponding author: “Dr. Samira Adnan”

<nnmst@hotmail.com>

Kamil Zafar                  BDS

Sheikh Bilal Badar        BDS

Farhan Raza Khan        BDS, MS, MCPS, FCPS

INTRODUCTION

he advent of rotary NiTi files has resulted in an undesirable increase in the incidence of instrument separation.¹ The prevalence of rotary endodontic instrument separation ranges between 5-21%.^{2, 3} Such complication is clinically dealt with the attempt to retrieve the separated instrument, bypassing the separated instrument or leaving the separated instrument in situ.⁴ However, at times there are clinical scenarios in which clinicians are left with no choice other than attempting extraction or intentional replantation.^{5, 6}

Intentional replantation is considered when the conventional forms of treatment options either fail or become impossible.⁷ It involves the removal of the offended tooth, execution of extra oral apicoectomy followed by its reinsertion into the socket.⁸ According to Cho et al.,⁶ the 12-year survival rate of intentional implantation teeth is 93% with 77% healing rate; however, the prognosis mainly depends upon the case selection and technique. The factors that should be considered while opting for this procedure includes patient, tooth and operator related factors.⁹ Intentional replantation is favoured in cases of endodontic failures where periradicular surgery is not feasible due to anatomic limitations or poor accessibility. Teeth having flared curved roots or with compromised crown should not be attempted for this procedure.¹⁰

Since there is a minimal soft and hard tissue injury, the postoperative healing is usually uneventful.¹⁰ The following case report describes the intentional replantation of a maxillary first molar which was otherwise suggested for extraction due to complications in the primary endodontic treatment.

• Resident, Operative Dentistry, Aga Khan University, Karachi, Pakistan.
• Resident, Operative Dentistry, Aga Khan University, Karachi, Pakistan
• Associate Professor, Dentistry, Aga Khan University, Karachi, Pakistan.

  Corresponding author: “Dr. Farhan Raza Khan”

<farhan.raza@aku.edu>

Case Report

A 30-year old otherwise healthy female presented to the Aga Khan University Hospital dental clinics with the complaint of moderate pain on chewing in the upper left posterior tooth since last two months. On clinical examination, tooth #26 (FDI) was found to be carious and tender on percussion. Radiographic examination revealed occlusal caries in tooth # 26 (FDI) encroaching upon the mesial pulp horn. Sensibility testing was carried out with electronic pulp tester (Gentle pulse, Parkell, USA) that exhibited non-vitality in the affected tooth. Based upon the clinical and radiographic examination, the diagnosis of necrotic pulp with acute apical periodontitis was made. Two treatment options were proposed to the patient: 1. Conventional root canal treatment followed by full coverage crown; 2. Extraction of tooth followed by prosthetic replacement. After detailed discussion regarding the treatment option, the patient opted for root canal treatment of the affected tooth.

Case Management

Informed consent was taken before the procedure. Root canal treatment was initiated under local anesthesia (2% lidocaine with 1:100,000 epinephrine) as a buccal infiltrate. The access cavity was prepared after removing the caries. Unfortunately during the initial preparation of the apical third of mesio-buccal canal, the rotary instrument (ProTaper, F1) got separated. Radiographs were taken using SLOB (same lingual opposite buccal) technique to determine the location and extent of separated file in the canal. Regrettably, it was extending 3mm beyond the apex. (Fig. 1) Patient was informed about the separation of instrument.

It was highly unlikely to retrieve the separated instrument from a non-surgical approach. The patient was told about the prognosis and the management options including root resection, periradicular surgery, intentional replantation and extraction. Since, maxillary sinus was closely related to the apex of #26, hence periradicular surgery or root resection would have been a potentially harmful undertaking. Also, the intentional replantation of maxillary molar involved the risk of fracture of root. Thus, extraction of the offending tooth was advised. The benefits and risks involved in the procedure were explained. After a detailed discussion, she consented for the procedure.

The extraction of tooth was attempted under local anesthesia using elevators and maxillary molar extraction forceps. However, despite of careful execution of the procedure, the apical third of palatal root got fractured. The fractured fragment was immediately removed using No. 40 H-File without damaging the socket. Tooth was inspected for any other fracture, crack or abnormality on the root surface. Although, the palatal root was fractured in the apical third, the tooth still had half of the palatal root substance left intact. It offered chances for attempting intentional replantation. Procedure for the intentional replantation was explained to the patient and as the patient was highly motivated and adamant in salvaging the tooth, she requested to select this management modality to maximize her chances of retaining the tooth. Procedure for intentional replantation was then followed.

Extra oral apicectomy was carried out in all three roots and apical areas were prepared with ultrasonic tip. A ZnO based intermediate restorative material (IRM, Dentsply, USA) was used to retrofill the resected apices. (Fig. 2) The broken instrument during all this procedure was pushed towards the pulp chamber, so that it could easily be retrieved later. The extra oral time was kept less than 15 minutes. The tooth was placed back into the socket using slight digital pressure and splinted using 0.7mm stainless steel wire and composite resin. Post-operative radiograph was taken to assess the position of replanted tooth and it was found to be in the desired position. (Fig. 3) Patient was followed up at 2 and 4 weeks. The symptoms showed gradual resolution. On the subsequent visit, the fragment of separated instrument was retrieved; obturation was done using protaper gutta percha points. Build up restoration was done with amalgam and the splint was removed. (Figure 4) The challenge was to obturate the disto-buccal canal as some kind of calcification or canal obliteration had taken place. Therefore, it was obturated well short of apex as further pushing of instrument could have resulted in the loss of apical plug.

Discussion

This case report describes an infrequently encountered approach namely intentional replantation, which can be used to manage complications that cannot be suitably dealt with the periradicular surgery. However, this technique should be considered as a last resort and should be limited to the cases which are otherwise deemed for extraction.

Intentional replantation carries the risk of fracture of the affected tooth during extraction, Moreover; extended extra oral time and extent of the damage to the periodontal ligament and cementum during extraction adversely affects the outcome. Therefore, careful planning is necessary.¹¹ If not appropriately managed, it can lead to progressive root resorption or ankylosis.^{6, 10} In our case, the palatal root got fractured during extraction; this was an alarming event as this could adversely affect the prognosis of the reimplantation. However, we decided to proceed with plan. We managed to remove the apical fragment without damaging the alveolus and completed the procedure within short time.⁶ The literature suggests that if extra oral time is less than 15 minutes, the results of reimplantation are superior.⁶

Root end filling is also an important factor in the long term survival of teeth. In our case, we had used IRM, although MTA (mineral trioxide aggregate) is presently considered as the gold standard for root end fillings. The Superior biocompatibility, sealing ability and capability to promote periradicular healing has made it favorite among all available root-end restorative materials. .¹² However, it is also noted that MTA has low initial compressive strength and a longer setting time, therefore, the pumping action that can occur at the root apex during the replantation procedure may result in the washout of unset MTA.

Conclusions

Intentional replantation is a treatment option that can be exercised in select cases. The present case demonstrates that this procedure works even after fracture of tooth root. However, long term follow-up is needed in such cases to monitor the success.

References

1. Ruddle CJ. Nonsurgical retreatment. J Endod. 2004;30:827-45.
2. Parashos P, Gordon I, Messer HH. Factors influencing defects of rotary nickel-titanium endodontic instruments after clinical use. J Endod. 2004;30:722-5.
3. Sattapan B, Nervo GJ, Palamara JE, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod. 2000;26:161-5.
4. McGuigan MB, Louca C, Duncan HF. Clinical decision-making after endodontic instrument fracture. Br Dent J. 2013;214:395-400.
5. Hoen MM, Pink FE. Contemporary endodontic retreatments: an analysis based on clinical treatment findings. J Endod. 2002;28:834-6.
6. Cho SY, Lee Y, Shin SJ, Kim E, Jung IY, Friedman S, et al. Retention and Healing Outcomes after Intentional Replantation. J Endod. 2016;42:909-15.
7. Messkoub M. Intentional replantation: a successful alternative for hopeless teeth. Oral Surg Oral Med Oral Pathol. 1991;71:743-7.
8. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol. 1993;76:623-30.
9. Asgary S, Marvasti LA, Kolahdouzan A. Indications and case series of intentional replantation of teeth. Iranian endodontic journal. 2013;9:71-8.
10. Peer M. Intentional replantation – a ‘last resort’ treatment or a conventional treatment procedure? nine case reports. Dent Traumatol. 2004;20:48-55.
11. Ward J. Intentional replantation of a lower premolar. Aust Endod J. 2004;30:99-102.
12. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J. 2008;41:905-12.

Hira Zaman                                     BDS

Saad Shahnawaz Ahmed                BDS

Anser Maxood                                             BDS, MSC (UK), FRACDS (Aus), FICD (USA)

CASE PRESENTATION

A 23years female patient reported to the Operative Dentistry Department, Shaheed Zulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences (PIMS), with the complaint of painless lesion on palate two days following tooth extraction under local anesthesia. It was determined that she had received a palatal infiltration of approximately 2 ml. of 2% lidocaine with 1:100,000 epinephrine in the area of the upper left canine region while extracting her tooth. The treatment went well and patient was sent home after giving post-operative instructions and prescribing medication i.e. Tab. Brufen (ibuprofen) 400mg B.D. Patient was medically stable with slightly compromised oral hygiene. On clinical examination, a well-defined palatal ulceration was evident on the hard palate as shown in Fig. 1.

Ulcer was 10mm in diameter surrounded by hematoma, roughly oval in shape, with well-defined punched out margins, and a depth of 2-3 mm. The central part of the ulcer was yellowish in color and covered by pseudomembranous slough, which on removal revealed a bleeding surface and non-tender on palpation. It was decided to do surgical intervention if not managed with the conservative treatment. Patient was prescribed antiseptic-analgesic gel (Somogel oral topical ointment) and chlorhexidine mouthwash. Patient came after 3days for follow up appointment, ulcer was healed partially with the presence of an erythematous area (Fig. 2).

We decided to place a COE-Pak dressing over the lesion for rapid healing so impression was taken and sent to laboratory for tray making (Fig. 3).

The next day of impression, Coe-Pak dressing was placed (Fig. 4).

and the patient recalled after 2 weeks for further evaluation. After a period of 3 weeks the lesion was healed completely (Fig. 5) thus, decision was made not to do any surgical intervention.

DISCUSSION

Complications following rapid and pressurized injection of local anesthetic solution containing vasoconstrictor is evident.1

In the present case report, infiltration was given in palate which is supplied by greater and lesser palatine arteries that plays an important role in providing oxygen and nutrients to the overlying tissues. Increase in pressure, either because of vasoconstrictor or due to poor faulty technique deprives the tissues of its necessary nourishment resulting in necrosis of the overlying epithelium. During vasoconstriction, contraction of smooth muscles within the arterial wall may lead to transient ischemia of structures at the injection site leading to tissue necrosis. Thus, epinephrine contained in local anesthetics can be a cause of ischemia and necrosis.5, 6

Allergic reactions to local anesthesia may also result in such lesions but will occur immediately after administration of the anesthetic solution and are generalized mostly. However, modern anesthetic solutions containing amide greatly reduced hypersensitivity reactions.3

Apthous ulcer, herpes simplex and necrotizing sialometaplasia are also included in differential diagnosis but clinical features of the present case concluded it to be anesthetic necrosis. It was well circumscribed, painless, deeply ulcerated lesion on hard palate at the location of local anesthesia with delayed healing.However, herpes simplex occurs extraorally and may occur intraorally in response to any traumatic injury to the tissues like aphthous ulcer while, necrotizing sialometaplasia is a self-limiting, benign, inflammatory disease of the minor salivary glands.7

Management of such lesions include only patient re-assurance and conservative treatment with topical antiseptic-anesthetic gel without vasoconstrictor. There is no need of surgical intervention unless sequestration of underlying bone is visible which occurs rarely. Post-traumatic neuralgia is also reported in some cases but it was absent in our case. For that counselling at regular intervals is important to be included in the treatment plan.6

CONCLUSION

Although palatal necrosis due to local anesthesia is rare but it should be kept in mind while diagnosing palatal lesions. Care should be taken while infiltrating local anesthesia on the palatal side to avoid such complications.

REFERENCES

1. Säkkinen J, Huppunen M, Suuronen R. Complications following local anaesthesia. Nor Tannlegeforen Tid 2005; 115: 48–52

2. Nerella G. Anaesthetic Necrosis – Causes, Clinical Features and Treatment [Internet]. Juniordentist.com. 2016 [cited 15 November 2016]. Available from: http://www.juniordentist.com/anaesthetic-necrosis-causes-clinical-features-and-treatment.html

3. Ghanem H, Suliman AM. Palatal ulceration: A complication of regional anesthesia of the oral cavity – A case report. Anesth Prog 1983; 30: 118-9.

4. Balaji S M, Balaji P. Surgical management of necrotizing sialometaplasia of palate. Indian J Dent Res 2015;26:550-5

5. Jain V, Triveni M G, Tarun Kumar A B, Mehta D S. Role of platelet-rich-fibrin in enhancing palatal wound healing after free graft. Contemp Clin Dent 2012; 3: S240-243

6. Gogna, S. Hussain, S. Palatal mucosal necrosis after administration of a palatal infiltration. Br. Dent. J 2015; 12: 219.

7. Ranjitha EG, Ramasamy, Austin RD, Ramya K. Necrotic Ulcer on the Palate: As a Sequelae of Local Anaesthetic Administration: A Rare Case Report. Int J Adv Health Sci 2015;2 :10-13.

Shazia Akbar Ansari          BDS, MPhil, PhD

Sofia Ali Syed                       BDS, MPhil

Fauzia Quadir                           BDS, FCPS

Kashif Aslam                             BDS, MSc

INTRODUCTION

Plaque associated periodontal disease involves inflammatory reaction that results in destruction of periodontal structures. The increased pocket depth, loss of clinical attachment, destruction of alveolar bone and ultimately tooth loss are common sequelae of periodontitis¹. The overgrowth of anaerobic Gram negative bacteria is usually responsible for periodontal infections. The two important Gram negative anaerobic pathogens responsible for periodontal disease are Actinobacillus actinomycetemcomitans (A. actinomycetemcomitans) and Porphyromonas gingivalis (P. gingivalis). A. actinomycetemcomitans secretes leukotoxin that kills human leukocytes, neutrophils and monocytcs while P. gingivalis produces lipopolysaccharides, capsular material and protreases^2,3.

Several studies have shown that periodontal pathogens are associated with substandard periodontal therapy. The absolute removal of plaque and calculus from deep pockets is difficult due to limited access compared to shallow pockets; as a result, pathogens are re-established after treatment. The optimal treatment of plaque associated periodontal disease includes marked reduction in pathogens by several methods including scaling and root planning, mechanical and chemical debridement^4,5,6,7. Another approach is the use of local and systemic antibiotics. Antibiotics can inhibit or kill pathogens that are found in deep pockets and furcation areas that are difficult to access by mechanical debridement^8,9. Prolong use of systemic antibiotics increases the risk of nausea, diarrhea, antibiotic resistance and pseudomembranous colitis¹⁰. Local antimicrobial drugs can attain high concentrations in gingival fluid and significantly suppress subgingival microbiota. In addition, it reduces the potential side effects caused by use of systemic antibiotics. Therefore, local application of antibiotics in periodontal pockets is becoming more frequent. Local administration of antibiotics in periodontal pockets through fibers, films and micro-particles is considered as an effective method in periodontal therapy7,9.

Among local antibiotics metronidazole is used as an appropriate antibiotic for the treatment of periodontitis, because of its limited action against anaerobes and restricted unwanted effects compared to tetracycline. Metronidazole selectively inhibits DNA synthesis in gram negative anaerobic bacteria found in oral cavity¹¹. Few clinical trial studies have established a significant effect on the adjunctive use of local antimicrobials compared to scaling and root planning (SRP) alone¹². Therefore, we designed this study to assess clinical effects of metronidazole gel in the treatment of periodontitis. We hypothesized that the combined therapy of scaling and use of 1% metronidazole gel has an increased reduction in periodontal pocket depth, compared to scaling only. The aim of the current study was to assess the clinical effects of topically applied metronidazole (1%) gel in periodontal pockets deeper than 4 mm as an adjunct to subgingival scaling and treatment of periodontitis.

MATERIALS AND METHODS

This study was conducted at the Department of Periodontology, Fatima Jinnah Dental College and Hospital, Karachi from December 2012 to December 2013, after its approval from Fatima Jinnah Dental College Institutional Ethical and Scientific Review Board BEH No.DEC-2012-PRO-01. Sample size calculation was performed using open epi website, by using the data collected from a study conducted by Stelzel.¹³ Total hundred (100) systemically healthy patients with diagnosed cases of chronic periodontitis, aged 25-50 years (66 males and 34 females), having at least one tooth in each quadrant with probing pocket depth (PPD) ≥ 4mm, were recruited in this single blind, split mouth randomized study. Smoking, non-plaque associated periodontal diseases, patients allergic to drugs, patients receiving periodontal therapy and antibiotic therapy or drugs for medical and dental conditions, pregnant or lactating females, and systemic conditions such as diabetes mellitus, tumor, radiation, or immuno-suppressive therapy were excluded from the study. After explaining objectives of study, written informed consent was obtained from selected patients. Detailed history was taken and general clinical examination was done. The clinical parameters including oral hygiene index (OHI), periodontal pocket depth (PPD), clinical attachment loss (CAL) and bleeding on probing (BOP) were recorded by CPITN^* at baseline before giving treatment. The quadrants of patients were randomly assigned by computer generated table to receive 1% w/w metronidazole gel^** after scaling and root planning by ultrasonic scaler^*** as an adjunctive treatment. The patients’ quadrants were divided into two groups. Group 1 received scaling and root planning (SRP) alone in one quadrant and group 2 received 1% w/w metronidazole gel after scaling and root planning (SRP) in contralateral quadrant. Oral hygiene instructions and demonstration on application of gel through applicator after morning and evening tooth brushing were reinforced. The patients were recalled for evaluation of clinical parameters (OHI, PPD, BOP and CAL) at day 30, 90 and 180 and oral hygiene instructions were reinforced during follow ups. These parameters were compared before and after application of metronidazole gel from baseline to day 180. The data was analyzed using SPSS version 20. Non parametric Wilcoxon Signed Rank test was used to analyze results.

RESULTS

Among hundred (100) patients 66 were males and 34 were females. The age range was 25 to 50 years. The clinical parameters showed statistically significant difference (p<0.05) in both treatment groups. The mean reduction of probing pocket depth at day 180 was 1.16 mm and 1.98 mm in scaling alone and scaling + metronidazole gel respectively (Table 1). Similarly the mean gain of clinical attachment at day 180 was 1.49 mm and 2.7 mm in scaling and scaling + metronidazole gel groups (Table 2). The mean depth at which bleeding on probing could be elicited was reduced to 0.12 mm in scaling alone group and 0.52 mm in scaling + metronidazole gel group (Table 3). The oral hygiene index was significantly improved in scaling alone (1.7) group and scaling + metronidazole gel group (2.64) (Table 4).

DISCUSSION

The efficacy of scaling and root planning (SRP) by retarding the bacterial plaque for the management of periodontal conditions is well-accepted. The SRP reduces bleeding and probing depths and facilitates the clinical attachment¹⁴. The microflora in diseased sites at one week following SRP is similar to healthy sites¹⁵. Pathogenic bacteria can recolonize within a few days of SRP, requiring regular visits. Since the periodontal disease is an infection, the use of antibacterial agents as an adjunct to mechanical debridement is persuasive, therefore, it would seem logical to use antibiotics to eliminate the problem. In our population, no data has been reported with locally formulated 1% metronidazole gel as an adjunct to SRP compared to international studies¹⁶. Therefore, the aim of this study was to see the effects of clinical parameters of periodontitis by using 1% w/w metronidazole gel as an adjunct to SRP. In this study, Group 1 and Group 2 showed statistically significant improvement in probing pocket depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP) and oral hygiene index (OHI) (p <0.0001) at day 180 (after 6 months) when compared to baseline (day 0). These findings are in consistence with other studies^17,18,19. However, Group 2 had statistically significant greater improvement in PPD, CAL, BOP and OHI than Group 1 at day 180 compared to baseline (day 0). These findings are in accordance with other studies^20,21,22. Griffith also reported that the metronidazole gel as an adjunct to SRP was superior to SRP alone regarding PPD, BOP and CAL and these differences were consistent for 9 months²³. Arthur et al.²⁴ in a systematic review of 11 studies of SRP in conjunction with metronidazole gel reported four studies that showed statistically significant reduction in periodontal pocket depth. Three studies reported a net periodontal depth reduction favoring treatment group. Another study reported significant difference between treatment and control groups at 12 weeks. Two studies reported gain of clinical attachment loss (CAL); 0.66mm and 0.4mm at 6 and 39 weeks respectively (p <0.001)²⁴. Several studies reported that local application of metronidazole in conjunction with SRP is more effective in improving clinical and microbial outcomes^25,26. Since anaerobic bacteria play important role in periodontitis, metronidazole is particularly suitable for the treatment of periodontitis, due to its action against anaerobes and its restricted unwanted effects compared to tetracycline. Also, metronidazole requires a lesser concentration to achieve complete reduction of the subgingival flora. In order to minimize adverse effects of systemic antibiotics other topical gel applications such as chlorhexidine and minocycline with controlled releasing properties are capable of being used as a therapeutic component for the treatment of periodontitis^27-32. Local delivery of antibiotics to pockets not only results in minimum side effects but it also reduces the chance of producing resistant bacteria compared to systemic antibiotics. Also, the concentration of the antibiotic at the diseased site can be 100 times greater than oral medication^5,7. However, it is important to note that local application of locally prepared metronidazole gel can be administered instead of systemic antibiotics in conjunction to SRP in our population. There were some limitations in our study like it was a single centre study, there was no control group in the other quadrant, minimum inhibitory concentration (MIC) of the drug was not evaluated , and molecular analysis of microbial culture was not performed. Moreover, reliable microbiological and clinical findings can be obtained by extending study period in future clinical trials.

CONCLUSION

Local metronidazole gel application is clinically effective as an adjunct to scaling and root planning in the treatment of chronic periodontitis.

* Community Periodontal Index Treatment Need (CPITN)

**1% w/w Revomet Gel 60 grams (Platinum Pharmaceuticals)

*** VRN Ultrasonic Scaler, Gullin Veirun Medical Technology Co. Ltd.

ACKNOWLEDGMENTS

Authors have not received any financial support for this research.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

REFERENCES

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2. Silva N, Abusleme L, Bravo D, Dutzan N,Garcia-Sesnich J, Vernal R, et al. Host response mechanisms in periodontal diseases. J Appl Oral Sci. 2015; 23: 329–55.
3. Kulkarni C, Kinane D. Host response in aggressive periodontitis. Periodontology 2000. 2014;65:79-91.
4. Zafar M. Comparing the effects of manual and ultrasonic instrumentation on root surface mechanical properties. Eur J Dent 2016; 10: 517-21.
5. Carvalho J, Novak MJ, Mota LF. Evaluation of the effect of subgingival placement of chlorhexidine chips as an adjunct to scaling and root planing. J Periodontol 2007; 78: 997-1001.
6. Niazi F, Naseem M, Khurshid Z, Zafar MS, Almas K. Role of salvadora persica chewing stick (miswak): A natural toothbrush for holistic oral health. Eur J Dent 2016; 10: 301-8.
7. Teche F, Paranhos H, Motta M, Zaniquelli O, Tirapelli C. Differences in abrasion capacity of four soft toothbrushes. Int J Dent Hyg 2011; 9: 274-8.
8. Bajaj N, Tandon S. The effect of triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res 2011; 2: 29-36.
9. Jothi M, Bhat K, Pratibha P, Bhat G. The evaluation of a biodegradable dental chip containing chlorhexidine in chitosan base as a targeted drug delivery in the management of chronic periodontitis in patients. Drug Dev Res 2009; 70: 395-401.
10. Herrera D, Matesanz P, Bascones-Martinez A, Sanz M. Local and systemic antimicrobial therapy in periodontics. J Evid Based Dent Pract. 2012;12:50-60.
11. Tiwari G, Tiwari R, Srivastava B, Rai AK. Design and evaluation of target retentive device containing metronidazole for the treatment of periodontal disease. Res J Pharm Tech. 2008;1:390-4.
12. Cortelli JR, Querido SMR, Aquino DR, Ricardo LH, Pallos D. Longitudinal clinical evaluation of adjunct minocycline in the treatment of chronic periodontitis. J Periodontol 2006; 77: 161-6.
13. Stelzel M, Florès-de-Jacoby L. Topical metronidazole application as an adjunct to scaling and root planing. J Clin Periodontol. 2000;27:447-52.
14. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: A systematic review. J Periodontol 2005; 76: 1227-36.
15. Benachinmardi KK, Nagamoti J, Kothiwale S, Metgud SC. Microbial Flora in Chronic Periodontitis: Study at a Tertiary Health Care Center from North Karnataka. J Lab Physicians. 2015;7: 49–54.
16. Perinetti G, Paolantonio M, Cordella C, D’Ercole S, Serra E, Piccolomini R. Clinical and microbiological effects of subgingival administration of two active gels on persistent pockets of chronic periodontitis patients. J Clin Periodontol. 2004;31:273-81.
17. Sgolastra F, Severino M, Petrucci A, Gatto R, Monaco A. Effectiveness of metronidazole as an adjunct to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontal Res. 2014;49:10-9.
18. Pandit N, Dahiya R, Gupta R, Bali D, Kathuria. A comparative evaluation of locally delivered minocycline and metronidazole in the treatment of periodontitis. Contemp Clin Dent 2013;4:48-53.
19. Matesanz-Pérez P, García-Gargallo M, Figuero E, A Bascones-Martínez, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontology. 2013;40:227-41.
20. Rabelo CC, Feres M, Gonclaves C, Figueiredo LC, Fveri M, Tu YK. Systemic antibiotics in the treatment of aggressive periodontitis. A systematic review and a Bayesian Network meta-analysis. J Clin Periodontol. 2015;42:647-57.
21. Sgolastra F, Severino M, Petrucci A, R Gatto, Monaco A. Effectiveness of metronidazole as an adjunct to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontal Res 2014;49:10-9.
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23. Griffiths GS, Smart GJ, Bulman JS, Weiss G, Shrowder J, Newman HN. Comparison of clinical outcomes following treatment of chronic adult periodontitis with subgingival scaling or subgingival scaling plus metronidazole gel. J Clin Periodontol 2000;27:910-17.
24. Arthur J. Bonito, Linda Lux, and Kathleen N. Lohr. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol 200;76:1227-36.
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Muhammad Rizwan Nazeer¹           BDS

Aisha Salim²                                   BDS

Robia Ghafoor³                               BDS, FCPS

Farhan Raza Khan⁴                                  BDS, MS, MCPS, FCPS

INTRODUCTION

Dental anxiety is defined as “An abnormal fear of visiting a dentist for preventive care or therapy and an unwarranted apprehension over dental procedures”.¹

It is a state of nervousness in which the sufferer beliefs that something terrible would happen in relation to dental treatment. It is often associated with the sense of losing control. ^{1, 2} The fear may arise directly when an unwanted situation is either experienced by oneself or one observing a dental procedure being done on someone else, or observed or being told. ³

The relation between dental anxiety and pain was first investigated by van Wijk and Hoogstraten.² According to him as a result of fear, a patient tends to get anxious which results in more fear of pain which ultimately leads to avoidance of treatment. The viscous cycle if not interrupted may lead to severe form of dental anxiety, which ultimately results in clinically significant deterioration of oral and dental health. Due to negligent attitude in seeking dental care, treatment options were often limited in anxious patients. ³

Understanding the frequency and seriousness of anxiety problem, multiple studies has been conducted to observe its prevalence among various populations worldwide. ^4-6 Its prevalence in United States of America ranges in between 8-15%. ⁴ In a study conducted in Australian population, it was reported to be 16.1%. ⁵ In United Kingdom, around 11.6% of the estimated population has from dental anxiety. ⁶

The aetiology of dental anxiety is multifactorial. The most common factor appears to be negative experience in relation to previous dental treatment. ³ Other factors that may influence the dental anxiety include patient’s age, gender, socioeconomic status etc. Women are generally more afraid of dental treatment than men. Moreover, dental anxiety is more common in young adults (19-32 years) as compared to teenagers (12-19 years) and middle aged people. ⁷

It is important to assess the level of dental anxiety, so the appropriate measures may be taken to reduce it. Patient behavior and attitude may be an improper indicator of dental anxiety. A detailed dental history about any adverse past experience is an important clue for the dentist. To further evaluate dental anxiety, many questionnaires have been reported in the literature, the most common being the modified dental anxiety scale (MDAS). ⁵, ^8-10 An advantage of the MDAS is that it is a cost-effective one for population-based research. It’s valid and reliable as well. ^{6, 11}

The management of an anxious patient is often a challenge for most of the dental practitioners. Such patients usually have compromised oral hygiene. ^{4-6, 12} The local literature on dental anxiety is mainly confined to the demographics and prevalence of the condition. ^13-14 To the best of our knowledge there are very limited local studies that evaluated factors affecting the dental anxiety. ^15,16 The aim of the present study was to assess the dental anxiety using Modified dental anxiety scale (MDAS) and to evaluate different factors related to dental anxiety among patients visiting at teaching hospital.

• Resident, Operative Dentistry, Aga Khan University & Hospital, Pakistan
• (exam eligible)
• Assistant Professor, Operative Dentistry, Aga Khan University & Hospital, Pakistan
• Associate Professor, Operative Dentistry, Head, Section of Dentistry, Aga Khan University & Hospital, Pakistan

Correspondence author: “Dr. Robia Ghafoor”

<robia.ghafoor@aku.edu>

Materials and methods

A cross sectional study was carried out at Aga Khan University Hospital dental clinics. The approval was obtained from the institution ethical review committee before commencing the study. A total of 174 otherwise healthy adult patients who presented to dental clinics for treatment were in study after taking the written informed consent from September 2008 to November 2008. Non probability purposive sampling technique was used for the sample collection. Illiterate, mentally or physically handicapped subjects were excluded from the study.

Data was collected using a self-administered questionnaire which consisted of three parts. These were:

1. 1. Demographics: Information regarding age, gender, and frequency of dental visits were obtained.
   2. Level of dental anxiety: The modified dental anxiety scale (MDAS) was used to measure the level of dental anxiety. It consisted of five questions related to different clinical situation. In the proforma, the subjects were required to rate on a five pointer scale (one point signifies non-anxious and five points indicates an extremely anxious patient). Total scores ranged from 5 to 25. A cut-off score of 19 and above were marked as highly anxious individuals. ^{4, 6, 14, 15}
   3. Factors related to dental anxiety. It consisted of eighteen questions about different factors related to dental anxiety and each question was rated on a four pointer scale ranging from “always” to “never”. The first three questions were about various factors related to patient anticipation of pain. The next eight questions were regarding treatment related factors, the four questions focused on the anxiety due to lack of confidence in treatment quality and the last three questions were related to fear of cross infection.

An independent sample T-test was used to compare the mean ages between highly anxious and non-anxious patients. The Chi-square test was used to assess an association between gender and regularity of visits in highly anxious patients. The associated factors were evaluated in both non anxious (NA) and highly anxious (HA) patients using chi-square test.

Results

Out of 174 patients participated in the study, the mean age of the participants were 35 ± 15years. There were 88 (50.6%) were males and 86 (49.4%) were females. Subjects were broadly categorized as anxious (Dental anxiety score ≤ 18) or non-anxious (Dental anxiety score ≥ 19). Independent sample T test revealed a significant difference between mean ages of the participants and level of dental anxiety (p– value = 0.046).

Females (13.95%) were more afraid of dental treatment than males (10%), however this difference was not statistically significant (p– value = 0.31). Similarly, when the association of regularity of dental visits was assessed with dental anxiety, we again found a non-significant relationship (p– value = 0.45). Demographic characteristics of age, gender and frequency of dental visits are shown in Table 1.

When the associated factors responsible for dental anxiety were asked, we found that that bleeding during treatment, local anesthetic injection, dental chair, pain during use of the dental drill showed a significantly associated with dental anxiety. Questions about different factors related to dental anxiety are shown in Table 2a (Anticipatory factors), Table 2b (Treatment related factors), Table 2c (factors responsible for lack of confidence in treatment quality) and Table 2d (Factors due to fear of cross infection).

Discussion

Maintenance of oral health is essential for wellbeing of human body. When neglected, results in certain problems like dental caries, periodontal disease etc. ¹⁷ Studies have shown that one of the most important reasons for neglecting oral health care is the dental anxiety or phobia which often results in deferring a dental appointment. ¹⁸ Dental anxiety is a classic conditioned response which may occurs due to a conditioned or unconditioned stimuli. The stimulus may be situations/ objects e.g. drilling, injections or to dental procedures in general. ^{3, 18} Anxious patients avoids dental care resulting in a more extensive disease, hence require more immediate treatment for relieve of their dental pain or infection when compared to a non–anxious individual. Dental caries is more extensive in these patients and hence put more financial burden on the patient. ^{2, 7} The management of an anxious patient is often a challenge for the dental practitioners. Such patients usually have compromised oral hygiene along with more missing and less restored teeth. ¹⁹

We observed that young adults were more afraid of dental treatment and tend to decrease with age. These are in accordance with the data reported in other studies. ^{14, 15, 20} This might be because of increase in pain threshold of adult as time passes. ¹⁴ We also observed that the frequency of dental visits do not affect the frequency of dental anxiety as no difference was observed between a regular dental attendee and a non-frequent visitor. However, the results were contradictory to that reported in another study. ¹⁸

It is imperative to assess the factors influencing the dental anxiety. When questions were asked to explore the anticipatory factors regarding dental treatment, participants responded that they are scared of the appearance of dental equipment. They felt nervous whenever their tooth was drilled by the dentist. Similar results are reported in another study. ²¹ Dental anxiety in such patients can be best managed by avoidance of negative experiences and by provision of smooth dental care.²²

When questions regarding treatment related factors were asked, most of the anxious patients expressed their fear regarding the pain during the treatment. It is important that all the procedural and sensory information should be thoroughly explained to such patient prior to start any procedure. Topical anesthesia should also be given prior injectable local anesthesia to minimize the pricking pain of the needle.⁷ A clinician must also ensure a profound local anesthesia so that any negative experience can be avoided. ²³

It is important that a dentist should built a rapport with the patient based on a trustful relationship. This may include building an alliance, expressing concern & empathy and by asking a patient to speak freely. A dentist can also encourage an anxious patient to bring another person to the appointment whom they trust, for their moral support during the dental procedure.21

Dentist should be calm, polite and carry the communicative stance with an anxious patient. Thorough explanation before initiating any procedure would be helpful, as anxious patients want to know the sensations which they will exactly feel during the procedure. Specific information and explanations are useful for anxious patients; the patients should be given an opportunity to influence dental treatment by giving sense of control, like the clinician can set certain stop signal so that patient confidence may be build.22, 24

It was also noted that most of the anxious patients were scared of cross infection from the dental operatory and instruments. A clinician must ensure proper sterilization and disinfection. The operatory should be clean and the environment should be well ventilated and sterile. Clinician should be open to any type of question regarding cross infection.25

It is important to know the limitations of this study. It was a single center study, adult patients visiting hospital for dental treatment were only included therefore we cannot extrapolate results to general population. Sometimes patient suffering from high anxiety levels or low socioeconomic status avoid dental consultation, therefore chances of missing such patients were there in our study. On the other hand patients visiting hospital because of dental pain were more anxious as compare to general population, as they had in mind that dental procedure is unavoidable. Therefore population based studies should be carried out to determine the actual prevalence of dental anxiety and its correlation with various factors.

Conclusions

1. Nearly 11.49% patients visiting AKUH dental clinics had increased dental anxiety.
2. Dental anxiety was more prevalent in young age, with females reporting more fear than males.
3. Factors such as bleeding during treatment, use of local anesthesia injection, appearance of dental chair, fear of pain during the use of dental drill were significantly associated with dental anxiety

Recommendations

Factors significantly associated with increased level of anxiety should be assessed prior to starting a procedure so that strategies can be adopted to provide a suitable environment for dental treatment. Application of anxiety assessment scales in routine practice and a multicenter study should be conducted with large sample size.

References

1. Moola S, Pearson A, Hagger C. Effectiveness of music interventions on dental anxiety in paediatric and adult patients: a systematic review. JBI Libr Syst Rev. 2011;9(18):588-630.
2. Suhani RD, Suhani MF, Badea ME. Dental anxiety and fear among a young population with hearing impairment. Clujul Medical. 2016; 89: 143-9.
3. Tran D, Edenfield SM, Coulton K, Adams D. Anxiolytic intervention preference of dental practitioners in the Savannah, Chatham County area: a pilot study. Am Dent Hyg Assoc. 2010; 84: 151-5.
4. Scott DS, Hirschman R, Schroder K. Historical antecedents of dental anxiety. J Am Dent Assoc. 1984; 108: 42-5.
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6. Humphris G, Crawford JR, Hill K, Gilbert A, Freeman R. UK population norms for the modified dental anxiety scale with percentile calculator: adult dental health survey 2009 results. BMC Oral health. 2013; 13: 29.
7. Tvermyr K, Hoem AF, Elde KM. Clinical management of the adult patient with dental anxiety. MS thesis. Universitetet i Tromsø; 2012.
8. Shaikh MA, Kamal A. Over dental anxiety problems among university students: perspective from Pakistan. J Coll Physicians Surg Pak. 2011; 21: 237-8.
9. Attaullah KA. Prevalence of dental anxiety among university students in Islamabad, Pakistan. J Khyb Coll Dent. 2011; 1: 71-7.
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11. Bhalla A, Singh SB, Sujata AS, Choudhary A. Self-Assessment of Dental Anxiety in Patients Visiting Comprehensive Rural Health Service Project. J Depress Anxiety. 2013; 2: 1-5.
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13. Raja GH, Malik FS, Bashir U. Dental anxiety among children of age between 5 to 10 years visiting a teaching dental hospital in Islamabad, Pakistan. J Ayub Med Coll Abbottabad. 2015; 27: 587-90.
14. Faisal S, Zehra N, Hussain M, Jaliawala HA, Faisal A. Dental anxiety among patients attending public and private dental hospitals of karachi. J Pak Dent Assoc. 2015; 24: 46-51
15. Sardar KP, Raza ISSA, Shafi M. Dental anxiety level in patients attending dental outpatient department at dow university of health sciences. J Pak Dent Assoc. 2015; 24: 145-51.
16. 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: 54-8
17. Armfield JM, Pohjola V, Joukamaa M, Mattila AK, Suominen AL, Lahti SM. Exploring the associations between somatization and dental fear and dental visiting. Eur J Oral Sci 2011; 119: 288-93.
18. Samorodnitzky GR, Levin L. Self-assessed dental status, oral behavior, DMF, and dental anxiety. J Dent Educ. 2005; 69: 1385-9.
19. Erten H, Akarslan ZZ, Bodrumlu E. Dental fear and anxiety levels of patients attending a dental clinic. Quintessence Int. 2006; 37: 304–10.
20. Liddell A, Locker D. Gender and age differences in attitudes to dental pain and dental control. Comm Dent Oral Epidemiol. 1997; 25: 314-8.
21. Tunc EP, Firat D, Onur OD, Sar V. Reliability and validity of the Modified Dental Anxiety Scale (MDAS) in a Turkish population. Comm Dent Oral Epidemiol. 2005; 33: 357-362.
22. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The management of dental anxiety: time for a sense of proportion? Br Dent J. 2012; 213: 271-4.
23. Auerbach S M, Kendall P C, Cuttler H F, Levitt N R. Anxiety, locus of control, type of preparatory infor­mation, and adjustment to dental surgery. J Consult Clin Psychol. 1976; 44: 809–18.
24. Richardson P H, Black N J, Justins D M, Watson R J. The use of stop signals to reduce the pain and distress of patients undergoing a stressful medical procedure: an exploratory clinical study. Br J Med Psychol. 2009; 72: 397–405.
25. McGrath C, Bedi R, McGrath C, Bedi R. The association between dental anxiety and oral healthrelated quality of life in Britain. Comm Dent Oral Eidemiol. 2004; 32: 67-72.

Muhammad Azeem¹             BDS, FCPS

Muhammad Ilyas²                 BDS, FCPS

Waheed Ul Hamid³               BDS, MCPS, MS, MOrth

Ahmad Shamim⁴                   BDS

INTRODUCTION

According to World Health Organization (WHO), the main oral diseases should be subjected to periodic epidemiological surveys. The epidemiological data on orthodontic treatment need is of great importance for public dental programs, orthodontic management, prioritizing patients, and third party funding.¹At present, malocclusion is the third most common dental disease after dental caries and periodontal diseases.¹Malocclusion is defined as lack of correct relation between upper and lower teeth while maximum intercuspation.² It can be caused by multiple etiological factors; including digit or thumb sucking, tongue habits, temporomandibular joint issue, and amelogenesis imperfacta.^3,4Association between any variation in cervical vertebrae morphology  and malocclusion is well established.^5-8 The implications of malocclusion are disturbances in esthetics, functions such as mastication and speech and difficulty in slicing from front teeth ⁹.

Edward Angle, is known as father of modern orthodontics and dentofacial orthopaedics, was the first to classify malocclusion on basis on maxillary first molar relationship ^10..According to him, the mesiobuccal cusp tip of the maxillary first molar should rest in buccal groove of the lower first molar. Furthermore teeth should be on an imaginary line of occlusion. This line of occlusion in maxilla is smooth curvy line via central fossae of the molar and cingulum region of cuspids and anterior teeth while in mandibular arch this line of occlusion is a smooth curvy line via labial cusp tips of the mandibular molars and incisal tips of canines and incisors.¹¹ Any deviation from above mentioned criteria of normal occlusion is known as malocclusion as per Edward angle. According to Angle classification¹²

• Assistant Professor Orthodontics, Health Department Government of Punjab, Lahore / Faisalabad Medical University, Pakistan
• Assistant Professor Orthodontics, de, Montmorency College of Dentistry, Lahore, Pakistan.
• Principal & Head of Orthodontics, de, Montmorency College of Dentistry, Lahore, Pakistan.
• Senior Demonstrator Orthodontics, de, Montmorency College of Dentistry, Lahore, Pakistan

Correspondence Author: “Dr. Muhammad Azeem”

<dental.concepts@hotmail.com>

Class I Malocclusion: The mesio-buccal cusp tip of the maxillary first molar should rest in buccal groove of the lower first molar but teeth are not on an imaginary line of occlusion.

Class II Malocclusion: The mesio-buccal cusp tip of the maxillary first molar lie anterior to the buccal groove of the lower first molar

Class III Malocclusion:The mesiobuccal cusp tip of the maxillary first molar lie posterior to the buccal groove of the lower first molar

Different studies have been conducted on the frequency of different types of malocclusion in various ethnic population subgroups. There is a high frequency of Class I malocclusion in White Americans, Black Americans and, in Nigerians. While, in Oriental populations, class III was found out to be most prevalent, whereas Class II problems are more prevalent in whites of northern European descent. Rationale of present study was to find out the frequency of different types of malocclusion in our population as identifying malocclusion frequency can help to determine the manpower needed in orthodontics, for public dental programs, orthodontic management, prioritizing orthodontic patients, and third party funding.¹³ The clinical implication from these finding could mean that the orthodontic management of certain type of malocclusion would be more commonly encountered in Pakistani community. As frequency in different populations is different; present study was designed to determine the frequency of malocclusion in Pakistani population of Punjab province. The data will be useful to compare the result of present study with data of different populations.

METHODOLOGY

After taking institutional ethical approval (ERB No. 2016/012) and informed consent from patients, this study was conceived at the Department of Orthodontic, de’Montmorency College of Dentistry, Lahore in which 300 untreated patients, irrespective of age and gender, were included to determine the prevalence of malocclusion. Duration of this study was May 2016 to May 2017.The sample size was determined by a power analysis using a sample size determination program of PASS Software (NCSS, Kaysville, Utah).

Inclusion Criteria

Ready to give informed consent

Orthodontic patients with Chronological ages of 15 and 25years

Residents of Punjab province of Pakistan

No previous history of orthodontic treatment

Exclusion Criteria

Any systemic or metabolic disease.

Craniofacial syndromes

=

History of trauma

Recent extractions

TMJ problems

Clinical examination was done by retracting cheeks with a mouth mirror to get a direct side view of molar relationship (class I, class II and class III).Dental history sheets were used to rule out any systemic disease and history of dental trauma. Casts were analyzed in occlusion to record angle’s classification for molar relationship as per following criteria: ^10,12

Molar Class I: Mesiobuccal cusp of the upper first molar occluded with the mesiobuccal groove of the lower first molar.

Molar Class II: Mesiobuccal cusp of the upper first molar occluded anterior to the Class I position.

Molar Class III: Mesiobuccal cusp of the upper first molar occluded posterior to the Class I position

The data was analyzed using SPSS 20 with P value of <0.05 was considered to be statistically significant. The mean age and gender distribution was calculated. Pearson chi-square was applied to find out the relationship between malocclusion (class I, II, III) to age and gender groups. For Intraexaminer reliability, 30 sets of study casts were randomly selected from the main sample and were reassessed 10 days after the initial assessment. The casual errors were calculated according to Dahlberg’s formula. The systematic errors were estimated with dependent t tests, for P<0.05.

Results

The range of casual errors were within acceptable levels, since there were no significant differences between the first and second measurements of molar relationship assessment, the first set of measurements was used, and no variable had a statistically significant systematic error.

The mean age was 19.21 ± 3.76 years. Out of 300, 195 (65%) patients had class I malocclusion, 78 (26%) had class II and 27 (9%) had class III malocclusion. The male to female ratio was 1:2. (Table 1). Calculations by chi square test showed that occurrence of class I, II, and III are not dependent to gender (Table 2).

Thus results showed that class I malocclusion was most frequently found in local population followed by class II and III malocclusion, and occurrence of any type of malocclusion was not dependent on gender.

Discussion

Disturbances in esthetics, functions such as mastication and speech and difficulty in slicing from front teeth, can happen as a result of malocclusion. . There are various causes of malocclusion such as non abrasive diet, abnormal sucking habits, and teeth grinding habits. Harmony of stomatognathic system is essential for esthetics, speech, swallowing and mastication. In cases of malocclusion, symptoms can appear in any region of stomatognathic system.

The prevalence of malocclusion has been studied various times in different countries of the world and the results vary from 11% to 93%.^14-17 There is a high frequency of Class I malocclusion in White Americans (Class I 52.5%, Class II 42.4% & Class III < 5%) and also in Black Americans (Class I 71%, Class II 16% & Class III 8.4%). Similarly, in Nigerians, Class I malocclusion is most common type of malocclusion (74%), while, in Oriental populations, class III was found out to be most prevalent, whereas Class II problems are more prevalent in whites of northern European descent. The most common type of malocclusion in Saudi Arabian population is Class I (69.3%), followed by Class II division 1(12.2%), Class III (9.8%), Class II division 2 (5%) and pseudo Class III (3.7%). These variations may depend on various factors such as registration methods, ethnic origin, social class, and age factors. ¹⁸The prevalence of class I, II, and III were found to be 65%, 26%, and 9% respectively, in present study. The results of this research revealed that class I malocclusion is more common than class II malocclusion. The male to female ratio in our study was 1:2. Calculations showed that occurrence of class I, II and III are not dependent to age or gender which is in agreement with results of recent studies.^19,20

Although several reported studies concluded the prevalence of malocclusion, the findings are difficult to compare because of different materials and methods, age groups, inter-investigator variation, and the unmatched sample sizes. In the present study, the frequency of malocclusion is similar to study by Rahman,¹⁸Nadim,²⁰Sari et al.²¹in Turkish patients, and to the results of Sayin,²²but different when compared with the study by Fida,¹³Jones,²³ Yang,²⁴Abualhaija²⁵ and Luthian²⁶. Result of current study is in contrast with the findings of Gulerum and Ijaz, also Hameed et al. reported Class II as the most common type of malocclusion. On the other hand Shehzad and Afzal et al. reported Angle’s Class I as the most frequent type of malocclusion, which is in agreement with findings of our study. The differences in frequency might be related to the racial differences and the setup in which they were conducted.

Early treatment should take into account the severity of the malocclusion and also its impact on the neuromuscular system by preventing asymmetries in the development of the alveolar bone and further disturbances in the permanent dentition, as well as inhibiting the progression and severity of the malocclusion.

Needless to say, the planning of public health policies should be grounded in knowledge about the needs of the population, by correlating causes, effects and solutions to the problems. With all the data presented here the authors hope to contribute to such planning by allowing the necessary material and human resources to be properly estimated. The limitation of this study is that   we did not investigate the etiological causes of malocclusion. We will focus on the aspect in the future large scale studies.

Conclusion

It was concluded that Class I malocclusion is the most prevalent followed by class II and class III . It provides a base line data for orthodontic treatment planning and also highlights the need for further large scale studies in various ethnic background population groups.

Financial Disclosure

We have no relevant financial interests in this manuscript.

Conflict of Interest

We have no conflict of interest that I should disclose.

CONTRIBUTION BY AUTHORS

Muhammad Azeem: Corresponding author, conceiving and designing the study, data recording, analysis and interpretation of data.

Muhammad Ilyas: written or critically reviewed the manuscript.

Waheed Ul Hamid: Main supervisor, critically reviewed the manuscript & final editing

Ahmad Shamim: written or critically reviewed the manuscript.

References

1. Brito DI, Dias PF, Gleiser R. Prevalence of malocclusion in children aged 9 to 12 years old in the city of Nova Friburgo, Rio de Janeiro State, Brazil. Revista Dental Press de Ortodontia e Ortopedia Facial. 2009;14:118-24.
2. Brezniak N, Arad A, Heller M, Dinbar A, Dinte A, Wasserstein A. Pathognomonic cephalometric characteristics of Angle Class II Division 2 malocclusion. Angle Orthod. 2002;72:251-7.
3. Huang GJ. Giving back to our specialty: Participate in the national anterior open-bite study. Am J Orthod Dentofac Orthop. 2016;149:4-5.
4. Ngan P, Fields HW. Open bite: a review of etiology and management. Pediatric Dent. 1996;19:91-8.
5. Kim P, Sarauw MT, Sonnesen L. Cervical vertebral column morphology and head posture in preorthodontic patients with anterior open bite. Am J Orthod Dentofac Orthop. 2014;145:359-66.
6. Fernández-Pérez MJ, Alarcón JA, McNamara Jr JA, Velasco-Torres M, Benavides E, Galindo-Moreno P, Catena A. Spheno-Occipital Synchondrosis Fusion Correlates with Cervical Vertebrae Maturation. PloS one. 2016;11:e0161104.
7. Samson RS, Varghese E, Kumbargere SN, Chandrappa PR. Fused cervical vertebrae: a coincidental finding in a lateral cephalogram taken for orthodontic diagnostic purposes. BMJ case reports. 2016;2016:bcr2016217566.
8. Nambiar S, Mogra S, Nair BU, Menon A, Babu CS. Morphometric analysis of cervical vertebrae morphology and correlation of cervical vertebrae morphometry, cervical spine inclination and cranial base angle to craniofacial morphology and stature in an adult skeletal class I and class II population. Contemp Clin Dent. 2014;5:456.
9. Maciel CT, Leite IC. Etiological aspects of anterior open bite and its implications to the oral functions. Pro-FonoRevista de AtualizacaoCientifica. 2005;17:293-302.
10. Angle EH. Classification of malocclusion. Dent Cosmos 1899;41:248-64.
11. Du SQ, Rinchuse DJ, Zullo TG, Rinchuse DJ. Reliability of three methods of occlusion classification. Am J Orthod Dentofac Orthop. 1998;113:463-70.
12. Ackerman JL, Proffit WR. The characteristics of malocclusion: a modern approach to classification and diagnosis. Am J Orthod. 1969;56:443-54.
13. Fida M. Pattern of malocclusion in orthodontic patients: a hospital based study. J Ayub Med Coll. 2008;20:43.
14. Vig KW, Fields HW. Facial growth and management of orthodontic problems. Pediatr Clin North Am. 2000; 47: 1085-123.
15. Freitas KMS, Freitas DS, Valarelli FP, Freitas MR, Janson G. PAR evaluation of treated Class I extraction patients. Angle Orthod. 2008; 78: 270-4.
16. Willems G, De Bruyne I, Verdonck A, Fieuws S, Carels C. Prevalence of dentofacial characteristics in a Belgian orthodontic population. Clin Oral investigat. 2001; 5: 220-6.
17. Hill P. The prevalence and severity of malocclusion and the need for orthodontic treatment in 9-, 12-, and 15-year-old Glasgow schoolchildren. J Orthod. 1992; 19: 87-96.
18. Rahman MM, Jahan H, Hossain MZ. Pattern of malocclusion in patients seeking orthodontic treatment at Dhaka Dental College and Hospital. Ban J Orthod Dentofac Orthop. 2015;3:9-11.
19. Louis M Muwazi CMR, Francis J Tirwomwe, Charles Sali, ArabatKasangaki,Moses E Nkamba, Paul Ekwaru. Prevalance of oral conditions and diseases in Uganda. Afr Health Sci. 2005; 5: 277-33.
20. NADIM KA, RIZWAN S. Prevalence of angles malocclusion according to age groups and gender. Pak Oral Dent J. 2014;34:362-65.
21. Sari Z, Uysal T, Karaman A, Basciftci F, Usumez S, Demir A. Orthodontic malocclusions and evaluation of treatment alternatives: an epidemiologic study. Turkish J Orthod. 2003; 16: 119-26.
22. Sayin M, Türkkahraman H. Malocclusion and crowding in an orthodontically referred Turkish population. Angle Orthod. 2004; 74: 635-9.

Fahad Qiam¹ BDS, FCPS
^{Muslim Khan2} BDS, FCPS MHPE

INTRODUCTION

Competence is defined as the ability to perform a task successfully or efficiently.1 With specific regards to dentistry, Competency is most often used to describe the skills, understanding and professional values of an individual ready for beginning independent dental or allied oral health care practice.2 Competence based evaluation is the new benchmark for assessing the quality of dental graduates being produced.

The reason for the shift from discipline based curriculum to one based on competence is that the former focused purely on knowledge retention and reproduction of knowledge through an end of year examination system. The latter highlights what students are expected to learn and lends itself to round the year evaluation.³ Competence based curriculum is assessed through learning specific outcomes. This approach can objectively ascertain what tools a dentist of tomorrow must possess; therefore it is the curriculum of choice in not only the developed countries, but is also making its way into the developing countries as well.⁴

The Pakistan Medical and Dental Council (PM&DC) persists with the discipline based curriculum when it comes to teaching dental clinical subjects. In this regard, the Higher Education Commission, Pakistan (HEC) published a revised Bachelor of Dental Surgery (BDS) Curriculum which introduced competencies for every dental clinical subject including Oral and maxillofacial surgery. They divided the competencies into major and supporting. According to HEC, major competencies are “simple reparative surgical procedures of the hard and soft tissues in patients of all ages, including the extraction of teeth, the removal of roots when necessary and the performance of minor soft tissue surgery, and to apply appropriate pharmaceutical agents to support treatment”. Amongst supporting competencies, HEC states that a general dentist should be (1) competent to perform uncomplicated extraction of erupted teeth, (2) Have knowledge of the management of trauma in deciduous and permanent dentitions and be familiar with the surgical and nonsurgical aspects of the management of maxillofacial trauma. (3) Competent to perform surgical extraction of an uncomplicated unerupted tooth and the uncomplicated removal of fractured or retained roots. (4) Be competent to perform uncomplicated pre-prosthetic surgical procedures. (5) Be competent to manage and treat common intra-operative and postoperative surgical complications. (6) Be competent to describe the indications and contraindications, principles and techniques of surgical placement of osseointegrated implant fixtures.⁵ The introduction of such competencies remains confined to the paper for the time being at an undergraduate level whereas postgraduate study institutions such as College of Physicians and Surgeons, Pakistan have introduced them for the fellowship residency program in Oral and maxillofacial surgery.⁶ Studies conducted in Saudi Arabia and Lahore, Pakistan have highlighted that final year students and house officers report high confidence in some areas pertaining to minor oral surgery such as local anesthesia administration, simple extractions, understanding extraction indications but reported low confidence in extracting third molars and performing tooth sectioning.^{7, 8} These deficiencies highlight a need to re-evaluate how undergraduate oral surgery is taught theoretically and practically.

The objective of this study was to determine the self reported confidence amongst final year BDS students and house officers regarding various competencies pertaining to minor oral surgery. This study is the first of its kind conducted among dental colleges of Khyber Pakhtunkhwa. It will provide a baseline assessment of the adequacy of discipline based curriculum; highlight its strengths and avenues for improvement as we try to produce a more equipped, competent and confident dentist of tomorrow.

METHODOLOGY

This cross sectional analytical study was carried out following approval from the Institutional ethical review committee at Khyber College of Dentistry, Peshawar. The study sample consisted of Final year BDS students and the House officers who had completed their oral surgery rotation at the Department of Oral & Maxillofacial Surgery. A customized questionnaire was designed which was validated through expert opinion. A total of 25 competencies were identified and Bloom’s taxonomy¹ was used to divide these competencies according to Knowledge (10 competencies), skill (11 competencies) and attitude (4 competencies). A 4 point Likert scale was used to grade each competency (1 = No confidence, 2 = Little confidence, 3 = Confident, 4 = Very confident). A total of 150 pro-forma’s were distributed. The collected data was analyzed using SPSS version 20. Mean scores plus standard deviation for each competency were calculated and stratified among the sample group (Final year BDS students versus House officers). The Pearson chi square test was used to assess the level of significance, if any, between the confidence scores reported by final year BDS students and house officers regarding the above mentioned competencies (critical p-value <0.05). Furthermore, Gamma value and test were applied to see the improvement or worsening of confidence scores among the sample groups (critical p-value <0.05)

RESULTS

A total of 150 proformas were distributed among final year BDS students and House Officers (75 each). Out of those, 117 were returned, which yielded a response rate of 78%. Among the 117 respondents, 44 were male and 73 were female. Final year BDS students comprised 44.4% of the sample (n=52) and House officers accounted for the remaining 55.6% (n=65). Both final year BDS students and house officers displayed confidence regarding the knowledge based competencies. The highest scoring knowledge based competency among final year BDS students and house officers was knowledge of forceps and elevators whereas the lowest scored competency was medico-legal aspects for both groups. There was a significant improvement in knowledge of forceps and elevators between the sample groups (p-value = 0.05).

House officers also scored the lowest in principles of biopsy for oral lesions, where they scored less than final year BDS students. This decrease in confidence was statistically significant (p-value = 0.04). Interestingly, house officers also displayed a decreased confidence in 4 other knowledge based competencies as compared to final year BDS students as indicated by the negative gamma values. The details of the stratification of knowledge based competency scores is given in Table 1.

As far as skill based competencies are concerned, final year BDS students scored highest in obtaining effective and profound anesthesia and the least in taking biopsies of oral lesions. The latter category was also the least scored competency by house officers. House officers scored highest in the use of elevators for tooth luxation, followed closely by obtaining effective anesthesia and use of forceps. Overall, house officers outscored final year BDS students in every skill based competency, however statistically significant improvement was noted only in performing open extraction (p-value= 0.00), extracting molars with separation (p-value= 0.00), extracting impacted third molars (p-value= 0.00), performing alveoloplasty (p-value= 0.00), and writing appropriate referrals (p-value= 0.02). The details of the stratification of skill based competency scores are given in Table 2.

House officers reported higher confidence scores than their final year BDS counterparts in all 4 attitude based competencies. Statistically significant improvement was seen in communicating effectively with patients (p-value= 0.01). The least scored competency amongst both sample groups was the handling of difficult/unco-operative patients. The details of the stratification are given in Table 3.

DISCUSSION

The training of tomorrow’s general dentist is an evolving science. As the requirements of providing healthcare in the 21^st century continue to grow, the task of educating and producing such doctors must also keep pace. The General Medical Council (GMC) published a report in 2015 titled “Tomorrow’s Doctors” which highlighted several outcomes that need to be met as a result of undergraduate medical education. Broadly, these outcomes were divided into the role a doctor must play as a scholar/scientist, as a practioner, and as a professional. As an allied medical field, the training of tomorrow’s dentist is not that different, and the same outcomes can be applied for assessment of the training that is being given and its adequacy in meeting our objectives as medical educationists.⁹

Dajani⁷ conducted a similar study in Aljouf University College of Dentistry where he compared self reported confidence scores regarding various oral surgical procedures being practiced and taught to fourth and fifth year students. They utilized a four point Likert scale to assess confidence, identical to the one used in this study. He found that students reported the highest confidence levels in giving local anesthesia, understanding indications for extractions and performing simple extractions. The lowest scored competencies were handling difficult extractions, extracting molars with separation and extracting third molars. Similar results were seen in this study. The average confidence in performing surgical procedures in that study was 2.88±0.55. The average surgical confidence (mean of skill based competency confidence scores) in this study sample was 2.64±0.77 for final year BDS students and 2.89±0.70 for house officers.

Dajani⁷ also reported an increased overall confidence level amongst fifth year students as compared to fourth year due to the fact that they had performed more tooth extractions. This increased confidence was statistically significant (p-value = 0.003) which was in conformity with the results of this study. Dajani⁷ did not evaluate any knowledge or attitude based competencies, focusing purely on skill based outcomes thus a comparison of those could not be done. It must be remarked that their study tested 19 surgical skills which included implant placement and management of localized odontogenic infections, in contrast to this study which evaluated only 11 skills. Dajani also found that students of fourth and fifth year reported low confidence regarding biopsies of oral lesions, and that the confidence decreased as students progressed from fourth to fifth year. Similar results were seen in the present study, and this can be attributed to the fact that biopsy cases are relatively scarce in the Department of Oral and Maxillofacial Surgery at Khyber College of Dentistry and they are routinely performed by postgraduate students or oral and maxillofacial surgeons.

Brand and co¹⁰ conducted a study evaluating student’s opinion of undergraduate theoretical and clinical training across 23 dental schools in Europe. Students from all dental schools reported to be confident regarding the anatomy related to tooth extraction and anesthesia, analgesic prescription, medico-legal aspects and medication problems. Among these, 40-60% of students from 7 of these dental schools reported insufficient preparation regarding use of forceps and elevators. Similar percentages were reported from 5 other schools regarding managing complications of extractions. These findings contradict those of the present study in almost all aspects except confidence regarding anatomy related to tooth extraction and anesthesia. Students at Khyber College of Dentistry study analegesics, prescription and medication problems in the second year of their studies, meaning it takes them two years to put their theoretical knowledge into practice therefore the low confidence regarding this competency can be attributed to this fact. High confidence scores seen in competencies pertaining to use of forceps and elevators as well as complications of extraction is because under the PM&DC BDS curriculum, an undergraduate BDS student is expected to carry out 200 extractions under local anesthesia.¹¹ The average number of extractions required by dental schools in Europe is in the range of 20 – 115, blamed partly on lack of cases available to dental schools.^{12, 13, 14}

Sadozai et al⁸ conducted a study to determine confidence in performing clinical procedures at a general dentist level amongst three different dental colleges of Lahore, Pakistan. Their sample of 180 students was evaluated in all disciplines of clinical dentistry and their confidence was assessed on a 5 point Likert scale. They assessed only three competencies pertaining to oral surgery i.e. the ability to perform simple extractions, impactions and surgical exodontia. Two of these three competencies related to oral surgery (simple extractions and surgical exodontia) for their study are in line with General Dental Council (GDC) framework for oral surgery competency, although the Association for Dental Education in Europe (ADEE) framework also includes competencies related to uncomplicated pre-prosthetic surgery and soft tissue diagnostic procedures which were included in the present study.¹⁵ Confidence regarding simple extractions was the highest of all 41 competencies being evaluated (4.32±0.86), impactions (2.76±1.20) and surgical extractions (2.49±1.24). These findings were in accordance with this study.

The mean score of all 3 domains (knowledge, skill, attitude) among final year BDS students in this study was 2.78 which increased to 2.86 among house officers. Several areas of weakness were identified at both final year BDS and house officer level which will require renewed focus through theoretical and clinical training. Overall, this signifies that graduates of Khyber College of Dentistry are almost at the level of confidence (score =3) by the time they are done with their house job with regards to minor oral surgery competencies. The competencies presented in this study were included after evaluating local and international literature, keeping in mind the local needs of the population as well as specific disease burdens. A recent study conducted by Bukhari and co¹⁶ highlighted that the existing curriculum and syllabus for BDS students contains elements that are supplementary or questionable at best such as frenectomies, extractions under general anesthesia, assistance or observation of jaw fractures, operculectomy, treatment of tongue tie, crysosurgery and laser excision. It also put emphasis on soft tissue biopsy as an essential competency for undergraduate studies due to increasing burden of oral cancer which is often compounded by late diagnosis.¹⁷

CONCLUSIONS AND RECOMMENDATIONS

From this study it is concluded that:

1. House officers are more confident than final year BDS students with regards to most knowledge, skill and attitude based competencies.
2. Obtaining effective anesthesia, use of elevators & forceps, and effective patient communication were the highest scoring competencies
3. Taking incisional biopsy and dealing with medico-legal aspects of minor oral surgery were two of the lowest scoring competencies.

Based on this study, the following recommendations are proposed:

• Seminars and workshops should be arranged for house officers to review and refresh the basics of their clinical studies.
• Inclusion of 5-10 cases of observing/assisting/performing biopsies of oral lesions under direct supervision.
• Introduction of 2 weeks rotation in Forensic medicine so students can understand medico-legal aspects of dentistry as a department of forensic dentistry does not exist nor is it taught as a subject at the undergraduate level.

CONTRIBUTION BY AUTHORS

Fahad Qiam: Execution and generation of idea for the study, principal author.

Muslim Khan: Supervisor of the study, helped in study design, discussion writing and proforma validation.

Acknowledgment

We acknowledge and regard the efforts of Dr. Humayun Afridi and Dr. Shaista Ali from (Khyber College of Dentistry, Peshawar, Pakistan) for data collection.

REFERENCES

1. Evans AW. Assessing competence in surgical dentistry. Br Dent J. 2001:14;190:343-6.
2. Boyd MA, Gerrow JD, Chambers DW, Henderson BJ. Competencies for dental licensure in Canada. J Dent Educ 1996; 60: 842-6
3. Yip HK,Smales RJ. Review of Competency-Based Education in Dentistry. Br Dent J.2000;189:324-6.
4. Ghani F, Salim I. Comprehensive Dental Care Teaching Clinics: A Concept For Inculcating General Dental Practice Skills In BDS Students J Pak Dent Assoc. 2010;19:75-7
5. Naqvi SSH, Shaikh AAG, Khan MJ, Mahmood MA, Shah TA, Bhatti AF.Curriculum Of Bachelor Of Dental Surgery (BDS) Five Years Programme. Higher Education Commission.2011.(pdf available at http://hec.gov.pk/english/services/universities/RevisedCurricula/Documents/2010 2011/Draft-BDS-2011.pdf)
6. Babar SF. Requirement for Post IMM Fellowship training in Oral and maxillofacial surgery.2012. (pdf available at http://elogbook.cpsp.edu.pk/eportal/eportal/docs/trainee/prospectus/fcps2/FCPS-II%20OMFS.pdf
7. Dajani MA. Dental students’ perceptions of undergraduate clinical training in oral and maxillofacial surgery in an integrated curriculum in Saudi Arabia. J Educ Eval Health Prof. 2015; 12: 45.Published online 2015 Sep 24. doi: 3352/jeehp.2015.12.45
8. Sadozai SRK, Bhutta N, Chatha MR. Self-reported confidence levels of dental graduates in performing clinical procedures. Pak Oral Dent J. 2015;35:681-6
9. General Medical Council. Outcomes for graduates (Tomorrow’s doctors). 2015. http://www.gmc-uk.org/Outcomes_for_graduates_Jul_15_1216.pdf_61408029.pdf
10. Brand HS, van der Cammen CCJ, Roorda SME, Baart JA. Tooth extraction education at dental schools across Europe. Br Dent J.2015. 1, [15002]. DOI: 10.1038/bdjopen.2015.2
11. Pakistan Medical & Dental Council. Regulations for the Degree of Bachelor of Dental Surgery (B.D.S). Available from: http://www.pmdc.org.pk/Regulation/RegulationsforBDS/tabid/116/Default.aspx. {Accessed 28th June 2017)
12. Macluskey M, Durham J. Oral surgery undergraduate teaching and experience in the United Kingdom: a national survey. Eur J Dent Educ 2008; 13: 52–7.
13. Durham J, Balmer C, Bell A, Cowan G, Cowpe J, Crean SJ, et al. A generic consensus assessment of undergraduate competence in forceps exodontia in the United Kingdom. Eur J Dent Educ 2010; 14: 210–4.
14. Honey J, Lynch CD, Burke FM, Gilmour AS. Ready for practice? A study of confidence levels of final year dental students at Cardiff University and University College Cork. Eur J Dent Educ 2011; 15: 98–103.
15. Macluskey M, Durham J, Cowan G, ,Cowpe J, Evans A, Freeman C, et al. UK national curriculum for undergraduate oral surgery subgroup for teaching of the Association of British Academic Oral and Maxillofacial Surgeons. Eur J Dent Educ 2008: 12: 48–58.
16. Bukhari SGA, Mahboob U, Ara N. Developing Consensus Over Course Contents Of Undergraduate Oral And Maxillofacial Surgery Curriculum. Pak Oral Dent J. 2017;37:19-25.
17. Garg P, Karjodkar F. “Catch Them before it Becomes Too Late”—Oral Cancer Detection. Report of Two Cases and Review of Diagnostic AIDS in Cancer Detection. Int J Prev Med. 2012; 3: 737–41.

• Demonstrator, Department of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar, Pakistan
• Associate Professor, Department of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar, Pakistan.

Corresponding author: “Dr. Fahad Qiam”

<fahad.qiam@gmail.com>

Farhan Raza Khan   BDS, MS, MCPS, FCPS

A factory is a place where products are manufactured from the raw materials. For any factory to prosper, there are few pre-requisites:

• It produces goods that are in demand by the public
• There must be some rules and regulation framework under which it operates
• Quality control mechanism
• Economic sustainability of the production
• A mission and vision statement for it to aspire its goals
• Warranty and after sales service of its products

Taking this analogy forward, a dental college is a place where future dentists are produced. In other words, dental institutions are dentist producing factories.1 Therefore, it would be interesting to apply the above principles on these institutions. Let’s discuss this.

DEMAND OF SERVICE

Pakistan is a country with an estimated population of over 190 million. The numbers of registered dentists are less than 18,000 which make the dentist to population ratio > 1:10,000. It means that there is a lot of room for the factories (dental colleges) to pump out their products (dentists) into the market. However, the catch here is that most of the dentists are based in the 10 big cities of Pakistan (Karachi, Lahore, Islamabad, Multan, Faisalabad, Peshawar, Abbottabad, DG Khan, Hyderabad and Quetta) showing virtually no interest to work in the rural settings. Therefore, a significantly skewed distribution of providers makes an even supply of the product (dentists) to the needy (patients residing in rural Pakistan) impossible.

RULES AND REGULATION

With bodies like PMDC, CPSP, HEC and PHC, the stringent rules and regulations are there to regulate the profession. These bodies carry out all the checks and balances regarding the quality assurance and assessment of the final product (graduating dentist). This ensures that dentist once graduated possess all the right competencies to practice independently and serves as a safe and ethical practitioner.

Consultant & Head of Dentistry, Aga Khan University, Karachi, Pakistan

farhan.raza@aku.edu

QUALITY CONTROL MECHANISM

Efficient factories do not initiate quality assessment at the end of manufacturing; rather, they evaluate their quality of their product throughout every stage of production until completion. If a dental college is to work efficiently then it must build the culture of self-assessment. A culture where quality is the responsibility of everyone, not just the faculty, but the entire dental team including surgery assistants and students. Students who self-assess are likely to identify their own weaknesses and seek help for the improvement. Traditional education model pushes the students to hide their lack of knowledge in weak areas and focus on just passing the exam. A cultural change in dental colleges is needed where students and teachers see each other as team member and where reflective practice is done and where quality in education and patient service should be the ultimate goal.

ECONOMIC SUSTAINABILITY

The dental education is an expensive business for the students and the institution. Dental materials, consumables and equipment are costly. Students are beginner in the profession who work slowly and inefficiently compared to experienced dentists; thus undergraduate students may not serve as productive clinical service provider and/ or revenue generator for the dental college. Thus, relying on dental students to run a dental service based institution would be a poor business model. Some financial experts recommend applying the Pareto’s principle of 80:20 on all business models. This model implies an unequal relationship between inputs and outputs. However, allocating 80% resources to 20% students or faculty is not academically justified. Similarly, allocating more money to certain groups of patients would create ethical problems in healthcare.²

MISSION AND VISION STATEMENT

A mission statement defines the organization’s business, its objectives and its approach to achieve those objectives. A vision statement describes the desired future position of the organization. The mission and vision statements are often combined to provide a statement of the organization purposes, goals and values. All dental colleges should have well-defined mission and vision statements. The institution should facilitate students, interns and faculty to achieve those goals. Lack of such mission and vision will make dental colleges into unregulated factories that produce dentists without knowing how their product will function later on.

WARRANTY AND AFTER SALES SERVICE

If dental colleges produce professionally competent clinicians who possess the noble attributes of life-long learning, self-assessment and ethical practices as the primary motto then the public at large will certainly develop a high level trust on their dentists. This trust is the “warranty” that patients will get the best possible care from their dentist. For after sales service, the dental institution should ensure that they regularly offer continuing dental education or continuing professional development session. These CDE/ CPD courses will ensure that the products of the dental factories (i.e. dentists) will remain professionally updated throughout their career.

REFERENCES

1. Nalliah RP. Five practices of efficient factories applied to dental education. J Investig Clin Dent. 2015; 6: 81-4.
2. Zupancic JA, Dukhovny D. Resource distribution in neonatology: beyond the Pareto principle. Arch Dis Child Fetal Neonatal Ed. 2015; 100: F472-3.

Fahad Umer                                  BDS, FCPS, FICOI, CAGS U-PENN

Muhammad Rizwan Nazeer      BDS

Samira Adnan                               BDS, FCPS

ABSTRACT:A successful endodontic outcome relies on the localization of all canals and complete debridement of root canal system. The success of any endodontic therapy becomes a challenge when aberrant root canal morphology is present, especially when this anatomy is difficult to visualize from radiographs. The present case report is about endodontic management of a mandibular second molar that presented with a middle mesial canal. This is an exceedingly uncommon morphology and this case report is expected to increase clinician knowledge of a variable root canal anatomy associated with this tooth.

KEYWORDS: Mandibular second molar, Middle mesial canal, aberrant root canal anatomy, endodontic failure.

HOW TO CITE: Adnan S. Endodontic Management of Elusive Middle Mesial Canal in Mandibular Second Molar. J Pak Dent Assoc 2017; 26(3): 137-140.

DOI: https://doi.org/10.25301/JPDA.263.137

Received: 16 May 2017, Accepted: 25 August 2017

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Kamil Zafar                     BDS

Sheikh Bilal Badar        BDS

Farhan Raza Khan        BDS, MS, MCPS, FCPS

ABSTRACT:

Intentional replantation is done in cases of endodontic failures where conventional forms of treatment options either fail or become impossible. It involves the removal of the offended tooth, execution of extra oral apicoectomy followed by its reinsertion into the socket. The present cases reports demonstrates a scenario where a maxillary left first molar had a separated endodontic file extending beyond the apex that could not be retrieved. The decision of intentional reimplantation was made but unfortunately, the tooth underwent fracture in the course of extraction. The procedure was still performed with a reduced palatal root length. Fortunately, a favorable outcome was observed. However, for recording the long term survival, the patient is kept on follow-up.

KEYWORDS: Endodontic failure, endodontic surgery, intentional reimplantation.

HOW TO CITE: Zafar K, Badar SB, Khan FR. Intentional Replantation in a Maxillary Molar with Undesirable Root Fracture: A Case Report. J Pak Dent Assoc 2017; 26(3): 132-136.

https://doi.org/10.25301/JPDA.263.132

Received: 15 May 2017,  Accepted: 25 August 2017.
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