Vol. 27 No. 02 Apr-Jun 2018

Haroon Rashid ¹                                             BDS, MDSc

Platelet-rich plasma (PRP) has become a great approach in tissue regeneration procedures and is becoming an important addition in measures where efficient healing of dental tissues is required. The use of PRP in old individuals is becoming even more relevant.¹ PRP is mainly derived from an individual’s blood by centrifugation process and contains several growth factors which may promote healing of the wounds and thus, plays a very vital role in tissue repairing and regenerative mechanisms.¹ Common formulation of PRP is gel, which is formed by derivatives of the autologous whole blood that contains calcium chloride and thrombin. It contains high concentrations of native fibrinogen and platelets.²

Recently in dental and oral surgical procedures, PRP has become an excellent adjunct which promotes healing.³ Common dental procedures which involve the use of PRP include the surgical procedures, mandibular repair/reconstruction and surgical repairs of alveolar clefts, treatment involving the correction of infra-bony defects of periodontium and perio-plastic reconstructive procedures. It is also used in procedures which are related to the placement of osseo-integrated dental implants.⁴ PRP is adhesive in nature and this allows for facilitation and easy handling of the grafting material, leading to predictable flap adaptation and good hemostasis, and thus, helps in achieving predictable seal than as compared to the primary closure alone.

The ease of use of PRP preparations are highly beneficial to be used in dentistry however; the evidence regarding the safety, efficacy and efficiency of PRP suggests that its use remains controversial since the majority of the studies were performed using different graft materials during different application procedures.^1,5,6

The literature suggests that using PRP into the alveolar socket soon after performing the exodontias improves soft tissue healing and it also certainly influences the bone regeneration process however; a few days after, the latter effect seems to diminish. PRP has also shown very good results in periodontal procedures when it is used in combination with other materials than when it is used alone, which suggests that PRP when combined with specific agents/materials could be important and may improve the surgical and periodontal results.^7,8 PRP is actually very promising in periodontal and regenerative procedures should be continued to be studied by scientists and clinicians.⁸ During the process of periapical healing, root lengthening and dentinal wall thickening in necrotic immature permanent teeth over the blood clot, platelet rich fibrin acts as a scaffold with concentrated micromolectures or storehouse of growth factors.¹⁰ Blood clot and PRP show comparative results in terms of apical closure, root lengthening, dentinal wall thickening, and periapical healing.^9,10

There have been no possible side effects which have been reported in many clinical studies involving PRP therapy. However; the only disadvantage of PRP preparations, one can mention would be the benefit outcome versus the costs involved during the application procedure. The success of procedures involving PRP may be termed doubtful and its use may not be justified because of the costs of the PRPprocessing systems and the kits for its use. In addition, a less important inconvenience during the treatment would be that the patients themselves have to undergo procedures for drawing their own blood which is a requirement for PRP preparation.

REFERENCES

1.  Carlson NE, Roach RB. Platelet-rich plasma: clinical applications in dentistry. J Am Dent Assoc. 2002;133: 13831386. https://doi.org/10.14219/jada.archive.2002.0054 
2. Kao RT, Murakami S, Beirne OR. The use of biologic mediators and tissue engineering in dentistry. Periodontol 2000. 2009;50:127-153. https://doi.org/10.1111/j.1600-0757.2008.00287.x
3. Anitua E, Andia I, Ardanza B, Nurden P, Nurden AT. Autologous platelets as source of proteins for healing and tissue regeneration. Thromb Haemost. 2004;91:4-15.
4. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet rich plasma. Oral Surg Oral Med Oral Pathol. 1998;85:638-646. doi: 10.1016/S10792104(98)90029 4. https://doi.org/10.1016/S1079-2104(98)90029-4
5. Saini N, Sikri P, Gupta H. Evaluation of the relative efficacy of autologous platelet-rich plasma in combination with β-tricalcium phosphate alloplast versus an alloplast alone in the treatment of human periodontal infrabony defects: a clinical and radiological study. Indian J Dent Res. 2011;22:107-115. https://doi.org/10.4103/0970-9290.80008
6. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasmathe perfect enhancement factor? A current review. Int J Oral Maxillofac Implants. 2003;18:93-103.
7. Alissa R, Esposito M, Horner K, Oliver R. The influenceof platelet-rich plasma on the healing of extraction sockets: an explorative randomised clinical trial. Eur J Oral Implantol. 2010;3: 121-134.
8. Ogundipe OK, Ugboko VI, Owotade FJ. Can autologousplatelet-rich plasma gel enhance healing after surgical extraction of mandibular third molars? J Oral Maxillofac Surg. 2011;69:2305-2310. doi: 10.1016/j.joms.2011.02.014. https://doi.org/10.1016/j.joms.2011.02.014
9. Alagl A, Bedi S, Hassan K, AlHumaid J. Use of plateletrich plasma for regeneration in non-vital immature permanent teeth: Clinical and cone-beam computed tomography evaluation. J Int Med Res. 2017 Apr;45(2):583-593. https://doi.org/10.1177/0300060517692935
10. Narang I, Mittal N, Mishra N. A comparative evaluationof the blood clot, platelet-rich plasma, and platelet-rich fibrin in regeneration of necrotic immature permanent teeth: A clinical study. Contemp Clin Dent. 2015 Jan-Mar; 6(1): 6368. https://doi.org/10.4103/0976-237X.149294.

1.Associate Professor, Division of Prosthodontics, Ziauddin University, Karachi, Pakistan.

Corresponding author: “Dr. Haroon Rashid” < drh.rashid@hotmail.com >

DOI: https://doi.org/10.25301/JPDA.272.87

Farhan Raza Khan ¹                                             BDS, MS, MCPS, FCPS

^{Maham Muneeb Lone 2}                                            BDS, FCPS

INTRODUCTION

Placement of implants into fresh extraction sockets and their immediate loading has been advocated in recent literature in an attempt to reduce the treatment time compared to the conventional protocol of delayed implant placement and loading.1-3 Immediate loading is defined as ‘functional loading of an implant within one week of its placement.4
This loading protocol of implants in edentulous and partially dentate arches has shown equally successful outcomes as those loaded after a delay of 2-3 months.5-7 Bisphosphonate are one of the most common antiresorptive drugs being prescribed for certain bone diseases, including osteoporosis. They act by decreasing the bone turnover rate; thereby increasing bone mineral density; and reducing the chance of fractures.8 In spite of its clinical efficacy, a known adverse effect of these drugs is the bisphosphonate related osteonecrosis of the jaw (BRONJ). BRONJ is defined as ‘an area of exposed bone in the maxillofacial region that did not heal within 8 weeks after identification by a healthcare worker, in a patient who was receiving, or had been exposed to, a bisphosphonate and had not had radiation therapy to the craniofacial region.9,10 To prevent this debilitating complication, a through medical and drug history should be sought by the dentist. Relevant radiographic and laboratory investigations should be undertaken before making a definitive treatment plan. This case report describes successful placement of implant supported prosthesis in a patient on oral bisphosphonate therapy after appropriate investigations.

CASE PRESENTATION

A 70 year old female presented to the Dental clinics of Aga Khan University Hospital, Karachi with complaints of difficulty in chewing food due to multiple mobile, broken down and missing teeth. The patient had similar complaints for the past few months. She had some of the missing teeth replaced by a tooth-implant supported prosthesis in her right upper arch almost one year ago. Her medical history revealed that she was affected by osteoporosis and was taking oral sodium aldronate (bisphosphonate) for over 4 years. Clinical examination revealed a tooth implant supported fixture in her upper right quadrant which was grade III mobile (figure 1a-c). After clinical evaluation, a panoramic radiograph was taken (figure 1d) which revealed that all teeth in her upper arch appeared non salvageable. The patient was advised extraction of all teeth in the upper arch. Extraction of broken

down roots was also advised in the lower arch; followed by replacement. As the patient expressed her interest in receiving only fixed prosthetic solution for dental rehabilitation; the option to restore her dentition was limited to provision of implant supported prosthesis.
The patient was advised blood tests to check the levels of Vitamin D, Calcium and carboxyl-terminal crosslinking telopeptide of type I collagen (CTX). Since no laboratory in our vicinity offered the CTX test; the patient was recommended to get the urine N-terminal crosslinking telopeptides of type I collagen (NTX) test instead.
After confirming the suitability of the patient to receive implants by discussing reports of laboratory tests with the concerned physician; patient was given the choice of placing implant supported prosthesis in both the upper and lower jaw.
The decision to give implant supported prosthesis was substantiated by the fact that the patient already had an implant fixture (ITI Straumann) in the upper right quadrant placed almost one year back which had osseointegrated and was serving her well.
After discussing the treatment plans thoroughly with the patient, her oral sodium aldronate was stopped by taking her physicians in confidence. The treatment was divided into 2 phases. Phase 1 included the extraction of mobile and broken down teeth; immediate implant placement and temporization in the upper arch. It was planned to retain the implant placed in the upper right quadrant and make it a part of the final prosthesis.
Impressions were made with alginate for study casts and to form vacuum formed clear acrylic stent for fabrication of temporary prosthesis in the upper arch. In the first visit, the upper prosthesis was sectioned and removed. The patient was advised to rinse with 0.2% Chlorhexidine gluconate solution. Under infiltration of local anesthestic solution (containing 1:100,000 epinephrine), extractions of the broken down roots and grossly carious teeth in the upper arch was done (figure 2a). A full thickness mucoperiosteal flap from the region of # 15 – # 25 was raised for better visualization of the

bone. After drilling the appropriate osteotomy sites, Zimmer tapered screw vent implant of 3.7 x 11.5 mm dimension were placed in the socket of tooth # 12, 22. Implant of dimensions 4.7 x 11.5 mm was placed in the position of tooth # 24 (figure 2b). After confirming primary stability of the implants, primary closure of the flap was done by using 3° vicryl interrupted sutures sparing the implant platforms. Plastic hex lock abutments were placed on the implants (figure 2c) and a screw retained temporary acrylic prosthesis extending from # 15- #25 was then fabricated using polymerizable acrylic resin in the vacuum formed stent (figure 3a). The finished provisional prosthesis was screwed into place and access opening closed with a temporary filling material (figure 3b). The patient was given post-operative instructions to minimize any risk of bleeding. The patient was advised soft diet during the healing period so as to avoid excessive loads on the osseointegrating implants. This was followed by prescription of Tab. Augmentin (Amoxicillin and Clavulanic Acid) 1g BID and Tab. Ansaid (Flurbiprofen) 100mg BID supplemented by Tab. Panadol (Paracetamol) 500 mg TID if needed for 5 days.
After 2 weeks, broken down root of #34 and #35 were extracted under local anesthesia. A full thickness mucoperiosteal flap was raised. After drilling the appropriate osteotomy sites, Zimmer tapered screw vent implant of 3.7 x 11.5 mm dimension were placed in the native bone of # 36 and # 46 region. Implant of dimensions 4.7 x 13.0 mm was placed in the socket of # 34. After confirming primary stability of the implants, primary closure of the flap was done by using 3° vicryl interrupted sutures and healing collars were placed. As lower anterior

teeth were intact so no temporary prosthesis was made for lower arch implants (figure 3c). The patient was given postoperative instructions to minimize any risk of bleeding. This was followed by prescription of Tab. Augmentin (Amoxicillin and Clavulanic Acid) 1g BID and Tab. Ansaid (Flurbiprofen) 100mg BID supplemented by Tab. Panadol (Paracetamol) 500 mg TID if needed for 5 days.
At follow up of 2 weeks, the upper temporary prosthesis was removed, cleaned and screwed back after minor adjustments. After 3 months, impressions were made using poly vinyl siloxane impression material (light and heavy body) for final prosthesis fabrication. The previously placed implant was included in the final prosthesis and a cement retained prosthesis extending from # 16 -25 was cemented using Glass ionomer based cement (figure 4 a-e). Single implant crown was cemented on # 46, while a 3-unit implant retained bridge was cemented in the region of #34- #36

Oral hygiene instructions were reinforced and the patient was advised for regular follow up visits at her regular dentist. Upon, her visit again to our center at 12 months interval from initial placement, we did routine prophylaxis and observed that she is doing well. The panoramic radiograph at 12 months follow-up showed favorable bone levels and absence of any pathology (figure 5).

DISCUSSION

This case report describes successful immediate placement and loading of implant supported prosthesis in edentulous maxilla and partially dentate mandible of a patient who had been on oral bisphosphonates for more than 4 years.
Immediate implant placement is defined as placement of implant into a fresh extraction socket just after tooth extraction.11 This treatment protocol been advocated in recent literature because of certain advantages of this treatment procedure over the conventional delayed implant placement. It reduces the number of surgical interventions; better maintains the soft and hard tissue architecture at the site of implant placement and has been reported to have better patient satisfaction.12,13 In the present case a reduction in the overall treatment time was of utmost importance as the patient was not a local resident, and had come from abroad only to get her treatment done. The provision of a screw retained temporary prosthesis at the same visit as that of the implant placement has a huge social and psychological impact on the patient as she was not without teeth for even a single day.
Success of implant supported restorations is dependent on various local and systemic factors. Bisphosphosphonates are said to impair the bone turnover rate, thereby decreasing chances of bone fracture.8 Serum C-terminal crosslinking telopeptides of type I collagen, (CTX biomarker) is said to be an effective biomarker to monitor bone turn over in patients.14 An alternate to CTX is the N-terminal crosslinking telopeptides of type I collagen, (NTX biomarker), utilized in some studies to assess the bone turnover rate.14,15 Since no laboratory in our area carried out the CTX test, the patient was advised the NTX test instead to assess the bone turnover. Successful osseointegration of implants in this case report shows NTX biomarker to be a reliable alternative to the CTX test.
Li et al16 in a retrospective study concluded that immediate loading protocol by fixed provisional prosthesis is an effective method for restoration of edentulous maxilla and mandible. The same protocol was used to restore the edentulous maxilla in this case; with the permanent prosthesis delivered after 3 months of implant placement. For immediate provisional loading of prosthesis, it is recommended that the implant placed should have a torque of at least 30Ncm.11 The implants placed in our study withstood a torque of 35Ncm when assessed with a torque wrench after their placement, and thus decision of immediately loading the implants was taken. Upon 12 months follow-up the results of immediate placement and loading in this case were excellent. The patient is advised to keep her regular visits at her family dentist.

CONCLUSION

This case report reiterates the fact that successful implant supported prosthesis can be placed in patients on long term oral bisphosphonates if comprehensive treatment planning including all relevant investigations are done and the surgical trauma is kept to a minimum.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest regarding the publication of this paper.

REFERENCES

1. Chrcanovic BR, Martins MD, Wennerberg A. Immediate placement of implants into infected sites: a systematic review. Clin Implant Dent Relat Res. 2015;17 Suppl 1:e1- e16. https://doi.org/10.1111/cid.12098
2. Ostman PO, Wennerberg A, Ekestubbe A, Albrektsson T. Immediate occlusal loading of NanoTite tapered implants: a prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2013;15(6):809-18. https://doi.org/10.1111/j.1708-8208.2011.00437.x
3. Avvanzo P, Ciavarella D, Avvanzo A, Giannone N, Carella M, Lo Muzio L. Immediate placement and temporization of implants: three- to five-year retrospective results. J Oral Implantol. 2009;35(3):136-42. https://doi.org/10.1563/1548-1336-35.3.136
4. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different
   times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878. https://doi.org/10.1002/14651858.CD003878.pub5
5. Degidi M, Piattelli A, Felice P, Carinci F. Immediate functional loading of edentulous maxilla: a 5-year retrospective study of 388 titanium implants. J Periodontol. 2005;76(6):1016-24. https://doi.org/10.1902/jop.2005.76.6.1016
6. Degidi M, Piattelli A. Immediate functional and nonfunctional loading of dental implants: a 2- to 60-month
   follow-up study of 646 titanium implants. J Periodontol. 2003;74(2):225-41. https://doi.org/10.1902/jop.2003.74.2.225
7. Jaffin RA, Kumar A, Berman CL. Immediate loading of implants in partially and fully edentulous jaws: a series of 27 case reports. J Periodontol. 2000;71(5):833-8. https://doi.org/10.1902/jop.2000.71.5.833
8. Rodan GA RA. Bisphosphonate mechanism of action. Curr Mol Med. 2002;2:571-7. https://doi.org/10.2174/1566524023362104
9. Lopez-Cedrun JL, Sanroman JF, Garcia A, Penarrocha M, Feijoo JF, Limeres J, et al. Oral bisphosphonate-related osteonecrosis of the jaws in dental implant patients: a case series. Br J Oral Maxillofac Surg. 2013;51(8):874-9. https://doi.org/10.1016/j.bjoms.2013.06.011
10. Arrain Y, Masud T. Recent recommendations on bisphosphonate-associated osteonecrosis of the jaw. Dent
    Update. 2008;35(4):238-40, 42.
11. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate-delayed and delayed implants). Cochrane
    Database Syst Rev. 2010(9):CD005968. https://doi.org/10.1002/14651858.CD005968.pub3
12. Schropp L, Kostopoulos L, Wenzel A. Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: a prospective clinical study. Int J Oral Maxillofac Implants. 2003;18(2):189-99.
13. Schropp L, Isidor F, Kostopoulos L, Wenzel A. Patient experience of, and satisfaction with, delayed-immediate vs. delayed single-tooth implant placement. Clin Oral Implants Res. 2004;15(4):498-503.https://doi.org/10.1111/j.1600-0501.2004.01033.x1
14. Marx RE, Cillo JE, Jr., Ulloa JJ. Oral bisphosphonateinduced osteonecrosis: risk factors, prediction of risk using
    serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg. 2007;65(12):2397-410. https://doi.org/10.1016/j.joms.2007.08.003
15. Kim JW, Kong KA, Kim SJ, Choi SK, Cha IH, Kim MR. Prospective biomarker evaluation in patients with
    osteonecrosis of the jaw who received bisphosphonates. Bone. 2013;57(1):201-5. https://doi.org/10.1016/j.bone.2013.08.005
16. Li W, Chow J, Hui E, Lee PK, Chow R. Retrospective study on immediate functional loading of edentulous maxillas and mandibles with 690 implants, up to 71 months of followup. J Oral Maxillofac Surg. 2009;67(12):2653-62. https://doi.org/10.1016/j.joms.2009.07.015

1.Associate Professor, Dentistry, Aga Khan University.
2. Senior Lecturer, Jinnah Sind Medical University.
Corresponding author: “Dr. Farhan Raza Khan” < farhan.raza@aku.edu >

Farhan Raza Khan                                              BDS, MS, MCPS, FCPS

^{Maham Muneeb Lone}                                               BDS, FCPS

Lubna Ali ¹                                                                MBBS, MCPS, FCPS

Ahmed Moiz²                                                           BDS

Hamna Abdul Samad³                                                      BDS

Sadaf Saeed⁴                                                                               BDS

Rumman Shahid⁴                                                                  BDS,MSc

INTRODUCTION

During the period of gestation, women encounter a myriad of emotional and physiological disturbances and changes in various parts of their body. The significant levels of hormonal changes experienced by pregnant women introduce variations and complications in several regions of the body, including the oral cavity. The oral cavity is subjected to a lot of changes and disturbances during pregnancy, of which periodontal changes are the mostcommonly experienced and linked with the state of pregnancy.¹

Most antenatal clinics and gynaecological/obstetric clinics and hospital wards do not routinely perform oral health screening on pregnant women, and a lack of implementation of standardized guidelines ensuring regular screening of nursing mothers has also been noted.² As a consequence, antenatal clinics do not bring gestating and nursing women’s attention towards the need for screening and identifying dental problems, nor are they then referred to specialized dental professionals for subsequent management and treatment of these dental problems. These findings indicate the growing need for creating awareness amongst gestating women regarding the need for caring for their oral hygiene, which will consequently have dire impacts on their overall health, as well as the health and well-being of their baby.³

In terms of dental health care administered during pregnancy, the foremost objective is the establishment and maintenance of a healthy oral environment in the mouth through regular tooth brushing for the control of plaque, flossing to prevent food remnants being stuck between teeth and encouraging growth of bacterial colonies, and professional prophylaxis (involving root planning, scaling and polishing) to keep significant oral health problems such as dental caries and periodontal disease at bay.⁴

Pregnancy has been established by various studies to propagate the occurrence and severity of oral problems in women. Pregnant women have time and again demonstrated a higher incidence of gingival inflammation and other signs of gingival disease as compared to women who are not pregnant.⁵

The socio-cultural status and characteristics of any pregnant woman in question is also learned to be a factor impacting her periodontal conditions, with hormonal changes, and overall systemic health being other factors.⁶

Periodontal disease may emanate in the oral cavity as either gingivitis or persistent gingival inflammation, or as periodontitis. Gingivitis is an acute inflammation of the soft tissues surrounding teeth, however there is no incidence of periodontal attachment loss. On the other hand, periodontitis involves the chronic inflammation and steady destruction of the soft tissues which support the teeth and keep them attached.⁷

Of these two conditions, periodontal disease has been found through numerous researches⁸ to have negative and harmful impacts on the outcomes of the pregnancy.  Incidence of periodontal disease has also been linked to lack of education and lower socio-economic conditions.⁹

Pregnant women are more vulnerable to developing periodontal disease as a result of greater concentrations of the hormones oestrogen and progesterone in the body. These hormonal variations lead to hyperaemia, oedema, and bleeding in the soft tissues surrounding and supporting the teeth. The periodontal tissues are subsequently more susceptible to invasion by bacterial colonies. Women belonging to higher socio-economic status are typically more educated and have greater access to knowledge and information pertaining to health, as well as greater exposure to healthcare professionals including dental professionals. As a result, they possess greater awareness regarding oral health care particularly during pregnancy and are more likely to be aware of and careful regarding oral health problems in pregnancy.

Studies have however, indicated that dental caries and periodontal disease both remain prevalent among pregnant women, particularly among those women who belong to ethnic or racial minorities and disadvantaged groups.¹⁰

Oral diseases are significantly prevalent worldwide, an impact a large proportion of the world’s population. As a result, they also inflict an unavoidable impact in terms of morbidity and mortality as well. The existing burden of oral diseases is largely concentrated among poor and disadvantaged populations, and this fact brings to like the “inverse care law”.¹¹ Oral disease is considered to be the fourth most expensive ailment to treat, yet it has a significant impact on the Quality of Life of any individual. Women who come from a low income background with only a single earning family member in the household, are more disadvantaged in terms of seeking dental care, and their Quality of Life is therefore impacted even more. Low socioeconomic factors, therefore, in addition to the level of mother’s education, are the main factors which cause a reduction in Quality of Life as a direct consequence of oral disease.¹²

The perception and understanding of oral health problems has been perceived to be an interfering factor for achievement of maternal oral health. The process of perception enables individuals to become enlightened regarding any situation, and they are then better able to interpret any information pertaining to it and are empowered to make choices regarding the situation. However, perception is essentially subjective in nature because it does not always accurately reflect the true nature of the situation. How an individual perceives their oral health is, albeit, one of the established measures of understanding the value that individual attaches to his/her oral health, and it also indicates their likelihood of seeking professional oral care to achieve optimal oral health status.¹³

Illogical perceptions are brought about due to several factors, largely due to irrational beliefs borne from old traditions and cultures and socio-economic and socio-cultural factors. In developing nations such as Pakistan, the population has generally been found through a number of

previous studies to consider signs and symptoms of waning oral health to be less important than indications of general physiological illness.¹⁴  Many people also garner false beliefs and perceptions towards oral treatments and their consequences. Resultantly, they are more prone to avoid or delay seeking out and obtaining oral care, and this leads to exacerbation of the problem, eventually to levels that threaten the Quality of Life or even, in some cases, life itself .¹⁵

The present study was designed in order to develop an informed understanding of the status of oral health awareness through investigating the oral health perceptions and practices during pregnancy among the women of Karachi, Pakistan. The study was thus conducted at a major government-funded tertiary care hospital which is frequented by the general, mixed population of Karachi. The majority of the patients who participated in the survey hailed from a lower socioeconomic background. This tertiary care hospital caters around 200-300 pregnant patients each month. Most of the women who frequented the hospital to visit the obstetrics and gynaecology department reported to living in rental houses, and reported being housewives who are completely dependent on a single earning member (usually their husband) of their family.

METHODOLOGY

The present research of cross-sectional and nonexperimental study design was conducted at the Gynaecology and Obstetrics Department of Ruth Pfau Civil Hospital Karachi. The study was conducted subsequent to its approval by IRB (168/DUHS/approval/2016/197). The study design was a self-administered, language friendly questionnaire survey, provided to women at random. The questionnaire interviewed all patients by asking various questions regarding sociodemographic and clinical variables. Women were asked to complete a questionnaire on their general and oral health which specifically targeted aspects regarding their oral hygiene, the level of dental care they employ on a regular basis, their sociodemographic details and other clinical variables which covered their health status, gestation period, previous pregnancies and knowledge, attitude & practice of oral hygiene during pregnancies. They were given an opportunity to rate oral and general health related questions on a well split point scale of 0-10, with scores 1-3 being ‘Mild’, 3-6 ‘Moderate’ and 6- 10 ‘Severe’. The sample size is calculated at 95% confidence with allowable error of 10%. The sample size comprised of 570 pregnant women who were assisted in filling of the questionnaires with complete information to the best of their knowledge and the questionnaire also comprised an option of “Don’t know” to prevent biased information. The data collected via the questionnaires was entered into and analysed statistically using SPSS version 16.0.

RESULTS

A total of 570 pregnant women, with mean age 23.8 (+/- 5.2 years) were involved in the study. Approximately half of women (46.4%) were illiterate, while 28.2% had studied till primary level, and 14.2% had studied till higher secondary level or beyond. Tobacco consumption was comparatively higher in the lower socio-economic class, it was highlighted amongst the pregnant women where 15% had a habit of chewing ghutka or mawa, 12% were addicted to naswar, and 11.2% reported being addicted to pan or chhalia.

Two-third (59.2%) of the study subjects belonged to a low socio-economic background. Whereas out of the remaining percentage, 29.1% represented lower middle class, 8.5% upper middle class, while 3.2% of the patients came from a high socio-economic class.

When asked about housing; 46.2% lived in a rental house, while 53.8% owned their houses. Approximately onethird of the women had access to boiled drinking water while an overwhelming majority of 71.3% used tap water for drinking purposes, which does not contain any fluoride or chlorine. Half of the women (51.8%) had only one earning member in their family, whereas 19.6% of the women reported having two earning members in the family.

Generally, the most frequently experienced oral health problems among the pregnant women were dental pain (toothache) (43.6%), bleeding gums (34.6%) and swollen gums (19%).

Bleeding gums, which was reported as one of the more common complaints among pregnant women, occurred in 34.6% out of which 17.5 % had experienced it in the last 6 months. Out of all the women who responded to the survey,

62.2% had never visited a dentist, while 20.5% visited more than one year ago and only 9.9% had visited during the last six months.

Upon being questioned regarding their brushing habits, 35.5% responded that they brushed their teeth twice a day, 45.8%, responded that they brush once a day, and 15.8% reported that they are not habitual of brushing. As for the cleaning aids used for brushing, 70.31% used a tooth brush, 25.51% responded that they used dandasa/miswak, while only 2.27% of the respondents reported use of dental floss/mouth wash. When asked about the barriers to visiting the dentist; 50.2% did not feel any need to visit the dentist, 30.4% chose fear of dentist to be a barrier, 16.7% mentioned high fees while 2.7% of the women responded that they had encountered permission issues.

Upon being asking for their opinion regarding who they would choose to consult in case of dental emergency; 11.8% said they would refer to their family members, 13.7% responded that they would choose to self-medicate, 17.6% said that they would refer to a family doctor for their dental problems, and 15.7 % said that they would consult a gynaecologist. Only 40.8% of the respondents said that they would opt to consult a dentist in the event of a dental emergency. Out of the total number of respondents, 25.6% perceived that dental visits are unnecessary during pregnancy, while 24.6% did not know whether dental visits were necessary or not.

DISCUSSION

The general results and overall response of the patient population at Civil Hospital Karachi suggested that there is a pressing need for interventions in order to increase awareness regarding the maintenance of oral health and hygiene. The questions were structured to assess the awareness and oral hygiene practices among the pregnant women frequenting a local general hospital. Majority of the patients interviewed hailed from rural areas, and from a low socioeconomic background. The results showed that 71% of the women used tap water for drinking, demonstrating the lack of awareness in regards to the significance of chlorine and fluoride levels in the water.

Perceived Barriers

Analogous to the outcome of our results (50.2%), most of the women surveyed in another similar study did not consider it important to have a dental check-up during pregnancy.⁶ Another comparable study deduced that the most common reasons for gestating women to not go to the dentist were, “I was not having a problem,” (89%), and “I chose to delay until after pregnancy,” (68%) (Habashneh et al., 2005).¹⁶

According to Lee et al. (2010), there are five perceived barriers, mostly related to attitude, associated with reluctance among dentists from it providing dental care to pregnant women. Such barriers include time over consciousness, economic reasons, deficiency in professional skills, dental staff resistance, and peer pressure(Lee et al., 2010).¹⁷ It was the perception of 25.6 % of the respondents that dental visits are unnecessary during pregnancy, whereas 24.6% of the women did not know whether dental visits hold any significance or not.

Socioeconomic disparities

Approximately one-third of the women had access to boiled drinking water while an overwhelming majority of two-third used tap water for drinking purposes. Some workers have emphasized on the importance of good oral health in pregnancy, suggesting that it is advantageous to both the mother and her baby. For instance, maternal periodontal disease has often been linked to preterm birth, low birth weight, and preterm low birth weight (Mills & Moses, 2002; Dasanayake et al. 2008).¹⁸

Misconceptions

Pregnant women are often subject to misconceptions pertaining to their oral health during pregnancy, which acts as one of the most significant barriers preventing them from seeking dental care. Among these misconceptions, brought about by lack of awareness, are the beliefs that compromised oral health and hygiene is usual and an accepted consequence of pregnancy, or provision of dental treatment during pregnancy will bring harm to the foetus (George et al., 2011).¹⁹

Among the perceived barriers noted by this study, the most predominant one was that most women were generally reluctant to visit the dentist. A large percentage of the surveyed population (27%) of the women found dental visits to be an unpleasant experience which they would rather avoid. The worrying lack of awareness among the women visiting the OPD was further highlighted by the fact that 30.47% reported that it is their understanding that every painful or problematic tooth should be removed.

The majority of mothers surveyed in a study similar to the present research had also reported that they did not seek treatment from a dentist during the time of their pregnancy because they had no dental complaints (Saddki, Yusoff, & Hwang, 2010).²⁰ Other studies indicate that nearly half of the pregnant women with dental problems sought no dental care for them (Lydon-Rochelle, Krakowiak, Hujoel, & Peters, 2004)²¹ or deliberately postponed any impending dental visits until after the pregnancy (Dinas et al., 2004).²²

CONCLUSIONS

Pregnancy serves as a “teachable moment” for gestating women, and is an opportunity for women to become educated and enlightened regarding self-oral-care, and future childcare in terms of oral health. There is a significant need to prioritize an educational intervention for mothers who are suffering from oral health problems during pregnancy. In this way, they will also learn to effectively prevent the development of these diseases in their children.

There is a critical need to bring to focus the power of prevention in this regard, as both dental caries as well as periodontal disease are largely preventable so long as wellrecognized, established strategies are implemented. The results of the study indicate lack of awareness regarding oral health and misconceptions about oral health problems during pregnancy. Education & enlightenment of pregnant woman in terms of oral health & dental care is crucial, for which the preliminary step is to establish a method of spreading awareness regarding the proven relationship between oral health & pregnancy.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Amar S, Chung KM. Influence of hormonal variation on the periodontium in women periodontol 2000. 1994;6(1): 79-87. https://doi.org/10.1111/j.1600-0757.1994.tb00028.x.
2. Gaffield ML, GILBERT BJ, MALVITZ DM, ROMAGUERA R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc. 2001;132 (7): 1009-16. https://doi.org/10.14219/jada.archive.2001.0306.
3. George A, Johnson M, Blinkhorn A, Ellis S, Bhole S, Ajwani S. Promoting oral health during pregnancy: current evidence and implications for Australian midwives. J Clin Nurs. 2010;19(23-24):3324-33. Silk, Hugh, Alan B. Douglass, Joanna M. Douglass, and Laura Silk. “Oral health during pregnancy.” American Family Physician 77, no. 8 (2008).
4. Kloetzel MK, Huebner CE, Milgrom P. Referrals for dental care during pregnancy. J Clin Midwifery Women
   Health. 2011;56(2):110-7. https://doi.org/10.1111/j.1542-2011.2010.00022.x
5. Boggess KA, Society for Maternal–Fetal Medicine Publications Committee. Maternal oral health in pregnancy.
   Obstet Gynecol. 2008;111(4):976-86. https://doi.org/10.1097/AOG.0b013e31816a49d3
6. Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nature Reviews
   Immunol. 2015;15(1):30-44. https://doi.org/10.1038/nri3785
7. Kloetzel MK, Huebner CE, Milgrom P. Referrals for dental care during pregnancy. J Midwifery Women Health.2011;56(2):110-7. https://doi.org/10.1111/j.1542-2011.2010.00022.x
8. Buchwald S, Kocher T, Biffar R, Harb A, Holtfreter B, Meisel P. Tooth loss and periodontitis by socio-economic status and inflammation in a longitudinal population-based study. J Clin Periodontol. 2013;40(3):203-11. https://doi.org/10.1111/jcpe.12056
9. Reisine ST, Fertig J, Weber J, Leder S. Impact of dental conditions on patients’ quality of life. Community Dent Oral Epidemiol. 1989;17(1):7-10. https://doi.org/10.1111/j.1600-0528.1989.tb01816.x
10. Hom JM, Lee JY, Divaris K, Baker AD, Vann WF. Oral health literacy and knowledge among patients who are pregnant for the first time. J Am Dent Assoc. 2012; 143(9):972-80. https://doi.org/10.14219/jada.archive.2012.0322
11. Fiscella K, Shin P. The inverse care law: implications for healthcare of vulnerable populations. J Ambulat Care
    Manag. 2005;28(4):304-12. https://doi.org/10.1097/00004479-200510000-00005
12. Conger RD, Conger KJ, Martin MJ. Socioeconomic status, family processes, and individual development. J Marr
    Fam. 2010;72(3):685-704. https://doi.org/10.1111/j.1741-3737.2010.00725.x
13. Rigo L, Dalazen J, Garbin RR. Impact of dental orientation given to mothers during pregnancy on oral health of their children. Einstein (São Paulo). 2016;14(2):219-25. https://doi.org/10.1590/S1679-45082016AO3616
14. Khan SA, Dawani N, Bilal S. “Perceptions and myths regarding oral health care amongst strata of low socio economic community in Karachi, Pakistan.” J Pak Med Assoc 2012;62:1198-1203.
15. Reisine ST, Fertig J, Weber J, Leder S. Impact of dental conditions on patients’ quality of life. Community Dent Oral Epidemiol. 1989;17(1):7-10. https://doi.org/10.1111/j.1600-0528.1989.tb01816.x
16. Al Habashnesh, R., Guthmiller, J.M., Levy, S., Johnson, G.K., Squier, C., Dawson, D.V. &
17. Lee RS, Milgrom P, Huebner CE, Conrad DA. Dentists’ perceptions of barriers to providing dental care to pregnant women. Women’s Health Issues. 2010;20(5):359-65.2.
18. Dasanayake AP, Gennaro S, Hendricks-Mu-oz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN: Am J Mat Child Nurs. 2008; 33(1):45-9.  https://doi.org/10.1097/01.NMC.0000305657.24613.47
19. George, A., Johnson, M., Duff, M., Ajwani, S., Bhole, S., Blinkhorn, A., & Ellis, S. (2011). Midwives and oral health care during pregnancy: perceptions of pregnant women in south-western Sydney, Australia. J Clin Nurs, 21(7-8), 1087–1096. https://doi.org/10.1111/j.1365- 2702.2011.03870.x
20. Saddki N, Yusoff A, Hwang YL. Factors associated with dental visit and barriers to utilisation of oral health care
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    18;10(1):75. https://doi.org/10.1186/1471-2458-10-75
21. Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. AM J Public Health. 2004;94(5): 765-71.
    https://doi.org/10.2105/AJPH.94.5.765
22. Dinas K, Achyropoulos V, Hatzipantelis E, Mavromatidis G, Zepiridis L, Theodoridis T, Dovas D, Tantanasis T, Goutzioulis F, Bontis J. Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece. Acta Obstet Gynecol Scan. 2007;86(8):938-44. https://doi.org/10.1080/00016340701371413.

1.Associate Professor, Department of Gynae & Obs, Civil Hospital Karachi.
2.House Officer, Department of Dental (DIKIOHS), Dow University of Health Sciences.
3.House Officer, Department of Dental (DIKIOHS), Dow University of Health Sciences.
4.House Officer, Department of Dental (DIKIOHS), Dow University of Health Sciences.
5. House Officer, Department of Dental (DIKIOHS), Dow University of Health Sciences.
Corresponding author: “Dr. Ahmed Moiz” < ahmed.mz93@gmail.com >

Lubna Ali ¹                                                                MBBS, MCPS, FCPS

Ahmed Moiz²                                                           BDS

Hamna Abdul Samad³                                                      BDS

Sadaf Saeed⁴                                                                               BDS

Rumman Shahid⁴                                                                  BDS,MSc

Marium Zaheer ¹                                                                       BDS, MDs

Arsala Urooj²                                                           BDS, MDs

Salik Rasool³                                                                               BDS, MDSc, M.Phil, Cert. OPOM

Waqas Ahmed Farooqi⁴                                                  MSc

Umer Irfan⁴                                                                                  BDS,MSc

INTRODUCTION

Oral cavity represents an overall health status of an individual.¹ An important component of any health care program is prevention from disease and early identification of individuals who are at increased risk of disease development. The early identification of diseased individuals reduces the morbidity and mortality rate and economic burden of the country. The part of dentist is imperative in providing the service of disease control, in terms of screening the dental patient at chairside by practicing proper history taking and examination skills.¹

A dentist must be aware of complete medical condition of his/her patient before performing dental treatment or prescribing any medications.² Therefore, it is crucial that dentists, residents and students working in dental OPDs take complete history of dental patient. Patients attending dental outpatient department would easily be screened for systemic diseases. Worldwide many studies have been conducted to identify most frequently screened systemic conditions in dental offices, which includes hypertension³ and other risk factors for heart diseases⁴, hepatitis, diabetes^5,6, allergies, peptic ulcer and rheumatoid arthritis in dental office. Type II Diabetes mellitus⁶ and hypertension are among the most afflicted global health

problems which remains insidious until complication arises, such as vascular damage, angina or myocardial infarction.⁷ In a research by Glick et al, it is suggested that future research must focus on screening risk factors of cardiovascular diseases, chronic obstructive pulmonary diseases, diabetes, or kidney disease.⁴ From strategic point of view dentist could be an important resource for integrated health care delivery to the patients who present in dental clinics with systemic disease. Recent studies suggest that majority of dentists give importance and show willingness to conduct medical history.⁸

There seems a dearth in literature review to report the practice of medical screening in dental settings in Pakistan, as well as the extent to which the dentists can broaden their horizon of knowledge and practice to screen dental patients for medical condition at chair side and refer them to concerned specialists. Therefore, we designed this study to identify the practical skills of dentist in terms of history taking, examination and advising laboratory investigations for systemic diseases in dental OPDs of Dow University of Health Sciences.

METHODOLOGY

The study was conducted in all three dental colleges {Dr. Ishrat-ul-Ebad Khan Institute of Oral health sciences (DIKIOHS), Dow International Dental College (DIDC) and Dow Dental College (DDC)} of Dow university of Health Sciences. The study was conducted from May 2016 to June 2016. A study sample was collected from participants who were present at the day of survey by convenience sampling. The students of third and final year BDS, house officers (attending dental departments for the last three months period), all post graduate trainees (MDS, MSc basic and clinical dental sciences, and FCPS clinical dental sciences) and dental faculty members were included. The faculty members comprise of lecturers, assistant professors, associate professors and professors. The dentists (post graduate trainees and faculty members) who were in basic dental sciences and reported to have dental practice in evening hours, thus have patients’ interaction were included. First and second year BDS students were excluded. The participants having no interaction with patients even in evening dental practice were also excluded.

In our cross sectional study,  total 450 survey forms with written consent were distributed in offices and dental OPDs. The forms were collected on the same day. The dentists were divided into two main domains that were basic dental sciences (oral pathology, oral biology, community dentistry and dental materials) and clinical sciences (operative dentistry, oral surgery, orthodontics, prosthodontics, oral medicine, periodontology).

Total 14 questions were included in questionnaire about chair side history taking, medical examination and advising laboratory investigations for the common systemic diseases.

All questions in a history taking practice that focus on the evaluation of medical condition were gathered and scored and a term history taking skill (HTS) was designated (scoring method is further described in section of statistical analysis of this paper). The HTS included questions about following systemic diseases: diabetes mellitus, hypertension, hepatitis A, B and C, gout, arthritis, peptic ulcer, anemia, tuberculosis, asthma, typhoid and drug allergies and question related to pregnancy and/or lactation from female of child bearing age. The next section of survey form comprised of medical examination skills (ES) of dentists. It includes the examination of patient conjunctiva, sclera and tongue for suspected anemia and jaundice. Furthermore, question regarding measurement of blood pressure of every patient was asked. The next part of survey form consisted of question about investigatory skills (IS) of dentist by asking what laboratory tests were advised for anemia, diabetes mellitus, arthritis, gout, peptic ulcer and tuberculosis from their dental patients with suspicion of above mentioned diseases.

Out of four hundred and eight filled survey forms, 87 forms were discarded due to insufficient data. The majority of participants (n=315, 98.1%) had patient interaction either in dental OPD’s during clinical posting or in evening dental clinics. Six forms were discarded due to no interaction with patient.

Statistical Analysis

The data was analyzed on IBM SPSS version 24.0 and the results were presented as frequency and percentages for all skills (HTS, ES, IS), demographics like gender, designation and sciences except age presented as mean ± SD. Satisfactory or unsatisfactory skills were created for history, examination and investigation. Initially dichotomous variable of satisfaction was created, the responses ‘often’ and ‘always’ were considered as having satisfactory skill and the response ‘rarely’ was considered as unsatisfactory skill. These skills score and dichotomous variable were created on 50% score. For investigation skills, 3 or more positive responses out of total 6 questions were considered as satisfactory investigation skills. The same 50% cutoff used for examination and history skills.

Statistical associations were performed using chi-square test for each skill separately with gender, designation and sciences. A p-value of 0.05 or less was considered statistically significant and 0.01 or less as highly significant.

By using PASS version 11 chi square test with 95 % confidence interval, effect size of 0.2478, df 2 and 0.1528, df 1 for designation versus history taking skills and sciences versus examination skills calculated power of test is 98% and 77 % respectively which is 80% around. This justifies our sample size of taking 315 participants. It is noted that power of test was computed only for significant factors.

RESULT

The response rate was 90.66 %.The mean age of participants was 23.4± 3.68 years ± SD. Total 315 forms were analyzed. It included maximum undergraduate dental students 243 (77.1%), followed by postgraduate trainees 39 (12.3%) than faculty 33 (10.5%). Table 01 reported that male was 66 (21.0%) and female were 249 (79.0%). The highest number of participants were from Department of Operative Dentistry (n=67) 21.3% followed by Prosthodontics Department (n=51)16.2%, followed by other departments;  Periodontology (n=50) 15.9%, Oral Surgery (n=42) 13.3%, Oral Medicine (n=35) 11.1%, Orthodontics (n=29) 9.2%, Community Dentistry (n=24) 7.6%, Oral Pathology (n=10) 3.2%, Oral Biology (n=4) 1.3% and Dental Materials (n=3)

1.0% in descending order. Most of the participants (n=246) 78.1% answered that they always take complete medical history (that is termed as satisfactory HTS in our study) at first visit, 20.3% (n=64) responded that they often take complete history (also marked as satisfactory HTS) and 1.6% (n=5) reported that they rarely take complete medical history (marked as unsatisfactory HTS).

The history taking practice of medical conditions was carried out well in dental settings at DUHS as it was revealed that (n=38) 92.7% basic sciences and (n= 237) 86.5% clinical sciences participants presented with satisfactory history taking skills (participants responded ‘always’ and ‘often’ to HTS question). There was no statistically significant difference observed in basic and clinical dental sciences HTS (p= 0.267). Majority of undergraduates (n=205) 84.4%, all of postgraduates (n=39) 100% and majority faculty members (n=31) 93.3% showed satisfactory skills of history taking. However, designation of dentists showed significant difference (p= 0.012). (table no. 2)

Medical examination skills of basic sciences participants

showed satisfactory result, (n=24) 58.5% participants examine patients thoroughly in respect of medical condition assessment. Whereas, (n=200) 73.0% clinical sciences participants also showed satisfactory examination skills and there was no significant difference observed (p= 0.057). The majority undergraduates (n=174) 71.6%, postgraduates (n=29) 74.4% and faculty members (n=21) 63.6% showed satisfactory examination skills. The p-value reported for designation was statistically non-significant (0.569).

The practice of lab investigation for systemic diseases was found satisfactory for undergraduates (n=161) 66.3%, postgraduates (n=20) 51.3% and for faculty (n=33) 66.7%. furthermore, it was found satisfactory also for basic sciences  (n=24) 58.5% and clinical sciences (n-179) 65.3%. There was no significant difference observed for dental sciences (p= 0.397) and designation of the dentists in context of advice for lab investigation (p=0.186).

DISCUSSION

Assessment of systemic diseases at chair side of dental patients is getting prominence in contemporary holistic medical and dental approach.⁹ The practice of dentist to recognize the insidious medical conditions reduces the latent period of disease. In our study, knowledge and skills related to chair-side assessment of medical conditions by dentists were evaluated and results revealed that dentists were well aware of and willing to conduct chair-side general health checks for dental patients. Post graduate students showed 100% satisfactory result in history taking skills (HTS) and faculty members also showed 93.9% satisfactory HTS, while undergraduate students showed 84.4 % satisfactory HTS. The difference was statistically significant (p value=0.012). This defines the importance of post graduate dental education that makes the dentist with broad sense of holistic approach in which he/she  takes care not only the dental issues but also considering systemic health of patient’s such as taking blood pressure and blood glucose level etc. as well. The results of our study are in contrast to study conducted by Shah et al. In that study the dentist showed undesirable results in history taking skills.¹⁰  The difference in result may be due to the sampling of dentist practicing in public and private sectors in Shah study, whereas, in our study participants were undergraduate and postgraduate students, house officers and faculty who are in continuous process of dental education in university environment.

Another study conducted in USA 2016, by Shimpi et al stated that majority of dentists believed in importance of performing chair-side screening for medical conditions in dental settings.¹¹ In the same study 85% of United States dental care providers stated that more frequently evaluated medical condition in dental settings was hypertension.¹¹ In our study’s examination skills (ES), evaluation of hypertension by dentists was found satisfactory without any difference between variables. Hypertension was also the most frequently conducted ES of dentists in our study.

Dentist related to basic sciences showed (58.5%) satisfactory result of examination skills (ES) while the dentist related to clinical sciences showed (73.0%) satisfactory result. However, the difference is not significant (p = 0.057). This shows clinical practice makes dentist to consider the systemic disease evaluation more important along with dental problem as compare to the dentist who were related to basic sciences.

The investigation skills (IS) were measured by asking about what tests were advised for diabetes, hypertension, anemia, gout, arthritis, peptic ulcer and TB from suspected patients. Out of six questions three positive responses with diabetes and hypertension as compulsorily investigated diseases were considered satisfactory. The importance of patient’s chronic diseases (above mentioned) information is crucial in prescribing medications for dental problem keeping in mind the possibility of gastric trouble caused by prolonged medicine intake for chronic diseases. There was no significant difference between the dentists of different gender or basic or clinical dental sciences or different designations in investigatory skills (IS). The average satisfactory IS was 61.71%, therefore it may be a room for improvement by further raising the significance of lab investigation.

In our study, sampling was done on the basis of dental practitioner presence at the time of survey or presence of dental students in dental OPDs. The sample was collected from three colleges of same university; other dental universities could also be incorporated. In this study only practical skills of dental care professionals were measured.

CONCLUSIONS

It was concluded that practice of medical history taking, medical examination and lab investigations by dental professionals of DUHS was adequate. Dentist skills were not dependent on gender, designation and basic or clinical sciences.

RECOMMENDATIONS

These skills of dentists must be further improved to serve the patients with superior dental care considering in the light of overall health related issues of the patient. It is recommended to put more emphasis on medical history taking skills of dental undergraduates in DUHS. Such dental professional approach saves time and is cost effective. This approach also refers patients towards medical treatment of diseases which are a global health burden.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Laurence B. Dentists consider medical screening important and are willing to incorporate screening procedures into dental practice. J Evid Based Dent Pract. 2012 Sep;12 (3 Suppl):32-3. https://doi.org/10.1016/S1532-3382(12)70008-8.
2. Sansare K, Raghav M, Kasbe A, Karjodkar F, Sharma N, Gupta A, et al. Indian patients’ attitudes towards chairside screening in a dental setting for medical conditions. Int Dent J. 2015;65(5):269-76. https://doi.org/10.1111/idj.12175
3. Greenberg BL, Glick M, Goodchild J, Duda PW, Conte NR, Conte M. Screening for cardiovascular risk factors in
   a dental setting. J Am Dent Assoc. 2007;138(6):798-804. https://doi.org/10.14219/jada.archive.2007.0268
4. Glick M, Greenberg BL. The potential role of dentists in identifying patients’ risk of experiencing coronary heart
   disease events. J Am Dent Assoc. 2005;136(11):1541-6. https://doi.org/10.14219/jada.archive.2005.0084
5. Barasch A, Safford MM, Qvist V, Palmore R, Gesko D, Gilbert GH. Random blood glucose testing in dental practice: A community-based feasibility study from The Dental Practice-Based Research Network. J Am Dent Assoc. 2012;143(3):262-9. https://doi.org/10.14219/jada.archive.2012.0151
6. Rey A, Thoenes M, Fimmers R, Meier CA, Bramlage P. Diabetes prevalence and metabolic risk profile in an
   unselected population visiting pharmacies in Switzerland. Vasc Health Risk Manag. 2012;8:541.
7. Genco RJ, Schifferle RE, Dunford RG, Falkner KL, Hsu WC, Balukjian J. Screening for diabetes mellitus in dental practices: a field trial. J Am Dent Assoc. 2014;145(1): 57-64. https://doi.org/10.14219/jada.2013.7
8. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. J Am Dent Assoc. 2010 Jan;141(1):52-62. https://doi.org/10.14219/jada.archive.2010.0021
9. Creanor S, Millward B, Demaine A, Price L, Smith W, Brown N, et al. Patients’ attitudes towards screening for
   diabetes and other medical conditions in the dental setting. Br Dent J. 2014;216(1):E2-E.
10. Shah I, Luqman U, Fayaz M, Ibrahim M, Babar A. Inadequacies in history taking and clinical examination by
    the dentists. Pak Oral Dent J. 2009;29(2):211-14.
11. Shimpi N, Schroeder D, Kilsdonk J, Chyou P, Glurich I. Assessment of Dental Providers’ Knowledge, Behavior
    and Attitude towards Incorporating Chairside Screening for Medical Conditions: a pilot study. J Den Oral Care Med. 2016;2(1):102.

1. Assistant Professor, Deptarment of Oral Pathology, Dr.Ishratul Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences.
2. Assistant Professor, Department of Oral Pathology, Dr.Ishratul Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences.
3. Associate Professor, Department of Oral Pathology, Dow International Dental College Dow University of Health Sciences.
4. Lecturer Department of Research, Dow University of Health Sciences. 5. MSc trainee Department of Oral Pathology, Dow International Dental College Dow University of Health Sciences.
Corresponding author: “Dr. Marium Zaheer” < marium.zaheer@duhs.edu.pk >

Marium Zaheer ¹                                                                       BDS, MDs

Arsala Urooj²                                                           BDS, MDs

Salik Rasool³                                                                               BDS, MDSc, M.Phil, Cert. OPOM

Waqas Ahmed Farooqi⁴                                                  MSc

Umer Irfan⁴                                                                                  BDS,MSc

Kashif Aslam ¹                                                                       BDS, MSc

Rizwan Nidam²                                                  BDS, MPH

^{Sofia Ali Syed3}                                                                    BDS, M.Phil

INTRODUCTION

Biological variations include genetic variation that affects dentition in general and environmental variation that affects specific tooth shape, size and function. Establishing or providing occlusion is the characteristic of dentistry. The synchronization of occlusion during mandibular movement is maintained by the posterior teeth that should not come in contact with opposite teeth. The posterior teeth depend on anterior teeth for their stability; therefore anterior guidance is of considerable importance. Anterior guidance is divided into canine guided, group guided and balanced occlusal scheme.¹

In canine guided occlusion, the overlap of maxillary and mandibular canines results in disengagement of maxillary and mandibular posterior teeth during excursive movement of mandible whereas group guided occlusion results in multiple contacts of maxillary and mandibular teeth on working side during lateral movement of mandible. Although there is no evidence to suggest which type of occlusion should be taken into account yet canine guided is preferred over group function. Canine guided is not only easy in designing and manufacturing but it also involves less muscular activity and less forces on teeth compared to group function.² Various studies reported the prevalence of canine guided or group guidance but the dependence of canine guided and group guidance occlusion in Angle’s classification is sparse.^3,4 Therefore, the purpose

of the study was to find out the dependence of canine guided and group guided occlusion among Angle’s classification and gender.

METHODOLOGY

The study was conducted at Altamash Institute of Dental Medicine (AIDM) and Dow Dental College from 2012 to 2014. Six hundred participants were selected using non randomized, purposive sampling technique according to Angle’s classification. Individuals containing at least 28 permanent teeth were selected irrespective of age. Individuals present in the study were either patients, patient’s attendants, doctors, and lower staff as the target population. Individuals undergoing orthodontic treatment, having bridges, undergone occlusal splint therapy and extractions were not involved due to the potential of alteration in original occlusion. To Aslam K/ Nadim R/ Syed SA

observe canine guidance or group guidance, articulating paper (Henry Schein, New York, U.S.A) of 40 micron meter was placed between upper and lower teeth during normal chewing pattern of individuals. Visual observation was done under dental chair light ( Dawn plus, Pakistan) with cheeks fully retracted with mouth mirror (United, Pakistan) to obtain a lateral view of Angles Class 1, Class 2 division 1, Class 2 division 2, and Class3 and articulating marks that were obtained during normal chewing pattern. Verbal consent was taken from head of the department and participants. Data was analyzed by using software SPSS 16.0. Pearson chi square was applied to observe the dependence of canine guided and group guided occlusion on Angles classification and gender

RESULTS

In this study 600 individuals were selected with age ranged from 15-50 year. The mean age was 26.6. Out of 600 individuals 375 (62.5%) were females and 225 (37.5%) were males. The female to male ratio was 1.6:1. (Figure 1).

Among 600 participants we observed Angle’s Class I in 376 (62.6%), Class II div 1 in 130 (21.7%), Class 2 div 2 in 33 (5.5%) and Class III in 61 (10.1%). Canine guided and group guided were seen in 332(55.3%) and 268(44.7%) participants respectively (Table 1).

Out of 376 (62.6%) cases of class I, 184 (49.09%) had canine guided and 192 (51.06%) showed group guided

occlusion. Among 130 (21.7%) cases of Class II div 1, 97 (29.2%) had canine guided and 33 (12.3%) had group

guided occlusion. In 33 cases of class 2 div 2, 25 (7.5%) had canine guided and 8 (3%) were group guided. However in 61(10.1%) participants of Class III, 26(42.6%) and 35(57.37%) showed canine guided and group guided occlusion respectively (Table 2). Canine guided and group guided occlusion were independent of Angles malocclusion (p>0.05) Out of 225 males, 126 exhibit canine guided while 99 showed group guided occlusion. In 375 females, 206 had canine guided while the remaining 169 showed group guidance (Table 3). Canine guided and group guided was also statistically insignificant in gender (p>0.05).

DISCUSSION

In many studies occlusal contacts in lateral position are recorded in an edge to edge position of canines which is about 3 mm from maximum intercuspation. This position is rarely used nowadays and recent studies have a range of 1-3 mm and 0.5 mm.⁴  In our study, instead of using any range of motion, the participants were asked to chew as they do in their normal routine and then contacts were observed on teeth marked by articulating paper. Articulating paper of 40 micron meter was used because of ease of availability which is in accordance with the previous study.⁵ However some studies proposed the use of shimstock.^6,7

We observed 376 patients with Angle’s class I in which 192 (51.06%) exhibited group guided and 184 (49.09%) were found to be canine guided which is similar to the

Aslam K/ Nadim R/ Syed SA previous studies.^8,9 By contrast Abduo et al observed prevalence of canine guided occlusion.³

A study¹⁰ reported 1200 participants from North America less than 25 years of age and found that majority had unilateral or bilateral canine guided occlusion. They also correlated that canine guided occlusion was associated with decreasing order in Angle class II, I and III occlusion. Abduo et al³ also found predominance of canine guidance in class 2 while group function in class 3 as seen in our study. Other studies by Al-Hiyasat¹¹ and Al-Nimri¹ showed similar results. In our study, group guided occlusion was more frequently found in Angle’s class III (57%), then class I (51%) and least in class II (25%) which is comparable to other studies.¹

Asawaworarit¹² reported group guidance as predominant occlusal pattern in Thai individuals. Similarly another study reported both group and canine.¹³

Among functional occlusion schemes, no single type is predominant. For example, However, Woda et al¹⁴ suggested balancing contacts compared to canine or group function occlusal relationships. Rinchuse et al reported loss of canine guidance in individuals who eat coarse and abrasive food.¹⁵ Ogawa et al⁴ also found no difference in the occurrence of canine and group guidance in relation to genders which is in accordance to our study. While canine guidance decreases with age, it is considered as the most suitable occlusal scheme in young patients undergoing orthodontic and prosthetic treatment.^16,17

During occlusal rehabilitation in restorative dentistry, where it is likely to use specific occlusal pattern, various epidemiological and physiological studies have been observed to establish a rational based on choosing group guided and canine guided occlusion.^12,18 A study showed a high frequency of tooth contacts on non-working sides; however, multiple tooth contacts on either working sides were also reported.¹⁹ Various studies showed occlusal relationship with tooth contacts on non-working side.²⁰

Limitation

Canine guided and group guided occlusion was observed intraorally which could have been counter checked by mounting them on adjustable articulators with face bow records.

CONCLUSION

Canine guided and group guided occlusion were independent of Angles classification and gender.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Al-Nimri KS, Bataineh AB, Abo-Farha S. Functionalocclusal patterns and their relationship to static occlusion.
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2. Sapkota B, Gupta A. Pattern of occlusal contacts in lateral excursions (canine protection or group function). Kathmandu Univ Med J. 2014;45(1):43-7.
3. Abduo J, Tennant M, McGeachie J. Lateral occlusion schemes in natural and minimally restored permanent dentition: a systematic review. J Oral Rehabil. 2013;40(10):788-802. https://doi.org/10.1111/joor.12095
4. Song J-H, Joo S-J, Lee H-S, Kang D-W, Lee G-J. An occlusal contact analysis of lateral mandibular movement
   using T-Scan system. J Korean Acad Prosthodont. 2015;53(2):128-37. https://doi.org/10.4047/jkap.2015.53.2.128
5. Panek H, Matthews-Brzozowska T, Nowakowska D, Panek B, Bielicki G, Makacewicz S, et al. Dynamic occlusions in natural permanent dentition. Quintessence Int. 2008;39(4).
6. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing clinical research: Lippincott Williams & Wilkins; 2013.
7. Gupta A, Shenoy VK, Shetty TB, Rodrigues SJ. Evaluation of pattern of occlusal contacts in lateral excursion using articulating paper and shim stock: An in vivo study. J Interdiscip Dent. 2013;3(2):109. https://doi.org/10.4103/2229-5194.126874
8. Touzi S, Chakroun M, Abderrahmen SB, Kallala R, Hadyaoui D, Harzallah B, et al. The Relationship between Static and Dynamic Occlusion in Natural Permanent Dentition: A Descriptive Epidemiological Study.Int J Health Sci Res. 2015;5(12):209-13.
9. Francová K, Eber M, Zapletalová J. Functional occlusal patterns during lateral excursions in young adults. J Prosthet Dent. 2015;113(6):571-7. https://doi.org/10.1016/j.prosdent.2014.12.004
10. Scaife RR, Holt JE. Natural occurrence of cuspid guidance. J Prosthet Dent. 1969;22(2):225-9. https://doi.org/10.1016/0022-3913(69)90249-2
11. Al-Hiyasat A, Abu-Alhaija E. The relationship between static and dynamic occlusion in 14-17-year-old school
    children.J Oral Rehab. 2004;31(7):628-33. https://doi.org/10.1111/j.1365-2842.2004.01283.x
12. Asawaworarit N, Mitrirattanakul S. Occlusal scheme in a group of Thais. J Adv Prosthodont. 2011;3(3):132-5. https://doi.org/10.4047/jap.2011.3.3.132
13. Miralles R. Canine-guide Occlusion and Group Function Occlusion are Equally Acceptable When Restoring the Dentition. J Evid Based Dent Pract. 2016;16(1):41-3. https://doi.org/10.1016/j.jebdp.2016.01.029
14. Woda A, Vigneron P, Kay D. Nonfunctional and functional occlusal contacts: a review of the literature. J Prosthet Dent. 1979;42(3):335-41. https://doi.org/10.1016/0022-3913(79)90226-9
15. Rinchuse DJ, Kandasamy S, Sciote J. A contemporary and evidence-based view of canine protected occlusion. Am J Orthod Dentofacial Orthop. 2007;132(1):90-102. https://doi.org/10.1016/j.ajodo.2006.04.026
16. Pasricha N, Sidana V, Bhasin S, Makkar M. Canine protected occlusion. Indian J Oral Sci. 2012;3(1):13. https://doi.org/10.4103/0976-6944.101670
17. Al-Nassar DB, Al-Hashimi HA. Orthodontic considerations of functional occlusion in Class I normal occlusion. J Baghdad Coll Dent. 2015;27(3):130-9. https://doi.org/10.12816/0015047
18. Funding So. Review analysis and evaluation canineguide occlusion and group function occlusion are equally acceptable when restoring the dentition article title and bibliographic information. J Prosthet Dent. 2015;114:193- 204.
19. Kaidonis J, Ranjitkar S, Lekkas D, Brook A, Townsend G. Functional dental occlusion: an anthropological perspective and implications for practice. Aust Dent J. 2014;59(s1):162- 73. https://doi.org/10.1111/adj.12133
20. Parnia F, Fard EM, Sadr K, Motiagheny N. Pattern of occlusal contacts in eccentric mandibular positions in dental students. J Dent Res Dent Clin Dent Prospects. 2008;2(3):85.

1. Associate Professor, Department of Prosthodontics, Dow Dental College, D.U.H.S.

2. PhD Scholar, Department of Community Dentistry, University of Wolverhampton.

3. Assistant Professor, Department of Oral pathology, Dow Dental College, D.U.H.S.

Corresponding author: “Dr. Kashif Aslam” < taimoor.links@gmail.com >

Kashif Aslam ¹                                                                       BDS, MSc

Rizwan Nidam²                                                  BDS, MPH

^{Sofia Ali Syed3}                                                                    BDS, M.Phil

Nabeel Naeem Baig ¹                                                        BDS, MPH

Khadijah Abid²                                                    MSc

Rabeya Fatima³                                                                   BDS

Syeda Batool Ahsan^{4                                                      MBBS}

INTRODUCTION

Morsicatio buccarum which is also known as cheek biting is a condition characterized by chronic irritation or injury to the buccal mucosa, caused by repetitive chewing, biting or nibbling.¹ It is a harmless condition for most of the people who accidentally bite their cheeks, but it can become a harmful condition for those who developed a habit of biting of their cheeks.

The common causes of morsicatio buccarum are misalignment of wisdom teeth, temporomandibular joint disorder, jaw closure problem and ill fitting dentures. On the other hand morsicatio buccarum are often observed in people who are under stress, anxiey or with psychogenic background.² Biting of oral mucosa is seen in 750 per million persons. In a Mexican dental school clinic of 23,785 patients, cheek-biting lesions were found to be fifth most common oral mucosal finding with a prevalence of 21.7 cases per 1000 patients.¹

The prevalence of cheek biting is more in children and females.¹ In a study conducted by A. P Vanderas et al. the prevalence of cheek biting was reported as 60.51%; whereas headaches showed statistical significance with cheek biting (P-value<0.05) among children.³ A case report on 10 year old boy with history of biting of cheeks associated with major depressive disorder.¹ In an another study conducted at Saudi Arab headache was observed as 33% among the oral parafunctions and cheek biting was the most prevalent 41%.⁴

Anxiety & stress are potential risk factors for impaired oral health status.⁵ The rationale for initiating this study was scarce data available on this topic although, it is a common phenomenon but it never gets the attention of the dentists. The main purpose of this study was to assess the prevalence of stress and anxiety among patients having habit of cheek biting in Pakistani population.

METHODOLOGY

It was a cross-sectional study conducted at Ameen Medical and Dental Center, Karachi from July 2016 to Jul 2017. After taking approval from hospital MD total of 101 patients were included in the study using non-probability consecutive sampling technique. Sample size of 101 was estimated using Open Epi online sample size calculator by taking statistics for anxiety disorder as 30.6%⁶ among facial pain disorder & margin of error as 9% at 95% confidence level. All the patients of age 16-65 years of either gender coming to OPD for routine dental check-up with complain of pain and burning in oral cavity were included in the study. Cheek biting was assessed clinically, injury to the buccal mucosa was labelled as positive. Patients with obesity,pregnancy, previous dental treatment specially proctitis or taking pan/gutka and with history of smoking or alcohol intake were excluded from the study.

Inform consent was taken from the participants. Perceived stress scale (PSS) was used to assess stress. The patient with score>20 was labeled as stressed. Hamilton Anxiety Rating Scale (HAM-A) was used to assess anxiety. The patient with score >20 was labeled as anxiety positive. We used a translated version of questionnaire for patients who cannot understand the language. All information was recorded in a pre-designed proforma by the researcher.

Data was analyzed using STATA version 11.1.

Quantitative variables were presented as mean and standard deviation. Qualitative variables were presented as frequency and percentage. Chi-sq test was applied and p-value <0.05 was taken as significant.

RESULTS

Total of 101 participants were enrolled in the study, out of which 58(57.4%) were females and 43(42.6%) were males. The mean age was calculated as 34.73years ±12.98

SD. Most of the participants were from adult age group 68.3%. Out of 101, 52.5% were graduate, 17(16.8%) were from secondary education, 16(15.8%) were from primary

education, 10(9.9%) were post graduate and only 5(5%) were illiterate. Majority of the patients were from middle income level 60.4%, 45.5% were married, 48.5% were employed, 61.4% were from joint family, 90.1% were without
history of psychiatric illness, 77.2% had family history of DM & 65.3% of the participants were physically active. (Table 1)

As depicted in Figure 1, out of 101 participants, stress was observed in only 37(36.6%) & anxiety was observed in
only 34(33.7%). In univariate analysis, stress showed significant difference with psychiatric illness (p=0.003) and with family history of DM (p=0.001) whereas anxiety was only statistical significant with family history of DM (p=0.033). (Table 2)

DISCUSSION

Oral mucosal lesions are a multi factorial disease. Therefore, recognizing the risk factors promoting this condition plays an important role in its management and prevention. It was found that psychological stressors and depression may propagate its progression.⁷ The aim of this study was to determine the frequency of stress and anxiety among patients with habit of cheek biting visiting dental clinic for routine checkups. We found about 36.6% patients were stressed and anxiety was present in 33.7% patients. A case report on a 10-year-old boy who presented with multiple ulcerations over lower lip, diagnosed as a case of Major Depressive disorder was treated with anti-depressant and his condition improved.¹ In another study, depression and anxiety were evaluated, the results showed 82% of TMD had anxiety and 57% had depression. In the present study most of the patients were from adults age group among them 78.4% had stress and 67.6% had anxiety.

In the present study, majority of the patients were females 57.4%, among them 64.9% had stress and 64.7% anxiety. A research conducted on patients with temporomandibular disorders showed similar results i.e. 82% females were affected. According to the study, this could be due to the fact that women seek medical help early or due to psychological and hormonal factors pertaining to females.⁵ A survey at Polish university gave similar results showing significant number of women presenting with temporomandibular disorders and increased psycho emotional activity and stress. The research concluded that people with emotional burden or easily excitable personalities suffered more from oral para functions.⁷

In the presented study, the ratio of graduated patients with stress & anxiety related cheek biting was high as compared to secondary, primary, post graduate and uneducated. The percentage of stress related cheek biting among employed, unemployed, house wives was found to be 45.9%, 29.7%, 21.6% respectively, the percentage of anxiety related cheek biting among employed, unemployed, house wives was found to be 41.2%, 38.2% &17.6% respectively. In a similar study 58% student or unemployed people with TMD identified themselves as stressed. Common stressors could be low income, peer pressure, large number of duties, uncertain future or living away from family in a new environment. They also emphasized the fact students are more exposed to social emotional physical and family problem.⁷

Socioeconomic status may be an influencing factor in this regard i.e. individual with low socioeconomic status 17.8%, middle class 60.4% & upper class 21.8% presented with cheek biting. As majority of the patients were from

middle level income they had high stress and anxiety level as 67.6% and 55.9%. According to this data we can conclude social life of a person may play as a stressor and can lead to oral problems.

With regard to marital status, it is indicated that 45.5% married patients are more prone to cheek biting while only 41.6% unmarried were affected, out of which stress was observed in 51.4% of married and 37.8% unmarried patients whereas anxiety was prevalent among 47.8% of married and 38.8% of unmarried patients. Family system plays an important role in the contribution of stress related cheek biting. In our study majority of patients belong from joint family system 61.4%, out of which is 59.5% had stress while 52.9% had anxiety. Other studies states that women who are widowed or married but living separately present more with oral problems as compared to men.⁸

In the present study we have also observed the role of history of psychiatric illness & diabetes mellitus in family among patients with habit of cheek biting as 9.9% and 22.8%. Among patients with history of psychiatric illness in family stress was present in 21.6% and anxiety was present in 11.8%, whereas among patients with history of DM in family stress was observed in 48.6% and anxiety was observed in 35.5%. In the present study, about 65.3% participants do physical activity in their leisure hours while 34.7% were physically in-active. Among physically in-active patients stress was prevalent in 32.4% and anxiety was prevalent in 23.5%.

Furthermore, perspective studies must be conducted with a large data collected from multiple hospitals, including patients of young age to elderly should be taken into account. Other oral conditions like TMD, oral ulcers, lip biting linked with stress, anxiety and depression can be added along with systemic conditions to draw up guidelines for the therapeutic approach to oral mutilation.

CONCLUSION

We found stress and anxiety were prevalent among patients with habit of cheek-biting. History of psychiatric illness and diabetes mellitus played significant role and showed statistical relation with stress and anxiety (p<0.05).

CONFLICT OF INTEREST

None declared.

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1. Senior Executive Officer Research, Department of Research Evaluation Unit, College of Physicians and Surgeons Pakistan.
2. Senior Biostatistician, Department of Research Evaluation Unit, College of Physicians and Surgeons Pakistan.
3. Dental Surgeon, Department of Dental section, Ameen Medical and Dental Center.
4. Medical Officer, Department of Clinical, Saifee Hospital.
Corresponding author: “Khadijah Abid ” < khadijahabid@gmail.com >