Vol. 27 No. 04 Oct-Dec 2018

Muhammad Asif Mushtaq¹                                                 BDS

Muhammad Waseem Ullah Khan²                                  BDS, FCPS

INTRODUCTION

The importance of cross-infection control cannot be overemphasized. Disinfection and sterilization methods are used to achieve   disinfection and sterility of the medical and surgical instruments. In order to avoid the spread of pathogens from patients to patient, patient to health care personnel and health care personnel to patient, it is the duty of the health care policies makers to allocate the appropriate methods of cleaning, disinfection and sterilization for various surfaces and instruments.¹ Cleaning is the removal of all foreign material (e.g. blood, saliva, debris) from objects while decontamination is the removal of pathogenic micro-organisms from objects. Disinfection is the process that eliminates many to all pathogenic microorganisms on inanimate objects except bacterial endospores. While sterilization is the complete elimination of all micro-organisms including spores.^[1]Disinfection can be divided into three categories according to their efficacy. High level disinfection involves bacterial spore inactivity along with other microbial forms. Intermediate level disinfection involves destruction of microorganisms like tubercle bacilli but not able to kill spore. Low level disinfection possesses narrow antimicrobial activity.

(Table 1).^3,4,5 Dental impressions are categorized under semi-critical objects in dental practice and require high level disinfection or sterilization.⁶ Sterilization in an autoclave will compromise the dimensional accuracy of the impression hence it is not feasible.⁷ Until 1991, the recommended procedure for disinfection of impression was rinsing under running water with which only 40% of bacteria, viruses and fungi were removed and potential for transmission of microorganisms remains there.^3,8,9 In recent times, a pre wash of the impression with running water is advocated first to cast off all particles, blood and saliva prior to active disinfection procedure.¹⁰ Disinfection of dental impression should be a routine procedure in the dental office and dental laboratory. By knowing all the methods and techniques, any dental personnel can make a better choice and get best results for impression disinfection. However, most of the dental professionals in private clinics, hospitals, dental schools and prosthetic laboratories are not following the required protocols for impression disinfection.^11,12 Keeping in view the above findings, it is of utmost importance to raise the level of awareness in dental professionals involved in any process of handling, transportation, processing and storage of the dental impressions. Different techniques of impression disinfection and other methods of cross-infection control must be a part of undergraduate curriculum of dental  universities and dental technician schools. The aim of this literature review is to generate an update on the various techniques of impression disinfection along with their mechanism of action and simple guidelines for their usage.

Table 1: Levels of Disinfection.3,4,5

Table 2: Types of Disinfectants.4,13,14,15

Disinfection Techniques: Disinfection solutions:

The details are given in Table 2.^4,13,14,15

Glutaraldehyde: It is a high level disinfectant and is available in neutral, alkaline and acidic forms.⁵ It is a broad spectrum chemical agent with fast killing capability. It is also called chemo sterilizer. If it is used in proper concentration and specialized equipment, it can destroy all types of micro-organisms including bacterial and fungal spores, tubercle bacilli and viruses.¹⁶ it is a colorless liquid with pungent odour. Although it is considered as the best disinfectant for cold sterilization of medical equipment, it also has many health hazards including irritation to skin, eyes and respiratory tract. It is a sensitizer of skin and respiratory tract, so special precautions are needed while using it e.g. wearing butyl or nitrile gloves, closed system for solution handling, exhaust ventilation of the places of handling and keeping the temperature of the solution low as it will reduce the airborne concentration of the solution.¹⁷

Sodium hypochlorite: It provides intermediate level disinfection and has a broad spectrum antimicrobial activity. It is very useful disinfectant with advantages including fast bactericidal activity, ease of use as it is soluble in water, relatively stable, nontoxic at use concentrations, low cost, non-staining, noninflammable and colorless. Disadvantages include mucous membrane irritation, less efficient in organic environment and corrosive effect on metals.¹³ According to one study, alginate impression disinfected with spray method using 1% Naocl did not show any severe dimensional changes or surface roughness of stone model that were fabricated from that impression.¹⁸ However, in another study impression disinfection by immersion method with 0.5% NaOCl for 15 min exhibited small dimensional change.¹⁹

Iodophors: These halogens provide low to intermediate level disinfection. These are bactericidal, mycobactericial and virucidal. It is also fungicidal but requires more contact time. These are mainly used as antiseptics rather than disinfectants. These are not sporicidal and cause staining of fabrics. They are not flammable. They have irritating effect on mucous membrane.^20,21  Organic material present on any surface can lead to neutralization of disinfectant capability of iodine.

Hence, more frequent application of disinfectant is required for complete disinfection.³ According to one study, 30 min exposure to 0.1 % povidine-iodine did not cause remarkable distortion of polysulfide and polysilixane impression material.⁵

Alcohols: These provide intermediate level disinfection and include isopropyl alcohol and ethyl alcohol. Isopropyl alcohol is normally used as antiseptic. Medical surfaces can also be disinfected with isopropyl alcohol. Ethyl alcohol is more potent in bactericidal than bacteriostatic activity. It is also tuberculocidal, fungicidal and virucidal for enveloped viruses as well.^14,20,22,23 Alcohols are contraindicated for impression disinfection because they can cause surface changes of impressions.³ They are also not suitable for disinfection of denture bases consisting of non-cross linked resins.²⁴

Phenols: Complex phenols are classified as intermediate level disinfectants. These are also known as protoplasmic poisons. At low concentration, they cause lysis of rapidly growing e.coli, staphylococci and streptococci. They possess antifungal and antiviral properties as well.²³ These are commonly used in mouthwashes, scrub soaps and surface disinfectants. Ideally not recommended for impression disinfection as simple phenols are low level disinfectants.They are incompatible with latex, acrylic, rubber and cause acute toxicity as well.^3,4

Chlorhexidine: It is an intermediate level disinfectant and antiseptic. It has broad spectrum of activity and also used as preservative .It is commonly used in hand washes and oral products. It is bactericidal, virucidal and mycobacteriostatic. Its activity declines in the presence of organic matter because its activity depends on specific pH.²³

2% chlorhexidine has shown activity against s.aureus,e.coli,b.surbititis, but no antifungal activity was seen in agar diffusion test at low concentration.0.2% chlorhexidine disinfectant solution can be used as water substitute in alginate mixing. Impression can also be immersed in chlorhexidine solution and it causes effective disinfection.²⁵ According to one study, 1.0 g/L chlorhexidine solution can be used to produce self-disinfecting alginate impression material for clinical use. In this way, it has shown antimicrobial activity and did not cause any changes in dimensional accuracy, flow ability and setting time of irreversible hydrocolloid impression material.^26,27

Ozonated water: Ozone is an inorganic gaseous molecule. Its chemical formula is O₃.It is less stable than O₂ in lower atmosphere.³ It has antimicrobial, antihypoxic, analgesic and immunostimulatory activities.²⁸   It is used for disinfection of water lines, oral cavity and dentures. It is also used as prophylactic agent before etching for the placement of restorations.²⁹ Ozonated water can also be used as impression disinfectant. According to one study, aqueous ozone is more biocompatible than other disinfectant solutions e.g. chlorhexidine, NaOCl, H₂O₂. Ozonated water can reduce the number of microorganisms on the surface of irreversible hydrocolloid impression materials and by increasing time of immersion   more effective disinfection can be achieved.²⁸

Other methods:

Microwave irradiation: Microwaves cause disruption of cell membrane integrity and cell metabolism which ultimately leads to microbial death.³ Microwaves are simple to use, low in cost and provide good disinfection. Dentures are being disinfected with microwaves and are found better disinfected than Naocl. Microwaves can be used as an effective tool for impression disinfection. Polyvinyl siloxane impression materials were disinfected with microwaves with no changes in physical properties of impression material.³⁰

Cast disinfection: Microorganisms have been recovered from dental cast as well. These dental casts can be a medium of cross infection between patients and dental health care workers. Therefore, dental casts should also be disinfected.⁷ The American Dental Association recommends various methods for cast disinfection. These include use of disinfectant spray, immersion in disinfectant solution, and incorporation of disinfectant in stone at the time of mixing.³¹ Immersion in 0.525% NaOCl did not cause any changes in dimensional accuracy, surface detail quality and compressive strength.³² Microwave irradiation can also be used for cast disinfection. Dental cast can also be sterilized.³

Sterilization of impression: Various methods are available for sterilization of impressions e.g. exposure to UV light, steam autoclave, ethylene oxide gas autoclave, and radiofrequency flow discharge etc.³

DISCUSSION

Cross-infection control is of prime importance in dental practice but impression disinfection is still a widely neglected aspect. The proper criteria for impression disinfection involves:

• The most suitable method (spray or immersion).
• Appropriate application (time of contact).
• Periodic check for efficacy.³³

The factors to be considered for any disinfection protocol for dental impression are effectiveness, chemical stability and efficacy of the disinfectant solution. The disinfection procedure should not alter the dimensions and surface details of the impression and resultant cast.^32,34  It has been proven that the most effective method of reducing the burden of micro-organisms from impression surface is chemical disinfection. Spray disinfection and immersion disinfection are the two methods of impression disinfection. However, immersion is the most reliable method because all surfaces of impression and tray come in contact with disinfectant solution. But immersion is not the method of choice for hydrocolloids material as they are extremely hydrophilic.^3,34

In 1996, the American Dental Association council on dental materials endorsed immersion for polysulphide and addition silicone impression material whereas spraying with chlorine compound was advocated for disinfection of polyether impression material for 2-3 min.³⁵ UV rays can be used for disinfection of water supplies, laboratory equipment, dental headpieces, dental impression and implants. In one study, while comparing UV rays disinfection with Glutaraldehyde and NaOCl, UV rays exhibited maximum efficacy.³⁶

The factors affecting the efficacy of NaOCl include concentration and life of solution, pH, temperature and contact time with the impression surface. According to Fahimeh et al, the compatibility of disinfectant solution with impression material should be assessed prior to disinfection procedure. Any compatible disinfectant solution should not cause any alteration on the surface detail reproduction.³⁷

Although some chemical disinfectants cause dimensional changes in impression surface, these changes are not expected to alter the clinical performance. This is why, chemical disinfection is considered the most harmless form of impression disinfecion.2% gluteraldehyde had exhibited more dimensional changes than 5.25% Naocl in immersion disinfection procedure.³⁸

The American Dental Association’s revised guidelines recommend chemical agents that are virucidal, bactericidal and sporicidal. These chemical agents are chlorine compounds, phenols, iodophors, formaldehyde and gluteraldehyde. Immersion in NaOCl at concentration of 1:10 (0.525%) is advised for 10 minutes. Samra and Neiman investigated the effects of gluteraldehyde, phenol, iodophors and chlorine compound immersion disinfection procedure on set stone cast. The results of this study showed that a 0.525% Naocl least affected the cast with regard to compressive strength, surface changes, surface hardness and chemical reactivity.³²

The Japan Prosthodontic Society has recommended the alginate impression in either 0.1-1% Naocl solution for 15-30 min or 2-3.5% gluteraldehyde solution for 30-60 minutes. But immersion in gluteraldehyde for more than 30 min has shown dimensional changes and altered surface quality of the resultant cast.¹⁹

Ethylene oxide gas autoclaving has shown significant structural changes of heavy and light body addition silicone impression material. Sterilization of dental stone cast has shown improved mechanical properties but decreased compressive strength. Addition or condensation silicone impression materials can be sterilized in steam autoclave without remarkable changes in dimensional accuracy.³

CONCLUSIONS

1. Cross infection control is very important aspect of patientsafety
2. Impression disinfection can prevent spread of infectionfrom dental clinic to dental laboratory technician, patients and dental auxiliaries
3. It is the responsibility of the dentist to make appropriatechoice of disinfection method for different impression materials.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Rutala WA, Weber DJ. Disinfection and Sterilization in Health CareFacilities: What Clinicians Need to Know? Clin Infect Dis; 2004; 39(5):702-9. https://doi.org/10.1086/423182
2. Rutala WA, Weber DJ. Infection control: the role of disinfectionand sterilization. J Hosp Infect; 1999; 43:S43-S55. https://doi.org/10.1016/S0195-6701(99)90065-8
3. Chidambaranathan AS, Balasubramanium M. ComprehensiveReview and Comparison of the Disinfection Techniques Currently Available in the Literature. J Prosthodont. 2017:12597.
4. Hemalatha, R., & Ganapathy, D. Disinfection of dental impressionA current overview. Int J Pharm Sci Res;2016;7(8):661-64.
5. Merchant VA, Kay McNeight M, James Ciborowski C, MolinariJA. Preliminary investigation of a method for disinfection of dental impressions. J. Prosthet. Dent; 1984;52(6):877-9. https://doi.org/10.1016/S0022-3913(84)80024-4
6. Rutala WA. APIC guideline for selection and use of disinfectants.Am J Infect Control; 1996;24(4):313-42. https://doi.org/10.1016/S0196-6553(96)90066-8
7. Leung RL, Schonfeld SE. Gypsum casts as a potential source ofmicrobial cross-contamination. J. Prosthet. Dent; 1983;49(2):210-1. https://doi.org/10.1016/0022-3913(83)90503-6
8. Badrian H, Ghasemi E, Khalighinejad N, Hosseini N. The Effectof Three Different Disinfection Materials on Alginate Impression by Spray Method. ISRN Dent; 2012:1-5. https://doi.org/10.5402/2012/695151
9. Rentzia A, Coleman DC, O’Donnell MJ, Dowling AH, O’SullivanM. Disinfection procedures: their efficacy and effect on dimensional accuracy and surface quality of an irreversible hydrocolloid impression material. J Dent; 2011;39(2):133-40. https://doi.org/10.1016/j.jdent.2010.11.003
10. Correia-Sousa J, Tabaio AM, Silva A, Pereira T, Sampaio-MaiaB, Vasconcelos M. The effect of water and sodium hypochlorite disinfection on alginate impressions. Rev Port Estomatol Cir Maxilofac; 2 0 1 3;54(1):8-12.
11. Ferreira FM, Novais VR, Júnior PC, Soares CJ, Neto AJ. Evaluationof knowledge about disinfection of dental impressions in several dental schools. Rev Odontol Bras Centra2011;19(51)285-89.
12. Yüzbasioglu E, Saraç D, Canbaz S, Saraç YS, Cengiz S. A surveyof cross-infection control procedures: knowledge and attitudes of Turkish dentists. J Appl Oral Sci. 2009;17(6):565-9. https://doi.org/10.1590/S1678-77572009000600005
13. Fukuzaki S. Mechanisms of actions of sodium hypochlorite incleaning and disinfection processes. Biocontrol Sci. 2006; 11(4):147-57. https://doi.org/10.4265/bio.11.147
14. Martínez JE. Mode of Action and Development of Resistance toDisinfectants, Part 2. Bioprocess Int. 2005;3(8):32-8.
15. 8.0 Disinfection and Sterilization | Environmental Health and Safety. [Online] Available at: https://ehs.research.uiowa.edu/80disinfection-and-sterilization [Accessed 24 Jun. 2018].
16. Gorman SP, SCOTT EM, Russell AD. Antimicrobial activity, uses and mechanism of action of gluteraldehyde. J. Appl. Microbiol. 1980; 48(2):161-90
17. Takigawa T, Endo Y. Effects of glutaraldehyde exposure on human health. J Occup Health. 2006;48(2):75-87. https://doi.org/10.1539/joh.48.75
18. Guiraldo RD, Borsato TT, Berger SB, Lopes MB, Gonini-Jr A,Sinhoreti MA. Surface detail reproduction and dimensional accuracy of stone models: influence of disinfectant solutions and alginate impression materials. Braz. Dent. J. 2012;23(4):417-21. https://doi.org/10.1590/S0103-64402012000400018
19. Hiraguchi H, Kaketani M, Hirose H, Yoneyama T. Effect ofimmersion disinfection of alginate impressions in sodium hypochlorite solution on the dimensional changes of stone models. Dent Mater J.2012; 31(2):280-6. https://doi.org/10.4012/dmj.2010-201
20. utala WA, Weber DJ. Disinfection, sterilization, and antisepsis: An overview. Am J Infect Control. 2016;44(5):e1-6. https://doi.org/10.1016/j.ajic.2015.10.038
21. Lawrence CA, Carpenter CM, Naylor-Foote AW. Iodophors asdisinfectants. J Am Pharm Assoc. 1957;46(8):500-5. https://doi.org/10.1002/jps.3030460813 
22. Morton HE. The relationship of concentration and germicidalefficiency of ethyl alcohol. Ann N Y Acad Sci.1950;53(1):191-6. https://doi.org/10.1111/j.1749-6632.19tb31944.x
23. McDonnell G, Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin. Microbiol. Rev. 2001;14(1):147-79.
24. Asad T, Watkinson AC, Huggett R. The effect of disinfection procedures on flexural properties of denture base acrylic resins. J Prosthet Dent. 1992;68(1):191-5. https://doi.org/10.1016/0022-3913(92)90303-R
25. Touyz LZ, Rosen M. Disinfection of alginate impression material using disinfectants as mixing and soak solutions. J Dent. 1991; 19(4):255-7. https://doi.org/10.1016/0300-5712(91)90133-J
26. Wang J, Wan Q, Chao Y, Chen Y. A self-disinfecting irreversible hydrocolloid impression material mixed with chlorhexidine solution. Angle Orthod.2007;77(5):894-900. https://doi.org/10.2319/070606-277.
27. Kollu S, Hegde V, Pentapati KC. Efficacy of Chlorhexidine in Reduction of Microbial Contamination in Commercially Available Alginate materials-in-Vitro Study. Global J Med Res. 2013;13(2): 19-24.
28. Savabi O, Nejatidanesh F, Bagheri KP, Karimi L, Savabi G. Prevention of cross-contamination risk by disinfection of irreversible hydrocolloid impression materials with ozonated water. Int J Prev Med. 2018; 9:37. https://doi.org/10.4103/ijpvm.IJPVM_143_16.
29. Azarpazhooh A, Limeback H. The application of ozone in dentistry: a systematic review of literature. J Dent. 2008; 36(2):104-16. https://doi.org/10.1016/j.jdent.2007.11.008
30. Choi YR, Kim KN, Kim KM. The disinfection of impression materials by using microwave irradiation and hydrogen peroxide. J Prosthet Dent. 2014;112(4):981-7. https://doi.org/10.1016/j.prosdent.2013.12.017
31. Infection control recommendations for the dental office and the dental laboratory. J Am Dent Assoc; 1996;127(5):672-80. https://doi.org/10.14219/jada.archive.1996.0280
32. Abdullah MA. Surface detail, compressive strength, and dimensional accuracy of gypsum casts after repeated mmersion in hypochlorite solution. J Prosth Dent. 2006; 95(6):462-8. https://doi.org/10.1016/j.prosdent.2006.03.019
33. Maillard JY, McDonnell G. Selection and use of disinfectants. In Prac. 2012; 34(5):292-9. https://doi.org/10.1136/inp.e2741
34. Lepe X, Johnson GH. Accuracy of polyether and addition silicone after long-term immersion disinfection. J Prosthet Dent. 1997; 78(3): 245-9. https://doi.org/10.1016/S0022-3913(97)70021-0
35. Samra RK, Bhide SV. Efficacy of different disinfectant systems on alginate and addition silicone impression materials of Indian and international origin: a comparative evaluation. J Indian Prosthodont Soc. 2010;10(3):182-9. https://doi.org/10.1007/s13191-010-0040-y
36. Shambhu HS, Gujjari AK. A study on the effect on surface detail reproduction of alginate impressions disinfected with sodium hypochlorite and ultraviolet light-An in Vitro study. J Indian Prosthodont
    Soc. 2010;10(1):41-7. https://doi.org/10.1007/s13191-010-0005-1
37. Rad FH, Ghaffari T, Safavi SH. In vitro evaluation of dimensional stability of alginate impressions after disinfection by spray and immersion methods. J Dent Res Dent Clin Dent Prospects. 2010; 4(4):130-35
38. Kotsiomiti E, Tzialla A, Hatjivasiliou K. Accuracy and stability of impression materials subjected to chemical disinfection-a literature review. J Oral Rehabil.2008;35(4):291-9. https://doi.org/10.1111/j.1365-2842.2007.01771.x

1. Resident, FCPS Department of  Prosthodontics, and Punjab DentalHospital/ de’Montmorency College of dentistry.
2. Assistant Professor, Department of Prosthodontics, Punjab Dental Hospital/de’Montmorency College of dentistry.

Corresponding author: “Dr. Muhammad Asif Mushtaq” < dr.asif100@yahoo.com >

Muhammad Asif Mushtaq¹                                                 BDS

Muhammad Waseem Ullah Khan²                                  BDS, FCPS

Nabiha Farasat Khan¹                                            BDS, M. Phil, MHPE

Muhammad Saeed²                                                           BDS

Attia Bari³                                                                  MBBS, FCPS, MHPE

Arshad Kamal Butt⁴                                              MBBS, FCPS, MHPE

INTRODUCTION

Organized technique to gather evidence about student’s performance is called assessment.¹ To meet the demand of universal change in medical education assessment tools have evolved over the years,² and currently the concept of examination is to assess for learning.^[1] In Western countries a number of different assessment techniques were utilized since 1950’s.^[2] In Pakistan higher authorities in medical education like Pakistan Medical

& Dental council (PM&DC) and Higher Education

Commission (HEC) have also encouraged the utilization of new learning and teaching strategies; and hence take steps to reform curricula according to the need of Global advancement in Health Profession Education.^5,6

Traditional assessment procedures are definitely essential to assess cognizance but are unsuitable and incomplete tools to measure higher cognitive levels.⁷ There have been issues regarding its reliability and validity from students and faculty about assessment. Continuous efforts were accomplished to assemble assessment more objective and reliable than subjective to confirm adequate knowledge of students in the concern subject with significant potential of scrutiny, recognition and acquisition of interpretation abilities.^8,9 Reported requirement of students’ knowledge according to Miller pyramid (1990) comprised knows the fact, show how accomplishment of clinical techniques and performance.¹⁰ OSCE/OSPE, SEQ and structured oral viva are the assessment formats that authorize the instructors to assess students all cognitive domains of Bloom’s taxonomy including cognition, application, interpretation, synthesis and judgment abilities.¹¹ OSCE is an established assessment tool; which helps to assess student’s clinical skills, its reliability and validity is also confirmed, whereas for the assessment of preclinical and para-clinical subjects a modified form of OSCE that is known as OSPE is used.^8,12,13 OSPE like OSCE is also a valid tool for assessment purposes.¹⁴ A structured oral viva reduces the bias, anxiety and luck factors. The validity and reliability of structured viva can be increased by making multiple checklists.¹¹ On the other hand SEQ’s are easier, have good reliability & validity.¹⁵

Students most likely wish to assess their cognizance through SEQ, whereas MCQ as an assessment tool is also appreciated by them.⁶ Consequences of Amin TT from Saudi-Arabia detected MCQ as the most approving assessment tool,¹⁵ however study participants of Anwar M from Riphah International University, Pakistan faced difficulties in MCQ pattern.¹⁶

Conventional assessment methods namely SAQ, MCQ and viva were applied in this department (Oral Pathology) previously. This study was conducted to check the student’s perception about new assessment tools that were applied for the first time in Oral Pathology Department of a public sector medical college.

METHODOLOGY

The study was conducted at The Dental section, Bolan Medical College (BMC), Quetta in December 2017. This was a qualitative exploratory research, conducted through interviews. Approval for the study was taken from the Institutional Review Board of BMC Letter No. AdminI/BMC/2018/2848/50. Universal sampling was done after informed consent with inclusion of all 25 students of both genders in 3rd year dentistry in BMC who had gone through all assessments methods including MCQ, SEQ, SAQ, Viva and OSPE. Interview was conducted by senior demonstrator by unstructured questions. The questions were about their liking of a particular method of examination among all the methods, reason for liking or disliking that method of assessment. Particular questions asked from the students were;

1. Why did you prefer OSCE as an assessment tool?
2. What are the causes of interest in SEQ?
3. What is the source of appeal in viva?

Our qualitative analysis was a thematic description which aided in organizing the content and arriving at a narrative description of the student’s liking about a particular method of assessment. We identified codes through open coding process.

RESULTS

More than half of the study population (60%) was female. Seventeen out of 25 students were 21-22 years of age with the mean age of 19±2years. Majority 13/25 (52%) liked OSPE followed by viva 6 (24%) shown in (Table 1).

Initially open coding based on important categories of interest generated a total of 26 codes and then through axial and selective coding these was condensed to 13 subthemes.

Table 1: Demographics of the study participants

Fig.1: Hierarchy of themes and subthemes

Finally, by merging of open codes and axial codes subcategories were arranged under three major themes. These themes seem to be discrete, but there is considerable overlap among them. The hierarchy of themes and subthemes are given in Fig.1.

Justice: Every examination method tests the knowledge, insight and skills of the student. The dentistry students liked the OSCE due to multiple reasons and the major reason was marking equality and justice. Majority of the student’s reply was the same narrations when researcher interrogated about the interest in assessment methods and the reason behind their interest in OSCE. They said that:

Student 2: “OSCE allow students to be judged on same parameters.”

In viva, some students are evaluated for longer time as compared to others depending upon the examiners will. Students perceived that this bias is removed in OSCE and every student gets equal time. Student 4, 9, 24: “I prefer OSCE as an assessment tool and the reason behind it is that this new test system where every student gets equal time to express their views which reduces examiners bias.” Students trusted OSCE because they have the trust that they will be given marks according to what they have performed. Student 7, 15: “Before introducing OSCE we were unsure about equality of marking but now as it tests the skills of students with equal marking, we are confident about our assessment, they claim that OSCE reduces the chance of inequality”. Student 10, 12: “I can do it comfortably, I prefer OSCE due to its equality in time and marks.”

Some students preferred OSCE as best method of assessment due to better time management.

Student 13, 14:  Some students state that “OSCE is very fair assessment method, it is easy to understand and solve. Applicable for time management”

Participants of current study felt happy with the introduction of OSCE as an assessment method and were of the view that they would prefer and recommend this exam format for use in future.

Students thinks OSPE is a true reflection of justice as the scores obtained in the orals are affected by student’s self-confidence, anxiety and examiner’s impression they do not truly reflect the student’s competence.

Time Management: Students were asked about the type of assessment method they feel to be most suitable for? What was the cause of interest in SEQ?

SEQ are often used as an assessment tool by examiners as it is considered to be a good method of assessing higher order thinking of students in a shorter time.

Student 1, 18: “I choose it because I think that SEQ is less time consuming, indicates precise notes easy to understand, and is more precise.”

As the SAQ require longer time for students to think, organize and compose their answers they can assess higher order thinking. The students who have studied thoroughly find this method of assessment a better method as they think they can answer the question properly in a short time. Student 16: “I like SEQ as an assessment instrument due to its time management quality and it is precise.” Students

22: “I think that SEQ is convenient to understand and solve”

CONFIDENCE

Viva or oral examination is an integral part of assessment in medical school examination system. The student’s response to questions is verbal instead of writing. The ability to express views, knowledge and confidence of facing the examiner is evaluated in viva examination. Similar is the perception of students who liked viva as best method of examination and mainly due to the reason that viva is helpful in building confidence. When students were inquired about the causes of their interest in viva they answer; Student 3, 23: “My choice for assessment method is viva as it builds up confidence and polishes knowledge.” they revise all learned material during viva,” and It covers all aspects of curriculum. Student 6: “I like viva as an assessment method. It flourishes our confidence level.”

Student 8, 25: Students declare that “Viva is the best method for assessment, it polishes practical skills.” It assesses the deep knowledge of students.” it covers the syllabus when it is taken along with SAQ.

Students 11: “Viva along with SAQ boosts belief. Students study deep and thorough for preparing viva.” Students 17: I believe that that “Viva has ability to explore the level of student’s cognition; moreover, it presents students ability to convey their knowledge. Viva is capable to increase confidence, students study in detail to prepare viva.”

DISCUSSION

This is the first study conducted to check the perception of medical students about SAQ, SEQ, MCQ, OSCE/OSPE in a public sector dental college in Balochistan and has provided important data to reorganize teaching/learning and examination format in dentistry to the faculty and examiners. Assessment tools assists in classification, prediction and accountability purposes.¹  Modification in assessment methods bring changes in students learning approach so instead of assessment of students learning (testing culture) it should be assessment for students learning (assessment culture).¹⁶ The aim of assessment is to balance between student’s knowledge and skills after completing their learning and to connect the discontinuity between their learning and working.¹⁶

Negligible number of teachers utilizes formative assessment procedures which provide not only feedback but heighten students’ self-esteem but it flourishes skills also.¹⁷ Literature reports of several studies have concluded that students approve those methods of assessment that enhance competencies pertinent for their future professional life and making a bridge between learning and working.¹⁶

New assessment techniques help in evaluating the student’s ability to solve the real life difficult problems. OSCE is a précised, objective, reproducible, valid and reliable assessment tool.¹⁸ In our study majority (52%) of 3rd year BDS students favor OSCE, they said that it was the best pattern of assessment as it was more convenient and it would not drag students into unwanted things. Students are allowed to be judged in a same para-meter. Our results were similar to Zayyan M and Abidullah et al.¹⁹ Zayyan M concluded that OSCE presents flexible and wide range of fairness, repeatable and is simple to remember.¹⁹ On the other hand 67 participants of Shitu B study recognize OSCE as a fair assessment tool in evaluation of their cognition and acquisition.²⁰ Our results indicated student’s satisfaction towards OSCE due to its equality in task and marks distribution. Moreover, analyzing other studies, we found that OSCE has potential to test all level of clinical skills including technical and interpersonal skills.²¹Outcomes of current research demonstrated student’s preference towards scenario based OSCE the reason behind it was its clarity.¹³, 10 Respondents of Shitu’s study confirm this statement as 87/122 samples were satisfied about the clarity and adequacy of this exam pattern.²⁰

An assessment of a student’s knowledge can be gathered through viva along with SAQ. If properly supervised viva assists in checking the communication skills and is also helpful in assessment of student’s professional attitude.⁹ In our study students show positive perceptions of oral structured viva and it was the second most popular method of assessment. According to Joughin it is the type of assessment where students transfer answer orally instead of written form.²² Results of research conducted by Anastakis et al present the perception of postgraduate residents; they assume that structured oral viva is a useful assessment method.²³ Same was true in our study where study samples were satisfied about the clear and understandable oral structured questions. They reported that viva questions were precise, were in a proper sequence and heighten their confidence. Hashim et al also confirmed these findings as majority of their study population (98%) were satisfied with structured viva.²⁴ Likewise 68% study participants of Gargi Dangre-Mudey also support our findings that structured viva is a successful assessment tool.²⁵

SEQ assist in evaluation of the student’s capacity to recognize the principal constitute of issue and its analytical solution. SEQ approach focuses on competencies that do not involve clinical demonstrations.²⁶ In our study 16% dental students of 3rd year liked SEQ, as it was found to be precise, was less time consuming and easy to understand. Same conclusion was identified in Shilpa GS where 35% (n=/150) students declared SEQ as less time consuming tool and 29% reported that SEQ was structured and precise.²⁷ Strengths, Limitation &Generalizability

It is the first qualitative study in Balochistan as well as in Pakistan which assesses the perceptions of dental students about assessment methods. Students of this study were keen to learn and willing to adopt innovative assessment strategies. This research work comprises students of 3rd year BDS of only one medical college therefore for more generalize results, investigations to check the perceptions of both medical as well as dental students should include students from different professional years and other medical colleges as well with an even larger sample size preferably comparing private and public sector institutions.

CONCLUSION

OSCE is the most accepted assessment method among 3rd year dental students of public sector Bolan Medical College, Quetta because the timing and markings are just and this gives OSCE its main strength. Second highly rated assessment tool is oral structured viva due to the reason that viva is helpful in building confidence.

ACKNOWLEDGEMENT

Authors acknowledge students of 3rd BDS for their voluntarily participation in this research.

Conflict of interest: None

Source of funding: Nothing to declare

REFERENCES

1. hmad S, Mussawy J. Assessment Practice: Student ‘ s and Teachers’ Perceptions of Classroom Assessment University of Massachusetts School of Education. Master Capstone Project. 2009.
2. Ferris HA, O’ Flynn D. Assessment in Medical Education; WhatAre We Trying to Achieve? Int J High Educ [Internet]. 2015;4(2): 139-44. Available from: http://www.sciedu.ca/journal/index.php/ijhe/article/view/6662
3. Birenbaum M, Feldman R a. Relationships between learning patterns and attitudes towards two assessment formats. Educ Res. 1998;40(1): 90-8. https://doi.org/10.1080/0013188980400109
4. Norcini JJ, McKinley DW. Assessment methods in medical education.Teach Teach Educ. 2007;23(3):239-50. https://doi.org/10.1016/j.tate.2006.12.021
5. Rauf A, Shamim MS, Aly SM, Chundrigar T, Alam SN. Formativeassessment in undergraduate medical education?: concept, implementation and hurdles. J Pak Med Assoc. 2014;1:72-5.
6. Batool H, Mumtaz A, Chughtai AS. Perception of UndergraduateMedical Students about different formats of assessment in subject of Pathology. JUMDS. 2017;8(2):40-5.
7. Miller GE. The assessment of clinical skills/competence/performance.Acad Med [Internet]. 1990;65(9):S63-7. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landin gpage&an=00001888-199009000-00045 https://doi.org/10.1097/00001888-199009000-00045
8. Malhotra S, Shah K, Patel V. Objective structured practicalexamination as a tool for the formative assessment of practical skills of undergraduate students in pharmacology. J Educ Health Promot[Internet]. https://doi.org/10.4103/2277-9531.119040
9. Zafar M, Yaqinuddin A, Ikram F, Ganguly P. Practical Examinations- OSPE, OSCE and Spot. J Uni Med Dent Coll. 2013:1-16.
10. Puryer J. Dental Undergraduate Views of Objective StructuredClinical Examinations (OSCEs): A Literature Review. Dent J 2016;4(4):6. https://doi.org/10.3390/dj4010006
11. Shenwai MR, Patil KB. Introduction of structured oral examinationas a novel assessment tool to first year medical students in physiology. J Clin Diagnostic Res. 2013;7(11):2544-7. https://doi.org/10.7860/JCDR/2013/7350.3606
12. Tabish SA. Assessment methods in medical education. Int J HealthSci (Qassim). 2008;2(2):3-7.
13. Sandila MP, Ahad a., Khani ZK. An objective structured practicalexamination to test students in experimental physiology. J Pak Med Assoc. 2001;51(6):207-10.
14. Kurdi MS. Essay type questions & their improvements & shortanswer questions. Conference paper. 2015.
15. Amin TT, Kaliyadan F, Al Qattan EA, Al Majed MH, Al KhanjafHS, Mirza M. Knowledge, attitudes and barriers related to participation of medical students in research in three Arab Universities. Educ Med J. 2012;4(1):43-56.
16. Masood A, FMH Hameed. Students’ Perceptions towards Formativeand Summative Assessment: A Single Institution Study. J Islam Int Med Coll. 2016;11(1):35-40.
17. Gulikers JTM, Bastiaens TJ, Kirschner P a., Kester L. RelationsBetween Student Perceptions of Assessment Authenticity, Study Approaches and Learning Outcome. Stud Educ Eval. 2006;32(4):381-400. https://doi.org/10.1016/j.stueduc.2006.10.003
18. O’Shaughnessy SM, Joyce P. Summative and Formative Assessmentin Medicine: The Experience of an Anaesthesia Trainee. Int J High Educ. 2015;4(2):198-206.
19. Zayyan M. Objective structured clinical examination: Theassessment of choice. Oman Med J. 2011;26(4):219-22. https://doi.org/10.5001/omj.2011.55
20. Khan A, Ayub M, Shah Z. An Audit of the Medical Students ‘Perceptions regarding Objective Structured Clinical Examination. Educ Res Int. 2016;2016:1-4. https://doi.org/10.1155/2016/4806398.
21. Shitu B, Girma T. Objective Structured Clinical (Osce) : Examinee’ S Perception At Department of Pediatrics and Child Health, Jimma University. Ethiop J Heal Sci. 2008;18(2):47-52.
22. Patricia Marten-Daniel HDD. Toolkit and Guide for Administratorsof IEN Programs. 2013. 26 p.
23. Joughin G. Dimensions of oral assessment. Assess Eval High Educ. 1998;23(4):367-78. https://doi.org/10.1080/0260293980230404
24. Anastakis DJ, Cohen R, Reznick RK. The structured oralexamination as a method for assessing surgical residents. Am J Surg. 1991;162(1):67-70. https://doi.org/10.1016/0002-9610(91)90205-R
25. Hashim R, Ayyub A, Hameed S, Ali S. “Structured viva as anassessment tool?: Perceptions of Undergraduate Medical Students.” Pak Armed Forces Med J. 2015;65(1):141-4.
26. Dangre-mudey G, Damke S, Tankhiwale N, Mudey A. Assessmentof perception for objectively structured viva voce amongst undergraduate medical students and teaching faculties in a medical college of central India. Int J Res Med Sci. 2016;4(7):2951-4. https://doi.org/10.18203/2320-6012.ijrms20161983
27. Kramer G a, Albino JEN, Andrieu SC, Hendricson WD, HensonL, Horn BD, et al. Dental student assessment toolbox. J Dent Educ. 2009;73(1):12-35.

1. Associate Professor, Department of Oral Pathology, Bolan Medical College, Quetta.
2. Senior Demonstrator, Department of Prosthodontics, Bolan Medical College, Quetta.
3. Associate Professor, Department of Paediatric, Children Hospital, Lahore, Pakistan.
4. Former Professor, Department of Medicine, Sheikh Zayed Federal Postgraduate Medical Institute, Lahore.

Corresponding author: “Dr. Nabiha Farasat Khan” < nabihasaeed@hotmail.com >

Nabiha Farasat Khan¹                                            BDS, M. Phil, MHPE

Muhammad Saeed²                                                           BDS

Attia Bari³                                                                  MBBS, FCPS, MHPE

Arshad Kamal Butt⁴                                              MBBS, FCPS, MHPE

Sanam Faheem¹                                       BDS

Shahida Maqsood²                                              BDS, M Phill

Faheem Shaikh³                                      BDS

INTRODUCTION

Knowledge and attitudes of parents may play an important role in moulding behaviour of their children toward health and hygiene.¹ Similarly, parental Oral health knowledge and belief  may positively impact child’s oral health.²  According to American Academy of Pediatric Dentistry “Early Childhood Caries (ECC) is defined as the presence of one or more primary teeth with caries in a child 6 years or younger”.^[1] ECC is highly prevalent disease worldwide; its prevalence among Pakistani children is 44.4%.³ Worldwide disease burden of the ECC varies greatly. In Europe, the disease is not very common, prevalence ranges in Sweden from 11.4% among 3 to 6 year old children to 19.0% in Italy.⁴ High Prevalence is seen in middle east countries, like Palestine (76%), and

UAE (83%). A prevalence of 51.9% was reported from India.⁵ It has been documented in previous researches that children who develop ECC are at high risk of developing caries in permanent dentition which results in long episodes of treatments and visits to dentists and hence affects the quality of life.⁵ There are many factors contributing to its development like excessive consumption of sugar containing food, less frequent tooth brushing habits with prolong breast feeding or falling asleep while feeding sweet or flavoured milk.⁶ Parents and caregivers play very important role in infant’s oral health as evidences shows that mother’s awareness of oral hygiene and its practices from pregnancy is good source of establishing infant’s good oral health.⁷

Age and educational level are broadly associated with parental knowledge and their practice towards oral hygiene, as its been observed that children of young parents with low socioecnomical status and less knowledge are more prone to decay and premature loss of deciduous teeth.⁸

Establishing good oral hygiene in early few years of child’s life includes regular brushing at early age assisted by mothers, their regular visits to dentists for prevention of premature loss of primary teeth is very important. In a developing country like Pakistan, majority parents are not taking their children oral problems as serious health issue due to their lack of  proper oral health knowledge.It has been observed that there is an increased incidence of early childhood caress due to lack of knowledge of ECC among parents. Therefore, the primary goal of the study was to assess the parental influence on ECC by assessing the relationship between age and education with knowledge, attitude and practices of parents visiting Dow Dental College OPD.

METHODOLGY

In this cross-sectional study questionnaires were distributed to 300 mothers from Dow Dental College OPD to assess their knowledge, attitude and practice towards their children oral health. Sample size was calculated after reviewing the sample size in an article by Shetty et. al.  and determining the population size (that is the number of patients with children visiting Dow Dental OPD).¹ By using software open Epi ^R keeping standard error of mean 5% with confidence interval of 95%, calculated sample was 298. Consent was taken before starting from all participants regarding to fill the questionnaire. All married couples having at least one normal child were included in the study. Children guardian or caretakers or special needs children were not included. Purposive sampling was used to recruit study participants. Self administered questionnaire was used in this study. The demographic data relating to area of residence, educational level and occupation were asked from the participants. Aspects of ECC and the knowledge of importance of primary teeth in child’s growth and development, oral hygiene practices, nursing habits and role of diet and fluoride in maintaining oral hygiene were assessed.

Data Analysis

Data was analyzed by SPSS version 20. P Values was considered significant when <0.05 (confidence interval of 95%). Descriptive statistics of demographic variables, knowledge, attitude and practice were presented as mean, standard deviation, frequency and percentages. For Inferential statistics responses were scored and were categorized into good, fair and poor. Further analysis to see the associations between multiple variables were done by using chi square and multinomial logistic regression analysis.

RESULTS

A total of 300 questionnaires were filled. Responses were assessed by scoring them based on Good, fair and poor. The demographic data is presented in Table:1, which shows majority were Mothers (99%), falling in age from < 30 years (55.7%), most had primary educational level and were housewives (84.3 %). Maximum patients were from Karachi South area.

Table: 2 represents the response of parents, a total of 122 participants (40.7%) of parents knew about the right time of first deciduous tooth eruption, most of them had no idea about the total number of deciduous teeth (66%). Two thirds knew that milk teeth are equally prone to decay (67%).

Almost all of parents (96%,n=290) knew that sugar commonly

Table 1: Demographic Variables

Table 2: Response of Parents

Association between Knowledge, Attitude and practice with age groups and educational level by logistic regression analysis.

Keeping Education level constant, logistic regression suggests for every “year” increase in age there is 0.913 times chance of having good knowledge and 1.006 times chance of having fair knowledge than poor.

Table 3-a              KNOWLEDGE

a. The reference category is: poor.

Keeping age constant:

1. There is 4.52 times chance forgraduates to have good knowledge than fair knowledge.
2. There is 0.50 times chance forintermediates to have good knowledge than fair knowledge.
3. There is 0.20 times chance forrespondents having at least primary education to have good knowledge than fair knowledge.
4. There is 0.30 times chance for respondents having at least primary education to have good knowledge than fair knowledge.

Table 3-b              ATTITUDE

a. The reference category is: poor.

Keeping education constant, for every “Year” increase in age there is 1.049 times chance of respondants having good
attitude, and 0.975 times chance of having fair attitude than poor

Keeping age constant:

1. There is 1.224 times chance of post graduates having fair knowledge than poor.
2. There is 0.30 times chance of respondents having primary education to pocess good attitude than fair.
3. There is 4.921 times chance for intermediates to have fair attitude than poor.

causes decay in early age. Most of the mothers believed that brushing should be started at 3-4 years of age (65%) however only 14.7% mothers accepted that ideal time of brushing is after the eruption of first primary tooth. Almost half (46%) believed that regular brushing could prevent early childhood decay. Awareness regarding role of fluoridated tooth paste was in less than the half of participants (42.3%). Parents of most chileren(70%) agreed that the child should have regular checkup but were not in practice of doing so.

Keeping education constant, for every “Year” increase in age , there is 0.992 times chance for respondents to acquire good habit of practice, and 0.943 times chance to acquire fair habit of practice than poor.
Keeping age constant:

1. There is 0.37 times chance for graduates to adapt good knowledge over fair
2.  There is 0.58 times chance for intermediates to adapt good knowledge over fair
3. There is 0.54 times chance for respondents having secondary education to adapt good knowledge over fair.
4. There is 0.80 times chance for respondents having at least primary education to adapt good knowledge over fair.

Table 3-c             PRACTICE

a. The reference category is: poor.

Association between Knowledge, Attitude and practice with Educational level and Age by using Multinomial logistic regression & chi square tests.

Table: 3-a, 3-b and 3-c shows Logistic regression which demonstrated 4.52 odds for graduates to have good knowledge, when age was kept constant. When education was kept constant, odds ratio was 4.921 for intermediates
to have fair attitude.

Table: 4 shows results of Chi square which demonstrated significant association of knowledge (0.042, 0.001) and practice (0.005, 0.000) with age and educational level however attitude was not found to a significant association

Pearson Chi square analysis

Table: 4 Pearson Chi square (Asymp.sig 2-sided)

with both of them.
While Figure 4-a, 4-b, 4-c, 4-d, 4-e, 4-f shows bar charts
relating to above results.

Bar Charts showing Association of Education with Knowledge, attitude and Practice by using Pearson chi-square test

DISCUSSIONS

Mothers are considered as role models for their children.¹ Childs oral health is strongly associated with mother’s oral hygiene practices and are established during infancy and practiced throughout life.⁹ As Pakistan is still a developing  country very few studies have been conducted in Pakistan regarding Parental influence on ECC. This study provides a new data about the awareness of mothers towards the oral hygiene of their children as the questionnaire focuses on basic knowledge and importance of primary teeth as they are important for child’s growth and development. In this study 40.7% of the mothers knew the right time for first deciduous tooth eruption however 66% had no idea about the numbers of total deciduous teeth, most of the mothers thought that only anterior four teeth are deciduous teeth, findings   were   in agreement to  a study conducted in India.¹⁰ Majority of the mothers knew about the dietary and feeding practices, 96.7% knew that excessive consumption of sugar cause early decay and these findings were consistent with other previous studies conducted in Pakistan, India and Malaysia.^1,8,11

In our society, most people think the primary teeth are temporary and its treatment is waste of time and money.¹² In our study, only 56.3% of mothers were aware of importance of primary teeth.

Pertaining to prevention of dental caries, 46% of mothers believe that regular brushing twice a day with fluoride toothpaste can help in reducing dental pain, findings were very close to a study in Mumbai¹⁰ More than half of participants had no idea that tooth paste should have fluoride or not (finding were consistent with study in india¹⁰) 42.3% knew that they use fluoride toothpaste at home. When questioned about importance of fluoride only 30% agreed that it can prevent or arrest early decays which is slightly  lower than in the other study.⁸ This finding is contrary to a study conducted in Malaysia showed that reported excellent (85%) knowledge of mothers.¹¹ However similar lower results were also seen in India.¹⁰ Mothers of 91% children believed that childrens’ early brushing should be supervised by them. The ratio is close to results of India but contrary to the results of study from Pakistan which stated that 96% of mothers did not know that they should supervise their children for brushing.^8,10 Majority of the parents believe that cleaning of teeth should commence at age when all milk teeth have erupted (at 3-4 years) which is much higher than the ideal age for the start of brushing. Our results are consistent with the findings of Riyadh and India.^13,10

The status of first molar has been studied in many studies to assess the oral health status of children because its early loss results in multiple problems in occlusion and function.¹⁴ Our results were slightly less than the findings found in Jordan.¹⁴

More than 80% of children use tooth paste and toothbrush for cleaning. These findings were   in line with the other study in India.¹⁰

Almost half of mothers (46%) reported that their children are brushing twice a day, which is quite close to results in India which reported 41% but less than the results reported in Malaysia.^10,11 Forty five percent of mothers are changing their children tooth brush after 3 months, while 37% are changing only when bristles are frayed out, these findings are contrary to reported literature.^8,10

When parents were asked about the time of consumption of sweet food, 60.7% replied that upon the demand of child, these findings are greater than those reported from India (41%).¹⁰

The limitations of our study are that the results cannot be extrapolated as sample size was small and included limited mothers who were visiting dental centers only. This study needs to be conducted on larger scale with large sample size on different pediatric hospitals to overcome the over estimation of Attitude towards dental treatment. Our population needs awareness programmes regarding oral hygiene practices to bring positive behavioural changes in Parents.

CONCLUSION

This study found positive association between the age and educational level of parents with their knowledge and practice towards oral hygiene.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Shetty RM, Deoghare A, Rath S, Sarda R, Tamrakar A. Influenceof mother’s oral health care knowledge on oral health status of their preschool child.Saudi J Oral Sci 2016;3:12-6. https://doi.org/10.4103/1658-6816.174291
2. Virgo-Milton M, Boak R, Hoare A, Gold L, Waters E, Gussy M,Calache H, O’callaghan E, Silva AM. An exploration of the views of Australian mothers on promoting child oral health. Aust Dent J. 2016; 1(1):84-92. https://doi.org/10.1111/adj.12332
3. Makhdoom S, Khan MA. Assessment of early childhood caries(ecc) and its relationship with feeding practices-a study. Pak Oral Dent J. 2015;35(2)254-57.
4. Zhang X, Yang S, Liao Z, Xu L, Li C, Zeng H, Song J, Zhang L.Prevalence and care in-dex of early childhood caries in mainland China: evidence from epidemiological surveys during 1987-2013. Sci Rep. 2016;6:18897.
5. Wigen TI, Wang NJ. Does early establishment of favorable oralhealth behavior influence caries experience at age 5 years?. Acta Odontol Scand. 2015;73(3):182-7.https://doi.org/10.3109/00016357.2014.976264
6. Watanabe M, Wang DH, Ijichi A, Shirai C, Zou Y, Kubo M, TakemotoK, Masatomi C, Ogino K. The influence of lifestyle on the incidence of dental caries among 3-year-old Japa-nese children. Int J Environ Res Public Health. 2014;11(12):12611-22. https://doi.org/10.3390/ijerph111212611
7. Thomas A, Jacob A, Kunhambu D, Shetty P, Shetty S. Evaluationof the knowledge and attitude of expectant mothers about infant oral health and their oral hygiene practices. J Int Soc Prev Community Dent. 2015;5(5):400-05. https://doi.org/10.4103/2231-0762.163405
8. Mubeen N, Nisar N. Mother’s Knowledge, Attitude and PracticesRegarding Dental Caries And Oral Hygiene Among Children (Age 1 To 5 Years) in Civil Hospital, Karachi. Int J Dent Oral Health. 2015;2(4).
9. Arrow P, Raheb J, Miller M. Brief oral health promotion interventionamong parents of young children to reduce early childhood dental decay. BMC Public Health. 2013;13(1):245. https://doi.org/10.1186/1471-2458-13-245
10. JJain R, Oswal KC, Chitguppi R. Knowledge, attitude and practicesof mothers toward their children’s oral health: A questionnaire survey among subpopulation in Mumbai (India). J Dent Res Sci Develop.2014;1(2):40-5. https://doi.org/10.4103/2348-3407.135073
11. Mani SA, John J, Ping WY, Ismail NM. Early childhood caries: parent’s knowledge, attitude and practice towards its prevention in Malaysia. Oral Health Care-Pediatr, Res, Epi-demiol & Clin Pract 2012. InTech.
12. Mounissamy A, Moses J, Ganesh J, Arulpari M. Evaluation of parental attitude and practice on the primary teeth of their children in Chennai: An hospital survey. Int J Pedod Rehabil. 2016;1(1):10-14.
13. Wyne A. Oral hygiene practices and first dental visit among early childhood caries chil-dren in Riyadh. Pak Oral Dent J. 2003;23 (2):161- 66.
14.  Jaradat T, Moa’th Gh, Showeiter M, Otom A, Kana’an N. The Awareness of Parents of the Time of Eruption of First Permanent Molar and Caries Prevalence in this Tooth In Children in the South of Jordan. Pak Oral Dent J. 2013;33(3):498-501.

1. 1. Postgraduate Trainee of Msc, Department of Oral Biology (Dental), Dow University of Health Sciences.
   2. Assistant Professor, Department of Oral Biology, Dow Dental College, Dow University of Health Sciences
   3. Dental Practitioner, Department of Oral Biology, London Dental Hospital Karachi.

Corresponding author: “Dr. Sanam Faheem” < sanamfaheem4479@gmail.com >

Sanam Faheem¹                                            BDS

Shahida Maqsood²                                              BDS, M Phill

Faheem Shaikh³                                           BDS

Marium Azfar¹                                            BDS, MPH

Imran Khan²                                                         BDS, MSc

Noureen Iqbal³                                           BDS, FCPS

Nausheen Khawar⁴                                          BDS, MCPS

Khadijah Abid⁵                                                    BSC, MSc

INTRODUCTION

Down syndrome is a congenital autosomal anomaly caused due to the changes in the sequence of DNA of chromosome 21. According to WHO the global incidence of Down syndrome (DS) is estimated as 1 out of 600-1000 live births.1,2 The syndrome is classified by characteristic facial features with a protruding tongue, congenital heart disease, short stature, a wide range of learning difficulties, gastrointestinal disorders, and other features.3,4

Down syndrome children have specific characteristics of orofacial related with the syndrome. The majority of the oral disorders consist of open bite, periodontal disease, mouth breathing, malocclusion, delayed teeth eruption, macroglossia, missing and malformed teeth, crowding, bruxism, microdontia, fissured lips and tongue, low level of caries and poor oral hygiene.1,5-7 Periodontal disease is the most prevalent oral health issue in the individuals with Down syndrome. Manual dexterity troubles may prompt oral hygiene issues, which may bring in accumulation of debris and plaque, thus supporting development of periodontal disease and gingivitis.

Extensively large number of youngsters with DS lose their permanent front teeth in their initial teens. The reasons of high risk of periodontal disease among Down syndrome individuals are cariogenic food choices and less food clearance from the mouth.8,9

In Pakistan, there is no appropriate data available with respect to oral health status of individuals with DS. Such data is necessary for the planning of treatment in DS individuals for dental practitioner and also to assist other health professionals in understanding the oral health status of DS patients and the importance of liaison with dental professionals. Therefore this study was proposed and conducted to evaluate the oral hygiene and caries status of individuals with DS attending special needs children at Karachi, Pakistan.

METHODOLOGY

It was a cross-sectional study conducted at the special needs children school Karachi, Pakistan and duration of study was 6 months. The sample size of 119 participants was obtained by using open epi online sample size calculator. The statistics considered for sample size estimation was good oral hygiene status as 50%10, margin of error as 9% and 95% confidence level. The non-probability purposive sampling technique was employed. All participants of 5-20 years of either gender with Down syndrome were included in the study. Participants exhibiting other forms of systematic diseases, compound disability or extremely uncooperative individuals were excluded from the study.
Informed consent was taken from school admin and parents of the children to participate in the study. The clinical examination was carried out according to World Health Organization (WHO) techniques11 in the OPD of Integrated Occupational Health Services (IOHS) by the examiner. The demographic information such as age, gender, weight & height of the children was recorded. BMI of each children was calculated by using the formula BMI =weight/heightt2 (kg/m2 ). Other related information regarding previous dental visits, frequency of tooth brushing, material used for brushing & food preferences were obtained under the supervision of school interpreters.

The children were then examined for oral status by making them sit on the upright chair in adequate light using autoclaved instruments. Each surface of mouth was checked by using plain mouth mirror and WHO probe. Caps, gloves, masks and gauze were used in accordance with infection control guidelines. Dental caries was evaluated by using DMFT (decayed, missing, and filled teeth) index.12 Children with DMFT=0 were labelled as “Caries-free” & children with DMFT>0 were labelled as “Caries Present”. Oral hygiene was evaluated by using the simplified oral hygiene index (OHI-S) introduced by Green and Vermillion.13 OIH-S score was labelled for oral cleanliness as “good” for score between 0.1-1.2, “fair” between 1.3-3.0 and “poor” between 3.1-6.0.14 Data analysis was carried out using the SPSS Version 23.
Frequencies and percentages was calculated for all the qualitative variables. Mean & SD was calculated for all the
quantitative variables. Independent t-test & chi-square were applied where appropriate. The confidence level was considered as 95% and P-value <0.05 was taken as statistically significant.

RESULTS

The study sample was consisted of 119 children with mean age as 14.19±5.54 years. Out of 116, 76 were males and 43
were females. The mean weight of individuals with Down syndrome was calculated as 50.69±15.74 kg. The mean DMFT was calculated as 1.10±1.31, debris index as 1.01± 0.69, calculus index as 0.56± 0.72 & OHI-S score as 1.79± 1.43. (Table 1)

The mean DMFT of males was calculated as 1.03±0.11 and female as 1.71±0.26. Hence the mean difference of DMFT with respect to gender was observed as at the edge of significance (p=0.057). The mean DMFT score was high

Table 1: Descriptive Statistics of study variables

in age group 11-15 years followed by 16-20 years and 5-10 years. The mean difference of DMFT with respect to age was fund as statistically significant (p<0.05). Out of 116 participants about 68.1% were presented with dental caries.

The prevalence of dental caries was high in males (59.2%) as compared to females (40.7%), hence the relationship is insignificant (p>0.05). The prevalence of dental caries was high in age group 16-20 years (48.1%) followed by 11-15 years (34.6%) and 5-10years (17.3%), hence the relationship was significant. (Table 2)

The gender and age wise mean OHI-S score was computed and compared. The significant difference was observed in mean OIH-S with respect to gender and age, p<0.05. The majority had good hygiene status (53.1%), 27.7% had fair hygiene status and 21% had poor hygiene

Table 2: Gender and Age wise distribution of DMFT and dental caries

Table 3: Gender and age wise distribution of OHI-S score and Oral hygiene status

status. Stratification with respect to gender and age was done for oral hygiene status, the relationship was found  asstatistically significant (p<0.05). (Table 3)

DISCUSSION

The oral disease is the most common problem among individuals with physical and mental disabilities.15 The frequency and severity of oral disease is high among people with disabilities as compared to normal population.16 The findings may be associated to less physical abilities and consequents difficulties in tooth brushing among them. Oral well-being might be influenced by several factors such as restricted comprehension on the significance of oral health management17, anticonvulsant medicines that effect upon gum health18, troubles in imparting oral health needs19, and a dread of oral health procedures.20 General anesthesia and physical restraints are usually used to treat adults with disabilities who have dread and correspondence troubles associated to oral health.21 The present study was conducted to know the current dental health status of individuals with Down syndrome in Karachi, Pakistan as data was required to plan proper oral health programme for them.

In the present study, mean DMFT was 1.10±1.31 and dental caries was prevalent among 68.1% of the participants. When stratification of DMFT indexes were evaluated with regard to sex, the mean DMFT was found to be higher among females as compared to males. However, the dental caries were prevalent among males. The previous literature22-25, has usually found high prevalence of dental caries among females than males. When stratification of DMFT indexes were evaluated with age, the mean DMFT was found to be higher among age group 11-15 years as compared to other age groups. Whereas the dental caries were prevalent among age group 16-20 years. In year 2014, a study was conducted among 90 individuals with Down Syndrome from Sarajevo and Tuzla Canton, Bosnia and Herzegovina, the mean DMFT index for age group 0-6 years was found as (6.40±6.05); 7-12 years (2.05±2.04) and 13-18 years (10.30±6.80). By using Pearson’s correlation value for DMFT, debris index and age of examinees with Down syndrome, statistically significant positive correlation was found.26 Another study conducted by Cornejo et al. in which they had compared oral health status of 3-19 years of Down syndrome individuals versus normal children. They observed the DMFT indexes were higher in Down syndrome children than control populace. They also found that in age onwards 10 years the DMFT indexes of the normal children were higher than the Down syndrome individuals.27 In a study conductedaby Singh V et al. total of 30 Down syndrome and 30 normal children were included. The dental caries were more prevalent among normal children (83.5%) as compared to children with down syndromes (70%).28 It has been observed that Down syndrome children had higher risk for the development of nursing bottle caries than typically developing children to be weaned off bottled milk at an older age or given syrupbased medicines for repeated infections because of swallowing problems.28

In the present study most of children had good oral hygiene status, followed by fair and poor. These findings are in disagreement with many previous studies which reported poorer status of oral hygiene and higher prevalence of periodontal diseases in DS children than their normal population.8,10,30,31 The reasons for this may include the reduced manual dexterity of the participants, joint laxity, and lack of comprehension of oral hygiene needs due to mental difficulties. They, therefore, need help to carry out routine oral hygiene measures.31 The present study found increased in OHI-S score with increase in age, which is in agreement with previous literature.33,34 In the present OIHS score is higher in males as compared to females. When oral hygiene status stratified with respect to gender most of the males had good oral hygiene and when stratified with respect to age, the children in the age group 11-15 years had good oral health status. In the previous analysis of oral hygiene of Down syndrome children by using the debris index, it was found that 43.9% had very good oral hygiene, 33.3% respondents had good oral hygiene, 15.8% were with poor oral hygiene, while the very poor hygiene was present in 7% of the subjects. However, no statistical significant difference was found in Debris index subjects with Down syndrome in relation to the age groups. The highest percentage of all age groups have very good oral hygiene, and good oral hygiene.26

CONCLUSION

A high prevalence of dental caries was observed among children with Down Syndrome. There is a high need for an epidemiological survey followed by the comprehensive dental care programs for these children, as well as efforts should be taken to encourage and promote parents of these children to improve their oral health.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Asokan S, Muthu M, Sivakumar N. Dental caries prevalence and treatment needs of Down syndrome children in Chennai, India. Ind J Dent Res. 2008;19(3):224-29. https://doi.org/10.4103/0970-9290.42955
2. Swisher T, Pryor H, Schurman D. At higher risk for oral disease, patients with Down syndrome require specialized oral care instruction.
3. Hall R. Pediatric orofacial medical pathology. London: Chapman & Hall Medical Co; 1994.
4. Shukla D, Bablani D, Chowdhry A, Jafri Z, Ahmad N, Mishra S. Oral health status and dental caries experience in mentally challenged individuals. Ann Public Health Res. 2014;1(2):1008.
5. Cohen MM, Winer RA. Dental and facial characteristics in Down’s syndrome (mongolism). J Dent Res. 1965;44(1):197-08. https://doi.org/10.1177/00220345650440011601
6. Asokan S, Muthu M, Sivakumar N. Oral findings of Down syndrome children in Chennai city, India. Indian J Dent Res. 2008;19(3):230. https://doi.org/10.4103/0970-9290.42956
7. Dharmadhikari P, Thosar N, Baliga S, Rathi N. Comparative evaluation of salivary constituents and oral health status in children with Down’s syndrome. European J Gen Dent . 2016;5(2):90-94.
8. Oredugba FA. Oral health condition and treatment needs of a group of Nigerian individuals with Down syndrome. Downs Syndr Res Pract. 2007;12(1):72-6. https://doi.org/10.3104/reports.2022
9. Kothari S, Bhambal A, Saxena V, Bhambhani G, Dubey P. Impact of various sociodemographic factors on oral hygiene of mentally retarded residing in Bhopal city, Madhya Pradesh: A cross-sectional study. J Indian Assoc
10. Krishnan C, Kumari BN, Sivakumar G, Iyer SP, Ganesh P. Evaluation of oral hygiene status and periodontal health in Down’s syndrome subjects in comparison with normal healthy individuals. J Indian Acad Dent Spec Res. 2014;1(2):47-49 https://doi.org/10.4103/2229-3019.148237
11. Organization WH. Oral health surveys: basic methods: World Health Organization; 2013.
12. Larmas M. Has dental caries prevalence some connection with caries index values in adults? Caries Res. 2010;44(1):81-4. https://doi.org/10.1159/000279327
13. Greene JG, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc. 1964;68(1):7-13. https://doi.org/10.14219/jada.archive.1964.0034
14. Al-Mutawa S, Shyama M, Al-Duwairi Y, Soparkar P. Oral hygiene status of Kuwaiti schoolchildren. East Mediterr Health J. 2011;17(5):387-91. https://doi.org/10.26719/2011.17.5.387
15. Newacheck PW, McManus M, Fox HB, Hung Y-Y, Halfon N. Access to health care for children with special health care needs. Pediatr. 2000;105(4):760-6. https://doi.org/10.1542/peds.105.4.760
16. Beange HP. Caring for a vulnerable population. Med J Aust. 1996;164(3):159-60.
17. Lindemann R, Zaschel-Grob D, Opp S, Lewis MA, Lewis C. Oral health status of adults from a California regional center for developmental disabilities. Spec Care Dentist. 2001;21(1):9-14. https://doi.org/10.1111/j.1754-4505.2001.tb00217.x
18. Marshall RI, Bartold PM. A clinical review of drug-induced gingival overgrowths. Aust Dent J. 1999;44(4):219-32. https://doi.org/10.1111/j.1834-7819.1999.tb00224.x
19. Faulks D, Hennequin M. Evaluation of a long-term oral health program by carers of children and adults with intellectual disabilities. Spec Care Dent. 2000;20(5):199-08. https://doi.org/10.1111/j.1754-4505.2000.tb00020.x
20. Gordon SM, Dionne RA, Snyder J. Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Spec Care Dent. 1998;18(2):88-92. https://doi.org/10.1111/j.1754-4505.1998.tb00910.x
21. Burtner AP, Dicks JL. Providing oral health care to individuals with severe disabilities residing in the community: alternative care delivery systems. Spec Care Dent. 1994;14:188-.
22. Farsi N. Dental caries in relation to salivary factors in Saudi population groups. J Contemp Dent Pract. 2008;9(3):16-23.
23. Lukacs JR, Largaespada LL. Explaining sex differences in dental caries prevalence: saliva, hormones, and “life-history” etiologies. Am J Hum Biol. 2006;18(4):540-55. https://doi.org/10.1002/ajhb.20530
24. Goe LC, Baysac MA, Todd KH, Linton JA. Assessing the prevalence of dental caries among elementary school children in North Korea: a cross-sectional survey in the Kangwon province. Int J Dent Hyg.
    2005;3(3):112-6. https://doi.org/10.1111/j.1601-5037.2005.00125.x
25. Zusman SP, Ramon T, Natapov L, Kooby E. Dental health of 12- year-olds in Israel-2002. Community Dent Health. 2005;22(3):175-9.
26. Porovic S, Zukanovic A, Juric H, Dinarevic SM. Oral health of Down syndrome children in Bosnia and Herzegovina. Mater Sociomed. 2016;28(5):370. https://doi.org/10.5455/msm.2016.28.370-372
27. Cornejo LS, Zak GA, Dorronsoro de Cattoni ST, Calamari SE, Azcurra AI, Battellino LJ. Bucodental health condition in patients with Down syndrome of Cordoba City, Argentina. Acta Odontol Latinoam. 1996;9(2):65-79.
28. Singh V, Arora R, Bhayya D, Singh D, Sarvaiya B, Mehta D. Comparison of relationship between salivary electrolyte levels and dental caries in children with Down syndrome. J Nat Sci Biol Med.
    2015;6(1):144. https://doi.org/10.4103/0976-9668.149113
29. Randell DM, Harth S, Seow WK. Preventive dental health practices of non institutionalized Down syndrome children: a controlled study. J Clin Pediatr Dent. 1992;16(3):225-29.
30. Al Habashneh R, Al-Jundi S, Khader Y, Nofel N. Oral health status and reasons for not attending dental care among 12- to 16-year-old children with Down syndrome in special needs centres in Jordan. Int J Dent Hyg. 2012;10(4):259-64. https://doi.org/10.1111/j.1601-5037.2012.00545.x
31. Ulseth JO, Hestnes A, Stovner LJ, Storhaug K. Dental caries and periodontitis in persons with Down syndrome. Spec Care Dentist. 1991;11(2):71-3. https://doi.org/10.1111/j.1754-4505.1991.tb00819.x
32. Al-Sufyani GA, Al-Maweri SA, Al-Ghashm AA, Al-Soneidar WA. Oral hygiene and gingival health status of children with Down syndrome in Yemen: A cross-sectional study. J Int Soc Prev Community Dent. 2014;4(2):82. https://doi.org/10.4103/2231-0762.139429
33. Al-Haddad KA, Al-Hebshi NN, Al-Ak’hali MS. Oral health status and treatment needs among school children in Sana’a City, Yemen. Int J Dent Hyg. 2010;8(2):80-5. https://doi.org/10.1111/j.1601-5037.2009.00398.x
34. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent. 2009;27(3):151-7. https://doi.org/10.4103/0970-4388.57095

1. Associate Professor, Department of Preventive & Community Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University.
2. Assistant Professor, Department of Preventive & Community Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University.
3. Assistant Professor, Department of Oral Surgery, Dr. Ishrat-ul-Ibad Khan Institute of Oral health sciences, DUHS.
4. Assistant Professor, Department of Dental Materials Sciences, Fatima Jinnah Dental College.
5. Senior Bio-Statistitcian, Departmnet of Research Evaluation Unit, College of Physicians & Surgeons. Pakistan.
   Corresponding author: “Khadijah Abid” < khadijahabid@gmail.com >

Marium Azfar¹                                            BDS, MPH

Imran Khan²                                                         BDS, MSc

Noureen Iqbal³                                           BDS, FCPS

Nausheen Khawar⁴                                          BDS, MCPS

Khadijah Abid⁵                                                    BSC, MSc

Suraiya Hirani¹                                                BDS

Amynah Tariq Charani²                                                          BDS, M.Phil

INTRODUCTION

Quality of life (QoL) is manifestation with many meanings. It is associated to individual subject to age, sexual characteristics and cultural situations. It’s not a measureable variable but can construct on different perception of each individual. QoL is also reflected by oral health.¹ Oral health related quality of life (OHRQoL) is “the absence of negative impacts of oral conditions on social life and a positive sense of dentofacial self-confidence”.^[1] Oral health has influence on general health both physically as well as mentally. WHO recognized OHRQoL in “Global

Oral Health program” (WHO, 2003). It has been generally used in abstract and concrete fields with dental research and medical trials assessing the results of protective and beneficial agendas. Slade,³ was the first one who invented the first instrument that measure OHRQoL.

OHRQoL is comparatively a new developing phenomenon. The concept of OHRQOL was first given in the early 1980s. Davis emphasized that except for pain, oral illness does not have any effect on society. It is only interconnected with cosmetic problems; others have reasons that oral disease can be due to recurrent complaints such as headache that were apparent as insignificant problems.⁴

Later, in 1970s; the OHRQOL concept is in progress to grow as more signs are cultivated of the impression of oral disease on society(5). Epidemiological inspection shows trends in OHRQoL, identified definite and natural characteristics that affect OHRQoL and helped in needs and health improvement for population-based initiatives. Research has establish that specific groups are at more risk for low OHRQoL.⁶

During few years, a variety of gadgets for assessing QoL comparative to oral health have been intended. Subject to the measures used, QoL linked to oral disorders has been described as difficulties in eating and social collaboration, emotional and psychological function. Oral Impact on Daily Performance (OIDP) has advantage of being used in population survey but measure feelings of individuals.⁷

“World Health Organization’s International Classification of Impairments, Disabilities and Handicaps” (ICIDH), has been modified for dentistry by Locker. Impairments means biophysical outcomes of disease. Functional limitation means limitation in body functions. Pain and discomfort is associated with oral disease. Disability and handicap indicates difficulties in performance of daily activities.⁸

With already established association on oral health and QoL most information are based on researches done locally and internationally. There are no such studies regarding relationship between clinical oral health and QoL in our population. Assessing OHRQoL of dental undergraduate and graduate is important as in clinical practice they are responsible for a good oral hygiene habits. Therefore, the objective of this study was to:

1. To assess oral health and quality of life in dental undergraduates and graduates of Dow University of Health Sciences.
2. To study correlation of Caries status using DMFT index and quality of life in Dow University of Health Sciences undergraduates and graduates.

METHODOLOGY

Study design and study area: A cross-sectional study was conducted at Dow Dental College both campus, OJHA and civil hospital campus. Aims of the study was discussed with head of departments and permissions were taken from all, who participated in this study. Sampling was done according to year of study they were studying for undergraduates and house officers were also included in graduate students sample. Sample size of two hundred and forty was calculated using Power Analysis and Sample Size (PASS) version II with estimated SD of 7.850.⁹ All participants were given validated OIDP survey questionnaire² for quality of life using eight score. OIDP depicts social impact on wellbeing. Participants were asked to score questionnaire accordingly. After that their caries status was checked and recorded using DMFT index by trained post graduate trainee of Dow University of Health Sciences. Students who had not undergone with any dental treatment or visit over the last two years were excluded from the study. Data was analyzed using SPSS version 22.0. Descriptive analysis was checked with the frequency distribution of study population and affected eight score of OIDP scale. Paired T-test was applied for OIDP score with pain status during dental treatment and satisfaction level of treatment. Correlation of coefficient between OIDP score and DMFT index was checked using 0.001 as statistically significant value.

RESULTS

Two hundred and forty undergraduates and graduates participated in this study amongst which 73.7% were females and 26.3% were males. The mean age of participants was 21.63±2.19. Out of two forty (240) one hundred and seventy one (171) were undergraduates and sixty nine (69) were graduates. From a total of 240, 86.7% were satisfied from their dental treatment that they received within last two year (Table 1).

Frequency distribution of affected OIDP illustrates highest percent of participants having difficulty with sleeping with 27.9% whereas 26.6% and 26.2% participants’ show difficulties with cleaning and emotional state correspondingly.

Table 1: Frequency distributon of students.

Table 2: Frequency distribution of eight oidp scores (% of affected and mean of oidp score).

Table 3: Mean comparision of age, gender and year of study with pain status.

Table 4: Mean comparision of age, gender and year of study with satisfaction level of treatment.

Table 5: mean comparision of oidp eight score with pain status.

Table 6: Mean comparision of oidp eight score with satisfaction level of treatment.

Table 7: Correlation for oidp with dmft index.

Detailed percentage distribution of participants having difficulties with affected eight measures of OIDP scale were described in table 2.

The mean comparison of age, gender and year of study with participants having pain during dental treatment was done in which age (p=0.037) and year of study (p=0.002) showed significant results. Age, gender and year of study showed statistically significant results when compared with satisfaction level of treatment (Table 4). Eating (p=0.006) and speaking (p=0.008) showed significant results when OIDP scale was compared with pain status (Table 5). Detailed mean comparison between eight score of OIDP and satisfaction level of treatment are described in table 6 showing statistically significant results in smiling (p=0.000031), emotional state (p=0.089) and interaction with people (p=1.9528).

Oral health and QoL when correlated with DMFT, eating, speaking, smiling, emotional state and interaction with people showed highest value. A detailed correlation was described in table 7.

DISCUSSION

Health is defined as a state absence of disease¹⁰ whereas, QOL is assessment of physical, mental and oral health care.¹¹ For evaluating relationship between quality of life with oral health researchers have developed many instruments. SF-36 health form measures relatively the quality of life of the individual whereas Oral Health Impact Profile (OHIP) and Geriatric Oral Health Assessment Index (GOHAI) measures the OHRQoL. OIDP is short and have advantage of not only being used in population survey but measure feeling of the individual.¹² A study was done on dental students in Malaysia using OIDP scale which showed similar

result to this study.¹³

Total 54.3% participants stated oral functional impact on their daily lives among which female ratio showed highest percentage. Usually key reason for dental visit is pain which could be before the treatment or after treatment, therefore pain during eating and speaking shows significant results in many studies.¹⁴ Pain is the leading factor to serious problems, but it is also a motivational factor for dental treatment as individual experiencing dental pain has impact on work from their daily lifestyle.¹⁵

Results of dental students and house officers in 2012 showed difficulty in sleeping while experiencing oral impact¹⁶, this studies also depicted difficulty in eating which is half that of the study conducted in Thai in 1996.¹⁷ Functional disability that is, having difficulty in eating and speaking, showed significant results when comparison to study that was conducted in Lahore.⁴

Caries index can be measured by many tools among which DMFT is used internationally. It is also used to evaluate manifestation of caries in individual evaluating decayed and filled teeth, therefore correlation among functional disability (eating and speaking), emotional state and social interaction with people and DMFT index were significant statistically.¹⁸ However esthetics and DMFT was also significant in other study.¹⁹ However, a negative association between OIDP and

DMFT among children was proved in another study.²⁰

Complete oral examination with plaque and gingival index and records of the dietary habit of individual may be recorded in further studies as it had greater impact on oral health which can further influence QoL.

CONCLUSION

DMFT is related to quality of life. This study showed less impact on daily performance in those individuals who had higher number of intact teeth. Oral health has a significant impact on social interaction of dental undergraduates and graduates.

CONFLICT OF INTEREST

None declared.

REFERNCES

1. Einarson S, Gerdin EW, Hugoson A. Oral health impact on qualityof life in an adult Swedish population. Acta Odontol Scand. 2009;67(2):85-93. https://doi.org/10.1080/00016350802665597
2. Santos CMd, Oliveira BHd, Nadanovsky P, Hilgert JB, Celeste RK,Hugo FN. The Oral Health Impact Profile-14:: a unidimensional scale? Cadernos de Saúde Pública. 2013;29(4):749-57. https://doi.org/10.1590/S0102-311X2013000800012
3. Slade GD, Spencer AJ. Development and evaluation of the OralHealth Impact Profile. Community dent health. 1994;11(1):3-11.
4. Idris SH, Shujaat NG, Hussain SZ, Chatha R. Oral Health RelatedQuality Of Life (OHRQoL) in dental undergraduates. Pak Oral Dent J. 2010;30(2)223-228.
5. Bennadi D, Reddy C. Oral health related quality of life. J Int SociPrevent & Community Dent.2013;3(1):1-6. https://doi.org/10.4103/2231-0762.115700
6. Sischo L, Broder H. Oral Health-related Quality of Life What, Why,How, and Future Implications. J Dent Res.2011;90(11):1264-70. https://doi.org/10.1177/0022034511399918
7. Astrøm AN, Okullo I. Validity and reliability of the Oral Impactson Daily Performance (OIDP) frequency scale: a cross-sectional study of adolescents in Uganda. BMC Oral Health. 2003;3(1):5. https://doi.org/10.1186/1472-6831-3-5
8. Locker D, Matear D, Stephens M, Lawrence H, Payne B. Comparison of the GOHAI and OHIP?14 as measures of the oral health-related quality of life of the elderly. Community Dent Oral Epidemiol. 2001;29(5):373-81. https://doi.org/10.1034/j.1600-0528.2001.290507.x
9. Isiekwe G, Onigbogi O, Olatosi O, Sofola O. Oral Health qualityof life in a Nigerian University undergraduate population. J West African Coll Surg. 2014;4(1):54-74.
10. Brown TM, Cueto M, Fee E. The World Health Organization andthe transition from “international” to “global” public health. Am J Pub health. 2006;96(1):62-72. https://doi.org/10.2105/AJPH.2004.050831
11. Group W. The World Health Organization quality of life assessment(WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41(10):1403-9. https://doi.org/10.1016/0277-9536(95)00112-K
12. Montero J, López J-F, Vicente M-P, Galindo M-P, Albaladejo A,Bravo M. Comparative validity of the OIDP and OHIP-14 in describing the impact of oral health on quality of life in a cross-sectional study performed in Spanish adults. Med Oral Patol Oral Cir Bucal. 2011;16(6):816-21. https://doi.org/10.4317/medoral.16851
13. Harsh P, Arunima C, Manoj K. Oral health quality-of-life amongundergraduate Malaysian dental students. Med J Malaysia. 2012;67(3):299-301.
14. Kaleem M, Jawad M. Association between Socio-demographicfeatures, Oral Hygiene practices and Oral Health utilization services among patients seen at AFID. Pak Oral Dent J. 2016;36(1)110-15.
15. Wilson KE, Opie R. Oral health status and oral impact on dailyperformance in an adult population with leprosy living in rural Tanzania. J Disability Oral Health. 2009;10(3):124-30.
16. Priya H, Sequeira P, Acharya S, Kumar M. Oral health relatedquality of life among dental students in a private dental institution in India. J Int Soc Prev Community Dent. 2011;1(2):65-70. https://doi.org/10.4103/2231-0762.97708.
17. dulyanon S, Vourapukjaru J, Sheiham A. Oral impacts affectingdaily performance in a low dental disease Thai population. Community Dent Oral Epidemiol. 1996;24(6):385-9. https://doi.org/10.1111/j.1600-0528.1996.tb00884.x.
18. Biazevic MGH, Rissotto RR, Michel-Crosato E, Mendes LA,Mendes MOA. Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res. 2008;22(1): 36-42. https://doi.org/10.1590/S1806-83242008000100007
19. Masalu JR, Åstrøm AN. Social and behavioral correlates of oralquality of life studied among university students in Tanzania. Acta Odontol Scand. 2002;60(6):353-9. https://doi.org/10.1080/000163502762667388.
20. Do LG, Spencer A. Oral health?related quality of life of childrenby dental caries and fluorosis experience. Journal of public health dentistry. 2007;67(3):132-9. https://doi.org/10.1111/j.1752-7325.2007.00036.x

1. MSc Trainee, Department of Oral Biology, Dow University of Health Sciences.
2. HOD, Department of Oral Biology, Dow University of Health Sciences.
   Corresponding author: “Dr. Suraiya Hirani” < drsuraiyahirani@gmail.com >

Suraiya Hirani¹                                                BDS

Amynah Tariq Charani²                                                          BDS, M.Phil