Vol. 28 No. 01 Jan-Mar 2019

Farhan Raza Khan                                       BDS, MS, MCPS, FCPS 

DOI: https://doi.org/10.25301/JPDA.281.1

The planning to build the faculty of any future dental institution should ideally be dictated by certain factors. These include presence of potential learners (students), prevalence of dental diseases in the catchment area of the institution and the need of manpower to address the anticipated oral health care problems in a professional manner.1 All of this should be governed by and done under the umbrella of regulatory and statutory bodies of the country. All over the world, dentistry is primarily a profession that is run in the offices (clinic setups) as solo, group or associated practices. However, scenario is different in the academic practice i.e. in dental colleges, hospitals and university dental centers. Unlike western world, where a dentist in a full time academic career is not indulged in practice and primarily focuses on teaching, research and scholarly activities; the dental academia in Pakistan is quite different.2 Here, most of the dental faculty carry out private practice in the evening and thus should better be considered as morning-time teachers and evening-time practitioners. Although, the benefits of private practice are undeniable; monetary gains, prosperity, fame and professional satisfaction to name a few but as dentistry is a physically demanding profession, a busy teacher-practitioner can seldom do justice with the academic workload.

Upon scrutiny of the workload distribution of any Pakistani dental faculty, it would be evident that 60-70% of professional time is spent in the patient care at private practice. It can be speculated that this unjust time is one of the reasons behind low academic productivity and not contributing to the research in the institution. The prime time of a faculty is spent in lectures, assessments and administrative responsibilities of the college/department, thus, there is hardly any time and energy left with the poor faculty to contribute in the educational innovation. How can this stagnation in the educational productivity among dental faculty be managed? A simple solution to this problem is to encourage institutional faculty practice with no provision of private practice by dental faculty outside institution of employment. Only institutional practice should be allowed with faculty members receiving an adequate financial compensation for the patient care services they provide in the colleges. This will not only improve the quality of care offered to the less-affording patients at the academic centers but will also offer a lot of learning opportunities for the students as they will observe the faculty members actually performing the procedures. Student would gain first-hand experience without spending money on the clinical courses outside. The learning that takes place with observation is undisputable.

Another problem is dealing with the demonstrators/ lecturers working in the dental colleges. Although, this group carries the academic title but infact have no formal residency training or advanced specialty credentials that should be an essential requirement for an academic appointment. In a nut shell, demonstrators are not eligible for a faculty status. Counting demonstrators as faculty members creates several problems: a- They constitute the biggest teaching group in any dental college. Thus, they artificially inflate the count of teachers and partially satisfy the PMDC (Pakistan Medical & Dental Council) criterion on the number of teachers per department. But being untrained, their clinical experience is limited and hence the quality of teaching is compromised.

In other words, the quantity over quality rule prevails in the college academia. b- Mostly, there is no criterion for their selection and appointment. Any graduate can become a demonstrator on the next day of completing house job. And above all there is no career ladder for them. A demonstrator can remain demonstrator for an entire career spanning over 30 or more years.

A simple and straight forward solution to the dead-end academic path faced by the demonstrators is to reclassify the faculty status of demonstrators. The present demonstrators should be ideally be classified as “Teaching Assistants”. This change should be brought in at the level of PMDC. The argument is not about demonstrators not doing their job; instead the point here pertains more to the misclassification of employment and expecting too much from cadre of people who are not trained for the job. The academic appointments should start from the position of Assistant Professor. This does not mean that all demonstrators that are presently employed in the colleges should be expelled out of the institutions. Infact, the demonstrator position should be reclassified as teaching assistants so that their job description matches their credentials. Moreover, demonstrators should be retained in as employees of the dental colleges but not in the faculty ranks. The faculty grade must be reserved for dentists with formal advanced education in the form of FCPS residency training or University based MDS/PhD training. In this manner, the educationally frozen group of demonstrators should be replaced with formally trained and educationally qualified people.

In summary, only those individuals should become faculty who have the right credentials and are on the academic ladder to potentially reach the professorial position provided they meet the requirements for the same.

REFERENCES 

• Bertolami Creating the dental school faculty of the future: a guide for the perplexed. J Dent Educ. 2007; 71:1267- 80. PMID:17923705.
• Khan FR, Mahmud S, Rahman Is there a difference in Operative Dentistry care offered by teaching versus non- teaching dentists? J Pak Dent Assoc. 2014; 23: 30-5.

Muhammad Waseem Ullah Khan1                           BDS, FCPS

Muhammad Asif Mushtaq2                                         BDS

Asif Ali Shah3                                                                   BDS, MDS

INTRODUCTION

Epulis Fissuratum or Denture Induced Hyperplasia is a reactionary hyperplastic lesion of the oral cavity.

The major etiologic factor is chronic trauma of low intensity from ill-fitting dentures or para functional habits. The appearance of the lesion is usually a symptomless single or multiple folds of hyperplastic tissue. These folds are lying in the alveolar vestibule with normal color, soft or firm consistency and smooth along the denture flange. Sometimes, severe ulceration or inflammation can occur in the depth of these folds.1,2

It is established that longer the duration of denture wearing, greater is the frequency of denture induced hyperplasia. This indicates that over the period of time, denture causes bone resorption leading to lose and ill-fitting dentures. This causes chronic low-grade trauma and inflammation of oral mucosa leading to Epulis Fissuratum.3 Chronic nature of the problem suggests that discomfort is usually not a prominent feature and patient continue to use the problematic denture until hyperplastic tissue takes a considerable size. Patients become aware and seek treatment for the condition usually because of the size of growth rather than any pain or discomfort.4

This condition often occurs in middle-aged and older. It is reported in 5-10% of individuals wearing dentures and it occurs more frequently in the anterior part of the jaw than the posterior. It is more common in women than men. It is more common in maxilla than mandible. The size of the lesion can be ranging from 1 cm to more extensive involving the complete vestibule of the jaw.4,5 Depending upon the size of the lesion, denture induced hyperplasia can be treated conservatively or surgically excised.6 Rosenquet has mentioned that chronic trauma from ill-fitting dentures with sharp borders can also cause oral carcinoma. Therefore, ill-fit dentures and sharp borders of dentures should never be left unaddressed.7

CASE REPORT

A 65-year-old male patient presented to the OPD of Department of Prosthodontics, Punjab Dental Hospital, Lahore with the complaint of painless swelling in the upper arch in left labial vestibule (figure 1). The patient had been wearing his previous set of upper and lower complete dentures for the last five years but did not notice any swelling till the last six months. On examination of denture, it was noticed that the border of left labial flange of the upper  complete removable denture was sharp and overextended causing chronic irritation and trauma to non-keratinized soft tissue of maxillary left labial vestibule (figure 2). Denture hygiene was average with signs of tooth wear on the occlusal surfaces of acrylic teeth. Medical history was non-significant for the lesion. Patient was suffering from controlled type 2 Diabetes Mellitus and on oral hypoglycemic. He had no injurious oral habits like tobacco chewing or smoking. Extra oral examination revealed no abnormal facial features. Intraoral examination revealed folds of hyperplastic tissue in the left maxillary labial vestibule extending from the left central incisor region to the second premolar area with maxillary denture flange lying medial to the tissue folds. The tissue folds were of normal color and firm. They were non-tender and mobile. There was no ulcer in the tissue folds or the labial vestibule. Palatal mucosa was normal and there was no abnormal findings intra orally. Keeping in view of clinical examination and history, provisional diagnosis of Denture Induced Hyperplasia or Epulis Fissuratum was made. Patient was instructed to discontinue the use of denture and oral hygiene instructions were given. Considering the extensiveness of the hyperplastic tissue, it was obvious that conservative measures will not completely resolve the lesion. So, a conventional surgical resection of the tissue was planned. Local anesthesia containing lidocaine 2% and adrenaline 1:80,000 was administered for anterior superior alveolar, infra orbital and lesser palatine nerve. Outline of the resection was made with no.15 surgical blade along the length of the hyperplastic tissue in a wedge shape. The resection was done from the midline to the first molar area in the left maxillary labial vestibule and primary closure was done using 3-0 Vicryl sutures (figure 3). Postoperative instructions were given to the patient along with antibiotics and analgesics. The sharp left labial flange of maxillary complete denture was rounded off and relined with tissue conditioner and given to the patient to wear it as surgical splint (figure 4). The excised tissue was submitted for histopathological evaluation which confirmed the diagnosis (figure 5). At first follow up visit after seven days, tissue healing was good. Tissue conditioner was replaced at the same appointment. Later on, patient was recalled after every one week up to one month to replace the tissue conditioner. Impressions were taken after one month of surgery for the fabrication of new dentures. The patient is on six monthly follow up and no recurrence is found till date. Figure 6 and 7 represent the presentation of patient at the time of initial reporting to the hospital and at the time of delivery of new set of dentures.

Fig 1

Fig 2                                                    Fig3

Fig 4

Fig 5

Fig 6                       Fig 7

DISCUSSION

 Denture irritation hyperplasia is a type of Reactive Localized Inflammatory Lesion of the oral mucosa. The etiologic factors involved in the development of such lesions can be low grade chronic irritation to the oral mucosa e.g. sharp edges of grossly carious teeth , dental plaque and calculus, faulty dental restorations, ill-fitting dentures, chronic biting habits and food impaction. Systemic factors include hormonal changes.8 Denture irritation hyperplasia can be the result of ill-fitting denture, poor oral hygiene, all day-night wearing of denture, smoking and age related changes.5 Residual Ridge Resorption is also very important etiologic factor for denture irritation hyperplasia. Gradual progression of residual ridge resorption induces decrease in ridge height and the denture flanges overextend into the vestibule. Chronic trauma from extended denture flanges into the vestibule over a long period of time causes reparative response, leading to fibrous tissue hyperplasia.9

In our case report, overextended and sharp left labial flange of maxillary complete denture and poor oral hygiene was the etiologic factor. Macedo Firoozmand et al had mentioned in their study that 78% of denture wearer were female that presented with denture irritation hyperplasia mostly in maxilla.10 Although in literature, it has been mentioned that irritation hyperplasia has female predilection, but our case report is on a male patient.10,11

Differential Diagnosis of denture irritation hyperplasia include denture fibroma, benign mesenchymal tumor and minor salivary gland tumour.5

Treatment options for denture induced hyperplasia include conservative therapy and surgical excision. Conservative measures include discontinue denture wearing for some time, placement of tissue conditioner on the tissue surface of denture and correction of denture faults. These measures are effective only in case of small lesions.4 Surgical treatment can be conventional surgical supra-periosteal excision or advanced surgical techniques e.g. electro surgery, cryosurgery and laser surgery.5,12 In our reported case, conventional surgical supra-periosteal excision was done. Although in most cases, histopathology reports of the excised tissue show inflammatory and fibrous changes, but still every specimen of excised issue should be submitted for histopathology analysis.

CONCLUSION

 A case of denture induced hyperplasia was treated successfully. The etiology of the condition is discussed in detail and emphasis on the need for treatment is given. Patient should be educated about the benign nature of the lesion and complete oral hygiene instructions should be given to the patient to avoid recurrence. Importance of removal of denture at night and regular follow up with dentist should be advised.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Mortazavi H, Safi Y, Baharvand M, Rahmani S, Jafari Peripheral Exophytic Oral Lesions: A Clinical Decision Tree. Int J Dent 2017; 9193831:1-19.
2. Canger EM, Celenk P, Kayipmaz S. Denture-related hyperplasia: a clinical study of a Turkish population group. Brazilian Dent J 2009;20:243-48. https://doi.org/10.1590/S0103-64402009000300013
3. Coelho CM, Sousa YT, Dare AM. Denture-related oral mucosal lesions in a Brazilian school of dentistry. J Oral Rehab 2004;31:135- 39. https://doi.org/10.1111/j.1365-2842.2004.01115.x
4. Veena KM, Jagadishchandra H, Sequria J, Hameed SK, Chatra L, Shenai An extensive denture induced hyperplasia of maxilla. Annals of Med Health Sci Res 2013;3:7-9.https://doi.org/10.4103/2141-9248.121208
5. Mortazavi H, Khalighi HR, Jafari S, Baharvand Epulis fissuratum in the soft palate: Report of a case in a very rare location. Dent Hypotheses 2016;1;7:67-69.
6. Mohan RP, Verma S, Singh U, Agarwal Epulis fissuratum: consequence of ill-fitting prosthesis. Brit Med J Case Reports 2013: 1-2https://doi.org/10.1136/bcr-2013-200054
7. Rosenquist K. Risk factors in oral and oropharyngeal squamous cell carcinoma: a population-based case-control study in southern Sweden. Swedish Dent J. Supplement 2005;179:1-66.
8. Awange DO, Wakoli KA, Onyango JF, Chindia ML, Dimba EO, Guthua Reactive localised inflammatory hyperplasia of the oral mucosa. East Afri Med J 2009;86:79-82. https://doi.org/10.4314/eamj.v86i2.46939
9. Esmeili T, Lozada-Nur F, Epstein Common benign oral soft tissue masses. Dent Clinics 2005;49:223-40. https://doi.org/10.1016/j.cden.2004.07.001
10. Macedo Firoozmand L, Dias Almeida J, Guimarães Cabral LA. Study of denture-induced fibrous hyperplasia cases diagnosed from 1979 to 2001. Quintessence Int 2005;36:825-29.
11. Cooper The current and future treatment of edentulism. Journal of Prosthodontics: Implant, Estheti Reconst Dent 2009;18:116-22. https://doi.org/10.1111/j.1532-849X.2009.00441.x
12. Infante-Cossio P, Martinez-de-Fuentes R, Torres-Carranza E, Gutierrez-Perez Inflammatory papillary hyperplasia of the palate: treatment with carbon dioxide laser, followed by restoration with an implant-supported prosthesis. Brit J Oral Maxillofac Surg. 2007; 45: 658-60.https://doi.org/10.1016/j.bjoms.2006.08.005

Muhammad Waseem Ullah Khan1                           BDS, FCPS

Muhammad Asif Mushtaq2                                         BDS

Asif Ali Shah3                                                                   BDS, MDS

 Sarah Ghafoor                               BDS, BSc, PhD 

Junaid Sarfraz Khan                   FCPS, FRCS, Dip. (Med. Edu), M. Med, PhD

INTRODUCTION

The main focus of an undergraduate dental education program is to equip the community with competent dentists who are able to serve societal needs and improve population oral healthcare.1 Pakistan Medical and Dental Council (PM&DC) is the national regulatory body that establishes minimum standards for education and licensure dentistry, and sets standards for the instructors in medical/dental colleges in Pakistan. In addition to basic medical sciences subjects, the initial two years of Bachelor of Dental Surgery (BDS) in Pakistan are devoted towards teaching of pre-clinical basic dental science subjects, which are followed by clinical component beginning in third year of BDS. At the end of each year, a comprehensive examination is taken for final assessment of the students. A minimum of one-year training in a recognized hospital setting is mandatory for registration of dental graduate as independent dental practitioner.2 Majority of the time, this clinical training is based  on  rotational duties in  oral  surgery, prosthetic, periodontology, orthodontics and restorative dentistry.2 Although, such rotations enable the beginner dentist to treat one specific dental problem at one given time but restricts the application of a holistic approach for comprehensively treating the dental patient.

Competency-based Dental Education

The type of training approach given to the graduate may depend on the type of the curriculum that is being taught to the students. Majority of curriculum taught in a dental school broadly fall into two main categories, prescriptive and outcome-based.3 In the former category, more focus is placed on teaching with little or no integration between subjects and across disciplines. This type of education is teacher- centered and requires a large volume of factual knowledge and learning of certain taught traits. The universities in Pakistan are following a change to be in line with the global trends and integrating outcome-based curriculum in which goals of the educational experience are clearly defined and also means to achieve those goals are clearly implemented. Thus undergraduate dental education is now evolving from a discipline-focused and largely teacher-centered approach to an out-come based or competency-based education.1,4 This type of curriculum is broadly student-centered. It also allows vertical and horizontal integration and challenges students for critical thinking.3 As the competency-based education is based on identification of clearly defined learning outcomes, it mainly includes statements of competency, learning experience that supports such competencies and methods for assessment or measuring attainments of these competencies.5

The introduction of a competency-based curriculum had started in the United States in 1993 when Chamber proposed that “Competencies are skills essential to begin practice of dentistry and allied dental practice. Competencies combine appropriate supporting knowledge and professional attitudes that are performed reliably in natural settings without assistance”.6 “Competence” can relate to professional performance or behavior that can include a wide range of personal attributes and qualities such as habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, perceptiveness, creativity, receptivity, social skills and reflection in daily practice for the benefit of the individual and the community being served. It builds on the foundation of basic clinical skills, scientific knowledge, and moral development and involves cognitive function of acquiring and using knowledge to solve real-life problems. 7 Competency can be a transition state toward expertise. It can also be defined as behaviors expected of a beginner and independent dental graduate that incorporates understanding, skills and values in an integrated response to the full range of circumstances that may be encountered in a general professional practice.8 Competency has been further defined by the working party of Competencies for Dental Licensure in Canada as “Competency is most often used to describe the skills, understanding and professional values of an individual ready for beginning independent dental or allied oral health care practice”.9

Since then, competency-based dental education is widely accepted in the profession and is believed to improve student’s performance with problem-solving, critical-assessment, discipline integration; and progressive autonomous self- assessment.10 Therefore, competency documents are constantly being developed by the educational experts and are used as framework to guide and encourage the development of curriculum and for assessment of students.11 They are also used in accreditation of a dental programs to ensure that a specific dental program has adequate depth and breadth of opportunities for students to achieve readiness for dental practice.12 The Association of Canadian Faculties of Dentistry (ACFD) has identified forty-seven competencies that act as a guide for the Canadian dental schools.12-14 Can-Meds is often used as frame work by many professional bodies to identify the core competencies in their graduates.15

The process of becoming a competent dental practitioner is not a simple on-going process but follows a continuum from novice to an expert stage depending upon both the individual and attaining mastery of the skill.1,6,16 For this reason, the educational principals of any dental school focus on facilitation of their graduate’s primary objective which is the integration of their theoretical knowledge into the clinical dental practice while ensuring that the students have gained essential competencies in providing a holistic quality dental treatment.4,17-19 The dental literature has described competency-based dental education relative to pre-clinical and clinical dental practice5,20,21 and dental educators have developed these competencies as a framework to prepare and evaluate dental students in technical, diagnostic knowledge, skills and abilities.8,22,23

It is however important to define, instruct and evaluate competency-based education in Pakistan so as to have a safe dental product. Fresh graduates are believed to be “competent” when they are able to function independently in a realistic practice environment.20 There is a difference that exists between perceived performance and the actual performance. The identification of this is the discrepancy or a “gap” analysis in which current behavior is compared with a “set” or an “accepted standard of practice” or intended competences. The exploration of factors or issues that create gap of practice in individual cases can also help identify the reason for such gaps.24,25

It has been suggested that newly graduated students are reluctant to openly admit a lack of confidence in skills that are essential for entry into a clinical dental practice.26 Therefore, it is necessary in for the undergraduate dental education to ensure that new graduated dentists are competent enough to be designated as safe independent practitioners, and are committed to continue to develop their professional knowledge, understanding and skills.1 Previous published studies highlight the importance of development and validation of a competency system for dental curriculum. The repeated iterations of goals, standard settings, design of experiences and appraisal is essential for transforming dental education institutes into true learning organizations.27,28 It has been shown that essential information leading to reforms in dental curriculum has been generated by surveying dentists regarding competencies in skills, knowledge and attitudes of the dental education program.29 Similarly, the University of Texas Health Sciences Center at San Antonio involved their faculty, students, alumni and outside consultants to re-evaluate the competencies of their program to ensure they are contemporary and methods to asses them are valid and reliable.30 Same has been achieved by assessing competencies for dental public health professionals and physical therapy specialists.31-33 It has been suggested that faculties of dentistry in Canada use the “competencies of beginner dentists” as a bench mark against which the dental curriculum offerings can be measured more appropriately.11

Need for Competent Dental Graduate in Pakistan

Dental education in Pakistan faces many challenges that may include issues related with the educational

environment, type of curriculum taught and limited research resources .34,35 There is a need to revisit the current curriculum design and educational strategies in line with the educational objectives.34 Researchers in Pakistan have proposed certain outcome competencies through brain storming and Delphi technique that (a) Pakistani graduate of dental profession should possess before entering into the community. These include thirty measureable outcomes that have been grouped under two broad categories of “clinical skills” and “professional behaviors”.3 These competencies are based on themes including clinical competence, confidence and multidisciplinary approach, role in health service, treatment planning, attitude, ethical stance and legal responsibilities communication skills, information handling and teaching. It was believed that these themes covered all areas of knowledge, skills and attitude, thus the dental graduates are expected to be functional and competent within our community.36 It is very important to be clear about the qualities of our Pakistani dental product (i.e., the dentist); only it can be ensured that the our graduated product is a safe dental practitioner and is able to perform competently as a junior practitioner in our community.36

Identification of Practice Gaps in Dental Education

In order to evaluate the success of any dental education program, it is very important to ensure that the goals of the curriculum are met with the expected standards. For this reason, it is important that stakeholders such as alumni, academic staff, employers and ultimately patients provide a global perceptive regarding the entire curriculum.11 Through such perspectives, it has been found that majority of dental students desire a curriculum that has a focus on developing clinical experience with more time in clinical environment.37 For this reason, it has been suggested that the professional preparedness of the graduating students can reflect the quality of the dental program. The Association of Canadian Faculties of Dentistry (ACFD) competency document has identified forty-seven competencies that guide Canadian dental schools. These competencies were later validated for a beginner dentist through validity surveys involving recent graduates, licensed dentists, examiners and deans of dental schools in Canada.13 Recently, studies have been done to analyze the importance of competencies expected from graduated Canadian dentists from a student’s perspective in order to identify essential gaps in Canadian dental education.12,38

The Gaps in dental education have been identified from perceptive of various sources such as students, alumni, faculty members, employers and patients. Alumni of the dental school can provide essential information regarding strengths and weaknesses of the curriculum that they have received. Extensive studies have explored graduated student’s perspectives to investigate preparedness of graduating dentists for integration into professional practice. Exploration of student’s perception regarding learning environment, knowledge, skills, confidence and practice management skills has generated valuable data regarding their well- or ill-preparedness and also provided a base-line for curriculum restructuring to prepare students before entering into a competitive dental work force.12,26,35,39-53 Such data from students also provides insights about graduating dental students and their experiences in dental school can help curriculum developer regarding newer trends in dental education, student’s future goals and in comprehensive care curriculum.37,53-56 Similarly, assessment from the teachers regarding performance of their students is also a useful tool to evaluate the overall clinical skills expected from the graduated dentists.57-59 Standardized patients have been used to assess communication and clinical skills of the graduates.60 Employer’s perceptions have also generated important data in assessing clinical competencies of the graduates in a real clinical setting. Such studies have identified low confidence in certain competencies that are expected in dental graduates thus generating valuable information for need of additional or prolong trainings at undergraduate level.61-63 It has been shown that although dental graduates perceived themselves excellent in certain competencies such as treatment planning, community-based skills, administrative and management skills, and professional development skills their employers felt opposite and expressed concern. Thus information generated from such investigation has led to suggestions regarding further reforms in the existing curriculum.63

CONCLUSION

 The curriculum developers and policy makers involved in designing and implementing dental curricula across Pakistan need to devise strategies to formulate an outcome- based dental curriculum that clearly guides educational institutes regarding competences expected from beginner Pakistani dentists and should work on gathering data regarding perception of students, alumni, faculty members, clinical trainers, employers and patients regarding quality of our dental graduate working as an independent dental health care professional.

ACKNOWLEDGMENTS

 We would like to thank all the staff of the Department of Medical Education, University of Health Sciences Lahore and Higher Education Commission of Pakistan (HEC) for providing access to the National e-Library.

CONFLICT OF INTEREST

None to declare

REFERENCES

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 Sarah Ghafoor                               BDS, BSc, PhD 

Junaid Sarfraz Khan                   FCPS, FRCS, Dip. (Med. Edu), M. Med, PhD

Usama Anwar Bhatti                                                      BDS, FCPS

INTRODUCTION

Composite resins have become a popular restorative material substituting amalgam, with longitudinal studies showing comparable results in terms of long term clinical performance.1 However, cross sectional studies have observed a disparity in the clinical performance of these two materials which can be explained in part by the lack of undergraduate training for composite restorations when compared with amalgam.2 Among the different reasons for the failure of composite restorations, postoperative sensitivity is a very common phenomenon, whereby the clinician has to deal with an embarrassing situation while trying to reassure a suffering patient.3 Studies have reported the frequency of postoperative sensitivity to be as low as 5% and as high as 30%.4,5,6 In order to avoid such instances it is important to understand the reasons for development of postoperative sensitivity following placement of composite restorations. This article reviews the reasons for development of postoperative sensitivity as identified in the literature.

The literature has theorized various causes of postoperative sensitivity, for example:

1. Polymerization shrinkage
2. Marginal gaps
3. Suboptimal adhesion
4. Inadequate polymerization
5. Unfavourable C-factor and residual dentin thickness
6. Pre-existing tooth related factors, such as cracks

Polymerization shrinkage

Many of the problems associated with composite resins stem from their inherent tendency to undergo shrinkage. Resin based materials like composites set by a polymerization reaction, which results in a shrinkage of varying degree.7 This polymerization shrinkage can either, generate stress at the bonding interface, transfer stress to the adjacent tooth structure or generate residual stress in the final set material.8 Stresses at the interface can potentially weaken the bond, particularly in cases where cavosurface margins exist entirely in dentin.9 Depending on the compliance of the remaining tooth structure, varying degrees of cuspal deflection has been observed and this may lead to enamel crazes or fracture lines.8,10,11 Cracks may increase flexure of tooth structure under occlusal loading or become an avenue for bacterial ingress. Moreover, movement of dentinal fluid in association with the cuspal deflection can potentially induce postoperative sensitivity depending on the rate and direction of fluid movement.12,13

There have been numerous improvements in material formulation of composite resins to improve clinical performance. In clinical dentistry two most notable areas of improvement have been the minimization of the amount of polymerization shrinkage and reduction in the development of shrinkage stress. The development of silorane based composites with the advantage of reduced polymerization shrinkage of about 1% have provided hope for minimizing the detrimental effects like postoperative sensitivity. However, a recent systematic review and meta analysis of the available clinical studies on siloranes concluded that silorane based composites are not better than conventional methacrylate       based composites in terms of the observed clinical performance in class I and class II restoration of permanent posterior teeth.14 Table 1 summarizes the results of different clinical studies on silorane based composites and postoperative sensitivity.15-25

Bulkfill composites with shrinkage stress relievers and polymerization modulators have been introduced to counter the development of shrinkage stress and in vitro studies have shown these materials exhibit less shrinkage stress than conventional composite resins.26 The results of clinical studies evaluating the postoperative sensitivity associated with the use of bulkfill composites are shown in Table 1. A recent double blind randomized clinical trial while investigating the effect of filling technique on occurrence and intensity of postoperative sensitivity concluded that the risk and intensity  of  postoperative sensitivity was not associated with the filling technique.

Table 1: Summary of clinical studies that evaluated postoperative sensitivity in relation to different types of composites and adhesive strategy

Marginal gap

The polymerization shrinkage stresses have the potential to create a marginal gap in areas deficient in enamel. It has been proposed that a gap at the tooth- restorative margin is a potential site for bacterial ingress as well as portal for fluid exchange leading to a movement of dentinal fluid in the tubules and subsequent postoperative sensitivity.27,28 Clinical situations with an extension of the cavity margin to dentin, like a deep class II and class V, create a challenge for the placement and adaptation of the composite to the dentinal margin. The formation of a gap along this cavosurface margin can potentially invite postoperative sensitivity,5 microleakage and secondary caries in the long run.2

However, the results from clinical studies have not been able to establish an unequivocal link between marginal gap and postoperative sensitivity.29,30 A systematic analysis of the literature found a lack of correlation between the percentages of margins with gaps and clinical outcomes; moreover, a correlation between microleakage and secondary caries, hypersensitivity and marginal discoloration could not be demonstrated.31

Additionally, the adaptation of the composite has been to shown to be affected by the c- factor and compliance of the cavity; with both bulk fills and conventional composites demonstrating inferior adaptation in such clinical situations.32 The findings from different in vitro studies concluded that bulkfill composites do not ensure an improvement in marginal adaptation in class II situations, rather the presence or absence of enamel at the restorative margin is a more important predictor of marginal adaptation.33,34,35,36 A recent systematic review also concluded that application of flowable composites cannot improve microleakage.37

Despite the improvement in adhesives, enamel still remains the most favorable substrate for bonding. Although reasonable bond strength can be achieved when bonding to dentin alone, the long term bond longevity is questionable due to the hydrolytic degradation of the hybrid layer components.9

Suboptimal adhesion

The technique sensitive nature of the adhesive procedure for composite restoration demands meticulous attention to detail by the clinician, failing to do so often results in postoperative sensitivity and  restoration  failure.4 A common mechanism for persistent postoperative sensitivity is when a gap forms beneath the restoration and fills with dentinal fluid. When cold or hot stimuli cause contraction or expansion of fluid in this gap, the consequent sudden movement of fluid in the dentinal tubules causes pain.28 This gap formation beneath the restoration could be either from a void in the composite material being placed on the floor of the cavity, the pulling away of composite from pulpal floor due to shrinkage stress38 or it could be a gap in the hybrid layer due to insufficient resin infiltration resulting in the formation of a “hybridoid layer”.39 Moreover, even the use of bulk fill flowable composites has not been able to eradicate the formation of gaps over the internal walls of the restored cavity,40 while the use of the traditional incremental technique with conventional composite has demonstrated a better internal adaptation.41 The research on the benefits of applying a flowable composite over the pulpal floor for the sake of eliminating postoperative sensitivity has shown conflicting results. However, a recent Cochrane review of the literature has deemed the evidence “low quality” and discredited the notion of perceived benefit of using flowable liners under composite restorations.42 It has been identified that the inadequate permeation of the demineralized dentin during the restorative procedure is a significant contributor to postoperative sensitivity. The risk of postoperative sensitivity and development of “hybridoid layer” has been regarded higher with etch and rinse adhesives as compared to self-etch adhesives due to the elimination of the smear layer in the former and the simultaneous demineralization and resin infiltration in the latter.43 The results of clinical trials investigating the role of adhesive strategy in causing postoperative sensitivity have shown mixed results with some studies24,43,44,45 claiming no association between the two while others46,47 have reported a statistically significant difference in the postoperative sensitivity and adhesive approach. However, meta-analysis and systematic reviews have found no significant association of bonding strategy with the risk and intensity of postoperative sensitivity.48,49 The details of different clinical studies comparing adhesive strategies in relation of postoperative sensitivity are summarized in Table 2.

Irrespective of the adhesion strategy used, the presence of a collagen matrix without any resin support is vulnerable to accelerated aging and degradation.9,50 Quality of substrate available for adhesion varies across the prepared tooth surface, with areas of caries affected dentin, sclerosis and high tubular density present an adhesive challenge due to a difference in water and mineral content.9 Presence of caries affected dentin at the marginal interface of the restoration makes it an unsuitable substrate for predictable adhesion and marginal adaptation contributing to postoperative sensitivity.5,9

Inadequate polymerization

Even the stiffest composites are relatively flexible in comparison to the stiffness of tooth enamel, as evident by the difference in the modulus of elasticity.51 The flexure of composite restoration in relation to the tooth can produce pressure changes in the dentinal tubular fluid and  a subsequent fluid movement can in turn provoke pain on chewing. 5 2       However , composites applied in sufficient bulk rarely exhibit flexure of this magnitude to induce sensitivity on biting unless     the      degree of polymerization of the material was not in the acceptable limits, leading to a “soggy bottom” phenomenon. 53

Clinical situations often require placement of composite in deep cavities where if adequate intensity of the curing light is not provided then the in situ polymerization of the adhesive resins and formation of the hybrid layer is jeopardized leading to a premature bond failure and postoperative sensitivity.54 The placement and subsequent curing of conventional composites in bulk can result in a similar situation, whereby complete polymerization of the material to the entire depth is not achieved. However, modern bulkfill composites have demonstrated a promising degree of polymerization in relation to conventional composites55,56 and clinical studies on comparison between bulk and incremental filling show no significant difference in the occurrence of reported p o s t o p e r a t i v e sensitivity.22,23,24,25

Table 2: Summary of clinical studies that evaluated postoperative sensitivity in relation to different adhesive strategies and adhesive systems

Table 3: Summary of clinical studies on postoperative sensitivity in relation to cavity type

In terms of the biological properties of the composite resins, the process of polymerization is not complete in the set material; 25-50% of the monomer double bonds remain unreacted and this monomer has the potential to irritate the

investigated under different conditions and it may take place either due to incomplete polymerization and/or material degradation, thus highlighting the importance of adequate polymerization to minimize the adverse effects from residual monomer like pulpal irritation and postoperative sensitivity. However, we cannot prevent material degradation in the oral environment and the eluted monomer can produce ill effects in the pulp. Luckily, the detrimental effects of the residual monomer are inversely proportional to the residual dentin thickness.58

Unfavourable C-factor and residual dentin thickness

The occurrence of postoperative sensitivity can be theorized to occur more frequently in the posterior teeth than the anterior. This can be explained by the difference in configuration of the cavities prepared on anterior and posterior teeth. The C-factor (ratio of bonded to unbonded surfaces) influences the ability of the unpolymerized portion of the composite to compensate for the shrinkage stresses.59 As understood the greater C-factor of the cavities prepared in the posterior teeth results in reduced compensation for shrinkage stress and leads to greater stress accumulation at the bonding interface, initiating the sequel of microleakage and sensitivity.60 The relatively large size of the cavities made in the posterior teeth require a larger bulk of the composite to restore them, the added bulk also contributes to an increased polymerization shrinkage and shrinkage stress.61 However, clinical studies fail to demonstrate this association of C-factor or cavity type with postoperative sensitivity.24,52 The frequency of postoperative sensitivity as reported in different clinical studies in relation to the type

of cavity is shown in Table 3.4,5,23,29,52,62

Another possible reason for postoperative sensitivity could be the increased cavity depth or reduced thickness of residual dentin. As the cavity preparation depth increases the tubular density is also increased making it more challenging to control dentin wetness and ensure optimal adhesion.9 The application of the etchant in such deep cavities as part of the etch and rinse approach removes the smear layer and increases the dentin permeability making the tooth vulnerable to postoperative sensitivity if adequate sealing of tubules is not achieved by hybridization. Initially it was believed that the use of acid etchants on the dentin can irritate the pulp but Fusayama’s total etch procedure eventually helped alleviate any concerns pertaining to acid etching of dentin.63 The higher percentage of postoperative sensitivity reported in multi surface restorations as seen in Table 3 could be explained by the greater removal of tooth structure and reduction in residual dentin thickness.24

The placement of composite restorations in close proximity to the pulp without an appropriate bonded liner/base would increase the risk of postoperative sensitivity in case of a compromised adhesion resulting from a failure in the hybridization process. Clinical studies on the other hand observed that a reduction of the residual dentin thickness in deep cavities was found to be associated with greater postoperative sensitivity irrespective of the presence or absence of a cavity liner.23,62 Although, the literature in the past has been split over the use of a resin modified glass ionomer (RMGI) base/ liner beneath composite restorations; in deep cavities with questionable bonding substrates placement of a RMGI base/liner has been regarded as a prudent practice.62,64 However, a recent Cochrane review concluded that the evidence regarding the use of liners in class I and II is inconsistent and low quality.65

Pre-existing tooth related factors

Prior to delivering a restoration to any tooth, thorough investigation should be carried out to exclude the presence of any pre-existing cracks or pulpal inflammation. Cracks can develop in the tooth due to masticatory insults over a period of time and can create a diagnostic puzzle.66 Restoring cavities with an intercuspal width exceeding one quarter are at an increased risk of crack development.67 Following cavity preparation any visible crack should be identified and the patient informed accordingly, as symptoms arising from a cracked tooth can mimic reversible pulpitis68 but may not be resolved with composite restoration. A clinical study evaluating the resolution of symptomatic cracked teeth following adhesive composite restorations with or without cuspal coverage reported only 50% teeth to be symptom free on clinical examination.69 Hence, restoration of a tooth with an unidentified crack can even result in symptoms that can be confused with postoperative sensitivity.70

CONCLUSION

 The development of modern adhesives combined with the improvement in handling of composites by the clinicians has resulted in a marked reduction of postoperative sensitivity. However, the occurrence of postoperative sensitivity is still a threat to the survival of the composite restorations along with bulk fracture, secondary caries and surface wear.43 In this article, following the review of literature, various reasons were explained for the phenomenon of postoperative sensitivity associated with composite restorations. An understanding of these reasons is important for the dental practitioner to avoid the development of postoperative sensitivity in the delivered restorations so they can survive and provide service to the patient.

The perpetual development of new composite resin materials creates a scarcity of long term clinical data on a particular type of material. A systematic review and meta- analysis is required for understanding the clinical implications of the results from the plethora of clinical studies on the subject of postoperative sensitivity.

CONFLICT OF INTEREST/ FINANCIAL DISCLOSURE

The author denies any plausible conflict of interest. The author denies any financial interest in the subject matter or materials discussed in this manuscript.

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59. Koshiro K, Inoue S, Sano H, De Munck J, Van Meerbeek B. In vivo degradation of resin-dentin bonds produced by a self-etch and an etch-and-rinse adhesive. Eur J Oral Sci. 2005;113:341-48 https://doi.org/10.1111/j.1600-0722.2005.00222.x
60. Ferracane Resin composite-state of the art. Dent Mater. 2011;27:29-38https://doi.org/10.1016/j.dental.2010.10.020 
61. Auschill TM, Koch CA, Wolkewitz M, Hellwig E, Arweiler Occurrence and causing stimuli of postoperative sensitivity in composite restorations. Oper Dent. 2009;31:3-10https://doi.org/10.2341/08-7 
62. Shortall AC, Palin WM, Jacquot B, Pelissier Advances in light curing units, four generations of led lights and clinical implications for optimizing their use, part2.From present to future. Dent Update. 2012;39:13-22https://doi.org/10.12968/denu.2012.39.1.13 
63. Dunne SM, Millar BJ. Effect of distance from curing light tip to restoration surface on depth of cure of composite Prim Dent Care. 2008;15:147-52 https://doi.org/10.1308/135576108785891150 
64. Leprince JG, Palin WM, Vanacker J, Sabbagh J, Devaux J, Leloup
65. Physico-mechanical characteristics of commercially available bulk- fill composites. J Dent. 2014;42:993-1000 https://doi.org/10.1016/j.jdent.2014.05.009 
66. Alrahlah A, Silikas N, Watts Post-cure depth of cure of bulk fill dental resin-composites. Dent Mater. 2014;30:149-54 https://doi.org/10.1016/j.dental.2013.10.011
67.  
68. Sharma S, Padda BK, Choudhary Comparative evaluation of residual monomer content and polymerization shrinkage of a packable composite and an ormocer. J Conserv Dent. 2012;15:161-65 https://doi.org/10.4103/0972-0707.94592
69.  
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71. Giachetti L, Scaminaci Russo D, Bambi C, Grandini A review of polymerization shrinkage stress: current techniques for posterior direct resin restorations. J Contemp Dent Pract. 2006;7:79-88
72. Dos Santos GO, Dos Santos ME, Sampaio EM, Diass KR, Da Silva Influence of C-factor and light-curing mode on gap formation in resin composite restorations. Oper Dent. 2009;34:544-50 https://doi.org/10.2341/08-035-L 
73. Opdam NJ, Feilzer AJ, Roeters JJ, Smale Class I occlusal composite resin restorations: in vivo post-operative sensitivity, wall adaptation, and microleakage. Am J Dent. 1998;11:229-34
74. Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine Composite resin restoration and postoperative sensitivity: clinical follow-up in an undergraduate program. J Dent. 2001;29:7-13 https://doi.org/10.1016/S0300-5712(00)00037-3 
75. Fusayama New concepts in operative dentistry. Chicago: Quintessence, 1980
76. Akpata ES, Sadiq Post-operative sensitivity in glass-ionomer versus adhesive resin-lined posterior composites. Am J Dent. 2001;14:34-38
77. Schenkel AB, Peltz I, Veitz-Keenan A. Dental cavity liners for Class I and Class II resin-based composite restorations. Cochrane Database Syst 2016 Oct 25;10:CD010526 https://doi.org/10.1002/14651858.CD010526.pub2 
78. Trushkowsky R. Restoration of a cracked tooth with a bonded Quintessence Int. 1991;22:397-400
79. Mondelli J, SteagallL, Ishikiriama Fracture strength of human teeth with cavity preparations. J Prosthet Dent. 1980;433:419-22 https://doi.org/10.1016/0022-3913(80)90213-9  
80. Banerji S, Mehta SB, Millar Cracked tooth syndrome. Part 1: aetiology and diagnosis. Br Dent J. 2010;208:459-63 https://doi.org/10.1038/sj.bdj.2010.449 
81. Opdam NJ, Roeters FJ. The effectiveness of bonded composite restorations in the treatment of painful, cracked teeth: six-month clinical evaluation. Oper Dent. 2003;28:327-33
82. Porto Post-operative sensitivity in direct resin composite restorations: clinical practice guidelines. Ind J Rest Dent. 2012;1:1- 12

Usama Anwar Bhatti                                                      BDS, FCPS

Talha M Siddiqui                                                                                  BDS, MCPS

Aisha Wali2                                                                                                         BDS, MPH

Mortaza Azimi3                                                                                            BDS

Tawoos Salehi4                                                                                             BDS

Sohaib Mahmood Siddiqui5                                                   BDS                                                                                            

INTRODUCTION

Social inequalities in health and oral health outcomes are measured by level of education, profession, monthly earnings and type of housing or combination of various indicators.1,2 Current evidences suggested that lower the standard of living, the worsen the health status that could be irrespective of the measure.1-4 When compared to adult populations, social differences in general health and oral health amongst children and adolescents have received relatively little attention.5 Socioeconomic status is classified into three categories, high socioeconomic status, moderate socioeconomic status and low socioeconomic status.

Oral health is an important part of general health and numerous studies reported an association between socioeconomic factors and oral health.7-12 Dental caries is one of the most common infectious diseases despite of its widespread preventive measures, this disease exerts a social, physical, mental and financial burden globally especially in developing countries.13 Although frequency of dental caries has declined in the past decades amongst adolescents and adults14,15 but still the burden remains high in underprivileged and adult populations. Waseem F16 in a study reported an association between the frequency of dental visits and the socioeconomic status. Amin M et al17 in a study reported an association between Dental caries and socioeconomic status. Schwendicke et al18 reported that adults with lower educational level or lower monthly earnings were more likely to fall in the category of higher risk of dental caries. There is an intricate association between socioeconomic status and oral health18-20 Hobdell et al21 in a study also reported a marked relationship between oral diseases and socioeconomic status. The results from the previous studies reported that people from low socioeconomic status have poor oral health than those with a higher socioeconomic status and that oral health deteriorate gradually from higher socioeconomic status to lower socioeconomic status.22,23 Low socioeconomic status, low monthly household earnings and low educational level are associated with least access to dental health facilities and oral hygiene products, poorer knowledge regarding oral and dental health and subsequently a greater frequency and severity of dental caries.24

The aim of the present study was to assess the relation between socioeconomic status and Dental caries in patients attending Out Patient Department of Baqai Dental College.

METHODOLOGY 

A cross sectional study was conducted in the Department of Oral Diagnosis, Baqai Dental College from 26th April 2017 to17th December 2017. The study was approved by Ethical Committee, Baqai Medical University. The sample size was calculated by taking 50% prevalence rate and computed using Open Epi version 3.03a at 95% confidence interval and a =5%. The sample size calculated was 384. The subjects were conveniently selected for the purpose of this study. Patients aged 18-45 years from all socioeconomic status were included in the study.6

Oral examination was conducted by two calibrated, trained examiners according to WHO criteria.24 Dental caries was recorded by using plain mouth mirror, Community Periodontal Index (CPI) probe with the patient seated on a dental chair. All teeth were examined in a systematic manner using international FDI nomenclature to identify each tooth. The patients were asked to rinse mouth thoroughly before intraoral examination starts and the teeth were then dried with cotton swab and dental caries was recorded using the DMFT index corresponding to the average number of decayed, missing and filled permanent teeth. A structured questionnaire was developed which included questions regarding decayed teeth, self-earners, house ownership, periodic loan dental visits, brushing habits.

Data was analyzed for frequency and percentages of different variables and chi square test was used to check for association between residence and socioeconomic status, decayed teeth and socioeconomic status by using IBM SPSS version 22. P- value was set at 0.05

RESULTS

A total of 384 patients (211 males and 173 females) were examined with the response rate of 100%. (Table 1)

Socioeconomic status was divided into low monthly income, average monthly income and high monthly income. Table 2 showed association of residence with socioeconomic status and out of 327 patients, 189(57.8%) belonged to rural area with an average monthly income. Distribution of decayed teeth and its association with socioeconomic status was reported in table 3 and 126(38.5%) of patients from an average monthly income, and 24(42.1%) from low monthly income, each reported only one decayed teeth. Association of socioeconomic status with different variables was shown in Table 4, 273 (83.5%) of patients were self -earners, 269(82.2%) from average monthly income had their own house, 206(63%) of the patients from average SES were too much concerned about their dental health, 214(65.4%) of the patients from average SES reported that there is a dental facility near their house.

Table 1: Distribution of gender and residence

DISCUSSION

The present study reported an inverse relationship between socioeconomic status and dental caries. Socioeconomic factors are key determinants of oral health inequalities.25 Numerous studies have shown inverse relationship between socioeconomic status and prevalence of dental diseases and as socioeconomic status increases, the incidence and prevalence of  dental  diseases and their consequences decreases, while on the other hand, the individuals with low socio-economic status have poor oral conditions.26 Amin et al17 in a study reported that monthly income level has no statistically significant association with decayed teeth. The present study reported that dental caries was more seen in individuals with average monthly income. Carmichael et al27 were unable to report statistically significant effect of monthly income and prevalence of dental caries. Wang et al28 in a study reported that participants with higher monthly earnings had lower prevalence of dental caries. Low monthly earnings has been closely associated with lower level of education29 and thus poor people display lack of knowledge of caries prevention with higher frequency of dental caries.30 It was reported in the present study that about 15% of the families were from low monthly income (< 10,000) and 85% of the families were from average monthly income (> 10,000). 126(38.5%) of the patients from average monthly income and 24(42.1%) of patients from low monthly income reported only one decayed tooth. Kattula D et al31 in a study reported 60% of the families in the area earned an income of less than Rs 5000 per month and only 2% of the households had a family income more than Rs.20000 per month. Sixty three percent of the families resided in permanent houses and 10.8% had crude or raw houses. The present study reported that 269(82.2%) of the patients from average monthly income owned houses and 35(62.5%) of the patients from low monthly income owned houses. Chandra Shekar B et al32 in a study reported that prevalence of dental caries was 29(43.3%) from upper socioeconomic status and 8(78.6%) from low socioeconomic status.

Factors that are associated with dental caries includes demographic profile, food intake , fluoride usage and access to oral and dental health care services.14,33 Results of some studies showed the effects of socioeconomic factors on oral health-related behaviours in adolescents and adults.34,35 Ashok B et al36 in a study reported that 91.8% of the patients in the lower socioeconomic status have a caries exposure, while only 82% and 73.4% of the moderate and higher socioeconomic status respectively. Waseem F et al16 in a study reported that tooth brushing was more frequent amongst high socioeconomic status whereas low socioeconomic subjects did not regularly brushed their teeth. Rasidi M et al37 in a study reported that dental caries from the low socioeconomic status was higher when compared to the patients belonging to average socioeconomic status. Wang et al28 in a study reported that only 32.8% of the patients brushed their teeth at least twice a day and only 1.2% flossed their teeth. The present study reported that 192(59.1%) of the patients from average monthly income brushed their teeth once a day and 35(61.4%) from low monthly income. Alvarez L et al38 reported that prevalence of dental caries was 55.9% and 28.9% in adults and elderly people, respectively. Severity of dental caries was related to older age individuals, low socioeconomic status, use of dental public health services, lack of frequent brushing, gingival bleeding, and self-perceived need for dental health care services.39

Attitudes towards oral health depends on their socioeconomic status. In the presence of high-socio economic status, better oral health is experienced, and lower dental caries rates are observed.40 The dental visits are important as oral diseases can be diagnosed, managed, and even avoided on time, and personal oral hygiene guidelines can be constantly reminded to dental practice visitors.41-47 Some studies have highlighted that low-socioeconomic status families visit a dentist more frequently due to pain or discomfort.48-50 Waseem F et al16 in a study reported statistically significant results observed between frequencies of dental visits with socioeconomic status. It has been reported that people from low socioeconomic status were less likely to have dental visits to a dental care specialist.51-53 The present study reported that 69(21.1%) of the patients from average monthly income often visits dental clinics once in 3 months and 258(78.9%) visited once in 6 months.

LIMITATIONS

The present study was limited around certain aspects which included inequality in the sample size. The sample should be collected on a larger scale. The measurement of socioeconomic status and monthly income was missing.

CONCLUSION

The present study reported an inverse relationship between socioeconomic status and dental caries. The number of patients from low socioeconomic status showed less number of decayed teeth.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Locker Deprivation and oral health: a review. Community Dent Oral Epidemiol 2000;28:161-69.https://doi.org/10.1034/j.1600-0528.2000.280301.x
2. Watt From victim blamimg to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol 2007;35:1-11.https://doi.org/10.1111/j.1600-0528.2007.00348.x 
3. Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG: Social gradients in oral and general health. J Dent Res 2007;86:992-96. https://doi.org/10.1177/154405910708601014 
4. Torsheim T, Leversen I, Samdal O: Adolescent health inequality: are behavioral factors important? Nor J Epidemiol 2007;17:79-8.
5. Polk DE, Weyant RJ, Manz MC: Socio-economic factors in adolescents’oral health: are they mediated by oral hygiene behaviors or preventive interventions? Community Dent Oral Epidemiol 2010; 38:1-9.https://doi.org/10.1111/j.1600-0528.2009.00499.x Afshan S. Defining income groups. dawn.com.
6. Petridou E, Athanassouli T, Panagopoulos H, Revinthi K. Socio- demographic and dietary factors in relation to dental health among Greek Community Dent Oral Epidemiol 1996;24:307-11. https://doi.org/10.1111/j.1600-0528.1996.tb00867.x 
7. Friere MD, Melo DR, Silva Dental caries prevalence in relation to socio-economic status of nursery school children in Goiania-GO, Brazil. Community Dent Oral Epidemiol 1996;24:357-61. https://doi.org/10.1111/j.1600-0528.1996.tb00876.x
8. Whittle JG, Whittle House hold income in relation to dental health and dental health behaviors: The use of super profiles. Community Dent Health 1998;15:150-54.
9. Hosani EA, Rugg-Gunn Combination of low parental educational attainment and high parental income related to high caries experience in pre-school children in Abu-Dhabi. Community Dent Oral Epidemiol 1998;26:31-6.https://doi.org/10.1111/j.1600-0528.1998.tb02080.x
10. Text book of clinical pedodontics. 4th ed. USA: WB Saunders Company; 1991. p. 470.
11. Cameron A, Widmer R. Handbook of pediatric dentistry. 3rd ed. Mosby Elsevier;
12. Pitts N, Amaechi B, Niederman R, et Global oral health inequalities: dental caries task group-research agenda. Adv Dent Res 2011;23:211-20.https://doi.org/10.1177/0022034511402016 
13. Do LG, Lg Distribution of caries in children: variations between and within populations. J Dent Res 2012;91:536-43. https://doi.org/10.1177/0022034511434355 
14. Waseem F, Hussain A, Maqsood A, Sultan M. Socioeconomic status and oral health care attitudes: A snapshot of Karachi based teaching hospital. Pak Oral & Dent J. 2015;35:49-52.
15. Amin M, Amanullah M, Tarar AM. Dental Caries, Periodontal Disease and their Associated Factors Among Patients Visiting Dental Teaching Hospital in Multan, Pakistan. J Pak Dent Assoc 2016;25: 98-102.
16. Schwendicke F, Dörfer CE, Schlattmann P, et al. Socioeconomic inequality and caries: a systematic review and meta-analysis. J Dent Res 2015;94:10-18.https://doi.org/10.1177/0022034514557546 
17. Listl Income-related inequalities in dental service utilization by Europeans aged 50+. J Dent Res 2011;90:717-23. https://doi.org/10.1177/0022034511399907
18. Han DH, Khang YH, Choi HJ. Association of parental education with tooth loss among Korean Elders. Community Dent Oral Epidemiol 2015;43:489-99.https://doi.org/10.1111/cdoe.12172 
19. Hobdell MH, Oliveira ER, Bautista R, et al. Oral diseases and socio-economic status (SES). Br Dent J 2003;194:91-6. https://doi.org/10.1038/sj.bdj.4809882 
20. Steele J, Shen J, Tsakos G, et The Interplay between socioeconomic inequalities and clinical oral health. J Dent Res 2015; 94:9-26.https://doi.org/10.1177/0022034514553978 
21. Kim DW, Park JC, Rim TT, et al. Socioeconomic disparities of periodontitis in Koreans based on the KNHANES Oral Dis 2014; 20:551-9.https://doi.org/10.1111/odi.12168
22. Holst , Schuller A.A., Aleksejuniené J., Eriksen H.M. Caries in population-A theoretical, causal approach. Eur. J. Oral Sci. 2001;109: 143-8.https://doi.org/10.1034/j.1600-0722.2001.00022.x 
23. World Health Organization. Oral Health Assessment form. Oral Health Surveys, Basic 4th ed. Geneva: W H O press; 1997. p. 26-9.
24. British Dental Association. Oral health inequalities London: British Dental Association, 2009. http://www.bda.org/inequalities (accessed March 2013).
25. Carmichael , French A., Rugg-Gunn A., Furness JA.: The relationship between social class and caries experience in five years old children in Newcastle and Northumberland after twelve years’ fluoridation. Community Dent. Health;1984;1:47 -54.
26. Wang, L., Cheng, L., Yuan, , Hong, X., & Hu, T. Association between socio-economic status and dental caries in elderly people in Sichuan Province, China: a cross-sectional study. Brit Med J Open, 2017. 7, e016557.https://doi.org/10.1136/bmjopen-2017-016557 
27. Kattula D, Venugopal S, Velusamy V, et al. Measuring Poverty in Southern India: A Comparison of Socio-Economic Scales Evaluated against Childhood Stunting. Zeeb H, PLoS ONE. 2016;11(8):e0160706. https://doi.org/10.1371/journal.pone.0160706 
28. Chandra Shekar B R, Reddy C. Oral health status in relation to socioeconomic factors among the municipal employees of Mysore Indian J Dent Res 2011;22:410-18. https://doi.org/10.4103/0970-9290.87063 
29. Cornejo-Ovalle M, Paraje G, Vásquez-Lavín F, et al. Changes in socioeconomic inequalities in the use of dental care following major healthcare reform in Chile, 2004-2009. Int J Environ Res Public Health 2015;12:2823-36.
30. https://doi.org/10.3390/ijerph120302823

Talha M Siddiqui                                                                                  BDS, MCPS

Aisha Wali2                                                                                                         BDS, MPH

Mortaza Azimi3                                                                                            BDS

Tawoos Salehi4                                                                                             BDS

Sohaib Mahmood Siddiqui5                                                   BDS                                                                                            

M Yousaf¹                                                                            PHD                                            

Adil Yousaf²                                                                            BDS

Farheen Khanum³                                                               M.Phil                               

Saleha Gul⁴                                                                               M.Phil

Saira Gul⁵                                                                                 DVM                                                                                                  

INTRODUCTION

Chronic periodontitis is the advanced stage of periodontal disease which leads to a significant loss in  the  supporting structure of  teeth and   their attachment at different stages.1,4 The disease is mostly common in adults but may affect all age groups depending upon the overall health status of an individual.5-7 The extent of the tooth disease can be assessed by measuring the level of biomarkers in saliva, gingival fluid or serum of the patient. The important biomarkers in the diagnosis and prognosis of periodontal disease are micro-organisms, their products or enzymes derived from the host cells which are released during degradation of connective tissue.7 The biomarkers widely used to assess the oral health, are Alkaline Phosphatase (ALP), Creatin Phospho Kinase (CPK) and serum Calcium. Saliva, Gingival Crevicular fluid, serum and dental plaque are often utilized for the quantification of these biomarkers. Among these biomarkers Alkaline phosphatase (ALP) is one of the strong diagnostic marker for periodontal disease and is usually measured to determine the extent of tooth disease.9 Its activity in periodontal ligament is an important parameter in assessing the severity of the disease.10 The high activity of ALP in periodontitis is the result of increase in bone turnover, bacterial plaque in periodontal pocket and inflammation.11

The activity of CPK increases in gingival inflammation and is considered as an important marker both in periodontal disease and cardiovascular diseases.

Shimazaki et al observed a significant negative association between normal serum CPK level and periodontitis in male subjects.12

Calcium is a potent biochemical marker for determination of decalcification and structural changes in alveolar bone, as calcium concentration rises in the patients with chronic periodontitis. In case of calcium deficiency desorption of alveolar bone show the initial structural changes in periodontitis.13,14

The potential role of ALP, CPK and Ca in measuring the extent and cause of periodontal disease could also be useful in measuring other diseases that are related to dental diseases.

Khyber Pakhtun Khwa is far behind in literacy rate, primary health care and other socioeconomic facilities. The dietary habits and unhealthy life style make them more vulnerable to various diseases including chronic periodontitis. We conducted this cross sectional analysis among male and female chronic periodontitis patients visiting Khyber College of dentistry in Peshawar Pakistan to compare their serum level of biochemical markers, the severity of the disease in both genders and also asses the associated risk of other diseases.

METHODOLOGY

This study was conducted in Khyber College of Dentistry (KCD) Peshawar from June 25, 2017 to August 18, 2017. The study was approved by the ethical committee of Khyber College of Dentistry, Peshawar. The subjects of the study include 40 male and 40 female confirmed periodontitis patients of different age groups visiting KCD for routine checkup. Informed consent was taken from each patient and information were collected on a standard questioner designed for this study.

Purposive sampling method was used in the selection of the study population. Five ml of fasting fresh blood sample was taken from all the patients and was analyzed for the quantification of serum ALP, CPK and Ca using standard methods.

Serum Alkaline phosphatase (Normal value: 52-192 U/I) and Creatine phosphokinase (Normal value: 26-171U/I) were determined according to the International Federation of Clinical Chemist (IFCC) recommendations.15,16

Serum Calcium ions (Normal value: 8.7-10.4 mg/dL) was determined by Spectrophotometric method (complexation with Arsenazo) and its concentration was measured at 650 nm.17,18

Statistical analysis of the acquired data was carried out using SPSS 21.0 software and Microsoft Excel. Values were reported as mean ± standard deviation. Pearson’s correlation analysis was also done to find correlation between the variables of our interests. A two-tailed P-value <0.05 was considered statistically significant.

RESULTS

The age and BMI of study population are shown in Table 1. The mean age (40.52 years) and BMI (24.70 kg/m2) of female population was slightly higher than the mean age (40.50 Years) and BMI (24.70 kg/m2) of male population. Tea and soft drinks users were found higher in males (92.5%) than females (82.5%). The percentage of smokers was higher in males (76.5%) than in female population (05%) as shown in Fig 01

Table 1: Age and BMI of the study patients

F: Female, M: Male, Min: minimum, Max: maximum, S.D: Standard Deviation

Mean values of serum ALP, CPK and Ca are given in table 2. The mean values of serum ALP (203.92 U/I) and Ca (10.28 mg/dL) was higher in female subjects as compared to the male subjects (ALP: 195 U/I; Ca: 10.12 mg/dL).

Fig 01: Comparison of tea, soft drinks users and smokers in study patients

Mean values of serum ALP, CPK and Ca are given in table 2. The mean values of serum ALP (203.92 U/I) and Ca (10.28 mg/dL) was higher in female subjects as compared to the male subjects (ALP: 195 U/I; Ca: 10.12 mg/dL).

Table 2: Comparison of ALP, CPK and Ca of the study patients

The noted in females and positive in male subjects. Significant correlation of CPK (p = 0.001) was found with age in females while positive correlation was found for CPK in both the groups with other variables. Negative correlation of CPK was found with BMI in both male and female population. Significant correlation for Ca was observed with age and BMI in females (P=0.01).

*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed

DISCUSSION

Biochemical markers are important in the diagnosis of diseases when these are leaked as the immune system of body becomes weak. There are a number of evidences which suggests strong relationship between high serum ALP and low CPK level in periodontitis and high CPK level in patients with coronary heart diseases.

In this study a higher mean level of ALP was found in both the study group (Male: 195.45 U/I, Female: 203.92 U/I) than the normal level (52-192 U/I). This finding is accordance with the observations of Jaiswal et al (2016) and Shaheen et al.19,20 They observed higher level of alkaline phosphatase among chronic periodontitis patients without any sub categorization of severity of the disease. Gibert also found higher serum level of ALP in both male and female patients.21

Mean values of CPK were found normal (26-171 U/I) for both groups (Male: 143.82 U/I; Female: 122.58 U/I) but was lower for female than the male subjects. Lower levels of creatine kinase, higher level of C-reactive protein and increased inflammation have been reported in patients suffering from severe periodontitis. It is believed that degradation of connective tissue in periodontitis leads to increase in release of creatine phosphokinase, thereby showing significant increase in chronic periodontitis subjects.22 We observed a higher level of CPK in male patients as observed in other similar studies.23

The mean serum values of Ca were 10.12 mg/dL and 10.28 mg/dL for male and female subjects respectively (Normal range; 9 – 11 mg/dL). In periodontitis patients, due to alveolar bone destruction, serum calcium level may increase as found in many research studies.24,25 Higher serum level of calcium was seen in male subjects as compared to female subjects in this study. The present study show that serum Ca has an important role in the formation of calculus which is carried by dental plaque and degree of attachment loss because the percentage of smokers in male subjects, soft drink and tea users was higher than females.

Periodontal diseases are strongly linked with cardiovascular and chronic kidney diseases, but the association is not very much clearly understood.26,27 The elevated level of CPK observed in this study add evidence in these relations and open up a new possible pathway in the complex puzzle that is a periodontal-systemic health relation. Periodontal disease is associated with many other diseases. ALP, CPK and Ca are not only used to detect the level/degree of dental diseases but are also used to measure the patient’s overall health status.28,29

The potential role of ALP, CPK and Ca in measuring the extent and cause of disease could be useful in measuring other diseases that are related to dental diseases.

Chronic periodontitis get worsen with age along with other risk factors. Various risk factors which can induce periodontitis can be minimized by maintaining proper oral hygienic measures and our study concluded that lifestyle related risk factors associated with chronic periodontitis results in the progression of disease. Prevention is the better way of limiting diseases. Dental diseases are mostly related with the person’s lifestyle.

The results of this study should be interpreted with caution to establish the mechanisms behind observed associations, as this study was conducted only on a limited number of subjects of Peshawar city only. Prospective studies involving larger population size are required to clarify the relationships between these serum markers and chronic periodontitis and their roles in the relationship between periodontitis and other diseases.

CONCLUSION

The results of our study suggests that female subjects are at greater risk of periodontitis and alveolar bone degradation in term of mean values of serum ALP and Ca than the male subjects while the higher mean values of serum CPK  in male subjects  put  them  at higher risk of cardio vascular disease than  the female subjects.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Mariotti Dental plaque-induced gingival diseases. Ann. Periodontol 2014;4:7-19. https://doi.org/10.1902/annals.1999.4.1.7
2. Van Dyke TE. The management of inflammation in periodontal disease. J Periodontol 2013;79:1601-08. https://doi.org/10.1902/jop.2008.080173
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