Vol. 28 No. 03 Jul-Sep 2019

Ayesha Iqbal                    BDS, MSc

Sarah Hanif                      BDS

Suraiya Hirani                  BDS, MSc

Faiza Arif                          BDS

Sarah Hussain                 BDS

INTRODUCTION

The virus Chikungunya is a single-stranded positive sense RNA virus from both Togaviriade and genus Alphavirus.  The   mode of   transmission is predominantly via an infected mosquito Aedes yet it is also transmitted vertically (mother to fetus), in addition transmission is also by cross infection through an infected person. A.aegypti and A.albopictus mosquitoes are the main vectors for transmission found dominantly in the areas of Asia and Africa where most of the cases were reported.1 The word chikungunya in some east African language means “to walk bent over” which is related to the symptom of severe arthralgia associated with the disease. The first significant outbreaks of the disease were first reported in 2004 in Kenya after which the large epidemic was reported in the areas of Indian Ocean and south East Asia.2  Chikungunya infection can manifest as an emergency sometimes and it was first reported as a clinical emergency requiring the need of intensive care unit (ICU) Reunion Island epidemic in 2006. Areas such as Comoros, Mauritius, Seychelles, Madagascar and Reunion were largely affected. In Reunion millions of cases were reported with a death rate of 1 per 1000 clinical cases. Regardless of the death rate the morbidity rates were quite high. Recently in the areas of India around 1.3 million cases were reported. Further increase in the number of case reported is expected this year as well. The disease has epidemic and inter epidemic periods. During the epidemic period humans are the main reservoirs, while during inter epidemic periods, vertebrates such as birds, rodents and other small mammals are involved. A bacterium Wolbachia, naturally present in 60% of insect species which is known to have vector control capacity, as it is an intracellular resident of many viruses including Chikungunya virus.3 The ability of Wolbachia to alter host physiology, its pathogen blocking phenotype, has provided a benefit to its host limiting insect population. Chikungunya virus usually hits draught affected areas where there is no proper water storage system, this promotes mosquitos to breed in the stored water. Furthermore the mosquitoes responsible for the spread of A. aegypti and

1. albopictus are capable of surviving at a high temperature range. This was the reason why most of the tropical regions were affected. These mosquitoes are very resistant to insecticides which makes the disease control further difficult.2The disease is divided into acute and post-acute phase.

In acute phase the patient presents with extreme fatigue, arthralgia and myalgia along with numerous muco-cutaneous manifestations which include blisters, erythema nodosum, exfoliative dermatitis, photosensitivity and ulcers4 whereas the post-acute phase begins 3 weeks after the acute phase the patient becomes asymptomatic showing transitory improvement but with persistent muscle and joint pain.5 If arthralgia persists for more than 3 months the disease enters chronic phase in which the patient may present with other clinical manifestations for months or even years. Results of scientific work demonstrates that the symptoms of adults are different from children. High grade fever for 4-7 days, vomiting, diarrhea, eye infection and loss of appetite are the symptoms variably in children whereas in adults all these symptoms are commonly seen along with headaches, body aches and joint pain which can be severe and disabling. Rare complications include encephalopathy, myocarditis  and hepatitis and multi organ failure. Patients with low immunity due to preexisting systemic disease such as diabetes and other cardiovascular and respiratory diseases are at a high risk of getting these complications. Neonates and children also presents complication. Uveitis and retinitis are also recently diagnosed complications.6

Clinical presentation, epidemiology and laboratory tests are required for the diagnosis of chikungunya.7 Differential diagnosis should comprise of other mosquito borne diseases (such as dengue and malaria) through proper laboratory tests and clinical examination. Laboratory tests are based on viral RNA identification through reverse transcription and real time PCR by detection of IgM and IgG antibodies through serological tests using ELISA or rapid immunochromatographic tests. The RT-PCR based technique provides a rapid and sensitive result but only on the seventh day of onset of symptoms.8

Absolute rest, maintain hydration and prescription of analgesics such as paracetamol to control muscular and joint pain was advised to treat the patient symptomatically.4 Non-steroidal anti-inflammatory drugs are only used once dengue is excluded and in cases of severe arthralgia. Studies have been carried out to produce antivirals and vaccines to control the disease. A live, attenuated vaccine was introduced but was not considered safe as arthralgia was reported in the few cases after the administration of the vaccine. Another safer and effective technique is also introduced using a combination of chimeric alphaviruses along with chikungunya virus structural protein genes. These vaccines succeeded in generating an antibody response to the chikungunya virus however residual ability to infect potential mosquito makes it still a question to the introduction of the vaccine.Through recent epidemics, a lot of information has been gained regarding the virus however no such vaccine has been introduced to control the spread. Measures should be taken to educate people about the disease and its spread in the epidemic areas to the travelers along with introducing strategies to control mosquito bites The failure of the vector control strategy to reduce the risk of the disease and lack of commercial vaccine has increased the need for more options to prevent the spread of this disease.9

CASE REPORT

A 29-year-old female patient, reported with complaint of mild trismus and high fever (>39°C), to my private practice. History revealed that she was suffering from fever and joint pain since last 7days, morning stiffness of all joints which aggravated within few hours making her unable to come the clinic on her own.

The patient was found exhausted and in severe pain. Intra oral examination revealed mucosal involvement with cheilitis, multiple small aphthae, erosions with severe pain, generalized gingivitis and burning sensation while speaking and swallowing compromised oral hygiene inability to chew food and loss of taste.

On examination patient was found to have trismus and facial swelling. We prescribed her mouth gels, mouth washes, some exercises to overcome trismus and advised lab investigation to rule out chikungunya. Furthermore the patient OPG revealed limited mouth opening, rest of dentition was normal. The patient was re scheduled after two days

Fig 1 & 2: Showing intra oral clinical pictures of patient suffering from chikungunya with limited mouth opening and ginigivitis.

with her reports but the patient sent the reports with her husband as she had severe joint pain and could not travel. According to the hematological lab report the total white blood cell count was 2.7×10ˆ9/L and the platelet count was

Fig 3: Showing OPG of same patient showing limited mouth opening

14×10ˆ9/L. The lab reports and patient’s history suggested leucopenia and thrombocytopenia along with joint pain which is an absolute signs of chikungunya. By looking at the finding we referred the patient to General physician for further investigations and treatment immediately. For our concern, our team did the follow up by contacting her and assured that the patient is visiting the referred physician.

DISCUSSION

Chikungunya fever is an acute delirious disease infected by an arthropod-borne alphavirus. This disease is principally transmitted by the virus to humans via the infected mosquito bite of Aedes species. A.albopictus is referred to as “Asian tiger mosquito” acting as the main vector for the spread and pathogenicity especially in area of Asia. During 1950s CHIKV was initially documented as a human pathogen in Africa, and subsequently then, cases have been acknowledged in multiple affected countries in Africa and Asia. In 2004, in Kenya CHIKV re-emerged and consequently had a blowout eastward affecting millions of people which reported cases in around the Indian Ocean. Later in 2007, this was then reported in Europe with massive outbreak in Italy which then move to Europe, Western Hemisphere and Australia. Clinical presentation of chikungunya can be confused with that of dengue as both presents with sever joint pain. However, symptoms such as gastrointestinal hemorrhage and shock were mainly presented by patients suffering from dengue, furthermore the onset of symptoms is more abrupt in patients with chikungunya than that of dengue.10

The spread of Chikungunya virus was noticed with some focal clinical symptoms manifesting fever (99.6%), muscle pain (97.7%), headache (84.1%) and joint pain (99.2%). Since the beginning of the outbreak in Reunion there was no reported case of direct death due to chikungunya infection. The mortality rate associated with chikungunya virus is quite low (case fatality rate 0.1%- 5%) as compared to the other similar diseases such as dengue and zika, however morbidity rates are higher due to persistent chronic arthritis. In immunocompromised patients and those undergoing transplants while having chikungunya, are seen to have comparatively less incubation period than those having dengue.

This disease according to the surveillance system is labelled as spatiotemporal trends and to identify early spread for optimize control and treatment measures. CHIKV has a low vectorial transmission and for that it is not reported in high altitudes areas.11 CHIKV disease represent with a range of multiple systemic complications such as ophthalmological, neurological, myocardial, oral and dermatological disorders. Chikungunya fever has emerged as a worldwide disease.

CONCLUSION

A challenging role as a dental professional is to rectify the oral status of the current infection which plays a major role in assessing the diagnosis and ultimately the treatment of it. In severe cases chikungunya virus is found rapidly affecting various organs in patients. As in this case the patient was found in acute phase so organ analysis was not done and the findings of the patient reported were high grade fever, trismus, joint pain, morning stiffness and intra oral ulcers. The laboratory reports revealed leucopenia therefore we referred the patient to General physician for symptomatic treatment.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Burt FJ, Rolph MS, Rulli NE, Mahalingam S, Heise Chikungunya: a re-emerging virus. The Lancet. 2012;379(9816):662- 71. https://doi.org/10.1016/S0140-6736(11)60281-X

2. Control CfD, CDC health information for international travel 2014: The yellow book: Oxford University Press; 2013.
3. Pham P, Williams L, Obot U, Padilla L, Aung M, Akinyemiju T, et al. Epidemiology of Chikungunya fever outbreak in Western Jamaica during July- December 2014. Res Reports Trop Med. 2016;55:7-16. https://doi.org/10.2147/RRTM.S122032
4. da Cunha RV, Trinta KS. Chikungunya virus: clinical aspects and treatment-A Review. Memórias do Instituto Oswaldo Cruz. 2017;112:523-31. https://doi.org/10.1590/0074-02760170044
5. Simmons G, Brès V, Lu K, Liss NM, Brambilla DJ, Ryff KR, et al. High incidence of chikungunya virus and frequency of viremic blood donations during epidemic, Puerto Rico, USA, 2014. Emerg infect dis. 2016;22:1221-28. https://doi.org/10.3201/eid2207.160116
6. Al Mahdy A, Jamal M, Kinoshita H, Hossan Chikungunya virus outbreak-a threat to global public health including Bangladesh. Bangl J Med Sci. 2018;17:183-84. https://doi.org/10.3329/bjms.v17i2.35868
7. Mahaver M, Sharma N, Khinchi M, Khan MS. A Brief Review on Chikungunya. Asian J Pharmaceut Res Develop. 2017:1-7.
8. van Aalst M, Nelen CM, Goorhuis A, Stijnis C, Grobusch Long-term sequelae of chikungunya virus disease: A systematic review. Travel med infect dis. 2017;15:8-22. https://doi.org/10.1016/j.tmaid.2017.01.004
9. Powers AM. Vaccine and therapeutic options to control Chikungunya virus. Clinic microbi reviews. 2018;31:e00104-16. https://doi.org/10.1128/CMR.00104-16
10. Gupta A, Juneja D, Singh O, Garg SK, Arora V, Deepak D. Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with chikungunya. Indian J criti care med. 2018;22:5. https://doi.org/10.4103/ijccm.IJCCM_336_17
11. Lee N, Wong CK, Lam WY, Wong A, Lim W, Lam CW, et al. Chikungunya fever, Hong Kong. Emerg infect dis. 2006;12:1790- 92. https://doi.org/10.3201/eid1211.060574

1. Senior Lecturer, Department of Oral Pathology, Sir Syed College of Medical
2. Lecturer, Department of Oral Biology, Sir Syed College of Medical
3. Senior Lecturer, Department of Oral Biology, Sir Syed College of Medical
4. Lecturer, Department of Oral Biology, Sir Syed College of Medical
5. Lecturer, Department of Community Dentistry, Sir Syed College of Medical

Corresponding author: “Dr. Ayesha Iqbal” < ayeshaiqbal690@yahoo.com >

Ayesha Iqbal                    BDS, MSc

Sarah Hanif                      BDS

Suraiya Hirani                  BDS, MSc

Faiza Arif                          BDS

Sarah Hussain                 BDS

Sumaiya Dossa                        BDS

Javeria Ali Khan                      BDS, FCPS

Arshad Hasan                          BDS, FCPS

INTRODUCTION

Knowledge of the normal anatomy and variations in the anatomy of the root canal system is important to perform good quality endodontic treatment.

Normal root canal anatomy of permanent mandibular first molars consists of three root canals; two mesial canals and one distal canal.1 Variations in the root canal anatomy of mandibular first molars is a common finding.2,3 A number of such anatomical variations have been reported one of which is the supernumerary root which, in the mandibular first molars, was first reported by Carabelli in 1884.4 The supernumerary root on the lingual surface of mandibular first molars was named as radix entomolaris by Mihaly Lenhossek in 1922.5

The endodontic treatment of a tooth with Radix entomolaris can present significant challenges due to the presence of root curvature. Ribeiro & Consolaro classified radix entomolaris into type I, II and III according to the buccolingual curvature.6 Root canal instrumentation of a curved canal with stainless steel files can produce errors such as ledges, zips, elbows, apical transportation, loss of working length, or perforations.7 The Nickel-titanium endodontic files can reduce the incidence of above mentioned errors, as they are more flexible in the canal curvature. However, these files can undergo unexpected fracture as a result of cyclic fatigue.8

The present report describes the endodontic treatment of a permanent mandibular first molar with radix entomolaris and separation of endodontic file in the root canal followed by its retrieval using the trephining technique.

REPORT 

A 38 years old female patient visited the Department of Operative Dentistry at the Dow University of Health Sciences with complain of pain and food impaction in tooth #46 since six months. According to the patient, pain started spontaneously from the right side of the lower jaw and lingered on until medicine was taken for pain relief. Moreover, she also reported of pain radiation to the ipsilateral side of the head. Aggravating factors for pain included hot and cold meals and food impaction and the pain was relieved by analgesics.

The family history, history of hospitalization and dental history were not significant. Her habits included tooth brushing once daily with fluoridated toothpaste, frequent intake of sweets not followed by tooth brushing or mouth rinsing and betel nut intake in childhood.

On extraoral examination and intraoral soft tissue examination, no significant findings were observed. Upon dental examination, it was observed that the patient had susceptible pits and fissures in all lower molars. Third molars were not present in the oral cavity. Tooth #46 had class II cavity. The tooth was not tender to percussion or palpation. There were no broken down roots; filled, mobile or traumatized teeth. Probing depths of all teeth were recorded by using Michigan probe and were found to be within normal range except for the distobuccal and distolingual pocket depths of the right mandibular first molar which were found to be 3.5 mm. Bleeding on probing was also observed on the same locations.

Two periapical radiographs of the right mandibular molars were recorded. The second radiograph (figure 1) was recorded with a slight cone shift (approximately 20 degrees) in the horizontal plane. A class II cavity on the distal surface

Figure 1: Pre-operative radiograph showing accessory root

of right mandibular first molar was observed in close proximity to the pulp. The periapical area of the same tooth was found to be normal. A supernumerary root was observed in the first molar on second radiograph.

Cold test of tooth #46 with endo ice (Henry Schein, NY, USA). Patient gave an exaggerated response on cold test. The pain lingered for more than 10 seconds.

Based on the endodontic diagnosis criteria provided by the American Association of Endodontists9, tooth #46 was diagnosed as irreversible pulpitis with normal periapical area.

A general treatment plan consisting of five phases was formed for the full mouth treatment of the patient. The treatment plan consisted of an emergency phase (emergency

chamber opening and pulpectomy of the painful tooth), non surgical phase (enforcing oral hygiene instructions, plaque control, scaling and fissure sealants for molars with susceptible fissures), surgical phase (continuation of endodontic therapy of right mandibular first molar), restorative phase (core buildup and porcelain fused to metal crown for the endodontically treated tooth) and maintenance phase (reinforcement of oral hygiene instructions and evaluation of fissure sealants).

Emergency chamber opening of the right mandibular first molar was performed to relieve the pain. The tooth was temporarily restored with Cavit (Meta Biomed Co. Ltd., Korea).

Single tooth isolation was achieved using rubber dam (Henry Schein, NY, USA). Four pulp canal orifices were observed with the distolingual canal orifice positioned slightly offset. The distolingual canal orifice was suspected to be the orifice for accessory root canal of the supernumerary root (radix entomolaris). Canal patency was established using patency files 06/0.02 and 08/0.02   and 10/0.02

(Mani, Inc., Tochegi, Japan). Orifices were then widened with gates gliden number 5 (Mani, Inc., Tochegi, Japan) in a slow speed handpiece such that half of the head of the gates gliden drill was inserted into the orifice while working (figure 2). Pulp  chamber  and pulp canals were kept moist with sodium hypochlorite (NaOCl) 2.5%.

Figure 2: Pulp chamber of the tooth with four canal orifices visible.

Next, the SX file of the rotary Protaper Universal (PTU) (Dentsply Tulsa Dental Specialities, Tulsa, OK) was used in brushing motion for coronal flaring. 17% EDTA (Meta Biomed Co. Ltd., Korea) was used as lubricant. The file was inserted into the canal in multiple strokes in crown down manner. When the file was taken out of the distolingual canal, it was found to be 3 to 4mm shorter in length. A periapical radiograph was recorded and a separated fragment of SX was confirmed in the accessory canal (figure 3). The separated fragment was present in the coronal and middle third of the root. Upon observing the pulp chamber, a silver spot (coronal portion of the separated instrument) was observed in the distolingual canal orifice. The tooth was temporarily filled with Cavit (Meta Biomed Co. Ltd., Korea) and the patient was recalled for an attempt to bypass the separated instrument.

Figure 3: Separated SX in accessory root canal

In the second visit, local anesthesia was administered and single tooth isolation was achieved using rubber dam. Distolingual canal was flared with gates glidden number 4 and 3 till the blocked area. Separated file was bypassed with manual stainless steel K files 06/ 0.02, 08/ 0.02, 10/ 0.02, 15/ 0.02, 20/ 0.02, 25/ 0.02, 30/ 0.02 and 35/ 0.02 (Mani Inc., Tochegi, Japan). Apical ends of all files used to bypass the separated fragment were bent at acute angle (figure 4). The tooth was temporarily restored.

Figure 4: Separated file by passed

In the third visit, local anesthesia was administered and single tooth isolation with rubber dam was achieved. Attempt to retrieve the separated SX file was performed. Gates glidden number 3 was modified by cutting its bud at its maximum cross sectional diameter perpendicular to its long axis (figure 5), as described in a previous article.10 A short straight fissure diamond bur (Mani Inc., Tochegi, Japan) was used to cut the bud of gates glidden. This modified gates glidden was then used to create a circumferential staging platform. The modified gates glidden was used in a slow speed handpiece (NSK, Japan), carried into the preenlarged canal and directed apically until it lightly contacted the head of

Figure 5: Modified gates glidden no. 3

the separated SX file. After the creation of staging platform the other orifices were covered with cotton pellets and trephining of dentine around the separated SX file was attempted. An ultrasonic scaler tip was used at low power. The ultrasonic tip was placed on the staging platform between exposed end of the separated file and the canal wall and was vibrated around the separated file in a counterclockwise direction. For appropriate visualization of the ultrasonic tip movement, it was used without water in a dry field. However, due to the increased increased thickness and short length of ultrasonic tip, trephining with it was discontinued. A gates glidden number 2 was modified in the same manner as mentioned above and was used for trephining. Approximately 3 mm of dentine around the head of the separated file was removed to expose it. No loosening of separated file fragment was observed. Since the separated fragment had been bypassed already, an attempt was made to remove the fragment with H files. H file number 20/ 0.02, 25/ 0.02 and 30/ 0.02 (Mani, Inc., Tochegi, Japan) were used in sequence in filing (translational in and out) motion which resulted in loosening of the separated fragment. The exposed coronal portion of the separated fragment was grasped with tweezer and removed from the canal (figure 6). Canal was irrigated

Figure 6: Separated SX retrieved

copiously with NaOCl and the tooth was temporized. A periapical radiograph was recorded to confirm complete removal of the separated SX file fragment (figure 7).

Figure 7: Radiograph confirming successful retrieval of separated file

In the next visit, the tooth was isolated under local anesthesia and cleaning and shaping of all four canals was completed. The mesiobuccal, mesiolingual and distobuccal canals were shaped with rotary Protaper Universal files in an endomotor (X-Smart, Dentsply Maillefer, Ballaigues, Switzerland) at a speed of 250 rpm and torque 2.6 nM. Apices of all three canals were prepared till F2. Calcium hydroxide (Ultradent Products Inc., Utah, USA) was placed in all four canals as an intracanal medicament using lentulospiral number 25 (Mani Inc., Tochegi, Japan) in a slow speed handpiece.

Figure 8: Post-operative radiograph

In the final visit, quadrant isolation was performed under local anesthesia and the calcium hydroxide was removed removed using 0.9% saline (Frontier Dextrose Ltd., Haripur, Pakistan.) Canals were dried with respective paper points. Calcium hydroxide based sealer Sealapex (Kerr Corporation, USA) was used and the mesiobuccal, mesiolingual and distobuccal canals were obturated using the single cone obturation technique. The accessory root canal was obturated using the lateral condensation technique with number 40 as the master apical gutta percha cone. Excess GP above the orifice levels was seared off. Sectional ivory retainer was placed. The cavity was etched (3M ESPE, USA) for 30 seconds with continuous brushing using a microbrush. Etchant was washed for 15 to 20 seconds. A cotton pellet was placed inside the cavity to dry excess water. Bonding agent (3M ESPE, USA) was applied using microbrush. Gentle air was blown over cavity for 15 seconds and the bonding agent was light cured for 15 seconds. The cavity was then restored with packable composite (3M ESPE, USA) (figure 8).

Followup visit was conducted after one week. The patient was asymptomatic and the tooth was not tender to percussion. Patient was referred for a full coverage crown on the root treated tooth.

DISCUSSION

Carlsen and Alexandersen classified radix entomolaris into type A, type B, type C and type AC according to the position of its cervical portion.11 According to the preoperative radiographic evaluation and evaluation of the access cavity, this case would fall into the category of type B i.e. distally located cervical part with one normal distal root component. Ribeiro & Consolaro classified radix entomolaris into type I, II and III according to the buccolingual curvature.6 According to our clinical judgement, this case would be classified as type II as a sharp curvature was felt at the canal entrance while scouting with small manual files. A case report described the Endodontic treatment of type II of radix entomolaris.6

Radix entomolaris is mostly superimposed over distal root buccolingually. A radiograph with a 30 degrees shift in horizontal plane makes the accessory root visible. In this case, no accessory root was visible on preoperative periapical radiograph recorded with cone beam parallel to the long axis of the tooth. However, when the cone beam was shifted mesially at an angle of 20 degrees, an accessory root was visible. Application of SLOB principle confirmed the position of accessory root to be lingual.

Due to eccentric location of radix orifice, the conventional access opening maybe modified to a trapezoidal shape for accurate location of the orifice.4,6 In this case, both the above mentioned points were applicable. If the canal orifice is covered by secondary dentine, the secondary dentine is differentiated from the pulp chamber floor which is comparatively darker than the calcified dentine.4 In this case,  the orifice was not completely covered with secondary dentine, however, it was narrow and therefore, flaring at orifice level was performed with gates glidden number 5. NiTi instruments have the ability to maintain original canal curvature and produce a tapering root canal shape However, broken or separated instruments is one of the disadvantages of NiTi instruments.10 Two factors which play an important role in instrument fracture include cyclic fatigue and torsional fatigue. Torsional failure develops when friction between the instrument and root canal dentine leads to increased torque that exceeds the torsional strength of the instrument, resulting in deformation and fracture.12 Glide path is important to reduce torsional fatigue. This helps in increasing the root canal diameter atleast equal to the tip diameter of the rotary instrument which is used for shaping the canals. This in turn reduces the torsional stress on the instrument.13 The cyclic fatigue is dependent upon the curvature of root canal. Moreover, as the file rotates, it undergoes repeated cycles of tension and compression. This continuous cyclic load may result in crack commencement and ultimately fracture of instrument.8 As the angle of curvature of root canal increases, cyclic stress acting upon the instrument increases. On the other hand, the lesser the angle of curvature, the more the severity of curvature, the more cyclic stress placed on curvature and therefore, the more chances of instrument fracture.8 Studies have shown that an curvature in the coronal or middle third of the root canal is more likely to lead to failure compared to an apical curvature.14 In this case, a sharp curvature in the coronal portion of the accessory canal was felt while scouting with the small files. The curvature was suspected in buccolingual plane. Therefore, cyclic fatigue of the rotary files could be the cause of instrument fracture in this case.

Single use of all rotary NiTi instruments has been recommended. However, due to the increased cost of the rotary NiTi instruments, reuse of the files is always pertinent. However, studies have shown that prolonged use of NiTi instruments reduces their cyclic fatigue resistance.15,16 In this case, reuse of the rotary PTU files could be a cause of their decreased cyclic fatigue resistance.

Several factors affect the instrument removal from the root canal. These include diameter, length and position of the fractured instrument and diameter, length and curvature of the root canal.10 Instruments that lie in the straightaway portions of the canal can typically be removed. In this case, the coronal portion of the fractured instrument was visible as the instrument was in coronal portion of the root canal, therefore an attempt to retrieve the separated fragment was planned.

A number of techniques have been described in different studies to remove fractured endodontic instruments from the canal.17-19 In this case, the technique for broken file removal, described by Cliff Ruddle was applied. In this technique, ultrasonic instruments are used for the removal of fractured instrument in conjunction with a microscope.

In this technique, coronal straight line access is achieved followed by creation of a staging platform on the coronal aspect of the separated instrument. This staging platform is created using modified gates glidden which works when activated in intimate contact with the separated instrument and moved in counterclockwise direction. The ultrasonic energy causes the separated instrument to unwind and sometimes jump out of the canal.10 In this case, coronal flaring was performed with gates glidden number 5 and 4. Gates number 3 was modified to create a staging platform. Ultrasonic tip was then used for trephining, however, due to the short length of the ultrasonic tip and the unavailability of the specialized ultrasonic tip for Endodontics, modified gates glidden number 2 was used for the purpose of trephining. Till date, no such case has been reported in which modified gates glidden have been used for trephining.

CONCLUSION

Clinicians should be aware of these unusual root morphologies in the mandibular first molars. Preoperative identification of radix entomolaris or paramolaris is important to facilitate the Endodontic procedure. Use of CBCT and dental operating microscope are significant in detection of morphologies.

The most important factors central to successful instrument removal are knowledge, training, and competency in selecting the best presently developed and proven technologies and techniques. Importantly, no single removal method will always produce the desired result. As such, successful removal oftentimes requires patience, perseverance and creativity.

CONFLICT OF INTEREST

None declared

REFERENCES

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2. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984;58:589-99. https://doi.org/10.1016/0030-4220(84)90085-9
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4. Abella F, Mercadé M, Duran-Sindreu F, Roig M. Managing severe curvature of radix entomolaris: three-dimensional analysis with cone beam computed tomography. Int Endod J. 2011;44:876-85. https://doi.org/10.1111/j.1365-2591.2011.01898.x
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7. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod. 2004;30:559-67. https://doi.org/10.1097/01.DON.0000129039.59003.9D
8. Pruett JP, Clement DJ, Carnes Cyclic fatigue testing of nickel- titanium endodontic instruments. J Endod. 1997;23:77-85. https://doi.org/10.1016/S0099-2399(97)80250-6
9. Endodontic diagnosis: American Association of Endodontists; 2013 [cited 2017]. Available from: https://www.aae.org/specialty/wp- content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf.
10. Ruddle CJ. Nonsurgical Retreatment. J Endod. 2004;30:827-45. https://doi.org/10.1097/01.don.0000145033.15701.2d
11. Carlsen OLE, Alexandersen Radix entomolaris: identification and morphology. Eur J Oral Sci. 1990;98:363-73. https://doi.org/10.1111/j.1600-0722.1990.tb00986.x
12. Blum JY, Machtou P, Ruddle C, Micallef Analysis of Mechanical Preparations in Extracted Teeth Using ProTaper Rotary Instruments: Value of the Safety Quotient. J Endod. 2003;29:567-75. https://doi.org/10.1097/00004770-200309000-00007
13. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of Manual Preflaring and Torque on the Failure Rate of ProTaper Rotary Instruments. J Endod. 2004;30:228-30. https://doi.org/10.1097/00004770-200404000-00011 
14. Peters OA, Paque F. Current developments in rotary root canal instrument technology and clinical use: a review. Quintessence Int (Berlin, Germany : 1985). 2010;41:479-88.
15. Gambarini Cyclic Fatigue of Nickel-Titanium Rotary Instruments after Clinical Use with Low-and High-Torque Endodontic Motors. J Endod. 27:772-74. https://doi.org/10.1097/00004770-200112000-00015
16. Plotino G, Grande NM, Sorci E, Malagnino VA, Somma A comparison of cyclic fatigue between used and new Mtwo Ni-Ti rotary instruments. Int Endod J. 2006;39:716-23. https://doi.org/10.1111/j.1365-2591.2006.01142.x
17. Yang Q, Shen Y, Huang D, Zhou X, Gao Y, Haapasalo Evaluation of Two Trephine Techniques for Removal of Fractured Rotary Nickel- titanium Instruments from Root Canals. J Endod. 2017;43:116-20. https://doi.org/10.1016/j.joen.2016.09.001
18. Ormiga F, da Cunha Ponciano Gomes JA, de Araújo Dissolution of Nickel-Titanium Endodontic Files via an Electrochemical Process: A New Concept for Future Retrieval of Fractured Files in Root Canals. J Endod. 2010;36:717-20. https://doi.org/10.1016/j.joen.2009.11.024
19. Terauchi Y, O’Leary L, Kikuchi I, Asanagi M, Yoshioka T, Kobayashi C, et al. Evaluation of the Efficiency of a New File Removal System in Comparison With Two Conventional J Endod. 2007;33:585- 88. https://doi.org/10.1016/j.joen.2006.12.018

1. MDS Trainee, Department of Operative Dentistry, Dow Dental College, Dow University of Health Sciences.
2. Assistant Professor, Department of Operative Dentistry, Dow Dental College, Dow University of Health Sciences.
3. Professor, Department of Operative Dentistry, Dow Dental College, Dow University of Health Principal, Dow Dental College, Dow University of Health Sciences.

Corresponding author: “Dr. Sumaiya Dossa” < sumaiya_aquarian@yahoo.com >

Sumaiya Dossa                        BDS

Javeria Ali Khan                      BDS, FCPS

Arshad Hasan                          BDS, FCPS

Maria Khan                               BDS

 Sarah Ghafoor                        BDS, BSC, PhD

INTRODUCTION

B one is a constantly remodeling, dense, regular, calcified, and brittle connective tissue. By composition, it is a calcified tissue in which mineral component is hydroxyapatite (HA). Bone remodeling is a continuous, systematic, tightly regulated physiological ongoing process throughout life. Pathology, trauma or iatrogenic factors may cause discontinuity in bone structure that gets repaired which leads to continuity in structure but not function. Bone regeneration, on the other hand, is a well- orchestrated spatio-temporal phenomenon under strict molecular regulation leading to complete physiological, morphological and structural continuity.1

CRITICAL SIZED DEFECT

Bone may get fractured or injured in a variety of ways during life. Usually it repairs itself but in certain cases the defect can be so large that the body is not able to regain the same form and function as that before injury.2 The orthotopic defects of bone which do not heal during life-time span of an individual without an external intervention are called as critical size defect. The dimensional variations for each bone

to be categorized as critical are different.3 In such cases, to mediate bone regeneration, strategies like Guided Bone Regeneration, bone replacement grafts, autograft (gold standard), allografts, xenografts, stem cell regeneration are employed.4

BONE REGENERATING MATERIALS

Most prevalent and successful technique to date is autologous bone graft and iliac crest graft due to minor or major infections, neurologic or vascular injuries, arterio- venous fistula, hematoma etc. at either donor or harvesting sites.5 Xeno-transplantation involves cross-transplant between humans and other species. Although it allows for sufficient donors and promises life saving benefits but then chances of cross-infection and ethical concerns reprimand it to be used frequently.5,6 Allografting is intraspecies exchange of tissuesfrom either cadaver or living body after sterilization and processing. While it offers viability, safer mode, less surgical intervention and good succes rate but graft rejection, expensive treatment, delayed wound healing and functional rejection may pose inefficiency.7,8 Bone regeneration can involve osteogenesis (autologous bone graft), osteoinduction and osteoconduction. The technique is based upon replacement of biomimetic material with living tissue as it starts to resorb iself providing basis and space for living tissue to ingrow.9

Biomaterials, so far have evolved through three chronological phases. The first type was bioinert materials which were least reactive and less corrosive generally for industrial use. Then second generation was developed which comprised of materials bearing properties of biodegradability and bioactivity, thus providing with ‘biomimetics’ that we use today. The third generation material developed was conceptual and theoretically it could guide and modify cellular functions at molecular level.10 This makes bioactive biomaterials a promising candidate for the reconstruction of calcified tissues of human body including tooth and bone.11 However, it is important to understand bioactivity or biological activity of a biomaterial. For that, the focus of biological activity is related to entity and expression can be stated to be: (1) what it is; (2) what it does, and (3) how much of it is present.12

BIOACTIVITY

Bioactivity can be classified into two types as tabulated in Table 1, which depend upon the rate of tissue response to the implants. Class A bioactivity is the most rapid bonding to hard tissue and it also bond to soft connective tissues. Class A bioactive materials produce bone throughout the particle array, and it is known as osteoproduction. These materials also exhibit osteoconduction, which is defined as “The process of bond migration along a biocompatible surface”. Class B bioactive material such as synthetic HA shows only osteoconduction. Therefore, they lead to a very slow bond to bone and incomplete proliferation of bone throughout a particular array.13

The bioactive ceramics, one of the second group of materials developed, not only have been useful in bone repairs and replacements, but also are inspiring new bioactive materials.14,15 Bioceramics such as calcium phosphate (hydroxyapatite, tricalcium phosphates, and dicalcium phosphates) and bioactive glasses have been used for biomedical applications. Calcium phosphate based materials are osteoconductive, whereas bioactive glass materials contain the advantageous properties of osteonductivity and osteoinductivity.16,17

BIOACTIVE GLASS

Larry Hench and co-workers developed a ceramic-based new class of materials known as “Bioactive Glasses” in 196918 which were capable of interacting with living host soft and hard tissues by promoting stable biological linkages and chemical bonds.19 Upon interaction with bodily fluids its components phosphorus and calcium impregnate into silicon rich surface layer of the material.20 45S5 Bioglass®

(45SiO₂-24.5CaO-24.5Na₂O-6P₂O₅) is the traditional bioactive glass that had later many modifications in it in terms of ratios and compositions each rendering its own specific properties to the material. 45S5 Bioglass® allows osteoblasts to become alkalinized leading to deposition of collagen and hydroxyapatite formation upon bone surface.21 Similarly, BG60S (silica 60%, calcium 35%, phosphate 5%) allows the osteoblast vacuole formation22 promoting bone deposition. With variations in composition and consistency of the bioactive glass there is also a demonstration of bacteriostatic activity in-vitro.23 In addition, it has been suggested how bioactive glass can initiate bone regeneration in animal model at a rate that even surpassed encapsulation by epithelialization.24 S53P4 (53SiO₂-20CaO-23Na₂O-4P₂O₅) is a product besides conventional 45S5 composition that has been allowed for use in medical purpose as bone substitute.25 Still many obstacles, shortcomings and frontiers need to be passed to actually make these beneficial to patients. Various studies have been conducted to evaluate the behavior of bioactive glass in animal models26-29 and critical size defects have been created and bioactive glass in the form of spherical particles, granules and pallets have been used.30 Histologically, rats differ from human bones as they do

not have a haversian system therefore, cellular organization is different.31 Innately, rats continue to have their property of bone regeneration almost throughout their adult life. Among multiple critical size defects that have been experimented upon animal models, tibial defect is one of most important. Critical size defects in tibial bone can relate to large defects in maxillofacial bones that can occur as a result of injury or disease such as bone resection during cancer therapy. Such large defects in facial bones cannot heal on their own leaving a life-long impairment to the patient quality of life both functionally and psychologically. Thus understanding biomaterials that can be related to therapeutic purpose for filling of critical size defects can lead clinicians towards understanding materials for filling defects in maxillofacial bones.

In this regards, authors could not find any review study where the relation of critical size defect in tibial bone has been discussed in relation to bioactive glasses. It is expected that this review paper will provide an updated information with respect to application of bioactive glasses in tibial defect area.

APPLICATION OF BIOACTIVE GLASSES IN TIBIAL DEFECTS

Cui et al32 induced osteomyelitis in New Zealand White rabbits by injecting Staphylococcus aureus suspension, sodium morrhate and PBS into the rabbit tibiae. A cortical bone window (2mm x 8mm) was prepared, and injectable vancomycin-loaded borate bioactive glass (6Na₂O.8K₂O.8MgO.22CaO.54B₂O₃.2P₂O₅)  cement was injected. In other group of rabbits, vancomycin-loaded calcium sulphate cement was injected. Both these groups were compared with non-loaded bone cavity. After 8 weeks of implantation, the results showed the calcium sulphate- based cements exhibited presence of fibrous tissue on the surface of the implant, whereas, borate bioactive glass cements showed the presence of newly formed apatite layer and attachment of proteins to the surface of apatite subsequently formation of bone-like tissue as shown in Fig. 1. Histological analysis also confirmed these results and new bone appeared to be well bonded to the implant and the defected bone area was filled with connective tissue.

© Copyright with permission, Cui X, Zhao C, Gu Y, Li L, Wang H, Huang W, et al. A novel injectable borate bioactive glass cement for local delivery of vancomycin to cure osteomyelitis and regenerate bone. J Mater Sci Mater Med. 2014; 25(3): 733-745.

Fig 1 (a): SEM image of a rabbit tibial defect implanted with vancomycin- loaded borate bioactive glass cement for 8 weeks and showed conversion of borate glass resulted in fairly dense implant integrated with host tissue. The arrows indicate the bone-implant interface, (b) SEM image of longitudinal section of implanted rabbit tibia showed the conversion of borate bioactive glass to HA and attachment of proteins to the surface of HA resulted in formation of a bone-like tissue.

In another study, osteomyelitis was induced and the bone cavities were filled with teicoplanin-loaded borate bioactive glass (6Na₂O, 8K₂O, 8MgO, 22CaO, 54B₂O₃, and 2P₂O₅) and calcium sulphate beads respectively. The morphology of newly formed bone was sponge-like structure, similar to human trabecular bone. Vascular tissue was distributed in both new bone and grafted glass, further, micropores (5-10µm) were also observed resulting due to glass conversion. The factors which help in bone healing include geometry, surface chemistry, and porous structure. In case of bioactive glass, osteoconduction is the main attributing factor and ion release of bioactive glass, which leads to conversion of glass to HA-like layer. This also promotes the in growth of vascular tissue into the bioactive materials.33 In another study34, teicoplannin-loaded borate bioactive glass (6Na₂O, 8K₂O, 8MgO, 22CaO, 54B₂O₃, and 2P₂O₅) was implanted for 12 weeks in osteomyelitis induced rabbit tibia. After 12 weeks implantation no infection and complications were found and conversion into HA layer was observed and comparative XRD pattern and SEM analysis showed fairly dense, firmed connection of newly regenerated and old bone. Osteoclasts adhered to the rough surface of newly formed HA layer attempted to break down calcium and phosphorous. Furthermore, there was concern about toxicity of boron in bioactive glass which decreased within 7-10 days.

Moimas et al35 synthesized cylindrical (8 mm in length x 3.75 mm diameter) bioactive glass [Na₂O (6wt.%), K₂O (12wt.%), MgO (5wt. %), CaO (20wt.%), P₂O₅ 4wt.%), and SiO₂ (53wt.%)] fibers scaffold were prepared and placed in tibia of New Zealand White rabbits in control and compared with morsels and PerioGlas® (Novabone, Jacksonville, FL, USA). After 6 months, the visual examination showed healthy tibial bone without inflammation. The tomography showed (Fig. 2) that defect reduced up to 3 mm, as scaffold acted as

© Copyright with permission, Moimas L, Biasotto M, Lenarda RD, Olivo A, Schmid C. Rabbit pilot study on the resorbability of three- dimensional bioactive glass fibre scaffolds. Acta Biomater. 2006; 2(2): 191-9.

Fig 2: SEM images of teicoplanin-loaded borate bioactive glass (TBDC) pellets after implantation for 12 weeks in a rabbit tibia osteomyelitis model The conversion of teicoplanin loaded borate bioactive glass was connected firmly with the old bone or with the regenerated bone within the 12-week implantation period, where (a) dense structure of regenerative bone was formed, (b) the cells appeared to attach firmly to the surface of the pores, even for the well compacted regions of the implants (c) Microchemical analysis of the boxed area (a) using energy dispersive X-ray (EDS) analysis in the SEM showed a calcium to phosphorus (Ca/P) atomic ratio of 1.54, which is lower than the value (1.67) for stoichiometric HA. (image taken after permission from authors)

© Copyright with permission, Zhang X, Jia W, Gu Y, Xiao W, Liu X, Wang D, et al. Teicoplanin-loaded borate bioactive glass implants for treating chronic bone infection in a rabbit tibia osteomyelitis model. Biomaterials. 2010; 31(22): 5865-5874.

Fig 3: 2D reconstructed section of a defect filled with glass fiber scaffold with a porosity of 55-60% on the surface of the defect, newly formed cortical bone in the defect surface. (image taken after permission from authors)

osteoconductive matrix. This study concluded that three dimensional implants are more effective than PerioGlas® particles.

Gorustovich et al36 created defect (1.5 mm diameter) in rat tibiae adding 2% boron-45S5 bioactive glass (SiO₂, CaCO₃, Na₂CO₃, CaHPO₄·2H₂O and B₄Na₂O₇·10H₂O) and 45S5 (45SiO₂. 24CaO. 5SrO. 24.5Na₂O and 6P₂O₅) bioactive glass respectively. The filled cavities were detected at 15 and 30 days after implantation and histological analysis, microchemical and histomorphometry measurements were taken. At 15 days boron-based 45S5 exhibited significantly high neoformed bone tissue around the particles and high Ca: P ratio than 45S5. However, at 30 day, no significant difference was observed. Thus, experimental bioactive glass demonstrates to provide a scaffolding site for osteoprogenitor cells and it also simulates rate of bone formation by osteoblasts. Same author’s group added 6% SrO in 45S5 (45SiO₂. 18.5CaO. 6SrO. 24.5Na₂O and 6P₂O₅) and implanted in rat’s tibia (1.5 mm diameter) for 30 days. The histomorphometric analysis showed that no significant difference was found with 45S5 after implantation, similarly no significant difference was observed in Ca: P ratio.12

A group of researchers created bilateral noncritical size (2.5 mm diameter) bone (upper third of the tibia) defects in Wistar rats, which were filled for 21 days with Bioglass® 45S5 and Biosilicate-based bioactive glass (40-50% SiO₂, 20-25% Na₂O, 20-26% CaO, 3-7% P₂O₅; wt %). The biomechanical analysis in this study showed similar biomechanical properties for defects filled with Biosilicate and intact cortical bone while exhibiting higher stiffness © Copyright with permission, Molecular biologic comparison of new bone formation and resorption on microrough and smooth bioactive glass microspheres. J Biomed Mater Res Part B, Appl Biomater. 2003; 65(1): 163-170.

Fig 4: (A)-(C), (E), and (F) Backscattered electron image (BEI)-SEM micrographs and (D) van Gieson stained section demonstrating bone regeneration inside medullary cavity of the rat proximal tibia filled with bioactive glass microspheres: (A) at 1 week, microroughened surface; (B) at 1 week, control surface At 1 week, no apparent differences were seen between the two sides in primary bone healing response, which included formation of immature woven new bone within the medullary canal; (C) at 2 weeks, microrough surface; (D) at 2 weeks, microroughened surface; At 2 weeks, the amount of new bone remained at the same level on the microroughened side and on the smooth control side. New bone formation occurred from the endosteal surface of the cortical bone. In addition, in situ osteogenesis was observed between the bioactive glass microspheres and on their surfaces. (E) at 8 weeks, microroughened surface; (F) at 8 weeks, control surface, at 8 weeks, the amount of new bone had almost doubled, but there were no significant differences between the two sides microroughened side and smooth control side. (image taken after permission from authors)

values than unfilled bone defects. Where, higher number of osteoblasts per unit of tissue area was observed with Biosilicate group than Bioglass 45S5 group indicating better.37,38 In another study, cortical holes (2.8 mm and 1 mm diameter) were created into the anteromedial cortex of the tibia of the rat models, filling them with roughened and smooth bioactive glass (SiO₂ 53 %, Na₂O 6%, CaO 20%, K₂O12%, MgO 5%, P₂O₅ 4% by weight) microspheres. The rats were sacrificed after 1, 2, and 8 weeks of implantation and were analyzed with micro-Computerized Tomography, Scanning Electron Microscopy, radiography and histomorphometric analysis. Larger cortical defects remained unhealed at 8 weeks with non-significant difference. After 8 week, the amount of new bone had almost doubled as shown in Fig. 4. Similarly, results showed that mRNA levels had non-significant change after 1 week, where as after 2 weeks, bones with roughened bioactive glass had significantly higher levels of osteopontin expression, similar trend was observed after 8 weeks, where MMP-9 mRNA levels were significantly higher in bones with roughened bioactive glass suggesting greater bone formation with roughened bioactive glass which might be due to microroughening process that altered the chemical composition and more leaching.39 Aza et al40 implanted bioactive glass (SiO₂=54.5; CaO=15.0;  Na₂O=12.0;MgO=8.5;  K₂O=4.0; P₂O₅=6.0, weight percentage) granules into diaphysis of left tibia of male Sprague-Dawley rats with average pore size was 100 µm. The rats were sacrificed after 6, 8 and 12 weeks and implants were excised. The results showed that after 6 weeks, the bioactive glass implants were well integrated with bone tissues. After 8 weeks, significant surface roughness was observed and a new calcium phosphate layer formed. At 12 weeks, a well-structured calcium phosphate phase was observed and results indicated mature bone with stoichiometric Ca/P ratio of natural bone.

CONCLUSION

Bioactive glass materials have shown excellent biocompatibility and with inherent properties of bone regeneration can be considered as materials of choice. Along with tissue regeneration, this material has an additional properties of osteogenic and angiogenic properties. This review showed that bioactive glass supported cell adhesion, proliferation, and osteogenic differentiation. Studies showed that bioactive glass were non-toxic and enhanced metabolic and mitochondrial activity. Though, there are few studies on tibial defect regeneration, where modified bioactive glass materials have been used, but showed excellent results. Improvisation in composition and synthesis process can enhance the abilities of revascularization, differentiation, enzyme activity, and osteoblast adhesion. Bioactive glass also act as a stimuli to allow angiogenesis i.e. blood vessel formation and revascularization. In future, it is important to explore the role of nano-bioactive glass particles in tibial defect.

CONFLICT OF INTEREST

None declared

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1. MPhil Trainee, Department of Oral Biology, University of Health Sciences,
2. Assistant Professor, Department of Oral Biology, University of Health Sciences,

Corresponding author: “Dr. Sarah Ghafoor” < sarahghafoor@uhs.edu.pk >

Maria Khan                               BDS

 Sarah Ghafoor                        BDS, BSC, PhD

Angabeen Anjum                              BDS

Mervyn Hosein                                  FDS RCS, FDS RCSE, FFD RCSI

INTRODUCTION

Diagnostic applications of saliva were established at the beginning of this century.1 Salivary testing for assessment of health or diseased states is gaining increasing importance.2 Saliva is one of the biologic fluids of the human body, heterogeneous in nature, slightly acidic (pH=6.0-7.0) and clear.3 Major and minor salivary glands secretions along with gingival crevicular fluid jointly constitute the saliva.4 Functions of saliva include lubrication, assistance in speech, digestion and general maintenance of oral health etc.5 Moreover saliva`s buffering capacity protects teeth enamel from acidic attack and helps in remineralization.6 Mucus secretions of saliva also act as a shield protecting the oral mucosa from irritants and infections.7 These functions are performed by its various chemical components including water, inorganic compounds (ions), organic compounds (non-proteins and lipids), proteins/polypeptides and hormones.6 Collection of saliva is straightforward, easy, requires little equipment and is repeatable without discomfort, making it an excellent diagnostic tool.1 For diagnosing and monitoring caries risk, microbial sepsis, inflammation and genetic pathologies including oral tumors and cysts, a variety of saliva based diagnostic approaches have been developed during the last decade.8 Salivary diagnostics which is gaining increasing importance is the subset of molecular diagnostics which has brought revolution in the field of medicine and dentistry. Successful role of molecular diagnostics has been documented in different areas including biomarkers discovery for detecting different systemic and oral diseases, drug development and personalized medicine (pharmacogenomics). The successful applications of salivary diagnostics is made possible by novel molecular approaches including transcriptomics, proteomics and genomics.9

Figure 1: Properties making saliva the best diagnostic tool

Diagnostic significance of saliva – A brief discussion Saliva as the best point of care diagnostic tool

Point-of-care medicine means to provide care, treatment and testing facilities to patients on presentation site.10 This improves patients outcomes in critical care settings, helps medical teams to get timely information and contributes to rational and time-critical decision making.11 Over the past few decades, saliva testing has increased as the liquid biopsy specimen for detection of different diseases.12 Oral diseases detectable through saliva include dental caries, gingivitis, periodontitis (chronic/aggressive), Behcet`s disease, squamous cell carcinoma, salivary gland diseases, leukoplakia and chronic graft-versus-host disease (cGVHD) etc.

Breast cancer, diabetes and AIDS(acquired immunodeficiency syndrome) are some of the saliva detectable systemic diseases.12

Figure 2: Diagnostic applications of saliva in different systemic diseases.

Salivary Biomarkers

Any cellular, biochemical, molecular, or genetic alterations which help to recognize and monitor disease susceptibility, progression, resolution , health status and treatment outcome in individuals is termed a biomarker.5 Biomarkers are found in blood ,saliva and other body fluids.12 Analytes found in saliva include steroid hormones, enzymes, mucins, cystatins, histatins, antibodies, cytokines etc.13 Salivary biomarkers and aanalytes also have the potential to predict health status of people including hormonal variations, substances abuse, status of infectious disease etc.13

Salivary biomarkers in Cardiovascular disease detection Salivary biomarkers serve as very important diagnostic tools for cardiovascular disease.12 These include Cardiac troponin I, Myoglobin, Creatine phosphokinase MB, Myeloperoxidase, C-Reactive Protein, brain natriuretic peptide, Matrix metalloproteinase-8, MMP-9.12 In emergencies, rapid diagnosis of acute myocardial infarction can be made through salivary biomarkers such as Creatine kinase muscle/brain (CK-MB), Troponin T(TnT), Troponin I(TnI), C-reactive protein (CRP)] and active matrix metalloproteinase (MMP)-8.14 Miller et al in their study evaluated salivary C reactive protein, soluble intercellular adhesion molecule-1 (sICAM-1) as well as Adiponectin as classical indicators of Acute Myocardial Infarction (MI).14 Under certain conditions (Childhood maltreatment and intimate partner violence (IPV),the conditions perceived as chronic stressors and provoke general inflammation reported in studies), low grade inflammation and risk status for cardiovascular disease can also be reflected in levels of salivary C reactive protein .15

Salivary biomarkers in premalignant and malignant disorders

Two types of biomarkers are used in cancer detection ; prognostic and diagnostic.16

A diagnostic biomarker helps in detection or confirmation of disease or condition of interest, while the disease progression, its likely course and recurrence is identified by prognostic biomarker.17 Salivary biomarkers have been investigated in different types of cancer.18 Different studies suggest that the level of IL-þ is fundamentally higher in cancer patients and is more easily detected in saliva than in blood.18Several salivary protein markers, for example, matrix metalloproteinase (MMP 2, 9), interleukins (8, 6, 1b), transferrin, tumor necrosis factor (TNF-a) ,transforming growth factor (TGF-1) and catalase have been identified in oral squamous cell carcinoma.19 Many protein biomarkers including Matrix metalloproteinases ,cytokines, vascular endothelial growth factor A (VEGF-A),Tumor necrosis factor alpha (TNF-a) and mRNA salivary biomarkers such as Ornithine decarboxylase antizyme 1 (OAZ1), Dual specificity phosphatase 1 (DUSP1), S100 calcium binding protein P (S100P),Spermidine/spermine N1-acetyltransferase 1 (SAT1) have been identified to detect OSCC with high sensitivity and specificity(20). In a study by Stott-Miller et al, concentrations of MMP1 and MMP3 were tested in saliva samples from 100 subjects (60 primary OSCC cases, 15 dysplasia cases, and 25 controls). The protein concentrations were higher in the saliva from OSCC patients compared to the saliva from cancer-free controls. As matrix metalloproteinases (MMP) use to cause degradation of the basement membranes and extracellular matrix so this study finding suggests its key role in cancer development. Studies have reported MMPs ,the potential cancer biomarkers and they have found to cause metastasis and tumor invasion.20 Cytokines especially Interleukin-6 (IL-6),Interleukin-8 (IL-8) and Tumor necrosis factor (TNF-a) are potential biomarkers of cancer because they are greatly expressed in the saliva of cancer patients and are involved in the pathogenesis of cancer(21).Salivary IL-6 also showed greater expression in oral premalignant disorders. In a study by Thalayan et al, significant differences in IL-6 concentration were noted between OSCC and premalignant disorder patients in both serum and saliva, with salivary levels being 2 to 3 fold higher than serum values across the groups.22 Significant rise in salivary TNF-a and INF-y has been demonstrated in oral lichen planus patients compared with healthy individuals.23

Salivary biomarkers in gastrointestinal disorders

Saliva can aid testing in a variety of GI disorders. Typhoid is a major enteric fever.In a study by Herath et al., evaluation of salivary IgA antibodies against Lipopolysaccharides (LPS) of Salmonella was done with assay sensitivity of 83% and specificity of 97%, respectively.24

Immune responses during typhoid infection can also be recognized through salivary IgA antibody against recombinant haemolysin E (rHlyE) protein from S. typhi and this can serve as a biomarker.25 Detection of typhoid fever using this rHlyE) antigen with a sensitivity of 70%, and a specificity of 100% is reported in a study.25 Salivary pepsin detection can help in the diagnosis of gastro- esophageal reflux disease (GERD) but further work is needed to make it a more accurate tool.26

Inflammatory reactions may manifest in the oral cavity of patients suffering from Ulcerative colitis (UC) ,Crohn’s disease(CD) and Irritable bowel disease(IBS) and detectable higher levels of salivary cytokines and IgA in these patients as compared to healthy individuals.27 In Crohn`s disease patients ,higher levels of TNF-a, IL-6 and IL-1þ have been observed and on the other hand raised salivary IL-8 level has been reported in IBS patients.27 Decreased levels of salivary lysozyme have also been reported in CD and UC patients compared with healthy individuals.27

Salivary biomarkers in sjogren syndrome

Primary Sjören’s syndrome (pSS) is an autoimmune disease in which the patients suffer from dry eyes and dry mouth, caused by nonfunctioning of salivary and lacrimal glands.28 Gross cystic disease fluid protein-15 (GCDFP-15)/prolactin-inducible protein (PIP) as a classical biomarker for primary Sjögren’s syndrome is established.28 The process of saliva production requires trans-epithelial water transfer from the glandular interstitium to the acinar lumen.29

A salivary gland water channel Aquaporin 5 (AQP5) is down-regulated in primary Sjören’s syndrome. This water channel helps in saliva formation, with this aquaporin 5, (GCDFP-15) binds and this is supposed to be the cause of reduced salivation.28 Baldini et al.in their study confirmed significant reduction of GCDFP-15/PIP in the saliva of pSS as compared to healthy individuals.30

Salivary biomarkers in infectious diseases ORAL BACTERIAL DISEASES

The two most common bacterial diseases of the oral cavity are caries and periodontitis.9 Periodontal disease parameters and the levels of matrix metalloproteinase (MMP)- 8, salivary IL-1 þ, and osteoprotegerin (OPG) in saliva have been studied by Teles et al. Greater concentrations of MMP- 8 and salivary IL-1þ were reported in periodontitis patients than in healthy controls suggesting that the oral epithelial cells increase the secretion of cytokines proportional to the progress of periodontal chronic inflammation and infection with periodontal pathogens.31 Raised levels of inflammatory mediators of þ-glucuronidase , TNF-a , IL-6 and IL-1þ in saliva and TNF-a ,IL-1þ and þ-glucuronidase in serum have been found in females suffering from periodontitis patients relative to healthy controls.32 Salivary diagnostics is equally important for caries assessment.9 Streptococcus mutans (S. mutans), Streptococcus sobrinus (S. sobrinus), and lactobacilli are the common caries causing pathogens. Caries susceptibility have been found to be raised in children having reduced salivary levels of alpha-defensins Human Neutrophil Peptides (HNP1-3) while the agglutination of streptococci is promoted by salivary mucins (i.e. MUC7). Salivary flow rate, salivary pH and buffer capacity can also help in assessing caries risk.7

ORAL VIRAL DISEASES

Antibody response to infection is the basis on which the majority of virology diagnoses are made.3 Diagnosis of congenital infections, acute viral infections and reactivation of latent infection can be made by detecting salivary antibodies against the viruses or their components.3 Human cytomegalovirus (HCMV) is the commonest pathogen causing congenital infection globally.33 The diagnosis of congenital infection is based either on viral isolation (in cell culture) or demonstration of HCMV DNA from the urine or saliva33. Immunoglobulins are important defensive shields , secretory IgA derived from plasma cells in the salivary glands, is the predominant one.34

In Dengue endemic regions, Dengue virus specific IgA in saliva was detected.35 Moreover antibodies directed against specific antigens of Plasmodium falciparum antigens, dengue virus, and Ebola virus have also been detected in saliva36 Human herpes virus, HIV infection, Epstein-Barr virus, Cytomegalovirus and hepatitis C virus can easily be detected using saliva as the bio specimen. It has good sensitivity and specificity and is the best alternative to serum.3 One of the common causes of diarrhea in children is Rotavirus (RV) infection that can lead to serious dehydration and the ultimate need of hospitalization. Rota virus affects the terminally differentiated enterocytes in the small intestine and cause villus atrophy ,epithelial cells necrosis and mucosal damage.Gómez-Rial et al in their study observed increased levels of salivary epidermal growth factor(EGF)in infants during the acute phase of rotavirus infection and levels correlated with the period of hospitalization.37 Study suggested the elevated levels of EGF as a result of host recovery response to the mucosal damaged caused by virus. Raised levels of EGF has reported in studies in diseases associated with mucosal disruptions and alterations, also expressed in the submandibular salivary glands, in order to restore the integrity of mucosa after infection.37

ORAL  FUNGAL DISEASES

Saliva is a diagnostic tool in oral fungal infections.3 Clinical examination along with analysis of saliva, swabs etc. are the diagnostic tools for oral mycoses including oropharyngeal candidiasis (OPC). Saliva and scrapings analysis involves in vitro culturing to isolate and identify the etiological agent, direct microscopic and histopathological examination for confirmation and to assess the severity of tissue damage.9

APPLICATIONS OF SALIVARY BIOMARKERS IN OTHER DISEASES

Three salivary biomarkers, procalcitonin (PCT), C-reactive protein (CRP), and neutrophil elastase (NE) are found to be raised during Chronic obstructive pulmonary disease (COPD) exacerbations.

In such exacerbations,CRP and PCT correlated well with patient-derived clinical metrics .So COPD can be better evaluated and managed by using these parameters38 Numerous salivary markers are related with end stage renal disease including uric acid , cortisol, nitrite, lactoferrin, sodium, chloride, pH etc.9 A study reported the use of colormetric test strips for screening salivary nitrate and uric acid before and after hemodialysis thus making patients aware of the right time for dialysis.9 Hyperphosphatemia, the major cause of cardiovascular calcification in chronic renal failure patients ,is detectable in salivary phosphate whose levels correlated positively with serum creatinine and the glomerular filtration rate and thus may serve as a better marker than serum phosphate in the management of chronic renal failure patients.9

Cortisol, salivary amylase, lysozyme, substance P, and secretory IgA are some of the stress and pain- related markers found in saliva.9 Violent behavior and strenuous physical activities also correlate with salivary testosterone levels.9 Cognitive behavior can be assessed by evaluating salivary tryptophan and serotonin levels.9 Thus salivary samples can be pivotal in psychological research and management.9 Forensic diagnostics have largely been through saliva samples along with other body fluids.39 DNA and blood-group antigens including A, B, H, and Lewis antigens are also detected in saliva and used for criminal identification and paternity law suit cases.9

Saliva can also facilitate neonatal diagnosis and prognosis utilizing different biomarkers found during neonatal infections. These include cytokines [TNF-a, interleukin (IL)-1 alpha/beta, IL-2, IL-6, IL-8], complement fragments (C3, C4), MMPs 1-3, 9, multiple antimicrobial proteins/peptides (lactoferrin, histatin, cathelicidin ,alpha and beta-defensins, S100 proteins), acute phase reactants (C-reactive protein, haptoglobin, transferrin, fibronectin) and immunoglobulins (IgG, IgE, and IgM).40

Incorporating newer technologies in salivary diagnostics can bring much improvement in infant and child health and also provide better options for disease investigations.41 Neonatal sepsis, one of the major causes of infant death is also associated with brain injury in many cases.42 Detection of C reactive protein in saliva can inform care givers about the risk status and progress of sepsis and other infections in infants and can reduce the need for repeated phlebotomies.42 Saliva is a very important medium for detecting drug abuse with noninvasive and point of care collection facilities.43 Various researches have been done regarding qualitative and quantitative drugs analysis and the pharmacovigilance potential of saliva.44 A significant positive correlation has been observed between serum and salivary drug levels in many studies.

Therapeutic drug monitoring (TDM), a procedure done in order to improve and assess patient’s management who is receiving the drug therapy is also flourishing as a result of salivary diagnostics. In therapeutic drug monitoring, drug concentration in patient’s biological fluid is measured and correlates with the clinical condition so that the finding can be used in adjusting the dosage or dosage intervals. Saliva is preferable over serum or blood for TDM because it can reflect the free non-protein bound pharmacologically active component in serum. Saliva has also facilitated drug testing in different conditions including drug identification of possible

drug-affected drivers, workplace testing particularly following a safety incident, to check for possible drug use, testing of persons in prisons and other correctional institutions, the monitoring of drug use by drug courts, or testing of detainees suspected of a crime who may be under the influence of a drug and for sport anti-doping test. Antiepilteptics, immunosuppresants, theophylline, cocaine, amphetamine, barbiturates, benzodiazipines and opioids are some of the drugs whose surveillance have been done using saliva.44

Table 1: Salivary biomarkers in different systemic diseases

CONCLUSION

Saliva as a diagnostic fluid fulfill many of the investigative needs for detection of different diseases and some times more beneficial than serum and blood. Screening of large population can be done with the help of salivary diagnostics as it has easy, cost effective and noninvasive approach. The examination of salivary fluid can play a very important role in clinical diagnosis of systemic diseases. Biomarkers found in saliva can assist in disease detection, management and progress. Progress through further studies can facilitate both patients and clinicians and help in improvement of health sciences.

CONFLICT OF INTEREST

None declared

REFERENCES

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1. Lecturer, Department of Pharmacology, Sir Syed College of Medical Sciences for Girls,Karachi.
2. Principal, Ziauddin College of Dentistry, Ziauddin

Corresponding author: “Dr. Angabeen Anjum” < angabeen.anjum@gmail.com >

Angabeen Anjum                              BDS

Mervyn Hosein                                  FDS RCS, FDS RCSE, FFD RCSI

Shamta Sufia                                       BDS, MSc, PhD

INTRODUCTION

Dental clinical settings pose a high biological risk of transmitting a wide range of microorganisms. Therefore, it is essential that in the dental settings measures are taken to minimize spread of infection to patients and the environment from all possible sources. It is mandatory to ensure that the care is provided in a clean and safe environment for both patients and staff. Besides a high standard of decontamination in practices, patients have a right to anticipate minimal risk of person to person infection transmission. Hence, dentists need to follow steps for prevention of infections e.g. using gloves, face masks and protective eye wear among other actions.1 Prevention is also deemed important because any lapse in the protocol can escalate the cost of care for patients and public at large, leading to un-necessary but avoidable wastage of large volume of funds. One such measure is following cross infection control protocols which help to evade infection transmission from the dental clinical environment to the patients and vice versa.

Over time an improved awareness among dental professionals towards the implementation of effective cross- infection control measures have been reported. This includes sterilization, disinfection, immunization, and the use of barrier techniques when contact with blood and body fluids occurs or is expected.2,3 In the past dentists in Lahore, too, have been reported to routinely use gloves and masks for self-protection.4 On the other hand, some researchers have painted a dismal picture of cross infection control practices in public sector hospitals.5,6 The authors state that majority of professionals do not follow correct cross infection control policies.5,6 The authors have pointed out non-existence of policies on hand hygiene or personal protection even though the supplies in sufficient quantities were available. Also, lapses in the knowledge and routines, lack of training, negligence in following guidelines, especially by frontline staff responsible for infection control in practices has been identified in the past.7-16Improper transportation of impressions and casts to and from the laboratory has also led to transmission of infections in dental settings.17 Although past research in Pakistan has focused on cross infection control practices by the medical and dental practitioners.4,6-18 Reports on awareness on cross infection control protocols and practices are not available in literature. Neither are audits for the same done in Pakistan, hence, non-availability of data for same.

This survey aimed to evaluate current awareness on existence of Cross Infection Control (CIC) protocols, procedures and guidelines at dental hospitals amongst the fresh graduates working as interns in their respective dental training institutes. It also aimed to assess their awareness and knowledge regarding training of staff for the same. The study also investigated existence of protocols for self- protection in work settings. The need to conduct such a study was because the author feels that dental institutes are responsible for the training of their students on infection control. Such training is essential for protection of patients for treatment in a safe working environment. Secondly, past studies have demonstrated varying levels of knowledge and awareness on the policies and practices related to Cross infection control in groups of medical staff. It has also been observed that these practices are greatly influenced by the examples set by senior staff members.19-20

METHODOLOGY

The study was a cross-sectional survey using a convenience sample of 250 subjects (freshly inducted interns/ house officers) in five dental hospitals of Lahore, was conducted. Only one of these hospitals was a public sector hospital. The survey was organized between June 2018- July 2018 after approval from the Institutional Review Board of de’Montmorency College of Dentistry, Lahore, and permission from heads of the respective dental hospitals. Australian Dental Board has published Guidelines on infection control (known as the Board’s Guidelines) to describe the infection control obligations of registered dental practitioners.21 The Dental Board has published a questionnaire for self-assessment of cross infection control. The questionnaire which is a self-audit tool is basically a guidance document which ensures compliance in decontamination in primary care dental practice. The purpose is to self-reflect on how well dentists comply with the requirements in their workplace. The questionnaire has sections assessing infection control with regard to documentation and education, personal and hand hygiene, clinical area, clinical equipment, sharps and waste disposal, and reprocessing areas. It is used as a self-audit tool for self-assessment of compliance with infection control protocols. The tool is easy to understand and can be implemented in any setting to easily identify deficiencies in infection control in dental practices. The instrument has statements regarding awareness on presence of cross infection control protocol manual, familiarity with contents, and continuing professional development training on infection control. Similarly, statements regarding presence of self- protection systems, such as vaccination, awareness on blood borne virus status, hand hygiene, wearing of gloves, eye shields and workplace injuries protocols was part of the questionnaire. The same questionnaire was used to obtain data in all dental hospitals selected for the study. Gender and year since graduation was the only demographic data collected in the study.

All subjects on any given day were invited to participate.

Verbal consent for participation was taken before implementation of the questionnaire. The purpose of the study was explained to all participants before execution of the tool. No attempt was made to contact the subjects in case of incomplete data. All information was kept anonymous and strict confidentiality was maintained. A total of 180 forms with completed data were analysed on SPSS (version 20). Number and percentage was used for reporting of results.

RESULTS 

Out of 250 survey forms distributed 180 were returned with complete data (response rate 72%). The mean age of the subjects was 24.9 ± 1.9 years. The sex distribution was 60% females (108) and 40% males (72). Majority of the subjects had graduated in the last three years of the study period. Table 1 gives information on knowledge on presence of cross infection manual on the premises, familiarity with contents and training for the same amongst the participants.

Table : Response in affirmative to queries related to presence of cross infection control protocols (n=180)

The table also delivers information on awareness on blood borne virus status for self, keeping vaccination record for self & staff and also presence of protocols for accidental injuries.

DISCUSSION 

First and foremost, it needs to be appreciated that the aim of the study was not to investigate the current knowledge, attitudes or practices on cross infection control but to explore if subjects were aware of existence of cross infection control protocols, procedures and guidelines in their respective dental training institutes. It also aimed to assess their awareness and knowledge regarding training of staff for the same besides investigating existence of protocols for self- protection in their work settings. Although not the aim of conducting this study, the researcher is considering the level of awareness on cross infection control as a proxy measure for infection control practices in training institutes. This proxy measure is used simply for purpose of comparisons with published data.

In 1996, the Centre for Disease Control, USA, adopted the term “standard precautions” to embrace a broader concept of the prevention and transmission of infections. Standard precautions integrate and expand the elements of universal precautions into a standard of care designed to protect health care professionals and patients from pathogens that can be spread by blood or any other body fluid, excretion, or secretion.13 The contents of standard precaution, universal precautions and guidelines are available on-line as well, for easy reference and practice use. These recommendations are meant to be followed irrespective of patient diagnosis and presumed infection status. It is important to follow the guidelines in order to avoid transmission of infection from and to the dental office. The protocols include hand hygiene, personal protection, environmental cleaning and safe waste disposal. Strict adherence to these protocols can break the links of infection chain. Pakistan is facing a rise in hepatitis and HIV cases amongst other transmissible infections. Dentistry has been implied in increasing trend of such diseases22 National guidelines for infection control in Pakistan were established in 2006 with the help of National Aids Control Program. Regarding infection control the guidelines clearly state “It must be made readily available for health care workers, by having at least one copy available at all patient care areas including laboratories. It must be updated in a timely fashion”.23 Availability of the guidelines at premises, familiarity with the contents, and proper training for the same are some of the references given in the manual for minimising infection spread.23 These guidelines recommend use of protective attire and barrier techniques, hand washing and care of hands, caution when using sharp instruments and needles, instrument sterilization or disinfection, disposal of waste materials and treatment of water and dental unit waterline.

Dental institutes are responsible for the training of their students on infection control. Such training is essential for protection of patients by providing them treatment in a safe working environment. Past studies have demonstrated varying levels of knowledge and awareness on the policies and practices related to Cross infection control in groups of medical staff. It has also been observed that these practices are greatly influenced by the examples set by senior staff members.19,20 In the past researchers have painted a dismal picture of cross infection control practices in public sector hospitals. The authors state that majority do not follow correct cross infection control policies.5 The researchers also reported non-existence of policies on hand hygiene or personal protection even though the supplies were present in sufficient quantities. Similarly, cross-sectional studies assessing knowledge, attitude and practices of infection control, reported a high percentage of dental personnel being aware on universal precautions and prevention of cross infection, but a large majority stated these were not being practiced.25-26 In the current study more than half of the subjects reported familiarity with the contents of universal precautions. This reported familiarity with contents need not be taken as a true reflection of actual practices, since this aspect was not aim of the present study. In opinion of Banglani and co-workers, a lack of training in cross infection control is the reason for not practicing these protocols.16 Other reasons given for not following infection control protocols included cost, resource deficiency and large number of patients.26 Lapses in the knowledge and routines, especially of frontline staff responsible for infection control in practices has been identified in the past researches as well.7-15 These lapses indicate a need for improvement in compliance of protocols when protocols have been implemented.27 Data on awareness on cross infection control protocols and practices are not available and neither are audits for the same done in Pakistan. Therefore, comparisons with the findings of current study are not possible. A Brazilian study comparing practices of dental students over a 10 year interval states no improvement in the attitudes and practices related to cross infection control or even worsening of practices in some aspects.24 Even though, subjects in the present study claimed that a manual on cross infection control was available on the premises, very few knew for certain that a hard copy was present. Only a little over half affirmed that they were familiar with the contents of the manual. This response is quite low and a point of concern since it may be suggestive of lack of awareness on infection prevention protocols and procedures necessary in a dental setting. Similarly, approximately a third of the sample reportedly received a training in cross infection control or claimed evidence of attendance. Such low number of practitioners having obtained this important aspect of training indicates the lapse in our undergraduate training program. It also indicates lack of stress placed on this important aspect; a gap that necessitates ensuring stricter adherence to protocols in the dental set up. Past research has also indicated very few dentists exercising these in clinical practice despite emphasis on standard precautions.28-41The reason for such a low number having received training may be absence of an infection control infrastructure in the teaching institutes and hospitals The current study supports the findings of Bangalani and his team who have pointed out lack of training as the reason for not practicing infection control protocols at institutes.16 Considering the importance of limiting infection spread, training in standard precautions need to be encouraged and ensured by all staff alike. It is suggested that students should be introduced to intense training program for cross infection control for the entire period of their stay in dental institutes. A way to overcome the inadequacy can be a mandatory training during the under graduate years for students before they enter the clinical years. Any lack of emphasis on prevention and cross-infection control can pose a major risk of infection transmission in Pakistan. The country already faces high risk of transmissible diseases.

Another observation in the current study was a gap in the reported training received by female dental graduates. A significantly low number of female graduates reported having received a training in standard precautions when compared to male counterparts. In recent years, females comprise around 80% of admissions every year to dental institutions across Pakistan and will, therefore, consist of major dental workforce practicing in future. Hence, this finding is alarming for dental practices in Pakistan in times to come. The reasons behind females not receiving training also needs to be investigated.

Importance of knowledge on cross infection control protocols is vital because a survey conducted by Pakistan Medical Research Council (PMRC) during 2007-2008, reported 2.5% of Pakistani population affected by Hepatitis B (HBV) and 5% with Hepatitis C (HCV) infection (42). The risk of developing hepatitis B ranges from 22% to 31% following a percutaneous exposure involving blood known to be infected by HBV and the presence of HBeAg. The numbers given in the report are the known cases of Hepatitis. Carrier of infection might not be known thus posing a very high risk of infecting others. If timely measures to control spread of infection are not taken the number is likely to increase many folds. The dental community from all health care personnel has the highest risk of infection to hepatitis

B.43 The incidence of HBV infection increases with the length of clinical practice of dentists, dentists age, irregular use of protective glasses and clothing and presumed contact with infected blood and the non-immune status. In the current study over 2/3rd of the sample stated they were aware of their blood borne virus status. We assume that the subjects had been vaccinated against hepatitis B. Previously, less than two third of healthcare workers (HCWs) surveyed by Baqi and coworkers were immunized against Hepatitis B.5 Singh et al. have reported a similar number of dental students having been vaccinated for Hep B while approximately 50% of the study subjects had not been vaccinated against most common infections encountered in dental offices.44

Hand hygiene is of utmost importance when it comes to prevention of infections to the patients and dental healthcare personnel. Risk of exposure to infection is through blood which can be passed on through hands. During dental procedures, if no protective barriers such as gloves are used, potentially infected blood may be retained beneath the fingernails for up to five days.45,46 Hence, the chances of transmission of infection in dental settings would increase, especially so when graduates are not appropriately trained for the purpose. The likelihood of infection can be decreased significantly by using infection control strategies. More than 80% of subjects in present study also claimed existence of protocols for hand hygiene including waterless hand hygiene. This response might have been prompted because of routine practices observed at the institute with waterless hand hygiene procedures. In comparison, an Indian study has reported less than two thirds of dental students practicing hand hygiene before and after patient examination.44 Due to lack of knowledge on indications and the steps involved in hand hygiene, inadequate hand washing practices and poor monitoring of hand hygiene by the health professionals in the health institution have been reported for developing countries like Nigeria.47 It may be pointed out that the present study did not inquire knowledge or the steps involved in hand hygiene. Soap and water, antiseptic soap and water less hand hygiene techniques have their indication and need to be followed accordingly. The current research did not investigate actual practices in waterless hand hygiene in conjunction with other methods used for the purpose. The study also did not investigate the frequency of changing gloves and masks in between patients by these young dentists which is a major limitation of current study and thus, need to be addressed in future research. Presence of protocols on use of gloves, protective eye wear and masks, claimed by a high percentage of current respondents, however, is an encouraging finding. Furthermore, response bias is a shortcoming of questionnaire based studies. Hence the results presented need to be interpreted with caution since these do not reflect actual practices.

A very high percentage of the respondents in the present study affirmed presence of splash injuries protocol but very few reported recording of workplace injuries or following such protocols. Considering that roughly 50% were aware of the protocols described in the manual, the response is not representative of practices in case of sharp injuries. Approximately three fourths of the sample claimed to be aware of their blood borne virus status but few (less than 50%) reported that a record for the vaccination status for the staff was kept. These loopholes in training and institutional practices need to be addressed and proper record keeping should be stressed and maintained. Past studies have also indicated that few dentists have adhered to standardized infection control procedures in their clinical practice.28-32 The current study too, indicated the low levels of knowledge on infection control protocols which is suggestive of lack of practices for the same.

RECOMMENDATIONS

It is recommended that all dental settings should have policies and protocols for early detection and management of potentially infectious persons at initial points of patient encounter. Ongoing education and training on the basic principles and practices to Dental Health Care Professionals (DHCP ) should be introduced during orientation to the setting, when new tasks or procedures are introduced. Records of such training should also be kept at a minimum, annually. These are critical for ensuring that infection prevention policies and procedures are in place, understood and followed. Additionally, regular supplies of products such as for hand hygiene, safer devices to reduce percutaneous injuries, and personal protective equipment are rendered available as these are critical for health of all at the health facilities. It is also necessary to conduct clinical research to observe and monitor infection control knowledge and practices among dental health care personnel and on dental occupational injuries. This would also assist in the development of educational interventions to improve adherence to guidelines and reduce injuries in future dental workforce in Pakistan and hence, help reducing burden of disease spread through dental settings

CONCLUSIONS

The study concludes that the fresh dental graduates working in various teaching hospitals of Lahore lack awareness on guidelines and protocols on Universal/ Standard precautions defined for dental practice use. Ongoing education and training for ensuring that infection prevention policies and procedures are in place, understood and followed are not only essential but critical for safe dental practices in Pakistan in future.

CONFLICT OF INTEREST

None declared

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Associate Professor, Principal Dental Surgeon, de’Montmorency College of Dentistry, Fort Road, Lahore.

Corresponding author: “Dr. Shamta Sufia” <ssufia@yahoo.com>

Shamta Sufia                                       BDS, MSc, PhD