Vol. 29 No. 01 Jan-Mar 2020

Nabeela Riaz                                      FCPS

Tooba Saeed                                      FCPS, MCPS

Shagufta Yasmin                               BDS

INTRODUCTION

Inverted papilloma is a benign sinonasal epithelial tumor categorized under sinonasal schneiderian papilloma. According to World Health Organization (WHO) 2005 classification, Schneiderian papilloma comprises inverted, oncocytic and exophytic papilloma.1 In 1854, Ward first described the inverted papilloma in the sinonasal cavity.2
Inverted papilloma arises from lateral wall of nasal cavity and it secondarily involves the maxillary, ethmoidal, frontal and sphenoidal sinuses. It is extremely rare for paranasal sinuses to be primarily involved, occurring only in 5% of the cases.3
It has three main characteristics that distinguish it from other benign sinonasal tumors, locally aggressive growth pattern, high rates of recurrence and increased tendency toward malignancy.4 10%-15% of the cases of the nasal cavity and paranasal sinuses are associated with squamous cell carcinoma.5
Inverted papilloma is 4 to 5 times more frequent in males in the 5th to 6th decade of life. Signs and symptoms are nonspecific, may include unilateral nasal obstruction which may cause pain, epistaxis, purulent discharge, olfactory disorders and recurrent rhinosinusitis.6
The pathogenesis of Inverted papilloma is unclear although allergy, chronic sinusitis and viral infections have been suggested as possible etiologic factors.

CASE REPORT

A 42 years old male presented to the department of Oral and Maxillofacial Surgery, Mayo Hospital Lahore on September, 2017 with left side swelling of the face and associated proptosis of the ipsilateral eye, for one year. Initially, there was only complaint of intermittent nasal obstruction and nasal discharge. After some time, a small nasal mass with associated facial swelling has been felt by the patient. Both nasal mass and facial swelling increased in size gradually. Eventually over a period of one year, left eye proptosis was also remarkable. Past medical and surgical histories were not significant. Clinically, there was a huge swelling on the left side of the face, extending cephalocaudally from the left supraorbital rim to the left angle of the mouth and mediolaterally from the left lateral nose to the left malar region, along with marked proptosis of the left eye that displacing the eyeball (Fig. 1). Swelling was soft to firm and non-tender on palpation. Overlying skin was intact in texture and temperature, but slight reddish in color. There was polypoid mass in the nose bilaterally, causing nasal obstruction. Mouth opening was normal. Intraorally, swelling also involved the hard palate bilaterally up to the junction of hard and soft palate, firm and non-tender with normal overlying mucosa.

CT scan revealed a soft tissue hypodense mass in bilateral nasal cavities extending into the bilateral ethmoidal, frontal and maxillary sinuses. Superiorly, mass had intracranial, extra axial extensions. Laterally mass was extending into the left orbital cavity, posteriorly into the nasopharynx and inferiorly it is eroding the hard palate (Fig. 2). Incisional biopsy was inconclusive showing benign inflammatory lesion.

Fig 2

Surgical excision under GA was planned. Lateral rhinotomy incision with infraorbital extension was used and mass was excised from the nasal cavities, sphenoidal, ethmoidal and bilateral maxillary sinuses (Fig. 3). Excisional biopsy was sent for histopathological
examination. Histological examination revealed polypoidal tissue lined by columnar cells with an admixture of mucin containing cells. Tissue enclosed in basement membrane which grows endophytically into the underlying stroma. Clinicohistopathologic correlation was suggestive of final diagnosis of Inverted papilloma.

DISCUSSION

The inverted papilloma also called Ringertz tumor, transitional cell papilloma, schneiderian cell papilloma, epithelial papilloma, is a group of benign neoplasm originating from the sinonasal mucosa. The name inverted is derived from the pattern of endophilic growth of the superficial epithelium to inside the adjacent stroma.
Typically, the schneiderian papillomas are unilateral, bilateral papillomas may also occur. 2
Inverted papillomas are generally diagnosed at a late stage,1-4 years after first onset of sinonasal symptoms. Functional signs and symptoms are nonspecific and vary according to the site of occurrence; they include nasal obstruction, anterior and/or posterior rhinorrhea, epistaxis, hyposmia or anosmia, symptomatic mass or facial pain. On clinical examination by endoscopic exploration of the nasal cavities, there is a reddish-gray lobulated tumor, firmer than an inflammatory polyp with a characteristic “raspberry” aspect. Inverted papillomas are friable on palpation and bleed on contact.1
Etiology is undefined, the possible etiologies are inflammatory origin and chronic infectious rhinosinusitis, allergies, Epstein-Barr virus and Human Papilloma virus.3 Pathologic examination is essential for diagnosis. Histologically inverted papillomas have an endophytic growth pattern consisting of invagination of the superficial IP epithelium into the underlying connective tissue stroma. The epithelium may be of squamous, transitional or respiratory type. The basal membrane is intact.2
Radiological assessment done with CT scan and MRI scan being the most common. Sinus CT is systematic. On CT scan, the aspect of IP is
nonspecific with an isodense unilateral homogeneous lesion mostly centered on the middle meatus of nose. Micro calcifications are found within the lesion in about 20% of cases. Bone erosions are frequently found. MRI is first imaging modality to perform for follow-up cases.1
Inverted papilloma is a benign neoplasm having association with squamous cell carcinoma. This association with malignancy, along with greater invasion potential and tendency for recurrence suggests the treatment paradigm for IP. Complete surgical excision including the adjacent uninvolved mucosa is the treatment of choice. Endonasal endoscopic approaches are used only for tumors of limited extensions while an external or combined external/endoscopic approach remains the treatment of choice for most of the lesions.4 Tumor recurrence usually occur in the first two years, but in some cases it occurs after 6 years of evolution so patient follow up for at least 6 years should be done.2

DISCLAIMER

The manuscript has not been published and is not under consideration for publication in any other journal.

CONFLICT OF INTEREST

We have no conflict of interests to declare.

FUNDING SOURCES

We have no funding sources to declare. This case report is being published after taking consent from the patient.

REFERENCES

1. Lisan Q, Laccourreye O, Bonfils P. Sinonasal inverted papilloma: From diagnosis to treatment. Europ Annals Otorhinolaryngol, head and Neck Dis. 2016;133:337-41. https://doi.org/10.1016/j.anorl.2016.03.006
2. Khandekar S, Dive A, Mishra R, Upadhyaya N. Sinonasal inverted papilloma: A case report and mini review of histopathological features. J Oral Maxillofac Pathol. 2015;1:405 https://doi.org/10.4103/0973-029X.174644
3. Salomone R, Matsuyama C, Giannotti Filho O, Alvarenga ML, Martinez Neto EE, Chaves AG. Bilateral inverted papilloma: case
   report and literature review. Revista Brasileira de Otorrinolaringologia. 2008;74:293-96. https://doi.org/10.1016/S1808-8694(15)31103-4
4. Neagos A, Alexandra C, Duca D, Iren C. Inverted papilloma of the nasal cavity-case report. Romanian J Rhinol. 2014;4:55-8.
5. Cabov T, Macan D, Manojlovic S, Ozegovic M, Spicek J, Luksic I. Oral inverted ductal papilloma. British J Oral Maxillofac Surg.
   2004;42:75-7. https://doi.org/10.1016/S0266-4356(03)00195-5
6. Jurgens PE. Inverted ductal papilloma of the lower lip: a case report. J Oral Maxillofac Surg. 2004;62:1158-61. https://doi.org/10.1016/j.joms.2003.08.043

1. Professor and HoD, Department of Oral Maxillofacial Surgery, Mayo Hospital Lahore.
2. SR, Department of Oral Maxillofacial Surgery, The University of Lahore.
3. PG Trainee, Department of Oral Maxillofacial Surgery, Mayo Hospital Lahore.
   Corresponding author: “Dr. Tooba Saeed” < drtoobasaeed@yahoo.com >

Nabeela Riaz                                      FCPS

Tooba Saeed                                      FCPS, MCPS

Shagufta Yasmin                               BDS

Mohsin Javaid                                      BDS

Muhammad Jamil                                BDS, FCPS

Mustafa Sajid                                       BDS, FCPS

INTRODUCTION

Dental care professionals including doctors and dental assistant are at high risk of getting infected with Hep B and HIV. As Dental healthcare workers are in direct contact with the infected patients, they are athigh risk of getting infected with hepatitis B and other
blood endured disorders.1 Hepatitis B is a common disease which can be fatal.2
Dentist are profoundly at risk of getting infected from patient’s saliva and blood.3
Stick Injuries with needle or other sharp instruments used during medical procedures and blood transfusion have the risk to transfer
hepatitis B among the medicinal services specialists,Thus it is important to prepare for safety measures to avoid cross infection with Hepatitis B.4
Dental assistants work closely with patients, under the guidance of a dental surgeon. They are at risk during handling of instruments especially sharp instruments with naked hands or without care.5
Practicing strict cross infection controlregulation activities are vital to guarantee the wellbeing and insurance of human service experts and other coordinating staff who might be indirectly associated with the dental treatment procedure.7 It is an ethical duty of an employee to protect the patient and health care assistant from cross infection contamination.6 Immunization against Hepatitis B should be mandatory for every health care worker. Prophylactic estimates like inoculation, the risk of infection increasesfrom 6%-30%in non-vaccinated individuals, and decreases the risk of cross infection from 90%-95%.8 According to the survey of
World Health Organization, Eighteen to Thirty nine percent therapeutic, oral health care workers have inoculation in developing nations e.g Argentina, Algeria.9 While in developed nations level of inoculated medicinal services specialists is raised up to Ninety-five percent.10,11,12 Cross infection of hepatitis B can be decreased if healthcare workers properly dispose-off the sharps and do proper
sterilization of the instruments.14
The Objective of this study was to find out the status of vaccinationagainst Hepatitis B virus among dental assistants of Multan. As the literature demonstrates that most of the studies regarding cross infection and hepatitis B vaccination status had been done on doctors and students but our study focused on the Dental assistants to overcome the knowledge gap. Dental assistants also have less awareness regarding cross infection and vaccination status against hepatitis B virus.

METHODOLOGY

This questionnaire-based cross-sectional study was conducted in Multan Medical and Dental College from September 2018 to November 2018. Dental Assistants working for last one year were included in this study.
Assistants who had less than one-year experience were excluded from the study because the tenure of complete vaccination process is at-least 6 months. 95 participants completed questionnaire including the vaccination status and if not vaccinated then the reasons for non-vaccination.Validity was confirmed by the pilot testing in hospital.Sample size was calculated by using Open-Epi online calculator with the level of significance of 5% and confidence interval of 95%, the final sample size was calculated as 95. Simple random sampling was used in
order to get desired sample size. Estimated number of dental assistants in Multan were approximately 250, adjustment was done by Cochrane correction formula. A pretest was conducted on a random sample of 10 dental assistants (n=10) that were not included in this study.
Ethical approval (MDC-0409) was taken from Multan dental hospital and after taking the informed consent from the participants.

RESULTS

Out of 95 participants, 65 were males and 30 were females. 44.2% dental assistants were vaccinated but 55.8% were not vaccinated and had different reasons for being notvaccinated, 40% participants did not get vaccinated due to lack of motivation. (Table 1) From a total of 55.8% non-vaccinated dental assistants,10.6% were non-vaccinated due to lack of awareness.Dental assistants who remained nonvaccinated due to lack of time were 8.42%.4
Among 13.68% participants reported that the distant vaccination center was the main reason for their non-vaccination. The participants who did not get vaccine due to non-motivation were 40% and among 23.1% dental assistants reported phobia to the injection while 4.2% participantsreported that they could not afford the said vaccination as it is very expensive.

Table 1: Percentage of Vaccinated Dental Assistants

DISCUSSION

According to CDC rules overall wellbeing measures are set of exercises which are fundamental to avoid hepatitis B infection. Vaccination against hepatitis B virus is extremely essential to control cross infection of hepatitis B in dental assistants and patients as well.15
Results of this research shows that forty-four percent dental assistant were vaccinated against hepatitis B virus which is contrary to another study in which 88% healthcare workers got vaccination in Saudi Arabia.16 Health department of Saudi Arabia has made sure that each health care worker must receive vaccination before getting job.
There are many reasons for not receiving vaccination like unawareness, injection phobic, expensive medicine, non-motivated participants, distant vaccination center and lack of time.17
Another study on vaccination status conducted in Bangladesh stated that 47% assistants were vaccinated in 2015 in tertiary care hospitals. These results are very much similar tothis study in which forty four percent assistants are vaccinated.18
In 2008 a study conducted in Japan concluded that dental health care workers are more prone to be infected with hepatitis B virus than general population. That is why dental health care workers must have vaccination against hepatitis B virus.19 Results of this study are similar to the study conducted in Japan. Percentage of vaccinated dental workers was 48% while in this study vaccination rate is 44%.19 It is extremely important to note that vaccination status of dental assistants around the world is between 33% to 97%. The percentage of vaccinated people were more secured to hepatitis B virus than non-vaccinated which shows that hepatitis B virus vaccination is an important measure for security against disease.19 A research was conducted in Nigeria which stated that 16% participants failed to receive
complete vaccination due to lack of knowledge while in this study 10.6% participants failed to get vaccination due to unawareness. In present study 44.2% received vaccination against Hep B where as another study shows contradicting results 60.02%.20 According to a study conducted in Oyebimpe. 5.3% participants did not received any vaccination because of unavailability but in this study percentage climbs up to 11.2%. In the study of Oyebimpe busy schedule has been reported to be a major cause 57.9% healthcare workers did not get vaccination owing to their busy schedule. While in this present study almost 8.42% participants didn’t received any vaccine against Hepatitis B due too busy schedule.
Distant vaccination center was second most common reason for non-vaccination after busy schedule. In the study of Oyebimpe 21.1% participants did not receive vaccination due to distant vaccination center but in our study it was 3.68%. Unawareness is also the cause which keeps the participants away from vaccination process. 15.3% healthcare workers in the study of Oyebimpe reported that they were
not aware of a vaccination process while in this study this percentage was 10.6 %.21
Another study was performed in Syrian private Medical University which revealed that 43.75% participants receive vaccination and the results corroborate to the result of present study. In this study most of the participants failed to get vaccine due to lack of motivation which is similar to Syrian study where lack of motivation was the major cause of failure. Needle phobia is major cause of non-vaccinated
participants. In this study 23.1% participants reported phobia to injection but in Syrian investigation the percentage was reduced to Eight percent.22
In 2007,Seventy-five percent health care workers were vaccinated in United States23 while in this study only 44.2% participants received vaccination. Results of this study are slightly better than another study from Lahore where vaccination rate was 42.20% among the health care providers.24
In Kuwait eighty-four percentdoctors and paramedical staff got vaccination against the hepatitis B virus. While in our study vaccination rate was very low ascompared to that of Kuwait.25

CONCLUSION

The self- reported rate of hepatitis B vaccination among Dental Assistants of Multan was low. Lack of motivation was the main impediment. Dental institutes should take responsibility to educate their health care workers regarding precautions and vaccination against hepatitis B virus.

CONFLICT OF INTEREST

None declared

REFERENCES

1.  Laheij AMGA, Kistler JO, Belibasakis GN, Välimaa H, de Soet JJ. Healthcare-associated viral and bacterial infections in dentistry. J Oral Microbiol . 2012 ;4:1-10 https://doi.org/10.3402/jom.v4i0.17659
2. Patil S, Rao RS, Agarwal A. Awareness and risk perception of hepatitis B infection among auxiliary healthcare workers. J IntSocPrev
   Community Dent. 2013;3:67-71 https://doi.org/10.4103/2231-0762.122434
3. What is dental PPE and why is it so important? | My Dental Uniform. August 2017.Cited from: http://www.mydentaluniform.co.uk
4. Setia S, Gambhir R, Jindal G, Setia S. Attitudes and awareness regarding hepatitis B and hepatitis C amongst health-care workers of
   a tertiary hospital in India. Ann Med Health Sci Res. 2013;3:551-58. https://doi.org/10.4103/2141-9248.122105
5. A Dental Assistant’s Guide to Infection Control. August 25 2015. Cited from: https://www.canadianacademyofdentalhygiene.ca
6. Mousa, AA, Mahmoud NM, El-Din, AZT. Knowledge, attitudes of dental patients towards cross-infection control measures in dental
   practice. Eastern Medit Health J,1997; 3: 263-73
7. Infection control in dentistry has never been more essential – Dental News Pakistan [cited 2017 Nov 25]
8. Viral hepatitis B. Fact sheet [online] October 1,2004. (last accessed on August 12, 2015)
9. CDC. Updated U.S: public health service guidelines for the man¬agement of occupational exposures to HBV, HCV, and HIV and
   recommendations for post exposure prophylaxis. MMWR 2001, 50 (No. RR-11):1-42.
10. Bhattarai S, K C S, Lama S, Rijal S. Hepatitis B vaccination status and needle-stick and sharps-related injuries among medical school
    students in Nepal: a cross-sectional study. BMC Res Notes. 2014;7:774. https://doi.org/10.1186/1756-0500-7-774
11. Khan N, SM, Siddiqui SH, Merchant AA. Effect of gender and age on the knowledge, attitude and practice regarding hepatitis B and
    C and vaccination status of hepatitis B among medical students of Karachi, Pakistan. J Pak Med Assoc.2010; 60:450-45.
12. Noubiap JJN, Ndoula ST, Agyingi LA. Occupational exposure to blood, hepatitis B vaccine knowledge and uptake among medical students in Cameroon. BMC Med Edu.2013;13:148. https://doi.org/10.1186/1472-6920-13-148
13. Holmberg SD, Suryaprasad A, Ward JW. Updated CDC recommendations for the management of hepatitis B virus-infected health-care providers and students. US Department of Health and Human Services, Centers for Disease Control and Prevention. 2012, 20;61:1-12.
14. Tanaka F. ICP Text of ICP for an infection control practitioner. Osaka: medicus Shuppan; 2006; page. 152-8.
15. Solanky P, Baria H, Nerulkar A, Chavda N. Knowledge and practice of universal precautions among nursing staff at a tertiary care hospital in South Gujarat, India. Int J Community Med Public Health. 2016;3:2373-76. https://doi.org/10.18203/2394-6040.ijcmph20162890
16. Haridi HK, Al-Ammar AS, Al-Mansour MI. Compliance with infection control standard precautions guidelines: a survey among
    dental healthcare workers in Hail Region, Saudi Arabia. J Infect Prev. 2016;17:268-76. https://doi.org/10.1177/1757177416645344
17. Taha F, Janakiram C, Joseph J, Dental Infection control Practices and Public perception: A Crossectional Study. J Inter Oral Health,
    2015;7:20-6
18.  Roy R, Karim M, Bhattacharjee B. Hepatitis B virus infection and vaccination status among health care workers of a tertiary care hospital in Bangladesh. J Sci Soc. 2015;42:176-79. https://doi.org/10.4103/0974-5009.165561
19. Nagao Y, Matsuoka H, Sata M. HBV and HCV infection in Japanese dental care workers. Int J Mol Med. 2008;21:791-99. https://doi.org/10.3892/ijmm.21.6.791
20. Azodo C.C • Ehigiator O, Ojo M.A. Occupational Risks and Hepatitis B Vaccination Status of Dental Auxiliaries in Nigeria. Med
    Princ Pract. 2010;19:364-66. https://doi.org/10.1159/000316374
21. Adenlewo OJ, Adeosun PO, Fatusi OA. Medical and dental students’ attitude and practice of prevention strategies against hepatitis B virus infection in a Nigerian university. Pan Afr Med J.2017;9:28:33.1-8. https://doi.org/10.11604/pamj.2017.28.33.11662
22.  Ibrahim N, Idris A. Hepatitis B Awareness among Medical Students and TheirVaccination Status at Syrian Private University. Hept Res and Treat. 2014; Article ID 131920.1-7 https://doi.org/10.1155/2014/131920
23. Simard EP, Miller JT, George PA, Wasley A, Alter MJ, Bell BP et al. Hepatitis B Vaccination Coverage Levels Among Healthcare
    Workers in the United States. Infect Control Hosp Epidemiol. 2007; 28: 783-90. https://doi.org/10.1086/518730
24. Singh SP, Swain M, Kar IB. HBV and Indian medical and dental students.Hep B Annual.2004;1:229-39
25. Habiba S, Alrashidi G, Al-Otaibi A, Makboul G, El-Shazly MK. Knowledge, attitude and behavior of health care workers regarding hepatitis B infection in primary health care, Kuwait. Greener Journal of Medical Sciences. 2012;2:77-83. https://doi.org/10.15580/GJMS.2012.4.GJMS1221

1. Demonstrator, Department of Community Dentistry, Multan Medical and Dental College Multan.
2. Associate Professor, Department of Operative Dentistry, Multan Medical and Dental College Multan.
3. Assistant Professor, Department of Operative Dentistry, Multan Medical and Dental College Multan.
   Corresponding author: “Dr. Mustafa Sajid” < mustafa_sajid_@hotmail.com >

Mohsin Javaid                                      BDS

Muhammad Jamil                                BDS, FCPS

Mustafa Sajid                                       BDS, FCPS

Hafiz Nasir Mahmood                                               BDS

Muhammad Waseem Ullah Khan                            BDS, FCPS

Muhammad Azeem                                                   BDS

Sabiha Naeem                                                           BDS, PhD

Asif Ali Shah                                                             BDS, MSc, MDS

Muhammad Mudassar Saleem                                BDS, FCPS

INTRODUCTION

Co-morbidity is a medical condition accompanied to the primary condition for which patient is seeking medical or dental care.1
Dental patients may possess various comorbidities to whom they are not aware and just appear as healthy individuals or they may have compromised quality of life due to chronic illness. Patients, on several medications for their systemic diseases can directly or indirectly have impact on dental treatment.2,3 Every dentist must have necessary skills to distinguish these co-morbid medical conditions which are related to their dental treatment.4
People usually do not find any relation between their systemic and dental health, so they are reluctant to report their past medical history. Old age group demands dental treatment with their co-morbid conditions and sometimes consultation with their physician becomes mandatory. Most frequently reported medical co-morbid conditions are diabetes, chronic bronchitis, cardiovascular diseases, hypertension and arthritis.2-4 As oral care is particularly important to the general health of elderly patient so, a detailed medical historyis a preventive tool to ascertain the health care of patients by avoiding any medical emergency in dental practices.5-7
A dental professional is obliged to have a command on various factors in relation to the co-morbid conditions when treating a patient. Those factors are: patient positioning on dental chair; duration and time span for the dental appointment; selection of particular type of anesthesia, control of pain, anxiety and bleeding; management of syncope, hyperventilation syndrome, local anesthetic intoxication, hypoglycemia,allergies, asthma, myocardial infarction and stroke etc.8 As body is a whole oral healthsystemic health connection, therefore a blended approach to practice an integral dentistry will achieve better results.
In the literature, self-administered questionnaires like Medical Risk-Related History (MRRH)4 or modified American Society of Anesthesiology (ASA) risk score9, were designed to evaluate the health status of patients.
Various studies have been conduced internationally and locally so far on the topic of prevalence of medical co-morbid conditions in dental patients,10-13 but no study conducted so far on the topic of frequency of medical co-morbid conditions in dental patients visiting oral surgery, prosthodontic and orthodontic departments. This will help in generation of dental speciality based data.
Every dentistry centre should be ready to counter any medical emergency. This preparation would include training of all the staff, training and knowledge of dental experts, and presence of emergency drugs and equipment. Following this rationale, the main objective of this study was to determine the frequency of medical co-morbid conditions in dental patients visiting oral surgery, prosthodontic and orthodontic departments.

METHODOLOGY

This study was conducted with an aim to find out the frequency of medical co-morbid conditions in dental patients. Patients attending outpatient department of our dental institute were included in the study. After obtaining informed consent from the patient, a comprehensive predesigned history from was utilized by one dental expert to record patient’s medical conditions. Estimated sample size was 450 patients, based on a type I error probability (0.01) and 90 % power of test, using previously conducted study, as a guide.9
The total sample size was 464 patients and duration of study was one year i.e. from 1.1.2018 to 1.1.2019. Different variables recorded for each participant were age, gender and history of medical co-morbid conditions including diabetes mellitus, hypertension, ischemic heart
diseases, renal disorders, typhoid, thyroid disorder, degenerative joint disorder, asthma, hepatitis B, hepatitis C, hepatitis A and E, HIV and tuberculosis.

STATISTICAL ANALYSIS

Data was analyzed using SPSS software. Chi square test was used to assess statistical significance in the frequency of medical conditions (P<0.05).

RESULTS

Data of 464 patients was included in this study. 152 patients out of 464 i.e. (32.8%) had a history of medical co-morbidity in addition to their presenting complaint. Age of these patients ranged from 18-75 years with mean age of 45.08 with SD ±13.9 years. Patients in 4th and 5th decade were mainly afflicted with medical co-morbidities (52.6%). 112 patients (73.7%) were male and 40 patients (26.3%) were female.
In this study, hypertension was reported with highest frequency of 9.5% in total number of patients followed by degenerative joint disorders and hepatitis C with the same frequency of 5.2%. Diabetes mellitus andhepatitis B accounted for 3.4% of the patients (Table 1). Frequency distribution of co-morbidities is graphically represented in Fig 1.
There were some patients with more than one co-morbidities (7.8%). Within the strata of medically compromised individuals, highest frequency reported for hypertension was 28.9% followed by degenerative joint

Table 1: Frequency of Medical Co-Morbidities

Figure 1: Graphical Representation of Frequency Distribution of Co-Morbidities

disorders and hepatitis C with frequency of 15.8%. Diabetes mellitus and hepatitis B reported with frequency of 10.5%. Hypertension and diabetes mellitus reported with higher frequency in males while degenerative joint disorder in females.

DISCUSSION

Oral health problems may be a manifestation of systemic disease or may significantly influence the health of entire body. Conventional dental treatment alone will not take care of systemic issues. Dentists must have understanding of medical co-morbidities so, they would be able to handle related complications and emergency situations.2
Before starting any dental procedure, a thorough history and physical examination is essential to assess the physical and mental health status of the patient.2,4 In medical technology, modern advancements have increased the life expectancy of patients. Non-invasive procedures are recommended for medically ill dental patients.4
Dental professionals can provide good oral care if they are aware of special needs of medically compromised patients. Short and early morning dental appointments must be scheduled for the patients suffering from cardiovascular diseases, arthritis, diabetes mellitus,
chronic obstructive pulmonary disease. Supine position is not comfortable for dyspneic patients while dental treattment.8
When treating the dental patients with blood disorders, an eye on patient’s tendency to bleed is mandatory. A proper plan is needed to implement preventive dental care to the patients undergoing radiotherapy, chemotherapy, dialysis and anti-coagulation therapy. Pain control is important in cancer patients. In diabetic patients, management of hypoglycemia is of utmost importance to avoid hypoglycemic shock while dental treatment. During elective dental procedures, control of blood pressure, anxiety and pain is of great concern in hypertensive patients to avoid complications like risk of cardio-vascular accident and uncontrolled bleeding. All staff members of a dental clinic must be trained for the emergencies. Dentists and their team members must be certified with Basic cardiopulmonary resuscitation (CPR) as a primary requisite.8
Apparently healthy patients may suffer from severe medical problems. It is the duty of dentists to treat such patients without any systemic complications.4
The purpose of this study is to determine the frequency of systemic diseases in dental patients presenting to tertiary care hospitals with a history form specificallydesigned to record medical conditions. Frequency of medical co-morbidities in this present study was 32.8%.
Epidemiological data shows the prevalence of medically compromised conditions in dental patients of northern India was 26.5%.2
Fernández-Feijoo et al., revealed the prevalence of systemic diseases 35.2% in the public system and 28.1% in the private system at Santiago de Compostela, Galicia, Spain.3
In the survey of Netherlands, prevalence reported was 28.2%.4 Umino et al., reported 64.2% prevalence of one or more medically compromised conditions in elderly Japanese dental patients.14 Nery et al., also detected high prevalence of systemic diseases in dental patients i.e.27.6% in private office group, 46.3% in academic dental center and 74.1% in hospital dental clinic.15
In this study, highest frequency reported for hypertension was 28.9%. Fernández-Feijoo et al., found 29.2% of dental patients as Hypertensive.16 Maryam A et al., reported 73.3% medical co-morbidities in Patients of Mashhad, out of which highest frequency was 34.1% for cardiovascular diseases.17 Dilhan Ilguy et al.,revealed percentage of hepatitis history 7.9%.5
In our study, hepatitis C accounted for 15.8% and hepatitis B for 10.5%. The result of study conducted on Pakistan population should prevalence of known diabetes 1.8-4.5%, hypertension 6.4-7.6%, and ischaemic heart disease 06-1.9%.18
In the literature, studies have shown that the frequency of systemic disorders in dental patients has significant value.19,20 Local study showed that there is critical requirement of for structural training of basic life support.21 The directions to get such training should be included with more emphasis organizational bodies like Pakistan Medical Comission (PMC), Healthcare Commission and Government Health Services department. Results of this study confirm the significance of medical co-morbidities in dental practice. It is the demand of present day, to have dental surgeons with enough knowledge and skills, so they can manage complications and cope up any emergency during dental procedures due to the co-morbid conditions.

CONCLUSION

This study concludes that presentation of medically compromised patients in dentistry is inevitable. Proper assessment of co-morbid conditions, in relation with dental procedure and pre or post medication, is a basic necessity.
In terms of in-depth evaluation of medical conditions, a dentist must have strong background knowledge of medical conditions and related medications before operating any dental treatment.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Chen H, Moeller J, and Manski RJ, The influence of comorbidity and other health measures on dental and medical care use among Medicare beneficiaries 2002. J Public Health Dent 2011;71:202-11. https://doi.org/10.1111/j.1752-7325.2011.00251.x
2. Walia IS, Bhatia L, Singh A, Kaur K, Duggal A. Prevalence of Medical Comorbidities in Dental Patients. AnnInt MedDen Res
   2017;3:21. https://doi.org/10.21276/aimdr.2017.3.1.DE7
3. Fernández-Feijoo J, Garea-Goris R,Fernández-Varela M, TomasCarmona I, Diniz-Freitaz M, Limeres-Posse J.Prevalence of systemic diseases among patients requesting dental consultation in the public and private systems. Med Oral Patol Oral Cir Bucal 2012;17: e89. https://doi.org/10.4317/medoral.17313
4. Smeets EC, de Jong KJ, Abraham-Inpijn L. Detecting the Medically Compromised Patients in Dentistry by Means of a Medical RiskRelated History: A Survey of 29,424 Dental Patients in the Netherlands. Prev Med 1998;27:530-5. https://doi.org/10.1006/pmed.1998.0285
5. Ilguy D, Ilguy M, Dincer S, Bayirli G. Prevalence of the patients with history of hepatitis in a dental faculty. Med Oral Patol Oral Cir
   Bucal 2006;11:29-32.
6. Chandler-Gutierrez L, Martinez-Sahuquillo A, Bullon-Fernández P. Evaluation of medical risk in dental practice through using the
   EMRRH questionnaire. Med Oral 2004;9:309-20.
7. Ide K, Seto K, Usui T, Tanaka S, Kawakami K. Correlation between dental conditions and comorbidities in an elderly Japanese population: A cross-sectional study. Med 2018;97:e11075. https://doi.org/10.1097/MD.0000000000011075
8. Scully C, Ettinger RL. The influence of systemic diseases on oral health care in older adults. J Am Dent Assoc 2007;138: S7-14. https://doi.org/10.14219/jada.archive.2007.0359
9. Walia IS, Bhatia L, Singh A, Kaur K, Duggal A. Prevalence of Medical Comorbidities in Dental Patients. Ann Inter Med Dent Res.
   2017;3:21. https://doi.org/10.21276/aimdr.2017.3.1.DE7
10.  Burris JL, Evans DR, Carlson CR. Psychological correlates of medical comorbidities in patients with temporomandibular disorders.
    J Am Dent Assoc. 2010;141:22-31. https://doi.org/10.14219/jada.archive.2010.0017
11. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospitalbased emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145:331-7. https://doi.org/10.14219/jada.2014.7
12. Allareddy V, Kim MK, Kim S, Allareddy V, Gajendrareddy P, Karimbux NY, Nalliah RP. Hospitalizations primarily attributed to dental conditions in the United States in 2008. Oral Sur, Oral Med, Oral Path Oral Rad. 2012;114:333-37. https://doi.org/10.1016/j.oooo.2012.03.024
13. Hassan SH, Shah I, Azhar M, Farooq M, Maqsood M, Mubeen T. Management of medical emergencies in dental practices-An audit.
    Pak Armed For Med J. 2011;95.
14. Umino M, Nagao M. Systemic diseases in elderly dental patients. Int Dent J 1993;43:213-18.
15. Nery EB, Meister Jr F, Ellinger RF, Eslami A, McNamara TJ. Prevalence of medical problems in periodontal patients obtained from
    three different populations. J Periodontol 1987;58:564-68. https://doi.org/10.1902/jop.1987.58.8.564
16. Fernández-Feijoo J, Nunez-Orjales J.L, Limeres-Posse J, PerezSerrano E, Tomas-Carmona I. Screening for hypertension in a primary care dental clinic. Med Oral Patol Oral Cir Bucal 2010;15: e467-72. https://doi.org/10.4317/medoral.15.e467
17. Maryam A, Atessa P, Pegah MM, Zahra S, Hanieh G, Davood A, Yeganeh K. Medical risk assessment in patients referred to dental clinics, Mashhad, Iran (2011-2012). Open Dent J. 2015;9:420. https://doi.org/10.2174/1874210601509010420
18. Claramunt Lozano A, Sarrion Perez MG, Gavalda Esteve C. Dental Management in patients with hemostasis alteration. J Clin Exp Dent 2011;3:e120-6. https://doi.org/10.4317/jced.3.e120
19. Hameed K, Kadir M, Gibson T, Sultana S, Fatima Z, Syed A. The frequency of known diabetes, hypertension and ischaemic heart disease in affluent and poor urban populations of Karachi, Pakistan. Diabetic Med. 1995;12:500-3. https://doi.org/10.1111/j.1464-5491.1995.tb00531.x
20. Amjad A, Lahooti RA, Abassi MS. Knowledge of basic life support (BLS) amongst dental practitioners. Pak Orthod J. 2017;9:61-4.
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    dental house officers working in two dental colleges. Pak Oral Dent J. 2019;39:133-36.

1. SR, Department of Oral & Maxillofacial Surgery, KEMU/Mayo Hospital, Lahore.
2. Assistant Professor, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore, Pakistan.
3. Assistant Professor, Department of Orthodontics, de’Montmorency College of Dentistry, Lahore, Pakistan.
4. PGR, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore, Pakistan.
5. Principal & Professor, Department of Prosthodontics, Dental Section Rashid Latif Medical & Dental College, Lahore, Pakistan.
6. Assistant Professor, Department of Oral & Maxillofacial Surgery, IMDC, Islamabad, Pakistan.
   Corresponding author: “Dr. Muhammad Azeem” < dental.concepts@hotmail.com>

Hafiz Nasir Mahmood                                               BDS

Muhammad Waseem Ullah Khan                            BDS, FCPS

Muhammad Azeem                                                   BDS

Sabiha Naeem                                                           BDS, PhD

Asif Ali Shah                                                             BDS, MSc, MDS

Muhammad Mudassar Saleem                                BDS, FCPS

Mehreen Wajahat                            BDS

Faisal Moeen                                   BDS, MSc

Syed Wilayat Husain                      PhD

Sumera Siddique                            BDS, PhD

Zohaib Khurshid                            BDS, MRes, MDTFEd, FPFA

INTRODUCTION

Literature indicates that individuals with malaligned teeth are more prone to periodontal problems owing to the difficulty in accessing areas hence crowding of teeth creates hinderance in maintaining proper oral hygiene.1
Patients with such crowding who are more susceptible to dental caries might benefit from the additional use of fluoride mouth rinses in addition to regular brushing.2 Patients experiencing orthodontic treatment are prone to caries and periodontal disease since the presence of a fixed appliance may compromise the efficacy to maintain ideal oral cleanliness. There is some proof that an everyday use of fluoride mouthwash will decrease the danger of tooth decay and gum disease during treatment with fixed braces.3,4 The success of orthodontic treatment apart from other factors depends on the sliding mechanism between the wires and brackets.5
Corrosion of these wires owing to any stimulus increases friction. This friction provides higher resistance to sliding5-7 and can ultimately prolong the treatment duration. Nickel-titanium (NiTi) is one of the most commonly used wire materials in orthodontic treatment. Generally, these wires are considered corrosion resistant because of a protective passive film, titanium oxide (TiO2) which is formed on these NiTi wires. This layer shields the wire from corrosion and other environmental effects. Corrosion may occur if this layer is compromised due to any factor which can create a reducing environment in the oral cavity.
After the placement of orthodontic appliances in the oral environment the occurrence of certain cases of stomatitis have been reported.8
A substantial number of proprietary products are available in the form of topical analgesics or antiseptic mouthwashes which contain active chemicals to reduce pain and soreness. These products also aim to prevent secondary infections associated with oral ulcers.9 Mouthwashes containing chlorhexidine gluconate have shown to reduce traumatic oral ulcers associated with the initial period of fixed appliance treatment.9 But the long term use of these mouthwashes can lead to a risk of corrosion in the orthodontic wires. The oral cavity is continuously bathed with saliva, which is a complex mixture of dissolved electrolytes with a high chloride content, as well as various organic substances.10 During the orthodontic treatment, wires are mechanically activated to achieve the required tooth movement.11 This relative movement of wires and the friction in the brackets may lead to the process of corrosion, for example, fretting corrosion.12 So, the mouthwashes prescribed and incorporated into the daily use of the patient during treatment with these mechanically activated orthodontic wires may initiate the process of corrosion.
In-vitro corrosion rate of frequently used NiTi archwires used for the orthodontic treatment was assessed and compared in variously prescribed mouthwashes in the patients with gingivitis. The basic purpose of this research was to select the least corrosive mouthwash that should be prescribed when patient is put on NiTi wires for longer durations during the orthodontic treatment.

METHODOLOGY

Nickel Titanium (NiTi) dental archwires (Ortho Organizer,USA) were tested. NiTi wires of the diameter 0.012mm were selected based on their long term use in oral cavity during the first phase of orthodontic treatment. Three commonly used mouthwashes to treat gingivitis in the orthodontic patients were selected. Artificial saliva was selected as a control immersion medium. The wires to be tested were made non-conducting with an epoxy resin coating, leaving behind 2cm of the wire which was to be

Table 1: List of testing materials

dipped in the electrolyte (immersion media). After overnight drying, the wires were cleaned with ethanol followed by a step which involved washing with distilled water.

Table 2: Composition of Mouthwashes

NiTi archwires manufactured by Ortho Organizer, USA were utilized in this study. Energy Dispersive Spectroscopy (EDS) of as-received arch wire was carried out showing the composition of NiTi arch wires. Although NiTi is known to be equiatomic alloy (having equal amounts of Nickel and Titanium), some other elements were also found to be added.

PREPARATION OF ARTIFICIAL SALIVA

A mineral medium with a composition similar to saliva was prepared as described by Levallois et al.13 700ml of distilled water was poured into a 1000 ml glass beaker and this was stirred using a magnetic bar at 37oC. After each

preceding reagent had completely dissolved, a new reagent was added. Reagents were dissolved in distilled water in the
sequence listed in table-3. Geigy in 1972 showed that its composition was very close to saliva. Hydrogen carbonate utilized in the preparation of this medium is known for its buffering effects which are close to that of real in-mouth conditions of saliva. Phosphates

Table 3: List of Reagents (composition) of the artificial saliva (pH=6.9)

contributed to maintaining the pH value as close to neutrality as possible. Mineralization was also achieved by the addition of phosphates and calcium.13

POTENTIODYNAMIC TESTING

A potentiostat (R-600, Gamry instruments) was used to perform the potentiodynamic tests for corrosion analysis. All the test wires utilized were under no mechanical deformation during the corrosion tests. Prepared wires were dipped into the electrolyte (Immersion media) for 2-3 hours stabilize the potential prior to starting the experiment.
Metal alloys are immersed in solution in which they are to be tested so that a stable open circuit potential (OCP) can be attained before starting the polarisation scan. OCP measurements indicated that the OCP of the alloy at 3 hours was almost identical to OCP measured at several hours, depicting that once a potential is attained, it can be considered as constant because there is no effect of varying dipping
time of sample in solution. Dipping for more than 2-3 hours should however be avoided. Therefore this dipping time ( t= 2-3 hrs) was approved as the time requisite to get a stabilization for all the electrochemical measurements so as to avoid addition of any misleading values of already existing potential when potential is applied for the experiment.14 Sample wire was used as a working electrode. A saturated calomel electrode (SCE) was used as the reference electrode whereas a graphite rod was used as a counter electrode.
The potentiodynamic polarization curves were obtained from – 500 mV toward the anodic direction, with a scan rate of 1 mV/s and a final voltage of 1500 mV. Corrosion resistance parameters, including the corrosion potential (at this potential the sum of the anodic and cathodic reaction rates on the electrode surface is zero) and the corrosion rate (Icorr; the anodic current density at the potential of Ecorr), were obtained from these potentiodynamic polarization curves. The surface of the NiTi wire after corrosion testing was observed using
a Field Emission Scanning Electron Microscope (FESEM) (mira TESCAN). One-way ANOVA was conducted to compare the mean corrosion rates between NiTi wires immersed in the different media using SPSS-23. The inter-group corrosion rates between the four solutions was compared using the post-hoc Tukey analysis.

RESULTS

Potentiodynamic polarization curves of the NiTi wires in artificial saliva and three types of mouthwashes revealed an active-to-passive transition behavior in the polarization curves. Representative potentiodynamic polarization curves of NiTi wires in different immersion media are given below (Figure 1).
In Figure 1, represents series of potentiodynamic polarization curves, the cathodic section (passive region i.e., from 0.5V to 0.4 V, for standard solution) of these polarization

Figure 1: Potentiodynamic polarization curves of NiTi wires in chlorhexidine gluconate + Benzydamine Hydrochloride mouthwash (EnziclorTM), Sodium Monofluorophosphate (SecureTM) and Dexapanthenol + permethol (Hi-ParadentTM). (x-axis is in logarithimic scale)

curves shows no vertical stage and consists only of one smooth slope. After cathodic stage anodic stage (active region i.e., from 0.4V to 1.3 V) starts. The corrosion potentials of sample wires in four test solutions were close to each other with small peaks in anodic current. The current density was found to be lowest in artificial saliva i.e. 6.900 nA/cm2. Among the mouthwashes lowest current density was found in Hi-ParadentTM i.e., 8.200 nA/cm2. Lowest current density

Table 4: Corrosion Parameters

Ecorr=Corrosion potential, Icor=Current density, MPY=Mills Per Year. Potentiodynamic test of NiTi in Enziclor mouthwash has
given maximum value of corrosion rate i.e, 0.02498 MPY whereas minimum value of corrosion rate among tested mouthwashes was obtained in Hi-Paradent i.e. 0.004341 MPY

density represents lowest corrosion rate. The curve having more fluctuations in anodic section had more pitting effect e.g, the curve of Enziclore test (Blue in Fig 1) has more fluctuations as compared to the curve of Secure (Green in Figure 1) which had intermediate fluctuations. Hi-Paradent (Red in Fig 1) showed lowest fluctuations of potentiodynamic curve representing lowest corrosion rate. This figure shows a comparison of representative values in each immersion medium. All the other values of corrosion parameters i.e.,
Ecorr, Icorr and corrosion rates calculated from potentiodynamic polarization curves of all the samples in various media one by one are given in Table-4.

STATISTICAL ANALYSIS

One way ANOVA showed that there was no difference in the corrosion rates among NiTi wires immersed in the 3 types of mouthwash (p < 0.001). Mean Corrosion Rate for Nickel Titanium (NiTi) = 10.9772 + 5.4594.
Basically an ANOVA test and s post-hoc Tukey analysis was conducted to compare the intergroup differences in the corrosion rates between the 4 different solutions. In the Table 5, the descending order of the corrosion rates is as follows: EnziclorTM, SecureTM, Hi-ParadentTM, Artificial saliva.

Table 6 illustrates the inter-group corrosion rates. These solutions can be placed in two groups (EnziclorTM with SecureTM and Hi-ParadentTM with Artificial Saliva). Means, both EnziclorTM and SecureTM have statistically different (higher) corrosion rates from both Hi-ParadentTM and Artificial Saliva.

Table 5: Corrosion Rates of NiTi Wires as Per Different Immersion Media.

However, there is no difference in the corrosion rates between EnziclorTM and SecureTM. Also, it holds true vice versa.

Table 6: Comparison of the Corrosion rates of NiTi Wires Per Immersion Media.

That is, both Hi-ParadentTM and Artificial Saliva have statistically lower corrosion rates than EnziclorTM and SecureTM. There is no statistical difference between the corrosion rates of Hi-ParadentTM and Artificial Saliva. The inter-group differences between the four different solutions have been illustrated in table 6.
As shown, EnziclorTM has significantly greater corrosion rates than both Hi-ParadentTM (p = 0.006) and Artificial Saliva (p < 0.001). Also, SecureTM has a significantly higher corrosion rate than both Hi-ParadentTM (p = 0.005) and Artificial Saliva (p = 0.074).

SURFACE ANALYSIS

FESEM images showed the surface irregularities and small pits in the wires tested in EnziclorTM, confirming the corrosion in this media.
The literature showed that the surface defects produced during the manufacturing process of NiTi alloy can cause corrosion.15 Oshida et al. also reported the possibility of corrosion on the sites of surface defects created during fabrication.16 Localized corrosion on the NiTi surfaces can be enhanced due to the surface defects.17 NiTi wires showed the maximum corrosion resistance in Hi-ParadentTM and the highest vulnerability to corrosion

Figure 2: The SEM observations ( Mag 1.00 kx) of the tested NiTi wires after potentiodynamic tests in Artificial saliva, Hi-ParadentTM, SecureTM and EnziclorTM (a-d)

Table 7: pH of test solutions

in EnziclorTM mouthwash. It can be linked to the pH of media provided other factors are kept at constant. Lower or more acidic mouthwashes are hence more corrosive. This feature decreases as pH of the media increases or moves to alkalinity. The decreasing trend of corrosion is exactly in accordance with the increase in pH of media, as shown in Table 7.

DISCUSSION

Electrochemical nature of the oral cavity must be understood to know the process of corrosion in the oral cavity. Literature establishes that the leading features for an environment to be corrosive include oxidation potential (Pourbaix, 1973) and an inconstant presence of oxygen and hydrogen.18 In the oral cavity, anaerobic bacteria are present which make a range in the pressures of oxygen and hydrogen possible. Variable amounts of oxygen and hydrogen give rise to either oxidation or reduction in the oral cavity. Factors that will provide oxidation environment are considered to be least corrosive and vice versa. Therefore, mouthwashes whose chemicals tend to take away oxygen atoms from the outermost protective layer of NiTi lead to the breakdown of this passive film initiating corrosion of the underlying wire.
According to Ewers and Greener, the range of oxidation potential (the potential at which oxidation occurs) present in the oral cavity ranges from -58 to +212 mV relative to saturated calomel electrode (SCE) suggesting that the wires are not susceptible to corrosion normally.19 Therefore, artificial saliva was utilized as a control medium in this study. Results clearly showed the minimum rate of corrosion in this media i.e, 5.6493+1.8297. There was no difference observed in the rates of corrosion in the NiTi wires immersed in artificial saliva (p = 1.00) proving that NiTi wires were impervious to corrosion in articial saliva.
The study by Kim and Johnson showed that the characterization of NiTi wires reveal extensive pitting and localized corrosion after potentiodynamic polarization tests in 0.9% NaCl solution. In the case of clinical implications, the use of different chemicals in the form of mouthwashes may lead to pitting corrosion on the wires, causing increased friction.20 In the present study pitting corrosion was observed
on the surfaces of tested samples under FESEM (Figure 2d). Fretting corrosion (corrosion due to the motion of two mating surfaces against each other) was not seen in tested samples because fretting is a type of wear and this experiment was carried out in a static controlled setup. Apart from pits, long wedges were also observed on surfaces of tested wires. This was due to cold rolling, which is the processing of alloy into wires. Due to cold rolling, grains arrange along specific lines (rolling direction). These regions are susceptible to corrosion so the lengthy wedges were observed in FESEM images.
In the present study, as the chemical assembly of protective film on all NiTi wires is identical, omprising mainly of TiO2 with lesser amounts of NiO, but corrosion of wires did occur. Statistical analysis showed a significant difference in the corrosion rates among the NiTi wires tested in different mouthwashes (p < 0.001). The trend of corrosion of the NiTi wires in different immersion media established from this study can be summarized as:

EnziclorTM> SecureTM > Hi-ParadentTM > Artificial Saliva

This trend is exactly opposite to pH of immersion media. Therefore corrosion and pH can be called inversely proportional to each other. If all the other factors remain constant, the pH of the immersion media can help explain the corrosion trends observed in reverse order. The lower the pH of the media, the greater the corrosion rate. In other words, as the immersion media becomes more acidic, the corrosion tendency increases, and the corrosion resistance of the archwire decreases. For the present study, EnziclorTM had the least pH (Table 7). As a result, the NiTi wires exposed to EnziclorTM displayed the greatest corrosion rate. As the acidity decreased and the alkalinity increased, the corrosion rate decreases as well.
Corrosion occurs in different environments i.e, air, water, acids and chorus environment etc. However behavior is different in different environments. In the present study ingredients of immersion media caused and accelerated corrosion process. Acidic pH may dissolve the surface oxide films and avoids its reorganization thereby enhancing corrosion.21 Based on the results of this research, EnziclorTM mouthwash produced substantial amounts of corrosion (16.2300 + 4.4705 MPY) in the NiTi wires as compared to the other mouthwashes. According to a study on ‘Surface characterizations and corrosion resistance of nickel-titanium orthodontic archwires in artificial saliva of various degrees of acidity,’ a decrease in pH of the electrolyte leads to a rise in the values of Ecorr and Icorr. Decreasing pH gives rise to an increase in the concentration of H+; as a consequence, it will increase the cathodic reaction 2H+ + 2e- H2 on the NiTi wire. Therefore, the reaction at anode causes the metal to dissolve and this hastens the delivery of electrons for the cathodic reaction at the potential of Ecorr. The values of Ecorr and Icorr were amplified (mixed-potential theory).22
In the present case, EnziclorTM has the lowest pH because of an acidic component in its formulation. Consequently, Ecorr and Icorr values were higher in this medium leading to an increased rate of corrosion as compared to others. So, the cause of highest rate of corrosion in this medium ows to acidic pH and the presence of HCl in its composition (i.e, Chlorhexidine gluconate + Benzydamine HCl). This HCl breaks down increasing the concentration of hydrogen ions in this medium, leading to further increase in dissolution of metal. The anodic region in the polarization curves of wires was as a result of localized or pitting corrosion and not due to the uniform corrosion.
Fluoridated mouthwash could also create acidic environment.21 Mean corrosion rate in SecureTM (Fluoride containing) mouthwash was observed as 13.7283 + 3.8306.
Mean corrosion rate of the NiTi wires in Hi-paradentTM medium was found to be 8.3012 + 3.7743, which is minimum among all mouthwashes utilized in this study. The passive film on the NiTi wires provided a maximum resistance to ion-transfer in medium, making this medium least corrosive during the treatment with NiTi wires. From the discussion above it can be inferred that passive film constancy of NiTi wire in Hi-ParadentTM immersion medium was maximum, providing an utmost shield in this medium from corrosion.
The biocompatibility of any metal is linked mostly to the passive film on the surface of that metal. AES surface-depth profile analysis suggests that the amount of Nickel oxide on the surface of NiTi wires is lower as compared to Titanium oxide (TiO2).23-25 This Titanium oxide (TiO2) can provide good biocompatibility of the NiTi alloy.23,24 Corrosion of NiTi leads to biologically negative effects.23,26-28 Sample wires showed low values of Icorr and immunity to pitting corrosion in the artificial saliva.
The difference in the rates of corrosion between the following mouthwashes was found to be significant (Significant P values): –

1. EnziclorTM and Hi-ParadentTM
2. EnziclorTM and Artificial Saliva
3. SecureTM and Hi-ParadentTM

As corrosion of these archwires can also be calculated with the individual chemicals present in these mouthwashes to assess the behaviour of different chemicals with different wires.
However further room of research exists in:-

a. Evaluation of the amount of nickel released after corrosion in the case of various mouthwashes (to avoid nickel allergy in patients with nickel hypersensitivity).
b. Evaluation of the effects of corrosion on American manufactured versus Chinese manufactured archwires using different mouthwashes.
c. Evaluation of the corrosion rate of archwires in various beverages (tea, coffee and acidic drinks).
d. Corrosion analysis of mechanically bent wires (as bends or curves manually placed in the SS wires by the dentist may become a target spot for corrosion).

CONCLUSIONS

Corrosion rate basically states, ‘rate of corrosion in Mills Per Year’ (1Mill=One 1000th of an inch) i.e, values of corrosion rate obtained convey the extent to which that specific mouthwash will cause corrosion in the wire in a year if repeatedly exposed to it whereas, the treatment time of orthodontic archwires (especially NiTi) inside the oral cavity is less than a year. But this is compensated in natural
environment as young orthodontic patients frequently take acidic drinks which may add to the effects of corrosion. Hence effects of corrosion which are obtained in a year’s period may practically be seen before the completion of one year in the oral cavity where the patient is not using mouthwash alone but taking other foods and drinks as well.
It can therefore be concluded that when the NiTi wire is used for longer periods during the orthodontic treatment, SecureTM and Hi-ParadentTM mouthwashes should be preferably recommended for treating gingival problems to ensure frictionless tooth movement as a result of minimum corrosion. EnziclorTM should be avoided in such cases owing to its corrosive effects on NiTi wires.

Author Contributions: Conceptualization, Mehreen Wajahat; Formal analysis, Sumera Siddique; Methodology, Mehreen Wajahat; Project administration, Faisal Moeen; Resources, Syed Wilayat Husain; Supervision, Faisal Moeen and Syed Wilayat Husain; Validation, Syed Wilayat Husain; Writing – original draft, Mehreen Wajahat; Writing – review & editing, Zohaib Khurshid.

Funding: “This research received no external funding” Acknowledgements: The author acknowledges the core backing of this research work to the team at the Institute of space technology especially Mr. Tahir, Engr. Abdul Moeez and Mr. Ahsan. The author is also very thankful to the team at the IRCBM COMSATS for their great cooperation. Dr Abdul Samad and Dr Akif Anwar are the names worth mentioning. Dr Sundus Iftikhar and Dr Tania Siddiqui were also very helpful.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

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20. Kim H, Johnson JW. Corrosion of stainless steel, nickel-titanium, coated nickel-titanium, and titanium orthodontic wires. The Angle Orthod. 1999;69:39-44.
21. Pataijindachote J, Juntavee N, Viwattanatipa N. Corrosion Analysis of Orthodontic Wires: An Interaction Study of Wire Type, pH and Immersion Time. Adv Dent &amp; Oral Health. 2018;10(1): 555780. https://doi.org/10.19080/ADOH.2018.10.555780
22. Wever D, Veldhuizen A, De Vries J, Busscher H, Uges D, Van Horn J. Electrochemical and surface characterization of a nickeltitanium alloy. Biomaterials. 1998;19:761-69. https://doi.org/10.1016/S0142-9612(97)00210-X
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    implants. J Vacuum Sci Technol A: Vacuum, Surfaces, and Films. 1995;13:2624-32. https://doi.org/10.1116/1.579461
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1. Lecturer + PGT, Department of Dental Materials, Islamic International Dental College.
2. Associate Professor, Department of Dental Materials, Islamic International Dental College.
3. Professor, Department of Material Science and Engineering, Institute of Space Technology.
4. Assistant Professor, Department of Physics and Astronomy, Texas Tech University, USA.
5. Lecturer, Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, KSA.
   Corresponding author: “Dr. Mehreen Wajahat” < mehrinwajahat09@gmail.com >

Mehreen Wajahat                            BDS

Faisal Moeen                                   BDS, MSc

Syed Wilayat Husain                      PhD

Sumera Siddique                            BDS, PhD

Zohaib Khurshid                            BDS, MRes, MDTFEd, FPFA

Nabiha Farasat Khan                            BDS, M.Phil, MHPE

Muhammad Saeed                                BDS

Usama Saeed                                        MBBS

INTRODUCTION

Research is an essential element in promotion and betterment of patient’s care and health system through bridging the gap between basic and clinical sciences.1
Components of research (systematic literature search, critical appraisal, independent learning and scientific paper writing) enhance physician skills, amplify under/postgraduate medical student’s scientific knowledge, help to figure out issues and works as main incentive
guaranteeing the key growth scale.2-5 Globally, many developed and under developed countries have implemented compulsory courses that flourish and nurture positive attitude towards research.6
Regardless of its importance, various researchers have pointed out barriers against scientific research so the number of researchers continues to dwindle worldwide,7-13 Although investigators recognize barriers towards research work, however none of them has investigate the role of demographic view (age, gender, marital status and maternal education) on research work among PG trainees
of medicine & dentistry. This study was therefore started to evaluate the effects of demographic views on research activities among postgraduate medical and dental students in 3 public center medical institutes.

METHODOLOGY

A questionnaire based cross-sectional survey was carried out on 72 PG trainees of Bolan Medical Complex Hospital (BMCH), Quetta Institute of Medical Sciences (QIMS) and Institute of Public Health (IPH). Permission to conduct the study was granted by the principal Bolan Medical College, Quetta. All participants working as PG trainees in BMCH, QIMS & IPH were included in the study, whereas house
officers were excluded from study. A demonstrator from dental section distributed & collected validated questionnaire formulated by Amin TT8 which recorded PG trainee’s demographic views (age in years, gender, parental education status, marital status, type of schooling). Confidentiality was confirmed. Attitudes and perceptions about research barriers were recorded with 16 questions using a Five point Likert scale; 1= Strongly Disagree (SD) 2= Disagree (D), 3=Neutral (N), 4= Agree (A), 5= Strongly Agree (SA) to assess trainee’s responses. Likert scale variables were recoded for further analysis by combining categories agree and strongly agree in to a single group agree recoded 3, categories strongly disagree and disagree into a single category disagree coded as 1 while neutral was retained and coded as 2. Higher the score, higher the attitude level and thus, barrier was measured.
The information collected was analyzed by using statistical software SPSS-20. Chi-square test was used to evaluate association between research barriers and demographic details. Normality assumption was evaluated with Kolmogorov-Smirnov test.

RESULTS

There were 80 PG trainees, 8 of them were absent at the time of data collection giving 90% response rate. Out of these remaining 72 PG trainees 38 (52.77%) participants belonged to BMCH, 15 (20.83%) from QIMS and 19 (26.38%) were MBBS doctors of IPH. Majority (61.1%) were males and between 28-30 years of age (mean age of

Table 1: Demographic view of PG Trainees from BMCH, CMH & IPH

23.3 ± 4.6 years). Detailed demographic data of participants is presented in Table 1.
Table 2 demonstrate the distribution of scores on attitudes and perceptions about barriers in scientific research among the dental and medical PG trainees. PG trainees exhibited willingness to conduct research (Mean±SD 4.36±.65) mean while they noticed lack of lab & other facilities as major

Table 2: Distribution of scores on Attitudes and Perceptions about Barriers in scientific research among the dental and medical postgraduate trainees

Table 3: Presenting association between research barrier & demographic view

hurdle in their research activities (Mean ±SD 4. 30) whereas lack of time, motivation and/or reward also becomes an issue among PG trainees towards their scientific approach (Mean±SD 4.23±0.91 & 4.23 ±0.77 respectively).
Attitudes and barriers scores of PG trainees in relation to socio-demographic and personal characteristics response rate is presented in Table 3. Low father educational level decreases PG trainees interest in research (p-0.01) whereas statistically significant correlation was found between low mother educational level and un co-operative faculty

Bar Chart presenting barriers towards research work among PG trainees of Medicine & Dentistry

(p-<0.001) causing deficient interest in research of PG trainees. Strong co-relation was also observed between undergraduate participation and their views about ready to conduct research in the absence of supervisor (p-0.004), whereas no correlation was observed between age and attitude and research barriers among PG trainees. Likewise schooling and marital status didn’t effect PG trainees research work.
Bar chart presented barriers towards research work among PG trainees of medicine & dentistry.

DISCUSSION

This study aims to highlight the obstacles faced by local postgraduate residents in conducting research with an aim to improve research productivity and overall health care in the field of dentistry.
This study evaluates outcome of demographic role of local PG trainees on research work with the aim to ameliorate research efficacy which would exhibit outcome in the field of medicine & dentistry. In developed countries like Canada & US research is mandatory,14however controversy exist between developed and under developed countries as in India 91% PG trainees did not demonstrates research work during their PG training.15 On the other hand Pakistani students express their interest in scientific activities as 68.7% medical students participated in research work,6 however as research is not essential nor mandatory for medical students; research work ratio is still unsatisfactory. 1,16 The main reason behind this deficient research work in developing countries is limited financial sources also lack of research skills and work senior faculty member do not have enough experience in research skills and writing which affecting in mentoring the new researchers. Therefore, new policies of PMDC and HEC are forcing the PG trainees to take interest in research. Moreover, students financial support for research enhance student participation in research activities. Thus paying special attention to students’ research budgets increases chance of student participation in the research works.2 Poverty, lack of resources, poor access to the literature, and poor knowledge about the research.17,18 created a large disparity in research productivity in low-income areas of the country such as in Balochistan. Research is not a high priority for medical students of this province to carry out; even then participants of our study demonstrated positive attitude towards research work by accepting the beneficial role of research in their medical education. Highest mean score was detected on item number 5 “students carry out clinical research” (Mean±SD 4.36 ± 0.65). Same results were identified worldwide as other researcher also declare medical students interest in scientific activities.8,19-21 Amin
TT, Khan H & Aslam A identified significant improvement in the attitudes of medical students with increasing years of study in medical college.8,14,19 Whereas in Morae’s study, participants presented highest interest (81.7%) in research activities.20 This positive attitude towards research is a response to early exposure to research methodology & its importance, introduction & participation in workshops &
conferences which enhance interest of under-graduate medical students in research work.22
Researchers noticed a significant effect of parental education on their children’s educational attainment, that effects on their mind setup providing a positive outcome that improves opportunities and decision making abilities and influences their children’s achievements. Results demonstrates a positive outcome, as environment created by educated parents ameliorate the chances for their children and decision process.23,24 Research proved positive correlation regarding the impact of family involvement on educational outcomes.24 This was confirmed in our study as a strong correlation was observed between PG trainees father educational level and lack of interest in their research work (p-.001). On contrary Amin TT recognized 56.3% highly qualified fathers of his study participants. The reason of this
two-fold difference is low literacy rate of males (39%) in Balochistan.25

Chevalier detected a positive relation between maternal education and her offspring’s education.23 In Saudia Arabia 46% mothers were highly qualified.8

Unfortunately this phenomenon was not true in case of our study as 25% mothers of our study participants were illiterate and the ratio
of highly qualified mothers was very low (only 10%) demonstrating almost doubled difference with well-known cause; very low female literacy rate in Balochistan (16%).
We also noticed statistically significant results in case of PG trainees of uneducated mother facing un co-operative faculty (p-<0.001). This is because the children belonging to uneducated parents are shy and less competent, unable to deal and explain their views to others.26 Researchers found highly qualified mothers exhibiting more positive beliefs, expressing higher expectations for their children’s academic
achievement and these expectations are related to their children’s subsequent achievements. Moreover, mothers’ education is predictive of parental warmth.24
Subsequent deficiency in research knowledge and skills of physicians could have negative effects on educational, clinical research and health care, shortening the translation of bridging between basics and clinical work.27 This fact was confirmed in current study as our findings demonstrated inadequate skill and knowledge of research of the faculty as a main personal barrier towards research (p-0.011). On the other hand, 37.1% (n=157/423) participants of Amin TT realizes faculty low research knowledge and skill reduces their involvement in scientific activities.8
In our research 24 % PG trainees feels lack of interest causing deficient research activities (p-.009), other studies also detected the origin of deficient interest in research is lack of motivation or shortage of funding, over loaded curriculum,13 time management,2,28 or lack of supervisor/mentor and/or limited facilities and high work load.2,29 Attractive stipend/scholarship, review/reformation of curriculum and trained and easy availability of supervisor/mentor, enrollment early in research of medical students have been recommended that can boost interest of under/postgraduate medical and dental students in scientific activities and assists undergraduate medical students to engage in research during their graduation which would make them able to conduct research easily in their post-graduation.27 Medical and electronic data availability assist in discovering knowledge gap thus helps PG trainees to initiate their research work. The students cited bounded approach to the relevant medical and other electronic databases made them difficult to initiate their research activities.4
PG trainees of current research also disclose the fact that restricted approach of relevant electronic and medical databases is inconvenient for them to work on knowledge gap (p-0.31).4
Poor economy & poverty may be a major cause of this problem in developing countries whereas this is not observed in developed countries.8
A number of barriers exhaust and discourage medical students to continue research activities. Time was seen to be a significant barrier to pursue research interest. Mohammad Ismial from Ireland recognized only 23 & 28 % medical students feeling easy to continue their research work with adequate time.30 On the other hand, in current research work we recognized 63% PG trainees (n=12/19) of medicine from IPH faces “Lack of time” to complete their research work (p-.034). The respondents of other research studies supported our observations where students reported lack of time as a major obstacle.4,8,11,13 Medical students declare lengthy medical curriculum and intense terms of contact hours as a main reason behind not participating in scientific work. Similarly, it was the main issue of Amin research participants where time management was a major obstacle in their research work (62.4%).8 Likewise Funston detected lack of time a 2nd major obstacle in research activities of his respondents.9
In comparison Pearson detected 84% students endorsed insufficient time to participate in research. This concern can be overcome through slotting a proper time in curriculum for research work.

STRENGTH & WEAKNESSES OF WORK

Although Pakistani researchers evaluate attitude and barriers of research among medical students of Punjab, KPK and Karachi however to the best of our knowledge this research is the first to assess the demographic role on attitude and find barriers of research among medical and dental PG trainees in Balochistan which is one of the most important strategical site in the world but unfortunately, also a least developed and most backward province in the country.
This research utilized self-reported questionnaire in which response rate may result in possible selection bias. Another limitation was that PG trainees of different departments face divergent obstacles which might not be discussed in the study. Further research can be undertaken in a more rigorous manner by increasing the sample size and using a more scientific approach. In addition, it could have been more interesting to survey the research hurdles with more generalized results obtained through conducting this research on medical students studying in Makran Medical College Turbat, Jhalwan Medical College Khuzdar and Lorali Medical College of Balochistan.

CONCLUSION

Majority of PG trainees accept the importance of research and its advantage in future through demonstrating good attitude towards research work. However, maternal education, faculty’s inadequate skills and knowledge in research, lack of interest, limited access to information sources, limited facilities and time management are the main barriers to research in medicine and dentistry PG trainees.

RECOMMENDATIONS

Conducting theoretical and practical research methodology courses/workshops, forming a responsive and helpful research team assistant to support students and providing them required facilities/equipment, and giving financial support for the student’s research activities in form of stipend/scholarship can help to remove the existing barriers to research. Young researchers should be encouraged through
attractive stipend/scholarship, conduction of conferences and research workshops to enhance their interest in research work. Faculty development programmes to improve research culture and increase students’ motivation and participation can be initiated.

ACKNOWLEDGEMENT

We are grateful to the PG trainees of BMCH, QIMS & IPH for their voluntarily participation in assessing hurdles towards scientific activities among PG trainees of dental and medical institutes.

FUNDING RESOURCES

None

CONFLICT OF INTEREST

None declared

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1. Associate Professor, Department of Oral Pathology, Bolan Medical College, Quetta.
2. Senior Demonstrator, Department of Prosthodontics, Bolan Medical College, Quetta.
3. Student 2nd Year, Dow Medical College, Karachi.
   Corresponding author: “Dr. Nabiha Farasat Khan” < nabihasaeed@hotmail.com >

Nabiha Farasat Khan                            BDS, M.Phil, MHPE

Muhammad Saeed                                BDS

Usama Saeed                                        MBBS