Vol. 29 No. 03 Jul-Sep 2020

Amjad H Wyne                                  BSc, BDS, MDS, DR MED DENT, FASDC, FADI

Diabetes mellitus (DM) is a metabolic disorder that affects carbohydrate metabolism.1 It is characterized by persistent hyperglycemia.2,3 It also causes disturbance in lipid and protein metabolism.4-6 People without DM have a considerably lower risk of mortality and longer life expectancy as compared to those with DM.7
The global DM prevalence was estimated to be 9.3% in 2019 (463 million people).8 The prevalence is estimated to increase to 10.2% (578 million people) by the year 2030.8
The prevalence is lower in rural (7.2%) populations than in urban (10.8%) ones, and in low-income populations (4.0%) than the high-income (10.4%) ones.8 Pakistan is
ranked 4th in the world in the list of countries with the highest DM in adults.9 There are approximately half million children under 15 years of age with Type 1 DM worldwide.10
According to National Institute of Child Health (NICH) “diabetes is a growing health condition in Pakistani children”.9
Therefore, it is essential that dental practitioners are aware about how to manage diabetic pediatric dental patients.

TYPES OF DIABETES MELLITUS

Two major clinical subgroups of DM are; Insulin Dependent DM or Juvenile Diabetes called Type 1; and Non-Insulin Dependent DM more common in adults called Type 2 DM.11 Both types of DM patients may use insulin for their glycemic control, however, the Type 1 patients are truly dependent on insulin for their survival. Due to autoimmune destruction, pancreatic beta cells no longer produces insulin in the Type 1 DM children. Young patients mostly suffer from Type 1 diabetes.12 These children present with typical symptoms of polyuria/polydipsia.11 About one-third of these children have diabetic ketoacidosis.13

MEDICAL CONSIDERATIONS

Once DM is established in a child, blood glycemic control becomes necessary to prevent complications associated with the disease. Micro-vascular and macro-vascular complications of DM affect multiple organs, resulting in high morbidity and mortality among these patients.14 They have an increased risk for coronary artery disease, myocardial infarction and stroke.15 These patients are also likely to suffer from blindness, kidney failure, neuropathy, and limb amputation consequent to development of gangrene.15 Poor wound healing is also common after surgery on poorly controlled diabetic patients.11
Relative or absolute deficiency of insulin and hyperglycemia over long period results in hyperglycemic (diabetic ketoacidotic) coma. This condition takes many hours/days to develop with the following features; too little insulin, infection, myocardial infarction, acute abdominal infection, acidosis causing vomiting, hyperventilation, ketonuria, polyurea, dehydration, hypotension, tachycardia, weak pulse, dry tongue and skin, and abdominal pain. Hypoglycaemic coma on the other hand has a rapid onset that may resemble fainting. It is the result of failure to take food in time, missed meals, over dosage of insulin or other hypoglycaemic drugs or extensive exercise. Adrenaline release causes sweaty skin, pounding rapid pulse, anxiety, tremors, dilated pupils, and tingling sensation round the mouth. Cerebral hypoglycemia results in headache, confusion, fits, dysarthria, and unconsciousness.15 Daily injection(s) of insulin (especially in type 1 diabetics) and a regulated diet is needed for good glycemic control (Table 1). Diabetic control in children is much more

Table 1: Blood glucose (BG) and HBA1c goals for children and adolescents with Type 1 diabetes.12

challenging than in adults because many factors interact to effect the degree of diabetic control in a diabetic child. The insulin dose is also effected by child’s growth and development, which makes insulin dose and diet more arduous to control. The physical activity in children is also widely variable that increases challenge of balancing the interaction between insulin intake and dietary regimes.16

DENTAL CONSIDERATIONS

DM children are predisposed to several possible oral problems due to neuropathy, immune dysregulation and vasculopathy in DM children. Their quality of life can be negatively effected due to enhanced risk for periodontal diseases, dental caries, mucosal lesions, salivary glands dysfunction and oral burning.16,17 The relationship between DM and periodontal diseases is said to be bi-directional i.e. periodontitis has negative effect on glycemic control and; poor glycemic control tend to worsen the periodontitis in
these children. DM children may also have xerostomia (due to salivary gland dysfunction), early tooth eruption, delayed healing of wounds, dysfunction of taste and frequent oral
candidiasis.18 Diabetic children and their parents/care takers are informed about the possible oral manifestations of DM; and educated on how to prevent any further complications.
Meticulous oral hygiene maintenance and a regular dental check-up routine is vitally important in these children.

MANAGEMENT OF THE PATIENT IN DENTAL CLINICS

The dentist must take a detailed medical history from all the patients/parents, and complete Oral Health Fact Sheet to ensure availability of all the useful facts.18 In case one
suspects that the child may be diabetic, then the parents and the child are asked about symptoms such as family history of DM, polyuria, polydipsia, polyphagia and weight
loss. The suspected child is then referred to a physician for further investigations. In case the child is already an established Type 1 DM patient, the parents and child are
asked about medications, their dosages and the time of administration. It is also determined if the child has developed any complications of DM which may effect dental treatment.19 The patient’s HbA1c (Hemoglobin A1c) test may be ordered. This Hemoglobin A1c test reveals the child’s average blood sugar level over the past 2-3 months.
The normal HbA1c ranges between 4% and 5.6%. “If the patient’s glycemic control is poor (HbA1c>10%), elective dental procedures are generally deferred until the glycemic
control improves”.14 However, in cases of urgent dental situations, the dentists need to talk to the patients’ physician to discuss medicament & dietary adjustment and discuss possible prophylactic antibiotic coverage.20

PRECAUTIONS IN DENTAL TREATMENT

Most Type 1 DM patients can be provided dental treatment as outpatients in dental clinics. However, those patients who have poor glycemic control (HbA1c>10%), head and neck infections that are severe, especially those with additional systemic diseases and complications are preferably treated in controlled hospital environment.20 Similarly, dental needs that require long-term alteration of medical regimen are considered for treatment under a more controlled medical environment. The DM patients need to bring insulin (pen or with syringe, if required), their blood glucose meter, a glucose source they usually use to avoid a hypoglycemic (hypo) episode and some light snacks at their appointment.20 It is also important to ask each patient of his/her signs/symptoms of a hypoglycemic episode onset.
This will help the dentist to stop dental treatment immediately in case any of the symptoms develop, and prevent the patient going into deep hypo episode.20 These patients should be scheduled for a morning appointment to decrease the risk of hypoglycemia during the dental appointment. In some patients, it may be necessary to modify insulin dose to prevent hypoglycemia especially if there is a possibility of delayed or reduced food intake due to extensive dental treatment. It is important to remember that production of epinephrine and cortisol during stressful situations tend to increase blood glucose levels.21 Therefore, pain and stress reduction are vitally important in treating diabetic patients.22
It is essential for dentists to confirm that the patient has eaten according to his/her normal routine and took the usual medicament. It is important to avoid dental treatment during peak insulin activity to reduce the risk of perioperative hypoglycemic episode.23 In case it is not possible to avoid peak insulin activity in patients who take frequent insulin
injections, the dentist must take extra precautions such as more frequent monitoring of the patient for perioperative hypoglycemia. The extra precautions include; checking pretreatment blood glucose level using a glucometer and keep carbohydrate source such as a fruit juice or regular soft drink readily available. A small amount of pre-treatment carbohydrate may prevent hypoglycemia if blood glucose level is at the lower end of the normal range (around 80mg/dl).24
A patient may be required not to take breakfast in some situations such as If you plan to use conscious sedation for a stressful procedure or an extensive surgical procedure is
planned. In these cases special dietary adjustment and medical consultation becomes necessary.25

POSSIBLE COMPLICATIONS DURING DENTAL TREATMENT

Hypoglycemic episode is the most common complication of diabetes therapy that occurs in dental clinics. A written protocol must exists defining the role of each dental team
member in case a diabetes related emergency arises. The patients’ blood sugar level drops severely when insulin and/or oral anti-diabetic drug level exceeds patients’ physiological needs. Mood changes, hunger, weakness and low spontaneity are initial signs and symptoms, which are followed by tachycardia, sweating, and incoherence. If the
condition remains unattended, then possible consequences include hypotension, hypothermia, seizures, coma and death.19 Dentist should terminate dental treatment at first
sign or symptom of hypoglycemia. The blood glucose level is immediately measured using a glucometer. If a glucometer is not available by any chance, the condition is presumed
as a hypoglycemic episode and treated as such. If the patient’s blood sugar is more than 60mg/dl, the patient is given 15 grams of a fast acting oral carbohydrate orally as glucose
or 4 – 6 ounces of fruit juice, regular soft drink, or 3 – 4 tablespoons of sugar as long as the patient is able to swallow.
If the patient is unable to take food by mouth or becoming unconscious, no attempt should be made to give anything through oral route. In such cases, glucagon should be
administered intramuscularly or subcutaneously at any body site and, medical emergency services are called. The schedule of pediatric glucagon dose is; 0.02-0.03 mg/kg or 0.5 mg for patients weighing less than 20kg, and 1.0 mg for patients weighing 20kg or more.18 It usually takes 10-15 minutes for the signs and symptoms of hypoglycemia to resolve.
The patient is observed for half an hour to one hour after the recovery.24,26 In rare cases, where the patient remains unconscious, the medical emergency services personnel
will shift the patient to a hospital. Severe hyperglycemia takes long time to develop, so risk of hyperglycemic crisis is low in a dental practice. Signs and symptoms of ketoacidosis include nausea, vomiting, abdominal pain and acetone odor. Treatment of hyperglycemia involves administration of insulin and medical intervention. However, to differentiate between hypoglycemia and hyperglycemia based on symptoms alone is difficult. Therefore, it is advisable to administer carbohydrate to such a patient presuming a diagnosis of
hypoglycemia. Even if the child is undergoing a hyperglycemic crisis, a small quantity of sugar is unlikely  to incur any significant harm to the patient.23

RISK OF INFECTIONS

Dentists should communicate with DM patients’ physicians to become familiar with their diabetic status. Poor glycemic control places the child at high risk for infection. Healing ability after surgical procedure is compromised. While it should not prevent the procedure, especially if it is contributing towards poor glycemic control, it has to be carried out with great caution. However, in case of ketosis, the procedure must be postponed until the ketosis is resolved. Antibiotic prophylaxis/coverage is also necessary in such patients and for those undergoing extensive dentoalveolar surgical procedures. Acute orofacial infections require close monitoring and might need adjustment of insulin dosages.26

SUMMARY

Most of the Type 1 Diabetes Mellitus children can be managed as outpatients for their routine dental treatment given that appropriate precautions are taken during the dental treatment. The dentist and the dental clinic staff should be familiar with how to effectively deal with hypoglycemic situation in diabetic children. Diabetic children need frequent dental visits for early detection and intervention of oral infections. However, greater attention and emphasis should be directed toward prevention of oral diseases in these patients.

ACKNOWLEDGEMENT

The author wishes to thank Dr. Rasha Aldhaban, Associate Professor of Pediatric Dentistry at King Saud University College of Dentistry for providing some hard copies of the literature utilized in preparation of this review.

CONFLICT OF INTEREST

The author does not have any conflict of interest.

DISCLAIMER

The professional guidelines and standards of care keep changing and continuously updated by various organizations. Readers are strongly encouraged to keep abreast of latest developments in their areas of health care.

REFERENCES

1. World Health Organization. Diabetes. https://www.who.int/newsroom/fact-sheets/detail/diabetes. Accessed on 31st March 2020.
2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2009;32 Suppl 1(Suppl 1):S62-S67. https://doi.org/10.2337/dc09-S062
3. Eisenbarth GS, Castano L. Diabetes mellitus. In: Frank MM, Austen KF, Claman HN, et al (eds). Samter’s Immunologic Disease. 5th edition. Boston: Little, Brown & Co, 1995:1007.
4. Ervasti T, Knuuttila M, Pohjamo L, Haukipuro K. Relation between control of diabetes and gingival bleeding. J Periodontol 1985; 56:154- 157. https://doi.org/10.1902/jop.1985.56.3.154
5. Becker DJ. Diabetes mellitus and hypoglycemia. In: Lifshitz F (ed). Pediatric Endocrinology. 3rd edition. New York: Marcel Dekker, Inc, 1996:555-66.
6. Nepomuceno R, Vallerini BF, da Silva RL, Corbi SCT, Bastos AS, et al. Systemic expression of genes related to inflammation and lipid metabolism in patients with dyslipidemia, type 2 diabetes mellitus and chronic periodontitis. Diabetes Metab Syndr 2019;13:2715-2722. https://doi.org/10.1016/j.dsx.2019.07.003
7. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population. Diabetes Care 1998; 21:1138-1145. https://doi.org/10.2337/diacare.21.7.1138
8. Saeedi P, Petersohn I, Salpea P, Malanda B Karuranga S, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract 2019:157:1-10. https://doi.org/10.1016/j.diabres.2019.107843
9. National Institute of Child Health. Diabetes a growing health condition for children in Pakistan. https://www.thenews.com.pk/latest/6563-diabetes-a-growing-healthcondition-for-children-in-pakistan. Accessed on 13th March 2020.
10. Patterson C, Guariguata L, Dahlquist G, Soltész G, Ogle G, Silink M. Diabetes in the young – a global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Res Clin Pract 2014;103:161-75.Epub o0 Dec 2013. https://doi.org/10.1016/j.diabres.2013.11.005
11. American Diabetes Association. The path to understanding diabetes starts here. https://www.diabetes.org/diabetes. Accessed on 12th March 2020/
12. American Diabetes Association. Children and Adolescents: Standards of Medical Care in Diabetes – 2018. Diabetes Care 2018 Jan; 41(Supplement 1): S126-S136.
    https://doi.org/10.2337/dc18-S012
13. American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020; 43 (Supplement 1): S14-S31.
    https://doi.org/10.2337/dc20-S002
14. Chawla A, Chawla R, Jaggi S. Microvasular and macrovascular complications in diabetes mellitus: distinct or continuum?. Indian J Endocrinol Metab. 2016;20:546-51
    https://doi.org/10.4103/2230-8210.183480
15. Scully C. Scully’s Medical Problems in Dentistry. 7th edition. London:Churchill Livingstone, 2016:256-65.
16. Faulconbridge AR, Bradshaw WCL, Jenkins PA, Baum JD. The dental status of a group of diabetic children. Brit Dent J 1981; 151:253- 55. https://doi.org/10.1038/sj.bdj.4804683
17. Díaz Rosas CY, Cárdenas Vargas E, Castañeda-Delgado JE, Aguilera-Galaviz LA, Aceves Medina MC. Dental, periodontal and salivary conditions in diabetic children associated with metabolic control variables and nutritional plan adherence. Eur J Paediatr Dent 2018;19:119-26. https://doi.org/10.23804/ejpd.2018.19.02.05.
18. School of Dentistry. University of Washington. Oral Health Fact Sheet for Dental Professionals. Children with Type 1 Diabetes. https://dental.washington.edu/wp-content/media/ sp_need_pdfs/ Diabetes-Dental.pdf.
19. Lalla RV, D’Ambrosio JA. Dental management considerations for the patient with diabetes mellitus. J Am Dent Assoc. 2001; 132:1425-432. https://doi.org/10.14219/jada.archive.2001.0059
20. Wray, L. The diabetic patient and dental treatment: an update. Br Dent J 2011, 211:209-215. https://doi.org/10.1038/sj.bdj.2011.724
21. Varon F, Mack-Shipman L. The role of the dental professional in diabetes care. J Contemp Dent Pract 2000;15:1-27. https://doi.org/10.5005/jcdp-1-2-44
22. Reese TD. The diabetic dental patient. Dent Clin North Am 1994; 38:447-463.
23. Mealey BL. Impact of advances in diabetes care on dental treatment of the diabetic patient. Compend Contin Educ Dent 1998; 19:41-58.
24. Mealey B. Diabetes Mellitus. In: Greenberg MS and Glick M (eds). Burket’s Oral Medicine, Diagnosis and Treatment. 10th edition. Hamilton: BC Deckers Inc. 2003:563-77.
25. American Academy of Periodontology. Diabetes and Periodontal Diseases. Committee on Research, Science and Therapy. J Periodontol 2000;71:664-78. https://doi.org/10.1902/jop.2000.71.4.664
26. Nirmala SG, Saikrishna D. Dental Care and Treatment of Children with Diabetes Mellitus- An Overview. J Pediatr Neonatal Care 2016;4:1- 14. https://doi.org/10.15406/jpnc.2016.04.00134

1. Professor and Head, Pediatric Dentistry Department, Institute of Dentistry, CMH Lahore Medical College, Lahore.
   Corresponding author: “Prof. Dr Amjad H Wyne” < ahwyne@gmail.com >

Amjad H Wyne                                  BSc, BDS, MDS, DR MED DENT, FASDC, FADI

Amber Kiyani                                   BDS, MS, FAAOMP, Dip-ABOMP

Rabia Ahmad

Maha Ahmad

Mahreen Tariq

INTRODUCTION

Tobacco is a recreational drug that contains a highly addictive substance called alkaloid nicotine. It is consumed as cigarettes, cigars, flavored shisha, snuff, chewing tobacco, dipping tobacco and snus. Despite its wide availability and use, tobacco is a documented health hazard that claims about 7 million lives yearly through cancer, pulmonary and cardiovascular diseases.1,2
In the oral cavity, tobacco consumption is linked to periodontal disease, delayed healing, treatment failures, staining of teeth, malodor, and oral cancer.2 Since patients with such problems see dentists first, they become crucial for appropriately guiding patients against hazards of tobacco use.3
Studies have shown that proper counseling about the hazards of smoking and information about cessation aids can encourage patients to quit. This can significantly improve
patient outcome.4,5 Dental students at University of Buffalo, College of Dentistry performed protocol-based tobacco cessation counseling on 189 patients. During the 6-month
follow-up survey, 32% of the sample had quit smoking and 22% had reduced the number of cigarettes they smoked per day.6
A Cochrane review published in 2012 demonstrated that increased quit rates can be achieved by dentists through active oral and video counseling. Similarly, Warnakulasuriya
showed in 2002 that effective counseling by dentists can increase abstinence by 10-15%.7 Despite this, a prior study from Pakistan shows that only one-third of dentists are confident in their knowledge and skills to counsel patients against tobacco cessation. This study also determined that most dentists feel that tobacco cessation counseling falls outside their domain of responsibility.8
These results are backed by a study that asked patients if their dentist had ever talked to them about tobacco cessation, only 35% responded yes.9 However, results from another study performed later in 2016 had relatively encouraging results, where 80% of the dentists recognized their role in tobacco cessation counseling and over 70% would offer help to patients that were willing quit.10
Although there have been a few studies that explored the role of dentists in tobacco counseling in Pakistan, to the best of our knowledge, no study has offered reasons for
dentists not providing tobacco cessation counseling. A study from the US found that lack of formal training in counseling, and no additional financial incentives for the effort were
the most common reasons for avoiding involvement. Other reasons included patient reluctance to listen, extra time needed for counseling, and general lack of awareness.11
The aim of this investigation was to determine the knowledge and current practices of dentists in Islamabad towards smoking cessation counseling, and reasons for not
offering it to their patients. This would help in prevention of tobacco related complications from occurring in these patients.

METHODOLOGY

This study was approved by the Ethical Review Board at Riphah International University (IIDC/IRC/2018/03/003). A cross-sectional study was designed to evaluate the knowledge and attitude of dentists towards smoking cessation. A questionnaire was formulated following a thorough literature search to assess the current practices of dentists in tobacco counseling through four main themes; history taking practices, counseling practices, reasons for not counseling and prior formal training in counseling. The questions about history taking practices determined if the dentist routinely asked patients about smoking habits. The next section focused on the counseling practices of the dentists, whether the dentists counseled patients routinely or only when a pathology was identified. There was also a question about dentists introducing patients to nicotine replacement therapy (NRT). The third section determined the reasons for dentists for avoiding counseling. The last section identified the gaps in formal training in counseling. It also asked dentists whether the current dental curriculum was insufficient in training dentists in counseling.
This questionnaire was content validated by a community medicine expert, community dentist and a group of general dentists. The feedback from the reviewers was used to
clarify some of the questions, and include questions that determined whether women were asked about their smoking habits, and the knowledge of dentists about NRT. This
questionnaire was piloted on a group of 10 dentists. The reliability of the questionnaire was calculated through Cronbach alpha that produced a score of 0.71.
The sample size was calculated using the WHO calculator. The population size of dentists was set as 4000,
population proportion 2%, confidence interval 95% and margin of error 5%. This produced a sample size of 30. The final questionnaire was distributed to 105 dentists across Islamabad between 15-01-2019 to 30-01-2019 through convenient sampling. This was done to ensure at least 100 forms would be returned. These self-administered
questionnaires were only given to private practitioners across Islamabad/Rawalpindi. Since the project was meant to focus on community practice all dentists who were in private practice for more than 6 months in Islamabad/Rawalpindi region were invited to participate in the study. Dentists who worked in academic settings were excluded from the sample. This was done because academic institutes enforce better practices of history taking and counseling for teaching purposes so would produce better results. Dentists who were not working at the time of data collection were also excluded.
Consenting dentists were either given a brief overview of our investigation verbally, or in cases where they were short of time, a written statement with the same information
was provided. The questionnaires were collected three days following distribution. The dentists who were unable to return the forms on our return visit were given a polite
reminder and were visited three days later . The data was recorded on SPSS version 20. The software was used to calculate descriptive statistics for each category.

RESULTS

Out of the 105 questionnaires that were distributed to private dental practitioners in Islamabad and Rawalpindi, only 97 were returned, response rate 92%. The practitioners
consisted of predominantly general dentists and a few specialists. Their qualifications were not recorded. From the 97 returned questionnaires, 49 (50%) were from female dentists, 48 (50%) were from males. Majority of the respondents were between the ages of 25-40 (mean 28.4 +/- 4.2). Thirteen (13.4%) admitted to being smokers, 37 (38%) left the question blank while 47 (48%) were non-smokers. While taking social history, 70 (81%) dentists ask their male patients about tobacco use, while 18 (19%) did not.
In comparison, only 47 (48%) routinely asked female patients about their tobacco history. As a reason for not asking female patients about their smoking habits, Sixty-five (67%) dentists would counsel patients against the hazards of smoking even when no pre-neoplastic or neoplastic disease was identified. Ninety-six percent (n=93) dentists would offer some form of counseling if such diseases were identified. The summary of results is highlighted in Table 1.
Dentists who avoided counseling patients against their tobacco habits, the frequently cited reason for their practice

Table 1: Responses of participating dentists to our questionnaire (N=97)

was that they believed that advising was interfering in patient’s personal business , this included 23 (35.3%) dentists. This was followed by a fear of offending the patient, 14
(21.5%). Less frequently cited reasons included fear of a negative impact on practice, 1 (1.5%), and dentist’s smoking habit, 3 (4.6%). Common reasons for not counseling are
highlighted in Table 2. Seventy-nine (71%) dentists were aware of nicotine

Table 2: Responses of participants for reasons of avoiding smoking cessation counseling in their pratices. (N=65)

replacement therapies available in the market. However, only 36 (37%) dentists offered them as possible replacements to tobacco consumption during counseling. Majority of the dentists were aware of nicotine patches and gum. Less were familiar with medications and e-cigarettes. Forty (40%) dentists believed that their dental training was sufficient in the aspect of tobacco counseling, however, 89 (92)% agreed that the curriculum should be modified to train students in addressing these issues with their patients.

DISCUSSION

Tobacco use is a significant risk factor for development of oral premalignancy and malignancy.12 Patient counseling about the hazards of tobacco use by dentists can encourage
patients to quit. This investigation aimed to determine the knowledge and current practices of Pakistani dentists in tobacco cessation counseling and the reasons for not offering it.
There were 81.4% dentists in our sample that routinely asked male patients about their tobacco habits. However, only 48.4% asked females. The participants assumed that
females don’t smoke because of the low prevalence of female tobacco users in the country. Dentists were also hesitant because they were afraid of offending females. Although
our results are encouraging when compared with an Australian survey in which only 14% dentists asked patients about their tobacco habits despite over 70% believing that it was their moral responsibility to counsel patients, they present an interesting gender-based discrepancy exclusive to our region.13
The prevalence of smokers in our sample was lower than previously reported in Pakistani dentists. We had only 13.4% smokers compared with 20.3% reported by Mumtaz
in 2008.8 However, we had a significant number of participants that refused to answer the question. So it is difficult for us to estimate the prevalence of dentists who
smoke. This information may have been kept from us due to embarrassment reasons.
Our study shows that 95.8% dentists counseled patients against tobacco use when a significant oral pathology was present. However, only 67% offered counseling in the absence of any oral disease. Our results are relatively better than those produced by an English study where 71% dentists counseled patients at a significant risk for oral cancer, while only 60% counseled patients with other smoking-related oral issues.14 While encouraging, we believe that this discrepancy results from our data collection in the IslamabadRawalpindi region. The dentists here have better access to continuing education opportunities, hence are better aware.
A similar study in the peripheral region would have produced different results. Studies show that graduates with less than 10 years of practice tend to be more vigilant in acquiring thorough social history and in tobacco cessation counseling when compared with older graduates.15 This appears consistent with our results as the majority of our participants had a mean age of 28.4. Similar to reduction in the prevalence of tobacco using dentists, this can be attributed to better awareness about the harmful effects of smoking in recent decades. Dentists trained several decades ago would be deficient in such knowledge.
The most common reason for not offering tobacco cessation counseling in our sample was fear of interfering in the patient’s business. Other studies have listed lack of time, inadequate formal training in tobacco cessation counseling, fear of losing patient and lack of financial incentive as possible causes for not counseling.16,17
In our study, 71% practicing dentists in our study were aware of replacement therapies available, however, this awareness was limited to nicotine patches and gums. The knowledge about medications, e-cigarettes, nasal sprays, vape, vaporizers, electronic devices and behavioral therapy centers was deficient. Only 37% dentists offered NRT to
their patients. A study showed that despite positive attitude of post-graduate dental students towards NRT, only 34% had offered it as a smoking cessation aid. Compliance issues
and cost were significant deterrents for these students.18 This may be an important consideration for our dentists as well while offering such solutions to their patients.
Our study indicated that 59% dentists did not feel competent in tobacco cessation counseling. A survey carried out by the Canadian Dental Hygienists Association revealed
that 44% of dental professionals restrained themselves from advising their patients about tobacco cessation because they believe that they do not have enough knowledge, or sufficient training to guide patients.19
About 92% of the respondents in our study believed that the dental curriculum should be modified to include training for smoking cessation. This opinion is common in other
studies.20,21 Although our curriculum incorporates the biological effects of tobacco use, tobacco culture and psychosocial aspects of tobacco use, we need to introduce knowledge of prevention and treatment of tobacco use and dependence, and clinical training in cessation counseling as recommended by the consensus report of first European workshop on tobacco use and prevention.21 Introducing these themes into the curriculum would make our graduates more confident in offering help to their patients.
Since the data was collected from a single city and an urban setting, our sample is not reflective of the entire Pakistani dentist population. Knowledge and practices of dentists working in the periphery would be very different than we are currently reporting. A stronger study would need a larger sample size, inclusion of dentists from private and government-based practices from urban and rural settings across Pakistan.

CONCLUSION

The majority of Pakistani dentists have adequate knowledge and positive attitudes towards tobacco cessation counseling. Fear of intervening in patient’s personal business
is the most common cause for avoidance of counseling. Formal trainings in cessation aids and counseling can make dentists more confident in offering help to tobacco users .

CONFLICT OF INTEREST

None declared

REFERENCES

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10. Farrukh U SS, Nisar s. Dentists’ practice and perceived barriers towards smoking cessation and Intervention in Karachi, Pakistan. J Pharma Care Health Sys. 2016;3. https://doi.org/10.4172/2376-0419.1000151
11. Albert D, Ward A, Ahluwalia K and Sadowsky D. Addressing tobacco in managed care: a survey of dentists’ knowledge, attitudes, and behaviors. Am J Public Health. 2002;92:997-1001. https://doi.org/10.2105/AJPH.92.6.997
12. Moreno-Lopez LA, Esparza-Gomez GC, Gonzalez-Navarro A, Cerero-Lapiedra R, Gonzalez-Hernandez MJ and Dominguez-Rojas V. Risk of oral cancer associated with tobacco smoking, alcohol consumption and oral hygiene: a case-control study in Madrid, Spain. Oral Oncol. 2000;36:170-74. https://doi.org/10.1016/S1368-8375(99)00084-6
13. Rikard-Bell G and Ward J. Australian dentists’ educational needs for smoking cessation counseling. J Cancer Educ. 2001; 16: 80-4.
14. John JH, Thomas D and Richards D. Smoking cessation interventions in the Oxford region: changes in dentists’ attitudes and reported practices 1996-2001. Br Dent J. 2003; 195: 270-5; discussion 61. https://doi.org/10.1038/sj.bdj.4810480
15. Albert DA, Severson H, Gordon J, Ward A, Andrews J and Sadowsky D. Tobacco attitudes, practices, and behaviors: a survey of dentists participating in managed care. Nicotine Tob Res. 2005; 7 Suppl 1: S9-18. https://doi.org/10.1080/14622200500078014
16. George B, Mulamoottil V, Cherian S, John J, Mathew T and Sebastian S. Awareness on smoking cessation counseling among dentists in Kerala, India. J Indian Assoc Publ Health Dentis. 2015;13:254-58. https://doi.org/10.4103/2319-5932.165245
17. Li KW and Chao DV. Current practices, attitudes, and perceived barriers for treating smokers by Hong Kong dentists. Hong Kong Medi J = Xianggang yi xue za zhi. 2014; 20: 94-101. https://doi.org/10.12809/hkmj134027
18. Shah S, Rath H and Sharma G. Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy. Indian J Dent Res. 2017; 28:629-36. https://doi.org/10.4103/ijdr.IJDR_231_17
19. Association CDH. Tobacco Use Cessation Services and the Role of the Dental Hygienist- A CDHA position paper. Can J Dent Hygiene. 2004;38:260-79.
20. Crail J, Lahtinen A, Beck-Mannagetta J, et al. Role and models for compensation of tobacco use prevention and cessation by oral health professionals. Int Dent J. 2010;60:73-9.
21. Ramseier CA, Mattheos N, Needleman I, Watt R and Wickholm S. Consensus report: First European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals. Oral Health Prevent Dentis. 2006;4:7-18.

1. Assistant Professor, Department of Oral Medicine, Riphah International University.
2. BDS Student, Islamic International Dental College (IIDC) Riphah.
3. BDS Student, Islamic International Dental College (IIDC) Riphah.
4. BDS Student, Islamic International Dental College (IIDC) Riphah.
Corresponding author: “Dr. Amber Kiyani ” < akiyani@gmail.com >

Amber Kiyani                                   BDS, MS, FAAOMP, Dip-ABOMP

Rabia Ahmad

Maha Ahmad

Mahreen Tariq

Umaima Khan                                   BDS

Beenish Fatima Alam                      BDS, MSc, MFDS RCS(Ed)

Talha Nayab                                      BDS, MSc

Ahsan Inayat                                     BDS

Muhammad Faisal Fahim               MSc

Ayesha Wahab Khan

INTRODUCTION

Tooth numbering system serves as a means for identification, recording and management of dental patients.1 It specifically identifies the teeth by numbers
or alphabets which are used for charting and communiqué purposes.2 Incisors, canine, premolars and molars are the dental expressions used worldwide for all human teeth.3 Miscommunication during referral cases among the dentist in specifying the tooth can cause serious misinterpretation.4 To avoid these mishaps it is necessary for the dentist to use tooth numbering system that allows accurate teeth identification.5
Most commonly opted tooth numbering systems are, Universal numbering system, Federation Dentaire Internationale (FDI) and Palmer notation, which are frequently used by the dental surgeons while the dental hygienists can freely select any system for detection and conveying of dental details to others.6
FDI is a two-digit numbering tool which is widely employed in various regions.7,8,9 In this system, among the two digits the first number represents the quadrant (1-4) starting from upper right, upper left, lower left, and lower right and the second number represents the tooth (1-8).7
The Universal Numbering System for permanent dentition starts from the third molar of upper right quadrant which is identified as # 1 and the further counting of teeth continues clockwise from the maxillary right quadrant to maxillary left quadrant and then from the mandibular left third molar to mandibular right third molar which is nominated as #32.7 Zsigmondy or Palmer notation system, another tool for denoting permanent dentition, begins from central incisor and continues to the third molar of each quadrant. It is counted from mesial end to distal end as 1 to 8 in each quadrant for example central is designated as #1 and the third molar designated as #.8 To identify the quadrant position, a gridiron sign located above or below the number.7,10
All the existing systems of tooth notation have its own advantages and disadvantages6.FDI system is safe and easy to utilize because of its accurateness and reliability to current technology, this system is considered as one of the best tooth numbering system.11 while the Zsigmondy/Palmer system is difficult to pronounce and interpret into computer input7,11,12,13 Similarly, the universal tooth numbering is difficult to memorize and communicate and there is no midline differentiation.11,12,13,14 Different notations are preferred in the different parts of the world, Federation Dentaire Internationale (FDI) system most commonly implemented within European region.
Whereas Universal numbering system is more common in the Canada and US.3,15 Additionally Palmer notation is quite popular in Great Britain and Asian countries.3,16 Previously conducted researches in Pakistan have focused on making comparison between Universal or FDI with the newer introduced (Molar, Incisor, Canine, Premolar and A-akram (the dentist) MICAP tooth numbering system.None of the studies conducted have focused on analyzing the most
commonly used tooth numbering system within various dental colleges of Pakistan. The main purpose of the current research was to detect the most preferred tooth numbering system by final year students and dentists to identify a particular tooth while working in the dental departments at Bahria University Medical and Dental College as well as the most preferred tooth notation system employed by different clinical departments.

METHODOLOGY

This is cross sectional study was conducted over 153 students of 4th year B.D.S and the House officers designated in dental OPD of Bahria University Medical and Dental College, over a period of 6 months from June 2019 to November 2019 . The ethical approval of the study was obtained by the ethical review committee of Bahria University Medical and Dental College (ERC 50/2019). Students willing to participate were included while the participants unwilling and students of 1st and 2nd year BDS were excluded as they did not visit the Dental OPD, while 3rd year visited the OPD partly and did not visit all the clinical departments hence
were excluded as well.
A written consent was obtained from all the students before distribution of questionnaires. The survey required 5 mins for completion. The questionnaire utilized for this study was modified from the study conducted by Al-Johany SS a previously reported study but the setting was performed according to our clinical setting.17 The initial part of the survey comprised of the gender and year at the dental college.
The subsequent part focused on the questions related to most understandable Tooth numbering system, Tooth notation preferred for primary, permanent dentition and for supernumerary teeth, dental coding system used by the clinical department, problems encountered by using incorrect tooth notation.

STATISTICAL ANALYSIS

Sample size was calculated using OpenEpiTM3. Statistical conditions used were 95% confidence interval with 5% margin of error. The required sample size was found to be 153.17 The collected data was analyzed using SPSS version 23.0 to enter data. All the qualitative variables are presented as frequency and percentages. Chi-square or Fischer exact test was applied to see the significance P-value < 0.05 considered to be statistically significant.

RESULTS

A total of 153 students participated in the study. This included 33% (n= 51) male participants while the female participants were 67% (n= 102). Final year B.D.S students were 48% (n=73) and 52% (n=80) House officers. FDI was most commonly understandable TNS by 66% (n= 48) Final year students and 49% (n=39) House officers, while the Universal system was chosen by 28.8% (n= 21) Final year students and 26.3% (n= 21) House officers. Coding system utilized for primary teeth was palmer system by 49% (n=39) House officers and 38% (n=28) Final year BDS students. For denoting permanent teeth FDI was favoured by 78% (n=62) House officers followed by 60% (n=44) Final year students. Tooth numbering system employed for identification of supernumerary teeth was universal system by 45% (n=33) Final year students, while 38% (n=30) House officers did not know.
When enquired regarding the most frequently used TNS within the department of Operative Dentistry, 85% (n=62) Final year students and 66% (n=53) House officers recommended using FDI system, followed by Palmer system.

Table 1: Analysis of responses received regarding the Tooth notation system

Table 2: Association between most preferred TNS used in different dental departments

FDI was also utilized by the 52% (n=38) Final year students and 47.5% (n=38) House officers within the Orthodontic department. While in the Oral surgery department Universal TNS was usually used.Major consequence of not following the correct TNS was wrong tooth extraction by 48.4% participants followed
by difficulty in communication between the clinicians by 33.3% of the participants.

DISCUSSION

Adequate knowledge of tooth numbering system is essential in performing adequate clinical practice of dentistry at both undergraduate and post graduate level. It not only helps in making the correct diagnosis but also helps during treatment planning sessions and in case of referring patients to dental specialists.
This study revealed that FDI is the most easily understood tooth numbering system by the 57% of the participants. These results are in accord with the research conducted by Sharma and Wadhwa, who stated that 74% of the dental students favored using FDI, as compared to other notation systems.18 It can be attributed to the fact that it is quite easy to understand and communicate with other fellow clinicians. Palmer notation system was commonly used by the 44% of the participants for denoting primary dentition. However these results contrasts with the study conducted by Al-Johany SS, who stated that 68% of the respondents used FDI system
to denote primary teeth, followed by palmer system.19 Palmer system being quite easy to understand and record manually and tends to denotes primary teeth with upper case letters (A-E) makes it accessible to use in our setting. For denoting permanent dentition FDI was chosen by 69% of final year students and house officers. These results are in agreement with the study carried out by different researchers who noted that FDI was primarily used notation system for communicating with their patients and colleagues, as this system is totally number based, unlike the other systems.19,20
Identifying supernumerary teeth helps in overcoming confusion and facilitates improved communication between the different dental professionals. In the current study, 45% of the Final year students identified Universal system to represent supernumerary teeth, while 38% of the house officers had no idea regarding the tooth numbering system for coding extra teeth. A study conducted by Toureno L et al, revealed that letter (for instance “A,” or “S”) can be added with the permanent tooth number to code the presence of extra teeth.21 Additionally other researchers identified Universal Supernumerary notation system that defines the teeth from #51 to #82 to supplement the original Universal System and hence overcomes any confusion within the system.22 About 85% of the participants answered using FDI system to identify the teeth within the department of Operative dentistry. Interestingly a research conducted in UK revealed contrasting results that majority of the dental colleges used Palmer system for clinical diagnosis and treatment planning as it allows multiple teeth to be coded quickly.23
In the current study statistically insignificant results were noted for tooth notations system used within the Orthodontic and Oral surgery department.50% of the
respondents replied using FDI system for coding teeth, in Orthodontic department, additionally Universal system was used 57% of the participants within the department of Oral surgery . Study carried out by Pogrel identified that in U.S.A Palmers system is preferred by the orthodontist, while majority of the oral surgeons employed Universal system.24 Universal notation system follows a sequential pattern of identifying the teeth, while Palmer system produces ‘graphical image of teeth’. However usage of two different notation systems amongst the dental specialists can cause alot of confusion while maintaining dental records or sending data
for insurance purpose, as upper right 6 in Palmer is tooth number 3 in Universal tooth numbering system.
Several potential problems can arise in case of not following correct tooth notation especially during referral cases. In the current study 48.4% identified wrong tooth extraction, followed by difficulty in communication, as consequence of not following the correct tooth coding system. Saksena et al reported five complains of wrong tooth extraction within the dental hospital of Manchester, in spite of having a checklist to follow.25 Research conducted by Janice et al, and Lee et al also stated that presence of several notation system can lead to dental misconduct.26,27
Likewise the disparity in maintaining dental records between different Dental departments within a hospital due to practice of different numbering system will have undesirable consequences as these dental records plays crucial role in serving as medicolegal reports and as forensic evidence.
Lastly one of the major prerequisites of clinical audit is maintain uniformity in dental records keeping. Currently there is a lack of studies related to tooth numbering
system followed by the different institutes worldwide. In Pakistan as well not much data is available. Hence there’s a need for more researches to be conducted in this regards.

CONCLUSION

This investigation clearly demonstrates that different methods of tooth numbers will be used by the dental professionals. Realistic approach is to make sure that dental professionals have sufficient knowledge regarding the most commonly used numbering systems and are responsive towards the pitfalls in each system. Additionally knowledge of the undergraduates can be improved by adding this component in the curriculum of operative dentistry. Workshops can be organised to improve the level of learning.

RECOMMENDATIONS

This research identifies the needs for multi-centre research to be conducted that will provide data from the greater sample size.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Akram A, Akram A, Hamid AH, Razak J, Hock TT. MICAP-a novel system for identification and communication of dental problems. Int Dent J. 2011;61:31-6. https://doi.org/10.1111/j.1875-595X.2011.00006.x
2. Scheid RC. Woelfel’s dental anatomy. Lippincott Williams & Wilkins; 2012, 3-41, 8th Edition, ISBN – 978-1-60831-746-2 .
3. Saeed M.H, Khan R, Shah M.U, Akram A and Butt F. Prospects of MICAP Notation in Dental Charting; A Qualitative Study. Acta Sci Dent Sci 1.1 (2017): 30-5
4. Ozdemir MH, Saracoglu A, Ozdemir AU, Ergonen AT. Dental malpractice cases in Turkey during 1991-2000. J Clin Forensic Med 2005;12:137-42. https://doi.org/10.1016/j.jcfm.2005.01.003
5. Daniele F. The Proper Dental Nomenclature, J Dent Oral Biol. 2018; 3: 1134
6. Akram A, Salam A, Bashir U, Maarof N, Meerah SM. Lesson plan on new method of teeth identification introduced at dental schools in Malaysia and Pakistan, J Dent Education. 2012 1;76:1691-96.
7. Peck S, Peck L. A time for change of tooth numbering systems. J Dent Educ. 1993, 1;57:643-47 .
8. Sandham JA. The FDI two-digit system of designating teeth. Int Dent J. 1983; 33: 390-92.
9. Kannan D, Gurunathan D. Comparison of two systems of tooth numbering among undergraduate dental students. Indian J Dent Res. 2016;27:378. https://doi.org/10.4103/0970-9290.191885
10. Türp JC, Alt KW. Designating teeth: the advantages of the FDI’s two-digit system. Quintessence Int. 1995, 1;26,501-04.
11. Keiser-Nielsen S. Federation Dentaire Internationale. Two-Digit System of designating teeth. DP. Dental Pract. 1971;3:6.
12. Yadav SS, Sonkurla S. Sanjeev’s supernumerary tooth notation system. A universally compatible add-on to the Two-Digit system. Indian J Dent Res 2013;24:395-96 https://doi.org/10.4103/0970-9290.118009
13. O’Connor JT. Let’s really standardize our tooth numbering system. Oper Dent. 1983;8:73-4.
14. Alt KW, Türp JC. Roll call: thirty-two white horses on a red field. The advantages of the FDI two-digit system of designating teeth. Dent Anthrop 1998, 41-55. Springer, Vienna. https://doi.org/10.1007/978-3-7091-7496-8_4
15. Akram A, Fuad MD, Bashir U, Pandiyan NJ, Chakravathy K, Vishnumukkala TR, Madlena M. An assessment of clinical application of a new tooth notation for primary teeth. J Int Dent Medi Res. 2015;8:7.
16. Blinkhorn AS, Choi CL, Paget HE. An investigation into the use of the FDI tooth notation system by dental schools in the UK. Europ J Dent Educ. 1998 Feb;2:39-41. https://doi.org/10.1111/j.1600-0579.1998.tb00034.x
17. Al-Johany SS. Tooth Numbering System in Saudi Arabia: Survey. Saudi Den J. 2016; 1;28:183-88 https://doi.org/10.1016/j.sdentj.2016.08.004
18. Sharma PS, Wadhwa P. Evaluation of the FDI two-digit system of designating teeth. Quintessence Int, Dent Dig. 1977;8:99.
19. Elderton RJ. Keeping up-to-date with tooth notation. Brit Dent J. 1989;166:55. https://doi.org/10.1038/sj.bdj.4806709
20. Ahlberg, J.E., 1987. We must get the numbers right. Fe’de’ration Dentaire Internationale News. 158, 8-9.
21. Manica S. A new website to aid the interpretation of ante-mortem dental records: www. internationaldentalcharts. org. J Forens Odontstomatolog. 2014 ;32:1.
22. Toureno L, , Park JH, Cederberg RA, Hwang EH, Shin JW. Identification of supernumerary teeth in 2D and 3D: review of literature and a proposal. J Dent Educ. 2013, 1;77:43-50.
23. Tooth IQ: supernumerary tooth. 2011. Cited from:- www.webcitation.org/5uW55SxoA. Accessed: August 14, 2011. Google Scholar
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25. Saksena A, Pemberton MN, Shaw A, Dickson S, Ashley MP. Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist. Brit Dent J.2014;217:357. https://doi.org/10.1038/sj.bdj.2014.860
26. Lee JS, Curley AW, Smith RA. Prevention of wrong-site tooth extraction: clinical guidelines. J O Maxillofac Surg. 2007, 1;65:1793-99. https://doi.org/10.1016/j.joms.2007.04.012
27. Janice S L, Arthur W C, Richard A S. Prevention of wrong site tooth extraction: Clinical guidelines. J Oral Maxil Surg 2007;65:1793-99. https://doi.org/10.1016/j.joms.2007.04.012

1. Lecturer, Department of Oral Biology, Bahria University Medical and Dental College.
2. Assistant Professor, Department of Oral Biology, Bahria University Medical and Dental College.
3. Assistant Professor, Dental Materials, Jinnah Sindh Medical University.
4. MDS Resident, Division of Prosthodontics, Dow University Health Sciences.
5. Researcher & Consultant Statistician, Department of Bahria University College of Physical Therapy (BUCPT).
6. BDS student, Department of Oral Biology, Bahria University Medical and Dental College.
   Corresponding author: “Dr. Beenish Fatima Alam” < nish_alam@yahoo.com >

Umaima Khan                                   BDS

Beenish Fatima Alam                      BDS, MSc, MFDS RCS(Ed)

Talha Nayab                                      BDS, MSc

Ahsan Inayat                                     BDS

Muhammad Faisal Fahim               MSc

Ayesha Wahab Khan

Usman Rahman                                            BDS

Ashar Nizamuddin Jamelle                        BDS, M Clin Dent

Yousuf Ansari                                               BDS

Noman Nasrullah                                         BDS

Gulrukh Askary                                            BDS, MSc

Hamid Baig                                                     BDS, MFDS

INTRODUCTION

Infection in our body can spread and be severe and sometimes, the number of harmful bacteria is excessive, and the immune system cannot fight them all. Antibiotics are useful in this scenario.1,2 Antibiotics, also known as antibacterials, are medications through their selected action can destroy or slow down the
growth of bacteria.1,2 A massive improvement in resolving infectious diseases has occurred since the introduction of antibiotics. Over the years, it has become a common practice among dental professionals to prescribe antibiotic ther apy for the treatment of various dental infections and as prophylactic protocols.1,2
The first antibiotic was penicillin. Penicillin-based antibiotics, such as ampicillin, amoxicillin, and penicillin G, are still available to treat a variety of infections and are commonly used against bacteria in periodontal disease. There are different types of antibiotics, which work in one of two ways. A bactericidal antibiotic, such as penicillin, kills the bacteria. These drugs usually interfere with either the formation of the bacterial cell wall or its cell contents. Bacteriostatic stops bacteria from multiplying.1,3 In the practice of antibiotic prescription, as per international guidelines, certain factors like age of the patient, renal and hepatic function, drug allergies, pregnancy, systemic involvement (fever, malaise or lymph node) impaired host defense and local factors like presence of pus, necrotic material should be taken into consideration while making a decision for selecting the appropriate antibiotic.4 However, antibiotics, highly effective they may be against numerous deadly diseases, can be very easily misused and mismanaged which can have adverse consequences on the health of the human. Some medical professionals have
concerns that people are overusing antibiotics.2,5 They also believe that this overuse contributes toward the growing number of bacterial infections that are becoming resistant to antibacterial medications.5
This concern is shared in the dentistry field.6 A study conducted in Canada, showed antibiotics prescribed by dentists had increased from 6.7% to 11 % from the year 1996 to 2013.7 Further studies show that dentists have been prescribing 7 to 11 % of all common antibiotics such as β-lactams, macrolides, tetracycline,
clindamycin, metronidazole.8 For more than twenty years, dental surgeons and microbiologist have taken the support of periodontal antibiotic therapy strongly in conjunction with conventional mechanical debridement for treatment and management of periodontal disease.4
It is important to identify the causative pathogens and arrive at correct diagnosis in order for antibiotic periodontal therapy to be effective. A variety of antibiotics
is available to treat various periodontal infections, but it is difficult to decide what drug will provide maximum benefits to the patients and will have little or no adverse effects.9 Lack of awareness and knowledge of the various antibiotics and their workings on the dentists’ behalf has in many cases, allowed over prescription of antibiotics which then would be viewed as an overuse of the antibiotic medicine.
This liberal use of antibiotics may lead to resistance to many microorganisms in humans and their environment.2,6 Few microbial species have completely become resistant towards the antibiotics in which methicillin – resistant staphylococcus aureus is a well-known example. Studies suggest that the prescription of systemic antibiotics should be restricted because almost all the dental and periodontal infections can be treated by clinical procedures and plaque control techniques.8
Numerous reports have been made about the unnecessary use of antibiotics by the dentist and the effect they have on antibiotic resistance including disturbance of protective commensal bacteria which is a problem being faced worldwide.6,10
According to the Centers for Disease Control (CDC), antibiotic use appears to be higher in some regions, such as the Southeast Asia.2
The variable of the amount of use of antibiotics varies from region to region, depending on a lot of factors namely; expertise, knowledge of antibiotics, freedom and permission to prescribe antibiotics, availability of the medicine in the area etc.2 Therefore, this study is to accurately assess the amount of usage of antibiotics and
knowledge of dental practitioners with reference to the prescription of antibiotics in patients with periodontitis in dental colleges in Karachi, Pakistan. By doing this
cross-sectional survey, gaps in the knowledge of the dental professional with reference to the prescription of antibiotics can be identified. The information can serve as a basis for further creation of educational measures that emphasize the need of antibiotic indications in periodontal therapy. A proper, controlled prescription of the antibiotics will then eliminate consequential risks of antibiotic resistance and hence, have a more positive impact on the health of the individual and the community overall.

METHODOLOGY

This cross-sectional study was conducted by using structured questionnaires with multiple-choice questions that allowed completion of responses. The study was conducted from January 2019 to May 2019, amongst four different teaching institutes of Karachi, Pakistan, that hold a lot of popularity for treatment of dental patients in Karachi.
They were namely Liaqat College of Medicine and Dentistry, Dow University of Health Sciences, Altamash Institute of Dental Medicine, and Fatima Jinnah Dental College. Three hundred and fifty subjects took part in the study which comprised of dental students of final year BDS, house officers, and lecturers. 1st year, 2nd year and 3rd-year dental students were excluded from the group as only seasoned dental professionals who have completed the study of periodontology and have sufficient exposure of clinical practice sufficed for the study. Sample size was calculated using previous studies in which dentists who performed periodontal treatment in private clinics or in public service voluntarily participated in the study18 were included.
The questionnaire was distributed to the subjects and they filled in their responses. Before the study, the questionnaire was pilot tested on 5 dentists not involved in this project. Participants gave a written informed consent prior to the study and since there was no human intervention, exemption was taken from the ethical review board (DEC-2018-PER01). The questionnaire consisted of twenty close-ended questions. The questionnaire was based on the prescription of antibiotics in different types of periodontal diseases and the type of their severity. Examples of periodontal cases were presented and multiple choices were given on its treatment and whether antibiotic therapy was used as a solution to that case and which antibiotic. Questions focused on whether antibiotics were used as a treatment for gingivitis and periodontitis, as a sole therapy or in conjunction with mechanical therapy for periodontal disease, its use in root planning and perio surgical cases and whether they prescribed antibiotics as adjunct to periodontal surgery.
It also investigated their knowledge of prescribing antibiotics in systemic conditions such as diabetes, kidney disease, organ transplant, prosthetics, thrombocytopenia, asthmatic and cardiac diseases. Subjects’ understanding of antibiotic therapy was tested in terms of effectiveness of types of antibiotics in periodontal cases either bacteriostatic, bactericidal or a combination of the two and the duration of antibiotic treatment in various examples of periodontal cases. Periodontal sampling for culture and sensitivity before prescribing antibiotics and the use of combination antibiotic therapy was looked into. The data was collected and SPSS software version 20 was used for the analysis of the quantitative data.
The data was presented in terms of the frequency of the prescription of the antibiotics commonly used in periodontal therapy, namely Amoxicillin, Tetracycline, Augmentin, and Metronidazole along with the frequency of the prescribing party who prescribed which antibiotic. The chosen antibiotics that have been presented in the data was concluded upon the results from the questionnaire that questioned which antibiotics were most commonly prescribed in periodontal therapy and how they were used. The sample were divided into three groups; undergraduates, house officers and demonstrators. Data was also presented in the frequency of the prescribing parties in prescribing antibiotics in systemic conditions namely diabetes, kidney disease, organ transplant, prosthetics, thrombocytopenia, asthmatic and cardiac diseases and the frequency of antibiotics usage in various cases of periodontal cases..

RESULTS

There were 330 (94.2%) professionals who responded to the survey out of 350. Mean age of the participants was 25 ± 2 years out of which 116 participants (35.2 %) were male and 214 (64.8 %) were females. Out of 330 respondents, 84 (25.5%) were undergraduates, 131 (39.7%) were House officers and 115 (34.8%) were graduates having more than
one year of experience.
When inquired about the indication of antibiotics in different types of periodontal disease 327 (99.1%) did not prescribe any antibiotics for gingivitis. In chronic Periodontitis 188 (57%) participants stated that they prescribe antibiotics, which out of this, 78% said they only prescribe antibiotics in severe chronic periodontitis cases while 20.5% said they give antibiotics in moderate and severe cases. The remaining 1.5% participants said they prescribe antibiotics in all forms of chronic periodontitis i.e. mild, moderate and severe.
In periodontal abscess 314 (95.2%) participants said they do not prescribe antibiotics. Patients with Necrotizing Ulcerative Periodontitis 148 (44.8%) participants said they give antibiotics, 168 (50.9%) said they prescribed the use of antibiotics in patients with Aggressive Periodontitis while 177 (53.6%) supported the prescription of antibiotics in patients suffering from Chronic Periodontitis associated with systemic diseases. Rest of the 50 % of the participants said they do not give an antibiotic in Necrotizing Ulcerative Periodontitis, Aggressive Periodontitis and Chronic Periodontitis patients with systemic disease. Results have been summarized in Table 3.
In healthy patients with no allergies, 175 (53%) participants said they prescribe amoxicillin in most of the periodontal cases followed by Augmentin 113 (34.2 %). (Table 1)
In combination therapies, 134 (37.6%) participants revealed they prescribe Augmentin and metronidazole as a combination therapy for periodontal cases while 118 (35.8%) said they prescribe amoxicillin-metronidazole as a combination therapy in periodontal cases. The rest prescribed Cefadroxil- metronidazole combination therapy. An overview of the results of the antibiotics usually prescribed is in Table 1.
When inquired about the practice of mono-therapy or combination therapy, 269 (81.5%) participants used combination therapy for moderate to severe Periodontitis

Table 1: Antibiotic prescription in various periodontal diseases

Table 2: Frequent antibiotic Prescriptions

cases, whereas, 237 (71.8 %) said they prescribe antibiotics in adjunct with Scaling and Root Planning. Fifty two percent of the participants stated that they do not consider prescribing antibiotics as prophylaxis before periodontal therapy in subacute bacterial endocarditis, while 47% confirmed that they do prescribe antibiotics as prophylaxis before periodontal

Figure 1

Table 3

Table 1: Antibiotic prescription by subjects

therapy in sub-acute bacterial endocarditis. More than eighty percent (82.7%) of the participants took systemic diseases into consideration before prescribing antibiotics while the remaining 17.3 % did not. For open flap debridement and root planning,70.3% of the participants prescribe antibiotics after periodontal surgeries.

In culture and sensitivity tests, 93% of the students did not perform periodontal sampling for culture and sensitivity before the prescription of antibiotics, In this practice, house officers were 76% and demonstrators 30%. More than a third (34.5 %) of the participants did not take proper medical and drug history while 65.5% took a detailed history before antibiotic prescription.

When inquired about prescription of antibiotics in gingival disease 79.4 % of the students, 83.5% house officers, and
92.5%. demonstrators did not prescribe antibiotics for Fibrous Gingival Enlargement (Hyperplasia). When asked about supportive use of antibiotics, in conjunction with periodontal therapeutic procedures, 67.9% of the participants prescribed antibiotics before and after scaling and Root Planing procedures while 15.5 % said they only prescribe antibiotics

Table 3: Gingival and Periodontal disease precsription

before the procedures and 16.7% said they prescribe antibiotics after the periodontal procedure. Around 82.7% of participants of our study agreed that it is important to take systemic consideration into account to prescribe a suitable antibiotic. Over ¾ (76%) of our participants prescribed antibiotics in periodontal patients with diabetes mellitus as shown in Table 2.
Regarding the effectiveness of different antibiotics on various periodontal diseases, 186 (56.4%) participants responded with sole bactericidal therapy whereas 31.8% chose bacteriostatic and bactericidal combination therapy
as most effective against aggressive periodontitis. When asked about the duration for use of antibiotic prescription during treatment of Chronic Periodontitis 69.4% said they prescribe antibiotics for 5 days, whereas for aggressive periodontitis 61.2% considered 1 week effective in the elimination of most periodontal pathogens.

DISCUSSION

Our study was a survey conducted in the teaching institutes specifically chosen as they are the root of medical and dental practitioners where undue prescription of antibiotics can be easily controlled. This study was conducted to accurately assess the rate of antibiotic prescription amongst dental professionals and to evaluate the prescription habits evaluating the various factors behind the reason for prescription of antibiotics. Current study reveals an accurate assessment of the frequency of usage of antibiotics by dentists in dental colleges of Pakistan by looking at the types of periodontal cases antibiotics are prescribed in, and which antibiotics are most commonly prescribed keeping in mind the subject’s knowledge of its type and effectiveness in treatment. The data fluctuates between each prescribing party all handling the same case, and reveals their knowledge and practice of antibiotic therapy. The data revealed serves as a basis on how to improve the usage of antibiotic therapy and to make it more controlled and effective Monitoring and regulation of education providers, institutes, their teaching skills and the awareness of the teachers educating at these institutes regarding hazards of prescribing antibiotics unnecessarily will help solve the problem. The study used the prescription practices as a proxy measure for their knowledge (a hidden objective) but did not test the knowledge except for one question on importance of prescribing anitbiotics for systemic diseases.
In our study, a great number of professionals (99.1 %) reported that they did not prescribe antibiotics in patients with gingivitis. When we compared our study with Ismail et al’s study we discovered that 50% of their participants said they do not prescribe antibiotics in gingivitis.11 The participants included house officers and faculty members of two dental colleges in Lahore. The reason behind this over prescription as suggested in this study was their inadequate knowledge of existing evidence of antibiotic use in dentistry.
The study showed that participants in dental colleges of Karachi may have more awareness and adequate knowledge
of gingivitis and the contradictory use of antibiotics in gingivitis cases.
Almost 70 % of the respondents of our study said that they prescribed antibiotics as an adjunct to scaling and root planning. On the other hand, a study conducted by Yousufi et al reported that 45.2% of their respondents prescribed
antibiotics as an adjunct to mechanical therapy.12
Participants (54.3%) supported the use of post-operative antibiotics post periodontal procedures like flap surgeries.
Little scientific evidence is present to support the use of antibiotics following periodontal flap surgery. Lack of awareness of evidence-based practice with regards to systemic antibiotic therapy may also be a reason.
Around 82.7% of participants of our study agreed that it is important to take systemic consideration into account and only then prescribe a suitable antibiotic. When specifically enquired about prescription of antibiotics in periodontal patients with diabetes mellitus, 69% of our participants agreed to give antibiotics in diabetic patients.
According to our study, 95.2 % of the participants chose not to prescribe antibiotics in periodontal abscess patients and that abscesses should be treated through incision and drainage and mechanical debridement of the affected area.
In a study carried out by Ismail et al it was found that 58% of their participants prefer giving antibiotics as an adjunct to mechanical debridement in periodontal abscess patients while 26% suggested no antibiotic prescription in patients with periodontal abscess.11 The studies showed that antibiotic therapy in patients with periodontal abscesses is unnecessary, as procedures like incision and drainage along with mechanical debridement and irrigation is enough to eliminate the cause and to eradicate the pathogenic microorganisms from the affected areas. In support of this point of view, it is recommended that use of antibiotic therapy in periodontal abscesses only if it is accompanied by systemic manifestations.4
In relevance to treatment of diseases like ANUG our study reported that 44.8%. participants were in favor of prescribing antibiotics whereas in a study by Monteiro et al it was found that45% of their participants preferred prescribing antibiotics to patients with Necrotizing ulcerative periodontitis which is similar to our study.14 Many studies suggest that patients with moderate or severe Necrotizing ulcerative gingivitis or necrotizing ulcerative periodontitis (NUP), local lymphadenopathy and systemic involvement need to be treated with antibiotic therapy, the recommended antibiotics are amoxicillin, metronidazole, and a combination of amoxicillin and metronidazole.4
When inquired about prescribing antibiotics to patients with aggressive periodontitis, 50% of the participants of our study suggested that antibiotics should be given in whereas in a similar study carried out by Monteiro et al it was reported that 62% of their participants agreed to give antibiotics in patients with aggressive periodontitis.14 Some studies have suggested that Aggregatibacter Actinomycetemcomitans are the primary causative pathogen in Localized Aggressive Periodontitis. These microorganisms can be eradicated effectively by using metronidazole-amoxicillin combination therapy.4
A question on prescription of antibiotics in relevance with chronic periodontitis was asked from the participants
of our study and 78% of the participant said they will only prescribe antibiotics in severe chronic periodontitis cases
and 20.5 % said they will give an antibiotic in moderate and severe cases whereas 1.5 % of the participants said they will prescribe antibiotics in all forms of chronic periodontitis whether Mild, Moderate of severe. A similar question
was asked from the participants of a study carried out by Monteiro et al14 and it was found that 87% of the professionals indicated use of antibiotic therapy for severe periodontitis, 38% for moderate and 6% for mild periodontitis, while another study conducted by Fahad et al11 found that 14 % of their participants said they give antibiotics only, for chronic periodontitis while 59% reported that they prescribed antibiotics as an adjunct to mechanical debridement, whereas 27% of the participants of the study said that they do not prescribe antibiotics.
Research based evidence suggests that in chronic periodontitis, antibiotic therapy is usually recommended for patients showing progressive periodontal breakdown even after conventional mechanical treatment and in patients not responding to periodontal therapy and patients with recurrent disease and this shows there was over prescription seen according to our results.
When asked about use of antibiotics in patients with chronic periodontitis in our study, 134 (37.6%) participants
said they prescribe Augmentin and metronidazole as a combination therapy for periodontal cases whereas 118 (35.8%) said they prescribe amoxicillin-metronidazole as a combination therapy in periodontal cases. Ongoing research and studies suggest that periodontal disease has a broad range of micro-organisms ; therefore, combination therapy of Antibiotics gives better results because they act on wider range of microorganisms as compared to single antibiotics. It also stops the bacterial resistance by utilizing agents with overlapping antimicrobial spectra.(4)A dual regimen of metronidazole and amoxicillin has been reported to be effective against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis -associated periodontal infections.13 Strict regulation of antibiotic policies is needed or else they will lose effectiveness against microbes.4
Antimicrobial resistance is a worldwide problem preferentially affecting low- and middle-income countries and our study has tried to highlight the overuse in periodontology. Our study did not cover other colleges in Karachi which would be ideal to get a better overview.

CONCLUSION

Interpretation of results of this study help us conclude that the prescription of antibiotics is still used abundantly by dental practitioners, without following any proper protocol or standard guidelines. Majority of the periodontal diseases gingivitis, mild, moderate or even/ chronic periodontitis or dental abscess can be treated with non-surgical or surgical periodontal interventions without the need of Antibiotics Even in necrotizing ulcerative periodontitis antibiotics should be only prescribed in severe cases. With evidence based and scientific literature strictly adhered to and followed over prescription in periodontal diseases can be avoided.

RECOMMENDATION

In Pakistan, there is no legal obligation to undertake any continuing professional development courses; therefore,
dentists may be following outdated guidelines, have inadequate knowledge of the use of antibiotics in periodontal cases. Use of antibiotics should be strictly monitored in hospitals and clinics. Special teams should be formed to control the misuse of antibiotics especially in the dental sector where prescribing antibiotics in those cases where it is not necessary. A consistent framework of guidelines with regards to antibiotic prescription in dental cases should be provided to teachers and students in all dental institutions and made easily accessible and a mandatory part of the curriculum. The guidelines need to be regularly reviewed and updated with new supporting evidence of treatment of periodontal cases with antibiotic therapy. Further studies and research for antibiotic therapy in periodontal cases should be supported and encouraged as part of the curriculum to create more supporting evidence. Other than teaching institutes, these regularly updated proper guidelines should be provided to all the hospitals and private clinics and strict monitoring should be done. All these measures can help construe a more coherent and consistent practice amongst dentists in the use and management of antibiotic treatment in periodontal treatment.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Davey P, Marwick CA, Scott CL, Charani E, Mcneil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews. 2017. https://doi.org/10.1002/14651858.CD003543.pub4
2. Antibiotics: Uses, resistance, and side effects [Internet]. [cited 2020 Apr 22]. Available from: https://www.medicalnewstoday.com/ articles/10278
3. Gaynes R. The Discovery of Penicillin-New Insights after More Than 75 Years of Clinical Use. Emerg. Infect. Dis. 2017;23:849-53 Google Search [Internet]. [cited 2020 Apr 22]. https://doi.org/10.3201/eid2305.161556
4. Kapoor A, Malhotra R, Grover V, Grover D. Systemic antibiotic therapy in periodontics. Dent Res J (Isfahan). 2012; https://doi.org/10.4103/1735-3327.104866
5. Llor C, Bjerrum L. Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety. 2014. https://doi.org/10.1177/2042098614554919
6. Cope AL, Chestnutt IG. Inappropriate prescribing of antibiotics in primary dental care: reasons and resolutions. Prim Dent J. 2014;3:33-37. https://doi.org/10.1308/205016814813877333
7. Marra F, George D, Chong M; Antibiotic prescribing by dentists has increased, why? J Am Dent Assoc. 2016;147:307-07 – Google Search [Internet]. [cited 2020 Apr 22]. https://doi.org/10.1016/j.adaj.2015.12.014
8. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk Manag 2010 ;6:301-306 – Google Search [Internet]. [cited 2020 Apr 22]. https://doi.org/10.2147/TCRM.S9736
9. Soares GMS, Figueiredo LC, Faveri M, Cortelli SC, Duarte PM, Feres M. Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs. J Applied Oral Sci. 2012. https://doi.org/10.1590/S1678-77572012000300002
10. Ramasamy A. A review of use of antibiotics in dentistry and recommendations for rational antibiotic usage by dentists. Int Arab J Antimicrob Agents. 2014;4:1-15.
11. Ismail F, Qazia S, SajjadaA. Antibiotics prescription habits and knowledge of dentists in a lahore sample Pak Oral Dent J. 2018;38: 79-84 – Google Search [Internet]. [cited 2020 Apr 22].
12. Yousufi S, Israr Y, Zaman S et al, Use of Antibiotics in Dental Teaching Hospitals of Peshawar, Pakistan: How Justified Are We? Int J Dent Oral Health. 2019;5:68-73 – Google Search [Internet]. [cited 2020 Apr 22].
13. Prakasam A, Elavarasu Ss, Natarajan R. Antibiotics in the management of aggressive periodontitis. J Pharm Bioallied Sci. 2012; https://doi.org/10.4103/0975-7406.100226
14. Monteiro AV , Ribeiro FV , Casarin RC. Evaluation of the use of systemic antimicrobial agents by professionals for the treatment of periodontal diseases. Braz J Oral Sci. 2013;12:285-291 – Google Search [Internet]. [cited 2020 Apr 22]. https://doi.org/10.1590/S1677-32252013000400003

1. MDS Resident, Department of Periodontology, Fatima Jinnah Dental College.
2. Assistant Professor, Department of Periodontology, Fatima Jinnah Dental College.
3. Demonstrator, Department of Oral Medicine, Fatima Jinnah Dental College.
4. Demonstrator, Department of Periodontology, Fatima Jinnah Dental College.
5. Assistant Professor, Department of Oral Pathology, Fatima Jinnah Dental College.
6. Assistant Professor, Department of Oral Surgery, Fatima Jinnah Dental College.
Corresponding author: “Dr. Usman Rahman” < usmanrahman20014@gmail.com >

Usman Rahman                                            BDS

Ashar Nizamuddin Jamelle                      BDS, M Clin Dent

Yousuf Ansari                                                BDS

Noman Nasrullah                                         BDS

Gulrukh Askary                                             BDS, MSc

Hamid Baig                                                     BDS, MFDS

Kamran Parvez                                    BDS, MDS

Khurram Parvez                                  BDS, MDS

Rooha Sultan                                       BDS

Azam Muhammad Aliuddin                BDS

INTRODUCTION

With the advances in medicine and increasing awareness a high proportion of elderly population (aged about 65 years and above) are more evident
in developed countries.1
The need to find effective and applicable solutions to the problems of elderly people has therefore become a priority for the improvement of their quality of life1. Physical, psychological and intellectual problems can be highlighted among various others that the elderly population comes across. Aging in a way is associated
with a number of limitations. Some of these might be recognizable in deteriorating intelligence, sight, hearing, muscle strength and bone mineral contents and also in evaluation of their own health.2-3
Oral health may involve many physical and psychological issues. Wearing dentures affects eating, speaking, facial expressions, and appearance of a person. A complaint is defined as an utterance of pain, discomfort, or dissatisfaction.4 The post-op care of patients is an essential part of a complete denture service. Generally, patients expect immense amount of positive difference between their new and previous dentures in terms of esthetics and function alike. Unavoidable compromises are not easily accepted.5
Hindrances in retention and stability, esthetics, chewing and accumulation of food are the most commonly reported complains of complete denture wearers.6-10 A recent study reports that oral health of edentulous individuals is associated with the avoidance of food and their satisfaction with dentures. The completely edentate patients reported better oral health and ease with their dentures than the partially edentate.11

An unsatisfactory denture can be the cause of insomnia and other irritating changes in eating and social behaviors of an individual. These changes can lead to deterioration of self-confidence making older people become less active socially. The psychological effects of such problems are important and should be considered in people of all ages.12-14 In this study we tried to observe the major oral complaints of elderly denture wearing patients and also if there is any age and gender association involved.

METHODOLOGY

A cross-sectional questionnaire based descriptive study with a convenience sampling technique was adopted for this research. During the period from May 2014 to August 2014, data of 51 patients of both genders having problems with their complete dentures were collected, after taking consent, using a structured eight categories questionnaire, three point scale Performa presented in Figure 1.16 The participants of study were patients who reported in Prosthodontics department of Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, and in the Department of Prosthodontics, Fatima Jinnah Dental College, Karachi. Inclusion criteria of patients were the ones who had been using dentures for at least 6 months with satisfactory general medical condition and psychological health. All those elderly complete denture wearers suffering from any systemic disorder, chronic debilitating conditions were excluded from study. Age range of patients was between 50 to 75 years. After taking history and demographic data from each patient, intra oral clinical examination and prosthesis examination was carried out by the principal investigator and a co-investigator. During history taking, patients were asked about the duration of denture use,
fabrication of dentures and about retention, pain, mastication, aesthetics and oral hygiene associated with the prosthesis.
During clinical examination retention, stability, occlusion, oral hygiene and prosthesis hygiene were assessed. The collected data was computed using SPSS Version 17. Ethical  Approval was obtained (BEH No. JAN-2014-OPR01)

RESULTS

Of the total 51 patients, 72.5% (37) were male and 27.4% (14) female. Patients were divided into five groups according to their ages. Group I (50 to 55 yrs.), Group II
(56 to 60 yrs.), Group III (61 to 65 yrs.), Group IV (66 to 70yrs), Group V (70 yrs. & above) as shown in Table 1.
The duration of use of dentures is given in Table 2. The responses for the questionnaire item number 7 with subparts are documented in Table 3. Problems associated with dentures

Table 1: Age distribution of patients

Table 2: Duration of use of dentures in relation to rendered ser

Table 3: Denture-wearing Patients responses to question 7 according to age groups

were more prominently observed in the elderly aged patients especially over the age of 60 years. Pain was recorded as the most common complaint of these complete denture wearers. No significant relationship could be determined between the patient’s gender and type or number of complaints.

DISCUSSION

All the patients observed in the current study reported problems with their complete dentures. Males outnumbered females, in comparison to other studies with ratio of 1.6: 4.0 female patients.15-16 A consideration in due with this finding might be that females do not usually seek dental treatments that often. They feel more home-bound in comparison to males. Also public hospitals are not generally their first choice in seeking dental treatment; they might feel more compelled to go to evening based private practices.
The results in this study are in agreement with Brunello and Mandikos.17 According to their study, most commonly recorded complaints of patients were pain and discomfort (75%), difficulty in eating (61%) and ill-fitting dentures (59%). Denture bases in these cases were observed as under extended (86%) or overextended (2%), pressurized oral tissues (86%) or had an inadequate posterior palatal seal. 94% of complete denture wearers showed incorrect jaw relationship while 63% of patients displayed erroneous tooth positions. Study concluded patient complain of ill-fitting dentures to be associated with problems in retention and difficulty in eating to be related to faults in jaw relationships.
Evren et al. (2011) studied elderly people of three different nursing homes 66.6% of whom were edentulous. In the study of Unluer et al (2007) among 193 of the elderly occupants examined at a nursing home of Ankara Turkey, a mere 7.3% were observed to possess functional dentition.15
The results show an immense need of consideration to the oral health of elderly residents in such establishments.18 Aesthetics play a major role in the success of any oral prosthesis.18-20 What a clinician perceives as a pleasant appearance may not always be in accord of what the patient had in mind.18,20 Patients often have a habit of comparing dentures to their natural teeth with unrealistic expectations.20,21 Interestingly, this study reported fewer complaints about the appearance of the dentures from the patients inspite of being the most common complaint otherwise.17,18 Psychological, anatomical and constructional put together are the factors on which patient satisfaction with complete dentures depends upon. Davis et al22 examines the difficulty of fabricating dentures for patients with impractical
expectations. Patient’s pretreatment assumptions influence their end reactions. Finishing and polishing of dentures might contribute to a better fit and function and should be given importance while fabrication.24 Along with this incorporation of antifungal agents into acrylic surface might improve the irritant effect of monomer that is associated with denture stomatitis.25 This in turn will affect the overall long term use of complete dentures. Regular dental care and oral hygiene maintenance for functional denture fit can influence nutritional risk in elderly people positively. Geriatric dentistry being an individual subject is not given enough
importance in Pakistani dental schools. Author of this paper agrees with de Lima et al (2006) about the organization of courses regarding geriatrics and geriatric dentistry.23

LIMITATIONS/WEAKNESS

The main limitation of the current study is the sample size available for consideration. We cannot determine if the findings of the study will remain same when large number of complete denture wearing patients will be evaluated. Also a very concise inclusion criterion had been set for the study participants mainly due to investigators convenience which can be elaborated.

CONCLUSION

In accord of various previous studies this study also affirms that the elderly patients with complete dentures report a range of complaints regarding chewing of food,
communication and social interactions and that these problems escalate with increasing age. Further research is needed to study the relationship of denture complains with the quality of life.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Ikebe k, Walkins CA , Etinger RL,Sajima H, Nokubi T. Application of short from oral health impact profile on elderly Japanese, Gerodontology, 2004;21:167-76. https://doi.org/10.1111/j.1741-2358.2004.00028.x
2. Leiberg B, Stlize L , Norlen P, wall B. Inadequate dietary habits and mastication in elderly man .Gerodontology 2007;24:41-6. https://doi.org/10.1111/j.1741-2358.2007.00150.x
3. N T, Haori K, Ikebe K, Nokubi, Nag S, Kumakural.Factors influencing eating ability in-patients in a rehabilitation hospitals in Japan. Gerodontology. 2003;20 24-31 https://doi.org/10.1111/j.1741-2358.2003.00024.x
4. Srivastava R, Post insertion complaints in complete denture. Journal of Indian dental association.2011;5(2):304
5. Brunella DL, Mandiks MN .Construction faults, age, gender and relative medical health: factors associated with complaints in complete denture patients. J Prosth. Dent 1998; 79:545-54. https://doi.org/10.1016/S0022-3913(98)70176-3
6. Jeganathan S, Payne JA. Common faults in complete denture: review. Quintessence international( Berlin Germany;1985) 1993;24:483-87
7. Ettinger R. Somme boservatins diagnosis and treatment of complete denture problems. Aust Dent J 1978:23;457-64 https://doi.org/10.1111/j.1834 7819.1978.tb03561.x
8. Rizwan M, Ghani F, Shahzad M. Functional assessment of removable complete dentures. Pak Oral Dent J Vol. 33, n.3 December 2013
9. Smith P , Hughes D . A survey f referred patients experiencing problems with complete dentures. J Prosth Dent 1988; 60:583-86. https://doi.org/10.1016/0022-3913(88)90218-1
10. Kotkin H. Diagnostic significance of denture complaints. J Prosth. Dent 1985; 16:364-67.
11. Celebiæ A, Knezoviæ-Zlatariæ D, Papiæ M, Carek V, Bauciæ I, Stipetiæ J. Factors related to patient satisfaction with complete denture therapy. J Gerontol. Series A. Biological Sciences and Medical Sciences. 2003;58:948-953. https://doi.org/10.1093/gerona/58.10.M948
12. Allen PF. Assessment of oral health related quality of life. Health and Quality of Life Outcomes.2003;1: 40. https://doi.org/10.1186/1477-7525-1-40
13. Ikebe k , Nokutubi T, Ettinger RL, Namba H, Tanika N , Iwase K . Dental status and satisfaction with oral function in sample of community -dwelling elderly people in japan. Special care dentistry 2002:22:33-40 https://doi.org/10.1111/j.1754-4505.2002.tb01207.x
14. Evren BA, Ukudmar A, Isre U, ozkan YK. The association between socioeconomic status, oral hygiene practice, denture stomatitis and oral status in elderly people living different residential homes. Gerontology 2011;53:252-257. https://doi.org/10.1016/j.archger.2010.12.016
15. Kotkin H. Diagnostic significance of denture complaints. J Prosth. Dent 1985; 53:73-77. https://doi.org/10.1016/0022-3913(85)90070-8
16. Bekinrgli N, Citfi A, Byaraktar K, yayuz A et al. Oral complaints of denture wearing elderly people living in two nursing homes in Istanbul, turkey. Oral health Dent manag. 2012;11:107-15.
17. Brunello DL, Mandikos MN. Construction faults, age, gender, and relative medical health: Factors associated with complaints in complete denture patients. J Prosth. Dent 1998;79:545-54. https://doi.org/10.1016/S0022-3913(98)70176-3
18. Unluer S, Gökalp S, Doðan BG. Oral health status of the elderly in a residential home in Turkey. Gerodontology. 2007;24:22-9 https://doi.org/10.1111/j.1741-2358.2007.00136.x
19. Aizawa F, Kishi M, Moriya T, Takahashi M, Inaba D, Yonemitsu M. The analysis of characteristics of elderly people with high VSC level. Oral Dis.2005;11:80-82 https://doi.org/10.1111/j.1601-0825.2005.01099.x
20. Nalcaci R, Baran I. Oral malodor and removable complete dentures in the elderly. Oral Surgery, Oral Medicine, Oral Pathol, Oral Radiol Endodo. 2008;105:5-9.1. https://doi.org/10.1016/j.tripleo.2008.02.016
21. Marshal TA, Warren JJ, Hands JS, XIE X, Stumbo PJ. Oral health, nutrient intake and dietary quality in the very old. J Am Dent Assoc.2002; 133:1369-379.
    https://doi.org/10.14219/jada.archive.2002.0052
22. Osterberg T, Carlsson GE. Dental state, prosthodontic treatment and chewing ability: a study of five cohorts of 70- year-old subjects. J Oral Rehabil.2007; 34:553-59. https://doi.org/10.1111/j.1365-2842.2006.01655.x
23. Lima SMV, Suza EH, Franca CJA. Geriatric dentistry in Brazilian universities. Gerodontology 2006; 23:231-36. https://doi.org/10.1111/j.1741-2358.2006.00128.x
24. Zafar, Muhammad Sohail and Ahmed, Naseer. ‘Nanoindentation and Surface Roughness Profilometry of Poly Methyl Methacrylate Denture Base Materials’. 1 Jan. 2014:573-81. https://doi.org/10.3233/THC-140832
25. Iqbal Z, Zafar MS. Role of antifungal medicaments added to tissue conditioners: A systematic review. J Prosthodon Res. 2016;60:231-9. https://doi.org/10.1016/j.jpor.2016.03.006

1. Lecturer, Department of Prosthodontics, Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences Dow University of Health Sciences.
2. Associate Professor, Department of Science of Dental Materials, Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences.
3. Lecturer, Department of Science of Dental Materials, Dr Ishrat ul Ebad Khan Institute of Oral Health Sciences.
4. Former Chief Resident (FCPS), Department of Operative Dentistry, Fatima Jinnah Dental College.
   Corresponding author: “Dr. Rooha Sultan” < rooha.sultan@duhs.edu.pk >

Kamran Parvez                                    BDS, MDS

Khurram Parvez                                  BDS, MDS

Rooha Sultan                                       BDS

Azam Muhammad Aliuddin                BDS