Vol. 30, Issue No. 04 – Oct-Dec 2021

Zudia Riaz1                     BDS
Muhammad Raza2         BDS, FCPS, MPH
Amjad Hanif 3                BDS, MSc
Beenish Haider4            BDS
Sadia Akram5                BDS
Shamayem Safdar6      BDS, M.Phil

OBJECTIVE: To compare the in-vitro antibacterial effectiveness in terms of enterococcus faecalis elimination of conventional
unmodified calcium hydroxide paste with an experimental calcium hydroxide impregnated with 1% silver nanoparticles.
METHODOLOGY: This in vitro study was conducted during the period July 2019 - January 2020 at Materials Research
Laboratory, Centralized Resource Laboratory (University of Peshawar) and Pathology Laboratory (Peshawar Medical College).
Sixty human premolar teeth having single root with mature apices were obtained. These were distributed into two groups
randomly (n=30); experimental group for testing the antibacterial efficacy of calcium hydroxide impregnated with 0.1% by
weight silver nanoparticles and the other was used as a control group for testing the antibacterial efficacy of unmodified calcium
hydroxide. Dentine specimens (size 4 x 4x 1mm) were prepared from the teeth using slow speed cutting saw machine. Smear
layer was removed with EDTA. Specimens were autoclaved to sterilize them. Then each specimen was contaminated with
enterococcus faecalis and incubated anaerobically for 24 hours at 37?C. After the application of medicaments, the zone of
inhibition was measured and number of viable bacteria were determined using SEM. Statistical significance was calculated
using t-test. p<0.05 was taken as significant.
RESULTS: After the application of medicament, the zone of inhibition was greater (9.63mm) in experimental group when
compared to control group (4mm) (p<0.001). Number of viable bacteria before application of medicament were 239 and 208
while after application of medicament reduced to 90 and 54 in control and experimental groups respectively (p<0.001).
CONCLUSION: The addition of silver nanoparticles to calcium hydroxide significantly enhanced its potential to eliminate
biofilm of enterococcus faecalis on dentin specimens.
KEYWORDS: Silver nanoparticles, Calcium hydroxide, Root canal infections, Root canal medicament.
HOW TO CITE: Riaz Z, Raza M, Hanif A, Haider B, Akram S, Safdar S. Antibacterial efficacy of silver nanoparticles
impregnated calcium hydroxide: An in vitro study. J Pak Dent Assoc 2022;31(1):1-4.
DOI: https://doi.org/10.25301/JPDA.311.1
Received: 05 April 2021, Accepted: 08 September 2021

 INTRODUCTION
The success of endodontic treatment depends on several factors in which the reduction or elimination of infections is one of the most important aspect. In teeth with apical periodontitis, microorganisms can persist after the endodontic treatment and remain harbored in the dentinal tubules.1 The mechanical preparation used during endodontic treatments alone do not completely eliminate the infection and inflammatory processes in the periapical tissues. Thus, the application of an intra canal medicine helps in eradication of microbes that exists even after preparation of the canal, therefore creating an atmosphere for repair of periapical tissue.2
Enterococcus faecalis is anaerobic gram-positive cocci accountable for majority of endodontic treatment failures.3 It has the ability to withstand adverse environmental conditions.4 It can invade into the tubules inside dentine and has the ability to form biofilm.5 To eliminate such microorganisms, antimicrobial intra canal medicament is
recommended.6 Among the intra canal medicaments, calcium hydroxide is most frequently used because of its wide
antimicrobial spectrum.
Calcium hydroxide Ca(OH)2 is commonly employed as an intra canal medicament. It releases hydroxyl ions which
causes high alkalinity. Nevertheless, the ability of calcium hydroxide in elimination of bacteria from the root canal has been questioned. Antibacterial ability of calcium hydroxide in aqueous environment is linked to the discharge of hydroxyl ions. It can cause damage to the cytoplasmic membrane, bacterial DNA as well as can cause protein denaturation.7 However, calcium hydroxide is not as much effective when used for canal disinfection having established enterococcus faecalis biofilm.8
Recently, numerous studies have introduced silver nanoparticles as an antimicrobial agent.9 Silver nanoparticles have antimicrobial activity and are biocompatible10, silver ions can cause damage to the bacterial cell wall. These are
productive against many microorganisms including E. faecalis.11 Nanoparticles have /polyanionic polycationic properties with a high surface area and positive charge density, which increases their antibacterial activity.12 The
particle size was also related to antimicrobial activity; the smaller particles give more bactericidal effects compared to larger particles.13
Calcium hydroxide do not always eradicate enterococcus faecalis biofilm from root canals.14 Hence, it is essential to
introduce advanced endodontic intracanal medicament approaches that are successful in eradicating biofilm bacteria
inside the root canals. Therefore, the aim of this was to determine the antibacterial efficacy of calcium hydroxide
cement containing silver nanoparticles

METHODOLOGY

The research protocol and the publication of results were approved by the institutional review board (Prime/IRB-2019- 313). The experimental work was performed at the Department of Dental Materials, Peshawar Dental College,
Pathology Laboratory of Peshawar Medical College and Material Research and Centralized Research Laboratory of
Peshawar University.
Total of sixty test specimens were prepared. Thirty specimens (n=30) were made to test the antibacterial ability of commercially available calcium hydroxide paste (Calcipex,Nishika Japan) while the remaining thirty specimens were used to test the antibacterial activity of calcium hydroxide paste containing 1% by weight of silver nanoparticles (Alfa aeser, Germany). Experimental silver nanoparticles impregnated calcium hydroxide was prepared by mixing 1 mg of silver nanoparticles with 1 gm of calcium hydroxide. Sixty human premolars having single root and mature apices were obtained to prepare dentine specimens.
Teeth were cleaned from gross debris by using ultra sonic scaler and then stored in normal saline. After cutting off crown and apical portion, teeth were sectioned vertically along midsagittal plane into equal halves. The cementum
from root surface was removed by using diamond bur. Dentin sections were made having dimensions of 4 x 4x 1mm (width x length x height). Smear layer from the specimens was removed by placing it in EDTA solution for four minutes. All the specimens were washed with sterile water for one minute and placed in autoclave (Hirayama, Japan) for 15mins at 121°C. Brain heart infusion was used to incubate the specimens at 37°C for 24 hrs.
Enterococcus faecalis used in this study was obtained from pathology laboratory of Lady Reading Hospital, Peshawar Pakistan. The bacteria were plated on BHI broth containing 1.5% (wt /vol) agar and incubated anaerobically at 37°C for 24 hrs to obtain colonies. Gram staining was performed and the grown colonies of bacteria were placed in sterile BHI broth at 37°C. Sterilized specimens of dentin were placed in test tubes having E.faecalis for bacterial inoculation on dentine specimen. Fresh BHI broth was exchanged every second day to eliminate dead cells and to confirm viability of bacteria. The specimens were removed from tubes after incubation and rinsed with sterile phosphate buffered saline to remove the culture medium and non adherend bacteria. The zone of inhibition of E.Faecalis was measured and number of viable bacteria were observed under SEM.
One pellet (0.01g) each of the control and experimental groups were placed on infected dentine specimens on a
sensitivity discs. Then anaerobic incubation of these specimens was conducted at 37°C for 14 days in a 100% humid environment. Then each specimen was washed with saline to eliminate the tested medicament. Citric acid (0.5%)
was used to neutralize the treated specimens treated with calcium hydroxide. Then the specimens were examined for
zone of inhibition and number of viable bacteria was determined by using SEM.
Data analysis was performed using the statistical package for social sciences (SPSS) version 22. Mean values and
standard deviations of the number of viable bacteria on dentine specimens were computed. Student’s t test was used
for estimating the significance of the differences of the mean values. p < 0.05 was used for statistical significant.

RESULTS

Mean and standard deviation of zone of bacterial colonies, zone of inhibition of bacterial colonies and number of viable bacteria in both control and experimental groups before and after application of medicament are given in Table 1. Zone of bacterial colonies before application of medicament shows that both groups (control and experimental) contain similar number of colonies with mean value of 20 mm. After the application of medicament, the zone of inhibition of bacterial colonies was more in experimental group (9.63±2.09) than control group (4±2.86) showing statistically significant difference (p<0.001). Number of viable bacteria before application of medicament were 239± 60.3 and 208.03±65.22 while after application of medicament reduced to 90±37.96 and 54.13±23.3 in control and experimental groups respectively (p< 0.001) (Table 1).

DISCUSSION

The current study was conducted to compare the in vitro antibacterial effectiveness of two root canal medicaments
in terms of elimination of bacterial colonies and reduction in the number of viable E. faecalis during a test period of
two weeks. The null hypothesis was rejected since experimental calcium hydroxide having 1% silver nanoparticles statistically significantly reduced the E. faecalis number as compared to the plain calcium hydroxide. In this study E. faecalis was used for the evaluation of antibacterial efficacy of root canal medicaments, as it has a key role in the aetiology of constant root canal infections. E. faecalis is responsible for high rate of root canal failures because these bacteria can stay alive in adverse environment.15 In our study, permanent teeth were used to replicate the real
clinical situation to the possible extent.
Samiei et al reported better efficacy of calcium hydroxide containing silver nanoparticles when compared to
conventional calcium hydroxide in the treatment of root canal infections.16 Balto et al (2020) treated dentine specimens with Ca(OH) 2 containing 0.02% AgNPs. The results of their study showed that the mixture of Ca(OH) 2 and AgNPs exhibited marked antibacterial activity against 3-week-old E. faecalis biofilms. It has been observed that silver has a high affinity for negatively charged molecules within bacterial cells, disables critical functions of bacteria and consequently prevents bacterial proliferation and formation of biofilm.17 The inhibitory effect of the mixture of Ca(OH) 2 and AgNPs on E. faecalis biofilms in our study is similar to that reported in numerous studies regardless of the variation in the assessment approach.16,17
Contrary to our findings, Yousefshahi et al reported statistically insignificant results when E. faecalis was treated
with 1% AgNPs impregnated calcium hydroxide for 24 hours as compared to conventional calcium hydroxide.18 The
difference in the results of the two studies might be due to variation in shape and size of the silver nanoparticles.
Javidi et al reported that after one week of incubation, the number of colony forming units of E. faecalis were
considerably less in specimens treated with calcium hydroxide containing silver nanoparticles as compared to unmodified calcium hydroxide paste (p<0.001.19 Similarly, Afkhami et al reported that the efficacy of calcium hydroxide containing silver nanoparticles against E. faecalis was better than unmodified calcium hydroxide paste when incubated for one week and one month.20 The findings of both the studies are in agreement with the findings of our study.
One of the limitations of this study was that only one concentration of AgNPs in combination with calcium hydroxide and one time period of two weeks was assessed and hence the maximum concentration of AgNPs which
could be added to calcium hydroxide and the minimum time period showing the maximum efficacy was not ascertained.
Although E. faecalis is the commonest bacterial strain present in most patients of persistent intra-radicular infections, but it also needs to understand that the infected root canal system typically has more than one species of bacteria. So the intra canal medicaments showing efficacy against E. faecalis in in-vitro research may not be essentially work well in poly-microbial infection in vivo studies of endodontic origin. However, our investigation may serve as a baseline for further research in this area that could assess the influence of silver nanoparticles and its various combinations on other endodontic pathologies.

CONCLUSION

Within the limitations of this study, it could be concluded that calcium hydroxide containing silver nanoparticles might be more effective in elimination of bacteria from root canal system than conventional unmodified calcium hydroxide. Further studies are required to explore its efficacy in in-vivo along with possible cytotoxicity and other adverse effects like tooth discolouration etc.

CONFLICT OF INTEREST

None declared

REFERENCES

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https://doi.org/10.1007/978-3-319-57250-5_3

2. Farhadian N, Godiny M, Moradi S, Azandaryani AH, Shahlaei M. Chitosan/gelatin as a new nano-carrier system for calcium hydroxide delivery in endodontic applications: Development, characterization and process optimization. Materials Science and Engineering: C. 2018;92:540- 6.
https://doi.org/10.1016/j.msec.2018.07.002

3. Siddiqui SH, Awan KH, Javed F. Bactericidal efficacy of photodynamic therapy against Enterococcus faecalis in infected root canals: a systematic literature review. Photodiagnosis and photodynamic therapy. 2013;10:632- 43.
https://doi.org/10.1016/j.pdpdt.2013.07.006

4. Zhang C, Du J, Peng Z. Correlation between Enterococcus faecalis and persistent intraradicular infection compared with primary intraradicular infection: a systematic review. J Endodontics. 2015;41:1207-13.
https://doi.org/10.1016/j.joen.2015.04.008

5. Du T, Wang Z, Shen Y, Ma J, Cao Y, Haapasalo M. Effect of longterm exposure to endodontic disinfecting solutions on young and old Enterococcus faecalis biofilms in dentin canals. J Endod. 2014;40:509- 14.
https://doi.org/10.1016/j.joen.2013.11.026

6. Ahmed S, Ahmed A, Sikander M. Comparison of postoperative pain frequency after single visit and multiple visits root canal treatment with rotary instruments on non-vital teeth. Pak Oral Dent J. 2017;37.

7. Silva LA, Dermody TS. Chikungunya virus: epidemiology, replication, disease mechanisms, and prospective intervention strategies. J Clin Investigation. 2017;127:737-49.
https://doi.org/10.1172/JCI84417

8. Ghabraei S, Bolhari B, Sabbagh MM, Afshar MS. Comparison of antimicrobial effects of triple antibiotic paste and calcium hydroxide mixed with 2% chlorhexidine as intracanal medicaments against Enterococcus faecalis biofilm. J Dentistry (Tehran, Iran). 2018;15:151.

9. Cheng L, Zhang K, Melo MA, Weir MD, Zhou X, Xu HH. Antibiofilm dentin primer with quaternary ammonium and silver nanoparticles. J dental Research. 2012;91:598-604.
https://doi.org/10.1177/0022034512444128

10. Motshekga SC, Ray SS, Onyango MS, Momba MN. Microwaveassisted synthesis, characterization and antibacterial activity of Ag/ZnO nanoparticles supported bentonite clay. J hazardous materials. 2013;262:439-46.
https://doi.org/10.1016/j.jhazmat.2013.08.074

11. Afkhami F, Pourhashemi SJ, Sadegh M, Salehi Y, Fard MJ. Antibiofilm efficacy of silver nanoparticles as a vehicle for calcium hydroxide medicament against Enterococcus faecalis. J Dent. 2015;43:1573-9.
https://doi.org/10.1016/j.jdent.2015.08.012

12. Du T, Wang Z, Shen Y, Ma J, Cao Y, Haapasalo M. Effect of longterm exposure to endodontic disinfecting solutions on young and old Enterococcus faecalis biofilms in dentin canals. J Endod. 2014;40:509- 14.
https://doi.org/10.1016/j.joen.2013.11.026

13. Zapór L. Effects of silver nanoparticles of different sizes on cytotoxicity and oxygen metabolism disorders in both reproductive and respiratory system cells. Archives of Environmental Protection. 201642:32-47.
https://doi.org/10.1515/aep-2016-0038

14. Wang Z, Shen Y, Ma J, Haapasalo M. The effect of detergents on the antibacterial activity of disinfecting solutions in dentin. J Endod. 2012;38:948-53.
https://doi.org/10.1016/j.joen.2012.03.007

15. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: its role in root canal treatment failure and current concepts in retreatment. J Endod. 2006;32:93-8.
https://doi.org/10.1016/j.joen.2005.10.049

16. Samiei M, Farjami A, Dizaj SM, Lotfipour F. Nanoparticles for antimicrobial purposes in Endodontics: A systematic review of in vitro studies. Materials Science and Engineering: C. 2016;58:1269-78.
https://doi.org/10.1016/j.msec.2015.08.070

17. Balto H, Bukhary S, Al-Omran O, BaHammam A, Al-Mutairi B. Combined Effect of a Mixture of Silver Nanoparticles and Calcium Hydroxide against Enterococcus faecalis Biofilm. J Endod. 2020;46:1689- 94.
https://doi.org/10.1016/j.joen.2020.07.001

18. Yousefshahi H, Aminsobhani M, Shokri M, Shahbazi R. Anti-bacterial properties of calcium hydroxide in combination with silver, copper, zinc oxide or magnesium oxide. European J translational myology. 2018;28.
https://doi.org/10.4081/ejtm.2018.7545

19. Javidi M, Afkhami F, Zarei M, Ghazvini K, Rajabi O. Efficacy of a combined nanoparticulate/calcium hydroxide root canal medication on elimination of E nterococcus faecalis. Australian Endodontic Journal. 2014;40:61-5.
https://doi.org/10.1111/aej.12028

20. Afkhami F, Pourhashemi SJ, Sadegh M, Salehi Y, Fard MJ. Antibiofilm efficacy of silver nanoparticles as a vehicle for calcium hydroxide medicament against Enterococcus faecalis. Journal of Dentistry. 2015;43:1573-9.
https://doi.org/10.1016/j.jdent.2015.08.012

Kiran Tariq                                                  BDS
Muhammad Waseem Ullah Khan              BDS, FCPS
Momina Akram                                            BDS, FCPS
Sahar Illyas                                                  BDS
Muhammad Azeem                                      BDS

Hypodontia can have an impact on speech, aesthetics, function and psycho-social behavior of individuals afflicted by the
problem. Rehabilitation of patients with hypodontia usually requires complex treatment planning, depending upon the pattern
of tooth absence, amount of residual spacing, presence of malocclusion and patient compliance. It is an interdisciplinary
intervention, involving prosthodontists, orthodontists, oral surgeons, speech pathologists and psychologists to achieve an optimal
outcome for the patient. This case report describes the close work of a committed team from orthodontic, oral surgery and
prosthodontic department of de'Montmorency College of Dentistry, Lahore, to reach final aesthetic and functional outcomes
for an 18 year old girl with oligodontia. Her chief complaint was poor esthetics and absence of multiple anterior teeth with
unsightly spacing between remaining teeth. Orthodontic redistribution of spaces followed by fixed full arch prosthetic rehabilitation
were the goals achieved at the end of her treatment.
KEYWORDS: Oligodontia, interdisciplinary team work, prosthodontic rehabilitation, fixed restorations.
HOW TO CITE: Tariq K, Khan MWU, Akram M, Illyas S, Azeem M. Prosthodontic rehabilitation of hypodontia- A team
approach. J Pak Dent Assoc 2021;30(4):279-284.
DOI: https://doi.org/10.25301/JPDA.304.279
Received: 22 October 2020, Accepted: 14 July 2021

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Kiran Tariq                                                 BDS
Muhammad Waseem Ullah Khan             BDS, FCPS
Momina Akram                                           BDS, FCPS
Sahar Illyas                                                 BDS
Muhammad Azeem                                     BDS

Hypodontia can have an impact on speech, aesthetics, function and psycho-social behavior of individuals afflicted by the
problem. Rehabilitation of patients with hypodontia usually requires complex treatment planning, depending upon the pattern
of tooth absence, amount of residual spacing, presence of malocclusion and patient compliance. It is an interdisciplinary
intervention, involving prosthodontists, orthodontists, oral surgeons, speech pathologists and psychologists to achieve an optimal
outcome for the patient. This case report describes the close work of a committed team from orthodontic, oral surgery and
prosthodontic department of de'Montmorency College of Dentistry, Lahore, to reach final aesthetic and functional outcomes
for an 18 year old girl with oligodontia. Her chief complaint was poor esthetics and absence of multiple anterior teeth with
unsightly spacing between remaining teeth. Orthodontic redistribution of spaces followed by fixed full arch prosthetic rehabilitation
were the goals achieved at the end of her treatment.
KEYWORDS: Oligodontia, interdisciplinary team work, prosthodontic rehabilitation, fixed restorations.
HOW TO CITE: Tariq K, Khan MWU, Akram M, Illyas S, Azeem M. Prosthodontic rehabilitation of hypodontia- A team
approach. J Pak Dent Assoc 2021;30(4):279-284.
DOI: https://doi.org/10.25301/JPDA.304.279
Received: 22 October 2020, Accepted: 14 July 2021

INTRODUCTION
One of the most common dentofacial malformation in humans is hypodontia.1 It is characterized by agenesis or developmental failure of dental germ to fully develop and erupt into final dentition. In more advance form hypodontia may present as oligodontia or anodontia, resulting in the absence of more than six to eight teeth or the absolute dentition.2 Women are more afflicted with this variation than men, and its prevalence ranges from 0.08% to 1.55% in primary dentition and 2.3% to 11.3% in secondary dentition, respectively.3,4 Hypodontia may be associated with recognized genetic syndromes involving growth and developmental defects, for instance Down’s syndrome, Crouzon’s syndrome and Ectodermal dysplasia5. It can also occur due to isolated non-syndromic genetic inheritance as a polygenic defect with point mutations in MSX1 gene (missing second premolars), PAX9 gene (missing upper lateral incisors) and AXIN2 gene (missing lower
incisors).6,7
Clinically, individuals with hypodontia have teeth that are generally smaller than normal- microdonts, and often have more simplified shapes. These teeth usually have enamel hypoplasia, shortened roots and ectopic positioning. Teeth are often rotated and normal occlusion is frequently disrupted. Skeletal patterns in hypodontia patients present with less than normal mandibular plane angles in association with
decreased lower anterior facial height and a tendency towards skeletal Class III. As the number of missing teeth increases (more than six), these patterns become more prominent.8 Patients with hypodontia may present at early mixed dentition, late mixed/early permanent and late permanent dentition. Treatment planning for mixed dentition includes prevention and reassurance, removable dentures/overdentures for psychological and functional reasons, composite build ups to improve aesthetics of microdonts, simple orthodontic space closures and schematic extractions of retained primary teeth to guide permanent tooth eruptions.9 Permanent dentition treatment planning aims at more definitive stabilization of occlusion with comprehensive orthodontic treatment and permanent bridge work including implant supported prosthesis after growth completion.10
Hypodontia can range in complexity from simple to severe forms. Simple cases are often straight forward to treat. They present with one or two missing teeth especially upper lateral incisors with usually adequate space available to restore with resin retained bridges or implants.11 Cases with crowding and drifting of adjacent teeth into missing tooth spaces add complexity in treatment planning and demand referral for orthodontic repositioning of teeth to create space followed by prosthetic restorations. Retained deciduous teeth may pose problems with eruption pattern/timing of permanent teeth and pediatric dentists are required to schedule extractions and guide eruptions of impacted permanent teeth. Severe hypodontia presents with multiple missing teeth in all quadrants, retained deciduous teeth, inadequate restorative space, loss of occlusal vertical dimension and disparities in occlusal plane. Targeting an ideal occlusion may not be possible in these cases and presents the most challenging scenario. Treatment planning includes multidisciplinary approach from different specialties to plan orthodontic tooth movements to optimize interdental spaces and occlusal plane, establishing occlusal vertical dimension for prosthetic restorations and sinus lift/bone augmentation surgeries to plan implant bridge-works.12,13
Multidisciplinary coordination among different specialties is important in treatment planning of individuals with hypodontia. It enables to provide an optimum care for patient in a scheduled way according to the complexity of presentation. It is an interdisciplinary intervention, involving prosthodontists, orthodontists, oral surgeons, pediatric dentists, speech pathologists and psychologists to achieve an optimal
outcome for the patient. The purpose of this case report is to describes the close work of a committed team from orthodontic, oral surgery and prosthodontic department of de’Montmorency College of Dentistry, Lahore, to reach final aesthetic and functional outcomes for a patient with oligodontia.

CASE REPORT
   An 18-year-old girl presented to the Outpatient Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore. Her chief complaint was poor esthetics caused by absence of multiple anterior teeth and unsightly spacing between remaining teeth. Detailed medical and dental history revealed that no previous dental treatment was received by the patient and medical history was insignificant. Family history revealed that one of her younger sibling also had the same dental problem. This finding highlighted the hereditary pattern of hypodontia.
During extra oral examination, no classical syndromic features were found in facial appearance. She had symmetric face with straight profile and normal hair, eyes, ears and nose. Lips were competent with normal perioral musculature. Lower anterior facial height was reduced with decrease in vertical dimension of occlusion. Temporomandibular joint examination revealed no abnormality in function or associated pain in muscles of mastication.
During intraoral examination, multiple permanent teeth were missing, (Figure 1a). Few deciduous teeth were retained with grade 2 mobility (Millers classification) 14, these were maxillary primary canines and the mandibular left primary canine.
   Maxillary central incisors were spaced with a midline diastema and were the most prominent teeth in the arch. Their incisal plane was near the crest of the mandibular anterior ridge, which was edentulous from canine to canine and narrow buccolingually (figure 1b). Remaining teeth were small and irregular in shape- microdonts (figure 1c, 1d). Anterior guidance was lost. Reduced occlusal vertical dimension with increased freeway space of up to 6mm was recorded. Regarding soft tissue status, oral mucosa, tongue and gingiva were normal in color and texture and oral hygiene status was satisfactory. Maxillary labial frenal attachment was low and thick. Panoramic radiograph evaluation revealed resorbed roots of retained primary teeth and absence of any
impacted or unerupted permanent tooth inside the jaws (figure 2a). On lateral cephalogram (figure 2b) skeletal class 1 was confirmed with low mandibular plane angle and deep bite. Upper inclinations were retroclined.
After a thorough clinical and radiographic examination, Oligodontia was diagnosed. Multidisciplinary treatment approach was planned to reach the final treatment outcomes. Diagnostic casts were obtained using alginate hydrocolloid impressions for both upper and lower arches.
Possible treatment options were worked out in a written form with an explanation of advantages and disadvantages for each option. A detailed consultation with the patient about the ideal to least ideal treatment plan was undertaken as follow:
1. Orthodontic treatment to correct alignment and spacing of upper central incisors, restoring height and shape of microdonts with individual crowns and replacement of missing teeth with osseointegrated implants.
2. Orthodontic treatment to correct alignment and spacing of upper central incisors and restoring missing teeth using fixed partial dentures (porcelain fused to metal bridges) in upper and lower arches.
3. Restoring the missing teeth using overlay type removable partial prosthesis. Due to financial constraints and esthetic demands, the
patient opted for treatment plan number 2. A multidisciplinary team from departments of orthodontics, oral surgery and prosthodontics was involved to initiate the treatment. Before commencement of treatment, a written in-formed consent was taken from the patient for the publication of this case report, and the patient refused to give consent to publish extraoral photographs.

Adjunctive orthodontics
First step was a consultation with an orthodontist for the correction of alignment and spacing of maxillary central incisors. Orthodontic repositioning of maxillary central incisors was planned. It was scheduled in three phases:
    Phase 1: leveling and alignment (figure 3a)
    Phase 2: intrusion and proclination of central incisors using protraction and intrusion utility arch wire (figure 3b)
    Phase 3: closure of midline diastema (figure 3c)
A six month duration was assigned to complete adjunctive orthodontics

Pre-Prosthetic Surgery
Second step was pre-prosthetic surgery by an oral surgeon. Following goals were achieved after pre -prosthetic surgery:
1: Frenectomy of thick upper labial frenum to prevent relapse after orthodontic closure of midline diastema (figure 4a)
2: Surgical crown lengthening with gingivectomy around central incisors (figure 4b)
3: Extraction of retained deciduous teeth with resorbed roots and clinical grade 2 mobility (upper primary canines and lower left                           primary canine.)

Prosthetic rehabilitation
 Final step was the restorative phase involving prosthetic rehabilitation. It was done in two stages: laboratory phase and clinical phase

Laboratory phase
  Diagnostic impression for both maxillary and mandibular arches was taken in irreversible hydrocolloid impression material. Discrepancy between resting vertical dimension and occlusal vertical dimension (OVD) was recorded on patient. A freeway space of 6mm was found to be present. Face bow transfer record was taken and the diagnostic casts were articulated on semi-adjustable Arcon type articulator (Bio-Art) in centric jaw relationship. Diagnostic wax-up was done on articulated casts (figure 5a, 5b). Occlusal vertical height was established with diagnostic wax-up with a total of 4mm increase in occlusal vertical dimension (2mm increase for each arch). Full arch segmented fixed partial dentures (porcelain fused to metal bridges) at established occlusal vertical dimension for both upper and lower arches were decided upon as final treatment outcome. Diagnostic wax up was translated to provisional fixed acrylic bridges in the lab.

Clinical phase
Tooth preparation for microdonts was done conservatively- margins were defined, undercuts and sharp line angles were removed and axial walls were made parallel. Only upper central incisors, which were larger in size, were reduced conventionally for porcelain fused to metal restorations preceded with elective endodontic. Mandibular arch teeth were prepared first and provisional restoration was delivered at a 2mm increase in occlusal vertical dimension (figure 6a, 6b). After 2 weeks, patient was recalled and her adaptation at increased occlusal vertical dimension was evaluated. Maxillary arch teeth were prepared and upper provisional restoration at 2mm increased occlusal vertical dimension was delivered (figure 7a,7b). Patient was kept on a two weekly follow-up for next 2 months, at every visit her adaptation at established occlusal vertical dimension was evaluated. After 2 months, no pain or difficulty in function was reported and temporomandibular joint examination was also normal. Final impression for tooth preparations was taken with putty wash technique in addition silicon
elastomeric impression material. Jaw relation records were repeated and sent to the laboratory for the fabrication of definitive porcelain fused to metal bridges at an established occlusal vertical dimension. Before final delivery of the prosthesis, an appointment for metal casting try-in was also scheduled. Definitive prosthesis was cemented with glass ionomer luting cement (figure 8a, 8b, 8c)

DISCUSSION
The treatment objective for this case was to create a fair starting point for prosthodontic rehabilitation. This was mainly accomplished by orthodontic intrusion and proclination of upper central incisors. Orthodontic tooth movements of maxillary central incisors were essential
because these were larger than the remaining microdonts and occlusal plane was disturbed due to their size and supra eruption against edentulous mandibular anterior ridge. Reduction in overbite must be taken into consideration whenever restoration of space is planned anteriorly. 15 Moreover, midline diastema closure created favorable spaces distal to central incisors for future prosthesis. Labial frenectomy was done to prevent relapse of midline diastema. Loss of occlusal vertical dimension (OVD) is a common manifestation among patients with multiple missing teeth and its re-establishment by fixed or removable prosthesis is the most challenging and a complex procedure. For this
reason an initial adaptation period with a provisional prosthesis at appropriate occlusal vertical height is required before final restoration.
16 This allows a prudent assessment of patient’s tolerance, functioning and esthetics at the proposed occlusal vertical dimension. An increase of upto 5mm in occlusal vertical dimension is an achievable alteration, as physiologic OVD occurs at a range, known as the comfort zone, rather than a specified value. 17 The patient can adapt to a change in OVD as long as it lies in this range. This case presents a 4 mm increase in occlusal vertical height using provisional fixed restorations for a 6-8 weeks adaptation period. Follow-up after 8 weeks revealed neither symptoms nor any temporomandibular joint dysfunction.
Conventional fixed prosthodontics depends on preparing healthy teeth next to the missing ones, and often require elective endodontics in teeth with large pulp chambers. 18 However, in this case, where a 2mm increase in OVD was planned per arch, need for excessive crown preparations was precluded, and tooth preparations were kept as minimal as possible for microdonts, only sharp line angles were removed, margins were defined and parallelism was established.
Treatment of hypodontia may require that osseointegrated dental implants be used to replace missing teeth. In this clinical case, a conservative approach was selected without the need for implants. 19 There is limited literature to address long term results for aesthetic, functional and satisfaction levels among hypodontia patients restored with dental implants. 20 Adequate alveolar bone and keratinized gingival biotype are prerequisite to successful implant insertion. However, reduced buccolingual width and apico-coronal height of alveolar ridges in patients with hypodontia, warrants bone augmentation before any dental implant placement. 21 Therefore, finances and time required to undergo extensive implant surgeries poses a limitation to patient’s preference to this treatment modality.
Patients presenting with few missing teeth can be treated by individual dental implants or minimal preparation fixed prosthesis. However for patients with multiple missing teeth, treatment options may range from osseointegrated implants and fixed prosthesis to overdentures and temporary/definitive removable partial dentures.

CONCLUSION
  There is an array of treatment modalities to dental rehabilitation of patients with hypodontia. However, early prosthetic intervention can improve masticatory function, speech, esthetics and self-esteem among these individuals. Early diagnosis and continuous dedication of preliminary management teams is important in the overall treatment plan. Well planned restorative approach in this case has contributed to achieve optimum final treatment outcomes.

CONFLICT OF INTEREST
None to declare

REFERENCES

1. Laganà G, Venza N, Borzabadi-Farahani A, Fabi F, Danesi C, Cozza P. Dental anomalies: prevalence and associations between them in a
large sample of non-orthodontic subjects, a cross-sectional study. BMC Oral Health. 2017;17:62.
https://doi.org/10.1186/s12903-017-0352-y

2. Al-Ani AH, Antoun JS, Thomson WM, Merriman TR, Farella M. Hypodontia: An Update on Its Etiology, Classification, and Clinical
Management. Biomed Res Int. 2017;2017:9378325.
https://doi.org/10.1155/2017/9378325

3: Jepson NJ, Nohl FS, Carter NE, Gillgrass TJ, Meechan JG, Hobson RS, Nunn JH. The interdisciplinary management of hypodontia:
restorative dentistry. Br Dent J. 2003;194:299-304.
https://doi.org/10.1038/sj.bdj.4809940

4. Gracco ALT, Zanatta S, Forin Valvecchi F, Bignotti D, Perri A, Baciliero F. Prevalence of dental agenesis in a sample of Italian
orthodontic patients: an epidemiological study. Prog Orthod. 2017;18:33.
https://doi.org/10.1186/s40510-017-0186-9

5. Rakhshan V. Congenitally missing teeth (hypodontia): A review of the literature concerning the etiology, prevalence, risk factors,
patterns and treatment. Dent Res J. 2015;12:1-13.
https://doi.org/10.4103/1735-3327.150286

6. Tangade SP, Ravishankar TL, Batra M, Shah AF. Familial Hypodontia: A Case Series. Kathmandu Univ Med J. 2015;13:167- 9.
https://doi.org/10.3126/kumj.v13i2.16792

7. Pemberton TJ, Das P, Patel PI. Hypodontia: genetics and future perspectives. Braz J Oral Sci, 2015;4:695-706.

8. Taju W, Sherriff M, Bister D, Shah S. Association between severity of hypodontia and cephalometric skeletal patterns: a retrospective
study. Eur J Orthod. 2017;40:200-05.
https://doi.org/10.1093/ejo/cjx049

9. Tong HJ, Tahmassebi JF. Management of a child with severe hypodontia in the mixed dentition stage of development. Eur Arch
Paediatr Dent. 2014;15:449-54.
https://doi.org/10.1007/s40368-014-0137-9

10. Hvaring CL, Øgaard B, Birkeland K. Tooth replacements in young adults with severe hypodontia: Orthodontic space closure, dental implants, and tooth-supported fixed dental prostheses. A follow-up study. Am J Orthod Dentofacial Orthop. 2016;150:620- 26.
https://doi.org/10.1016/j.ajodo.2016.03.023

11. Hobson RS, Carter NE, Gillgrass TJ, Jepson NJ, Meechan JG, Nohl F, Nunn JH. The interdisciplinary management of hypodontia: the relationship between an interdisciplinary team and the general dental practitioner. Br Dent J. 2003;194:479-82.
https://doi.org/10.1038/sj.bdj.4810184

12. Harrison J. Management of patients with hypodontia: What has changed? J Orthod. 2019;46:60-64.
https://doi.org/10.1177/1465312519840043

13. Attia S, Schaaf H, El Khassawna T, Malhan D, Mausbach K, Howaldt HP, Streckbein P. Oral Rehabilitation of Hypodontia Patients
Using an Endosseous Dental Implant: Functional and Aesthetic Results. J Clin Med. 2019;8:1687.
https://doi.org/10.3390/jcm8101687

14. Wu CP, Tu YK, Lu SL, Chang JH, Lu HK. Quantitative analysis of Miller mobility index for the diagnosis of moderate to severe
periodontitis – A cross-sectional study. J Dent Sci. 2018;13:43-47. https://doi.org/10.1016/j.jds.2017.11.001

15. Carter NE, Gillgrass TJ, Hobson RS, Jepson N, Eechan JG, Nohl FS, Nunn JH. The interdisciplinary management of hypodontia:
orthodontics. Br Dent J. 2003;194:361-6.
https://doi.org/10.1038/sj.bdj.4809995

16. Marin DO, Leite AR, de Oliveira Junior NM, Compagnoni MA, Pero AC, Arioli Filho JN. Reestablishment of Occlusal Vertical
Dimension in Complete Denture Wearing in Two Stages. Case Rep Dent. 2015;2015:762914.
https://doi.org/10.1155/2015/762914

17. Abduo J. Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int. 2012;43:369-80.

18. Sadaqah N, Tair J. Management of Patient with Hypodontia: Review of Literature and Case Report. Open J Stomatol. 2015;05:293- 308.
https://doi.org/10.4236/ojst.2015.512036

19. Filius MAP, Vissink A, Cune MS, Raghoebar GM, Visser A. Long-term implant performance and patients’ satisfaction in oligodontia. J Dent. 2018;71:18-24.
https://doi.org/10.1016/j.jdent.2018.01.007

20. Burns B, Grieg V, Bissell V, Savarrio L. A review of implant provision for hypodontia patients within a Scottish referral centre.
Br Dent J. 2017;223:96-99.
https://doi.org/10.1038/sj.bdj.2017.623

21. Bertl K, Grotthoff VS, Bertl MH, Heimel P, Gahleitner A, Ulm C, Stavropoulos A. A wide mesio-distal gap in sites of congenitally missing maxillary lateral incisors is related to a thin alveolar ridge. Clin Oral Implants Res. 2017;28:1038-1045.
https://doi.org/10.1111/clr.12915

Humayun Kaleem Siddiqui          BDS, FCPS
Jawad Safdar                                BDS, MDS, PhD
Kanza Ghauri                                BDS

The novel-coronavirus (2019-nCOV) emerged in Wuhan City in December 2019, this resulted in a quick and catastrophic health
problem all over the world but our country is slightly less affected by the pandemic. There could be a number of reasons for
less numbers of Covid positive cases and lack of awareness and reduced Covid testing capacity and hence less mortality in
Pakistan. In order to provide assistance to an ever increasing number of infected patients and, at the same time taking care of
urgent maxillofacial conditions. This manuscript gives the reader in a nutshell the overall surgical experience of oral and
maxillofacial practice at Aga Khan University Hospital, Karachi, Pakistan in the COVID-19 pandemic and would like to provide
a number of recommendations that would assist the scheduling process of surgical management during the COVID-19 pandemic
and reduce the risk of infection among healthcare workers and others involved with the service.
KEYWORDS: Maxillofacial surgery; Coronavirus; COVID-19; Pandemic
HOW TO CITE: Siddiqui HK, Safdar J, Ghauri K. Management strategies for oral & maxillofacial surgery amid the
COVID-19 pandemic. J Pak Dent Assoc 2021;30(4):275-278.
DOI: https://doi.org/10.25301/JPDA.304.275
Received: 02 March 2021, Accepted: 01 August 2021

INTRODUCTION
 The COVID 19 outbreak originated in Wuhan, Hubei province, China, and rapidly spread to other provinces and 190 other countries, was declared a global pandemic by WHO on March 9, 2020, becoming a “public health emergency of international concern”. In Pakistan, first in the province of Sind followed by others imposed a strict lock down on public gatherings and limited the working hours of shops.
The patients with COVID-19 infections and are positive are the principle source of spread, the asymptomatic ones are highly infectious with a strong chance of spread in the incubation period from 1 to 14 days. The person-to- person transmission of the infection includes direct transmission from sneezing, coughing, droplets, and contact transmission, such as contact with nasal, oral, and eye mucous membranes.
The oro-faecal route yet to be explored for the spread of infection. Infection control strategies are very important to stop the virus from further spread and to help contain the outbreak. The risk of spread during the diagnosis and treatment of oral diseases was also quickly assessed, adjourning non-urgent outpatient oral treatments and continuing emergent oral maxillofacial problems represented by trauma, malignant neoplasms, and infections, which require timely management.
The oral & maxillofacial fraternity belongs to a specific group of healthcare workers as they generally come in close contact with the oral cavity, airways along with patient’s secretions (for example saliva, blood, mucus,) during the diagnosis and treatment process, exposes in high risk of contracting the infection and in turn, a source of contagion. There are high viral burdens in the nasal mucosa and the
viruses in aerosols that can persist for up to 3 hours in the air and 48 to 72 hours on the tops. The objective of this work is to present a working line of action while observing precautions for the patients as well as minimizing the risks pertaining to surgeons.

Our Response to pandemic:
As early as when this was intended to move toward emergency only patient management, we took guidelines from The Center of Disease Control and Prevention (USA) and The American Dental Association as well as availability of rapid scientific researches that were invaluable assets which directed our line of action.

Initial lock down
Largely for the next four months after countrywide lockdown, maxillofacial ER patients were being admitted and if found positive, shifted to Covid ward. Although emergency surgeries were performed using full PPE with protocols, maxillofacial injuries including fractures were delayed due to increased risks of exposure and hospital policy. When they became Covid negative, only then maxillofacial fractures
were managed by ORIF and IMFs. During this period, the natural flow of patients to our hospital was reduced possibly due to scarce traffic hence reduced RTAs. However, few left the hospital following recoveries and were lost to follow up.

Criteria for Patient Selection during Covid Time
Selection of patient for surgery was challenging in these times. Only selected emergencies including RTA cases, tooth abscess which need emergency incision & drainage. To prevent corona virus infections, we followed and developed our SOPS that can help maxillofacial surgeon when they are required in emergency department.

Phasic approach to operating rooms 
At first, the hospital management as well chief anesthesia
decided to immediately halt all elective procedures in operating
rooms allowing only emergency operations. At the end of
three months and better understanding of viral transmissions,
the elective cases were allowed with PPE following Covid
negative tests and with guarded OR timings. Only few hours
of operation theatre were allowed. Later on as the disease
burden lessened, the operating rooms were opened for more
elective procedures but with Covid protocols. All elective
patients must have had a negative Covid PCR and mandatory
use of PPE.

Anesthetic and supporting staff
Most of the anesthesia team were busy managing patients at ICUs and new Covid wards. Soon many skilled physicians including intensivists, residents, interns became the virus positive and were not readily available for elective procedures and greatly affected work. Similarly, nursing staff and the upporting staff were being called on rotations to reduce exposure and following social distancing practices. This greatly reduced the workforce necessary for maxillofacial patients.

The use of personal protective equipment (PPE)
There is scarce data which compares the utility of respirators versus surgical masks in containing the virus; however, fortunately there are a variety of published papers with discussion about the two against SARS and influenza virus. 6 Wen et al tested the performance of various surgical masks and respirators and described that protection with N95 has shown to be thirty times higher than common surgical masks. 7
Moreover, the N95 superiority over surgical masks was demonstrated too when used for SARS complimenting in a series of case control researches. 8 on the other hand a recent systematic review and meta-analysis did not show the superiority of N95 respirators compared
to surgical masks in the course of influenza pandemics. 9 This is still contradictory to the current practices against COVID-19.
To sum up, in a new challenge with the outbreak of virulent strain like COVID-19, it should be judicious to utilize respirator because it offers a seal around the nose and mouth and resistance to fluid penetration in comparison to the surgical masks and which provides protection only
against droplets and similar particles including bigger respiratory droplets. The surgical masks do not provide adequate face seal and fail to filter smaller particles from the aerosols or air resulting in leakage around the mask and hence exposure to harmful droplets. Currently, the American Dental Association (ADA) recommends a quarantine of fourteen days for both health care personnel and patient if an aerosol generating procedure (AGP) was carried out using only a surgical mask and/or the patient is tested for COVID.

Rate of infection in dental OPD staff and doctors
First elective case of impacted third molars was admitted as daycare patient following hospital protocols, Covid screening and RT-PCR. Later on a strategy of Covid Pool testing was evolved and used for quick screening to reduce the economic burden on the patients and make it cost effective

DISCUSSION
The pandemic is life threatening as well as a great mental burden on the minds of those who are disease free. In order to practice safe and prevent further spread of the disease we followed to reduce exposures to all our staff and healthcare workers. We have developed protocols along with consultation from the literature and institutional policies.

Protocol for AGPs in OPDs
Till writing of this paper, as dental, maxillofacial and ENT has extremely high chances of aerosol generation and viral loads, negative Covid-PCR are required results before any procedure. However, when rubber dam can be used patients were not tested.

Protocol for AGPs in Operating Rooms
  We ensured that prior to getting into ward, the triage was carried out again and swab from nasopharynx (RT-PCR) was done both at admission followed by after 24 hours. Meanwhile, patients were allowed only in a separated area up to the time result arrived. A summary of flow chart can be seen in Table 2.2

Intraoperative protection
Healthcare workers were asked to implement strict preventive strategies as directed by interim directions of WHO. All patient caring staff have used our personal protective equipment (PPE): FFP2 or N95 mask, respirators (3M), surgical gloves, fluid-resistant gown and eye protection. The total staff and materials were reduced while in the operation.

Postoperative management
The prospective patients were kept at the separated rooms. After admission they received medical management lowering use of glucocorticoids, oxygen saturation along with monitoring of vital signs. All the equipment was individualized for each patient.10 The wounds dressings were given by the paramedical staff and medical with eye protection, gloves, medical masks and surgical gowns. Patients were mobilized early so as to reduce hospital stay. The overall hospital stay was around five days apart from those who were operated for oral cancer which lasted for more than five days.

Protocol after accidental exposures of peers at work or other places
  All positive coworkers and staff were required to quarantine for 14 days and tested negative before returning to work. In this matter, a unique mobile App and website is used daily by all to ensure self-screening for the symptoms. The application screens for 24 hours and gives a reminder message when expired.

Home based protocols
We used 72-hour window to operate within and patients were asked to remain inside their home until after the surgery.
Covid positive patients told to quarantine and test was repeated for negative results.

SOPs for Surgery
During the period of COVID-19 emergency, commonly reported patients in the oral and maxillofacial regions were trauma and oncological diseases. The head and neck oncology team had to take care of oncology after testing negative and in some patients who were positive were operated in designated operating rooms. This included extremely necessary staff with full PPE code including N 95 or respirators. However, many elective cases of maxillofacial region were differed until end of July 2020 when the active cases declined.
All patients had negative results before surgery. Since many were admitted for daycare surgery, after successful recovery from general anesthesia were allowed to go home and remain with few attendants in the home. All the family members were explained to use surgical masks even in home when around the patient. Attendants were asked and limited to single person with protection equipment. Body temperature, heart rate, blood pressure and oxygen saturation were monitored. As all the patients had COVID-19-negative on PCR, routine preoperative tests were performed. Intraoperative barriers for healthcare staff must be strictly implemented as advised by directions of WHO.

Resurgence of the active cases 
As the lockdown has eased in our country and regular gatherings are allowed, there are resurgence of the infected cases. Uniform protection for patients and healthcare personnel should be our priority. This may include revisiting our practices protocols, SOPs and implementation.

CONCLUSION
COVID-19 infection is a disease of concern. Strict adherence to PPE and hospital policy is required to limit and contain the virus. There is an urgent need to have a uniform policy in all the health care facilities which require resources and training of the individuals. Use of internet
services including online teaching and health applications (Apps) should be used extensively to train the healthcare staff in remote areas.

RECOMMENDATIONS
  The authors recommend following
1. No or minimum direct contact with the individuals.
2. Gatherings should be minimal unless necessary.
3. Where possible online mode may be used.
4. Staying home would minimize risk of exposure.
5. Improve immunity by sleeping and healthy life patterns.
6. Health care workers are responsible and should follow international as well as local governmental policies to prevent prolonged effects of deadly pandemics.
7. Regular updates on the rate of infectivity and review of institutional policies are must.

CONFLICT OF INTEREST
  None to declare

REFERENCES

1. Umer F, Haji Z, Zafar K. Role of respirators in controlling the spread of novel coronavirus (COVID-19) amongst dental healthcare
providers: a review. Int Endod J. 2020
https://doi.org/10.1111/iej.13313

2. Rana RE, Ather MH, Enam SA. Change in surgical practice amidst COVID 19; example from a tertiary care centre in Pakistan. Ann Med
Surg (Lond). 2020;54:79-81.
https://doi.org/10.1016/j.amsu.2020.04.035

3. Government of Pakistan, See the real time Pakistan and Worldwide COVID-19 situation, [Internet]. [accessed date: 22 Apr 20] Available
from: http://covid.gov.pk/.

4. American College of Surgeons, COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures, [Internet]; c1996-2020 (2020)
Mar 17 [cited 11 April 2020]. Available at: https://www.facs.org/covid19/clinical-guidance/triage.

5. World Health Organisation, Pakistan key indicators, [Internet]; c2016, [cited 12 April 2020]. Available at: https://apps.who.int/gho/
data/node.cco.ki-PAK

6. Umer F, Haji Z, Zafar K. Role of respirators in controlling the spread of novel coronavirus (COVID-19) amongst dental healthcare
providers: a review. Int Endod J. 2020;53:1062-067.
https://doi.org/10.1111/iej.13313

7. Wen Z, Yu L, Yang W, Hu L, Li N, Wang J, Li J, Lu J, Dong X, Yin Z, Zhang K. Assessment the protection performance of different level
personal respiratory protection masks against viral aerosol. Aerobiologia (Bologna). 2013;29:365-372.
https://doi.org/10.1007/s10453-012-9286-7

8. Seto WH, Tsang D, Yung RW, Ching TY, Ng TK, Ho M, Ho LM, Peiris JS; Advisors of Expert SARS group of Hospital Authority. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome
(SARS). Lancet. 2003;361(9368):1519-20.
https://doi.org/10.1016/S0140-6736(03)13168-6

9. Long Y, Hu T, Liu L, Chen R, Guo Q, Yang L, Cheng Y, Huang J, Du L. Effectiveness of N95 respirators versus surgical masks against
influenza: A systematic review and meta-analysis. J Evid Based Med. 2020;13:93-101.
https://doi.org/10.1111/jebm.12381

10. Barca I, Cordaro R, Kallaverja E, Ferragina F, Cristofaro MG. Management in oral and maxillofacial surgery during the COVID-19 pandemic: Our experience. Br J Oral Maxillofac Surg. 2020;58:687-91.
https://doi.org/10.1016/j.bjoms.2020.04.025

Humayun Kaleem Siddiqui          BDS, FCPS
Jawad Safdar                                BDS, MDS, PhD
Kanza Ghauri                                BDS

The novel-coronavirus (2019-nCOV) emerged in Wuhan City in December 2019, this resulted in a quick and catastrophic health
problem all over the world but our country is slightly less affected by the pandemic. There could be a number of reasons for
less numbers of Covid positive cases and lack of awareness and reduced Covid testing capacity and hence less mortality in
Pakistan. In order to provide assistance to an ever increasing number of infected patients and, at the same time taking care of
urgent maxillofacial conditions. This manuscript gives the reader in a nutshell the overall surgical experience of oral and
maxillofacial practice at Aga Khan University Hospital, Karachi, Pakistan in the COVID-19 pandemic and would like to provide
a number of recommendations that would assist the scheduling process of surgical management during the COVID-19 pandemic
and reduce the risk of infection among healthcare workers and others involved with the service.
KEYWORDS: Maxillofacial surgery; Coronavirus; COVID-19; Pandemic
HOW TO CITE: Siddiqui HK, Safdar J, Ghauri K. Management strategies for oral & maxillofacial surgery amid the
COVID-19 pandemic. J Pak Dent Assoc 2021;30(4):275-278.
DOI: https://doi.org/10.25301/JPDA.304.275
Received: 02 March 2021, Accepted: 01 August 2021

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Nosheen Sarwar              BDS
Saba Ansar                      BDS
Momminah Qamar          BDS

OBJECTIVE: Orofacial granulomatosis (OFG) is a relatively rare entity. The information pertaining to it is accessible to
patients and care-givers on the internet in a scarce quantity. The aims of the current study were to evaluate quality, readability,
understandability and actionability of information regarding the disease-orofacial granulomatosis-available to the public on
the internet. The purpose of the study was to evaluate ease of access and understandability of language available for individuals
affected by OFG. Although the incidence of the disease is very low in Pakistan, patients with symptoms of OFG rarely report
to clinics due to social stigma.
METHODOLOGY: A vivid selection process was chosen for the study. The study was conducted online on 'google scholar'
website. Four different search terms were used 'ofg disease', 'orofacial granulomatosis', 'cheilitis granulomatosa' and 'Melkersson
Rosenthal Syndrome' to seek information on orofacial granulomatosis. All of this was done during July, 2020 to October 2020.
The first 100 results from each term were shortlisted and evaluated further. Exclusion criteria was used and several repetitive
sites, non-functional links, sites containing content irrelevant to the search were excluded. This resulted in 58 websites relevant
to the search that were then categorized according to affiliation, specialisation, content type as well as content presentation.
Three grading assessments were utilized to assess the quality of this online information; the Journal of the American Medical
Association (JAMA) benchmarks, the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) and
the presence of Health on the Net (HON) seal. In order to assess the readability of the content in the websites, the Flesch Reading
Ease Score (FRES) and Simple Measure of Gobbledygook (SMOG) were used.
RESULTS: The overall quality of online information on orofacial granulomatosis is difficult to comprehend and act upon as
assessed by the PEMAT. The HON seal was visible on only 5 (9%) websites. In terms of readability, only one (2%) website
was fairly easy to read.
CONCLUSIONS: The online information on orofacial granulomatosis is qualitatively poor and does not serve its purpose in
true sense. There is a need to devise better, high quality online readable information for patients and the public to understand.
KEY WORDS: Orofacial granulomatosis, cheilitis granulomatosa, PEMAT.
HOW TO CITE: Akram Z, Anwar MA. Quality and readability of online information available for the general public on
orofacial granulomatosis. J Pak Dent Assoc 2021;30(4):267-274.
DOI: https://doi.org/10.25301/JPDA.304.267
Received: 02 February 2021, Accepted: 02 July 2021

INTRODUCTION
 In the early 20th century discovery of a disease characterized by temporary facial oedema and recurrent facial palsy was first documented and reported by two authors- Hubschamann and Rossolimo.1 Many authors have reported cases since then. Luscher2 described the presentation of lip swelling accompanied by features of lower motor neuron lesion in 1949. Weisenfield described a similar presentation.3
Melkersson reviewed a case of short-lasting oedema of the face with recurrent facial palsy, supplementing a link between the two.4
Rosenthal described a triad of clinical features; facial oedema, facial palsy and a fissured tongue.5 This clinical triad came to be known as ‘MelkerssonRosenthal syndrome’ (MRS).
Although orofacial granulomatosis remains a relatively rare disease, the number of individuals that have OFG is increasing, leading them to seek information on several aspects of the disease on the World Wide Web.5 However, based upon some previous studies of oral diseases,7,8 it is possible that information available to the public will vary qualitatively and may possibly be difficult to read and/or comprehend. Since there are no previous studies on the quality of information on the web pertaining to OFG, there is a requirement to determine how likely it is for patients and/or their carers to find easily readable information without compromising the accuracy of the material on the disorder

METHODOLOGY
On the 22nd of March, 2018 four key terms; ‘OFG disease’, ‘orofacial granulomatosis’, ‘cheilitis granulomatosa’ and ‘Melkersson Rosenthal Syndrome’ were searched on the web using the search engine google.co.uk. They yielded 253000, 111000, 21,200 and 146 results respectively. No advanced sorting or refinement was done on these results at this stage and only the top 100 consecutive sites were
shortlisted from each of these searches. These top 100 websites were screened and assessed. The irrelevant and repeated sites were not included. Furthermore, exclusion criteria were applied. Scientific research articles, book excerpts or reviews, websites that demanded authenticated password access and links that contained information in a language other than English were excluded. This resulted in 58 links that were then characterized as done in the Ni Riordain and McCreary (2009) paper based on 4 criteria, namely, affiliation (if it was commercial, belonged to a nonprofit organisation, government or a university or medical centre), specialisation (exclusively confined to orofacial granulomatosis or partly related to orofacial granulomatosis), content type (whether the content contained medical facts, clinical trials, human interest stories or question and answers) and content presentation (image, video and audio).
Three instruments were used to assess the quality of information in the shortlisted websites. These were the Journal of the American Medical Association (JAMA) benchmarks for website analysis (Silberg et al, 1997), the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) (Shoemaker et al, 2013) and the presence of Health on the Net (HON) seal. An excel spreadsheet was created to aid in systematic collection of data
The aim of the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) is to determine understandability as well as actionability of education material available to patients. Understandability refers to materials being easily understood when people from different backgrounds (health related or non-health related) and of variable knowledge on the topic of health can understand and interpret messages from the text. Actionability refers to the individuals identifying and acting upon the information provided (Shoemaker et al, 2013). The PEMAT-P for printable materials (e.g., brochures, pamphlets, PDFs) contains a total of 24 questions-17 pertaining to understandability and 7 relevant to measuring actionability. Each question has a response action of 0 or 1 (0=Disagree, 1=Agree). Additionally, some questions can also be answered with a ‘not applicable’ (N/A) response depending on available information (e.g., tables or diagrams being absent). The material’s scores are then calculated individually for understandability and actionability. A higher score is representative of higher
understandability and actionability. For example, an understandability score of 90% is more understandable than a material with a score of 50%. The same rule applies for actionability. Although the PEMAT cannot be used for podcasts or to evaluate friendliness of websites, it is the only tool that measures actionability of a material. The questionnaire used in PEMAT is shown in Table 1.
The material being assessed by PEMAT may be highly understandable but it cannot be relied upon entirely for accuracy or comprehensiveness. For this reason, supplemental quality assessments are essential. The JAMA benchmarks were hence used to evaluate the quality of each website analysed by PEMAT. This instrument requires fulfilment of 4 criteria; display of authorship (authors and contributors

along with their credentials), display of attribution (citations), disclosure (enlistment of ownership of medical content, sponsorship, commercial funding availability and conflict of interest) and currency (dates on which the material was posted or updated) (Silberg et al,1997).
The HON seal was founded in 1995 by a non-profit organisation. This Swiss-based seal deems medical information as a source of quality information for health professionals, patients and laymen alike (Hon.Ch, 2015). This seal (Figure 1) is displayed on websites that abide by
ethical conduct set down by HON. Eight outlined principles are required to fulfil the criteria to be accredited by HON. These are authority, privacy, attribution, justifiability, transparency, complementarity, financial disclosure and advertising policy (Table 2). The explanation of each principle
is listed below in the table. It must be kept in mind, however, that the HON seal is neither an indicator of accuracy nor of comprehension.
To evaluate the readability of health content online, two assessment tools were used. These were the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG).
The Flesch Reading Ease Score (FRES) was developed by Rudolph Flesch in 1948. It uses a formula to indicate the reading ease of a given text, thereby grading it from very easy to very difficult. The formula it uses is: 206.835 – (1.015 x average sentence length) – (84.6 x average
number of syllables per word)
A higher score correlates to a more readable passage and vice versa. In the current study, the readability score was calculated using the online programme (https://readability-score.com) by pasting a text of up to 500 words from the website onto the calculator. The readability
ease is indicated in the Table 3.
  The SMOG Readability Formula was created by McLaughlin (1969). It is a simple method used to determine reading level of written materials. It was enhanced by Harold C. McGraw in 2008. It makes use of sentences and words with 3 or more syllables in a text and a conversion table to assess the readability. It is available for short as well as long materials. The SMOG conversion tables are shown as Table
4.1 and Table 4.2. The site used was http://www.readability formulas.com/free-readability-formula-tests.php.

RESULTS
The search from the four different keywords yielded a total of 385,346 results. The results were narrowed down to 400 the top 100 consecutive websites from each of the term searched. Among these 400 results, a total of 32 links were repeated and were excluded. Two links were non-operational and hence excluded. Out of the remaining 366 links, further 261 websites were removed as they were links to scientific articles or research papers, 10 links were removed because they were links to book pages, 7 links were removed because they were blogs or discussion panels, 5 required a password for access, 11 had information in a language other than English and 14 contained either just pictures or no information on the disease and were deemed irrelevant.
This process resulted in 58 websites (12 from OFG disease, 15 from orofacial granulomatosis, 15 from cheilitis granulomatosa and 16 from Melkersson Rosenthal Syndrome) that were then assessed and reviewed for further analysis. The process of selection and exclusion is illustrated below in Figure 1.
Categorisation of the 58 websites was based on affiliation, specialisation, content type and content presentation. Figure 2 shows the categorised data. Majority of the websites represented data from non-profit organisations (60%), followed by commercial websites (26%). All websites except one exclusively contained information regarding the search term used (e.g. orofacial granulomatosis). Twenty-one websites (36%) contained at least one image to aid understanding. All of the sites had medical facts. There were neither clinical trials nor human interest stories.
Quality of information was variable. The results of the questions answered and their respective percentages are recorded according to the PEMAT in Table 5. The total understandability score was just 55%, making it difficult for the reader to understand and comprehend on most websites. The total actionability score was only 22% for the 58 websites and hence poor
Only one website (https://www.guysandstthomas.nhs.uk/ resources/patient-information/nutrition-and-dietetics/ cinnamon-and-benzoate-free-diet-OFG.pdf) had the highest understandability and actionability score of 84.6% and 83% respectively, whereas the lowest score for understandability was 20% scored by two websites. The lowest actionability
score was 0, scored by 17 (29%) websites.
Out of the 58 websites, 42(72%) made their purpose evident. Nine (16%) websites contained a distraction in the form of advertisements. Only eighteen (31%) used understandable language and even fewer (24%) defined and explained medical terminology used on the website. Only one website required calculations and explained how to do so. Information was broken into shorter sections in fortyseven (81%) sites. Text was presented in logical sequence in forty-four (76%) websites. Only one (2%) website provided a summary. Approximately half (48%) used highlights and bullet points to direct to key points. Forty (69%) websites identified at least one action to be taken, however, instructions
were directly addressed only in eight (14%) websites. None of the web-links made the use of visual aids to make instructions regarding taking action easier
With regard to JAMA benchmarks fifty-one (88%) websites fulfilled the benchmark for the disclosure, whereas attribution benchmark was met by only nineteen (33%) websites. The authorship and currency benchmarks were fulfilled by twenty-four (41%) and thirty-seven (64%)
websites. There were seven (12%) websites that achieved all four benchmarks. Table 6 shows the percentages of benchmarks achieved.
A minimum of one benchmark was achieved by all 58 websites.
Only 5 (9%) websites had the HON seal displayed on their page
The Flesch Reading Ease score ranged from a minimum of 0 on multiple websites to a maximum of 69.9 on one website indicating that available information online ranged from being very difficult to standard in comprehension. The mean score was 22.7. Fifty-four (93%) of the websites contained material that was difficult to very difficult. Only one (2%) website had fairly easy content.
The Simple Measure of Gobbledygook (SMOG) index ranged from 7.6 to 22.2. The mean score was 13.4. According to the SMOG index, all the material available online on the 58 websites was readable for a 6th-8th Grader as illustrated below.

DISCUSSION
Quality of life is severely affected in individuals with chronic conditions who have poor health literacy.9 In this modern day and age, accessibility to information has become easy and readily available, mainly due to technological advancements.10,11 Health information online has enriched patients with knowledge to bridge the gap between themselves and the physician, prior to their appointment with a health consultant.12 Many individuals report conducting successful online searches related to a disease before visiting their
physician.13
The health related information on the internet is certainly advantageous but the drawbacks must also be considered. Immediate access, personal privacy, perceptual variety from various sources, reduced appointment time and convenience of the patient are some of the advantages highlighted in the literature.14 Some identified disadvantages include excessive information, complicated medical terminology, lack of credibility and misleading support groups.15 It is essential that health information available online should be easily readable and understandable for the target population i.e. patients/general population.16 A website should be an effective communication tool directed towards the patient which is only possible when the information enlisted is easily understood.17
This means that in addition to assessing the quality of online readable health information, assessment of readability is also important.
Orofacial granulomatosis is a rare disease and hence, information on it is scarce and scattered on the internet. Prior to this study, there have been no quality and readability assessments of online information on OFG. The details of epidemiology are limited with variable knowledge on clinical features. The treatment strategies vary according to different authors, ranging from diet modifications to use of systemic
immunosuppressants and surgery.
The objective of this study was to investigate online information comprehensively which could be easily accessible to patients and laypersons alike. In the current study, the Google search engine (google.co.uk) was used as Google remains the most commonly used search engine
according to statistics from the Statista website (www.statista.com) in 2018.
A recent study suggests that information found online can mislead individuals from non-medical backgrounds.18 Although online information plays a role in increasing knowledge of an individual regarding the disease and its treatment, younger and more educated people benefit from these websites more than the aged and less educated.19 In the current study, it is evident that patients would find information challenging or carers might find it difficult to gather information regarding orofacial granulomatosis. The search was narrowed down to 58 links out of 385,346 hits from the four search terms initially used. After excluding the non-functional and duplicated webpages, it was found
that only 24% of the websites had easy language that did not require a medical background to understand. This indicates that individuals seeking information on OFG might fail to find the relevant comprehensive answers. Sources of information were classified broadly into four different categories-university/hospital, non-profit organizations, commercial and governmental.20 Majority of the websites (60%) belonged to non-profit organizations and therefore one would hope that the information provided would not be distorted by a hidden commercial agenda. However, the material contained therein could be considered too complicated for a lay person.
It was seen that at least one action was mentioned in many websites (69%) to help resolve the symptoms. However, all 58 websites focused heavily on the aetiology of OFG. Contrary to a study by Houts et al.,21 which highlighted that the use of graphic content such as pictures
along text can benefit the reader, none of the 58 websites included pictures of treatment options to make understanding
of the reader better.
Levels of health literacy, defined as the ability of a person to retrieve, process, understand and apply basic health information, is known to be low. The assessment of the quality of online information is therefore key to determine whether patients of questionable health literacy levels can benefit from their online read.
The public faces a challenge to access accurate health care information especially due to low levels of health literacy.22 Many tools have been devised to assess quality which include the CDC Clear Communication Index but they do not consider the audience (www.cdc.gov) and hence
are not as effective as the PEMAT. The Knee Osteoarthritis Patient Education Questionnaire (KOPEQ) is another disease specific tool which has been used to assess validity of a patient education material. In addition to possessing all the advantages of PEMAT it also evaluates the pedagogic value of information available.23 COMDQ has also shown to be a valid and reliable outcome measure for patients with chronic oral mucosal diseases in a UK population.24 As this is the first study on patient information in OFG, no disease specific tool was available for use.
The quality of online information can be assessed via The Patient Education Materials Assessment tool (PEMAT) which is considered a consistent and reliable quality assessment tool. The PEMAT for printable material was used in this study as it demonstrates good inter-rater
reliability (IRR) and adds objective value to patient education materials.25 A second reviewer assessed the results conducted using the PEMAT tool in this study to increase the reliability of the findings.
The mean understandability score of the study using PEMAT was 7 (55%) with a standard deviation of 2.8. The mean actionability score was 1 (22%) with a standard deviation of 1.1. The threshold value for PEMAT to deem a material qualitatively valid is 70%22,hence in this case
the quality was poor overall. These results were influenced by websites having the right content but unable to present it in a simple, understandable manner.
In 1997, Silberg et al. published the JAMA benchmarks as a proposed quality standard for health information online. It mentions four criteria that must be clearly apparent on a website. These are authorship (author name and credentials), currency (date of publishing and updating), attribution (references and citations) and disclosure (conflict of interest).
With regard to JAMA benchmarks less than half (41%) of the websites clearly stated the author, however, even fewer (33%) listed the credentials and qualifications they possessed. Only a small proportion of these websites (12%) mentioned the author, their credentials, date of publishing and declared that there was no conflict of interest. The fulfilled benchmarks serve as a reliable source of knowledge whereas lack of credentials makes the information less conclusive and hard to rely on by the general public.
Health care workers should be aware of patients using the World Wide Web as a means of gaining medical and dental information and be ready to assist patients in browsing through available medical information online.27 The health on the HON code is such a seal that indicates reliability of online health information to its users. Due to its long certification processing time, it is not commonly used by many authors since its initiation in 1995 (www.hon.ch). There is also a monetary contribution required for any website to be accredited by HON. The fees are £142 and £288 for a non-profit organisation and commercial website respectively to acquire the HON seal. In the current study only five (9%) of the online sources had the HON seal. This is lower than a study conducted on online information on treatment of leukoplakia which had 17% of the websites displaying the HON code.7 Another indicator of highly reliable information-The Information Standard-was recently made available by NHS but is under review to develop an improved and sustainable model (www.england.nhs.uk) and was not used in this study.
The question arises whether the information accessed is easy to read for patients seeking online material about their condition or treatment. The readability of a text is defined
As the level of comprehension an individual should have to understand and comprehend the material (Weiss et al 2003). The FRES is a commonly used readability tool and was supplemented by the SMOG in this study. Only one website had a readability score interpreted as fairly easy and it was simple to comprehend the information listed, whereas, the readability of the remaining websites varied from difficult to very difficult. The National Institute of Health (NIH) and American Medical Association recommend that information meant for general public or patients should not surpass the sixth-grade level. The mean reading score was above sixth grade in this study, showing that most websites were hard to understand for the general population. Long words may make a sentence complicated.28 It is also suggested that simplified information and shorter words in sentences may fail to inform individuals of the disease properly if they are aware of commonly used medical/scientific terminology.29

SUMMARY AND CONCLUSION
This study is the first of its kind, assessing the quality and readability of online information on orofacial granulomatosis. OFG is a rare, yet increasingly apparent disease entity. The information pertaining to it is scarce and difficult to understand for the general public. This study has demonstrated that even using four different search terms the Google search engine failed to deliver good quality, easily readable text for patients.
It would be reasonable to conclude that improvements need to be made in order to make information regarding OFG on the internet simplified yet comprehensive, so modern day patients can understand it, irrespective of the education level they possess. This process of betterment can be made by information providers and healthcare workers on the web for people who wish to study their symptoms online. Emphasis should however, be made by professionals warranting patients to visit a dentist or other healthcare providers for effective diagnosis and relevant treatment.

SOURCE OF FUNDING
Nil

CONFLICT OF INTEREST 
There are no conflicts of interest

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https://doi.org/10.1089/thy.2013.0252

Zain Akram                      BDS, MSc
Malik Adeel Anwar           BDS, M.Phil

OBJECTIVE: Orofacial granulomatosis (OFG) is a relatively rare entity. The information pertaining to it is accessible to
patients and care-givers on the internet in a scarce quantity. The aims of the current study were to evaluate quality, readability,
understandability and actionability of information regarding the disease-orofacial granulomatosis-available to the public on
the internet. The purpose of the study was to evaluate ease of access and understandability of language available for individuals
affected by OFG. Although the incidence of the disease is very low in Pakistan, patients with symptoms of OFG rarely report
to clinics due to social stigma.
METHODOLOGY: A vivid selection process was chosen for the study. The study was conducted online on 'google scholar'
website. Four different search terms were used 'ofg disease', 'orofacial granulomatosis', 'cheilitis granulomatosa' and 'Melkersson
Rosenthal Syndrome' to seek information on orofacial granulomatosis. All of this was done during July, 2020 to October 2020.
The first 100 results from each term were shortlisted and evaluated further. Exclusion criteria was used and several repetitive
sites, non-functional links, sites containing content irrelevant to the search were excluded. This resulted in 58 websites relevant
to the search that were then categorized according to affiliation, specialisation, content type as well as content presentation.
Three grading assessments were utilized to assess the quality of this online information; the Journal of the American Medical
Association (JAMA) benchmarks, the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) and
the presence of Health on the Net (HON) seal. In order to assess the readability of the content in the websites, the Flesch Reading
Ease Score (FRES) and Simple Measure of Gobbledygook (SMOG) were used.
RESULTS: The overall quality of online information on orofacial granulomatosis is difficult to comprehend and act upon as
assessed by the PEMAT. The HON seal was visible on only 5 (9%) websites. In terms of readability, only one (2%) website
was fairly easy to read.
CONCLUSIONS: The online information on orofacial granulomatosis is qualitatively poor and does not serve its purpose in
true sense. There is a need to devise better, high quality online readable information for patients and the public to understand.
KEY WORDS: Orofacial granulomatosis, cheilitis granulomatosa, PEMAT.
HOW TO CITE: Akram Z, Anwar MA. Quality and readability of online information available for the general public on
orofacial granulomatosis. J Pak Dent Assoc 2021;30(4):267-274.
DOI: https://doi.org/10.25301/JPDA.304.267
Received: 02 February 2021, Accepted: 02 July 2021

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Nosheen Sarwar              BDS
Saba Ansar                      BDS
Momminah Qamar          BDS

OBJECTIVES: The current study is conducted to assess the knowledge and behavior of dentists in Pakistan and various practice
modifications adopted in response to current outbreak of COVID-19.
METHODOLOGY: Well-constructed online questionnaires were distributed among 300 subjects including dental students
(3rd year and 4th year), house surgeons, and dental surgeons of two public hospitals of Punjab, Pakistan.
RESULTS: 90% of dentists are afraid of getting the infection and reluctant to continue their dental practice. Most of the dentists
95% are aware of the mode of transmission of disease and follow WHO guidelines but still a large number of dentists are in
fear and anxious to perform only emergency dental procedures.
CONCLUSION: Most dentists resume their dental practice by following WHO new guidelines related to practice in
COVID -19 outbreak but still a significant number of dentists close their dental practice for an indefinite period due to anxiety
and fear of being ill or got infected by COVID-19.
KEYWORD: anxiety and fear, practice modifications, outbreak, COVID-19, knowledge and behavior
HOW TO CITE: Sarwar N, Ansar S, Qamar M. Knowledge and behavior of dentists, and practice modifications in response
to the outbreak of novel COVID-19 in dentists of Pakistan. J Pak Dent Assoc 2021;30(4):261-266.
DOI: https://doi.org/10.25301/JPDA.304.261
Received: 27 November 2020, Accepted: 07 August 2021

Download PDF
Read More

Nosheen Sarwar              BDS
Saba Ansar                      BDS
Momminah Qamar          BDS

OBJECTIVES: The current study is conducted to assess the knowledge and behavior of dentists in Pakistan and various practice
modifications adopted in response to current outbreak of COVID-19.
METHODOLOGY: Well-constructed online questionnaires were distributed among 300 subjects including dental students
(3rd year and 4th year), house surgeons, and dental surgeons of two public hospitals of Punjab, Pakistan.
RESULTS: 90% of dentists are afraid of getting the infection and reluctant to continue their dental practice. Most of the dentists
95% are aware of the mode of transmission of disease and follow WHO guidelines but still a large number of dentists are in
fear and anxious to perform only emergency dental procedures.
CONCLUSION: Most dentists resume their dental practice by following WHO new guidelines related to practice in
COVID -19 outbreak but still a significant number of dentists close their dental practice for an indefinite period due to anxiety
and fear of being ill or got infected by COVID-19.
KEYWORD: anxiety and fear, practice modifications, outbreak, COVID-19, knowledge and behavior
HOW TO CITE: Sarwar N, Ansar S, Qamar M. Knowledge and behavior of dentists, and practice modifications in response
to the outbreak of novel COVID-19 in dentists of Pakistan. J Pak Dent Assoc 2021;30(4):261-266.
DOI: https://doi.org/10.25301/JPDA.304.261
Received: 27 November 2020, Accepted: 07 August 2021

INTRODUCTION
The outbreak of COVID-19 started from Wuhan, a city in China now spread globally and adversely affects every aspect of life.1 The disease-causing organism identified as a single strand RNA virus, a new strain of severe acute respiratory syndrome-Coronavirus2 (Sars-CoV-2) named coronavirus 19 or COVID-19.2 After the initial case was reported the WHO declared the COVID-19 pandemic, a worldwide public health-related emergency.3
Data from published epidemiological and virologic studies provide evidence that COVID-19 is primarily transmitted from symptomatic persons to others who are in close contact through respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces.4 The average incubation period of the virus is 2 weeks range from 3-14 days.5
The clinical manifestations show by the patients are mainly upper respiratory tract symptoms and fever.6 But now studies supported those respiratory symptoms are not initial symptoms presented in COVID-19 patients but the earliest symptoms seen are headache, fever ageusia,
anosmia, and in some cases, diarrhea was also reported.7
In this pandemic situation, health care workers perform a main front line role so they are more prone to the virus as compared to the normal population.8 Similarly, the dentist treated the patient in close vicinity and dental instruments produce aerosols and splashes of saliva in the
oral cavity which can affect the dentists and dental assistants.9 So in this situation when everyone is in the fear of getting infection people are reluctant to go to their workplaces.10 On the other hand, dentists which are at high risk are expected to develop fear and anxiety of getting an
infection, being isolated and being infected to their family.11 Considering the rapid spread of disease the American Dental Association (ADA) highlights the additional precautions along with slandered universal precautions including the travel history, temperature checking,
pre-rinse with antiseptic mouth wash, and cleaning and disinfecting the areas which are in contact with patients and public.12 These guidelines help to reduce fear and anxiety in dentists but still mostly dentists are unaware of ADA guidelines they are reluctant to perform
procedures.13,14 The current study is conducted to evaluate the factors which are causing fear and anxiety in dentists and accessing the practice modifications to combat the COVID 19.

METHODOLOGY
A cross-sectional study was carried out, by an online organized questionnaire, among the dental students and dental professionals of Punjab Dental Hospital Lahore, Pakistan (de’ Montmorency College of Dentistry) and the Dental section of Allied Hospital (Faisalabad Medical
University) Faisalabad, Pakistan. The study participants included are Dental surgeons, House Surgeons, 3rd year and 4th-year dental students that were practicing during the pandemic. The students of non-clinical years, dental technicians and paramedics were excluded from the study. The time duration to conduct this study was about one week from 21-06-2020 to 28-06-2020. The approval for this study was taken from the ethical committee of respective institute (FMU/08/2020/03).
The response form appendix no. 1 was prepared in Google forms and send through WhatsApp and Email. The informed consent was also taken online. The response form was sent to 300 subjects out of which 270 were filled and used in the study. The sample size was calculated by Open Epi online software by taking 50% knowledge awareness with a 5.05% margin of error and 92% confidence interval. The size obtained was 265 and it is considered 300 to compensate for any flaws and data errors.
The questionnaire was based on three sections. The first section was about demographic data of participating candidates; the second section contains questions exploring fear and anxiety of dental students and professionals related to COVID-19, the questions of the third section are about knowledge and practice modifications of dental students and professionals to prevent the cross-infection of COVID19 among dentist and patient. The total number of questions in the questionnaire were 28. The time taken to fill this questionnaire was approximately 2-3 minutes.

STATISTICAL ANALYSIS
 The questionnaire/Proforma was made on Google form and results from data was compiled using SPSS version 21.0 (SPSS Inc., Chicago, IL, USA). The descriptive variables like age, gender and designation of study participants were described in the form of frequency and
percentages. A Chi-Square test was used to assess the relation of gender and knowledge of COVID-19. p < 0.05 was considered significant in statistic.

RESULTS
A total of 300 questioners were distributed among dental students, house surgeons, and dental surgeons of two public teaching hospitals of Punjab. By considering the current lockdown and pandemic situation all the questionnaires were filled by online Google forms. The
time duration of the response form filing was 3 days. A total of 270 forms were collected back so the response rate of the study was 90%. The questionnaire was divided into 3 sections. The first section is about the demographic details of participants which are elaborated in Table 1. Out of 270 participants, 202 (74.8%) were female and 68 (25.2%) were

males so the ratio of female participants was more like other epidemiological studies. About the designation of participants, there were 48 (17.8%) dental students of 3rd and 4th year who practice their clinical rotations in a hospital setting. 65 (24.1%) were house surgeons and the remaining were dental surgeons 157 (58.1%). Related to the age distribution of participants 83.1% of participants were between 20-30 years. 0nly 6% were below 20 and the remaining 10.9 % above 30 years. The p-value of 0.07, which is negligible, indicates that there is no direct relationship between gender and COVID-19 practice modifications.
In section 2 of the response form, dentists’ behaviors in coronavirus outbreaks were assessed and the factors which cause fear and anxiety were also tried to rule out. The 217 (80.4%) dentists were afraid of being ill with COVID -19. 91% of participants were reluctant to come to
their workplace in the current pandemic. 76.3% of dental persons feel anxious when taking the patient in close vicinity. Due to this anxious behavior, most of the dentists (71.9%) feel reluctant to perform an oral examination of their patients. The reason for this fear can be that they are afraid to carry infection to their home which can infect their family or friends (88.1%). The other factor of being afraid is that dentists are anxious about the cost of treatment (67.4 %) and the other reason can be that there is only symptomatic treatment is present and there is no vaccine available for the treatment of COVID -19 (table 2).
The third section is about the practice modifications and knowledge about the coronavirus in dentists and dental students. 249 (92.2%) dentists were aware of the mode of transmission of COVID -19. But only 88.1 % of dentists know the current WHO guidelines about
COVID -19.
Related to practice modifications in response to outbreaks it is a common practice in dentists to ask about the travel history and history of fever and recent illness to the patients (85.2%). It is also common to check the temperature of the patient before entering a hospital which is a good practice in this outbreak. Most of the dentists (84.1%) defer the dental treatment of the patient who shows any suspicious symptom. Only 105 (38.9%) dentists considered that a surgical mask is enough for protection from the virus. While 93 % of dental persons are agreed
that N-95 masks should wear in routine dental practice. On the other hand, a very small number (23.3%) of dentists ever wear the N-95 mask in their dental practice.
Almost all of the dentists (87.8%) followed the universal precaution of infection control in their dental practice. But ask the Patient to Rinse His/her Mouth with Anti-Bacterial Mouthwash before treatment is not a common practice in dentists 72(26.7%) .69.6 % of dentists use personal protective
equipment (PPE) to examine the patients and only 16.7% of dentists know the procedure to Contact the Authority if they Come Across a Patient with Suspected COVID-19 Infection. In this outbreak situation, most of the dentists (83.3%) only perform emergency dental procures due to anxiety and fear related to COVID-19.

DISCUSSION
The study was conducted online by preparing and then filling out a questionnaire from dental students and dental professionals in two large public dental teaching hospitals of Punjab, Pakistan to access the dentists’ awareness and behavior, as well as the effect of the COVID-19 outbreak on dental practice in Pakistan
A close-ended questionnaire was prepared and after filling assessed by statistical software to carry out complete results. The candidates included in this study have submitted their consent online through Google Form. The number of female participants 202 (74.8%) is higher than male participants 68 (25.2%) that result contradict the study result of Italy.15 By the designation, the number of dental students of the third year and final year who participate in clinical work was is 48 (17.8%). The house surgeons were 65(24.1%) and the remaining (58.1%) are dental surgeons.
In this pandemic situation of COVID-19 anxiety among every person especially in medical professionals are common. By analysis of the data obtained from the study, the result is that 76.3% of dental professionals feel anxious when taking the patient in close vicinity that have similar result with the study of Dolar Doshi in India.10 Due to this anxious behavior, most of the dentists (71.9%) feel reluctant to perform an oral examination of their patients. The reason for this behavior is that there is no medicine and proper treatment of COVID-19 is still available and it is difficult to control due to its fast-spreading ration all around the world. It is affecting every person irrespective of gender
and age. As the infected person doesn’t show symptoms before two weeks but they remain the source to infect the other persons come in contact with them during this symptomless incubation period. So, diagnosing an infected person during this incubation period is difficult. And lack of diagnostic test kits due to limited resources, every person testing for COVID-19 is not possible. Another reason which makes the diagnosis difficult is that its cost is not affordable for every person as the economic condition of most of the population is already not good due to lockdown in the country. This damage to the economy of the country and its population also worsens the situation and increases the
anxiety among the population
The fear to get infected by COVID -19 from patients is also present in this alarming situation of COVID-19 in 217 (80.4%) dental practitioners the results supported by the study in South Sulawesi, Indonesia where 86% of dentists have fear of getting infected.17 As the main source of transfer of infection is droplets and aerosols coming from airway passage during breathing through nose and mouth and it is the part of the body to which the dentist has to deal. So, the dentist would be at greater risk to get infected during the treatment of a person infected with COVID-19.
Dental practitioners are also worried about spreading the infection to their families.8 That is the reason, dentists avoid continuing their practice in this situation they close their clinics and quit private practice temporarily during this alarming condition of COVID-19, which affects their economies. In this situation of COVID-19 to continue their profession and to protect themselves and their family members, the proper knowledge about COVID-19 must have dental professionals. This knowledge should include COVID-19 mode of transmission, its sign, and symptoms, measurements are taken to prevent the cross-infection between dental, professionals, and patients, what to do if they get infected or susceptive to have an infection, whom to contact in this situation. All of this knowledge is very necessary for dental professionals to cope up with this pandemic of COVID-19. In this study, we have to try to explore the knowledge of dental professionals about
COVID-19.
The presence of this knowledge is not enough but the implication of this knowledge in his routine and professional practice is also necessary. By keeping in mind this knowledge dental professionals have needed to modify their practice for the best advantage of themselves, their families, and patients. In this study, these practice modifications by dental professionals have also been explored.18 These practice
modifications are a sign of the implication of knowledge which is necessary to cope up with this situation of COVID-19. There is no evidence or confirmation that when vaccine or proper treatment for COVID-19 will be invented. So, we have to live and survive in this condition. For
survival, time demands to continue their practice with modifications (85.2%). Dental professionals are taking complete history including travel history, any sign and symptoms related to COVID-19 like sour throat, cough (if present either productive or non-productive), fever, or recent illness, and these results are also supported by the study of COVID-19.1 All these parameters of the history are important, the presence or absence of these points gives a clue to the dentist either is the patient is a suspect for COVID-19 or not. If the presence any positive clue the patient can be advised to test for COVID-19. Thus, early diagnosis and early treatment will be advantageous for the patient and indirectly for society.19 This application of history questionnaire will reduce the number of people infected by asymptomatic COVID-19 positive individuals.
The results of the current study are supported by the other studies of Covid in dentists of Pakistan.20 Study on the phycological fear of COVID-19, a high level of anxiety and fear reported in Pakistani dentists.21 In other study, 75% of dentists are afraid of getting Infected, and about more than 80 percent are anxious while treating the patients.22 Dentists in Pakistan are now well aware of the mode of transmission of COVID-19 still, a large population of the population don’t utilize the basis isolation equipment’s.23
The 69.6% use the PPA kit in their dental set up to examine the patients. It is a positive sign that dentists adopted the essential safety measure to reduce the speed of disease these are according to ADA guidelines.14 About (93%) dentists wear the N-95 masks in their routine practice that supported with the study results of clinical practice adjustments.18 The percentage of dental professionals taking other modifications like doing only emergency procedures like managing trauma and deferring from elective and routine dental procedures, wearing a surgical mask, agreeing on wearing N-95 mask, contact the authority if come across a susceptive COVID-19 positive patient, although not hundred percent still is appreciable. Which is a good sign towards the good surviving and managing ability during this pandemic COVID-19 situation.

CONCLUSION
The purpose of the current research is to rule out or evaluate the knowledge and behavior of dental students and dental professionals and practice modifications they followed in the COVID-19 outbreak. Most of the dentists are afraid of becoming ill since there is no medicine available and the cost and resources to fight against COVID-19 are not enough. WHO Infection Management Guidelines or ADA guidelines are14 effective in relieving this anxiety and uncertainty, but it will still take some time to overcome the current situation until new ways are discovered to cope with the novel virus.

CONFLICT OF INTEREST
 None to declare

REFERENCES

1. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat novel
coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17: 2821.
https://doi.org/10.3390/ijerph17082700

2. Consolo U, Bellini P, Bencivenni D, Iani C, Checchi V. Epidemiological aspects and psychological reactions to COVID-19 of dental practitioners in the Northern Italy districts of modena and reggio emilia. Int J Environ Res Public Health. 2020; 17: 3459.
https://doi.org/10.3390/ijerph17103459

3. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med.
2020; 382:1708-1720.
http://.doi.org/10.1056/NEJMoa2002032

4. Khurshid Z, Asiri FYI, Al Wadaani H. Human saliva: Non-invasive fluid for detecting novel coronavirus (2019-nCoV). Int J Environ
Res Public Health. 2020; 17:17-20.
http://.doi.org/10.3390/ijerph17072225

5. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019 nCoV) infections among travellers from
Wuhan, China, 20 28 January 2020. Eurosurveillance. 2020; 25:1- 6.
https://doi.org/10.2807/1560-7917.ES.2020.25.5.2000062

6. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel
coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet.2020; 395(10223):507-13.
http://.doi.org/10.1016/S0140-6736(20)30211-7

7. Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DKW, et al. Detection of 2019 novel coronavirus (2019-nCoV) by
real-time RT-PCR. Eurosurveillance. 2020; 25:1-8.
https://doi.org/10.2807/1560-7917.ES.2020.25.3.2000045

8. Kumar J, Katto MS, Sahito B, Ahmed B, Siddique AA, Jamil M, et al. Predictive Factors Associated with Fear Faced by Healthcare
Workers during Covid-19 Pandemic: A Questionnaire Based Study. (Preprint) [Internet]. JMIR Publications Inc.; 2020. Available from:
http://doi.org/10.2196/preprints.20881

9. Bizzoca ME, Campisi G, Muzio L Lo. Covid-19 Pandemic: What Changes for Dentists and Oral Medicine Experts? A Narrative Review
and Novel Approaches to Infection Containment. Int J Environ Res Public Health. 2020; 17(11)379.
https://doi.org/10.3390/ijerph17113793

10.Doshi D, Karunakar P, Sukhabogi JR, Prasanna JS, Mahajan SV. Assessing Coronavirus Fear in Indian Population Using the Fear of
COVID-19 Scale. Int J Ment Health Addiction [Internet]. 2020 May 28; Available from:
http://doi.org/10.1007/s11469-020-00332

11. Cagetti MG, Cairoli JL, Senna A, Campus G. COVID-19 outbreak in North Italy: An overview on dentistry. A questionnaire survey. Int
J Environ Res Public Health. 2020; 17(11).
https://doi.org/10.3390/ijerph17113835

12. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental
Care. J Endod. 2020; 46:584-95.
https://doi.org/10.1016/j.joen.2020.03.008

13. Barabari P, Moharamzadeh K. Novel Coronavirus (COVID-19) and Dentistry-A Comprehensive Review of Literature.
Dent J. 2020; 8:53.
https://doi.org/10.3390/dj8020053

14. American Dental Association. Summary of ADA guidance during the COVID-19 crisis. Ada [Internet]. 2020;19-20. Available from:
https://www.ada.org/en/press-room/news-releases/2020- archives/april/summary-of-ada guidance-during-the-covid-19-crisis.

15. Amato A, Ciacci C, Martina S, Caggiano M, Amato M. COVID-19: The Dentists’ PerceivedImpact on the Dental Practice. Eur J Dent [Internet]. 2021 Feb 23; Available from:
https://doi.org/10.1055/s-0040-1721910

16. Weiss SR, Navas-Martin S. Coronavirus Pathogenesis and the Emerging Pathogen Severe Acute Respiratory Syndrome Coronavirus. Microbiol Mol Biol Rev. 2005; 69:635-64.
https://doi.org/10.1128/MMBR.69.4.635-664.2005

17. Pasiga BD. Relationship knowledge transmission of covid-19 and fear of dental care during pandemic in South Sulawesi, Indonesia.
Pesqui Bras Odontopediatria Clin Integr. 2020; 21:1-12.
https://doi.org/10.1590/pboci.2021.017

18. Schultz L, Link MP, Rheingold S, Hawkins DS, Dome JS, Wickiser J, et al. Summary of COVID-19 clinical practice adjustments across
select institutions. Pediatr Blood Cancer.2020;67:1-2.
https://doi.org/10.1002/pbc.28411

19. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical Pathway for Early Diagnosis of COVID-19: Updates from Experience to Evidence-Based Practice. Clin Rev Allergy Immunol. 2020; 59:89- 100.
https://doi.org/10.1007/s12016-020-08792-8

20. Almas K, Khan AS, Tabassum A, Nazir MA, Afaq A, Majeed A. Knowledge, Attitudes, and Clinical Practices of Dental Professionals
during COVID-19 Pandemic in Pakistan. Eur J Dent. 2020; 14 (S 01): S63-S69.
https://doi.org/10.1055/s-0040-1718785

21.Majeed MM, Saleem Z, Sarwar H, Ramzan Z, Iqbal SN, Naeem MM. The Psychology of Coronavirus Fear: Are Dentists of Pakistan
Suffering from Corona-Phobia?. J Pak Dent Assoc. 2021; 30:1-6.
https://doi.org/10.25301/JPDA.301.1

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2021; 21(1).
https://doi.org/10.1186/s12903-021-01413-6

23. Rauf S. Anxiety, Fear and Awareness of Pakistani Dentists Against Novel Coronavirus Disease (COVID-19): A Cross-Sectional Study.
J Dent Oral Sci. 2021; 3:1-8.
https://doi.org/10.37191/Mapsci-2582-3736-3(1)-076

Ayesha Zafar                              BDS
Samira Adnan                            BDS, FCPS, MHPE
Naseer Ahmed                           BDS, FCPS
Maria Shakoor Abbasi              BDS, FCPS
Muhammad Adeel Ahmed        BDS, FCPS, MFDS RCSEd
Rizwan Jouhar                          BDS, FCPS
Saqib Hameed                           BDS, FCPS

OBJECTIVE: To assess the perception of patients visiting a dental OPD in Karachi regarding cross infection control measures
that should be taken in dental practice.
METHODOLOGY: A cross-sectional study was conducted at the OPD of Altamash Institute of Dental Medicine from January
to August 2020. A total of 546 patients aged 20-75 years of either gender coming for routine dental check-ups were included
in the study using non-probability convenience sampling. A well-structured and validated questionnaire was used to assess the
knowledge, attitude and practices of patients regarding cross infection measures that should be present in dental practices.
SPSS-25 was used to analyse the data. Descriptive statistics was used to calculate frequency and percentage of qualitative
(gender, socioeconomic and education status, knowledge attitude and practice levels of patients) and quantitative variables
(age groups). Chi-square test was used to detect the relation of patient's knowledge levels with potential factors like the age
groups, gender, socioeconomic and education status. The p-value of (< 0.05) was considered as significant.
RESULTS: Out of the total participants, 79.1% had good knowledge about cross infection control measures in dental practice.
Majority of the patients (84.6%) agreed that dentists should wear gloves during treatment, though majority were of the opinion
that a dentist can treat several patients with the same set of gloves. About 4.9% of the patients said that they ask the dentist to
wear face mask and gloves while treating them, and only 3.3% said that they ask the dentist about sterilization of instruments.
The knowledge level of patients showed variation with their education status but not with respect to socioeconomic status, age
and gender.
CONCLUSION: Although overall the patients visiting dental clinics had good perception and showed positive attitudes towards
cross infection control, the dental health practitioners need to disseminate basic technical information about the infection-control
practices required for safe dental practice to dental patients and the community at large.
KEYWORDS: cross infection, knowledge, dentist, dental patients, perception
HOW TO CITE: Zafar A, Adnan S, Ahmed N, Abbasi MS, Ahmed MA, Jouhar R, Hameed S . Evaluation of cross infection
control in dentistry; A patients’ perception study. J Pak Dent Assoc 2021;30(4):249-254.
DOI: https://doi.org/10.25301/JPDA.304.249
Received: 01 January 2021, Accepted: 15 June 2021

INTRODUCTION
Tooth wear is a term defined as the loss of dental hard tissue in a damaged tooth if there is no existing dental caries or trauma.1 Tooth wear can be sub-classifies as attrition, erosion, abrasion and abfraction.2 Attrition is a mechanical type of wear, which results due to the grinding of teeth. Abrasion is also mechanical wear caused by oral hygiene measures and biting habits. Erosion is chemical wear that results from the ingestion of acidic foods /drinks/ gastroesophageal reflux.3-5 Abfraction is a non carious tooth loss which is characterized by v shaped notch
or wedge shaped at the cervical area of tooth.
inically and experimentally in combination.6 It might be unnoticeable in its initial developmental stage but it may affect aesthetics and appearance in some patients especially if anterior teeth are involved.7,8 Excessive tooth wear leads to hypersensitivity and exposed dentin.9
The prevalence of tooth wear varies with wide-ranging values reported due to different study populations, methodologies, recording indices used.10 These studies reported that the prevalence of tooth wear varies from one population to another. It was reported 38.6% in Pakistani
population11, 64% in Norway12,13 75% in Sweden14 and 95% in Saudi Arabia.7
There are many techniques to measure tooth wear both in vitro and in vivo. Techniques to quantify tooth wear in vitro are profilometry, microradiography, scanning electron microscopy, atom force microscopy, nano- and microhardness test, iodide permeability test.15,16 To measure tooth wear in vivo, many indices are used like the Eccles index of dental erosion, Smith and Knight index, and Erosion index by
Lussi.17 Some of these indices measure tooth wear on every surface of each tooth, some measures selected sites and specific surfaces.17 Smith and Knight19 introduced tooth wear index (TWI) which is capable of measuring all four visible surfaces (buccal, cervical, lingual, and occlusalincisal) of all teeth present. Except for a few studies, not much work has been done in Pakistan on this topic. Toufique H et al 201719 in a study reported that only 10% of the patients had tooth wear whereas in the present study 92.4% of them had tooth wear. Therefore, the present cross-sectional study was done to Evaluate Tooth wear and its causative risk factors amongst Patients Attending the Dental Hospital
of Karachi

METHODOLOGY
The current study was a cross-sectional study conducted on adult patients recruited from the Out-Patient Department of Oral Diagnosis from May 2018 – December 2018. Patients were examined for the presence of tooth surface loss by using the Tooth Wear Index (TWI). The Ethical Review Board (ERB ) DC/ERB/2018/010), Baqai Dental College, gave ethical approval to proceed with this study. Patients with the complaint of tooth surface loss aged 18-45 years were included in the study.A consecutive sampling technique was used and 250 adult patients were selected for the study. Open Epi version 3.01software was used to calculate the sample size. Keeping a 20% prevalence rate with a 95% confidence interval with a 5% error, n=250 sample size was calculated based on the prevalence tooth wear reported by
Daly et al.20
Oral and Dental examinations were performed using the dental chair with a sterile mouth mirror and dental probe after signing a written consent by the patient. The chief examiner examined the patients while the dental chair assistant recorded the readings. A structured questionnaire prepared by those skilled in the restorative subject was used, which included etiological aspects of parafunctional habits, oral
hygiene measures, eating habits, and clinical history. Tooth wear was assessed by using Smith and Knight Tooth Wear Index (TWI index).18 The surfaces were designated as cervical surface (C), buccal surface (B), the lingual surface (L) or palatal surface (P) Incisal surface (I) or, occlusal surface (O). Patients who reported having symptoms of sensitivity were further assessed by a blast of air from the air-water syringe for 3 sec at a distance of 1cm from the tooth surface. Any uncomfortable feeling aroused by the blast was recorded on the clinical form according to different tooth surfaces.21 Data was entered and analyzed for Descriptive analysis (frequency and percentages). A Chi-square test was performed to assess the association between gender and its etiological factors by using IBM SPSS version 20.

RESULTS
The subject populations of 250 adult patients were assessed for tooth surface loss by using the Tooth wear index. According to Smith and Knight TWI, 201018 reported that 7.6% scored 0, 11.6% scored 1, 24.4% scored 2, 25.2% scored 3 and 31.2% scored 4. Out of which 178 were male (71.2%) and 72 (28.8%) were females aged 18 to 48 years old. Table 1 showed the Demographic profile.
In table 2,association of gender with etiological factors is mentioned which shows insignificant association that is 42 (23.6%) males and 17 (23.6%) females reported sensitivity, followed by 20 (11.2) males and 9 (12.5%)females with poor previous tooth aesthetics. (p = 0.535), 33 (18.5%) of males and 19 (26.4%) females reported a history of scaling. (p = 0.110). A significant association was seen when 89
(50%) of males and 24 (33.3%) of women had a history of pan/ betel nut chewing, (p<0.001). No significant association was reported regarding toothbrush technique and 121 (68%) men and 52 (72.2%) women used horizontal brush technique (p = 0.136)
Regarding tooth wear and dentin sensitivity, it was found that dentinal sensitivity increased with the age group. This
difference was not found to be statistically significant. (p=0.10) Table 3.
It was found that tooth wear increased with age group. For the age group, 18-28, 29-39 and 40-50 scores 2 and 4,

DISCUSSION
The present study was done to evaluate tooth surface loss in patients attending the Out-Patient Department of Baqai Dental College. In this study, 92.4% of them reported tooth wear and only 31.2% has extended to severe stage of the tooth wear and men reported severe tooth wear than women did.
A study done in the Dutch population reported that tooth surface loss was a common condition amongst the adult population.22 In this present study, 7.6% of participants reported no tooth surface loss and 92.4% of them reported tooth wear however, only 31.2% had reached to severe stage of tooth wear. Toufique H et al. in 201719 reported dissimilar results that only 10% of participants had tooth wear while
90% did not have tooth wear in their study. A study by Van’t Spijker23 reported the frequency of patients with tooth surface loss was increased to 3 % at the age of 20 years, 17% increased at 70 years of age
The present study according to Smith and Knight TWI, 2010 18 reported that 7.6% scored 0, 11.6% scored 1, 24.4% scored 2, 25.2% scored 3 and 31.2% scored 4. R Wirdatul et al24 in a study reported different values, 17.4% surfaces had tooth wear; 80% scored 1, 18% scored 2 and
2% scored 3. Oral habits are repetitive behaviors within the oral range, leading to loss of dental structure, such as eating habits, brushing techniques, bruxism, functional habits, and regurgitation. The effect depends on the nature, manifestation, and duration of the habit. The role of acids in food and beverages can be important in the development of toot wear. Laboratory studies have shown that low acid foods and
beverages cause erosion of enamel and dentin which may lead to dentin sensitivity.25-27
Dentinal hypersensitivity (DH) is a common symptom which affects 8-57% of adult and is associated with the oral hygiene.28 The present study reported an association of tooth wear with dentin hypersensitivity and age groups. Deshpande S29 in a study reported that there is a connection between grades of tooth wear with dentin sensitivity. Ayer A et al30 in a study reported that dentin hypersensitivity is associated with tooth surface loss. Idon P et al31 in a study reported an association of dentin hypersensitivity with tooth surface loss. Kehua Q et al.21 in a study reported that there is an association between dentin hypersensitivity and age groups. Ali K et al.32 find abnormal tightening and bruxism with a significant relationship with tooth surface loss. The present study reported that only 7.6% experienced tooth surface loss due to tightening/ bruxism, while 45.2% experienced tooth surface loss due to chewing pan. As tooth surface loss is multifactorial, therefore the abrasive effect of tooth brushing can cause a tooth surface loss. The present study reported that people using a brush with medium bristles (41.2%) in horizontal technique (69.2) % with medium force (40.4) % tend to have more tooth surface loss which shows a correlation with the study reported by Ahmed et al32 that brushing with moderate type of brush (48.4) % shows relevant tooth surface loss. Another study reported by Mushtaq et al.33 also observed a substantial association between participants using different types of toothbrushes and hard tissue abrasive lesions was reported(p<0.05). The cause of these injuries is important to prevent further injuries and to prevent existing injuries. Enamel reduced by acids (erosion), may be scrubbed away with tooth brushing (abrasion) and damaged away by chewing or tooth grinding.25
Males in the present study were more liable to have tooth surface loss possibly due to majority of males assessed as compared to females and this result was similar to other various studies.7,34,35 The factors which result in more tooth surface loss in males were mainly due to age, biting force, reduced tendency for malocclusion, more muscle mass, decreased occlusal tactile sensitivity.36,37
Generally, patients are more concerned about their esthetics and wish that their age process could be delayed and evidence revealed that tooth wear is related to the aging process.28 The present study reported that tooth wear increase with increasing age. Deshpande S28 and Meshramkar R38 et al. in a study also reported similar results.
Proper steps need to be taken for immediate action, as they are essential to restore the form and function of teeth. Dental wear is a preventive and curable condition. To avoid the problem of getting worse in the future, we must try to fight the problem from its early stages. One of the methods to prevent and cure the condition is to increase awareness among practitioners and to develop general public prevention programs among individuals. The present study has some limitations, which include that it was a single centre study, there were more male participants, and lacks the inclusion of other demographic variables. Evaluation of tooth wear should be added as a component of regular dental checkups amongst patients attending dental hospitals.

CONCLUSIONS
Recognizing the multifactorial nature of the condition is the first step in managing it, as a misunderstanding, it can lead to inadequate management and the ultimate failure of rehabilitation therapy. The present study concluded that tooth surface loss is associated with its etiological factors and was observed more in males when compared to females. However, steps should be taken to increase awareness among people regarding their teeth and the management of several condition .

CONFLICT OF INTEREST
None to declare

ETHICS APPROVAL /DISCLOSURE
The study Titled “A cross-sectional study: Evaluation of Tooth wear and its causative risk factors amongst Patients Attending Dental Hospital of Karachi.” is approved by the Ethical Review Board of Baqai Dental College under the reference # BDC/ERB/2018/010.

AUTHORS CONTRIBUTIONS 
AS contributed in writing and tabulating research paper AW analyzed and interpreted the patients’ data TMS provided overall supervision MH and KA contributed to the collection of patients’ data.

ACKNOWLEDGMENTS
Thanks to the institution for supporting the study.

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