Comparison of Repeated Chemical and Microwave Disinfection on Dimensional Accuracy of Gypsum Casts

 

 

Mariya Khalid                              BDS, FCPS
Mohammad Ali Chughtai           BDS, FCPS, MHPE, FFDRCSI
Sohrab Shaheed                         BDS, FCPS, FFDRCSI
Syed Nasir Shah                         BDS, FCPS

 

OBJECTIVE: The aim of this experimental study is to compare the dimensional accuracy of gypsum casts after repeated
disinfection in microwave at 900 Watts, 2450 MHz (5 minutes) and immersion in 0.5% Sodium hypochlorite (10 minutes).
Disinfecting casts is recommended to prevent cross infection but may cause dimensional changes. During fabrication of
prosthesis, a cast may get contaminated several times so there is a need of repeated disinfection.
METHODOLOGY: Sample size was 33 (11 in each group), calculated through WHO software for sample size determination
by using standard deviation of 0.16 at 95% confidence interval and 80% power of study. Impressions in irreversible hydrocolloid
were recorded of an acrylic cast fabricated for this study. The impressions were poured with die stone and were randomly
divided into 3 groups; Group I: Microwave disinfection, Group II: Immersion disinfection in 0.5% Sodium hypochlorite, Group
III: Control group. For Groups I and II, each cast was disinfected 7 times with 5 minutes interval between two disinfection
cycles, after every cycle anteroposterior and mediolateral measurements were recorded using digital Vernier caliper (accuracy
upto 0.01 mm). For group III, casts were rinsed with distilled water, dried in open air within temperature range of 28+/-2OC
for 10 mins followed by anteroposterior and mediolateral measurements. This procedure was repeated seven times for each
cast.
RESULTS: Anteroposterior and Mediolateral differences of dimensional change between and within the Group A, B and C
was calculated by One Way ANOVA. Inter/intra examiner reliability was taken into consideration at the time of study.
Mean dimensional change in the casts were insignificant through six disinfecting cycles. However, in the seventh cycle, a
significant difference (p=0.003) was observed in the anteroposterior dimension (0.03% dimensional change for Group A and
1.26 % for Group B whereas, in mediolateral dimension, dimensional change was 0.35% for Group A and 0.59% for Group B
(p=0.004). Dimensional change of >0.5% was considered as the cutoff value for casts to be considered as dimensionally accurate.
Casts disinfected through immersion disinfection did not produce dimensionally inaccurate casts in anteroposterior dimension
after third cycle and in seventh cycle in mediolateral dimension. However, result is significant only in seventh cycle. Microwave
disinfection produced dimensionally accurate casts throughout all cycles.
CONCLUSION: Microwave disinfected casts remained dimensionally stable compared to immersion disinfection.
KEYWORDS: Disinfection, microwave, immersion, dimensional stability, gypsum casts
HOW TO CITE: Khalid M, Chughtai MA, Shaheed S, Shah SN. Comparison of repeated chemical and microwave disinfection
on dimensional accuracy of gypsum casts. J Pak Dent Assoc 2021;30(4):235-242.
DOI: https://doi.org/10.25301/JPDA.304.235
Received: 13 January 2021, Accepted: 01 August 2021

INTRODUCTION
 Impression recording is the first step in fabrication of oral prosthesis.1 When a dental impression is recorded, it comes in contact with plaque, saliva and blood which may contain pathogenic microorganisms.2
When cast is poured against a contaminated impression, it also gets contaminated and becomes a source of infection for the dental personnel.3-4 Many studies have shown that pathogenic organisms were recovered from the casts.5-7 Up to 1991, washing impression under running water was a recommended practice.8 However, just washing impression does not remove pathogenic organisms causing Hepatitis
B,C and Tuberculosis.9 According to guidelines of infection control in dentistry, all prosthodontic items should be cleaned, disinfected and rinsed with an active disinfectant before sending them to laboratory.10
Irreversible hydrocolloid is the impression material which is widely used over the entire world.3 Alginate can be used in recording preliminary impressions, impressions for fabrication of temporary fixed dental prosthesis, study casts, impression of opposing dentition, orthodontic models, impression for fabrication of sports mouth guards and bleaching trays.11 Alginate is dimensionally unstable material, as hydrocolloids constitutes about 85 % water, they undergo imbibition in the presence of moisture and undergo syneresis when left dry.12 In past, different studies have been conducted to evaluate the dimensional stability of irreversible hydrocolloid using different disinfectants and different methods. The most common chemical disinfectants routinely used by dentists are alcohols, aldehydes, chlorine combination,
phenols, bisguanides, iodide combinations, and ammonium.13 Disinfection methods used for alginate impression material are
1. Spraying
2. Immersion
3. Incorporation of disinfectant in alginate by manufacturer
4. Mixing alginate with disinfectant
Each method has its own advantages and disadvantages. According to previous studies, spraying causes the least dimensional changes but is not capable of disinfecting all surfaces. On the other hand, Immersion is the most reliable method of disinfection as it comes in contact with all surfaces but produce dimensional changes15, especially if dental impression is immersed for a long period of time.4 High
level disinfectants cannot be incorporated while mixing impression material because of health hazards rendering third and fourth method not very useful. In most of the studies, chlorhexidine is incorporated while mixing alginate but according to Souza et al. AIDS virus and hepatitis B are deactivated by 2% Glutaraldehyde and 1% Sodium hypochlorite; however, these microorganisms are more resistant and are not eliminated with 0.5% Chlorhexidine.2
Keeping in mind the sensitive nature of alginate impression material, the suitable alternative is to disinfect dental casts instead of alginate impression as it is the cast on which prosthesis will be fabricated. Gypsum casts can be disinfected by spraying, immersing into a disinfecting
solution, by adding an antimicrobial agent to the plaster mix, by manipulating the plaster with a disinfectant solution16, microwave disinfection13 and autoclave disinfection.17 Different disinfectants used for disinfection of dental gypsum are formaldehyde, chlorine compounds, glutaraldehyde, phenols, iodophors18 and ozonated water.19 Immersion in sodium hypochlorite for 10 min at a concentration of 1:10 dilution (0.525%) is recommended for immersion disinfection.18 As previously mentioned, spraying does not provide effective disinfection whereas autoclave disinfection and incorporation of disinfectant while mixing plaster affects the physical properties of dental casts.14 Microwave disinfection of dental gypsum cast has shown to reduce the of bacteria on the casts after 5 minutes of microwave oven
irradiation in an ordinary household microwave oven set at 900 wattage.20 So, for the purpose of this study, disinfection methods selected were chemical disinfection by immersion method and microwave disinfection as both of them have proved to be effective in disinfection of gypsum casts.21 In case of microwave disinfection, there is no effect on the efficacy whether the casts are wet or dry at the time of disinfection.22 In addition to efficacy, another important requirement of disinfection is that it should not affect dimensional accuracy of casts23 so, now, there is a need to compare both of these methods in terms of dimensional accuracy
According to Stern et al, during the fabrication of complete denture, a need may arise to disinfect dental cast seven times.24 A dental cast can be contaminated when poured against contaminated impressions or during trial of the denture base prosthesis several times in clinic.25 This study was carried out to compare the effect of repeated microwave disinfection of gypsum cast to repeated immersion disinfection. Both of these disinfection methods have been studied separately and are considered acceptable in terms of efficacy and dimensional accuracy, however there is no study comparing these methods by repeated disinfection. This study was aimed to compare these two methods (microwave disinfection and immersion disinfection) and to determine the best disinfection method for the gypsum cast which produce the least dimensional changes.

METHODOLOGY
This experimental study using non- probability consecutive sampling technique was conducted in Prosthodontics Department of Sardar Begum Dental College and Hospital, Peshawar. Sample size was 33(11 in each group) calculated through WHO software for sample size
determination by using standard deviation of 0.162 at 95% confidence interval and 80% power of study. The three groups are:

Group I:
Gypsum casts irradiated in a microwave oven (Samsung,
Korea) for 5 minutes at 2,450 MHz and 900 Watt.

Group II:
Gypsum casts immersed in 0.5% Sodium Hypochlorite
(Haq chemicals, Pakistan) for 10 minutes

Group III:
Gypsum casts rinsed with distilled water, dried in open
air within temperature range of 28+/-2 degrees for10 mins
followed by anteroposterior and mediolateral measurements.

SAMPLE SELECTION

Inclusion criteria:
All casts poured in the impression recorded from acrylic cast.

Exclusion criteria:
1. A crevice or deficiency in the midline of palatal vault of impression.
2.
An impression short in one or more regions of the sulci, especially around the tuberosities or the labial sulcus.
3.
Tray flange showing through the impression material.
4. Impression material detached from the tray.
5. Impressions from incompletely seated tray.
6. Casts having broken, distorted and entrapped air at metal rod duplicates.
7. Any void present in the cast.
8. Cast fractured at the time of separation from the impression material
The above mentioned conditions act as confounders
and if included will introduce bias in the study
results.

Acrylic master cast:
An acrylic master cast representing edentulous maxillary arch was constructed in heat cure acrylic (FDS, Pakistan) using long curing cycle. Reference points (A, B, C) for measurements on cast were made on the acrylic cast by inserting metal rods in the approximate position of incisive papilla (A) and in the region of right and left second molar (B and C). A hole was drilled in the position of each reference point and a metal rod was inserted and secured in place with auto polymerized acrylic resin (Figure 1). The distance between points A and C was kept 40 mm, after polymerization shrinkage, this distance was reduced to 39.96 mm. The distance

between points A and C was kept 40 mm, after polymerization shrinkage, this distance was reduced to 39.96 mm. The distance between points B and C was kept 55 mm which was reduced to 54.66 mm after polymerization shrinkage.

Custom tray construction:
For the uniform thickness and distribution of impression material, a custom tray was constructed using auto polymerized acrylic resin (FDS, Pakistan) after application of 4mm spacer on master cast. Perforations were made in the custom tray (Figure 2).

Alginate impression material (Alginmajor, UK) was mixed according to manufacturer’s instructions using distilled water. Ions in different concentrations might be present in tap water which can interfere with chemical reaction of irreversible hydrocolloid27 , that’s why distilled water was used. Acrylic master cast impression was recorded in alginate and rinsed under tap water for 10 seconds. The excess water was shaken off and impression was poured with type IV gypsum (Dentamerica, Taiwan).
The cast was allowed to set for 40 minutes before removal. Casts were allowed to dry in air for 24 hours, as stone casts may take 24 to 48 hours in losing excess water and gaining enough strength to be handled without damage.28 After 24 hours, casts were randomly subjected to one of the groups by simple random sampling.
For Group I, cast was irradiated in microwave at 900 watt and 2450 MHz for 5 minutes. After 5 minutes, cast was allowed to cool for 5 minutes. Then, anteroposterior (AB) and mediolateral measurements (BC) were recorded (Figure 3) using digital vernier caliper
(Tianhe, China). Same procedure was repeated seven times.
Ame procedure was repeated seven times. For Group II, gypsum cast was immersed in 0.5% Sodium hypochlorite for 10 minutes. Then, anteroposterior (AB) and mediolateral measurements (BC) were recorded using digital vernier caliper. This procedure was repeated seven times.
                Figure 3: Anteroposterior and mediolateral dimensions measured on cast
For Group III, gypsum casts were not disinfected. Anteroposterior (AB) and mediolateral measurements (BC) were recorded using digital vernier caliper seven times with duration of 10 minutes between two readings.

RESULTS
  Anteroposterior and Mediolateral differences of dimensional change between and within the Group A, B and C was calculated by One Way Anova, While Paired Sample T Test was used to do Reliability analysis of measurements by rater 1 and 2.

ANTEROPOSTERIOR DIMENSION
Anteroposterior dimension between the points A and C was 39.96mm. Maximum percent dimensional change was 0.43 while minimum value recorded was 0.03 with the range of 0.4 in the Microwave disinfection Group A. Maximum percent dimensional change in the chemically disinfected Group B was 1.26 and minimum change was 0.20 with the range of 1.06. Whereas 0.45 was the maximum and -0.13
minimum percent dimensional change with the range of 0.1 noticed in the Control Group C (Table 1, Figure 4)

MEDIOLATERAL DIMENSION
 The Mediolateral dimension between the points B and C (BC) was 54.66mm. Maximum percent mean dimensional change in the Group A was 0.35 and minimum change was 0.16 with the range of 0.19. Maximum percent mean dimensional change in the Group B was 0.59 and minimum was 0.20 whereas 0.31 and 0.11 was the maximum and minimum percent dimensional changes with the range of 0.2 noticed in the Control Group (C). (Table 2, Figure 5).

INTERGROUP COMPARISONS
  Mean dimensional changes in anteroposterior and mediolateral dimension of the casts were insignificant through six disinfecting cycles. However, in the seventh cycle, a significant difference (p=0.003) was observed in the anteroposterior dimension and mediolateral dimension(p=0.004) within and between the groups. (Table 1 and 2). Mean dimensional expansion was observed inchemical disinfection group.
Maximum percent dimensional change observed in the Anteroposterior dimension between Group A and C was 0.02. While minimum percent dimensional change observed was 0.07 with the range of 0.05. Whereas 0.66 and 0.009 was the maximum and minimum differences in the Anteroposterior dimension among the Group B and C respectively with the range of 0.651.
Maximum difference of change observed in the Mediolateral dimension between Group A and C was 0.81mm, while minimum difference observed was 0.07. On the other side 0.147mm and 0.02mm was the maximum and minimum differences in the Mediolateral dimension
among the Group B and C respectively.
Paired Sample T test was applied to get the Inter and Intra rater Reliability analysis. Mean difference in the readings by rater 1 and 2 was 0.018 mm ±0.37 while 0.46mm ±1.61 in the Mediolateral Dimension. But, difference between the measurements by rater 1 and 2 was insignificant. Similarly Mean difference observed in the readings by the rater 1 at two different occasions in the Anteroposterior dimension was 0.52mm±1.6 while 0.06mm±0.34 in the Mediolateral Dimension. Similarly there was insignificant difference in the measurements observed by the rater 1 at two different occasions. This shows reliability of the overall results.

DISCUSSION
Cross infection control is mandatory in any field of medicine. Likewise, there is an increased chance of cross infection in dentistry as oral flora constitutes of a number of microorganisms which can be transported to laboratory via impression, casts and prosthesis.29
For this reason, disinfection of impressions and casts is considered very necessary to control cross infection.30 The impression material chosen for this study was irrerversible hydrocolloid because of its hydrophilic nature31 and sensitivity to disinfection procedures.32 Disinfection methods selected were microwave disinfection method and immersion method because of their increase efficacy against
most of the organisms.1,33 Acceptable methods to measure dimensional change are travelling microscope, measuring microscopes, micrometers, dial gauges and calipers.34 Digital caliper was used for the purpose of this study.
This study was carried out to compare the effect of repeated disinfection on dimensional accuracy of gypsum casts using microwave disinfection and immersion disinfection. It is difficult to relate the results of this present study with the literature since there are no available studies that compare the effect of repeated microwave and immersion disinfection on dimensional accuracy of gypsum casts.
When intergroup comparison was made, mean dimensional changes in mediolateral and anteroposterior dimension of the casts were insignificant through six disinfecting cycles whereas in the seventh disinfecting cycle a significant difference (p=0.003) was observed within and between the groups. This means that up to six cycles both microwave and immersion disinfection were acceptable in terms of dimensional accuracy but in seventh cycle there was a significant difference.
Cast expansion was observed in a study18 when cast was subjected to immersion disinfection in 0.5% Sodium hypochlorite for seven times. Our study also showed the same results. The reason for increased dimension may also be because of the dissolution of gypsum metal rod duplicates resulting in increased distance between reference points. According to Malaviya Neha, microwave irradiation causes loss of water as steam35 which may be the probable reason for the shrinkage of microwave disinfected gypsum casts. In our study, shrinkage also occurred in microwave disinfection group in anteroposterior dimension. According to the results of this study, casts disinfected through immersion disinfection did not produce dimensionally accurate casts in anteroposterior dimension after third cycle (percent dimensional change greater than 0.5) and in seventh cycle of mediolateral dimension. However, result is significant only in the seventh cycle of
Anteroposterior dimension (P value= 0.003) and in seventh cycle of mediolateral dimension (P value= 0.004)
In a study performed by Saleh26, when microwave irradiated gypsum casts and casts obtained by immersing impression in sodium hypochlorite were compared, there was a statistically significant difference (P < 0.05) of the overall dimensional accuracy of casts between the control group, sodium hypochlorite disinfection group and microwave irradiation group. The results of this study showed that casts treated with microwave irradiation present similar or improved dimensional accuracy when compared to the casts in the control group.26 Our study also showed the same results i.e.; microwave irradiation produced dimensionally accurate casts and there was statistically
significant difference between control, chemical disinfection and microwave irradiation group in the seventh disinfecting cycle. However, in our study, casts are immersed in sodium hypochlorite instead of impression and repeated disinfection was performed.
In a study conducted by Anaraki et al.36, there was no significant difference in dimensional accuracy of gypsum casts between case and control samples when samples were exposed to 7 consecutive rounds of 900 watts (W) microwave irradiation for five minutes each time. In our study, microwave disinfection gave dimensionally accurate casts throughout seven disinfecting cycles but a significant difference between chemical disinfected casts and control samples was observed in the seventh disinfecting cycle.
Kumar et al. studied dimensional stability of gypsum cast after repeated immersion in 0.5% sodium hypochlorite and 2%gluteraldehyde. The results of his study revealed that stone casts immersed in 0.525% sodium hypochlorite and 2% glutaraldehyde solutions showed significant linear dimensional change compared to stone casts in slurry (control group). Our study also showed the same results i.e.; casts disinfected through immersion disinfection did not produce dimensionally accurate casts after third cycle in anteroposterior dimension and in seventh cycle of mediolateral dimension. However, result is significant only in anteroposterior and mediolateral dimension in the seventh cycle. This difference may be because immersion time was 30 minutes in Kumar’s study as compared to 10 minutes used in our study.18
Goel K et al37 performed a study comparing microwave irradiation with chemical disinfection (using 0.07 % Sodium Hypochlorite) on the dimensional accuracy of gypsum cast. The results showed that there was no significant difference between the microwave irradiated group and chemical disinfection group. However, Goel et al did not study effect of repeated immersion and microwave disinfection. In our
study, repeated disinfection was performed according to which, there was no significant difference between the three groups upto six disinfecting cycles.

CONCLUSION
Microwave disinfected casts remained more dimensionally stable as compared to casts disinfected through immersion.

LIMITATIONS
1. A similar study with larger sample size should be designed.
2. A more precise measuring instrument will give more reliable results.
3. Another study should be performed with time interval between two disinfecting cycles of 24 hours so as to simulate the clinical situation more closely.
4. Another study should be designed focusing on the effect of repeated microwave and immersion disinfection on hardness, compressive and tensile strength of gypsum casts.

CONFLICT OF INTEREST
The authors declare that there is no Conflict of interest

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Evaluation of the Marginal Location and Periodontal Health in Crowns and Bridges – A Patient Preference Based Study

Misha Salim                                   BDS

Rija Tirmizi                                     BDS

Maria Shakoor Abbasi                   BDS, FCPS

Naseer Ahmed                               BDS , FCPS 

Muneeb Ahmed Lone                    BDS, FCPS

Haroon Rashid                               BDS,MDSC

Rizwan Jouhar                              BDS, FCPS

OBJECTIVE: The objective of this paper was to evaluate the marginal location preference and periodontal health in extra
coronal restoration of anterior and posterior teeth.
METHODOLOGY: In this prospective case control study, a total of 652 patients who had crown and bridge for not less than
six months were included. The gingival margin location preference and reasons behind choosing a particular gingival margin
was asked from the patients. Additionally, the teeth with and without restoration were also examined for periodontal health.
Split mouth technique was used as unrestored, healthy contra lateral teeth in the same individual served as controls. Descriptive
statistics and Chi square test were used for analysis to formulate the results.
RESULTS: Ironically, 92% patients were not given a chance by their dentist to give input about margin location preference.
The majority of patients preferred equi gingival margin for their anterior crowns 495 (75.92%) and supra gingival margin 586
(89.87%) for their posterior teeth, with esthetics 547 (83.89%) and hygiene 599 (91.87%) respectively being the most common
reasons for selecting the particular margin location. The clinical examination revealed that supra gingival and equi gingival
margins demonstrated superior gingival health indices as compared to subgingival margins
CONCLUSION: This study concluded that the supra gingival and equi gingival margins demonstrated superior gingival health
indices as compared to subgingival margin and in order to achieve optimal periodontal health and patient satisfaction the health
professionals should wisely consider the margin location and involve the patient in treatment decisions wherever possible.
KEY WORDS: Crown and Bridge, Margin location, Patient preference, Periodontal Health.
HOW TO CITE: Salim M, Tirmizi R, Abbasi MS, Ahmed N, Lone MA, Rashid H, Jouhar R. Evaluation of the marginal
location and periodontal health in crowns and bridges - A patient preference based Study. J Pak Dent Assoc 2021;30(3):194-198.
DOI: https://doi.org/10.25301/JPDA.303.194
Received: 18 July 2020, Accepted: 02 April 2021

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Burnout and Sense of Coherence in Dentistry Students of Karachi

 

 Fasiha Moin Kazi                      BDS, MBA     

 Shoaib Ahmed                          MBBS, FCP

 Shama Asghar                          BDS, FCPS           

 

OBJECTIVE: This study aimed to assess burnout and sense of coherence levels in dentistry students of Karachi.
METHODOLOGY: A cross-sectional study involving 361 students from four renowned dental colleges in Karachi was carried
out. The students were distributed a questionnaire derived from the Mayo Clinic Well-being Index (WBI) and a modified
13-item Antonovsky's Sense of Coherence Scale (SOC scale). They were stratified on the basis of gender, age, professional
year, institution, relationship status, history of chronic medical condition and history of chronic psychiatric condition. Scores
for the WBI and SOC scale were calculated. For the WBI, a score of >4 was a sign that an individual was at risk of developing
burnout or other severe outcomes. A high or low total score on the SOC scale demonstrated whether the individual was able
to cope with his environment or not. MS Excel and SPSS version 23 were used for data compilation and statistical analysis.
Descriptive statistics were calculated. Chi-square test of independence was applied to gauge any association between the strata
and outcome variables. After determination of statistical difference, Mann Whitney-U Test and Kruskal Wallis Test were applied
to compare the means where a significant association was found. A p-value of 0.05 or less was considered significant.
RESULTS: The mean WBI score was found to be 4.07. Around 64% respondents were at-risk of burnout (score > 4). A greater
percentage of females was at risk (66%) as compared to males (50%). Third professional students were found to be the most
affected (77% with WBI score > 4 and 9% in the low coherence category). The mean SOC score was found to be 36.39 (moderate
levels of coherence). Overall, around 4-9% of each professional year students exhibited a low sense of coherence. Age,
relationship status, institution and a history of chronic medical and/or psychiatric condition were not found to have a significant
association with the outcome variables (p>0.05).
CONCLUSION: A significant number of dentistry students are at risk of burn-out and suffer from a low sense of coherence.
The risk factors need to be evaluated and solutions need to be found to create a healthy and conducive environment for the
growth and learning of the students. More research needs to be focused on gathering data related to the well-being of dentistry
students.
KEYWORDS: Burnout, sense of coherence, well-being index, dentistry.
HOW TO CITE: Kazi FM, Ahmed S, Asghar S. Burnout and sense of coherence in dentistry students of Karachi. J Pak Dent
Assoc 2021;30(3):170-177.
DOI: https://doi.org/10.25301/JPDA.303.170
Received: 12 November 2020, Accepted: 28 March 2021

INTRODUCTION
Burnout was first defined in the 1970s by American psychologist Herbert Freudenberger as the “extinction of motivation or incentive, especially where one’s own devotion to a cause or relationship fails to produce the desired results”.1 It is known as the situation of physical or mental collapse caused by overwork or stress. Burnout consists of three dimensions; emotional exhaustion, depersonalization, and reduced personal accomplishment. Traditionally, burnout has been considered a workplace related concept but various studies have proven it to be very much prevalent amongst the medical student community2,3; dentistry being no exception. Infact there have been studies citing severe stress, emotional exhaustion and depression to be positively associated with the dental student and professional.3,4 The reason for this relationship may not be clearly defined; various factors have been implicated.For one, the very nature of the work may contribute to an overwhelming burden on the student The combination of intensive theoretical study and development of psychomotor skills, learning to deal with patients at an early stage during the course and a frequent encounter with intense pain related symptoms is a difficult domain for the average student.5 The associated difficulties related to workload, procurement and management of instruments, materials, meeting work quota, deadlines for assignments, attitudes of peers, patients  supervisors and the inevitable multiple examinations form the backdrop for a very stress intensive environment.5-7 In the local context where there is also the absence of adequate career counselling, many students opt for dentistry without actually knowing what to expect and many times with very preconceived unrealistic notions about the nature of the profession. Reality checks may occur after spending considerable time battling the issues in dentistry and may contribute to stress and uncertainty about the future.8 Considering the abundance of literature on the subject in the European context2,3,7,9, it remains to be seen whether this is a purely western phenomenon or not.
Internationally, the structure of dental programs varies to some degree from region to region.10 In some countries, a 5-6 year program is the norm whereas in others the traditional 4 year format is being followed. Integrated problem based teaching is being adopted by several modern universities whereas most centers follow the conventional teaching methodologies and find them as effective. Financial aids and programs are available to varying degrees as well. In Pakistan, bachelors in dental surgery comprises a 4 year program followed by a year of house job.11 The first two years are pre-clinical in nature consisting broadly of basic sciences in medicine and dentistry; lectures, tutorials and lab work which prepares the student for the upcoming clinical years. The clinical years consist of aggressive clinical course work along with rotations in various specialty outpatient departments of dentistry. The examination pattern has been varied lately with semester/modular pattern being followed in some institutions whereas annual examination pattern remained the norm in others. Lately, this has been revised to conform to a uniform annual examination pattern. The variations in the facilities at different medical institutions in Pakistan, the fee structure of the programs, the availability or otherwise of well-run out-patient departments (OPDs) and adequate dedicated faculty for dentistry training appear to be the sources of stress in the local context.8 However, there is a dearth of available literature on the prevalence of stress-related outcomes in our dental student population and as yet there are no reliable statistics to understand the gravity of the situation.
Sense of coherence (SOC) is defined as the enduring though dynamic feeling of confidence that a) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable, b) the resources are available to meet the demands posed by these stimuli and c) these demands are challenges worthy of investment and engagement.”.12,13 These three components are labelled comprehensibility, manageability and meaningfulness respectively. These traits help individuals in developing coping strategies and deal with the challenging situations in life in a healthy manner.13 SOC has been found to be associated with less anxiety, depressive and burn out findings.12 It can be used as a measure of psychological health and well-being. Although SOC continues to develop with time, it has been observed by researchers to be formative and crucial during the second and third decade of life, setting the direction for further progress.12,13 This is also the very time that an individual is a university student and hence its applicability in the current context. A lack of coherence can therefore lead to stress, anxiety and burnout in an individual; burnout being the other variable of interest in this study.
Various studies have pointed out an increasing level of stress and mental illness in the Pakistani population.14-17
However, there is a dearth of reliable data to indicate the prevalence of stress in students of dentistry. As a bustling
metropolis and home to multiple dental teaching institutions in Pakistan, data from Karachi would be crucial to our
understanding on the topic. 
         The study presented here investigated the prevalence of burnout and sense of coherence in students of dentistry
in Karachi.

METHODOLOGY
        A cross-sectional, questionnaire based study was carried out involving a total of 361 dentistry students from four
renowned dental teaching institutions of Karachi. Data for the total number of registered institutions and dental students in Karachi was obtained from the Pakistan Medical Commission (PMC) website at the following URL:
1. www.pmc.gov.pk/Colleges/PublicDentalColleges
2. www.pmc.gov.pk/Colleges/PrivateDentalColleges
The total number of recognized public and private dental colleges in Karachi was found to be 14. The sample size
was calculated using Openepi software. At a 95% confidence level, using simple random sampling, sample size was
obtained to be 348. Prior to sampling, the institutions were divided into public and private sector. Then simple random sampling was done using the manual lottery method to select two institutions from each group. Four institutions were sufficient to obtain the required sample size calculated by Openepi software. The actual number of participants in the study were 361 (n). Participation in the study was completely voluntary. The study was conducted from MayDec 2019 after obtaining ethical approval from the ERC of Bahria University Medical and Dental College (Reference no. ERC 20/2020).
The first seven items of the questionnaire were based on the Mayo Clinic Well-Being Index (WBI). The next thirteen questions were based on the modified Antonovsky’s 13-item Sense of Coherence Scale (SOC scale). The Mayo Burnout and sense of coherence in dentistry students of Karachi Clinic Well-being Index is available for IRB-approved studies on request; thereby the WBI Research Document was obtained from MedEd Web Solutions (MEWS) and The Mayo Clinic after submission of an Academic User License Agreement. An individual’s score was compared to the normative data from a large national sample of US medical students and professionals. A score of 4 or more was considered to be a sign of distress that warranted seeking help.
Antonovsky’s Sense of Coherence Scale (SOC scale) is available in the public domain and describes the individual’s Ability to adjust with his immediate environment. Various modifications of the scale are available.12,18,19 For Instance, the revised 13-item sense of coherence scale (SOC-R) has been narrowed down to a 5 point Likert in many Countries.19,20 In this study, a modified 13-item version was used with a 4-point Likert Scale (1=always, 2=rarely, 3=sometimes, 4=never) to quantify the responses to each item.20 A 4-point Likert has been effectively utilized by other scales like the Brief Coping Scale21, General Selfefficacy Scale22 and Depression, Anxiety and Stress Scale.23 In this study, a 4-point Likert was used by taking advantage of the flexibility of the original scale to allow for cultural modifications and to bring clarity to the students who were finding it confusing to respond to the 7-point version. Crohnbach’s alpha reliability coefficient provided a value of 0.721 revealing a high value of internal validity for the scale. A score of 13-52 was calculated with a high score indicating a high sense of coherence. A high sense of coherence is required to deal with stress and related conditions like burnout effectively.
Data was compiled using Microsoft Office (MS Excel) 2010 and analyzed SPSS version 23. Descriptive statistics
(frequency, percent values, mean, median, mode, standard deviation) of the variables under study were calculated. The total scores for WBI and SOC scale were considered dependent variables. Age, gender and professional year
were considered as independent variables.
Chi-square Test was used to determine any association between the independent and dependent variables. Mann
Whitney-U Test and Kruskal Wallis Test was used to compare means between the groups where a positive association was found.
A p-value of equal to or less than 0.05 was considered significant.

RESULTS

A total of 361 students from four dental institutions of Karachi were surveyed for the study. Data was compiled in
SPSS version 23.
From the total number of respondents, 289(81%) students were females, 68(19%) were males (Table 1).
There were 210(58%) students in the 20-22 years of age bracket, 135(38%) students were less than 20 years of age and 14 students (4%) were more than 22 years of age (Table 1).
A total of 170(47%) respondents were from second year BDS, 68(19%) were in their third professional, 66(18%) in
the first professional and 57(16%) in their final professional year. In a cumulative sense, 236(65%) students were in their pre-clinical years and 125(35%) in their clinical years (Table 1).
A total of 170(47%) respondents were from second year BDS, 68(19%) were in their third professional, 66(18%) in
the first professional and 57(16%) in their final professional year. In a cumulative sense, 236(65%) students were in their pre-clinical years and 125(35%) in their clinical years (Table 1).

were 22(6%) while 13(4%) reported a history of chronic psychiatric condition (Table 1).Descriptives for the WBI scores obtained showed a mean value of 4.07 (95% CI, Std. Dev=2.07) and a median
of 4.00 (IQR=3; Table 2). The total students in the “at-risk” category, reporting a score of 4 or more, were found to be 230 (64%; Fig. 1)

(A score of 0-3 indicates minimal or no risk for burnout; a score of 4-7 indicates a high risk for burnout)

SOC scores produced a mean of 36.39 (95% CI, Std. Dev=6.10) and a median of 37.00 (IQR=8; Table 2). A total of 205(57%) respondents reported a moderate sense of coherence ranging from 27-39 while 134(37%) reported a score of 40 or above. A low sense of coherence was reported in 22(6%) students (Fig. 2)
A significant association was found between gender and WBI scores (p=0.023). The female students who fell in the at-risk” category with a score of 4 or more were 192(66%;

Fig 2: SOC Scale scores obtained for the total sample (n=361) (1 denotes a score of 13-26; 2 denotes a score of 27-39;
3 denotes a score of 40-52)

Table 3: Descriptive analysis of WBI and SOC Scale Scores for males and females.

Table 3). For the males, equal numbers (34 students each; 50%) were reported in the safe (less than 4) and “at-risk”
(4 or more) category (Table 3).
For the SOC Scale, no significant association was found between the gender and the scores obtained (p=0.511).
A significant association was found between the professional year and the WBI scores obtained (p=0.001). A total of
52(77%) third year BDS students, 117(69%) second year BDS students, 34(52%) final year students and 28(49%)
first year students were found in the “at-risk” category for the WBI (Table 4).
No significant association was found between year of study and sense of coherence (p=0.057). However, the
highest sense of coherence was found in first year BDS students: 31(47%). This was reduced successively in second
year BDS: 64(38%) and third year BDS: 15(22%) whilethere was a relative increase in final year BDS: 24(42%). Around 4-9% of each professional year students exhibited a low sense of coherence (Table 4).

Table 4: Descriptive analysis of WBI and SOC Scale Scores for males and females.

Mann Whitney-U Test revealed a significant difference in the mean scores of males and females for the WBI (p=0.041; Table 5). For SOC, no significant difference in means was found between the genders (p=0.294; Table 5).
Kruskal Wallis Test revealed a significant difference in the mean scores of each professional year for the WBI
(p=0.012, Table 6) as well as SOC (p=0.045, Table 6).

Table 5: Comparison of gender-wise score for WBI and SOC Scale using Mann-Whitney Test

Table 6: Comparison of professional year-wise score for WBI and SOC Scale using Kruskal-Wallis Test

No significant associations could be established between the other variables and the scores obtained for the WBI. A p-value of 0.607, 0.613, 0.063, 0.649 and 0.306 was found for age, relationship status, institution and history of chronic medical and psychiatric condition respectively. Similarly, no significant associations were found between these variables and the scores obtained for the SOC. A p-value of 0.702, 0.109, 0.164, 0.787 and 0.731 was found for age, relationship status, institution and history of chronic medical and psychiatric condition respectively.

DISCUSSION
      As per the data provided by the Mayo Clinic Well-being Index, the overall mean value from their sample of US students was 2.5 and median was 2.024,25; the overall mean values obtained for burnout in this study (mean and
median=4.0) suggest that the population under study is atrisk of severe outcomes related to stress and burnout. There is a serious need for therapeutic intervention in dental students of Karachi. A systematic review on the subject reveals that atleast 34.1% of the literature available reports high levels of stress and related conditions in undergraduate dental students and 54.1% reports moderate levels.26 The stress is attributed mainly to the demanding nature of the training.26 On the other hand, the SOC values in the current study showed moderate levels of coherence (mean=36, median=37). These may not be sufficient for those students who report a high risk of burnout.
The results of the current study also suggest that there is a significant association between year of study and the
total scores obtained for the well-being index; third year BDS exhibited the highest risk followed by second year
BDS students. There was a relative improvement in the final professional. This can be a logical result as the newly adopted OPD environment in third year can pose a significant challenge for students.27 However, the gradual increase in risk from first year to third year needs to be addressed. There may be more than one factor for the increased propensity to stress and burnout.28 There is a similar pattern to be observed with the SOC scale. The levels of coherence in this study also drop gradually from first year to third year with a relative improvement observed in the final professional.
M Scholz et al. in a study performed on German pre-clinical dental students3 showed similar results with the
levels of burnout increasing through each semester upto the end of 2.5 years. The research goes on to state that the
students started out at levels comparable with the general population but massive deterioration was observed till the
time they were facing their 5th semester examinations. The same trend was observed when reviewing the same cohort of students using a different set of scales. P.H.M Burger et al. reported that the average levels observed
in the fifth semester were equivalent to those of clinical depression. This was in sharp contrast to the levels observed
when the students started out their dentistry course in the first semester.3 In another study of the dental students
of University of Saskatchewan, Western Canada, Alyssa Hayes et al7 reported a higher level of stress among first year dental students in many areas, attributed to a fear of failing exams, living away from home, developing manual
dexterity etc.
There was also a significant association between gender and the scores obtained for the WBI. A majority of the female students were found to be at risk for developing burn-out while the same could be said about half of the males. What needs to be ascertained is whether this difference actually points to a greater vulnerability of females to stress29,30 and/or to some specific work related factors affecting females.31 In another study conducted on Pakistani medical and dental students from Lahore, Najma Naz et al. have also reported that females are more prone to depression, stress and anxiety than males.32 Similar results were reported in other7,28,31 studies which implicates an association of gender with stress related factors like burnout. However, no significant difference
in the levels of coherence between the two genders in this study. This may suggest that a large number of students at
risk of burnout need to be facilitated to aid in creating an adequate protective coping mechanism. The fact that more
than 80% of the students in the study were females; which is representative of the current gender imbalance in dentistry students, makes this situation worthy of a quick intervention.
Although some studies have also reported an association between age, relationship status, institution and history of chronic medical and/or psychiatric condition.2,7,27,33, no such associations were found in this study. Karla
Gambetta-Tessini et al. in their study of Australian, New Zealand and Chilean dental students showed an interesting
finding that those students who opted for dentistry as their first preference for study had decreased stress levels as
compared to those students who had wanted to study medicine.
Only a healthy body and mind can deal with the responsibility of thinking logically, producing accurate
diagnoses and treating the ailing patients. The importance of a healthy state of mind and well-being for future healthcare professionals dictates that we start paying attention to the creation of a stress-free and conducive environment in our institutions. More research needs to be done to identify the factors implicated in creating stress in our institutions of higher learning. Once we are sure of the significance of each factor, we can gear up to create smart and well-tailored solutions to improve the well-being of our dental students. A major limitation of most studies conducted on the subject including this one was that this was a cross-sectional study. Longitudinal studies following the same cohort of students over the years can provide more accurate information about the students’ mental state and the influence of the dental school on them. Also, a baseline measurement of the outcome variables before the start of the academic year for first year students was not available. There was the absence of comparative data from the general population as well. Theavailability of WBI and SOC Scale scores from a comparable
group of Pakistanis or Karachiites would have provided valuable insights into our research. Also, the number of
pre-clinical students who responded to the questionnaire was more than that of clinical students.

CONCLUSION AND RECOMMENDATIONS
     Within the limitations of this study, we can conclude that there is a significant number of dental students at risk
for burnout and related conditions. There is a need to find ways to raise the levels of coherence in the student community. Further investigation including qualitative research should be carried out to gather data in detail
especially regarding the factors contributing to the current scenario. Future studies on this topic may incorporate
qualitative assessments, face to face interviews or focus group discussions to yield a more accurate and well-rounded
interpretation of findings. Solutions need to be introduced to alleviate the problem at the community as well as
institutional level.

ACKNOWLEDGEMENT
     The authors of this study would like to thank MedEd Web Solutions (MEWS) and The Mayo Clinic for providing The Mayo Clinic Well-being Index Research Document after submission of an Academic User License Agreement.
Disclaimer: The abstract has neither been previously presented nor published in a conference; nor the manuscript
was part of a research, PhD or thesis project.

CONFLICT OF INTEREST
     There are no financial, personal, or professional interests that could be construed to have influenced the work.

FUNDING DISCLOSURE
   The authors received no financial support for the research, authorship, and/or publication of this article.

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Burnout and Sense of Coherence in Dentistry Students of Karachi

 Fasiha Moin Kazi                      BDS, MBA     

 Shoaib Ahmed                          MBBS, FCP

 Shama Asghar                          BDS, FCPS

 

OBJECTIVE: This study aimed to assess burnout and sense of coherence levels in dentistry students of Karachi.
METHODOLOGY: A cross-sectional study involving 361 students from four renowned dental colleges in Karachi was carried
out. The students were distributed a questionnaire derived from the Mayo Clinic Well-being Index (WBI) and a modified
13-item Antonovsky's Sense of Coherence Scale (SOC scale). They were stratified on the basis of gender, age, professional
year, institution, relationship status, history of chronic medical condition and history of chronic psychiatric condition. Scores
for the WBI and SOC scale were calculated. For the WBI, a score of >4 was a sign that an individual was at risk of developing
burnout or other severe outcomes. A high or low total score on the SOC scale demonstrated whether the individual was able
to cope with his environment or not. MS Excel and SPSS version 23 were used for data compilation and statistical analysis.
Descriptive statistics were calculated. Chi-square test of independence was applied to gauge any association between the strata
and outcome variables. After determination of statistical difference, Mann Whitney-U Test and Kruskal Wallis Test were applied
to compare the means where a significant association was found. A p-value of 0.05 or less was considered significant.
RESULTS: The mean WBI score was found to be 4.07. Around 64% respondents were at-risk of burnout (score > 4). A greater
percentage of females was at risk (66%) as compared to males (50%). Third professional students were found to be the most
affected (77% with WBI score > 4 and 9% in the low coherence category). The mean SOC score was found to be 36.39 (moderate
levels of coherence). Overall, around 4-9% of each professional year students exhibited a low sense of coherence. Age,
relationship status, institution and a history of chronic medical and/or psychiatric condition were not found to have a significant
association with the outcome variables (p>0.05).
CONCLUSION: A significant number of dentistry students are at risk of burn-out and suffer from a low sense of coherence.
The risk factors need to be evaluated and solutions need to be found to create a healthy and conducive environment for the
growth and learning of the students. More research needs to be focused on gathering data related to the well-being of dentistry
students.
KEYWORDS: Burnout, sense of coherence, well-being index, dentistry.
HOW TO CITE: Kazi FM, Ahmed S, Asghar S. Burnout and sense of coherence in dentistry students of Karachi. J Pak Dent
Assoc 2021;30(3):170-177.
DOI: https://doi.org/10.25301/JPDA.303.170
Received: 12 November 2020, Accepted: 28 March 2021

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Association of Oral Health Literacy Level and Periodontal Health Status: A Contributory Step Towards Prevention of Periodontal Diseases

 

 Wardah Ahmed                              BDS, MSPH, PhD

 Mehmil Aslam                                BDS, MCPS

 Syed Imran Hassan                       BDS, MCPS

 Khalil Ahmed                                 BDS, MSc

 Syeda Farhat Bukhari                   BDS, MSc

 Permanand Mahi                           BDS, MSc

 Ayesha Kaleem                             BDS

Fatima Zafar                                   BDS

OBJECTIVE: To Evaluate the level of oral health literacy (OHL) among new patients seeking care at the private teaching dental hospital.
METHODOLOGY: A cross-sectional study conducted at Department of Oral Diagnosis & Periodontology at Private Teaching Dental Hospital. Adults (>18years) was recruited in the study using non-probability convenient sampling technique. Participants verbally consented to participate, then interview based validated questionnaire was administered. Data collected from April 2019 to August 2019. The study was approved by Scientific Review  Committee of Private Teaching Dental Hospital. OHL was measured by REALD-20. Clinical assessment was performed using periodontal index. Two investigators and 2 house surgeons were trained for increasing inter examiner reliability. Demographic variables were examined as exploratory covariates. Statistical analysis was performed using SPSS 21.Fisher’s exact test used to determine bivariate association and Multivariate regression analysis showed the relationship.
RESULTS: The total sample size was n=236 out of which 100 (42.6%) were male and 136 (57.6%) were female. Mean age of the sample was 36 years (±13.6) and majority 150(64%) had 12 years of education completed. Smokers were 50 (21%) were smokers. Respondents 173(73.3%) brush at least once in a day and 93% used toothpaste as dentifrice. Respondents belong to low-OHL had moderate 84 (36%) and severe periodontal 72 (31%) diseases. The mean Periodontal Index Score: 2± 0.54. OHL was significantly associated with periodontal disease (p 0.01). Smokers showing significant association (p 0.04) with periodontal disease. Multivariate regression analysis revealed that for one- point decrease in OHL score, the occurrence of periodontal disease reduced by 25% (Adjusted OR=0.75).
CONCLUSION:This has been concluded that oral health literacy associated with periodontal health status. Understanding of periodontal health knowledge and its implication is vital for prevention of periodontal diseases. Future intervention researches are required to develop etiological relationship between oral health literacy and periodontal health status.
KEYWORDS: Periodontal disease, dental oral health, smokes adults
HOW TO CITE: Ahmed W, Aslam M, Hassan SI, Ahmed K, Bukhari SF, Mahi P, Kaleem A, Zafar F . association of oral health literacy level and periodontal health status: a contributory step towards prevention of periodontal diseases. J Pak Dent Assoc 2021;30(3):164-169.
DOI: https://doi.org/10.25301/JPDA.303.164
Received: 07 September 2020, Accepted: 06 May 2021

INTRODUCTION
Generally Oral Health Literacy (OHL) conceptualized as the degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions.1
Low health literacy identified as the main hindrance in health care utilization and could be a key factor in negative health outcomes of particular interest and concern for vulnerable population.1,3,4 Unable
to self-rating of health, less understanding of prevention and self-care instructions, less compliance to adherence to
medicinal and health instructions, compromised selfmanagement skills, high burden of mortality and morbidity
hazards directly linked to low health literacy that consequently increase in healthcare costs.5-7 Previous studies
have shown that marginalized populations for low health literacy effected from inequalities in health status, they are
more prone to diseases like cardiovascular disease, diabetes mellitus, obesity, HIV, malignancy, lead poisoning and low birth weight.8-10 OHL seen as a major contributing risk factor of an individual oral health behavior and oral health status.11- 13 Periodontal disease is a term “which includes all pathological conditions of the periodontium”. Periodontal problem are true infection of oral cavity. Periodontal diseases defined as “infectious progressions that require bacterial presence and a host response and are further affected and modified by other local, environmental and genetic factors”. Periodontal infection is instigated by specific invasive oral pathogens that colonize dental plaque biofilms on dental enamel in the absence of oral hygiene maintenance.14 Thus, it has been evidently proved that oral hygiene has direct relationship with periodontal diseases. Periodontal diseases are preventable and maintained with patient compliance. OHL linked with deeper understanding of oral care information and its application for observance to the management of periodontal disease.15 Nevertheless, patient strict compliance may help in successful treatment of the causes of all stages of periodontal diseases.16 Additionally, oral health status correlated with quality of life that ultimately associated with periodontal diseases.17,18OHL-instruments comprised of contemporary measures of oral health literacy expertise. Broadly, used oral health literacy measurement tools derived from Rapid Estimate of Adult Literacy in Dentistry
(REALD-99), Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D) administered for word
recognition and Test of Functional Health Literacy in Dentistry (TOFHLiD) used to assess reading comprehension
and numeracy. In literature, conceptual knowledge assessed form comprehensive oral health knowledge (COHK) tool and general oral health knowledge tool. Oral health knowledge (OHK) considered as independent component
of oral health literacy effecting the oral health outcomes. Conceptual knowledge helps in understanding and decision
making component of oral health literacy. These tools comprise of extensive items and questions related to oral
health.19-23
Periodontal diseases are among the most widely prevalent disease of oral cavity worldwide.4,24,25 In Pakistan overall prevalence of periodontal diseases is 80% as reported in situation analysis of Pakistan.26
The rationale of conducting this study that general literacy level in the urban Karachi is reportedly 70%.28
Basic Oral health knowledge of regarding oral hygiene is almost universal that covers knowledge about usage of
toothbrush and toothpaste.26 However, the occurrence of periodontal diseases is high. In previous study it was found that almost 70% of adult population have limited oral health literacy.29 Prevention of periodontal diseases and promotion of healthier oral care requires understanding of consequences of periodontal disease. Nevertheless, oral health literacy augment people’s ability to read and write. The knowledge gained from understanding periodontal disease and how best to reach individuals with low OHL will help in providing optimal periodontal care, education, and support.
In the context of Pakistan and to the basis existing scarce literature, this kind of study conducted for the first time.
This study assess the association between oral health literacy and periodontal health status.

The specific objectives of this study:
1. Estimate the level of Oral Health Literacy (OHL) among new patients utilizing care at the private
teaching dental hospital
2. Assess association of Oral health Literacy (OHL)with periodontal health status
3. Assess association of Oral health knowledge (OHK) with periodontal health status

METHODOLOGY

Sample and Data Collection
        Newly visited adult patients (>18years of age) to Department of Oral Diagnosis & Periodontology at a private
teaching dental hospital were recruited in the study using non-probability convenient sampling technique. It was cross sectional study. Medical records number was used for marking unique identity of respondent for the study. Patient with other morbidity such as acute dental pain and oral cancers was not included in the study. If they verbally consented to participate, then interview based validated structured questionnaire was administered. Sample size was calculated using software “OpenEpi”. Prevalence of low oral health literacy (31%) in previous study was taken as reference to estimate sample size.11 The calculated sample size turned out to be n=236 at 95% confidence level at power 0.05. Data collected from September 2018 to April 2019. Principal investigator, 2 co-authors and 2 house surgeons trained
and calibrated in a single training session for increasing inter-examiner reliability. This study was approved by
Scientific Review Committee of the private teaching dental hospital.

Data Collection Tool
     The tool used for data collection had 4 sections. Section 1: Socio-demographic characteristics including age, gender and education. In addition, the oral health behavior section assessed through six items on dental hygiene and
habits.
Section 2: Oral health literacy (OHL) measurement tool adapted from Rapid Estimate of Adult Literacy in Dentistry
(REALD-20).The REALD involved “word recognition test” that assess respondents’ capacity to read dental words from a preformed list and interpreted as grade-range assessments of reading capability. REALD-20 administered to evaluated OHL by using flash cards. Dentistry related 20 words written on flash cards from less difficult to more difficult word consulted and piloted with periodontology experts. Cronbach’s =0.87 showed instrument validation. Each respondent was asked to read loudly the words written on flash cards. If there was any difficulty in reading and
recognition by the respondents, interviewer asked to skip the word. Collectively, score (0-20) was enumerated, 0
marked as lowest and 20 as highest. Distribution of respondents done, based on these OHL- Categories (i) low
(<14), (ii) moderate (15 to 17) and (iii) high (>18).
Section 3: Comprehensive oral health knowledge (CMOHK) and Oral health knowledge (OHK) comprised
of 9 questions administered to knowledge specific to periodontal disease. Although considering independent
component, oral health knowledge helps in understanding and decision making for the better outcomes. Single correct answer of true/false response item marked as score 1.
Section 4: Periodontal health status assessed through clinical assessment. Periodontal diseases was measured
using periodontal index. Widely used periodontal disease case definition in accordance with CDC used in this study:
Severe Periodontitis: >2 interproximal sites with CAL >6 mm (on more than one tooth) and >1 interproximal site with PD >5 mm;
Moderate Periodontitis: >2 interproximal sites with CAL >4 mm (on more than one tooth) or >2 interproximal sites with PD >5 mm (on more than one tooth); Healthy or Mild Periodontitis: neither “moderate” nor
“severe” periodontitis”.11

Data Analysis

Outcome variable was periodontal health status. The independent variable was REALD-20 score. Other covariates
included gender; education (college, graduate and post graduate); smoking status whether present or previous
smokers; OHK and CMOHK score. Statistical analysis done by using SPSS 21. Descriptive statistics reported in
percentages for categorical variables (Education, Oral health Literacy level, distribution of respondent according to
periodontal health status)and mean and standard deviation for numeric variables (age). Fisher’s exact test statistics was used to determine association. Multivariate regression analysis was used to see the relationship between the
significant independent variables and outcome.

RESULTS

Socio-Demographic Characteristics
      The total sample size was n=236 out of which 100 (42.6%) were male and 136 (57.6%) were female.
Respondents sample mean age was 36 years (±13.6), majority 150(64%) had 12 years of education completed while 72 (30%) completed their graduation.

 

Oral Health Behavior
    In the study sample, 50 (21%) were smokers, covered current and former smokers and all were male.
Pan/chhalia/tobbaco chewing and other addictive items were prevalent in 15% respondents. Majority of the respondents 173(73.3%) brush at least once in a day and 93% used toothpaste as dentifrice. Flossing and mouthwash rinses was not adopted by 195 (83%) and 189 (80%) respondents respectively.

Oral Health Knowledge (OHK) and Comprehensive Measure of Oral Health Knowledge (CMOHK)
     Distribution of respondents in questions related to OHK and CMOHK tabulated in table -1. Majority of the respondents had incorrect knowledge about periodontal diseases. Similarly, mostly responses were incorrect regarding comprehensive knowledge

Table 1: Periodontal Health Status by Oral Health Literacy Level (OHL) and Oral Health knowledge (OHK)

Periodontal Health Status by Oral Health Literacy (OHL) Level
The proportions of respondents among mild, moderate and severe periodontal disease according to oral health literacy (OHL) level illustrated in figure 1. Respondents belong to low oral health literacy level had moderate 84 (36%) and severe periodontal 72 (31%) diseases. The mean Periodontal Index Score: 2± 0.54.

Association of Oral health Literacy with Periodontal Disease
   Bivariate analysis showed Oral health literacy was significantly associated with periodontal disease (p 0.001).There was no significant difference found among oral health knowledge regarding their periodontal health status.
Although, 21% of the respondents were smokers in our study, however, it was significantly associated (p 0.04) with periodontal disease. Other characteristics such as age and education were not significantly associated.
Multivariate regression analysis revealed that for one-point decrease in OHL score, the occurrence of periodontal disease reduced by 25% (Adjusted OR=0.75). Similarly, respondents who smokes (Adjusted OR =1.58) were significantly more likely intended to have periodontal disease. This demonstrates that people with higher oral health literacy level tended to achieve better periodontal health status.

DISCUSSION
     Pakistan is a developing country and problems such as increase in population growth, low economic resources and burden of communicable and non-communicable diseases escalating exponentially. Thus, oral diseases grasp comparatively less importance and resources allotment than other diseases with high mortality rate. Little is known about dental utilization or unmet dental need in this population and the existing dental care delivery system has failed to reduce the burden of oral diseases in the country.27,29
This study aim to estimate the level of oral health literacy among new patients utilizing care at private dental
hospital in the department of Oral Diagnosis and Periodontology and to assess its association with periodontal
health status on the targeted population. Result findings determined that oral health literacy score reduced by 1 unit,
probability of getting severe periodontal disease was increased by 25 percent. Similar to our results other studies
reported majority of the respondents scored in low OHL level.28,29
In our results education and age were not significantly associated to periodontal diseases. This finding advocates
in the favor that years of education have no direct relationship with oral health literacy level of the individual. Thus, even highly educated patients have scarce understanding of periodontal issues contributing in development of the
disease.
Our analysis revealed that few respondents from sample were habitual smokers, still periodontal diseases (mild,
moderate and severe) strongly associated with smoking. Therefore, emphasize not on just knowledge rather
understanding and application of healthy behavior. Assessment of oral health knowledge and comprehensive health knowledge revealed that respondents were aware of conditions that require tertiary care. However, it was found that knowledge regarding initial stage of periodontal disease which can be prevented, were lacking. For example, a question what are the behaviors that may cause periodontal disease? Majority of the respondents incorrectly respondent that improper brushing may cause gum disease. These findings consistent with other studies conducted in developed countries found that low oral health literacy interconnected to less oral health knowledge and increasing risky oral-health behavior.7,24,30 It is inevitable for the patient to understand the contributing risk factors and causes of periodontal disease.11 Sociocultural and environmental factors play imperative part in oral disease and general health consistent with results demonstrated in several reports.23,30 The link between socio economic status of the patient and OHL was also recorded but most of the patients were reluctant to give any information, therefore the relationship between these two cannot be evaluated.
Results of this study strengthen the evidence of fruitful two-way communication between dentist and patient. Despite, a report claimed that due to overburden health providers might not conveniently address the basic health literacy requirements, yet this can be resolved by effective oral health education programs and implication for their patients.12 Similar pattern found in recent study in Pakistan. Low oral health literacy could be address by simple measures include observing reading capacity of informed consent, prescription reading, medicines leaflets and other patient to identify patients with low literacy.29
The study sample limited to the patients visited to OPD in private teaching dental hospital, who already have some
level of dental literacy that might overestimated the OHL-score. Furthermore, it would be useful to enlarge the
sample size for increasing generalizability of the results in general population. Future, interventional studies in
communities encompassing dental health literacy proven to be effective and have positive impact on oral health
status.31

CONCLUSION
       This has been concluded that oral health literacy associated with periodontal health status. Understanding of periodontal health knowledge and its implication is vital for prevention of periodontal diseases. Future intervention researches are required to develop etiological relationship between oral health literacy and periodontal health status.

 

CONFLICT OF INTEREST
None to declare

REFERENCES

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2. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dental Clinics of North America. 2008;52: 333-44.
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3. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health promotion international. 2000;15:259-67.
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4. Parker EJ, Jamieson LM. Associations between indigenous Australian oral health literacy and self-reported oral health outcomes. BMC Oral health. 2010;10:1-8.
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5. Toçi E. Health literacy in the Western Balkans. 2015.

6. Nutbeam D. The evolving concept of health literacy. Social science & medicine. 2008;67:2072-078.
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7. Griffey RT, Kennedy SK, McGownan L, Goodman M, Kaphingst KA. Is low health literacy associated with increased emergency department utilization and recidivism? Academic Emergency Medicine. 2014;21:1109-15.
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8. Tutu RA, Busingye JD. Health Literacy of Migrants: Environmental Risks to Health. Migration, Social Capital, and Health: Springer; 2020. p. 71-96.
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9. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes. Archives of internal medicine. 1998;158:166-72.
https://doi.org/10.1001/archinte.158.2.166

10. Rawal I, Ghosh S, Hameed SS, Shivashankar R, Ajay VS, Patel SA, et al. Association between poor oral health and diabetes among Indian adult population: potential for integration with NCDs. BMC oral health. 2019;19:191.(1-0)
https://doi.org/10.1186/s12903-019-0884-4

11. Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY. The impact of oral health literacy on periodontal health status. J Public HealthDentistry. 2014;74:80-7.
https://doi.org/10.1111/j.1752-7325.2012.00375.x

12. Dental NIo, Craniofacial Research NIoH, US Public Health Service, US Department of Health, Services H. The invisible barrier: literacy and its relationship with oral health. A report of a workgroup sponsored by the National Institute of Dental and Craniofacial Research, National Institute of Health, US Public Health Service, Department of Health and Human Services. J Public Health Dent. 2005;65:174-82.
https://doi.org/10.1111/j.1752-7325.2005.tb02808.x

13. da Costa Dutra L, de Lima LCM, Neves ÉTB, Gomes MC, de Araújo LJS, Forte FDS, et al. Adolescents with worse levels of oral health literacy have more cavitated carious lesions. PloS one. 2019;14.
https://doi.org/10.1371/journal.pone.0225176

14. Saini R, Marawar P, Shete S, Saini S. Periodontitis, a true infection. J Global infectious diseases. 2009;1:149-50.
https://doi.org/10.4103/0974-777X.56251

15. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc. 2007;138:1199-208.
https://doi.org/10.14219/jada.archive.2007.0344

16. Vann Jr W, Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: impact on oral health outcomes in early childhood. J Dent Res. 2010;89:1395-400.
https://doi.org/10.1177/0022034510379601

17. Cunha-Cruz J, Hujoel P, Kressin N. Oral health-related quality of life of periodontal patients. J periodontal Res. 2007;42:169-76.
https://doi.org/10.1111/j.1600-0765.2006.00930.x

18. Ng SK, Leung WK. Oral health-related quality of life and periodontal status. Community Dentistry Oral Epidemiology. 2006;34:114-22.
https://doi.org/10.1111/j.1600-0528.2006.00267.x

19. Dickson-Swift V, Kenny A, Farmer J, Gussy M, Larkins S. Measuring oral health literacy: a scoping review of existing tools. BMC oral health. 2014;14:148.
https://doi.org/10.1186/1472-6831-14-148

20. Naghibi Sistani MM, Montazeri A, Yazdani R, Murtomaa H. New oral health literacy instrument for public health: development and pilot testing. J Invest Clin Dent. 2014;5:313-21.
https://doi.org/10.1111/jicd.12042

21. Macek MD, Haynes D, Wells W, Bauer-Leffler S, Cotten PA, Parker RM. Measuring conceptual health knowledge in the context of oral health literacy: preliminary results. J Pub Healt Dent. 2010;70: 197-204.
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https://doi.org/10.1186/1472-6831-14-135

23. Wanichsaithong P, Goodwin M, Pretty IA. Development and pilot study of an oral health literacy tool for older adults. J Investigative and Clinical Dentistry. 2019;10:e12465.
https://doi.org/10.1111/jicd.12465

24. Atchison KA, Gironda MW, Messadi D, Der-Martirosian C. Screening for oral health literacy in an urban dental clinic. J Pub Healt Dent. 2010;70:269-75.
https://doi.org/10.1111/j.1752-7325.2010.00181.x

25. Roter DL. Oral literacy demand of health care communication: challenges and solutions. Nursing outlook. 2011;59:79-84.
https://doi.org/10.1016/j.outlook.2010.11.005

26. Khan AA, Ijaz S, Ayma S, Qureshi A, Padhiar I, Sufia S, Oral health in Pakistan; A situation analysis. Dev Dent. 2004;5:35-44

27. Abdullah M, Zakar R. Health Literacy in South Asia: Clarifying the Connections between Health Literacy and Wellbeing in Pakistan. Health. 2019;34:575-89.

28. Ahmed W, Shaikh ZN, Soomro JA, Qazi HA, Soomro AK. Assessment of health literacy in adult population of Karachi: a preliminary investigation for concept-based evidence. Int J Health Promotion Edu. 2018;56:95-104.
https://doi.org/10.1080/14635240.2017.1421866

29. Ahmed W, Shah S, Khayyam U, Sheikh T, Anwer N. Measuring Oral health literacy in dental patients: Contribution towards preventive dentistry in Pakistan. J Pak Dent Assoc. 2017;26:176-80.
https://doi.org/10.25301/JPDA.264.176

30. Sistani MMN, Virtanen JI, Yazdani R, Murtomaa H. Association of oral health behavior and the use of dental services with oral health literacy among adults in Tehran, Iran. Eur J Dent. 2017;11:162.
https://doi.org/10.4103/ejd.ejd_332_16

31. P. R. GeethaPriya SA, D. Kandaswamy, M. S. Muthu & Shyam S. . Effectiveness of different modes of school dental health education on the oral health status of children – an interventional study with 2-year follow-up, Int J Health Promotion Edu, 58:1, 13-27.
https://doi.org/10.1080/14635240.2019.1658536

Association of Oral Health Literacy Level and Periodontal Health Status: A Contributory Step Towards Prevention of Periodontal Diseases

 Wardah Ahmed                               BDS, MSPH, PhD    

 Mehmil Aslam                                 BDS, MCPS

 Syed Imran Hassan                        BDS, MCPS

 Khalil Ahmed                                  BDS, MSc

 Syeda Farhat Bukhari                    BDS, MSc

 Permanand Mahi                            BDS, MSc

 Ayesha Kaleem                               BDS

Fatima Zafar                                     BDS

OBJECTIVE: To Evaluate the level of oral health literacy (OHL) among new patients seeking care at the private teaching dental hospital.
METHODOLOGY: A cross-sectional study conducted at Department of Oral Diagnosis & Periodontology at Private Teaching Dental Hospital. Adults (>18years) was recruited in the study using non-probability convenient sampling technique. Participants verbally consented to participate, then interview based validated questionnaire was administered. Data collected from April 2019 to August 2019. The study was approved by Scientific Review Committee of Private Teaching Dental Hospital. OHL was measured by REALD-20. Clinical assessment was performed using periodontal index. Two investigators and 2 house surgeons were trained for increasing inter-examiner reliability. Demographic variables were examined as exploratory covariates. Statistical analysis was performed using SPSS 21.Fisher’s exact test used to determine bivariate association and Multivariate regression analysis showed the relationship.
RESULTS: The total sample size was n=236 out of which 100 (42.6%) were male and 136 (57.6%) were female. Mean age of the sample was 36 years (±13.6) and majority 150(64%) had 12 years of education completed. Smokers were 50 (21%) were smokers. Respondents 173(73.3%) brush at least once in a day and 93% used toothpaste as dentifrice. Respondents belong to low-OHL had moderate 84 (36%) and severe periodontal 72 (31%) diseases. The mean Periodontal Index Score: 2± 0.54. OHL was significantly associated with periodontal disease (p 0.01). Smokers showing significant association (p 0.04) with periodontal disease. Multivariate regression analysis revealed that for one- point decrease in OHL score, the occurrence of periodontal disease reduced by 25% (Adjusted OR=0.75). CONCLUSION:This has been concluded that oral health literacy associated with periodontal health status. Understanding of periodontal health knowledge and its implication is vital for prevention of periodontal diseases. Future intervention researches are required to develop etiological relationship between oral health literacy and periodontal health status.
KEYWORDS: Periodontal disease, dental oral health, smokes adults
HOW TO CITE: Ahmed W, Aslam M, Hassan SI, Ahmed K, Bukhari SF, Mahi P, Kaleem A, Zafar F . association of oral health literacy level and periodontal health status: a contributory step towards prevention of periodontal diseases. J Pak Dent Assoc 2021;30(3):164-169.
DOI: https://doi.org/10.25301/JPDA.303.164
Received: 07 September 2020, Accepted: 06 May 2021

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Daily Impacts of Missing Teeth in Adult Population in Lahore, Pakistan

 

 Hazik B. Shahzad                                BDS, MSc     

 Faiza Awais                                           BDS, M.Phil

 Noor-Ul-Huda Raza                          BDS, M.Phil

 Hanna A Majeed                                BDS, FCPS

 Maliha Shahbaz                                BDS, M.Phil

 Farhat Kazmi                                   BDS, M.Phil, PhD

OBJECTIVE: The objective of this study is to evaluate the impact of tooth loss on oral health related quality of life in adults.
METHODOLOGY: The survey was conducted during March – June 2019 at Rashid Latif Dental Hospital. A sample size of 373 adults aged 18-80 years was randomly selected from the out-patient department. Number of missing teeth was the main exposure, and it was clinically assessed. OHRQoL was evaluated through “Oral Impacts on Daily performance (OIDP) questionnaire”.
RESULTS: From total patients presented in OPD 44% had one or more missing teeth. Top reported impacts of missing teeth included difficulty eating and relaxing/sleeping problems. Adults with missing teeth showed 1.28 (95%CI 1.04-4.55) (P=0.01) times higher odds for reporting higher oral impacts compared to those without missing teeth.
CONCLUSION: Individuals with missing teeth likely had frequent difficulties in their daily lives due to missing teeth including trouble with eating, speaking, and oral infection, which could spread to the rest of your body.
KEYWORDS: OIDP, Tooth-loss, Adults, Missing teeth, Lahore
HOW TO CITE: Shahzad HB, Awais F, Raza NUH, Majeed Ha, Shahbaz M, Kazmi F. Daily impacts of missing teeth in adult population in Lahore, Pakistan. J Pak Dent Assoc 2021;30(3):157-163.
DOI: https://doi.org/10.25301/JPDA.303.157
Received: 13 July 2020, Accepted: 26 April 2021
INTRODUCTION
Oral diseases being rarely life-threatening are often a low priority for health policy makers.1
Health is not merely the absence of disease but also constitutes a relationship between social and psychological
wellbeing.2 World Dental Federation defines oral health as a multi-faceted ability to speak, smile, smell, taste, touch,
chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.3 Oral diseases including untreated caries, severe tooth loss and severe periodontitis, were listed among the top 100 Global Burden of Diseases in 2010, and severe tooth loss ranked at number 36.4 These oral diseases collectively affect 3.9 billion people worldwide.4 The World Health Organization’s (WHO) Global Oral Health Programme has identified dental caries, periodontal diseases, and dental trauma as the main causes of tooth loss.5 Loss of permanent teeth is associated with significant chances of mesial drifting of neighbouring teeth to fill the empty space.6 Eventually tooth loss may results in further carious teeth and periodontal disease. Teeth are important for improving aesthetics and their loss is also responsible for functional impairments in the form of chewing limitations.7 This century has seen a shift from infectious diseases to non-communicable diseases.8 Treatments for chronic diseases are mostly management of symptoms without eradication of the disease. This elevates the need for subjective outcome measures.8 Clinical indicators alone are not adequate to describe health status.9 It has been seen that people with chronic diseases can observe their quality of life as being better than healthy individuals.10
          Quality of Life (QoL) is defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.11 With aging population, there should be adequate resources for improving QoL.12 It is a multi-dimensional and comprehensive concept that contains both positive and negative aspects of a person’s physical or psychological states, independence levels, social relationships, personal beliefs and environmental features.11 In epidemiological studies, measure of QoL along with clinical measures complement perceived needs of the population.12 Subjective measures provide important information to a patients functional, social and psychological wellbeing.13 Subjective measures allow healthcare professionals to evaluate the efficacy of treatment options from the viewpoint of a patients.14 QoL is gradually acknowledged as a valid and significant indicator of service need and intervention outcomes in research and practice.15 Several instruments are currently in used to assess subjective oral health issues, hence Oral Health Related Quality of Life (OHRQoL).16 They also help us to understand the influence
on oral health as well as clinical interventions on patients’ wellbeing, at individual and population level.17 Factors such as gender age, or cultural background of the patient play an significant role in the perception of health.18 Other variables such as demographic, socio-economic, dental care use, may also affect the subjective perceptions of OHRQoL.19,20 Young people might consider aesthetics (staining, holes, malalignment) to be more relative to their OHRQoL. However, functional teeth for eating and speaking may be far more important for elderly.16 It is thus important to obtain knowledge of what people perceive about their oral health in order to direct health strategies to provide treatment of oral diseases and rehabilitation in cases of tooth loss.21 Quality of Life (QoL) is defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.11 With aging population, there should be adequate resources for improving QoL.12 It is a multi-dimensional and comprehensive concept that contains both positive and negative aspects of a person’s physical or psychological states, independence levels, social relationships, personal beliefs and environmental features.11 In epidemiological studies, measure of QoL along with clinical measures complement perceived needs of the population.12 Subjective measures provide important information to a patients functional, social and psychological wellbeing.13 Subjective measures allow healthcare professionals to evaluate the efficacy of treatment options from the viewpoint of a patients.14 QoL is gradually acknowledged as a valid and significant indicator of service need and intervention outcomes in research and practice.15 Several instruments are currently in used to assess subjective oral health issues, hence Oral Health Related Quality of Life (OHRQoL).16 They also help us to understand the influence on oral health as well as clinical interventions on patients’ wellbeing, at individual and population level.17 Factors such as gender age, or cultural background of the patient play an significant role in the perception of health.18 Other variables such as demographic, socio-economic, dental care use, may also affect the subjective perceptions of OHRQoL.19,20 Young people might consider aesthetics (staining, holes,
malalignment) to be more relative to their OHRQoL. However, functional teeth for eating and speaking may be far more important for elderly.16 It is thus important to obtain knowledge of what people perceive about their oral health in order to direct health strategies to provide treatment of oral diseases and rehabilitation in cases of tooth loss.21
METHODOLOGY
This cross-sectional research was conducted at the out-patient department of Rashid Latif Dental Hospital,
Lahore. It was completed in 4 months (March 2019 to June 2019) with a sample size (n) of three hundred and seventy tree individuals aged between 18-80 years. Ethical permission was obtained from Rashid Latif Dental College Research Department. (Ref No. RLDC/001344/19). Verbal consent was taken from all participants before clinical examination and questionnaire. All participants were informed of their voluntary participation, data protection and option of opting out at any time. The size of the sample was calculated based on an expected prevalence of 30% and 95% confidence interval (CI) and z value of 1.96 level.25 A minimum sample size of 322 people was calculated and further increased to account for possible losses. Inclusion criteria comprised
random selection of all adult patients coming to the outpatient department, having at-least ten teeth aged between1 8-80 years, patients with systemic illness and people refusing to take part in the study were excluded. Three examiners were trained and calibrated against a gold standard to perform all oral examinations following WHO guidelines.26 Intra-observer agreement after 2 days of examining the same patients was found to be 99% for missing teeth (Kappa score 0.9).
        After an introduction to the research, the respondents were asked about the effect of oral impacts on their daily
life in the last six months. The Oral Impacts on Daily Performance (OIDP) questionnaire is founded on Locker’s
models of the World Health Organisation’s (WHO) classification of disabilities impairments, and handicaps.27
It measures the impact of oral conditions on performing everyday activities in terms of severity of the self-reported
impacts.27 Both English and other language (Urdu) version of OIDP were on hand for ease of management. Responses were coded from 0 (no effect) to 5 (severe effect). To determine the prevalence of each oral impact, original responses were dichotomised by a strict cut-off point (>3). The total OIDP score was calculated by adding the values for individual responses respectively, dividing by the maximum score (45) and multiplying by 100. Thus, the score ranges between the values of 0 to 100. Higher OIDP scores represent poorer OHRQoL. The total OIDP score (0-100) was divided into three categories of low impact score
158 Daily impacts of missing teeth in adult population in Lahore, Pakistan JPDA Vol. 30 No. 03 Jul-Sep 2021
Bari YA/ Waqar SM/ Nasir S/ Zafar K/ Baig NN/ Shoro FN/ Abid K/ (0-33.3), medium impact score (33.4-66.6) and high impact score (66.7-100). Ordered Logistic regression was run as all three categories of the score were equal
      The intraoral examinations were performed on dental chair under dental unit light, using mouth mirrors and probes as recommended by the WHO.26 Each missing tooth was entered into its respective box on the scorecard. Cause of missing teeth was not considered as missing due to caries, mobility or trauma would have similar impacts. Third molars, bridges and edentulous patients were not considered. For regression analysis missing teeth were simply dichotomised into the basic two categories of either having missing teeth or not. For purposes of Chi square and trend the number of missing teeth for each person was divided into varying categories based on few, more or many missing teeth. Table 1 shows further details of the categorization. The other clinical variables used were number of carious teeth, previously filled teeth and other oral conditions including crowns, bridges, periodontal status and impactions were recorded. Demographic variables included gender and marital status. The independent variables studied were categorized.
Table 1: Categorization of Number of Missing Teeth
Age was divided into three groups: young adults 18-30, middle age adults 31-50, and older adults 51-80 years old. Education was classified into four groups: “Primary,” “Secondary,” “University” and “No education”. Occupations were classified into four groups: Manager, Employed, Manual Labour and Unemployed. All data collected was entered into statistical software package STATA-14 (STATA Corp, College Station, Texas, USA) for further analysis. Chi2 for trend and Mantel-Haenszel (MH) analysis were used to determine the association of difference of impacts for participants having missing teeth compared to participants with normal number teeth, along with ordered logistic regression. 95% significance level (p-value <0.05) was selected for P-value.
RESULTS
A final sample consisted of 373 participants. The sample had more female participants (68.7%) as compared to male participants. The mean age was 33.7 years (95% CI 30.7- 36.7), with young adults (18-30 years) representing 57.5% and middle age adults (31-50 years) representing 31.5% of the sample. Majority of the participants were educated to some extent, and 69.8% of the sample was either unemployed or a homemaker (Table 2).
       Mean number of missing teeth was found to be 1.70 (95%CI 0.95-2.44). Among missing teeth left mandibular
second molar had highest frequency of being missing with
Table 2: Characteristics and Socio-demographics of study sample (n=373)
17% of the total number of samples. Followed by left and right mandibular 1st molar with 14% each of the total sample.
      The mean OIDP score among participants was 23.43 (95%CI 17.1-29.7). Using the strict cut-off point of impacts scored 3 and above (OIDP>3), 63.1% of the participants were showing oral impacts. The highest prevalence was found for difficulty eating (52.1%), followed by difficulty in relaxing/sleeping (30.1%). However, 36.9% of the  population was free from severe oral impacts and only 22.1% experienced more than 5 different oral impacts scored >3. Table 3 shows the prevalence for all the oral impacts due to teeth loss. 159
       The bivariate association was performed between each OIDP impact score and number of missing teeth. Table 4
shows the relation between OIDP impacts and number of
Table 3: Prevalence and mean OIDP reported for severity <3 (n=373)
Table 4: Chi square test for trend for Number of Missing Teeth and each Impact on daily performance, and Mantel-Haenszel Analysis with crude and adjusted ratios (* for significant values) (n=373)

missing teeth using the Chi-squared for trend and MantelHaenszel (MH) analysis. Chi-square for trend showed that higher number of missing teeth significantly affected quality of life as difficulty eating, difficulty speaking and difficulty relaxing/sleeping. Furthermore, MH odds showed significant difficulty in eating and relaxing/sleeping only. For ordered regression analysis between the three ordered categories of OIDP score and missing teeth, it was observed that people with missing teeth are 1.33 (95%CI 0.84-5.8) times more likely to be in the higher categories of OIDP score when compared to people without missing teeth. It indicated a significant p-value of 0.03. After adjusting for sociodemographic variables and other clinical conditions, the odds ratio (OR) drops to 1.28 (95%CI 1.4-5.9) (Table 5) and p-value was significant to be 0.01. It was noticed that age, education and marital status did not show significant results in the analysis. Overall the results revealed that tooth-loss is directly associated to higher OHRQoL score which means it caused major effects in everyday life.

 Table 5: Ordered Logistic regression for association between Missing Teeth (Yes/No) and Categories of OIDP score
(Low, Medium, High): Odds ratio, 95% confidence intervals, p-value (n=373)

DISCUSSION

At the time of the study, 44% of the sample had one or more missing tooth.28 In this study, effect of missing tooth
was compared with OHRQoL on the basis of age, gender, occupation and education. In general, the association between missing teeth and OIDP was strong.
When the effect of age was compared with OHRQoL, the results showed that this did not have a significant effect
on the subjects OHRQoL. These results are similar to findings in previous studies that OHRQoL was not significantly
influenced by age.28,29 In previous studies men reported greater impacts on OHRQoL than women, although
statistically men and women were observed clinically to have similar tooth loss prevalence. Differences in the
discernment of OHRQoL between the two genders may be due to individual subjective notions formed through social
life and personal needs.30 However, In this study women showed greater tooth loss compared to men. In Pakistani society women may still be far less socially interactive than men. Women might also show least concerns about their
oral health conditions which eventually result in tooth loss. There were clear trends for managerial occupations for
having low impacts and manual occupations having more impacts. Burt et al. also determined that total tooth loss was a social issue as much as being related to disease.31 This may be because socio-economic status is related to
inequalities in health, and socioeconomically deprived people have higher risks of disease and suffer more from health issues.32 The results of this study showed a significant association between tooth loss and the different
socio-economic groups. More oral health impacts were noticed in unemployed (69.8%) and manual labour job
individuals (16.4%) compared to employed patients. This may be because of fact that employed patient shows more
concern about oral health and manages to bear expenses for dental check-ups.
Trend could be seen that more educated people visited the hospital for treatment. Around 89% of the sample had
at least some formal education. Educated individuals usually have better knowledge of their underlying disease, persuading themselves to get treatment.33 This study reported that 31.5% of educated individuals showed oral impacts when compared with less educated individuals. Previous studies suggested that people with higher education status tend to have the lowest risk for toothloss.34 However, the results of this study showed a lack of significant association between toothloss and education. Such finding may be due to a hospital setting of the research where a higher number of educated individuals came to get treated.
A study conducted by Susin et al., the early eruption of molars makes it the most susceptible tooth of the permanent dentition.35 Similarly, current study reported that the most common missing teeth are permanent molars. Difficulty eating, and relaxing/sleeping were the top reported impacts. The significant impact of smoking on missing teeth supports the opinion that tooth loss is also related to social behaviours, especially those related to oral hygiene practices, dietary habits, smoking and regular dental check-ups. These factors also cause caries and tooth loss.6 Similar to this report present study also concluded that poor oral hygiene and smoking effect oral health which eventually results in tooth loss. It was also noticed that tooth loss has a definite impact on OHRQoL of the patients. The severity of impact on OHRQoL increased with higher number of teeth loss leading to greater oral impairment. Study participants with more than 10 teeth lost showed highest OIDP score indicating higher oral impairment. This result is similar to the study reported by Batista et al., in which the impact on OHRQoL was higher with loss of more than 13 teeth.36 Similar findings of more frequent oral impacts was reported among individuals with fewer natural teeth.37 It has been already published, that the higher number of missing teeth, the more impacts on
OHRQoL.
Dentistry faces serious challenges, addressing them would require major changes in strategy. In epidemiological studies, both normative and subjective needs should be accounted for by professionals.38 Measuring OHRQoL is necessary to account for different perceptions about individual responses to the same diagnosis.16 It would be unethical to treat a person not wanting specific treatments. Subjective measures answer the missing link of why an individual wants treatment which is directly linked to the impacts on the persons daily life.
Due to the cross-sectional nature of this study, it is not suitable to evaluate causal relationships. Other limitations are regarding timeline to exposure and its impact. Potential limitations may also include change of exposure over the assessment period. OHRQoL data being self-reported varies from individual to individual. Different combination of self-reported impacts can lead to similar scores and are difficult to interpret.16 There is a chance for having recall bias.
The study may be over reporting the results as all the sample was taken from a hospital setting. Another limitation would be the demarcation for categorisation of Missing teeth used for this study. One might argue that the position of the missing tooth may have a different impact, thus may require more elaborate categorisation.

 

CONCLUSIONS

At the time of the study, 44% of the population had one or more missing tooth. Difficulty eating, and relaxing/sleeping were the top reported impacts with significant results. Participants with missing teeth were more likely to report higher scores and increased number of impacts on their OHRQoL than people without missing teeth. In this sample, education and age did not appear to play a role in the association between missing teeth and OHRQoL. Within the limitations of the study, it can be concluded that tooth loss has a definite negative impact on OHRQoL. As the severity of toothloss increases, the OIDP score amplified indicating higher oral health impacts.

FURTHER RESEARCH

Further research is needed to confirm these findings, using longitudinal studies looking at the association between
missing teeth and OHRQoL along with the number and position of the missing teeth.

OTHER INFORMATION

No funding was required or obtained for this study.

CONFLICT OF INTEREST STATEMENT

Authors declare no conflict of interest in this research

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Daily Impacts of Missing Teeth in Adult Population in Lahore, Pakistan

 Hazik B. Shahzad                            BDS, MSc     

 Faiza Awais                                      BDS, M.Phil

 Noor-Ul-Huda Raza                          BDS, M.Phil

 Hanna A Majeed                               BDS, FCPS

 Maliha Shahbaz                                BDS, M.Phil

 Farhat Kazmi                                    BDS, M.Phil, PhD

OBJECTIVE: The objective of this study is to evaluate the impact of tooth loss on oral health related quality of life in adults.
METHODOLOGY: The survey was conducted during March – June 2019 at Rashid Latif Dental Hospital. A sample size of 373 adults aged 18-80 years was randomly selected from the out-patient department. Number of missing teeth was the main exposure, and it was clinically assessed. OHRQoL was evaluated through “Oral Impacts on Daily performance (OIDP) questionnaire”.
RESULTS: From total patients presented in OPD 44% had one or more missing teeth. Top reported impacts of missing teeth included difficulty eating and relaxing/sleeping problems. Adults with missing teeth showed 1.28 (95%CI 1.04-4.55) (P=0.01) times higher odds for reporting higher oral impacts compared to those without missing teeth.
CONCLUSION: Individuals with missing teeth likely had frequent difficulties in their daily lives due to missing teeth including trouble with eating, speaking, and oral infection, which could spread to the rest of your body.
KEYWORDS: OIDP, Tooth-loss, Adults, Missing teeth, Lahore
HOW TO CITE: Shahzad HB, Awais F, Raza NUH, Majeed Ha, Shahbaz M, Kazmi F. Daily impacts of missing teeth in adult population in Lahore, Pakistan. J Pak Dent Assoc 2021;30(3):157-163.
DOI: https://doi.org/10.25301/JPDA.303.157
Received: 13 July 2020, Accepted: 26 April 2021

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Infection Control Measures in Pakistani Dental Practices During COVID-19 Outbreak

 

Yashfika Abdul Bari                          BDS

Syeda Maliha Waqar                         BDS

Saqif Nasir                                         BDS

Kamil Zafar                                        BDS,FCPS

Nabeel Naeem Baig                          BDS,MPH

Farhana Nazir Shoro                        BDS

Khadijah Abid                                   BS Hons, MSc, MSPH

OBJECTIVE: The objective of this study is to assess infection control measures in dental practices during COVID-19 outbreak in Pakistan.
METHODOLOGY: It was a cross-sectional web based survey conducted during COVID-19 outbreak from the period of June 2020 to August 2020. The study participants were the dental surgeons who were either working in hospital setup or running their own private practice or working in private dental setup. The survey consisted of sets of questions to assess whether dental practitioners have implemented strategies to combat novel corona virus infection in their practice. It also consists of questions that assess aerosol generating procedures are commencing with or without out any COVID-19 symptoms.
RESULTS: About 39.1% participants reported that 75% of the number of patients in their clinic had been reduced and 52.2% of the participants reported that >50% of the patients came for endodontic procedures with pain. Eighty one percent of the participants were maintaining hand hygiene before touching all patients, 71.7% before any cleaning, 78.3% before any aseptic procedure, 81% after exposure to patient’s fluid and 80.4% after touching. There was low compliance regarding the use of personal protective equipment and almost 62.6% were using eye wear for all patients, 58.7% were disinfecting whole clinical room before new patient and 43.9% were using single use (disposable) examination set during COVID-19 outbreak.
CONCLUSION: Majority of dentist in Pakistan were following the recommendations and guidelines of infection control practices related to COVID-19 pandemic.
KEYWORDS: COVID-19, coronavirus, infection control measures, practices, dentistry
HOW TO CITE: Bari YA, Waqar SM, Nasir S, Zafar K, Baig NN, Shoro FN, Abid K. Infection control measures in Pakistani dental practices during COVID-19 outbreak. J Pak Dent Assoc 2021;30(3):152-156.

INTRODUCTION
The recent outbreak of COVID-19 has created havoc and chaos all over the world. It started from a small
city of China known as Wuhan in December 2019 and seized the entire universe gradually.1 The dental setup
has affected severely since the outbreak of this disease and the dental practitioners are considered amongst the highest risk due to the procedures which generate aerosols especially while using drills and ultrasonic devices which are responsible for aerosol production.2 Patients infected with COVID-19 will not only affect the dental practitioner but the surrounding and environment will also be contaminated during the dental procedures therefore many non-urgent and elective procedures has to be suspended or postponed and only emergency cases have to be catered.3 In order to minimize the risk, many guidelines and recommendations have been made while dealing the patients in this pandemic to ensure the safety of dentist as well as patient. the use of personal protective equipment which includes facemasks, gloves, gowns and protective eyewear, rinsing patient’s mouth before performing any dental procedure and disinfecting dental units by chemical or non-chemical means have been emphasized to stop the
spread of infection
         With all the guidelines, it should be of prime importance to gauge the number of dentist practicing the guidelines made post COVID-19 outbreak. Hence, no studies has been conducted in Pakistan to assess the practice of dental practitioners regarding guidelines of COVID-19 infection, therefore the aim of current study was to assess the infection control measures in dental practices during COVID outbreak in Pakistan. The study would aid in assessing infection control practices that dentists were following and assist us in designing and devising strategies to combat COVID-19 among dental practices.
METHODOLOGY
It was a cross-sectional web based survey conducted during COVID-19 outbreak from the period of June 2020
to August 2020. The study participants were the dental surgeons who were either working in hospital setup or
running their own private practice or working in private dental setup in Pakistan. The proforma was transferred into
Google Forms to be accessible to number of dental surgeons via Facebook, WhatsApp and emails. The non-probability convenience sampling technique is used to recruits the study subjects. The age of dental practitioners was 20-50 years and both genders were included
            Ethical approval of the study was taken from ethical review board of Ameen medical and dental center (ERC-AMDC/025/2020). Informed consent was taken from all the study participants digitally through the google forms.
The survey form was devised using international guidelines that should be opt in dental practices post COVID-19.
Ge Z-y et al. stated all the major changes that should be implemented in dental practices post COVID-19 outbreak
to mitigate the contamination and transmission of infection.5 The survey form was also devised according to the guidelines set by Bouguezzi A et al. regarding measures taken before
each dental treatment. The survey consist of sets of questions to assess whether dental practitioners have implemented strategies to combat novel Corona virus infection in their
practice. It also consists of questions that assess aerosol generating procedures are commencing with or without out
any COVID-19 symptoms.
Before analysis responses were checked for duplication and missing values by principal investigator. All the duplicate responses and missing data were excluded from the analysis. Data was analyzed using SPSS version 23. Descriptive analysis of all variables were performed. Results were presented as frequencies and percentages in tabular forms.
RESULTS
 Almost 250 participants were approached out of which 230 responded back and filled the survey. Most of the participants were practicing as dental practitioners from 2-5 years (63%) and the least from 10-15 years (5.2%). The
results regarding the setting of dentists practicing, dentist shutting down their clinics, patient outflow in dental clinics, COVID-19 patient’s management and patients awareness about the infection control practices specific to COVID-19 are summarized in table 1
Table 1: Practice of dental practitioners during COVID-19

About 52.2% of the participants reported that >50% of the patients came for endodontic procedures
with pain whereas 20.4% of the participants reported that >50% of the patients came for restorative procedures without pain post COVID-19 outbreak. There was a high compliance regarding the participants taking medical and travel history thoroughly every time i.e., 73%. However, low compliance was reported in checking vitals by the participants. The responses related to the practice of whether the participants had removed the reading material and toys (non-essential objects) from waiting area, changed seating distance of 2 meter, to schedule the patient apart enough to avoid their presence at same time and adequate ventilation of 60L/s per room in their waiting areas is mentioned in table 2. Hygiene and practices for infection control during COVID-19 are

Table 2: During COVID-19 different procedure percentage, precautions and guidelines

Table 3: Hygiene related practices for infection control during COVID-19

summarized in table 3. Participants were shown to follow hand hygiene practices almost 70-81%. There was low
compliance of using other personal protective equipment’s i.e., eye wear, and gowns. The details of other hygiene and infection control practices during COVID-19 is listed in table 3.

DISCUSSION
    The COVID-19 is an exceptional condition that has affected the health care workers globally especially dental
health care providers. This cross-sectional study evaluates the compliance and practices of the infection control measures taken by Pakistani dentist.
The COVID-19 pandemic have resulted in significant change in the practices of dentist affecting the working hours
and thus substantial reduction in number of patients. The present study reported almost 95% of drop in the working
hours due to complete shutdown or just few hours of working at alternate days as per local government policies.
According to the American Dental Association, all elective dental care procedures such as fillings, scaling and
polishing, orthodontic, cosmetic dentistry and prosthodontic work should be postponed during the pandemic. This has resulted in only dealing with dental emergencies including symptomatic irreversible pulpitis, acute apical abscesses, avulsion or luxation injuries and cellulitis. The finding of this study are in accordance with these guideline and the most commonly performed procedure was endodontics with more than 50% of patients presented to the clinics with severe pain.
With regards to the question of taking history and pre-operative assessment before treating the patients, most
of the practitioners responded that they perform thorough assessment only in COVID-19 suspected individuals. In
contrary to this, studies in Jordanian, Norwegian and Italian dentists have reported lack of effective pre-operative
assessment of patients related to COVID-19 signs and symptoms.
Question was also asked about the precautions taken at the waiting area. In this study, 76.1% of dentist were following seating distance protocol in their clinical setting areas. The result of our study is in line with the Cagetti et al. study who also reported 74% of dentist following the seating distance protocol.8 This needs to be improved until the pandemic completely ends. WHO recommends the use of negative pressure rooms with a minimum of 12 air changes per hour or at least 160 L/s per patient for the treatment of confirmed or suspected cases of COVID-19. Only 54% of dentist in the present study were having adequately ventilated rooms. These findings are in contrary to the study in Italian dentist who were having 88% ventilated rooms.
Before starting any treatment in COVID-19 suspected or confirmed patient certain measures such as pre-operative
mouth rinse, rubber dam application, high suction evacuator etc. are followed to prevent contamination of operatory with the aerosol generating procedures (AGP).11 Only 23% of Pakistani dentist were using Chlorhexidine as a pre-operative mouth rinsing protocol in COVID-19 suspected or confirmed cases. However, 54% Italian dentist were turned out to using the same protocol.
The practice of using personal protective equipment such as N-95 mask. Eye wear, gloves, gowns and face shields
has been recommended to prevent cross infection. In this study, 62% of dentist were wearing goggles, where as 55.2%, 80.4% and 22.2% were using face shields, face masks, and respirators, respectively. The findings of Khader et al. assesses awareness only and Modi et al. were found out to be similar to our study.9,12 However, Gambhir et al. reported the lack of awareness of one third of dentist about the proper PPE in Indian dentists.13 Studies have also been conducted comparing the masks and respirators in controlling the infection in similar pandemics previously which showed thirty times greater superiority of N95 or respirators over masks.14-16 Respirators offer considerably better resistance to fluid penetration forming the seal around the mouth and nose. The lower numbers of respirator use by dentist can have serious consequences. Hence it is recommended to use respirators during this COVID-19 pandemic.
The strengths of the study are its good response rate, practice and attitudes of dentists towards infection control
measures were assessed. This study will also help in improving and setting up guidelines further regarding the
infection control practices. The limitations are small size and thus lack of generalizability of results to Pakistani
dentists. Another limitation of our survey is response bias. Similar studies were also conducted in different parts of the world with variable questionnaire. So there is also a need to formulate a uniform questionnaire form for assessing the infection control practices particularly for pandemics.

CONCLUSION
Majority of dentist in Pakistan were following the recommendations and guidelines of infection control practices
related to COVID-19 pandemic. However, there are still few areas such as waiting area settings, use of respirators and other PPEs which needs improvement.

CONFLICT OF INTEREST
None to declare

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Infection Control Measures in Pakistani Dental Practices During COVID-19 Outbreak

Yashfika Abdul Bari                          BDS

Syeda Maliha Waqar                         BDS

Saqif Nasir                                         BDS

Kamil Zafar                                        BDS,FCPS

Nabeel Naeem Baig                          BDS,MPH

Farhana Nazir Shoro                        BDS

Khadijah Abid                                   BS Hons, MSc, MSPH

OBJECTIVE: The objective of this study is to assess infection control measures in dental practices during COVID-19 outbreak in Pakistan.
METHODOLOGY: It was a cross-sectional web based survey conducted during COVID-19 outbreak from the period of June 2020 to August 2020. The study participants were the dental surgeons who were either working in hospital setup or running their own private practice or working in private dental setup. The survey consisted of sets of questions to assess whether dental practitioners have implemented strategies to combat novel corona virus infection in their practice. It also consists of questions that assess aerosol generating procedures are commencing with or without out any COVID-19 symptoms.
RESULTS: About 39.1% participants reported that 75% of the number of patients in their clinic had been reduced and 52.2% of the participants reported that >50% of the patients came for endodontic procedures with pain. Eighty one percent of the participants were maintaining hand hygiene before touching all patients, 71.7% before any cleaning, 78.3% before any aseptic procedure, 81% after exposure to patient’s fluid and 80.4% after touching. There was low compliance regarding the use of personal protective equipment and almost 62.6% were using eye wear for all patients, 58.7% were disinfecting whole clinical room before new patient and 43.9% were using single use (disposable) examination set during COVID-19 outbreak.
CONCLUSION: Majority of dentist in Pakistan were following the recommendations and guidelines of infection control practices related to COVID-19 pandemic.
KEYWORDS: COVID-19, coronavirus, infection control measures, practices, dentistry
HOW TO CITE: Bari YA, Waqar SM, Nasir S, Zafar K, Baig NN, Shoro FN, Abid K. Infection control measures in Pakistani dental practices during COVID-19 outbreak. J Pak Dent Assoc 2021;30(3):152-156.

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