Vol. 31 No. 02 Apr-Jun 2022

Hamna Khawaja1                  BDS, MCPS
Uzma Shahid2                       BDS, MCPS
M Waseem Ullah Khan3       BDS, FCPS
Hira Asghar4                         BDS, M.Phil
HM Owais Nasim5                BDS, M.Phil
Ali Farooq6                           BDS, FCPS

OBJECTIVE: The objective of this study was to assess the location of foveae palatinae in relation to vibrating line for
developing posterior palatal seal to enhance retention of maxillary complete dentures. Retention of a complete denture is the
major factor to resist the forces of dislodgement along the path of insertion. In complete denture fabrication, fovea palatinae
is the guideline for the posterior extension in the maxilla. Fovea palatinae mucous gland secretion helps in the retention by
forming a thin layer within the maxillary complete denture.
METHODOLOGY: The study was conducted in Sharif College of Dentistry in Lahore, Pakistan on a sample size of two
hundred and fifty dentate, partially dentate and edentate patients with different age groups. Clinical examination of the maxilla
was conducted for assessment of the vibrating line, whether it was at, anterior to or posterior to the fovea palatinae. The
researcher used an indelible pencil to mark the ah line i.e vibrating line and its distance with fovea palatinae was measured.
RESULTS: Results were concluded using SPSS Version 23. The fovea palatinae were mostly found to be located at 1.68
mm±1.11 anterior to the vibrating line. Thus, the dentists should assess this distance for the posterior extension of the maxillary
denture.
CONCLUSION: Fovea palatinae location in relation to vibrating line is an important landmark for posterior palatal seal in a
complete denture. In the majority of cases, fovea palatinae were located 1.68 mm±1.11 anterior to the vibrating line.
KEYWORDS: Foveae Palatinae, Vibrating line, Retention, Posterior palatal seal.
HOW TO CITE: Khawaja H, Shahid U, Khan MWU, Asghar H, Nasim HMO, Farooq Ali. Relation of vibrating line to location
of fovea palatinae in local population. J Pak Dent Assoc 2022;31(2):81-85.
DOI: https://doi.org/10.25301/JPDA.312.81
Received: 16 July 2021, Accepted: 07 January 2022

INTRODUCTION
Although a lot of patients maintain good care of their teeth but still many patients require dental prostheses in the oral cavity to establish esthetics, speech, mastication and to restore the lost structure of the oral cavity like teeth, mucosa and ridge.1 The oral cavity of every
individual is unique with respect to anatomical landmarks, yet there are more innovations with respect to area and genetic differences in populations of that specific area. Therefore, proper evaluation of landmarks provides positive guidance in the fabrication of denture and population-related differences for the specifically constructed prosthesis. The removable denture is expected to satisfy fundamental principles of retention, support, stress distribution and also of tissue preservation. Successful prosthodontic treatment requires dental prosthesis to be retentive.2
Retention of the denture is defined as “resistance of a denture to vertical movement away from the basal tissues’ and as ‘that quality inherent in the prosthesis acting to resist the forces of dislodgement along the path of insertion.2 ” Contributory factors in removable denture retention are atmospheric pressure, surface tension, vacuum, adhesion, cohesion, viscosity, border seal, base adaptation, seating
force and muscular control. Among these most important factors for retention are good base adaptation and border seal.2,3 In upper complete denture, good base adaptation and the posterior palatal seal of the denture are formed to bring denture into contact with adjacent oral tissues to exclude the air from between the denture and the supporting mucosa. This will establish an effective valve seal.4
Fovea palatinae are the mucous gland in the maxilla. This anatomical landmark can be located as two small pits (fovea palatinae) one on either side of the midline on the anterior part of the soft palate in maxilla.4,5 Mostly during the procedure of insertion of a denture, fovea palatinae is given relief for removal of pressure on this specific area. The posterior limit of maxillary complete denture has a great impact with respect to the location of fovea palatinae.5,6 The fovea palatine should not be covered in patients with thick and ropy saliva since the thick consistency of saliva makes denture unretentive due to increased hydrostatic pressure. Fovea palatinae are located in close proximity to the vibrating line and considered as useful guide.7 The Vibrating line is an imaginary line located on the posterior part of the palate, differentiating between moveable and immovable tissue of the soft palate.3,4,5,6,7,8 It extends from one hamular notch to the other. The vibrating line can be identified when the soft tissue in the palate is moving and are used to clinically establish the posterior extent of the maxillary complete dentures.9 The location of the vibrating line can be detected by using different techniques.
. Phonation ‘Ah’ sound
. Nose blowing method
. Swallowing method10
A vibrating line can be located by asking the patient to say AH with short intervals not vigorously but in small bursts. It is a curved line between both hamular processes. Mostly it is carved in a butterfly shape. The vibrating line makes the most posterior extension of maxillary denture base.11
According to Boucher, fovea palatinae are always present in soft tissue and close to the vibrating line that is the best guide for the posterior denture extension.12 The prosthodontists had consensuses about the relation between the posterior border of the maxillary denture and vibrating line.13 The posterior palatal seal is located in the soft tissue at thebjunction of the hard and soft palate on which the posterior
part of the maxillary denture can insert pressure within the physiological limit of tolerance on tissue, which will ultimately help to improve the retention of the denture  GPT).14 It provides stability, retention, compressibility and comfort.
The posterior palatal seal is three-dimensional area where pressure within tolerable limits of the tissues can be applied, to increase retention of the maxillary removable denture by providing an effective seal, prevents food entrapment under the denture base, reduces gagging, makes the palatal border of maxillary denture less problematic to the tongue.11,15,16
The anteroposterior dimension of the posterior palatal seal is influenced by the type of soft palate which indicates the broad, medium and narrow posterior palatal seal area respectively. The soft palate is classified as
1. Class 1: it indicates horizontal soft palate with a
10-degree angle to the hard palate that is with very less
muscular activity
2. Class 2: palatal contour lie between class 1 and class
3 and have around a 45-degree angle to the hard palate
3. Class 3: it indicates a high v-shaped palatal vault with around a 75-degree angle to the hard palate.17
There are several ways for the establishment of the seal at the posterior palate. The technique that is mostly used is by marking the vibrating line when the patient says ah.3,6,9,17,18 In this approach, the dentist draws a line with an indelible pencil through pterygomaxillary notch anterolaterally when the patient pronounces ah sound in short bursts, then the moveable and immovable part of the palate is visible.3,6,9,18

METHODOLOGY
Inclusive criteria
The patients which were included are
. Both gender [male and female]
. The age range of 20 to 79 years
. The normal pink color palatal mucosa with clinically visible fovea palatinae

Exclusive criteria
The patients which were excluded from the study are
. Patients with a history of surgery/ trauma in the craniofacial region.
. Patients with acquired and congenital craniofacial defects
. The patient presented with any pathology or inflammation of palatal mucosa
. The patient presented with limited mouth opening

This cross-sectional observational study sample size was two hundred and fifty patients dentate, partially dentate and edentate. The sample size was calculated according to sample size determination in health studies; a practical manual of World Health Organization (WHO) Genava5. There are many methods to evaluate fovea palatine, vibrating line, and posterior palatal seal but in this study, the most convenient
method with the marking of the ‘Ah’ line in patients is used. People who could pronounce the “Ah” sound repeatedly with their mouths open were considered in this study. After individual’s education and counseling, written Informed consent was obtained from them before including them in the study. All patients were examined and the individual patient was seated on a dental chair, turned on dental unit
light for proper illumination inside the oral cavity. The individual was instructed to be seated in a normal relaxed position and wide open his/her mouth. With the help of gauze, the palatal mucosa was dried before any evaluation. Initially, it was determined whether the foveae palatinae was visible or not visible in the soft palate mucosa and then the position of foveae palatinae was marked. The researcher marks the palate with an indelible pencil to record the vibrating line across the soft palate by asking the patient to say “Ah” repeatedly with the mouth open. In the end, the relationship of the vibrating line with the fovea palatinae was identified and the distance of fovea palatinae was
measured with a divider. The findings were recorded in proforma as to whether fovea is present anterior, posterior or at the vibrating line and the distance with vibrating line was also measured. The procedure was repeated twice to verify the accuracy of markings.

RESULTS
    The results were analyzed using SPSS Version 23. The mean age of the male and female patients was calculated. Mean distance of fovea palatinae to ah line in both the gender were calculated. Then the frequency of various location of fovea palatinae with respect to vibrating line were calculated. The fovea palatinae mostly existed 1.68 mm±1.11 anterior to the vibrating line. The mean age of the male patients in
this study was 34.41years ± 15.82, while that of female patients was 30.15 years± 11.99. There was no statistically significant difference between the mean ages of both genders.P=0.072 (Mann Whitney U test) Table 1. The mean distance of the fovea palatine to ah line in male patients was
1.37mm± 1.17 while in females was 1.53mm± 1.11. We found no statistically significant difference between the mean distance in both genders. P= 0.141 (Mann Whitney U test) Table 2. Out of total number of 250 patients (n= 250), 167 patients (n=167) 66.8% have fovea palatinae anterior to vibrating line (ah line), 46 patients (n= 46) 18.4% have fovea palatinae posterior to vibrating line (ah line) and 37 patients (n=37) 14.8% have fovea palatinae at vibrating line (ah line).
   In Figure 1, the Mean distance of fovea palatinae to ah line when fovea is anterior to ah line is 1.68mm ±1.11, Mean distance of fovea palatinae when it is posterior to ah line is 1.52mm ±0.95.T test was used to compare the mean distances p= 0.38. The result is not significant that is there is no statistically significant difference between the mean distance of fovea palatinae to ah line (vibrating line) regardless of its
location with respect to ah line (vibrating line).

DISCUSSION
   There is more advancement in the field of dentistry including implants which increase a lot of retention in the prosthesis but still the need for physiologically retentive complete denture is there in developing countries like Pakistan1. Therefore, useful and precise treatment of
edentulous patients in the form of a retentive and functionally efficient complete denture is inevitable. So different techniques to enhance retention in complete denture including AH sound method, palpatory method, swallowing method and nose blowing method i.e Valsalva maneuver is used.2 In these techniques ah sound method is the easiest and mostly used by dental colleges and institutions.7,10,12 Previously
various studies have been done for finding the location of the vibrating line and fovea palatinae. TL LYE conducted a study with a sample size of 100 patients and found that radiographic, clinical, and histological studies indicate the location of the fovea palatinae was 1.31mm in front of the vibrating line. Out of 100 patients, fovea palatinae was visible in 92 patients. The patients who have fovea palatinae posterior to vibrating line were 12, 16 patients have fovea palatinae on vibrating line and 64 patients have fovea palatinae anterior to vibrating line. Our study also shows these type of results as in our study the patients have fovea palatinae anterior to vibrating line, posterior to vibrating line and also at vibrating line. Most of patients had fovea palatinae anterior to ah line that is single vibrating line. Silverman describes
that the posterior palatal seal could be extended 8.2 mm further dorsally to increase retention and stability. The vibrating line and fovea palatinae determines the extent of posterior palatal seal area. For good retention the posterior palatal seal should be in compressible soft tissue so that maxillary denture become retentive and sealed at post dam area. Here the soft palate type consideration is very important. In ClassI and Class II type soft palate there is expected wide compressible area of posterior palatal seal but in Class III always sharp margin of post dam is required as a little increase in size of posterior palatal seal can cause gagging , nausea and poor denture seal. Alaousi also conducted a study on 200 subjects and concluded that fovea palatine is a very important posterior palatal seal landmark that aids in denture retention. He selected patients randomly without inclusive criteria of soft palate type. In his study 50.9% of patients had their fovea palatinae and vibrating line coinciding, 44.5% of patients had vibrating line in front to the fovea palatinae and only 6.4% had vibrating line posterior to the fovea palatinae. Chen et al. also carried out a study on 104 subjects. Out of which 72 have visible fovea palatine. 25 % have coinciding fovea palatine and vibrating line and 75% have vibrating line anterior to fovea palatine but these results have less coincidence with our study as our subjects show more subjects with fovea palatine anterior to vibrating line and fewer subjects have fovea palatine posterior to vibrating
line. We also suggest a single ah line that is vibrating line concept, it is more reliable than confusion between anterior and posterior ah line or vibrating line concept. As it is demarcated in patients when they pronounce ah in short vigorous bursts. Fenn and associates and Anderson and Storer defined fovea palatine in the glandular region of the soft palate. Sears and Nagle suggest the fovea palatine mark the posterior limit of the hard palate and Sicher suggests the fovea palatine is present immediately behind the boundary of the hard and soft palate junction. Swenson suggests that the vibrating line is 2mm anterior to the fovea palatine

CONCLUSION
The location of the fovea palatine is of utmost importancevduring forming the posterior palatal seal in the maxillary denture. Its location helps the dentist in creating an adequate seal of the maxillary denture by pressing the soft tissue. The exact location and demarcation of fovea palatine and ah line whether fovea is anterior, posterior or at ah line i.e. vibrating line provides an ideal guide for the posterior palatal seal of the maxillary denture.

CONFLICT OF INTEREST
None declared

REFERENCES

1. Kumar B, Naz A, Rashid H, Butt AM. Location of the Vibrating Line with Respect to Fovea Palatini in Class I, Class II and Class III
Soft Palate Types. J Pak Dent Assoc. 2016;25:60-66.

2. Zarb G, Hobkirk JA, Eckert SE, Jacob RF. Prosthodontic treatment for edentulous patients. (13th Ed.) St. Louis: Elsevier
Mosby. 2013:176-252.

3. Krysinski ZJ, Prylinski M. Carving of a master cast to obtain a posterior palatal seal of a complete maxillary denture as performed
by four prosthodontists: A pilot study. J Oral Sci. 2007;49:129-32.
https://doi.org/10.2334/josnusd.49.129

4. Yasmen T. Reliability of fovea palatinea in determining the posterior palatal seal. J Baghdad Coll Dent. 2009;21:41-55.

5. Sanofer AA, Gounder R. Assessment of the location of fovea palatine in relation to vibrating line in South Indian population. J Int Dent Med Res. 2017;10:883-6.

6. Goyal S, Goyal MK, Balkrishanan D, Hegde V, Narayana AI. The posterior palatal seal: Its rationale and importance: An overview. Eur
J Prosthodont. 2014;2:41-7.
https://doi.org/10.4103/2347-4610.131972

7. Kyung KY, Kim KD, Jung BY. The study of anatomic structures in establishing the posterior seal area for maxillary complete dentures.
J Prosthet Dent. 2014;112:494-500.
https://doi.org/10.1016/j.prosdent.2014.01.002

8. Lye TL. The significance of the fovea palatini in complete denture prosthodontics. J Prosthet Dent. 1975;33:504-10.
https://doi.org/10.1016/S0022-3913(75)80162-4

9. Akhtar N, Tanveer S, Chaudhary MA, Ahmad S. The reliability of foveae palatinae in determining the location of vibrating line in
edentulous patients. Pak Oral Dent J. 2017; 37:368-70.

10. Limbu IK, Basnet BB. Relationship of fovea palatinae to vibrating line as a reliable guide in determining the posterior limit of maxillary
denture. J Oral Res Review. 2019;11:68.
https://doi.org/10.4103/jorr.jorr_1_19

11. Thapa D, Chandra S, Karki S. Verifying relationship between fovea palatini, vibrating lines and junction between hard and soft palate.
Orthodontic J Nepal. 2016;6:32-4.
https://doi.org/10.3126/ojn.v6i1.16177

12. Hussain SZ, Samejo I, Qamar K. An investigation in to the concepts and techniques used for establishing postpalatal seal in undergraduate dental curriculum. Pak Oral Dent J. 2010;30.

13. Kumar B, Rameez M, Rashid H. Methods used to establish the posterior palatal seal for maxillary complete denture prosthesis. The
Pak J Medicine Dentistry. 2019;8:6-.

14. Ferro KJ, Morgano SM, Driscoll CF, Freilich MA, Guckes AD, Knoernschild KL, McGarry TJ, Twain M. The Glossary of Prosthodontic
Terms.

15. Mishra S, Rashmi BM, Ravishankar K, Khan S, Sharma A, Midhula V. Contemporary concepts and techniques of teaching posterior palatal seal among dental colleges of karnataka: a cross-sectional survey. J Clin Diag Res. 2020;14.
https://doi.org/10.7860/JCDR/2020/43743.14006

16. Lekay-Adams MR. A comparison of posterior palatal seal creation in complete dentures by private practitioners and students at the
University of Pretoria (Doctoral dissertation, University of Pretoria).

17. Chhetri S, Rathi A, Gupta N. Relation of fovea palatine and vibrating line in different soft palatal forms. J Nobel Med Coll. 2019;8:12-5.
https://doi.org/10.3126/jonmc.v8i1.24449

18. Maller SV. arthi KS. A review posterior palatal seal. J Ind Acad Dent Spec. 2010;1:16-21.

Hamna Khawaja1                  BDS, MCPS
Uzma Shahid2                       BDS, MCPS
M Waseem Ullah Khan3       BDS, FCPS
Hira Asghar4                         BDS, M.Phil
HM Owais Nasim5                BDS, M.Phil
Ali Farooq6                           BDS, FCPS

OBJECTIVE: The objective of this study was to assess the location of foveae palatinae in relation to vibrating line for
developing posterior palatal seal to enhance retention of maxillary complete dentures. Retention of a complete denture is the
major factor to resist the forces of dislodgement along the path of insertion. In complete denture fabrication, fovea palatinae
is the guideline for the posterior extension in the maxilla. Fovea palatinae mucous gland secretion helps in the retention by
forming a thin layer within the maxillary complete denture.
METHODOLOGY: The study was conducted in Sharif College of Dentistry in Lahore, Pakistan on a sample size of two
hundred and fifty dentate, partially dentate and edentate patients with different age groups. Clinical examination of the maxilla
was conducted for assessment of the vibrating line, whether it was at, anterior to or posterior to the fovea palatinae. The
researcher used an indelible pencil to mark the ah line i.e vibrating line and its distance with fovea palatinae was measured.
RESULTS: Results were concluded using SPSS Version 23. The fovea palatinae were mostly found to be located at 1.68
mm±1.11 anterior to the vibrating line. Thus, the dentists should assess this distance for the posterior extension of the maxillary
denture.
CONCLUSION: Fovea palatinae location in relation to vibrating line is an important landmark for posterior palatal seal in a
complete denture. In the majority of cases, fovea palatinae were located 1.68 mm±1.11 anterior to the vibrating line.
KEYWORDS: Foveae Palatinae, Vibrating line, Retention, Posterior palatal seal.
HOW TO CITE: Khawaja H, Shahid U, Khan MWU, Asghar H, Nasim HMO, Farooq Ali. Relation of vibrating line to location
of fovea palatinae in local population. J Pak Dent Assoc 2022;31(2):81-85.
DOI: https://doi.org/10.25301/JPDA.312.81
Received: 16 July 2021, Accepted: 07 January 2022

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Ahmed Tariq1                               BDS
Juzer Shabbir2                             BDS, MDS
Naheed Najmi3                             BDS, MCPS
Muhammad Athar Khan4            MPH, MCPS, MBA, MBBS
Tazeen Zehra5                             BDS, FCPS
Tahera Ayub6                              BDS, FCPS
Muhammad Anas Kamran7       BDS

OBJECTIVE: To determine and compare the frequency of endodontic emergencies (EE) with other dental conditions in patients
attending Qamar Dental Hospital (QDH), Karachi during first wave of COVID-19 pandemic.
METHODOLOGY:The dental records of all the dental patients (n= 1824) who attended the QDH during first wave of
COVID-19 Pandemic peak were retrieved and divided into 3 groups based on diagnostic conditions:1) - non-emergency
(NE), 2)- Emergency endodontic (EE), and 3) - Emergency non-endodontic (ENE). The age groups were also divided into 3 group
of 0 to 25, 26 to 50, and >50. Categorical variables were reported as %. Chi-square test was used to find inter-group difference.
p <0.05 was regarded as significant.
RESULTS: Dental records of 1823/1824 patients were analysed. Results suggested that 54.6% of the patients were females and
50.1% of patients belonged to age range 0 to 25. Moreover, 1040 (57%) patients suffered with EE conditions, and 805 (77.4%)
with symptomatic irreversible pulpitis. Analysis showed that significantly higher number of females and patients with age < 50
suffered with EE as compared to males and age >50 (p <0.05). Significantly higher number of patients aged >50 years had ENE
conditions as compared to 0 to 25 age group (p= 0.007)
CONCLUSIONS: Emergency endodontic conditions, especially symptomatic irreversible pulpitis was most prevalent during
COVID-19 pandemic. This condition was experienced more by females and patients of age group <50 years. Efficient allocation
of resources and cross-training is recommended to facilitate treatment of such patients during the pandemics.
KEYWORDS: COVID-19; Dental care; Dental emergency; Demographics; Endodontic emergency; Frequency
HOW TO CITE: Tariq A, Shabbir J, Najmi N, Khan MA Zehra T, Ayub T, Kamran MA. Determination and comparison of
frequency of endodontic emergency, non-endodontic emergency, and non-emergency conditions in patients attending qamar dental
hospital, Karachi during early COVID-19 pandemic. J Pak Dent Assoc 2022;31(2):76-80
DOI: https://doi.org/10.25301/JPDA.312.76
Received: 09 July 2021, Accepted: 30 March 2022

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Ahmed Tariq1                               BDS
Juzer Shabbir2                             BDS, MDS
Naheed Najmi3                             BDS, MCPS
Muhammad Athar Khan4            MPH, MCPS, MBA, MBBS
Tazeen Zehra5                             BDS, FCPS
Tahera Ayub6                              BDS, FCPS
Muhammad Anas Kamran7       BDS

OBJECTIVE:The objective of this study was to determine potential differences among male and female genders regarding
the mesiodistal widths of permanent maxillary anterior teeth in adult dentate individuals.
METHODOLOGY: This was an analytical cross-sectional study which was conducted in Out Patient Department of Peshawar
Dental College, Peshawar from February to April 2019.
The sample comprised of 180 individuals with a mean age of 15-25years selected from a population visiting Peshawar Dental
College that fulfilled the inclusion criteria. JPEG file format of OPG images were graphically analyzed by Autodesk AutoCAD
software 2017 version to calculate the mesiodistal widths of permanent maxillary anterior teeth. Independent t test was used
to compare mesiodistal teeth dimensions between males and females.
RESULTS: Mesiodistal widths of permanent maxillary anterior teeth, in males, were greater than females but the difference
in their mean values were statistically insignificant (P>0.05). The mesiodistal width of permanent maxillary right lateral incisor
in males was larger (8.023± 1.083 mm) than females (7.853± 1.319 mm) but the difference was statistically insignificant
(P>0.05).
CONCLUSION: It can be concluded that gender had statistically non-significant association with the mesiodistal widths of
permanent maxillary anterior teeth.
KEYWORDS: Gender, Mesiodistal width, Permanent maxillary anterior teeth, Autodesk AutoCAD software
HOW TO CITE: Rashid M, Safdar S, Khattak MA, Arbab S, Shah SA, Khattak I. Gender as a variable influencing the mesiodistal
width of permanent maxillary anterior teeth: an analysis using autocad software. J Pak Dent Assoc 2022;31(2):70-75.
DOI: https://doi.org/10.25301/JPDA.312.70
Received: 06 January 2021, Accepted: 15 March 2022

INTRODUCTION
In December 2019, Chinese health authorities were alerted by the presentation of pneumonia of unknown aetiology in individuals living in Wuhan, Hubei province, China.1 . Later on, Chinese Centre for Disease Control and Prevention isolated the causative agent, categorizing it as a novel coronavirus (2019-nCoV). The virus was later named as Severe Acute Respiratory Syndrome Coronavirus-2 (SARSCoV-2).2,3 The most common routes of transmission identified for the SARS-CoV-2 included the inhalation of infected respiratory droplets or by having a contact with the infected surface (3,4). Common signs and symptoms of Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2 included but not limited to high fever, dry cough, shortness of breath, malaise, lethargy, myalgia, headache, nausea, vomiting, and
diarrhoea.2,4 High contagiousness of COVID-19 resulted in a widespread lockdown of the societies with countries closing off borders, limiting social mobility, and banning the international travel. In dentistry, the guidelines were developed  by many scientific dental societies and researchers5-8 and vroutine dental practices became limited. Most of the guidelines for treating a dental patient included a prior dental triage on call, and treatment of patients with dental emergencies only under strict isolation protocols.4,5,9,10 Tele-dentistry was preferred for managing ill patients through telephonic conversations.9 The dental setting was considered as a high risk contagion as many dental treatments including periodontal, surgical, endodontic, and restorative involved aerosol-generating procedures.3,7,11,12 Moreover, dental emergency conditions that were recommended to be treated pharmacologically, or definitively during COVID-19 pandemic included Symptomatic Irreversible Pulpitis (SIP), Symptomatic Apical Periodontitis (SAP), Acute Apical Abscess (AAA), Avulsion/luxation, Tooth fracture with pain, and life-threatening trauma and cellulitis. 13-15
It has been postulated that two-thirds of all dental emergencies are of endodontic origin for which the patient seeks the dental treatment.7,16 Similarly, it was highlighted in a study conducted by Yu et al that an increased percentage of patients reported with endodontic emergencies (EE) in year 2020 during COVID-19 pandemic as compared to previous years (16). A wide array of literature reported similar rise in number of patients reporting with EE andnon-endodontic emergencies (ENE) during COVID-19 pandemic.1,17,18 This increased number of patients may exert pressure on the overburdened dental practitioners, especially those in endodontic departments during COVID-19 pandemic.
With the implementation of lockdown by the Government of Pakistan, patients had limited access to the dental care facilities. Additionally, there were diminished number of dental care practitioners available to cater the need of patients. In this scenario, a crucial local data was needed about the prevalence and types of dental emergencies with which the patients may seek an urgent dental treatment during a pandemic. This data could have helped the decision makers in planning an efficient strategy. However, to the best of our knowledge, no such type of data was available. As stated before, global data have suggested that EE was the most common condition because of which the patient may seek dental care during COVID-19 pandemic. Therefore, our study aimed to determine and compare the frequency of EE with other dental conditions in patients attending oral diagnosis department of Liaquat College of Medicine and Dentistry (LCMD), Karachi during first wave of COVID-19 pandemic.

METHODOLOGY
   This single-centre retrospective cross-sectional study was conducted at Qamar Dental Hospital (QDH), LCMD after getting approval from the Institutional Review Board (Ref no.: IRB/D-00009/21). The records of all the patients who visited oral diagnosis department of QDH from 28th February 2020 to 31st August 2020 were retrieved and included in the study. Incomplete dental records were excluded. Non- probability convenience technique was used for sampling. For meaningful analysis, the diagnostic conditions of the patients were divided into three groups: Non-emergency (NE), Emergency non-endodontic (ENE), Emergency endodontic (EE). A pre-made proforma comprising of elements such as date of visit, registration number, age, gender and diagnosis was used to collect data from the patient records.
Principal investigator was responsible to collect the data of the study. The data analysis was performed with the help of SPSS Statistics, version 24.0 (IBM Corp., Armonk, NY, USA). Categorical variables were presented as percentages. Chi-square test was used to find the statistical difference between the groups. The significance level was considered as <0.05.

RESULTS
A total of 1824 patients attended the dental OPD during a period of six months. The record of one patient was excluded during analysis because of presence of incomplete information. Out of 1823 patients, 828 (45.4%) patients were males and 995 (54.6%) were females. Similarly, 491 (26.9%) patients belonged to the age range of 0 to 25 years, 913 (50.1%) belonged to age range 26 to 50 years, and 419 (23%) belonged to age of >50. Furthermore, 595 (32.6%) patients presented with NE conditions. Whereas, 1040 (57%) patients came with EE conditions, and only 188 (10.3%) with ENE conditions (Table 1). Out of all EE conditions, 805 (77.4%) were diagnosed as SIP followed by necrotic teeth/previously initiated or treated with SAP (n= 123 [11.8%]). Similarly, out of all ENE conditions, 73 (38.8%) patients were experiencing acute gingival or periodontal conditions followed by discomfort associated with dislodged fixed prosthesis (n= 56 [29.7%]). On the other hand, the most common NE condition for which patient attended the oral diagnosis department was reversible pulpitis (n= 105 [17.6%]) followed by requirement of routine scaling/polishing procedure (n= 103 [17.3%]) (Figure 1).
Significantly (p= 0.042) higher number of females (n=589) were suffering from EE as compared to males (n= 451). On the other hand, the number of males (n= 294) visiting the diagnosis department with NE condition was significantly (p= 0.017) greater than females (n= 301).
Highest frequency of patients presenting with EE condition

n, number; NE, Non-emergency; EE, Emergency Endodontic; ENE, Emergency Non-Endodontic

belonged to age group 26 to 50 (n= 564). This was followed by the age group 0 to 25 (n= 291). Patients with age <50 attended diagnosis department most with ENE (n= 56) and

NE (N= 161) conditions. Patients belonging to age group of 26 to 50 and 0 to 25 attended the diagnosis department with significantly more EE and NE conditions as compared to age group of more than 50 years (p<0.005). On the other hand, significantly higher number of patients in this age groups attended the diagnosis department with ENE conditions as compared to the age group 0 to 25 (p= 0.007)
(Table 2).

DISCUSSION
The unprecedented nature of COVID-19 put systems on hold and societies under lockdown. The healthcare sector also took a surprise hit due to unavailability of established practicing guidelines initially. Moreover, the decision makers including the governments, the leaders of the healthcare bodies, and the doctors in Pakistan did not know where to concentrate the resources because not enough data was
available to answer the following question: With which type of dental conditions do the patients attend the dental OPD the most during a pandemic? This data, we believe, will be crucial for stakeholders and policy-makers alike in order fo r them to decide the allocation of appropriate equipment and resources to the dental care practitioners in this and any future pandemics.
The results of our study suggested that during the COVID-19 pandemic peak, more than half of the patients who attended the dental OPD were diagnosed (through standard investigations)19 as having an EE condition (57%). Among EE conditions, SIP was most prevalent (44.2%). This finding was found to be similar to the study conducted by Yu et al.16 In their study, 50.26% of the patients attended
the hospital due to EE, and out these, 53.10% were suffering from SIP. Similarly, another study20 found that the most common condition with which the patient attended the dental setup was SIP. It was also observed that in the current study that during the six months of COVID-19 pandemic peak, there was a substantially decreased attendance of patients who sought the dental treatment. This result might be related to the country wide lock down and fear among the patients for contraction of COVID-19 disease.21
Previous studies (1,22) reported that increased percentage of males utilized emergency dental services as compared to females during the COVID-19 period. The authors were of the opinion that the females were more afraid of getting infected with SARS-CoV2 virus resulting in decreased visits to emergency dental centres. Contrarily, in our study, we found that slightly higher percentage of females (59.2%)
presented with EE as compared to males (54.5%). This difference may be due to the reason that in this region of the world, males are considered as a sign of endurance and support for females because of which they often ignore or tolerate their health conditions leading to their decreased attendance in dental centres for dental treatments. Results of the current study revealed that the patients with age less than 50 years sought increased number of EE and NE treatments as compared to older age (>50 year). According to a recent study, people belonging to older age group perceive themselves as more vulnerable to contracting the SARS-CoV-2.23 Moreover, a local study suggested that older population of Pakistan prefer to get their teeth extracted instead of saving it with an endodontic treatment.24 This may result in fewer teeth available to be affected by pulpitis or apical periodontitis with the advancement of age. The combination of these two reasons may explain why there was an overall decrease in attendance (especially with EE conditions) of the patients belonging to old-age group. The
reason for increased attendance of the patients of age less than 50 with NE conditions was that the younger patients are generally more conscious about their smile. This was indicated by the results of our study that the most common non-emergency conditions among age groups of <50 were the requirement of a restoration (reversible pulpitis) and scaling and polishing.
Nonetheless, certain limitations need to be highlighted about our study. No comparison of dental records of patients
was made between pre-COVID-19 and COVID-19 era. Moreover, the results of our study were based on a singlecentre. Therefore, the results of our study cannot be generalized. However, this centre was among only few dental hospitals that were operational during the peak of first wave of COVID-19 pandemic in Karachi, attracting a wide array of patients. Moreover, the results of this study gave a snapshot
of the prevalent dental emergency conditions during COVID-19 pandemic and may help the authorities to allocate resources accordingly.

CONCLUSION
The endodontic emergency was the most prevalent reason among all the dental conditions for which the patient sought dental care. Symptomatic irreversible pulpitis was the most common type of endodontic emergency. Cross-training and increasing the number of dental practitioners that are able to treat endodontic emergencies and a concomitant allocation of enough resources for this purpose is recommended during COVID-19 pandemic or alike in future.

CONFLICT OF INTEREST
None

FUNDING
None

AUTHORS CONTRIBUTION
     JS: Conceptualization; AT: Data curation; MAK2: Formal analysis; MAK1: Investigation; JS, NN: Methodology; AT, TA: Resources; MAK2: Software; NN, TA: Supervision; JS, AT: Validation; TZ: Project Administration; AT, TZ, MAK1: Initial draft; NN, TA, MAK2, JS: Review; AT, JS: Final Draft. Additionally, the authors declare that the data will be provided on request and the authors are responsible
for accuracy and integrity of the data.

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6. Sinjari B, Rexhepi I, Santilli M, D Addazio G, Chiacchiaretta P, Di Carlo P, et al. The Impact of COVID-19 related lockdown on dental
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7. Patel B, Eskander MA, Ruparel NB. To Drill or Not to Drill: Management of Endodontic Emergencies and In-Process Patients
during the COVID-19 Pandemic. J Endod. 2020;46:1559-69.
https://doi.org/10.1016/j.joen.2020.08.008

8. Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PMH. Clinical endodontic management during the COVID-19
pandemic: a literature review and clinical recommendations. Int Endod J 2020;53:1461-71.
https://doi.org/10.1111/iej.13406

9. Kafle D, Mishra RK. Incidence and pattern of dental emergencies and their management during Covid-19 pandemic: An experience of
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10. Sarfaraz S, Shabbir J, Mudasser MA, Khurshid Z, Al-Quraini AAA, Abbasi MS, et al. Knowledge and attitude of dental practitioners
related to disinfection during the COVID-19 Pandemic. Healthcare. 2020;8:232.
https://doi.org/10.3390/healthcare8030232

11. Shabbir J, Qazi F, Farooqui W, Ahmed S, Zehra T, Khurshid Z. Effect of Chinese propolis as an intracanal medicament on postoperative endodontic pain: A double-blind randomized controlled trial. Int J Environ Res Public Health. 2020;17.
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12. Shabbir J, Khurshid Z, Qazi F, Sarwar H, Afaq H, Salman S, et al. Effect of Different Host-Related Factors on Postoperative Endodontic
Pain in Necrotic Teeth Dressed with Interappointment Intracanal Medicaments: A Multicomparison Study. Eur J Dent. 2021;15: 152-7.
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Momena Rashid1                   BDS, M.Phil
Shamayem Safdar2               BDS, M.Phil
Munawar Aziz Khattak3        BDS, M.Phil
Sana Arbab4                          BDS, M.Phil
Syed Amjad Shah5                BDS, FCPS, MFDSRCPS, FDSRCPS
Imran Khattak6                      BDS

OBJECTIVE:The objective of this study was to determine potential differences among male and female genders regarding
the mesiodistal widths of permanent maxillary anterior teeth in adult dentate individuals.
METHODOLOGY: This was an analytical cross-sectional study which was conducted in Out Patient Department of Peshawar
Dental College, Peshawar from February to April 2019.
The sample comprised of 180 individuals with a mean age of 15-25years selected from a population visiting Peshawar Dental
College that fulfilled the inclusion criteria. JPEG file format of OPG images were graphically analyzed by Autodesk AutoCAD
software 2017 version to calculate the mesiodistal widths of permanent maxillary anterior teeth. Independent t test was used
to compare mesiodistal teeth dimensions between males and females.
RESULTS: Mesiodistal widths of permanent maxillary anterior teeth, in males, were greater than females but the difference
in their mean values were statistically insignificant (P>0.05). The mesiodistal width of permanent maxillary right lateral incisor
in males was larger (8.023± 1.083 mm) than females (7.853± 1.319 mm) but the difference was statistically insignificant
(P>0.05).
CONCLUSION: It can be concluded that gender had statistically non-significant association with the mesiodistal widths of
permanent maxillary anterior teeth.
KEYWORDS: Gender, Mesiodistal width, Permanent maxillary anterior teeth, Autodesk AutoCAD software
HOW TO CITE: Rashid M, Safdar S, Khattak MA, Arbab S, Shah SA, Khattak I. Gender as a variable influencing the mesiodistal
width of permanent maxillary anterior teeth: an analysis using autocad software. J Pak Dent Assoc 2022;31(2):70-75.
DOI: https://doi.org/10.25301/JPDA.312.70
Received: 06 January 2021, Accepted: 15 March 2022

INTRODUCTION
During the last few decades patients and dentists have taken greater interest in dental esthetics.1 Dental esthetics is most dominant aspect of facial attractiveness and encompasses not only tooth colour, size and shape2 but also other aspects like upper lip position3 and
gingival morphology.4
Maxillary anterior teeth are considered the most dominant element in dental and facial esthetics because of the amount of visible coronal structure.5 Research has been carried out on determining the approximate width of maxillary anterior teeth by studying their relation with gender, race6 facial profile7 facial measurements8 and malocclusions.9
A study conducted in Chile observed that mesiodistal width of maxillary central incisors and canines had different statistically significant values between males and females. A flaw in the design of that study was the use of sample size of 303 subjects (177 females and 126 males), while for a comparative study, it is better to consider equal number of male and female subjects. In the present study we will be taking equal number of male and female subjects.10Another study conducted in Saudi Arabia stated that all maxillary anterior teeth had greater mean values for mesiodistal width in males as compared to the females with a mean of 49.4 mm in males and 48.2 mm in females.11
A study in India found that the mean mesio-distal width for central incisors was 8.9mm in males and 8.6mm in females, while for lateral incisors it was 6.89 mm in males and 6.79 mm in females and for canines it was 9.8 mm in males and 8.6 mm in females. It showed that mesiodistal width of maxillary central incisors and canines was significantly greater in males than in females with canines showing significantly greater values as compared to central incisors.12 According to a study conducted in India, maxillary right and left canines exhibit a mean width of 1.0cm in males and 0.9cm in females but this study examined only canines13 due to the reason that canines are least frequently extracted teeth possibly because of relatively decreased incidence of caries and periodontal disease.14 In a study conducted in Lahore, Pakistan on 14-30 years old subjects with orthognathic profile having aligned and fully erupted set of permanent maxillary anterior teeth with no caries or attrition were studied and it was found that the ratio of the mean mesio-distal crown width of the maxillary lateral incisor to that of the maxillary central incisor was approximately 80.7% in males and 78.6% in females, maxillary canine to that of the maxillary central incisor was approximately 90.77% in males and 87.95% in females, maxillary lateral incisor to that of the maxillary canine was approximately 88.93% in males and 89.36% in females.15
In all the previously conducted studies, old methodologies were used for measuring mesiodistal width of permanent maxillary anterior teeth. Most of the studies used vernier calipers and took measurements either directly on the subjects teeth12, orodental models.10,11,13,15, Thread11 and manual divider12 have also been used for this purpose.
According to a recent study conducted based on evaluating an association of tooth form with the face shape, photographs of subjects face and teeth were analyzed by using AutoCAD software.8 In present study however we will be taking standardized images obtained from OrthoPantomoGram (OPG). Mesiodistal width of individual teeth will be measured, from the OPG images, with the help of Autodesk AutoCAD 2017 version software which is the latest version in AutoCAD series and considered as the best tool for this purpose.
Another limitation of previously conducted studies was improper identification of landmarks for measuring the mesiodistal width of permanent maxillary anterior teeth. In Pakistan and India, mesial and distal contact points were taken as reference.10,11,13,15 In a study conducted in Saudi Arabia mesiodistal measurements were taken from a line drawn perpendicular to the long axis of teeth following their
maximum contours11. In present study we will geometrically find mesiodistal width in AutoCAD software by drawing two vertical lines (tangent to mesial and distal contour) and two horizontal lines (one on upper intersection of distal tangent and one on lower intersection of mesial tangent). A horizontal line equidistance to previous two horizontal lines will represent the greatest mesiodistal width. 8
The aim of this study was to determine that gender is an important variable for the mesiodistal width of permanent maxillary anterior teeth in adult dentate subjects of age 15-25 years, using AutoCAD software. This will help in providing data to dentists for fabricating denture teeth in teeth selection for edentulous patients16, use in forensic odontology for criminal identification.12,13,10 orthodontic treatment planning17 and restorative treatment.18

METHODOLOGY
It was an analytical cross-sectional study which was conducted in Oral diagnosis department of Peshawar Dental College, Peshawar from February to April 2019. This study was ethically approved by instituitional review board (IRB) of Prime Foundation Pakistan. Data was collected in Out Patient Department (OPD) of Peshawar Dental College. Sample size of of 180 individuals was calculated by nonprobability consecutive sampling. Both male and female gender were included, out of which 90 were males and 90 were females. The age range was from 15-25 years. Informed consent was taken from all subjects. Exclusion criteria was subjects with missing permanent maxillary anterior teeth, anterior prosthesis or restorations, developmental anomaly of permanent maxillary anterior teeth, proximal surfaces alteration, history of orthodontic treatment. Inclusion criteria was subjects having fully erupted, structurally and periodontally sound maxillary anterior teeth that are having satisfactory alignment.
Sexual dimorphism is defined as the effect of gender (i.e. male and female) on the mesiodistal widths of permanent maxillary anterior teeth.
Mesiodistal widths of permanent maxillary anterior teeth shall be the widest horizontal distance between the maximum convex points of mesial and distal margins from labial surface of maxillary anterior teeth. It was calculated from OPG images of subjects which were analyzed in Autodesk AutoCAD software 2017 version by drawing two vertical lines (tangent to mesial and distal contour) and two horizontal lines (one on maxillary intersection of distal tangent and one on mandibular intersection of mesial tangent). A horizontal line equidistance to previous two horizontal lines shall represent the greatest mesiodistal width8.

STATISTICAL ANALYSIS
The data were entered & analyzed using computer program SPSS version 20.0. Frequencies and percentages were computed. Mean and standard deviations were calculated for all numerical variables like age and all maxillary anterior mesiodistal teeth widths. Independent t test was used to compare mesiodistal teeth dimensions between males and females. P<0.05 was considered to be significant level.

RESULTS
    Total 180 subjects were equally distributed in both genders. Gender distribution was equal i.e. n=90(50%) males and n=90(50%) females. The mean age was 22.19±2.57 (SD) years with a range of 15-25 years. The most common age group of the participants was 22 to 25 years with 116(64.44%) subjects followed by those having age group of 19-21 years that had 45(25%) subjects. Subjects in the age group 15-18 years were 19(10.56%). These details are graphically depicted in figure 1.
The mean mesiodistal width of right maxillary canine, lateral incisor and central incisor was 9.826±1.038 mm, 7.94±1.206 mm, and 9.47±1.43 mm respectively. The mean
mesiodistal width of left maxillary canine, lateral incisor and central incisor was 9.82±1.085 mm, 8.031±1.105 mm, and 9.57±1.37 mm respectively. The detailed mean and standard deviation of age and maxillary anterior teeth is shown in table 1 and figure 2.
Though the mesiodistal widths of teeth in males were
larger than those in the females but the difference for mean values were statistically insignificant (P>0.05). For right maxillary canine the mean width in females was 9.79± 1.12 mm while in males it was 9.86± 0.94 mm (95% CI= -0.37 , 0.23; P=0.66). Similarly, right maxillary lateral incisor in males was larger (8.023± 1.083 mm) than females (7.853± 1.319 mm) but the difference was statistically insignificant (95% CI= -0.52, 0.18; P=0.34). Similarly, the average value for the mesiodistal width of right maxillary central incisor in males was larger (9.65± 1.29 mm) than females (9.28± 1.53 mm) but again the difference was statistically insignificant (95% CI= -0.79, 0.03; P=0.12). Similarly, the difference in the mesiodistal widths values of teeth on the left and right maxillary arch were insignificant results. The detailed results are shown in table 2.

DISCUSSION
Sexual dimorphism is a term used for the variations in stature, size, and shape between males and females. This is applicable to dental identification too, as no two mouths are similar.19 The sexual dimorphism existence in permanent dentition is an established phenomenon and reported in literature. Sexual dimorphism, therefore, has a vital significance in forensic odontology and medicine.20 Teeth are useful to differentiate gender by calibrating their buccolingual and mesiodistal dimensions. Use of teeth to determine gender have an essential role in young people where the skeletal secondary sexual features like breast, hip broadening and moustaches have not yet developed.21 Many
reasons like genetic, environmental and ethnicity can be held responsible for non-concordance between our study and previous literature.
This study aims to determine if gender can be an important variable for assessing the mesiodistal widths of permanent maxillary anterior teeth in adult dentate subjects of age 15-25 years, visiting Out-Patient Department of Peshawar Dental College in a 6-12 months’ time interval, the measurements of teeth were done using soft images of subjects OPGs using Autodesk AutoCAD 2017 version software for measuring widths of teeth.
For all permanent maxillary anterior teeth, the mesiodistal widths were larger in males as compared to females. In this study mesiodistal width of central incisors was 9.7mm for males and 9.3mm for females, for lateral incisors it was 8.0mm for males and 7.8mm for females, while for canines it was 9.9mm for males and 9.7mm for females with P>0.05 (Table 2). Our results showed that sexual dimorphism in mesiodistal widths of maxillary anterior teeth was present but was not statistically significant. So, in our population the sexual dimorphism cannot be used to determine gender in forensic
cases.
Alqahtani et al recorded the mesiodistal width for central incisor was 8.8mm for men and 8.6mm for women, lateral incisor was 6.7mm for men and 6.4mm for women, and canines was 8.0mm for men and 7.6mm for women. He concluded that though the values for mesiodistal tooth width were larger for males as compared to females but no statistically significant difference was found. These results were in concordance with present study.22
Srivastava et al assessed and determined the role of permanent maxillary incisors and cuspids for sex determination of undergraduate dental students. They measured with the help of a digital vernier caliper as well as manual divider to measure the mesiodistal dimensions of
the maxillary front teeth from canine to canine. They found that mean mesiodistal width of central incisors was 8.9mm in males & 8.6mm in females, for lateral incisors it was 6.8mm in males & 6.7mm in females and for canines it was 9.8mm in males & 8.6mm in females this shows that the mesiodistal dimensions and left maxillary canines and central incisors were significantly larger in males than females.
They concluded that sexual dimorphism in maxillary canine and central incisors are helpful in gender determination.12
Neves et al23 stated that among the mesiodistal widths of all maxillary and mandibular teeth, canines were more sexually dimorphic as compared to other teeth. Peckmann at al15 found that maxillary central incisors and canines showed significant sexual dimorphism (P<0.008) as compared o lateral incisors (P>0.008) while in this study none of the maxillary anterior teeth showed significant results (P>0.05). These results were in accordance with our study that showed that canines were more sexually dimorphic as compared to
other teeth, although the difference was not statistically significant.
Rajat et al.11 stated that all maxillary anterior teeth had a greater mean of 49.4mm in males and 48.2mm in females while in this study it was 55mm in males and 53.9mm in females.
Leung et al measured the mesiodistal widths of incisors, canines, premolars and first molars of mandibular and maxillary jaws from digital e-models with the help of 03DM digital model software and showed that females had significantly smaller teeth as compared to males. These results were not in accordance with present study which can be attributed to the fact that two different types of softwares
were used for this purpose.24
Tehranchi et al.25 conducted a comparative study to measure mesiodistal widths of casts and reported AutoCAD software provides more precise results while the manual method is only reliable when taken with extreme caution. While the previously conducted studies used vernier caliper and manual measurement which are less accurate and time consuming. These authors reported that vernier caliper and manual measurement needs extreme caution during calibration, duplicate measurements and averaging and experience is an essential factor for accurate measurement.10,11,12,13,15 .
On the basis of this study, it has been observed that gender can be used for the purpose of selection of maxillary anterior teeth but it is not recommended to use it as a sole method for selection of maxillary anterior teeth; rather it should be used as a supplemental method. This is a single centre, small sample and a hospital based study which may not represent the Peshawar population. Further large sample and community based studies are recommended which will explore this area in depth.

CONCLUSION
   According to this study, it can be concluded that gender had a statistically non-significant association with the mesiodistal widths of permanent maxillary anterior teeth, so these findings cannot be used as an appropriate guide for determining gender in forensic cases.

ACKNOWLEGMENT
We are deeply grateful to Dr Saad Sajjad, Dr Arbab Zia and Dr Shiraz Alam for this research and Dr Sobia Salam who moderated this paper and in that line improved the manuscript significantly.

CONFLICT OF INTEREST
None declared

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a sample of the Turkish population. Eur J Orthod, 2010; 33:592-96.
https://doi.org/10.1093/ejo/cjq111

10. Peckmann TR, Logar C, Garrido-Varas CE, Meek S, Pinto XT. Sex determination using the mesio-distal dimension of permanent
maxillary incisors and canines in a modern Chilean population. Sci Justic, 2016;56:84-89.
https://doi.org/10.1016/j.scijus.2015.10.002

11. Rajat RK, Rishav S, Romil S, Nauseen H. Comparative evaluation of mesiodistal width of six maxillary anterior teeth in J&K population.
Int J Sci Study, 2017;5:4-7.

12. Srivastava R, Jyoti B, Jha P, Gupta M, Devi P, Jayaram R. Gender determination from the mesiodistal dimension of permanent maxillary
incisors and canines: An odontometric study. J Ind Acad Oral Med Radiol, 2014;26:287.
https://doi.org/10.4103/0972-1363.145007

13. Sravya T, Dumpala RK, Venkateswara Rao Guttikonda PKM, Narasimha VC. Mesiodistal odontometrics as a distinguishing trait:
a comparative preliminary study. J Forensic Dent Sci, 2016;8: 99.
https://doi.org/10.4103/0975-1475.186368

14. Kapila R, Nagesh K, Iyengar AR, Mehkri S. Sexual dimorphism in human mandibular canines: a radiomorphometric study in South
Indian population. J Dent Res Dent Clin Dent Prospects, 2011; 5: 51.

15. Asad S, Bokhari F, Ahsan W. Proportional mesio-distal dimension of permanent maxillary teeth. Pak Orthod J, 2015;7:30-34.
16. Park DJ, Yang JH, Lee JB, Kim SH, Han JS. Esthetic improvement in the patient with one missing maxillary central incisor restored with
porcelain laminate veneers. J Advanc Prosthod, 2010;2:77-80.
https://doi.org/10.4047/jap.2010.2.3.77

17. Brandão RCB, Brandão LBC. Finishing procedures in Orthodontics: dental dimensions and proportions (microesthetics). Dent Press J
Orthod, 2013; 18:147-74.
https://doi.org/10.1590/S2176-94512013000500006

18. Frese C, Staehle HJ, Wolff D. The assessment of dentofacial esthetics in restorative dentistry: a review of the literature. J Am Dent
Assoc, 2012;143:461-66.
https://doi.org/10.14219/jada.archive.2012.0205

19. Vishwakarma N, Guha R. A study of sexual dimorphism in permanent mandibular canines and its implications in forensic
investigations. NMCJ, 2011; 13:96-99.

20. Galdames IS, López MC, Farías BL, Marchant CS, Muñoz ST, Rojas PG,Lopez F. Sexual dimorphism in mesiodistal and bucolingual
tooth dimensions in Chilean people. Int J Morphol, 2008; 26:609-14.
https://doi.org/10.4067/S0717-95022008000300016

21. Hemanth M, Vidya M, Karkera BV. Sex determination using dental tissue. Med Leg Update, 2008;8:13-15.

22. Alqahtani AS, Habib SR, Ali M, Alshahrani AS, Alotaibi NM, Alahaidib FA. Maxillary anterior teeth dimension and relative width
proportion in a Saudi subpopulation. J Taibah University Med Sci. 2021;16:209-16.
https://doi.org/10.1016/j.jtumed.2020.12.009

23. Neves JA, Antunes-Ferreira N, Machado V, Botelho J, Proença L, Quintas A, Mendes JJ, Delgado AS. Sex Prediction Based on Mesiodistal Width Data in the Portuguese Population. Applied Sciences. 2020;10:4156.
https://doi.org/10.3390/app10124156

24. Leung EM, Yang Y, Khambay B, Wong RW, McGrath C, Gu M. A comparative analysis of tooth size discrepancy between male and
female subjects presenting with a class I malocclusion. The Scientific World J. 2018;2018.
https://doi.org/10.1155/2018/7641908

25. Tehranchi A, Nouri M, Massudi R, Katchooi M. Diagnostic value of manual and computerized methods of dental casts analysis. J Dent
(Tehran), 2009;6:30-35.

Momena Rashid1                   BDS, M.Phil
Shamayem Safdar2               BDS, M.Phil
Munawar Aziz Khattak3        BDS, M.Phil
Sana Arbab4                          BDS, M.Phil
Syed Amjad Shah5                BDS, FCPS, MFDSRCPS, FDSRCPS
Imran Khattak6                      BDS

OBJECTIVE:The objective of this study was to determine potential differences among male and female genders regarding
the mesiodistal widths of permanent maxillary anterior teeth in adult dentate individuals.
METHODOLOGY: This was an analytical cross-sectional study which was conducted in Out Patient Department of Peshawar
Dental College, Peshawar from February to April 2019.
The sample comprised of 180 individuals with a mean age of 15-25years selected from a population visiting Peshawar Dental
College that fulfilled the inclusion criteria. JPEG file format of OPG images were graphically analyzed by Autodesk AutoCAD
software 2017 version to calculate the mesiodistal widths of permanent maxillary anterior teeth. Independent t test was used
to compare mesiodistal teeth dimensions between males and females.
RESULTS: Mesiodistal widths of permanent maxillary anterior teeth, in males, were greater than females but the difference
in their mean values were statistically insignificant (P>0.05). The mesiodistal width of permanent maxillary right lateral incisor
in males was larger (8.023± 1.083 mm) than females (7.853± 1.319 mm) but the difference was statistically insignificant
(P>0.05).
CONCLUSION: It can be concluded that gender had statistically non-significant association with the mesiodistal widths of
permanent maxillary anterior teeth.
KEYWORDS: Gender, Mesiodistal width, Permanent maxillary anterior teeth, Autodesk AutoCAD software
HOW TO CITE: Rashid M, Safdar S, Khattak MA, Arbab S, Shah SA, Khattak I. Gender as a variable influencing the mesiodistal
width of permanent maxillary anterior teeth: an analysis using autocad software. J Pak Dent Assoc 2022;31(2):70-75.
DOI: https://doi.org/10.25301/JPDA.312.70
Received: 06 January 2021, Accepted: 15 March 2022

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Hafiza Asma Jawaid1           BDS, MDS
Asmi Shaheen2                    BDS, M.Phil, FCPS
Muhammad Ilyas3                BDS, FCPS
Waheed-ul-Hamid4               BDS, M.Orth RCSED, MS (Ortho)
Ahmad Shamim5                  BDS, MDS
Asif Shakoor6                       BDS, M.Phil

OBJECTIVE: The present study was under taken to determine the anti-fungal effect of Silver Nano partial coating in
concentrations of 0.1%, 0.2%, 0.5% and 1% on heat cure acrylic denture through diffusion disc method. Poly methyl methacrylate
(PMMA) or simply acrylic is most commonly used material for construction of complete dentures. Denture stomatitis is an
inflammatory disorder of oral mucosa, frequently observed in denture wearers. The unpolished intaglio surface of PMMA base
dentures coupled with adverse conditions such as poor hygiene, dry mouth and compromised immune system leads to denture
related stomatitis in 50-70% of complete denture wearers. Antifungal agents such as silver have been added to acrylic denture
bases to in part self-disinfect property.
METHODOLOGY: The supplied modeling wax sheet was cut in to 25 specimens of dimensions 10x10x 2mm with help of
wax knife. The wax sheet was invested in stone plaster with in metal flask using open flasking method for mould formation.
Heat cured acrylic resin polymer and monomer (Meadway Royale Heat Cure, MR. Dental, and UK) was mixed according to
manufacturer's instructions of 2.5gm powder to 1ml monomer. The mixed acrylic was packed in dough stage followed by
pressure packing in hydraulic bench press for 30 minutes under 9.8 MPa. Curing was done by placing the flask in water at room
temperature until boiling. It remained in boiling water for 45 minutes and then allowed to cool down in water bath. A total of
25 acrylic plates were recovered from the flask and divided into five groups. Group A have no coating , group B coated with
0.1% sliver nano particles, group C coated with 0.2% silver nano particles, group D coated with 0.5% silver nano particles and
group E coated with 1% silver nano particles solution. Each specimen was cut in to 6mm disc by Laser Engraving Machine.
These discs were utilized for calculating zone of inhibition through diffusion disc method in agar media.
RESULTS: The diameter of zone of inhibition increased with the increasing concentrations of silver nano particles. When the
concentration of silver nano particles was 1%, the zone of inhibition size was maximum (20.48mm). When the concentration was
0.1%, the size of zone of inhibition was minimum (10.02mm) .This difference was statistically found to be highly significant (0.005).
CONCLUSION: This study results demonstrate that silver nano-particles have good antifungal activity against Candida Albicans
when used as surface coating. This antifungal property is directly influenced by the concentration of silver nano particles used.
KEY WORDS: Antifungal property, Silver nano particles (AgNPs), Candida Albicans (CA).
HOW TO CITE: Haider B, Imran M, Raza M, Riaz Z, Hanif A, Akram S. Antifungal effect of silver nano particles coating
on denture base specimens made of acrylic resin. J Pak Dent Assoc 2022;31(2):59-64.
DOI: https://doi.org/10.25301/JPDA.312.59
Received: 17 June 2021, Accepted: 07 January 2022

INTRODUCTION
Fixed appliances are mostly the appliance of choice for orthodontic treatment.1 The advantages of fixed orthodontic treatment are patient comfort and conservative method of bonding.2 Disadvantages include surface roughness, scratches, discoloration, demineralization
and caries.3 After fixed orthodontic treatment, the most difficult problem is the control of enamel demineralization.4 The rough surfaces of bands, wires and brackets confine the cleaning activity of cheeks, tongue and lips.5 Thus, plaque accumulation and cariogenic micro-organisms increase widely during orthodontic treatment.6 Clinically visible
demineralized lesions arise as quickly as 4 weeks following placement of orthodontic appliances with the incidence of 24.9% to 96%.7,8
Demineralization is the removal of enamel’s inorganic constituents by acids that are produced by bacteria existing
in the plaque.9 These acids soften calcium phosphate content of dentine and enamel, and result in demineralization.10 Few
teeth are extra prone to demineralization such as maxillary lateral incisors, canines, especially in the gingival third and
first molars in the middle third.9,11 Demineralization presents an aesthetic concern because it compromises the aesthetics of smile.12 Regular remineralization via mineral ions existing in saliva occurs simply in the shallow layers of demineralized
lesions.13
Though, different managements are mentioned to support remineralization. The scientific base of fluoride use is that fluoride be able to enter into crystal-like arrangement of enamel, reduces its solubility plus increase resistance for acids. Fluoride ions substitute hydroxyl assembly of hydroxyapatite, then form fluorapatite.13 Thus low dose fluoride application is advised for sub surface remineralization.11
A new remineralizing agent CPP-ACP, is a derivative of milk casein, has ability to absorb through enamel surface.14,15 It preserves supersaturated position of enamel mineral, phosphate and calcium in plaque and encourage remineralization,16 delays the growth of biofilm plus hinders the adhesion of bacteria to tooth surface.17,18 It works like buffering agent that stop a fall of pH and regulate acid-base
balance.17 So, CPP-ACP has been included in various manufactured goods for example, chewing gums, mouth rinses, sports drinks, glass ionomer cements, topical creams and water based mousse.19,5
Therefore, the rationale of this research was to determine the most effective method for remineralization of demineralized enamel
which facilitates the clinicians to overcome the demineralization of enamel after orthodontic debonding.

METHODOLOGY
    This experimental study of twelve months was performed in Orthodontics department of de’Montmorency College of Dentistry, Lahore. The sample size was calculated by convenient sampling technique followed by randomization, keeping power of study equal to 90% and level of significance equal to 5% using formula.
(no caries, no cracks, no exposure to chemicals, no filling) are collected from department of Oral Surgery, Punjab Dental Hospital, Lahore and divided into 3 groups A, B and C, each of 15 teeth. The labial surface of teeth was “ground wet” by using 200, 400, plus 600 grit paper of silicon carbide (Automata A, JearWirtz, West Germany) and then buffed by alumina suspension (BUEHLER, IL, USA) to representUSA) was poured in Customized molds of plastic. The roots of teeth were detached 2 mm beneath the cemento-enamel joint with a diamond disk (3M UnitekCorp. Monrovia, Calif) and coronal portion were fixed horizontally into self-cured acrylic resin. Then teeth were burnished with non-fluoridated pumice, washed with water and dried with oil free air.
The baseline Microhardness of samples was determined using Microvickers Hardness Tester (Wilson Wolpert Microvickers, 402 MVD, Japan) with a force of 100 grams for 15 seconds. 5 indentations, at a distance of 120 micrometer were made and baseline MH of every sample was determined by averaging the value of all five indentations. The objective of baseline MH determination was to evaluate the alterations
that occur following demineralization and remineralization.
Then teeth were etched by 37% phosphoric acid gel “(3M/ESPE, St. Paul, MN, USA)” for 30 sec, showered by water, then dry with air for 10 sec. to obtain frosty white appearance. Light cure primer “(Transbond XT of 3M Unitek Monrovia, CA, USA)” was applied on enamel surface. Then resin composite (Transbond XT of 3M Unitek) was coated on bracket base, the bracket was bonded and resin was light
cured using high intensity blue light (intensity 5 W, wavelength 420 nm~480 nm, Woodpecker Medical Instrument) for 20 sec. All samples were saved in deionized water for 1 week. The brackets were deboned with a debonding plier (UnitekCorp. Monrovia, Calif) and remaining
composite was removed by Sof Lex aluminum oxide finishing disks (3M UnitekCorp. Monrovia, Calif) in low speed hand piece (NSK, Pana Air, Japan) operated at 10,000 rpm. Then the teeth of all groups were stored in separate beakers containing deionized water. The artificial caries solution/demineralizing solution was prepared with the pH of 4.4 [2.2mM/L CaCl2, 2.2 Mm/L NaH2PO4, 50Mm/L acetic acid, 100 Mm/L NaCl (Merck, USA)][20] . In order to create artificial demineralization, all samples were immersed in 100ml demineralizing solution at room temperature for 1 week. The demineralizing solution was replaced every day to avoid accumulation of substances formed through demineralization. After 1 week, they were kept in separate bottles that contain deionized water. After verification of demineralized lesion by visual inspection, SMH of each sample was re-measured for demineralization as described above. After that, surface treatments were carried out.
“CPP-ACP” was applied on the teeth of gp B and NaF  was applied on the teeth of gp C two times daily for 3 minutes for remineralization. All teeth were cycled between deionized water and surface treatment with remineralizing agent for 12 weeks. Group A was considered as control gp for assessment of remineralization. The MH of gp B and gp C samples was re-measured for remineralization. The result of study shows that here is substantial enhancement in microhardness after using CPP ACP and NaF. But group B shows more significant improvement in microhardness than group C. This shows that CPP-ACP is extra efficient remineralizing agent as compared to NaF.

DATA ANALYSIS
   The collected information was assessed by IBM SPSS Statistics 20 (Statistical Package for Social Sciences). Mean ± SD were given for quantitative variable (MH). One way ANOVA was applied to compare the mean differences in MH and following demineralization among the groups. Paired t-test was practiced to match the MH prior to and following demineralization. Independent t-test was applied to compare MH among gp B and gp C. P value of < 0.05 was measured statistically significant.

RESULTS
The MH of every group A (Deionized water), B (CPP ACP) and C (NaF) was measured for demineralization and remineralization. The outcome of CPP-ACP and NaF on the alterations in MH of enamel (%age of microhardness retrieval, %VHNR) was concluded by following formula: % VHNR = (remineralized enamel microhardness – demineralized enamel microhardness) / (baseline enamel microhardness – demineralized enamel microhardness) x 100.
Results proved that here was a considerable decrease in enamel micohardness among three groups after demineralization (P < 0.001).
The results of the current study shows that CPP-ACP is statistically significant than NaF in increasing MH of demineralized enamel. Thus CPP-ACP is helpful in our clinical practice if used daily during orthodontic treatment as it increases the rate of remineralization.

DISCUSSION
Demineralization is one of the causes of tooth loss that causes molecular alterations in apatite minerals of tooth, to an obvious demineralized area, association of dentin, and ultimate cavitation.15 Following the end of fixed orthodontic treatment, the most difficult problem is the control of enamel demineralization. Usually, surface treatment of demineralization was concerned about the mineral loss and
mineral gain to the tooth. Thus objective is the facilitation of recovering new minerals.21 Hence, demineralization persist as primary apprehension for both patients and orthodontists. Since the increased incidence of demineralization in orthodontic patients and the importance of esthetics, occurrence of demineralization must be prohibited. Therefore, we assessed the efficiency of NaF and CPP ACP for inhibition of demineralization to find the best effective agent for this goal.13
Techniques for delivering calcium and phosphorous to assist remineralization have been backbone of this kind of study.21 Fluoride becomes incorporated into the tooth, and replace the hydroxyl group of the hydroxyapatite.15 By the use of low-concentration of calcium and phosphate solution, no remineralization occur because this is not effective in localizing the ions on surface of tooth in large concentrations.22
The CPP contains multiple phosphoryl sequences with ability to stabilize calcium phosphate complexes in solutions such as ACP.15 Previously, the researchers had focused on primary prevention of demineralization, but in current study, we have emphasised on secondary prevention, chiefly, management of persisting demineralized lesions. In previous studies, numerous techniques have been practiced to evaluate the amount of remineralization, comprising quantitative light-induced fluorescence (QLF), DIAGNOdent, x-ray spectrophotometer, polarized light microscope and microcomputed tomography.15,23,24 In our study, we have used Vickers indenter for measurement of MH of enamel and baseline SMH value range from 290.0 to 289.8 VHN that was related to preceding study by Lussi et al. in 2000. The sharp decrease in SMH occurred after demineralization. The test materials (NaF and CPP ACP) were applied to enamel for remineralization. After that, mean SMH of samples raised by 230.2 VHN and 207.5 VHN in both groups. The percentage of SMHR show maximum improvement of 41.2% in CPP-ACP and 19.1% in NaF group. Thus, NaF encourage remineralization of enamel, but not as efficiently as CPP-ACP.
This study is in line with Kumar et al. Qiong et al. Guçlu et al. and Lopatiene. Kumar described that CPP-ACP is more efficient as compared to fluoride in decreasing lesion depth. Though fluoride causes an increase in enamel resistance, but resulting remineralization, is a self-restricting phenomenon. This explain the increased efficacy of CPP-ACP in increasing MH than that of fluoride.25 Qiong et al, conducted an in vitro study to compare CPP-ACP crème with 500 ppm NaF solution for prevention of primary caries in childhood. The result showed that CPP-ACP cream is useful for remineralization of premature enamel lesions of deciduous teeth, extra efficient as compared to 500 ppm NaF.26 Guçlu et al, told that application of CPP-ACP paste can manage demineralized lesions in permanent teeth, and additional application of 5% NaF varnish had no useful results. They alleged that fluoride causes hyper mineralization of superficial layer, which blocks entry of mineralizing ions into subsurface area.27 In a systematic analysis, Lopatiene proved that ACP as well as fluoride are equally efficient in
treatment of demineralized lesions throughout and afterward fixed orthodontic treatment, but CPP-ACP was extra useful in improving lesions.28
Farzanegan et al. compared the efficiency of amorphous calcium phosphate (ACP) and fluoride on MH recovery of damaged enamel. Results showed that MH of samples in the ACP and fluoride groups had considerably enhanced afterward treatment as compared to control gp. Conferring to the above study, both 0.05% ACP as well as 0.05% fluoride solutions improved micro-hardness of enamel in the management of demineralized lesions.29
Actually, CPP stop the quick conversion of calcium phosphate phase and thus, ions become stable and retained at tooth surface. So, CPP has ability to transport phosphate, fluoride and calcium ions deeply  into the subsurface lesions.30 Nano-sized crystals were organized on body of lesions after application of CPP-ACP with less inter crystalline gaps.26 The efficiency of CPP-ACP could be improved in mouth
when a biofilm is present, that could attach to CPP and used as storage for phosphate and calcium ions.25 Thus CPP-ACP may be helpful in our clinical practice if used on regular basis during the period of orthodontic treatment.

CONCLUSION
After this study, it is concluded that, a remineralizing cream having CPP-ACP has promising results in remineralization of demineralized lesions as compared to NaF. CPP-ACP increases MH of enamel more efficiently as compared to NaF with the addition of few minerals and has aesthetic benefits for patients.

CONFLICT OF INTEREST
None declared.

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10. Uysal T, Amasyali M, Ozcan S, Koyuturk AE, Akyol M, Sagdic D. In vivo effect of amorphous calcium phosphate-containing
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11. Willmot DR. White spot lesions after orthodontic treatment. Sem in Orthod 2008;14:209-19.
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12. Bailey DL, Adams GG, Tsao CE, Hyslop A, Escobar K, Manton DJ, Reynolds EC, Morgan MV. Regression of post orthodontic lesions
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13. Tahmasbi S, Mousavi S, Behroozibakhsh M, Badiee M. Prevention of white spot lesions using three remineralizing agents: An in vitro
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14. Bhadoria N, Gunwal MK, Kukreja R, Maran S, Devendrappa SN, Singla S. An in vitro evaluation of remineralization potential of
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https://doi.org/10.1074/jbc.M413504200

Hafiza Asma Jawaid1           BDS, MDS
Asmi Shaheen2                    BDS, M.Phil, FCPS
Muhammad Ilyas3                BDS, FCPS
Waheed-ul-Hamid4               BDS, M.Orth RCSED, MS (Ortho)
Ahmad Shamim5                  BDS, MDS
Asif Shakoor6                       BDS, M.Phil

OBJECTIVE: To compare the result of "casein phosphopeptide amorphous calcium phosphate" with "sodium fluoride"
(900 ppm) in remineralization of enamel after orthodontic debonding.
METHODOLOY: This study was performed on premolars. Teeth were distributed into 3 groups A, B and C. The baseline
microhardness of samples was measured. To create artificial demineralization, all samples were dipped in demineralizing
solution. Surface microhardness (SMH) was re-measured for demineralization. Then, CPP-ACP was applied on teeth of gp B
and NaF (900 ppm) was applied on teeth of gp C for remineralization. All teeth were cycled between deionized water and
surface treatment for 12 weeks. The SMH of gp B and gp C was re-measured for remineralization. Paired t-test and Independent
t-test were practiced to match MH before and after demineralization while keeping P value < 0.05. One way ANOVA was
practiced to match mean difference in baseline MH and after demineralization.
RESULTS: The baseline SMH of enamel decrease after demineralization. After application of test materials, mean SMH
increased by 230.2 VHN and 207.5 VHN respectively. The %age of SMHR reveal the recovery rate of 41.2% in CPP-ACP and
19.1% in NaF group.
CONCLUSION: For treating post orthodontic demineralized lesions, a remineralizing cream having casein phosphopeptide
stabilized amorphous calcium phosphate is useful with some mineral and aesthetic improvements.
KEYWORDS: Casein Phosphopeptide Amorphous Calcium Phosphate (CPP-ACP), Sodium Fluoride (NaF), Surface
Microhardness (SMH), Vickers Hardness Number (VHN), Rmineralization.
HOW TO CITE: Jawaid HA, Shaheen A, Ilyas M, Hamid WU, Shamim A, Shakoor A. Comparison of remineralization effect
of casein phosphopeptide amorphous calcium phosphate and sodium fluoride on enamel surface after orthodontic debonding:
An in vitro study. J Pak Dent Assoc 2022;31(2):65-69.
DOI: https://doi.org/10.25301/JPDA.312.65
Received: 06 October 2021, Accepted: 27 March 2022

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Beenish Haider1           BDS
Mehreen Imran2            BDS, M.Phil
Mohammad Raza3        BDS, FCPS
Zudia Riaz4                    BDS, M.Phil
Amjad Hanif5                 BDS, MSc
Sadia Akram6                BDS, M.Phil

OBJECTIVE: The present study was under taken to determine the anti-fungal effect of Silver Nano partial coating in
concentrations of 0.1%, 0.2%, 0.5% and 1% on heat cure acrylic denture through diffusion disc method. Poly methyl methacrylate
(PMMA) or simply acrylic is most commonly used material for construction of complete dentures. Denture stomatitis is an
inflammatory disorder of oral mucosa, frequently observed in denture wearers. The unpolished intaglio surface of PMMA base
dentures coupled with adverse conditions such as poor hygiene, dry mouth and compromised immune system leads to denture
related stomatitis in 50-70% of complete denture wearers. Antifungal agents such as silver have been added to acrylic denture
bases to in part self-disinfect property.
METHODOLOGY: The supplied modeling wax sheet was cut in to 25 specimens of dimensions 10x10x 2mm with help of
wax knife. The wax sheet was invested in stone plaster with in metal flask using open flasking method for mould formation.
Heat cured acrylic resin polymer and monomer (Meadway Royale Heat Cure, MR. Dental, and UK) was mixed according to
manufacturer's instructions of 2.5gm powder to 1ml monomer. The mixed acrylic was packed in dough stage followed by
pressure packing in hydraulic bench press for 30 minutes under 9.8 MPa. Curing was done by placing the flask in water at room
temperature until boiling. It remained in boiling water for 45 minutes and then allowed to cool down in water bath. A total of
25 acrylic plates were recovered from the flask and divided into five groups. Group A have no coating , group B coated with
0.1% sliver nano particles, group C coated with 0.2% silver nano particles, group D coated with 0.5% silver nano particles and
group E coated with 1% silver nano particles solution. Each specimen was cut in to 6mm disc by Laser Engraving Machine.
These discs were utilized for calculating zone of inhibition through diffusion disc method in agar media.
RESULTS: The diameter of zone of inhibition increased with the increasing concentrations of silver nano particles. When the
concentration of silver nano particles was 1%, the zone of inhibition size was maximum (20.48mm). When the concentration was
0.1%, the size of zone of inhibition was minimum (10.02mm) .This difference was statistically found to be highly significant (0.005).
CONCLUSION: This study results demonstrate that silver nano-particles have good antifungal activity against Candida Albicans
when used as surface coating. This antifungal property is directly influenced by the concentration of silver nano particles used.
KEY WORDS: Antifungal property, Silver nano particles (AgNPs), Candida Albicans (CA).
HOW TO CITE: Haider B, Imran M, Raza M, Riaz Z, Hanif A, Akram S. Antifungal effect of silver nano particles coating
on denture base specimens made of acrylic resin. J Pak Dent Assoc 2022;31(2):59-64.
DOI: https://doi.org/10.25301/JPDA.312.59
Received: 17 June 2021, Accepted: 07 January 2022

INTRODUCTION
Edentulism is defined as irreversible condition resulting in loss of teeth affecting masticatory function, nutrition, speech, and esthetics.1 Edentulisum is considered to be an effectual indicator for proficiency of a nation dedication toward their oral health care. Complete
dentures weather tissue supported or implant supported are considered to be the most obvious rehabilitation technique
for geriatric patients.2
Various treatment options for edentulism have been proposed. One of them is implant retained over denture. This denture is retained by dental implant. Disadvantages of implant retained over denture is that as it is supported by mandible, resorption of supporting structure will results in increase tipping of denture results in dislodgment. Another option is fixed hybrid prosthesis. Such dentures are fixed so patients cannot remove it for cleaning and repairing require dentist to removal and resetting.3
Acrylic removable complete dentures are considered to be treatment of choice for edentulisim due to good aesthetics, ease of manipulation and cost effectiveness.4 Like any other material acrylic have inherent draw backs such as water sorption and release of monomer leading to low impact strength. Additionally the unpolished intaglio surface of heat cure acrylic resin dentures attract fungal growth in deep crevices, contributed by poor oral hygiene, dry mouth and compromised immune system intern leading to denture stomatitis.5 According to Fonda et al denture stomatitis is 50-70% prevalent in complete denture wearers.6 Mostly (78%) the denture stomatitis is associated with candida
growth out of which 68% are Candida Albicans.7 Prevention of denture related stomatitis includes orals rinses, mechanicals or chemical disinfection, denture replacement and educating the patient not to wear the denture over night. Management of denture stomatitis also includes systemic or topical antifungal therapies.8Systemic anti-fungal therapies have disadvantage of recurrence and can induce side effects. Topical therapies are associated with microbial resistance development and their miss use or improper application leads to reduced efficiency.9 Many of antifungal medicaments were used in tissue conditioner for treating denture stomatitis but these medicaments have antifungal effects for short period of time.
In view of recent trend towards making material bioactive, various releasing and non-releasing anti-fungal agents have been added to acrylic denture base material.11 Silver ions (Ag) have great antimicrobial proficiency with low toxicity and good biocompatibility with human tissues. Studies show long-term antimicrobial activity due to sustained ion release and low microbial resistance.12 Since alloy powder act as
bioactive fillers in resin matrix, they can be added to a limited concentration for it can affect the mechanical properties during use.11
Silver nano particles have been used as Coating of various instruments and implant prosthesis to avoid or at least decrease the microbial colonization without compromising the instruments and prosthesis mechanical properties.13 Adhesion of biofilm formation is reduced in
denture base resin due to silver nano particles coating.1 In view of above review of literature, the present study proposes to use silver coating over intaglio surface of acrylic complete denture to impart anti-fungal properties in acrylic denture base material. The unpolished surface of acrylic plates was coated with different concentrations of silver ions to test the null hypothesis. It was considered that the silver coating will not induce antifungal activity at concentrations of 0.1%, 0.2%, 0.5% and 1%. Additionally time dependent anti-fungal behavior of these silver coated acrylic plates were assessed through Agar plate diffusion test method.

METHODOLOGY
A laboratory based experimental study was carried out to manufacture 25 heat cure acrylic plates. The wax patterns was fabricated with modeling wax (Metrowax Metrodent, Ltd. UK) having dimension of 2x 80x 40mm. A total 25 specimens of dimensions 10x10x2 mm were engraved into wax with help of wax knife. The mould was made by mixing 60gms of dental stone powder (manufacturer.) with 100gm
of water. The mixed dental stone slurry was vibrated on vibrator to remove an entrapped air bubbles. Wax pattern was carefully placed on dental stone slurry surface and slightly pressed. Once the stone was set separating media was applied to facilitate the clean opening of open mould. After the application of separating media the wax pattern was completely invested in dental stone.15
Heat cure acrylic resin polymer and monomer (Meadway Royale Heat Cure, MR. Dental, and UK) was mixed according to manufacturer’s instructions with 2.5gm powder to 1ml monomer in a ceramic container and covered with a lid to prevent evaporation of monomer. The mixture at dough stage was kneaded, rolled and packed into prepared gypsum moulds. Two trials closure were done by closing flask each
time in hydraulic press at 9.8MPa. The heat cure acrylic flash was removed with scalpel blade no 15. The flask was finally closed and placed under 9.8MPa pressure in hydraulic press for 5 minutes before clamping Bench curing was done for 30 minutes after which the flask was placed in a water curing bath (Model:HH-S4SN:301171726) at room temperature and temperature was set to raise 1°C per minute
until temperature reached 100°C that temperature was maintained for 45 minutes to complete curing cycle followed by bench cooling for half an hour and then immersed in water for 15 min prior to opening.5
The acrylic plate was recovered from the flask and was separate into 25 specimens of 10x10x2 mm. The excess of resin was removed gently by tungsten carbide using micro motor (Marathon SDE-M35LS Taiwan).Silicon Carbide sand  paper (400-600-800 grit) was used for finishing. The finished specimens were polished using wet rag wheel and pumice slurry and then with Laser Engraving Machine
(BCL-1610X) these specimens were cut in to round discs of 6mm.
The prepared specimens were checked for any imperfections, cracks, bends, visible porosities and fractures. The selected specimens were immersed in 5ml of distilled water in their respective sterile air tight containers for a period of 48 ± 2 hours to eliminate and release residual
monomers if any. Specimens were divided into five groups i.e. A, B, C, D and E having five specimens each. Group A specimens was not
coated and assigned as control. Specimens in group B, C, D and E were coated with preformed AgNPs (Sigma Aldrich, Germany obtained from a local supplier) in the Single Wafer Spin Processor (WS-400E-6NPP-LITE) in physics department of Peshawar University in concentration of 0 .1%, 0.2%, 0.5% and 1% respectively.
Saboraud dextrose broth (SDB) was prepared by mixing 3.5mg SDB powder in 250ml distilled water (manufacturer’s recommended ratio). The suspension was stirred until complete mix before it is autoclaved at 115°C under 1.5 bars pressure. The media was stored at 0°C as a stock in refrigerator till use (MIDAS international LB-LWB1. 5-5X33R).
The Candida Albicans standard strains were obtained from the laboratories of Pakistan Council Scientific and Industrial Research (PCSIR). The antifungal activity was evaluated by agar disc diffusion assay by measuring the zone of inhibition against test microorganism by using method of Kirby-Bauer.16 A 48 hours culture of Candida Albicans was standardized to 0.5 McFarland’s standard in a test tube using normal saline. The standard 0.5 McFarland’s 106 CFU/ml of 100ul of standardized microbial culture was spread with help of glass spreader.
Saboraud dextrose agar (SDA) was prepared by mixing 8.2mg SDA powder in 125ml distilled water (manufacturer’s recommended ratio). The suspension was stirred until complete mix before it is autoclaved at 115°C under 1.5 bars pressure. Laminar flow was cleaned with 70% ethanol solution and decontaminated with ultra violet light for 20 minutes. Sterile Petri plates were arranged in laminar flow and SDA was poured in Petri plates (10ml/plate). The prepared Petri-plates after sufficient hardening was stored at 0oC as a stock in refrigerator till use
Various concentrations of AgNPs coating over discs by spin coater (MODEL WS-400BZ-6NPP/LITE). Group A specimens were not coated while Group B specimens coated with 0.1%, Group C specimens coated with 0.2%, Group D specimens coated with 0.5% and Group E specimens coated with 1%.
The antifungal activity was compared by zone of inhibition in different concentration of silver nano particles coating specimen.
Petri dishes that were prepared and having fungal growth were loaded with discs. Discs were placed on the surface of the agar, using sterile forceps. Once discs had contacted the agar surface they were not moved. Petri dishes were covered with lid to minimize exposure of the agar surface to room air and placed them in a 35°C air incubator for 1 hour, 3hours, 8hours and 12 hours

DATA ANALYSIS PROCEDURE
The data was entered in to SPSS version 20 for analysis. Arithmetic means and SDs were calculated for zone inhibition of all specimens in Group A, Group B, Group C, Group D and Group E. For comparison of means of various groups for zone of inhibition, one-way analysis of variance (ANOVA) was used. P-value less than 0.05 was considered significant.

RESULTS
   Specimens in group A were negative control with no coating of AgNPs. No zone of inhibition was observed when the specimens were checked after 1 hour, 3hours, 8hours and 12hours. For group B, heat cured PMMA acrylic resins coated with 0.1% AgNPs, the average Zone of inhibition was 10.02mm at 1 hr. This zone of inhibition was constantly maintained at 3hours, 8hours and 12hours (Figure 1). For
specimens in group C, coated with 0.2% silver nano particles, the average zone of inhibition was 13.04mm after 1 hour, 3 hours, 8 hours and 12 hours. Heat cured acrylic resins used for fabrication of specimens in group D were coated with 0.5% silver nano particles. The average zone of inhibition was 15.04mm after 1 hour, 3 hours, 8 hours and 12 hours. The zone of inhibition for group D was maximal (20.04mm)
which also remained constant after 1 hour, 3 hours, 8 hours and 12hours (Table 1)

When comparing the means of all groups (One-way ANOVA) revealed that the antifungal activities of specimens in experimental group B, C, D and E showed statistically significant results(p= 0.05) as compared to negative control (group A) at all-time intervals (Table 2).
For multiple comparisons the specimens were paired in ten pairs as A-B, A-C, A-D, A- E, B-C, B-D, B-E, C-D, C-E, and D-E (Table 3). The analysis of multiple comparison revealed that the experimental groups B, C, D, and E showed a statistically significant difference in antifungal activity against Candida Albicans via agar diffusion test. Amongst all the groups the experimental Group E had elevated values
of antifungal activity.

DISCUSSION
   In the present study, it was observed that silver coating over acrylic did impart anti-fungal properties in acrylic denture base material. The unpolished surface of acrylic plates when coated with different concentrations of silver ions produced zone of inhibition that proportionately increased with increased concentration of silver in the coating. Thus the null hypothesis was rejected. Additionally time dependent anti fungal behavior of these silver coated acrylic plates were assessed through Agar plate diffusion test method. This showed significant improvement at 1 hr subsequently at 3, 8 and 12 hr the anti-fungal effect was effectively maintained but no significant improvement was observed. Thus the maximal antifungal effect was expressed at 1 hour and found to be constant till 12 hour time.
Silver has been tested to be a potent anti-fungal agent. Correa et al12 synthesized AgNPs by chemical reduction method. The incorporation of silver nano particles in tissue conditioner with concentration of 0.1%, 0.5%, 1%, 2% and 5% showed effective antimicrobial property. Silver nano particles when incorporate in to polymethylmethacrylate PMMA show unpredictable outcome in regards to its physical properties. Some studies reports degradation of physical properties17, while other studies show improvements in properties like surface roughness.18
The result of a study done by Chladek et al are in agreement with present work. As silver nano particles in both studies increase the antifungal effect.19 To overcome the unpredictable outcomes of silver incorporation, Kagami et al used Argon (Ar) for implanting silver on PMMA. The PMMA plates were simultaneously implanted with both Fluoride (F) and Ag ions using or Ar/F gases and Ag mesh by a plasma -based ion implantation PBII process increasing surface contact angle by both ion implantations inhibiting the growth of S. mutants
but no significant antifungal activity against C. albicans. The author in their study failed to provide any substantial reasons for poor anti-fungal property of AgNPs when used with argon deposition.20
Work done by Kamikawa et al. is in support of present study. Their work showed a high antifungal activity with no mechanical impairment of PMMA when coated with AgNPs. The thickness of specimens used in Kamikawa et al. work were not recommended for the dental denture bases. The present study has specimen made out in geometric shape, in accordance to the actual denture base thickness. Additionally in the present study the sustain anti-fungal behaviors or effect was also tested.21
Queiroz et al. treated surface of denture base material by chemical vapour deposition method, and reported decreased Candida Albicans bio film formation. However their work lack on time dependent performance of silver when coated through chemical vapour method.22
Khan et al. worked with silver nano particles synthesized from Aspergillus niger. Their results support the present work as the antifungal properties of AgNPs coating were profound. In fact the zone of inhibition was almost 100mm.23 The large zone of inhibition might be due to difference in process of synthesis of AgNPs. In their study the natural source for silver was used and the particles were freshly made and may
be more active. In the present study commercially available particles were used. The present study particle size and surface activation both can be different from the Khan et al work.24
In one of study the different nystatin was added in to tissue conditioner having effective antifungal property but hardness and roughness increased with time. As roughness increased there is greater chance for growth of fungi leads to denture related stomatitis. This method decreases its antifungal property with time .The present study shows sustained antifungal effect.25
It’s beyond the scope of this study to comment on such aspects as no such investigations were carried out. Never the less they also did not profile the effect of time on anti-fungal effect.

LIMITATIONS OF THE STUDY
   The present work is an experimental study in which the surface characterization of samples coated with silver nano particles was not done. Scanning electron microscopy (SEM) is used for taking image before and after coating with silver nano particles for measuring particle distribution and silver nano particles were not treated for better adhesion.

CONCLUSIONS
This study results demonstrate that silver nano-particles have good antifungal activity against Candida Albicans when used as surface coating. This antifungal property is directly influenced by the concentration of silver nano-particles used. Furthermore AgNPs coating on acrylic reached its maximal potential within 1 hr and could maintain it effectively for 12 hrs.

RECOMMENDATION
    Since AgNPs have excellent anti-fungal effect, there is potential in further studying the characterization of cytotoxicity of such potent agent. Sensitivity of AgNPs coating to species other than Candida Albicans should be tested. Comparison of antifungal effect of other antifungal agents with antifungal effect of silver nano particles and silver nano particles activation potential according to source (natural or synthetic) should also be studied. Additionally the prolong anti-fungal effectiveness and integrity of this surface coating to mechanical challenges like wear should be studied.

CONFLICT OF INTEREST
None declared

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3. Hartmann R, Bandeira AC, Araújo SC, Brägger U, Schimmel M, Leles CR. A parallel 3-group randomised clinical trial comparing
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J Oral Rehabi. 2020;47:1264-77.
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proof-of-concept case report. BMC Oral Health. 2019;19:1-7.
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6. Gad MM, Fouda SM, Al-Harbi FA, Näpänkangas R, Raustia A. PMMA denture base material enhancement: a review of fiber, filler,
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https://doi.org/10.2147/IJN.S130722

7. Jovanovic M, Obradovic R, Pejcic A, Stanišic D, Stošic N, Popovic Ž. The role of Candida albicans on the development of stomatitis in
patients wearing dentures. Sanamed. 2018;13:175-81.
https://doi.org/10.24125/sanamed.v13i2.236

8. Rodrigues ME, Gomes F, Rodrigues CF. Candida spp./bacteria mixed biofilms. J Fungi. 2020;6:5.
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9. Miccoli G, Cicconetti A, Gambarini G, Del Giudice A, Ripanti F, Di Nardo D, Testarelli L, Seracchiani M. A New Device to Test the
Bending Resistance of Mechanical Endodontic Instruments. App Sci.
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10. Iqbal Z, Zafar MS. Role of antifungal medicaments added to tissue conditioners: A systematic review. J Prosthod Res. 2016;60:231-9.
https://doi.org/10.1016/j.jpor.2016.03.006

11. Rodrigues ME, Gomes F, Rodrigues CF. Candida spp./bacteria mixed biofilms. J Fungi. 2020;6:5.
https://doi.org/10.3390/jof6010005

12. Corrêa JM, Mori M, Sanches HL, Cruz AD, Poiate E, Poiate IA. Silver nanop nanoparticles in dental biomaterials. Int J Biomate.
2015;2015.
https://doi.org/10.1155/2015/485275

13. Erkoc P, Ulucan-Karnak F. Nanotechnology-Based Antimicrobial and Antiviral Surface Coating Strategies. Prosthesis. 2021;3:25-52.
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14. Lu L, Sun RW, Chen R, Hui CK, Ho CM, Luk JM, Lau GK, Che CM. Silver nanoparticles inhibit hepatitis B virus replication. Antiviral
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https://doi.org/10.1177/135965350801300210

15. Alfahdawi IH. Effect type of flasking technique and investing materials on movements of teeth during complete denture construction.
Int Medical J. 2019;26:516-9.

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17. Köroglu A, Sahin O, Kürkçüoglu I, Dede DÖ, Özdemir T, Hazer B. Silver nanoparticle incorporation effect on mechanical and thermal
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18. De Matteis V, Cascione M, Toma CC, Albanese G, De Giorgi ML, Corsalini M, Rinaldi R. Silver nanoparticles addition in poly (methyl
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20. Kagami K, Abe Y, Shinonaga Y, Imataki R, Nishimura T, Harada K, Arita K. Antibacterial and Antifungal Activities of PMMAs Implanted
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https://doi.org/10.3390/ma13204525

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against oral Candida species using a denture base coated with silver nanoparticles. J Nanomaterials. 2014;2014.
https://doi.org/10.1155/2014/780410

22. Queiroz JR, Fissmer SF, Koga-Ito CY, Salvia AC, Massi M, Sobrinho AS, Júnior LN. Effect of diamond-like carbon thin film
coated acrylic resin on Candida albicans biofilm formation. J Prosthod. 2013;22:451-5.
https://doi.org/10.1111/jopr.12029

23. Khan NT, Mushtaq M. Determination of antifungal activity of silver nanoparticles produced from Aspergillus Niger. Bio Med. 2017;9:
https://doi.org/10.4172/0974-8369.1000363

24. Prasad R, Swamy VS, Varma A. Biogenic synthesis of silver nanoparticles from the leaf extract of Syzygium cumini (L.) and its
antibacterial activity. Int J Pharm Bio Sci. 2012;3:745-52.

25. Shaikh MS, Alnazzawi A, Habib SR, Lone MA, Zafar MS. Therapeutic Role of Nystatin Added to Tissue Conditioners for Treating
Denture-Induced Stomatitis: A Systematic Review. Prosthesis. 2021;3:61-74.
https://doi.org/10.3390/prosthesis3010007

Beenish Haider1           BDS
Mehreen Imran2            BDS, M.Phil
Mohammad Raza3        BDS, FCPS
Zudia Riaz4                    BDS, M.Phil
Amjad Hanif5                 BDS, MSc
Sadia Akram6                BDS, M.Phil

OBJECTIVE: The present study was under taken to determine the anti-fungal effect of Silver Nano partial coating in
concentrations of 0.1%, 0.2%, 0.5% and 1% on heat cure acrylic denture through diffusion disc method. Poly methyl methacrylate
(PMMA) or simply acrylic is most commonly used material for construction of complete dentures. Denture stomatitis is an
inflammatory disorder of oral mucosa, frequently observed in denture wearers. The unpolished intaglio surface of PMMA base
dentures coupled with adverse conditions such as poor hygiene, dry mouth and compromised immune system leads to denture
related stomatitis in 50-70% of complete denture wearers. Antifungal agents such as silver have been added to acrylic denture
bases to in part self-disinfect property.
METHODOLOGY: The supplied modeling wax sheet was cut in to 25 specimens of dimensions 10x10x 2mm with help of
wax knife. The wax sheet was invested in stone plaster with in metal flask using open flasking method for mould formation.
Heat cured acrylic resin polymer and monomer (Meadway Royale Heat Cure, MR. Dental, and UK) was mixed according to
manufacturer's instructions of 2.5gm powder to 1ml monomer. The mixed acrylic was packed in dough stage followed by
pressure packing in hydraulic bench press for 30 minutes under 9.8 MPa. Curing was done by placing the flask in water at room
temperature until boiling. It remained in boiling water for 45 minutes and then allowed to cool down in water bath. A total of
25 acrylic plates were recovered from the flask and divided into five groups. Group A have no coating , group B coated with
0.1% sliver nano particles, group C coated with 0.2% silver nano particles, group D coated with 0.5% silver nano particles and
group E coated with 1% silver nano particles solution. Each specimen was cut in to 6mm disc by Laser Engraving Machine.
These discs were utilized for calculating zone of inhibition through diffusion disc method in agar media.
RESULTS: The diameter of zone of inhibition increased with the increasing concentrations of silver nano particles. When the
concentration of silver nano particles was 1%, the zone of inhibition size was maximum (20.48mm). When the concentration was
0.1%, the size of zone of inhibition was minimum (10.02mm) .This difference was statistically found to be highly significant (0.005).
CONCLUSION: This study results demonstrate that silver nano-particles have good antifungal activity against Candida Albicans
when used as surface coating. This antifungal property is directly influenced by the concentration of silver nano particles used.
KEY WORDS: Antifungal property, Silver nano particles (AgNPs), Candida Albicans (CA).
HOW TO CITE: Haider B, Imran M, Raza M, Riaz Z, Hanif A, Akram S. Antifungal effect of silver nano particles coating
on denture base specimens made of acrylic resin. J Pak Dent Assoc 2022;31(2):59-64.
DOI: https://doi.org/10.25301/JPDA.312.59
Received: 17 June 2021, Accepted: 07 January 2022

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