Vol. 31, Issue No. 03 – Jul - Sep 2022 Archives

Benign Spindel Cell Neoplasam: A Central Myofibroma of Maxilla in Male Child of Seven Years of Age: A Case Report

November 18, 2022November 17, 2022 by JPDA

Hira Nisar1 BDS
Abul Khair Zalan2 BDS, MDS
Mehreen Ismail3 BDS
Sabeen Masood4 BDS
Ahsan Inayat5 BDS

Myofibroma is a rare benign spindle cell neoplasm which occurs predominantly in infants and young children. It can occur as
a solitary mass or as a multicentric lesion, consisting of myofibroblasts. In oral cavity, the sites most commonly involved are
the mandible, tongue, lips and buccal mucosa however, it rarely involves the maxilla. It has aggressive clinical presentation
mimicking malignancies. We report a case of a male child seven years of age presented with intraoral swelling on the left palatal
aspect of the maxilla that extended from deciduous upper left second molar to the distal of upper permanent left first molar
causing the mobility of these teeth. Radiologically, the lesion was osteolytic causing marked resorption of alveolar bone and
displacement of permanent maxillary left second molar. A differential diagnosis of peripheral giant cell granuloma, central giant
cell granuloma, fibroma, aggressive fibromatosis, nodular fasciitis, peripheral ossifying fibroma and spindle cell neoplasm was
made. After the excluding malignant and vascular involvement, the surgical excision of the lesion was planned and was carried
out under general anesthesia. Histologically, benign proliferation of spindle cells was seen giving the diagnosis of benign spindle
cell neoplasm. Reports also showed positive immunoreactivity with vimentin and ?SMA while non-responsive to desmin,
validates the diagnosis of myofibroma.
KEYWORDS: spindle cell neoplasm; myofibroma; maxilla
HOW TO CITE: Nisar H, Zalan AK, Ismail M, Masod S, Inayat A. Benign spindel cell neoplasam: a central myofibroma of
maxilla in male child of seven years of age: A case report. J Pak Dent Assoc 2022;31(3):157-160.
DOI: https://doi.org/10.25301/JPDA.313.157
Received: 18 August 2021, Accepted: 01 May 2022

INTRODUCTION
yofibroma was first described in 1954 by Stout as “congenital generalized fibromatosis”1 which was renamed as “infantile fibromatosis” by
Chung et al. in 1981.1 However, later in 1989 Smith et al introduced the term “myofibroma” for these lesions.1
Afterwards, the terms “myofibromatosis” and “myofibroma” were adopted by the World Health Organization. 2 It can occur as solitary or multicentric lesion. 3
The presence o solitary lesion is uncommon in oral and maxillofacial region and the prevalence is not more than two percent of the total cases reported. Oral and perioral regions are commonly involved. However, intraosseous lesion of the jaw most commonly accounts for mandible and is rarely found in maxilla.3
Myofibroma occurs most commonly within the first ten years of life and 90% of these cases usually present before 2 years of age. 4
The exact etiology of this condition is unknown with most reported cases suggestive of its sporadic nature; however, some cases reported its familial pattern of
nheritance.4
Clinically Intraosseous myofibroma usually shows swelling of the jaws and sometimes when perforated can be presented as soft tissue mass. The distinctive characteristic of central myofibroma of the jaws is that it includes the teeth that displays clinical or radiographic picture indicative of odontogenic or nonodontogenic lesions.5
In this study, a central myofibroma of maxilla in a male child of seven years of age is presented, which is a very rare clinical entity.

CASE REPORT
A male child of seven years of age presented to the outpatient department of pediatric dentistry, children hospital, PIMS, with the complaint of swelling in upper left jaw extending to the palate for two months that was slowly increasing in size and was causing eating difficulties

(Figure 1). There was history of trauma in the involved site two months back. There was no medical history and the family history was also not significant. Oral hygiene of the patient was compromised. The swelling was asymptomatic with no pain and bleeding. However, the lesion occasionally bled slightly on manipulation. An informed and written consent was also taken from the patient or the attendant.
On extra-oral examination, there was no facial swelling or asymmetry with no associated lymphadenopathy. On intraoral examination there was a 3×3cm pedunculated, pinkish soft tissue mass on palatal aspect of the attached gingiva extending from upper primary left second molar to the distal of permanent left first molar causing the mobility of these teeth (Figure 2).

The mass had a firm consistency on palpation with no bruit and central ulceration thus excluding the vascular involvement. Intraoral periapical radiograph and orthopantomogram revealed marked resorption of alveolar bone along with distal drifting of permanent maxillary left second molar. (Figure:3).

A provisional diagnosis of central giant cell granuloma was made. Peripheral giant cell granuloma, central giant cell granuloma, fibroma, aggressive fibromatosis, nodular fasciitis, peripheral ossifying fibroma and spindle cell neoplasm were kept as differential diagnosis. After performing all baseline blood investigations, and anesthetist and maxillofacial surgeon consultation, excisional biopsy of the lesion was planned under general anesthesia excluding any other underline co morbidities. Since upper primary left second molar and permanent left first molar was in close approximation to the lesion so, the teeth were extracted along the lesion (Figure:4).

Following extraction of the teeth blunt dissection was done to remove all the remanants of the lesion. Primary closure was done with vicryl 3/0 followed by the placement of an absorbable hemostat, surgicel (Ethicon,10.2 cm×20.3cm) to control bleeding and periodontal dressing Coe Pak (Gc America) to facilitate healing (Figure:5).

The specimen was immersed in 10% formalin and was submitted for histopathologic examination. Histopathological studies revealed the benign proliferation of spindle cells arranged in streaming fascicles running in all directions giving the diagnosis of benign spindle cell neoplasm (Figure:6).

Immunohistochemical studies were done for the definitive diagnosis and the specimen showed positivity for αSMA and vimentin and negativity for desmin which was suggestive of myofibroma of the maxilla (Figure:7). The patient is currently undergoing routine follow-up (figure:8,9).

DISCUSSION
Myofibroma or myofibramatosis is a rare neoplasm of mesenchymal origin which is benign in nature, and consists of myofibroblasts.. It can be present as single lesion (myofibroma) or multiple (myofibramatosis) lesions. Soft tissues in the head and neck region are usually involved and are rarely found in the jaws, with only few cases reported in literature.5 However, when found in jaws, mandible shows greater predilection as compare to maxilla.6 In the presentcase the patient presented with the solitary myofibroma of the maxilla.
The etiology of these lesions is unclear. Some authors suggested that they are transmitted as an autosomal dominant or recessive characteristic while other suggested that trauma can be an important causative factor. They were of the view that as benign proliferation of myofibrolasts plays an important role in the wound healing then trauma to the tissues can be the leading cause in the formation of such lesions.7 The etiology in the present case can be the trauma which have resulted in the proliferation of myofibroblasts. Myofibromas are most commonly found in early age with slight male predilection.8Clinically the lesion presents as hard, protuberant swelling with no symptoms resulting in bony expansion of the jaws and disturbing the facial symmetry.9 In our case a hard, pedunculated, movable mass was noted on the palatal aspect of left posterior maxillary region in a male child seven years of age which is suggestive of the clinical findings of myofibroma as mentioned in various reported studies.
Myofibromas can be present as unilocular or multilocular radiolucency encircled by a well-defined border on radiograph. Some case reports presented thinning of the cortical plate along with the displacement of involved teeth.10 The present case also shown a unilocular radiolucency, with excessive
bone resorption resulting in mobility of primary maxillary left second molar and permanent maxillary left first molar and displacement of permanent maxillary left second molar.
Histologically the lesion consists of light and dark stained regions. Spindle cells contributes to the light area of the lesion which contains eosinophilic cytoplasm and tapered shaped nuclei at the periphery of the lesion whereas, the dark areas are composed of round or spindle shaped cells which are distributed centrally. These cells contains basophilic nuclei with eosinophilic cytoplasm and hazzy cell borders. The light and dark stained regions produces zoning pattern which is the characteristic of soft tissue lesions and are not found in intra osseous lesions.11
These features are often misleading and the disease can be wrongly diagnosed as benign or malignant spindle cell lesions of nerve or muscle origin (leiomyoma).7,11 Immunohistochemical staining is the key to the accurate diagnosis. It aids to differentiate between myofibroma and fibrosarcoma.In case of myofibroma vimentin, α-SMA will be positive whereas desmin and S-100 will be negative , while in fibrosarcoma α-SMA will be negative. Certain distinctive characteristics such as abnormal mitoses, atypical nuclear features and “herring bone” phenomenon also helps to distinguish fibrosarcoma from myofibroma.12 The present case showed positivity for α-SMA and vimentin which was suggestive of myofibroma. Treatment involves complete surgical excision. Local recurrence has been found to be 7% to 31% in cases of myofibramatosis. Prognosis is quite good in case of solitary lesions however, it can be aggressive and fatal in case of multicentric lesions.9,12,13

CONCLUSION
Central myofibroma is a benign tumor commonly present in young age. Mandible is commonly involved. The novelty in our case is that it showed a unique occurrence and presentation of myofibroma that originates from the maxilla. As myofibroma of the jaws can be very aggressive causing bone resorption and displacement of the permanent teeth sometimes mimicking malignancies so, thorough clinical and pathological findings are important tool along with the immunohistochemical studies to eliminate the risk of misdiagnosis and unnecessary invasive treatment modalities.

ACKNOWLEDGEMENTS
The author are grateful to the seniors, colleagues and to the oral pathology team who made efforts and prepared a very presentable slides.

ROLE AND CONTRIBUTION OF AUTHORS:

H.N data collection and drafted the manuscript. A.K.Z
Conception and design of the study, Collection of data and
assembly and article writing M.I data collection and drafted
the manuscripts S.M and A.I data collection, drafted the
manuscript and performed literature search.

CONFLICT OF INTERESTS
The authors declare that they have no conflicts of interest in relation to the publication of this article.

FUNDING
None to declare

REFERENCES

1. Brasileiro BF, Martins-Filho PR, Piva MR, Da Silva LC, Nonaka CF, Miguel MC. Myofibroma of the oral cavity. A rare spindle cell neoplasm. Med Oral Patol Oral Cir Bucal. 2010;15:e596-600. https://doi.org/10.4317/medoral.15.e596

2. – Narayen V, Ahmed SA, Suri C, Tanveer S. Myofibroma of the gingiva: a rare case report and literature review. Case Reports in Dent. 2015, Article ID 243894.
https://doi.org/10.1155/2015/243894

3. Dhupar A, Carvalho K, Sawant P, Spadigam A, Syed S. Solitary intra-osseous myofibroma of the jaw: a case report and review of literature. Children. 2017;4:91.
https://doi.org/10.3390/children4100091

4. Venkatesh V, Kumar BP, Kumar KJ, Mohan AP. Myofibroma-a rare entity with unique clinical presentation. J Maxillofac Oral Surg. 2015;14:64-8.
https://doi.org/10.1007/s12663-011-0299-5

5. Sundaravel S, Anuthama K, Prasad H, Sherlin HJ, Ilayaraja V. Intraosseous myofibroma of mandible: A rarity of jaws: With clinical, radiological, histopathological and immunohistochemical features. J Oral Maxillofac Pathol. 2013;17:121.
https://doi.org/10.4103/0973-029X.110703

6. Smith MH, Reith JD, Cohen DM, Islam NM, Sibille KT, Bhattacharyya I. An update on myofibromas and myofibromatosis affecting the oral regions with report of 24 new cases. Oral Surg, Oral Med, Oral Pathol Oral Radiol. 2017;124:62-75.
https://doi.org/10.1016/j.oooo.2017.03.051

7. Kaur P, Chowalta R, Lata J. Central myofibroma of the maxilla. Contem Clin Dent. 2016;7:71.
https://doi.org/10.4103/0976-237X.177109

8. Satomi T, Kohno M, Enomoto A, Abukawa H, Fujikawa K, Koizumi T, Chikazu D, Matsubayashi J, Nagao T. Solitary myofibroma of the mandible: an immunohistochemical and ultrastructural study with a review of the literature. Medical molecular morphology. 2014;47:176- 83.
https://doi.org/10.1007/s00795-013-0062-8

9. Chattaraj M, Gayen S, Chatterjee RP, Shah N, Kundu S. Solitary Myofibroma of the mandible in a six-year old-child: Diagnosis of a rare lesion. J Clin Diagn Res.2017;11:ZD13. https://doi.org/10.7860/JCDR/2017/25506.9677

10. Nashef R, Fleissig Y, Abu-Tair J, Heyman O, Doviner V. Solitary central myofibroma of the maxilla: a case report.
J Oral Maxillofac Surg Med Pathol. 2014;26:558-62. https://doi.org/10.1016/j.ajoms.2013.06.010

11. Andreadis D, Epivatianos A, Samara A, Kirili T, Iordanidis F, Poulopoulos A. Myofibroma of the oral mucosa: a case report. Med Princ Pract. 2012;21:288-91.
https://doi.org/10.1159/000334587

12. Shibuya Y, Takeuchi J, Sakaguchi H, Yokoo S, Umeda M, Komori T. Myofibroma of the mandible. Kobe J Med Sci. 2008;54:E169-73.

13. Lingen MW, Mostofi RS, Solt DB. Myofibromas of the oral cavity. Oral Surg Oral Med, Oral Pathol, Oral Radiol Endodontol. 1995;80:297- 302.
https://doi.org/10.1016/S1079-2104(05)80387-7

1. MDS Resident, Department of Pediatric dentistry, Pakistan Institute of Medical
Sciences, Islamabad.
2. Registrar, Department of Pediatric Dentistry, School of Dentistry, Islamabad.
3. Lecturer, Department of Orthodontics, Sardar Begum Dental College.
4. FCPS Resident, Department of Operative Dentistry, Altamash Institute of Dental
Medicine, Karachi.
5. MDS Resident, Department of Prosthodontics, Dow University of Health sciences,

Benign Spindel Cell Neoplasam: A Central Myofibroma of Maxilla in Male Child of Seven Years of Age: A Case Report

December 1, 2022November 17, 2022 by JPDA

Hira Nisar1 BDS
Abul Khair Zalan2 BDS, MDS
Mehreen Ismail3 BDS
Sabeen Masood4 BDS
Ahsan Inayat5 BDS

Myofibroma is a rare benign spindle cell neoplasm which occurs predominantly in infants and young children. It can occur as
a solitary mass or as a multicentric lesion, consisting of myofibroblasts. In oral cavity, the sites most commonly involved are
the mandible, tongue, lips and buccal mucosa however, it rarely involves the maxilla. It has aggressive clinical presentation
mimicking malignancies. We report a case of a male child seven years of age presented with intraoral swelling on the left palatal
aspect of the maxilla that extended from deciduous upper left second molar to the distal of upper permanent left first molar
causing the mobility of these teeth. Radiologically, the lesion was osteolytic causing marked resorption of alveolar bone and
displacement of permanent maxillary left second molar. A differential diagnosis of peripheral giant cell granuloma, central giant
cell granuloma, fibroma, aggressive fibromatosis, nodular fasciitis, peripheral ossifying fibroma and spindle cell neoplasm was
made. After the excluding malignant and vascular involvement, the surgical excision of the lesion was planned and was carried
out under general anesthesia. Histologically, benign proliferation of spindle cells was seen giving the diagnosis of benign spindle
cell neoplasm. Reports also showed positive immunoreactivity with vimentin and ?SMA while non-responsive to desmin,
validates the diagnosis of myofibroma.
KEYWORDS: spindle cell neoplasm; myofibroma; maxilla
HOW TO CITE: Nisar H, Zalan AK, Ismail M, Masod S, Inayat A. Benign spindel cell neoplasam: a central myofibroma of
maxilla in male child of seven years of age: A case report. J Pak Dent Assoc 2022;31(3):157-160.
DOI: https://doi.org/10.25301/JPDA.313.157
Received: 18 August 2021, Accepted: 01 May 2022

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Knowledge, Attitude and Practices of Dental Surgeons about Dental Waste Management in Dental Clinics of Karachi

March 1, 2023November 17, 2022 by JPDA

Zahid Ali1 BDS, FCPS
Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI
Saqib Zafar3 BDS, MPhil
Muhammad Saeed Mughal 4 BDS
Syeda Hala Raza5 BDS, FCPS
Mehwash Kashif 6 BDS, FCPS

OBJECTIVE: This study aims to assess the contempory situation of dental waste management in private dental practices in
Karachi.
METHODOLOGY: A cross-sectional study was done in 5 districts of Karachi (East, West, South, Centre, Malir) from 26th
January to 26th April 2021. Total 100 private dental practitioners were recruited using non-probability consecutive sampling.
A pretested, 20 items questionnaire was used for recording data of the research participants, and their knowledge, attitude and
practices (KAP) of managing dental waste. Inclusion criteria was both male and female dentists, above 25 years of age, who
run dental clinics in 5 districts of Karachi. Dental students were excluded. Data were analysed using SPSS version 17. 00
RESULTS: Total 79% of the participants were males and 21% were females. Approximately 68% belonged to the age group
of 25-35 years. Total 51% had an experience of 10-20 years and32% were using colour coded bins while 35% were following
segregation methods for waste disposal. Only 16% had attended professional training programs for waste management.
CONCLUSION: Waste management in dental clinics in Karachi is inadequate and improper. The government should enact
monitoring of all dental practices, enforcing the recommended regulations.
KEYWORDS: Dental waste management, Knowledge, attitude and practices (KAP), private dental practitioners
HOW TO CITE: Ali Z, Khan NA, Zafar S, Mughal MS, Raza SH, Kashif M. Knowledge, attitude and practices of dental
surgeons about dental waste management in dental clinics of Karachi. J Pak Dent Assoc 2022;31(3):153-156.
DOI: https://doi.org/10.25301/JPDA.313.153
Received: 27 April 2022, Accepted: 28 June 2022

INTRODUCTION
A ccording to WHO, healthcare waste is defined as ‘any disposed material from healthcare activities, which can be a potential source of infection to humans’.1 The infectious biomedical waste produced in Pakistan is not less as compared to other countries.2 Literature shows that approximately 2 kg of waste per bed per day is produced out of which 0.1- 0.5 comprises of risk waste.3 Dental clinics make up a minute amount of healthcare waste in comparison to hospitals. Still, this waste poses grave health and environmental risks if not appropriately managed.4 Most of the waste produced by dental practices is classified into three groups i.e. infectious, chemical and office.5 Hazardous dental waste includes mercury in amalgam, silver, lead, X-ray films and fixer solution, disinfectants, needles, blades, burs, orthodontic appliances, contaminated gauze and latex gloves etc.5 Exposure to infectious biomedical waste can result in dermatological, gastrointestinal, respiratory diseases or worse Hepatitis and HIV / AIDS.6
In order to minimize hazardous outcomes of dental waste, there should be proper waste segregation, handling, transport and disposal. There is limited awareness of handling biomedical waste in third world countries.2 Therefore, professional training for waste management is required for the betterment of knowledge and practices of medical and dental healthworkers.2
The research aimed to appraise the existing situation of waste management in private dental practices in Karachi to assess the severity of the situation and also come up with recommendations for the government to implent in order to minimize exposure and also lead to the safe management of hazaradous waste substances

METHODOLOGY
A cross sectional study was done in 5 districts of Karachi (i.e. East, West, South, Centre, Malir) for three months, from 26th January 2021 to 26th April 2021. 100 private dental practitioners were recruited for the study using nonprobability consecutive sampling. The sample size was calculated using Raosoft software with the accepted margin of error 5%, 95% confidence level, population size of 134 and response distribution of 50%. Ethical approval was acquired from the Ethical Review Committee of the KMDC. Informed consent was taken from all the research participants. A pre-tested, automated, 20 items questionnaire with closedended questions was designed for recording data relating to participants’ demographics and their relevant knowledge and practice of waste handling in dental practices. Pretesting was carried out on 20 doctors for validity. Total 100 private practitioners were given questionnaires which were duly completed and collected.
Both male and female dentists, 25 years of age and above, running dental practices in 5 districts of Karachi were included in the study. Dental students were excluded. Data collected were analyzed using SPSS software version 17.00

RESULTS
Total 100 dentists were invited and participated in this study, with a 100% response rate.The male to female ratio of the practitioners was 1: 3.8 male to female. Among respondents 10% were house officers 55% were general dental practitioners 15% postgraduate trainees and 15% were consultants.
Figure 2 shows the distribution of dental practitioners in 5 districts of Karachi. Table 3 shows the distribution of respondents by their understanding, inclination and practices.
35% participants were following segregation methods of waste disposal, 58% were not and 7% were unaware. In this study we found that most of the practitioners improperly dispose infectious and sharp waste. 70% had no dental waste management policy document and 74% participants did not attend any CDE programs on dental waste management.
76% clinics disposed final dental waste directly into corporation bins, 14% handed it over to certified collectors
A total of 100 participants were recruited for this study, with a 100% response rate. As shown in Fig. 1, the male to female ratio of the practitioners was 1: 3.8 male to female.

Out of 100 participants, 16% had attended professional training programs on waste management, 74% participants had not attended any continuing dental education program on dental waste management, and 10% had no idea regarding any program that offers training regarding waste management. 32% of the participants were using color-coded bins, 62% were not, and 4% were unaware. 35% participants were following segregation methods of waste disposal, 58% were not and 7% were unaware. 70% of practitioners had no dental waste management policy document, 19 % claimed to have a policy document for their clinics and 11% were unaware of any such documents. 58% disposed used x-ray films into a common bin. 51% disposed x-ray lead foil in common bin and only 23% stored and disposed in a separate container. Regarding the disposal of x-ray film fixer solution, 32% emptied it directly into the sewer, 18% diluted the solution and then disposed it into the sewer, 6% returned it to the suppliers and 44% were unaware of the policymadopted by their clinic. Waste collection storage and handling was done by dental assistants in 62% clinics, whereas in 21% of clinics, the cleaner was assigned this task and in 12% clinics dental surgeons themselves were responsible for this duty. 76% clinics disposed final dental waste directly into corporation bins, 14% handed it over to certified collectors and 10% were unaware of how the final disposal took place. 55% stored the final dental waste inside their clinics, 29% outside the clinics, 11% stored in the lab area and remaining 5% had no idea.

and 10% were unaware of how the final disposal took place. 55% stored the final dental waste inside their clinics, 29% outside the clinics, 11% stored in the lab area and remaining 5% had no idea.
Less than 32% of the research candidates used the segregation method. 44% were unaware of the standard methods to dispose x-ray fixer waste. In the studied centers, dental assistants mostly did handling of dental waste by improper methods.

DISCUSSION
Systematic and organized management of possibly hazardous waste is basic for the wellbeing of patients, dental practitioners and our environment.4
Dental clinicians and their assistants can assure proper sterilization in clinics and handle problems related to dental waste disposal if they follow set guidelines for the management of biomedical waste. 4,7
The entire amount of dental waste processed in a single day can be divided into the following subtypes: infectious, non-infectious and domestic.8 Nabizadeh R et al. reports in a study, that approximately 71.15% of dental waste consisted of domestic waste, 21.40% was infectious waste, 7.26% was chemical waste, whereas only 0.18% was toxic waste.9
According to a study done in Sydney, Australia, it was found that out of 14 dental clinics only 5 were following proper guidelines for the collection and disposal of infectious waste.10 Another study in New Zealand demonstrated that almost 25% of dental facilities directly threw dental sharps in common bins.11
A report of a similar study carried out in Hamadan, Iran, revealed all the amalgam waste was disposed into the main sewerage line and used sharps were thrown into the common waste.9 Research carried out in Pakistan reports that most private practitioners disposed amalgam waste in the dustbin or simply into the sewer, only 6 out of 221 dentists, used a sealed container for storage of amalgam waste.12 Although , dental waste management protocol is outlined by the government, the knowledge regarding this subject is still lacking which suggests the need for continued dental education programs, and the need for continuous monitoring of the practices.2,12
In most developing countries including Pakistan, management of biomedical waste disposal is becoming a major problem and if not addressed promptly it will further worsen the environmental crisis.13 Although guideline documents devised by the Health Department on dental waste management is available, but practitioners do not have a storage standardization policy and hardly any practitioner coordinates with pollution control boards.13
In this study, we found that most practitioners improperlydispose of infectious and sharp waste. 70% had no dental waste management policy document and 74% of participants did not attend any CDE programs on dental waste management.
Universally, yellow plastic bags are used for segregation of infectious waste, whereas sharps should be collected in safety containers.7 These are incinerated or autoclaved and finally buried under the ground of designated dumps.7
The above-mentioned findings of this research reveal the voids in knowledge and application of dental practitioners in Karachi, Pakistan.Small sample size and cross sectional designs were the limitations of study. It is recommended that CDE programs on dental waste management must be planned and initiated which will increase awareness of dental undergraduates and dental personnale towards proper waste management. Waste management should be taught at all levels of dentistry especially dental personnel and dental hygienist and assistants. Further research is recommended with large sample size and longitudinal design for more better results.

CONCLUSION
Dental waste is perilous to all creatures in the environment. The dental practices of Karachi are handling this insufficiently and improperly. The government ought to take the initiative and enforce adequate monitoring for all dental practices to highlight refractory activity and impose recommended directives.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Pandey A, Ahuja S, MAdAn M, ASthAnA AK. Bio-Medical Waste Management in a Tertiary Care Hospital: An Overview. J Clin Diagnostic Res. 2016;10.10:DC01-DC03. https://doi.org/10.7860/JCDR/2016/22595.8822

2. Zaib N, Umer N, Masood R. Waste Management at Dental Hospitals Of Rawalpindi-Islamabad Region. Biomedica. 2015;31:277.

3. Khan MJ, Hamza MA, Zafar B, Mehmod R, Mushtaq S. Knowledge, attitude and practices of health care staff regarding hospital waste handling in tertiary care hospitals of Muzaffarabad, AJK, Pakistan. Int J Sci Reports. 2017;3:220-6.
https://doi.org/10.18203/issn.2454-2156.IntJSciRep20173094

4. Al-Khatib IA, Monou M, Mosleh SA, Al-Subu MM, Kassinos D. Dental solid and hazardous waste management and safety practices in developing countries: Nablus district, Palestine. Waste Manag Res. 2010;28:436-44.
https://doi.org/10.1177/0734242X09337657

5. Agarwal B, Singh S, Bhansali S, Agarwal S. Waste management in dental office. Indian J Com Med. 2012;37:2201-202. https://doi.org/10.4103/0970-0218.99934

6. Amsalu A, Worku M, Tadesse E, Shimelis T. The exposure rate to hepatitis B and C viruses among medical waste handlers in three government hospitals, southern Ethiopia. Epidemiol Health. 2016;38. https://doi.org/10.4178/epih.e2016001

7. Danaei M, Karimzadeh P, Momeni M, Palenik CJ, Nayebi M, Keshavarzi V, Askarian ME. The management of dental waste in dental offices and clinics in Shiraz, Southern Iran. Int J Occup Environ Med. 2014;25;5:336-18.

8. Vieira CD, de Carvalho MA, de Menezes Cussiol NA, AlvarezLeite ME, dos Santos SG, da Fonseca Gomes RM, Silva MX, de Macêdo Farias L. Composition analysis of dental solid waste in Brazil. Waste Manag. 2009;29:1388-91. https://doi.org/10.1016/j.wasman.2008.11.026

9. Nabizadeh R., Koolivand A., Jafari A.J., Yunesian M., Omrani G. Composition and production rate of dental solid waste and associated management practices in Hamadan, Iran. Waste Manag. Res. 2012;30:619-624. https://doi.org/10.1177/0734242X11412110

10. Zazouli MA, Rostami E, Barafrashtehpour M. Assessment of dental waste production rate and management in Sari, Iran. J Adv Enviro Health Res. 2014;2:120-5.

11. Sushma MK, Bhat S, Shetty SR, Babu SG. Biomedical dental waste management and awareness of waste management policy among private dental practitioners in Mangalore city, India. Tanzania Dent J. 2010; 16:39-43. https://doi.org/10.4314/tdj.v16i2.69867

12. Mumtaz R, Khan AA, Noor N, Humayun S. Amalgam use and waste management by Pakistani dentists: an environmental perspective. Eastern Mediterranean Health J.2010;16:334-39

13. Mushtaq A, Alam M, Shahid Iqbal MS. Management of dental waste in dental hospital of Lahore. Biomedica. 2008;24:61-3.

1. Professor, Department of Oral Maxillofacial Surgery, Abbasi Shaheed Hospital and
Karachi Medical Dental College, Karachi.
2. Assistant Professor, Department of Oral Maxillofacial Surgery, Karachi Medical
Dental College, Karachi.
3. MPhil Scholar, Department of Microbiology, Dadabhoy Institute of Higher Education
4. MPhil Scholar, Department of Microbiology, Dadabhoy Institute of Higher Education
5. FCPS Resident, Department of Oral Maxillofacial Surgery Abbasi Shaheed Hospital
Karachi.
6. Professor, Department of Oral Pathology Karachi Medical Dental College, Karachi
Corresponding author: “Dr. Nazish Ashfaq Khan” < aansa19@yahoo.com >

Knowledge, Attitude and Practices of Dental Surgeons about Dental Waste Management in Dental Clinics of Karachi

March 1, 2023November 17, 2022 by JPDA

Zahid Ali1 BDS, FCPS
Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI
Saqib Zafar3 BDS, MPhil
Muhammad Saeed Mughal 4 BDS
Syeda Hala Raza5 BDS, FCPS
Mehwash Kashif 6 BDS, FCPS

OBJECTIVE: This study aims to assess the contempory situation of dental waste management in private dental practices in
Karachi.
METHODOLOGY: A cross-sectional study was done in 5 districts of Karachi (East, West, South, Centre, Malir) from 26th
January to 26th April 2021. Total 100 private dental practitioners were recruited using non-probability consecutive sampling.
A pretested, 20 items questionnaire was used for recording data of the research participants, and their knowledge, attitude and
practices (KAP) of managing dental waste. Inclusion criteria was both male and female dentists, above 25 years of age, who
run dental clinics in 5 districts of Karachi. Dental students were excluded. Data were analysed using SPSS version 17. 00
RESULTS: Total 79% of the participants were males and 21% were females. Approximately 68% belonged to the age group
of 25-35 years. Total 51% had an experience of 10-20 years and32% were using colour coded bins while 35% were following
segregation methods for waste disposal. Only 16% had attended professional training programs for waste management.
CONCLUSION: Waste management in dental clinics in Karachi is inadequate and improper. The government should enact
monitoring of all dental practices, enforcing the recommended regulations.
KEYWORDS: Dental waste management, Knowledge, attitude and practices (KAP), private dental practitioners
HOW TO CITE: Ali Z, Khan NA, Zafar S, Mughal MS, Raza SH, Kashif M. Knowledge, attitude and practices of dental
surgeons about dental waste management in dental clinics of Karachi. J Pak Dent Assoc 2022;31(3):153-156.
DOI: https://doi.org/10.25301/JPDA.313.153
Received: 27 April 2022, Accepted: 28 June 2022

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Interventions for the treatment of Radiotherapy Induced Trismus: A Systematic Review of the Literature

November 17, 2022 by JPDA

Mohammad Annas Aslam1 BDS, MSc
Obaid Bajwa2 BDS
Anum Ahmed Raja3 BDS
Nissa Khan4 BDS

OBJECTIVES: To systematically assess the outcome of interventions used to treat patients who have trismus as a
result of radiotherapy to the head and neck region in the treatment of Head and Neck Cancer (HNC).
METHODOLOGY: Searches were carried out on online databases (Medline, Embase and The Cochrane Central Library) on
the 19th of June 2019 and then again using the same search terms on the 6th of June 2021. Randomized and 
NonRandomized trials aimed at treating trismus as a side effect of head and neck radiotherapy (RT) were included
for this systematic review. A total of 5 papers were reviewed for the purpose of this systematic review.
RESULTS: Results show that there is limited evidence to support the use of any treatment modality other than
structured jaw exercises to help treat trismus in patients with a history of HNC and RT induced fibrosis. There is
no evidence to support the use of Botulinum toxin A, while further studies are needed to clarify the effectiveness
of Pentoxifylline (with or without conjunction with Vitamin E) and Pregabalin in the treatment of postradiotherapy
fibrosis.
CONCLUSION: There is a need for more randomized control trials to identify treatment modalities for radiotherapy
induced trismus. Rehabilitation exercises have been implemented across all papers involved in this study which
indicates the need for analysis and identification of a pharmaceutical intervention.
KEYWORDS: Head and neck cancer, trismus, lockjaw, radiotherapy, randomized controlled trial, placebo
HOW TO CITE: Aslam MA, Bajwa O, Raja AA, Khan N. Interventions for the treatment of radiotherapy induced trismus: A
systematic review of the literature. J Pak Dent Assoc 2022;31(3):147-152.
DOI: https://doi.org/10.25301/JPDA.313.147
Received: 25 August 2021, Accepted: 28 April 2022

INTRODUCTION
HNC comprises of malignancies related to the oral cavity and the head and neck area. Cancer of the bones of the craniofacial region, the glands in the head and neck and the structures and epithelium inside the oral cavity are all included within this group of malignancies.1
HNC entails a long list of comorbidities, and as it stands, HNCs have a potential to be fatal, with a 5-year survival rate post diagnosis for 50% of patients. According to an update by the World Health Organization in 2018, oral cancer was recognized as the 10th most frequently occurring cancer in the world and ranks 7th at cancer induced mortality.2
As a standard, radiotherapy remains the first line treatment in the management of HNCs. The total dosage given to patients can be in the range of 50-70 Grays (Gy) overall with a daily fraction of 2 Gy over several weeks to effectively eliminate tumour cells while minimizing side effects to surrounding soft tissues.3 Radiotherapy can have multiple side effects to the head and neck region considering that a lot of important structures are present in the area (nerves, glands, muscles, etc.).4 These side effects (acute or late/delayed) include, but may not be limited to5 :
– Osteoradionecrosis
– Salivary gland hypofunction (Xerostomia)
– Dental Caries
– Thyroid gland hypofunction
– Oral mucositis
– Neuropathic pain
– Radiation Induced Muscle Fibrosis:

o Trismus
o Dysphagia
o Dysgeusia
Side effects of the therapy/interventions leave patients with, in most cases, a permanent morbidity.
This is due to the effect of given therapies/interventions, which may target important structures in the head and neck region (salivary glands, muscles, etc.) and cause irreversible damage. Patients may feel difficulty in speaking, swallowing, opening their mouths, stretching/turning their neck among other things.
Trismus is a condition characterized by limited mouth opening; it may result from the growth of a tumour into the temporomandibular joint (TMJ) or into the muscles of mastication.6 The complete aetiology of trismus is discussed later under a separate sub-heading.
Trismus as a side effect is resultant limited mouth/jaw opening and mobility, leading to a reduction in patient qualityof life (QOL).7 Currently, there is no clear consensus in the definition of trismus, but most authors suggest the cut-off measurement for trismus to be less than or equal to 35mm interincisal distance.8,9
Complications of trismus present as an inability to open the mouth widely. As a result, oral hygiene may be impaired, there is difficulty in patients trying to chew or eat, rehabilitation of teeth presents to be a challenge. There may also be concomitant dry mouth which in turn leads to impaired speech and difficulty in wearing dentures. Patients are at an increased risk of dental infections.10
The point of this review was to establish:
• Are there any effective therapies?
• Are there any trials which have confirmed effectivetherapies?
• Is there a knowledge gap in this area?
The purpose of this review was to systematically assess the outcome of interventions used to treat patients who have trismus as a result of radiotherapy to the head and neck region in the treatment of HNC.

METHODOLOGY
Literature Search
Two researchers (M.A.A & O.B) entered search terms on 3 separate online databases. The following electronic online databases were searched after developing an inclusion and exclusion criteria, complying with the preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement11:
• Embase (Ovid) – 1980 to present
• Medline (Ovid) – 1946 to present
• Cochrane Library (central)
Search strategies with filters for RCTs were identified and the searches were carried out on the following dates:
• Embase: 19th of June 2019 and 5th of August 2020 with the OVID ISSG filter – InterTASC
• Medline: 19th of June 2019 and 5th of August 2020 with the Cochrane Filter (Cochrane Highly Sensitive Search Strategy – HSSS)
• Cochrane Library: 19th of June 2019 and 5th of August 2020

Inclusion Criteria:
• Randomized and non-randomized controlled trials were reviewed
• Trials aimed at treatment of radiotherapy induced trismus specifically

Exclusion Criteria:
• Animal studies were not considered.
• Articles reporting patients with accidental exposure to radiations were not considered
• Preventative measures before or during radiotherapy to prevent trismus were excluded
• All retrospective studies were dismissed

Data Collection and Analysis
Cochrane Collaboration tool for assessing the risk of bias was used to evaluate the quality of articles.12 This tool has been cited multiple times in many studies which shows the validity of the tool in assessing the risk of

bias.13,14 The articles included have been published in various medical and dental journals and no articles are incomplete or in press.

RESULTS
We identified 5 studies which were targeted towards the treatment of RT induced Trismus. Trials using preventative measures before or during treatment were not
considered.
A total of 5 trials (Table 2) were identified to have directly dealt with the treatment of RIF, incorporating a totalof 365 patients. All trials used the difference in measurement of MIO before and after treatment to determine the success/failure of the trial (through measurement tools such as a ruler). Patient Questionnaires were also used to assess patient-based feedback. Patient questionnaires used for these studies included the Gothenburg Trismus Questionnaire (GTQ)15-17 , European Organization for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) (15-18) and the EORTC Head & Neck Questionnaire
(EORTC QLQ-H&N35).16
These studies assess MIO before and after treatment, with the following timelines:
1. At the start, at 4 weeks then at 10 weeks after intervention with a follow up of 3 months.16
2. At the start and 8 weeks after intervention with follow up of 24 months.15
3. At the start and 3 months after intervention.17
4. At the start, at 3 months and at 6 months after intervention.18
5. At the start, then at every month for 3 months.19

An open-label trial assessed the efficacy of a 10-week structured exercise program with exercise five times a day with Therabite® or Engstrom jaw mobilizing device versus no intervention. Participants (n=101) were invited to be part of the study if they had trismus (MIO<35mm) and had completed radiotherapy by at least 3 months. The primary endpoint in this study was MIO and secondary endpoints were trismus-related symptoms (assessed through Gothenburg Trismus Questionnaire) and QoL (EORTC QLQ C30 including the H&N35 module and Hospital Anxiety and Depression Scale). The results of this study were not reported for single interventions (Therabite® or Engstrom device) but at 3 months the authors reported a statistically significant difference of 6.4mm (intervention) vs 0.7mm (control) when the maximal interincisal opening was compared to the baseline. There was a statistically significant difference in trismusrelated symptoms and quality of life for the intervention vs control group. The study was considered at high risk of detection and performance bias.
The following year Pauli’s research group also published a randomised trial comparing two different jaw exercise devices. The authors included 50 patients and randomly allocated them to 2 groups of 25, one to undergo exercises with the Therabite® device (mean use was 2.5
months) and one to undergo therapy with the Engstrom device (mean use was 2.7 months). The trial proved successful, with the maximum change noticed after 4 weeks of jaw exercises. 10-week exercises were carried out with MIO measurements at 4 weeks, 10 weeks and at a 3 month follow up appointment. The GTQ was used to assess patient feedback and response.7 patients, 4 from the Therabite® group and 3 from the Engstrom group reported to have used the exercise sporadically due to a variety of reasons (depression, soft tissue necrosis, could not stand the taste of wood, uncomfortable sensation and others). For both groups, MIO increased at 7.2mm for the Therabite® group and 5.5mm for the Engstrom group. At the end of the trial, 21 patients from the Therabite® group and 15 patients from the Engstrom group were reported to not fulfilling the criteria for trismus. The authors reported on patient feedback through the GTQ and exercise diaries were kept for record to reflect on patient compliance to the exercises themselves. No dverse effects were recorded for any of the exercise using both different systems. Allocation bias was not present; patients were randomly selected to have therapy targeted by either one device or the other.15 The study was considered at high risk of performance bias.
In 2016 Pauli et al. included 50 patients with a history of HNC treatment and trismus to compare with a control group of another 50 participants (31 men and 19 women in both groups). The control group was comparable to the intervention group in terms of age, tumour location, radiation dose and comorbidity. This non-randomized study reported a higher MIO at the 2 year follow up mark of 40.5mm in the intervention group compared to a 34.3mm MIO in the control group. Patient based assessment was made through the GTQ, QLQ-H&N35 and the QLQ-C30 questionnaires. The study reported a positive outcome with the use of the structured jaw exercises with the Therabite® and the Engstrom devices, this time made significant by the comparison of the intervention and the control groups. However, it was not reported how many patients were using the Therabite® device and how many were using the Engstrom devices. Overall, there were no side effects reported. After a 2 year follow up out of the 50 patients in the intervention group, 6 were lost to follow up, 2 died 4 were lost to unspecified reasons. Of the 50 patients in the control group, 7 were lost to follow up, 6 died and 1 was lost to an unspecified reason. The authors reported a positive outcome of using jaw exercises to treat trismus, along with better QOL and better trismus related symptoms (16). This study is at the risk of selection (randomization), performance and detection bias.
In 2010, Tang et al. conducted a randomized prospective study with 43 patients who had undergone radiotherapy for nasopharyngeal carcinoma. Trismus was evaluated through the LENT/SOMA score as well as measuring the MIO. Quality of life was not assessed through any questionnaire. Two groups were made with 21 patients in the control group versus 22 in the rehabilitation group.
The rehabilitation group was asked to conduct jaw exercises by:
1. Opening and closing the mouth
2. Opening the mouth slightly and inducing lateral movements in the mandible
3. Stretching the chin downwards
4. Using the Therabite® device
MIO was measured at the start of the trial and then once a month for 3 months. The rehabilitation group showed
a lesser decrease in MIO (Pre-treatment = 1.89+/-0.69cm vs. 3-month post-treatment=1.7+/-0.68cm) as compared to the control group (Pre-treatment = 1.8+/-0.56cm vs. 3-month post-treatment=1.1+/-0.36cm). The results were statistically significant. This study, however, does not clarify the details of the two groups formed for this trial and hence is at the risk of allocation and detection bias.
In 2018 Lee et al. assessed the efficacy of the Therabite® device versus wooden spatulas in a total of 71 patients with n=37 and n=34 respectively. QOL was measured by the use of EORTC QLQ-C 30 and the Head and Neck module (EORDC QLQ H&N 35). Baseline values for MIO in the Therabite® group was at a mean of 24 mm and 21.8 mm for the spatula group. This trial found that the difference between the two groups in terms of increased MIO was not statistically significant. A comparison was not made with other subjects due to the absence of a control group. A few patients were lost because of noncompliance. This trial did not include a control group hence a comparison could not be made with regards to proving which device served better against participants who were not receiving any treatment. This study is at the risk of performance bias. The results have been summarized in Table 3 below: [Table 3]

MIO – Maximum Interincisal Opening
GTQ – Gothenburg Trismus Questionnaire
H&N35 – European Organization for Research and Treatment of Cancer Head and Neck Questionnaire
QLQ-C30 – European Organization for Research and Treatment of Cancer Core Questionnaire

DISCUSSION
Head and Neck Cancer (HNC) related side effects have been long documented. Trismus is one of the most debilitating side effects associated with the treatment of
HNC, but there is a distinct lack of the interventions to ameliorate trismus, thus the need arises for us to find a good treatment(s) option. This systematic review was carried out keeping in mind the absence of HNC radiotherapy induced trismus related interventions.
We included 5 studies in this systematic review with a total of 365 participants. All 5 studies used exercise-based interventions. The above studies, although reporting on patient outcomes of intervention, lack strong evidence provided by Randomized Controlled Trials. A clinical trial is planned by the University College London and the National Institute for Health Research in the United Kingdom to study the effects of Pentoxifylline and Tocopherol in the management of RT induced trismus (due to end in late 2021). This trial will be one of the first Randomized Controlled Trials to research the effect of the above stated drugs in the management of RT induced trismus, and will provide solid, robust evidence in comparison to the rest of the available literature. The results of this trial will help in determining whether the use of Pentoxifylline is justified in patients with RT induced trismus.
Chua et al. selected a total of 16 patients (12 men and 4 women) to undergo an 8-week course of Pentoxifylline 400mg, 3 times a day. During this course, 4 patients developed side effects and were given the same dose only twice daily until the end of the timeline. The mean MIO before the experiment was 12.5 mm and the trial reported an increase to a mean of 16.5 MIO at the end for all patients. 10 patients were reported to have a range increase of 2-25 mm of MIO, 5 patients were reported to have no measurable change and 1 patient had a reduced MIO after therapy.
The authors did not report patient feedback regarding the trial or the effect of outcome experience by the patients. The reported adverse effect was dizziness, reported in 4 patients which warranted a dose reduction in these patients.20 This trial was excluded as it had no control group. Hartl et al. selected a total of 19 patients (12 men and 7 women) to undergo therapy with Botox injections (50 units) or Dysport injections (250 units). These transcutaneous injections were given to the masseter muscle.
The author reported no significant change in the MIO before and after injections were given up to a period of 1 month. The author did however report that after the injections were made, patients reported betterment of the functional pain and cramps associated with their conditions, but no improvement was mentioned for trismus. Patient feedback was taken through a questionnaire which was designed for the trial but not been used anywhere else in the literature.
However, all patients were reported to have an improvement in the aspect of their pain and it was reported that they would recommend the treatment to others experiencing the same symptoms, even though the therapy had no effect on the trismus. Seven patients described the
njections as ‘painful’. The authors did not evaluate the symptoms of trismus. No adverse side effects were reported for this trial.21 This trial was excluded as it had no control group.

CONCLUSIO
1. Trials are warranted as there is a need to manage RT induced trismus to improve trismus related symptoms as well as to improve patient QOL. Further research is needed to assess the best treatment intervention for HNC patients with established radiotherapy induced trismus.
2. Preliminary reports suggest the efficacy of structured jaw exercises or rehabilitation exercises as a treatment for trismus however there is limitation due to the absence of randomized controlled trials.
3. Proper RCTs with a low risk of bias, proper blinding techniques and a large sample size will help develop robust evidence to find interventions which are useful in the management of RT induced trismus.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Tobias JS. Cancer Of The Head And Neck. Br Med J. 1994;308(6934):961 https://doi.org/10.1136/bmj.308.6934.961

2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394-424. https://doi.org/10.3322/caac.21492

3. De Felice F, Polimeni A, Valentini V, Brugnoletti O, Cassoni A, Greco A, et al. Radiotherapy Controversies and Prospective in Head and Neck Cancer: A Literature-Based Critical Review. Neoplasia. 2018;20:227-32. https://doi.org/10.1016/j.neo.2018.01.002

4. Popanda O, Marquardt JU, Chang-Claude J, Schmezer P. Genetic variation in normal tissue toxicity induced by ionizing radiation. Mutation Research – Fund Mol Mech Mutag. 2009;667:58-69. https://doi.org/10.1016/j.mrfmmm.2008.10.014

5. Okunieff P, Augustine E, Hicks JE, Cornelison TL, Altemus RM, Naydich BG, et al. Pentoxifylline in the treatment of radiation-induced
fibrosis. J Clin Oncol. 2004;22:2207.

6. Dijkstra P, Roodenburg J. Trismus: Oxford University Press; 2010. https://doi.org/10.1093/med/9780199543588.003.0011

7. Wranicz P, Herlofson B, Evensen J, Kongsgaard U. Prevention and treatment of trismus in head and neck cancer: A case report and a systematic review of the literature2010. 84-8 p.

8. Dijkstra PU, Kalk WWI, Roodenburg JLN. Trismus in head and neck oncology: a systematic review. Oral Oncology. 2004;40:879-89. https://doi.org/10.1016/j.oraloncology.2004.04.003

9. Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the head and neck. J Laryngol Otol. 1993;107:1017-20.
https://doi.org/10.1017/S0022215100125149

10. Collin JD, Main BGJ, Barber AJ, Thomas SJ. Airway compromise by dislodged obturator in a patient with severe trismus. J Prosth Dent.
2014;112:83. https://doi.org/10.1016/j.prosdent.2013.08.021

11. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group*. Preferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. Annals of Internal Medicine. 2009;151: 264-9.

12. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J. 2011;343:d5928. https://doi.org/10.1136/bmj.d5928

13. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Int Med. 2011;155:529-36.

14. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and metaanalysis protocols (PRISMA-P) 2015: elaboration and explanation. Br Med J. 2015;349:g7647.
https://doi.org/10.1136/bmj.g7647

15. Pauli N, Andrell P, Johansson M, Fagerberg-Mohlin B, Finizia C. Treating trismus: Aprospective study on effect and compliance to jaw exercise therapy in head and neck cancer. Head Neck. 2015;37:1738- 44.
https://doi.org/10.1002/hed.23818

16. Pauli N, Svensson U, Karlsson T, Finizia C. Exercise intervention for the treatment of trismus in head and neck cancer – a prospective two-year follow-up study. Acta Oncol. 2016;55:686-92. https://doi.org/10.3109/0284186X.2015.1133928

17. Pauli N, Fagerberg-Mohlin B, Andréll P, Finizia C. Exercise intervention for the treatment of trismus in head and neck cancer. Acta Oncol. 2014;53:502-9.
https://doi.org/10.3109/0284186X.2013.837583

18. Lee R, Yeo ST, Rogers S, Caress A, Molassiotis A, Ryder D, et al. Randomised feasibility study to compare the use of Therabite®mwith wooden spatulas to relieve and prevent trismus in patients with cancer of the head and neck. Br J Oral Maxillofac Surg.
2018;56:283-91.

19. Tang Y, Shen Q, Wang Y, Lu K, Peng Y. A randomized prospective study of rehabilitation therapy in the treatment of radiation-induced dysphagia and trismus. Strahlentherapie und Onkologie. 2011;187: 39-44.
https://doi.org/10.1007/s00066-010-2151-0

20. Chua DT, Lo C, Yuen J, Foo YC. A pilot study of pentoxifylline in the treatment of radiationinduced trismus. Am J Clin Oncol. 2001;24:366-9.
https://doi.org/10.1097/00000421-200108000-00010

21. Hartl DM, Cohen M, Julieron M, Marandas P, Janot F, Bourhis J. Botulinum toxin for radiation-induced facial pain and trismus. Otolaryngol Head Neck Surg. 2008;138:459-63. https://doi.org/10.1016/j.otohns.2007.12.021

1. Senior Registrar, Department Oral Medicine, University College of Medicine and
Dentistry, The University of Lahore.
2. Demonstrator, Department of Oral Biology, University College of Medicine and
Dentistry, The University of Lahore.
3. Demonstrator, Department of Operative Dentistry, University College of Medicine
and Dentistry, The University of Lahore.
4. Demonstrator, Department of Dental Materials, University College of Medicine and
Dentistry, The University of Lahore.
Corresponding author: “Dr. Mohammad Annas Aslam” <annas.aslam7@gmail.com>

Interventions for the treatment of Radiotherapy Induced Trismus: A Systematic Review of the Literature

November 17, 2022 by JPDA

Mohammad Annas Aslam1 BDS, MSc
Obaid Bajwa2 BDS
Anum Ahmed Raja3 BDS
Nissa Khan4 BDS

OBJECTIVES: To systematically assess the outcome of interventions used to treat patients who have trismus as a
result of radiotherapy to the head and neck region in the treatment of Head and Neck Cancer (HNC).
METHODOLOGY: Searches were carried out on online databases (Medline, Embase and The Cochrane Central Library) on
the 19th of June 2019 and then again using the same search terms on the 6th of June 2021. Randomized and 
NonRandomized trials aimed at treating trismus as a side effect of head and neck radiotherapy (RT) were included
for this systematic review. A total of 5 papers were reviewed for the purpose of this systematic review.
RESULTS: Results show that there is limited evidence to support the use of any treatment modality other than
structured jaw exercises to help treat trismus in patients with a history of HNC and RT induced fibrosis. There is
no evidence to support the use of Botulinum toxin A, while further studies are needed to clarify the effectiveness
of Pentoxifylline (with or without conjunction with Vitamin E) and Pregabalin in the treatment of postradiotherapy
fibrosis.
CONCLUSION: There is a need for more randomized control trials to identify treatment modalities for radiotherapy
induced trismus. Rehabilitation exercises have been implemented across all papers involved in this study which
indicates the need for analysis and identification of a pharmaceutical intervention.
KEYWORDS: Head and neck cancer, trismus, lockjaw, radiotherapy, randomized controlled trial, placebo
HOW TO CITE: Aslam MA, Bajwa O, Raja AA, Khan N. Interventions for the treatment of radiotherapy induced trismus: A
systematic review of the literature. J Pak Dent Assoc 2022;31(3):147-152.
DOI: https://doi.org/10.25301/JPDA.313.147
Received: 25 August 2021, Accepted: 28 April 2022

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Factors Affecting Awareness of Infection Control Measures among Dental Practitioners of Karachi

November 17, 2022 by JPDA

Aishah Aijaz1 BDS, MPH
Asghar Ali Shigri2 BDS, MPH
Saima Asim3 BDS, MPH
Muhammad Hassan4 BDS
Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH
Shikoh Naz6 B DS, MPH

OBJECTIVES: To determine the factors affecting awareness of infection control measures among dental practitioners working
in universities and teaching hospitals of Karachi.
METHODOLOGY: A cross-sectional study was conducted from May 2017 to January 2018 among 190 conveniently sampled
practitioners from four dental clinics of tertiary care hospitals of Karachi. The study population consisted of dental practitioners
that included graduates and post graduates of either gender with an experience of two years and above while practitioners
refusing to give written informed consent were excluded from the study. The questionnaires were distributed and collected on
same day by the principal investigator. All the collected data were analyzed on Statistical Package for Social Sciences version 20.
RESULTS: A majority of dental practitioners (>90%) were aware that contact with blood may transmit pathogenic microorganisms;
goal of infection control is to eliminate the transfer of microorganisms; steam autoclave sterilizes by using steam under pressure;
disinfection of dental chair, clinic, and dental office; wearing gloves, face masks and having protective eye wear on while
checking patients; changing gloves, extraction instrument, saliva ejectors and burs in operative dentistry after checking each
patient is necessary for a dental practitioner. Moreover, the awareness scores of dental practitioners were found to be significantly
different across categories of experience (p=0.008).
CONCLUSION: A majority of dental practitioners was aware about most measures of infection control. Further confirmation
of study results by studies with larger sample sizes is recommended.
KEYWORDS: Risk Factors, Awareness, Infection Control, Dentists
HOW TO CITE: Aijaz A, Shigri AA, Asim S, Hassan M, Naqvi SMZH, Naz S. Factors affecting awareness of infection control
measures among dental practitioners of Karachi. J Pak Dent Assoc 2022;31(3):141-146.
DOI: https://doi.org/10.25301/JPDA.313.141
Received: 12 January 2021, Accepted: 01 May 2022

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Factors Affecting Awareness of Infection Control Measures among Dental Practitioners of Karachi

November 16, 2022 by JPDA

Aishah Aijaz1 BDS, MPH
Asghar Ali Shigri2 BDS, MPH
Saima Asim3 BDS, MPH
Muhammad Hassan4 BDS
Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH
Shikoh Naz6 B DS, MPH

OBJECTIVES: To determine the factors affecting awareness of infection control measures among dental practitioners working
in universities and teaching hospitals of Karachi.
METHODOLOGY: A cross-sectional study was conducted from May 2017 to January 2018 among 190 conveniently sampled
practitioners from four dental clinics of tertiary care hospitals of Karachi. The study population consisted of dental practitioners
that included graduates and post graduates of either gender with an experience of two years and above while practitioners
refusing to give written informed consent were excluded from the study. The questionnaires were distributed and collected on
same day by the principal investigator. All the collected data were analyzed on Statistical Package for Social Sciences version 20.
RESULTS: A majority of dental practitioners (>90%) were aware that contact with blood may transmit pathogenic microorganisms;
goal of infection control is to eliminate the transfer of microorganisms; steam autoclave sterilizes by using steam under pressure;
disinfection of dental chair, clinic, and dental office; wearing gloves, face masks and having protective eye wear on while
checking patients; changing gloves, extraction instrument, saliva ejectors and burs in operative dentistry after checking each
patient is necessary for a dental practitioner. Moreover, the awareness scores of dental practitioners were found to be significantly
different across categories of experience (p=0.008).
CONCLUSION: A majority of dental practitioners was aware about most measures of infection control. Further confirmation
of study results by studies with larger sample sizes is recommended.
KEYWORDS: Risk Factors, Awareness, Infection Control, Dentists
HOW TO CITE: Aijaz A, Shigri AA, Asim S, Hassan M, Naqvi SMZH, Naz S. Factors affecting awareness of infection control
measures among dental practitioners of Karachi. J Pak Dent Assoc 2022;31(3):141-146.
DOI: https://doi.org/10.25301/JPDA.313.141
Received: 12 January 2021, Accepted: 01 May 2022

INTRODUCTION
Infection may be defined as an invasion and multiplication of microorganism, such as bacteria, viruses, fungi, parasites, etc. collectively called pathogens, in body tissues.1 Infection control aims to prevent the exposure from such infections and its transfer from one person to another.2 Infection and its control is a major
problem for healthcare delivery systems worldwide.3 In healthcare settings, the risk of infection to patients is greatly increased, and appropriate infection control techniques can help prevent the spread of many hospital acquired infections.4 These techniques include, but are not limited to, wearing gloves, facemasks, eye protection with lateral shields and other protective clothing; sterilization of instruments and materials used in dental procedures and proper monitoring of the sterilizer.5
As dentistry is mainly a surgical field that involves saliva, blood and potentially infectious material exposure, dental health personnel are at increased risk of exposure to cross-infection.6-8 Cross-infection is the transmission of infectious agents between patients and staff within a clinical environment. Therefore, dental
practitioners need a very strong infection control effort to avoid cross-contamination and occupational exposures to saliva and blood borne diseases.9,10
Adequate infection control is an important issue in health care settings, particularly dentistry; it is therefore critical that necessary steps are taken for protection against cross infection in a dental setup11,12, where transfer of infections from one person to another or from object to the person can take place through both direct and indirect transmission.13 Direct transmission of pathogens can occur during examining of the oral cavity with bare hands and when contact is made with blood/serum of infected patients while indirect transmission can occur through contact with the contaminated needle, dental units, surfaces, or improperly sterilized instruments.14
In order to stop this transmission, and to reduce the risk of accidental injuries by dental instruments, dentists should take necessary measures during patient treatment.11,15,16 According to Center for Disease Control and Prevention’s guidelines on infection control updated in 2019, if infection control methods are consistently applied, they result in prevention of environmentally related infections in high risk populations.17 Although adequate emphasis has been placed on the importance of adherence to these protocols, literature shows that few dentists actually adhere to the standardized infection control procedures in their daily
practice.18
Though the awareness of dental students regarding infection control measures has been studied previously, recent literature about dental practitioners’ awareness and the factors affecting is particularly limited, especially in our local setting. Tahir MW et al., found dental students to be adequately aware about infection control measures19 , though Qamar MK et al., reported the awareness of dental students regarding infection control measures to be unsatisfactory.20 With regard to dental practitioners, Mohiuddin S and Dawani N reported a need to improve the awareness of dental professionals to minimize cross infection in dental set up.21
It was hypothesized by the authors that certain dental practitioner related factors, such as their age, gender, qualification and experience may affect their awareness of infection control measures. In the given context, this study was carried out to determine the factors affecting awareness of infection control measures among dental practitioners working in universities and teaching hospitals of Karachi.

METHODOLOGY
Ethical approval letter was obtained (No. FHM 42-2017). After taking ethical approval from Baqai Institute of Health Sciences, a cross-sectional study was conducted from May 2017 to January 2018 among 190 conveniently sampled practitioners from four dental clinics of tertiary care hospitals of Karachi namely Baqai Medical University, Hamdard College of Medicine and Dentistry, Karachi Medical and Dental College and Jinnah Sindh Medical University. The study population consisted of dental practitioners that included graduates and post graduates of either gender with an experience of two years and above while practitioners refusing to give written informed consent were excluded from the study.
A pre-designed closed-ended questionnaire was given to all participants who consented to participate in this study. The questionnaire was developed in English. The questions were adopted from different sources after literature search and review and were modified according to the study population. It was first checked for face validity by asking the participants how relevant the questionnaire appeared to the study objective; and then for reliability by calculating Cronbach’s alpha that was found to be 0.709, indicating an acceptable level of internal consistency.
The questionnaire was divided into two sections. The first section consisted of five questions on demographic characteristics of dental practitioners i.e. age, gender, qualification, faculty, and experience while the second section of the questionnaire consisted of fourteen questions to assess the awareness of dentists regarding the infection control measures. The questionnaire was circulated and collected by the principle investigator on the same day. At the completion of the data collection, all the responses of the participants were coded by giving the value of 1 to a correct response and a value of 0 to an incorrect response. By summing up the scores of each participant, their total awareness scores out of maximum 14 were calculated.

Sample size estimation: Keeping the percentage frequency of the study outcome at 40.8%13 with 95% confidence level and 7% precision, the required sample size was calculated to be 190 participants using the following formula: n=z2 (p)(1-p)/c2
.
DATA ANALYSIS
The data were entered analyzed on SPSS version 20. Descriptive analysis was performed by generating frequencies and percentages for categorical variables and means and standard deviations for continuous variables. After checking normality, inferential analysis was performed using Mann Whitney U test and Kruskal Wallis test for comparison of awareness scores across categories of demographic variables whereas the significance level was set at 0.05.

RESULTS
Out of total of 190 participants enrolled in the study, 104 (54.7%) were aged 30 years or above, 118 (62.1%) were females, 153 (80.5%) were graduates, 185 (97.4%) were clinical faculty members whereas 112 (58.9%) had 2 to 5 years’ experience (table 1).

The study results further showed that 185 (97.4%) respondents were aware that contact with blood may transmit pathogenic microorganisms from one person to another, 118 (98.9%) respondents were aware that the goal of infection control is to eliminate the transfer of microorganisms, 185 (97.4%) respondents were aware that steam autoclave sterilizes by using steam under pressure, 137 (72.1%) respondents were aware that minimum 15 minutes are required for sterilization in autoclave, 185 (97.4%) respondents were aware that apart from instruments, disinfection of dental chair and clinic is necessary, 183 (96.3%) respondents were aware that wearing gloves is necessary for a dental practitioner, 182 (95.8%) respondents were aware that changing gloves after checking each patient is necessary, 182 (95.8%) respondents were aware that wearing face masks while checking patients is necessary, 153 (80.5%) respondents were aware that changing face masks between patients is necessary, 171 (90.0%) respondents were aware that having protective eye wear on while checking patients is necessary, 170 (89.5%) respondents were aware that changing hand pieces between patients is necessary, 181 (95.3%) respondents were aware that changing extraction instrument after every patient is necessary, 178 (93.7%) respondents were aware that changing saliva ejectors after each patient is necessary whereas 177 (93.2%) respondents were aware that changing burs in operative dentistry after every patient is necessary (table 2).
The comparison of awareness scores across demographic characteristics of dental practitioners showed that the awareness scores were significantly different according to

their experience (p=0.008) where practitioners with more than 10 years’ experience had higher awareness scores than practitioners with 2 to 5 years’ or 6 to 10 years’ experience (table 3).

DISCUSSION
Being part of the healthcare system, it is important that the dental practitioners don’t ignore the potential risk of transmission of infection which not only affects them and their patients but also doctor assistants and laboratory technicians associated with them. This study was therefore an effort to identify key awareness gaps among dental practitioners in this regard in the local setting. In this study 97.4% of the respondents had awareness regarding transmission of organisms through blood. Similar result was reported in a study by Askarian M et al. in 2009 where 96.7% of the respondents had this awareness.11 Moreover, 98% of the respondents correctly knew the goal of infection control is to eliminate the transfer of microorganism. Similarly, 95.6% of the respondents were reported to have such awareness in a study by Naik S et al. in 2014.22
In our study 97.4% of the dental practitioners had awareness regarding steam autoclave sterilization while 72.1% were aware regarding the minimum time required for sterilization in an autoclave. Similar results were reported in a study by Bargale S et al. in 2016.23 Moreover, 97.4% of the respondents were aware about the necessity of disinfecting dental chair, clinic, and dental office other than the sterilization of instruments. Likewise, 93.8% of the respondents were found to have similar awareness in a study by Shetty D et al. in 2011.24
In current study 96.3% respondents were aware that wearing gloves while checking patients is necessary for a dental practitioner. Moreover, 95.8% respondents were aware that changing gloves after checking each patient is necessary for a dental practitioner. Dagher J et al. in 2017 reported 92.4% and 97.5% of the dentists to have compliance with these requirements respectively.25
In current study 95.8% of the participants replied that it is necessary for a dental practitioner to wear a mask for checking each patient. Similarly, 94.7% of the respondents were found to have similar awareness in a study by Askarian M et al. in 2009.11 Mohiuddin S and Dawani N in 2015 also reported 74.2% of the respondents to be compliant with this necessity.21 Furthermore, 80.5% of the dental practitioners were aware that a face mask must be changed between patients. This was among the measures about which the respondents had least awareness in the study.
In our study 90% of the participants were aware about the necessity of protective eye wear. Likewise, a study by Askarian M et al. in 2009 found 97.4% of the respondents to have similar awareness.11 Moreover, in our study 89.5% of the participants knew about the necessity of changing hand pieces between patients. Likewise, a majority of respondents were reported to have similar awareness in a study by Mohiuddin S and Dawani N in 2015.21 Similarly, Mandourh MS et al. in 2017 found 95.4% of the dentists to be aware of the importance of using a new hand piece for every patient.26
Furthermore, 95.3% of the participants in our study were aware that it is necessary to change extraction instruments after every patient. In line with these results, Mohiuddin S and Dawani N in 2015 reported 97.5% of the dental practitioners interviewed to be aware of the importance of changing extraction instruments after every patient.21 In our study 93.7% of the dental practitioners were aware that changing saliva ejectors after each patient is necessary. Moreover, 93.2% of the participants were aware that changing burs in operative dentistry after every patient is necessary. Similar results were reported by Mohiuddin S and Dawani N in 2015 where 96.7% and 75.8% of the respondents were found to have this awareness respectively.21
It is acknowledged that the study had several limitations. Certain aspects of infection control measures could not be covered in the study questionnaire in order to keep it brief due to time limitation, such as disinfection of the blood spillage/contamination and impression material, use of disinfectants prior to sterilization of instruments and of different sinks for scrubbing and rinsing the instruments, types of autoclaves, checking their validity and storage of sterilized instruments after autoclaving, transferring dental instruments from dirty to clean zone, sterilization of x-raysensors, film holders and collimeters, maintenance of dental unit water line and disposal of needles and other sharps after surgical procedures etc. Furthermore, use of non-probability sampling technique and a moderate sample size may limit the generalizability of the study findings.

CONCLUSION
A vast majority of dental practitioners was aware about transmission of pathogenic microorganisms through contact with blood, goal of infection control, sterilization through steam autoclaves, importance of disinfecting dental chair and office, wearing and changing gloves, wearing and changing face masks, having protective eye wear on while checking patients and changing hand pieces, extraction instrument, saliva ejectors and burs after each patient. Moreover, dental practitioners with more experience had higher awareness scores than those with less experience.

RECOMMENDATIONS
Though a majority of dental practitioners were aware about many aspects of infection control, given the limitations of the study findings, further confirmation of these results is recommended by studies with more rigorous designs. Moreover, in any case, the importance of continuing dental educational programs to provide awareness of and familiarity with infection control measures to dental practitioners can never be over stated.

DISCLAIMER
None

CONFLICT OF INTEREST
None

REFERENCES

1. The Free Dictionary. Infection. Available from: http://medicaldictionary.thefreedictionary.com/infection [Accessed 8th December 2020]

2. Shah AH, Wyne AH. Cross-infection control in dentistry: a review. Pak Oral Dent J. 2010;30:168-74.

3. Yüzbasioglu E, Saraç D, Canbaz S, Saraç YS, Cengiz S. A survey of cross-infection control procedures: knowledge and attitudes of Turkish dentists. J Appl Oral Sci. 2009;17:565-9. https://doi.org/10.1590/S1678-77572009000600005

4. World Health Organization Regional Office for Europe. Infections and infectious disease. Available from: https://www.euro.who.int/__data/assets/pdf_file/0013/102316/e79822. pdf [Accessed 8th December 2020]

5. American Dental Association. Infection Control and Sterilization. Available from: https://www.ada.org/en/member-center/oral-healthtopics/infection-control-and-sterilization [Accessed 8th December 2020]

6. Halboub ES, Al-Maweri SA, Al-Jamaei AA, Tarakji B, Al-Soneidar WA. Knowledge, attitudes, and practice of infection control among dental students at Sana’a University, Yemen. J Intern Oral Health. 2015;7:15. https://doi.org/10.4103/2231-0762.156152

7. Ebrahimi M, Ajami B, Rezaeian A. Longer Years of Practice and Higher Education Levels Promote Infection Control in Iranian Dental Practitioners. Iran Red Crescent Med J. 2012;14:422-9.

8. Rahman B, Abraham SB, Alsalami AM, Alkhaja FE, Najem SI. Attitudes and practices of infection control among senior dental students at college of dentistry, university of Sharjah in the United Arab Emirates. Eur J Dent. 2013;7(Suppl 1):S15-9. https://doi.org/10.4103/1305-7456.119058

9. Gupta S, Rani S, Garg S. Infection control knowledge and practice: A cross-sectional survey on dental laboratories in dental institutes of North India. J Indian Prosthodont Soc. 2017;17:348. https://doi.org/10.4103/jips.jips_5_17

10. Santra DK, Tripathi S, Ganger A. Study to access the level of knowledge, attitude and practices of infection control among dental professionals. J Dent Sci Oral Rehabil. 2010;57-60.

11. Askarian M, Assadian O. Infection control practices among dental professionals in Shiraz Dentistry School, Iran. Arch Iran Med. 2009;12:48-51.

12. Singh A, Purohit BM, Bhambal A, Saxena S, Singh A, Gupta A. Knowledge, attitudes, and practice regarding infection control measures among dental students in central India. J Dent Educ. 2011;75:421-7. https://doi.org/10.1002/j.0022-0337.2011.75.3.tb05055.x

13. Jain M, Sawla L, Mathur A, Nihlani T, Ayair U, Prabu D, et al. Knowledge, attitude and practice towards droplet and airborne isolation precautions amongs dental health care professionals in India. Med Oral Patol Oral Cir Bucal. 2010;15:e957 61. https://doi.org/10.4317/medoral.15.e957

14. Ali M F, Hussain A, Maqsood A. Knowledge, attitude and practices concerning infection control measures among dental health care providers of Dow University of Health Sciences. Pak Oral Dent J. 2014;34:452-56.

15. Sebastiani FR, Dym H, Kirpalani T. Infection Control in the Dental Office. Dent Clin North Am. 2017;61:435. https://doi.org/10.1016/j.cden.2016.12.008

16. Mutters NT, Hägele U, Hagenfeld D, Hellwig E, Frank U. Compliance with infection control practices in an university hospital dental clinic. GMS Hyg Infect Control. 2014;9.

17. Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities. Availablfrom: https://www.cdc.gov/infectioncontrol/ pdf/guidelines/environmental-guidelines-P.pdf [Accessed 8th December 2020]

18. Alavian SM, Mahboobi N, Mahboobi N. Anti-HBs antibody status and some of its associated factors in dental health care workers in Tehran University of Medical Sciences: Anti-HBs Ab and associated factors in dental society. Hepat Mon. 2011;11:99-102.

19. Tahir MW, Mahmood A, Abid AN, Ullah MS, Sajid M. Knowledge, attitude, and practices of cross infection control among dental students of Punjab Pakistan. Pak J Med Health Sci. 2018;12:238-42.

20. Qamar MK, Shaikh BT, Afzal A. What do the dental students know about infection control? A cross-sectional study in a teaching hospital, Rawalpindi, Pakistan. BioMed Res Int. 2020;2020. https://doi.org/10.1155/2020/3413087

21. Mohiuddin S, Dawani N. Knowledge, attitude and practice ofinfection control measures among dental practitioners in public setup of Karachi, Pakistan: cross-sectional survey. J Dow Uni Health Sci. 2015;9:89-93. 14

22. Naik S, Khanagar S, Kumar A, Vadavadagi S, Neelakantappa HM, Ramachandra S. Knowledge, attitude, and practice of hand hygiene among dentists practicing in Bangalore city-A cross-sectional survey. J Int Soc Prev Community Dent. 2014; 4:159-163. https://doi.org/10.4103/2231-0762.142013

23. Bargale S, Patel N, Dave B, Poonacha KS, Ardeshana A, Mehta D. Assessment of sterilization technique practices at dental clinics of Vadodara, Gujarat, India. Scholars J Dent Sci. 2016;3:240-6.

24. Shetty D, Verma M, Shetty S, Dubey S, Walters S, Bernstein I. Knowledge, attitudes and practice of dental infection control and occupational safety in India: 1999 and 2010. World J Dent. 2011;2:1-9. https://doi.org/10.5005/jp-journals-10015-1045

25. Dagher J, Sfeir C, Abdallah A, Majzoub Z. Infection Control Measures in Private Dental Clinics in Lebanon. Int J Dent. 2017;2017. https://doi.org/10.1155/2017/5057248

26. Mandourh MS, Alhomaidhi NR, Fatani NH, Alsharif AS, UjaimiGK, Khan GM. Awareness and implementation of infection controlmeasures in private dental clinics, Makkah, Saudi Arabia. Int J Infect Control. 2017;13:1-4.

Influence of Education, Demographic Variables and Duration of Denture Use on Patients’ Satisfaction with Complete Dentures

November 14, 2022 by JPDA

Mahvish Jabeen1 BDS, FCPS
Muhammad Waseem Ullah Khan2 BDS, FCPS
Momina Akram3 BDS, FCPS

OBJECTIVE: This study was conducted to determine the influence of education, demographic variables and duration of
denture use on satisfaction level among complete denture wearer.
METHODOLOGY: A sample of 230 patients, fulfilling the inclusion criteria, were participated in this study. The level of
education, demographic details, duration of denture use and patients' satisfaction with complete denture therapy in term of
comfort, esthetics, phonetics, chewing, retention and ease of cleaning were recorded by using a questionnaire. Statistical analysis
was performed by Statistical Packages for the Social Sciences (SPSS) 20.0. Post-stratification Chi-square test was applied by
taking p-value <0.05 as significant.
RESULTS: The mean age of the respondents was 60.37±9.055 years, 165(71.74%) were females. Out of 230 respondents,
literacy level of 78(33.91%) was matric & above. The average duration of use of denture was 7.09+3.295 months. On the basis
of overall satisfaction scores 151(65.5%) patients were satisfied with the denture. There was statistically significant difference
in age and patients' satisfaction level with dentures (p< 0.05).
CONCLUSION: This study concluded that approximately 65% of the patients are satisfied with complete denture therapy.
The demographic variables (except age) and duration of use of denture have no influence on patients' satisfaction level with
dentures.
KEYWORDS: Edentulism, Complete Denture, Satisfaction.
HOW TO CITE: Jabeen M, Khan MWU, Akram M. Influence of education, demographic variables and duration of denture
use on patients’ satisfaction with complete dentures. J Pak Dent Assoc 2022;31(3):136-140.
DOI: https://doi.org/10.25301/JPDA.313.136
Received: 19 August 2021, Accepted: 23 May 2022

INTRODUCTION
Conventional complete dentures are the most prescribed therapy worldwide to restore the functions and esthetics for edentulous patients because of financial and biological limitations.1 The outcome of complete denture mainly depends on denture quality, patients’ psychological state and biological condition.2 Although the majority of previous studies have reported the high level of patients’ satisfaction with complete denture in different aspects. However a considerable percentage
about 10% to 20% of complete denture wearers are dissatisfied with their dentures.3 Patient perception have a key role to improve the oral health care quality, so patients’ feedback assessment on satisfaction regarding treatment outcomes is important.4 Considering that patients’ satisfaction is the ultimate objective to achieve during oral rehabilitation several studies have been conducted to evaluate the different factors and their associations with patients’ satisfaction including patients’ age, gender, literacy level, previous denture experience, patients’ personality , psychological state, oral conditions, pretreatment expectations and patients-dentist
communication.1,2,4
Expectations can vary from one patient to the other due to differences in demographic and psychological variables, population groups and socioeconomic background. Kovac et al. conducted a study about patients’ satisfaction with complete dentures and found that 70% patients were highly satisfied with their complete dentures.5 Miranda et al evaluated the patients’ perceptions regarding outcome of complete denture therapy and concluded that average score for positive perception (4.01±0.43) was higher than negative perception (3.69±0.52).They found that satisfaction is not influenced by gender, education status and evaluation of previous denture.1 Santos et al studied the patients’ expectations before and satisfaction after complete denture therapy. They found that 70% patients were satisfied with their dentures and patients’ literacy level influence the satisfaction level.2 McCunnif et al found that patients were esthetically more satisfied (9.4 ±1.2) than that they expected (9.0±1.2) and demographic variables (i.e. age, gender) did not influence the satisfaction with dentures.6 A study carried out by M.G. Gaspar et al on patients’ satisfaction with complete denture in Brazilian population found that satisfaction score for all evaluated criteria (i.e. chewing=7.25±3.12, phonetics=8.64±2.02, comfort of use=7.64±2.92) was less than that of exceptions score (i.e. chewing=9.42±0.94, phonetics=9.51±0.85, comfort of use=9.57±0.83).7 G.P. de Siqueira et al. conducted the similar study regarding patient expectations and satisfaction with removable dental prosthesis and found that expectations
were higher than satisfaction.8 SM Fouda et al carried out a study on the effect of patients’ personality on denture satisfaction and concluded that 55% patients were satisfied after treatment and personality type effect the satisfaction with their dentures.9 In a study Ahmad et al found that pretreatment expectations were high(49% patients exhibited relatively high expectations while 37% exhibit very high expectations) and there was no significant association with
demographic variables.10 The results of these studies7,8,9,10 were in contrast to other studies.1,2,5,6
In existence of differing results of previous studies on patients’ satisfaction with their dentures in different population, it is demanding to evaluate the patients’ satisfaction regarding complete denture outcome and influence of associated variables on satisfaction level in our local population. This study will help the clinician to have better understanding of patients’ expectations and treatment needs that should be addressed at the time of treatment planning before fabrication of complete dentures which will increase denture acceptance. This will also be useful to establish a good patient-dentist relationship by explaining the limitations and possibilities of denture treatment which will help the patients to fit their expectation to a realistic level and subsequent increase in satisfaction level with treatment.
Based on previous studies1,6,8,13,20, hypotheses formulated was that education level, duration of denture use and demographic variables has no effect on patients’ satisfaction level.

METHODOLOGY
After approval from ethical committee, a cross sectional descriptive study was conducted in Prosthodontics department, de’ Montmorency College of Dentistry/Punjab Dental Hospital Lahore. The sample size, 230 patients, was calculated by using WHO sample size calculator considering 70% prevalence of satisfaction with 95% confidence level and 6% margin of error. Patients were selected randomly who received their dentures made by postgraduate students, supervised by faculty. Patients with temporomandibular disorders (TMD,) intra or extra oral pathologies and with diagnosed systemic diseases, e.g., metabolic disorders, hematological disorders, endocrine disorders were excluded from this study. Informed consent was taken from each participant of this study. A non-probability consecutive sampling technique was used. A questionnaire designed by the principal researcher was adopted as standardized measuring tool for uniform series of data collection. This questionnaire contains 6 questions to assess the outcome of complete denture therapy in terms of esthetics, comfort, retention, ease of cleaning, ability to chew and speak properly. The answer to each question will be marked in “YES” which will be scored as “1” or “NO” which will be scored as “0”. This makes the total score of “6”. Out of 6, score of 3 or greater than 3 will be labeled as “Satisfied”. Score of less than 3 will be labeled as “Not satisfied”. All the patients were interviewed by the principal researcher to avoid biasness.

STATISTICAL ANALYSIS
Statistical analysis was performed by Statistical Packages
for the Social Sciences (SPSS) 20.0. Post-stratification Chi-square test was applied by taking p-value <0.05 as significant.

RESULTS
In this study total 230 respondents participated. The average age of the respondents was 60.37±9.055 years with minimum and maximum ages of 45 & 65 years respectively. Among 230 respondents, 65(28.26%) were males while 165(71.74%) were females.
The average duration of use of denture of the respondent
was 7.09±3.295 months with minimum and maximum duration of 2 & 12 months respectively.
Out of 230 respondents, 53(23.04%) were illiterate, 52(22.61%) had primary education, 47(20.43%) had middle and 78(33.91%) had matric & above educational status. According to this study, the respondents who felt comfortable
wearing dentures were 113 (49.1%), and 129 (56.1%) respondents were able to eat properly with dentures. Whereas the number of respondents satisfied with speaking was 115 (50.0%), and 121 (52.6%) thought that dentures were retentive during function. The respondents satisfied with their appearance were 98 (42.6%). However, 107 (46.5%) respondents thought that it was easy to clean their dentures. The mean total satisfaction score of the respondents was
2.97±1.33 with minimum and maximum scores of 0 & 6 respectively. On the basis of satisfaction scores, 151(65.7%) respondents were satisfied with the denture. In respondents with age <50 years, 22(51.2%) were satisfied with denture whereas in respondents having age more than 50 years, 129(69%) were satisfied. Statistically
there was significant difference observed between the satisfaction of use of denture and age groups there was significant difference observed between the satisfaction of use of denture and age groups

In male respondents, 37(56.9%) were satisfied with denture whereas in female respondents, 114(69.1%) were satisfied with use of denture. Statistically there was no
significant difference observed between the satisfaction of use of denture and gender i.e. (p-value=0.08). (Table 2)

In respondents with duration of use of denture <6 months, 72(68.6%) were satisfied with denture whereas in respondents having duration of use of denture more than 6 months, 79(63.2%) were satisfied. Statistically there was no significant difference observed between the satisfaction of use of denture and duration of use of denture i.e., (p-value=0.39). (Table 3)
In respondents having education up to middle, 97(63.8%) were satisfied with denture whereas in respondents having education matric & above, 54(69.2%) respondents were

satisfied. Statistically there was no significant difference observed between the satisfaction of use of denture and education of the respondents i.e. (p-value=0.41). (Table 4)

DISCUSSION
Complete dentures have been widely used for the oral rehabilitation of edentulous patients, who are usually satisfied with their dentures.1-4 Dental professionals should be aware of the importance of these variables and should pay attention to patients’ perceptions and expectations during treatment to perceive patients’ wishes using culturally contextualized questions and to know how and when to limit patients’
expectations.6,8
This study was conducted to determine the frequency of satisfaction among complete denture wearers. The average age of the respondent was 60.37±9.05 years with minimum and maximum age of 45 & 65 years, respectively. Among 230 respondents, 65(28.26%) were males while 165(71.74%) were females. The average duration of use of denture of the respondents was 7.09±3.29 months with minimum and maximum duration of 2 & 12 months respectively. Out of 230 respondents, 53(23.04%) were illiterate, 52(22.61%) had primary education, 47(20.43%) had middle and 78(33.91%) had matric & above educational status. The mean total satisfaction score of the participant was 2.97±1.33 with minimum and maximum scores of 0 & 6 respectively. Based on satisfaction scores 151(65.5%) respondents were satisfied with the denture.
This study showed that the age was only variable that significantly influence the patients’ satisfaction level. In respondents with age <50 years, 51.2% were satisfied with denture whereas in respondents having age more than 50 years, 69% respondents were satisfied. Statistically there was significant difference observed between the satisfaction of use of denture and age groups. Some previous studies have shown the results similar to the present study while some have contrasting results. Singh et al found that patient’s age was an influential factor on denture satisfaction. The results showed that level of denture satisfaction was higher in age group belonging to 45 – 65 years of age as compared to age group >65 years of age in relation to comfort, health, and denture care.11 G P Siqueira et al. and Elhout found in their study that there was no significant difference in patients’ satisfaction score and age.8,6 In another study, McCunnif et al. concluded that age did not correlate to patient’s expectations and satisfaction with denture esthetics.6 In our opinion, the younger age group (<50 ) has higher esthetics concern and also, compare mastication with complete dentures to mastication with natural teeth. These unrealistic expectations for aesthetics and function may lead to dissatisfaction with complete dentures.
Statistically there was no significant difference observed between the satisfaction with the use of denture and demographic variables including gender, education level and duration of use of denture. Similar to this study, some previous studies found that there was no significant difference between genders and patient’s satisfaction.1,6,8,18,20,21, In contrast, some studies have observed significant differences between genders and duration of denture use regarding patient satisfaction with dentures.1,11,12 Similar to this study, some previous studies conducted by Miranda et al.1 and Turker et al.13, involving education level found no significant association between satisfaction and education level. While some studies2,7,18,22 showed contrasting results. The fact that everyone is equally concerned about their appearance can be used to justify the findings of our study. Everyone has access to media in this age of technology, whether it’s through television, movies, publications, commercials, social media, or digital media. Regardless of gender or education, the media has had a significant impact on people’s perceptions of personal appearance, leading to equal aesthetic demands.
In this study, 65.65% respondents were satisfied with the denture. There are some other studies about satisfaction of complete dentures. In a study by Miranda et al1 demonstrated that patients presented a positive perception of complete denture therapy, and the risk factors (negative perceptions) received the lowest scores. Santos et al. studied the patients’ expectations before and satisfaction after complete denture therapy. They found that 70% patients were satisfied with their dentures and patients’ satisfaction regarding complete denture therapy exceeded expectations.21
Kovac et al. conducted a study about patients’ satisfaction with complete dentures and found that 70% patients were highly satisfied with their complete dentures. 80% patients were satisfied with maxillary denture esthetics & speaking ability, 70% with retention & chewing ability.5 Miranda et al. and Santos et al. evaluated the complete denture therapy outcomes and association of related variables. They found that 70% patients were satisfied with their dentures and patients’ satisfaction regarding complete denture therapy exceeded expectations.1,2 Some studies showed comparatively low score of satisfaction with complete denture. Gaspar et al.7 and Siqueira et al.8 found low score of satisfaction than expectations. SM Fouda et al carried out a study on the effect of patients’ personality on denture satisfaction after increasing occlusal vertical dimension in Egyptian patients and concluded that 55% patients were satisfied after treatment and personality type effect the satisfaction with their dentures.9 According to Van der Waas14 55% of patients were completely satisfied with their CDs.
The success of complete denture therapy is mainly determined by patients’ satisfaction. Patients’ satisfaction with complete denture rehabilitations are influenced by individual characteristics, such as psychological factors, the adaptation process, personality traits, perceived health needs, previous denture experience, period of edentulism and patient-dentist relationship which have to be considered in a sociocultural and economic context.4,5,6,15,17,19
A possible interpretation for the comparatively low level of satisfaction in this study can be justified by multiple factors that affect the patient satisfaction with complete denture. Firstly, patient might not be aware of his or her oral condition. Secondly, the patients might have unrealistic expectations regarding the outcome of complete denture therapy.
The process of assessing treatment outcome is essential for determining the success of therapy. The self-assessment method can be used to evaluate the degree of patients’ satisfaction with their complete dentures subjectively. The primary limitation of this study involve that data collection was done by using self-designed questionnaire, so the results were mainly based on participant response. Furthermore, for the convenience of researchers a very precise inclusion criterion had been established which can be expanded. Also, pre-treatment expectations were not evaluated in the study. Further research can be performed to grasp more about complete denture wearers’ perspectives.

CONCLUSION
This study concluded that approximately 65% of the patients are satisfied with conventional complete denture therapy. According to this study, education level, duration of denture use and demographic variables, except age, have no influence on patients’ satisfaction level with complete dentures. So, younger age group must be counselled to keep their unrealistic expectations in check. It can also be suggested to the teaching institutes and dental clinics to evaluate the patients’ satisfaction which can ultimately improve the quality of services.

CONFLICTS OF INTEREST
There are no conflicts of interest.

SOURCE OF FUNDS
There are no sources of funds included in this study.

REFERENCES
1. Miranda BB, dos Santos MBF, Marchini L. Patients’ perceptions of benefits and risks of complete denture therapy. J Prosthodont. 2014;23:515-20.
https://doi.org/10.1111/jopr.12164

2. Santos BFO, dos Santos MBF, Santos JFF, Marchini L. Patients’ evaluations of complete denture therapy and their association with related variables: a pilot
study. J Prosthodont. 2015;24:351-7. https://doi.org/10.1111/jopr.12286

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1. Senior Registrar, Department of Prosthodontics, ‘Multan Medical & Dental College,
Multan.
2. Associate Professor, Department of Prosthodontics, Dental Institute, Punjab Medical
College, Faisalabad Medical University, Faisalabad.
3. Associate Professor, Department of Prosthodontics, de’Montmorency College of
Dentistry/ Punjab Dental Hospital, Lahore.
Corresponding author: “Dr. Mahvish Jabeen” < pmcian3344@gmail.com >

Influence of Education, Demographic Variables and Duration of Denture Use on Patients’ Satisfaction with Complete Dentures

November 13, 2022 by JPDA

Mahvish Jabeen1 BDS, FCPS
Muhammad Waseem Ullah Khan2 BDS, FCPS
Momina Akram3 BDS, FCPS

OBJECTIVE: This study was conducted to determine the influence of education, demographic variables and duration of
denture use on satisfaction level among complete denture wearer.
METHODOLOGY: A sample of 230 patients, fulfilling the inclusion criteria, were participated in this study. The level of
education, demographic details, duration of denture use and patients' satisfaction with complete denture therapy in term of
comfort, esthetics, phonetics, chewing, retention and ease of cleaning were recorded by using a questionnaire. Statistical analysis
was performed by Statistical Packages for the Social Sciences (SPSS) 20.0. Post-stratification Chi-square test was applied by
taking p-value <0.05 as significant.
RESULTS: The mean age of the respondents was 60.37±9.055 years, 165(71.74%) were females. Out of 230 respondents,
literacy level of 78(33.91%) was matric & above. The average duration of use of denture was 7.09+3.295 months. On the basis
of overall satisfaction scores 151(65.5%) patients were satisfied with the denture. There was statistically significant difference
in age and patients' satisfaction level with dentures (p< 0.05).
CONCLUSION: This study concluded that approximately 65% of the patients are satisfied with complete denture therapy.
The demographic variables (except age) and duration of use of denture have no influence on patients' satisfaction level with
dentures.
KEYWORDS: Edentulism, Complete Denture, Satisfaction.
HOW TO CITE: Jabeen M, Khan MWU, Akram M. Influence of education, demographic variables and duration of denture
use on patients’ satisfaction with complete dentures. J Pak Dent Assoc 2022;31(3):136-140.
DOI: https://doi.org/10.25301/JPDA.313.136
Received: 19 August 2021, Accepted: 23 May 2022

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Hira Nisar1 BDS Abul Khair Zalan2 BDS, MDS Mehreen Ismail3 BDS Sabeen Masood4 BDS Ahsan Inayat5 BDS

Hira Nisar1 BDS Abul Khair Zalan2 BDS, MDS Mehreen Ismail3 BDS Sabeen Masood4 BDS Ahsan Inayat5 BDS

Zahid Ali1 BDS, FCPS Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI Saqib Zafar3 BDS, MPhil Muhammad Saeed Mughal 4 BDS Syeda Hala Raza5 BDS, FCPS Mehwash Kashif 6 BDS, FCPS

Zahid Ali1 BDS, FCPS Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI Saqib Zafar3 BDS, MPhil Muhammad Saeed Mughal 4 BDS Syeda Hala Raza5 BDS, FCPS Mehwash Kashif 6 BDS, FCPS

Mohammad Annas Aslam1 BDS, MSc Obaid Bajwa2 BDS Anum Ahmed Raja3 BDS Nissa Khan4 BDS

Mohammad Annas Aslam1 BDS, MSc Obaid Bajwa2 BDS Anum Ahmed Raja3 BDS Nissa Khan4 BDS

Aishah Aijaz1 BDS, MPH Asghar Ali Shigri2 BDS, MPH Saima Asim3 BDS, MPH Muhammad Hassan4 BDS Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH Shikoh Naz6 B DS, MPH

Aishah Aijaz1 BDS, MPH Asghar Ali Shigri2 BDS, MPH Saima Asim3 BDS, MPH Muhammad Hassan4 BDS Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH Shikoh Naz6 B DS, MPH

Mahvish Jabeen1 BDS, FCPS Muhammad Waseem Ullah Khan2 BDS, FCPS Momina Akram3 BDS, FCPS

Mahvish Jabeen1 BDS, FCPS Muhammad Waseem Ullah Khan2 BDS, FCPS Momina Akram3 BDS, FCPS

Hira Nisar1 BDS
Abul Khair Zalan2 BDS, MDS
Mehreen Ismail3 BDS
Sabeen Masood4 BDS
Ahsan Inayat5 BDS

Hira Nisar1 BDS
Abul Khair Zalan2 BDS, MDS
Mehreen Ismail3 BDS
Sabeen Masood4 BDS
Ahsan Inayat5 BDS

Zahid Ali1 BDS, FCPS
Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI
Saqib Zafar3 BDS, MPhil
Muhammad Saeed Mughal 4 BDS
Syeda Hala Raza5 BDS, FCPS
Mehwash Kashif 6 BDS, FCPS

Zahid Ali1 BDS, FCPS
Nazish Ashfaq Khan2 BDS, MFDS RCS ENG, FFD RCSI
Saqib Zafar3 BDS, MPhil
Muhammad Saeed Mughal 4 BDS
Syeda Hala Raza5 BDS, FCPS
Mehwash Kashif 6 BDS, FCPS

Mohammad Annas Aslam1 BDS, MSc
Obaid Bajwa2 BDS
Anum Ahmed Raja3 BDS
Nissa Khan4 BDS

Mohammad Annas Aslam1 BDS, MSc
Obaid Bajwa2 BDS
Anum Ahmed Raja3 BDS
Nissa Khan4 BDS

Aishah Aijaz1 BDS, MPH
Asghar Ali Shigri2 BDS, MPH
Saima Asim3 BDS, MPH
Muhammad Hassan4 BDS
Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH
Shikoh Naz6 B DS, MPH

Aishah Aijaz1 BDS, MPH
Asghar Ali Shigri2 BDS, MPH
Saima Asim3 BDS, MPH
Muhammad Hassan4 BDS
Syed Muhammad Zulfiqar Hyder Naqvi5 MBBS, MSBH
Shikoh Naz6 B DS, MPH

Mahvish Jabeen1 BDS, FCPS
Muhammad Waseem Ullah Khan2 BDS, FCPS
Momina Akram3 BDS, FCPS

Mahvish Jabeen1 BDS, FCPS
Muhammad Waseem Ullah Khan2 BDS, FCPS
Momina Akram3 BDS, FCPS