Working in Collaborative Practice: Conflict Management Styles in Dental Professionals

 

Laila Shakeel Abbasi1                  BDS, MHPE
Taliya Sajjad2                                BDS, MHPE
Khaulah Jawed3                           BDS, ICMT, MHPE
Aqsa Akhtar4                                BDS

 

 

OBJECTIVE: Conflicts are inevitable in all human interactions. Clinicans at workplaces experience both personal and
professional conflicts. Dental clinicians engage in multidisciplinary teamwork during their practice, which exposes them to a
variety of conflicting situations. The study aimed to explore the trend of different conflict management styles practiced by
dentists while working in collaborative practices.
METHODOLOGY: The study was cross sectional descriptive survey in which 146 dental clinicians from multiple institutions
participated with voluntary and informed consent. Rahim Organizational Conflict Inventory-II (ROCI-II) tool was used to
collect data against the use of conflict management styles namely, Collaborating, Accommodating, Competing, Avoiding and
Compromising. The obtained data were analyzed through SPSS 25.0. The data were categorized according to the 5 styles of
conflict management and association with the variables of gender, position in organization, and type of organization was seen
for each conflict management style.
RESULTS: The study revealed that 54.8% of participants had collaborating style followed by avoiding style (18.5%) whereas,
competing style was least predominant (3.4%). Both genders had collaborating style as most predominant style. No strong
difference was seen in the frequency of conflict management styles between the dentists belonging to private and public
institutions.
Every cadre of clinicians was more inclined towards "collaborating" and "avoiding" conflict management style. Besides these
two styles, house officers and demonstrators were more "accommodating" while residents and assistant professors were more
"compromising".
CONCLUSION: Dental clinicians in the present study mostly used collaborative style for conflict management in their practices.
The awareness of conflict management styles is important so that the use of positive conflict management styles could be
maximized. The use of effective conflict management styles should be taught to young dentists in order to equip them with
necessary tools for everyday collaborations at clinical workplaces.
KEYWORDS: Conflict, Conflict management, dentists, workplace
HOW TO CITE: Abbasi LS, Sajjad T, Jawed K, Akhtar A. Working in collaborative practice: Conflict management styles in
dental professionals. J Pak Dent Assoc 2022;31(3):131-135.
DOI: https://doi.org/10.25301/JPDA.313.131
Received: 30 December 2021, Accepted: 23 May 2022

INTRODUCTION
Unresolved conflicts among health care professionals may lead to difficult patient care consequences.1 Unproductive tension and conflict across boundaries and hierarchies will remain significant issues in health care.2 Health care institutions are units where complex ambiguities and multiple unpredictable complicated processes arise more often than in other units.3 From hospital administrators to physicians and nurses and support staff, collaboration is needed in health care settings not only to ensure patient compliance and satisfaction but also to foster a healthy work environment and personal relations.4 Effective interprofessional teamwork is a critical component of providing safe healthcare to patients, as it contributes towards the improvement in clinical performance and patient outcomes.5 Understanding conflicts between health care professionals involves several interconnected dimensions, such as sources, consequences, and responses to conflict.6
Collaborative teamwork in Health care settings leads to conflict between the team members leading to compromised interrelationships and reduced patients’ satisfaction. The provision of quality healthcare is dependent on a positively directed work relation between the team members of the healthcare system.7 The Oxford Online Dictionary defines the term “conflict” as “a situation in which people, groups or countries participate in a serious disagreement or argument.” Literature shows that conflicts in workplaces are raised due to individual, interpersonal, and organizational sources of conflict. The individual sources are dependent on personal traits like self-focus, self-esteem, and regulation of emotions.2 Interpersonal conflicts are rooted in disagreements around healthcare goals and behaviors, workflows, or collegial relationships.1 Breakdown in interpersonal communication is also a key feature for such conflicts, whereas organizational factors may include ambiguity in professional roles, the scope of practice, job satisfaction, and a demanding work environment.1 The person’s mental and physical health as well as the conflict management styles affect both the conflicts and consequences.
The primary strategies listed in conflict management include integrating, dominating, avoiding, obliging, and compromising.8 Gunkel et al. (2016) proposed a two-dimensional taxonomy of conflict handling styles by merging two major perspectives established in the literature regarding conflict management strategies from Rahim (1983) and Thomas and Kilmann (1974).9 The taxonomy is shown in Figure 1 (adapted from Gunkel et al).

Conflicts are an intrinsically unavoidable feature of human activities. The conflict management styles dictate the success or failure of teamwork. It is important to identify the conflict management styles of dentists in our health care units. Dental clinicians engage in multidisciplinary teamwork during their practice, which exposes them to a variety of conflicting situations.
The study aimed to explore the trend of different conflict management styles practiced by dentists and correlate them to variables of gender, organizational structure, and position in a hierarchy.

METHODOLOGY
A cross-sectional descriptive study design was employed targeting the dental practitioners working in healthcare and academic institutions. The Ethical approval for the study was obtained from the Institutional Review Board of Shifa international Hospital (Reference # IRB# 321-21). Convenience sampling was used. Sample size was calculated by using a population of 1000. Open Epi calculator was used that yielded a sample size of 200 with a confidence level of 90%. Out of 200 professionals included in the study, a total of 146 participated in the study. The participants were briefed about the purpose of the study and participation in the study was voluntary. Informed consent was taken participation was taken from the participants electronically prior to filling the data collection questionnaire. Rahim Organizational Conflict Inventory-II (ROCI-II) tool was used to collect data regarding the different conflict management styles of dentists when they encounter conflicts with their colleagues.
The ROCI- II tool is a self-reporting tool comprising a 28 items questionnaire measuring the conflict management styles of the individual.10 The questionnaire measures 5 independent styles of conflict management which are Collaborating, Accommodating, Competing, Avoiding, and Compromising. Each style is measured by a set of statements in the questionnaire given in Table # 1. Each statement is marked on a 5-point Likert scale, with the higher value representing the greater use of the said strategy. The collected data were analyzed by the researchers using SPSS version

25.0. The data were categorized according to the 5 styles of conflict management and association with the variables of gender, position in an organization, and type of organization was seen for each conflict management style.

RESULTS
The questionnaire was administered to 200 professionals, out of which 146 responded. The response rate was 73%. The sample included house officers, demonstrators, residents, registrar/assistant professors, and professors from both public and private institutions. For analyzing the conflict management style of individuals, the score of each participant was calculated for all five styles addressed in the questionnaire. The style with the highest average score was identified as a conflict management style for that particular participant. It was found that more than half (54.8%) of the participants adopted collaborating conflict management style followed by Avoiding style (18.5%), whereas Competing style was the least predominant style (3.4%). The distribution of the sample along with the frequency distribution of the styles adopted by the participants is given in Table-2.

In terms of gender association, it was seen that the most adopted style was “collaborating” in both gender groups with 26 (55.3%) males and 54 (54.5%) females. It was interesting to note that more males (23.4%) were inclined to have an “avoiding” style than females (16.2%). Also, females (12.1%) were more “compromising” as compared to their counterparts (6.4%). The comparison of conflict management styles within each gender group is represented in the bi-directional bar chart given in Figure 2.

No strong difference was seen in the frequency of conflict management styles between the dentists belonging to private and public institutions. The results of association for the association of institutional setup to conflict management styles is given in Figure 3.

The comparison of various positions at a workplace concerning the conflict management styles is displayed in Table-3. As observed in the case of gender and institution, every professional position group was more inclined towards “collaborating” and “avoiding” conflict management style.

Besides these two styles, house officers and demonstrators were more “accommodating” while residents and assistant professors were more “compromising”.

DISCUSSION
Healthcare providers work in collaborative practices daily and the development of positive conflict resolution styles among them is the dire need of contemporary workplaces. Workplace conflicts result in stress, psychological turmoil, and emotional exhaustion in medical professionals.11 A study conducted to explore the health care professional’s experiences with conflicting situations and their nature showed that factors responsible for conflicting situations include disagreements on patient care served as a primary trigger.12 As dentists work in close collaboration on dental rehabilitation clinical cases, the disagreement arising from the difference in treatment options could be one factor. Hospitals and organizations tend to look for individuals that have positive interactions with colleagues and foster a healthy
working climate.13
The studies done on other health care providers show consistent results as the present study. A study conducted on nurses in Turkey revealed that nurses prefer collaborating conflict resolution style followed by the compromising, avoiding, competing, and accommodating approaches as it has a positive influence on the situations of conflict. The study aimed to explore the factors related to organizational conflict and it was seen that many factors affect the type of conflict. Similarly, many factors dictate which style of conflict resolution is chosen by nurses during a conflict.3 A study conducted in Nigeria on medical doctors, nurses and administrative staff showed that the professionals who use collaboration, accommodation and compromise style in conflict management experience more career and job satisfaction and hence the conflict management styles have significant positive relationship with overall career satisfaction.14
Literature suggests that cultural factors affect the selection of conflict management styles by individuals.15 The variables of position, gender, organizational structure studied in the present study suggest that conflict management style may
be affected by the individual characteristics and the surrounding environments. Effective conflict resolution has been shown to enhance team performance, increase patient safety, and improve patient outcomes.16 Interprofessional and multidisciplinary collaborative events may help improve relations and reduce conflicts in the workplace.2
The personal abilities of interprofessional team members and their interactions improve professional relationships, collaboration, and quality of care for patients.4
It is crucial to build a climate of teamwork and trust amid complexity and uncertainty in the health care setting.17 While the capabilities are usually considered with individuals, researchers believe that they can apply to teams and have the potential to optimize a team’s effectiveness.18 Studies reveal that most conflicts origin within teams rather than with individuals. Working in a team is probably much more complex than expected and the true dynamics of the workplace are defined by how well individuals work together.19 Professional health care delivery encompasses immense focus on patient care and the professionals must be free to focus their energy on patient care rather than issues among the staff members hence each professional has the responsibility to provide interactive opportunities for multidisciplinary interactions so that effective conflict resolution and conflict management skills could be fostered and have a positive effect on the interpersonal  environment.20s
The present study was not without limitations. The sample size of the study is small and there is unequal distribution among the various positions of dentists. Future studies can be conducted to target a greater sample size which ensures equal representation of all the involved hierarchical positions. A future study could be done to explore the pertinent factors that result in conflicts when dental clinicians work in collaboration on advanced dental rehabilitation cases.

CONCLUSION
Dental clinicians display the use of different conflict management strategies in collaboration at their workplace. The awareness of conflict management styles is important so that the use of positive conflict management styles could be maximized, and the destructive consequences of inevitable personal and professional conflicts are minimized. The use of effective conflict management styles should be taught to young dentists, thus enabling them to practice with necessary tools at clinical workplaces.

AUTHOR CONTRIBUTION
  All Authors contributed towards the data collection, analysis, and preparation of the manuscript for submission in the journal.

DISCLAIMER
The information provided in this article is the original work of the authors and has not been submitted before to any journal. However, the author has acknowledged all resources used and cited these in the reference section.

CONFLICT OF INTEREST
None declared

REFERENCES

1. Kim S, Bochatay N, Relyea-Chew A, Buttrick E, Amdahl C, Kim L, et al. Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. J Interprof Care [Internet]. 2017;31:282- 90.
https://doi.org/10.1080/13561820.2016.1272558

2. Eppich WJ, Schmutz JB. From ‘them’ to ‘us’: bridging group boundaries through team inclusiveness. Med Educ. 2019;53:756-8.
https://doi.org/10.1111/medu.13918

3. Özkan Tuncay F, Yasar Ö, Sevimligül G. Conflict management styles of nurse managers working in inpatient institutions: the case of Turkey. J Nurs Manag. 2018;26:945-52. https://doi.org/10.1111/jonm.12609

4. Johnson DR. Emotional intelligence as a crucial component to medical education. Int J Med Educ. 2015;6:179-83.
https://doi.org/10.5116/ijme.5654.3044

5. Fox L, Onders R, Hermansen-Kobulnicky CJ, Nguyen TN, Myran L, Linn B, et al. Teaching interprofessional teamwork skills to health professional students: A scoping review. J Interprof Care [Internet]. 2018;32:127-35.
https://doi.org/10.1080/13561820.2017.1399868

6. Bochatay N, Bajwa NM, Cullati S, Muller-Juge V, Blondon KS, Junod Perron N, et al. A Multilevel Analysis of Professional Conflicts in Health Care Teams: Insight for Future Training. Acad Med. 2017;92:S84-92.
https://doi.org/10.1097/ACM.0000000000001912

7. Almost J, Wolff AC, Stewart-Pyne A, McCormick LG, Strachan D, D’Souza C. Managing and mitigating conflict in healthcare teams: an
integrative review. J Adv Nurs. 2016;72:1490-505.
https://doi.org/10.1111/jan.12903

8. Basogul C, Özgür G. Role of Emotional Intelligence in Conflict Management Strategies of Nurses. Asian Nurs Res (Korean Soc Nurs
Sci). 2016;10:228-33.
https://doi.org/10.1016/j.anr.2016.07.002

9. Gunkel M, Schlaegel C, Taras V. Cultural values, emotional intelligence, and conflict handling styles: A global study. J World Bus
[Internet]. 2016;51:568-85.
https://doi.org/10.1016/j.jwb.2016.02.001

10. Rahim MA. A measure of styles of handling interpersonal conflict. Acad Manage J. 1983;26:368-76.
https://doi.org/10.5465/255985

11. Raykova EL, Semerjieva MA, Yordanov GY, Cherkezov TD. Dysfunctional Effects of a Conflict in a Healthcare Organization. Folia
Med (Plovdiv). 2015;57:133-7.
https://doi.org/10.1515/folmed-2015-0032

12. Bochatay N, Bajwa NM, Blondon KS, Junod Perron N, Cullati S, Nendaz MR. Exploring group boundaries and conflicts: a social identity
theory perspective. Med Educ. 2019;53:799-807.
https://doi.org/10.1111/medu.13881

13. Tadmor T, Dolev N, Attias D, Lelong AR, Rofe A. Emotional intelligence: A unique group training in a hematology-oncology unit. Educ Heal Chang Learn Pract. 2016;29:179-85.

14. Onwuegbule OF. Conflict managemnet styles and career satisfaction; A study of tertiary health institutions in rivers state. Electron Res J
Purnal Behav Sci. 2018;1:62-73.

15. Al-Hamdan Z, Adnan Al-Ta’amneh I, Rayan A, Bawadi H. The impact of emotional intelligence on conflict management styles used
by jordanian nurse managers. J Nurs Manag. 2019;27:560-6.
https://doi.org/10.1111/jonm.12711

16. Sexton M, Orchard C. Understanding healthcare professionals’ self-efficacy to resolve interprofessional conflict. J Interprof Care
[Internet]. 2016;30:316-23.
https://doi.org/10.3109/13561820.2016.1147021

17. McCallin A, Bamford A. Interdisciplinary teamwork: Is the influence of emotional intelligence fully appreciated? J Nurs Manag. 2007;15:386- 91.
https://doi.org/10.1111/j.1365-2834.2007.00711.x

18. Goleman D. Vital lies, simple truths: the psychology of selfdeception [Internet]. 1996. p. 288. Available from:
http://books.google.com/books?hl=en&lr=&id=R_jF5yUjYSEC&p gis=1

19. Goleman D. Social Intelligence: The New Science of Human relationships. Bantam Dell; 2006.

20. Forte P. The high cost of conflict. Nurs Econ. 1997;15:119-123.

Working in Collaborative Practice: Conflict Management Styles in Dental Professionals

Laila Shakeel Abbasi1                  BDS, MHPE
Taliya Sajjad2                                BDS, MHPE
Khaulah Jawed3                           BDS, ICMT, MHPE
Aqsa Akhtar4                                BDS

 

OBJECTIVE: Conflicts are inevitable in all human interactions. Clinicans at workplaces experience both personal and
professional conflicts. Dental clinicians engage in multidisciplinary teamwork during their practice, which exposes them to a
variety of conflicting situations. The study aimed to explore the trend of different conflict management styles practiced by
dentists while working in collaborative practices.
METHODOLOGY: The study was cross sectional descriptive survey in which 146 dental clinicians from multiple institutions
participated with voluntary and informed consent. Rahim Organizational Conflict Inventory-II (ROCI-II) tool was used to
collect data against the use of conflict management styles namely, Collaborating, Accommodating, Competing, Avoiding and
Compromising. The obtained data were analyzed through SPSS 25.0. The data were categorized according to the 5 styles of
conflict management and association with the variables of gender, position in organization, and type of organization was seen
for each conflict management style.
RESULTS: The study revealed that 54.8% of participants had collaborating style followed by avoiding style (18.5%) whereas,
competing style was least predominant (3.4%). Both genders had collaborating style as most predominant style. No strong
difference was seen in the frequency of conflict management styles between the dentists belonging to private and public
institutions.
Every cadre of clinicians was more inclined towards "collaborating" and "avoiding" conflict management style. Besides these
two styles, house officers and demonstrators were more "accommodating" while residents and assistant professors were more
"compromising".
CONCLUSION: Dental clinicians in the present study mostly used collaborative style for conflict management in their practices.
The awareness of conflict management styles is important so that the use of positive conflict management styles could be
maximized. The use of effective conflict management styles should be taught to young dentists in order to equip them with
necessary tools for everyday collaborations at clinical workplaces.
KEYWORDS: Conflict, Conflict management, dentists, workplace
HOW TO CITE: Abbasi LS, Sajjad T, Jawed K, Akhtar A. Working in collaborative practice: Conflict management styles in
dental professionals. J Pak Dent Assoc 2022;31(3):131-135.
DOI: https://doi.org/10.25301/JPDA.313.131
Received: 30 December 2021, Accepted: 23 May 2022

Download PDF

A Comparative Study on Anxiety Towards COVID-19 Among Dental Postgraduate Trainees of Different Specialties in Karachi, Pakistan

 

Nayab Raza1                                       BDS
Syed Yawar Ali Abidi2                        BDS, FCPS
Samira Adnan3                                   BDS, FCPS, MHPE
Maham Muneeb Lone4                      BDS, FCPS, MHPE
Isma Sajjad5                                       BDS, FCPS
Jamshed Ahmed6                              BDS, FCPS

 

 

OBJECTIVE: Dental health care workers around the globe are potentially vulnerable of contracting COVID-19 disease. Many
studies have investigated the presence of anxiety and mental health issues amongst the healthcare worker, especially the dental
professional, during COVID-19. This study aimed to compare the anxiety of dental postgraduate trainees of different specialties
towards COVID-19.
METHODOLOGY: An online questionnaire comprising 11 items was forwarded to dental postgraduate (PGs) trainees in
Karachi for specialties of Endodontics/Operative Dentistry, Oral Surgery, Prosthodontics and Orthodontics. Responses to 9
questions were recorded on a 3-point Likert scale, where ‘Agree’ indicated anxiety and ‘Disagree’ showed no anxiety. Questions
also inquired PGs opinion about the specialty and dental procedures which they perceived to have the greatest risk of infection.
RESULTS: Almost 62% of responses by the participants affirmed their anxiety as demonstrated by their reply to various
questions based on Likert scale. Gender (p =0.012) and marital status (p= 0.036) revealed significant difference with respect
to anxiety related to closure of dental OPD in face of second wave of COVID-19 and treatment cost if infected, respectively.
Treatments like ultrasonic scaling (84%) and endodontics (79%) while training in specialty of Endodontics/Operative Dentistry
(88%) and Oral Surgery (69%) were considered having greatest risk to contract COVID-19.
CONCLUSION: Anxiety was expressed among trainees of all dental specialties, with training in specialties of Endodontics
and Oral Surgery considered at the highest risk of contracting COVID-19, with ultrasonic scaling and endodontics regarded
as most risky procedures.
KEYWORDS: Anxiety, COVID-19, Endodontics/Operative Dentistry, Oral Surgery, Orthodontics, Prosthodontics.
HOW TO CITE: Raza N, Abidi SYA, Adnan S, Lone MM, Sajjad I, Ahmed J. A Comparative study on anxiety towards
COVID-19 among dental postgraduate trainees of different specialties in Karachi, Pakistan. J Pak Dent Assoc 2022;31(3):125-130.
DOI: https://doi.org/10.25301/JPDA.313.125
Received: 13 April 2022, Accepted: 14 August 2022

INTRODUCTION
The novel coronavirus (SARS-CoV2) is an enveloped virus whose genetic material comprises of a positivesense single-stranded RNA.1 It is responsible for a
deadly disease called coronavirus disease 2019 (COVID-19).2 Due to its highly contagious nature and an increased number of confirmed cases and death counts across the globe, World Health Organization (WHO) declared COVID-19 as a high-risk pandemic on March 11th, 2020. The worldwide dramatic spread of coronavirus 2019 (COVID-19) pandemic has caused an immense public health crisis.3
The effect of the COVID-19 pandemic is not only directly related to health issues. In fact, the stress and anxiety23 regarding the morbidity and mortality associated with the COVID-19 pandemic has had devastating consequences on the mental and intellectual wellbeing of individuals. This anxiety has been coupled with negative social and psychological effects.4 Due to the nature of their professional commitments, the health care professionals are at a greater risk of exposure to a pandemic infection leading to more psychological distress as compared to the general public, causing an additional impact on their mental health.5 Also, determinants like lack of expertise in dealing with the relatively novel disease, greater influx of ill patients, long working hours, changes in lifestyle, lack of sufficient PPEs, and the
unavailability of an effective treatment for a potentially fatal disease has not only overwhelmed the health care system but has also increased the incidence of fear, anxiety, and despair in healthcare workers, adversely affecting their mental wellbeing.6
Dental health care workers around the globe are potentially vulnerable of contracting COVID-19 disease.7 The SARS-CoV2 viral load in human saliva is proven to be very high and its spread is primarily through droplets and aerosols. This feature of the spread of COVID-19 has made dentists especially more prone to contracting COVID-19 owing to the nature of dental procedures they perform.8 Exposure of dental professionals and patients to the pathogenic microorganism is a concern in dental care setting, due to the specificity of its procedures, which include close contact with patients, aerosol generation, repeated exposure to blood, saliva and other body fluids and also its spread by asymptomatic carriers, places dentists in a high-risk group.9 High speed handpiece is the hazardous source of bio-aerosols generation,  which has the potential to remain airborne, easily entering the respiratory system of the dental team and patients.10 This fact has resulted in the development of even higher levels of anxiety among dentists.11 Also, due to its devastating effects on the healthcare system, all routine dental care had been
suspended in many countries affected by COVID-19 disease during the period of the pandemic, becoming limited to dental emergency and urgent procedures only.12
The data comparing presence of anxiety specifically among the dental postgraduate (PGs) trainees belonging to different specialties is scarce. This study therefore was designed to evaluate the psychological burden among dental postgraduate students during the coronavirus pandemic and to find out if there is an established difference between various specialty groups. This data would be crucial to highlight the issues related to anxiety pertaining especially to postgraduate residents in the current pandemic, and for providing recommendations towards provision of psychological support, improvement of the psychological health support services and strengthening mental healthcare nationwide.

METHODOLOGY
After taking ethical approval from Institutes’ Research and Ethics Committee mention the IRB number, an online cross-sectional survey was conducted on postgraduate trainees currently enrolled in the CPSP recognized FCPS training programs of Endodontics/Operative Dentistry, Oral Surgery, Prosthodontics and Orthodontics using google forms, from May to June 2021. Items were designed for the questionnaire after extensive literature search of pertinent studies. To ensure
the validity of the questionnaire, it was examined by specialists in dentistry and dental education experts to determine the clarity of the questions and context relevance of the questions. A pilot study was conducted on 10 trainees to ascertain any complexity in the questionnaire and then the items were modified in light of the feedback of these residents. The questionnaire was divided into 3 sections. In the first section, consent was requested from the respondents, indicated by ticking the consent checkbox. Only respondents who consented to be part of the study could fill the remainder of the form. The second section included socio-demographic
details like age, gender, marital status, specialty, year of practice and email address. The third section consisted of 11 questions out of which responses to 9 questions were recorded on a 3-point Likert scale (Agree, Neutral, Disagree) where Agree indicated anxiety, Neutral indicated neither agree/disagree and Disagree showed no anxiety. Questions also inquired PGs opinion about the specialty and dental procedures which they perceived to have the greatest risk of transmitting the corona virus.
The final questionnaire comprising of 11 items was forwarded through a link to all dental postgraduate (PGs) trainees currently enrolled in the CPSP recognized FCPS training programs of Endodontics/Operative Dentistry, Oral Surgery, Prosthodontics and Orthodontics using social media platforms such as WhatsApp Messenger, Facebook and Gmail. The study population was based on the total CPSP enrolled trainees in Karachi, with a total of 203 trainees as was communicated through official correspondence with the CPSP official email. A reminder was sent one week later to ensure maximum number of responses. No further responses
were included after 2 weeks. Any trainee who did not consent or was not currently actively pursuing training or on long leave was excluded. Data was collected and analysed using SPSS v23. Chi-square test was used to determine any significant difference between the responses of different < 0.05).

RESULTS
   On the basis of unfilled or partially filled forms received, 9 participants were excluded and a total of 103 correctly filled forms were analysed for this survey. The 50.7% response rate was within the general acceptable degree for online based survey responses.13
The mean age of the study participants was found to be 28.07±2.58 years. Frequencies and percentages of the demographic data of participants was calculated. Out of the total 103 participants, 41 (39.8%) were male and 62 (60.2%) female. Around 36.9% (n=38) were married. By field of specialty 50 (48.5%) trainees were in the field of Endodontics/Operative Dentistry, 18 in (17.5%) Orthodontics, 22 in (21.4%) Oral and Maxillofacial Surgery and 13 (12.6%) in Prosthodontics. Chi-square test was used to determine any significant difference between the responses of different post-graduate trainees (p-value < 0.05). No significant difference (p-value < 0.05) was found in this regard (Figure 1). Almost 62% of responses by the participants affirmed their anxiety as demonstrated by their reply to

various questions (Question 1 to Question 9 in Table I) based on Likert scale while 20% responses showed disagreement. The items that yielded a statistically significant response are mentioned in Table II. Treatments like Ultrasonic Scaling followed by Root canal treatment/ dental fillings as shown in Figure 2a, while training in specialty of Endodontics/Operative dentistry, Oral Surgery and Periodontic were perceived to have a greatest risk for contracting COVID-19 Figure 2b.

Figure 2a): PGs opinion about the dental procedures which causes them to become anxious in terms of cross-infection during COVID-19 pandemic b) PGs opinion about the specialty trainees which they think to have the greatest risk to get infection based out he procedures they perform

DISCUSSION
This study compared the anxiety exhibited by postgraduate trainees belonging to different dental specialties. The mental wellbeing of dentists may be affected with an elevated level of anxiety and hesitation when providing dental treatment in current circumstances, due to the fear of getting infected with corona virus from patients or co-workers. The same is supported by the findings of thisstudy where in 57.3% and 79.6% postgraduate trainees reported positively in their hesitation while performing dental procedures during the pandemic and while doing an elective dental procedure, respectively. Irrespective of the demographics, the overall anxiety in the postgraduate trainees was found to be high i.e. 62% which is congruent to various studies reported in the literature.14,15 Besides the fear of being
isolated or quarantined as a result of COVID-19 and how their family would cope during this stressful period, the additional burden in terms of treatment costs of the illness further aggravates ones’ anxiety.16
The infection control measures for cross infection in the dental practice should be strictly followed in the current circumstances.17 The findings obtained through our study show 23.2% postgraduate trainees believed that wearing of PPEs (double mask, double gloves, eye shield, gown) is not sufficient to prevent the possibility of cross infection from COVID-19. This further exacerbates their anxiety while communicating with or treating patients in close proximity. The majority of respondents were of the opinion that these cross infection control measures would help mitigate the chances of acquiring infection. This highlights the importance of provision of proper cross infection control measures and equipment for these post graduates trainees by training centers, so that they can continue their training without the fear and anxiety of getting infected during their clinical practice. In the current study, 77.7% postgraduate trainees agreed that their postgraduate clinical training was adversely affected during the lockdown period, which includes different aspects like reduced number of clinical cases related to specialty, transition to online lectures from physical interaction with their supervisors, cancellation of educational conferences, and completion of the stipulated training time before they appear for their certification exams.18
COVID-19 pandemic has affected the dental practices nationwide following the closure or partial opening of OPDs. Female postgraduate trainees showed significantly higher level of COVID-19 anxiety (80.6%) than males (53.7%) favouring closure of practices until the number of cases start
declining, indirectly signifying fear and anxiety amongst them. This finding is in accordance with the findings of other studies. A study in Greece during COVID-19 pandemic revealed high levels of COVID-19 related fear and anxiety in women as compared to men. Similarly, study of the Chinese population showed greater level of anxiety, stress, and depression among women, compared with men.19,20 Furthermore, a study conducted in Pakistan’s general population during COVID pandemic showed higher anxiety in female population than in male.21 The findings are in line with evidence that suggest women report more fear and anxiety than men.22 The reason could also be the fear that in case of getting infected and falling ill, individuals in the family like their children who are dependent on them would
suffer.
The prolonged incubation period (7-14 days) before the onset of symptoms makes it difficult to limit the spread since it is challenging to identify individuals who may be infected.14 The anxiety of being isolated in case one develops symptoms of infection is a legitimate fear when considering the struggle
that the remaining family members are likely to endure. Since the various aspects associated with this particular disease, including the potential spread to other family members, and the required measures of quarantine are a possibility as a result of contracting this disease, the apprehension is not unfounded. Similar results are obtained in the present study where 63.1% of the postgraduate trainees reported fear of getting quarantined as a result of suspected disease or actual infection.
In the current study, questions also inquired about the respondents’ opinion about the specialty and dental procedures which they perceived to have the greatest risk of acquiring infection. The results showed that dental procedures like ultrasonic scaling/polishing and operative dentistry procedures (RCT/dental fillings) caused them to become more apprehensive in terms of cross infection in the coronavirus pandemic as compared to implant surgery, tooth extraction, endodontics surgery and braces/orthodontic appliances. Also, the training in specialty of Endodontics/Operative Dentistry, Oral Surgery and Periodontics were considered to be at the greatest risk to contract COVID-19 infection as compared to Prosthodontics, Pediatric Dentistry, Orthodontics, and basic sciences. This is generally due to the nature of dental procedures that the identified specialties include which mainly generates aerosols and splatters contaminated with viruses and bacteria thereby posing greater chances of transmitting acute viral respiratory infection.8 This causes even higher levels of concern among dentists with increased risk of exposure to infectious diseases via respiratory droplets as they work in a closer proximity with the patients, particularly their mouth, thus increasing the transmissibility of coronavirus through saliva.23
Some limitations of this study is that it was conducted during the peak of the pandemic, and therefore anxiety of the dentists may alter overtime with emerging research, availability of various vaccines and the possibility of developing treatment of COVID-19. Although the questionnaire was sent to the dental postgraduate trainee of all dental specialties in Karachi, but responses from trainees of clinical specialties like Prosthodontics was low. Only the dental postgraduates from Karachi were included, so the findings cannot be generalized for the entire population of dental postgraduates in Pakistan. Also, we were not able to explore all the dental specialties like Periodontology, Pediatric Dentistry etc, as training in these specialties is not currently being conducted in Karachi. Despite these limitations, this study identifies factors which are contributing to the anxiety of postgraduate trainees in terms of getting infected during their clinical training.

CONCLUSION
Anxiety was expressed among trainees of different dental specialties, with ultrasonic scaling and endodontic treatment considered the highest risk procedures for contracting COVID. Training in specialties of Endodontics/Operative Dentistry and Oral Surgery was regarded as being the most risky by the trainees in terms of contagiousness for COVID-19.

CONFLICT OF INTEREST
None declared

REFERENCES

1. Al-Balas M, Al-Balas HI, Al-Balas H. Surgery during the COVID19 pandemic: a comprehensive overview and perioperative care. Am
J Surg. 2020;219:903-6.
https://doi.org/10.1016/j.amjsurg.2020.04.018

2. Faccini M, Ferruzzi F, Mori AA, Santin GC, Oliveira RC, de Oliveira RC, et al. Covid-19 pandemic and challenges of Dentistry: dental care during COVID-19 outbreak: a web-based survey. Eur J Dent. 2020;14(Suppl 1):S14.
https://doi.org/10.1055/s-0040-1715990

3. Fiest KM, Leigh JP, Krewulak KD, Plotnikoff KM, Kemp LG, NgKamstra J et al. Experiences and management of physician psychological symptoms during infectious disease outbreaks: A rapid review. BMC Psychi. 2021;21:1-4.
https://doi.org/10.1186/s12888-021-03090-9

4. Sallam M, Dababseh D, Yaseen A, Al-Haidar A, Ababneh NA, Bakri FG, et al. Conspiracy beliefs are associated with lower knowledge and higher anxiety levels regarding COVID-19 among students at the University of Jordan. Int J Environ Res Pub Health. 2020;17:4915.
https://doi.org/10.3390/ijerph17144915

5. Pandey U, Corbett G, Mohan S, Reagu S, Kumar S, Farrell T, et al. Anxiety, depression and behavioural changes in junior doctors and medical students associated with the coronavirus pandemic: a crosssectional survey. Int J Gynaecol Obstet. 2021;71:33-7.
https://doi.org/10.1007/s13224-020-01366-w

6. Barranco R, Ventura F. Covid-19 and infection in health-care workers: an emerging problem. Med Leg J. 2020;88:65-6.
https://doi.org/10.1177/0025817220923694

7. Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care. 2020;9:241-7.
https://doi.org/10.1177/2048872620922795

8. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135:429-37.
https://doi.org/10.14219/jada.archive.2004.0207

9. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12:1- 6.
https://doi.org/10.1038/s41368-020-0075-9

10. Ge ZY, Yang LM, Xia JJ, Fu XH, Zhang YZ. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J
Zhejiang Univ Sci B. 2020;21:361-368.
https://doi.org/10.1631/jzus.B2010010

11. Zemouri C, de Soet H, Crielaard W, Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PloS one.
2017;12:e0178007.
https://doi.org/10.1371/journal.pone.0178007

12. Falahchai M, Babaee Hemmati Y, Hasanzade M. Dental care management during the COVID-19 outbreak. Spec Care Dent. 2020;40:539-548.
https://doi.org/10.1111/scd.12523

13. Funkhouser E, Vellala K, Baltuck C, Cacciato R, Durand E, McEdward D. Survey methods to optimize response rate in the National
Dental Practice-Based Research Network. Eval Health Prof. 2017;40:332-58.
https://doi.org/10.1177/0163278715625738

14. Ahmed MA, Jouhar R, Ahmed N, Adnan S, Aftab M, Zafar MS, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17:2821.
https://doi.org/10.3390/ijerph17082821

15. Soraci P, Ferrari A, Abbiati FA, Del Fante E, De Pace R, Urso A, et al. Validation and psychometric evaluation of the Italian version of the Fear of COVID-19 Scale. Int J Ment Health Addict. 2020:1-10.
https://doi.org/10.1007/s11469-020-00277-1

16. Almas K, Khan AS, Tabassum A, Nazir MA, Afaq A, Majeed A. Knowledge, attitudes, and clinical practices of dental professionals during COVID-19 pandemic in Pakistan. Eur J Dent. 2020;14(S 01):S63-9.
https://doi.org/10.1055/s-0040-1718785

17. Izzetti R, Nisi M, Gabriele M, Graziani F. COVID-19 Transmission in dental practice: brief review of preventive measures in Italy. J Dent
Res. 2020;99:1030-8.
https://doi.org/10.1177/0022034520920580

18. Algiraigri AH. Postgraduate medical training and COVID-19 pandemic: should we stop, freeze, or continue?. Health Prof Educ.
2020;6:123-5.
https://doi.org/10.1016/j.hpe.2020.04.002

19. Parlapani E, Holeva V, Voitsidis P, Blekas A, Gliatas I, Porfyri GN, et al. Psychological and behavioral responses to the COVID-19
pandemic in Greece. Front Psychiatry. 2020;11:821.
https://doi.org/10.3389/fpsyt.2020.00821

20. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Pub Health. 2020;17:1729.
https://doi.org/10.3390/ijerph17051729

21. Zafar SM, Tahir MJ, Malik M, Malik MI, Akhtar FK, Ghazala R. Awareness, anxiety, and depression in healthcare professionals, medical students, and general population of Pakistan during COVID-19 Pandemic: A cross sectional online survey. Med J Islam Repub Iran. 2020;34:131.

22. McLean CP, Anderson ER. Brave men and timid women? A review of the gender differences in fear and anxiety. Clin Psychol Rev. 2009;29:496-505.
https://doi.org/10.1016/j.cpr.2009.05.003

23. Olivieri JG, de España C, Encinas M, Ruiz XF, Miró Q, OrtegaMartinez J, et al. General anxiety in dental staff and hemodynamic changes over endodontists’ workday during the Coronavirus Disease 2019 Pandemic: a prospective longitudinal study. J Endod. 2021;47:196- 203.
https://doi.org/10.1016/j.joen.2020.10.023


1. Postgraduate trainee, Department of Operative Dentistry, Sindh Institute of Oral Health
Sciences, JSMU, Karachi, Pakistan.
2. Dean & HOD/Supervisor, Department Operative Dentistry, Sindh Institute of Oral
Health Sciences, JSMU, Karachi, Pakistan.
3. Assistant Professor, Department of Operative Dentistry, Sindh Institute of Oral Health
Sciences, JSMU, Karachi, Pakistan.
4. Assistant Professor, Department of Operative Dentistry, Sindh Institute of Oral Health
Sciences, JSMU, Karachi, Pakistan.
5. Assistant Professor, Department of Operative Dentistry, Sindh Institute of Oral Health
Sciences, JSMU, Karachi, Pakistan.
6. Lecturer, Department of Operative Dentistry, Sindh Institute of Oral Health Sciences,
JSMU, Karachi, Pakistan.
Corresponding author: “Dr. Nayab Raza” < nayab.raza@jsmu.edu.pk >

A Comparative Study on Anxiety Towards COVID-19 Among Dental Postgraduate Trainees of Different Specialties in Karachi, Pakistan

Nayab Raza1                                       BDS
Syed Yawar Ali Abidi2                        BDS, FCPS
Samira Adnan3                                   BDS, FCPS, MHPE
Maham Muneeb Lone4                      BDS, FCPS, MHPE
Isma Sajjad5                                       BDS, FCPS
Jamshed Ahmed6                              BDS, FCPS

 

 

OBJECTIVE: Dental health care workers around the globe are potentially vulnerable of contracting COVID-19 disease. Many
studies have investigated the presence of anxiety and mental health issues amongst the healthcare worker, especially the dental
professional, during COVID-19. This study aimed to compare the anxiety of dental postgraduate trainees of different specialties
towards COVID-19.
METHODOLOGY: An online questionnaire comprising 11 items was forwarded to dental postgraduate (PGs) trainees in
Karachi for specialties of Endodontics/Operative Dentistry, Oral Surgery, Prosthodontics and Orthodontics. Responses to 9
questions were recorded on a 3-point Likert scale, where ‘Agree’ indicated anxiety and ‘Disagree’ showed no anxiety. Questions
also inquired PGs opinion about the specialty and dental procedures which they perceived to have the greatest risk of infection.
RESULTS: Almost 62% of responses by the participants affirmed their anxiety as demonstrated by their reply to various
questions based on Likert scale. Gender (p =0.012) and marital status (p= 0.036) revealed significant difference with respect
to anxiety related to closure of dental OPD in face of second wave of COVID-19 and treatment cost if infected, respectively.
Treatments like ultrasonic scaling (84%) and endodontics (79%) while training in specialty of Endodontics/Operative Dentistry
(88%) and Oral Surgery (69%) were considered having greatest risk to contract COVID-19.
CONCLUSION: Anxiety was expressed among trainees of all dental specialties, with training in specialties of Endodontics
and Oral Surgery considered at the highest risk of contracting COVID-19, with ultrasonic scaling and endodontics regarded
as most risky procedures.
KEYWORDS: Anxiety, COVID-19, Endodontics/Operative Dentistry, Oral Surgery, Orthodontics, Prosthodontics.
HOW TO CITE: Raza N, Abidi SYA, Adnan S, Lone MM, Sajjad I, Ahmed J. A Comparative study on anxiety towards
COVID-19 among dental postgraduate trainees of different specialties in Karachi, Pakistan. J Pak Dent Assoc 2022;31(3):125-130.
DOI: https://doi.org/10.25301/JPDA.313.125
Received: 13 April 2022, Accepted: 14 August 2022

Download PDF

Oral and Systemic Manifestations of Systemic Lupus Erythematosus; Exploring the Association

 

Hafiz Muhammad Shahzad Khurshid1          BDS, MPhil
Taffazul H Mahmud2                                       MBBS, MRCP, FRCP
Saima Chaudhry3                                            BDS, PhD

 

 

OBJECTIVE: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with variety of clinical and oral
mucosal presentations. Our study aimed to record all those oral pathological changes which occur in patients of SLE and observe
the associations between the clinical signs and oral disease status.
METHODOLOGY: Present study was conducted in Rheumatology Department of Shaikh Zayed Medical Complex, Lahore,
Pakistan. Consecutive sampling was done, and 130 diagnosed patients with SLE of both genders and all ages were recruited
in the study after getting written informed consent. Patients with any comorbid conditions were excluded from the study. Detailed
clinical and oral examinations were performed, and relevant disease findings were recorded. Associations between oral and
clinical manifestations were computed through chi-squared test of significance keeping the confidence level at 95%.
RESULTS: Out of 130 patients, 115 were females and 15 were males. Mean age of patients reported with SLE was 31.65 ±
9.5 years. Arthritis was the most common clinical finding followed by photosensitivity. Among the oral pathologies, oral ulcers,
xerostomia, gingivitis, glossitis, mucositis, gingival bleeding, and hyperplasia were observed. Nephritis was associated with
most oral manifestations, followed by psychosis, hair loss and skin rash.
CONCLUSIONS: SLE has a strong component of oral mucosal pathologies. The most common skin findings were rash,
followed by photosensitivity and arthritis. Commonest oral manifestation was oral ulceration present and past. Significant
associations were found between certain oral and systemic manifestations.
KEYWORDS: Systemic Lupus Erythematosus, Systemic, Oral, Ulcer.
HOW TO CITE: Khurshid HMS, Mahmud TH, Chaudhry S. Oral and systemic manifestations of systemic lupus erythematosus;
Exploring the association. J Pak Dent Assoc 2022;31(3):120-124.
DOI: https://doi.org/10.25301/JPDA.313.120
Received: 14 September 2022, Accepted: 21 September 2022

INTRODUCTION
S ystemic lupus erythematosus (SLE) is the multisystem autoimmune disease with a broad spectrum of clinical manifestations that involve almost all organs and tissues of the body. It is characterized under autoimmune disease, in which the patient’s immune system attacks its
own body tissues, especially the cellular nuclei or its components.1 The geoepidemiology of SLE demonstrates ethnic differences which are largely due to genetic susceptibility and environmental factors.2 Risk of developing SLE is great among non-white people especially South
Asian and East Asian countries where the prevalence rate of SLE is between 30 to 50 per 100,000.3 Disease is caused by a complex interaction between different genetic, hormonal, epigenetic and environmental factors. Overload of immune complexes in the form
of nuclear autoantigens and uncontrolled production of IFN-Alpha are the hallmarks.4 However, complete pathogenesis of SLE is still not clearly understood. SLE belongs to the group of diseases which show immense diversity in its clinical parameters.5-7 Patients report broad
variety of symptoms some are representative while others are constitutional features of disease both systemic and oral.8,9
Pakistan has relatively younger lupus patients as compared to other countries.10 Understanding about oral pathological spectrum is necessary because early detection of oral mucosal changes may help in starting treatment early leading to decrease disease morbidity and improved quality of life. The aim of this study is to present the spectrum of oral mucosal pathologies of SLE and record if there are any
associations between oral and systemic manifestations of disease in these patients.

METHODOLOGY
This descriptive study has been conducted in division of Rheumatology, Sheikh Zayed Hospital Lahore, in collaboration with Department of Oral Pathology, Department of Morbid Anatomy & Histopathology and Department of Immunology University of Health Sciences Lahore.
Consecutive sampling was done, and 130 diagnosed patients of both genders and all ages were recruited in the study after getting written informed consent. Patients with any comorbid condition were excluded from the study. General physical examination involving detailed clinical evaluation of the disease was done under supervision of concerned medical specialist and relevant disease findings were recorded. Intraoral examination was performed under proper illumination with the help of dental mirror and probe. Oral mucosal changes from erythema to ulceration in any part of the mouth at the time of examination were recorded.
Sizes of oral ulcers (in mm) and their numbers were recorded in questionnaire. Periodontal changes of the diseases were evaluated according to basic periodontal examination guidelines by British Society of Periodontology (BSP) (Dietrich et al., 2019). In addition, the gingival assessment was performed by Silness-Loe index (Nimbulkar et al., 2020). Subjective xerostomia was evaluated through a
question “Does your mouth usually feel dry?” using a dichotomous response technique including ‘YES’ or ‘No’ responses (Fleming et al., 2020). Above mentioned clinical examination was supported by evident history findings and recorded for each study participants.
The current study was approved by ethical review committee of University of Health sciences Lahore, Pakistan vide letter number UHS/REG-17/ERC/4382.

STATISTICAL ANALYSIS
Data was coded analyzed using IBM SPSS Version: 25.0. Mean and standard deviation was calculated for age of patient, number of oral ulcers and their sizes. Frequency and percentage were calculated for gender and stage of disease. The associations between oral and clinical manifestations was done using chi-square test of significance. For all analysis, a p-value of < 0.05 was considered as statistically significant with a confidence level of 95%

RESULTS
    Out of 130 patients, 115 were females and 15 were males highlighting a significant female predominance. Mean age of patients reported with SLE was 31.65 ± 9.5. Family history of SLE was positive in 28 patients. 59% of patients presented with moderate stage of disease while 32% had mild stage and only 9% had severe stage of SLE. On clinical examination Arthritis was present in 96.9 % of patients while photosensitivity in 87%. These two clinical findings were present in every spectrum of disease. On the other hand, CNS involvement in the form of seizures or psychosis was present only 18 patients with severe disease manifestations. Malar rash was present in 78%, skin rash in

On oral examination oral ulcers were present in 39.2 % while 80% of the patients gave history of oral ulcerations which were present at certain point of their disease progression but now had been healed at the time of their oral examination. Xerostomia was present in 69% of patients while gingivitis in 59%, gingival bleeding in 38%, gingival hyperplasia in 18%, mucositis in 42% and glossitis was present in 43% of
patients (Table-2).

Statistical associations were computed among oral and systemic manifestations of the disease and as shown in Table 3, significant association was observed between oral mucosal changes with the systemic conditions of nephritis, psychosis, hair loss and skin rash.

DISCUSSION
SLE being a multisystemic autoimmune disease has gained primary attention in current era all over the world where abundant pollutants and genotoxic agents are present to derange the life and life care systems. In current study, we have tried to understand the wide spectrum of oral diseases present in SLE along with other clinical variables. Systemic lupus erythematosus exhibits sexual dimorphism, being more common in females than in males. Out of 130 patients who were included in our research, 115 were females and only 15 were males. These results are in accordance with the previous studies in Pakistan.11 Similar findings were observed by Rabbani and colleagues from Karachi.12 Another study in U.S suggested the similar picture about gender distribution of disease which was nine times more common in females as compared to males. It was observed that the acquisition of SLE is highly gender bias in which presence of ‘X’ chromosome, the hormonal makeup, the female sex steroid; estradiol and its receptor chemistry can explain the etiology but the underlying mechanisms are still enigmatic.5
In present study, mean age of patients reported with SLE was 31.65 ± 9.5 years. A local study in Karachi, Pakistan, by Rabbani and colleagues also reported the mean age of SLE patient being 31 years.12. It is important to note that most of the patients belongs to childbearing age. So,
this is not a disease of geriatric population.
Family history in term of patient’s first-degree relatives was positive in 21.5% of patients. Similar findings were observed in a study conducted in Italy reported 22.7% of patients who had positive family history of SLE.13 Presence of disease in family is a potential risk factor for a person to develop SLE during some part of his/her life. Its justification lies in a fact that disease susceptible genes runs in succeeding generations, environmental triggers may play a role which might result in differences in various populations.14
Regarding clinical manifestations, arthritis was found to be the commonest sign followed by photosensitivity followed by other clinical manifestations. Another study in Lahore, Pakistan shows similar findings as photosensitivity (60%), malar rash (60%) and skin lesions (58%).15 A study conducted in Karachi, Pakistan reported malar rash (29%), photosensitivity (6%), arthritis in (38%) and seizures or psychosis in 14% of patients.12 Study in Saudi Arabia reported 624 SLE patients in which arthritis was present in 80.4%, malar rash (48%), nephritis (47.9%), neuropsychiatric manifestations were 27.6%.16 While a study in U.S reported nephritis in 37% of SLE patients. Above minor differences in different populations might be due to inter-ethnic variations and genetic differences.
Complete intra-oral examination was performed for 130 patients included in our study. Oral ulcers, the pathognomonic for SLE were present in 39% of patients at the time of clinical examination. History of presence of oral ulceration during any part of disease course in patients was consistent finding which was present in 80% of patients. Another important finding was presence of xerostomia or dryness of mouth which was present in 69% of patients and most of them belong to geriatric population. Similar findings were observed in a study conducted in Brazil which showed 58% of the patients reported with xerostomia due to immune attack on salivary glandular parenchyma.17 Gingivitis was observed in 59% of patients while glossitis and mucositis were observed in 43% and 42% of patients respectively. 17% of patients who were using cyclosporine reported gingival hyperplasia.
Cyclosporine drugs used as an immunosuppressant in SLE patients stimulate gingival fibroblast which results in unusual gingival overgrowth.18 Oral findings reported in other studies include mucositis, gingivitis, angular cheilitis, dry mouth, dental caries, hypogeusia, dysgeusia, glossodynia and burning sensation of mouth. Xerostomia is reported to be present in almost all patients of SLE while periodontitis has been observed in 93.8% of the patients.19 As Hyposalivation increases the chances of dental caries and extensive tooth decay, apart from this mucosa becomes susceptible to mechanical injuries leading to non-infectious mucositis and pharyngitis.
Oral health in SLE in intimately connected with the overall health of patient. Most of the time oral health evaluation creates a window of understanding about the systemic health issues of SLE patients. A significant link was observed between some oral and systemic manifestations of SLE which support the concept of oral-systemic health connection. Significant association was observed between nephritis and many oral manifestations of SLE like gingivitis, oral ulcers, gingival hyperplasia, and glossitis. The increased systemic inflammatory burden in chronic renal disease potentiates the proinflammatory cascades of SLE and ultimately results in vasculitis and gingival inflammation.20 Vasculitis of Lupus is far away different from normal vasculitis in terms of targeting medium and small sized blood vessels especially without involving large sized vessels. As a consequence; involvement of oral mucosa in the form of gingivitis, glossitis and oral ulcerations co-manifest with nephritis and other systemic vasculitis.21
Cutaneous involvement of SLE in the form of skin rash was found to be significantly associated with history of oral ulceration. Vascular attack by abnormal immune complexes formed in SLE disintegrate the epithelium of skin, gingival tissue, and oral mucosa resulting in ulcerations.22 The bodywise inflammation in Lupus affects the skin and its appendages leading to in destruction of hair follicles which depicts as alopecia or thinning of hair.23 Similar finding was observed in our study in which a significant link was observed between hair loss and glossitis or mucositis.
Another significant association in our study was observed between seizures and gingival inflammation or gingivitis. Here we can observe the gingivitis as a disease; involving those patients with SLE complications and involvement of vital organs like CNS or gingivitis as a condition; depicting plethora of problems in patients who are unable to maintain oral hygiene in episodes of seizures. In both situations an
evident need is present to deal the SLE manifestations as a whole, without fractioning the systemic problems and treating them individually. Maintenance of meticulous oral hygiene is helpful in treating the oral conditions which usually fade out under the blanket of systemic problem.

CONCLUSION
The patients examined had significant oral manifestations along with and skin manifestations. The most common skin findings were arthritis, followed by photosensitivity and rash. Commonest oral manifestation was history of oral ulceration xerostomia and gingivitis. Significant associations were found between certain oral and systemic manifestations that need to be further evaluated in future investigations. Understanding about oral pathological spectrum is necessary because early detection of oral mucosal changes may help
in designing treatment therapy thus, lessening the disease burden and improving the quality of life.

ACKNOWLEDGEMENT
The authors are grateful to all the patients who consented to be part of the study and the faculty and staff of Department of Rheumatology, Shaikh Zayed Hospital for their support.

CONFLICT OF INTEREST
    None declared

REFERENCES

1. Tsokos, G. C. Autoimmunity and organ damage in systemic lupus erythematosus. Nature immunol. 2020; 21: 605-14.
https://doi.org/10.1038/s41590-020-0677-6

2. Rees, F., Doherty, M., Grainge, M. J., Lanyon, P. & Zhang, W. The worldwide incidence and prevalence of systemic lupus erythematosus:
a systematic review of epidemiological studies. Rheumatol. 2017; 56: 1945-61.
https://doi.org/10.1093/rheumatology/kex260

3. Jaswal, V., Raghuvanshi, V., Kumar, V. & Dhatwalia, A. Epidemiology of Systemic Lupus Erythematosus; Indian Perspective. Himal J App
Med Sci Res. 2021; 2: 64-8.

4. Wu, Y. R., Hsing, C. H., Chiu, C. J., Huang, H. Y. & Hsu, Y. H. Roles of IL-1 and IL-10 family cytokines in the progression of systemic
lupus erythematosus: Friends or foes? International Union of Biochemistry and Molecular Biology life. 2022; 74: 143-56.
https://doi.org/10.1002/iub.2568

5. Rider, V., Abdou, N. I., Kimler, B. F., Lu, N., Brown, S. & Fridley, B. L. Gender bias in human systemic lupus erythematosus: a problem
of steroid receptor action? Front Immunol. 2018; 9611.
https://doi.org/10.3389/fimmu.2018.00611

6. Chen, H.-Y., Lin, J.-J., Yang, B. & Lin, M.-C. Risk of systemic autoimmune diseases in gastric disease patients with proton pump
inhibitor use: a nationwide cohort study in Taiwan. Clin Rheumatol. 2020;39:2773-80.
https://doi.org/10.1007/s10067-020-05012-8

7. Tang, S. P., Lim, S. C. & Arkachaisri, T. Childhood-onset systemic lupus erythematosus: Southeast Asian perspectives. J Clin Med.
2021;10:559.
https://doi.org/10.3390/jcm10040559

8. Sahin, S., Adrovic, A., Barut, K., Canpolat, N., Ozluk, Y., Kilicaslan, I., Caliskan, S., Sever, L. & Kasapcopur, O. Juvenile systemic lupus
erythematosus in Turkey: demographic, clinical and laboratory features with disease activity and outcome. Lupus 2018;27:514-9.
https://doi.org/10.1177/0961203317747717

9. Hammoudeh, M., Al-Momani, A., Sarakbi, H., Chandra, P. & Hammoudeh, S. Oral manifestations of systemic lupus erythematosus
patients in Qatar: a pilot study. Int J Rheumatol, 2018; 6053326.
https://doi.org/10.26226/morressier.5a83dfbed462b8029238bb43

10. Mumtaz, S., Ali, M., Khan, N. B., Mehmood, B., Azhar, M. & Farhan, F. Oral ulcers in systemic lupus erythematosus-relationship with disease duration and severity. J Khyber Coll Dentistry; 2020;10:121-5.

11. Anwar MA, Naseem N, Tayyab MA, Khan SEA, Saeed MA, Ahmad NM, Nagi AH. Clinico-oral Presentation of Systemic Lupus
Erythematosus Patients. Int J Contemp Med Res. 2015;2:887-91.

12. Rabbani, M. A., Siddiqui, B. K., Tahir, M. H., Ahmad, B., Shamim, A., Shah, S. M. & Ahmad, A. 2004. Systemic lupus erythematosus in
Pakistan. Lupus. 2004;13:820-5.
https://doi.org/10.1191/0961203303lu1077xx

13. Ulff-Møller, C. J., Simonsen, J., Kyvik, K. O., Jacobsen, S. & Frisch, M. 2017. Family history of systemic lupus erythematosus and
risk of autoimmune disease: Nationwide Cohort Study in Denmark 1977-2013. Rheumatol. 2017; 56: 957-64.
https://doi.org/10.1093/rheumatology/kex005

14. Cortés Verdú, R., Pego-Reigosa, J. M., Seoane-Mato, D., Morcillo Valle, M., Palma Sánchez, D., Moreno Martínez, M. J., Mayor González,
M., Atxotegi Sáenz De Buruaga, J., Urionagüena Onaindia, I. & Blanco Cáceres, B. A. Prevalence of systemic lupus erythematosus in Spain:
higher than previously reported in other countries? Rheumatol 2020;59:2556-62.
https://doi.org/10.1093/rheumatology/kez668

15. Kapadia, N. & Haroon, T. S. Cutaneous manifestations of systemic lupus erythematosus: study from Lahore, Pakistan. Int J Dermatology
1996;35:408-9.
https://doi.org/10.1111/j.1365-4362.1996.tb03021.x

16. Bawazir, Y. M. & Aljohaney, A. A.. Pulmonary Manifestations of Systemic Lupus Erythematosus: Global and Saudi Arabian Populations.
Saudi J Intern Med 2019; 9: 45-51.
https://doi.org/10.32790/sjim.2019.9.1.7

17. Kudsi, M., Nahas, L. D., Alsawah, R., Hamsho, A. & Omar, A.. The prevalence of oral mucosal lesions and related factors in systemic
lupus erythematosus patients. Arthri Res Therap 2021; 23: 1-5.
https://doi.org/10.1186/s13075-021-02614-8

18. Torkzaban, P. & Talaie, A. Drug-Induced Gingival Overgrowth inan 8-Year-Old Girl: A Case Report.
Avicenna J Dent Res 2021;13: 109-112.
https://doi.org/10.34172/ajdr.2021.21

19. Sete, M. R., Figueredo, C. M. & Sztajnbok, F. Periodontitis and systemic lupus erythematosus.
Rev Bras Reumatol Engl Ed 2016; 56: 165-70.
https://doi.org/10.1016/j.rbr.2015.07.006

20. Oyetola, E., Ojo, M., Mogaji, I. & Aremu, A. Oral ulcerations in chronic kidney disease patients: exploring the relationship between
clinical presentation of the ulcers and blood urea concentration: Oral ulcerations in chronic kidney disease. Afr J Oral Maxillofac Pathol
Med 2020;6:13-20.

21. Leone, P., Prete, M., Malerba, E., Bray, A., Susca, N., Ingravallo, G. & Racanelli, V. Lupus vasculitis:
An overview. Biomedi 2021; 9: 1626.
https://doi.org/10.3390/biomedicines9111626

22. Pires, J. R., Nogueira, M. R. S., Nunes, A. J. F., Degand, D. R. F., Pessoa, L. C., Damante, C. A., Zangrando, M. S. R., Greghi, S. L. A.,
De Rezende, M. L. R. & Sant’ana, A. C. P. Deposition of immune complexes in gingival tissues in the presence of periodontitis and
systemic lupus erythematosus. Front Immunol 2021; 12663.
https://doi.org/10.3389/fimmu.2021.591236

23. Udompanich, S., Chanprapaph, K. & Suchonwanit, P. Hair and scalp changes in cutaneous and systemic lupus erythematosus.
Am J Clin Dermatol. 2018;19:679-94.
https://doi.org/10.1007/s40257-018-0363-8

Oral and Systemic Manifestations of Systemic Lupus Erythematosus; Exploring the Association

Hafiz Muhammad Shahzad Khurshid1          BDS, MPhil
Taffazul H Mahmud2                                       MBBS, MRCP, FRCP
Saima Chaudhry3                                            BDS, PhD

 

 

OBJECTIVE: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with variety of clinical and oral
mucosal presentations. Our study aimed to record all those oral pathological changes which occur in patients of SLE and observe
the associations between the clinical signs and oral disease status.
METHODOLOGY: Present study was conducted in Rheumatology Department of Shaikh Zayed Medical Complex, Lahore,
Pakistan. Consecutive sampling was done, and 130 diagnosed patients with SLE of both genders and all ages were recruited
in the study after getting written informed consent. Patients with any comorbid conditions were excluded from the study. Detailed
clinical and oral examinations were performed, and relevant disease findings were recorded. Associations between oral and
clinical manifestations were computed through chi-squared test of significance keeping the confidence level at 95%.
RESULTS: Out of 130 patients, 115 were females and 15 were males. Mean age of patients reported with SLE was 31.65 ±
9.5 years. Arthritis was the most common clinical finding followed by photosensitivity. Among the oral pathologies, oral ulcers,
xerostomia, gingivitis, glossitis, mucositis, gingival bleeding, and hyperplasia were observed. Nephritis was associated with
most oral manifestations, followed by psychosis, hair loss and skin rash.
CONCLUSIONS: SLE has a strong component of oral mucosal pathologies. The most common skin findings were rash,
followed by photosensitivity and arthritis. Commonest oral manifestation was oral ulceration present and past. Significant
associations were found between certain oral and systemic manifestations.
KEYWORDS: Systemic Lupus Erythematosus, Systemic, Oral, Ulcer.
HOW TO CITE: Khurshid HMS, Mahmud TH, Chaudhry S. Oral and systemic manifestations of systemic lupus erythematosus;
Exploring the association. J Pak Dent Assoc 2022;31(3):120-124.
DOI: https://doi.org/10.25301/JPDA.313.120
Received: 14 September 2022, Accepted: 21 September 2022


Download PDF

Efficacy of Calcium Hydroxide and Mineral Trioxide Aggregate in the Formation of Dentin Bridge – A Randomized Controlled Trial

 

Rafia Ruaaz1                                   BDS, FCPS
Muhammad Bilal Bashir2              BDS, MDS
Madiha Anwar3                              BDS, MDS
Saqib Rashid4                               BDS, FCPS, MSc
Sadaf Ali5                                      BDS, FCPS
Azam Muhammad Aliuddin6       BDS, FCPS

 

OBJECTIVE: This study is to compare the dentin bridge thickness achieved using calcium hydroxide and MTA using
radiographs.
METHODOLOGY: Single blinded randomized controlled trial conducted in the Operative Dentistry department at Fatima
Jinnah Dental College and Hospital, Karachi. A total of 100 premolar and molar teeth with class I and II cavities were included
in this study. The study participants were assigned into two groups, A and B of 50 participants each. Under local anesthesia,
Group A was indirectly pulp capped with Calcium hydroxide (Dycal) and Group B received Mineral Trioxide Aggregate as
an indirect pulp capping material. Both groups were then restored with Glass Ionomer Cement. Radiographic follow up was
carried out at three and six months to determine mean dentin thickness of reparative dentin bridge.
RESULTS: Statistical analysis was performed using SPSS v 23. Independent Sample t-test was applied to evaluate the formation
of dentin bridge formation using Ca(OH)2 and MTA at 3 months & 6 months, the outcomes were highly significant
(p-value<0.001). Paired sample t-test was applied to evaluate the difference in dentin bridge formation at three months and 6
months, the results were highly significant (p-value <0.001).
CONCLUSION: Statistically significant difference was observed in the dentin thickness of reparative dentin bridge amongst
the two groups after three months and six months. A greater success rate was noted in the MTA group as compared to the
Ca(OH)2 group after 6 months.
KEYWORDS: Dentin bridge, Endodontic treatment, Indirect pulp capping, Reparative dentin, randomized controlled trial.
HOW TO CITE: Ruaaz R, Bashir MB, Anwar M, Rashid S, Ali S, Aliuddin AM. Efficacy of calcium hydroxide and mineral
trioxide aggregate in the formation of dentin bridge - A randomized controlled trial. J Pak Dent Assoc 2022;31(3):114-119.
DOI: https://doi.org/10.25301/JPDA.313.114
Received: 05 March 2022, Accepted: 14 August 2022

INTRODUCTION
Adentin bridge seals off the dental pulp from bacterial toxins and helps in maintaining pulp vitality.1 It is formed when a protective dressing is placed over a tinny layer of carious dentin remaining above the dental pulp (indirect pulp cap).2
Pulp capping can be achieved on vital teeth with normal pulp or with reversible pulpitis. Many materials have been used for this purpose such as Calcium Hydroxide (Ca(OH)2), Resin Modified Glass Ionomer Cement (RGMIC), Mineral Trioxide Aggregate (MTA) & Biodentin. Ca(OH)2 is the most used material for pulp capping procedures and has been measured a gold standard.3 Studies have revealed that one hour contact with Ca(OH)2 results in a 100% reduction in infection causing organisms.4 It is also known to stimulate a variety of proteins such as Bone Morphogenetic Protein (BMP) and Transforming Growth Factor Beta One (TGF) which induce dentinogenesis.5
Mineral Trioxide Aggregate (MTA) is a hydrophilic & biocompatible cement which stimulates remedial & bone formation in cases of root resorption, apexification, perforation and as a pulp-capping material.6 It provides a good seal, an antibacterial pH, and results in rapid dentinal bridge deposition. It has also been reported to be less toxic and the incidence of pulpal inflammation is fewer when matched to Ca(OH)2 . However, it has a longer setting time and higher cost compared to Ca(OH)2 which is in most cases unacceptable and inconvenient for both patients and dentists.7
The antimicrobial activity of MTA is also less strong when compared with that of Ca(OH)2 . Tooth discoloration has also been reported with the use of MTA. Researches have been done to compare the effectiveness of different pulp capping material for dentin formation.8,9
Ca(OH)2 and MTA both have proven to be clinically effective in root repair and dentin bridge formation.10 However, the literature for comparison of the use of these two materials is limited and particularly in Pakistan there is no data available. Additional researches are required to emphasize and compare the capability of these two materials. The rationale of this research is to evaluate the mean thickness
of the dentin bridge formation after indirect pulp capping using Calcium Hydroxide (Dycal®) and MTA.
One of the major concerns during the endodontic treatment is the maintenance of pulp vitality. The current study will be beneficial for dentists as it will help them decide the best treatment modality using the best material which will restore the tooth’s strength and vitality, be costefficient, generate faster outcomes & guard the patient from the hassle of root canal treatment or tooth loss.
The clinical performance of MTA reportedly has been significantly higher when compared to Ca(OH))2 . The goal of this prospective single blinded randomized controlled trial was to compare the mean thickness of dentin bridge formation after indirect pulp capping with calcium hydroxide and mineral trioxide aggregate in human pre-molar and molar teeth after a period of three and six months.

METHODOLOGY
     It was single blinded randomized controlled trial (RCT) which was done in the Operative Dentistry department, Fatima Jinnah Dental College and Hospital, Karachi. The ethical approval for conducting this study was taken from Institutional Ethical Review Committee of
Fatima Jinnah Dental College and Hospital (Ref No: FJDC/OPR-01) to conduct the study on human subjects.
The sample size was calculated using OpenEpiEpidemiologic calculator software. As per the literature search Calcium hydroxide and Mineral Trioxide Aggregate showed mean dentin bridge formation of 0.221±0.05mm and 0.235±0.11mm respectively at six months follow ups. Confidence level 95%, and power 80%, the sample size obtained was 58 (29 in each group). To overcome the possibility of dropouts due to reinfection, or patients not turning up, the sample size was doubled to 116. The patients visiting the Fatima Jinnah Dental OPD for any restorative procedure were evaluated and recruited in the study, after taking informed consent, if they fulfilled the inclusion criteria. The inclusion criteria involved patients aged between 20 to 40 years of age, who were able to maintain good oral hygiene and showed good compliance with the procedure. The teeth that were included involved vital premolars and molars of both arches and having deep occlusal caries (3-4 mm) on the surface of posterior teeth (Class I or Class II).
The posterior teeth which had deep caries but were periodontally compromised or showed root resorption on radiographs were excluded. The patients who had any systemic diseases such as diabetes mellitus, hypertension or any other illness were also omitted from the study.
A written consent was taken from the patients, and they were fully explained about the advantages and disadvantages of the procedure. A sealed enveloped enclosing the material to be applied with the label of alphabet A or B was used. Patient was asked to pick one envelope which determined which material they would be treated with. Group A subjects were provided pulp capping using Ca(OH)2 (Dycal® Ivory,
Caulk, Dentsply, L.D. Caulk, Milford, DE, USA) while Group B patients were given MTA (ProRoot; Dentsply/Tulsa Dental, Tulsa, OK, USA) as indirect pulp cap agent.
Periapical radiographs were taken preoperatively and pulp vitality tests were also performed. To test the pulp vitality cold and electric pulp tests were applied. Ethyl Chloride spray was applied to the surface of the tooth to perform cold testing. Electric testing was performed by using an electric pulp tester (Electric Pulp Tester Averon® PT 2-0, VEGA-PRO, Ekaterinburg, Russia). The readings were recorded in the data collection form. Thee tooth to be treated was anesthesized using lidocaine 2 % solution in 1.8 ml unit accessible for dental use. The moisture control of the operational field was maintained by using rubber dam. High-speed handpiece (NSK) with round diamond bur (no
1/6 or ¼) was used to prepare the cavity. The soft carious dentin was removed using a spoon shaped excavator and a round tungsten carbide bur in a slow hand piece. A 2 mm thin layer of carious dentin was left over the pulp. The pulp capping agent was mixed and placed in the cavity. The Glass ionomer cement (Chemfill superior Caulk, Dentsply, L.D. Caulk, Milford, DE, USA) was then positioned as over the
pulp capping material as a temporary filling material for the duration of the study.
The patients were recalled at 3 months and 6 months for follow up. The radiographs taken at baseline & follow-up were exposed on a metallic 1-mm Fixott-Everett grd (Fixott-Everett X-ray Grid Large Ea, Miltex Instrument Co, Inc., York, PA, USA). The instrument was used to perform the radiologic scaling of the digital images so the measurements could be done later, using the Mesurim Pro® Software (©J-F. Madre, Academy of Amiens, Amiens, France). The thickness of the newly made dentin bridge by both the materials was measured and compared. The radiographic evaluation was performed by two calibrated examiners to rule out discrepancy in measurements.
The statistical analysis of the data was accomplished using the SPSS software version 23 (SPSS Inc., Chicago, IL, USA). Descriptive statistics of age and gender were tabulated. Cohen’s Kappa statistic test was applied to calculate the inter-examiner reliability of the radiographic measurements by the examiners (K=0.771, significant agreement in quantities11). Student’s t-test was applied to compare mean dentin thickness in both groups after three and six months. Paired Sample t-test was applied to compare the outcome of dentin bridge formation at 3 months and 6 months. P-value <0.05 was kept as significant.

RESULTS
    The figure 1 shows the allocation of the participants in the group and loss of participants due to loss of follow-up and failure of the restoration. The failure of the restoration was judged as negative pulp test on the follow-up visit. At 3 months the failure rate of MTA was more than the failure rate of Ca(OH)2 and a total of 7 participants did not appear for follow up visit at 3 months. At 6 months, there was no

loss of the participants due to negative pulp testing, however, one was excluded in Ca(OH)2 group due to loss of restoration. A total of 4 participants did not appear for their 6 months follow-up visit. Therefore 100 patients were analyzed in the final analysis.

DISCUSSION
     The current study is a single blinded randomized controlled trial which was conducted to assess the efficacy of MTA and calcium hydroxide during indirect pulp capping procedures. The procedure involves using a pulp capping material over a thin layer of carious dentin. The procedure is done to retain the vitality of the pulp rather than risking its exposure. The tooth is kept on follow up for 3-6 months and then it is re-assessed. The time of 3-6 months is important for the proliferation, migration & differentiation of secondary odontoblasts before they begin forming reparative dentin. Studies have reported that there is little evidence of formation of reparative dentin before 30 days of application of pulp capping agents. Initially the rate of formation is highest during the 27 to 48 days interval (3.5 u/ day), 49-71 days interval (0.74 u/ day) & 72-132 days interval (0.23 u/day).12
Ca(OH)2 possesses an alkaline pH which does low grade
pulpal irritation and results in forming a zone of obliteration in the tissue adjacent to the pulp capped dentin.13 The subjacent area results in a zone of coagulative necrosis which reorganizes and resumes normal architecture within thirty days.14 It is also reported that it solubilizes certain bioactive molecules like BMP and TGF which are released from dentin and plays significant role in restoration of the pulp.15,16
In this study MTA, was compared with the existing conventional Ca(OH)2 . MTA permits the formation of the
dentin bridge while maintaining the pulp vitality. It is a biocompatible material and induces matrix formation and mineralization by odontoblasts and other hard tissue forming cells.17 It also interacts with phosphate containing fluids to create apatite crystals which trigger the dentinogenic activity of MTA. In addition its physical properties are also superior to Ca(OH)2 in terms of lower degree of dissolution, thus providing a better seal and structural integrity.18
The findings of Group A in this study demonstrated mean values of 0.13±0.01mm dentin bridge thickness at the end of three-month period. Similar results were seen in studies by Aeinehchi et al.19 where a thickness of 0.02 mm and Benoist et al.8 where a 0.13mm thickness was recorded. The MTA group B showed results of 0.11±0.01 mm thickness at three months which was lesser than the dentin thickness
of Group A. The findings are like the findings of Benoist et al.8 but differ from the study of Aeinehchi et al.19 The difference in the findings could be due to a difference in the methodology and a different radiographic software being used without a radiographic grid.
Six-month results of Group A 0.21±0.02 mm was again comparable with the findings of Aeinehchi et al.19 results of 0.15mm and Benoist et al. 0.221mm. George et al.20 saw a difference from the results of study with 0.097mm dentin thickness at three months in the MTA group. This can be explained by difference in permeability in dentinal tubules of primary and permanent teeth. The density & the diameter of the dentinal tubules in deciduous molars are found to be less than the permanent teeth. Six-month results of MTA group B showed a thickness of 0.23±0.02 mm. This was confirmed by findings from Benoist et al.8 while Aeinehchi et al.19 showed differing values of 0.43mm in their studies, which could be because of reasons stated above. Difference in dentin bridge deposition can be explained by differences in release concentration of growth factors by MTA and Ca(OH)2 . Histological studies show more inflammatory cells and greater zones of necrosis formed when Ca(OH)2 was used when compared with MTA.21,22
In this study, it was perceived that the formation of the dentin bridge at six months was greater in Group B when compared to Group A. The findings support the fact that MTA can store Calcium Hydroxide ions over a longer period and releases them slowly over time.23
Studies have been done which evaluated outcomes with percentages with success of 97.96% in favor of MTA24 but the results of this study have been provided in quantitative data which is more accurate and gave exact values of mean dentin thickness. MTA has produced greater thickness of dentin bridge at both 3 months and 6 months, despite its disadvantages it has proven to be a superior material over Ca(OH)2 . The findings are in accordance with long term clinical trials that have been conducted over a period of 9-10 years and provided 92-97 % success rate of MTA.25
The current study was single centered study and lacked controls which if included could have given even more reliable data and result evaluation. The current study was based on radiographic evaluation using conventional 3D periapical radiographs, better results could have been observed using 3D radiographic methods. Furthermore, the evaluation
should be extended over a longer period to further confirm the results. The histological observations can give further evidence of outcome which should be conducted to accurately observe the thickness and quality of dentin bridge formed. Further studies and clinical trials are required to find a better cost effective material to promote dentin formation and improve clinical outcome while preserving the tooth.

CONCLUSION
Greater thickness of the dentin was noted in the MTA group as compared to the Ca(OH)2 group. MTA exhibited a superior performance as indirect pulp capping material when compared to Ca(OH)2.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of
healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial.
Int Endod J. 2008; 41:128- 50.
https://doi.org/10.1111/j.1365-2591.2009.01558.x

2. Sahin N, Saygili S, Akcay M. Clinical, radiographic, and histological evaluation of three different pulp-capping materials in indirect pulp
treatment of primary teeth: a randomized clinical trial. Clin Oral Investig. 2021:3945-955.
https://doi.org/10.1007/s00784-020-03724-4

3. Kunert M, Lukomska-Szymanska M. Bio-Inductive Materials in Direct and Indirect Pulp Capping-A Review Article.
Materials (Basel). 2020;13:1204.
https://doi.org/10.3390/ma13051204

4. Baroudi K, Samir S. Sealing Ability of MTA Used in Perforation Repair of Permanent Teeth; Literature Review.
Open Dent J. 2016;10:278-86.
https://doi.org/10.2174/1874210601610010278

5. Arandi NZ. Calcium hydroxide liners: a literature review. Clin, Cosm Investig Dent. 2017; 9:67.
https://doi.org/10.2147/CCIDE.S141381

6. Kim JR, Nosrat A, Fouad AF. Interfacial characteristics of Biodentin and MTA with dentin in simulated body fluid.
J Dent. 2015 1;43: 241-7.
https://doi.org/10.1016/j.jdent.2014.11.004

7. Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: maintaining pulp vitality. Cochrane
Database of Systematic Reviews 2007(2).
https://doi.org/10.1002/14651858.CD004484.pub2

8. Benoist FL, Ndiaye FG, Kane AW, Benoist HM, Farge P. Evaluation of mineral trioxide aggregate (MTA) versus calcium hydroxide cement
(Dycal®) in the formation of a dentin bridge: a randomised controlled trial. Int Dent J. 2012.1;62:33-9.
https://doi.org/10.1111/j.1875-595X.2011.00084.x

9. Zhu C, Ju B, Ni R. Clinical outcome of direct pulp capping with MTA or calcium hydroxide: a systematic review and meta-analysis.
Int J Clin Exp Med. 2015;8:17055.

10. Sharma V, Nawal RR, Augustine J, Urs AB, Talwar S. Evaluation of Endosequence Root Repair Material and Endocem MTA as direct
pulp capping agents: An in vivo study. Aus Endod J 2021.
https://doi.org/10.1111/aej.12542

11. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometri. 1977:159-74
https://doi.org/10.2307/2529310

12. Stanley HR, White CL, McCray L. The rate of tertiary (reparative) dentin formation in the human tooth. Oral Surg, Oral Med, Oral Pathol.
1966 1;21:180-9.
https://doi.org/10.1016/0030-4220(66)90240-4

13. Reddy S, Prakash V, Subbiya A, Mitthra S. 100 years of Calcium Hydroxide in Dentistry: A review of literature. Indian J Foren Medi
Toxicol. 2020;14:1203.
https://doi.org/10.37506/ijfmt.v14i4.11692

14. Cooper PR, Duncan HF, Widbiller M, Galler KM. Treatment of Immature Teeth with Pulp Necrosis. Endod Mat in Clin Prac.
2021;14:47-79.
https://doi.org/10.1002/9781119513568.ch3

15. Duncan HF, Kobayashi Y, Shimizu E. Growth factors and cell homing in dental tissue regeneration.
Current Oral Health Rep. 2018;5:276-85.
https://doi.org/10.1007/s40496-018-0194-y

16. Youssef AR, Emara R, Taher MM, Al-Allaf FA, Almalki M, Almasri MA, Siddiqui SS. Effects of mineral trioxide aggregate, calcium hydroxide, biodentin and Emdogain on osteogenesis, Odontogenesis, angiogenesis and cell viability of dental pulp stem cells. BMC Oral Health. 2019;19:133.
https://doi.org/10.1186/s12903-019-0827-0

17. Hosoya N, Takigawa T, Horie T, Maeda H, Yamamoto Y, Momoi Y, Yamamoto K, Okiji T. A review of the literature on the efficacy of
mineral trioxide aggregate in conservative dentistry. Dent Mat J. 2019 27;38:693-700.
https://doi.org/10.4012/dmj.2018-193

18. Okiji T, Yoshiba K. Reparative dentinogenesis induced by mineral trioxide aggregate: a review from the biological and physicochemical
points of view. Int J Dent; 2009:1-12.
https://doi.org/10.1155/2009/464280

19. Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in
human teeth: a preliminary report. Int Endod J. 2003 1;36:225-31.
https://doi.org/10.1046/j.1365-2591.2003.00652.x

20. George V, Janardhanan SK, Varma B, Kumaran P, Xavier AM. Clinical and radiographic evaluation of indirect pulp treatment with
MTA and calcium hydroxide in primary teeth (in-vivo study). J Indian Soc Pedodo Prevent Dent. 2015;33:104.
https://doi.org/10.4103/0970-4388.155118

21. Yaemkleebbua K, Osathanon T, Nowwarote N, Limjeerajarus CN, Sukarawan W. Analysis of hard tissue regeneration and Wnt signalling
in dental pulp tissues after direct pulp capping with different materials. Int Endod J. 2019;52:1605-16.
https://doi.org/10.1111/iej.13162

22. Vural UK, Kiremitci A, Gokalp S. Randomized clinical trial to evaluate MTA indirect pulp capping in deep caries lesions after 24-
months. Operative dentistry. 2017;42:470-7.
https://doi.org/10.2341/16-110-C

23. Song W, Li S, Tang Q, Chen L, Yuan Z. In vitro biocompatibility and bioactivity of calcium silicate-based bioceramics in endodontics.
Int J Mol Med. 2021;48:1-22.
https://doi.org/10.3892/ijmm.2021.4961

24. Rasaratnam L. Review suggests direct pulp capping with MTA more effective than calcium hydroxide.
Evid-Based Dent. 2016;17: 94-5.
https://doi.org/10.1038/sj.ebd.6401194

25. Daniele L. Mineral Trioxide Aggregate (MTA) direct pulp capping: 10 years clinical results. G. Ital. Endod. 2017;31:48-57.
https://doi.org/10.1016/j.gien.2017.04.003

Efficacy of Calcium Hydroxide and Mineral Trioxide Aggregate in the Formation of Dentin Bridge – A Randomized Controlled Trial

Rafia Ruaaz1                                   BDS, FCPS
Muhammad Bilal Bashir2              BDS, MDS
Madiha Anwar3                              BDS, MDS
Saqib Rashid4                               BDS, FCPS, MSc
Sadaf Ali5                                      BDS, FCPS
Azam Muhammad Aliuddin6       BDS, FCPS

OBJECTIVE: This study is to compare the dentin bridge thickness achieved using calcium hydroxide and MTA using
radiographs.
METHODOLOGY: Single blinded randomized controlled trial conducted in the Operative Dentistry department at Fatima
Jinnah Dental College and Hospital, Karachi. A total of 100 premolar and molar teeth with class I and II cavities were included
in this study. The study participants were assigned into two groups, A and B of 50 participants each. Under local anesthesia,
Group A was indirectly pulp capped with Calcium hydroxide (Dycal) and Group B received Mineral Trioxide Aggregate as
an indirect pulp capping material. Both groups were then restored with Glass Ionomer Cement. Radiographic follow up was
carried out at three and six months to determine mean dentin thickness of reparative dentin bridge.
RESULTS: Statistical analysis was performed using SPSS v 23. Independent Sample t-test was applied to evaluate the formation
of dentin bridge formation using Ca(OH)2 and MTA at 3 months & 6 months, the outcomes were highly significant
(p-value<0.001). Paired sample t-test was applied to evaluate the difference in dentin bridge formation at three months and 6
months, the results were highly significant (p-value <0.001).
CONCLUSION: Statistically significant difference was observed in the dentin thickness of reparative dentin bridge amongst
the two groups after three months and six months. A greater success rate was noted in the MTA group as compared to the
Ca(OH)2 group after 6 months.
KEYWORDS: Dentin bridge, Endodontic treatment, Indirect pulp capping, Reparative dentin, randomized controlled trial.
HOW TO CITE: Ruaaz R, Bashir MB, Anwar M, Rashid S, Ali S, Aliuddin AM. Efficacy of calcium hydroxide and mineral
trioxide aggregate in the formation of dentin bridge - A randomized controlled trial. J Pak Dent Assoc 2022;31(3):114-119.
DOI: https://doi.org/10.25301/JPDA.313.114
Received: 05 March 2022, Accepted: 14 August 2022


Download PDF

Determination of the Frequency of Various Anatomical Forms of the Hard Palate for Complete Denture Fabrication

 

Muhammad Waqas 1              BDS, FCPS
Nazia Yazdanie2                      BDS, FCPS, MSc, PhD
Khuda-e-Dad3                         BDS, FCPS
Hina Aslam4                            BDS
Ayesha Bashir5                       BDS, FCPS
Mohid Rehman6                      BDS, FCPS

 

OBJECTIVE: To determine the frequency of patients with various anatomical forms of the hard palate for complete denture
fabrication and to compare the mean distortion in heat cure denture base polymer in millimetres in different hard palate forms.
METHODOLOGY: Informed consent was taken from total of seventy six patients and divided into low and medium hard palate
forms. Dental casts were prepared from alginate impression and poured in type III stone and reference point R was marked on
the deepest part of the posterior palatal seal area at the junction of hard and soft palate on each cast. After curing, the cast along
with the cured denture base was retrieved from the flask. After 48h of curing cycle the distortion was measured in millimetres
from R to R' via traveling microscope.
RESULTS: Among seventy six participants the frequency of low palate forms was 45 (59.2%) and medium palate forms was
31 (40.8%). For each sample three readings were taken R1, R2 and R3. The mean distortion measured in low hard palate form
was 0.52mm with a standard deviation of 0.18, the mean distortion measured in medium hard palate form was 0.76mm with a
standard deviation of 0.27, which were clinically significant with a p-value of 0.0001.
CONCLUSION: The hard palate forms has direct influence on retention of maxillary complete denture in posterior palatal area.
KEY WORDS: Heat Cure denture base, distortion in hard palate forms, dimensional changes in heat cure, hard palate anatomy
and denture bases
HOW TO CITE: Waqas M, Yazdanie N, Dad KE, Aslam H, Bashir A, Rehman M. Determination of the Frequency of Various
Anatomical Forms of the Hard Palate for Complete Denture Fabrication. J Pak Dent Assoc 2022;31(3):110-113.
DOI: https://doi.org/10.25301/JPDA.313.110
Received: 07 March 2021, Accepted: 05 April 2022

INTRODUCTION
The retention in maxillary denture base depends upon its intimate contact with the supporting tissues and other forces of adhesion, cohesion and negative atmospheric pressure.1,2 The most critical area to achieve this intimate contact is posterior palatal area as this is the
most common area of discrepancy/distortion leading to clinical loss of retention in maxillary denture bases. The discrepancy at the posterior palatal seal depends upon various variables i.e recording techniques , processing changes due to polymerization , stress and strain induced by heat after processing and variation in anatomy of the hard and soft palate.3,4
It has been emphasized that the hard palate configuration has direct influence on the adaptation of denture bases especially after processing.5 Hard palate has three forms according to depth/height, which can be assessed quantitatively and qualitatively. The frequency of qualitative analysis of LOW and MEDIUM hard palate forms are 39.2% and 55.4% respectively.6 These forms when flasked for denture processing have different depths from the base of the flask. This variation can change the amount and rate of transfer of heat and thus induce dimensional changes/distortion in acrylic especially in short heat curing cycle.7,8
According to Glazier et al. the polymerization shrinkage at the posterior peripheral seal area was statistically significant with a p-valve 0.001 but there was a difference in results like in ridge height of 11mm there was a distortion of 0.43mm and in the ridge height of 12.75mm there was a distortion of 0.41mm which should be greater, also the thickness of the heat cure polymer was not constant for every ridge height. This could be a confounding factor. Maria et al. observed that there has been no study conducted faced hard palate forms of low, medium and high hard palate in which distortion could be assessed.6

METHODOLOGY
After obtaining the ethical approval from institutional review board (FMH-12-2020-IRB-842-M). Informed consent was taken from total of 76 patients visiting the dental outpatient department of Fatima Memorial Hospital Lahore, Pakistan for the fabrication of complete dentures. They were divided into two groups based on their anatomical hard palate forms into group (L) low and group (M) medium. Patients based on both genders with age range of 30 to 80years had been included who visited the dental OPD for complete denture fabrication and edentulous from 5 to 10years. Patients with any ulceration and soft tissue and hard tissue pathology were excluded from the study Dental casts were prepared with properly extended stock tray and muco–static impression technique from alginate impression material. Impressions were poured in type III stone (with recommended water to powder ratio) and reference point R was marked on the deepest part of the posterior palatal seal area at the junction of hard and soft palate on the each impression and cast, as it is the area where distortion in heat cure denture base polymer occurs more prominently that influence the retention of the maxillary complete denture.
(Fig-1, 2)

The wax pattern for all the denture bases was standardized to a uniform thickness of 3mm (figure-3) on the hard palatal area and thinned out towards the alveolar ridge area and posterior palatal seal area to 1.5mm thickness because the thickness of the base plate in posterior palatal area effects the adhesion and cohesion forces of saliva and influence the retention of the maxillary complete denture. As the thickness of the base plate in posterior palatal seal area is decreased the less saliva is needed to achieve the retention by adhesive and cohesive forces. The graduated periodontal probe was used to measure the thickness of the wax pattern (figure-4).

After flasking (using type II stone with recommendedwater to powder ratio), de-waxing and application of two layers of cold mould seal (separating media) (figure-5), the flask was packed with heat-cure acrylic resin using compression moulding technique. For polymerization the flasks were placed in the electric curing tank at 74 degrees

for 3Hours. After curing, the cast along with the cured denture base was retrieved from the flask. After 48h of curing cycle, the distortion was measured in millimetres from R to R’ (figure-6) via traveling microscope. Three readings of each sample were recorded and their mean calculated.

RESULTS
   Descriptive analysis for age, gender and distortion in heat cured denture base polymer at posterior palatal seal area of low and medium hard palate forms was made. The analysed date for age, gender and the mean difference in distortion between low and medium hard palate forms is represented in frequency and percentage. Independent sample t-test applied with value p<0.05 taken as statistically significant.
A total of 76 subjects participated in this study of which 37 (48.7%) were females and 39 (51.3%) were males (TABLE-1).The age range of 76 participants was 30 to 80 years. Among 76 participants the frequency of low palate forms was 45 (59.2%) and medium palate forms was 31 (40.8%) (TABLE-2). The participants were divided into low and medium hard palate forms. For each sample three readings were taken reading 1 (R1), reading 2 (R2) and reading 3 (R3) and the mean reading was taken as final reading for both medium and low palatal forms. The mean distortion measured in low hard palate form was 0.52mm with a standard deviation of 0.18mm and the mean distortion measured in medium hard palate form was 0.76mm with a standard deviation of 0.27mm.
The different was clinically significant, with a p-value 0.0001. (TABLE-3).

DISCUSSION
The morphology of hard palate forms has been previously assessed in growing children with different variables like nasal and mouth breathers9 , perennial allergic rhinitis10 and influence of respiratory disturbances in growth and development of orofacial complex11 and various classifications has been mentioned in the literature.12,13,14 Maria et al. evaluated the depth of the hard palate and proposed the classification from which low and medium hard palate forms were derived and included in this study.15
Researchers have observed variables like temperature.16,17 Komiyama and kawara found out that the stress induced by contraction due to polymerization shrinkage is relieved gradually over a period of time when the base is removed from the cast.18,19 Anusavice demonstrated the shrinkage from density change as the methyl methacrylate is polymerized from 0.945 to 1.19 g/cm3
of 21%.20 Hardy et al. rationalized in his study that posterior palatal area is critical to achieve the desired retention in maxillary complete
dentures and that scoring of the cast may play a role in countering the dimensional changes in posterior palatal area.1 Woelfel et al. was the first to assess the dimensional changes in linear dimension across the posterior part of the denture and stating it is the area where greater dimensional changes in heat cure denture base polymer occurs21, Glazier et al. compared the polymerization shrinkage in heat cure denture base by incremental increase in the height of hard palate which was significant with p-value of 0.0001 to assess the cross-sectional dimensional changes in hard palate.5
In the current study the conventional method was used for denture fabrication to assess the polymerization shrinkage at posterior palatal area in the anatomically classified hard plate forms frequently faced by the clinician. The number of patients with low hard palate forms were 45 and medium hard palate forms were 31. The polymerization shrinkage for low hard palate form was 0.52mm with a p-value of 0.001 and medium hard palate form was 0.76mm with a p-value of 0.001. Hence the depth of the palatal vault should be considered in maxillary complete denture fabrication as it influences the distortion in heat cure denture base polymer and in turn retention of the posterior palatal seal.
It is further hypothesized that high palate forms would represent the increase in amount of shrinkage at posterior palatal area since they are generally less common were not included in the study

CONCLUSION
   This mean distortion in the medium depth hard plate denture bases are significantly higher than the denture bases fabricated in low depth palate patients.

LIMITATIONS
    Both short and long curing cycle of polymerization can be compared along with various types of denture base materials. High depth palate patients were not included.

FUTURE WORK
Study of distortion at posterior palatal area of high palate forms and comparison of denture base soaked in water and without water after polymerization can further help in measuring the dimensional changes of heat cured denture based materials in local practice.

CONFLICT OF INTEREST
None declared

REFERENCES

1. Hardy IR, Kapur KK. Posterior palatal seal-its rationale and importance. J Prosthetic Dent 1958;8:386-94
https://doi.org/10.1016/0022-3913(58)90064-7

2. Craig RG, Berry GC, and Peyton FA. Physical factors related to denture retention. J Prosthetic Dent 1960;10:459
https://doi.org/10.1016/0022-3913(60)90009-3

3. Goyal et al. The posterior palatal seal: Its rationale and importance: An overview. Our J Prosthodont 2014;2:41-7
https://doi.org/10.4103/2347-4610.131972

4. Wolfaardt J. The influence of processing variables on dimensional changes of heat cured poly methyl methacrylate .J prosthetic Dent
1986;55:518-25
https://doi.org/10.1016/0022-3913(86)90191-5

5. Glazier S et al. Posterior Peripheral seal distortion related to the height of maxillary ridge. J Prosthetic Dent 1980;43:508-10
https://doi.org/10.1016/0022-3913(80)90321-2

6. Maria CM et al. Evaluation of hard palate depth: Correlation between quantitative and qualitative method.
Rev.CEFAC.2013 set-out; 15:1292-99
https://doi.org/10.1590/S1516-18462013005000029

7. Firtell DN. Posterior peripheral seal distortion related to processing temperatures. J Prosthetic Dent 1981;5:598-61
https://doi.org/10.1016/0022-3913(81)90418-2

8. Pasam et al. Effect of different temperature on posterior palatal seal distortion. Ind J Dent Res 2012; 23:301-4
https://doi.org/10.4103/0970-9290.102209

9. Berwig, L.C., Silva, A.M., Côrrea, E.C., Moraes, A.B., Montenegro, M.M. and Ritzel, R.A.Hard palate dimensions in nasal and mouth
breathers from different etiologies. Jornal da Sociedade Brasileira de Fonoaudiologia, 2011:23:308-314.
https://doi.org/10.1590/S2179-64912011000400004

10. Ghasempour M, Mohammadzadeh I, Garakani S. Palatal arch diameters of patients with allergic rhinitis. Iran J Allergy Asthma
Immunol. 2009;8:63-4

11. Drevensek M, Papic JS. The influence of the respiration disturbances on the growth and development of the orofacial complex. Coll Antropol.
2005;29:221-5

12. Marchesan IQ, Krakauer LR. The importance of respiratory activity in myofunctional therapy. Int J Orofacial Myology. 1996;22:23-7.
https://doi.org/10.52010/ijom.1996.22.1.4

13. Bianchini AP, Guedes ZC, Vieira MM. A study on the relationship between mouth breathing and facial morphological pattern. Braz J
Otorhinolaryngol. 2007;73:500-5
https://doi.org/10.1016/S1808-8694(15)30101-4

14. Cattoni DM, Fernandes FD, Di Francesco RC, Latorre MR. Characteristics of the stomatognathic system of mouth breathing
children: anthroposcopic approach. Pró-Fono. 2007;19:347-51
https://doi.org/10.1590/S0104-56872007000400004

15. Maria CM et al. Evaluation of hard palate depth: Correlation between quantitative and qualitative method. Rev. CEFAC.2013 setout; 15:1292-99
https://doi.org/10.1590/S1516-18462013005000029

16. Phillips, R. W.: Skinner’s Science of Dental Materials, ed 7. Philadelphia, V. B. Saunders Co. 1973:157-204.

17. Osborne, J.: Internal strain in acrylic denture base material. Br Dent J 1947; 82:204.

18. Kawara M, Komiyama O, Kimoto S, Kobayashi N, Kobayashi K, Nemoto K. Distortion behavior of heatactivated acrylic denture-base
resin in conventional and long, low-temperature processing methods. J Dent Res.1998;77:1446-53.
https://doi.org/10.1177/00220345980770060901

19. Komiyama O, Kawara M. Stress relaxation of heat-activated acrylic denture base resin in the mold after processing.
J Prosthet Dent 1998; 79:175-81.
https://doi.org/10.1016/S0022-3913(98)70213-6

20. Anusavice KJ. Phillip’s sciences of dental materials. 12th ed. St. Louis: Saunders; 2004: 721-57.

21. Woelfel, ,J. B. et al. Dimensional changes occurring in dentures during processing. J Am Dental Assoc 1960; 61:15-32.
https://doi.org/10.14219/jada.archive.1960.0205

Determination of the Frequency of Various Anatomical Forms of the Hard Palate for Complete Denture Fabrication

Muhammad Waqas 1              BDS, FCPS
Nazia Yazdanie2                      BDS, FCPS, MSc, PhD
Khuda-e-Dad3                         BDS, FCPS
Hina Aslam4                            BDS
Ayesha Bashir5                       BDS, FCPS
Mohid Rehman6                      BDS, FCPS

OBJECTIVE: To determine the frequency of patients with various anatomical forms of the hard palate for complete denture
fabrication and to compare the mean distortion in heat cure denture base polymer in millimetres in different hard palate forms.
METHODOLOGY: Informed consent was taken from total of seventy six patients and divided into low and medium hard palate
forms. Dental casts were prepared from alginate impression and poured in type III stone and reference point R was marked on
the deepest part of the posterior palatal seal area at the junction of hard and soft palate on each cast. After curing, the cast along
with the cured denture base was retrieved from the flask. After 48h of curing cycle the distortion was measured in millimetres
from R to R' via traveling microscope.
RESULTS: Among seventy six participants the frequency of low palate forms was 45 (59.2%) and medium palate forms was
31 (40.8%). For each sample three readings were taken R1, R2 and R3. The mean distortion measured in low hard palate form
was 0.52mm with a standard deviation of 0.18, the mean distortion measured in medium hard palate form was 0.76mm with a
standard deviation of 0.27, which were clinically significant with a p-value of 0.0001.
CONCLUSION: The hard palate forms has direct influence on retention of maxillary complete denture in posterior palatal area.
KEY WORDS: Heat Cure denture base, distortion in hard palate forms, dimensional changes in heat cure, hard palate anatomy
and denture bases
HOW TO CITE: Waqas M, Yazdanie N, Dad KE, Aslam H, Bashir A, Rehman M. Determination of the Frequency of Various
Anatomical Forms of the Hard Palate for Complete Denture Fabrication. J Pak Dent Assoc 2022;31(3):110-113.
DOI: https://doi.org/10.25301/JPDA.313.110
Received: 07 March 2021, Accepted: 05 April 2022

Download PDF