Vol. 31 No. 04 Oct-Dec 2022

Sara Qureshi.                                      BDS
Muhammad Waseem Ullah Khan.     BDS, FCPS
Momina Akram                                    BDS, FCPS
Zarish Anjum.                                     BDS
Hafiz Muhammad Aamir Riaz            BDS

Missing teeth in the anterior region can be a source of great aesthetic concern for the patient and its restoration presents an even greater challenge to the dentist. Invasive prosthodontic treatment modalities have many biological and biomechanical shortcomings. This clinical report presents a minimally invasive treatment option for a 17-year-old boy who wanted a replacement for his missing upper left central incisor, primarily due to aesthetic concerns. Missing tooth was restored with cantilevered zirconia resin bonded fixed dental prosthesis that has a durable functional and aesthetic outcome.
HOW TO CITE: Qureshi S, Khan MWU, Akram M, Anjum Z, Riaz HMA. Restoration of missing central incisor with cantilevered zirconia resin bonded fixed dental prosthesis. J Pak Dent Assoc 2022;31(4):194-197.
DOI: https://doi.org/10.25301/JPDA.314.194
Received: 18 March 2022, Accepted: 27 July 2022

Sara Qureshi.                                           BDS
Muhammad Waseem Ullah Khan.          BDS, FCPS
Momina Akram                                        BDS, FCPS
Zarish Anjum                                           BDS
Hafiz Muhammad Aamir Riaz                 BDS

OBJECTIVE: To determine the frequency of parafunctional oral habits and their association with types of malocclusions in all three planes among the adolescents.
METHODOLOGY: This cross-sectional study involved 610 students studying in 8 different schools of Raiwind, Lahore. Ethical approval for the study was obtained from Sharif Medical and Dental College, Lahore. Data was collected by the primary researcher and recorded in predesigned proforma. Each student was inspected while seated in an upright position in natural day light, using disposable wooden blades to retract the cheek to record posterior dental relationships and to retract lips to record anterior dental relationships. Data was scrutinized using SPSS and chi-square test was used to find the statistical significance of the association between various parafunctional oral habits and types of malocclusions.
RESULTS: The frequency of parafunctional oral habits was 57.3% among 610 adolescent students, being more prevalent in females (72.9%) than males (52.3%). The most common oral parafunctional habit was bruxism (18.0%) and least frequent was thumb sucking (8.4%). Association between oral parafunctional habits and malocclusion in all three planes was found to be significant (p=0.0).
CONCLUSION: The parafunctional oral habits such as bruxism, tongue thrusting, nail biting, mouth breathing and thumb sucking are very commonly found among adolescents in the same descending order. Most common malocclusions found to be associated with parafunctional oral habits are exaggerated over-jet, open bite and deep bite. Parafunctional oral habits have a strong influence on developing malocclusion traits in all three dimensions.
KEYWORDS: Parafunctional oral habits, malocclusion, thumb sucking, tongue thrusting, mouth breathing, bruxism, nail biting.
HOW TO CITE: Malik F, Haq H, Mehmood R, Haroon K, Hussain M, Khan F. Parafunctional oral habits: Frequency and association with malocclusion traits in adolescents. J Pak Dent Assoc 2022;31(4):188-193.
DOI: https://doi.org/10.25301/JPDA.314.188
Received: 28 March 2022, Accepted: 15 December 2022

Aushna Khushbakht Rana        BDS, FCPS, CHPE
Hooria Haq.                                 BDS
Rashid Mehmood                       BDS
Kashif Haroon                            BDS, M Orth RCS Ed
Mazhar Hussain                         BDS
Fiza Khan                                    BDS

OBJECTIVE: To determine the frequency of parafunctional oral habits and their association with types of malocclusions in all three planes among the adolescents.
METHODOLOGY: This cross-sectional study involved 610 students studying in 8 different schools of Raiwind, Lahore. Ethical approval for the study was obtained from Sharif Medical and Dental College, Lahore. Data was collected by the primary researcher and recorded in predesigned proforma. Each student was inspected while seated in an upright position in natural day light, using disposable wooden blades to retract the cheek to record posterior dental relationships and to retract lips to record anterior dental relationships. Data was scrutinized using SPSS and chi-square test was used to find the statistical significance of the association between various parafunctional oral habits and types of malocclusions.
RESULTS: The frequency of parafunctional oral habits was 57.3% among 610 adolescent students, being more prevalent in females (72.9%) than males (52.3%). The most common oral parafunctional habit was bruxism (18.0%) and least frequent was thumb sucking (8.4%). Association between oral parafunctional habits and malocclusion in all three planes was found to be significant (p=0.0).
CONCLUSION: The parafunctional oral habits such as bruxism, tongue thrusting, nail biting, mouth breathing and thumb sucking are very commonly found among adolescents in the same descending order. Most common malocclusions found to be associated with parafunctional oral habits are exaggerated over-jet, open bite and deep bite. Parafunctional oral habits have a strong influence on developing malocclusion traits in all three dimensions.
KEYWORDS: Parafunctional oral habits, malocclusion, thumb sucking, tongue thrusting, mouth breathing, bruxism, nail biting.
HOW TO CITE: Malik F, Haq H, Mehmood R, Haroon K, Hussain M, Khan F. Parafunctional oral habits: Frequency and association with malocclusion traits in adolescents. J Pak Dent Assoc 2022;31(4):188-193.
DOI: https://doi.org/10.25301/JPDA.314.188
Received: 28 March 2022, Accepted: 15 December 2022

Introduction

Faiza Malik                                   BDS, FCPS, CHPE
Hooria Haq.                                 BDS
Rashid Mehmood                       BDS
Kashif Haroon                            BDS, M Orth RCS Ed
Mazhar Hussain                         BDS
Fiza Khan                                    BDS

OBJECTIVE: To determine the frequency of parafunctional oral habits and their association with types of malocclusions in all three planes among the adolescents.
METHODOLOGY: This cross-sectional study involved 610 students studying in 8 different schools of Raiwind, Lahore. Ethical approval for the study was obtained from Sharif Medical and Dental College, Lahore. Data was collected by the primary researcher and recorded in predesigned proforma. Each student was inspected while seated in an upright position in natural day light, using disposable wooden blades to retract the cheek to record posterior dental relationships and to retract lips to record anterior dental relationships. Data was scrutinized using SPSS and chi-square test was used to find the statistical significance of the association between various parafunctional oral habits and types of malocclusions.
RESULTS: The frequency of parafunctional oral habits was 57.3% among 610 adolescent students, being more prevalent in females (72.9%) than males (52.3%). The most common oral parafunctional habit was bruxism (18.0%) and least frequent was thumb sucking (8.4%). Association between oral parafunctional habits and malocclusion in all three planes was found to be significant (p=0.0).
CONCLUSION: The parafunctional oral habits such as bruxism, tongue thrusting, nail biting, mouth breathing and thumb sucking are very commonly found among adolescents in the same descending order. Most common malocclusions found to be associated with parafunctional oral habits are exaggerated over-jet, open bite and deep bite. Parafunctional oral habits have a strong influence on developing malocclusion traits in all three dimensions.
KEYWORDS: Parafunctional oral habits, malocclusion, thumb sucking, tongue thrusting, mouth breathing, bruxism, nail biting.
HOW TO CITE: Malik F, Haq H, Mehmood R, Haroon K, Hussain M, Khan F. Parafunctional oral habits: Frequency and association with malocclusion traits in adolescents. J Pak Dent Assoc 2022;31(4):188-193.
DOI: https://doi.org/10.25301/JPDA.314.188
Received: 28 March 2022, Accepted: 15 December 2022

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Aushna Khushbakht Rana        BDS
Samira Adnan                             BDS, FCPS
Syed Yawar Ali Abidi                  BDS, FCPS

OBJECTIVE: To gain an insight into cross infection protocols being followed by dental postgraduate residents in the prevention of the spread of coronavirus.
METHODOLOGY: A cross-sectional survey-based study was conducted using questionnaires, which were distributed among dental postgraduate residents working in different public and private institutes in Karachi, through social media. Data was analysed using SPSS, version 21.0 with p-value <0.05 to determine significant differences between both sectors.

RESULTS: Ninety seven residents from both institutes responded. 60 (93.75%) and 29 (87.87%) residents from the public and private institutes respectively, reported to having the patient's temperature checked with an infrared thermometer. However, a lower compliance was noted in regard to the use of hand sanitization with a hydro alcoholic solution by both institutes with 28 (43.75%) from public and 24 (72.72%) from private institutes. 11 (17.18%) residents from public institutes responding with disposal of PPE after every patient, whereas 1 (3.03%) resident from a private institute responded with disposal after every patient. However, due to a smaller sample size, the differences were not statistically significant.

CONCLUSION: The pandemic has exposed numerous shortcomings in the dental healthcare system, regardless of the sector. Since COVID-19 is likely to become an endemic, compliance with cross infection protocols needs to be improved so as to prevent its rapid spread. In a third world country like Pakistan, where resources are already scarce, greater emphasis needs to be placed on funding the dental healthcare system to enhance basic cross infection controls.

HOW TO CITE: Rana AK, Adnan S, Abidi SYA. Infection control practices followed by postgraduate residents of public and private dental institutions of Karachi during the COVID-19 pandemic. J Pak Dent Assoc 2022;31(4):182-187.
DOI: https://doi.org/10.25301/JPDA.314.182
Received: 04 January 2022, Accepted: 13 September 2022

INTRODUCTION

Coronavirus 2019 (COVID-19), originally discovered in Wuhan, China, has rapidly spread globally, resulting in the 2019-2020 pandemic, as declared by the World Health Organization (WHO) and the Public Health Emergency of International Concern (PHEIC).1 It has wreaked havoc, leaving economies, cultures, and societies distraught.2 It began with a few cases of severe pneumonia of unknown etiology detected by local hospitals using a surveillance system developed in 2003 after the severe acute respiratory syndrome (SARS) outbreak.3 All cases were being linked to the Huanan seafood market.4.

The primary route of transmission seems to be through human to human interaction between COVID-19 affected individuals via airborne droplets.5 The virus also has been known to possess the ability to persist outside a living host, in the form of aerosol or on fomites, hence the main mode of contagion seems to be through inhalation of aerosol droplets.6.

The extensive spread of the disease before detection may be attributed to an extent to its incubation period, estimated to range from two to fourteen days, averaging at about 6 days.7 This incubation period between infection and symptoms allows pathogens to move covertly across borders before being detected.

Due to close contact of dental practitioners and their patients, they are exposed to saliva, blood and other bodily fluids, putting them at a greater risk of coronavirus infection. Dental practitioners are faced with two major concerns. Firstly, the ease of spread of the viral agents due to aerosol droplets generated with the use of ultrasonic instruments. Furthermore, the persistence of aerosol droplets in the air and on operating surfaces placing the practitioner at risk after removal of all PPE and exposure to it.9 In addition to the lack of interpersonal distance, dental treatment requires the use of instruments that generate aerosol, increasing the risk of airborne infection in a closed operating room.10 The ongoing pandemic has proven that people can be coronavirus positive and spread the viral agents around without any signs or symptoms of the biological agent.11 As a precautionary measure, the dental team, apart from performing the double triage, should consider each patient as coronavirus positive until proven otherwise and use personal protective equipment in all cases.

With over a million people of the population being infected, it has become prudent to set in place rigid and precise operating protocols capable of classifying dental procedures centered on risk assessment for the dental team, as well as for the patients.13 The Center for Disease Control has published guidelines that should be implemented in dental care settings in the prevention of the spread of the coronavirus.14 The aim of the study was born from the awareness that a necessary change in the decision making process is required. It involves highlighting the relevant changes that have taken place in order to build protocols and provide practical advice addressed to dentists, to assess and modulate the risks of contagion in the dental practice.

METHODOLOGY

After taking approval from the ethical committee, extensive literature search items were selected for the questionnaire. The pilot study was conducted to ascertain any complexity in the questionnaire and perform changes accordingly.

The framework for the survey form for the present study centered on feedback from postgraduate residents employed in either public or private institutions regarding their concerns about personal protective equipment. In addition, pertinent literature search was made to identify items that could be modified and used in the local context. The process ensured that relevant items were developed for the questionnaire. The final survey included nine sections ranging from patient screening, patient’s entry, appointment scheduling, access modalities for dental staff, personal protective equipment for non-sterile procedures, clinical procedures performed, removal of personal protective equipment and treatment room disinfection.

The first section recorded the primary demographic data of the participants. The second section consisted of items related to preoperative triage to establish the urgency for treatment. The third section contained questions related to precautionary measures being taken on the patient’s entry into the clinical setting. The fourth section assessed the importance regarding social distancing and waiting room organization. The fifth section assessed the access modalities for dental office staff. The sixth section established the importance given to the usage of personal protective equipment for non-sterile procedures. The seventh section addressed disinfection protocols during clinical procedures performed. The eighth section was focused on determining the training regarding adequate disposal of personal protective equipment. The ninth section dealt with protocols regarding treatment room disinfection after every patient.

DATA COLLECTION

An equal number of public and private institutes were selected and a coordinator chosen from each institute to share the link to the questionnaire via social media. The link to the questionnaire along with the consent form was distributed among dental residents through a social media platform (Whatsapp®) for the sake of convenience and to ensure social distancing. The total population of dental postgraduate trainees in Karachi under CPSP is 203. As there was no specific outcome target, the sample size was calculated based on the assumption that the expected maximum frequency of the outcome factor is 50%. Using version 3.01 of Open Epi software for epidemiological statistics the required sample size for 95% confidence level was be 134 dental postgraduate trainees. However, only 97 residents responded.

Furthermore, the sample was stratified by the type of institute in order to get a more representative sample of the dental postgraduate residents in Karachi.

The instructions to fill the form were mentioned along with the link. The potential respondents were reminded at one week’s interval to maximize the number of responses collected. Confidentiality of the data was ensured and only the primary investigators had access to any identifiers.

DATA ANALYSIS

The data was analysed by using the Statistical Package for the Social Sciences (SPSS) software program, version 21.0 (IBM, Armonk, New York). Mean and standard deviation was be calculated for numerical data while frequencies and percentages were be analysed for the categorical variables. Two groups of participants based on type of institute were be tested with Chi-square test, and statistical significance was be set at p-value <0.05. Data was be entered via private computer with password protection and could be accessed only by the principal investigator.

RESULTS

A total of 97 dental postgraduate residents participated in this study out of which 64 (65.97%) were practicing in public institutes and 33 (34.02%) in private institutes based in Karachi, Pakistan.

Of significance were the items in relation to the patient’s entry into the dental office, where the patient’s temperature was checked via an infrared thermometer and the provision of a hydro alcoholic solution Of the participants, 60 (93.75%) and 29 (87.87%) residents from the public and private Institutes respectively, reported to having the patient’s temperature checked with an infrared thermometer, as shown mean in n Table 1. However, a lower compliance was noted in regard.

A noteworthy concern were the responses regarding the disposal of personal protective equipment with 11 (17.18%) residents from public institutes responding with disposal after every patient, 24 (37.5%) at the end of the day, and 29 (45.31%) responding with no disposal and re use of the equipment. Similarly, 1 (3.03%) resident from a private institute responded with disposal after every patient, 20 (60.06%) at the end of the day, and 12 (36.36%) responding with no disposal and re use of the equipment. The results are depicted in Table 3.

13 (39.39%) from private institutes reporting accurate sanitization on all surfaces of the dental unit, as shown in Figure 4. However, a higher compliance was noted in regard to sanitizing of the floors and other surfaces being carried out at the end of every day by 47 (73.43%) and 33 (100%) residents from the public and private institutes respectively, as shown in Table 4.

In comparison, cross infection protocols being followed by residents from public and private institutes were computed, showing a marginally better compliance in the private institutes. However, due to a smaller sample size, the differences were not statistically significant.

DISCUSSION

COVID-19, a rapidly spreading virus being transmitted by aerosols has made dental professionals re-evaluate their routinely followed infection control protocols. The protocol measures have been augmented and made more stringent to prevent the spread of the infection. In this context, the present study has provided insights into cross infection protocols being followed by dental postgraduate residents in the prevention of the spread of coronavirus from both public and private institutes across Karachi, Pakistan. The aim was to compare compliance with these protocols among residents in both settings.

About 9.37% of the residents from public institutes reported to performing a telephonic triage with the patient compared with 27.27% residents from private institutes. However, a higher compliance was noted by the participants from both institutes, in taking the patient’s history in relation to COVID-19 symptoms, prior contact with a COVID-19 positive patient and recent travel. Telephonic screening of patients before the dental visit is recommended to identify the patients with suspected or possible COVID-19 infection as well as to establish the urgency of treatment required. According to the guidelines provided by the American Dental Association, all elective dental care procedures must be shelved, however, the results of this study do not conform to the guidelines.

Dentists from the private sector are known to uphold a certain standard where cross infection protocols are concerned, however due to the financial impact left by COVID-19, postgraduate residents from private institutes, in addition to those from public institutes, reported that they were not being provided personal protective equipment by their institutes and had to arrange their own.15 Appropriate training regarding its disposal is another vital step in the prevention of spread of such a contagious virus. Residents from both sectors reported to have not received any formal training regarding the disposal of the personal protective equipment. In addition, a majority of residents from both public and private institutes reported that the patient was also not provided with any personal protective equipment. A surgical mask was the only form of personal protective equipment that was provided to majority of the patients in both institutes. A likely implication of the above could be the deficiency in funding received by public institutes. A study done by Hams Abdelrahman reported that 75% dentists worldwide were forced to shut down their practices during the first wave, adding to the financial crisis.16.

The lack of availability of personal protective equipment has remained an issue worldwide and with a constant influx in cases, the healthcare system in Pakistan came under pressure with supplies being stretched forcing doctors and dentists to work with limited to no personal protective equipment with many being required to reuse it.17 This trend was noted by residents from both public and private institutes. Absence of knowledge around adequate training regarding the disposal of personal protective equipment is a vivid reflection of the lack of health education workshops and decreased willingness to attend them as concluded by a study done by Khalid Almas.18 A research conducted in Poland found that about 71.2% of the participating dentists entirely suspended their dental practice due to similar reasons.19

The current study provided an encouraging insight onto hand hygiene practices before and after treating every patient. This step is vital in prevention of the spread of COVID-19. The guidelines provided by the WHO for infection control states that frequent hand washing and disinfection with a hydro alcoholic solution can help evade the spread of respiratory viruses.20

There was low compliance regarding organization of the waiting room to allow for adequate interpersonal distance with majority of the residents from both sectors reporting no changes in the daily limit of appointed patients. The most likely implication could be due to the financial impact already left on the respective businesses during the initial lockdown in the country during which the frequency of patients at dental practices had significantly declined and the costs of the personal protective equipment having been borne entirely by the employer.21

Ventilation systems using HEPA filters are imperative to help prevent the spread of the virus by reducing airborne contaminants. However, a very low proportion of residents reported to employing their use, a likely reason being their high cost and maintenance.22

A study conducted in Pakistan concluded that additional educational measures should be taken on the mechanism of the spread of COVID-19, while also encouraging patients to be more cautious towards the cross-infection control measures being employed.23

LIMITATION

There was no specific outcome target therefore the sample size happened to be quite small. Similarly, the data that was collected was centered on quantitative responses; hence the conceivable reasoning behind the participants responses was not determined.

CONCLUSION

The rapid spread of the corona virus led to the closure of many public and private dental offices, with the remaining practices struggling to keep up with cross infection protocols and procurement of personal protective equipment while maintaining a steady patient flow. The pandemic has exposed numerous shortcomings in the dental healthcare system across both the public and private sectors. The trend observed during the course of the study showed that the public sector was more greatly affected due to the paucity of resources allocated for cross infection controls.

Since COVID-19 is likely to become an endemic, compliance with cross infection protocols needs to be improved so as to prevent its rapid spread. In a third world country like Pakistan, where resources are already scarce, greater emphasis needs to be placed on funding the dental healthcare system to enhance infection control protocols

ACKNOWLEDGEMENT

None

CONFLICT OF INTEREST

None declared

REFERENCES

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6. Farooq I, Ali S. COVID-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers. Postgraduate Med J. 2020;96(1142):791-2. https://doi.org/10.1136/postgradmedj-2020-137781
7. Bak A, Mugglestone MA, Ratnaraja NV, Wilson JA, Rivett L, Stoneham SM, Bostock J, Moses SE, Price JR, Weinbren M, Loveday HP. SARS-CoV-2 routes of transmission and recommendations for preventing acquisition: joint British Infection Association (BIA), Healthcare Infection Society (HIS), Infection Prevention Society (IPS) and Royal College of Pathologists (RCPath) guidance. Journal of Hospital Infection. 2021.
8. Amato A, Caggiano M, Amato M, Moccia G, Capunzo M, De Caro F. Infection control in dental practice during the COVID-19 pandemic. Int J Environ Res Public Health. 2020;17:4769. https://doi.org/10.3390/ijerph17134769
9. Cheng C, Zhang D, Dang D, Geng J, Zhu P, Yuan M, Liang R, Yang H, Jin Y, Xie J, Chen S. The incubation period of COVID-19: a global meta-analysis of 53 studies and a Chinese observation study of 11 545 patients. Infectious diseases of poverty. 2021;10:1-3. https://doi.org/10.1186/s40249-021-00901-9
10. Izzetti R, Nisi M, Gabriele M, Graziani F. COVID-19 transmission in dental practice: brief review of preventive measures in Italy. Journal of dental research. 2020;99:1030-8. https://doi.org/10.1177/0022034520920580
11. Fiorillo L, Cervino G, Matarese M, D’amico C, Surace G, Paduano V, Fiorillo MT, Moschella A, La Bruna A, Romano GL, Laudicella R. COVID-19 surface persistence: a recent data summary and its importance for medical and dental settings. Int J Environ Res Public Health. 2020;17:3132.
12. Al Kawas S, Al-Rawi N, Talaat W, Hamdoon Z, Salman B, Al Bayatti S, Jerjes W, Samsudin AR. Post COVID-19 lockdown: measures and practices for dental institutes. BMC Oral Health. 2020;20:1-7. https://doi.org/10.1186/s12903-020-01281-6
13. Rivett L, Sridhar S, Sparkes D, Routledge M, Jones NK, Forrest S, Young J, Pereira-Dias J, Hamilton WL, Ferris M, Torok ME. Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission. elife. 2020;9:e58728.
14. Bizzoca ME, Campisi G, Lo Muzio L. An innovative risk-scoring system of dental procedures and safety protocols in the COVID-19 era. BMC Oral Health. 2020;20:1-8. https://doi.org/10.1186/s12903-020-01301-5
15. Bizzoca ME, Campisi G, Lo Muzio L. Covid-19 pandemic: What changes for dentists and oral medicine experts? A narrative review and novel approaches to infection containment. International journal of environmental research and public health. 2020;17:3793. https://doi.org/10.3390/ijerph17113793
16. www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww. cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fdental- settings.html
17. Kamran R, Saba K, Azam S. Impact of COVID-19 on Pakistani dentists: a nationwide cross sectional study. BMC oral health. 2021;21:1- 7.
18. https://doi.org/10.1186/s12903-021-01413-6
19. Abdelrahman H, Atteya S, Ihab M, Nyan M, Maharani DA, Rahardjo A, Shaath M, Aboalshamat K, Butool S, Shamala A, Baig L. Dental practice closure during the first wave of COVID-19 and associated professional, practice and structural determinants: a multi- country survey. BMC oral health. 2021;21:1-0. https://doi.org/10.1186/s12903-021-01601-4
20. Dhahri AA, Iqbal MR, Khan AF. A cross-sectional survey on availability of facilities to healthcare workers in Pakistan during the COVID-19 pandemic. Annals of Medicine and Surgery. 2020;59:127- 30.
21. 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.
22. Tysiac-Mista M, Dziedzic A. The attitudes and professional approaches of dental practitioners during the COVID-19 outbreak in Poland: a cross-sectional survey. International journal of environmental research and public health. 2020;17:4703. https://doi.org/10.3390/ijerph17134703
23. World Health Organization. Considerations for the provision of essential oral health services in the context of COVID-19: interim guidance, 3 August 2020. World Health Organization; 2020.
24. Sarwar H. A Nation-wide Survey on Financial Impact of COVID-19 on Employers of Private Dental Practices of Pakistan. JPDA. 2020;29.
25. https://doi.org/10.25301/JPDA.294.172
26. Buising KL, Schofield R, Irving L, Keywood M, Stevens A, Keogh N, Skidmore G, Wadlow I, Kevin K, Rismanchi B, Wheeler A. Use of portable air cleaners to reduce aerosol transmission on a hospital COVID-19 ward. medRxiv. 2021. https://doi.org/10.1101/2021.03.29.21254590
27. Ahmed MA, Jouhar R, Adnan S, Ahmed N, Ghazal T, Adanir N. Evaluation of Patient’s Knowledge, Attitude, and Practice of Cross- Infection Control in Dentistry during COVID-19 Pandemic. Eur J Dent. 2020;14(S 01):S1-6.

1. FCPS-II Resident, Department of Operative Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University.
2. Assistant Professor, Department of Operative Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University.
3. Professor and Head of Department, Operative Dentistry, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University.
4. Corresponding author: “Dr. Aushna Khushbakht Rana” <aushna.rana@gmail.com>

Aushna Khushbakht Rana        BDS
Samira Adnan                             BDS, FCPS
Syed Yawar Ali Abidi                  BDS, FCPS

OBJECTIVE: To gain an insight into cross infection protocols being followed by dental postgraduate residents in the prevention of the spread of coronavirus.
METHODOLOGY: A cross-sectional survey-based study was conducted using questionnaires, which were distributed among dental postgraduate residents working in different public and private institutes in Karachi, through social media. Data was analysed using SPSS, version 21.0 with p-value <0.05 to determine significant differences between both sectors.

RESULTS: Ninety seven residents from both institutes responded. 60 (93.75%) and 29 (87.87%) residents from the public and private institutes respectively, reported to having the patient's temperature checked with an infrared thermometer. However, a lower compliance was noted in regard to the use of hand sanitization with a hydro alcoholic solution by both institutes with 28 (43.75%) from public and 24 (72.72%) from private institutes. 11 (17.18%) residents from public institutes responding with disposal of PPE after every patient, whereas 1 (3.03%) resident from a private institute responded with disposal after every patient. However, due to a smaller sample size, the differences were not statistically significant.

CONCLUSION: The pandemic has exposed numerous shortcomings in the dental healthcare system, regardless of the sector. Since COVID-19 is likely to become an endemic, compliance with cross infection protocols needs to be improved so as to prevent its rapid spread. In a third world country like Pakistan, where resources are already scarce, greater emphasis needs to be placed on funding the dental healthcare system to enhance basic cross infection controls.

HOW TO CITE: Rana AK, Adnan S, Abidi SYA. Infection control practices followed by postgraduate residents of public and private dental institutions of Karachi during the COVID-19 pandemic. J Pak Dent Assoc 2022;31(4):182-187.
DOI: https://doi.org/10.25301/JPDA.314.182
Received: 04 January 2022, Accepted: 13 September 2022

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Juzer Shabbir                            BDS, MDS
Ayesha Anis                              BDS
Syed Masood ul Hasan            BDS, MDS
Naheed Najmi4                         BDS, MCPS, MDS
Muhammad Moiz Anis             BE, PhD
Tazeen Zehra                            BDS, FCPS
Wajiha Saghir                           BDS

OBJECTIVE: This study aimed to assess the amount of moisture present in the TWS of dental units in dental teaching hospitals (DTH) and private clinics (PC) across Karachi. 
METHODOLOGY: A total of 285 dental units were included in the study out of which 250 belonged to DTH and 35 to PC. Gushing was initially performed on hand to remove visible moisture from the TWS. The number of gushes required to remove visible moisture were recorded and the moisture-sensing device was used to assess the amount of invisible moisture in dry-air released from the TWS. SPSS v 22 was used to compare data of DTH and PC with the help of Mann Whitney U test. The pre- and post-exposure humidity of the sensing chamber was analyzed through Wilcoxon signed rank test. p value of < 0.05 was considered as significant. 
RESULTS: The power of the study was found to be > 99%. The moisture was present in 77.6% of the TWS in DTH and 37.1% in PC (p <0.001). Significantly higher number of hand gushes were required in DTH to eliminate the visible moisture as compared to PC (p= 0.022). Similarly, TWS in DTH were seen to liberate significantly increased amount of invisible moisture as compared to PC (p-value<0.001). CONCLUSION: Alarmingly high number of three-way syringes of dental units in dental teaching hospitals had moisture. This moisture can jeopardize restorative treatment and may expose patient to lethal microbes. 
KEYWORDS: Three way syringe; Restorative; Moisture; Resin Composite; Contamination 
HOW TO CITE: Shabbir J, Anis A, Hasan SMUL, Najmi N, Anis MM, Zehra T, Saghir W. Evaluation of presence and amount of moisture in dry air of three way syringes in dental teaching hospitals and private clinics: A cross-sectional study. J Pak Dent Assoc 2022;31(4):176-181. DOI: https://doi.org/10.25301/JPDA.314.176
 Received: 19 May 2022, Accepted: 18 August 2022

INTRODUCTION

The predictability of restorative dental treatment is dependent on several elements including operators’ skill, the type of material, the environment, and the patient factors.1,2 One environmental factor that is often overlooked, is the condition of dental operating unit machinery. The faults in the devices may unknowingly impact the quality of dental treatment negatively. One such flaw is the presence of water or oil in the dry air of threeway syringe (TWS) attached to the dental units. The uncontrolled and contaminated moisture can affect the bonding procedure negatively, put the health of the patient at risk, and corrode the dental instruments and equipment.3,4

Resin composite is a technique-sensitive, widely used restorative dental material. It is preferred by the dental professionals and the patients for a variety of direct and indirect restorative procedures due to favorable esthetics, conservation of tooth structure, bonding, high strength, cost effectiveness, and absence of mercury content.5,6 However the resin composite is a moisture sensitive material and requires several steps to be performed judiciously during restoration of a tooth structure.7,8 The most crucial step while doing a resin composite restoration is the bonding procedure. It determines the quality of adhesion of the composite material to the dental substrate.9 The bonding procedure includes etching, washing and drying of the tooth structure followed by application and air-thinning of primer or bonding agent with simultaneous evaporation of the solvent.8 A complete drying evident by a frosty appearance is especially important when enamel substrate is used for bonding.10 On the other hand, for bonding of dentin substrate, wet bonding without absolute drying is recommended for successful bonding.11 Even so, wet bonding requires the air thinning step.

During bonding, the drying of tooth structure and airthinning of the adhesive are conveniently done with the help of TWS attached to the dental unit.12,13 However, there is a chance that a seemingly dry air may hold a minute amount of invisible moisture that may escape through the TWS tip and coat the dried tooth, or the adhesive. The excess moisture may result in immediate or delayed failure of composite restorations due to inadequate formation of the hybrid layer. The failure is often detected as a secondary caries.1,14 The latter, if undetected or untreated, may cause irreversible inflammation of the pulp that would require an exhaustive treatment.15-17 On the other hand, the impact of small amount of undetected or invisible moisture on composite restoration is yet to be determined.

The visible moisture could be easily observed when dry air is sprayed through TWS. Whereas, the invisible moisture in the gushed air is not readily visible and can only be detected with the help of moisture detecting device. To the best of our knowledge, the presence and amount of visible and invisible moisture in the dry air of TWS has not been assessed till date. Therefore, the aim of our study was to assess the amount of moisture present in the TWS attached to the dental units in Dental Teaching Hospitals (DTH) and Private Dental Clinics (PC) across Karachi.

METHODOLOGY

The present study was a multi-center analytical crosssectional study. The ethical approval of the study was taken from Institutional Review Board (Ref no.: EC/25/19). The study followed STROBE (STrengthening the Reporting of Observational studies in Epidemiology) guidelines. The TWS attached to dental units of Operative/Restorative Dentistry departments of the teaching hospitals and private dental clinics were included in the study. The Exclusion criteria consisted of non-working units, defective TWS, dental units that were not used at least once per day, and the colleges/clinics that did not give permission to collect the data. Furthermore, the TWS that produced visible moisture even after 5 hand-gushes prior to start of testing of dry air were also excluded.

An electronic device was assembled to detect and measure the amount of residual moisture present in the dry-air gush of TWS. It consisted of an LCD to display the numerical readings and two DHT-22 sensors. One sensor was fixed inside (internal sensor) a hollow chamber (sensing chamber) opened from one side to facilitate gushing of air inside with the help of TWS tip and simultaneously maintain the humidity for a brief period of time. The sensing chamber was designed to simulate the oral cavity. A second sensor was placed outside (external) the sensing chamber and exposed to the environment for detection of the environmental moisture (Figure 1).

The detection of residual or invisible moisture was based on a differential logic. The device dis-played two humidity readings on the screen with the help of embedded regular averaging. It was designed smart enough to guide the operator about the readiness of the sensors, specifically when to gush the dry air in the cavity and when to stop. The mechanism of action of the device was based on the principle that a constant gush of air for few seconds results in reduction of humidity inside the sensing chamber, indicating a dry-enough air. The operator was trained to use the device for a week by the Engineers who designed the device. The device was tested with the help of a pilot study consisting of 40 TWS.

Written permission was obtained from various dental colleges of Karachi for data collection. TWS of 285 dental units were included from 7 DTH (n= 250) and 23 PC (n= 35) across Karachi. The data of the study was obtained by using convenience sampling method from 1st October 2020 to 31st March 2021. A maximum of five gushes (10 seconds/gush) for each TWS were done on the gloved hand to eliminate visible moisture before the start of the testing. The device was then started and the initial humidity reading inside the sensing chamber before gushing (HUM 1) on the internal sensor was noted. The dry air from the TWS was then gushed on the internal sensor (HUM 2; 10 seconds/gush) and the reading was noted. With this, the first cycle was completed. After 20 seconds, the HUM 2 was reverted back to HUM 1 with the restoration of original humidity inside the sensing cavity. The cycle was repeated 5 times on each TWS (Figure 2). The following formula was used to calculate the difference between pre- and post-exposure humidity: HUM3 = HUM2 – HUM1.

The positive HUM 3 values (value > 0) indicated the presence of moisture while values < 0 indicated the absence of the moisture. All values of HUM 3 below zero were adjusted to 0 during analysis (to denote absence of moisture). Out of five HUM 3 readings, highest positive value was included in the analysis if majority of the HUM 3 readings were positive. On the other hand, a value of “0” was included in analysis If the majority of the readings were 0 or below. These final values were pooled using Microsoft Excel and analyzed.

The statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 21.0. Mean, standard deviation (SD), median and interquartile range (IQR) were reported to de-scribe continuous variables such as number of gushes and amount of moisture content. Frequencies and percentages were reported to describe categorical variable like presence or absence of moisture. Chi-square test was applied to check the association between TWS and presence or absence of moisture. Assumption of normality of continuous variables was checked using ShapiroWilk test. Mann Whitney U test and Wilcoxon signed rank test were used to check the mean differences in amount of moisture between and within the groups. p-value of < 0.05 were considered as statistically significant.

RESULTS

Power of the study was calculated using PASS version 11 by including the mean amount of moisture present in the TWS from the results of the current study (DTH: n= 250, mean=1.67, SD ±2.86; PC: n=35, mean=0.36, SD ±0.55), 95% confidence interval and 0.05 significance level. The calculated power of the study was found to be > 99%, thereby justifying the sample size of the study. The analysis of presence or absence of visible moisture during hand-gushing revealed a statistically significant difference (p= 0.022) between DTH group and PC group. On an average, 1.9 gushes were required to remove the visible moisture from TWS in DTH as opposed to 1.5 gushes in PC (Table 1).

The descriptive statistics showed that out of 250 TWS of DTH, moisture was present (reading > 0) in 194 (77.6%) TWS. On the other hand, out of 35 TWS of PC, only 13 (37.1%) TWS had moisture. TWS of DTH (1.67 ± 2.86) had significantly greater amount of moisture as compared to PC (0.36 ± 0.55; p<0.001) (Table 1). The intragroup analysis revealed a significant difference (p < 0.001) between pre-(66.37) and post-gush (67.74) humidity within sensing chamber of the moisture sensing device in the DTH setting. To the contrary, no significant difference (p= 0.694) in this regard was found in the PC setting (Table 2)

DISCUSSION

The bonding and associated longevity of resin restorations is a complex process contingent on the formation of the hybrid layer between the resin tags and collagen fibrils.18 Aberrations in the bonding process may result due to various reasons that include hydrolytic instability of hydrophobic methacrylate monomers, interaction of resins with excess moisture, below par resin penetration, incompetence of bonding resins to entirely replace the loosely bound water in the collagen matrix, and degradation of collagen by proteinases.18,19 Interestingly, the common denominator in all these circumstances is water. The maximum amount of permissible moisture, in the presence of which no detrimental effects are expected for bonded restorations has not been reported. Our study was first to report the presence and amount of visible and invisible moisture present in TWS of dental units in DTH and PC.

Gushing of dry-air through TWS may consist of imperceptible moisture as highlighted by the current study. This moisture may hypothetically exert various effects. During post-etching drying of the prepared cavity, the unseen moisture may impede the activity of the primer.4 Likewise, during primer evaporation and air-thinning of bonding resin, the unaccounted moisture may act as a barrier and diluent for the adhesive resin.4 In both the scenarios, the bonding strength may be adversely affected. In addition, lethal microbes like SARS-CoV-2 may also be transferred to the oral cavity via the unwarranted moisture from the TWS.20-22.

The results of our study revealed that the humidity inside the sensing chamber was substantially increased after dry-air was gushed within the DTH setting group. Similarly, the presence and amount of moisture in TWS of DTH was significantly greater as compared to PC. These findings suggest that TWS of DTH were leaking excessive moisture in the gushed dry-air. This flaw may be attributed to the increased usage of dental units by multiple operators, and absence of regular maintenance in DTH.23 The increased and repeated usage may lead to incompetence and leakage in the valves of the TWS. The aged-out, un-monitored, and un-replaced O-rings inside the head assembly of the TWS act as a major reason for the release of water droplets alongside dry-air.23 Moreover, the absence of regular maintenance of the compressor and its key components such as air-intake filtration, post-compression filtration and drying system may lead to contaminated and moist air.24 Another reason that may contribute to the production of moisture is the increase in temperature of the compressed air. The increases in temperature holds the water in the vapor form. When the air leaves the compressor and enters the pipeline, it cools down and causes water to condense out. The ideal temperature range for compressed air equipment is from 50 to 85°F (10 to 30°C), above which the functioning of compressor and dryer is critically impaired.25 Moreover, the amount of resulting moisture is dependent upon the atmospheric conditions. Therefore, it is recommended that the placement and maintenance of the compressor system must be according to the manufacturer`s guidelines.

The current study had few limitations. Firstly, the number of maintenance cycles, age of dental units and compressors were not recorded. Therefore, only an assumption could be made that DTH lacked regular and/or inferior maintenance. Moreover, there was a considerable difference between the number of assessed TWS of DTH and PC. Lastly, no comparison was done between public and private sectors. However, our study was first to highlight the presence of invisible moisture in the TWS across multiple centers. In our study, various lacunae were identified that needs to be filled such as: Does invisible or minute amount of moisture have a negative impact on the bond strength of resin composite? what is the permissible amount of invisible moisture that has no adverse effect on filling materials and instruments? and what are the microbial types and counts present in the seemingly dry air liberated from TWS.?

CONCLUSION

Within the study limitations, it can be concluded that a high number of three-way syringes of the dental teaching hospitals had imperceptible moisture and the amount of this moisture was significantly higher as compared to private clinics. This increased amount of moisture might play a crucial role in failure of restorations, corrosion of instruments, and may pose a health risk to the patient.

ACKNOWLEDGEMENT

We are grateful to Electrical Department of Dhanani School of Science and Engineering, Habib University and its Engineers namely Syed Sarim, Zuhair Haider, Aoun Hussain, Anusha Rehman and Dr. Muhammad Moiz Anis for fabricating and providing us the moisture sensor device specifically for the present study

DISCLAIMER

The authors have nothing to disclose

CONFLICT OF INTEREST

None to declare

FUNDING DISCLOSURE

None to declare

AUTHORS CONTRIBUTION

Juzer Shabbir (JS): Conceptualization; Ayesha Anis (AA): Data curation; Muhammad Moiz Anis (MMA): Formal analysis; Wajiha Saghir (WS): Investigation; JS, Tazeen Zehra (TZ): Methodology; JS, AA: Resources; MMA: Software; Naheed Najmi (NN): Supervision; JS: Validation; SMH: Project Administration; JS, Syed Masood ul Hasan (SMH), AA: Roles/Writing – original draft; JS, TZ: Writing.

REFERENCES

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9. Reis A, Pellizzaro A, Dal-Bianco K, Gones OM, Patzlaff R, Loguercio AD. Impact of adhesive application to wet and dry dentin on longterm resin-dentin bond strengths. Oper Dent. 2007;32:380-7. https://doi.org/10.2341/06-107
10. Han F, Liang R, Xie H. Effects of Phosphoric Acid Pre-Etching on Chemisorption between Enamel and MDP-Containing Universal Adhesives: Chemical and Morphological Characterization, and Evaluation of Its Potential. ACS omega. 2021;6:13182-91. https://doi.org/10.1021/acsomega.1c01016.
11. Zhang Z, Yu J, Yao C, Yang H, Huang C. New perspective to improve dentin-adhesive interface stability by using dimethyl sulfoxide wet-bonding and epigallocatechin-3-gallate. Dent Mater. 2020;36:1452- 63. https://doi.org/10.1016/j.dental.2020.08.009
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13. Jose SC, Khosla E, Abraham KK, James AR, Thenumkal E. Effects of different dentinal drying methods on the adhesion of glass ionomer restorations to primary teeth. J Indian Soc Pedod Prev Dent. 2019;37:127-32. https://doi.org/10.4103/JISPPD.JISPPD_337_18
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16. Shabbir J, Khurshid Z, Qazi F, Sarwar H, Afaq H, Salman S, et al. Effect of Different Host-Related Factors on Postoperative Endodontic Pain in Necrotic Teeth Dressed with Interappointment Intracanal Medicaments: A Multicomparison Study. Eur J Dent. 2021;15:152- 7. https://doi.org/10.1055/s-0040-1721909
17. Shabbir J, Farooq I, Ali S, Mohammed F, Bugshan A, Khurram SA, et al. Dental Pulp. An Illus Guid to Oral Histol. 2021;69-79. https://doi.org/10.1002/9781119669616.ch5
18. Breschi L, Maravic T, Cunha SR, Comba A, Cadenaro M, Tjäderhane L, et al. Dentin bonding systems: From dentin collagen structure to bond preservation and clinical applications. Dent Mater. 2018;34:78-96. https://doi.org/10.1016/j.dental.2017.11.005
19. Betancourt DE, Baldion PA, Castellanos JE. Resin-Dentin Bonding Interface: Mechanisms of Degradation and Strategies for Stabilization of the Hybrid Layer. Int J Biomater. 2019;2019:5268342. https://doi.org/10.1155/2019/5268342
20. Inger M, Bennani V, Farella M, Bennani F, Cannon RD. Efficacy of air/water syringe tip sterilization. Aust Dent J. 2014;59:87-92. https://doi.org/10.1111/adj.12146
21. Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PMH. Clinical endodontic management during the COVID-19 pandemic: a literature review and clinical recommendations. Int Endod J. 2020;53:1461-71. https://doi.org/10.1111/iej.13406
22. Sarfaraz S, Shabbir J, Mudasser MA, Khurshid Z, Al-Quraini AAA, Abbasi MS, et al. Knowledge and Attitude of Dental Practitioners Related to Disinfection during the COVID-19 Pandemic. Healthcare. 2020;8:232. https://doi.org/10.3390/healthcare8030232
23. Pegg JE, Lothamer C, Rawlinson JE. The Air-Driven Dental Unit: Form and Function at a Mechanical Level. J Vet Dent. 2019;36:202-8. https://doi.org/10.1177/0898756419892635
24. Bloor C. How to maintain dental machines and instruments. Vet Nurse. 2012;3:630-6. https://doi.org/10.12968/vetn.2012.3.10.630
25. Taylor B. Optimal Temperature Range for Compressed Air Equipment [Internet]. Fluid-Aire Dynamics. 2020. Available from: https://fluidairedynamics.com/how-to-determine-the-optimaltemperature-range-for-compressed-air-equipment/#:~:text=The ideal operating temperature for,50 and 85-degrees Fahrenheit.&text=Maintaining ambient temperatures at 85,the 105°F max.

1. Assistant Professor, Department of Operative Dentistry, Baqai Dental College, Baqai Medical University, Karachi, Pakistan.
2. Lecturer, Department of Health Professions Education, Liaquat College of Medicine and Dentistry, Karachi, Pakistan.
3. Senior Registrar, Department of Operative Dentistry & Endodontics, Liaquat College of Medicine & Dentistry, Karachi, Pakistan.
4. Professor, Head, Department of Operative Dentistry and Endodontics, Liaquat College of Medicine and Dentistry, Karachi, Pakistan.
5. Associate Professor, Department of Dhanani School of Science and Engineering, Habib University, Karachi, Pakistan.
6. Assistant Professor, Department of Operative Dentistry & Endodontics, Liaquat College of Medicine and Dentistry, Karachi,
7. Lecturer, Department of Operative Dentistry & Endodontics, Liaquat College of Medicine and Dentistry, Karachi, Pakistan. Corresponding author: “Dr. Juzer Shabbir” < dr.juzer.shabbir@gmail.com >

Juzer Shabbir                            BDS, MDS
Ayesha Anis                              BDS
Syed Masood ul Hasan            BDS, MDS
Naheed Najmi4                         BDS, MCPS, MDS
Muhammad Moiz Anis             BE, PhD
Tazeen Zehra                            BDS, FCPS
Wajiha Saghir                           BDS

OBJECTIVE: This study aimed to assess the amount of moisture present in the TWS of dental units in dental teaching hospitals (DTH) and private clinics (PC) across Karachi. 
METHODOLOGY: A total of 285 dental units were included in the study out of which 250 belonged to DTH and 35 to PC. Gushing was initially performed on hand to remove visible moisture from the TWS. The number of gushes required to remove visible moisture were recorded and the moisture-sensing device was used to assess the amount of invisible moisture in dry-air released from the TWS. SPSS v 22 was used to compare data of DTH and PC with the help of Mann Whitney U test. The pre- and post-exposure humidity of the sensing chamber was analyzed through Wilcoxon signed rank test. p value of < 0.05 was considered as significant. 
RESULTS: The power of the study was found to be > 99%. The moisture was present in 77.6% of the TWS in DTH and 37.1% in PC (p <0.001). Significantly higher number of hand gushes were required in DTH to eliminate the visible moisture as compared to PC (p= 0.022). Similarly, TWS in DTH were seen to liberate significantly increased amount of invisible moisture as compared to PC (p-value<0.001). CONCLUSION: Alarmingly high number of three-way syringes of dental units in dental teaching hospitals had moisture. This moisture can jeopardize restorative treatment and may expose patient to lethal microbes. 
KEYWORDS: Three way syringe; Restorative; Moisture; Resin Composite; Contamination 
HOW TO CITE: Shabbir J, Anis A, Hasan SMUL, Najmi N, Anis MM, Zehra T, Saghir W. Evaluation of presence and amount of moisture in dry air of three way syringes in dental teaching hospitals and private clinics: A cross-sectional study. J Pak Dent Assoc 2022;31(4):176-181. DOI: https://doi.org/10.25301/JPDA.314.176
 Received: 19 May 2022, Accepted: 18 August 2022

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Fatima Khattak                            BDS, FCPS
Sadia Paiker                                 BDS, FCPS
Syed Muhammad Zaki Mehdi     BDS, FCPS
Adam Khan Danish                     BDS, FCPS
Muhammad Azhar Sheikh          BDS, MSc, FDSRCS, FFDRCS, FDS
Muhammad Wasim Ibrahim      BDS, MCPS FCPS, OJT

BACKGROUND: The Hepatitis B infection is a universal health issue, which causes considerable morbidity in humans.
Students of dentistry in clinical rotations are prone to risks of HBV transmission. The Dentistry students should be informative
about preventive steps and actions that can hamper the spread of hepatitis B virus.
OBJECTIVE: To determine the frequency of hepatitis B vaccination coverage and sero-protective levels of anti-HBs antibody
titers among dental students.
METHODOLOGY: A cross sectional study was undertaken over the course of 6 months i.e. 9th May, 2019 to 9th Nov, 2019
on 130 dentistry students in Foundation University College of Dentistry, Islamabad. Permission was taken from hospital ethical
committee FUCD for the study. Students who received full course of HBV vaccination after recording in a given performa and
who gave consent for testing were sampled for anti-HBs antibody titers.
RESULTS: It was found that out of 130 dental students only 5 (3.8%) have checked Anti-HBs titer levels after full course of
vaccination and 113 (86.9%) students reported to have received three complete doses of hepatitis B vaccine. After estimation
of anti-Hbs antibody levels of 113(86.9%) students, it was found that 34 (30.1%) possessed negative seroprotective level while
79 (69.9%) positive seroprotective level.
CONCLUSION: The study concluded inadequate vaccination coverage among dentistry students where 86.9% students were
fully vaccinated, with considerable reduction in anti-HBs titters found among 30.1% students.
KEYWORDS: Hepatitis B, Anti HBs Titer, Seroprotection, Dental students, HBV transmission, Vaccination
HOW TO CITE: Khattak F, Paiker S, Mehdi SMZ, Danish AK, Sheikh MA, Ibrahim MW. Analysing anti-HBS titer levels
in vaccinated students of dentistry in a tertiary care hospital. J Pak Dent Assoc 2022;31(4):170-175.
DOI: https://doi.org/10.25301/JPDA.314.170
Received: 16 July 2022, Accepted: 09 January 2023

INTRODUCTION
 

Hepatitis B infection is a universal health issue, which causes considerable morbidity in humansbecause this sickness is responsible for ill health and fatality, primarily through the consequences of chronic infection.1 Worldwide approximately two billion people are infected
according to the WHO, of those 260 million arechronic carriers.3 Central Africa and South-Eastern Asia has the highest prevalence of HBV infection.4 There are around 9 million Hepatitis B virus carriers in Pakistan.2 HBV genome gets conserve in the liver for the life time of carriers as infection becomes chronic.5

For a health care provider possibility of contracting HBV infection is four times greater in comparison to the general population and the likelihood of acquiring this infection after a single exposure is 6 to 30% in an unvaccinated person.1,4,6 Amongst the professionals, the most susceptible group as the actual sufferers and carriers are the dentists.1
Risk of HBV infection is greatest among the dental students in clinical training. Needle stick injuries and patient’s bodily fluids contact make them prone to HBV transmission risk as their exposure rate is similar to that of hospital staff.7 In majority circumstances antibody titers fail to increase due to either improper vaccination or loss of immune response.8 In long-term follow-up studies of individuals who received 3 doses of the hepatitis B vaccine starting at birth, a significant portion of participants showed declining protection 5-15 years after the initial immunisation9,10,11,12 and one of the study in India showed 11% to 24% of dental students had a moderate to poor immune response.13 Similar studies in Pakistan found low anti-HBs titer levels of 25.8% among dental professionals and dental students in Karachi14 and only 13.7%15 of healthcare providers in Peshawar who had had vaccinations.Similar study among Multan dental students reported 46.7% of students who had never received vaccinations.16

If the Anti-HBs antibody levels to hepatitis B surface antigen is >10mIU/ml it is considered as protective response.If the titer is >100 mIU/ml then no infection is seen among the patients.14 Since qualifying dental students go on to make the future healthcare providers, it is of grave importance that they should be mindful of the probability of spreading around and catching communicable diseases and infectious pathogens such as the HBV, during patient care and treatment and should be well aware about their immune response. This occupational hazard can be controlled to a major extent with the extensive use of HBV vaccination and to detect the anti HBs titer level which appears to be the main predictor of initial response to the vaccine and implementation of universal precautions.17.

This study aimed to highlight the number of students who have been vaccinated against hepatitis B and their attitude towards checking post vaccine antibody titers and to find the number of students who have positive immune response in a tertiary care hospital & it will create awareness among dental graduates regarding the significance of hepatitis B vaccination and of post vaccination immune response which if not in protective range will be a consistent risk for the student to acquire infection while treating high risk patients during clinical practice. The objective of this study was to determine the frequency of hepatitis B vaccination coverage and sero-protective levels of anti-HBs antibody titers among dental students.

METHODOLOGY

A cross sectional study was undertaken over the course of 6 months i.e. 9th May, 2019 to 9th Nov, 2019 on dentistry students in Foundation University College of Dentistry & Hospital, Islamabad. The sample size was calculated using the WHO calculator. The Anticipated population proportion was 13.7%.14 The sample population was estimated at 130 participants and level of confidence was set at 95%. However, to achieve best outcomes and obtain more precise findings, supplementary questionnaires were given to 150 students so that incomplete responses can be excluded. Permission was taken from hospital ethical committee (Approval letter no. FF/FUCD/632/ERC001 dated 5July2021) FUCD&H for the study. Dental students of 1st year till final year were included in the study while those who were already diagnosed with hepatitis B, immunocompromised, taking corticosteroids or immunosuppressant’s were excluded. Non probability consecutive sampling technique was used. Written informed consent was taken from the subjects. Using a validated questionnaire from a prior study by Rizvi et al14, a data collection format was created.Particulars of all the students who met the inclusion and exclusion criteria were recorded in proforma including age, gender, year of study, history of comorbidities and vaccination status including the number of doses,time elapsed since last dose and post vaccination titer levels whether checked or not. Those who received full course of HBV vaccination and who gave consent for testing were sampled for anti-HBs antibody titers. Charges of the tests were borne by hospital administration. The anti-HBs ELISA test was used for evaluating antibody levels. SPSS 23.0 was used to analyze data. Quantitative variables like age and antibody titer levels were calculated by mean and standard deviation. Frequency and percentage was calculated for qualitative variables like gender, student year of study and status of hepatitis B vaccination coverage regarding complete vaccinated, incomplete vaccinated and seroprotective levels. Effect modifier like age, gender, year of study of participant was stratified. Post stratification was done using Chi-square test. P value < 0.05 was taken as significant.

RESULTS

There were total 130 dental students who took part in this study. Out of 130, there were 34 males and 96 females. The mean age was calculated to be 22.35±2.84. The baseline demographic characteristics shows participation of 26 first year, 27 second year, 35 third year and 45 fourth year students respectively. Table 1 gives summary of findings related to vaccination status, number of doses administered and duration to last dose administered. It was found that 119 dental students were vaccinated for Hepatitis B and only 3.8% dental students had checked their anti-Hbs antibody titers after complete vaccination while rest of them never checked the titers as shown in figure 1. After estimation of anti-Hbs antibody levels, it was found that 30.1% students possessed negative seroprotective level while 69.9% positive seroprotective level i.e. anti-HBs antibody titer >10 mlU/ml in blood, as shown in figure 2.

The frequency of hepatitis B vaccination coverage and sero-protective levels of anti-HBs antibody titers among dental students were compared with respect to age, gender and year of study.

Among male students, after estimation of anti-Hbs antibody levels it was found that 51.4% students possessed negative seroprotective level while 17.9% positive seroprotective levels i.e. anti-HBs antibody levels >10 mlU/ml in blood as given in table 2.

DISCUSSION

Hepatitis B infection is one of the most common blood borne viral infection and carries a major health concern, making medical and dental professionals and health care workers especially dentists amongst high risk occupational group.18 The most common route of spread in dental setting is from infected patient bodily fluids contact like saliva and blood and needle stick injuries. The probability of spread of HBV after getting exposed to gingival crevicular fluid and saliva has been proven, which also endangered the oral health care provider against hepatitis infection.19

CDC guidelines for infection control in dental setting includes, but not limited to, wearing a face mask, eye protection, protective clothing, and other cautionary materials. Unfortunately, even dental students do not always conform to these practices, leading to greater risk to themselves and their patients.17 The most cost-effective predictor for protection against HBV infection is anti-HBs.20

In the current study total 130 dental students were analyzed for hepatitis B vaccination coverage. The mean age (years) in the study was 22.35+2.84 with an age range of 16-28 years. SA Ara et al.13 showed mean age of 28.12 ± 2.55 years with age range of 22-31 years.In another study by Acchammachary et al21 mean age was 25.5 years. Study by Sernia et al22 mean age was 25.4 years. Rizvi et al.9 reported varying ages with age range between 18-45 years with mean age of 40 years. No remarkable association was seen between the level of anti-HBs and the age of participant in the present study most likely due to minimal differences in participant’s age.

In our study among 130 participants 34 were males 26.2% and 96 were females which makes 73.8%. Study by SA Ara et al13 showed 52 females and 48 were males out of 100participants. In another study21 56.4% were males and 43.5% females make up the study population.

Vaccinated subjects percentage in this study was 91.5% while 8.5% were never vaccinated. This is higher than the studies conducted in India18,21 where percentage of vaccinated subjects against hepatitis B was only 51.50%18, 65%21 and 25% were not vaccinated at all.21 Similarly In a study conducted in Africa 18% were adequately vaccinated, 30.6% inadequately vaccinated and 51.4% were not vaccinated.23 Other studies showed 78.1% among dental students of Saudi Arabia24 and 76.8% amongst Palestinian students25 and 60% among dental students of Pakistan.26.

The disparity in immunisation rates among different groups may be caused by discrepancies in the laws already in place, a lack of awareness, or the existence of vaccination programmes in the locations where these studies were conducted.

In our study the vaccination coverage is highest amongst first year students (100%) followed by subsequent years. This is contradicting to the studies21,27 conducted in India where it is highest amongst post graduate residents. This might be due to the fact that 1st year students were not included in those studies. Contradicting results were also reported by a Brazilian study28, where also sixth year students have higher vaccination coverage as compared to first and subsequent years.

Findings of this study indicate 69.9% reactive HBs Ab titer among dental students and non-reactive HBs Ab titer in 30.1% which is considerable failure rate but lower as compared to other studies.A study by Mangkaraa et al.29 reported only 33.1% had serological evidence of vaccination while 66.8% participants were unprotected against infection. Similarly Lingawi HS30 reported 73.6%, failure rate. However, Rizvi et al14 28.7%, Monica et al 24.9%31 and SA Ara13 (11%) reported much reduced failure rate. This study is in harmony with another study13,14 which reported antibody levels of 65% and 71.3% which is much higher than other studies. The current study revealed significant antibody titers among dentistry students .This may be due to the fact that they might have completed vaccination before joining the college as part of admission policy and time elapsed was shorter.

The result of this study regarding the association between gender and seroprotectivity was in line with other studies.6,14,32 Even though 51.4% of the participants with < 10 mIU/ml antibody titer levels were male, only 17.9% with > 10 mIU/ml were male.This indicates that there might be a negative relation between immune response and this gender. (p-value 0.000). The perspective or attitude of dental students with respect to exploring their post vaccine titer level was poor in our study as only 3.8% of them checked their antibody levels as compared to studies undertaken in Turkey33 5.8% and India 7.4%18 but it is better than another study34 which have shown only 1.41% checked their titer post vaccination. Therefore, dental professionals after complete vaccination should opt for serological monitoring after 1-2month period.14

The limitations of the present study were that he majority of the factors, such as chronic illnesses, patients taking steroids or immunosuppressants, smoking, stress, and immunosuppression, which may affect a patient’s response to a vaccine, were not taken into account. Additionally, the dental college where the study was conducted did not have a policy prohibiting previously immunised individuals from receiving the vaccination again, therefore there may be a probability for booster shots.

CONCLUSION

The study concluded inadequate vaccination coverage among dentistry students of Foundation University College of Dentistry, where 86.9% students were fully vaccinated and considerable reduction in anti-HBs titers was found among 30.1% post-vaccination. Consequently, it is imperative to consider serological testing after vaccination and before start of clinical practice to lessen the chance of infection and to refine the immunization programs.

CONFLICT OF INTEREST

Nil

ACKNOWLEDGEMENT

Nil

REFERENCES

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1. Senior Registrar, Department of Oral & Maxillofacial Surgery, Dental College HITEC Institute of Medical Sciences, Taxila Cantt, Pakistan.
2. Senior Registrar, Department of Oral & Maxillofacial Surgery, Islamabad Medical & Dental College, Islamabad, Pakistan.
3. Registrar, Department of Oral & Maxillofacial Surgery, Rawal Institute of Health Sciences Islamabad, Pakistan.
4. Registrar, Department of Oral & Maxillofacial Surgery, Dental College HITEC Institute of Medical Sciences, Taxila Cantt, Pakistan. Professor, Department of Oral & Maxillofacial Surgery, Islamic International Dental College and Hospital, Islamabad, Pakistan.
5. Professor, Department of Oral & Maxillofacial Surgery, Foundation University College of Dentistry and Hospital, Islamabad, Pakistan. Corresponding author: “Dr. Fatima Khattak” < fatimakhattak12@gmail.com >

Fatima Khattak                            BDS, FCPS
Sadia Paiker                                 BDS, FCPS
Syed Muhammad Zaki Mehdi     BDS, FCPS
Adam Khan Danish                     BDS, FCPS
Muhammad Azhar Sheikh          BDS, MSc, FDSRCS, FFDRCS, FDS
Muhammad Wasim Ibrahim      BDS, MCPS FCPS, OJT

BACKGROUND: The Hepatitis B infection is a universal health issue, which causes considerable morbidity in humans.
Students of dentistry in clinical rotations are prone to risks of HBV transmission. The Dentistry students should be informative
about preventive steps and actions that can hamper the spread of hepatitis B virus.
OBJECTIVE: To determine the frequency of hepatitis B vaccination coverage and sero-protective levels of anti-HBs antibody
titers among dental students.
METHODOLOGY: A cross sectional study was undertaken over the course of 6 months i.e. 9th May, 2019 to 9th Nov, 2019
on 130 dentistry students in Foundation University College of Dentistry, Islamabad. Permission was taken from hospital ethical
committee FUCD for the study. Students who received full course of HBV vaccination after recording in a given performa and
who gave consent for testing were sampled for anti-HBs antibody titers.
RESULTS: It was found that out of 130 dental students only 5 (3.8%) have checked Anti-HBs titer levels after full course of
vaccination and 113 (86.9%) students reported to have received three complete doses of hepatitis B vaccine. After estimation
of anti-Hbs antibody levels of 113(86.9%) students, it was found that 34 (30.1%) possessed negative seroprotective level while
79 (69.9%) positive seroprotective level.
CONCLUSION: The study concluded inadequate vaccination coverage among dentistry students where 86.9% students were
fully vaccinated, with considerable reduction in anti-HBs titters found among 30.1% students.
KEYWORDS: Hepatitis B, Anti HBs Titer, Seroprotection, Dental students, HBV transmission, Vaccination
HOW TO CITE: Khattak F, Paiker S, Mehdi SMZ, Danish AK, Sheikh MA, Ibrahim MW. Analysing anti-HBS titer levels
in vaccinated students of dentistry in a tertiary care hospital. J Pak Dent Assoc 2022;31(4):170-175.
DOI: https://doi.org/10.25301/JPDA.314.170
Received: 16 July 2022, Accepted: 09 January 2023

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