Restoration of Missing Central Incisor with Cantilevered Zirconia Resin Bonded Fixed Dental Prosthesis

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

INTRODUCTION

Missing teeth in the anterior region can be a source of various psychological implications for the patient due to compromised aesthetics and phonetic difficulties.1 The replacement of a single anterior tooth in maxilla is one of the greatest challenges faced by dentists around the world. Implant supported crowns and conventional three unit fixed partial dentures are considered to be invasive prosthodontic treatment options with many biological and biomechanical complications.2,3,4 Resin bonded fixed dental prosthesis is a minimally invasive treatment modality especially for young adolescents. This reversible, cost-effective approach doesn’t compromise the abutment tooth and the failures are often less disastrous when compared with the conventional bridge.5 The early resin bonded bridges were ‘Rochette-bridges’ with perforated metal retainers. Since they had limited longevity therefore, metal retainer surface was altered to provide micromechanical retention with the aid of chemically active resin cements.6 The development of resin cements significantly improved the bond strength between the tooth surface and metal alloy.

Zirconia Resin bonded Fixed Dental Prosthesis provides an aesthetic alternative to conventional metal framed resin bonded bridges. The superior aesthetic and mechanical properties of zirconia have made its use increasingly popular in restorative dentistry.8 Zirconia offers better strength, fracture resistance and toughness when compared with other ceramics.9 Single retainer cantilevered zirconia Resin Bonded Fixed Dental Prosthesis has shown promising results for the replacement of missing anterior maxillary tooth with significantly lower risk of failure.10 The decreased survival rate associated with the two-retainer design is due to the differential mobility of the abutment teeth which induces stress at the bonding interface and consequently results in debonding of the restoration.11 Moreover two-retainer all ceramic RBFDP commonly experience unilateral fracture of the proximal connector due to interabutment stresses and eventually serve as a cantilever RBFDP later in life.

This clinical report presents a viable treatment option for the replacement of a missing anterior tooth with careful treatment planning for a young patient who was extremely concerned about his aesthetics.

CLINICAL REPORT

A 17-year-old male patient reported to the Outpatient

Department of Prosthodontics, de’Montmorecy College of Dentistry, Lahore with the chief complaint of compromised aesthetics due to a missing maxillary left central incisor (figure 1a). The intra oral examination of the patient revealed healthy dentition with no signs of bruxism or wear facets on the occlusal surfaces. The patient had a vertical and horizontal overlap of approximately 2.5mm. Periapical X-ray of the abutments adjacent to the missing left central incisor showed no signs of bone loss or peri apical lesions (figure 1b). Extra oral examination of the patient exhibited no abnormal facial features or facial asymmetry (figure 1c) and the medical history of the patient was insignificant. Since the patient was not in favour of receiving any invasive dental treatment so porcelain veneered zirconia cantilever RBFDP was considered to be the most suitable treatment modality for the patient.

CLINICAL PROCEDURE

The clinical procedure began with the preparation of the maxillary right central incisor, which was chosen to serve as an abutment for the cantilever zirconia RBFDP. It was prepared minimally on the lingual aspect with a supragingival finish line and 2mm short of incisal edge. A small proximal box of 2mm length, 1mm width and 0.5mm depth was prepared. Additionally, a pinhole (0.5mm depth; 1mm diameter) was made on the cingulum (figure 2a, 2b). After the abutment tooth preparation full arch dual phase single stage impression of the maxillary arch was taken in polyvinyl siloxane impression material, putty and light body(Zhermack Addition Silicone). The impression of the opposing arch was recorded in irreversible hydrocolloid. Shade selection was done using VITA tooth guide 3D Master (figure 2c).

Medit scanner was used to accurately scan the stone die. Exocad DentalCAD software created a 3D digital model of the dental restoration which was then milled from Y-TZP zirconia blanks and sintered to full density by Arum 5X milling machine. The thickness of the retainer wing was kept approximately 2mm. It was very important to consider the correct dimensions of the connector, because a properly designed and fabricated connector is fundamental to the success of zirconia restorations. The height of the connector was kept 4mm and the thickness was 4mm gingivally that gradually decreased to 2mm incisally with the cross-sectional area >12mm2 (figure 2d). Porcelain veneering was only done at the labial surface of the pontic. Prior to insertion the retainer wing was air abraded with 50-μm alumina particles.

The fit of the restoration was checked intra orally. After the maintenance of proper isolation, the prepared enamel surface of the abutment was etched with 37%phosphoric acid for 30 seconds. It was washed with water and then air dried. Bonding agent was applied and light cured for 10-20 seconds. The restoration was cemented with Calibra Universal resin cement (dual cure, self-adhesive). A thin, uniform layer of the resin cement was applied on the retainer wing of the restoration with the help of an auto mix syringe tip. The restoration was seated and light finger pressure was applied to prevent its movement during the initial light curing that was done for 20-40 seconds. Excess cement was cleaned as it remains in the gelled state for 45 seconds following light exposure. Afterwards the restoration was allowed to self-cure for approximately 6 minutes (figure 3a, 3b).

The pontic and retainer wing were made to be free of occlusal contacts in maximum intercuspation and dynamic excursions. Minimal occlusal adjustment was performed in the opposing arch while the zirconia restoration was left undisturbed. Various dietary instructions and necessary precautions were explained to the patient. Sticky foods like gum and chewy candies should be avoided which can cause potential damage to the restoration. Moreover, hard food items should not be incised from the anteriors. Patient was instructed to practice oral hygiene habits and clean around the bridge using a floss threader and dental floss.

Patient was recalled after two weeks for initial examination. He reported no discomfort and was very satisfied with the clinical outcome (figure 3c). Next follow-up visits were scheduled after one month and two months. Patient was then recalled after six months and the examination showed a completely intact restoration that was serving adequately in the oral cavity.

DISCUSSION

Replacement of a single missing anterior tooth in maxilla by zirconia cantilever RBFDP is relatively a simple and conservative treatment approach especially in young adolescents with aesthetically pleasing and durable clinical results.13 Careful treatment planning and skillful designing is a pre requisite for the clinical success of resin bonded bridges.14

Proper shade selection is vital to achieve perfect aesthetics. Shade selection should be done quickly to avert undue color fatigue of the eye. Since the fracture of the proximal connector is the most common cause for the failure of Zirconia RBFDP therefore vigilant designing of the connector with correct dimensions provide an essential basis for the survival of these restorations. Air abrasion of the fitting surface of the retainer with 50μm alumina particles at a distance of 10mm from the bonding surface with 2.5bar pressure significantly improved the bond strength of resin cements to zirconia.15

The incidences of debonding can be substantially avoided by proper placement and careful cementation of the restoration. Surface pretreatment of enamel with etchant and bonding agent application comparatively improves the bond strength of self-adhesive resin cements than its single step application on the enamel without any prior surface treatments.16,17

Evaluation of occlusion is very important such that contact on the pontic and retainer should be minimized in static and functional occlusion.18 The contact at the margin of the retainer should be avoided strictly to prevent any consequential episode of the restoration debonding.19 According to the literature, the ten-year clinical survival rate of anterior cantilever zirconia ceramic RBFDPs is found to be 95%.20.

CONCLUSION

The beneficial aspects of choosing a cantilever zirconia resin bonded restoration for the prosthodontic rehabilitation of a missing anterior tooth over invasive dental treatment modalities are lauded with great fervor. Careful case selection, framework design, occlusal management and cementation are imperative for the enduring success of these restorations.

CONFLICT OF INTEREST

None declared

REFERENCES

  1.  Gautam R, Nene P, Mehta K, Nene S, Hegde A, Jaju R. Treatment Strategies for Missing Maxillary Central Incisor-An Orthodontist’s Perspective. J Prosthod. 2014;23:509-13. https://doi.org/10.1111/jopr.12133
  2.  Sones AD. Complications with osseointegrated implants. J Prosthetic Dent. 1989;62:581-5. https://doi.org/10.1016/0022-3913(89)90084-X
  3.  De Kok IJ, Duqum IS, Katz LH, Cooper LF. Management of Implant/Prosthodontic Complications. Dental Clinics of North America. 2019;63:217-31.
    https://doi.org/10.1016/j.cden.2018.11.004
  4.  Tan K, Pjetursson BE, Lang NP, Chan ESY. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. III. Conventional FPDs. Clin Oral Implants Res. 2004;15:654-66. https://doi.org/10.1111/j.1600-0501.2004.01119.x
  5. Balasubramaniam GR. Predictability of resin bonded bridges – a systematic review. Bri Dent J. 2017;222:849-58. https://doi.org/10.1038/sj.bdj.2017.497
  6.  Durey KA, Nixon PJ, Robinson S, Chan MFW-Y . Resin bonded bridges: techniques for success. Bri Dent J. 2011;211:113-8. https://doi.org/10.1038/sj.bdj.2011.619
  7. Miettinen M, Millar BJ. A review of the success and failure characteristics of resin-bonded bridges. Bri Dent J. 2013;215:E3-3. https://doi.org/10.1038/sj.bdj.2013.686
  8. Yoshida K, Tsuo Y, Atsuta M. Bonding of dual-cured resin cement to zirconia ceramic using phosphate acid ester monomer and zirconate coupler. J Biomedical Materials Res Part B: Applied Biomaterials. 2006;77B:2 https://doi.org/10.1002/jbm.b.30424
  9. Bona A, Pecho O, Alessandretti R. Zirconia as a Dental Biomaterial. Materials. 2015;8:4978-91. https://doi.org/10.3390/ma8084978
  10. Sasse M, Eschbach S, Kern M. Randomized clinical trial on single retainer all-ceramic resin-bonded fixed partial dentures: Influence of the bonding system after up to 55 months. J Dent. 2012;40:783-6. https://doi.org/10.1016/j.jdent.2012.05.009
  11.  Sasse M, Kern M. Survival of anterior cantilevered all-ceramic resin-bonded fixed dental prostheses made from zirconia ceramic. J Dent. 2014;42:660-https://doi.org/10.1016/j.jdent.2014.02.021
  12.  Mourshed B, Samran A, Alfagih A, Samran A, Abdulrab S, Kern M. Anterior Cantilever Resin-Bonded Fixed Dental Prostheses: A Review of the Literature. J Prosthodontics. 2016;27:266-75. https://doi.org/10.1111/jopr.12555
  13.  Sailer I, Hämmerle C. Zirconia Ceramic Single-Retainer Resin- Bonded Fixed Dental Prostheses (RBFDPs) After 4 Years of Clinical Service: A Retrospective Clinical and Volumetric Study. International J Periodontics Restorative Dent. 2014;34:333-43. https://doi.org/10.11607/prd.1842
  14.  Ibbetson R. Clinical Considerations for Adhesive Bridgework. Dental Update. 2004;31:254-65. https://doi.org/10.12968/denu.2004.31.5.254
  15.  Yang B, Barloi A, Kern M. Influence of air-abrasion on zirconia ceramic bonding using an adhesive composite resin. Dent Materials. 2010;26:44-50. https://doi.org/10.1016/j.dental.2009.08.008
  16.  Sekhri S. Tensile Bond Strength of Self Adhesive Resin Cement After Various Surface Treatment of Enamel. J Clin Diagnostic Res. 2016;https://doi.org/10.7860/JCDR/2016/13409.7026
  17.  Lin J, Shinya A, Gomi H, Shinya A. Bonding of self-adhesive resin cements to enamel using different surface treatments: bond strength and etching pattern evaluations. Dent Materials J. 2010;29:425- 32. https://doi.org/10.4012/dmj.2009-140
  18. Zitzmann NU, Özcan M, Scherrer SS, Bühler JM, Weiger R, Krastl G. Resin-bonded restorations: A strategy for managing anterior tooth loss in adolescence. J Prosthetic Dent. 2015;113:270-6. https://doi.org/10.1016/j.prosdent.2014.09.028
  19.  Gulati JS, Tabiat-Pour S, Watkins S, Banerjee A. Resin-bonded bridges – the problem or the solution? part 1: assessment and design. Dental Update. 2016;43:506-21. https://doi.org/10.12968/denu.2016.43.6.506
  20.  Kern M, Passia N, Sasse M, Yazigi C. Ten-year outcome of zirconia ceramic cantilever resin-bonded fixed dental prostheses and the influence of the reasons for missing incisors. J Dent. 2017;65:51-5. https://doi.org/10.1016/j.jdent.2017.07.003

  1. MDS Resident, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore.
  2. Assistant Professor, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore.
  3. Assistant Professor, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore.
  4. MDS Resident, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore.
  5. MDS Resident, Department of Prosthodontics, de’Montmorency College of Dentistry, Lahore.
  6. Corresponding author: “Dr. Sara Qureshi” < sara.fq14@gmail.com >

Restoration of Missing Central Incisor with Cantilevered Zirconia Resin Bonded Fixed Dental Prosthesis

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

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Parafunctional Oral Habits: Frequency and Association with Malocclusion Traits in Adolescents

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

Oral habits can be broadly divided into two groups: functional and parafunctional habits. Functional oral habits are a result of repeated normal function, whereas habits attained as a result of practices other than normal are labelled as parafunctional habits.1 Parafunctional habit is a repeated abnormal act that targets the oral complex, which includes digit sucking, tongue thrusting, bruxism, nail biting and mouth breathing.2 Some of these are also sleep related such as bruxism, thumb sucking and mouth breathing. Etiology of malocclusion involves genetic as well as environmental factors. Inappropriate oral habits can affect the dental and skeletal development in adverse way.3

Environmental factors such as digit sucking which is a habit acquired during early years due to putting thumb in mouth for non-nutritive purpose, often cause maxillary incisors proclination, anterior open bite, posterior crossbite, exaggerated overjet,midline diastema and risk of maxillary incisor trauma.3 The crossbite of posterior teeth is due to downward positioning of the tongue and increased action of the cheek muscles during sucking that builds negative intra-oral pressure.3 Blockage of upper respiratory tract, resulting in mouth breathing, refers to the act of breathing through the mouth which often occurs habitually or as a result of an obstruction to breathing through the nose, alters the sequence of craniofacial growth with classic dental and facial characteristics such as elongated face, high arched palate and incompetent lips.3 There are other adverse effects associated with extended parafunctional habits. Tongue thrusting, which is the anterior placement of the tongue at rest, lips lies against or in between the anterior teeth can cause, anterior open bite, maxillary incisor proclination, lip trap, distoclusion and incompetent lips.4,7.

Non-nutritive sucking habits are common in young infants, however as children grows up, sucking habits tends to get reduced. Malocclusion occurs when these habits persist during and after the eruption of permanent dentition.5 The frequency of oral habits and their consequences varies in different communities relying on factors such as type of parafunctional habit, its extent, frequency and intensity.7 Bruxism is defined as the unintentional habitual grinding of teeth, which may cause attrition, periodontal problems and malocclusion.8 There is a positive correlation between crowded anterior teeth and bruxism-associated parafunctional habits.9.

The extended use of pacifiers and feeding bottles is more frequent in toddlers, while nail biting or onychophagia and digit sucking are more frequent in pre-schoolers and school children.11 Its frequency increases in teenage years and drops later and its incidence is more amongst boys than girls.12 There has been a surge in incidence of oral parafunctional habits in children, though not as widespread as dental caries, however, it is still a matter which needs to be addressed in early years.13.

According to a study conducted in Jeddah, Saudi Arabia in 2021, it was concluded that 3.9% participants were mouth breathers, 39.6% participants had habit of nail biting and digit sucking was quite unusual among the subjects with 6.8% frequency. Bi-maxillary protrusion was found among 11.1%, edge to edge incisor relation in 6.6%, severe overjet in 3.1%, anterior crossbite in 1.3%, open bite in 3.1% and deep bite in 2.7% of the subjects. Another study conducted in Taif, Saudi Arabia in 2020, showed percentages of thumb sucking, tongue thrusting and mouth breathing to be 10.7%, 20.8% and 6.1% respectively. An investigation conducted in India in 2020 to find the association between oral habits and its effects on dentition among children showed similar results. The most common habit was tongue thrusting (44%), followed by thumb sucking (24%). It also showed that class I incisor relation was mostly seen in tongue thrusting habit (42%) and class II division 1 incisor relation was mostly seen in thumb sucking habit (12%).

Parafunctional habits constitute a significant etiological factor for developing malocclusion. Treatment of these malocclusions should focus on detecting and intercepting these etiological factors early on for better treatment outcomes and long-term stability. Awareness regarding parafunctional habits and their consequences on dentofacial characteristics is of prime importance. In a developing country like Pakistan, where orthodontist to population ratio is very low, community outreach programs to raise general awareness, should be encouraged for timely interception of parafunctional oral habits and prevention of malocclusion. Therefore, the objective of this research was to find out the frequency of parafunctional oral habits in a sample of adolescent population and its association with different types of malocclusions.

METHODOLOGY

This cross-sectional study involved 610 students studying in 8 different schools of Raiwind, Lahore. The sample was collected using non-probability consecutive sampling technique. Firstly, ethical approval was obtained from Sharif Medical and Dental College, Lahore. Thereafter, permission was taken from the schools’ principals for history taking and intra-oral examination of the students fulfilling the selection criteria. Informed consent was also taken from their parents prior to the history and examination date. The study duration was 3 months. The inclusion criteria were adolescent males and females aged 13-20 years, having fully erupted permanent dentition except third molars. The exclusion criteria were students with on-going or prior history of orthodontic treatment, dentofacial trauma, dentofacial deformity or craniofacial syndrome.

Data was collected by the primary researcher and recorded in predesigned proforma. To avoid visual fatigue, the number of students examined per day was kept to a minimum of 30-40. Complete demographic details and medical/dental history was taken. Exclusive history of oral parafunctional habits was taken from each participant and recorded in the proforma. All intra-oral inspections were carried out in direct vision with gloved hands and disposable wooden blades. 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. Overbite, which is the vertical distance between the maxillary and mandibular central incisal edges and overjet, which is the horizontal distance between the maxillary and mandibular central incisal edges, were measured using a stainless-steel ruler to the nearest 1 mm. Disposable clear plastic sleeve was used to cover the measuring end of the ruler and changed before use on every participant.

The following parameters were assessed and data was recorded in a pre-designed proforma:

  1. Digit Sucking
  2. Tongue Thrusting
  3. Nail Biting or Onychophagia
  4. Mouth Breathing
  5. Bruxism

   . Malocclusion:

I. Sagittal Plane
Over-jet: Overjet is the horizontal overlap of the maxillary central incisors over the mandibular central incisors1, which can be classified as:

  1. Normal Overjet (2-3mm)
  2. Exaggerated Overjet (>3mm)
  3. Reverse Overjet (<0mm)

II. Vertical Plane:
Over-bite: The normal vertical over-lap between maxillary and mandibular central incisors21, which can be classified as:

  1. Open Bite (<0mm)
  2. Normal Over bite (1-2mm)
  3. Deep Bite (>5mm)

III. Transverse Plane:
Crossbite: Crossbite is a transverse malocclusion where maxillary teeth fit inside of mandibular teeth. It can be anterior crossbite for anterior teeth and posterior crossbite if it involves posterior teeth.16

STATISTICAL ANALYSIS

Data was scrutinized using Statistical Package for the Social Sciences software, version 25.0 (SPSS, Inc., Chicago, IL, USA) developed by IBM. Descriptive analyses were performed using frequencies and percentages for gender, malocclusion features and parafunctional oral habits. Quantitative variable like age was represented as mean ±SD. Chi-square test was applied to verify the statistical significance of the association between various parafunctional oral habits and types of malocclusions. The level of significance was set at 5% (p<0.05).

RESULTS

A total of 610 adolescents participated in this study with a mean age of 15.47±1.6 years, out of which 462(75.7%) were males and 148(24.3%) were females. The prevalence of parafunctional habits was 57.3%, among which 108(72.9%) were females and 242(52.3%) were males.

Figure 1 shows the frequency distribution of parafunctional oral habits. The most frequently found oral habit was bruxism (18%) followed by tongue thrusting (15.2%), nail biting (12.8%), mouth breathing (8.7%) and lastly thumb sucking (8.4%).

Figure 2 shows the gender-based comparison of parafunctional oral habits. There was a total of 610 participants in this study out of which 462(75.7%) were males and 148(24.3%) were females. The prevalence of parafunctional habits was 72.9% for females and 52.3% for males.

Figure.1: Frequency Distribution of oral habits among subjects

Figure 3 shows the age-related distribution of the parafunctional oral habitswhich concludes that age has no effect on the presence or absence of deleterious oral habits.

Figure 4 shows the frequency distribution of malocclusion in total sample. Table 1 displays detailed distribution of individual parafunctional oral habits in both genders.

Table 2-4 show the association of parafunctional oral habits with malocclusion in sagittal, vertical and transverse planes, using chi-square test for statistical significance

DISCUSSION

DISCUSSION Parafunctional oral habits are repetitively acquired number of units
automatisms, which present as an altered pattern of orofacial muscle contraction which proceeds unconsciously on consistent basis.2 Parafunctional oral habits result in various malocclusions, temporomandibular joint problems, loss of tooth structure and increase in psychosocial distress.1 The consequences of these habits depends on character, commencement and prolongation of habit. These pertinacious parafunctional habits might result in complications in long run which can affect the orofacial functions which leads to imbalance between outer and inner muscle activity.

The current study showed that 57.3% adolescents had history of parafunctional habits, being more prevalent in females than males. The result of our study shows greater frequency for tongue thrusting parafunctional habit (15.2%) and lesser frequency for mouth breathing (6.18%). which closely matches with the results of a study conducted by Aldawood which also shows that mouth breathing was less frequent while tongue thrusting was more frequent among parafunctional oral habits in people of Taif, Saudi Arabia.This similarity was probably due to the almost similar age group of the participants in both studies.

Gender-based comparison concluded that parafunctional oral habits were more prevalent in females (72.9%) than males (52.3%) unlike another study reported by Grippaudo that showed insignificant difference with respect to gender.3,8 However, comparison of individual parafunctional oral habits did not yield any statistically significant difference for thumb sucking, mouth breathing and tongue thrust. Females reported with higher frequencies for nail biting and for bruxism. Another study conducted by Zakirulla et al also showed significant presence of bruxism and nail biting.14 The association between age and parafunctional oral habits was statistically insignificant, similar to a study done by Gurunathan on Indian population.

In this study, the malocclusion parameters found were exaggerated overjet, reverse overjet, open bite, deep bite and crossbite. Association of thumb sucking, mouth breathing and tongue thrust, with exaggerated overjet and open bite showed significant results (p=0.001). A study conducted by Grippaudo concluded that parafunctional oral habits were directly related to malocclusion.3 Another investigation conducted by Ahmed et al revealed similar results to our study.

Kharat et al concluded in his research that negative oral habits can lead to malocclusion. A total of 40% cases of malocclusion were found to be related to oral habits15, which is consistent with our results. Children with exaggerated overjet presented with tongue thrusting (73%), thumb sucking (61%) and mouth breathing (60%). Most of the children (80%) with open bite had a habit of thumb sucking. Arora concluded similar results that digit sucking habit can cause significant complications such as open bite and increased overjet.10 However, the cause-and-effect relationship of open bite with mouth breathing and tongue thrusting remains inconclusive.

There are many factors that can adversely affect the development of dentition and occlusion. Abnormal sucking habits such as thumb sucking can cause transverse discrepancy which presents as crossbite.8 The current study found a significant association between thumb sucking habit and crossbite (p=0.001).

Breathing patterns have a major impact on the maturation of orofacial features. Any situation which disrupts normal breathing physiology may affect the facial development. It has been reported that due to chronic mouth breathing, the mandible gets rotated downwards and backward leading to open bite.8,10 Similarly, in our study a statistically significant association (p=0.001) was seen among mouth breathing and open bite.

Tooth grinding, clenching or bruxism is related to several etiological factors ranging from psychological, neuromuscular and occlusal disharmonies.9,12 It can lead to the development of deep bite due to attrition of posterior occlusal surfaces. The current study shows that 54.4% of adolescents who had deep bite also gave history of bruxism or clenching, which was more prevalent in females (25.7%).

Anterior placement of the tongue at rest is known as tongue thrusting.12 An anterior tongue placement where the tongue rests between incisors may hinder incisor eruption leading to development of anterior open bite, increased overjet and generalized spacing.15 This current study shows similar results, whereby 73 % individuals with tongue thrusting had exaggerated overjet and 52.1% had open bite. Similarly, a study done by Zakirullah et al showed open bite and exaggerated overjet in children with tongue thrusting.14

Various previous studies predicted a deep-rooted association between parafunctional oral habits and malocclusion. In order to minimize the bad oral habits and their adverse effects, a comprehensive approach is required, which consists of patient-parent guidance, behavior modification procedures, habit breaking devices, frequent follow up visits. Prevention and interference of these harmful oral habits during childhood is very crucial for the optimal oral health and dentofacial development. Hence, it is essential to raise awareness in our communities regarding early interception of parafunctional oral habits to avoid the development of dental and skeletal malocclusion.

CONCLUSION

The most common parafunctional habits in descending order were bruxism, tongue thrusting, nail biting, mouth breathing and thumb sucking. Sagittal malocclusions were significantly associated with parafunctional habits such as tongue thrust, mouth breathing and thumb sucking. Vertical malocclusions were significantly associated with thumb sucking, mouth breathing, tongue thrusting and bruxism. Association between transverse malocclusion and thumb sucking was statistically significant. Gender-based comparison was statistically significant, with oral parafunctional habits being more prevalent in females, whereas age- related differences were statistically insignificant. Therefore, oral parafunctional habits have a strong adverse influence on dentofacial development of adolescent, leading to malocclusion in all three dimensions.

LIMITATIONS OF STUDY

Firstly, it was a community-based study, therefore, detailed history and examination to discern the severity of parafunctional oral habit could not be done. Secondly, the cross-sectional design of this study limited the potential to rule out the cause-effect relationship of oral parafunctional habit and malocclusion.

FINANCIAL DISCLOSURE

We have no relevant financial interests in this manuscript.

ACKNOWLEDGEMENTS

The authors are thankful to Prof. Dr. Amna Nauman, Head of Department of Community and Preventive Dentistry, SMDC, who arranged community field trips that helped us to collect data for our research.

CONFLICT OF INTEREST

We have no conflict of interest that we should disclose.

REFERENCES

  1.  Aldawood MM, et al. The Prevalence of Parafunctional Habits in Taif, Kingdom of Saudi Arabia. Ann Med Health Sci Res. 2020;10: 942-945
  2.  Baeshen HA. Malocclusion trait and the parafunctional effect among young female school students. Saudi J Biol Sci. 2021;28:1088-1092 https://doi.org/10.1016/j.sjbs.2020.11.028
  3.  Paolantonio EG, Ludovici N, Saccomanno S, La Torre G, Grippaudo C. Association between oral habits, mouth breathing and malocclusion in Italian preschoolers. Eur J Paediatr Dent. 2019;20:204-208
  4.  Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ital. 2016;36:386-394 https://doi.org/10.14639/0392-100X-770
  5.  Ahmed ZN et al. Etiology of thumb sucking habit and its effect on developing malocclusion. Int J Community Med Public Health. 2021; 8:905-909
    https://doi.org/10.18203/2394-6040.ijcmph20210017
  6.  Mélou C et al. Relationship between Occlusal Factors, Oral Parafunctions and Temporomandibular Disorders: A Case Control Study. Int J Dent Oral Health. 2019;5:1-5 https://doi.org/10.16966/2378-7090.295
  7.  Abbasi AA et al. Prevalence of Parafunctional Oral Habits in 7 to 15 Years Old School children in Saudi Arabia. J Orthod Endod. 2017; 3:1-4
    https://doi.org/10.21767/2469-2980.100045
  8.  Mutlu E, Parlak B, Kuru S, Oztas E, Pinar-Erdem A, Sepet E. Evaluation of Crossbites in Relation with Dental Arch Widths, Occlusion Type, Nutritive and Non-nutritive Sucking Habits and Respiratory Factors in the Early Mixed Dentition. Oral Health Prev Dent. 2019; 17;447-455
  9.  Ramya G, Pandurangan K, Ganapathy D. Correlation between anterior crowding and bruxism related parafunctional habits. Drug Invent Today.2019;12;2274-276
  10.  Arora B, Mahajan M, Kaur A, Sekhon H. Anterior Open Bite: Review and Management. J Med Dent Sci. 2016;15;01-06
  11.  Pruneda J, Marquez M, Valdes L, Torres R. Frequency of parafunctional oral habits and their relationship with age group. Appli Sci Dent. 2021:1;1-10
  12.  Sundeep CB, Jacob J, Tom A, Thaliyil C. Oral Parafunctional Habits- A hawkey-Eye View. J Interdiscip Multidiscip Res. 2017; 4; 2263-265
  13.  Reshma T, Mahesh R, Balaji Ganesh S. Association between deleterious oral habits and its effect on dentition among 5-15 years children. Int J Res Pharm Sci. 2020;11(SPL3);408-12 https://doi.org/10.26452/ijrps.v11iSPL3.2953
  14.  Zakirulla M et al. Oral habits: prevalence and effects on occlusion among 7-13 years old school children in Aseer, Saudia Arabia. Pesqui Bras Odontopediatria Clin Integr. 2020; 20:e0005 https://doi.org/10.1590/pboci.2020.094
  15.  Kharat S et al. Oral habits and its relationship to malocclusion: A review. J Adv Med Dent Scie Res 2014;2:123-2
  16.  Proffit WR. The Etiology of Orthodontic Problems. In: Proffit WR, Fields HW, Larson BE. Sarver D(Eds). Contemporary Orthodontics. 6th Ed. Philadelphia: Elsevier;2019.
  17.  Garde J et al. An epidemiological study to know the prevalence of deleterious oral habits among 6- to 12-year-old children. J Int Oral Health. 2014;6:39-43
  18.  Dhull KS, Verma T, Dutta B. Prevalence of Deleterious Oral Habits among 3- to 5-year- old Preschool Children in Bhubaneswar, Odisha, India. Int J Clin Pediatr Dent. 2018;11:210-13 https://doi.org/10.5005/jp-journals-10005-1513
  19.  Gurunathan D, Shanmugaavel A. Dental neglect among children in Chennai. J Indian Soc Pedod Prev Dent. 2016;34:364-9 https://doi.org/10.4103/0970-4388.191420
  20.  Reboucas PD et al. Prevalence of oral habits in children. Rev Bras Odontol. 2017; 74:272-8
  21.  Islam Z, Shaikh A, Fida M. The correlation of overbite with skeletal, dental and soft tissues characteristics. Pakistan Oral Dent J. 2020;40;149-54.
  22.  Ekici O. Association of malocclusion, parafunctional habits and quality of life in patients with temporomandibular joint disorder. Turkiye Klinikleri J Dent Sci. 2021;27:551-8 https://doi.org/10.5336/dentalsci.2020-79483
  23.  Sharma A, Upmanyu A, Kasat VO. Oral implications of parafunctional habits in children: A mini review. Neonat pediatr Med. 2021;7:1-3

  1. Assoicate Professor, Department of Orthodontics, Sharif Medical and Dental College, Lahore.
  2. Post-Graduate, FCPS- II Resident, Department of Orthodontics, Sharif Medical and Dental College, Lahore.
  3. Manager, Department of Monitoring and Evaluation, Punjab Health Care Commision.
  4. Assistant Professor, Department of Orthodontics, Azra Naheed Dental College (SuperiorUniversity)
  5. Post-Graduate, FCPS- II Resident, Department of Orthodontics, Sharif Medical andDental College, Lahore.
  6. Post-Graduate, FCPS- II Resident, Department of Orthodontics, Sharif Medical andDental College, Lahore.

Corresponding author: “Dr. Faiza Malik” < dr.faizahash@gmail.com >

Parafunctional Oral Habits: Frequency and Association with Malocclusion Traits in Adolescents

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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Infection Control Practices Followed by Postgraduate Residents of Public and Private Dental Institutions of Karachi During the COVID-19 Pandemic

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

  1. Zhu H, Wei L, Niu P. The novel coronavirus outbreak in Wuhan, China. Global health research and policy. 2020;5:1-3. https://doi.org/10.1186/s41256-020-00135-6
  2. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, Ren R, Leung KS, Lau EH, Wong JY, Xing X. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. New England J Med. 2020.
  3. https://doi.org/10.1056/NEJMoa2001316
  4. Helmy YA, Fawzy M, Elaswad A, Sobieh A, Kenney SP, Shehata AA. The COVID-19 pandemic: a comprehensive review of taxonomy, genetics, epidemiology, diagnosis, treatment, and control. J Clin Med. 2020;9:1225.
  5. https://doi.org/10.3390/jcm9041225
  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>

Infection Control Practices Followed by Postgraduate Residents of Public and Private Dental Institutions of Karachi During the COVID-19 Pandemic

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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Evaluation of Presence and Amount of Moisture in Dry Air of Three Way Syringes in Dental Teaching Hospitals andPrivate Clinics: A Cross-Sectional Study

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

  1. Nedeljkovic I, De Munck J, Vanloy A, Declerck D, Lambrechts P, Peumans M, et al. Secondary caries: prevalence, characteristics, and approach. Clin Oral Investig. 2020;24:683-91. https://doi.org/10.1007/s00784-019-02894-0
  2. Avoaka-Boni M-C, Djolé SX, Désiré Kaboré WA, D Gnagne-Koffi YN, E Koffi AF. The causes of failure and the longevity of direct coronal restorations: A survey among dental surgeons of the town of Abidjan, Côte d’Ivoire. J Conserv Dent. 2019;22:270-4. https://doi.org/10.4103/JCD.JCD_541_18
  3. Pawar A, Garg S, Mehta S, Dang R. Breaking the Chain of Infection: Dental Unit Water Quality Control. J Clin Diagn Res. 2016;10:ZC80- 4. https://doi.org/10.7860/JCDR/2016/19070.8196
  4. Pranckeviciene A, Narbutaite R, Siudikiene J, Damaševicius R, Maskeliunas R. An in vitro evaluation of microleakage of class V composite restorations using universal adhesive under different level of cavity moisture conditions. Stomatologija. 2019;21:113-8.
  5. Varughese RE, Andrews P, Sigal MJ, Azarpazhooh A. An Assessment of Direct Restorative Material Use in Posterior Teeth by American and Canadian Pediatric Dentists: I. Material Choice. Pediatr Dent. 2016;38:489-96.
  6. Geier DA, Geier MR. Dental Amalgams and the Incidence Rate of Arthritis among American Adults. Clin Med Insights Arthritis Musculoskelet Disord. 2021;14:11795441211016260. https://doi.org/10.1177/11795441211016261
  7. Hashimoto M, Tay FR, Svizero NR, de Gee AJ, Feilzer AJ, Sano H, et al. The effects of common errors on sealing ability of total-etch adhesives. Dent Mater. 2006;22:560-8. https://doi.org/10.1016/j.dental.2005.06.004
  8. Stape THS, Viita-Aho T, Sezinando A, Wik P, Mutluay M, TezvergilMutluay A. To etch or not to etch, Part I: On the fatigue strength and dentin bonding performance of universal adhesives. Dent Mater. 2021;37:949-60. https://doi.org/10.1016/j.dental.2021.02.016
  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
  12. Iwashita T, Mine A, Matsumoto M, Nakatani H, Higashi M, Kawaguchi-Uemura A, et al. Effects of three drying methods of post space dentin bonding used in a direct resin composite core build-up method. J Prosthodont Res. 2018;62:449-55. https://doi.org/10.1016/j.jpor.2018.04.006
  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
  14. Ali S, Gilani SBS, Shabbir J, Almulhim KS, Bugshan A, Farooq I. Optical coherence tomography’s current clinical medical and dental applications: a review. F1000Research. 2021;10:310. https://doi.org/10.12688/f1000research.52031.1
  15. Varma SR, Damdoum M, Alsaegh MA, Hegde MN, Kumari SN, Ramamurthy S, et al. Immunomodulatory Expression of Cathelicidins Peptides in Pulp Inflammation and Regeneration: An Update. Curr Issues Mol Biol. 2021;43:116-26. https://doi.org/10.3390/cimb43010010
  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 >

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

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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Analysing Anti-HBS Titer Levels in Vaccinated Students of Dentistry in A Tertiary Care Hospital

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

  1. Kashyap B, Tiwari U, Prakash A. Hepatitis B virus transmission and Health care workers: Epidemiology, Pathogenesis and Diagnosis. IJMS. 2018;9:30-35. https://doi.org/10.1016/j.injms.2018.01.003
  2. Pondé RA. Expression and detection of anti-HBs antibodies after hepatitis B virus infection or vaccination in the context of protective immunity. Archives of Virology. 2019;164:2645-58. https://doi.org/10.1007/s00705-019-04369-9
  3. Mangkara B, Xaydalasouk K, Chanthavilay P, Kounnavong S, Sayasone S, Muller CP, et al. Hepatitis B virus in lao dentists: a crosssectional serological study. Annals of Hepatology. 2021; 22:100282. https://doi.org/10.1016/j.aohep.2020.10.010
  4. Mbamalu C, Ekejindu I, Enweani I, Kalu S, Igwe D, Akaeze G. Hepatitis B virus precore/core region mutations and genotypes among hepatitis B virus chronic carriers in South-Eastern, Nigeria. International J Health Sci. 2021;15:26.
  5. Tariq S, Tareen MA, Uddin I, Qiam F. Assess the knowledge of dentists regarding Hepatitis B serological profile: a cross-sectional study. J Infection in Developing Countries. 2020;14:1210-6. https://doi.org/10.3855/jidc.12295
  6. Nagpal B, Hegde U, Kulkarni M. Hepatitis B Seropositivity and Immune Status in Dental Students. J Advanced Medi Dent Sci Res. 2019;7:9-12.
  7. Adenlewo OJ, Adeosun PO, Fatusi OA.Medical and dental students’ attitude and practice of prevention strategies against hepatitis B virus infection in a Nigerian university. PAMJ. 2017; 28:28-33. https://doi.org/10.11604/pamj.2017.28.33.11662
  8. Dowran R, Malekzadeh M, Nourollahi T, Sarkari B, Sarvari J. The prevalence of hepatitis B virus markers among students of Shiraz University of Medical Sciences. Advanced Biomedical Research. 2021;10. https://doi.org/10.4103/abr.abr_173_20
  9. Bialek SR, Bower WA, Novak R, Helgenberger L, Auerbach SB, Williams IT, et al. Persistence of protection against hepatitis B virus infection among adolescents vaccinated with recombinant hepatitis B vaccine beginning at birth: a 15-year follow-up study. Pediat J Infect Dis. 2008; 27:881-885. https://doi.org/10.1097/INF.0b013e31817702ba
  10. Gara N, Abdalla A, Rivera E, Zhao X, Werner JM, Liang TJ,et al. Durability of Antibody Response Against Hepatitis B Virus in Healthcare Workers Vaccinated as Adults. Clin J Infect Dis. 2015; 60:505-13. https://doi.org/10.1093/cid/ciu867
  11. Salama II, Sami SM, Said ZN, Salama SI, Rabah TM, Abdel-Latif GA,et al. Early and long term anamnestic response to HBV booster dose among fully vaccinated Egyptian children during infancy. Vaccine. 2018; 36:2005-2011. https://doi.org/10.1016/j.vaccine.2018.02.103
  12. Shabanah W, Bukhari A, Alandijani A, Alyasi A, Youssef AR. Prevalence of HBV and Assessment of Hepatitis B Vaccine Response among Dental Health Care Workers in Dental Teaching Hospital, Umm Al-Qura University, Saudi Arabia. Egyptian J Immunology. 2019;26:11-7.
  13. Ara SA, Fatima A. Acquired Immunity in Dentistry Students After Hepatitis B Vaccination. J Res Dent Maxillofacial Sci. 2020;5:33-6. https://doi.org/10.29252/jrdms.5.3.33
  14. Rizvi KF, Arslaan M, Raza H, Hira A, Hamid S, Fatima A. Assessing sero-protective levels of anti-hbs titer in pre-vaccinated dental students and dental professionals at bahria university medical & dental college (BUMDC), Karachi. Pak Oral Dent J. 2017;37:472-6.
  15. Attaullah S,Khan S,Naseemullah,Ayaz S,Khan S,Ali I,et al. Prevalence of HBV and HBV vaccination coverage in health care workers of tertiary hospitals of Peshawar. Pakistan.Virol J. 2011;8:275- 81. https://doi.org/10.1186/1743-422X-8-275
  16. Sajid M, Jamil M, Javed M. Vaccination Status Of Dental Students Of Multan Dental College Multan Against Hepatitis B Virus. Pak Oral Dent J. 2018;38:513.
  17. Peeran SW, Peeran SA ,Al Mugrabi M,Abdalla K , Murugan M, Alsaid F,Hepatitis B: Knowledge and Attitude of Graduating Dentists from Faculty of Dentistry, Sebha University, Libya. Dent Med Rcs.2017; 5:18-23. https://doi.org/10.4103/2348-1471.198785
  18. Benarji KA, Anitha A, Suresh B, Aparna V,Praveena A, Penumatsa LA. Knowledge and attitude of dental students toward hepatitis B virus and its vaccination – A cross-sectional study. J Oral Maxillofac Pathol. 2021;25:553. https://doi.org/10.4103/jomfp.jomfp_387_21
  19. Cocchio S, Baldo V, Volpin A, Fonzo M, Floreani A, Furlan P, et al. Persistence of anti-HBs after up to 30 years in health care workers vaccinated against hepatitis B virus. Vaccines. 2021;9:323. https://doi.org/10.3390/vaccines9040323
  20. Lasemi E, Haddadpour N, Navi F, Rakhshan A, Rakhshan V. Rate of acquired immunity in dental students after hepatitis B vaccination. Dent Res J (Isfahan). 2011;8:128-31.
  21. Acchammachary AA, Ubale M, Belurkar DD, Bhave PP, Malgaonkar AA, Kartikeyan S. A cross-sectional study of post-vaccination antiHBs titer and knowledge of hepatitis B infection amongst medical students in a metropolitan city. Int J Research in Medical Sciences. 2017;5:83-8. https://doi.org/10.18203/2320-6012.ijrms20164528
  22. Sernia S, Ortis M, Antoniozzi T, Maffongelli E, La Torre G. Levels of anti-HBs antibody in HBV-vaccinated students enrolled in the faculty of medicine, dentistry and health professions of a large Italian University. BioMed research international. 2015; 2015. https://doi.org/10.1155/2015/712020
  23. Noubiap JJN, Nansseu JRN, Kengne KK, Ndoula ST, Agyingi LA. Occupational exposure to blood, hepatitis B vaccine knowledge and uptake among medical students in Cameroon. BMC Med Educ. 2013;13:148. https://doi.org/10.1186/1472-6920-13-148
  24. Saquib S, Ibrahim W, Othman A, Assiri M, Al-Shari H, Al-Qarni A. Exploring the knowledge, attitude and practice regarding hepatitis B infection among dental students in Saudi Arabia: A cross-sectional study. Open access Macedonian J Medical Sci. 2019;7:805. https://doi.org/10.3889/oamjms.2019.111
  25. Al-Dabbas M, Abu-Rmeileh NM: Needlestick injury among interns and medical students in the occupied Palestine territory. East Mediterr Health J. 2012;18:700-6. https://doi.org/10.26719/2012.18.7.700
  26. Kiyani A, Zafar M, Abbasi A, bin Saeed MH. Hepatitis B Vaccination Status of Students and Dentists in Dental Colleges of Pakistan. J Liaquat University of Medical & Health Sciences. 2020;19:62-5.
  27. Malhotra V, Kaura S, Sharma H. Knowledge, attitude and practices about hepatitis B and infection control measures among dental students in Patiala. J Dent Allied Sci. 2017;6:65. https://doi.org/10.4103/2277-4696.219977
  28. Souza EP, Teixeira Mde S. Hepatitis B vaccination coverage and postvaccination serologic testing among medical students at a public university in Brazil. Rev Inst Med Trop Sao Paulo. 2014;56:307-11. https://doi.org/10.1590/S0036-46652014000400007
  29. . Mangkara B, Xaydalasouk K, Chanthavilay P, Kounnavong S, Sayasone S, Muller CP,et al. Hepatitis B virus in lao dentists: a crosssectional serological study. Annals of Hepatology. 2021;22:100282. https://doi.org/10.1016/j.aohep.2020.10.010
  30. Lingawi HS, Afifi IK. Seroprotection of Hepatitis B Vaccine in Dental Students Two Decades after Infant Immunization and the Possible Need for Revaccination. European J Dentistry. 2022. https://doi.org/10.1055/s-0042-1743151
  31. 31 Lamberti M, Garzillo EM, Muoio MR, Arnese A, Nienhaus A, Abbondante E,et al. Seropositivity for Hepatitis B Virus, Vaccination Status and Response to Vaccine in a Cohort of Dental Students. Open J Preventive Medicine. 2017;7:32-9. https://doi.org/10.4236/ojpm.2017.72003
  32. Roupa Z, Noula M, Farazi E, Stylianides A, Papaneophytou C. Vaccination coverage and awareness of Hepatitis B virus among healthcare students at a university in Cyprus. Materia Socio-medica. 2019;31:190. https://doi.org/10.5455/msm.2019.31.190-196
  33. Yildirim TT, Kaya FA, Kaya CA. Assessment of Hepatitis B vaccination status of students of faculty of dentistry. Int Dent Research. 2017;7:46-53. https://doi.org/10.5577/intdentres.2017.vol7.no3.1
  34. Aparajita D Shitoot, Mukta Motwani, Durga P Chamele, Abhinay P Shitoot, Jay Chamele, Akash Ghosh. Hepatitis B awareness and attitudes among dental professionals in Central India. J Indian Acad Oral Med Radiol 2016;28:270-73 https://doi.org/10.4103/0972-1363.195650

  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 >

Analysing Anti-HBS Titer Levels in Vaccinated Students of Dentistry in A Tertiary Care Hospital

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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