Surgical and Prosthodontic Management of Denture Induced Hyperplastic Lesion in Maxillary Arch – A Case Series

Uzma Anam Iqbal1                   BDS
Ahsan Inayat2                          BDS
Afsa Mujahid3                          BDS
Muneeb Ahmed Lone4            BDS, FCPS
Bilal Hussain5                         BDS

 

Denture irritation hyperplasia is a hyper plastic lesion of the oral mucosa which results from chronic irritation as a result of
wearing poorly adapted dentures. It is most commonly seen in maxillary arch with female patients being mostly effected. The
lesion varies in size from only a few millimeters to extending to involve the entire quadrant. The clinical management of denture
induced hyperplasia depends upon the size of lesion and involves the elimination of causative factors, excision of excess fibrous
tissue accompanied by an appropriate prosthetic rehabilitation. This case series presents the management of denture induced
hyperplastic lesion of varying sizes present in maxillary arch by providing appropriate tissue rest and tissue conditioning as
well as by surgical excision followed by new denture fabrication to achieve acceptable function for patients.
KEYWORDS: Denture hyperplasia, Epulis fissuratum, Tissue conditioning, Prosthesis
HOW TO CITE: Iqbal UA, Inayat A, Mujahid A, Lone MA, Hussain B, Kumar B. Surgical and prosthodontic management
of denture induced hyperplastic lesion in maxillary arch - A case series. J Pak Dent Assoc 2023;32(1):27-30.
DOI: https://doi.org/10.25301/JPDA.321.27
Received: 11 April 2022, Accepted: 08 December 2022

INTRODUCTION

Denture induced hyperplasia also known as epulis fissuratum is an overgrowth of intraoral tissues resulting from chronic irritation. 1 It is considered as a common tissue reaction resulting from chronic ill-fitting dentures and presents as an occurrence of hyper plastic tissue along the denture border. 2 This process results in resorption of the ridge which may occur as a result of over extended denture borders resulting in chronic irritation to oral tissues in the vestibular region. 3 It is characterized by slow development of elongated roll of tissues in the muco-buccal fold region into which denture flange fits and is symptomless until the lesion become ulcerated. Epulis fissuratum is usually treated by conservative management or it is surgically excised depending on the extent of the lesion. 4 Rosenquist stated that persistent trauma to the oral tissues by the rough borders of ill-fitting dentures or sharp edges of teeth may predispose patients to oral cancer. Therefore, ill-fitting dentures and their sequelae should never be neglected. 5
CASE 1
A 63-year-old female patient reported to the department of Prosthodontics, Dr Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Karachi for fabrication of a new set of complete dentures. Past dental history revealed that the patient was a denture wearer since last ten years. On examination of her existing maxillary denture a suction disk was present on the intaglio surface and the borders of left labial flange were sharp and overextended (Fig 1a). Patient had an average denture hygiene with signs of occlusal wear of teeth. Medical as well as family history were non-contributory. Patient had no habit of pan, chalia or tobacco chewing. Extra oral examination showed no atypical features. Intraoral examination disclosed palatal mucosa with a well-defined depression at the middle in the hard palate which was non-tender on palpation.
Furthermore, there was a well-defined multi-lobular hyperplastic lesion in the left vestibular region in maxillary arch extending from central incisor to premolar region with flange of denture fitting in between the tissue folds (Fig 1b). On palpation, the tissue folds were non tender, mobile and had no ulceration on the base of the lesion. Patient did not give any history of pain or swelling hence it was an accidental finding. On basis of history and clinical evaluation a preliminary diagnosis of denture irritation hyperplasia was made. Patient was advised not to use her denture and oral hygiene instructions were given to her. Due to extensive size of hyperplastic tissue pre-prosthetic surgery was planned since conservative management alone would not completely resolve the lesion. Local anesthesia was administered for infraorbital, anterior superior alveolar and lesser palatine nerve. The periphery of the lesion was marked with an indelible pencil and was resected from its base with a no.15 surgical blade followed by primaryclosure with sutures. Patient was given postoperative instructions along with antibiotics and analgesics. The specimen excised was sent for histopathological examination which confirmed the diagnosis (Fig 1c). The patient was recalled after 15 days for follow up and suture removal. On 02 months follow-up, the tissues had healed completely and impression for fabrication of new complete denture was made (Fig 1d). The patient was kept on follow up visits for 7 months and no relapse of lesion was found till date. (Fig 1e).

A 50-year-old female presented to the Prosthodontic department with complaint of an ill-fitting maxillary denture and a painless soft tissue mass in the maxillary arch since last one year. The patient was wearing the denture since the last six years, without removing it at nighttime. Lower arch was rehabilitated with a distal extension RPD which the patient misplaced around 5 years back. On denture examination, over-extended left labial flange border was observed, along with an imprint of suction disk in the center of fitting surface of denture. (Fig 2 a). Extra oral examination was within normal limits. On intraoral examination, generalized erythematous mucosa and folds of fibrous hyperplastic tissues were observed in the maxillary anterior labial sulcus (Fig 2 b). There was no pain and tenderness on palpation of the fibrous tissues. In the mandibular arch, anterior teeth were present with bilateral free end saddle in the posterior region. A provisional diagnosis of denture induced hyperplasia was made based on history and clinical examination. The patient was advised discontinuing wearing of denture to give appropriate tissue rest. Oral hygiene instructions were given such as regular brushing, use of Chlorhexidine mouth wash, warm saline rinses 3 times a day and finger massage of the affected area. On follow-up visit at three weeks, the fibrous tissue showed regression with no sign of inflamed mucosa. Oral hygiene instructions were reiterated. A new prosthesis was fabricated after two months when there was marked decrease in the size of lesion
(Fig 2c & 2d).

A 71-year-old male patient visited dental outpatient department of Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, with chief complaint of loose maxillary complete denture since last 3 months. History revealed that
he was wearing the denture since past two years. There was no significant medical history. Extra oral examination revealed no atypical features. On intraoral examination, inflamed mucosa and fibrous hyperplasia was noticed that was not tender to palpation (Fig 3a). It was associated with a sharp, over extended maxillary denture flange in anterior labial sulcus. Maxillary denture was opposed by full arch porcelain fused to metal fixed prosthesis with which the patient was satisfied and had no complaints. Denture examination revealed poor denture hygiene, worn occlusal surfaces and improperly repaired midline fracture. A provisional diagnosis of denture induced hyperplasia was made based on history and clinical examination. The patient was educated regarding maintenance of oral and denture hygiene, immediate discontinuation of denture wearing, finger massage of affected area and use of anti-inflammatory mouth wash. On recall visit after 2 weeks mucosa was still inflamed, hence maxillary denture was relined with tissue conditioner for improved mucosal healing (Fig 3b). This procedure was repeated twice till the size of lesion regressed. After improvement in health of oral tissues new dentures were fabricated (Fig 3c & 3d).

DISCUSSION
Chronic irritation and continuous trauma to oral mucosa by ill-fitting denture are main causative factors associated with the occurrence of epulis.6 Clinically, epulis fissuratum presents as a raised sessile lesion in folds with a smooth surface that may have a normal or erythematous overlying mucosa.7 The lesion may also occur due to gradual ridge resorption, which leads to reduced ridge height and overextended denture flanges causing chronic irritation to the mucosa.8 The size of the fibrous tissue ranges from a smaller mass to an extensive lesion which may involve the entire vestibule. Although the lesion is often symptomless, occasionally inflammation and ulceration may occur.9
In our reported cases, overextended and ill-fitting denture flanges of maxillary complete denture were the main etiologic factors identified. These findings are similar to other studies in which ill-fitting denture flanges were the main reason for denture induced hyperplasia.10,11

Firoozmand and Buchner et al reported occurrence of these lesions mostly in the maxillary arch with female patients (78%) being mostly affected.12,13 These findings are comparable to our reported cases where two out of three cases were female patients with the lesion present in maxillary arch.
In two of our reported cases, patient presented with rubber suction disk retained maxillary dentures. These were placed in palatal region on the intaglio surface to improve retention of the maxillary denture. Suction cup induces immense negative pressure on the mucosal surface and may cause soft tissue changes and in extreme cases loss of palatal bone and perforation.14 Despite its known ill effects many cases of suction disc dentures are still reported in our clinical settings. Palatal suction cups should be highly discouraged as they have pathological effects on palatal tissues. In our reported cases, palatal soft tissue changes due to suction disk were minimal. Therefore, patients were advised to discontinue use of dentures and apply analgesic gel, which lead to complete healing of palatal tissues. Denture-irritation hyperplasia may be managed conservatively or surgically. In early stages of fibrous hyperplasia, nonsurgical treatment with soft-liners is frequently sufficient for elimination or reduction of the hyperplastic tissues.9
Two of the patients in our reported cases were managed with conservative approach (case 2 and 3). Patients were instructed to discontinue the use of denture for some time. Denture faults were corrected and tissue surface was relined with tissue conditioning material (GC Soft Liner). This procedure was repeated for 2-3 times over the span of 15 days till the size of lesion regressed. However, these measures were effective since size of fibrous tissue lesion was small. After complete healing of the tissues, new dentures were fabricated.
Tissue conditioning is a non-invasive treatment that can be solely used to manage clinical cases of small mucosal hyperplastic lesions. However it has limitations in cases with extensive mucosal lesions where there is significant fibrosis and surgical excision of hyperplastic tissue is required in such cases.15,16 In our reported Case 1, the size of lesion was extensive and hence it was surgically excised. These results are similar to a study conducted by Khan WU et al15 in which extensive hyperplastic lesion in the maxillary arch was managed surgically. Surgical techniques include conventional surgical supra-periosteal and advanced techniques eg: cold blade, electro-surgery, lasers or cryosurgery.17 In our case conventional surgical supra- periosteal excision was performed.
CONCLUSION
Denture-induced hyperplasia is a sequelae of wearing complete denture, which commonly occurs due to chronic irritation and ill-fitting dentures. Few cases of epulis fissuratum are presented which were managed by both conservative and surgical approach. Once the lesion is identified patient should be reassured about its benign nature. Instructions regarding meticulous oral and denture hygiene should be provided and patient should be kept on regular recall and follow-up visits to prevent recurrence.

CONFLICT OF INTEREST
None declared

REFERENCES
1. The Glossary of Prosthodontic Terms: Ninth Edition. J Prosthet Dent. 2017;117(5S):e1- e105.
https://doi.org/10.1016/j.prosdent.2016.12.001

2. Agarwal AA, Mahagan M, Mahagan A, Devhare S. Application of diode laser for excision of inflammatory vascular epulis fissuratum. Int J Case Reports Images. 2012;3:42-45.

3. Bhasker RM, Davenport JC, Thomson JM. 5th ed. UK: WillyBlackwell; 2001. Prosthetic treatment of the edentulous patients.

4. Mohan RP, Verma S, Singh U, Agarwal Epulis fissuratum: consequence of ill-fitting prosthesis. Brit Med J Case Reports.2013;1- 2.
https://doi.org/10.1136/bcr-2013-200054

5. Rosenquist K. Risk factors in oral and oropharyngeal squamous cell carcinoma: a population- based case-control study in southern Sweden. Swedish Dent J. 2005;179(Suppl):1-66.

6. Kafas P, Upile T, Stavrianos C, Angouridakis N, Jerjes W. Mucogingival overgrowth in a geriatric patient. Dermatol Online J. 2010;16:7.
https://doi.org/10.5070/D399Z2D3TC

7. Janosi K, Popsor S, Ormenisan A, Martha K. Comparative study of hyper plastic lesions of the oral mucosa. Eur Scientific J. 2013;9.

8. Budtz-Jørgensen E. Oral mucosal lesions associated with the wearing of removable dentures. J Oral Pathol Med. 1981;10:65-80.
https://doi.org/10.1111/j.1600-0714.1981.tb01251.x

9. Veena KM, Jagadishchandra H, Sequria J, Hameed SK, Chatra L, Shenai An extensive denture induced hyperplasia of maxilla. Annals Med Health Sci Res. 2013;3:7-9.
https://doi.org/10.4103/2141-9248.121208

10. Ayyaz M , Afzal S, Mehdi H, Kaukab H. Prevalence of reactive hyperplastic oral lesions. Pak Oral Dent J. 2020;40:162-6.

11. Rizvi SHA, Aqeel R, Zaki A, Ijaz S, Syed S, Nadeem A. Prevalence and distribution of denture induced oral mucosal lesions among patients managed in Lahore teaching hospital. Pak J Med Health Sci. 2022;16.
https://doi.org/10.53350/pjmhs22165179

12. Firoozmand LM, Almeide JD, Cabral LA. Study of denture-induced fibrous hyperplasia cases diagnosed from 1979-2001. Quintessence Int. 2005;36:825-9.
https://doi.org/10.1016/j.prosdent.2006.03.010

13. Buchner A, Begleiter A, Hansen LS. The predominance of Epulis Fissuratum in females. Quintessence Int Dent Dig. 1984; 15:699-702.

14. Rao Y, Yadav P, Singh J, Patel D, Aggarwal A. Surgical and prosthetic management of suction cup induced palatal perforation: Case report. J Clin Diagnostic Res. 2013;7:2086.
https://doi.org/10.7860/JCDR/2013/6300.3413

15. Khan MWU, Mushtaq MA, Shah AA. A massive denture induced hyperplastic lesion in maxilla- a case report. J Pak Dent Assoc. 2019;28:47-9
https://doi.org/10.25301/JPDA.281.47

16. Monteiro LS, Mouzinho J, Azevedo A, Câmara MI da, Martins MA, La Fuente JM. Treatment of epulis fissuratum with carbon dioxide laser in a patient with antithrombotic medication. Braz Dent J. 2012;23:77-81.
https://doi.org/10.1590/S0103-64402012000100014

17. Ibrahim AH. Prosthetic and surgical management of a sizeable epulis fissuratum: a case report. Pan African Med J. 2022;41:9. https://doi.org/10.11604/pamj.2022.41.49.31339

Surgical and Prosthodontic Management of Denture Induced Hyperplastic Lesion in Maxillary Arch – A Case Series

Uzma Anam Iqbal1                   BDS
Ahsan Inayat2                          BDS
Afsa Mujahid3                          BDS
Muneeb Ahmed Lone4            BDS, FCPS
Bilal Hussain5                         BDS

 

Denture irritation hyperplasia is a hyper plastic lesion of the oral mucosa which results from chronic irritation as a result of
wearing poorly adapted dentures. It is most commonly seen in maxillary arch with female patients being mostly effected. The
lesion varies in size from only a few millimeters to extending to involve the entire quadrant. The clinical management of denture
induced hyperplasia depends upon the size of lesion and involves the elimination of causative factors, excision of excess fibrous
tissue accompanied by an appropriate prosthetic rehabilitation. This case series presents the management of denture induced
hyperplastic lesion of varying sizes present in maxillary arch by providing appropriate tissue rest and tissue conditioning as
well as by surgical excision followed by new denture fabrication to achieve acceptable function for patients.
KEYWORDS: Denture hyperplasia, Epulis fissuratum, Tissue conditioning, Prosthesis
HOW TO CITE: Iqbal UA, Inayat A, Mujahid A, Lone MA, Hussain B, Kumar B. Surgical and prosthodontic management
of denture induced hyperplastic lesion in maxillary arch - A case series. J Pak Dent Assoc 2023;32(1):27-30.
DOI: https://doi.org/10.25301/JPDA.321.27
Received: 11 April 2022, Accepted: 08 December 2022

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Revisiting the Role of Periodontal Plastic Surgery in Regenerative Therapies Clinical Criteria and Biological Principles

Muhammad Haris Zia             BDS, (Pak) MClindent (UK)

 

One of the manifestations of periodontitis is bone loss and tooth mobility. Thus, periodontal regeneration plays a vital in
reinstating the lost alveolar bone and periodontal tissue. This study aims at the different literary resource that highlight the role
of periodontal plastic surgery; clinical criteria and biological principles that facilitates the process of regeneration. Several
corrective steps are implemented for the management of chronic periodontal disease, such as the first line of intervention which
is the non-surgical treatment that consists of Oral hygiene instructions and removal of biofilms. After non-surgical phase of
treatment once the tissue is healed, surgical techniques are to be considered for the management of the remaining pockets also
known as residual pockets or to formulate a gingival apparatus that promotes plaque control. However, if there is a loss of tissue
it is quintessential to take into consideration regenerative procedures.
KEYWORDS: Periodontal plastic surgery, biological principals, regeneration
HOW TO CITE: Zia MH. Revisiting the role of periodontal plastic surgery in regenerative therapies clinical criteria and
biological principles. J Pak Dent Assoc 2023;32(1):22-26.
DOI: https://doi.org/10.25301/JPDA.321.22
Received: 02 August 2022, Accepted: 01 April 2023

INTRODUCTION

The purpose of periodontal regeneration is to rehabilitate the loss of supporting structures surrounding the tooth other than injury or periodontal disease. (Villar and Cochran, 2010).1 Several corrective steps are implemented for the management of chronic periodontal disease, such as the first line of intervention which is the non-surgical treatment that consists of oral hygiene instructions and removal of biofilms. (Reynolds et al., 20102
: Table 1). After nonsurgical phase of treatment once the tissue is healed, surgical

techniques are to be considered for the management of the remaining pockets also known as residual pockets or to formulate a gingival apparatus that promotes plaque control. (Koop et al., 2002).3 However, if there is a loss of tissue it is quintessential to take into consideration regenerative procedures. (Rojas et al., 2019).4 Illustrated in Fig 15 ; regeneration is a multifactorial approach which need several steps such as appropriate patient selection based on the potentiality of wounding healing, also the extent of the periodontal tissue loss and the influence of the nonsurgical regenerative methods. ( Rojas et al.,2019).4

Fig 1: Influental factors in periodontal regeneration. This figure illustrates the needs to control disease and consider a range of factors associated with inflammation and biofilm formation in order to justify regenerative approaches in periodontal surg

CLINICAL STANDARD FOR SURGICAL AND REGENERATIVE THERAPY

Periodontal plastic surgery may be incorporated to facilitate wound healing as it can provide a conductive environment for the healing process. A variety of factors influence whether periodontal plastic surgery is appropriate for an individual patient, including their condition and whether specific surgical approaches are necessary. (Villar and Cochran,2010).1 It is to be understood that periodontal plastic surgical techniques to regenerate are divergent in context thus they consist of a variety of techniques, resulting in a general lack of consensus over the ideal or the best possible strategy and a wide range of factors contribute to this lack of consensus and one of them is patient suitability. (Tatakis et al., 2015).6 This argument has also put forward a debate that has been held responsible for the use of specific regenerative therapies, including guided tissue regeneration (GTR) and enamel matrix derivatives, both of which may have specific applicationsdepending on the clinical context in which they are applied (Rojas et al., 2019).4 Nevertheless, at the forefront remains an early and safe wound closure that leads to a successful regeneration. However, the integrity of wound closure is dependent upon the stability of the wound in the first postoperative week. Facilitated by the use the use of biomodulators that are the guided tissue regeneration and Enamel Matrix derived protein for primary intention healing. (Rojas et al., 2019).4 Although to advocate the practice of surgical approaches, in all forms of regenerative therapy, there is no well-defined and consistent clinical criteria. However, the results of several studies indicate that patient with specific characteristics may be subservient to surgical approaches. (Walter et al.,2011; Rojas et., 2019).7

The above-mentioned specific characteristics are elimination of toxins from the root surface, space maintenance to facilitate movement of cells from intact periodontal ligament, wound stabilisation, and primary healing due to passive adaptation of the flap and complete wound closure (Hagi et al., 2014).8 To promote regeneration at times the surgical intervention may require augmentative materials. A non-resorbable membrane is the best possible example of augmentative material as tend to stabilize the site and promote wound healing. (Tatakis et al., 2015).6

SURGICAL METHODS FOR REGENERATIVE THERAPY
In regenerative periodontal therapy the surgical methods implemented may vary. Thus, resulting in complexity in patient selection along with the indication for specific procedures. However, most surgical approaches evolve in concert with the formulation of flaps to encourage healing and to amplify local tissue (Rojas et al., 2019).4 Immobilized flaps or sedentary flaps also known as passive flaps can be advantageous for wound healing when regenerative bone procedures are performed, however, importance must be given to stability at the site of primary closure and not to allow tension to be introduced across the wound (Ronda and Stacchi,.2011).9 As if the flaps are to be unstable it may result in premature exposure of the augmented site Ronda and Stacchi, 2011).9 Overall, the dynamics of the flaps should be maintained throughout the regenerative procedure.
An analysis carried by Cortellini et al., 201710; In which they studied the patient outcomes and cost related to the applicability of the modified papilla preservation flaps, access flaps with membrane use and access flaps alone to illustrata long-term effect of regenerative approaches. Resulted in regenerative approaches (modified papilla preservation and access flaps with membrane) superseding the access flaps alone when it comes to long term outcomes. The use of the formal facilitates wound healing and tissue regeneration. Additionally, in the same study it was also illustrated that with the help of regenerative approaches the periodontal inflammation subsided and there was a minimal tooth loss. However, the cost associated with the regenerative approaches were higher. Concurrently, Nickles et al., 2017.11 In their retrospective case series also demonstrated that the implementation of periodontal regenerative approaches hampers an improved root coverage. Overall, considering the above-mentioned studies sufficient evidence can be drawn to support the role of regenerative approaches in patient with infraboney defects. However, it should be noted that these studies had some heterogeneity in patient analysis in lieu of the size and site of wound, therefore a tailored approach can also be an important aspect for care planning.
In periodontal plastic surgery a common technique used for regeneration is the use of coronally advanced flap (Nickkles et al., 2017).11 As it is found to be in high probability in cases of patients having gingival recession and are in dire need of root coverage either alone with the support of coronally advance flap or with the use of connective tissue graft underneath the flap (Cairo et al., 2016).12 However, it must be considered that in cases of root coverage the underlined thickness of the keratinized tissue is of significance as the interplay of the keratinized tissue resulted in esthetical
appealing results and determines the need of connective graft in addition to the coronally advanced flap alone. The  use of coronally advance flap has also shown to reduces the surgical time, morbidity related to graft harvesting and maintaining a stable clinical outcome (Cortellini and pini prato.,2012).13
Overall, the leading strategy for periodontal plastic
surgery remains the use of coronally advance flap (Tatakis et al.,2015).6In clinical scenarios where there is a deep lingual recession and a lack of keratinized tissue the connective tissue graft wall method has been illustrated. (Zucchelli et al., 2016).14 This method incorporates placement of a connective tissue graft underneath a coronally advance flap, imparting a shape of gentle tissue wall. (Zucchelli et al., 2016).15 Evaluation of this method in exercise has in large part been restricted to case research or series (Gonzalez et al., 2015; Zucchelli et al., 2016; Zucchelli et al., 2017).15,16,17 even though proof shows that this method might also additionally promote root coverage and upgrades the volume/thickness of keratinised tissue. Further research might be required to triumph over the restrictions of case study.

FACTORS INFLUENCING SURGICAL OUTCOMES
The selection of the surgical technique, anatomical factors and biological/physiological factors has an influence in the surgical outcome of periodontal plastic surgery (Nickles et al., 2017).11 Some of factors are depicted in
Fig 2.

Fig 2: Patient-related factors that influence regenaertive periodontal therapy outcomes. A range of factors can influence the sucess of periodontal techniiques during regenerative therapy, including local, systematic and behavioural factors. Bop, bleeding on probing; FMPS, full-mouth plague score. Adapted from Hagi et al., (2014: 188) 8 The healing pathology in periodontal plastic surgery or any periodontal therapy is influenced by the treatment of infections and control of systematic disease (e.g. diabetes). Thus, it is of significance to consider these factors before initiating therapy (Hagi et al.,2014).8 Evidence also points out towards sufficiency of the local blood supply next to the graft bed, attributes of the graft (size, characteristics of the border and thickness) parafunctional habits of patient such as smoking. (Camargo et al.,2001; Shkreta et al.,2018).18,19 Structural integrity of the defect is also a factor that influence the surgical outcomes. An intraosseous defect having a depth of more than 3mm with defect angle of less than 25 degrees results in greater potential of regeneration in contrast to shallower defect. Also, the number of the remaining walls surrounding the defects play a vital role. A defect with high number of remaining walls also called a contained defect is more likely to have an optimal heal (Hagi et al., 2014).8
A successful wound healing is dependent on vascularity of the surgical site. As immunological response and blood clotting is triggered by an adequate blood supply (Sculean et al.,2015).20 Certain areas such as root surface where is a scarcity of vascularity, alternative technique is implemented. Such as the use of scaffold formation in which matrix of growth factors and stem cells are held responsible for wound healing and repair (Lin et al.,2009).21 It is of clinical significance that the scaffold design should be sufficient for the cells to carry out adhesion/attachment and proliferation. However, challenges may arise in compromised soft tissues or areas of poor vascularity for the clot to form. Thus, rehabilitation is carried out by the support of platelet rich fibrin membranes. (Jankovic et al., 2012).22 Which provides an ideal environment for the blood clot to adhere resulting in wound healing and closure. It must be noted that systematic factors related to the patient are of paramount for the clotting factor to provide an optimal result.
Failure of periodontal regeneration is common among smokers. Literary resources (Silva et al.,2010)23 illustrated that excessive smoking that is 10 cigarettes per day downgrade
the success rate of periodontal regeneration because it effects  the blood supply and immunological activity during healing.
Additionally, it also minimizes the risk of infection resulting in a stable post-surgical environment to ease the process of wound healing. Usually, wounds that are in context with periodontal surgery are sensitive in nature as the tooth structure projection hamper bacterial contamination of the wound. (Susin et al., 2015).24
To guarantee the effectiveness of regenerative treatments, firstly it is of significance to identify patients who are suitable for surgery. This consist of pre-surgical protocol that ensures in reducing the risk of infection and compromised healing. Secondly, selection of the appropriate surgical techniques based on the clinical scenario, and lastly, maintaining optimal post-surgical care. (Rojas et al., 2019).4
In aspect to uncontained defects, with limited number of adjacent osseous wall present variation in the surgical approach is justified. In such cases crestal incision is preferred. However, there is a general scarcity of consensus in the evidence comparing the effectiveness of different techniques and approaches, therefore clinician should opt for the

CONCLUSION
There is no doubt now that when it comes to optimal regeneration in patient with chronic periodontal disease and loss of tissue, periodontal plastic surgery remains at the forefront. However, as a clinician it is important to carry out a comprehensive assessment of patient health, variables associated with wound size and shape. Also, the risk factors that can result in compromised wound healing because all  these factors will affect the choice of surgical approach and the precise nature of the technique. Whereas to improve results, patient behaviour and parts of surgical methods should be targeted. Still more research is needed to assess alternative regeneration techniques in conjunction with periodontal plastic surgery, taking both clinical and cosmetic outcomes into account.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Villar, C. C., & Cochran, D. L. (2010). Regeneration of periodontal tissues: guided tissue regeneration. Dent Clin, 54:73-92.
https://doi.org/10.1016/j.cden.2009.08.011

2. Reynolds, M. A., Aichelmann-Reidy, M. E., & Branch-Mays, G.L. (2010). Regeneration of periodontal tissue: bone replacement
grafts. Dent Clin, 54;55-71. https://doi.org/10.1016/j.cden.2009.09.003

3. Koop, R., Merheb, J., & Quirynen, M. (2012). Periodontalregeneration with enamel matrix derivative in reconstructive periodontal therapy: a systematic review. J Periodontol. 83:707-20
https://doi.org/10.1902/jop.2011.110266

4. Rojas, M. A., Marini, L., Pilloni, A., & Sahrmann, P. (2019). Early wound healing outcomes after regenerative periodontal surgery with enamel matrix derivatives or guided tissue regeneration: a systematic review. BMC Oral Health. 19:76-86
https://doi.org/10.1186/s12903-019-0766-9

5. Larsson, L., Decker, A. M., Nibali, L., Pilipchuk, S. P., Berglundh,T., & Giannobile, W. V. (2016). Regenerative medicine for periodontal and peri-implant diseases. J Dent Res. 95;255-266.
https://doi.org/10.1177/0022034515618887

6. Tatakis, D. N., Chambrone, L., Allen, E. P., Langer, B., McGuire,M. K., Richardson, C. R., & Zadeh, H. H. (2015). Periodontal soft tissue root coverage procedures: A consensus report from the AAP Regeneration Workshop. J Periodontol. 86: S52-S55.
https://doi.org/10.1902/jop.2015.140376

7. Walter, C., Weiger, R., & Zitzmann, N. U. (2011). Periodontal surgery in furcation-involved maxillary molars revisited-an introduction of guidelines for comprehensive treatment. Clin Oral Investi.15;9-20.

8. Hagi, T. T., Laugisch, O., Ivanovic, A., & Sculean, A. (2014).Regenerative periodontal therapy. Quintessence Int. 45;185-92.

9. Ronda, M., & Stacchi, C. (2011). Management of a coronally advanced lingual flap in regenerative osseous surgery: a case series introducing a novel technique. Int J Period Rest Dent. 31, 505-15

10. Cortellini, P., Buti, J., Pini Prato, G., & Tonetti, M. S. (2017). Periodontal regeneration compared with access flap surgery in human intra-bony defects 20-year follow-up of a randomized clinical trial: tooth retention, periodontitis recurrence and costs. J Clin Periodontol, 44;1-10
https://doi.org/10.1111/jcpe.12638

11. Nickles, K., Dannewitz, B., Gallenbach, K., Ramich, T., Scharf, S., Röllke, L., & Eickholz, P. (2017). Long-term stability after regenerative treatment of infrabony defects: A retrospective case series.
J Periodontol. 88;536-542.
https://doi.org/10.1902/jop.2017.160704

12. Cairo, F., Cortellini, P., Pilloni, A., Nieri, M., Cincinelli, S., Amunni, F., & Tonetti, M. S. (2016). Clinical efficacy of coronally advanced flap with or without connective tissue graft for the treatment of multiple adjacent gingival recessions in the aesthetic area: a randomized controlled clinical trial. J Clin Periodontol. 43;849-856.
https://doi.org/10.1111/jcpe.12590

13. Cortellini, P., & Pini Prato, G. (2012). Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience. Periodontol 2000.
59;158-184.
https://doi.org/10.1111/j.1600-0757.2011.00434.x

14. Zucchelli, G., Bentivogli, V., Ganz, S., Bellone, P., & Mazzotti, C. (2016). The connective tissue graft wall technique to improve root coverage and clinical attachment levels in lingual gingival defects. Int J Esth Dent. 11;538-48.

15. Zucchelli, G., Mounssif, I., Marzadori, M., Mazzotti, C., Felice, P., & Stefanini, M. (2017). Connective Tissue Graft Wall Technique and Enamel Matrix Derivative for the Treatment of Infrabony Defects. Int J Period Rest Dent. 37;1-10
https://doi.org/10.11607/prd.3083

16. Gonzalez, D., Cabello, G., Olmos, G., & Niñoles, C. L. (2015). The saddle connective tissue graft: a periodontal plastic surgery technique to obtain soft tissue coronal gain on immediate implants-a case report. Int J Esth Dent. 10;444-455.

17. Jepsen, K., Stefanini, M., Sanz, M., Zucchelli, G., & Jepsen, S. (2017). Long-term stability of root coverage by coronally advanced flap procedures. J Periodontol. 88; 626-633.
https://doi.org/10.1902/jop.2017.160767

18. Camargo, P. M., Melnick, P. R., & Kenney, E. B. (2001). The use of free gingival grafts for aesthetic purposes. Periodontol 2000, 27;72- 96.
https://doi.org/10.1034/j.1600-0757.2001.027001072.x

19. Shkreta, M., Atanasovska-Stojanovska, A., Dollaku, B., & Belazelkoska, Z. (2018). Exploring the Gingival Recession Surgical Treatment Modalities: A Literature Review. Macedoni J Medical Sci. 6; 698-712
https://doi.org/10.3889/oamjms.2018.185

20. Sculean, A., Chapple, I. L., & Giannobile, W. V. (2015). Wound models for periodontal and bone regeneration: the role of biologic research. Periodontol 2000. 68;7-20.
https://doi.org/10.1111/prd.12091

21. Lin, N. H., Gronthos, S., & Mark Bartold, P. (2009). Stem cells and future periodontal regeneration. Periodontol 2000. 51;239-51.
https://doi.org/10.1111/j.1600-0757.2009.00303.x

22. Jankovic, S., Aleksic, Z., Klokkevold, P., Lekovic, V., Dimitrijevic, B., Barrie Kenney, E., & Camargo, P. (2012). Use of platelet-rich fibrin membrane following treatment of gingival recession: a randomized clinical trial. Int J Period Rest Dent. 32;165-75

23. Silva, C. O., Ribeiro, É. D. P., Sallum, A. W., & Tatakis, D. N. (2010). Free gingival grafts: graft shrinkage and donor-site healing in smokers and non-smokers. J Periodontol. 81;692-701. https://doi.org/10.1902/jop.2010.090381

24. Susin, C., Fiorini, T., Lee, J., De Stefano, J. A., Dickinson, D. P., & Wikesjö, U. M. (2015). Wound healing following surgical and regenerative periodontal therapy. Periodontol 2000. 68;83-98.
https://doi.org/10.1111/prd.12057

Revisiting the Role of Periodontal Plastic Surgery in Regenerative Therapies Clinical Criteria and Biological Principles

Muhammad Haris Zia             BDS, (Pak) MClindent (UK)

 

One of the manifestations of periodontitis is bone loss and tooth mobility. Thus, periodontal regeneration plays a vital in
reinstating the lost alveolar bone and periodontal tissue. This study aims at the different literary resource that highlight the role
of periodontal plastic surgery; clinical criteria and biological principles that facilitates the process of regeneration. Several
corrective steps are implemented for the management of chronic periodontal disease, such as the first line of intervention which
is the non-surgical treatment that consists of Oral hygiene instructions and removal of biofilms. After non-surgical phase of
treatment once the tissue is healed, surgical techniques are to be considered for the management of the remaining pockets also
known as residual pockets or to formulate a gingival apparatus that promotes plaque control. However, if there is a loss of tissue
it is quintessential to take into consideration regenerative procedures.
KEYWORDS: Periodontal plastic surgery, biological principals, regeneration
HOW TO CITE: Zia MH. Revisiting the role of periodontal plastic surgery in regenerative therapies clinical criteria and
biological principles. J Pak Dent Assoc 2023;32(1):22-26.
DOI: https://doi.org/10.25301/JPDA.321.22
Received: 02 August 2022, Accepted: 01 April 2023

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Knowledge and Attitude of Dental Professionals, Students and Dental Auxiliary Staff Towards Needle Stick Injury and Sharp Injuries

Fizza Jawaid Baig1                        BDS, RDS
Hiba Qazi2                                      BDS
Maham Nadeem3                           BDS
Shahid Islam4                                BDS,FCPS
Elham Habib5                                BDS
Azam Aliuddin6                             BDS, FCPS

 

OBJECTIVE: The present study aims to evaluate the knowledge and attitude of dental professionals, students and auxiliary
towards needle stick and sharp injury.
METHODOLOGY: A cross-sectional questionnaire-based survey was carried out among 200 dental practitioners, students,
and auxiliary staff using OpenEpi calculator. Final data were analyzed using SPSS version 23.0.
RESULT: The result revealed that 97% of the participants had an understanding of NSI and the risks associated with it and
about 87.5% participants were found to be vaccinated against Hepatitis B.
In addition to that, 72% of dental healthcare workers especially the auxiliary staff (96.3%) had experienced needle stick injury
and 97% of the subjects were found to have a habit of recapping the needle after use.
CONCLUSION: The knowledge of dental practitioners especially the auxiliary staff concerning needle stick injury was found
to be inadequate. More awareness should be raised regarding NSIs for the dental healthcare workers and practicing of universal
guidelines must be emphasized greatly.
KEYWORDS: Needle stick injury and sharp injuries
HOW TO CITE: Baig FJ, Qazi H, Nadeem M, Islam S, Habib E, Aliuddin A. Knowledge and attitude of dental professionals,
students and dental auxiliary staff towards needle stick injury and sharp injuries. J Pak Dent Assoc 2023;32(1):17-21.
DOI: https://doi.org/10.25301/JPDA.321.17
Received: 03 February 2023, Accepted: 05 February 2023

INTRODUCTION

A puncture or tear from a needle or any razor-sharpobject that is contaminated with blood or bodily fluid of an individual carrying an infectious disease. Healthcare workers in hospitals and clinics, including doctors, paramedical staff, assistants, and technicians, all are liable to such injuries caused by soiled needles or sharp objects, therefore they are at a greater risk of acquiring heamatogenic infectious diseases due to increased exposure to viruses and microorganisms. Needle stick injury (NSI) is the most common cause for the spread of blood borne communicable diseases such as Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV). Dental practitioners and students are exposed to blood and body fluids during work on a daily basis and dental auxiliary are exposed while handling of used instruments; hence, they are all at a risk of acquiring blood borne diseases as a result of needle stick and sharp injuries (NSIs).
As per WHO, the annual approximate proportion of healthcare workers (HCWs) exposed to blood borne pathogens globally were 2.6% for HCV, 5.9% for HBV and 0.5% for HIV.1,2 More than 90% of these transmissible infections occur in developing countries but most of these needle stick injuries remain unreported.3 Occupational sharp injuries can be a consequence of insufficient experience , inadequate training and exhaustion.4 The existence of blood and mucus, and the vast variety of microbial flora in the
oral cavity along with the regular usage of sharp instruments  in dental treatment, contributes to elevated risk of blood borne infections in the dental office.5 The load of SIs and NSIs can be diminished in the dental work environment, when dental professionals act in accordance with the contemporary and universally approved quality precautionary measures against needle stick injuries.6 Possible exposures are unregulated to needle sticks alone as manipulation of other sharp instruments or mucous membrane disclosure to infected bodily fluids also can result in the conveyance of infectious diseases.7
So, the aim of this study is to evaluate knowledge and attitude towards preventing needle stick and sharp injury, its complications and awareness regarding post exposure prophylactic measures amongst dental healthcare workers. Previously, limited and brief studies have been conducted on this subject. Hence, the rationale for our study is to deeply assess the understanding of NSI and sharp injuries in dental professionals, students and auxiliary staff members of different tertiary care dental hospitals in our country. This will help us determine the severity of this issue and allow us to take steps to alleviate the frequency of NSI injuries within our dental community.

METHODOLOGY
This cross-sectional study was held in Karachi, Pakistan during 2019 and 2020 and the study population comprised of final year dental students, dental house- officers, dental practitioners and dental auxiliary staff from four prestigious dental institutions in Karachi. The dental institutes involved were Fatima Jinnah Dental College and Hospital (FJDC), Karachi Medical and Dental College (KMDC), Baharia University (BU) and Dow University of Health Sciences (DUHS).
The sample size for this study was calculated by using OpenEpi calculator and was estimated to be 200. It was randomly collected from dental students, practitioners and auxiliary staff from the above mentioned four colleges. Written consent was also taken from the participants before taking samples.
A valid questionnaire that comprised of 14-close ended questions was designed specially to test the knowledge and attitude of participants regarding NSI and its risks and the cross infections associated with use of needle and sharp instruments, the preventive measures and techniques and immediate management after experiencing NSI. The status of vaccination of the participants against Hepatitis B and their techniques for prevention against NSI were also evaluated in the present study. The information collected in this study was then carefullyntabulated and the statistical analysis was performed to get the percentages which were then further calculated and the final result was obtained by using SPSS version 23.0.

RESULT
In total 200 subjects were included in the study and the participants comprised of 64.5% female and 35.5% male. Among them were undergraduate students (20.5%), house officers (50.5%), dental postgraduates (11.5%), dental consultants (4%) and dental auxiliary staff (13.5%). According to the study majority (97%) of participants were aware of needle stick/sharp injury and the communicable

DISSCUSION
Even though universal precautionary guidelines and general awareness among healthcare providers have lowered the risk of needle stick injuries (NSIs) all around the world
over the past 30 years, these injuries continue to occur till this day, albeit at a much lower rate. Mostly surgeons, dental practitioners and nurses are found to be most susceptible to NSI.
Dental health care providers and the auxiliary staff have higher chances of exposure to blood and oral fluids and therefore they are at a greater risk of acquiring communicable blood-borne illnesses. The degree of risk depends upon the amount of patients that are infected and the level of precautionary measures taken by the dental healthcare workers while dealing with these patients.
The current study shows that 96.5% of the Dental healthcare workers were aware about needle stick injury (NSI) and its association with communicable infections such as Hepatitis B, C and HIV. Only 4% of them which majorly involved the auxiliary staff were quite oblivious about it. Similar results were found in the study done by Pavithran VK9 in which, 88% of the dental practitioners count NSIs as a leading cause of Hep B, C and HIV communication.
We also found that 91.5% of the dental HCW practiced general precautionary guidelines while treating patients and only 8.5% which mostly comprised of auxiliary staff (37%). Whereas in a study by Santhosh Kumar7 only 37% of dental students and in a study by Pavithran VK9 58% dental professionals practiced universal precautions. We also discovered that 89.5% of the Dental HCW majority being dental practitioners and dental students took detailed medical history of their patients before starting any dental procedures. When asked about the vaccination status of the dental health workers we found out that about 87.5% participants acquired vaccination against hepatitis B while the remaining 12.5% of DHW especially the auxiliary staff (48%) were unfortunately not vaccinated against hepatitis B. Similar results were seen in the studies done by Muhammad Shahzad13 (68%), Rana Pratap Maurya11 (94-100%), Santhosh Kumar7 (87%) in which it was noted that majority of the participants had been vaccinated against Hepatitis B.
In the current study 72% of dental HCW especially the auxiliary staff (96.3%) experienced NSI. 50% have had NSI once a year followed by 31% participants who had NSI once a month. In a study by T. Akhund12 54.2% qualified dentists and 51.1% of dental technicians had experienced NSI at least once in 12 months. Also 58% dental practitioners experienced NSI during the treatment and the remaining 42% that majorly include the auxiliary staff experienced NSI at the end of dental treatment while disposing off the used instruments.
It was noted in this study that 65% of the participants reported injection needle as the commonest cause of sharp injury. While 21% reported dental probe and 7% reported endodontic files as the common cause of sharp injury. Another study done by Maurya RP11 reported orthodontic wires as the most frequent cause of NSI (18.75%) followed
by explorer (15.63%). In the study by Pavithran VK9 about 21% of the participants considered surgical instruments as the most common cause for NSI. Upon further questioning about measures taken immediately after NSI, among those who had experienced NSI about 42.5% of them assert that they squeeze their blood and wash the injured site with alcohol swab, followed by 19.5% who squeeze their blood and washed with water alone. Only 7% participants washed the site first with soap then with water. The results were found to be drastically different to the findings by Maurya RP11, who stated in his
study that 93.33% participants washed the affected site with soap and water and knew about post exposure prophylaxis. In current study maximum number of participants had knowledge about post exposure prophylaxis and also knew that thorough cleaning of the affected side with either soap water or alcohol swab should be done right after contracting a sharp injury. In contrast to our findings, in the study by Alam M14 not many participants were aware about proper post exposure prophylaxis.
In this present investigation 63% of the dental HCW asserted that they would inform the health care department after experiencing NSI, whereas in a study conducted by Pavithran VK9 81% dentists stated that they would first report to the medical emergency department. In addition to this we also believe that it is most significant to educate our colleagues and staff about hazards of NSI and its prevention. In our study we determine that 85% of the participants guided their staff/colleague regarding NSI and its prevention.
Far too many studies consider recapping of needles as a major source of contracting NSI and therefore condemn recapping of needle after use and state that it greatly helps in preventing NSI. According to the Occupation Safety and Health Administration guidelines, recapping of the needles has been interdicted.10 In our current study, 97% of the subjects had a habit of recapping the needle after use. In a study by Rana Pratap11 (80%), Santhosh Kumar7 (76%) and A. Malik6 (88%) dental personnel believed that all needles should indeed be recapped after use. In this study 83% participants practiced the single-handed scoop technique while the remaining (14%) practiced two-handed technique, 44% of them were auxiliary staff. Pavithran VK9 and Santhosh Kumar4 stated that majority practiced singlehanded technique for needle recapping (69% and 82%, respectively).
One of the most notable issue is disposal of used needles. According to our study 65% subjects used needle cutter for needle disposal, 17% used puncture resistant sealed containers and 9% used needle burner or syringe destroying device, similarly 9% used needle incinerator. In contrast Pavithran VK9 found that 54.5% dental professionals used needle heater and syringe destroyer, 21% used needle cutting appliance, 14% used impenetrable secured containers and 10.5% used needle incinerator machine. Rana Pratap11 reported that only 43% participants had knowledge regarding the safe disposal of sharps in puncture proof containers. In the present study 65% of the dental HCWs were aware and practice all measures to prevent NSI out of which only 22% were auxiliary staff. 63% auxiliary staff believed that only careful handling of instruments can prevent NSI. Education concerning prevention of NSIs and its PEP measures should not only be provided to dental students but
also to the auxiliary staff.

CONCLUSION
It was concluded that the awareness of dental professionals, students and especially dental auxiliary regarding NSIs and their prevention were quite inadequate. NSI can be prevented further by thoroughly instructing and training dental staff and healthcare workers. Moreover, importance of universal precautions should also be made clear to the dental HCWs, students and paradental staff. In addition to that, vaccination against Hepatitis B should be made compulsory for all dental HCWs. The status of their vaccination should also be reviewed yearly. Post exposure prophylaxis should be taught thoroughly so that all dental HCWs know what measures should be taken after contracting NSI/SI and how to report it to the healthcare department.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Rapiti E, Hutin YJ. Sharps injuries: global burden of disease from sharps injuries to health-care workers. 2003.

2. Tadesse M, Tadesse T. Epidemiology of needlestick injuries among health-care workers in Awassa City, Southern Ethiopia. Tropical doctor. 2010;40:111-3.
https://doi.org/10.1258/td.2009.090191

3. World Health Organization. The world health report 2002: reducing risks, promoting healthy life. World Health Organization; 2002.

4. Askarian M, Malekmakan L, Memish ZA, Assadian O. Prevalence of needle stick injuries among dental, nursing and midwifery students in Shiraz, Iran. GMS Krankenhaushygiene interdisziplinär. 2012;7.

5. Lee JJ, Kok SH, Cheng SJ, Lin LD, Lin CP. Needlestick and sharps injuries among dental healthcare workers at a university hospital. J Formo Med Assoc. 2014;113:227-33.
https://doi.org/10.1016/j.jfma.2012.05.009

6. Malik A, Shaukat MS, Qureshi A. Needle-stick injury: A rising biohazard. J Ayub Med Coll Abbottabad. 2012;24:144-6.

7. Santhosh K. Knowledge, attitude and practices regarding needlestick injuries among dental students. Asian J Pharm Clin Res. 2016;9:312- 5.

8. Shen C, Jagger J, Pearson RD. Risk of needle stick and sharp object injuries among medical students. Am J infect Con. 1999;27:435-7.
https://doi.org/10.1016/S0196-6553(99)70010-6

9. Pavithran VK, Murali R, Krishna M, Shamala A, Yalamalli M, Kumar AV. Knowledge, attitude, and practice of needle stick and sharps injuries among dental professionals of Bangalore, India. J Int Soc Prevent Comm Dent. 2015;5:406.
https://doi.org/10.4103/2231-0762.165932

10. Occupational Safety and Health Administration. Healthcare Wide Hazards: Needlestick/Sharps Injuries.
https://www.osha.gov/etools/hospitals/patient-care-unit/needlesticksharps-injuries

11. Maurya RP, Maurya MK, Kushwaha R, Verma SL, Kumari R. Knowledge, Awareness and Practices regarding Sharp Injuries amongst the Dental students. Int J Oral Health Dent. 2017;3:181-7.

12. Jan S, Akhund T, Akhtar MJ, Shaikh JM. Needle Stick Injuries among dental health care providers: a survey done at Hyderabad and KarachI. Pak Oral Dent J. 2014;34.

13. Shahzad M, Hassan SG, Memon MR, Bashir U, Shams S. Needle stick injuries among dental students, house officers and paradental staff working at liaquat medical university hospital, Hyderabad. Pak Oral Dent J. 2013;33.

14. Alam M. Knowledge, attitude and practices among health care workers on needle-stick injuries. Annals of Sau Medi. 2002;22:396-9.
https://doi.org/10.5144/0256-4947.2002.396

Knowledge and Attitude of Dental Professionals, Students and Dental Auxiliary Staff Towards Needle Stick Injury and Sharp Injuries

Fizza Jawaid Baig1                        BDS, RDS
Hiba Qazi2                                      BDS
Maham Nadeem3                           BDS
Shahid Islam4                                BDS,FCPS
Elham Habib5                                BDS
Azam Aliuddin6                             BDS, FCPS

 

OBJECTIVE: The present study aims to evaluate the knowledge and attitude of dental professionals, students and auxiliary
towards needle stick and sharp injury.
METHODOLOGY: A cross-sectional questionnaire-based survey was carried out among 200 dental practitioners, students,
and auxiliary staff using OpenEpi calculator. Final data were analyzed using SPSS version 23.0.
RESULT: The result revealed that 97% of the participants had an understanding of NSI and the risks associated with it and
about 87.5% participants were found to be vaccinated against Hepatitis B.
In addition to that, 72% of dental healthcare workers especially the auxiliary staff (96.3%) had experienced needle stick injury
and 97% of the subjects were found to have a habit of recapping the needle after use.
CONCLUSION: The knowledge of dental practitioners especially the auxiliary staff concerning needle stick injury was found
to be inadequate. More awareness should be raised regarding NSIs for the dental healthcare workers and practicing of universal
guidelines must be emphasized greatly.
KEYWORDS: Needle stick injury and sharp injuries
HOW TO CITE: Baig FJ, Qazi H, Nadeem M, Islam S, Habib E, Aliuddin A. Knowledge and attitude of dental professionals,
students and dental auxiliary staff towards needle stick injury and sharp injuries. J Pak Dent Assoc 2023;32(1):17-21.
DOI: https://doi.org/10.25301/JPDA.321.17
Received: 03 February 2023, Accepted: 05 February 2023

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Awareness of Orthodontic Treatment among Primary, Middle, and High School Teachers in Pakistan

Ambar Farooq                                        BDS, FCPS
Verda Ahmad Khan2                              BDS
Sardar Daniyal Hafeez3                         BDS
Syed Majid Hussain Shah4                   BDS, FCPS
Maimoona Afsar5                                   BDS
Huma Ghazanfar Kiani6                         BDS, FCPS, M-Orth

 

OBJECTIVE: The aim of this study was to assess the level of awareness of schoolteachers towards orthodontic treatment and
treatment options, as they can play a pivotal role in the early treatment of cases by motivation and referring the patients.
METHODOLOGY: A 16 questions based questionnaire was circulated among schoolteachers. The responses received to the
online form were analyzed for the level of awareness of schoolteachers towards orthodontic treatment. Chi-square test was
applied to study the means between gender, level of teaching, and other questions. P-value of <0.05 was considered significant.
RESULTS: There was significant association between the response of question 12 (Braces treatment is expensive) with groupIII and age group 31-40 years old, question 5 with group-III and question 16 with group-I, p-value < 0.05.
CONCLUSION: The questionnaire found that there is a lack of awareness towards orthodontic treatment, treatment timings
and payment information among the primary, middle and high school teachers in Pakistan.
KEYWORDS: Age, Awareness, School, Socioeconomic status, Teachers, Treatment
HOW TO CITE: Farooq A, Khan VA, Hafeez SD, Shah SMH, Afsar M, Kiani HG. Awareness of Orthodontic Treatment among
Primary, Middle, and High School Teachers in Pakistan. J Pak Dent Assoc 2023;32(1):13-16.
DOI: https://doi.org/10.25301/JPDA.321.13
Received: 05 March 2022, Accepted: 01 April 2023

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Awareness of Orthodontic Treatment among Primary, Middle, and High School Teachers in Pakistan

Ambar Farooq                                        BDS, FCPS
Verda Ahmad Khan2                              BDS
Sardar Daniyal Hafeez3                         BDS
Syed Majid Hussain Shah4                   BDS, FCPS
Maimoona Afsar5                                   BDS
Huma Ghazanfar Kiani6                         BDS, FCPS, M-Orth

 

OBJECTIVE: The aim of this study was to assess the level of awareness of schoolteachers towards orthodontic treatment and
treatment options, as they can play a pivotal role in the early treatment of cases by motivation and referring the patients.
METHODOLOGY: A 16 questions based questionnaire was circulated among schoolteachers. The responses received to the
online form were analyzed for the level of awareness of schoolteachers towards orthodontic treatment. Chi-square test was
applied to study the means between gender, level of teaching, and other questions. P-value of <0.05 was considered significant.
RESULTS: There was significant association between the response of question 12 (Braces treatment is expensive) with groupIII and age group 31-40 years old, question 5 with group-III and question 16 with group-I, p-value < 0.05.
CONCLUSION: The questionnaire found that there is a lack of awareness towards orthodontic treatment, treatment timings
and payment information among the primary, middle and high school teachers in Pakistan.
KEYWORDS: Age, Awareness, School, Socioeconomic status, Teachers, Treatment
HOW TO CITE: Farooq A, Khan VA, Hafeez SD, Shah SMH, Afsar M, Kiani HG. Awareness of Orthodontic Treatment among
Primary, Middle, and High School Teachers in Pakistan. J Pak Dent Assoc 2023;32(1):13-16.
DOI: https://doi.org/10.25301/JPDA.321.13
Received: 05 March 2022, Accepted: 01 April 2023

INTRODUCTION

Dental awareness has increased in the past few years amongst the Pakistani population. Although it is a major step toward better dental health, many people still only consider filling and tooth pain as dental treatment possibilities. People are slowly but gradually getting more and more awareness about the different fields in dentistry and the existing treatment options. Orthodontics is one such field where a lack of awareness leads to the option of either never getting a treatment or one where the patient reports at a stage where the problem has been complicated by several factors. Awareness about Orthodontics and the different treatment options available for different age groups can easily solve this problem.
There has been a huge increase in the number of orthodontic treatment options and their availability in developed as well as developing nations over the past few decades. It is a well- known fact that patient satisfaction isinfluenced by sex, age,1,2 total treatment time, socioeconomic and financial status, as well as convenience of orthodontic facilities.3-6 Studies have observed and confirmed that girls, on average, receive orthodontic treatment more frequently than boys and that a large number of people undergo orthodontic treatment7 because they were told by a relative or friend that your dental problem can be corrected.
To expect awareness about orthodontics in the general population it is vital to start from the younger generation. Children and teenagers8 are the majority of orthodontic patients.9 Their parents and teachers play a vital role in introducing orthodontic care. Parents and teachers are the most important factor in the motivation for orthodontic treatment. Orthodontic awareness campaigns should be focused on targeting school children. The aim of these campaigns should be to convey knowledge about their occlusion and malocclusion and when should one visit a dentist or an orthodontist concerning a dental issue. School teachers are a group that has a close routine association with these children and teenagers, and they are highly inspired by them.6,8-9 Ehizele et al.10 concluded that teachers may accomplish the function of oral health educators if they have good knowledge, attitude, and practice of oral health; therefore, primary school teachers can help as oral health educators after organized training to expand their understanding of oral health.10 It is thus important to know as to what degree our schoolteachers are aware of the field of orthodontics and how often can we rely upon them to recommend and refer their students to an orthodontist.

METHODOLOGY
This observational study was performed after the ethical approval of institutional review board at Abbottabad International Dental College. The data collection and manuscript writing were done within a period of six months. A questionnaire was converted into online forms (via google forms) and circulated among schoolteachers. The responses received were then compiled into the results of this study. The inclusion criteria were based on schoolteachers of primary (Grade 1-5), middle ( Grade 6-8) and high school (Grade 9-12). Any form missing a response to one or more questions, or any form where more than one option is selected were excluded from the study.

DATA ANALYSIS
A total of One hundred and seventy-five responses were received. Data was analyzed using SPSS version 24. The categorical data like age groups, gender and responses were analyzed. Chi-square test was applied to see association between categorical variables (e.g., groups, age groups, and gender) taking p-value < 0.05 as significant.

RESULTS
Two of the One hundred and seventy-five responses received were rejected due to failure of answering a question. The remaining One hundred and seventy-three responses  were analyzed statistically. The categorical data like age groups, gender and responses are presented in form of frequency (Table-1). Association between categorical

STATISTICAL ANALYSIS
In this study 58(33.5%) subjects were 20-30 years old, 61(35.3%) were 31-40 years old, 46(26.6%) subjects were 41-50 years old, and 8(4.6%) subjects were 51-60 years old. There were only 4(2.3%) male participants and 169(97.7%) female participants. Group-1 (n=50, 28.9%) was comprised  of teachers teaching preschool, primary school i.e., Grade 1-5, group-2 (n= 43 i.e., 24.9%) consisted of teachers involved in teaching to Middle School i.e., Grade 6-8 while grade-3 (n= 80 i.e., 46.2%) consisted of teachers teaching students at high school i.e., grade 9-12. There were 23(13.3%) teachers who had ever taken braces treatment, 166(96.0%) heard
about braces, 97(56.1%) knew that braces treatment is called orthodontics, 104(60.1%) knew that teeth can be moved in bone, 154(89.0%) teachers knew anyone who had used braces and 107(61.8%) knew that braces treatment can be done at any age. A total of 138(79.8%) teachers knew that age is important in beginning braces treatment, 159(91.9%) told that braces treatment is more beneficial at young age and 79(45.7%) teachers were agreed that braces treatment cannot be done at advanced age. There were 166(96.0%) knew that braces treatment is done for straight teeth, 137(79.2%) were agreed that braces treatment is done for cosmetic purpose and according to 149(86.1%) teachers that brace treatment is expensive, 147(85.0%) said braces treatment lasts for years, 99(57.2%) knew anyone whose teeth has gone back after braces treatment, 94(54.3%) told that they or anyone did not get treatment because of expensive and 57(32.9%) teachers knew treatment payment can be done in installments (Table-2,3).
There was significant association between the response of braces treatment is expensive with group-III, know anyone who had braces with group-III and know treatment payment can be done in installments with group-I, p-value < 0.05 (Table-3). Braces treatment is expensive was also significant with 31-40 years old teachers, p-value < 0.05 (Table-2).

DISCUSSION
The study was aimed at finding the level of awareness schoolteachers had about Orthodontic treatment and its timing. Studying the results showed that most of the teachers knew or had known someone who had undergone orthodontic treatment, a favorable point for our study as it shows that Orthodontic awareness indeed is present up to a certain level among the population. This can help with our task of teaching them how to identify orthodontic cases and give a general overview regarding treatment, while encouraging a student or his/her parents to seeks treatment. Although the level of awareness towards what orthodontics is? was found to be sufficient but a major lack of awareness is present towards what the treatment is and how is it achieved? This lack of information can be met by conducting educational seminars and giving presentations at schools. Brochures can also be distributed among teachers for this purpose. Educational seminars and presentations can be given directly to students as well. Ilyas2 and Wang6 concluded that schoolteachers are probably one of the major elements in our society for influencing young students to demand for orthodontic treatment. They also play a pivotal role in their compliance towards the treatment progress by encouraging them every step of the way.
Teachers are mostly aware of the socioeconomic status of their students and can thus help them in asking for affordable treatment options. They will not only be able to encourage their students but can also help them overcome bullying from peers.10
86% of the teachers responded positively to orthodontic treatment being expensive. This can be considered a major disadvantage. Lack of interest in finding out about different treatment modalities can be tied to this perception9. Although some treatment options are indeed expensive not all can be termed the same, and sometimes instead of a comprehensive treatment plan a minor correction is enough to solve an
individual’s malocclusion. Anderson et al concluded that providing adequate knowledge to teachers via different information packages is helpful in creating awareness toward orthodontics and orthodontic treatment options. It can also help with providing treatment at the right time and age.8 The following study did not include teachers from all over Pakistan. Forms were circulated among friends and family members who were teachers or had access to teachers. Requesting individuals to respond to forwarded forms was the hardest part of data collection procedure. Similar studies should be carried out on a wider scale and include teachers from remote areas as well. No conflict of interest is present.

CONCLUSION
The questionnaire assessed the knowledge of schoolteachers regarding orthodontics and orthodontic treatment. The was a lack of sufficient knowledge regarding the treatment method and timing of the treatment while most people only knew that the treatment was expensive but were not aware of the different methods the expenses could be handled in.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Shaw WC. Factors influencing the desire for orthodontic treatment. Eur J Orthod. 1981;3:151-62.

2. Ilyas M , Shaheen A, Amjad S, Zubair T,Tariq A. Comparison of knowledge and perception of orthodontic treatment among dental students and local population. Saudi J Oral Dent Res.2021;6:59-62.
https://doi.org/10.36348/sjodr.2021.v06i01.012

3. Sheikh S, Nene S, Kalia A, Gupta G, Mehta K, Mirdehghan N. Awareness of orthodontic treatment and perceptions of dental attractiveness among school children. Univ Res J Dent 2015;5:63-7.
https://doi.org/10.4103/2249-9725.157727

4. Abeleira MT, Pazos E, Ramos I, Outumuro M, Limeres J, SeoaneRomero J, et al. Orthodontic treatment for disabled children: A survey of parents’ attitudes and overall satisfaction. BMC Oral Health.2014;14:1-8.
https://doi.org/10.1186/1472-6831-14-98

5. Singh H, Munish Reddy C, Khera A, Raghav P, Phull TS, Singh N. Awareness of orthodontic treatment in rural school children of Western Uttar Pradesh (Meerut District). IRJCM. 2016;1:7-12.

6. Wang S, Zhang Y. Relationships among satisfaction, treatment motivation, and expectations in orthodontic patients: A prospective cohort study. Patient Prefer Adherence 2016;10:443-7.
https://doi.org/10.2147/PPA.S101825

7. Rastogi S, Jatti RS, Keluskar KM. Assessment of awareness and social perceptions of orthodontic treatment need in adult age group: A questionnaire study. J Oral Health Community Dent.2014;8:95-100.
https://doi.org/10.5005/johcd-8-2-95

8. Anderson LE, Arruda A, Inglehart MR. Adolescent patients’ treatment motivation and satisfaction with orthodontic treatment. Do possible selves’ matter? Angle Orthod 2009;79:821-7.
https://doi.org/10.2319/120708-613.1

9. Rafighi A, Foroughi Moghaddam S, Alizadeh M, Sharifzadeh H. Awareness of orthodontic treatments among schoolteachers of two cities in Iran. J Dent Res Dent Clin Dent Prospects. 2012;6:25-8.

10. Ehizele A, Chiwuzie J, Ofili A. Oral health knowledge, attitude, and practices among Nigerian primary school teachers. Int J Dent Hyg. 2011;9:254-60.
https://doi.org/10.1111/j.1601-5037.2010.00498.x

Final Year BDS Student’s Perception and Feedback Regarding Prosthodontics and its Teaching Methodologies

Naveed Inayat1                                                      BDS, FCPS, FICD, CMT
Muhammad Aamir Rafique2                                 BDS, MDS
Nadia Munir3                                                          BDS, M.Phil, PhD
Mahvish Wahad Khan4                                         BDS, FCPS
Shoaib Alvi5                                                          BDS, FCPS
Aamir Rafiq6                                                         BDS, FCPS
Haroon Raza7                                                       BDS

OBJECTIVE: Teaching and learning methodologies have been a topic of concern for everyone for a decade. Dental education
involves both academic and clinical understanding of subjects included in the curriculum. The study aims to determine the
success of a system that could achieve the desired learning outcomes.
METHODOLOGY: In this cross-sectional study 229 BDS students at five different dental colleges affiliated with the University
of Health Sciences, Lahore responded to a predesigned structured questionnaire regarding the prosthodontic subject. Feedback
on the Perception of students regarding prosthodontics as a subject was asked from BDS final year regular batch, before their
university final exam.
RESULTS: Most students found prosthodontics an interesting subject (82%). On enquiring about the level of difficulty of
prosthodontics compared to other dental clinical subjects, 56.9% of students responded negatively. The majority were satisfied
with the content (79.1%), delivery, and pace of the lectures (78.2%).85.4% of students reported lecture material was easy to
follow and satisfactory. The highly reported useful method for learning and understanding prosthodontics was PowerPoint slides
69%, followed by group discussion 52.70%.MCQs as the mode of assessment reported positive by 75.70%, whereas 77.4%
of students want to have an integrated teaching method.
CONCLUSION: The majority of the students found the subject interesting but considered it difficult to understand. Further
teaching methodologies must be improved to enhance the student's understanding of the subject. Better comprehension will
also help in flourishing prosthodontics as a specialty.
KEYWORDS: Teaching methodology, Prosthodontics, Effective learning, Assessment, Feedback
HOW TO CITE: Inayat N, Rafique MA, Munir N, Khan MW, Alvi S, Rafiq A, Raza H. Final year BDS student’s perception
and feedback regarding prosthodontics and its teaching methodologies. J Pak Dent Assoc 2023;32(1):8-12.
DOI: https://doi.org/10.25301/JPDA.321.8
Received: 22 Septembery 2022, Accepted: 04 February 2023

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Final Year BDS Student’s Perception and Feedback Regarding Prosthodontics and its Teaching Methodologies

Naveed Inayat1                                                      BDS, FCPS, FICD, CMT
Muhammad Aamir Rafique2                                 BDS, MDS
Nadia Munir3                                                          BDS, M.Phil, PhD
Mahvish Wahad Khan4                                         BDS, FCPS
Shoaib Alvi5                                                          BDS, FCPS
Aamir Rafiq6                                                         BDS, FCPS
Haroon Raza7                                                       BDS

 

OBJECTIVE: Teaching and learning methodologies have been a topic of concern for everyone for a decade. Dental education
involves both academic and clinical understanding of subjects included in the curriculum. The study aims to determine the
success of a system that could achieve the desired learning outcomes.
METHODOLOGY: In this cross-sectional study 229 BDS students at five different dental colleges affiliated with the University
of Health Sciences, Lahore responded to a predesigned structured questionnaire regarding the prosthodontic subject. Feedback
on the Perception of students regarding prosthodontics as a subject was asked from BDS final year regular batch, before their
university final exam.
RESULTS: Most students found prosthodontics an interesting subject (82%). On enquiring about the level of difficulty of
prosthodontics compared to other dental clinical subjects, 56.9% of students responded negatively. The majority were satisfied
with the content (79.1%), delivery, and pace of the lectures (78.2%).85.4% of students reported lecture material was easy to
follow and satisfactory. The highly reported useful method for learning and understanding prosthodontics was PowerPoint slides
69%, followed by group discussion 52.70%.MCQs as the mode of assessment reported positive by 75.70%, whereas 77.4%
of students want to have an integrated teaching method.
CONCLUSION: The majority of the students found the subject interesting but considered it difficult to understand. Further
teaching methodologies must be improved to enhance the student's understanding of the subject. Better comprehension will
also help in flourishing prosthodontics as a specialty.
KEYWORDS: Teaching methodology, Prosthodontics, Effective learning, Assessment, Feedback
HOW TO CITE: Inayat N, Rafique MA, Munir N, Khan MW, Alvi S, Rafiq A, Raza H. Final year BDS student’s perception
and feedback regarding prosthodontics and its teaching methodologies. J Pak Dent Assoc 2023;32(1):8-12.
DOI: https://doi.org/10.25301/JPDA.321.8
Received: 22 Septembery 2022, Accepted: 04 February 2023

INTRODUCTION

Over the past few years, voices have been raised globally to develop standard criteria for dental education and curriculum. Modification in teaching and assessment strategies has been an ongoing process to achieve and improve the set goals. Even the best teaching methods may contain flaws and mistakes. To achieve effective learning, teaching, and training, feedback is one of the most important factors that can bring fruitful outcomes with a positive attitude toward the learner’s behavior.1,2 The effectiveness of the curriculum may be best achieved by student feedback with mental compatibility and understanding between facilitators, learners, and stakeholders.3
A dental student is most likely to learn through an efficient teaching mehodology.4 Adopting an effective learning technique that increases and improves the absorption of a subject is a true learning method.5 Varieties of teaching tools and methods like; Didactic and Interactive lectures, Problembased learning, Process Oriented Guide Inquiry Learning (POGIL), Peer Review, Peer-Led Team Learning (PLTL), Evidence-Based Dentistry, Computer Assisted Learning
(CAL), role play, and models, which are available and is
practiced in many institutes.6
The blended learning technique is a student-centered learning process that promotes and enhances the learning environment by decreasing direct student-to-teacher contact time. However, a study on blended
learning in prosthodontics is still lacking.7
Teaching and training, testing, and examination are crucial to run side by side to develop effective learning dental competencies at the institutional level. Assessment methods should address validity, reliability, acceptance, cost, feasibility, and influence on teaching and learning. MCQs, SEQs, SAQs, OSCE, OSPE, workplace base assessment, Mini-CEX, DOPS, Portfolio, and Viva’s voice are the common assessment tools being practiced in Pakistani institutes.1,8 In most undergraduate dental education systems main focus is  on the development of the contents of the course along with setting the examination pattern for assessment of students’ performance.mPreviously, obtaining feedback from students for their learning improvement was not in focus.9,10 Students are the best judges, who can effectively determine the most appropriate teaching tools and systems. They are in a position to critically assess and logically comment on teaching and evaluation methodology.11,12
The objective of this study was to evaluate the final year BDS students’ perception of prosthodontics as a subject and their feedback on teaching methodologies and assessment tools.

METHODOLOGY
This cross sectional study was conducted in five different dental colleges affiliated with University of Health Sciences, Lahore (UHS). The BDS final year students, (regular batch) who were going to appear for their final university exam having at least 75% attendance were included in the study. Repeaters, detainees and debarred students from the university exam were excluded from study. Sample size calculation was done by using WHO calculator and standard formula (Yates Formula) used was Z= Confidence interval= 95%=1.97 P= Population Proportion= 78%=0.78 d= Margin of error= 5% =0.05
The calculated sample size was 264 students by using 78%15 prevalence of students reported to choose prosthodontics as subject of specialty, 95% confidence interval and 5% margin of error.
A total of 229 final year BDS students of dental colleges affiliated with University of Health Sciences, Lahore participated and responded the survey form questions, with 86.742% participation rate. Data was collected at the end of prosthodontic final year session just before appearing in UHS annual examination 2021 using a predesigned structured questionnaire.13 Electronic informed consent was taken from students prior to data collection. Data was entered and analyzed in SPSS version 25.0. Percentages were used to analyze the data. Percentages and Frequencies were calculated and reported.

The highly reported method useful for learning and understanding prosthodontics was PowerPoint slides 69%, followed by group discussion 52.70%, integrated teaching 38.50%, black board teaching 34.70%, and seminar, the responses in favor of quiz and presentation were 30.10%. (Table 1)
MCQs as mode of assessment was reported in positive by majority of students 75.70%. Students who reported Practical exam, SEQs, VIVA, OSCE and Long essay question answers as the mode of assessment helpful in improving knowledge and application of skills were 61,90%, 59.80%, 45.20%, 42.30%, and 7.10%. (Graph 1)

Majority of students want to have integrated teaching method 185(77.4%). Introduction of case based learning was supported by 218(91.2%). Introduction of group discussions was supported by 199(83.3%) students. (Graph 2)

Recommendations to improve learning in prosthodontic as a subject (Table 2)

DISCUSSION
Prosthodontics treatment planning requires a lot of time for patient interaction and communication, which in turn builds and increases student interest in prosthodontics.14 A majority (82%) of the dental students who participated in this study showed positive learning experiences with prosthodontics. Prosthodontics role in developing and improving patients’ quality of life was well perceived and appreciated by students. Another study conducted at Harvard School of Dental Medicine (HSDM) reported 70% positive with only 7% negative responses of students for prosthodontics as a subject whereas the current study showed 14% negative responses.15 For better understanding 93% of participants of this study were in favor of integrated teaching of prosthodontics with basic subjects. In another study conducted at the University of Texas Health Science Center at Houston – School of Dentistry (UTSD) 98% of the students agreed to an integrated system.16
On enquiring about the level of difficulty of prosthodontics compared to other dental clinical subjects, the response of 136 students (56.9%) was negative. Conventional teaching with inadequate clinical exposure contributes to increasing difficulty in understanding the concepts of prosthodontics.17
According to the results of our study, the students reported powerpoint slides (69%) as the most useful method of learning followed by group discussions both of which are traditional methods of teaching under the results of a study done in Spain by Montero et al18 in which students perceived competence through learning by traditional learning methods was significantly higher than that by PBL methods. In a study by Manzar and Manzar, most of the students (77.1%) also thought multimedia to be the most effective teaching tool followed by transparencies and traditional blackboard
teaching.19 In another study by Eslami et al it was reported that although PBL has been known as a useful approach for a long to encourage lifelong learning, the literature lacks properly designed studies to assess its effectiveness. Therefore, more randomized clinical trials and longitudinal studies with proper comparators and control groups comparing actual diagnostic and clinical skills will shed more light on its effectiveness in prosthodontics learning. 2 0
In another study conducted at Harvard School of Dental Medicine, which also uses hybrid PBL, the majority of students reported the feeling of having not acquired enough knowledge from the lectures, and the majority did not feel confident in treating prosthodontics patients in the clinic.21 In a study by Deshpande et al, it was suggested that blended teaching methods employing didactic lectures as well as computer-assisted case-based learning can be used to overcome the drawbacks of conventional teaching such as compartmentalization of knowledge and promote clinical  problem-solving skills since educational reforms in medical and dental teaching are on-going globally.22 Another study also favored blended learning as it fosters student-focused learning to develop didactic and laboratory skills to achieve competency.23
In our study, students liked MCQs as an assessment mode the most (76%) followed by a practical exam. In a  study carried out by Oyebola et al, the majority of the participants also supported MCQ-based assessment.24 Whereas, in another study, students favored the best choice question (BCQ) system of assessment, as it promoted critical thinking followed by multiple choice question (MCQ).19
The majority of the students were satisfied with the contents, explanations, and duration of lectures as per our study. In two other studies as well, students were satisfied with the quality of prosthodontics education and teaching.25,26
However, in another study, most of the students were dissatisfied with the quality of teaching (57.2%) and also with the pattern of typical lecture-based teaching.19 The participants of our study were also satisfied with the number and duration of lectures allocated for prosthodontics. As per another study majority of students believed that 30 minutes should be the ideal duration of the lecture.19 In a study done at Harvard School of Dental Medicine students reported that shortened preclinical clock hours brought them anxiety and stress and they felt they did not gain adequate knowledge from the lectures, resulting in low self-esteem (confidence) in treating patients in the clinic but still their performance was at-par with students of other institutions and they choose prosthodontics as a specialty for future.21

CONCLUSION
BDS final-year students were interested in learning prosthodontics and its clinical practice, but they found prosthodontic concepts difficult to understand due to conventional teaching with inadequate clinical exposure.

RECOMMENDATIONS
Alternative teaching methodologies sush as integrated teaching should be opted. In future more randomized clinical trials and longitudinal studies with comparators and control groups are required to understand better outcome of the learning methodologies opted.

CONFLICT OF INTEREST
There was no conflict of interest among authors

REFERENCES
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2. Rafique S & Rafique H., 2013. Student’s feedback on teaching and assessment at Nishtar Medical College, Multan. J Pak Med Assoc., 63:1205-1209

3. Smith W, Sa B. Students’ Perspectives on the Educational Environment in a Caribbean dental School during Pre-clinical Years. 2014;4:457-64

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5. Zhu HR, Zeng H, Zhang H, Zhang HY, Wan FJ, Guo HH, Zhang CH. The preferred learning styles utilizing VARK among nursing students with bachelor degrees and associate degrees in China. Acta Paulista de Enfermagem. 2018; 31:162-9.
https://doi.org/10.1590/1982-0194201800024

6. Gopinath V, Nallaswamy D. A systematic review on the most effective method teaching dentistry to dental students compared to video based learning. Am J Educ Res. 2017;5:63-8.

7. Ab Ghani SM, Abdul Hamid NF, Lim TW. Comparison between conventional teaching and blended learning in preclinical fixed prosthodontic training: A cross-sectional study. European J Dent Educ.
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https://doi.org/10.1111/eje.12712

8. Gerhard-Szep S, Güntsch A, Pospiech P, Söhnel A, Scheutzel P, Wassmann T, Zahn T. Assessment formats in dental medicine: An overview. GMS. J Med Educ. 2016;33.

9. Henzi D, Davis E, Jasinevicius R, Hendricson W. North American dental students’ perspectives about their clinical education. J Dent Educ. 2006;70:361-77.
https://doi.org/10.1002/j.0022-0337.2006.70.4.tb04091.x

10. Henzi D, Davis E, Jasinevicius R, Hendricson W. In the students’ own words: what are the strengths and weaknesses of the dental school curriculum?. J Dent Educ.2007;71:632-45.
https://doi.org/10.1002/j.0022-0337.2007.71.5.tb04320.x

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https://doi.org/10.1111/eje.12253

12. Naqvi SH, Mobasher F, Afzal MA, Umair M, Kohli AN, Bukhari MH. Effectiveness of teaching methods in a medical institute: perceptions of medical students to teaching aids. J Pak Med Assoc. 2013;63:859-64.

13. Vijayan P, Ponniah A. A survey study based on undergraduate
medical students’ feedback regarding pathology and the teachinglearning methodologies employed. Trop J Pathol Microbiol. 2017;3:149-
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https://doi.org/10.17511/jopm.2017.i02.14

14. Zarchy M, Kinnunen T, Chang BM, Wright RF. Increasing predoctoral dental students’ motivations to specialize in prosthodontics. J Dent Educ 2011;75:1236-43.
https://doi.org/10.1002/j.0022-0337.2011.75.9.tb05167.x

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https://doi.org/10.1002/j.0022-0337.2015.79.1.tb05853.x

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https://doi.org/10.1007/s40670-019-00884-1

17. Shigli K, Jyotsna S, Rajesh G, Wadgave U, Sankeshwari B, Nayak SS, Vyas R. Challenges in learning preclinical prosthodontics: A survey of perceptions of dental undergraduates and teaching faculty at an Indian dental school. J clinical and diagnostic research: JCDR. 2017;11:ZC01.
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18. Montero J, Dib A, Guadilla Y, Flores J, Santos JA, Aguilar RA, Gómez-Polo C. Dental Students’ Perceived Clinical Competence in Prosthodontics: Comparison of Traditional and Problem-Based Learning Methodologies. J Dent Educ. 2018;82:152-62.
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21. Sukotjo C, Thammasitboon K, Howell H, Karimbux N.Students’ perceptions of prosthodontics in a PBL hybrid curriculum. J Prosthodont 2008;17:495-501
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23. Faraone KL, Garrett PH, Romberg E. A blended learning approach to teaching pre-clinical complete denture prosthodontics. European J Dent Educ. 2013;17:e22-7.
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24. Oyebola DD, Adewoye OE, Iyaniwura JO, Alada AR, Fasanmade AA, Raji Y: A comparative study of students’ performance in preclinical physiology assessed by multiple choice and SEQs. Afr J Med Sci 2000, 29:201-5.

25. Puryer J, Woods K, Terry J, Sandy J, Ireland AJ. The confidence of undergraduate dental students when carrying out prosthodontic treatment and their perception of the quality of prosthodontic education. Eur J Dent Educ. 2018;22:e142-8.
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26. Sampaio-Fernandes M, Dutra M, Oliveira SJ, Reis-Campos JC, Azevedo Á, Figueiral MH. Students’ self-confidence and perceived quality of prosthodontics education: A study in the Faculty of DentaMedicine of the University of Porto. Eur J Dent Educ. 2020;24:559- 71.
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