Vol. 32 No. 01 Jan-Mar 2023

INTRODUCTION

In the field of medicine Empathy is one of the cornerstones of effective physician-patient relationship.1
It originates  form Greek words, “em” and “pathos”, meaning ‘feeling into’ and a German word “Einfulung”.2 Empathy is described as having two domains; cognitive and affective. The understanding of an individual’s inner experiences along with his / her outside world from another person’s view of point is described as cognitive domain. In contrast, the affective domain is solely to enter the experiences of another individual1. Empathy contributes greatly in understanding the patient’s perspectives, experiences and concerns.3 In terms of patient care, empathy would be defined as “a cognitive attribute that involves an ability to understand the patient’s perspective, experiences, pain, suffering and a capability to communicate this understanding with the sole intention to help”.4 According to Pedersen (2009) empathy is defined as “Understanding the Patient Properly”.5 Although sharing is the common element of empathy as well as sympathy; empathy however, lies truly under cognitive understanding and sympathy as sharing emotions with the patients.2 Multiple studies agree on the fact that competence, respect and empathy are the true qualities of professionalism.8 These attributes not only augment patient’s satisfaction and comfort, but also boost up his / her level of trust.6 Patients who trust their doctors are considered to be more open hence give an effective history; leading to better diagnosis and decision making.7 The empathy and sympathy can be differentiate on the basis that empathy is intellectual understanding, while sympathy is sharing feelings. Empathy is considered as the second most important competency for dentistry.8 Dentists with emotional intelligence and empathetic nature have proved to reduce patient’s anxiety level, continued patient’s adherence to orthodontic treatment plan, and increased pediatric patient’s cooperation; thus leading to higher rate of patient compliance.1 It is the need of the hour to understand and identify the in-campus practice of empathy among undergraduate dental students at Lahore Medical and Dental College. This will also allow us to plan improvements in the future.

AIMS AND OBJECTIVES
To assess the gender difference and measure the empathy scores of Dental students of Undergraduates (3rd, 4th year, Interns) and Clinical Post graduates of Lahore Medical and Dental College.

METHODOLOGY
Study Design: Quantitative Cross-Sectional Descriptive Study.

Study Settings: College of Dentistry, Lahore Medical and Dental College, Lahore Pakistan.

Study Duration: January to March, 2022.

Inclusion Criteria: Willingness in research participation with written consent
form.

Exclusion Criteria:
Incomplete questionnaire

Target Population:
3rd & 4th year BDS students, House officers and DentalnPost graduates at Lahore Medical and Dental College, who fulfil the inclusion criteria.

Sample Size: 180 students responded out of 230.

Data Collection Instrument:
Self-reported questionnaire by using Jefferson Empathy Scale of Health Care Provider- Student’s Version, [Table 1] has two parts.
Part I – Questions related to participants demographics data.
Part II – 20 items with 7point Likert scale ranging fromstrongly disagree (1) to strongly agree (7). Out of these 20, 10 are positively phrased questions and 10 are negatively phrased questions. The scores are reverse for negatively phrased questions. 20 to 140 is a range of total score, greater the score, greater is the empathetic level.

Data Collection
Ethical clearance of the study had been received from
Ethical Committee Dental College LM&DC. A written consent form was signed before the start of study and the words ’empathy’ and ‘sympathy’ were well explained and differentiated.
The questionnaires were hand distributed to 3rd and 4th year students at the end of their respective lectures in the classroom. While it was circulated to the postgraduates and interns during their clinical rotations (collected after completion).

Data Analysis:
Data was entered and analyzed using SPSS 20. Pilot testing of the questionnaire has been done, Internal
Consistency was analysed using Cronbach’s coefficient alpha for the JSPE and value of the scale was 0.80, indicates acceptable and satisfactory.
Kolmogorov-Smirnov one sample test used to assess the normality of data. Independent t-test and one-way analysis of variance (ANOVA) used to test the significance difference (P <0.05).

RESULT
A total of 180 students gave their consent to participate in the study; with their mean age of 23.2 ± 2.7 years. There was an overall female predominance in our participants

(74.4%). Most of them were from 4th year of BDS (28.3%) and house officers (27.8%). The total score ranged from 20 to 140, with a minimum score of 60 to a maximum of 113.
The male participants had mean empathy score of 81.8 ± 8.2, and the female participants had mean empathy score of 85.3 ± 10.7. Gender differences were compared using Independent sample t test and results indicated that the female empathy score was significantly higher as compared to male students (p-value = 0.041).
Oneway ANOVA showed that the differences on mean scores in different academic years was statistically significant (p-value = 0.024).
The postgraduates mean empathy level (88.1 ± 11.9) was find to be higher, 4th year students (86.1 ± 10.2) followed by 3rd year students. Post hoc Tukey test revealed that that the mean empathy score of house officers (80.7 ± 9.0) was significantly lower as compared to 4th year students (86.1 ± 10.2) (p-value = 0.025).

DISCUSSION
In this study empathy among male and female was compared, female Dental undergraduates, scored higher than males; the finding being consistent with studies reporting American and Indian Dental paticipants.7,9
Post graduates and 4th year students scored higher, this can be attributed to the fact that they have exposure to, hence a routine of patient assessment and examination. This leads to development of a professional attitude; this finding being contrary to the study by Aggarwal et al.7 Mean score of 3rd year BDS students was one point less than that of 4th year and post graduates. The reason can be linked to the reason that they come in contact with patient on chair for the first time, although academically there are more subjects but the pressure of clinical quota completion leads to a decline in empathy level. Interns (House Officers) scored the lowest, these students lay more of their efforts on practical skills rather than on “life skills”. They are also more mentally relaxed during their internship after completion of their 3rd and 4th year which is accompanied by a vigorous routine.
In this study, the participants had total mean empathy score of 84.4, which was similar to Indian (84.80)1 and Malaysian (84.76)2 , these scores were lower than that stated by Hojat for American Dental students (mean115)3 , and Japanese samples (104.3).10
There are many factors which influence the variation of scores in different countries. These could be age, sex, psychological well-being, culture, course content, the hidden curriculum, the communication skills, timing of clinical training and the scholastic interventions.6
According to Hojat et al. Empathy attributes are: social behavior, respect of elderly, moral rational, the lack of malpractice, emphasis on clinical history and the physical examination, patient and physician relationship, good clinical results.11
Empathy depends on a dialectical relationship in which the undergraduate dental or allied health sciences students are not exempted, being acore ingredient of good health care system.In curriculum empathy is generally taught in context and should be formally evaluted to improve the dentist -patient relatioship.12

CONCLUSION
Empathy-related teaching exercises like ‘taught’ by peer assisted learning, documentaries, role-playing and interviewing skills, must be implemented among the dental students to endorse its growth.

LIMITATIONS
Future studies required more Longitudinal research to investigate the outcomes of communication exercise, interest in joining dental course. Empathy was constructed on validated questionnaire, limited to reflecting student’s orientation not actual behavior.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Assessment of Empathy among Clinical Dental Students in a Teaching Dental Institution in Telangana State, Dr. V. Siva Kalyan, etal. India.
http://www.jiaphd.org on Tuesday, 2017, IP: 186.240.18.

2. An assessment of dental students’ empathy levels in Malaysia. Muneer G. Babar etal,… International Journal of Medical Education. 2013;4:223- 229 ISSN: 2042-6372
https://doi.org/10.5116/ijme.5259.4513

3. The Jefferson Scale of Physician Empathy: development and preliminary psychometric data. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, et al. Educ Psychol Meas. 2001;61:349-65
https://doi.org/10.1177/00131640121971158

4. Jefferson Scale of Empathy (JSE). Center for research in medical education and health care (CRMEHC). [cited 1 July 2013]; Available from: http://www.jefferson.edu/jmc/crmehc/jse.html.

5. Empirical research on empathy in medicine- a critical review. Pedersen R. Patient Educ Couns. 2009;76:307-22.
https://doi.org/10.1016/j.pec.2009.06.012

6. Undergraduate medical students’ empathy: current perspectives.Quince etal. Advances in Medical Education and Practice 2016.

7. Exploring the missing link – Empathy among dental students: An institutional cross-sectional survey. Pal Aggarwal etal, Accepted 2016 Jun.

8. Empathy levels among practicing dental surgeons – a cross-sectional study. Shabbier etal , Pakistan Oral & Dental Journal Vol 36, No. 3 (JulySeptember 2016).

9. Measurement of changes in empathy during dental school, Sherman JJ J. Dent Edu 2005;69:338-45.
https://doi.org/10.1002/j.0022-0337.2005.69.3.tb03920.x

10. Measurement of Empathy Among Japanese Medical Students: Psychometrics and Score Differences by Gender and Level of Medical Education. Kataoka, etal .Academic Medicine. 84:1192-1197, September 2009.
https://doi.org/10.1097/ACM.0b013e3181b180d4

11. Physician Empathy: Definition, Components, Measurement and Relationship to Gender and Specialty. Hojat, M., Gonella, J.S., Nasca, T.J., Mangione, S., Vergare, M. and Magee, M. (2002) .American Journal of Psychiatry, 159, 1563- 1569.
https://doi.org/10.1176/appi.ajp.159.9.1563

12. Levels of Empathy among Dental Students in Five Chilean Universities. V. P. Díaz-Narváez et al. Health, 2016, 8, 32-41 Published Online January 2016 in SciRes. http://www.scirp.org/journal/health
https://doi.org/10.4236/health.2016.81005

INTRODUCTION
Effectiveness of masticatory function is one of the  prime objectives in prosthetic rehabilitation of partially dentate patients. The ability to masticate effectively is not only a reflection of a healthy stomatognathic system but has also been associated with good general physical health. Masticatory performance is known as the percentage distribution of food particles size when masticated for a particular no. of strokes.9 Primary determinants of masticatory efficiency in subjects having natural teeth are number and size of teeth in contact. Occluding surfaces of teeth determine the total surface area accessible for grinding and shearing of food during every single cycle of chewing.1 Minimum total of teeth required for functional demands of mastication are 8 premolars and 4 molars.2 1st molars provide greatest effective occlusal contact area that is 36.7% for masticatory performance. The 2nd and 3rd molar provide 27.9 and 15.4 % occlusal contact area respectively.3 The concept of shortened dental arch was first proposed in 1981 as the minimum treatment intervention based on the notion
that for successful and satisfactory oral function all exclusive functions performed by molars are also provided by anterior teeth and premolars and the lost teeth do not always need replacement.13,14 This concept was evolved mainly for the older patients suggesting that the minimal number of pairs
of occluding teeth needed to provide adequate oral function can be variable depending on age with 12 occluding pairs of teeth for 20-40 years of age and only 10 occluding pairs for 50-70 years of age.2
Clinical studies supporting shortened dental arch concept have highlighted that even enough of adaptive capacity persists in subjects having left with a minimum of four occluding units and it has no reported impairment in masticatory performance except when less than 10 occluding pair of teeth were present.9,12 However conflict still exists about ideal number of functional tooth units required for satisfactory masticatory performance.13 Loss of only mandibular 1st molar in healthy dentate patients causes 40% reduction in chewing efficiency.4 Moreover 2nd and 1st premolar provide least amount of occlusal contact area required for mastication 12.9, and 8.1% respectively.3
Removable partial dentures improve masticatory performance by increasing number of functional or occluding dental units.5 It is believed that restoration of posterior teeth
by removable partial denture prevents posterior collapsed bite, drifting of premolar teeth, increasing interdental spacing, lowering of occlusal vertical dimension, alterations in temporo-mandibular condylar position, over eruptions among unopposed teeth and anterior teeth flaring along with increase in overbite and overjet.15 MM August et al. evaluated that in middle age patients after 5 year follow up, provision of removable partial denture showed improvement in masticatory efficiency. Their study concluded that dietary fiber intake was more in people having more artificial tooth replacements.5 Feuki et al. found in their study that young age, number of missing teeth, asymmetry in dental arches and chewing complaints are significant reasons for pursuing prosthetic solution in shortened dental arch patients.8 Another study conducted by M Bessadet et al. with 1 year follow up concluded that rehabilitation with removable partial denture prosthesis improved ability to reduce food bolus particles size.6 Further investigation by Allen et al. showed significant improvement in masticatory efficiency following RPD
insertion in subjects having shortened dental arches2 , but notice must be taken regarding lesser than optimal oral function, an increased caries risk, periodontal problems and poor patient compliance with removable prosthesis.12 Some studies reported no difference in masticatory effectiveness of patients having shortened dental arches with and without removable partial denture treatment.8 However, dialogue on most suitable treatment modality is still ongoing.7
In existence of differing opinions in previous studies on improvement of masticatory efficiency of shortened dental arch patients with removable partial dentures, it is demanding to analyze masticatory efficiency of shortened dental arch patients after insertion of dentures. This study will help clinician to have better understanding of treatment needs of shortened dental arch patients and also will provide guidelines for management of shortened dental arch patients.

METHODOLOGY
Using non- probability (consecutive) sampling, this cross-sectional study was carried out in prosthodontics department, Punjab dental hospital, Lahore between 1st December 2019 to 30th May 2020. Patients with Shortened Dental Arches comprising bilateral free end saddle in upper and lower arches not involving 1st and 2nd premolars and intact anterior teeth were included in this study. Patients with Temporomandibular disorders, Periodontal disease, Attrition and malocclusion were excluded from study.
Patients who presented in Outdoor of Prosthodontics department at Punjab Dental Hospital, Lahore, among them, 66 shortened dental arch patients with age range 34 64 were selected. After approval from local ethical committee, and after fulfilling inclusion criteria, informed consent was signed and taken from each subject after taking demographic history (age, gender, place of living, socioeconomic status). Masticatory performance in subjects with pre and post removable partial denture treatment was evaluated as explained by Gunne9 i.e. the study subjects were asked to chew 5g of raw carrot with 20 number of chewing strokes. The chewed carrot then was recovered in a cup and mesh sieve measuring 5mm x 1mm was used to strain it. It was air-dried for up to 30 minutes, weighed using a FEM mini digital weighing scale. Volume remaining on sieve and that which passed through it was calculated and determined.
The ratio of masticatory efficiency was determined by calculating the volume of raw carrot that passed through the sieve and dividing it by the total volume of raw carrot recovered and was expressed as percentage. The values were recorded, calculated and entered on data collection sheets. The test was repeated after 3 months of RPD provision with denture inserted in subject mouth. Outcome variable was recorded as per operational definition by researcher herself.

RESULTS
SPSS version 25 was used for data analysis. Mean and standard deviation was calculated for age and change percentage was calculated for gender. Effect modifiers like
age, place of living (rural/urban) and gender was controlled through Stratification. T-test was applied and p < 0.05 was taken as significant. In this study total 66 patients participated. The mean age was 47.74±9.00 years-Table 1. Out of 66 patients 48(72.73%) were male and 18(27.27%) were females-Fig 1. Out of 66 patients, 36(54.55) patients were from rural area and 30(45.45%) patients were from urban area-Fig 2. In our study the mean value of pretreatment masticatory performance of participants was 34.66±2.96 while mean value of post-treatment masticatory performance of the patients was 53.98±45.91. Statistically significant difference

was established between before and after comparison ofmasticatory performance of the patients. i.e. p-value <0.001- Table 2. The mean change from pre and post treatment of masticatory performance of the patients was 19.32±3.03 with minimum and maximum values of 11.54 & 32.39 respectively-Table 3. Among patient’s form < 50 years the

mean change on masticatory performance of the patients was 20.61±2.66 while in patients from age >50 years the mean change on masticatory performance of the patients was 17.86±2.78. Statistically insignificant difference was established between age and change in masticatory performance i.e. p-value =<0.001-Table 4. Among male patients the mean change on masticatory performance of the patients was 19.77±3.12 while in female patients the

mean change on masticatory performance of the patients was 18.12±2.48. Statistically significant difference was established between gender and change in masticatory performance. i.e. p-value=0.048-Table 5.

DISCUSSION
The replacement of missing dentition with removable partial denture is often done to enhance masticatory functions of the patients.5
The connection between masticatory performance and dental/ prosthodontic status has attracted many cross-sectional studies having most of them describing a strong interrelation.10 MZ Nassani et al. reported that pursuing prosthodontic replacement was found in 3% of shortened dental arch patients with missing 2nd molars, in 58% with missing 1st and 2nd molars and in 93% with missing premolars.8 Methods to measure masticatory performance include subjective and objective method. Sieve method is gold standard to measure masticatory efficiency. Smaller the particle size of masticated test food obtained using sieves, greater will be the masticatory efficiency.15 In this study the mean change from pre and post treatment of
masticatory performance of the patients was 19.32±3.03 with minimum and maximum values of 11.54 & 32.39 respectively. The mean value of pretreatment masticatory performance of the patients was 34.66±2.96 while the mean value of post-treatment masticatory performance of the patients was 53.98±45.91 with significant difference between the before and after comparison of masticatory performance of the patients. This is in accordance with previous studies.
The significant improvement in the masticatory performance after RPD treatment could be explained by having a greater occlusal surface area due to additional occlusal units accessible for mastication.10 Male subjects showed greater masticatory performance after provision of removable partial denture than female subjects. It is in compliance with other studies 5,6 stating that a greater masticatory performance in males is due to more muscle mass and bite force.9
Superior masticatory efficiency was noted in younger subjects when compared to the older ones. This is also in accordance to the earlier studies.9,21 This could be attributed to having greater adaptability, increased biting forces and
optimal neuromuscular control and coordination in younger subjects.9 Witter et al observed that the study group having at least 21 functional teeth had no eating difficulties. S. Van Waas et al revealed that the study subjects were more satisfied when the occlusal units that were replaced by partial denture
were increased.16,17 More the occlusal surface area more is the probability of better grinding and crushing of food.18,19 Yurkstas stated that masticatory performance can be relatively predicted if occlusal contact surface area is known.16 Some studies stated that with a minimum of 20 well aligned teeth or 4 functional occluding units, adequate adaptive capacity ensuring sufficient masticatory ability can be achievable.12 On contrary some other studies stated that adequate masticatory ability was achievable with 20 or more teeth or six functional tooth units having premolars along with at least one occluding pair of molars.11 A review of literature unfolded that bilateral distal extension removable partial denture in SDA compensated for only fifty percent of the masticatory efficacy of complete dentate arches.10,20 People with fixed dental prosthesis can achieve masticatory performance nearer to natural dentition.16,19 Dental literature states that dental arches having teeth up to premolar region, fulfills the requisites of a functionally sound dentition. Nevertheless, functional requirements, and the number of occluding pairs of teeth to cater them, varies from person to person, and therefore dental rehabilitation must be  considered according to individual’s adaptive capability and needs.23,24,25

CONCLUSION
According to this study there is after insertion of  removable partial denture insertion has shown evident improvement in mastication among subjects having shortened dental arches. Hence provision of removable partial dentures in individuals having shortened dental arches should be practiced to improve masticatory performance.

CONFLICT OF INTEREST
None declared

REFERENCES
1. English JD, Buschang P, Throckmorton G. Does malocclusion affect nmasticatory performance? The Angle Orthodontist. 2002;72:21-7.

2. Fernandes VA, Chitre V. The shortened dental arch concept: A treatment modality for the partially dentate patient. J Indian Prosthodontic Society. 2008;8:134.
https://doi.org/10.4103/0972-4052.49016

3. Yurkstas A, Manly R. Measurement of occlusal contact area effective in mastication. Am J Orthodontics.1949;35:185-95.
https://doi.org/10.1016/0002-9416(49)90028-7

4. Bowley J. Minimal intervention prosthodontics: current knowledge and societal implications. Medical Principles and Practice. 2002;11(Suppl. 1):22-31.
https://doi.org/10.1159/000057775

5. Augustin MM, Joke D, Bourleyi SI, Shenda LP, Fidele NB, Van TM, et al. The effect of partial removable denture use on oral health related quality of life and masticatory function, after 5 years use. Open J Stomatology. 2016;6:201.
https://doi.org/10.4236/ojst.2016.610026

6. Bessadet M, Nicolas E, Sochat M, Hennequin M, Veyrune J-L. Impact of removable partial denture prosthesis on chewing efficiency. J Applied Oral Scie. 2013;21:392-6.
https://doi.org/10.1590/1679-775720130046

7. Nassani MZ, Ibraheem S, Al-Hallak KR, El Khalifa MOA, Baroudi K. A study of dentists’ preferences for the restoration of shortened dental arches with partial dentures. European J Dent. 2015;9:183-8.
https://doi.org/10.4103/1305-7456.156802

8. Nassani MZ, Tarakji B, Baroudi K, Sakka S. Reappraisal of the removable partial denture as a treatment option for the shortened dental arch. European
J Dent. 2013;7:251.
https://doi.org/10.4103/1305-7456.110199

9. Omo J, Sede M, Esan T. Masticatory efficiency of shortened dental arch subjects with removable partial denture: A comparative study. Nigerian J Clinical Practice. 2017;20:459-63.

10. Zhang Q, Witter DJ, Bronkhorst EM, Creugers NH. The relationship between masticatory ability, age, and dental and prosthodontic status in an institutionalized elderly dentate population in Qingdao, China. Clinical oral investigations. 2019;23:633-40.
https://doi.org/10.1007/s00784-018-2477-z

11. Naka O, Anastassiadou V, Pissiotis A. Association between functional tooth units and chewing ability in older adults: a systematic review. Gerodontology. 2014;31:166-7
https://doi.org/10.1111/ger.12016

12. Kumar AB, Walmsley AD. Treatment options for the free end saddle. Dental update. 2011;38:382-8
https://doi.org/10.12968/denu.2011.38.6.382

13. Olley RC, Renton T, Frost PM. Observational study investigating tooth extraction and the shortened dental arch approach. Journal of Oral Rehabilitation. 2017;44:6106.
https://doi.org/10.1111/joor.12523

14. Alam M, Joshi S, Joshi P. Shortened dental arch: A simplified treatment approach. J Nepal Dent Assoc. 2014;14:1-4.

15. Oliveira NM, Shaddox LM, Toda C, Paleari AG, Pero AC, Compagnoni MA. Methods for evaluation of masticatory efficiency in conventional complete denture wearers: a systematized review. Oral health and dental management. 2014;13:757-62.

16. Mazurat NM, Mazurat RD. Discuss Before Fabricating: Communicating the Realities of Partial Denture Therapy. Part I: Patient Expectations. J Canadian Dent Assoc. 2003;69:90-4.

17. Magalhães IB, Pereira LJ, Marques LS, Gameiro GH. The influence of malocclusion on masticatory performance: a systematic review. Angle Orthodon. 2010;80:981-7.
https://doi.org/10.2319/011910-33.1

18. Owens S, Buschang PH, Throckmorton GS, Palmer L, English J. Masticatory performance and areas of occlusal contact and near contact in subjects with normal occlusion and malocclusion. Am J Orthod Dentofac Orthopedics. 2002;121:602-9.
https://doi.org/10.1067/mod.2002.122829

19. Oliver S, Micheal H. Impact of shortened dental arch on oral health-related quality of life. J Evidence Based Dental Practice.2021;21:
https://doi.org/10.1016/j.jebdp.2021.101622

20. Reissmann DR, Wolfart S, John MT. Impact of shortened dental arch on oral health -related quality of life over a period of 10 yearsA randomized controlled trial. J Dent.2019; 80:55-62
https://doi.org/10.1016/j.jdent.2018.10.006

21. Micheal H Jens D, Torsten M. Periodontal health in shortened dental arches: A 10- year RCT. J Prosthodontics Res. 2020;64:498- 505
https://doi.org/10.1016/j.jpor.2020.01.005

22. Saadika.B. Translation of the shortened dental arch research into clinical practice: a stakeholder mapping approach. BDJ Open. 2020; 6:10
https://doi.org/10.1038/s41405-020-0039-3

23. Javed MU, Asim MA. Association of tooth loss with temporomandibular disorders. Khyber Medical University J.2020;12:29- 33

24. Narendra B, Lama A, Othman W. Role of shortened Dental Arch (SDA) concept in treatment planning- A case report. J Dent Medi Sci.2019;18:48-52.

25. Sulema G, Chaturvedi S, Shareef RA. An assessment of Dentist’s Attitude to the shortened dental arch Concept. Open Access Macedonian J Medi Sci.2020;8:14-22
https://doi.org/10.3889/oamjms.2020.3748

INTRODUCTION
Pulpotomy is the most frequently used vital pulp therapy procedure in carious primary teeth where caries removal results in pulpal exposure.1 It involves amputation of the coronal pulp and placement of a medicament over the radicular pulp stumps in order to promote healing. It is based on the rationale that the healthy radicular pulp is capable of healing after removal of the affected coronal pulp tissue. The ideal pulpotomy agent should be bactericidal, biocompatible, promote healing of the remaining pulp, not
interfere with the normal physiologic root resorption and preserve the radicular pulp health clinically and
radiographically.2
Formocresol (FC) was the first pulpotomy agent to be used in primary teeth in 1930.3
FC contains formaldehyde which is a known carcinogen.4 This has raised concerns regarding its use in dentistry. Additionally at histological level, FC does not produce a favorable pulpal response.5 It causes chronic inflammation within the pulp which may initiate root resorption that is commonly associated with teeth treated with FC .
In 1995, Torabinejad introduced Mineral Trioxide Aggregate (MTA). Its excellent biocompatibility, high pH, sealing ability and high compressive strength makes it an
ideal choice for pulpotomy agent.6 It stimulates cytokines production and induces hard tissue barrier formation by virtue of its dentinogenic and antimicrobial properties.7 MTA has the ability to heal the tissue and cause regeneration which has brought a revolution in the modern endodontic approach. Based on the recent clinical studies, MTA appears to be the new gold standard for pulp capping and pulpotomy procedures.8
Management of deep carious lesions poses a challenge to the pediatric dentist. Diagnosis of pulp inflammation is the key to the success of pulp therapy as the degree of the
inflammation determines the repair and regeneration capacity of the pulp-dentine complex.9 Inflammation is a response by the pulp to eliminate pathogens. In order to make accurate diagnosis, patient’s history and clinical signs and symptoms must be correlated.10 There are five main parameters in history to aid in diagnosis if a patient presents with complain of pain; localization, commencement, intensity, provocation and duration.11 History of pain is an important diagnostic tool to assess the reversible and irreversible inflammation of the pulp with transient, stimulated pain associated with reversible pulpitis and intense, lingering pain of spontaneous origin associated with irreversible pulpitis.12 The American Academy of Pediatric Dentistry recommends the use of both FC and MTA as pulpotomy agent and advocates the use of the medicament based on individual preferences.13 The  routine use of MTA however, has been limited due to its high cost.14 The current study aims to evaluate if presence of pre-operative pain affects the success of pulpotomy and if either FC or MTA performs better in patients with positive history of pain. Both clinical and radiographic parameters were evaluated at one year follow-up. This is a variable which has never been accounted for in the studies on pulpotomy in primary teeth.

METHODOLOGY
It is a retrospective study conducted in Children Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Data was collected retrospectively from the patient records of Department of Pediatric Dentistry, Children Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Approval from the institutional Ethical Review Board was taken. The study Records of the children aged between 4- 8 years meeting the following criteria were selected:
. Patients with complete pre-operative and one-year
follow-up clinical and radiographic records.
. No significant medical history.
. One-visit pulpotomy with either FC or MTA was  performed.
The children with incomplete records and non-standardized radiographs were excluded. The sample size was calculated using WHO sample size calculator. A quota sampling of total 60 teeth was done from the data which met the inclusion and exclusion criteria. 30 of the selected teeth were symptomatic i.e., a positive history of pre-operative pain was associated with the pulpotomized tooth, 15 of which had been treated with FC and 15 with MTA. Similarly, 30 asymptomatic teeth i.e., no history of pre-operative pain associated with the pulpotomized tooth were selected of which 15 had been treated with FC and 15with MTA.
Pre-operative and one-year follow-up clinical and radiographic findings for each selected tooth were noted on a proforma and statistically analyzed. Both clinical and radiographic outcomes were determined. The teeth were recorded as clinically successful if they were asymptomatic at one-year follow-up i.e., having no signs and symptoms such as history of spontaneous or nocturnal pain, tenderness on percussion or palpation, abscess formation, swelling/fistula and/or mobility. If any of these were present, the tooth was recorded as failure. The follow-up radiographs were evaluated for external or internal root resorption, periapical or furcation radiolucency and periodontal ligament (PDL) widening. If any of these were present, the tooth was recorded as failure.
Data was analyzed using Statistical Package for Social Sciences (SPSS version 23). Chi-square test was applied to compare the effect of pre-op pain on the clinical and radiographic success. Uni-variant analysis was done to compare the clinical and radiographic outcomes of both the agents in the respective groups. p-value <0.05 was considered significant.

RESULTS
The age of the patients included in the study was 4-8 years with a mean of 4.9 years (SD+ 1.18). The overall success rate of the pulpotomized teeth at the end of 1 year was 78.3% clinically and 65% radiographically. The results showed a positive association between pre-operative (pre-op) pain and clinical and radiographic success at the end of 12 months. The clinical success rate of pulpotomy in teeth without pre-op pain was 86.7% (n=26) while it was found to be 70% (n=21) in those with positive history of pre-op pain with a p-value of 0.117 which is statistically not significant. The radiographic success of the teeth without pre-op pain was found to be 76.7% (n=23) while it was 53.3% (n=16) in teeth with positive history of pain. The p-value was calculated to be 0.058 which is marginally significant. The results are summarized in
Table 1.

In patients with pre-op pain, FC treated teeth showedv60% (n=9/15) success while MTA treated teeth showed 80% success (n=12/15) as shown in Figure 1. The p-value was calculated to be 0.232 which is not statistically significant.
The radiographic success rate was found to be 33.3% (n=5/15) and 73.3% (n=12/15) for FC and MTA respectively in patients with pre-op pain as shown in Figure 2. The pvalue was calculated to be 0.028 which is statistically significant.

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

INTRODUCTION