JPDA

Sara Qureshi                                                   BDS
Muhammad Waseem Ullah Khan                  BDS, FCPS, CMT
Momina Akram                                                BDS, FCPS

INTRODUCTION

Ectodermal Dysplasia (ED) is a rare heterogenous group of genetic disorders primarily attributed to the mutational changes in the genes which encode for the development of embryonic ectodermal structures and their appendages; skin, nails, teeth, hair and eccrine glands.1 Since ectodermal dysplasias have a genetic etiology, they commonly follow a mendelian inheritance pattern. However, it has been conjectured that they can also occur in individuals with no previous family history where a de novo mutation might have occurred.

Skimming through the literature divulged that approximately, more than 200 different types of ectodermal dysplasias have been identified till this date.3 Ectodermal dysplasia can be broadly classified into hypohidrotic and hidrotic forms based upon the clinical manifestations of the syndrome.4 Hypohidrotic ectodermal dysplasia (HED 1) also known as Christ-Siemens-Touraine Syndrome is the most common variant of ED, which is characterized by the expression of hypohidrosis, hypodontia or anodontia and hypotrichosis .5 The genetic pathogenesis of this form is described by the mutations in the EDA gene which presents an X-linked recessive mode of inheritance thereby predominantly affecting males.6 However, X-linked carrier females exhibit an intermediate expression in the form of mild hypodontia and spottily reduced sweating. The hidrotic type (HED 2) is also known as Clouston syndrome which is inherited as an autosomal dominant disorder. It exhibits a phenotypical triad of nail dystrophy, palmoplantar hyperkeratosis and patchy alopecia with normal dentition and eccrine glands.

Dental manifestations of ectodermal dysplasia are characterized by conical, peg-shaped malformed teeth, hypodontia or complete anodontia of primary or permanent teeth with accompanying skeletal discrepancies which can be a cause of great esthetic concern for the patient.7 Literature has been very generous in unfolding a variety of treatment modalities for these patients and has time and again advocated an early intervention based on a multidisciplinary approach for their successful rehabilitation.
This clinical report aims to illustrate the Prosthodontic rehabilitation of an adolescent patient having oligodontia associated with ectodermal dysplasia and severe skeletal class III malocclusion

CLINICAL REPORT

A 20-year-old female patient reported to the outpatient Department of Prosthodontics de ‘Montmorency College of Dentistry, Lahore with the chief complaint of unpleasant aesthetics and difficulty in mastication due to deranged occlusion, multiple missing teeth and conical malformed appearance of remaining teeth with wide spacing between them (Figure 1a). Detailed medical and dental history revealed

extraction of grossly carious deciduous mandibular left first and second molar almost six months ago. However, the medical history was insignificant. Family history revealed normal parents with a consanguineous marriage. Two of her thirteen siblings and a few of her maternal relatives had the same dental problem which was indicative of a mendelian inheritance pattern.

Intraoral examination of the patient evinced the presence of retained deciduous dentition with congenital absence of maxillary lateral incisors and multiple missing permanent teeth (Figure 2a). The existing teeth were small, peg shaped, malformed microdonts. A unilateral free-end saddle area

(Kennedy class II) was present distal to mandibular left canine (Figure 2b). She had a skeletal class III maxillomandibular relationship with an anterior and right posterior crossbite. A forward and upward displacement of mandible was observed with a complete loss of anterior guidance and an anterior negative overjet of -3mm was recorded. The freeway space was measured to be 8mm. Soft tissue evaluation of mucosa, tongue and gingiva revealed normal color and texture. Oral hygiene status was satisfactory.

Panoramic radiograph of the patient showed poor crown-toroot ratios for deciduous maxillary and mandibular incisors (Figure 2c). There was complete anodontia of permanent

dentition as no signs of impacted or unerupted permanent teeth were found in the jaws.

Thorough clinical and radiographic evaluation led to the diagnosis of oligodontia associated with hypohidrotic ectodermal dysplasia. Diagnostic casts were obtained using alginate hydrocolloids to work out for a viable treatment plan. Since the Patient desired for complete arch fixed reconstructions, further diagnostic imaging with a CBCT was done for the 3-D analysis of maxillary and mandibular bone to determine any possibility of implant placement. Regrettably CBCT analysis revealed hypoplasia of the alveolar bone structure with inadequate bone volume at the prospective implant sites. Autogenous bone grafting could not be done due to the potential risks of morbidity and financial constraints associated with it. Hence the consideration for implant placement was laid aside.
After a meticulous discussion with the patient regarding the limitations of various treatment options, a combination of fixed and removeable Prosthodontics was deemed to be the most befitting treatment plan in the present case scenario. A removeable cast partial denture to replace the four maxillary incisors with individual surveyed crowns on remaining teeth to restore their height and shape was planned for the maxillary arch. Likewise, a removeable cast partial denture was planned for the mandibular arch to replace the four incisors and the free-end-saddle area along with individual surveyed crowns.
on the remaining teeth in the arch. Deciduous maxillary central incisors and mandibular central and lateral incisors with poor crown-to-root ratios were not extracted, rather it was decided to preserve them as over denture abutments after their elective endodontics. Prior to beginning the treatment, written informed consent was taken from the patient for the publication of this case report.

CLINICAL PROCEDURE

Maxillary and mandibular diagnostic impressions were taken in an alginate hydrocolloid. A free way space of 8mm was recorded after determining the discrepancy between resting vertical dimension (RVD)and occlusal vertical dimension (OVD) on the patient. Facebow transfer record of the patient was taken and diagnostic casts were mounted using a centric relation record on a semi adjustable Arcon type articulator. A 4mm increase in the occlusal vertical dimension was planned thus evenly distributing a 2mm increase for each arch. As the patient desired an early restoration of maxillary arch for the purpose of improving the esthetic smile line, it was decided to first restore the maxillary arch and then mandibular arch was restored accordingly.

MAXILLARY ARCH REHABILITATION

Diagnostic wax up was done on the articulated maxillary cast such that the existing three teeth on each side of the arch were contoured as canine, 1st premolar and 1st molar (Figure 3a, 3b). Thermoplastic vacuum-formed template was fabricated after the duplication of waxed-up maxillary

cast to facilitate the intra oral mockup and composite build ups. An intra oral mockup of maxillary arch was done with an auto polymerizing acrylic resin to validate the position of esthetic plane of occlusion which was found to be appropriate relative to the patient’s interpupillary line and facial proportions. After the esthetic verification, the mockup was removed, and composite buildups of maxillary teeth were done to restore their height and shape prior to their crown preparations. The patient was recalled after two weeks and her adaptation to increased occlusal vertical dimension was evaluated, for which she reported no pain or discomfort. Tooth preparations were carried out conservatively with vertical finish lines (knife edge, feather edge) to allow for the enamel preservation in the cervical area. Final impression of the preparations was taken in an addition silicon impression material by employing a dual phase two step technique. Facebow transfer and jaw relation records were repeated and sent to the laboratory for the fabrication of porcelain fused to metal surveyed crowns on the prepared abutments. Provisional crowns were cemented while the definitive restorations were being fabricated. Prior to the final delivery of surveyed crowns, they were tried in with Cavit Provis to verify esthetics and occlusal plane orientation (Figure 4a). A fox’s bite plane was used to check for the parallelism between campers’ plane and occlusal plane. Definitive

surveyed crowns were cemented with glass ionomer luting cement. Meanwhile elective endodontics of maxillary central incisors were carried out and they were subsequently prepared to have a dome shaped contour, only 1mm above the gingival margin to serve as overdenture abutments (Figure 4b). A Scandinavian design was chosen for maxillary cast partial denture. The final impression for the cast partial denture

was taken in an alginate irreversible hydrocolloid impression material which was then sent to laboratory for framework fabrication. The cast metal framework try inn was done to ensure adequate marginal adaptation. Processed maxillary

cast partial denture replacing the four incisors was insertedat the subsequent appointment (Figure 5a, 5b).

MANDIBULAR ARCH REHABILITATION

Enameloplasty of the facial surfaces of mandibular left canine, right second deciduous molar was done after their elective endodontics, so that future crowns can be fabricated with a slight lingual inclination to eliminate the existing anterior crossbite and possibly reduce the posterior crossbite. A diagnostic impression of mandibular arch and a pick-up impression of the restored maxillary arch was taken in an alginate impression material. The maxillary and mandibular casts were rearticulated at the planned occlusal vertical dimension using a facebow transfer and centric relation record. Diagnostic wax-up on the articulated mandibular cast was done (Figure 6a, 6b). Composite build ups of mandibular teeth were done prior to their crown preparations

as had been previously done for maxillary arch using a clear vacuum formed template. The patient was recalled after one week to evaluate the adaptation to increased vertical dimension of occlusion. Afterwards, conservative vertical crown preparations were carried out and a dual phase two step impression of the prepared teeth was taken in an addition silicone elastomeric impression material. Jaw relation records were repeated and sent to laboratory for the fabrication of porcelain fused to metal surveyed crowns. Prior to the cementation of final prostheses with glass ionomer cement, occlusion was adjusted with the help of an articulating paper such that class I canine relationship was achieved on both sides of the arch (Figure 7a, 7b). Mandibular central and lateral incisors were prepared as overdenture abutments after their elective endodontics (Figure 8a). The impression for the cast partial denture was taken using the selective pressure

impression technique. The distal extension region was recorded in impression compound and final wash impression was taken in alginate impression material which was then sent to laboratory for framework fabrication. After the try inn of the cast metal framework, the tooth setup was done such that anterior teeth were retroclined to eliminate anterior cross bite. Moreover, they were ground to thin veneers due to the limited interarch space availability. The processed mandibular cast partial denture was inserted, and patient was evaluated for esthetics, phonetics and mastication

DISCUSSION

Implants have not always been a very predictable treatment modality in ectodermal dysplasia patients with severely reduced alveolar bone volume. As in these patients, invasive bone augmentation procedures are often deemed necessary for implant placement in a prosthetically driven position.9 Consequently, extensive bone augmentation has its own possible repercussions; tissue dehiscence, graft exposure which ultimately leads to augmentation failure. As the perpetual preservation of what remains is more important than the meticulous replacement of what is missing, therefore in this clinical case a less invasive approach was employed to preserve the alveolar ridge by retaining the natural teeth with poor crown to root ratios as over denture abutments instead of extracting them. Moreover, remaining teeth were restored with individual crowns due to their better prognosis when contrasted with fixed partial dentures.

The loss of occlusal vertical dimension is a common finding in patients presenting with ectodermal dysplasia .11 Hence determining the tolerance for the planned increase in occlusal vertical dimension is of paramount importance prior to beginning any irreversible treatment. Contemporary literature advocates that there is no well-defined time frame to assess the tolerance for an increased occlusal vertical dimension and it is based on patient’s subjective perception of comfort.12 In the present clinical scenario, the occlusal vertical dimension was sequentially raised to slowly improve the tolerance to increased vertical dimension. The adaptation to raised occlusal vertical dimension was evaluated after two weeks of composite build ups and fortunately the patient reported no muscle fatigue or pain in temporomandibular joint.
Interpupillary line and ala-tragus line (Camper’s plane) are regarded as reliable facial references for an esthetic dental reconstruction.13 The esthetic occlusal plane of the underdiscussion patient was verified by determining the parallelism of maxillary occlusal plane to interpupillary line anteriorly and ala-tragus line posteriorly. The patient’s esthetic perception was given a significant weight while selecting the shade of artificial teeth. A lighter shade was chosen to harmonize with the corresponding fair complexion of the patient. Maxillary cast partial denture was designed by employing a Scandinavian approach which leaves the gingival margins of remaining teeth exposed and devoid of any major connector coverage to prevent any hindrance to mouth’s self-cleansing ability.14 Thereby extracting the biological benefits of maintaining gingival health and limiting the buildup of plaque. For mandibular cast partial denture, a lingual plate was the major connector of choice to provide indirect retention in the presence of a distal extension base.

CONCLUSION

Oral rehabilitation of ectodermal dysplasia with a skeletal class III discrepancy presents an arduous challenge to dentists around the world. However early prosthodontic intervention is cardinal to prevent the long-term sequelae. The aforementioned hybrid rehabilitation with fixed and removeable prosthodontics gave a successful esthetic and functional outcome. Thereby positively building the social confidence and self-esteem of the patient.

CONFLICT OF INTEREST

None declared

REFERENCES

1. Wright JT, Fete M, Schneider H, Zinser M, Koster MI, Clarke AJ, et al. Ectodermal dysplasias: Classification and organization by phenotype, genotype and molecular pathway. Am J Med Genetics Part A. 2019;179:442-7. https://doi.org/10.1002/ajmg.a.610457
2. . Modesto A, Ventura C, Deeley K, Studen-Pavlovich D, Vieira AR. Medical sequencing of de novo ectodermal dysplasia in identical twins and evaluation of the potential eligibility for recombinant EDA therapy. J Dent Res, Dental Clinics, Dental Prospects. 2017;11:135-9. https://doi.org/10.15171/joddd.2017.025
3. Grange DK. Ectodermal Dysplasias. Elsevier eBooks. 2013;1-26. https://doi.org/10.1016/B978-0-12-383834-6.00157-9
4. Grover R, Mehra M. Prosthodontic Management of Children with Ectodermal Dysplasia: Review of Literature. Dentistry. 2015;5. https://doi.org/10.4172/2161-1122.1000340
5. Pigno MA, Blackman RK, Cronin RM, Cavazos E. Prosthodontic management of ectodermal dysplasia: A review of the literature. The J Prosthetic Dentist. 1996;76:541-5. https://doi.org/10.1016/S0022-3913(96)90015-3
6. Deshmukh S, Prashanth S. Ectodermal Dysplasia: A Genetic Review. Int J Clinical Pediatric Dentist. 2012;5:197-202 https://doi.org/10.5005/jp-journals-10005-1165
7. Van Sickels JE, Raybould TP, Hicks EP. Interdisciplinary Management of Patients With Ectodermal Dysplasia. J Oral Implantol. 2010;36:239-45. https://doi.org/10.1563/AAID-JOI-D-09-00043R1
8. Alajami H, Saker J. Rehabilitation of ectodermal dysplasia patient with a telescopic denture in the maxilla and mandibular implant assisted overdenture: A case report. Clinical Case Reports. 2021;9. https://doi.org/10.1002/ccr3.5206
9. El Charkawi H, Barakat A, Alm Eldean HI. Full mouth implants rehabilitation of a patient with ectodermal dysplasia after 3-Ds ridge augmentation. A clinical report. Future Dent J. 2016;2:4-14. https://doi.org/10.1016/j.fdj.2016.02.002
10. Misch CE. Rationale for Dental Implants *. Elsevier eBooks. 2015;1- 25. https://doi.org/10.1016/B978-0-323-07845-0.00001-4
11. . Koyuncuoglu CZ, Metin S, Saylan I, Calisir K, Tuncer O, Kantarci A. Full-Mouth Rehabilitation of a Patient With Ectodermal Dysplasia With Dental Implants. Journal of Oral Implantology. 2014 Dec 1;40:714-21. https://doi.org/10.1563/AAID-JOI-D-12-00072
12. Vailati F, Urs S, Belser C. Full-Mouth Adhesive Rehabilitation of a Severely Eroded Dentition: The Three-Step Technique. Part 2. THE European J Esthetic Dentist. 2008;3.
13. Sabbah A. Smile Analysis. Dental Clinics of North America. 2022;66:307-41. https://doi.org/10.1016/j.cden.2022.03.001
14. . Berg E, Isidor FI, Öwall B. Prosthodontics for the elderly patient – a Scandinavian approach. Prosthodontics. 2018 Aug 15;68(3):255-66. https://doi.org/10.5604/01.3001.0012.2556

Sara Qureshi                                                   BDS
Muhammad Waseem Ullah Khan                  BDS, FCPS, CMT
Momina Akram                                                BDS, FCPS

Mariyah Javed                                 M.Phil
Zartashia Arooj                               M.Phil
Sadia Manzoor
Kashif Haroon                                 FCPS
Saima Rubab Khan                         PhD
Muhammad Anwaar Alam              Msc

INTRODUCTION

Patients on antiplatelet drugs are routinely advised to hold or discontinue their therapy before any surgical procedure owing to fright for extravagant bleeding. In spite of the fact that there is expanded likelihood of intraoperative and postoperative blood loss if antiplatelet therapy is continued there is expanded chance of venous thromboembolism, for example, cerebrovascular mishaps and myocardial infarction, if drug is changed or stopped. Usually dental treatments are considered as minor surgical procedures with a low probability of bleeding, often selflimiting and are manageable by coagulation promoting agents. But, in some cases like dental trauma short term suspension of antiplatelet drugs becomes necessary. Hence, considering all dental procedures as a congruent group for likelihood of bleeding may not be justified.

Although Dentistry-related management of patients on direct oral anticoagulants (DOAC) and new oral antiplatelet drugs (NOAC) has been documented infrequently and their implications been thoroughly examined since 2012.2 With recent advances in medicine and expectation of expanded life span, post procedural use of oral anticoagulants or antiplatelet agents for prophylaxis of cardiovascular accidents is becoming fairly normal.3 Treatment of such patients becomes challenging for the clinicians to achieve balance between hazard of bleeding episodes and with chances of thrombotic event due to interim discontinuation of antiplatelet therapy. It was shown in former studies have that during dental treatments, thrombotic events are at high risk to occur because of change or discontinuation in antithrombotic treatment.

The dental aspect of oral anticoagulants and oral antiplatelets have only studied since 2012 and hence very few studies are available in this field.5 A survey was conducted which showed that there was a lack of clear protocols for Oral & Maxillofacial surgeons and general dental practitioners on patient’s management, These patients need dentoalveolar surgical procedures and they are on dual antiplatelet therapy (DAPT).6 Another survey found that, prior to dental treatments, dentists are mostly knowledgeable about managing traditional anticoagulants and antiplatelet agents. However, new treatment options are always emerging, and dentists should be aware of them in order to advance their knowledge and expertise. Additionally, under the light of past studies it was suggested that most dentists misjudge the risk of bleeding. Continual Dental Education [CDE] Seminars and teaching in this aspect are required for better understanding.7 So the main objective of present study is to evaluate bleeding gums prevalence in antiplatelet therapy patients reporting in Azra Naheed Dental Hospital.

METHODOLOGY

A descriptive research work was accompanied in Chaudhary Muhammad Akram Dental Hospital during May 2020 to November 2020. Inclusion criteria is Age 20 to 60 years. Patient on antiplatelet therapy. Exclusion criteria is patient’s taking any anticoagulant drugs, Diabetic patients and those who are suffering from Chronic Vascular Disease.

DATA COLLECTION

A total of 120 patients who satisfied the study’s inclusion and exclusion criteria were registered from Chaudhary Muhammad Akram Dental Hospital after taking informed consent. Complete history and intra oral examination of a patient was done. Ben-Dor et al. provided the following definitions of bleeding: frightening bleeding, internal bleeding, and annoyance bleeding. Hematuria, melena, hematemesis, vaginal bleeding, hematoma, epistaxis, and ocular bleeding were among the internal bleeding symptoms. During routine clinical follow-up, nuisance bleeding was evaluated and included easy bruising, bleeding from tiny incisions, petechia, and ecchymosis.Only one bleeding episode was recorded for every individual. Without any stasis, venous blood was extracted from the antecubital vein and combined with 0.11 mol/L sodium citrate in stasis. Platelet-Rich Plasma (PRP) Centrifugation at 150 ×g for 10 min at ambient temperature was used to achieve injections; PRP was centrifuged at 900 ×g for 15 min at 20°C to obtain platelet-poor plasma (PPP). Using autologous PPP, PRP was adjusted to a platelet count of 290,000-310,000/µL. Haemostasis researches, activated partial prothrombin time, platelet count and prothrombin time were completed. When necessary, additional hemostasis-related tests like platelet function analyses were carried out in compliance with a standardised technique. Analysis of Platelet function was also done by following standard protocols

STATISTICAL ANALYSIS

Data analysis will be done using SPSS 20.0 system. Expression of Continuous variables will be done as mean ± SD (Standard deviation) while categorical variables were shown as frequencies and percentages.

RESULTS

A total of 120 patients’ data were gathered. The age distribution was 35.67±2.56 years old. The bleeding time ranged from 5 to 20 minutes, with an average of 19.5 ± 5.2 minutes. There was a 32% bleeding frequency. Out of the 120 patients, 17 had bleeding times longer than 20.5 minutes but not longer than 26 minutes, 5 had minor bleeding, and 1 patient had bleeding in the urine that ceased after

anti-platelet medication [Dabigatran (direct thrombin inhibitor), Edoxaban, Rivaroxaban, and Apixaban (direct factor Xa inhibitors); and direct oral anticoagulants (DOAC)] agent was stopped.

DISCUSSION

Four medications have been approved by national or supranational medicinal agencies: Dabigatran (direct thrombin inhibitor), Edoxaban, Rivaroxaban, and Apixaban (direct factor Xa inhibitors); and direct oral anticoagulants (DOAC).7,8 These novel compounds have a wide range of applications, such as being used as direct inhibitors of FXa. Additionally, promising data is beginning to emerge regarding certain antithrombotic molecules and aptamers that target intrinsic pathway factors (i.e., FIXa, FXIa, and FXIIa) in the crucial management of deep vein thrombosis (DVT), venous thromboembolism (VTE), and PE, as well as the prophylaxis of these conditions following orthopaedic surgery.8,9,10 Elderly patients or those with renal problems are prescribed reduced dosages of medications.11 Bleeding time [BT] and LTA [light transmission aggregometry] are not considered accurate and reproducible procedure owing to their dependence on numerous variables. The gold standard test for platelet function is LTA, which is used to separate individuals into groups based on how anticoagulant medication is used. These groups include patients receiving ASA (acetylsalicylic acid aspirin), CLOP (clopidogrel; used for cardiac problems), dual therapy, and whether or not they are drug-resistant responders. Moreover, recently a research compared LTA with IPA (inhibition of platelet aggregation) among those patients who got therapy, either ticagrelor or CLOP. Previous research has shown a high association between flow cytometric measures and LTA same as present study.12 Gremmel et al. presented four distinct assays of platelet function that substantially linked with LTA. Previous studies have demonstrated the therapeutic effectiveness of the FCA [flow cytometric platelet aggregation] assay; however, there was limited comparison between the LTA and FCA assay results in bleeding patients for the purpose of underlying platelet function deficiencies (PFD) diagnosis. Thus, this study assesses the clinical efficacy of the FCA assay for PFD detection and links the findings to LTA.13 Recently, based on a variety of techniques documented in the literature, Bonello et al. provided their opinion on the definition of high treatment platelet reactivity to ADP [adenosine diphosphate ADP] and suggested that LTA be one of the four tests linked to clinical risk that is quite similar to present study. Very recently, Parodi et al. discovered that increased residual platelet reactivity as determined by LTA and ADP as an antagonist has been associated with an elevated risk of ischemic events during both the short and long-term follow-up among patients receiving clopidogrel following percutaneous coronary intervention (PCI).

CONCLUSION

According to the results and previously performed researches the conclusion of our study was that many of dental procedures can be done without interfering with antithrombotic therapy. More supportive studies are required to develop plans for pre procedural antithrombotic therapy of direct receiving oral anticoagulants patients.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

REFERENCES

1. Lillis, T., et al., Safety of dental extractions during uninterrupted single or dual antiplatelet treatment. Am J Cardiol, 2011;108:964-7. https://doi.org/10.1016/j.amjcard.2011.05.029
2. Muhammad Ahmad1, Shafaq Mannan2, Sibgha Aziz, Incidence of Gum Bleeding in Patients Taking Antiplatelet Therapy, P J M H S 2022. 16, No. 05, 2022; 1277-79. https://doi.org/10.53350/pjmhs221651277
3. Evans, I.L., et al., Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg, 2002; 40:248-52. https://doi.org/10.1054/bjom.2001.0773
4. Bajkin, B.V., S.L. Popovic, and S.D. Selakovic, Randomized, prospective trial comparing bridging therapy using low-molecularweight heparin with maintenance of oral anticoagulation during extraction of teeth. J Oral Maxillofac Surg, 2009; 67: 990-5. https://doi.org/10.1016/j.joms.2008.12.027
5. Cannon, P.D. and V.T. Dharmar, Minor oral surgical procedures in patients on oral anticoagulants–a controlled study. Aust Dent J, 2003; 48: 115-8. https://doi.org/10.1111/j.1834-7819.2003.tb00019.x
6. Morimoto, Y., H. Niwa, and K. Minematsu, Hemostatic management of tooth extractions in patients on oral antithrombotic therapy. J Oral Maxillofac Surg, 2008; 66: 51-7. https://doi.org/10.1016/j.joms.2007.06.655
7. Costantinides, F., et al., Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications. BMC Oral Health, 2016;16: 5. https://doi.org/10.1186/s12903-016-0170-7
8. Lippi, G., R. Gosselin, and E.J. Favaloro, Current and Emerging Direct Oral Anticoagulants: State-of-the-Art. Semin Thromb Hemost, 2019;45: 490-501. https://doi.org/10.1055/s-0039-1692703
9. Sivolella, S., et al., Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants. Odontology, 2015;103: 258-63. https://doi.org/10.1007/s10266-015-0195-4
10. Patel, N., et al., Dual anti-platelet therapy and dento-alveolar surgery. How do we manage patients on anti-platelet medication? Br Dent J, 2014;217: E24. https://doi.org/10.1038/sj.bdj.2014.1055
11. . Chinnaswami, R., et al., Dentists’ Knowledge, Attitude and Practice in Treating Patients Taking Oral Antithrombotic Medications – A Survey. J Clin Diagn Res, 2017; 11: Zc88-zc91. https://doi.org/10.7860/JCDR/2017/23648.9236
12. Sharma, P., et al., A comparative study between light transmission aggregometry and flow cytometric platelet aggregation test for the identification of platelet function defects in patients with bleeding. Blood Res, 2021;56: 109-118. https://doi.org/10.5045/br.2021.2020232
13. Steg, P.G., et al., ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J, 2012;33: 2569-619. https://doi.org/10.1093/eurheartj/ehs215
14. Breet, N.J., et al., High on-treatment platelet reactivity to both aspirin and clopidogrel is associated with the highest risk of adverse events following percutaneous coronary intervention. Heart, 2011;97: 983-90. https://doi.org/10.1136/hrt.2010.220491 636-39.

Mariyah Javed                                 M.Phil
Zartashia Arooj                               M.Phil
Sadia Manzoor
Kashif Haroon                                 FCPS
Saima Rubab Khan                         PhD
Muhammad Anwaar Alam              Msc

Erum Behroz Khan                              BDS, FCPS, CHPE, MTFPDP
Imran Ullah Khan                                 BDS
Asad Ullah Mohmand                          BDS
Muhammad Zaheen Khan                   BDS
Pari Gul                                                 BDS
Neelam Shah Jehan                             BDS

INTRODUCTION

Traditionally, the ideal timing for orthodontic growth modification treatment has been linked to the pinnacle of skeletal maturity in developing individuals.1 Understanding the growth events in orthodontics is crucial for accurate diagnosis, treatment planning, appliance selection, and achieving desired treatment outcomes. Detecting periods of rapid growth or growth spurts can greatly aid in addressing skeletal irregularities in patients. Various techniques have been documented for identifying maturation indicators that denote stages of bone development across different age groups.3 Hand-wrist radiographs and the stages of cervical vertebral maturation have been extensively investigated as sign of skeletal developmental stage.
The method of cervical vertebral maturation (CVM), introduced by Baccetti et al.5 , is an accepted and definitive approach for estimating skeletal maturity.1 By conducting an analysis of the structural characteristics of the 2nd, 3rd, and 4th cervical vertebrae on lateral cephalograms, the growth phase can be identified.6 The benefit of this approach lies in its reliance on the lateral cephalogram, a commonly employed radiographic tool in orthodontic diagnosis and treatment planning. Nevertheless, it doesn’t serve as a universally applicable diagnostic tool for every patient. Therefore, to ensure logical treatment planning for growing individuals, the recognition of additional reliable diagnostic tools would be highly beneficial.
Dental maturation stages can also provide insights into the growth stage of an individual.4-7 Evaluation of dental development can be accomplished through tooth eruption, the process of tooth mineralization, encompassing crown and root development stages. Among these, dental mineralization has been acknowledged as the most dependable method for assessing dental maturation.8,9 On the other hand, skeletal maturation (SM) involves a series of physiological changes within the body. This process is characterized by a phenomenon in which the rate of progression may vary among developing individuals due to differences in their biological timing.10 Consequently, both bodily maturation and chronological age have proven inadequate in reliably gauging SM, primarily due to the significant divergence in the initiation of pubertal growth spurts (PGS).11 Additionally, panoramic radiographs, routinely taken in orthodontic practice, can serve as a definitive diagnostic tool for dental maturation stages.12 These radiographs are important for patients in need of orthodontic treatment and can minimize their exposure to radiation. This approach is straightforward, practical, and more convenient to implement when compared to other existing methods. Evaluating dental maturity can be additionally linked to forecasting an individual’s growth stages.
The rationale for the study lies in exploring the potential connection between skeletal maturity, as indicated by cervical vertebral maturation, and dental development, as indicated by the calcification stages of the mandibular canine. The aim of the study was to assess skeletal maturity using calcification stages of the mandibular canine.

METHODOLOGY

This descriptive correlation study was done at the Department of Orthodontics, Saidu College of Dentistry, Swat, from April 10, 2023, to September 10, 2023, using a non-probability consecutive sampling method. Approval was granted by the hospital’s ethical review board (ERB No, 133-ERB/023).
The sample size was calculated to be 11, taking into account a 5% Type 1 error and 10% power of the test, while considering an anticipated correlation coefficient of r = 0.82 between skeletal maturity and mandibular canine calcification.1 However, to ensure normality, we opted for a sample size of 130 cases.
Inclusion criteria encompassed the availability of excellent quality pre-treatment panoramic and lateral cephalometric radiographs, along with children aged 8 to 16 years displaying Typical growth and maturation. Conversely, exclusion criteria comprised cases involving Radiographs of children exhibiting congenital anomalies, syndromes, or congenitally absent teeth, as well as patients with severe dental or periodontal conditions that could potentially influence dental maturation. Additionally, patients with systemic medical conditions or medications known to impact skeletal or dental development, those with a history of craniofacial trauma or surgery, and individuals with severe systemic or medical conditions affecting craniofacial growth and development.
The research incorporated de-identified digital orthopantomograms and lateral cephalogram records from 130 orthodontic patients undergoing treatment. Radiograph anonymization was performed by a non-affiliated radiograph technician for the study. Radiographs not meeting the inclusion criteria were omitted from the analysis. The panoramic radiographs were used to assess the calcification stages of the right mandibular canine, employing the modified Gleiser and Hunt method for simplified scoring, reduced from 10 to 5 stages.24 Additionally, the growth phase of skeletal maturation will be determined on lateral cephalograms following the CVM (Cervical vertebral maturation) method introduced by Baccetti et al.
The data underwent statistical analysis using SPSS version 24.0. Mean and standard deviation (SD) were computed for numerical variables like age, while qualitative variables such as gender, MCC, and tooth mineralization stages were analyzed using frequency and percentage calculations. Relationships between variables were assessed through the Chi-square test and Spearman’s rank correlation. The statistical significance threshold was established at P < 0.01

RESULTS

The mean age was 11.86 ± 1.76 years. Females were 63 (48.46%) and males were 67(51.54%). Age was normally distributed shown by bell shape histogram. (Fig1) Canine calcification stages were evaluated among the 130 participants included in the study. The distribution of participants across different stages of canine calcification was as follows: MCC1 (Mandibular canine calcification)was observed in 2 participants (1.54%), MCC 2 in 39 participants (30.00%), MCC 3 in 32 participants (24.62%), MCC 4 in 18 participants (13.85%), MCC 5 in 38 participants (29.23%), and MCC 4 in 1 participant (0.77%). (Fig 2) Table 1 presents a cross tabulation of the stages of canine calcification and cervical vertebral maturation (CVM) stages. The distribution of participants across different stages is

as follows: For MCC 1, 2 participants (14.29%) were in CS1, while no participants were observed in the other stages. For MCC 2, 11 participants (78.57%) were in CS1 (Cervical vertebral maturation stage) 28 participants (87.50%) were in CS2, and no participants were in the remaining stages. For MCC 3, 1 participant (7.14%) was in CS1, 4 participants (12.50%) were in CS2, and 27 participants (72.97%) were in CS3. For MCC 4, 8 participants (21.62%) were in CS3, 10 participants (29.41%) were in CS4, and no participants were in the other stages. For MCC 5, 1 participant (2.70%) was in CS3, 24 participants (70.59%) were in CS4, all 12 participants in CS5 (100.00%) were in CS5, and the only participant in CS6 (100.00%) was in CS5. MCC4 was observed in 1 participant (2.70%) in CS3. The p-value indicates a statistically significant association between canine calcification stages and CVM stages (p < 0.001).
Table 2 also presents a cross tabulation of the stages of canine calcification and cervical vertebral maturation (CVM) stages in male and female .The p-value indicates a statistically a highly significant association between canine calcification stages and CVM stages (p < 0.001). The correlation between cervical maturation stage and calcification stage was perfect (r=0.96) and highly statistically significant (p<0.001). The regression equation and co-efficient of determination is shown in Fig 3.

DISCUSSION

The findings of this research have significant implications for orthodontics, as accurately assessing an individual’s growth maturation status is essential for diagnosis, treatment planning, and achieving successful treatment outcomes.

The primary duty of an orthodontist involves evaluating an individual’s growth status and gathering information about their remaining growth potential to ensure the effective treatment of malocclusion with skeletal causes. Hence, it is essential to record the potential direction, magnitude, and potentially the timing of a patient’s growth. Every child undergoing a standard growth pattern encounters a pubertal growth spurt. Nevertheless, it is crucial to acknowledge that there are differences in the initiation, duration, pace, and scope of this growth during puberty for each individual Consequently, orthodontists rely on various assessment methods, including chronological age, stage of dental development, tracking standing height measurements on growth charts, monitoring the progression of secondary sexual characteristics, and utilizing radiographic measurements of skeletal maturation to make informed treatment decisions.
The current study employed the MCC stages to assess growth phases, considering that mandibular canine calcification starts at four months and completes by seven years, with permanent canines typically emerging between 9 to 10 years of age. Panoramic radiographs were used to identify calcification stages, and prior research had already established a strong connection between developmental stages and mandibular canines.17 Hypodontia occurrence in permanent canines was found to be rare (0.18%-0.29%), with minimal morphological variations in their development, emphasizing the reliability of using this tooth as a growth marker.

The choice of age range (8 to 16 years) for the study aligned with similar investigations by other researchers and was considered relevant as orthodontic interventions are often performed within this age bracket21 he current study found a significant link between CVM Stages 1, 2, and 3, as well as MCC Stages 2, 3, and 4, in relation to skeletal age and calcification stages. Conversely, CVM Stages 4, 5, and 6 corresponded with the full development of mandibular canines, specifically Stage 5. This indicates that the stages of canine calcification predominantly mirror growth status during the early phases, consistent with earlier studies conducted by Džemidžic et al

Nasir ZB,et al.cunducted a study in pakistan with the mean age of the sample was 13.29±1.86 years. The Hassel and Farman CVM stages on a lateral cephalometric radiograph and Dimerijan canine calcification stages on a panoramic radiograph showed a significant positive correlation (r= 0.785, p= 0.000).25 Overall, while both studies support the correlation between cervical maturation stages and canine calcification stages, our study provides more detailed information and a larger sample size, and it identifies an exceptionally strong correlation between these developmental stage.
To support their findings, the study referenced a prior cross-sectional study conducted on 300 orthodontic patients in the same age group. This study utilized the Gleiser and Hunt method to assess mandibular canine calcification and the CVM method developed by Baccetti et al. to evaluate skeletal maturation phases. The results of this previous study also indicated positive correlations between CVM Stages 1, 2, 3, and mandibular canine calcification Stages 2, 3, 4, reaffirming the clinical relevance of using canine calcification stages as a marker for assessing skeletal maturity.

LIMITATIONS

While the study makes valuable contributions, it is important to recognize several limitations. Among the limitations are the modest sample size of 130 participants, potentially restricting the broad applicability of the conclusions. Moreover, the confined age bracket of 8 to 16 years might limit how widely the results can be applied across different populations

The study was done at a single institution, introducing potential biases related to the patient population. Exclusion criteria may have introduced selection bias, and variations in radiograph quality could affect the accuracy of the assessments. The Gleiser and Hunt method’s subjective scoring and the absence of causal inference were other limitations. Ethnic and genetic influences were not explored, and the clinical application of the findings may require further validation. Finally, the simplification of calcification stages may not fully capture the complexity of growth maturation.
Our current study provides valuable insights into the correlation between CVM staging and MCC stages as markers for growth maturation assessment. While the findings support the clinical relevance of mandibular canine calcification stages in evaluating skeletal maturity, Acknowledging the study’s constraints is crucial, highlighting the necessity for additional research to validate and broaden these findings within a more diverse and comprehensive range of patients.

CONCLUSION

Based on our research and data analysis, a significant association appears to exist between the calcification stages of mandibular canines and skeletal maturity. It’s important to note that this conclusion is context-specific, and to determine the broader applicability and reliability of this correlation across various populations and settings, further research is warranted.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Singla R, Urala AS, Vineetha R, Singla N. Skeletal maturity assessment using calcification stages of mandibular canine. J Int Oral Health. 2017;9:126. https://doi.org/10.4103/jioh.jioh_89_17
2. Magalhães MI, Machado V, Mascarenhas P, Botelho J, Mendes JJ, Delgado AS. Chronological age range estimation of cervical vertebral maturation using Baccetti method: a systematic review and metaanalysis. Eur J Orthod. 2022;44:548-55. https://doi.org/10.1093/ejo/cjac009
3. Hussain U, Ayub A, Zia AU, Kamran M, Rasool G. Diagnostic accuracy of tooth mineralization in growth spurt determination using modified middle phalanx (MP3) as a gold standard. Pak Orthod J. 2022;14:97-101.
4. Prokop-Piotrkowska M, Marszalek-Dziuba K, Moszczynska E, Szalecki M, Jurkiewicz E. Traditional and new methods of bone age assessment-an overview. J Clin Res Pediatr Endocrinol. 2021;13:251- 8. https://doi.org/10.4274/jcrpe.galenos.2020.2020.0091
5. ul Hassan F, Ayub A, Hussain N, Hussain S, Memon MK, Rizvi AA, Bokhari SA, Shah AM, Shams S. Comparison of Cervical Vertebral Maturation with Fishman’s Skeletal Maturity Index Method in Assessment of Growth Status: Cervical Vertebral Maturation with Fishman’s Skeletal Maturity Index. Pak J of Health Sci. 2022:118-21. https://doi.org/10.54393/pjhs.v3i07.422
6. Bhadana S, Indushekar KR, Saraf BG, Sardana D, Sheoran N. Comparative assessment of chronological, dental, and skeletal age in children. Indian Journal of Dental Research. 2019 Sep 1;30(5):687. https://doi.org/10.4103/ijdr.IJDR_698_17
7. Mauricio-Vilchez C, Mauricio F, Vilchez L, Cadenillas A, Medina J, Mayta-Tovalino F. Radiographic correlation of skeletal maturation using the stages of dental calcification in a Peruvian population. Sci. 2020;2020:1-5. https://doi.org/10.1155/2020/4052619
8. Al-Dharrab AA, Al-Sulaimani FF, Bamashmous MS, Baeshen HA, Zawawi KH. Radiographic evaluation of dental age maturity in 3-17- years-old saudi children as an indicator of chronological age. Journal of orthodontic science. 2017;6:47. https://doi.org/10.4103/jos.JOS_1_17
9. Aghimien OA, Aghimien-Osaronse O. Estimation of the predictive effect of body mass index-percentile on skeletal maturation in a Nigerian population. Nigerian Dent J. 2023;31:27-40. https://doi.org/10.61172/ndj.v31i1.104
10. Ferrillo M, Curci C, Roccuzzo A, Migliario M, Invernizzi M, De Sire A. Reliability of cervical vertebral maturation compared to handwrist for skeletal maturation assessment in growing subjects: A systematic review. J back and musculoskeletal rehabilitation. 2021;34:925-36. https://doi.org/10.3233/BMR-210003
11. Kasimoglu Y, Marsan G, Gencay K. Skeletal Maturity Prediction Using Radiographs of the Medial Phalanx of the Third Finger and Cervical Vertebrae. International Journal of Medical Investigation. 2020;9:42-9.
12. Pinkowsky GJ, Winthrop Z, Hennrikus WL. Assessment of Skeletal Maturity. In: Parikh SN, editor. The Pediatric Anterior Cruciate Ligament. Springer International Publishing; 2018. https://doi.org/10.1007/978-3-319-64771-5_5
13. Almeida FT, Gianoni-Capenakas S, Rabie H, Figueiredo R, PachecoPereira C. The use of panoramic radiographs to address the oral health needs of vulnerable Canadian populations. Canadian J Dent Hygiene. 2024;58:19.
14. Ferrillo M, Curci C, Roccuzzo A, Migliario M, Invernizzi M, De Sire A. Reliability of cervical vertebral maturation compared to handwrist for skeletal maturation assessment in growing subjects: A systematic review. J back and musculoskeletal rehabilitation. 2021;34:925-36. https://doi.org/10.3233/BMR-210003
15. . Bittencourt MV, Cericato G, Franco A, Girão R, Lima AP, Paranhos L. Accuracy of dental development for estimating the pubertal growth spurt in comparison to skeletal development: a systematic review and meta-analysis. Dentomaxillofacial Radiology. 2018;47:20170362. https://doi.org/10.1259/dmfr.20170362
16. Alansari RA. Diagnostic performance of eruption stages for identification of skeletal maturity. Saudi Med J. 2019;40:954. https://doi.org/10.15537/smj.2019.9.23831
17. Gopalakrishnan S, Jayaram M, Chacko T, Jacob J, Anuradha P, Menon VV. Mandibular canine calcification stages as an indicator of skeletal maturity. Jo Pharmacy & Bioallied Sci. 2020;12(Suppl 1):S6. https://doi.org/10.4103/jpbs.JPBS_78_20
18. Hafezi L, Sakhtari SH, Valaee N, Zamani H. Evaluation of mandibular canine roots and canals symmetry and related factors in CBCT images of patients referred to Radiology department of Dental branch, Islamic Azad University at 2016. Res Dent Sci. 2018 Jul 10;15:112-8. https://doi.org/10.29252/jrds.15.2.112
19. Chen Y, Dai Y, Yan Z, You Y, Wu B, Lu B. Morphological analysis of anterior permanent dentition in a Chinese population using conebeam computed tomography. Head & Face Medicine. 2023;19:1-2. https://doi.org/10.1186/s13005-023-00357-2
20. Karobari MI, Noorani TY, Halim MS, Ahmed HM. Root and canal morphology of the anterior permanent dentition in Malaysian population using two classification systems: a CBCT clinical study. Australian Endod J. 2021;47:202-16. https://doi.org/10.1111/aej.12454
21. Javangula PT, Uloopi KS, Vinay C, Rayala C, Kumar NM, Chandra SP. Comparison of middle phalanx of the middle finger and cervical vertebrae as skeletal maturity indicators. Indian J Dent Sci. 2017;9:84. https://doi.org/10.4103/IJDS.IJDS_16_17
22. Oncan E, Akan S. Assessment of the relationship between skeletal maturity and the calcifications stages of permanent canines and second premolars. Turkish J Orthod. 2021;34:31. https://doi.org/10.5152/TurkJOrthod.2021.20028
23. Firouzinia M, Khafri S, Mirzaie M, Abesi F, Hamzeh M. Correlation between Skeletal Maturation and Developmental Stages of Canines and Second Molars among Iranian Population. J Dentist. 2022;23:95.
24. Monirifard M, Sichani AV, Yaraghi N. Correlation of Dental age and Cervical Vertebral Maturation and Chronological Age in an Iranian Population Based on Radiography. International Journal of Orthodontics (Milwaukee, Wis.). 2017;28:23-9.
25. .Nasir ZB, Jan A, Khalid Z, Tariq QUA, Zia R, Arshad N. Skeletal Maturity Assessment using Mandibular Canine Calcification Stages. Pak Armed Forces Med J 2023; 73: 464-467. https://doi.org/10.51253/pafmj.v73i2.8868

Erum Behroz Khan                              BDS, FCPS, CHPE, MTFPDP
Imran Ullah Khan                                 BDS
Asad Ullah Mohmand                          BDS
Muhammad Zaheen Khan                   BDS
Pari Gul                                                 BDS
Neelam Shah Jehan                             BDS

Maria Khadija Siddiqui                           BDS, MSc
Hana Pervez                                            BDS, FCPS
Marium Khawaja                                     BDS
Shaqufta Naqvi                                       MBBS, MPH
Marium Iqbal                                           BDS, FCPS, MHPE
Arif Mansoor                                           BDS
Muhammad Saad Shaikh                       BDS, MSc

INTRODUCTION

The use of stem cells in regenerative medicine is a proven beneficial innovation in treating incurable diseases or injuries. Depending on the developmental stage from which they are derived, there are two kinds of stem cells: adult stem cells (ASCs), also known as somatic cells, and embryonic stem cells (ESCs).1,2 Dental stem cell (DSC) is a type of ASC is further subdivided into different types, based on their origin. Tooth germ progenitor cells derived from third molars (TGPCs), dental pulp stem cells (DPSCs), stem cells from human exfoliated deciduous teeth (SHED), periodontal ligament derived stem cells (PDLSCs), dental follicle stem cells (DFSCs), immature dental pulp stem cells from deciduous teeth (IDPSCs), and stem cells from the apical papilla (SCAP) are some of these stem cells.3-7 Among all DSCs, SHEDs had demonstrated the finest multipotent results, high proliferative capacity, minimal risk of oncogenesis and immunosuppressive ability.7-10 Tissue treatments including, regeneration of damaged tooth structures, bone regeneration and treatment of neural tissue injuries or other degenerative diseases by means of SHED had already been reported previously.11 In addition to that, procedure of collecting and preserving SHED was costeffective, noninvasive, painless and ethically sound.3-7 Consequently, considering all of SHED’s benefits, it might be a better option for regenerative medicine than any other kind of stem cell.
The findings of earlier research revealed varying degrees of clinical applicability and stem cell expertise among medical and dental practitioners. For instance, recent dental graduates’ attitudes about stem cells and their therapeutic applications in dentistry were generally relatively positive, according to a recent study conducted in several Saudi Arabian dental schools; nonetheless, their understanding was insufficient.
The results of a study conducted by Kerman indicated that Iranian dentists’ attitudes on dental stem cells are acceptable. Positivity toward the use of stem cells can result in increased utilization and improved clinical applications.
There is insufficient data regarding Pakistanis health care professionals understanding and awareness of DPSCs and their banking, despite the fact that they have the capacity to regenerate. While SHED is a potential medical breakthrough, understanding Pakistan’s health professionals’ attitudes and preferences toward SHED practice is essential to predicting the program’s effective adoption in this developing nation. In addition to clarifying the acceptance of this therapy by health care professionals, the results of this study would be helpful in establishing ethical guidelines in this area.
The objectives of our study were to assess the attitude of health professionals, regarding the use of SHED in regenerative medicine and to explore its prospects in a developing country like Pakistan

METHODOLOGY

A cross-sectional study was conducted in Karachi, which is the biggest and most diverse city in Pakistan. A convenient sampling procedure was used for the study where dental and medical health professionals were reached. Bachelor’s degree in medicine or dentistry was assigned as the primary inclusion criteria for health professionals in the study. In Pakistan, MBBS is a verified degree for the medical field and BDS for the field of dentistry. The exclusion criteria was auxiliaries, including nursing staff and any health professionals who were unemployed at the period of data collection. The Jinnah Medical and Dental College’s ethical committee at Sohail University (Protocol # 000025/20) provided approval to conduct the study.
The sample size calculation was determined by using Openepi, on the basis of 89%14 prevalence, 5% margin of error, 80 % power and 95% confidence interval level. A minimum sample size of 150 was estimated, using prevalencebased formula. To improve the generalization of the study, the final sample size was increased to 250.

The data was collected from December 2019 to June 2020, using a self-constructed questionnaire. Data was collected from practitioners in medicine and dentistry working in clinical offices and tertiary care hospitals located in the city including Medicare Cardiac and General Hospital, Karachi Medical Complex and Medicenter Karachi. A convenient sampling procedure was used to approach these premises and health professionals. Prior to data collection, written informed consent was obtained from each participant. The participants were given consent of leaving the study at any time.
A questionnaire was designed to collect data including age, sex, a field of study, graduation/specialty and question related to interest and attitude towards SHED. The questionnaire commenced with demographic and professional background questions and followed by 11 descriptive questions. Those 11 questions include, awareness of the term SHED, interest rating on a 5-point Likert scale, choice to use SHED for research purposes and regenerative therapy, opinion of storing and donating stem cells in a stem cell storage facility, medico-legal support for SHED in Pakistan and lastly medium of choice to raise awareness regarding SHED.

The data was collected from December 2019 to June 2020, using a self-constructed questionnaire. Data was collected from practitioners in medicine and dentistry working in clinical offices and tertiary care hospitals located in the city including Medicare Cardiac and General Hospital, Karachi Medical Complex and Medicenter Karachi. A convenient sampling procedure was used to approach these premises and health professionals. Prior to data collection, written informed consent was obtained from each participant. The participants were given consent of leaving the study at any time.
A questionnaire was designed to collect data including age, sex, a field of study, graduation/specialty and question related to interest and attitude towards SHED. The questionnaire commenced with demographic and professional background questions and followed by 11 descriptive questions. Those 11 questions include, awareness of the term SHED, interest rating on a 5-point Likert scale, choice to use SHED for research purposes and regenerative therapy, opinion of storing and donating stem cells in a stem cell storage facility, medico-legal support for SHED in Pakistan and lastly medium of choice to raise awareness regarding SHED.

The data was collected from December 2019 to June 2020, using a self-constructed questionnaire. Data was collected from practitioners in medicine and dentistry working in clinical offices and tertiary care hospitals located in the city including Medicare Cardiac and General Hospital, Karachi Medical Complex and Medicenter Karachi. A convenient sampling procedure was used to approach these premises and health professionals. Prior to data collection, written informed consent was obtained from each participant. The participants were given consent of leaving the study at any time.
A questionnaire was designed to collect data including age, sex, a field of study, graduation/specialty and question related to interest and attitude towards SHED. The questionnaire commenced with demographic and professional background questions and followed by 11 descriptive questions. Those 11 questions include, awareness of the term SHED, interest rating on a 5-point Likert scale, choice to use SHED for research purposes and regenerative therapy, opinion of storing and donating stem cells in a stem cell storage facility, medico-legal support for SHED in Pakistan and lastly medium of choice to raise awareness regarding SHED.
Questionnaires were circulated by hand to the health professionals, irrespective of the specialty within their respective fields and years of experience. All participants were instructed to complete the questionnaire and returned it to the researcher.
Version 21 of the SPSS software was used for evaluating the data. Variables were initially classified for descriptive statistics, after which frequencies and percentages were generated. Groups were divided into medical and dental fields based on their category of qualification. The chi-square test was used to compare the results and determine if there were any significant differences in the responses between the dentistry and medical groups. P-values less than 0.05 were deemed statistically significant.

RESULTS

All 250 distributed questionnaires were returned to the researchers. Forms were returned fully completed by 114 medical and 133 dental practitioners, making a total data of 247 with a response rate of 98.8 %. The 3 questionnaires out of 250 received were incomplete so they were not considered for data analysis. The study sample’s demographic distributions are provided in Table 1. 56.7% of the participants (n = 140) were unfamiliar with the term SHED and majority [30.7 % (n = 76)] of them were medical professionals, as shown in Table 2. There was a slight difference in frequency between dentists who were aware of term SHED (n = 69) and those who were not (n = 64).

43.3 % (n = 107) of all health professionals were aware of the term SHED and the internet was the primary information source [51% (n = 55)], with the Journal/Article [30 % (n = 32)] coming in second as shown in Figure 1.

Figure 2 shows comparison of dentistry and medical professionals’ interest rates. All participants (38.6% medical and 36.1% dental) showed an overall moderate degree of

interest in SHED, which equates to level 3 on the Likert scale. Table 3 indicates that there existed a significant difference (p = 0.015) in the two groups’ interest in SHED.

with dental professionals showing a greater interest (moderate to high) in SHED [81.2% (n = 108)] than medical professionals [64.9% (n = 74)].

A comparison of all responses from participated health professionals, on questions related to attitude towards SHED practice, is presented in Table 4. 77.4 % (n = 103) of dental and 76.3 % (n = 87) of medical professionals agreed to use SHED in reconstructive or recuperative medicine. Approximately 50% of medical professions 49.1 % (n = 56) concurred to employ exfoliated primary teeth stem cells to treat neurological and degenerative illnesses, however only 47.4% (n = 63) of dental practitioners were unsure about it. Medical professionals (58.8%; n = 67) and dental professionals (60.2%; n = 80) agreed to using primary teeth for stem cell research purposes as shown in Table 4. When asked about tooth banking, 63.2 % (n = 84) of dental and 60 % (n = 68) of medical professionals agreed on recommending their own child’s primary teeth as well as their patients to donate their child’s exfoliated teeth (dental 60.2 %, n = 80 and medical 59 %, n = 67) in stem cell respository. 50.6 % (n = 125) of respondents accepted to support the medico-legal status of SHED practice in Pakistan followed by 30.8 % (n = 76) of health professionals, who were not sure of supporting the medico-legal status of SHED, as given in Table 4.

77.3% (n=191) health professionals [dental; 83.5% (n = 111) and medical; 70.2% (n=80)] responded yes when questioned about raising knowledge of the advantages of SHED practice among Pakistanis, where dental professionals demonstrated significantly (p= 0.015) more interest in creating awareness regarding the benefits of SHED practice, as presented in Table 4.

Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second.

DISCUSSION

SHED offers various regenerative and repairing functions in medical and dental fields without immense cost or hassle. For this reason, it can emerge as a successful practice in a low-income country like Pakistan. Therefore, authors attempted to estimate the prospect of SHED in Pakistan by evaluating the attitude and level of interest among health professionals toward SHED practice in the country. According to the study’s results, a moderate interest in SHED practice was reported by health professionals. Dental professionals have more awareness of the term SHED than medical professionals and likewise exhibited more interest in creating a relevant awareness in Pakistan.

Due to the scarcity of literature related to SHED, authors have compared the results of the current study with the results of previous studies done on DSCs
The current study’s findings demonstrated that over half of the participated health professionals in Karachi have never heard about SHED before. Although, more dental professionals were aware of the term SHED as compared to the medical professionals, still a minor difference in frequency was reported between dentists who were aware of the term SHED (n = 69) and those who were not (n = 64). Differing Indian studies where a large proportion of dentists were aware of SHED15,17,18 and DSCs in general.19 The internet source has appeared as the most common source of information about SHED among Pakistani health professionals in our study, followed by the journals/articles, in contrast to previous Indian studies where reading journals appeared more than the internet as a source of information on SHED for health professionals in India.17,19 Dental curriculum and undergraduate training have also been reported as the main source of information on SHED in other previous Indian studies with health professionals.
Although a majority of health professionals in our study have demonstrated a moderate level of interest in SHED, dentists comparatively have shown greater interest in SHED compared to medical practitioners. This is similar to previous studies including an Indian study in which 78% of the responding dentists expressed an interest in regenerative practice.13 Interest in learning through CMEs, articles, or advanced training about DSCs applications appeared common among dentists in previous studies.15,18,20,21 Moreover, according to a previous study, most Italian doctors had an interest in stem cells in general and were aware of the benefits of creating stem cell programs in their nation22 matching the interest level of medical professionals in our study.
Despite growing anticipations, stem cell research (SCR) still carries ethical and religious worries in different societies23 , which may restrain many health professionals to perform SCR. Among all the Muslim countries, the total number of SCR publications from Pakistan is the lowest24 thus, signifies that the SCR field is still in its infancy in Pakistan. Since dental stem cells carry no major religious or ethical obstacle as they can easily be obtained from primary extracted or exfoliated teeth25, DSCs or SHEDs research should be promoted in Pakistan. In our survey, most medical experts expressed a strong desire to use deciduous teeth for SCR. Results show similarity with the findings of a a chinese study on health professionals revealed that participants were very enthusiastic about SCR in any forms.26 The mainstream health professionals in our study favored using stem cells from exfoliated primary teeth in regenerative or reconstructive therapy, matching South African dentists’ willingness to use teeth for regenerative treatments.
SHED is a proven beneficial source of tissue repair including treatment for neural tissue injuries and degenerative diseases11,28 According to studies conducted on Saudi healthcare providers, multitude of medical experts concurred that stem cells can be utilized for medical and dental treatments21 including neurological conditions like Parkinson’s and Alzheimer’s.23 These verdicts are consistent with the findings of the current study, in which most medical specialists acknowledged that SHED should be used in curing, neural and degenerative diseases. Patients are advised by medical specialists to undergo stem cell-based restorative therapy due to its regenerative potential rather than repair.15 The current study found that dental experts were unaware of the application of SHED to treat neurological and degenerative illnesses, in contrast to medical specialists. This response is contradictory to a previous study, where, about three-quarters of Indian dentists acknowledged that DSCs are useful for non-dental tissue development.
Ease of exfoliated or extracted tooth collection with limited ethical concern has gained popularity in tooth preservation and dental stem cell extraction for allogenic and autologous cell therapies.25,29 Globally health professionals, irrespective of their social and religious backgrounds, appeared to favor tooth donation and banking including exfoliated deciduous teeth. According to Indian, South African and Iranian studies, the majority of health professionals agreed to suggest to their patients regarding donation of their teeth for dental stem cell preservation.17,18,30,31 Similarly, the majority of health professionals in our study agreed on suggesting their own child’s exfoliated teeth as well as their patients child teeth for contribution to stem cell repositories.
Discussion about stem cell therapy is intense due to the involvement of religious, political, ethical and societal opinions. Since, SHED collection is simple, non-invasive and painless carrying wide-ranging medical benefits, they have been identified as the most ethical cell source for regenerative treatments. National bioethics committee Pakistan (http://nbcpakistan.org.pk/) has provided guidelines on stem cell use for transplantation from blood and bone marrow sources only. Regulation authorities should support the recognition of SHED practice as legal practice since it has no religious, ethical, or safety concerns. In the current study, except for a few health professionals, many were ready to support the medico-legal status of SHED practice in Pakistan. Similarly, the majority of health professionals across the globe have supported the use of DSC as legal practice, including regenerative dentistry.18,20,27 Moreover, Health professionals including Muslim health professionals, claim that DSC practice does not contradict religious ethical principles.21,27,31 The majority of health professionals in the current study agreed on raising public awareness about the benefits of SHED practice in Pakistan using the internet and social media, mirroring the Saudi health professionals, who supported the idea of spreading knowledge by arranging programs about stem cells and their therapeutic implementation.21 Overall, dentists in the study showed more interest and were more aware of the term SHED than medical doctors.
One of the study’s limitations is the scarcity of original studies availability on health professionals’ attitudes toward SHED. The majority of the studies that have been discovered were focused on dental stem cells or stem cells in general, which has resulted in a limited specific comparison aiming at SHED. The study was conducted only in one city therefore, a similar study should be conducted on a larger scale to get generalized results from Pakistani health professionals.

CONCLUSIONS

SHED practice will open new door in the field of research and in the management of various incurable conditions in Pakistan. Currently, a large number of Pakistani healthcare workers are unfamiliar with the phrase SHED. Despite showing a moderate level of interest in SHED, few health professionals still seemed hesitant to support the medico-legal status of SHED practice in Pakistan. Thus, the implementation of SHED practice in medicine remains uncertain. It is recommended that educational interventions, regarding the economical and medical benefits of SHED including its limited ethical concern, should be organized for health professionals, to develop confidence in its use

CONFLICT OF INTEREST

None declared

REFERENCES

1. Saez DM, Sasaki RT, da Costa Neves A, da Silva MC. Stem cells from human exfoliated deciduous teeth: a growing literature. Cells Tissues Organs. 2016; 202:269-280. https://doi.org/10.1159/000447055
2. Dwivedi A, Dwivedi SS, Tariq MR, Qiu X, Hong S, Xin Y. General Idea About the Reach of Stem Cell Regenerative Medicine: Evidence Based Review. J Res Med Dent Sci. 2020;8:57-64.
3. Zeitlin BD. Banking on teeth-Stem cells and the dental office. Biomedical J. 2020; 43:124-33. https://doi.org/10.1016/j.bj.2020.02.003
4. Sugiaman VK, Djuanda R, Pranata N, Naliani S, Demolsky WL, Jeffrey. Tissue Engineering with Stem Cell from Human Exfoliated Deciduous Teeth (SHED) and Collagen Matrix, Regulated by Growth Factor in Regenerating the Dental Pulp. Polymers. 2022; 14:3712. https://doi.org/10.3390/polym14183712
5. Madiyal A, Babu S, Bhat S, Hegde P, Shetty A. Applications of stem cells in dentistry: A review. Gu¨lhane Tip Dergisi. 2018;60:26. https://doi.org/10.26657/gulhane.00012 6. Chopra H, Hans MK, Shetty S. Stem cells-the hidden treasure: A strategic review. Dent Res J. 2013; 10:421.
6. Chopra H, Hans MK, Shetty S. Stem cells-the hidden treasure: strategic review. Dent Res J. 2013; 10:421.
7. Xu Y, Chen J, Zhou H, Wang J, Song J, Xie J, Guo Q, Wang C, Huang Q. Effects and mechanism of stem cells from human exfoliated deciduous teeth combined with hyperbaric oxygen therapy in type 2 diabetic rats. Clinics. 2020;3:75. https://doi.org/10.6061/clinics/2020/e1656
8. Naz S, Khan FR, Khan I, Zohra RR, Salim A, Mohammed N, Ahmad T. Comparative analysis of dental pulp stem cells and stem cells from human exfoliated teeth in terms of growth kinetics, immunophenotype, self-renewal and multi lineage differentiation potential for future perspective of calcified tissue regeneration. Pak J Med Sci. 2022;38:1228. https://doi.org/10.12669/pjms.38.5.5187
9. Su J, Ge X, Jiang N, Zhang Z, Wu X. Efficacy of mesenchymal stem cells from human exfoliated deciduous teeth and their derivatives in inflammatory diseases therapy. Current Stem Cell Research & Therapy. 2022;17:302-16. https://doi.org/10.2174/1574888X17666220417153309
10. Chalisserry EP, Nam SY, Park SH, Anil S. Therapeutic potential of dental stem cells. J Tissue Eng. 2017; 23:1-17. https://doi.org/10.1177/2041731417702531
11. . Zhang X, Lei T, Chen P, Wang L, Wang J, Wang D, Guo W, Zhou Y, Li Q, Du H. Stem cells from human exfoliated deciduous teeth promote hair regeneration in mouse. Cell Transplantation. 2021;30 https://doi.org/10.1177/09636897211042927
12. Alhadlaq A, Al-Maflehi N, Alzahrani S, AlAssiri A. Assessment of knowledge and attitude toward stem cells and their implications in dentistry among recent graduates of dental schools in Saudi Arabia. Saudi Dent J. 2019;31:66-75. https://doi.org/10.1016/j.sdentj.2018.10.006
13. Ez-Abadi AR, Ahmady AE, Fahimeh S. Tabatabaei. Dental Residents’ Knowledge and Attitude towards Stem Cells and Regenerative Dentistry. J Dent Sch Shshid Beheshti Univ Med Sci. 2017;35:200- 214.
14. Chitroda PK, Katti G, Attar NM, Shahbaz S, Sreenivasarao G, Patil A. Stem cells in dentistry: A study regarding awareness of stem cells among dental professionals. Indian J Dent Res. 2017; 28:711. https://doi.org/10.4103/ijdr.IJDR_771_16
15. Jose N. Assessment of knowledge, attitude, and practice regarding applications of stem cells in dentistry among dental house surgeons, postgraduate students, and teaching faculties in two dental colleges in Ernakulam, Kerala, India. Int J Oral Care Res. 2018; 6:65-68. https://doi.org/10.5005/jp-journals-10051-0151
16. Rahman FA, Lin CS, Qing CY, Ying CC, Vien CY, Wei CT. Knowledge, Awareness and Perception of Dental Stem Cell and Their Applications in Regenerative Medicine Among Professional Groups. Open Dent J. 2022;16(1). https://doi.org/10.2174/18742106-v16-e2207130
17. Goswami M, Kumar G, Sharma S. “Dental Stem Cells”: Awareness, knowledge, and attitude of dental professionals-A cross-sectional study. Spec Care Dentist. 2020; 40:90-96. https://doi.org/10.1111/scd.12442
18. Prasada LK, Bukhari SM. A survey on knowledge, attitude and beliefs of regenerative endodontics among postgraduate dental residents. Al Ameen J. Med. Sci. 2019;12:49-53.
19. . Katge F, Shetty AJ, Rusawat B, Vamsi KC. Knowledge and attitude of Indian dentists regarding dental stem cells: A cross-sectional descriptive survey. Indian J Dent Res. 2017; 28:367. https://doi.org/10.4103/ijdr.IJDR_389_16
20. Siva Pillai A. S., Swetha R., Sunayana Manipal, Prabu D., Rajmohan M. and Naveenraj, N. Evaluation of oral health care professionals knowledge and awareness regarding scope of stem cells, Int J Current Res. 2016; 8:36386-36390.
21. Almaeen A, Wani FA, Thirunavukkarasu A. Knowledge and attitudes towards stem cells and the significance of their medical application among healthcare sciences students of Jouf University. PeerJ. 2021;9:e10661. https://doi.org/10.7717/peerj.10661
22. Frati P, Gulino M, Pacchiarotti A, D’Errico S, Sicuro L, Fineschi V. A survey of Italian physicians’ opinion about stem cells research: what doctors prefer and what the law requires. Biomed Res Int. 2014; 30:1-9. https://doi.org/10.1155/2014/480304
23. Tork H, Alraffaa S, Almutairi K, Alshammari N, Alharbi A, Alonzi A. Stem cells: knowledge and attitude among health care providers in Qassim region, KSA. Int. J. Adv. Nurs. Stud. 2018;7:1-7 https://doi.org/10.14419/ijans.v7i1.8524
24. Ahmad S, Zeeshan S, Hussain A, Hasan R, Ghias K, Mian A, Enam SA. The Landscape of Stem Cell Research in Pakistan. J Pak Med Assoc. 2023;73(Suppl 1) (2): S19-S24 https://doi.org/10.47391/JPMA.AKUS-04
25. Aydin S, Sahin F. Stem cells derived from dental tissues. Cell Biology and Translational Medicine, Volume 5: Stem Cells: Translational Science to Therapy. 2019;1144:123-132. https://doi.org/10.1007/5584_2018_333
26. Luo D, Ran W, Zhao G, Guan C, Wang C, Jia W. Knowledge, attitudes, and beliefs of healthcare workers regarding stem cell research. Sci China Life Sci. 2016; 59:325-327. https://doi.org/10.1007/s11427-015-4884-6
27. Basson, R. A., Moodley, D. S., Oliviera, A., & Basson, N. J. A survey of the opinions of Dentists regarding stem cells in Dentistry. South African Dent J. 2016;71:351-355.
28. Sánchez-Vásquez E, Bronner ME, Strobl-Mazzulla PH. Epigenetic inactivation of miR-203 as a key step in neural crest epithelial-tomesenchymal transition. Development. 2019;146:dev171017. https://doi.org/10.1242/dev.171017
29. Taguchi T, Yanagi Y, Yoshimaru K, Zhang XY, Matsuura T, Nakayama K, Kobayashi E, Yamaza H, Nonaka K, Ohga S, Yamaza T. Regenerative medicine using stem cells from human exfoliated deciduous teeth (SHED): a promising new treatment in pediatric surgery. Surg Today. 2019; 49:316-322. https://doi.org/10.1007/s00595-019-01783-z
30. Al-Shahrani M, Al-Qahtani SA, Al-Nefaie M, Al-Enezi G, AlNazhan S. Attitude and opinions of general dental practitioners, pedodontists, and endodontists toward regenerative endodontics in the Kingdom of Saudi Arabia. Saudi Endod J. 2020;1;10:88-94. https://doi.org/10.4103/sej.sej_88_19
31. Jahanimoghadam, F., Farokh Gisour. E.,Askari, R., Rad, M. Attitude Regarding Dental Stem Cells among Dental Practitioners in Kerman, Iran. Arch Pharma Pract. 2018;9:10-3.

Maria Khadija Siddiqui                           BDS, MSc
Hana Pervez                                            BDS, FCPS
Marium Khawaja                                     BDS
Shaqufta Naqvi                                       MBBS, MPH
Marium Iqbal                                           BDS, FCPS, MHPE
Arif Mansoor                                           BDS
Muhammad Saad Shaikh                       BDS, MSc

Muhammad Irshad                            BDS, Phd
Ismail Alam Khan                              BDS, MPH, MHPE
Aziza Alam                                         MBBS, DCH, MPhil, CHPE
Sahibzadi Fatima Tariq                     BDS, MPhil
Hina Shabir                                        BDS, MPhil
Sahd Rashid                                       BDS, MDS

INTRODUCTION

Conventional teaching methods have been in use for centuries. Although, these are time-tested and effective methods, the current global pandemic has led us to explore newer and more convenient options for teaching. Most teaching institutions have shifted towards online teaching due to the current pandemic which has given us an opportunity to search for teaching strategies better suited for online teaching.

Microscopes have been in use for studying pathological slides for more than 200 years.1 Very little advancements have been made since then to improve the quality of teaching microscopic slides. The process of archiving, moving and replacing glass microscopic slides is cumbersome and has many limitations. Conventional microscopy pose many challenges to students as well as teachers and these have been well documented earlier.2 Therefore, many international educational institutes have shifted from conventional to virtual microscopy.

A virtual slide is a digitally captured glass slide that can be viewed and zoomed on a computer screen. These are usually high-quality images captured with advanced technology which can be zoomed considerably without loss of quality. Using virtual microscopy can simplify the whole process of teaching histopathology by eliminating the need for most equipment and materials used to prepare and view slides on conventional microscopes.2 This in turn can decrease the overall cost of teaching pathological slides. In addition, virtual slides are useful for teaching large groups of students, teaching online and eliminates the variability associated with glass slides while maintaining high quality.2,4 Moreover, virtual microscopy is a better tool for online assessments of pathological slides.

The effectiveness of virtual microscopy in teaching pathological slides has already been documented elsewhere.6 To the best of our knowledge, such an evaluation has not been carried out in Pakistan. We hypothesized that virtual slides would enhance students’ interest in learning the histopathological features and enhance their understanding. Therefore, the purpose of this study was to assess the effectiveness of virtual slides in teaching histopathology of oral pathological lesions at undergraduate level.

METHODOLOGY

This cross-sectional study was carried out at the department of oral pathology, Rehman College of Dentistry, Peshawar, Pakistan in February 2020. Verbal informed consent was obtained from all the participants and the study protocol was approved from the institutional ethical committee. Conventional glass slides (n = 10) of various pathological lesions that are taught in our practical oral pathology course, were used for the study. In total, forty 40 out of 50 enrolled 3rd year Bachelor of Dental Surgery (BDS) students who were present on the day of data collection, participated in the study. The virtual pathology slide library of the University Leeds was used for the purpose of evaluation. It is an open source, free for all slide library which can be accessed online at; http://www.virtualpathology.leeds.ac.uk/slides/.

All students first viewed the conventional glass microscope slides under the light microscope at 10X and 20X magnifications. The students received instructions about the histological features of the slides from three teachers. The students were asked to fill a structured questionnaire at the end of the session. On the second day, the same students viewed virtual slides of the same pathological lesions on the “webscope” software of the University of Leeds virtual slide library and were supervised by the same teachers. The students were able to zoom in and zoom out the virtual slides according to their preference.

At the end of the session participants filled a structured questionnaire consisting of Likert scale with (5 = strongly agree; 4 = agree; 3 = neutral; 2 = disagree; 1 = strongly disagree), and comparison was made between conventional glass microscopy and virtual microscopy. Student’s t-test was used to compare the differences in responses to each question. GraphPad Prism version 6.04 for Windows (GraphPad Software, La Jolla California USA) was used to analyse the data.

Out of 50, 40 3rd year dental students were included in the study. The students reported significantly better performance (p = 0.01) with virtual microscopy compared to conventional glass microscopy. Use of virtual microscopy needed significantly less time in selecting, navigating and focusing as compared to conventional microscopy. Moreover, the accessibility, scanning and magnification was found to be much easier in case of virtual microscopy as compared to conventional glass microscopy. Students had better understanding of histopathological features using virtual microscopy as they were able to focus and navigate slides with ease as compared to manual focussing of conventional microscopy (Table 1).

DISCUSSION

Teaching of histopathological features of oral lesions at undergraduate level is a challenging job. Textbooks are a good source of knowledge however certain aspects can only be covered by microscopic study of the histopathological slides.6 Recently, the switching of teaching process from a conventional microscope to a virtual microscope has shown an increased motivation of undergraduate students, significant improvement in understanding of histopathological features and have increased the standard of teaching methodology.4

The present study results have shown increased efficiency of the virtual microscope as compared to the conventional glass microscope. Students have shown a drastic interest in friendly handling, selecting focusing and navigation of a certain lesion oral pathology lesion. Apart from usage, their identification and understanding towards a lesion’s histopathological structures have greatly increased their learning skills and thus, making them more motivated towards their subject.
Results of the present study were in line with previous reports4,5,6,8,11 where students have shown increased inclination towards the virtual microscope instead of light microscope because of its easy handling, efficiency and accessibility. The digital microscope does not require any kind of readjustments, refocusing and redirection as needed by a light microscope. Moreover, the increased effectiveness of virtual microscopy is partly due to ease of accessing slide just on a single click from a computer or a cell phone. The available digital slides are usually scanned using high quality equipment, therefore, the image resolution and contrast are much better compared to glass microscopy. This enhances the students’ ability to visualize histopathological features much better. 5 Virtual microscopy is much less technique sensitive compared to conventional microscopy.

Additionally, virtual slides can be visualized by multiples students at the same time. 14 Teaching virtual slides are much more convenient and less time consuming for the instructor since more than one student can be engaged at the same time and understanding is easier due to collaborative learning. 5 According to Rosas C. et.al. 13 some of the students still prefer traditional teaching methodology for learning histopathological features and are therefore, not receptive to the transition from a traditional teaching methodology to a digital one. However, virtual microscopy has the potential to raise teaching standards provided that enough computer and information technology support is available in the institute.

CONCLUSION

We conclude that oral pathology teaching and learning with virtual microscopy is more efficient compared to conventional glass microscopy.

CONFLICT OF INTEREST

Nil

REFERENCES

1. Somera dos Santos F, Osako MK, Perdoná GD, Alves MG, Sales KU. Virtual microscopy as a learning tool in Brazilian medical education. Anatomical Sciences Education. 2021;14:408-16. https://doi.org/10.1002/ase.2072
2. Rani RV, Manjunath BC, Bajpai M, Sharma R, Gupta P, Bhargava A. Virtual microscopy: The future of pathological diagnostics, dental education, and telepathology. Indian J Dent Sci. 2021;13:283-8. https://doi.org/10.4103/IJDS.IJDS_194_20
3. Congress A. Quantitative Image Analysis for Tissue Biomarkers use: A White Paper From the Digital Pathology Association.2022
4. Lakhtakia R. Virtual microscopy in undergraduate pathology education: an early transformative experience in clinical reasoning. Sultan Qaboos University Med J. 2021;21:428. https://doi.org/10.18295/squmj.4.2021.009
5. Rodrigues-Fernandes CI, Speight PM, Khurram SA, Araújo AL, Perez DE, Fonseca FP, Lopes MA, de Almeida OP, Vargas PA, SantosSilva AR. The use of digital microscopy as a teaching method for human pathology: a systematic review. Virchows Archiv. 2020 ;477:475- 86. https://doi.org/10.1007/s00428-020-02908-3
6. Chaudhari P, Gupta S, Srivastav S, Sanker V, Medarametla GD, Pandey A, Agarwal Y. Digital Versus Conventional Teaching of Surgical Pathology: A Comparative Study. Cureus. 2023;15. https://doi.org/10.7759/cureus.45747
7. Sharmin N, Chow AK, Dong AS. A Comparison Between Virtual and Conventional Microscopes in Health Science Education. Canadian Journal of Learning and Technology. 2023;49(2):1-20. https://doi.org/10.21432/cjlt28270
8. Blake CA, Lavoie HA, Millette CF. Teaching medical histology at the University of South Carolina School of Medicine: transition to virtual slides and virtual microscopes. Anat Rec. 2003;275:196-206. https://doi.org/10.1002/ar.b.10037
9. Hortsch M, Koney NK, Oommen AM, Yohannan DG, Li Y, de Melo Leite AC, Girão-Carmona VC. Virtual microscopy goes global: the images are virtual and the problems are real. InBiomedical Visualisation: Volume 16-Digital Visualisation in Biomedical Education 2023 Aug 1;79-124 https://doi.org/10.1007/978-3-031-30379-1_5
10. Francis DV, Charles AS, Jacob TM, Ruban A, Premkumar PS, Rabi S. Virtual microscopy as a teaching-learning tool for histology in a competency-based medical curriculum. Med J Armed Forces India. 2023;79:S156-64. https://doi.org/10.1016/j.mjafi.2022.02.002
11. . Ali SA, Syed S. Teaching and Learning Strategies of Oral Histology Among Dental Students. Int J Morphology. 2020;38. https://doi.org/10.4067/S0717-95022020000300634
12. Kruse AB, Isailov-Schöchlin M, Giesler M, Ratka-Krüger P. Which digital learning strategies do undergraduate dentistry students favor? A questionnaire survey at a German university. GMS J Med Educ. 2023;40.
13. Tauber Z, Lichnovska R, Erdosova B, Zizka R, Cizkova K. Teaching Histology in the Age of Virtual Microscopy and E-resources: Is a Tailored Approach to Domestic and International Students Warranted?. Interdisciplinary J Virtual Learning in Med Sci. 2021;12:97-105.
14. Brierley DJ, Speight PM, Hunter KD, Farthing P. Using virtual microscopy to deliver an integrated oral pathology course for undergraduate dental students. British Dent J. 2017;223:115 https://doi.org/10.1038/sj.bdj.2017.626

Muhammad Irshad                            BDS, Phd
Ismail Alam Khan                              BDS, MPH, MHPE
Aziza Alam                                         MBBS, DCH, MPhil, CHPE
Sahibzadi Fatima Tariq                     BDS, MPhil
Hina Shabir                                        BDS, MPhil
Sahd Rashid                                       BDS, MDS