June 2015, Vol.10, No · Maryam Shan, Shazia Imran, Iram Iqbal An Assessment of Dentists' Knowledge of Evidence 163 Based Terms Fareha Liaqat, Muhammad Humza Bin Saeed, Anum Zehra

June2015,Vol.10,No.2

ISSN (Print) 1815-4018ISSN (Online) 2410-5422ISSN (Print) 1815-4018ISSN (Online) 2410-5422

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PATRON-IN-CHIEFMaj.Gen.(R)MuhammadZulfiqarAliKhan,TI(M),SBtManagingTrustee,IslamicInternationalMedicalCollege

PATRONMr.HassanMuhammadKhanProChancellorRiphahInternationalUniversity ADVISORProf.Dr.AnisAhmedViceChancellorRiphahInternationalUniversity

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June2015;Vol.10,No.2ISSN(Print):1815-4018ISSN(Online):2410-5422

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CONTENTS

ORIGINALARTICLES

Volume10 Number2

INSTRUCTIONSFORAUTHORS 187

EDITORIAL 144

June2015

OralCancerScreeningandItsImplementationinPakistan

MuhammadHumzaBinSaeed

147AnAssessmentofDentists'OralHealth MuhammadHumzaBinSaeed,AnumZehraKhan,NageenAkhtar,SundasTanveer,SumayyaMehbub,RabbiaSana,AlinaQureshi

151CorrelationofHemoglobinwithLungFunctionTests SidraJahangir,AmbreenAsad,IdreesFarooqButt

155AnInsightintotheAntibioticPrescriptionPracticesofPost-GraduateDentists,DiscernedthroughaClinicalDentalAudit

SyedaAyeshaAbsar,RohmaQasim,SairaKhan,RijaTehseen,M.HumzaBinSaeed,AnumZehra

159EffectofNicotineandCamelliaSinensisontheLengthofChick

MaryamShan,ShaziaImran,IramIqbal

163AnAssessmentofDentists'KnowledgeofEvidenceBasedTerms

FarehaLiaqat,MuhammadHumzaBinSaeed,AnumZehraKhan

168AnAssessmentofAssociationbetweenCarbonatedDrinkConsumptionandDentalCariesPrevalence:ACross-SectionalStudy

ZainabAsifSukhera,SyedaMeharRaza,NehaRana,TehreemZafar,AnumZehraKhan,MuhammadHumzaBinSaeed

177CurrentBDSCurriculum:AnEvaluationbaseduponCIPPModel

ShaziaRafiqNawabi,AyeshaMaqsood,SidraAamir

MEDICALEDUCATIONSECTION

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173OpenVersusClosedHaemorrhoidectomy:EvaluationofMorbidityandComplications

AhmedNurusSami,MalihaYunus,ShaziaRiaz

182'ProblemBasedLearning'asaNovelmodeofInformationTransferforFacultyDevelopmentinPakistan:APhenomenologicalStudy

RahilaYasmin,ShahjahanKatpar

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iv

144

Oral cancers are by definition, cancers of the lip,1

tongue and mouth. Combined together withpharyngeal cancers, oral cancer is the 6th most

1common cancer in the world. Although theincidenceoforalcancerisgreaterincertainpartsoftheworld,suchasSouthandSouthEastAsia,certainparts of France, Eastern Europe, Latin America,CaribbeanandthePacificRegion,itisprevalentall

1over theworld. Oral Cancerhas an annual globalincidenceofabout275,000.The5yearsurvivalratesfororal cancer remainedatabout50%during the

2greaterpartof the twentiethcentury. However,arecentimprovementintheoralcancersurvivalrateshas been observed with the 2010 reported rates

3beingashighas65.5%. The5yearsurvivalratesvaryaccordingtothesiteandthestageatwhichdetected.Animprovementinthesurvivalratehasbeenseeninthepastfewyearsincertainpartsoftheworld,suchas Canada, owing to a reduction in related riskfactors,suchassmoking.Poorsurvivalrateamongtheoralcancerpatientshasbeenattributabletotheadvanced extent of the disease at the time ofdiagnosis. More than 60% of these cancers arediagnosed when the patient has already reached

4stagesIIIorIVofthecancer. Oralcancerarisesinthesurfaceoralepithelium,whichiseasilyaccessiblefordirect visual and tactile examination. It is known,throughevidencethatsurvivalratesoforalcancervaryaccordingtothestageofcanceratthetimeofdiagnosis. A randomised controlled trial studyreported that 5 year survival rates for oral cancerdiagnosedatstageIis66.2%,whilethatforacancer

2diagnosedatstageIVis22.2%. Earlydiagnosisoforalcancer increases the survival rate, improving thequality of life along with that. Also, the cost oftreatinganoral cancerpatientat stage IV is three

5timesthatof treatingoneatstage I. Hence,earlydiagnosis of oral cancer is cost efficient as well.Althoughalltheabovementionedfactsapparentlysuggest that screening for oral cancer should becarriedout, therearecertain factors thatmustbe

EDITORIAL

OralCancerScreeninganditsImplementationinPakistanMuhammadHumzaBinSaeed

-------------------------------------------------Correspondence:Dr. Muhammad Humza Bin SaeedAssistant Professor, Community DentistryIslamic International Dental CollegeRiphah International University IslamabadE-mail: [email protected]

consideredbeforeanyscreeningprogrammecanbeimplemented.Firstofall,itmustbeensuredthatthescreeningforthediseaseinquestionissuggestedonsoundscientificevidence.Inthecaseoforalcancer,theneedforscreeningandtheimportanceofearlydetectionof disease has been shown through theearliermentionedargument.Then,beforeanyscreeningprogramme isput intopractice,itmustbeensuredthatthebenefitofthespecificprogrammeclearlyoutweighstheharm,forexample,ifthediseaseisdiagnosedearlieronduringitsclinicalcourse,doesaneffectiveinterventionexistthat would improve the disease prognosis? Is theinterventionavailableacceptabletothepublicandisiteconomicallyfeasible?Ifanyoftheseproblemsarerealised once the programme is fully functional,efforts tomodify the programme or to stop it alltogether might be faced by severe criticism andopposition from the general public and the

6media. Any screening program fulfilling its criteriaautomat ica l ly caters for any assoc iated

7problems. Themainaimofscreeningistodetectthe

8diseaseanditspredictors.PrinciplesofScreeningasappliedtoOralCancerWhenoralcancerscreeningisevaluatedinthelightoftheprinciplesofscreening,itisobservedthatall

7the criteriaarenot fulfilled. Thenaturalhistoryoforalcancerisnotyetfullyknownandunderstood.Theeconomicfeasibilityofanoralcancerscreeningprogramhasyetnotbeenestablished.Choosing the right Implementation Strategy forOralCancerScreeningThe next question that needs to be addressed iswhetherthewholepopulationshouldbetargetedorwouldahigh-riskpopulationtargetedapproachbebetter?Arandomisedcontrolledtrial,carriedoutinIndiaconcludedthatthemostcost-effectivewayofcarrying out oral cancer screening is by visual

5inspectionoffered tohigh-riskpopulationonly. Inorder to implement a programme for a high-riskpopulation, we have to determine how to defineone. As there are no set criteria for a high-riskpopulation for oral cancer, we must evaluate theevidenceavailablewithregardstothis.Olderpeople(peopleaged40yearsandabove)areatahigherriskofdevelopingoralcancer,ascomparedtoyoungerpeople.Incidenceat40yearsofageis10-20times

145

JIIMC2015Vol.10,No.2 OralCancerScreeninginPakistan

9that at age 20. Also, the number of screeningexaminations required to detect a case would bereducedbyonly screeningolderpeople.However,employingsuchastrategywouldmeanthatyoungerpeople developing oral cancer would not be

11detected. Individuals that smoke and consumealcoholareata30timesgreaterriskofdevelopingoralcancerthanthosewhodonot.Also,75%oforal

10cancer patients have these habits. However, bytargetingpeoplewhosmokeanddrink,25%ofthosepeoplewhoarenotinvolvedwithanyofthesehabitswouldbeleftout.Ifahigh-riskapproachtoscreenolder individuals who smoke and/or consumealcoholisused,thenthecostssavedcanbeusedtocarryoutscreeningmorefrequentlyinthehigh-riskpopulation, increasing thepotential to detect oral

11cancer.EpidemiologyofOralCancerinPakistanIn order to implement a screening programme inPakistan, there are certain facts that must beconsideredfirst.PakistanissituatedinSouthAsia–theregionwheresomecountrieswiththegreatestincidence rates are situated. Some recent reportshave placed Sri Lanka and Pakistan as having thegreatest incidence rates of oral cancer in the

1world. RecentreportssuggestthatKarachihasthe1highestincidencerateoforalcancerintheworld. As

comparedtoKarachi,theincidenceoforalcancerisquitelowintherestofthecountry.Therefore,anoralcancer screening programme targeting the city ofKarachiwouldbemoreappropriatethanoneforthewhole country.Due to the religious cultureof thecountry; alcohol consumption is low all overPakistan.However,otherriskfactorsfororalcancerareincommonpractice.Amongsttheseareincludedcigarette smoking, betel quid (pan) chewing,sheesha and bidis. Pan chewing is especially verycommon in Karachi and is a considered to be acommonlifestylechoice,ratherthananaddiction.OralCancerScreeningImplementationinPakistanKarachi is the largest city in Pakistan with apopulation of over 20million. It is divided into 5divisions.Fortunately,eachdivisionhastertiarycarehospitals and the health infrastructure is welldeveloped across the city. As Pakistan has a lowhealthbudget,asubstantialamountoffinancesmaynotbeallocatedforsuchaprogram.Hence,insteadof a whole population approach, a high-riskpopulationstrategyneedstobeemployed.Peopleof40yearsofageorabove,whosmoke,eatPan,chewany form of tobacco or use all of the afore-mentioned substances, should be included in theprogramme.Approachingapopulationsuchasthat

describedabovewouldbeacumbersomeprocess.Ithas been reported that oral cancer screening, ifcarriedoutbydentistsismorecost-efficient,thanifdonebymedicaldoctors.Hence,thescreeningtestcan be performed by dentists on routine dentalcheck-ups. The problem lies in approaching thoseindividuals,whodonotcomeforregularcheck-upswith the dentist, as themajority of the people ofKarachiarefromthisgroup.Tosolvethisproblem,screeningsitesneedtobesetupinareasotherthanthemajorhospitalsanddentalclinicswhichwouldbemoreaccessibletothegeneralpopulation,suchasthehundredsofbasichealthunits(BHUs)alloverthe district. At these BHUs, the training ofparamedicalstaffanddentalauxiliarieshasmultipleadvantages. Firstly, thiswill serve that part of thehigh-risk population that donot visit thedentists.Secondly,thisstrategywillinturnbemorecostandtimeeffective.Variousscreeningmethodshavebeenidentified in the literature, including oralexamination, toluidineblue, brush cytology, tissue

5reflectance and autofluorscence. As visual oralexaminationisthemostcost-effectivescreeningtestfororalcancer,thismethodshouldbeemployedfor

11screening. Individuals testing positive with orallesionspersistingforthreeweeksaftertheremovalofanypotentialirritant,sheshouldbereferredforabiopsytothenearesthealthcarefacility.Ifthebiopsyis negative, the person should be kept undermonitoringduringher regulardental visits, duringwhich the screening should be repeated. If thebiopsy shows dysplasia, the person should bereferredtoahospitaltobeseenbyanoncologistfor

9risk assessment and treatment. For a successfulscreeningprogrammetobeplacedintopractice,anappropriateteamneedstobeputtogether,inwhichthemanagementisinvolvedintheprojectasmuch

6as the workers. One central and five divisionalcommitteesshouldbemade,withacentralmanagerand fivedivisionalmanagers.Committeemeetingsshould be held on a regular basis. Programmeprogressshouldbeevaluated;anyproblemsfacedbytheteamsshouldbediscussed,witheffortstocomeupwithpracticalsolutions.ConclusionComplyingwithalltheabovementionedprinciplesmeansthatascreeningprogrammeshouldachieveits desired results, at any cost. To implement asuccessful screening program in a city such asKarachi, with an alarming incidence rate for oralcancer, a multi-sectoral approach needs to beadopted.Aclearlydefinedgovernmentpolicyneedsto be designed, implemented and monitored.

OralCancerScreeninginPakistan

Screeningsitesneedtobesetupinthehundredsofbasichealthunitsalloverthedistrict.Theselectionofparticipantsshouldbedeterminedonthebasisofthehistoryoforalcancerriskfactors,includingthesmoking,panandalcohol.Thedentalauxiliariesandparamedicalstaffshouldbetrainedandcalibratedtoperformscreeningprocedures,inordertooptimisetime and financial resources. There should be anestablished protocol for following up withparticipantswithpositivescreeningresults.

REFERENCES1. Warnakulasuriya S. Global epidemiology oral and

oropharyngealcancer.OralOncology2009;45:309-15.2. ChenYW,LinJS,WuCJ,LuiMT,KaoSY,FongY.Applicationof

invivostainofMethyleneBlueasadiagnosticaidintheearly detection of oral squamous cell carcinoma andprecancerlesions.JournalofChineseMedicalAssociation2007;70:11,497-503.

3. NationalCancerInstitute.5-YearRelativeSurvival(Percent)by Year o f D iagnos i s . http ://seer.cancer.gov /csr/1975_2011/ browse_csr.php?sectionSEL=20&pageSEL=sect_20_table.10.html.Accessedon24-4-2014.

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4. Lingen MW, Kalmar RJ, Karrison T, Speight PM. Criticalevaluation of diagnostic aids for the detection of oralcancer.OralOncology2008:44,10-22.

5. SubramanianS,SankaranayarananS,BapatB,SomanathanT, ThomasG,MathewB et al. Cost-effectiveness of oralcancer screening: results from a cluster randomizedcontrolledtrialinIndia.BulletinWorldHealthOrganization2009;87:200-6.

6. RaffleA,GrayMScreening:EvidenceandPracticeOxfordUniversityPress,Oxford.2007.

7. Wilson JMG, Jungner G. The principles and practice ofscreening fordisease.PublicHealthPapersno.34.WorldHealthOrganization,Geneva (1968) In: RaffleA,GrayMScreening:EvidenceandPractice.OxfordUniversityPress,Oxford.2007.

8. Pine C, Harris. Community Oral Health. QuintessenceBooks,Surrey.2007.

9. College of Dental Surgeons of British Columbia (CDSBC).Guidelinefortheearlydetectionoforalcancer inBritishColumbia.CDSBC,Vancouver,BritishColumbia.2008.

10. LarondeDM,HislopGT,ElwoodJM,RosinMP.OralCancer:justthefacts.JournalofCanadianDentalAssociation2008;74:3,269-72.

11. MusaZ,JohnstonK,PeacockS,RosinPM,ElwoodJM.PointsofCare:Whyshoulddentistsscreenfororalcancer?JournalofCanadianDentalAssociation2008;74:3,243-4.

JIIMC2015Vol.10,No.2

ORIGINAL ARTICLE

ABSTRACTObjective:Theaimofthestudywastoaccesstheoralhealthmaintenancebehaviorpatternsamongdentists.StudyDesign:Questionnairebasedcrosssectionalstudy.PlaceandDurationofStudy:ThestudywasconductedinthecommunitydentistrydepartmentofIslamicInternationalDentalCollege,IslamabadfromMarch2013toAugust2013.MaterialsandMethods:Atotalof65dentistsfromIslamabadwereincludedinthisstudy.Thedentistsweresampledconveniently fromIslamabad.Descriptivedatawasdescribedfor thereported frequenciesofdentists'attitudesandpracticesrelatedtooralhealth.Results:Outof65,61dentistshadshownpositiveattitudeinrespondingclose-endedquestionnaires.Mostofthedentistsreportedbrushingtheirteethtwiceaday(n=40,65.5%).Atotalof34(55.7%)dentistsreportedcarryingoutbrushingforabout2-4minutes. The self-reportedDecayedMissing FilledTeeth (DMFT) score for 21(34%)dentistswas zero. Themajorityofdentists(n=48,78.7%)didnotconsiderthemselvestobehavinganydentalproblems,while42(68.9%)dentistsperceivedtheiroralhealthasbeingverygood.Conclusion:Althoughmostofthedentistsreportedashavinggoodoralhealth,alargenumberoftheparticipantsdidnotmaintaintheiroralhealthadequately.DentistsfollowROSC(Recommendedoralself-care)recommendationstoimprovetheiroralhealthstatus.

Keywords:Oral Health, Oral Health Professionals, Oral Health Practices.

expectedtobetterthanthegeneralpopulation.Totheextentofourknowledgeeveryfewstudieswere

3,5,6reported to assess the oral health of dentists. Mostlystudiesweredonotcomparetheoralhealthbehaviorandattitudeofdentists'withotherhealth

4professionals orgeneralpopulation.Therefore,thisstudywasconductedtoassesstheoralhealthstatusandbehaviorofdentists.

MaterialsandMethodsThis was a questionnaire based, crosssectionalstudy. The studywas designed to access dentists'attitudes and practice of maintaining their oralhealth.Thisstudywasconductedattwohospitalsbasedinthe twin cities of Rawalpindi and Islamabad. Theparticipating hospitals were Holy Family Hospital(HFH),Rawalpindiand Islamic InternationalDentalHospital (IIDH), Islamabad. TheQuestionnairewasgiven to 65 dentists including general dental-practitioners (GDPs); post-graduate trainees,demonstrators and house officers. Four dentistsdeclined to participate in the study. Thus, a totalsampleof61dentistswasachieved.Outofthese61dentists, all participants completed and returnedtheirquestionnaires.Thedatacollectionwascarriedout within the morning working hours of thehospital. The questionnaire was divided into two

IntroductionOralhealthisaprimarycomponentofoverallhealth

1and well-beingofaperson. Oral health can bedefinedas“Astandardofhealthoforalandrelatedtissueswhichenableanindividualtoeat,speakandsocialize without active disease, discomfort orembarrassment and which contribute to general

2well- being”. Good oral health depends on theknowledgeandpracticeofrecommendedoralself-care (ROSC). ROSC includes ''tooth brushingmorethan once a day, lesser consumption of sugarcontainingsnacksoncedailyorrarelyandregularuse

3of fluoride containing toothpastes”. The dentistshaveanimportantroleindeliveringgoodoralhealthcare to a community. The dentists are also a rolemodel not only for their families but for thecommunityaswell,owingtotheirroleasheathcareprofessionals being involved in oral health

4promotion. Byvirtueof theirprofession,dentists'knowledge and practice of oral health care is

AnAssessmentofDentists'OralHealthMuhammadHumzaBinSaeed,AnumZehraKhan,NageenAkhtar,SundasTanveer,SumayyaMehbub,RabbiaSana,AlinaQureshi

Dentists'OralHealthJIIMC2015Vol.10,No.2

147

Correspondence: Sundas TanveerIslamic International Dental CollegeRiphah International University, IslamabadE-mail: [email protected]

Department of Community DentistryIslamic International Dental CollegeRiphah International University, Islamabad

Received: February 11, 2015; Accepted: May 15, 2015

sections.Thefirstsectionincludedquestionsrelatedtothedentists'oralhygienemaintenance.Questionsfrom the following topics were included in thissection:brushingfrequency,brushingtime,brushingaids,oralproductsusedforhalitosis,self-reported.DMFTscore,self-reporteddentalhistory,thegeneralfoodproductsconsumed,theuse(ifany)ofaddictivesubstances,andtheparticipants'perceptionabouttheiroralhealth.Thesecondsectioninquiredaboutthe participants' demographic details. Questionsabout the age, gender, experience, job type andparticipants'citywereincluded.ThedataprocessingandanalysiswasdonebyusingtheStatisticalPackagefortheSocialSciences,SPSSversion17.0.Thetrendsintheparticipants'practiceof oral health care was presented in the form offrequenciesandpercentages.

ResultsQuestionnaire was completed by a total of 61dentists. The frequencies of the oral health caretrends were calculated separately for GDPs, post-graduate trainees, demonstrators and houseofficers.Outof61dentists,49(80.3%)werefemaledentistsand12(19.0%)weremaledentistsfilledourquestionnaire.Fortythree(70.5%)participantswerefromIslamabad,while15(24.6%)ofthemwerefromothercities.TableIillustratestheagedistributionofthe participating dentists. Out of 61 dentists,40(65.6%)ofdentistsbrushedtwiceaday,15(24.6%)onceaday,five(8.2%)morethantwiceadayandone(1.6%) after meal. The oral hygiene aids and thefrequencyoftheirusehavebeenillustratedingiventable I.Atotalof8(13.1%)dentistsreportedusingmouthfreshenersinordertoremovehalitosiswhile14(23.0%)usedmouthwash,five(8.2%)usedtonguecleaners,while33(54.1%)didnotreporttohaveanyhalitosis.Further-more,48(78.7%)dentistsdidnothavedentalproblems.However12(19.7%)didhavedentalproblems.Atotalof54dentistsreportedtohave dental treatment history; 27(44.3%)participants received dental treatment forpreventive reasons, while 27(44.3%) of them hadcurativedentaltreatment.Theself-reportedDMFTscoresforthedentistswerereportedasillustratedbelowwasreportedaswell.ThisdatahasbeenillustratedintableII.Themajorityofthedentistsreportedusingtetrapackjuices(n=42,68.9%).Onlyasmallnumber(n=17,27.9%)reported

the consumption of fresh fruit juices. Two (3.3%)participants did not answer this question. Thedentists were asked about the frequency ofconsumption of junk food. Also, control of theirdesiretoconsumejunkfoodandsweets

TableI:FrequencyDistributionsandforAge,OralHygieneAidsusedandAddictiontowardsCarbonatedDrinks

TableII:Responsetoquestionsonoralhygienemaintenance(n=60)

Fig1:BarchartshowingDMFTscoresofdentists


148

Outof61,16 (26.2%)ofdentistshadaddiction tocarbonated soft drinks, 1 (1.6%) to smokingwhile44(72.1%) have no addiction and 1(1.6%) did notshow any response. The majority of the dentistsreportedusingtetrapackjuices(n=42,68.9%).Onlyasmall number (n=17, 27.9%) reported theconsumption of fresh fruit juices. Two (3.3%)participantsdidnotanswerthisquestion.Outof61

dentists, 26 (42.6%) dentists reported examiningtheir oral cavity daily while standing in front of amirror, 15(24.6%) practiced this once a week,five(8.2%) fortnightly, nine(14.8%) once amonth,4(6.6%)neverexaminedand two(3.3%)didnotanswerthisquestion.Nine(14.8%)dentistswerehighly conscious regarding their oral health,45(73.8%)moderatelyconscious,seven(11.5%)notmuch conscious. Nine (14.8%) dentists perceivedtheiroralhealthasbeingverygood,42(68.9%)asbeing good, nine (14.8%) as being fair while one(1.6%)participantdidnotanswerthisquestion.

DiscussionThis questionnairewas set out to assess the self-reportedpracticeoforalhealthmaintenanceamongasampleofdentists.Oralself-carepracticesleadtopreventivemeasures for themaintenanceofgoodoral health. The dentists' oral health preventionpracticewas accessedby asking themabout theirdaily routine activities related to their oral healthmaintenance.Thepresentstudyreportedthat themajorityofdentistspracticedbrushing their teethtwicedaily(n=40,65.6%)thiswasinagreementwithseveral earlier studies reporting similar results:

3 6Gopinath (55.9%) ,Ghasemi (73%) ,Tseveenjav5

(81%). HoweverBaseeretal.conductedasurveyinRiyadh,SaudiArabiawhichreportedonlyabout(4%)

7ofthesampleddentistsbrushingtwice. Morethanhalf of the dentists brushed their teeth for 2-4minutes(n=34,55.7%).TheseresultsaresimilartothatofaNigerianstudy,whichreportedthatabouthalf(52.1%)ofthedentalstudentsincludedinthestudyreportedtobrushtheirteethregularlyfor3-5

8minutes. Theseresultsarealarmingfromthepointof view that dentists, who are consideredresponsible for delivering oral health awarenessamong the general population are not practicingproper oral health maintenance guidelines. Thefrequencyanddurationoftoothbrushingcorelateswith oral hygiene and oral health which is alsosupportedbythepresentstudy.Brushingtwicedailyforaproperdurationplaysavitalroleinmaintainingoralhealthasrecommendedbymostdentists.8Mostofthedentistsdidnotuseanyotheroralhygieneaidsalongwithtoothbrushing17(27.9%).FlossusageinthepresentstudywasmorethanthatreportedbyanIndianstudybyGopinathetal.However,anIranianstudy reported a greater frequency of flossing by


149

6dentists. For effective preventive care, oralproblems like caries, halitosis or plaque must beprevented by using other aids along with toothbrushing.Alargepopulationofdentistsalwaysusedfluoridated toothpastes forbrushing36(59%)andless percentage of those who used any particularbranded tooth pastes13(21.3%).In the study ofGopinath, (55%)dentists used fluoridated

3toothpastesdaily. 62%ofMangoliandentistswereusing fluoridated toothpastes always or almost

5always. Around (74%)Iranian dentists used

6fluoridatedtoothpastesregularly. Ahighpercentageofthedentistsoccasionally28(45.9%)oralways22(36.1%) rinse their mouth after eating anythingwhereas a few 8(13.1%) of them rarely do so.Halitosisnotonlyeffectsanindividual'slifebutitcanalsoresultintheembarrassmentoftherelativesand

9friendsofaffectedindividual. Inourstudyhalfofthedentistsdidnothavehalitosis33(54.1%).Theoneswhohadthisproblempreventeditbyusingmouthfresheners8(13.1%)andfewusedtonguecleaner5(8.2%)aswell.InastudyofNigeriaitwasseenthatinordertopreventhalitosis,tonguecleaningiscarriedout bymajority using toothbrush and only (9.5%)

9usedtonguecleaners. Ahighpercentage48(78.7%)ofdentistshadvisitedotherdentistsfortheirdentalproblemsandonly12(19.7%)hadnevervisitedanydentist.Therewasequalpercentageofdentistswhovisited for their dental examination either forcurativeorpreventivepurpose.Thirtyfour(55.7%)ofdentistshadtheirlastdentalexaminationwithinlast yearwhereas24 (39.3%)had their lastdentalexaminationmorethanayearago.Incomparisonto

4thepresentstudy(40%)SouthIndiandentists ,(41%)Irani dentists 6, (75%) Mongolian dentists visited

5dentalclinicatleastonceayear. DMFTscorefortheevaluation of oral health status of dentists wascalculated.Itwasfoundthatmajorityofdentist21(34.4%)had0score,7(11.5%)hadscore1,9(14.8%)had score 2. Very few among the remaining hadhigher scores.Asdentistshadmoreknowledgeoftheirprofessionandawarenessofimportanceoforalhygienethanlaymen,sotheyhavealessDMFTscoreindicating that they had a better oral health.Moreover, our study included the dentalprofessionals belonging to good socio-economicstatussothiscanalsoberelatedtotheirgoodoralhealth status. Majority of the dentists claimed of

havingnoaddiction44(72.1%)whereas16(26.2%)had addiction to something. Most of them hadaddiction to tea/coffee. These results are inaccordancewithAlmasstudyinwhichteadrinking

10was common among (81%) participants. A highintakeof caffeinateddrinkmaybeassociated toabusy,stressfulworkschedule.Morethanhalfofthedentistssometimes33(54.1%)takejunkfoodintheirdailymealswhereastherewaslessnumberofthosewho did not eat junk food 10(16.4%).Twenty six(42.6%)ofthedentistsconsumecarbonateddrinksweekly and 22(36.1%)of them rarely takecarbonateddrink.Betteroralhealthisrelatedwithpositive behavior and adherence to good oral

11hygiene practices. This supports our results asdentistsareconcernedtomaintaintheiroralhealth.We have also seen that many dentists neverrestricted theireatingdesires for thesakeof theiroralhealthbutsomeoftenandevenrarelydoso.Morethanhalfofdentistsusedtetra-packjuices42(68.9%) whereas only some of them use freshlyextractedjuices17(27.9%).Theunhealthyandbusylifestylecouldbeconsideredareasonofthenegativeresponseshownintheabovequestions.Therewere26(42.6%)ofthedentistswhichdailyexaminedtheiroralcavitywhilestandinginfrontofthemirrorandthose examining weekly were 15(24.6%) andmonthly were 9 (14.8%). As majority of ourparticipantswerefemalessoweobtainedahigherscoreontheself-examinationquestion,asfemalesarealwaysmoreconcernedabouttheirappearanceandsocial image.Ahighpercentageofdentists45(73.8%) rank themselves moderately consciousabouttheiroralhealthwhereasonly9(14.8%)arehighly conscious and only few are not muchconscious. Forty two (68.9% ) of dentists perceivetheir oral health as good whereas less 9(14.8%)percentage isof thosewhoperceive iteitherverygoodorfair.

Limitations Due to lack of resources, the research was

restrictedtotwohospitalsonly. The participants included house officers and

belongingtothesameagebracket.

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The resultswerebasedondata thatwas self-reported by the dentists. Therefore their oralhealthstatusmaybebiasedthroughoverandunderreportinginordertomaintaintheirbettersocialimage.

ConclusionOralhealthofmostofthedentistswasconsiderablygood. Oral health attitudes and practices amongdentistswere influenced by factors like gender asmostofthedentistswerefemale.

REFERENCES1. MehtaA,KaurG.Oralhealth-relatedknowledge,attitude,

andpracticesamong12-year-oldschoolchildrenstudyinginrural areas of Panchkula, India, Indian J Dent Res.2012;23:293.

2. CarneiroL,KabulwaM,MakyaoM,MrossoG,ChoumR.Oralhealthknowledgeandpracticesofsecondaryschoolstudents,tanga,Tanzania.IntJDent.2007;14:1-7.

3. GopinathV.OralhygienepracticesandhabitsamongdentalprofessionalsinChennai.IndianJDentRes.2010;21:195-200.

4. SinghMS,TuliAK.Acomparativeevaluationoforalhygienepractices, oral health status, and behavior betweengraduate and post-graduate dentists of North India: Anepidemiologicalsurvey.J IntSocPreventCommunitDent.2013;3:19-24.

5. TseveenjavB,VehkalahtiM,MurtomaaH.OralhealthanditsdeterminantsamongMongoliandentists.ActaOdontolScand.2004;62:1-6.

6. GhasemiH,MurtomaaH,VehkalahtiMM,TorabzadehH.Determinants of oral health behaviour among Iraniandentists.IntDentJ.2007;57:237-42.

7. BaseerMA,AlenazyMS,AlasqahM,AlgabbaniM,MehkariA. Oral health knowledge, attitude and practices amonghealth professionals in King FahadMedical City, Riyadh. DentResJ(Isfahan).2012;9:386-92.

8. AzodoCC,EhizeleAO,UmohA,OjehanonPI,AkhionbareO,OkechukwuR,etal.Toothbrushing,tonguecleaningandsnacking behaviour of dental technology and therapiststudents.LibyanJMed.2010;5.

9. Azodo CC, Onyeagba MI, Odai CD. Does concern abouthalitosis influence individual's oral hygiene practices? NigerMedJ.2011;52:254-9.

10. AlmasK,Al-Hawish,Al-KhamisW.Oralhygienepractices,smoking habit, and self-perceived oral malodor amongdentalstudents.JContempDentPract.2003;15;4:77-90.

11. ShardaAJ,ShettyS.Relationshipofperiodontalstatusanddental caries statuswithoralhealthknowledge,attitudeandbehavior amongprofessional students in India. Int JOralSci.2009;1:196-206.

ORIGINAL ARTICLE

ABSTRACTObjective:Purposeofthisstudywastoknowanyexistingcorrelationbetweenhaemoglobinandlungfunctiontestsforrespiratorystatusevaluationinyounghealthyindividuals.StudyDesign:Crosssectionalstudy.PlaceandDurationofStudy:PhysiologyLaboratoryofYusraMedicalandDentalCollege,IslamabadfromJanuary2012toJanuary2013.MaterialsandMethods:OnehundredandsixtystudentsofYusraMedicalanddentalcollegewereincludedinthestudy.Bloodsamplesofthesubjectswerecollectedforhaemoglobin(Hb)estimationbySahlimethodandmeasurementofthelungfunctiontestswasdonebySpirometryusingvolumeSpirometer.Lungfunctiontestsincludedtidalvolume(TV),Inspiratoryreservevolume(IRV),expiratoryreservevolume(ERV)andvitalcapacity(VC).DatawasanalysedusingSPSS15andcorrelationwascalculatedusingPearson'scorrelationco-efficientbetweenhaemoglobinandthelungfunctionstests.Results:ThepvalueindicatessignificantpositiverelationexistbetweenhaemoglobinandInspiratoryreservevolume(r=0.39,p<0.0001),expiratoryreservevolume(r=0.43,p<0.0001)however,nosignificantrelationexistsbetweenvitalcapacityandhaemoglobin(p=0.242).Conclusion:ThereispositivecorrelationbetweenhaemoglobinandLungFunctionTests.

KeyWords:Spirometry, Haemoglobin, Vital Capacity, Lung Function Tests.

1,2,3abnormallungfunctions sointhisstudywechose4

hemoglobin assecondentityfordirectcomparisonwith IRV,ERVandVC. Inadevelopingcountry like

12 13Pakistan,wherelungfunctionstests aretoocostly 14

for an average person and according to study conductedinurbanareasofPakistananemiaisquitecommon,ourstudywascarriedoutwithanaimtofind any co-relation that exists betweenhaemoglobinandlungfunctiontestssoinfutureby

15knowingHb levelofapersonindirectassessmentoffunctioningoflungcouldbemade.

MaterialsandMethodsThestudywasconductedatPhysiologyLaboratoryofYusraMedicalandDentalCollege, Islamabad fromJanuary2012toJanuary2013. Itwasananalytical(Crosssectional)study.Atotalof160healthyyoungadultsofbothsexesbetweenages18to24selectedthroughpurposive sampling,were included in thestudy.Patientswithexistinglungdiseasesofasthma,dyspnoea, pneumonia were excluded from study.Before starting the study, formal approval fromYMDCmedicalethicscommitteewasobtained.Datafor haemoglobin (Hb) and lung function testswasanalysedusingPearsonco-relationco-efficientthatgivenumeralvaluesbetweentwovariablesthataremeasured on same interval and results werecalculatedusingSPSS15.Weapproachedpotentiallyhealthy students regularly attending classes inYMDC. Participants provided signed informed

Introduction1

Various studies have shown that restrictive and2

obstructivelungpathologies areaccountablefor3million deaths every year world widely withestimatedmortalityrateof71deathsper100,000in

3Pakistan. Respiratorystatusofpatientisevaluated

4using lung function tests, that are non-invasivediagnostic tests and helps in monitoring offunctioningoflungandalsogivesanoverallideaofprognosis for diseases. Though there are severaldifferent kinds of lung function tests, recent data

5,6suggests spirometry, is first andmost commonly

7usedmethod.Spirometer monitorslungfunctionbymeasuringamountofgasinhaledandexhaledthat

2,4showshoweffectivelygas travels fromthe lungsintothebloodwhichallowstoestimatehowwellthe

8lungsmoveoxygenthatiscarriedbyhaemoglobin fromtheairintothebloodstream.Differentstudieshave shown that due to decrease haemoglobinconcentration poor delivery of oxygen to lungs

9 10makes, anaemic patients usually lethargic and

11breathless, thus, they are more prone to have

CorrelationofHemoglobinwithLungFunctionTestsSidraJahangir,AmbreenAsad,IdreesFarooqButt

CorrelationofHBwithLungFunctionTestsJIIMC2015Vol.10,No.2

151

Received: April 11, 2015; Accepted: May 21, 2015

Department of PhysiologyYusra Medical and Dental College, Rawalpindi

Correspondence: Dr. Ambreen AsadAssociate Professor of PhysiologyYusra Medical & Dental College, RawalpindiE-mail: [email protected]

consent, predesigned questionnaire Performa andunderwentbloodsamplecollectionforhaemoglobin(G/dl),blood group, bleeding time, red blood cellcount, white blood count cell count, and lungfunction tests that is spirometer testing includesTidalvolume,Inspiratoryreservevolume,ExpiratoryreservevolumeandTotallungcapacity.Erythrocytesedimentation rate (mm at end of first hour)wasmeasuredusingWestergrenMethod.Haemoglobin

16ofparticipantswasestimatedusingSahliMethoddue to its simplicity and cost effectiveness.Haemometer kit of Sahli method included in it aComparator tube, Hb pipette and acid. SahliHaemometer method utilizes the conversion ofhaemoglobinintoacidhaematinwhichhasabrowncolour in solution. The intensity of the colour isrelatedtotheamountofhaemoglobininthebloodsample.Waterisaddedtodilutethebrownsolutionuntil it matches that of a standard. The morehaemoglobin,themorewaterrequiredtoobtaina

17colourmatch .Haemoglobinvaluesarereadatthemeniscus of the brown solution. Hence,Haemoglobin levels of individualswere taken and

17estimated. Lung function test swere measured18

usingSpirometer withitsaccessoriesthatincluded

amouthpiece, soda limecontainer, floatingdrumandtheresultswereobtainedonKymograph.Datawas noted from the recorded Spirogram forInspiratory reserve volume, tidal volume andexpiratoryreservevolumewererecordedwhereasVital capacity values were calculated. Analysis ofcovariancewasperformedtocomparethelevelsofdifferentpulmonaryfunctionparametersinrelationtohaemoglobin.Dataforhaemoglobin(Hb)andlungfunction tests was analysed using Pearson co-relation co-efficient which give numeral valuesbetweentwovariablesthataremeasuredonsameintervalandresultswerecalculatedusingSPSS15.Though,ourapproachofusingPearsonco-efficientisquite novel in biomedical field, however, in otherfields such as statistics, Pearson method is wellknownfortacklingco-relationfinancialphenomena.

ResultsThe lung function tests and haemoglobin arecomparedbytakinglungfunctiontests(IRV,ERV,VC)onYaxiswhereas,HaemoglobinistakenonXaxisand results were calculated using PearsonCorrelation co-efficient as shown in table II. ForInspiratory reserve volume and haemoglobin

comparisonvarianceis3.9001,standarddeviationof0.1623, whereas, co-relation co-efficient 'r' wasevaluatedas0.3862whichshowedsignificancelevelp<0.0001 and 95% confidence interval for 'r'calculated as 0.2398 to 0.5154 hence the p valueindicated the significant positive relation existbetween Inspiratory reserve volume andhaemoglobinasshownintableIIandfigure1.The95% confidence interval for mean is 12.8995 to13.5411.

Fig1:ScatterplotshowingsignificantpositivecorrelationbetweentheHB&IRV

On comparing expiratory reserve volume andhaemoglobin,varianceis3.8515,standarddeviationof 1.9625, whereas, the co-relation co-efficient rvalue is0.4321 ,significance levelofp<0.0001and95%confidenceintervalforrcalculatedas0.2910to0.5547therefore,apositiverelationco-existamonghaemoglobin and expiratory reserve volume. Theconfidence interval for mean is 12.8828 to13.5226.Results are shown in table II. When vitalcapacity was compared with haemoglobin, itshowed variance of 3.8710, standard deviation of1.9675,whereas,co-relationco-efficientcalculatedtobe0.2110,significancelevelofp=0.242andtheconfidence interval for 'r' calculatedas0.02816to0.3801.HenceresultsshowednosignificantrelationexistsbetweenVCandhaemoglobin,shownintableII. The 95% confidence interval for the mean is12.8852 to 13.5201. The positive relation ofhaemoglobinwith Inspiratory reserve volume and


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expiratoryreservevolumeindicatesthatbyknowingoneparametereitherhaemoglobinorlungfunctiontestonecanpredictaboutworkingofother.ThestatisticalsummaryisgivenintableI.

TableI:StatisticalanalysisofHBandlungfunctiontests

95%CI:95%confidenceinterval.SD:standarddeviation

DiscussionWhen the co-relation of haemoglobin with lungfunction test parameters (Inspiratory reservevolume, expiratory reserve volume and vitalcapacity) is done using Pearson co-relation co-efficient method, there exists positive relation of

19haemoglobin with Inspiratory reserve volume (pvalue<0.0001) and expiratory reserve volume (pvalue<0.0001).Haemoglobinandlungfunctiontestareseparateparametersandusuallyevaluatedoutseparatelyhowever,itisfoundbyourstudyresultsthat with having just haemoglobin values of anindividualonecanpredictabouthis lungfunction.Decreasehaemoglobinconcentrationresultsinpoordelivery of oxygen to lungs disturbing breathing

9,10,11mechanism,thus,anaemicpatients arelethargic

anddyspnoeicbeingmorepronetohaveabnormallungfunctiontests.Asinpoorcountries,itisdifficultfor people to go for lung function tests due toexpenses, hence by taking blood samples forhaemoglobin, fair prediction about functioning oflung could be done and if any doubt still persistsregarding poor functioning of lung, then forconfirmation, lung function tests such as

20Spirometry couldbeprescribedforsuchpatients.Inaccordance to best of our knowledge, no directnationalorinternationalstudyhasyetbeencarriedout on comparison of haemoglobin with lungfunctiontest,however,thereisevidenceofmatchingofourstudyresultswiththat,conductedinyear2012byJ.N.Oko-Oseetal.inUniversityOfBeninTeaching

21hospital, which compared lung function test in22

sicklecellpatient. Thoughthesamplesizewaslessthanhalfofthatwhatwechoseforourstudy(160),astheychose60subjects,howevertheanalysisofdatawasdoneusingTtestandPearsonco-relationthat

wehavealsoutilizedforresults.Inthatstudy,otherparameterssuchasforcedexpiratoryvolumeinonesecond(FEV1)andforcedvitalcapacity(FVC)werealsoincluded,thoughtheyhavenotbeenutilizedinour study, but we have future plans of exploringtheseareasalso.According to the study, the lung function indiceswere lower in females than males in sickle cell

23patient,that differsgreatlywithourresultsastheywere same for both genders in regards, that lowhaemoglobin values for both genders will predictequallyforpoorlungfunctioning,however,thisareaneeds further extensive exploration and thedifferenceingenderresultmaybeduetodifferentgeographical areas and different races beingexaminedinbothstudies.FurtherrecommendationregardingourstudyisthathaemoglobinestimationbyDrapkinmethod,Forcedexpiratoryvolume,forcedvitalcapacityanddiseasedindividualsshouldalsobeincluded.

ConclusionHaemoglobin level in future can serve as goodindicatorforassessinglungfunctionofthepatientswithouthistoryofanylungdiseaseespeciallyinpoorsocioeconomicconditionsandenvironmentwhereanaemia ismore prevalent, patients are prone tohaveabnormallungfunctiontests.

TableII:CorrelationbetweenHB&lungfunctiontests

CorrelationofHBwithLungFunctionTests*ForHaemoglobinandInspiratoryreservevolume,the“r”valueis0.38sothereexistsfairco-relationamongthem.**ForHaemoglobinandExpiratoryreservevolume,the“r''value0.43depictsagoodsignificantrelationbetweenthetwo.***ForHaemoglobinandVitalcapacity,the“r”valueof0.2showsaweakco-relationamongthem.IRV:Inspiratoryreservevolume.ERV:ExpiratoryreservevolumeVC:vitalcapacity


153

REFERENCES1. Stam H, Splinter TA, Versprille A. Evaluation of diffusing

capacity in patientswith a restrictive lungdisease. Chestjournal2000;117:752-7.

0.3862*<0.0001

0.4321**

<0.0001

0.2110***0.0242

2. Qaseem A, Wilt TJ Ann. Diagnosis and management ofstable chronic obstructive pulmonary disease: a clinicalpractice guideline update from the American College ofPhysicians.AmericanCollegeofChestPhysicians2011;155:179-91.

3. Tazeen H Jafar, Benjamin A Haaland, Atif Rahman Non-communicablediseasesandinjuries inPakistan:strategicpriorities.TheLancet2013;381:p2281-90.

4. MillerMR,CrapoRO,HankinsonJL,GeneralConsiderationsof Lung Function Testing. European Respiratory Journal2005;26:319-38.

5. HyattRE,ScanlonPD,NakamuraM.Spirometry,dynamiclungvolumes.InterpretationofPulmonaryFunctionTests:APracticalGuide.Philadelphia:Lippincott-Raven;1997.

6. StanojevicS,WadeA,StocksJ,HankinsonJL,CoatesAL,PanHetal.ReferenceRangesforSpirometryacrossallages.Anewapproach.AmericanJournalofRespiratoryandCriticalCareMedicine2008;177:253-60.

7. GoldWM.Pulmonaryfunctiontesting.In:MurrayJF,NadelJA, eds. Textbook of Respiratory Medicine, 3rd ed.Philadelphia:WBSaunders,2000:781-882.

8. Quan-ZhouFeng,Yu-ShengZhaoandYu-FengLi.Effectofhaemoglobin concentration on the clinical outcomes inpatientswithacutemyocardial infarctionandthefactorsrelated to haemoglobin. British Medical Journal 2011;4:142.

9. DriskellJA.NutritionalAnemia:TheGuidebook:NutritionalAnemia.JournaloftheAmericanMedicalAssociation2008;299:2690-1.

10. WilliamMcClellan,StephenLAronoff,WKlineBolton.Theprevalence of anemia in patients with chronic kidneydisease.JournaloftheAmericanMedicalAssociation2004;20:1501-10.

11. Pasricha SR, Flecknoe-BrownSC , AllenKJ,Gibson, et al.Diagnosisandmanagementofirondeficiencyanaemia:aclinicalupdate.TheMedicalJournalofAustralia,2010;193:525-32.

12. Nicole Beydon, Isabelle Pin, Regis Matran. PulmonaryFunction Tests in Preschool Children with Asthma.AmericanJournalofRespiratoryandCriticalCareMedicine,2003;168:640-4.


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13. Luis Puente Maestú. Lung Function Tests in ClinicalDecision-Making.ArchBronconeumol.2012;48:161-9.

14. Baig-AnsariN,BadruddinSH,KarmalianiR,HarrisH,JehanI,Pasha O, et al. Anemia prevalence and risk factors inpregnantwomen inanurbanareaofPakistan.FoodandNutritionalBulletin2008;29:132-9.

15. MayC,RivellaS,CallegariJ,HellerG,GaenslerKM,LuzzattoL.Therapeutichaemoglobinsynthesisinbeta-thalassaemicmice expressing lentivirus-encoded human beta-globin.BritishMedicalJournal2000July6;406:82-6.

16. PrashantJijabraoPatil,GirishVithalThakare.VariabilityAndAccuracyofSahli'sMethodinEstimationofHaemoglobinConcentration.NationalJournalofIntegratedResearchinMedicine2013;4:38-44.

17. HarpreetRanu, Michael Wilde, Brendan Madden.PulmonaryFunctionTests.TheUlsterMedicalJournalMay2011;80:84-90.

18. Hnizdo E, Glindmeyer HW, Petsonk EL. Workplacespirometrymonitoringforrespiratorydiseaseprevention.International Journal of Tuberculosis and Lung Disease2010;14:796-805.

19. OttoJM,DohertyAFO.Associationbetweenpreoperativehaemoglobinconcentrationandcardiopulmonaryexercisevariables: a multicentre study. Perioperative MedicineJournal2013;1:2-18.

20. QuanjerPH,BorsboomGJ,KivastikJ,MerkusPJ,HankinsonJL, Houthuijs D, et al. Cross-sectional and longitudinalspirometry in children and adolescents: interpretativestrategies.AmericanJournalofRespiratoryandCriticalCareMedicine2008;178:1262-70.

21. Oko-OseJN,IyaweV,EgbagbeE,EbomoyiM.LungFunctionTests in Sickle-Cell Patients in Benin City. Pulmonology2012;210:1-5.

22. OharaDG,RuasG,Walsh IA,CastroSS, JamamiM.Lungfunction and six-minute walk test performance inindividuals with sickle cell disease. Brazilian Journal ofPhysicalTherapy2013;18:79-87.

23. ConnesP,MachadoR,HueO,ReidH.Exerciselimitation,exercisetestingandexerciserecommendationsinsicklecellanemia. Canadian Medical Association Journal 2011;49:151-63.

ORIGINAL ARTICLE

ABSTRACTObjective:TheaimofthisstudywastoevaluatethereportedpracticeofantibioticsprescribedbyPostGraduatetrainees,workingintheOperativeDepartmentofIslamicInternationalDentalHospital(IIDH),Islamabad.StudyDesign:Aclinicalauditstudy.PlaceandDurationofStudy:ThestudywasconductedinthedepartmentofoperativedentistryatIslamicInternationalMedicalCollege,IslamabadfromApril2014toJuly2014.MaterialsandMethods:AclinicalauditevaluatingtheantibioticsprescriptionpracticeofPostGraduatetraineesatIIDHwasperformed.AlloftheeighttraineesworkingintheOperativedepartmentwereincludedinthestudy.Theprescribedantibiotic;itsdosage,frequencyandduration,aswellastheclinicalconditionsandreasonsforwhichtheprescriptionhadbeengivenwasinvestigatedusingquestionnairesineightypatients(tenpatientsperdentist).DatawasanalyzedusingStatisticalPackageforSocialSciences(SPSS)softwareversion17.0,(SPSS,Inc.,Chicago,IL).Frequenciesandpercentagesweredescribedfortheantibioticprescriptions.Results:Amoxicillinn=42(53.5%)andMetronidazolen=37(46.3%)werethemostcommonlyprescribedantibiotics.OtherprescribedantibioticsincludedErythromycinn=1(1.3%),Penicillinn=1(1.3%),Clindamycinn=1(1.3%),Cefalexinn=1(1.3%)andothersn=2(2.5%).Tetracyclinewasalsoprescribedn=14(17.5%).Conclusion: This study identified gap between the antibiotics prescription practice of postgraduate trainees andrecommendedclinicalguidelines.Thefindingssuggestneedforare-assessmentoftheantibioticsprescriptionpracticeinaccordancewithevidencebasedguidelines.

Keywords:Reported Practice, Antibiotic Prescription, Post Graduate trainees, Operative Department.

antibiotic prescription for patients seeking4,7

treatment. WHO described rational use ofmedicines as “Patients receive medicinesappropriatetotheirclinicalneedsandindosesthatmeettheindividualrequirements,foranadequateperiodoftimeandatthelowestcosttothemand

8theircommunity”. Manycasesofpatientdiagnosisshowing both inappropriate and suboptimalreported practices of Antibiotic prescription,evidenced by worldwide 50% of inappropriately

2,3,8-10prescribed, dispensed, sold drugs which areoften substituted for operative intervention of a

5dentalinfection orasanadjunct,withoutsystemic10

involvement. Such practices have long-termramifications including anaphylactic reactions toPenicillin with an estimated incidence of 0.015%-

110.004%. Theaimofthisstudyistoinvestigatethemultifacetedareasthatplayapivotalroleindentists'antibioticsprescription.Secondarily,thisstudyalsoinvestigates the protocol of antibiotic prescriptionfollowed at Islamic International Dental Hospital(IIDH). More effort is needed to comprehend thepatient expectations and educating them withrelevantinformationinordertostepoutof“foliea

12duex”.

IntroductionClinicalaudithasbeenknownasthesystematicandcritical analysis of clinical care quality. Antibioticprescription has been considered to be a “broadarea” for audit analysis since the professionmustclearly accept its responsibility “to use antibioticssensibly”.However,therehasbeenavariationinhowevery healthcare practitioner view sensible

1prescription .Dental practitionersworldwide regularly prescribeantibioticsfordental infectionsandthistreatmenthas been influenced by personal experience and

2-4knowledge. Many times, antibiotics were4-5prescribedinappropriatelytopatients. Thusaneed

for an investigation of the conditions for which6unnecessaryantibioticsare prescribed. Thereisa

paucity of literature on dentists' antibioticsprescription practices and trends. Drug useevaluation, is amean todetermine thepatternof

AnInsightintotheAntibioticPrescriptionPracticesofPost-GraduateDentists,DiscernedthroughaClinicalDentalAuditSyedaAyeshaAbsar,RohmaQasim,SairaKhan,RijaTehseen,MuhammadHumzaBinSaeed,AnumZehra

PrescriptionpracticesofPostGraduateDentistsJIIMC2015Vol.10,No.2

155


Department of Community DentistryIslamic International Dental College, Islamabad

Correspondence: Syeda Ayesha AbsarIslamic International Dental CollegeRiphah International University, IslamabadE-mail: [email protected]

MaterialsandMethodsA cross sectional study was carried out in theOperative Department of Islamic InternationalDental College, Islamabad. Post Graduate (PG)dentistswhowereemployedfulltimewereaskedtoparticipatevoluntarilyinthestudy.A'ClinicalDental

13Audit' tool approved by the American DentalAssociation (2011) was used. The dental auditcomprisedofquestions;(i)diagnosisandhistoryofpatientsandtheantibioticprotocoltobefollowed,(ii) clinical features present, (iii) antibioticsprescribed, (iv) influences on choice of antibiotic,and(v)influencingfactorsondecisiontoprescribe

14antibiotic. The aim of the Clinical Dental Audit' approvedbytheAmericanDentalAssociation(2011)wastohelpdentistsdevelopandfollowaconsistentrationaleforprescribingantibiotics;toreviewtheirprescribingpatternsinordertoensureanupdatedevidencebasedprescriptionpractice.Confidentialityandsupervisionwasassured.Datawascollectedonthemostrecenttenpatientrecords of each dentist. For each case, theprescriptionpracticewasassessed,accordingtotheclinical diagnosis. Confounding factors, such aspatients' condition at the time of arrival forappointment,drughistory,andpatientallergy;wereconsidered.Factorslikepatients'expectations,timepressures, and uncertainty of diagnosis, patientfailedtoco-operatewithothertreatmentthatwereincludedintheAudit.Atotalofeightypatientswereselected for this study. Eight PG trainees of theOperative Department were asked about the tenmost recent patients that they had treated. Theresults obtained were transferred from AuditRecordingFormaspercentagesintoActionSummaryForm and discussed with the Head of theDepartmentoftheOperativeDentistryDepartment.DatawasanalyzedusingStatisticalPackageforSocialSciences (SPSS) software version 17.0, (SPSS, Inc.,Chicago,IL).Methodofdataentryinvolvedaddingup the number of ticks in each row and thenrecordedasapercentage.

ResultsEightPGtraineestookpartinthisstudyandfilledoutthe audit form for ten patients each. The mostcommon clinical signs of the presenting patientswere evidence of systemic spread (swelling and

pyrexia), pain, localized swelling, gross diffuseswelling, periodontal abscess and difficulty inswallowing.AnalysisofthequalitativedatarequiredathoroughdiscussionwiththeHeadofDepartmentofOperativeDentistry.

TableI:AntibioticPrescriptionInformation

In73outof80(91.3%),thePGsfollowedtheprotocolfor prescribing antibiotics. In 60 out of 80 cases(75%),thetraineeshadanuptodatemedicalhistoryavailable.For74outof80cases(92.5%)thedosageandfrequencyofantibioticswasrecordedincontrasttothe80outofatotal80cases(100%)forwhichtherecordsofclinicaldiagnosiswerereadilyavailable.

TableII:ClinicalFeaturesPresentAndAntibioticsPrescribed

Mostof thepatients in theOperativeDepartmentfrequently presented with pain (n=52, 65%), andwith (n=35, 43.8%) of the total 80 cases having alocalized fluctuant swelling. A few patients alsopresentedwithaswellingwithoutanypain(n=28,35%). 43 of the 80 cases (53.8%) came in withevidenceofsystemicspread(swellingandpyrexia).Asopposedtothelocalizedfluctuantswellingonly6outof80cases(7.5%)ofthepatientswerediagnosed


156

patients,alongwithacombinationofMetronidazole18

the most effective drug against anaerobes. Asrecorded in theAction Summary Form, antibioticswerenotprescribeduntilstrongevidenceexistedtosuggestthatthe infectionwassystemicand itwasreiteratedfrom previousfindingsthatperiodontalabscessesarehardlyacasewherebyantibioticswill

15,19be prescribed. The rationale for prescribingTetracycline however is still unclear as there has

15been a resistance against these drugs. Similartrendwasseeninpresentstudy.Consequently,thefact that Erythromycin and Cefalexin wereprescribedin1.3%ofthecaseseachdespitethese

20drugshavinganyuseineachoftheclinicalfeatures. Clindamycinwasprescribedin1.3%ofthecasesandotherunspecifieddrugsaccountedfor2(2.5%)outof the total 80 cases (2.5%). Clindamycin hassignificanttherapeuticpropertiespromptingPGstouse this as an anti-infective with good oral

21absorption. Most common presenting symptomwaspainin52outofatotal80cases(65%)andothersymptoms; localized fluctuant swelling and grossdiffuseswellingthoughnotindicativeforantibioticprescription had been used as an indication toprescribethem.MostPGskeptthegeneralconditionof the patient under assessment. If patient wasoriginally prescribedAmoxicillin orMetronidazole,failure to alleviate symptoms of systemic spreadcaused switching drug therapy to amore suitableantibiotic.Thisrevelationcomesdespitetheearlierconflicting evidence suggesting that PGs did notfollow the correct guidelines. A Norwegian studycarriedoutexpressedthatpatientswhopresentedwithsymptomswantedfewerprescriptionsandnotvice-versa,necessitatingdentiststoeliminate“foliea

13deux” from influencing them. The findings of thisdiscussionclearlyshowedthattherehavebeencaseswhereantibioticswereundulyprescribed.Butduetomultifacetednatureofthefactors,wecannotclearlysay that therewas no protocol followed. There is still, a substantial need for education resulting in

22,23behavioral changes in prescription practice Incaseswhereodontogenic infections exist, prudentuse of antibiotics in conjugation with surgical

24procedures is necessary. Certain limitationswerealsofoundinthestudyincludingwhatappearedtobe prophylactic use of antibiotics in high risk

25endodonticdentalprocedures. Thisstudyisacross

withgrossdiffuseswellingand5ofthe80cases(6.3%) had difficulty in swallowing. Periodontalabscesses were found in 17 out of the total 80patients (21.3 %). Major reigning antibioticprescriptionwiththePGtraineeswereAmoxicillinin42casesoutof80(52.5%)andMetronidazolein37casesoutof80(46.3%)speciallyprescribedincasesofsystemicspread.Otherclassesofantibioticswerenot so avidly prescribed. There were cases inOperative Department exclusively where

TableIII:InfluenceonChoiceofAntibiotic

Tetracyclinewasprescribedapproximatingto14outof80cases(17.5%).In1outof80cases(1.3%),thePGsfelttheneedtodosomething“active”.Thetimepressuresdidnotaccountformostoftheantibioticprescriptions,thePGtraineesoftheOperativeDepartmenttickedthebox innegative. Inpatientswhohadhadpreviousendodontictreatments,n=5(6.3%)ofthetotal80patientsobservedantibioticprescription.

DiscussionThisstudyevaluatedvariousaspectsthatinfluencedantibiotic prescription practices of PG trainees.Response percentageswere recorded in the auditrecording form, and then transferred to an actionsummary form and responses discussed with theHeadofDepartment,andvariablesthatcontributedweregauged.Significantpercentage,in80(100%)ofthecases,theclinicaldiagnosiswasrecordedaswellastheantibioticdrugdose,frequencyanddurationin74(92.5%),reflectiveofprofessionalismwithinPGtrainees.Consequently, themost common“go-to”antibiotic drug prescribed in the OperativeDepartment by the PGs was Amoxicillin (n=42,52.5%).Inthepast,Amoxicillinwasnotthedrugof

15,16choiceforodontogenicinfections. However,mostofthedentalabscessescontainanaerobicflorathatmay be resistant to Penicillin but only 5% areresistanttoAmoxicillinmakingitanidealfordruguse

15,17in odontogenic infections. This accounts forincreased frequency Amoxicillin prescription for


157

sectionalstudybutalongitudinalstudywouldbeofgreater benefit. Caseswhere indication for use of


158

ORIGINAL ARTICLE

ABSTRACTObjective:Tostudytheoxidativestressofnicotineonthegrowthofchick,andtoobservetheroleofantioxidantsuchascamelliasinensisinreducingtheharmfuleffectsofnicotine.StudyDesign:Randomizedcontrolledtrial.PlaceandDurationof Study:The studywas conductedatArmymedical college inAnatomydepartment from2ndNovember2011to2ndNovember2012incollaborationwithpoultryresearchinstituteRawalpindi(PRI).MaterialsandMethods:FertilizedeggsofFayoumispecieswereselectedatzerohourofincubation.Fourgroupsweremade,eachgroupcomprisingofteneggs.Controlgroup(G1)wasgivennormalsaline,experimentalgroup(G2)wasgivengreenteaextract,experimentalgroup(G3)wasgiven0.0001%nicotinesolution,andexperimentalgroup(G4)wasgivenboth0.0001%nicotinesolutionandgreenteaextract.Firstexposurewasat48hoursofincubationandsecondat48hoursofhatching.Chicklengthwasmeasuredafteronemonthofhatching,withthehelpofinchtapefromvertextillthethirdtoetip.Results:Itwasobservedthatnicotinetreatedgroupsuchas(G3)and(G4)wereweakascomparedtothe(G1),thelengthofchickwhichwasmeasuredatonemonthofagewas less incomparisonto (G2)and (G1). Incaseof (G4),havingadministrationofboththesolutionthatisnicotineandgreenteaextract,showedbettergrowthincomparisontonicotinetreatedgroup(G3),butitsgrowthwaslessincomparisonwithcontrolgroup(G1)andexperimentalgroup(G2).Conclusion:Greenteaextracthelpstoundothetoxiceffectsofnicotinebutcannotovercomethereverseeffectofnicotinetoxicity.

KeyWords: Chick, Nicotine, Camellia Sinensis, length.

oxidationbytheprocessofsoakinginwarmwater.Greenteacatechinswhicharethemainconstituentsofthecamelliasinensisextractshavebeenfoundtohavemanyuniqueantimicrobiologicalactivities.Theanti microbiological activities includes such asantibacterial, antifungal, antiviral and antitoxic

4effects. Theseeffectshelped todetoxify the toxiceffects by the presence of free radicals after theexposureofnicotinetothedevelopingembryointhepresentstudy.

MaterialsandMethodsThe studywas randomized controlled trial. In thisstudywhichwascarriedoutatAnatomydepartmentof Army Medical College Rawalpindi from 2ndNovember 2011 to 2nd November 2012 incollaboration with the Poultry Research Institute(PRI)Rawalpindialltheprocedureswereapprovedby Ethical Review Committee of Army MedicalCollegeRawalpindi.Durationofthestudywastwomonth. Fertilized eggs with normal shape (oval),colour(offwhite),andsize(medium)wereincludedinthestudy.Whereasdifferentcolourofeggs,shapeandsizewasexcludedfromthestudy.Tennumberofeggs in each groupwere selected total forty eggswereused.FertilizedFayoumispecieseggsofchick

IntroductionBone health problem increasing around the

1world. Bone mineral density are affected by the2

different health issues like osteoporosis. In thisstudynicotinewhichisconsideredtobeoneofthemain constituent of cigarette smoke, showed its affectsonthedevelopingskeletonofchick.Asnotmuchworkdone to see the teratogenicaffectsbyactiveorpassivesmoking.Inpresentstudynicotineaffect on developing bone by reducing the cellproliferatingactivityoftheosteoblasts,supportingtheevidencethatithasadirecteffectonbonecellsasnicotineandtobaccoextractstimulatesglycolysisand inhibits bone synthesis and mitochondrial

3activity. Camellia sinensis extracts was obtainedfrom itsdried leavesof green tea.Dried leavesofgreenteahadtoundergonetheprocessofminimal

EffectofNicotineandCamelliaSinensisontheLengthofChickMaryamShan,ShaziaImran,IramIqbal

EffectofNicotineandCamelliaSinensisJIIMC2015Vol.10,No.2

159

Received: March 16, 2015, Accepted: June 09, 2015

Department of AnatomyIslamabad Medical and Dental CollegeBharakahu, Islamabad

Correspondence: Dr. Maryam ShanSenior lecturer, Anatomy Islamabad Medical and Dental College BharakahuIslamabadE-mail: [email protected]

wereselectedatzerohourofincubation.Incubationof eggs was done after properly fumigating andclearingthehatchery.Temperaturewasmaintainedat37.50C,therelativehumiditywaskeptbetween75% and proper ventilation was maintained.Rotationsofeggsweredone4hourly.Placementofeggsinhatcherywastakenasdayzero.Fourgroupswere made each group was comprising of tennumbers of eggs. Control group(G1)was givennormal saline in 0.1ml of quantity. Experimentalgroup(G2)wasgivengreenteaextractin0.1mlofquantity, experimental group (G3) was given

50.0001% nicotine solution in 0.1ml of quantity, experimental group (G4) was given both 0.0001%nicotine solution and green tea extract in 0.1mlquantity. All the working solutions were giventhroughthebluntendof theeggwiththehelpofinsulingaugeneedle.Doubleexposureofdoseswasgiven.Firstexposurewasat48hoursofincubationandsecondat48hoursofhatching(postnataldose).Attheageofonemonth,chickslengthwasmeasuredwiththehelpofinchtapefromvertextilltipofthe

6third toe (Fig1). Data was entered in a databaseusing SPSS (Statistical Package for Social Science)version16.Datawaspresentedastables.Chi-squaretest was used for the comparison between thegroups.pvalue<0.05wasconsideredsignificant.

ResultsFor results and observations the gross features ofone-month-old chick were taken into account.Lengthofchicksof(G1)andexperimentalgroup(G2)both showed mean value 37.833±0.117cm. Themeanvaluesof(G3)and(G4)were20.000±0.00cmand26.000±0.000cmrespectively(TableI).

(G3)and(G4)bothshowedsignificantresultswithpvalues (0.000). Comparison of (G3) and (G4) witheachothershowedstatisticallysignificantResultwithpvalue(0.000)(TableII).

TableI:MeanvaluesofLengthofonemontholdChick(cm)

Controlgroup(G1)incomparisonwithexperimentalgroup(G2)showedinsignificantresultwithpvalue(1.000).Whereaspvaluesofcontrolgroup(G1) incomparisonwithexperimentalgroup(G3)and(G4)were(0.000).Experimentalgroupswhencomparedwith each other such as, (G2) in comparisonwith

TableII:Comparisonoflengthofonemontholdchickswitheachother

*Pvalue<0.05statisticallysignificant.

DiscussionIn this study wok nicotine shows its toxicity by


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3. HermiziH,FaizahOINS,AhmadN,ShuidDA,Luke,NorazlinaM.Negativeeffectsofnicotineonbone-resorbingcytokinesand bone histomorphometric parameters in male rat. JBoneMinerMetab2007;25:93-8.

4. MichiH,KoushiY,YousukeI,YuusukeI,MasafumiI,MitsuruA, etal. Antimicrobial activities of catechin of green tea.Department of microbiology and immunology, Showauniversityschoolofmedicine,1-58,Hatanodai,Shinagawa-Ku,142-8553Tokyo,Japan2002;13:1363-73.

5. HamamachiS,Nishigori,H.Establishmentofachickembryoshelllessculturesystemanditsusetoobservechangesinbehaviourcausedbynicotineandsubstancefromcigarettesmoke.J.Toxicol.Letters2000;119:95-102.

6. HamburgerV,HamiltonHL.Aseriesofnormalstagesinthedevelopmentofthechickembryo.J.Morphol1951;88:49-92.

7. FlickerTM,GreenSA.Comparisonofgas-phasefreeradicalpopulationintobaccosmokeandmodelsystemsbyHPLC.Department of chemistry technological university,Haughton,MichiganU.S.A.Environ.Health.Perspect2001;109:765-71.

8. FangMA,FrostPJ,Iida-KleinA,HahnTJ.Effectsofnicotineon cellular function in UMR 106-01 osteoblast-like cells.Bone1991;12:283-6.

9. TanakaH,TanebaN,SuzukiN,ShojiM,TorigoeH,SugayaA,et al. icotine affects mineralized nodule formation byhumanosteosarcomacelllinesaos-2.J.Life.Scien2005;77:2273-84.

10. CrowleyWeber CL, Dvorakova K, Crowley C, Berstein H,BersteinC,GarewalH,etal.Nicotine increasesoxidativestress,activatesNF-kBandGRP78,inducesapoptosisandsensitizes cells to genotoxic / xenobiotic stressses by amultiple stress inducer, deoxycholate relevance to coloncarcinogenesis.Chemic.Biol.Interac2003;145:53-6.

11. ShawD,al'AbsiM.Bluntedopiatemodulationofprolactinresponseinsmokingmenandwomen.PharmacolBiochemBehav2010;95:1-5.

12. Xiao D. Fetal Nicotine Exposure Increases the Risk ofCardiovascular Disease in Late Life. A Review of theLiterature.AustinJPharmacolTher2014;2:1-6.

12betweendopamineandProlactin. Nicotineamajorcomponent of tobacco smoke shows its adverseeffectduringpregnancyasitdoesnotonlyreducesfetalbodyweightbutalsoimpairs developmentoffetusby involving the indirect regulationofutero-

12placentalcirculation. Excessiveboneresorptioncancausedeteriorationintrabecularbonestructureinnicotine group which may be due to excessiveo s t e o c l a s t o g e n e s i s a n d i n a d e q u a t e

3osteoblastogenesis in male rats. Nicotine and itsmetabolites are proven for causing number ofmedical problems during developing stages ofvariousexperimentalanimals.AsitwasobservedonSwissalbinorats,whichweretreatedwithnicotine,the functioning of gonadswas abnormal affectingspermatocytecount.GreenteatreatmentgiventosameSwissalbinoratshelpedtorestorethenumberof spermatocyte and spermatids to nearly normallevel.Bythisitwasprovedthatgreenteaantioxidant

13propertyhelpedtosuppressthetoxicityofnicotine. Nicotine is considered to be responsible for theostreoporosis as work was done on male rats

14decreasingthebonestrength. Smokingdecreasesbody mass, as it provide an osteogenic stimuluswhichis linkedtohigherlossofmineraldensityof

15bones. Bony fractures which occur due to anyreasonresultsincausingbackpain,heightlossand

16physicaldisability. Thepresentworkwasdesignedtostudythegrosschangesinthedevelopingchickexposedtonicotineoneofthemainconstituentoftobaccosmokeandtoobservethepreventiveeffectsofantioxidantsuchasgreentea.Thecurrentstudyrevealedthatgreenteasignificantlypreventedsomeof the harmful effects of nicotine on developingchick.

ConclusionToconcludethatnicotine,oneoftheconstituentofcigarette smoke causes toxic effects on thedeveloping chick and administration of green teaextract neutralizes some of the harmful effects oftobaccosmokeshowingitsantioxidantproperties.

REFERENCES1. Van Staa TP, Dennison EM, Leufkens HG, Cooper C.

Epidemiology of fractures in England and Wales. Bone2001;29:517-22.

2. PooleKE,CompstonJE.Osteoporosisanditsmanagement.BMJ2006;333:1251-6.

Fig1:Photographshowingmeasurementofchicklengthwiththehelpofinchtapebyplacingitbetweenthevertexandthethirdtoe


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13. GawishAM,IssaAM,AzizaMA,SherinR.Morphmetrical,histopathologicalandcytogeneticalamelioratingeffectsofgreenteaextractonnicotinetoxicityofthetestisofrats.J.Cytol.Histol2010;1:401-11.

14. BroulikPD,RosenkrancovaJ,RuzickaP,SedlacekR,KurcovaI. TheEffect of ChronicNicotineAdministrationonBoneMineral Content and Bone Strength in Normal andCastratedMaleRats.Horm.Metab.Res2007;39:20-4.

15. WongPK,ChristieJJ,WarkJD.Theeffectsofsmokingonbonehealth.ClinSci(Lond)2007;113:233-41.

16. Lane NE. Epidemiology, etiology, and diagnosis ofosteoporosis.AmJObstetGynecol2006;194:3-11.


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ORIGINAL ARTICLE

ABSTRACTObjective:Thestudywasconductedtoassessdentists'understandingoftermsusedinevidencebasedhealthcare.StudyDesign:Cross-sectionalquestionnairebasedstudy.PlaceandDurationofStudy:ThisstudywasconductedinthedepartmentofcommunitydentistryatIslamicInternationalDentalHospitalIslamabadfromApril2013toAugust2013.MaterialsandMethods:Aquestionnairebasedcross-sectionalstudywasconductedamongfacultymembersoftheFacultyofDentistry,RiphahInternationalUniversity.Asampleof38facultymembers(n=38)wasselected.Thesamplewasstratifiedintosenior(n=17)andjunior(n=21)facultymembers.Aself-administeredquestionnaire,including10questions,wasdistributedbyhandamongthefacultymembers.Theparticipantswereaskedabouttheirknowledgeaboutthemethodologicaltermsusedinevidencebasedliterature.Results:Majority(82%)oftherespondentshadbasicknowledgeofthetermsusedinquestionnaireandmanyofthemwhodidnotknowshoweddesiretoknow.Eightpercent(3)oftherespondentssaidthattheyknewdummytermandcouldexplainittootherswhereas21.1%(8)hadsomeknowledgeoftheterm.Evidencebasedpracticeshouldbeencouragedamongyoungdentistsbyseniormembersanditshouldbepartofcurriculumforthedentalstudents.Conclusion: Senior facultymembers aremore knowledgeable compared to juniors. Althoughmajority (82%) of therespondentshavebasicknowledgebutnotallofthemcanexplainittoothers,indicatingtheirpoorunderstanding.

Keywords:Evidence Based Practice, Dental Education, Evidence Based Dentistry.

5,6FivefundamentaltiersofEBDinclude.1) Generatingananswerablequestiontoaproblem

relatedtopatients.2) Literaturesearchfortheproblem.3) Criticalappraisalofbestavailableevidencefor

theparticularproblem.4) Implementation of the findings into clinical

practice.5) Evaluation of its impact on dental practice,

dentistsandpatientsEBDbenefitsallof its threecomponentsofdentalhealthcare system (dentists, dental practice andpatients) alike. For dentists, it provides life-longopportunityoflearningnewadvancesintheirfield.Dental treatments based on evidence rather thanopinionsprovidealongtermmonitoringofdentists'capabilitiesandskills.Treatmentsofpatientsinthelight of best available evidence considering their

1,7-9preferencesenhancetheirfaithindentists.However,practicepatternofmostofthedentistsisgovernedbythetrainingtheyreceiveduringoraftergraduation. Afewpractitionerstakethetroubletoupdatetheirknowledgeaboutnewinnovativestepsthus giving away potential opportunity to provide

10quality healthcare service to their patients. Inaddition, literature research reveals that a lack oftimetostudyscientificliterature,complexityofusedwords, lack of skill in critical appraisal, pooravailabilityofevidenceandfailuretocastasidean

IntroductionEvidencebasedpracticeisatriadofevidence,clinical

1experience and patient preference. Although it isnotanewconceptas itsorigindatesbacktomid-19thcenturybutinthepastfourdecadesevidencebasedpracticehadattainedparamountimportancein making effective and efficient health-care

2decisions. Itisdefinedas“thepracticeofdentistrythat integrates the best available evidence withclinical experience and patient preferences in

3making clinical decisions”. With changing times,rapid technical advances, maturing health-careconsumersandadvancing information technology;implementationofevidencebasedpractice isever

1more important. Challenging and complex casesnow demand innovations in thought process ofdentists which can only be made possible if theprofessionalsarewellequippedwithknowledgeof

4EBD. Criticalappraisalofscientificliteraturewhichforms the core of EBD helps in bridging researchfindingswithrealworlddentalpractice.

AnAssessmentofDentists'KnowledgeofEvidenceBasedTermsFarehaLiaqat,MuhammadHumzaBinSaeed,AnumZehraKhan

Dentists'KnowledgeofEvidenceBasedTermsJIIMC2015Vol.10,No.2

163


Department of Community DentistryIslamic International Dental CollegeRiphah International University Islamabad

Correspondence: Fareha LiaqatIslamic International Dental CollegeRiphah International University, IslamabadE-mail: [email protected]

orthodox mind-set in the provision of healthcareservicesarethemajorshort-comingsinapplication

11,12ofEBD. ConsideringtheimportanceofEBDinrealworld dental practice a study was conducted toassesstheunderstandingofEBDtermsamongthedentists at the Faculty of Dentistry, RiphahInternationalUniversity(RIU),Islamabad.

MaterialsandMethodsA cross-sectional, questionnaire based study wasconductedatRiphahInternationalUniversity,afterthe ethical approval from Research EthicsCommittee of the Faculty of Dentistry, RiphahInternationalUniversity.AllcurrentmembersoftheFaculty of Dentistry were included in the study.Faculty members of all other departments of theuniversitywereexcluded.Datawascollectedfrom38faculty members, which were divided into twogroupsuponthebasisofseniorityintoseniorfacultymembers(n=17)andjuniorfacultymembers(n=21)by a self-administered, structured questionnairedistributedbyhandamongthefacultymembersofthecollegeinSeptember,2013.Completeanonymityoftheparticipant'sdatawasmaintainedtoincreaseresponse rateand reducebiasduring the study.Aquestionnaire was designed at the CommunityDentistryDepartmentofRIU.Thequestionnairewasdistributed amongst eight senior facultymembersand they were requested to give a qualitativelyevaluate the questionnaire for validity andappropriateness. Modifications were made in thequestionnaireinthelightofthesuggestionsmade.Briefintroductionofthestudywasgivenonthefrontpageofquestionnaire.Questionnaireprovided10questionstoparticipantsto self-evaluate their knowledge about the termscommonlyusedinresearchliteraturein4possiblewaysi.e.a) Iunderstandandcanexplainittoothersb) Ihavesomeknowledgeaboutitbutcan'texplain

toothersc) Ihavenoknowledgeaboutitbutwouldliketo

knowd) I have no knowledge about it and it has no

relevancetomeFollowingresearchrelatedterminologieswereasked(in the order in which they were given inquestionnairefromquestion''1-9''):Meta-analysis, linear regression, cohort study,selection bias, odds ratio, relative risk, null

hypothesis, p-value and confidence interval. Adummy term, relative odds ratio reduction(question10)wasalsousedtoassessbiasduringthestudy.DatawasanalysedusingSPSSVersion.17.0.Meanand standard deviation were calculated for theanswersofthedifferentquestions.

ResultsResponserate:All of the faculty members (38) returned thequestionnaire. Thus, a 100% response rate wasachieved.KnowledgeofEBD-relatedterms:Table I shows dentists' self-reported knowledgepertainingtoEBDtermsusedinquestionnaire.Thetable shows thatmajorityof theparticipantshavebasicknowledgeaboutEBD-relatedtermsandthosewhodidnotknowshoweddesiretoknow.

TableI:Dentists'self-reportedknowledgeofEBD-relatedterms

The participants who selected either of the twooptions i.e., to explain the terms to others'' and“havesomeknowledgebutcan'texplainittoothers'were considered as the ones having basicknowledge.TableII illustratesthebasicknowledgeforeachof thetermused inquestionnaireamongthisgroupK-scoreParticipantwith the basic knowledge of one term


164

Meta-analysis

LinearregressionCohortstudy

Selec�onbias

Oddsra�o

Rela�verisk

Nullhypothesis

p-value

Confidence

IntervalRela�veodds

ra�oreduc�on

TableII:CumulativepercentagesforEBD-relatedterms

wasgivenK-scoreof1.Thusparticipantswithk-scoreof five or above had the basic understanding ofmajorityofterms.Resultsshowed,almost82%oftheparticipants(31outof38)hadk-scorefiveorgreatershowing that they had basic understanding ofmajority of the terms. However, not all theparticipantswithbasicknowledgecouldexplainthetermstoothers.TableIIIrepresentsthepercentageofparticipantswithbasicknowledgewithoutabilityto explain, termed as 'basic understanding'participants with knowledge with ability explain,termed as good understanding, and participantswithnounderstanding.

TableIII:Percentageofparticipantswithrespecttotheirlevelofunderstanding

32% (ten out of thirty one) participants who hadbasicknowledge(K-scoregreaterthan,equaltofive)couldnotexplain5ormore termstoothersMostrecognizedandleastfamiliarterms:Resultsshowedthatoutofnineterms(excludingthedummyterm)the most recognized term was null hypothesis92%(35)andtheleastfamiliartermwasoddsratio50%(19).Theresultshowedthatinsevenoutofnineterms(excludingthedummyterm)seniormembershadgreaterknowledgecomparedtojuniorandtwo

TableIV:Comparisonofcumulativepercentagesbetweenseniorandjuniorfaculty

ofthetermsi.e.“OddsRatio”and“RelativeRisk”aremorefamiliartothejuniormembers.KnowledgeofDummyTermEightpercent(n=3)oftheparticipantssaidthattheyhad strong knowledge of dummy term ''Relativeodds ratio reduction'' and 21.1% (n=8) had poorunderstandingoftheterm.Majorityofthemembers65.8%(n=25) didn't know it and showed desire toknow.2 of the members 5.3%(n=2) neither hadknowledgenortheydesiredtoknowandconsidereditirrelevant.Thegroup7.9+21.1=29%(11)claimingthattheyhadknowledgeofthedummytermmaynothavereportedtheirknowledgeofothertermsappropriately.

DiscussionThepresentquestionnairesurveydemonstratesthatmajorityoftheparticipantseitherhadknowledgeordesiretoknowthetermsusedinquestionnaire,reiteratingtheimportanceofEBDinsolvingdaytodayhealthcareproblemsaswellasimprovingtheir

7ownknowledge. Thisisevidentfromthecumulativepercentagealso,which ismore than50%foreachvariable (EBD terms used in questionnaire).However, the participants' understanding do notreflectaccurateunderstandingoftheterms,as32%oftheparticipantshavingknowledgeofmajorityofthetermscouldn'texplainthesetermstotheothers.Thelackofknowledgeamongsomefacultymembersmay represent a substant ia l barr ier to implementation of EBD into clinical practice.Common practices such as continuing trainingcourses, reading print journals, consultation withother healthcare professionals and referring toelectronic databases can help to increase the

13knowledge about EBD and to bridge itsimplementationintoclinicalpractice.Thestudyalsoshows that the terms ''cohort study'','' selectionbias'',''nullhypothesis'',''relativerisk''and''p-value''


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expresseddesiretofindoutmoreinformationaboutEBD. As senior members reported to have betterknowledge,stepsshouldbe takento inculcate thecultureofpracticingEBDamongyoungdentistsbygivingthemincentivesorrelatinglicensurevaliditywithfewhoursofEBDtrainingyearlyEBDshouldalsobeincludedinthedentalundergraduatecurriculum.Periodicresearchesshouldbedonetoevaluatetheknowledgeofdentists so that theeffectivenessofimplemented steps can be judged and; improveddentalpractice,increasedpatients'satisfactionandcost-effective healthcare facilities should beensured.

REFERENCES1. Iqbal A, Glenny AM. General dental practitioners'

knowledge of and attitudes towards evidence basedpractice.BrDentJ2002;193:587-91.

2. Sackett DL. Evidence-based medicine. Semin Perinatol1997;21:3-5.

3. New Zealand Dental Association practice guidelines onevidence-baseddentistry.NZDentJ2003;99:30-2.

4. RushW,RindalDB,EnstadC,JohnsonN,FrictonJ,JohnsonK, et al. PS2-52: Building a Simulation System to TrainDentiststoPracticeEvidence-BasedDentistry.ClinMedRes2013;11:157.

5. Sackett DL, Rosenberg WM. On the need for evidence-basedmedicine.HealthEcon1995;4:249-54.

6. YusofZY,HanLJ,SanPP,RamliAS.Evidence-basedpracticeamongagroupofMalaysiandentalpractitioners. JDentEduc2008;72:1333-42.

7. RichardsD,LawrenceA.Evidencebaseddentistry.BrDentJ1995;179:270-3.

8. Sutherland SE. Evidence-based dentistry: Part I. Gettingstarted.JCanDentAssoc2001;67:204-6.

9. BaderJ,IsmaliA,ClarksonJ.Evidence-baseddentistryandthedentalresearchcommunity.JDentRes1999;78:1480-3.

10. OliveriRS,GluudC,Wille-JorgensenPA.Hospitaldoctors'self-ratedskillsinanduseofevidence-basedmedicine-aquestionnairesurvey.JEvalClinPract2004;10:219-26.

11. McKibbonKA.Evidence-basedpractice.BullMedLibrAssoc1998;86:396-401.

12. Rabe P, Holmen A, Sjogren P. Attitudes, awareness andperceptions on evidence based dentistry and scientificpublicationsamongdentalprofessionals inthecountyofHalland, Sweden: a questionnaire survey. Swed Dent J2007;31:113-20.

13. Straub-MorarendCL,MarshallTA,HolmesDC,FinkelsteinMW. Informational resources utilized in clinical decisionmaking:commonpractices indentistry.Journalofdentaleducation2011;75:441-52.

14. Straub-MorarendCL,MarshallTA,HolmesDC,FinkelsteinMW. Toward Defining Dentists’ Evidence-Based Practice:InfluenceofDecadeofDentalSchoolGraduationandScopeof Practice on Implementation and Perceived Obstacles.Journalofdentaleducation2013;77:137-45.

15. AldersonP. TheCochrane collaboration: an introduction.

werewidelyknown,whereas ''odds ratio'',''meta-analysis'','' linear regression'' and ''confidenceinterval''wererelativelylessknowntothedentists.Regarding dummy term the group 29% (n=11)claimingthattheyhadknowledgedidn'tsignificantlyoverrate themselves in other terms asked in thequestionnaire. It alsopredicted that senior facultymembers have more understanding of the termsused in EBD as compared to the junior ones thusdirectly relating years of clinical experience andknowledgeaboutthetermsusedinEBD.ThefindingsofthestudycanbecomparedtoastudycarriedinUniversityofLowabyCherylL.Straub-MorarendandTeresa A. Marshall, which shows higher levelunderstanding and comfort in implementation ofEBD among dental consultants (having moreexperience and clinical practice) compared to

14general practitioners. The knowledge about EBDcanbeincreasedbytakinghelpfromcolleaguesandexperts rather than just relying on textbooks orscientific journals as these can no longer be

10considered sufficiently updated. Moreover it is

12imperativethattherelevantliteratureisavailable. Ideally clinicians should be turning to electronicdatabases of secondary research e.g. Pub Med,

1,15CochraneLibrary,DARE,EMBASEetc. Moreoveremphasis should be made towards training,accessing and interpreting evidence, and thenspendingtimeputtingtheseskillsintopractice.Itisimportantbecausecriticalappraisalofthescientificliterature require specific skills. Thus, evidence-retrieving skills from scientific literature andevidence based practice only can be boosted

16,17throughworkshops, courses and seminars. Thepresentstudyhadseverallimitations.Firstly,itwasaself-administered questionnaire based study andparticipantstendtoover-ratetheirknowledgesonoverification of data could be done. Questions toassess the participants' understanding of theseterms would have been a more valid tool, ascomparedtoself-reportedunderstanding.Secondlyitwasahospital-basedstudyandresultscannotbegeneralizedassuch.Lastly,weonlycoveredtermsrelatedtoEBDnotthewholestepsincludedinEBD.However, the results of the study had potentialimplications such as implementation of EBD incurriculumsoastogroomthefuturedentistsinthelightofit,andlicensuretobelinkedwithEBDtrainingfordentalpractice.

ConclusionCompared to the past researches, knowledge ofdental practitioners has progressed in evidencebased dentistry. Even if they didn't know, they


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Evidence-BasedDentistry1998;1:25-6.16. SackettDL,HaynesRB,TugwellP.Clinicalepidemiology:a

basic science for clinical medicine: Little, Brown andCompany,1985.

17. Amin FA, Fedorowicz Z, Montgomery AJ. A study ofknowledge and attitudes towards the use of evidence-basedmedicineamongprimaryhealthcarephysicians inBahrain.SaudiMedJ2006;27:1394-6.


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ORIGINAL ARTICLE

ABSTRACTObjective:Toassesstheassociationbetweendentalcariesexperienceandcarbonateddrinksconsumptioninapopulationofadolescents(12-19years)fromIslamabadandRawalpindi,Pakistan.StudyDesign:Cross-sectionalstudy.PlaceandDurationofStudy:ThisstudywasconductedinthedepartmentofCommunityMedicineatIslamicInternationalDentalHospital(IIDH)IslamabadfromApril2014toAugust2014.MaterialsandMethods:Asampleof50participantswasselectedthroughconveniencesampling.Onlythoseparticipantswereincludedwhobelongedtotheselectedagegroupof12-19years.ThesamplewasexaminedbydentalstudentsatIIDHandavalidated,dietaryquestionnairewascompletedthroughface-to-faceinterviewwitheachparticipant.CariesseveritywasmeasuredviatheDMFT(no.ofDecayed,MissingandFilledTeeth)Index.Results:ResultswereanalyzedforthesampleunderstudythroughSPSSVersion17.ThemeanDMFTformales(38%)was1.31±1.60andforfemales(62%)was1.77±1.76.Cariesprevalenceinrelationtocarbonateddrinkconsumptionwasfoundtobe62%withmorethan7%oftheparticipantshavingaDMFTscoreof4andabove.AdecreaseinDMFTscorewasobservedwiththe increase in frequencyoftoothbrushing.OncomparisonofmeanDMFTscoreswithfrequencyofcarbonateddrinkconsumption,nodistinctivepatterncouldbeseen.Conclusion:Conclusiveresultsestablishingastrongassociationbetweencarbonateddrinksanddentalcariescouldnotbederived.Furtherresearchworkisrequiredformorevalidresults.Whileconsumingcarbonateddrinks,safetyguidelinesfordrinkingshouldbefollowed.

Keywords:Dental Caries, Beverages, Diet Drinks, Caries Prevalence.

4,7fruitjuices. Despitethedifferencesincarbohydratecontent, both seem to have similar cariogenic

8potential. Inadditiontothehighamountsofsugar,carbonatedbeveragesalsocontainphosphoric,citricandcarbonicacidswhichshowadeleteriouseffect

9,10on enamel. Caffeine, which makes up aconsiderableportionofcarbonatedbeverages,isamildlystimulantdrugand itmaycontributetothetendency for frequent consumption of suchbeverages. All the fore-mentioned factors areresponsible towards the rapid initiation and

11progressionofcaries. Dietdrinkswhichuseartificialsweeteners instead of refined sugars have beenpopularlyusedsoastoreducethecaloriccontent.Although,dietdrinksareconsideredlesscariogenicthanregularbeverages,theirgreatererosiveabilityand the use of artificial sweeteners do not make

12themahealthieralternative. TheAimofthisCross-sectional study was to assess the associationbetweenprevalenceofdentalcariesandcarbonateddrinkconsumptioninapopulationof12to19yearsoldchildrenfromIslamabadandRawalpindi.

MaterialsandMethodsA questionnaire-based cross-sectional study wasconducted at the Islamic International DentalHospital,IslamabadduringthemonthofJune.The

IntroductionDentalcariesmaybedefinedas“abacterialdiseaseof the hard tissues of the teeth characterized bydemineralizationoftheinorganicanddestructionof

1the organic substance of tooth”. It is the most2

prevalent oral disease worldwide. It is a multi-factorialdiseasecausedbytheinteractionofthreeprincipalfactors;asusceptiblehosttissue,cariogenic

3,4microfloraanddiet. Dietespeciallyrefinedsugars,is an important etiological factor of dental caries.Boththefrequencyandthetotalamountofrefinedsugars consumed play a significant part in theetiologyofcaries.“Theevidenceestablishingsugarsas an etiological factor in dental caries is

5overwhelming”. Sugars are mostly contained inmanufactured food and beverages and form an

6essential component of human diet. Mostcarbonatedbeveragescontainupto10tea-spoonsofsugarper12oz.asopposedto1-2tea-spoonsin

AnAssessmentofAssociationbetweenCarbonatedDrinkConsumptionandDentalCariesPrevalence:ACross-SectionalStudyZainabAsifSukhera,SyedaMeharRaza,NehaRana,TehreemZafar,AnumZehraKhan,MuhammadHumzaBinSaeed

CarbonatedBeveragesandDentalCariesJIIMC2015Vol.10,No.2

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Department of Community MedicineIslamic International Dental College, Islamabad

Correspondence: Zainab AsifIslamic International Dental CollegeRiphah International University, IslamabadE-mail: [email protected]

completedquestionnairesanddentalexaminations.Thesampleincluded19males(38%)and31females(62%).Outof the totalnumberofparticipants,15(30%)werefromtheagegroupof12-14years,14(28%)fromthe15-17yearsgroupand21(42%)fromthe 18-19 years age group.Table I displays thenumberandpercentagesofparticipantsinrelationto beverage consumption and socio-demographicdetails. In terms of daily consumption, milk andjuices were themost popular drinks (n=35, 70%),whilecarbonateddrinkswereconsumedbyonly17(34%)participantsonadailybasis. In theyoungerage group of 12-14 years, 93% (n=14) preferredcarbonated beverages whereas, coffee and juiceswerethemainpreferencesoftheothertwogroups(15-17years,18-19years)beingconsumedby100%(n=14) and 95% (n=20) of the participantsrespectively.

studycomprisedaquestionnairesurveyfollowedbya visual oral examination. The participantscomprisedaconveniencesampleof12-19yearsoldadolescents,whowerevisiting thehospital atanytimeduring16thto20thJune,2014.Theparticipantswere mostly from Islamabad and Rawalpindi. Asampleof50adolescentswasselectedconveniently.Verbalconsentwasobtainedfromeachparticipantandhis/her guardian beforehand.A questionnairewascompletedthroughaface-to-faceinterviewwitheachparticipantwhichhelpedinachievinga100%responserate.TheQuestionnaireconsistedofthreesections.SectionAdealtwiththeoralhygienehabitsand the beverage consumption habits ofparticipants.InQuestion1,thefrequencyofintakeofdifferentbeverageswasrecordedbyusingascaleof5values;Never,Rarely,Onceaweek,1glassdailyand 2 or more glasses daily. In the next set ofquestions, theparticipantswereaskedabout (Q2)their preferred time of drink consumption (atmealtimesorbetweenmeals);(Q3)theirpreferenceofeitherregularordietdrinksand(Q4)theuseofstraw. Questions 5-7 assessed their oral hygieneknowledge. Section B dealt with the socio-demographic details and section C recorded theDMFTscoreofeachparticipant.Aftertheinterview,eachparticipantwasorallyexaminedbya2ndyearBDS student. The examination took place under atube-lightwith the participant seated in a normalchair. No mouth mirror or CPI (CommunityPeriodontal Index)probewasusedtoassist in thediagnosis of caries. Only a tongue depressor wasutilizedbytheexaminer.TheseverityofcarieswasassessedviatheDMFTindex.Atoothwasconsidereddecayed (D) if a carious lesion was visiblyappreciated;missing(M) ifextractedduetocariesand filled (F) if a restorationwas seen.A restored

13toothwithrecurrentdecaywasalsocountedas(D).StatisticalPackageforSocialSciences(SPSS)Version17.0 was used to enter, organize and analyze thedata.Theeffectofdifferentvariables;frequencyandtimeofconsumptionofdrinks,demographicfactorsand oral hygiene habits on the DMFT scores ofparticipantswas analyzedbyderiving frequencies,meansandstandarddeviations.

ResultsResults were obtained for the sample of 50participants by analyzing the data from their

TableI:FrequencyDistributionofDifferentDrinksasperConsumptionandDemographics

Table II illustrates the prevalence and severity ofdental caries in relation to different types ofbeveragesconsumed.Amongtheparticipantswhoconsumedjuices,68%(n=32)hadcariesincontrasttothe62%(28)forcarbonateddrinks.Cariesseverityfor carbonateddrinkswashighestwithalmost7%(n=3) participants having recorded DMFT ofmorethan4.TableIIIshowstheeffectofdifferentvariableson DMFT score including time of consumption ofcarbonated drinks, use of straw, drink type, oralhygiene habits and demographic details. Around56% (n=28) of participants reported consumingcarbonated drinks at mealtimes. However, their


169

BasicTypesofBeverages

CarbonatedDrinksn(%)

Juicesn(%)

Milkn(%)

Coffeen(%)

Teen(%)

n

Frequency ofConsumption

Never 5(10) 3(6) 0(0) 16(32) 12(24)

Rarely 7(14) 10(20) 8(16) 24(48) 12(24)

Onceaweek 21(42) 10(20) 7(14) 9(18) 6(12)

1glassdaily 12(24) 23(46) 31(62) 1(2) 7(14)

2ormoreglassesdaily

5(10) 4(8) 4(8) 0(0) 7(14)

Age Groups:

1512-14yrs. 14(93) 14(93) 13(87) 13(87) 12(80)

1415-17yrs. 13(93) 13(93) 13(93) 14(100) 9(64)

2118-19yrs. 18(86) 20(95) 16(76) 19(90) 17(81)

Gender:19Male 17(89) 18(95) 15(79) 18(95) 14(74)

31Females 28(90) 29(94) 27(87) 28(90) 24(77)

'Filled' (n=17, 21%) and 'Missing' (n=3, 4%)components,respectively.Participantswho“Never”consumed carbonated drinks had a mean DMFTscore of 2. Whereas, participants who consumedcarbonateddrinks“rarely”,“onceaweek”or“oneglass daily” had mean DMFT of 1, 1.52 and 1.92respectively.“1.60”wastherecordedmeanDMFTofthose who consumed two or more glasses ofcarbonateddrinksdaily.

DiscussionAstrongassociationbetweencarbonatedbeveragesand dental caries has been indicated by many

11,14-16previous studies while a few indicate amuch17,18

weakerassociation. Weassessedthishypothesisbyconductingacross-sectionalstudyinasampleof50participantsfromIslamabadandRawalpindi.Theresultsfromourstudyfoundnoassociationbetweencarbonated drink consumption and dental caries.Those participants who had 'Never' consumedcarbonateddrinksshowedthehighestmeanDMFT.Cariesprevalenceandcariesseverity inrelationtocarbonateddrinkconsumptionwashighandsimilar

8,19tothatforjuices, indicatingsimilarcariogenicity. Mean DMFT of those who consumed carbonateddrinks 'atmealtimes'wassurprisinglygreaterthanforthosewhoconsumed'betweenmeals';adirect

20contrastwithapreviousstudyfromSlaterP.etal. Results from the current study showed that themeanDMFTdecreasedwiththeuseofastrawduringconsumption.ThisisinaccordancewithastudybyTahmassebietal.whichprovedthat if juiceswereconsumed through a straw, there was a less

21pronouncedpHdropinplaque. Sincecarbonatedbeverages and juices possess similar cariogenicpotential, the same situation might be true forcarbonated beverages. Oral hygiene (frequency oftooth-brushing)hadastrongeffectondentalcariesexperience.DMFTwashighestforthosewhodidnotbrushdailyandlowestforthosewhobrushedthriceaday.Thispatternisincongruitywiththefactthatdespitetheintakeofsugarydrinks,oralhealthisanimportantfactorintheetiologyofdentalcariesesp.

22withtheadventoffluoridatedtoothpastes. MeanDMFToffemaleswasfoundtobehigherthanthatofmales.Thismaybeduetotheunevendistributionofmales(38%)andfemales(62%)inourstudysampleoritmayalsoindicatethatdentalcariesisstatisticallydependentongendertosomeextent,asprovenby

TableII:CariesExperiencewithreferencetoBeveragesConsumption(n=Totalnumberofconsumersofaparticulardrink)

DMFT score was unexpectedly higher than thosewho consumed their carbonated drinks betweenmeals(36%,n=18).Dietdrinkswerepreferredbyonly4%(n=2)oftheparticipantsandtheircariesexperiencewaslowascompared to those who consumed regular drinks(94%,n=47).Accordingtothefindings,30%(n=15)ofparticipantsuseda strawduringconsumptionandhad amuch lower DMFT score of 1.07 (±1.22) incontrast to the 1.76 (±1.82) score for those thatdidn'tusestraw(n=34,68%).

TableIII:EffectofcarbonateddrinkrelatedvariablesanddemographicsonmeanDMFT

FrequencyofbrushingshowedasignificanteffectontheDMFTscorebydecreasingitwitheachincreaseinfrequency.Intermsofgender,meanDMFTscoreoffemaleswashigher(1.77±1.76)thanthatofmales(1.31±1.60).Amongthethreeage-groups,the15-17year age group showed a slightly higher cariesexperiencethanothertwogroups.MeanDMFTofthesamplewas1.60±1.702.OutofthetotalDMFTscoreof80, 'Decayed'componenthadthehighestfrequency percentage (n=60, 75%), followed by


170

TypesofBeverages

CarbonatedDrinksn(%)

Juicesn(%)

Milkn(%)

Coffeen(%)

Teen(%)

Caries Prevalence

withCaries 28(62) 32(68) 32(64) 20(59) 25(66)

withoutCaries 17(38) 15(32) 18(36) 14(41) 13(34)

Caries Severity:

DMFT<4 42(93) 44(94) 47(94) 33(97) 36(95)-DMFT>4 3(7) 3(6) 3(6) 1(3) 2(5)

Variables

Time of consumption

Number(%) MeanDMFT+Std.Deviation

-

Atmealtimes 28(56%) 1.71+1.86-Betweenmeals 18(36%) 1.05+1.16-

Both 3(6%) 3.00+2.00-Type of Drink

Diet 2(4%) 0.50+0.71-Regular 47(94%) 1.59+1.70-

Use of StrawYes 15(30%) 1.07+1.22-No 34(68%) 1.76+1.82-

Frequency of tooth brushing

Onceaday 22(44%) 1.86+1.75-Twiceaday 25(50%) 1.44+1.73-Thriceaday 2(4%) 0.50+0.71-

Idon’tbrushdaily 1(2%) 2.00+0.00-

12. Tahmassebi J, DuggalM,Malik-Kotru G, CurzonM. Softdrinksanddentalhealth:areviewofthecurrentliterature.Journalofdentistry2006;34:2-11.

13. CappelliDP,MobleyCC.Prevention inclinicaloralhealthcare:ElsevierHealthSciences,2007.

14. ChengR,YangH,ShaoM-y,HuT,ZhouX-d.Dentalerosionandseveretoothdecayrelatedtosoftdrinks:acasereportandliteraturereview.JournalofZhejiangUniversityscienceB2009;10:395-9.

15. LimS,SohnW,BurtB,SandrettoAM,KolkerJL,MarshallTA,etal.Cariogenicityofsoftdrinks,milkandfruitjuiceinlow-incomeAfrican-Americanchildren.JournaloftheAmericanDieteticAssociation2008;139:959-67.

16. SohnW, Burt B, Sowers M. Carbonated soft drinks anddental caries in the primary dentition. Journal of dentalresearch2006;85:262-6.

17. MarshallTA,LevySM,BroffittB,WarrenJJ,Eichenberger-Gilmore JM, Burns TL, et al. Dental caries and beverageconsumptioninyoungchildren.Pediatrics2003;112:e184-e91.

18. Vartanian LR, SchwartzMB, Brownell KD. Effects of softdrink consumptiononnutritionandhealth: a systematicreview and meta-analysis. American journal of publichealth2007;97:667-75.

19. BirkhedD.Sugarcontent,acidityandeffectonplaquepHoffruit juices, fruitdrinks, carbonatedbeveragesand sportdrinks.Cariesresearch1984;18:120-7.

20. SlaterP,GkoliaP, JohnsonH,ThomasA. Patternsof softdrink consumption and primary tooth extractionsinQueensland children. Australian dental journal2010;55:430-5.

21. TahmassebiJ,DuggalM.TheeffectofdifferentmethodsofdrinkingonthepHofdentalplaqueinvivo.InternationalJournalofPaediatricDentistry1997;7:249-54.

22. Burt BA, Pai S. Sugar consumption and caries risk: asystematic review. Journal of dental education2001;65:1017-23.

23. Cariesfor12-Year-OldsbyCountry/Area.24. DawaniN,NisarN,KhanN,SyedS,TanweerN.Prevalence

and factors related to dental caries among preschoolchildrenofSaddartown,Karachi,Pakistan:across-sectionalstudy.BMCOralHealth2012;12:1-9.

25. MoynihanP,PetersenPE.Diet,nutritionandthepreventionofdentaldiseases.Publichealthnutrition2004;7:201-26.

26. ConvenienceSampling.27. A Textbook of Public Health Dentistry: Jaypee Brothers,

MedicalPublishers,2011.

3earlier studies. Relation of social status withbeverageconsumptionpatterns,oralhygiene,DMFT


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172

ORIGINAL ARTICLE

ABSTRACTObjective:TocomparetheoutcomeofopenMilligan-Morganhaemorrhoidectomy(MMH)withthatofclosedFergusonhaemorrhoidectomy(FH)regardingpostoperativepain,woundhealingandcomplications.StudyDesign:QuasiExperimentalstudydesign.Place and Duration of Study: The study was conducted from 1st ofMay 2008 to 31st December 2013 at IslamicInternationalMedicalcollegeHospitalIslamabad.Materials andMethods: Forty eight patients suffering from haemorrhoids were divided into two equal groups byconsecutivesamplingmethod.In24patients(groupI)haemorrhoidectomywasdonebyopenmethod(Milligan-Morgan),andremaining24patients(groupII)weretreatedbyclosemethod(Ferguson).Outcomeinthetwogroupssuchaspostoperativepain,woundhealing,analstenosisandanalincontinencewerecompared.Results:Postoperativepainwaslessingroup-II(close)comparedtogroup-I(open).Ingroup-IIpainscoreonVASwas4.8at8hourspostoperativelywhichsubsidedto2.1at48hours,meanscorewas2.9.Ingroup-IpostoperativepainonVASwas7.2at8hourswhichcamedownto3.8at48hours,meanscorewas5.28.Woundhealingingroup-II(close)took7to12days,whileingroup-I(open)itoccurredin15to25days.Postoperativelyanalgesiawasrequiredforanaverage10daysingroup-II,andfor19daysingroup-Ipatients.Analstenosisandanalincontinencewerenotnotedineithergroupwithin6months.Conclusion:Closehaemorrhoidectomyhasshownbetteroutcomecomparedwithopenhaemorrhoidectomyintermsofpostoperativepain,analgesicrequirementandwoundhealing.Analstenosisandanalincontinencearenotseenineithergroupwithinobservationperiodof6months.Key words: Open Haemorrhoidectomy, Close Haemorrhoidectomy, Complications of Haemorrhoidectomy, Anal Incontinence, Anal Stenosis.

3the commonest cause of rectal bleeding. Haemorrhoids have been treated by surgeons forcenturies.EarliesthistoryofsurgicaltreatmentdatesbacktoEgyptianperiodof1700BC,andismentionedinHippocratic treatisesof460BCwhichdescribes

4transfixingthemwithathickwoolenthread. Surgeryis the mainstay of treatment for grade III and IVhaemorrhoids or grade II disease in case

5sclerotherapy or band ligation has failed. Non-surgicalmodalitiesof treatmentaresclerotherapy,rubber band ligation, photocoagulation and

6cryotherapy. The two popular techniques ofhaemorrhoidectomyare the conventional openas

7described by Milligan and Morgan in 1937 and

8closedhaemorrhoidectomydescribedbyFerguson. A lot of work has been done comparing the twotechniquestofindabetterpostoperativeoutcome.Some s tud ies have shown that c lo sed haemorrhoidectomygivesbetterresultsthanopenmethod regarding postoperative pain and earlyrecoverybutthereareotherstudieswhichdonot

9agreewiththis. Weareconstantlyconfrontedwithpatients' complains of moderate to severe postoperative pain and there is a constant effort toalleviatethediscomfortofthepatient,andtoadopt

IntroductionTheanalcushionsconsistof threespaces filledbyarteriovenouscommunicationssupportedbyfibrousmatrixandsmoothmuscle,locatedwithintheanalcanal.Thesecushionsallowtheanalliningtoexpandduringdefecationbutformacompletesealwhenthecanalisclosed.Degenerationofsmoothmuscleandfibroelastictissuewhichsupportthecushionsresultsin their prolapse in the anal canal. Contributingfactors to degeneration are constipation andstraining at stools although exact cause is not

1known. Haemorrhoids affect between 4.4 and2

36.4% of the general population world wide. Insome geographical regions the condition is verycommon,astudyfromAustraliahasestimatedthat50%oftheAustralianpopulationhashaemorrhoidsbytheageof50years,theyhavebeenfoundtobe

OpenVersusClosedHaemorrhoidectomy:EvaluationofMorbidityandComplications

1 2 3AhmedNurusSami ,MalihaYunus ,ShaziaRiaz

OpenVersusClosedHaemorrhoidectomyJIIMC2015Vol.10,No.2

173

Received: February 18, 2015; Accepted: June 08, 2015

1 3Department of Surgery/ Gynae and Obs Islamic International Medical College, Islamabad2Department of Surgery Nafees Medical College, Islamabad

Correspondence: Dr. Ahmed Nurus SamiAssociate Professor, SurgeryIslamic International Medical CollegeRiphah International University, IslamabadE-mail: [email protected]

hadbeen followedup to complete thedata.DatacollectedwasenteredonSPSS-20andanalyzed.

ResultsAtotalof48patientswereincludedinthestudywhowereoperateduponoverthecourseoffiveandahalfyears at IIMC hospital, Islamabad. Group I wasoperateduponbyopenmethod(MMH),andgroupIIbyclosemethod(FH).Meanageofthepatientswas45.5years.

thetechniquewhichmaybeassociatedwithlesserpostoperativepain.Patientalsohasaconsiderableconcern about the wound healing time, anxietyincreaseswithtimeaftersurgeryespeciallywhenthepain is persisting, which invariably does till thewound heals. In view of contrasting results anddisagreementinthestudiesonthebettertechniqueof haemorrhoidectomy regarding post operativepain and wound healing time we decided toconducted this study in our set up, aimed atselectingatechniqueofhaemorrhoidectomybasedon our own observation and experience so as toprovideusguidanceforourfuturecourseofaction.

MaterialsandMethodsIn this quasi experimental study we included 48patientsoperatedbetween1stofMay2008and31stDec2013at IIMChospital Islamabad.Thepatientswererandomlyallocatedequallytotwogroupsbyconsecutive sampling method. Inclusion criteriawere, if the patient has Grade III or grade IVhaemorrhoids or Grade II haemorrhoids withbleeding resistant to rubber band ligation orsclerotherapy.Exclusioncriteriawere,ifthepatienthashadpreviousoperationforhaemorrhoidswithinthelast1year,or ifthepatienthadanactiveanalfistulaorfissure.Operationwasdoneunderspinalanaesthesia;noloco-regionalanaestheticblockwasdone.Thesamesurgeonperformedallthesurgeries.IngroupA(n=24)openhaemorrhoidectomy(MMH)wasdone.Pediclewasligatedwith2/0vicrylandthewoundwasleftopen.Theanalcanalwaspluggedforabout8hours. IngroupB(n=24)closedtechnique(FH)wasused.Skinincisionwasmadeonthemuco-cutaneous junction and diathermy dissection wasdone like in the Milligan-Morgan surgery.Haemorrhoidal pediclewas ligatedwith 2/0 vicrylandmucosawasclosedwith3/0vicryl interruptedsutures after attaining homeostasis. Anal canalpackingwasdoneforabout8hours.Postoperativelyidenticaltreatmentwasbeguninbothgroupswithhighfiberdiet,analgesics,antibioticsandsitzbaths.Post operatively pain was recorded on visualanaloguescale(VAS)from0-10every8hourlyfor48hours.Thepatientswerefollowedupweeklytillthewoundhealed.Monthlyfollow-upfor6monthswascarriedontorecordcomplicationsofanalstenosisorincontinenceiftheymayarise.Studywascompiledafterrequisitenumberofpatientsfromeachgroup

TableI:Comparisonofopenandclosedhaemorrhoidectomy(n=48)

Post operative pain was recorded on the visualanaloguescalerangingfrom0-10,every8hourlyfor48hoursinboththegroupsandcomparedasshowninTableI.Consideringgroupaverageseverityofpain(VAS)ingroup-IIwaslessseveretobeginwithat8hours(4.8)comparedtogroup-I(7.2).Inbothgroupspainsubsidedgradually,butsubsidedmorerapidlyingroup-IIwhichwasdonebyclosemethodinwhichthe pain came down to 2.3 at 24 hours, while ingroup-Itheaveragepainscorewas5.0onVASat24hours.At48hoursmeanpainscoreingroup-I(MMH)was5.28,while ingroup-II (FH) itwassignificantlylow at 2.9. Post hospitalization oral analgesic(Diclofenac)wasrequiredforanaverageof19daysingroup-I, and for an average of 10 days in group-IIpatients. (Table I)Woundhealingwas significantlyquickeringroup-II,wheresurgerywasdonebyclosemethod, as expected, because the raw area hadalreadybeencoveredinthismethod.Ittook7to12days(average9.5days)forcompletewoundhealinginthisgroupcomparedto15to25days(average20days)forcompletewoundhealingingroup-I(open).


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divergent results. A study by Mohan S V andDhananjaya Kumar differs from our study bysuggestingthatclosedmethodalthoughassociatedwithearlyrecoveryisassociatedwithmorepainandlonger operating time compared to the open

18method. Another study byKhalilUr Rahmanhasconcludedthatclosehaemorrhoidectomyprovidesabetter outcome in terms of lesser post operativebleeding and complete wound healing but isassociatedwithmore pain compared to the open

19method.Rafiq K and Scott P D in their study conducted inMayohospital Lahorehave foundout that after 3weeks 70% treatedby closedhaemorrhoidectomyhadcompletelyhealedwoundswhileonly15%afteropen haemorrhoidectomy had complete wound

20healing, thus showing the advantage of closedmethod.StudybySheikhAR,andDalwaniAGhasshown results similar to ours regarding both postoperative pain and time taken in wound healing.Accordingtotheirstudyittook4weeksforwoundhealinginclosedgroupcomparedtoabout8weeksintheopengroup.Postoperativepainscorewasalso

21considerablylowerinclosedsurgerygroup. Earlierwoundhealingand lesserpostoperativepainwasdescribed in thestudybyMalikGAandWahabAconducted in BVH Bahawalpur, which has shownwoundhealingtimeoflessthanhalf,whileintensityof post operative pain on VAS was approximately25.6% less in the patients treated by Ferguson

22methodcomparedtoMilliganMorgantechnique. Resultsfromourstudyareconsistentwiththeabovementioned studies showing advantage of closemethodcomparedtoopenmethodintermsofpostoperativepainandwoundhealing.Althoughavastnumberofstudiesasmentionedaboveshowbetteroutcomeafterclosemethodofhaemorrhoidectomyregarding post operative pain, there are somestudieswithdivergentresults.AstudybyMohanSVand Dhananjaya Kumar differs from our study bysuggestingthatclosedmethodalthoughassociatedwithearlyrecoveryisassociatedwithmorepainandlonger operating time compared to the open

18method. Another study byKhalilUr Rahmanhasconcludedthatclosehaemorrhoidectomyprovidesabetter outcome in terms of lesser post operativebleeding and complete wound healing but isassociatedwithmore pain compared to the open

(TableI)Thepatientswerefollowedupmonthlyuptosixmonths tonoteanysignificantcomplications iftheymightoccur.NoanalstenosiswasnotedinanypostoperativecaseofgroupIorgroupIItilltheendof this period. No case of anal incontinence wasreportedpostoperativelyineithergrouptilltheendof6monthobservationperiod.

DiscussionAnalcanalisarichlyinnervatedtissue,exposedareaafter open haemorrhoidectomy has beenconsideredasthemaincauseofpain.Postoperativepainwhichmaybeintenseandprolongedisaseriousissue.Several techniqueshavebeenexperimentedandcomparedoverthecourseoftimetoaddressthisparticularproblemaswellastoreducethewoundhealing time. There are various techniques ofhaemorrhoidectomy,themostcommonlypracticed

7 8are Milligan and Morgan and Ferguson. Other10 11techniquesliketheuseoflaser andcircularstaples

have been added in the recent past. Stapledhaemorrhoidectomy gained popularity due to lesspostoperativepainbutisassociatedwithanumber

12ofreportedcomplicationsreducingitspopularity. However there is a recent study by R S Bhandariwhich shows better outcome of stapledhaemorrho idec tomy compared to open haemorrhoidectomy in terms of post operative

13pain. Ferguson closed haemorrhoidectomy hasreportedlybeenassociatedwithlesspost-operative

14painandfasterhealingasinthestudybyMKamran. Similarly, A Sabeto and M Hashim in theircomparisonofopenandclosehaemorrhoidectomyreportedlesserpostoperativepainandbleedingby

15closedtechnique. AstudybyAzizA,AliI,etalfromKarachihas foundmilderpostoperativepainafterclosed haemorrhoidectomy compared to opentechnique.This studyalso recordedearlierwound

16healing in surgery done by close method. StudyfromNepalbyNPokhareandRKChhetrihasshownthatpainonVASislesserbyapproximately40%inthoseoperatedbyclosedmethodcomparedtothe

17open method. He has further found out thathospital stay was prolonged in the open surgerygroup due to prolonged pain and slower woundhealing. Although a vast number of studies asmentionedaboveshowbetteroutcomeafterclosemethod of haemorrhoidectomy regarding postoperative pain, there are some studies with


175

19method. Contrastingresultsonpostoperativepainaftercloseandopentechniquesarefoundasevident


176

ORIGINAL ARTICLE

ABSTRACTObjective:ObjectiveofthisstudywastoevaluatecurrentBDScurriculumtoidentifytheneedforreviewingandupdatingtheexistingcurriculum.StudyDesign:Itwasadescriptivecross-sectionalstudy.PlaceandDurationofStudy:ThisStudywasconductedinfourprivatesectordentalcollegesofIslamabadfrom5thJuneto25thDecember2013.MaterialsandMethods:Twohundredandninetysixfacultymembersandstudentswereincludedinthestudybaseduponrandomsamplingtechnique.Demonstratorsandjuniordentalstudentswerenotincludedinthestudy.Facultyofdifferentlevelsincludingprofessors,associateprofessors,assistantprofessors,seniorregistrarsandfinalyearBDSstudentswereincludedinthestudy.Aself-administeredstructuredquestionnairebaseduponStufflebeams'CIPPModelofprogramevaluationwasusedasdatacollectiontoolandprincipalauthorpersonallyvisitedallfourdentalcollegestocollectdata.MSExcelwasusedfordataentry,descriptiveanalysisandgenerationofgraphs.Results:ResultsofthepresentstudyindicatedthatthereareweaknessesinthecurrentDentalcurriculum.Conclusion: Integrationaccording to latest trendsandapproachesare required tomake it atparwith internationalstandards.

Keywords: Integrated Curriculum, CIPP Model, Outcome Based Dental Education, Community Oriented Curriculum, Student Centered Education, Hybrid Curriculum.

students, institutions, and society. Alternateapproaches and guidelines have been used in

4literatureforevaluatingprogrammes. Stufflebeam'sCIPPModelofprogramevaluationwasdevelopedinlate1960s,andwasapplied inmany institutes forevaluationoftheircurricula.Reasonforselectingthismodel of evaluation in the present study was itssimple system model approach for all the fourdomains, C: context, I: input, P: process and P:product of a program. By employing thiscomprehensive evaluation model, curriculumdevelopers can strengthen existing program andmeetaccountabilityrequirements,asitoffersboth

5formative and summative evaluation. CIPPmodelhas been used in literature to evaluate health

6, 7professionsprogramindifferentpartsoftheworld ,but it has not been used in Pakistan to evaluatecurriculumofanyinstitute.AlthoughtherearefewresearcharticlespublishedinPakistanemphasizingtheneedanddemandofrevisitingdentalcurriculumaccordingtoneedsofcurrentlearnersandPakistani

8community, but no evidence based scientificmethodofcurriculumevaluationhasbeenused.Soaim of this study was to evaluate current BDScurriculumusingCIPPmodeltoidentifytheneedforreviewingandupdatingtheexistingcurriculuminamoresystematicmanner.

MaterialsandMethodsItwasacrosssectional,descriptivestudy,doneat

IntroductionDentistryisanoblefield,exclusivelyinvolvedinthestudy, diagnosis, prevention and treatment of

1diseasesoforalandperioralstructures. Incurrentscenario,allDentalcollegesinPakistanarefollowingPMDC curriculum (draft version 2003). The term'curriculum'wasoriginallyrelatedtotheconceptofacourseofstudies.Itisacomprehensiveplanforaneducationaltrainingprogramtoimprovemanpower

2tofulfilltherisingneedsofadynamicsociety.Evaluation is an essential part of the educationalprocess.Teachinginstitutionsrequireevaluationaspartoftheirqualityassuranceprocedures,butthevalue of evaluation is much greater than theprovision of simple audit information. It providesevidenceofhowwellstudents' learningobjectivesare being met and teaching standards are being

3maintained. Importantly, it also enables thecurriculumtoprogressinthedesiredway.Similarlyamedical and dental curriculum needs to bedeveloped constantly in response to the needs of

CurrentBDSCurriculum:AnEvaluationbaseduponCIPPModel1 2 3ShaziaRafiqNawabi ,AyeshaMaqsood ,SidraAamir

CurrentBDSCurriculumJIIMC2015Vol.10,No.2

177

Received: April 01, 2015; Accepted: June 09, 2015

1 2Department of Prosthodontic/ Maxillofacial Rawal Institute of Health Sciences, Islamabad3Department of Dental Materials Foundation University Dental College, Rawalpindi

Correspondence: Dr. Shazia Rafiq NawabiAssistant Professor, Prosthodontic Rawal Institute of Health Sciences, IslamabadE-mail: [email protected]

members pointed out issues in integration andorganizationofcurriculum,reflectingdissatisfactionwithtraditionaldisciplinebasedcurriculumandlackoforganizationincurrentcurriculum.Almostsamepercentage of students pointed out issue ofintegrationandorganizationofcurriculum.Lastbutnot the least 82% of faculty and 70% of studentsrecognizedlackoflearningobjectivesinallsubjectsof BDS curriculum. Input and process evaluationrevealed,90%ofStudentsindicatingissuesinprocessof curriculum including didactic lecturing, lack ofproblem based learning and teacher centeredapproach.Twentytwopercentoffacultyand10%ofstudents recognized problems in input of BDSprogram, including entrance criteria, merit andresourcesrequiredforBDSprogram. Eightpercentof the faculty and 63% of students exhibitedreservations with assessment system, and finally38% of faculty and 21% of students identifiedproblem in product of current BDS curriculum,showingreservationswithcompetenciesofcurrentdentalgraduates.

fourprivatesectordentalcollegesofIslamabadfrom5thJune2013to25thDecember2013.Seniorfacultymembers(professors,associateprofessors,assistantprofessorsandseniorregistrars),andfinalyearBDSstudentswere included inthestudyusingrandomsamplingmethod.Ethicalcommitteeapprovalwasobtained and counter signedby co-chairpersonofRIHS.EthicsBoardhadnoobjectionstothecontentofthesurvey.FacultyandStudentswereinformedaboutcontentandintentofstudyandwereassuredaboutmaintenanceofconfidentialityregardingtheirnames and the name of their institute, and weredirected to fill a close ended questionnaire.QuestionnairewasbasedonCIPPmodelofprogramevaluationandconsistedof32questionsfromallthefourdomainsofevaluation(9questionsforcontext,9questionsforinput,9questionsforprocessand5questions for product evaluation). Baseline dataincluded the name of the person (optional), age,designation/class,teachingexperienceandnameofthe institution.Theparticipantswere supposed toanswer each question on a five point Likert scale,comprising of categories: strongly disagree;disagree;notsure;agreeandstronglyagree.Beforedistribution,thequestionnairewaspilottestedonagroup of 15 teachers/students each from ownmedicalcollege,(notincludedinthestudy)toseetheclarityoflanguageandunderstandingofthetermsused in the questionnaire. Total 296 participants(210 students and 86 faculty members) weredistributed questionnaire either by investigator orfocalpersonineachinstitute.Only227participants(152Studentsand75facultymembers)respondedbyfillingquestionnaire.MSExcelwasusedfordataentry,descriptiveanalysisandgenerationofgraphs.

ResultsOutof total227questionnaires somehadmissingdata and final analysis was done on 207questionnaires, with adequate data available foranalysis.Theoverallresponseratewas79%.Seventypercent of respondents were students and 30 %werefacultymembers.Dataanalysisrevealedthat48%ofdentalfacultyand26%ofstudentsidentifiedissuesinthecontextofcurriculumregardinglackofcommunity orientation. Seventy four percent offaculty members were not agreed with currentduration of BDS course, while 35% of studentsshowed same concern. Another 30% of faculty

TableI:Distributionofrespondentsaccordingtocategory(n=296)

TableII:Viewsofrespondentsregardingcontextofcurriculum


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TableIII:Viewsofrespondentsregardinginputandprocessofcurriculum

DiscussionCurriculum evaluation is an essential phase ofcurriculum development. Through evaluation a

facultydiscoversscientifically,whetheracurriculumis fulfilling its purpose and whether students are

9actually learning. Therearemanymodelsavailableintheliteratureforcurriculumevaluation.TheCIPPmodel is one of the most widely used models,developedbyStufflebeamin1971.CIPPstandsforContext, Input, Process and Product. One ofStrengthsofCIPPmodelisitsemphasisondecisionmakingwhichseemsappropriateforadministratorsconcernedwithimprovingcurricula.Itisausefulandsimpletoolforhelpingevaluatorsproducequestionsof vital importance to be asked in an evaluation

10process. CIPPmodelofcurriculumevaluationhasbeenusedsuccessfullynationallyandinternationallyforevaluationofdifferentprogramsandcourses.

Fig1:illustratesaccumulativeresponseoffacultyandstudentsregardingninequestionsaboutcontextofcurriculum

Fig2:illustratesaccumulativeresponseoffacultyandstudentsregardingninequestionsaboutinputofcurriculum

Fig3:illustratesaccumulativeresponseoffacultyandstudentsregardingninequestionsaboutprocessofcurriculum


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According to Dubrowski et al. process basedevaluationmodels such as CIPPmodel provides adeeper understanding of a program functionbecauseassessmentinstrumentsareacriticalpartof

11program evaluation. Tseng et al. also used CIPPmodelforevaluationofengineeringcurriculumandfound it appropriate for assessing effectiveness ofanyprogram.Theirresultsindicatedthatadetailedanalysisof all theessentialdomainsof curriculumproved this model to be a dynamic assessment

12model. Steinert et al used the CIPP model toevaluateafacultydevelopmentprogramdesignedtopromotetheteachingofprofessionalismtomedicalstudents and residents. Theauthors conductedallfourelementsoftheCIPPmodelandalsoprovidedpreliminary evaluations of their program. Theirfaculty development initiative was, therefore,evaluatedfromtheinitialstepsofitsplanningtotheimplementation and evaluation of its educational

13benefitsandimpacts. AnotherstudydonebyZhangetal.reportedthatthe issueofmultiplegoals isamajorchallengeinevaluatingprograms.Withoutaguiding evaluationmodel that iswell-alignedwiththe unique features of a program, assessing theprojectmaybechallenging.TheyfoundCIPPmodel

14ofcurriculumevaluationusefulforthispurpose. InthepresentstudyevaluationofBDScurriculumwasdone using CIPP model. Results of evaluationindicatedthattherearedeficienciesincontext,inputandprocessofBDScurriculum.Seventyfourpercentof faculty members pointed out deficienciesregarding context, including duration of BDSprogram and educational strategies. According to90% of students BDS curriculum was old andtraditional (teacher centered) and not at parwithinternational curriculaandwerenot satisfiedwithtraditionalteachingmethods.63%ofthempointedout that knowledge is being transferred withoutunderstanding of its use and practical application,duetolackofintegration.Another22%offacultyand10% of students showed reservations regardingentrancecriteriaofBDSprogram,whichshouldbeclearlymentioned in curriculum to improve inputespeciallyinprivatedentalcolleges.Analysisofsamework done by Tseng K H to evaluate engineeringcurriculum, CIPP model was found effective inobtaining essential information regardingweaknesses of curriculum to help establishing

foundation for improvement in future curricularchange.SteinertetalanalyzedhisworkusingCIPPmodel and proposed that such an integratedprogramevaluationmodelmayprovideevaluatorswith a better understanding of the multitude offactors influencing not only the success of theprogrambut also its sustainability The strengthofcurrent BDS curriculum according to faculty andstudents was comprehensive Year wise courseoutlineprovidedforeverysubject,buttheythoughtitdifficulttocoverthiscoursecontentinfouryearduration Results of the present evaluation alsoindicated that current BDS curriculum is like asyllabusorcourseoutline. It is rich incontents forevery subject but no guidelines for educationalstrategiesandcompetenciesofadentalgraduateareprovided i.e. it's descriptive but not prescriptive.Whileacurriculumisnotonlyacourseoutline,butasetofdetaileddocumentsaboutalltheobjectives,educational and assessment strategies etc.throughouttheyear.Resultsofpresentstudycanbeconfidently used to suggest need of curriculumreview, as 12 years have been passed since lastcurricularrevision.Latesttrendsandapproachesinthe field of medical education may be used asguidelineformodifyingexistingdentalcurriculum.

ConclusionEvaluationofBDScurriculumbydentalfacultyandstudentsrevealedthatthereareshortcomingsinthecurrent dental curriculum and work needs to bedoneindentaleducationsectortomakecurriculumintegratedandstudentoriented.Thesedeficienciesmay end up in dental graduates with a goodknowledge base but little problem solving,leadership and research skills. Awareness ofcommunity needs and practice of evidence baseddentistryisalsolackingincurrentdentalstudents.


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Evaluation.BMJ:BritishMedicalJournal2003;326:385-7.4. Fitzpatrick, Jody L, James R Sanders, Blaine RWorthen.

"Programevaluation:Alternativeapproachesandpracticalguidelines."2004.

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9. DiFlorio I, Martin B, Middlemiss MA, Duncan PA. Curriculum evaluation. Nurse education today 1989; 9:402-7.

10. StufflebeamDL,ShinkfieldAJ.Stufflebeam'simprovement-oriented evaluation. In Systematic evaluation, SpringerNetherlands1985;151-207.

11. Dubrowski A, Paule-MorinM. Valuating pain educationprograms:AnintegratedapproachPainResManag2011;16:407-10.

12. TsengKH.DiezCR.UsingtheContext, Input,ProcessandProductmodeltoassessanengineeringcurriculum:WorldTransactions on Engineering and Technology Education2010;8:256-61.

13. SteinertY,CruessS,CruessR,SnellL.Facultydevelopmentfor teaching and evaluating professionalism: Fromprogramme design to curriculum change. Med Educ.2005;39:127-36.

14. ZangG, ZellerN. Using the Context, Input, Process, andProduct Evaluation Model (CIPP) as a ComprehensiveFramework to Guide the Planning, Implementation, andAssessment of Service-learning Programs: Journal ofHigherEducationOutreachandEngagement2011;15:57-83.


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ORIGINAL ARTICLE

ABSTRACTObjective:Toexplorefacultyexperiencesabout'problembasedlearning'usedasafacultydevelopmentapproachinunderstandingandapplyingthecoreconcepts&issuesinhealthprofessionseducationthroughtheirviewsandopinions.StudyDesign:Itwasaqualitativephenomenologicalstudy.PlaceandDurationofStudy:ThestudywasconductedatIslamicInternationalMedicalCollege,Rawalpindi,Pakistan.Datawascollectedin2006,2010and2013respectivelywiththreebatchesofM.Philbasicmedicalsciencesstudentsanddataanalysisdonein2013.Hence,totaldurationofstudyisthreeandhalfyears.MaterialandMethods:Theselectedstudysubjectswere16facultymembers(medical&dental)fromthreebatchesofM.PhilbasicmedicalsciencescoursewhoparticipatedinaPostGraduateCertificateCourseinMedicalEducation.Inthisstudy, semi structured interviewswere conducted and interview noteswere taken, in order to explore the facultyexperiences about the 'problem based learning' used as a mode of information transfer and faculty developmentapproach.Thedataverbatimtranscribedthroughinterviewnotes,codedandthematicanalysiswasdonemanually.Results:Resultswereintheformofdescriptionoffaculty'livedexperienceswiththePBL.Findingsindicatedthatfacultyperceivedproblembasedlearning'asaveryusefullearningtool.Conclusion:Thisstudyindicatedthatawell-constructedPBLcasescenario,basedoncommonandrealteachingproblemsin medical education can have a substantial effect on enhancing the performance of faculty/medical teacher'sperformancethathelpsinbetter'learningtransfer'ofteachingskill.

Keywords:Faculty Development, Problem Based Learning, Phenomenological Study.

analysis, planning, executionwithmaintenance ofquality assurance & evaluation of faculty at their

3 , 4respective workplace institutes. Facultydevelopmentisoneofthemechanismforimprovingthe teaching competencies of faculty (medical &dental teacher's) in order to adapt the modern

5,6medicaleducationreforms. Uptillnow,diverseandvarious approaches of faculty development arebeingusedbytheinstitutionstotraintheirfacultyinorder to demonstrate various competencies androlesi.e.ateacher,curriculumplanner&evaluator,educational,administratorandscholaratallleveloftheeducationalcontinuumi.e.atmicro,mesoand

7,8macro levels. It is imperative to create anenvironmentandapproachthathelpsfacultytoseetheireverydayexperiencesas'learningexperiences'andencouragetoreflectwiththeircolleagues/peersandstudentsonlearningexperiences.Thisisbasedon principles of adult learning, those which haveoccurred in classroom or clinical setting throughformal or informal approaches to promote the

8'learningtransfer'ofteachingskillandknowledge. Theseapproachesoffacultydevelopmentneedtobeexaminedandexploredoutforitseffectson'learningtransfer' of 'teaching skills' from individualexperiences to group learning and through ourresearchworkweareaimingtoachievethis.Itisthe

IntroductionDue to the ongo ing g loba l i za t i on and internationalization in medical education, non-western countries have undertaken a pedagogicalreform,byadoptingneweducationalstrategiesandmodes of information transfer being popular. Thisincludes: problem-based learning, case baselearning, team based learning and time efficient

1,2precepting. Their introduction and teachingrequiresfaculty(medical&dentalteacher's)shiftofrolefrominformationprovidertoa'facilitator'ora'tutor'.Duringproblembasedorcasebasedlearningsessionstheyneedtobetrainedinthisspecificnewareas of teaching skills in order to expandpedagogicalunderstandingabouttheirnewrolesin

3teaching and learning process. Hence, facultydevelopment is one of the essential and mostimportantcomponenthealthprofessionseducationthatneedstobecriticallythoughtoutfor itsneed

'ProblemBasedLearning'asaNovelmodeofInformationTransferforFacultyDevelopmentinPakistan:APhenomenologicalStudy

1 2RahilaYasmin ,ShahjahanKatpar

PBLaNovelModeofInformationTransferJIIMC2015Vol.10,No.2

182

Received: April 27, 2015; Accepted: June 11, 2015

1Department of Riphah Academy of Research and Education Riphah International University Islamabad2Department of Oral & Maxillofacial Surgery Institute of Dentistry, Liaquat University of Medical & Health Sciences, Jamshoro

Correspondence: Dr. Raheela YasminAssociate Professor, Medical Education, RARERiphah International University, IslamabadE-mail: [email protected]

on the day of PBL session. In this study, semistructuredinterviewswereconductedandinterviewnotes were taken, in order to explore the facultyexperiences about the 'problem based learning'usedasamodeofinformationtransferandfacultydevelopmentstrategy.Thefacultyconsentwastakenfor the interviews and study and there was noconflictofinterestraised.Facultieswereaskedabouttheir experiences and reflections with 'problembasedlearning'usedtotrainthemincoreconceptso f h e a l t h p ro fe s s i o n s e d u c a t i o n a n d facilitation/tutoringskills.Facultywhichwewanttotrainwasofmicro(teachingthestudents)andmeso(coordinating the courses) organizational levels ofperformance and teaching domains. They areinvolved in the development of courses and theirexecution, coaching of students & assessment,

9according to the teaching competencies. Thecompetency which we want to enhance was'facilitation /tutoring skills' via problem basedlearningat 'showshow'and 'does' level.Wehaveselected thephenomenological researchapproachbecause;wewanttoexplorethequintessenceofasocialphenomenonfromtheperspectiveoffacultywho has experienced it. In phenomenologicalresearch we put aside the researcher's ownperspectives in order to understand the existing

13experiencesoftherespondents/participants. Thedatawasanalyzedqualitativelyusingpsychologicalphenomenology.The interviewsareguidedby thepredeterminedsetofopenendedquestions-asemistructuredinterviewscript(attachedinannexure1).The data verbatim transcribed through interviewnotes, open codingwas donemanually, results inthematicanalysis.Whiledoingtheopencoding,thecollecteddatawasdividedintosegmentsandthesewere scrutinized for commonalities that helped inreflectingthecategoriesorthemes.Whiledoingthisprocess theyareexamined forproperties/ specificattributes of each category. We examined andidentified the meaning of the data by askingquestions, making comparisons and looking forsimilarities and differences between theircomments.Inthisway,similarcommentsaboutthephenomena are grouped together to formcategories. Hence, open coding helped us inreducingthedatatoasmallsetofthemesthatseemto describe the phenomenon that was under

quality of staff which forms, the most important9,10,11

determinantofsuccesscriteria. Thechallengeisto deepen and enhance their cognition about aneducationalexperiencethroughadaptinginnovativefaculty development approaches, which helps inlearning'transferofskill'atworkplacei.e.classroomorclinicalsetting.Inthisstudywehaveused'PBL'asa faculty development approach as a modernteaching & learning strategy by exploring ourresearchquestioni.e.howdofacultylearnandapplythe core concepts in health professions educationthroughateachinglearningapproachi.e.PBL?Itwasa qualitative study based on 'phenomenologicaldesign',usedtoexplorehowfacultyexperiencedthe'problembasedlearning'asanovelstrategytoteachthem about its core concepts & issues in health

12,13professions education. We feel that, PBL isunderdevelopedinPakistanintermsofitsutilityatour medical and dental academics, therefore its

14importance and need becomesevident. The maintheoretical conceptual framework of our researchstudyisembeddedandbasedon'theoriesofsociallearning'-constructivistsocioculturaltheory-Marxisti.e. it applies by using Problem based learningapproach for faculty development. This theorysupports the significance of social involvement oflearner in the learningprocess, so is this problembased learning process, through which we are

14trainingourfacultytolearn.

MaterialsandMethodsIt was a qualitative, phenomenological study. Thestudy was conducted at Islamic InternationalMedical College, Rawalpindi, Pakistan. Data wascollectedin2006,2010and2013respectivelywiththree batches of M. Phil basic medical sciencesstudentsanddataanalysisdonein2013.Hence,totaldurationofstudyisthreeandhalfyears.Theselectedstudysubjectswere16facultymembers(medical&dental)fromthreebatchesofM.PhilbasicmedicalsciencescoursewhoparticipatedinaPostGraduateCertificate Course in Medical Education in 2006,2010and2012respectivelyanditwasa2credithour,onesemester longcourse.These facultymemberswere from different disciplines of basic medicalsciences i.e. Anatomy, Physiology, Biochemistry,Pharmacologyanddentistry.TheinclusioncriterionwasthepostgraduatestudentsofM.Philprogramandtheexclusioncriteriathestudentswhoabsent


183

Above findings indicate that, faculty responded tothePBLasaveryusefullearningtooltounderstandits process and outcomes. The answer to ourresearchquestion,'HowdofacultylearnandapplythecoreconceptsinHealthProfessionsEducation'isevidentintheresultsthattheylearndifferentskillsthrough' constructionof knowledge',byobservingothers, role playing and rolemodeling.Moreover,theyexperiencedthattheynotonlyunderstandthecore concepts in health professions education bysolvingthe'realteachingproblemscenario'buttheyalsounderstandthePBLprocessandfacilitationskillaswellandacquiredpeer feedbackand reflectionskills.

DiscussionInansweringanddiscussingthedifferentquestionsthefacultyresponseswerecollectedandsummarieswithidentificationofthemes/mainpointsasunder;Question#1:Couldyoutalkandshareaboutyourexperience of learning core concepts of healthprofessions education through problem basedlearning?Mostofthefacultymembersfind itasaveryusefultooltounderstandthecoreconceptsandissuesofhealthprofessionseducationbyusingreal

15medicaleducationproblemsas triggers and thenexploring themselves during the discussion withtheirpeers.Oneofthefacultymemberrespondedthat;' hmm well, usually we were getting trainedthrough the 'workshops' comprised of lecturesfollowedbysomeactivitybutlearningcoreconceptsofhealthprofessionseducationbyinvolvingmyselfin problem based learning really helped meenhancingmyknowledge,skillandattitudeinhealthprofessionseducationthrough interactionwithmypeers.”Question#2:'Howdidyoulearnduringtheprocess of problem based learning? Please relatewithyourexample'.Facultymembersrespondedtothis question that they learn during the problembasedlearningfromeachotheri.e.thepeers,self-direction,by identifyingtheirpriorknowledgeand

investigation.Finallyconclusionsweredrawnbasedontheconnectionsaboutitsmeaningpersonallyandtheoretically. The data was validated throughmember checking by involving two other medicalfacultymemberswellversedandtrainedinPBLforanalysis.

ResultsResultswereintheformofdescriptionofthefaculty'livedexperienceswiththe'ProblembasedLearning'.FollowingThemeswereidentified;


184

effect on faculty(medical and dental teachers)performancethathelpsinbetter'learningtransfer'of teaching skill. Furthermore, it is recommendedthat,regularfacultydevelopmentprogramsmustbestartedtoattainitsdesiredresults,astheneedofthehour to promote medical and dental educationthroughoutPakistan.

buildingnewknowledgebasedontheirexistingoneand constructs their meanings, through reflectionand constructive feedback of the facilitators andpeers. Question # 3: What is your understandingaboutthefactorswhichhelpsin'transfer'ofteachingskill during the workshop? In response to thisquestion faculty members expressed that, thepowerful factor are: well-constructed PBL case,facilitatorstyle&training,studentstraining,relevantlearning resources, self-study timeduring the twosessions of problem based learning sessions.Student'smotivationtowardssubjectandprocess,facilitator'senthusiasm,constructive feedbackandattitudeoffacilitatorarealsoverycrucial.Question#4:Whatdoyouthinkinyourunderstandingaretheskillsgainedthroughproblembasedlearning?Couldyouexplainthroughexamples?Thefacultyresponseto this question yielded that they acquire bettercommunications skills, critical thinking, problemsolving, and self-reflection along with feedbackskills.Moreover,theyalsolearnthat,PBLenhances'facilitationskills'byobservingtheroleplayandrolemodelingoffacilitatorduringthesessions.Question#5:Couldyoureflectonstrengthsandweaknessesof the 'problem based learning' approach to trainyou? The strengths identified by the facultyresponsesweremostlytheskillstheygainedduringthesessions.Asfarastheweaknessesareconcernedtheydidn'tpointoutanyparticularonebuttakingcareofthefactorsidentifiedinquestion(#3)/threeareimportanttopreventitseffectsonlearningandstudent'smotivation.Question#6:Howdoes thisapproachhelpsin'transferofskills'learnedatyourworkplace? Faculty members responded to thisquestionasthat;byapplyingthereallifeproblemsinteaching and learning they can understand theconceptsbetter,insteadofonlyreadingfrombooks.Bysharingthelearningexperiencefromcommunityof training to community of workplace, helps intransfer of skill i.e. by building the community ofpractice.3They further explains that these trainingmust be supported and encourage by theleadership/headsofthedepartmentstotransferthisskillsatworkplace.

ConclusionThisphenomenologicalstudyindicatedthatawell-constructedPBLcase/scenariobasedoncommonand real teaching problems, can have substantial

Annexure 1


185

Annexure 2

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The'JIIMC'agreestoacceptmanuscriptspreparedinaccordancewiththe“UniformRequirements

submittedtotheBiomedicalJournals”publishedintheBritishMedicalJournal1991;302:334-41.

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appeareitheraspapersorasshortcommunications.

Thepapersshouldbeofabout2000words,withno

more than six tables or illustrations; short

communications shouldbeabout600words,with

one table or illustration and not more than five

references.ClinicalCaseReportandbriefornegative

researchfindingsmayappearinthissection.Review

187

the requirement for a Fellowship can be sent for

publication after it has been approved by the

ResearchandTrainingMonitoringCell(RTMC).The

maindifferencebetweenanarticleanddissertation

isthelengthofthemanuscript.Dissertationbased

articleshouldbere-writteninaccordancewiththe

instructionstoauthor

TABLEANDILLUSTRATIONS

Tablesandillustrationsshouldbemergedwithinthe

textofthepaper,andlegendstoillustrationsshould

betypedonthesamesheet.Tableshouldbesimple,

and should supplement rather than duplicate

informationinthetext;tablesrepeatinginformation

willbeomitted.Eachtableshouldhaveatitleandbe

typed in double space without horizontal and

verticallinesonan8½”x11'paper.Tablesshouldbe

numberedconsecutivelywithRomannumeralinthe

ordertheyarementionedinthetext.Pagenumber

shouldbeintheupperrightcorner.Ifabbreviations

areused,theyshouldbeexplainedinfootnotesand

when they first appear in text. When graphs,

scattergrams, or histogram are submitted, the

numericaldataonwhichtheyarebasedshouldbe

supplied.AllgraphsshouldbemadewithMSExcel

andbesentasaseparateExcelfileevenifmergedin

themanuscript. For scanned photographs highest

resolutionshouldbeused.

SIUNITS

SystemInternational(SI)Unitmeasurementsshould

beused.Alldrugsmustbementionedintheirgeneric

form. The commercial name may however be

mentionedwithinbrackets,ifnecessary.

FIGURESANDPHOTOGRAPHS

FiguresandPhotographsshouldonlybesentwhen

datacannotbeexpressed inanyother form.They

must be unmounted, glossy prints in sharp focus,

5”x7” insize.Thesemaybe inblack&whiteor in

colour. Negatives, transparencies and X Ray films

shouldnotbesubmitted.Thenumberoffigure,the

nameoftheauthor(s)shouldbeprintedontheback

of each figure/photograph. The top of the figure

mustbeidentifiedbytheauthor.Thesefiguresand

photographsmustbecitedinthetextinconsecutive

order. Legendsmustbe typedon the samepaper.

Legends forphotomicrographs should indicate the

magnifications, internal scale and method of

staining.Photographs inpublishedarticleswillnot

bereturned.

REFERENCES

References should be numbered in the order in

whichtheyarecited inthetext.Attheendofthe

article, the full list of references should give the

names and initials of all authors (unless there are

morethansixwhenonlythefirstsixshouldbegiven

followedbyetal).Theauthor'snamesarefollowed

by the title of the article; title of the journal

abbreviated according to the style of the Index

Medicus (see “List of Journals Indexed”, printed

yearlyintheJanuaryissueofIndexMedicus);year

volumandpagenumber;e.g.Hall,RR.Thehealingof

tissues byC02 laser. Br J. Surg: 1970; 58:222-225.

References to books should give the names of

editors,placeofpublication,publisherandyear.The

authormustverifythereferencesagainsttheoriginal

documentsbeforethearticle.

ABSTRACT

Abstractsoforiginalarticleshouldbeinstructured

formatwithfollowingsub-headings:i.Objective,ii.

Design,iii.Place&Durationofstudyiv.Materials&

Methods, v. Result, vi. Conclusion. Four elements

shouldbeaddressed:whydidyoustart,whydidyou

do,whatdidyoufindandwhatdoesitmean.Whydid

you start in the objective. What did you do

constitutes the methodology and could include

design, setting, patients or other participants,

interventions,andoutcomemeasures.Whatdidyou

find is the results, and what does it mean would

constitute; our conclusions. Please label each

section clearlywith the appropriate sub-headings.

Structuredabstractforanoriginalarticle,shouldnot

bemorethan250words.Reviewarticle,casereport

and other requires a short, unstructured abstract.

Commentariesdonotrequiredabstract.

INTRODUCTION

Thisshouldincludethepurposeofthearticle.The

rationale for the study or observation should be

summarized; only strictly pertinent references

should be cited; the subject should not be

extensivelyreviewed.Dataorconclusionsfromthe

workbeingreportedshouldnotbepresented.

MATERIALSANDMETHODS

Study design and sampling methods should be

188

mentioned. Obsolete terms such as retrospective

studies should not be used. The selection of the

observationalorexperimentalsubjects(patientsor

experimentalanimals,includingcontrols)shouldbe

described clearly. Themethodsand theapparatus

usedshouldbeidentified(withthemanufacturer's

nameandaddressinparentheses),andprocedures

describedinsufficientdetailtoallowotherworkers

toreproducetheresults.Referencestoestablished

methods should be given, including statistical

methods; references and brief descriptions for

methodsthathavebeenpublishedbutarenotwell

known should be provided; new or substantially

modified methods should be described, giving

reasons for using them, and evaluating their

limitationsalldrugsandchemicalsusedshouldbe

identified precisely, including generic names(s),

dose(s)androute(s)ofadministration.

RESULTS

Theseshouldbepresentedinlogicalsequenceinthe

text,tablesandillustrations.Allthedatainthetables

or illustrationsshouldnotberepeated inthetext;

onlyimportantobservationsshouldbeemphasized

orsummarized.

DISCUSSION

Theauthor'scommentontheresultssupportedwith

contemporaryreferences,includingargumentsand

analysisofidenticalworkdonebyotherworkers.A

summary is not required Brief acknowledgement

maybemadeattheend.

CONCLUSION

Conclusion should be provided under separate

headingandhighlightnewaspectsarisingfromthe

study.Itshouldbeinaccordancewiththeobjectives.

PEERREVIEW

Everypaperwillbebreadbyatleasttwostaffeditors

ortheeditorialboard.Thepapersselectedwillthen

be sent to one or more external reviewers. If

statistical analysis is included, furtherexamination

byastatisticianwillbecarriedout.

PLAGIARISMPOLICYJIIMCfollowstheguidelinesofICMJE,PMDCandHECforanykindofplagiarism.Theseguidelinescanbeaccessed at www.icmje.org, www.pmdc andwww.Hec.gov.pk Author is advised to go throughtheseguidelinesbeforesubmittingtheirmanuscript

with JIIMC. The cases of plagiarismwill be dealtaccordingtorulesandregulations/recommendationof the ICMJE, PMDC and HEC. The disciplinarycommitteeofJIIMCcomprisesofthestaff,Managingeditors and Editor in Chief to deal with cases ofplagiarism. Furthermore, authors are advised tosubmit a similarity index report generated by antiplagiarism software “TURNITIN”. Articles withsimilarityindexmorethan19%willnotbeacceptedforprocessing.ETHICALCONSIDERATIONSAuthorofthemanuscriptisrequiredtosubmitthecertificate of approval by the Institutional ReviewCommittee (IRC)/Ethical Review Board (ERB).Manuscripts comprising of the reports ofexperiments on human subjects should explicitlyindicate that the procedures followed were inaccordance with the ethical standards of theresponsiblecommitteeonhumanexperimentationandwiththeHelsinkiDeclarationof1975,revisedin1983. When reporting experiments on animals,indicate whether the institution or a nationalresearchcouncil'sguidelinesfororanynationallawon the care and use of laboratory animals werefollowed.CONFLICTOFINTERESTAnyfundingsourcefortheresearchworkmustbeinformedatthetimeofsubmittingthemanuscriptforpublicationinJIIMC.Anyassociationsthatmightbe construed as a conflict of interest (stockownership, consultancies, etc.) shall be disclosedaccordingly.COPYRIGHTMaterialprintedinthisjournalisthecopyrightoftheJIIMC and may not be reproduced without thepermissionoftheeditorsorpublishers.Instructionsto authors appear on the last page of each issue.Prospective authors should consult them beforewriting their articles and other material forpublication.TheJIIMCacceptsonlyoriginalmaterialforpublicationwiththeunderstandingthatexceptforabstracts,nopartofthedatahasbeenpublishedorwillbesubmittedforpublicationelsewherebeforeappearinginthisjournal.TheEditorialBoardmakeseveryefforttoensurethataccuracyandauthenticityof material printed in the journal. However,conclusionsandstatementsexpressedareviewsofthe authors and do not necessarily reflect theopinionsoftheEditorialBoardoftheJIIMC.

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