MALAYSIAN DENTAL JOURNAL · Dr. Yap Yoke Yong Dr. Sharifah Tahirah Al-Junid Dr. Nurshaline Pauline...

Editor: Associate Professor Dr. Ngeow Wei CheongBDS (Mal), FFDRCSIre (Oral Surgery), FDSRCS (Eng), AM (Mal)Department of Oral & Maxillofacial Surgery,Faculty of Dentistry, University of Malaya,50603 Kuala Lumpur, Malaysia.E-mail: [email protected]

Assistant Editor: Dr. Haizal Mohd HussainiDr. Chai Wen Lin

Secretary: Dr. Zamros YuzadiTreasurer: Dr. Lee Soon BoonEx-Officio: Dr. Wong Foot Meow

Editorial Advisory Board:We wish to express our sincere thanks to all members of the Editorial Advisory Board who gave their time willingly toreview article as well as to assist with the editorial work of this journal.

Dr. Elise Monerasinghe Professor Dr. Michael Ong Professor Dr. Phrabhakaran NambiarDr. Seow Liang Lin Dr. Lam Jac Meng Dr. Roslan SaubDr. Nor Adinar Baharuddin Assoc. Prof. Dr. Nor Zakiah Mohd Zam Zam

The Editor of the Malaysian Dental Association wishes to acknowledge the tireless efforts of the following referees toensure that the manuscripts submitted are up to standard.

Dato’ Dr. Chin Chien Tet Prof. Dr. Ong Siew Tin Prof. Dato’ Dr. Ishak Abdul RazakProf. Dr. Toh Chooi Gait Dr. Roslan Abdul Rahman Prof. Dr. Ghazali Mat Nor Prof. Dr. Michael Ong Dr. Lam Jac Meng Prof. Dr. Rahimah Abdul Kadir Dr. Haizal Hussaini Dr. Elise Monerasinghe Prof. Dr. Tara Bai Taiyeb AliDr. How Kim Chuan Dr. Sadna Rajan Prof. Dr. Phrabhakaran NambiarDr. Ismadi Ishak Dr. Ajeet Singh Prof. Dr. Nasruddin JaafarDr. Shahida Said Dr. Roslan Saub Prof. Dr. Nik Noriah Nik HusseinDr. Roszalina Ramli Dr. Norliza Ibrahim Prof. Dr. Zainal Ariff Abdul RahmanDr. Norintan Ab. Murat Pn. Rathiyah Ahmad Prof. Dr. Dasan SwaminathanDr. Ros Anita Omar Dr. Siti Mazlipah Ismail Prof. Dr. Rosnah Mohd ZainDr. Zamros Yuzadi Dr. Chai Wen Lin Assoc. Prof. Dr. Datin Rashidah EsaDr. Siti Adibah Othman Dr. Wong Mei Ling Assoc. Prof. Dr. Raja Latifah Raja JallaludinDr. Reginald Sta Maria Dr. Dalia Abdullah Assoc. Prof. Dr. Khoo Suan PhaikDr. Seow Liang Lin Dr. Chew Hooi Pin Assoc. Prof. Dr. Tuti Ningseh Mohd DomDr. Noriah Hj. Yusoff Dr. Lew Chee Kong Dr. Nor Adinar BaharuddinDr. Yap Yoke Yong Dr. Sharifah Tahirah Al-Junid Dr. Nurshaline Pauline Hj KipliDr. Nor Azwa Hashim Dr. Wey Mang Chek Dr. Zeti Adura Che Abd. Aziz

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MALAYSIAN DENTAL JOURNAL

Malaysian Dental Journal (2006) 27(1) 1-2© 2006 The Malaysian Dental Association

Malaysian Dental Association Council 2006-2007President: Dr. Wong Foot MeowPresident-elect: Dato’ Dr. Low TeongImmediate Past President: Dr. Shubon Sinha Roy Hon. General Secretary: Dr. How Kim ChuanAsst. Hon. Gen. Secretary: Dr. Abu Razali bin SainiHon. Financial Secretary: Dr. Lee Soon BoonAsst. Hon. Finan Secretary: Dr. Sivanesan SivalingamHon. Publication Secretary: Assoc. Prof. Dr. Ngeow Wei Cheong Chairman, Northern Zone: Dr. Koh Chou HuatSecretary, Northern Zone: Dr. Neoh Gim BokChairman, Southern Zone: Dr. Steven Phun Tzy ChiehSecretary, Southern Zone: Dr. Leong Chee SanElected Council Member: Dr. Sorayah SidekElected Council Member: Dr. Chia Ah ChikNominated Council Member: Dr. V. NedunchelianNominated Council Member: Dr. Xavier Jayakumar Nominated Council Member: Dr. Hj. Marusah Jamaludin Nominated Council Member: Dr. Lim Chiew Wooi

The PublisherThe Malaysian Dental Association is the official Publication of the Malaysian Dental Association. Please address all correspondence to:

Editor,Malaysian Dental Journal

Malaysian Dental Association54-2, (2nd Floor), Medan Setia 2,

Plaza Damansara, Bukit Damansara,50490 Kuala Lumpur

Tel: 603-20951532, 20947606, Fax: 603-20944670Website address: http://mda.org.my

E-mail: [email protected]@streamyx.com

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Aim And ScopeThe Malaysian Dental Journal covers all aspects of work in Dentistry and supporting aspects of Medicine. Interactionwith other disciplines is encouraged. The contents of the journal will include invited editorials, original scientificarticles, case reports, technical innovations. A section on back to the basics which will contain articles covering basicsciences, book reviews, product review from time to time, letter to the editors and calendar of events. The mission is topromote and elevate the quality of patient care and to promote the advancement of practice, education and scientificresearch in Malaysia.

PublicationThe Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half yearly (KDN PP4069/12/98)

SubscriptionMembers are reminded that if their subscription are out of date, then unfortunately the journal cannot be supplied. Sendnotice of change of address to the publishers and allow at least 6 - 8 weeks for the new address to take effect. Kindly usethe change of address form provided and include both old and new address. Subscription rate: Ringgit Malaysia 60/- foreach issue, postage included. Payment in the form of Crossed Cheques, Bank drafts / Postal orders, payable to MalaysianDental Association. For further information please contact :

The Publication SecretaryMalaysian Dental Association

54-2, (2nd Floor), Medan Setia 2, Plaza Damansara, Bukit Damansara,50490 Kuala Lumpur

Back issuesBack issues of the journal can be obtained by putting in a written request and by paying the appropriate fee. Kindly sendRinggit Malaysia 50/- for each issue, postage included. Payment in the form of Crossed Cheques, Bank drafts / Postalorders, payable to Malaysian Dental Association. For further information please contact:

The Publication SecretaryMalaysian Dental Association

54-2, (2nd Floor), Medan Setia 2, Plaza Damansara, Bukit Damansara,50490 Kuala Lumpur

Copyright© 2006 The Malaysian Dental Association. All rights reserved. No part of this publication may be reproduced, stored ina retrieval system or transmitted in any form or by means of electronic, mechanical photocopying, recording or otherwise without the prior written permission of the editor.

Membership and change of addressAll matters relating to the membership of the Malaysian Dental Association including application for new membershipand notification for change of address to and queries regarding subscription to the Association should be sent to HonGeneral Secretary, Malaysian Dental Association, 54-2 (2nd Floor) Medan Setia 2, Plaza Damansara, Bukit Damansara,50490 Kuala Lumpur. Tel: 603-20951532, 20951495, 20947606, Fax: 603-20944670, Website Address:http://www.mda.org.my. Email: [email protected] or [email protected]

DisclaimerStatements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the editor(s), publishers or the Malaysian Dental Association. The editor(s), publisher and the MalaysianDental Association disclaim any responsibility or liability for such material and do not guarantee, warrant or endorse anyproduct or service advertised in this publication nor do they guarantee any claim made by the manufacturer of such productor service.

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Malaysian Dental Journal (2006) 27(1) 3© 2006 The Malaysian Dental Association

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CONTENT

Editorial : Selling Our Content to the International Community 5

Malaysian Private Dental Practitioners in Continuing Professional EducationRazali AS, Rozima Y, Shamsuddin A 6

Oral Squamous Cell Carcinoma – Relevant Laboratory DiagnosisSolomon MC, Rao NN, Carnelio S 14

Amelogenesis Imperfecta with Gingival Hyperplasia and Anterior Open Bite – A Case ReportMadhu S 20

Orthodontics and Restorative Management of Hypodontia in an Adult: A Case PresentationHow KC 24

Non-extraction Orthodontic Treatment in Management of Moderately Crowded Class II Division 2 Malocclusion: A Case ReportOthman SA 30

Randomised Clinical Trial: Comparing the Efficacy of Vacuum-formed and Hawley Retainers in Retaining corrected tooth rotationsRohaya MAW, Shahrul Hisham ZA, Doubleday B 38

Dental Students’ Reflections: A Study of Video-triggered Reflections in Dentist-patientCommunication Skill ClassMurat NA 45

The Expert Says…Raja Latifah RJ, Saub R 49

Malaysian Dentists’ Opinion on Fixed Prosthodontics Teaching during Undergraduate TrainingTandjung YRM, Morad SM, Zakaria N, Ibrahim N 52

Instructions to contributors 60


Cover page : Photomicrographs showing various states and cellular appearances of oral squamous cell carcinoma using Periodic Acid Schiff stain (10X magnification), Silver stain (40X magnification) andImmunohistochemical stain (40X magnification). Picture courtesy of Professor Dr. Monica Solomon.

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In the second issue of the 2005 Malaysian Dental Journal editorial. I have promised to look into the possibility ofindexing the Malaysian Dental Journal

Well, in a way, we are getting back to the world community, though not directly via indexing, but throughpartnership in selling our content. And for all this to happen, I must first thank YBhg Professor Dato’ Dr. IshakAbdul Razak, an active member of the Malaysian DentalAssociation (MDA) who first set up a communication forme with Ms Heather Rahhal of the EBSCO Publishing. Weare now in the midst of signing a contract with this publishing company, who will under take to sell the content of the Malaysian Dental Journal. Let me tell you alittle bit more about our partner.

Established in 1984, and headquartered in Ipswich,Massachusetts, EBSCO Publishing (EP) is a subsidiary ofEBSCO Industries. EBSCO Publishing is chartered with delivering full-text and bibliographic research databases to the school, public, academic, medical, corporate and government library marketplace.

EBSCO Publishing currently licenses the full text contentof over 8,000 well-known periodicals and databases. They license content from thousands of well-known publications including: Fortune, National Geographic,Newsweek, the New Yorker, the Washington Post, Time,Atlantic Monthly, the Harvard Business Review, BusinessWeek, U.S. News & World Report, Vanity Fair, andConsumer Reports. Of course, it would be nice for theMalaysian Dental Journal to eventually rank similar tothese high impact publications.

The primary benefit for the Malaysian Dental Associationfor working with EBSCO Publishing is the greatlyincreased American and international exposure. Theirresearch database products are installed in close to 90% of

the public and academic libraries in the United States andCanada. EP also has excellent penetration in WesternEurope, and, due to an exclusive arrangement with a philanthropic organisation, their products are installed inevery college, university and public library in the following countries: Albania, Armenia, Azerbaijan,Bangladesh, Belarus, Bosnia Herzegovina, Bostwana,Bulgaria, Czech Republic, Estonia, Finland, Georgia,Ghana, Guatemala, Haiti, Kazakhstan, Kenya, Latvia,Lithuania, Macedonia, Malawi, Moldova, Mongolia,Mozambique, Namibia, Nigeria, Poland, Russia, Serbia,Slovakia, Slovenia, South Africa, Sri Lanka, Sweden,Tanzania, Uganda, Ukraine, Uzbekistan, Zambia,Zimbabwe. In Asia-Pacific, EBSCO Publishing has anactive sales force, with strong and growing product penetration in the libraries of Australia, New Zealand,Japan, China, Hong Kong, S. Korea, Taiwan, and thePhilippines. This means the Malaysian Dental Journal willbe made available to all these corners of the world.

The Malaysian Dental Association signed a standard, non-exclusive agreement that will not prevent it in any wayfrom working with other companies like EP, nor from distributing full-text via the Web or other electronic channels. Hence, members will still be able to access to theMalaysian Dental Journal when it is eventually uploadedto the MDA webpage.

Thank you.

Associate Professor Dr. Ngeow Wei CheongEditorMalaysian Dental Journal


Editorial : Selling Our Content to the International Community

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Malaysian Private Dental Practitioners in Continuing Professional EducationContextRazali AS BDS Malaysian Private Dental Practitioners’ Association, Kuala Lumpur, Malaysia.

Rozima Y MSc. Malaysian Private Dental Practitioners’ Association, Kuala Lumpur, Malaysia.

Shamsuddin A BSc., Ed.D. Malaysian Private Dental Practitioners’ Association, Kuala Lumpur, Malaysia.

ABSTRACTThis cross-sectional survey research was done to identify the current scenario of participation in Continuing ProfessionalEducation (CPE) among private dental practitioners in Malaysia. The findings serve as empirical evidence and the foundationof framework for mandatory CPE proposed by Ministry of Health Malaysia. A cross-sectional survey research was conducted. A systematic random sampling technique was used to select every 5th individuals from the 1,426 private dentalpractitioners (N) listed in the Malaysian Dental Council register, to give a total of 313 sample individuals (n). Survey questionnaires were mailed to the sample individuals and 233 questionnaires were collected, giving a response rate of 74 percent. The findings implied that private dental practitioners who join higher number of professional associations, whoread/comment/write higher number of journals, and who earn higher income, participate in higher number of CPE. Privatedental practitioners showed highest preference to learning from experience and from peers. The utmost important factor ofparticipation in CPE was suitability of courses to practice. However, the level of participation in CPE was found to be farbelow the expectation, the level of attitude towards CPE was low, and the level of self-esteem among private dental practitioners in Malaysia was of serious handicap. Significant relationships were established between attitude towards CPEand participation in CPE, between participation in CPE and self-esteem, and between attitude towards CPE and self-esteem.

Key words:continuing professional education, private dental practitioners, participation, attitude, self-esteem

INTRODUCTION

Malaysian Private Dental Practitioners’Association(MPDPA) has been actively organising ContinuingProfessional Education (CPE) programs for its membersand non-members in collaboration with independentproviders such as dental suppliers, but the number of members who actively involved in CPE programs is relatively small, be it in organising or participating. As of December 2003, there are 1,426 private dental practitioners and 992 public dental practitioners inMalaysia (a total of 2,418 dentists), giving dentists to population ratio as 1:10,612.1 As of July 2004, there areonly 411 active members in MPDPA, which constituteonly 29 percent of the private dental practitioners inMalaysia. Many private dental practitioners remain passiveand do not involve and participate in many of the CPE programs organised by the association, with an averagenumber of 100 participants per CPE program (Source:MPDPA).

This has created apprehension among some privatedental practitioners that each of these non-participativepeers would lag behind in the development of the latest

jargon in technology, skills, opportunities and knowledge,also challenges in the new era of globalisation, and facedifficulties to cater to the needs of 10,612 people in dentalcare. Thus MPDPA is firm with its stand to spearheadefforts to implement mandatory CPE for dental practitioners and to give its full support to the Ministry ofHealth (MOH) Malaysia for its implementation.

At the time this research was conducted, CPE amonghealthcare professionals were left to individuals’ prioritiesand conscience, and voluntary. There was no objective measurement, or yardstick that could be used for appraisal,recertification, or promotional prospects. Hence, the lowlevel of participation in CPE among private dental practitioners is associated with the voluntary basis of participation, thus there is no strong need for them to engageor participate in CPE and the importance of CPE is not givenpriority. But with the proposal by the MOH to implementmandatory CPE for recertification of Annual PracticeCertificate (APC) on healthcare professional, dental practitioners must accept the notion that the MOH has recognised CPE as the tool to equip them with certain competency required in their practice. Through active participation in CPE programs, private dental practitioners



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Razali / Rozima / Shamsuddin

are exposed to a new ASK (attitude, skills, knowledge) level.Dental practitioners don’t get to grow alone if they are confined to their professional practices and busy makingmoney on whatever basic skills they have. They couldbecome deprived of professional updates on the newer concepts, advance techniques and latest armamentarium.They must seek whatever available means to improve theirskills and knowledge, and act in the right attitude to add values in their practices and to secure success in their profession.

Increase in ASK level is often associated withimproved self-esteem.2 Baumeister et al.3 concluded that inperformance context, high self-esteem people appear touse better self-regulating strategies than low self-esteempeople and there are positive correlations between job performance and self-esteem. Orpen4 indicated that thosewho received more formal training received superior ratings of improved job performance and that those withmore formal training had greater confidence in their ability to do their jobs. Daley5 indicated that professionalsreported CPE as a tool to help them reaffirm their knowledge; contributes to their personal growth andincreases their confidence. Knowledge learned in CPEbecomes meaningful through processes they use to linkinformation with their practice and that meaning is directly to the nature of professional work in which theyengage.

However, attendance at CPE programs is still relatively small. In order to increase participation in CPE,thus increasing the status of dental profession and improving the standard of dental health care in Malaysia,MPDPA aspires to assist the MOH in constructing theframework of mandatory CPE by providing empirical evidence of the current scenario of participation in CPEamong private dental practitioners.

OBJECTIVES

The general objective of this study is to identify thecurrent scenario of participation in CPE among privatedental practitioners in Malaysia, and its relationships withattitude towards CPE and self-esteem, and to use it as thefoundation for the mandatory CPE point system framework. The specific objectives are:(1) to determine the level of participation in CPE, the level

of attitude towards CPE and the level of self-esteemamong the respondents;

(2) to determine the relationships of level of participationin CPE, the level of attitude towards CPE and the levelof self-esteem among the respondents with selectedvariables in demographic factors;

(3) to determine the relationships between participation inCPE and attitude towards CPE, between participationin CPE and self-esteem, and between attitude towardsCPE and self-esteem; and

(4) to determine factors that contribute to the participationin formal CPE among the respondents.

MATERIAL AND METHOD

Population and Sampling

The target population for this study is the privatedental practitioners in Malaysia who are currently registered to the Malaysian Dental Council (MDC). As atDecember 2003, the population size was 1,426 (N). A systematic sampling was used, where every 5th individualsfrom the register of dental practitioners in Malaysia wereselected, regardless of the state in which they practice, andgender. Hence, a total of 313 sample individuals wereselected from the population of private dental practitionersin Malaysia.

A structured self-administered mailed survey questionnaire was developed and was use as an instrumentfor data collection. Descriptive measures such as mean,minimum, maximum, and percentages were used todescribe the variables in demographic attributes and learning preference in non-formal CPE. Comparisonanalysis (t-test and ANOVA) was carried out to determinethe differences in participation in CPE, attitudes towardsCPE and self-esteem between and among variables indemographic attributes and learning preference.Correlation analysis of Pearson Product Moment was usedto determine the relationships between participation inCPE and self-esteem, and 8 other relationships betweenselected variables.

RESULT

Of the 313 sample individuals selected in thisresearch, 233 individuals responded to the questionnaire,which gives the value of response percentage 74 percent.

Most of the respondents were aged between 31 to40 years old, which consist of about 37 percent of the total.Majority of the respondents (39 percent) have been practicing for 11 to 20 years. About 81 percent of therespondents were private dental practitioners who havetheir own practice. In terms of monthly earned income,about 25 percent of the respondents earn medium income(RM6001 to RM9000) and 23 percent of them earn veryhigh income of more than RM15000 per month. Therespondents were evenly distributed in terms of graduationorigin i.e. from local universities and overseas. However,about 88 percent of the respondents were general dentalpractitioners and the rest were specialists. Majority of therespondents (about 89%) belonged to at least one professional association, whereas the other 11 percent didnot belong to any professional association at all. About 42percent of the respondents did not subscribe to any professional journal and the rest subscribed to at least oneprofessional journal. In terms of total number of journalsread/commented/written in the past year, about 20 percentof the respondents did not engage in any of these activities.On the average, the respondents read/commented/wroteabout only 3 journals per year. In terms of learning preference in non-formal CPE, the respondents showed

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Malaysian Private Dental Practitioners in Continuing Professional Education Context

highest preference to learning from experience and lowestpreference to transformational learning. The 2 most significant factors of participation in formal CPE weresuitability of courses to the respondents’ practice and personal and professional development, whereas the 2least significant factors were accreditation of CPE pointsand certificate of attendance.

A total of 93 percent of the respondents did notmeet the expectation to acquire minimum CPE credithours within a year, with about 19 percent of them did notparticipate at all in any CPE program. About 31 percent ofrespondents between the ages of 21 to 30 years old, andzero percent of those who were more than 71 years oldnever participated in any CPE. Detail analysis of distribution of participation in formal CPE found thatrespondents who met and exceeded the minimum requirement of CPE hours in a year are between the agesof 31 to 70 years old (a total of 7%), have been practicingfor 6 to 30 years (a total of 7%), who have their own practice (a total of 7%), reported medium to very highincome (a total of 7%), graduated from overseas (5%), aregeneral practitioners (6%), belonged to more than one professional association (7%), subscribed to more than oneprofessional journal (5%), and read/commented/wrotemore 1 to 3 journals a year (6%). The rest of the respondents do not meet the minimum requirement of CPEhours in a year. However, further comparison analysisfound that there was no difference in participation in formal CPE between and among groups in types ofemployment, graduation origin, level of qualification, agecategories, and period of practice, but there were significant difference in participation in formal CPEamong the groups in income categories (higher participation among dental practitioners who earn higherincome), among the groups in enrollment to professionalassociation categories (higher participation among practitioners who enroll in higher number of professionalassociations) and among the groups in number of journalsread/commented/write (higher participation among practitioners who read/comment/write more journals).

Majority of the respondents had low attitudetowards CPE (84%). On the average, the respondents werefound to have low attitude towards CPE. However, most of

the respondents honor people who continuously learnthroughout life and were open to learning from their peers.Further comparison found that there were significant difference in attitude towards CPE between and amonggroups in level of qualification (higher attitude towardsCPE among specialist compared to general practitioner),age categories (higher attitude towards CPE amongyounger respondents compared to older ones), period ofpractice (higher attitude towards CPE among respondentswho had shorter period of practice compared to those oflonger ones), and participation categories (higher attitudetowards CPE among respondents who participated in higher number of CPE compared to those of lower ones).On the average, the respondents were of serious handicapof self-esteem. Only a total of 17 percent of the respondents had good self-esteem (9%) and sound self-esteem (8%). Majority of the respondents were mostagreed that when they complete a task, large and small,they feel proud of their accomplishment, but they weremost disagreed that they are not hurt by other’s opinions orattitudes. Further comparison found that there were significant difference in self-esteem between and amonggroups in graduation origin (higher self-esteem amongspecialists compared to general practitioners), age categories (higher self-esteem among respondents whowere older compared to those who were younger), periodof practice (higher self-esteem among respondents whohad longer period of practice compared to those of shorterones), participation categories (higher self-esteem amongrespondents who participated in higher number of CPEcompared to those of lower ones), and attitude categories(higher self-esteem among respondents who had higherattitude towards CPE compared to those of lower ones).

Further analysis found that there were significantrelationships between participation in CPE and self-esteem, attitude towards CPE and self-esteem, age andself-esteem, period of practice and self-esteem, betweenparticipation in CPE and attitude towards CPE, andbetween attitude towards CPE and period of practice. Nosignificant relationships were established between participation in CPE and age, participation in CPE andperiod of practice, and attitude towards CPE and period ofpractice (Table 1).

Table 1: Summary of correlational analysis between selected variables

Dependent Variables Independent Variables Pearson Correlation, r Sig-r Significant Relationship

Self-esteem Participation 0.188 0.004 YesSelf-esteem Attitude 0.361 0.000 YesSelf-esteem Age 0.288 0.000 YesSelf-esteem Period of Practice 0.325 0.000 YesParticipation Attitude 0.247 0.000 YesParticipation Age -0.037 0.570 NoParticipation Period of Practice -0.023 0.725 NoAttitude Age 0.099 0.133 NoAttitude Period of Practice 0.131 0.045 Yes

Significant level, _ = 0.05

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DISCUSSION

There are 1,426 private dental practitioners and 992public dental practitioners in Malaysia (a total of 2,418dentists), giving dentists to population ratio as 1:10,612.1

The samples in this study were systematically selected inrandom, thus it can be generalised to the whole populationof private dental practitioners in Malaysia.6 Alreck &Settle7 stated that it was seldom necessary to sample morethan 10 percent of the population. They disputed the logic that sample size was necessarily dependant upon population size. However, choice of sample size is often asmuch a budgetary consideration as a statistical one, and bybudget it is useful to think of all resources (time, space andenergy) not just money.7 Generally choice of sample size isas much a function of budgetary considerations as it is statistical considerations. When they can be afforded, largesamples are usually preferred over smaller ones. Based onthese reasons, a sample size of 313 (n) was selected fromthis population, consistent with recommendations fordetermining size of a random sample.8

The original population register was in randomorder, thus systematic sampling would yield a sample thatcould be statistically considered a reasonable substitute fora random sample.9 Randomisation is used to eliminatebias, both conscious and unconscious, that the researchermight introduce while selecting a sample. Kerlinger6

described randomisation as the assignment of objects (subjects, treatments, groups, etc.) of a population to subsets (sample) of the population in such a way that forany given assignment to a subset (sample), every memberof the population has an equal probability of being chosen.Randomization is essential for probability samples whichare the only samples that can generalise results back to thepopulation. Gay10 reported that random sampling was thebest single way to obtain a representative sample. No technique, not even random sampling, could guarantee arepresentative sample, but the probability is higher for thisprocedure than for any other.

Any deficiency or lack of professional competencyin a single dental practitioner would affect 10,612 people.Thus, it is very imperative to ensure dentals practitionersare soundly equipped with relevant competencies in theirpractice, and have high confidence in carrying out theirduties as caregivers. The smaller number of specialists ascompared to general practitioners among private dentalpractitioners shows that there is a serious lack of participation in CPE or further education. Private dentalpractitioners need to be made aware of the importance ofspecialisation in their profession in relation with their ethical obligation to serve the community. They should beaware that if they do not engage in further education orCPE, each of them will be responsible in failing to meetthe increasing demand and fulfilling growing needs in thewellbeing of 10,612 people in dental care. The followingsare the discussion on some of our finding:

Finding #1: Age, period of practice, graduation origin,level of qualification and type of employment do notcontribute to participation in CPE. However, privatedental practitioners who earn lower level of incomehave constraint to participate in CPE, and they avoidpossible loss of income.

When linking participation in CPE with demographic attributes, it is observed that the participationlevel in CPE is of no significant difference between practitioners who have their own practice and those who are employed, between specialists and general practitioner, between practitioners who graduated fromlocal universities and overseas, between younger and olderpractitioners, and between those who have more experience in this profession and those of less. This contradicts the findings in earlier research by Buck &Newton11 who found that dental practitioners who havebeen qualified for between 21 and 30 years, and those whohave gained additional qualifications after qualifying as adentist, participate more in CPE. They continued to pointout that attendance at postgraduate dental courses is related to possessing additional qualification, and notbeing a general practitioner. It also contradicts that thoseless likely to be doing 50 hours of continuing dental education are those with more years in practice and single-handed practitioners.12

However, private dental practitioners in Malaysiawho earn higher income participate in more numbers ofCPE than those who earn less. This agrees with Shugars etal.13 who said dentists who report higher incomes, attendmore continuing education. This can be associated withwhat Carrotte et al.14 found in his study, that the mostimportant barrier to participation is loss of income when dental practitioners attend CPE programs. Dental practitioners who report lower income may have constraintto participate in CPE, such as finding locum dentists, andthey avoid possible loss of income. This can be the reasonfor low participation in formal CPE among private dentalpractitioners in Malaysia.

Finding #2. Private dental practitioners learn in thecontext of practice and develop their skills by learningfrom experience, utilising increasing perception andintuitive recognition of systems within practical situations.

In terms of learning in non-formal CPE, majority ofprivate practitioners in Malaysia belonged to at least oneprofessional association and read at least one professionaljournal. Private dental practitioners who enrol in highernumber of professional associations, and who read/comment/write more journals participate in higher numberof CPE as compared to those of the opposites. Buckley &Crowley14 earlier indicated that dentists who actively participated in continuing dental education belonged tomore than one professional association, and subscribed tomore than one journal. However, about 20 percent of

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private dental practitioners in Malaysia do not read journals at all and on the average, those who read only read3 journals in a year. When linking this to the learning preference in non-formal CPE, it can be said that privatedental practitioners in Malaysia prefer to learning fromexperience and peers, thus the low number of journalsread. This is congruent with Daley5 who pointed out thatfor professionals, experience, attendance at CPE programs,and dialogue with colleagues all contribute to the continual growth and refinement of meaningful knowledge. However, since dental profession is volatilewith changes in regulations, techniques, technologies andincreased expectation from the public, it is imperative thatdental practitioners get first hand knowledge and updatesfrom the most recent journals, rather than being reactive toexperiences and getting conveyer belt information fromtheir peers. Therefore, private dental practitioners learn inthe context of practice and develop their skills by learningfrom experience, utilising increasing perception and intuitive recognition of systems within practical situations.

Finding #3. Suitability of courses is not only seen fromthe clinical perspective, it includes courses that coverpersonal and professional development as well. Privatedental practitioners are highly selective in making decision to participate in CPE that are perceived to bebeneficial to them.

According to Tseveenjav et al.16 a dentist's field ofpractice and attitude towards CPE are the significant factors for participation. In Malaysia, the most significantfactor of participation in formal CPE among private dentalpractitioners is suitability of courses to the practice. This isfollowed by personal & professional development,reputation of instructor/speaker, hunger for knowledge,time/duration of CPE programs and reasonable fee. Thiscoincides with Daley5 who implies that new informationlearned in CPE programs is added to a professional’sknowledge through a complex process of thinking about,acting on, and identifying their feelings about new information, and it has to connect to other concepts beforeit is meaningful to them, and part of the process of makingknowledge meaningful is to use it in practice in some way.In reality, the elements of professional practice link withthe information from CPE programs to create meaning forpractice. This is further emphasised by Wiskott et al.,17

who found that the course contents should be aimed at satisfying the demands of practicing dentists, and thatbasic science issues and theoretical concepts should also be included. As indicated by some of the dental practitioners, suitability of courses should not only be seenfrom the clinical perspective, it should include courses thatcover personal and professional development as well. Thisis in line with what Nowlen18 discussed about theCompetence Model that current and relevant knowledgemust be combined with other skills (such as critical thinking or interpersonal relationship skills), personaltraits and characteristics (such as initiative or a sense of

ethics), an individual schema or self-image as a professional, and self-direction or a motive that serves to direct one’s action in practice. McGivncy19 also emphasised that the barriers to participation are centredaround the lack of advice and guidance on the opportunities available; lack of appropriate part-timecourses delivered in a way that is flexible to student’ timepressures; lack of affordable childcare, the levels of feescharged and the geographical constraints presented by having to travel to an often far location.

Some of the dental practitioners in Malaysia avoidloss of income that can occur while attending CPE by notgoing. This loss of income can happen when they have toclose their clinics due to failure in getting suitable locumdentists to substitute them while they are away. This can berelated to the time and days of courses scheduled for them.These factors should be the basis for providers of CPE inMalaysia to cater to the needs of these professionals.Private dental practitioners are highly selective in makingdecision to participate in CPE that are perceived to be beneficial to them.

Finding #4. Private dental practitioners perceive thatthey do not need to participate in CPE that are not relevant to their practice and not beneficial to them.

This conclusion is in harmony with that of Buckley& Crowley15 who found that there was a generally lowlevel of involvement in elements of CPE, such as attendance at scientific conferences, professional coursesand occasional meetings. As noted by Tseveenjav et al.,16 adentist's field of practice and attitude towards CPE are the significant factors for participation, whereas length of working experience, field of practice, holding a postgraduate degree, and having attended CE courses aresignificant factors for perceiving a need for CPE. However, since there is no significant difference in participation between and among groups in types ofemployment, graduation origin, level of qualification, agecategories, and period of practice, these factors do not significantly contribute to the participation in CPE amongprivate dental practitioners in Malaysia. Therefore,regardless of which group they are from, they may perceive that they do not need CPE, thus the low level ofparticipation in formal CPE.

This is contrary to the Update Model, CompetenceModel, or Performance Model due to the high wall of barrier, i.e. self-perceive. When they perceive they do notneed CPE, this becomes an ethical issue in the practice. Asstated by Lawler & Fielder,20 ethical problems arise whenpeople are faced with questions about fairness and aboutobligations owed to colleagues, customers, participants,and other stakeholders, in this case, to the patients and thesociety in which dental practitioners practice. Ethics setlimits regarding what people can do in pursuit of their owninterests, and prescribes standards of behaviour governingtheir dealings with others. CPE is seen as an ethical obligation to the dental practitioners towards themselves,

11


their patients, and the profession. The low level of participation in formal CPE may be best explained throughSkill Acquisition Model that explains how professionalslearn.21

The emphasis is on learning from experience,utilising increasing perception and intuitive recognition ofsystems within practical situations, rather than actionbased on rote learning. As such, CPE providers mustrecognise these factors in constructing the framework ofcourses in order to increase the perception among theseprofessionals that CPE is worth participating and to makethem recognise the CPE providers as systems that are ableto provide relevant courses to their practical situations.When linking this to factors of participation, some of theprivate dental practitioners in Malaysia see CPE as notbeneficial to them and not worth the fees that are usuallyhigh. Some of them equate attending CPE with loss ofincome. Thus, dental practitioners who earn lower incomeparticipate in less CPE compared to those of higherincome because they want to avoid loss of income (See Finding #3).

Finding #5. Private dental practitioners do not see CPEas a tool to help them reaffirm their knowledge, to contribute to their personal growth and to increasetheir confidence.

Generally, private dental practitioners in Malaysiahave low attitude towards CPE. As noted by Tseeveenjavet al.,16 attitude towards CE is one of the significant factorsfor participation. Thus, the low level of attitude towardsCPE among private dental practitioners in Malaysia mayhave contributed to the low level of participation formalCPE among them. This is in line with Cross22 who postulated that learners must have a certain degree of self-confidence and a positive attitude to learning for them toengage in formal education. This contradicts the findingsby Daley5 who indicated that professionals have high attitude towards CPE as they see CPE as a tool to helpthem reaffirm their knowledge, contributes to their personal growth and increases their confidence. Therefore,the finding of this study suggests that the private dentalpractitioners in Malaysia do not see CPE as a tool to helpthem reaffirm their knowledge, to contribute to their personal growth and to increase their confidence. Whenrelating this to McGregor22 in his Theory X, suggested thatthe average person dislikes work (or in the case of thisstudy, the obligation to continuing pursuing education fordevelopment) and will avoid it if he/she can. Thereforemost people must be forced with the threat of punishmentto work towards the objectives. Realising the existence ofsuch situation, it may be a reason for the Ministry ofHealth to propose a mandatory CPE point system for dental practitioners in order to draw more crowds to CPEand to ensure continuous updating of current level of skillsand knowledge.

As what happened in the Philippines where dentalpractitioners are regarded as not adequately matured toreach a professional mindset to allow them to pursue continuing education voluntarily,24 perhaps it is time forthe Malaysian Government to think of a way to jumpstartan effort in promoting continuing professional educationas part of professional culture. O’Sullivan25 identified thatthe key features of clinical governance are accountabilityfor clinical performance and mechanisms for improvingclinical performance. Individual health professionals areexpected to be responsible for the quality of their own clinical practice. Furthermore, the determination of quality is closely aligned to clinical effectiveness, cost-efficiency and CPE. Maintaining quality in practice andimproving patient care requires individuals to keep up-to-date with practice, highlighting the need for research, auditand evidence-based practice. Perhaps, the step to introducemandatory CPE points for re-license would promote highattitude towards learning. CPE should be viewed as aninformation exchange system of creating and maintainingnetwork of communication among professionals.26 Suchnetworks are important to enhance one’s personal statusand relationships with others in establishing support andenhancing decision-making through wider informationgathering and exchange of ideas. Dental practitioners inMalaysia should be guided accordingly so that they wouldhave higher attitude towards CPE and be matured enoughto look at CPE from this point of view.

Finding #6. Private dental practitioners have low levelof self-perceived competence, self-confidence, self-image and success expectancy.

Since self-esteem is highly associated with self-confidence and high performance, the poor level of self-esteem among private dental practitioners in Malaysiashould be looked into seriously. Based on this finding, itcan be concluded that private dental practitioners have lowlevel of self-perceived competence, self-confidence, self-image and success expectancy. However, higher self-esteem is found among specialists, practitioners who areolder, who have longer period of practice, who participatein higher number of CPE, and who have higher attitudetowards CPE. Generally, when they complete a task, largeand small, they feel proud of their accomplishment, but arehurt by other’s opinions or attitudes. This is congruent withHamid & Mohamad2 who noted that individuals with lowself-esteem show such symptoms as depression, anxiety,the attitude of attribution of their defeats to others, anddecrease in performance, lack of educational success andinterpersonal problems. They continued to say that newskills and increasing abilities are among the important factors in creating self-esteem. Therefore, to increase self-esteem among dental practitioners, they must engage inmore CPE because Moner27 indicated that individuals withhigh self-esteem have higher self-perceived competence,self-image and success expectancy.

12


Baumeister et al.3 concluded that in performancecontext, high self-esteem people appear to use better self-regulating strategies than low self-esteem people. Thisserves as a strong foundation for effective CPE point system for dental practitioners in Malaysia. It is in linewith the nation’s aspiration to embark on health/dentaltourism. Private dental practitioners should have soundself-esteem to successfully meet increased demand inpatients’ care and greater expectations from local communities, foreign tourists and expatriates. They mustbe as adequately competent as their peers in other countries in order to acquire the confidence among foreigners who seek dental care in Malaysia. This will provide greater opportunities for Malaysian private dentalpractitioners to extend their service and acquire international experience in other countries.

Finding #7. The missing link is the attitude towardsCPE. Low level of attitude towards CPE explains thelow level of participation in CPE and serious handicaplevel of self-esteem among private dental practitioners.

There are significant positive relationships betweenparticipation in formal CPE and self-esteem, attitudetowards CPE and self-esteem, age and self-esteem, periodof practice and self-esteem, between attitude towards CPEand participation in formal CPE, and between attitudetowards CPE and period of practice. Practitioners who areolder and who have been in practice for longer period havehigher self-esteem. Thus this group of practitioners isexpected to engage more in CPE.

However, the findings showed that participationdoes not have significant relationship with age and periodof practice. Thus, the missing link here is the attitudetowards CPE. Low level of attitude towards CPE explainsthe low level of participation in CPE and serious handicaplevel of self-esteem among private dental practitioners.That means when the attitude towards CPE is high, privatedental practitioners will engage in more CPE, thus increasing the level of self-esteem and enhancing theimage of this profession among these professionals.Nevertheless, in general, the current level of attitudetowards CPE among private dental practitioners inMalaysia is low. If the attitude towards CPE can beincreased, this will add to the participation in CPE and willboost the self-esteem among private dental practitioners.

As Daley5 clearly noted, professionals should notsee transfer of learning as an outcome of their educationalendeavours; they must view transfer of learning as an integral part of the meaning-making process. New information learned in CPE programs is added to a professional’s knowledge through a complex process ofthinking about, acting on, and identifying their feelingsabout new information. Therefore, rather than debating themandatory issue or arguing whether competency standardsare appropriate for professionals, a preferable alternativemight be to focus on lessening the problems associatedwith CPE as a tool for improving professional practice as

in the case of this study, the low level of attitude towardsCPE among private dental practitioners. As mentioned earlier, CPE should not be seen as an extension to theknowledge base of universities. It should be viewed as aninformation exchange system of creating and maintainingnetwork of communication among professionals.26 Suchnetworks are important to enhance one’s personal statusand relationships with others. They are important in establishing support and enhancing decision-makingthrough wider information gathering and exchange ofideas. Dental practitioners in Malaysia should be guidedaccordingly so that they would have higher attitudetowards CPE and be matured enough to look at CPE fromthis point of view.

CONCLUSION

The findings implied that private dental practitioners who join higher number of professional associations, who read/comment/write higher number ofjournals, and who earn higher income, participate in higher number of CPE. Private dental practitioners showedhighest preference to learning from experience and frompeers. The utmost important factor of participation in CPEwas suitability of courses to practice. However, the level ofparticipation in CPE was found to be far below the expectation, the level of attitude towards CPE was low, andthe level of self-esteem among private dental practitionersin Malaysia was of serious handicap. Significant relationships were established between attitude towardsCPE and participation in CPE, between participation inCPE and self-esteem, and between attitude towards CPEand self-esteem.

ACKNOWLEDGMENT

We would like to acknowledge the contribution andsupport of Dato’ Dr. Wan Mohamad Nasir b. Wan Othman,the Director of Oral Health Division, the Malaysian PrivateDental Practitioners’ Association, Westminster ConsultingSdn Bhd and Universiti Putra Malaysia for this study.

REFERENCES

1. Information and Documentation System Unit, Planning &Development Division. Ministry of Health Malaysia. HealthFacts. 2003. Retrieved from www.gov.moh.my

2. Hamid RA, Mohamad RA. The Relationship Between Self-Esteem and Job Satisfaction of Personnel in GovernmentOrganizations. Public Personnel Management. 2003:32(4).

3. Baumeister RF, Campbell JD, Kruger JI, Vohs KD. DoesHigh Self-Esteem Cause Better Performance, InterpersonalSuccess, Happiness, or Healthier Lifestyles? PsychologicalScience in the Public Interest, 2003:4(1).

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4. Orpen C. The Impact of Self-Efficacy on the Effectiveness ofEmployee Training. Journal of Workplace Learning.Employee Counseling Today. 1999;11:119-22.

5. Daley BJ. Learning and Professional Practice: A Study ofFour Professions. Adult Education Quarterly. 2001;52:39-54.

6. Kerlinger FN. Foundations of Behavioral Research, NewYork. 1986. Holt, Riverhart & Winston.

7. Alreck PL, Settle RB. The Survey Research handbook, 2ndEd., 1995. Chicago: Irwin.

8. Krejcie RV, Morgan DW. Determining Sample Size forResearch Activities. Educational & Psychological Measurer.1970;30:607-610.

9. Ary D, Jacobs LC, Razavieh A. Introduction to Research inEducation. 5th Ed., 1996. Harcourt Brace College Publishers.

10. Gay LR. Educational Research: Competencies for Analysisand Application. 3rd Ed., 1987. Meirill, Columbus, USA.

11. Buck D, Newton T. Continuing Professional Developmentamongst Dental Practitioners in United Kingdom: How farare we from lifelong learning targets? European J Dent Educ.2002;6:36-9.

12. Bullock A, Firmstone V, Fielding A, Frame J, Thomas D,Belfield C. Participation of UK Dentists in ContinuingProfessional Development. Br Dent J. 2003;194:47-51.

13. Shugars DA, DiMatteo MR, Hays RD, Cretin S, Johnson JD.Professional satisfaction among California General Dentists.J Dent Educ. 1990;54:661-9.

14. Carrotte PV, Walker ADM, Rennie JS, Ball G, Dodd M.Personal learning plans for General Dental Practitioners: AScottish perspective - Part 2. Br Dent J. 2003;194: page

15. Buckley GJ, Crowley MJ. The Continuing Dental Education(CDE) activities of a Regional cohort of Irish Dentists - Abaseline study. J Ire Dent Assoc. 1993;39:54-9.

16. Tseveenjav B, Vehkalahti MM, Murtomaa H. Attendance atand self-perceived need for ontinuing education amongMongolian dentists. European J Dent Educ 2003;7:130-5.

17. Wiskott HW, Borgis S, Simoness M. A Continuing EducationProgram for General Practitioners. Status Report after 5 yearsof function. European J Dent Educ. 2000;4:57-64.

18. Nowlen P. A new approach to continuing education for business and the professions: the performance model. 1988,Old Tappan, NJ.: Macmillan.

19. McGivncy V. Women, education and training: barriers toaccess, informal starting points and progression routes. 1993,National Institute of Adult Continuing Education and HilcrottCollege, London.

20. Lawler P, Fielder J. Ethical problems in continuing highereducation: Results of a survey. J Continuing Higher Educ.1993;41:25-33.

21. Dreyfuse H, Dreyfuse S. Mind over machine: the power ofhuman intuition and expertise in the era of the computer.1985, New York: Free Press.

22. Cross P. Adults as learners. 1982, San Francisco: Jossey-Bass.

23. McGregor D. The Human Side of Enterprise, 1960, bookpublisher and city?

24. Philippine Dental Association. CPE as a compulsory requirement for membership in PDA: A justification. 2003.

25. O’Sullivan J. Research in post-compulsory education. 2003,Volume 8, Number 1.

26. Chambers D. The continuing education business. J DentEduc. 1992;56:672-679.

27. Moner 1992???

Address for correspondence:

Dr. Abu Razali Saini,Malaysian Private Dental Practitioners’ Association,c/o Malaysian Dental Association,54-2, Medan Setia 2, Plaza Damansara50490 Kuala Lumpur, MalaysiaTel : 603-20951532Fax: 603- 603-20944670Email: [email protected]

14

Oral Squamous Cell Carcinoma – Relevant Laboratory DiagnosisSolomon MC Professor, Department of Oral Pathology and Microbiology, Manipal College of Dental Sciences, Manipal576104, India.

Rao NN Professor and Head, Department of Oral Pathology and Microbiology, Manipal College of Dental Sciences,Manipal 576104, India.

Carnelio S Associate Professor, Department of Oral Pathology and Microbiology, Manipal College of Dental Sciences,Manipal 576119, India.

ABSTRACTOral Squamous cell carcinoma is a serious oral health problem. The structure and behavior of this neoplasm varies greatly.Advances in scientific technology, has paved the way to comprehend the genetic changes a keratinocyte undergoes during carcinogenesis. The knowledge of the molecular mechanism underlying this neoplasm enables assessment of its behaviour andabove all is the foundation for developing biologic therapeutics to target specific molecules. A few relevant diagnostic modalities are briefly described and their importance highlighted

Key words:Squamous cell carcinoma, diagnosis, behaviour, prognosis

The progression of an oral keratinocyte from itsnormal status to dysplasia and eventually to neoplasia is amulti-step process involving many complex factors. Therehave been numerous scientific approaches aimed at understanding the biochemical aspects of the developmentand progression of oral squamous cell carcinoma (OSCC).Grading of the tumor relies greatly on the light microscopyexamination of hematoxylin and eosin stained tissue sections. However, histological assessment is less reliableas there is considerable inter and intra examiner variations.Over the years with more sophisticated scientific technology, the behavior of tumor cells is more clearlydetermined. This article intends to describe some of thediagnostic methods that are employed for diagnosis andprognostication of Squamous cell carcinomas of the oralcavity

Exfoliative Cytology

Exfoliative cytology is a rapid, non-invasive procedure that was primarily used in the screening of theuterine cervix for dysplasia and carcinoma. With the introduction of alcohol-based stains by Papanicalaou,examination of smears was simplified and standardized.This facilitated its use in the early diagnosis of oral squamous celI carcinomas. It is also used for assessingpotentially malignant lesions

The exfoliated cells of OSCC exhibit features ofincreased keratinization, increased nuclear area, increasednuclear-cytoplasmic ratio, nuclear pleomorphism, nuclear-hyperchromatism and Chromatin clumping1 (Fig 1).

With recent advances in immunohistochemistry,cytophotometry and DNA analysis of smears, there has bean reappraisal of the value of exfoliative cytology in thediagnosis of oral cancer2

Histopathology

Histopathologic grading of squamous cell carcinoma represents the anticipated biological behavior ofthe neoplasm. Broder initiated a quantitative grading systemfor Squamous Cell Carcinomas. This classification system is based on the estimated ratio of differentiated to undifferentiated elements in the tumor.3 However, as squamous cell carcinomas usually exhibit a heterogenouscell population with differences in the degree of differentiation, it is difficult to determine the prognosis of thetumor by this system.4 A new multi-factorial grading systemput forth by Anneroth emphasizes on the morphologic features of tumor cells, the degree of differentiation of thecells and the tumor host response5 (Fig 2). In addition; Bryneet al found that deep invasive tumor cells appeared to be histologically less differentiated than cells in the more superficial parts.6 Thus, malignancy grading at the invasivemargins (‘Invasive front grading”) has shown to be of higher prognostic value



15

Solomon / Rao / Carnelio

Histochemistry

The application of special stains such as PeriodicAcid Schiff (PAS) is becoming a part of routine histology.PAS stain reveals the loss of glycogen content in the dysplastic epithelium, areas of discontinuity of the basement membrane and colonies of candidal hyphae.7 Byobserving the staining pattern of the basement membranein PAS stained sections, areas of tumor invasion can beidentified. (Fig 3)

Nucleolar organizer regions (NORs) are segmentsof chromosomes that are encoded for rRNA and are present on specific loops of DNA. Some of the NOR associated proteins can be demonstrated as black dots ofby silver staining techniques and are know as AgNORs.8 Inpoorly differentiated OSCC, AgNORs appear as exceedingly numerous tiny black dots that are more irregular in size and shape (Fig 4) than the AgNORs inwell- differentiated OSCC. The number of AgNORs pernucleus reflects the rate of cellular proliferation of the neoplasm and a higher AgNOR count suggests a poorprognosis.9

Immunohistochemistry

The advent of monoclonal antibodies to various cellular antigens resulted in discovery of several tumor markers.Immunohistochemical methods recognize antigen-antibody complexes with the help of a chromogen. lmmunohistochemical techniques have an. advantage overother techniques because the tissue architecture is intact, thecell-cell relationship is maintained and proliferating cells can be visualized in relation to other histological features.Immunohistochemical techniques can be utilized to identifyepithelial surface antigens, intercellular products,constituents of the basement membrane, markers of cell proliferation, and changes in the adjacent connective tissuestroma, oncogenes and oncosupressor genes.

Immunohistochemical staining procedures havedemonstrated overexpression of Epidermal growth factor(EGFR) in OSCC. EGFR immunoreactivity extends to alllayers of the epithelium in OSCC.10 Higher levels of EGFRmight enable tumor cells to respond to low levels of epidermal growth factor that is not mitogenic to normalcells.11 Overexpression of EGFR also predicts a decrease inpatient survival.12

Cytokeratins are intermediate filament proteinthat maintains the cytoskeletal framework of epithelialcells. Immunohistochemical techniques carried out onfrozen tissue samples using a panel of antibodies againstsimple keratins revealed variations in the keratin profilesaccording to the tumour differentiation. Analysis of keratin expression refines both tumour diagnosis and subsequently prognosis13 Keratin expressions have alsobeen used to determine whether a poorly differentiatedtumour is of epithelial or mesenchymal origin.14

Laminin, a basement membrane associated glycoprotein is distributed exclusively in the epithelial portion of the basement membrane.

Immunohistochemical staining reveals the presence of laminin in invasive tumors with well definedtumor host borders and cohesive patterns of stromal invasion (Fig 5). Invasive carcinomas with irregular cordsor single tumour cells distributed throughout the host stroma invariably lack laminin at the tumor-host interface.15 The balance between basal lamina productionand degradation is an important aspect of tumor invasion.Tumor cells that can produce basement membrane components belong to differentiated cell phenotype.16

Tenascin is extracellular matrix glycoprotein synthesized by fibroblasts and muscle cells. It appears tobe involved in epithelial mesenchymal interactions duringembryogenesis and tumor development and acts as a signaltransduction extracellular protein. Squamous cell carcinomas almost invariably show intense and extensivestromal tenascin immunoreactivity being more distinct atthe advancing edges of the tumor islands.17 Expression oftenascin is closely associated with invasive and metastaticpotential of the tumor.18

Proliferation of cells is the key characteristic feature of a tumor. Proliferating cell nuclear antigen(PCNA) is a 36KD, non-histone acidic nuclear proteinwhich is synthesized in the G1 and S phase of a cell cycle.It is necessary for cell cycle progression and cellular replication.l9 Increased expression of PCNA is seen only inwell differentiated and moderately differentiated squamous cell Carcinomas. While the proliferating cells inpoorly differentiated squamous cell carcinoma are in astate of the cell cycle with undetectable levels of PCNA20

Oncogenes may be associated with differentstages of neoplasia. Immuno-reactivity of C-myc oncogene is seen in the nucleus, perinuclear cytoplasm andentire cytoplasm of cells in the mitotic phase. The expression of these genes is found among the proliferatingcells of the tumour.21 Over expression of the ras family ofgenes occurs commonly in squamous cell carcinomas ofthe head and neck region. Immunohistochemical studieshave shown that the expression of these genes was more inlarger tumors and in the later stages of the tumourigenesis.22

Oncosuppressor genes are regulators of cell proliferation. P53 gene produces a protein that usuallyblocks the progression of cell growth. Mutations in the p53gene are found to be the most common genetic alterationin OSCC. Immunohistochemical techniques detect mutantforms p53 (Inactive p53). Elevated levels of p53 gene arefound in patients who are heavy smokers and alcoholics.This indicates that the carcinogens in tobacco and alcohol are responsible for the mutations in the p53 oncosuppressor gene.23

16

Oral Squamous Cell Carcinoma – Relevant Laboratory Diagnosis

Fig 1: Photomicrograph showing exfoliated oral epithelialcells exhibiting Nuclear hyperchromatism and increasednuclear-cytoplasmic ratio (Papanicalaou stain-40X)

Fig 2: Photomicrograph showing highly keratinized,well delineated tumor Islands exhibiting mild nuclearpleomorphism invading the lamina propria and a moderate lympho-plasmacytic infiltration.(Haematoxylin and Eosin-10X)

Fig 3: Photomicrograph showing absence of basementmembrane and presence. Of tumor islands in the lamina propria (Periodic Acid Schiff stain -10X)

Fig 4: Photomicrograph showing increased number ofsmall, well separated AgNORs in the nucleus of tumorcells in Oral Squamous cell carcinoma (Silver stain-40X)

Fig 5: Photomicrograph showing the expression oflaminin in the basal lamina around tumor islands.(Immunohistochemical stain -40X)

Fig 6: Photomicrograph showing bright and uniforminter-cellular substance demonstrated by indirectimmunofluorescence in tumor islands(Immunoflourescent stain 40X)

17


Immunofluorescence

The cell surface of malignant cells exhibits profoundalterations. It could be loss of surface antigens or the appearance of new antigens. Indirect immunofluorescencewith sera from pemphigus patients can demonstrate intercellular substance (ICS) antigen (Fig 6). Absence of lCSreactivity indicates the presence of cellular atypia.24 The intensity and pattern of immunofluorescence staining is related to the degree of differentiation. Few individual cellsshow intercellular substance reactivity in highly anaplasticsquamous cell carcinoma. Antigen loss represents impaireddifferentiation of neoplastic cells and which facilitates localtumour invasion.25

Electron Microscopy

Although, ultrastructural studies may not be utilizedmuch in routine diagnostic procedure, it can add to understandthe biology of the disturbances in epithelial differentiation incarcinomas. The changes observed are alterations of nucleiand nucleoli, cellular organelles, tonofibrils, cell membrane,desmosomes, and basement membrane. Loss or decrease inthe number of keratohyaline granules. dyskeratosis necrosis,Fibrillar dyskeratosis ,formation of immature keratin withremnants of organelles, lack of stable membrane formationand organoid keratosis( Keratin pearls).26 Electron microscopicstudies have also shown that malignant cells are ovoid,pleomorphic and larger compared to normal epithelial cells27

Flow cytometry

Flow cytometry is a fast and automated techniqueof measuring the nuclear DNA content of 20,000-50,000cells with accuracy, resolution and reproducibility.28 Flowcytometric analysis enables elucidation of characteristicfeatures of malignant tumor cells that cannot be clarifiedby routine histopathological methods. In OSCC as thedegree of differentiation decreases from well to poor theincidence of aneuploidy increases.29 Patients with diploidtumors have a significantly longer relapse- free and survival period than those with aneuploid tumors.30

In-situ hybridization

In-situ hybridization permits the direct analysis ofDNA or RNA in tissues. Thus, specific cells, population ofcells or chromosomes can be detected. This method is a.combination of advanced technology and light microscopyfor detecting virus infected cancer cells. The host cell forHuman Papilloma virus (HPV) is a keratinocyte and theviral genome can be detected by localization of a specificHPV DNA sequence, In situ hybridization with HPV-16DNA, probes shows nuclear hybridization in well-differentiated parts of the tumour while in poorly differentiated areas hybridization is absent.31

Southern Blot hybridization

This is a molecular technique for the analysis ofgenes wherein oncogene probes are utilized to identifygene amplification; Oncogene C,erb-.l is amplified andoverexpressed in oral carcinoma cell lines.32 A 2 fold-11fold amplification of Int-2 oncogene has been detected inSquamous cell carcinomas of the head and neck.33

Polymerase chain reaction

OSCC subjected to Polymerase chain reactiontechnique show cells containing DNA HPV 16, HPV 6,and HPV 18. This supports the concept of HPV as an etiological factor of OSCC wherein the virus probably actssynergistically with other carcinogens.34

Analysis of cell products in circulating blood

Serum markers that are of prognostic value fororal squamous cell carcinoma are mainly immune-related circulating substances such as immune complexes, complement binding molecules. interlukins.immunoglobulins and leukocytes.35 Elevated serum levelsof complement binding molecules and IgA was found tosignify a poor prognosis.36

Serum level of _2 microg1obulin is increased inpatients with Squamous cell Carcinoma. _2 microglobulin isa cell membrane component that is related to HLA domain.An accelerated cell membrane turnover or accelerated celldivision could increase its release into the circulatory system.Malignant cells release _2 microglobulin more rapidly thannormal cells37

Laser Spectroscopy

Small primary tumours shed viable tumour cells, anentire array of enzymes and surface molecules into the circulatory system. Techniques have made use of the presenceof these bimolecular in physiological samples like blood andsaliva for early detection of tumors. Defensin 1 a specific peptide has been detected in the saliva of OSCC patients.38

Laser induced fluorescence spectroscopy is capable of detecting and recording the spectra of sub picograms of proteins as they flow past a probing laser beam.39

Oral squamous cell carcinoma is a life threatening disease of oral tissues. Its pathogenesisincludes dysplastic transformation of normal oral epitheliafollowed by invasion into the underlying connective tissue.Although the assessment of the biological potential ofOSCC relies on light microscopic histological examination, more sensitive tests are employed to identifytumor markers. These tumor markers have become diagnostic tools as they herald malignant transformationand some have been found to be excellent prognostic indicators. Advances in immunohistochemical techniquehas opened avenues for single formalin fixed, paraffinembedded biopsy specimen to be subjected to a battery of

18

Oral Squamous Cell Carcinoma – Relevant Laboratory Diagnosis

monoclonal antibodies. The major recent advance in cancer research hopes to unravel the molecular mechanisms of oncogene activation.

The various diagnostic modalities (Table 1)enable an accurate assessment of tumor behavior and prog-nosis of individual cases, monitor the response to therapy,and provide the necessary information for formulating spe-cific and effective treatment regimes.

TABLE 1

DIAGNOSTIC IMPLICATIONMODALITY

Exfoliative Cytology Cellular atypia of exfoliated cells

Histopathology Grading of tumor

Identify changes in the basement membrane that

Histochemistry signifies tumor invasionDetect Nucleolar Organizer regions and identify proliferative cells

Expression of markers of cellular proliferation,

Immunohistochemistry basement membrane and cytoskeletal components,oncogenes and oncosu-pressor genes

Detect the presence or Immunofluoroscence absence of antigens of the

inter-cellular substance among tumor cells

Electron Microscopy Shows the Ultra structural features of malignant cells

Flow Cytometry Demonstrates Aneuploidy of tumor cells

In-situ Hybridization Viral genomes in the nucleus of tumor cells

Southern blot hybridization Enables amplification of oncogenes

Polymerase Chain reaction Viral genomes in the nucleus of tumor cells

Serum Analysis Presence of tumor markers in serum

Laser spectroscopy Detects biomarkers in serum and saliva

ACKNOWLEDGEMENT

Mr Shreepathy Upadhyaya, Senior Technician,Department of Oral Pathology, MCODS, Manipal

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19) Tsai S T, Jin Y T. Proliferating cell nuclear antigen expression in oral squamous cell carcinoma. J Oral PatholMed 1995:24:313-315

20) Mohanty L, Rao N N , Kotian M S Expression of proliferatingcell nuclear antigen (PCNA) in Leukoplakia and Squamous cellcarcinoma-An immunohistochemical study. Malaysian Dent J2002;23(1):65-71

21) Sakai H, Kawano K, Okamura K, Hashimoto N.Immunohistochemical loclization of C-myc oncogene product and EGF receptor in oral squamous cell carcinoma. JOral Pathol Med 1990;19(1):1-4.

22) Mc Donald J S, Jones H, Pavelic Z P, Pavelic LJ, StambrookP J, Gluckman J L. Immunohistochemical detection of the H-ras, K-ras and N-ras oncogene in squamous cell carcinoma of the head and neck J Oral Pathol Med1994;23:342-346

23) Field J K, Spandidos D A, Malliri A, Yiagnisis M, Gosney JR, Stell P M Elevated p53 expression with a history of heavysmoking in squamous cell carcinoma of the head and neck BrJ Cancer 1991;64:573-577

24) Tosca A, Varelzidis A, Nicolis G et al: Antigenic alterationsin tumors of epidermal origin. Cancer 1980;45:2284-2290

25) Bovopolou 0, SkIavounou A, Laskaris G. Loss of intercellularsubstance antigen in oral hyperkeratosis, epithelial dysplasiaand squamous cell carcinoma. Oral Surg Oral Med Oral Pathol1985;60:648-654

26) Burkhardt A. Advanced methods in the evaluation of premalignant lesions and carcinoma of the oral mucosa. J OralPathol Med 1985;14:751-778

27) Sow yeh Chen, Robert D. Ultrastructural findings in oralsquamous cell carcinoma. Oral Surg Oral Med Oral Pathol1977:744-753

28) Jalal Uddin M, Ruey-Bin C et al. Flow cytometric analysis ofsquamous cell carcinomas of the oral and maxillofacialregion with review of literature Indian J Dent Research1996;7(3) 81-95

29) Chen R B. Flow cytometric analysis of benign and malignanttumors of the oral and maxillo facial region. J OralMaxillofacial Surg 1989;47:596-560

30) Goldsmith M M, Cresson D H, Arnold L A et al. DNA flowcytometry as a prognostic indicator in head and neck cancer.Otolaryngol Head Neck Surg. 1987;96:307-318

31) Milde K, Loning T. Detection of papilloma virus DNA in oralpapillomas and carcinomas-application of in-situ hybridizationwith biotinylated HPV 16 probes. J oral Pathol Med1986;15:292-296

32) Yamamoto T, Kamata N, Kawano H et al. High incidence ofamplification of epidermal growth factor gene in humansqnamous carcinoma cell lines. Cancer Res 1986;46:414-416

33) Merritt W D, Weissler M C, Turk B F, Gilmer T M. Oncogeneamplification in squamous cell carcinoma of the head andneck. Arch Otolaryngol Head Neck Surg. 1990;116:1394-1398

34) Chang F, Syrjanen S, Nuutinen J, Syrjanen K. Detection ofhuman papilloma (HPV) DNA in oral squamous cell carcinoma by in-situ hybridization and polymerase chainreaction. Arch Dermatol Res 1990;282(8):493-497

35) Cohn S L, Lincoln ST. Present status of serum tumour markers in the diagnosis, prognosis evaluation of therapy.Cancer Invest. 1989;4:305-327

36) Schantz S T, Liu F J, Taylor D et al. The role of circulatingIgA to Cellular immunity in head and neck cancer patientsLarnygoscope 1998;98: 671--678

37) Manzar W, Raghavan M R V, Arror A.R, Murthy K R.Evaluation of serum _2 microglobulin in oral cancer. AustDent J 1992;37:39-42

38) Mizukawa N, Sugiyama K. Fukunaga J, et al. Defensin-l. apeptide detected in the saliva of oral squamous cell carcinoma patients. Anticancer Res 1998;18(6):4645-4649

39) Kartha.V B, Venkatakrishna K. Dept of Science andTechnology project. Govt of India "Investigation of Laserspectroscopy methods of early diagnosis of neoplasia:Development of instrumentation and analytical Techniques"project no. SP/SL/LOl/98


Professor Dr. Monica SolomonProfessorDepartment of Oral Pathology and Microbiology,Manipal College of Dental Sciences,Manipal 576104, India.Email: [email protected]

20

Amelogenesis Imperfecta with Gingival Hyperplasia and Anterior Open Bite –A Case ReportMadhu S. Senior Lecturer in Paedodontics, Govt. Dental College, Kozhikode, Kerala (state), India – 673008.

ABSTRACTAmelogenesis Imperfecta (AI) represents a group of hereditary defects of enamel due to ectodermal defects. It is found to beassociated with skeletal anomalies, gingival enlargements and systemic diseases like nephro calcinosis in many cases. A casepresentation of AI with skeletal anterior open bite and gingival hyperplasia was discussed. Various concepts of co-existence ofthese pathologies were compiled. The different treatment options, importance of multi disciplinary approach, and the importance of preserving the existing dental status in a healthy state was impressed upon.

Key words:amelogenesis imperfecta, dental defects, enamel

INTRODUCTION

Defects of the development of teeth can be broadlyclassified as followes:1

(a) Defects of development of tooth alone,(b) Dental defects in genetic syndromes,(c) Dental defects from acquired or metabolic disorders.

Amelogenesis Imperfecta (AI) represents a groupof hereditary defects of enamel due to ectodermal defects.Enamel formation occur in three stages i.e.; formative,calcification and maturation stages. The defect of enamelformation in these stages can lead to hypoplastic,hypocalcification and hypomaturation types of AI respectively.1,2 Inheritance is mainly autosomal dominant,but autosomal recessive also occur.2,3,4,5

Presented here is a case report of a 13 year oldfemale patient with AI associated with skeletal anomalyand gingival hyperplasia.

CASE REPORT

Clinical examination

A thirteen year old female patient presented at theDepartment of Paedodontics and Preventive Dentistry withcomplaints of yellowish, fragile and sensitive teeth.

There was no history of any systemic disease ormedication. Family history revealed consanguineous marriage. Nobody else in the family had this defect,except the younger brother who was 2_ years old. She was unsatisfied with previous dental treatment with overdenture.

Extra oral examination showed bimaxillary prognathism and anterior open bite. She showed frequenttongue thrusting and gave a history of mouth breathing(Fig. 1).

Intra oral examination showed generalized enlargement of gingival tissue with pseudo pocket in anterior region (Fig. 2), covering considerable amount ofthe crowns on the permanent teeth.



Figure 2 : Enlarge gingival tissue

Figure 1 : Extra oral view

Radiographic evaluation with OPG showed unerupted permanent canines and premolars (Fig. 5). Lateral cephal-logram showed skeletal anterior open bite with bimaxillary prognathism (Fig. 6).

Blood and urine analysis and ultrasound scan were carried out and no abnormalities were detected in any of theseinvestigations.

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Treatment

Treatment of AI with skeletal and gingival anomalies requires proper diagnosis and treatment planning. In mixeddentition period gingivectomy was done to improve the crown length and to eliminate pseudo pocket (Fig. 7). Compositeveneering of upper and lower anteriors to decrease the sensitivity, protect pulp and improve aesthetics and gain confidence of the patient was undertaken. Extraction of deciduous molars and canines followed by alveoloplasty to stimulate eruption of permanent canines and premolars was done. Stainless steel crowns for molars were done following root canal treatment to protect the teeth and to improve the vertical height.

All the permanent incisors and first molars were present except permanent right lower first molar which wasextracted earlier. Deciduous canine and molars were retained and were severely attrited (Figs. 3 & 4). Enamel defectswere found to be similar to hypoplastic type (Type I-G of AI)6,7 with granular and irregular surface morphology.

Figure 7 : Photograph gingivectomy

Figure 5 : Unerupted permanent

Figure 3 & 4 : Retained deciduous teeth

Figure 6 : Lateral cephalogram shows bimaxillary prognathism

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Amelogenesis Imperfecta with Gingival Hyperplasia and Anterior Open Bite – A Case Report

DISCUSSION

Amelogenesis Imperfecta (AI) I is defined as thoseinherited, congenital defects that primarily affect onlyenamel formation and are not accompanied by morphologicor metabolic defects in other body systems other than toothformation or eruption.6

Among various causes of AI, the mutations ofgenes which are primarily involved in amelogenesis is themost important mechanism.6 Consanguineous marriageand similar defect in the younger brother implies that thiscould be a possible cause in the present case too.

The clinical description of the teeth in this caseresembled AI type IG,6,7 showing rough, granular tooth surface with yellow discoloration. Anterior open bite andmultiple unerupted teeth are other features of this type ofAI.6 These features are seen in the present case also.

This type of AI showed association with conditioncalled nephrocalcinosis.8,9,10 as well in which renal tissueshowed abnormal foci of calcific masses. To rule outnephrocalcinosis, ultrasound scan and 24 hour urine citrateexamination were carried out. Ultrasound scan showed noevidence of calcification in renal tissue. A 24 hour urinecitrate output showed 3.5mg/kg/24hr which was normal(N= more than 2mg/kg/24hr). Therefore nephrocalcinosiswas ruled out.

Association of AI with skeletal anterior open bite iswell reported in literature.11,12,13 Witkop et al.14 associatedthis anterior open bite to local factors. They suggested thatsince the teeth in AI were rough and sensitive, this can leadto tongue trusting which in long run can lead to anterioropen bite. A more credible explanation was given bySchulze15 who reported anterior open bite associated withhypo plastic variety of AI in 3 families. He suggested thatthis open bite is more due to skeletal dysgnathia than localhabit. He also proposed the tongue thrusting as an effectrather than a cause of anterior open bite.

Rowley & Winter11 further gave support toSchulze’s15 proposed theory and gave an etiological modelfor anterior open bite. They proposed that the primary etiological factor for anterior open bite is vertical dysgnathia, which acts to increase the distance between themaxillary and mandibular base anteriorly leading to anterior open bite. Increased lower anterior facial height asseen in the present case can further lead to incompetentlips. Existing anterior open bite was increased or maintained by the abnormal position of the tongue.

Stewart & Prescot16 suggested that the common origin of enamel and cranio facial skeleton as the maincause of the co-existence of enamel and cranio-facialskeletal defects.

Biopsy report showed idiopathic gingival enlargement. This could be due to the mouth breathinghabit of the patient.2

Treatment of AI in mixed dentition period is variable. Importance should be given to preserve the existing dentition. Since pseudo pockets are seen in manycases of AI, gingivectomy as in present case may be needed. RCT, composite facings and ceramic crown are tobe considered systematically to improve function and aesthetics. Modifications of treatment like a semi fixedpartial denture as in present case may be needed in manycases to improve aesthetics and function.

CONCLUSION

The aetiopathogenesis and clinical presentation ofAI is variable. Skeletal anterior open bite is a commonproblem found associated with AI. Various concepts oftheir co-existence are discussed here. Treatment of AI withskeletal and gingival anomalies in mixed dentition periodis of long duration and complex. The treatment goalsshould be directed towards preserving the existing dentalstatus and improving it systematically through a multi disciplinary approach.

Once the eruption of incisors completed and crown length improved, metal-ceramic crowns were given. (Fig 8). A semi fixed partial denture of 13, 14, 23 and 24 was planned to improve aesthetics. It was prepared by attaching these teeth to a palatal wire running from buccal tubes of 16 and 26 (Fig 9 & 10).

Patient has to be evaluated further after growth completion. Orthognathic surgery may be needed finally toimprove skeletal open bite and bimaxillary prognathism.

Figure 8 : Placement of crowns Figure 9 : Placement of partial denture Figure 10 : Extra oral view pro-operative

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REFERENCES

1) Roderick AC, John WE. Oral pathology and diagnosis.Colour atlas with integrated text 1st edn. William Heinmann.Medical Books. London, 1987:2.2-2.3.

2) William GS, Maynard KH Hine, Barnet ML. A text book ofOral Pathology 4th edn: W B Saunders Co, 1983:51-53.

3) Seow WK. Clinical diagnosis and management strategies ofamelogenesis imperfecta varients. Pediat dent 1993;15:384-393.

4) Seow WK. Enamel hypoplasia the primary dentition: areview. ASDC1991;58:441-52.

5) De Sort KD. Amelogenesis Imperfecta, the genetics,classification and treatment. J Prosthet Dent 1983;49:786-92.

6) Witop CJ Jr. Amelogenesis Imperfecta, dentinogenesisimperfecta and dentin dysplasia revisited. problems in classification. J Oral pathol 1989;17:547-553.

7) Sundell S, Valentin J. Heredity aspects and classification ofheriditory Amelogenesis Imperfecta. Comm Dent OralEpidemiol 1986;14:211-16.

8) Isabelle NT. Amelogenesis Imperfecta and nephrocalcinosis:a new case of this rare syndrome. J Clin Pediat Dent2002;27:171-176.

9) Mac Gibbon D. Generalised enamel hypoplasia and renaldysfunction. Aust Dent J 1972;17:61-63.

10) Hall RK, Phakey P, Palamara J, Mc Credi DA. AmelogenesisImperfecta and nephrocalcinosis syndrome. Case studies ofClinical feature and ultra structure of tooth enamel in two siblings. Oral Surg Oral Med Oral Pathol Oral Radiol End1995;79:583-592.

11) Rowley R, Winter GB. An investigation of the associationbetween anterior open-bite and amelogenesis imperfecta. AmJ Orthod 1982;81:229-35.

12) Subtelny JD, Sakuda M. Open-bite: Diagnosis and treatment.Am J Orthod 1964;50:337.

13) Nahoum HI, Horowitz SL, Benedicto EA. Varities of anterior open bite. Am J Orthod 1972;61:486.

14) Witkop CJ, Rao S. Inherited defects in tooth structure. Birthdefects 1971;8:153.

15) Gorlin RJ, Goldman HM, Schulze, Thoma’s Oral Pathology6th edn. St Louis: The CV Mosby Co., 1970:130.

16) Stewart RE, Prescott GH, Oral Facial Genetics. 1st edn . StLouis: The CV Mosby Co., 1976:46.


Dr. Madhu S. Senior Lecturer in Paedodontics,Govt. Dental College, Kozhikode,Kerala (state), India – 673008Email: [email protected]

24

Orthodontics and Restorative Management of Hypodontia in an Adult:A Case PresentationHow KC MSc. Orthodontics (London), How’s Orthodontic and Specialist Clinic, Bangsar, Malaysia.

ABSTRACTTreating patient with hypodontia is a challenging and yet rewarding experience for the clinician. Patients with hypodontia donot merely present with lesser number of teeth, it comes along with other problems such as microdontia and asymmetry ofdental centreline to the facial midline. Other orthodontic problems are deep overbite, spacing and rotation of teeth. The congenital absence of teeth can seriously disable a person both physically and emotionally, especially during the turbulentyears of adolescence. There are reports of the impact of self confidence on the social life of patients with hypodontia. There ismuch to be gained from the interdisciplinary management of young people who have hypodontia. Hypodontia does not present in isolation but it is related to the frequency of other missing teeth, the size of the remaining teeth and the rate of dental development. An early investigation has shown that there is an antero-posterior gradient in relative crown size reduction and a posterior-anterior gradient for tooth formation in people with missing third molar teeth. This article highlights the comprehensive management of a patient with hypodontia

Key words:hypodontia, orthodontics, restoration

INTRODUCTION

Hypodontia is a genetic condition that is characterized by congenitally missing tooth or teeth.1 It isusually genetically linked, polygenic and autosomal recessive.2 The tooth/teeth that is missing is usually thedistal end of the dental lamina germ,3 for instance, lateralincisor in the incisor region, second premolar in the premolar region, third molar in the molar area. Patient canhave one or multiple missing teeth. In patients who suffered from multiple missing teeth, they usually havesmallish teeth (microdontia) and aberrations in tooth sizeand shape.4 Hypodontia occurs in up to 7% of the UK population5 but is more prevalent in some conditions,notably, ectodermal dysplasia, Down syndrome and cleftsof the lip and palate.6

The clinical significance of Hypodontia is that itposes a severe aesthetic, functional, periodontal and ortho-dontic problem to the patients and its managementinvolves Paedodontics, Restorative Dentistry andOrthodontics,7,8,9 This article describes the comprehensivemanagement of a patient with hypodontia.

CASE DISCUSSION

A young adult Chinese lady, age 28 years, presentswith a severe Hypodontia with a total of 14 missing permanent teeth in both upper and lower arches. The missing teeth are bilateral upper lateral incisors, upper andlower right first and second premolars, and lower left second premolars, lower bilateral second and third molarsand upper bilateral third molars; these are consistent with thetheory that they are the teeth that situated at the distal end ofthe dental lamina germ. According to the patient, she wasunhappy with her smile because it was “off-centred”, spacingin between the teeth and the incisors are “pointed” in shape(Figure 1). She had sought treatment from many dentists butwas told that nothing could be done.

Clinical presentation

Patient presented with edge to edge Class III incisor relationship on a mild skeletal III base, slightlyhigh mandibular plane angle but average anterior lower facial height proportion. The OPG revealed multiple missing teeth (Figure 2). The lateral Cephalographrevealed the mild Class III skeletal profile with anincreased mandibular plane angle (Figure 3).



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There was no jaw asymmetry; however there wasdental asymmetry due to centerline shift. This presentedwith the “off-centred” smile which had been bothering thepatients for many years. The upper and lower arches werespaced apart due to multiple missing teeth, the teeth weresmaller and pointed in size and the bone in the edentulousareas were resorbed.

Buccal segment was not well occluded because ofmultiple missing teeth in the posterior region. There waseven an over-eruption of the upper right first molar due to

absence of the lower corresponding tooth. Therefore thepatient rely heavily on the anterior teeth for function(Figures 4 & 5).

In essence, she presented with aesthetic, functionaland periodontal problem and potential temporo-mandibular joint dysfunction problems. Treatment planwas formulated after the preliminary investigation and acomprehensive treatment of orthodontic and restorativetreatment plan was proposed to the patient.

Figure 1. The “off-centered” smile – notice that the incisors had drifted to the left due to missing left lateral incisor. Themicrodont teeth and lack of “Golden Proportion” as well as spacing of teeth also contributing to this unaesthetic smile.

Figure 2. Panoramic radiograph confirms total missing of 14 permanent teeth. Notice the mesial tipping of teeth, spacingof teeth and overeruption of upper right molar and left premolar in the absence of opposing lower teeth.

Figure 3. The lateral Cephalographreveals the mild Class III skeletal profile with an increased mandibularplane angle. This is a “blessing-in-disguise” for the patient as the edgeto edge bites prevents deep overbiteand the high mandibular plane angle prevents deepening of skeletaldeep bite which is a very difficultorthodontic problem to deal with in hypodontia patient.

Figure 4 & 5. Note the spacing and rotation of teeth in the spaced upper arch. The bone in the edentulous area is resorbed. According to the Functional Matrix Theory, if there is no teeth in an area,the alveolar bone would resorb because there is no functional stimulation.

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Orthodontics and Restorative Management of Hypodontia in an Adult: A Case Presentation

Treatment planning

The principal aims in orthodontic treatment are tocorrect the unfavourable position of teeth such as rotation,tipping of teeth and the appropriate spatial position of teethin relation to the dental arch. This would then create anocclusion which is conducive for the subsequent restorativemanagement. The final objective for the restorative management is the maintenance of aesthetic and function.

Orthodontic Treatment for Hypodontia patient

The restorative management of spacing is oftenhampered by unfavorable tooth positions of the teeth thatare present and the result can therefore be compromised. Inmany cases of hypodontia, orthodontic treatment cangreatly facilitate any restorative treatment or sometimeseven eliminates the need for it. Orthodontics can help torectify problems such as unfavorable space distribution,tooth alignment and deep overbite

Patients with hypodontia often present with a number of associated traits that should be considered priorto determining the definitive orthodontic treatment plan. Inmost patients there is a tendency of reduced mandibularplane angle, associated with reduced anterior lower faceheight and lip protrusion which becomes more markedwith increasing severity of the hypodontia. Intra-orally,retroclination of lower incisors, increase in the inter-incisalangle and over-eruption of the lower incisors alsofrequently contribute to an increased overbite. The spacedarch also increase the possibility of rotation of teeth duringeruption.

The orthodontic treatment plan for this hypodontiapatient is:

1. Space management2. Uprighting and aligning teeth3. Management of overbite4. Restorative management5. Retention and stability

1. Space ManagementThe following factors should be considered in the treatment planning for space management:

i) Severity of hypodontiaIn this case, the patient had a total of 7 missing teeth inthe upper arch and the lower arch respectively. Withsuch a large number of missing teeth, it is not practicalto close up all the spaces as the dental arch lengthwould be reduced too much. This would severely compromise function. It was decided to open up thespace for the missing upper lateral incisors for aesthetic purpose and to shorten the missing premolarsby one unit. The mesially tipped molar would beuprighted. The missing units would eventually bereplaced with a combination of bridge and implants.

ii) Degree of crowdingCrowding does not exist in this case. As has beendescribed above, space is open up for the replacementof the upper laterals for aesthetic purpose. The objective is to re-create the “Gull-wing” appearance10

as well as to obtain the “Golden proportion”11,12 in theupper anterior segment. In the posterior segment, thepatient agreed not to restore the missing second andthird molars. The edentulous space on the upper leftsecond premolar was closed orthodontically. The edentulous space on the upper right side was shortenedby one unit. The overerupted molar was leveled.

2. Uprighting and Aligning TeethAs well as closing space or optimizing its distributionin the arch, orthodontic treatment can also improve thealignments of the teeth to facilitate the provision ofprostheses. Many of these procedures, rather thanbeing described as definitive orthodontic treatment; fitmore closely into the adjunctive category with limitedorthodontic goals. Common examples are uprightingtilted teeth, correction of rotated teeth and forced tootheruption (extrusion) to improve crown length prior torestoration. Uprighting molars can aid in the preparation of abutment teeth, improve distribution ofocclusal forces and re-establish marginal ridge relations. The following questions need to be answeredprior to tooth uprighting include:

• Is space required distal to the tooth to be uprighted?• Should the tooth be uprighted by crown movement,

root movement or a combination of both?• Should extrusion of the tooth be permitted with the

uprighting procedure?• Does the tooth at the other side of the space require

any tooth movement?

In this case, the treatment plan was to consolidate thespacing of the lower anteriors, establish a good inter-incisor angle with adequate root torque, derotatethe premolar and upright the mesially tipped molars(Figure 6 & 7).

3. Management of OverbiteOverbite correction is extremely difficult in hypodontiacase with uprighted or retroclined incisors and largeinter-incisal angle. Chung et al13 found that patientswith hypodontia showed a tendency to a Class IIIskeletal pattern. In this case, although we are fortunateto have an edge to edge bite that prevents the deepening of the overbite, we have to bear in mind thatafter correcting the Class III edge to edge bite into aClass I incisor relationship with positive overjet andoverbite, there is a high likelihood that the overbitewould be deepened iatrogenically. Therefore it isimportant to torque the root sufficiently and maintain a

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good interincisal angle to maintain the overbite.14 It is also important to upright the molar and establish a good posterior support to reduce wear of the anterior teeth as well as to maintain the overbite control (Figure 8 & 9).

Figure 6 & 7. Most patients with severe hypodontia tend to have deepening of overbite and low mandibularplane angle. This patient is fortunate that the incisor is biting at an edge to edge relationship (due to mildskeletal III) thereby preventing the deepening of the overbite although there is a large inter-incisal angle.

Figure 8. The edentulous space on the upper left second premolar was closed orthodontically.

Figure 10. The polycarboxylate crowns were bonded with orthodontic brackets and supported by rigid archwire. Note the gingival levels of the polycarboxylate laterals is higher than the central incisors. This is not aesthetic for it should be the other way round.

Figure 9. The edentulous space on the upper right side was shortened by one unit. Notice the overerupted molar had been levelled.

4. Restorative ManagementAt the end of the orthodontic phase, the arches wereleveled, the teeth were uprighted and spaces were consolidated (Figure 10). The Class III edge to edgebite was corrected into a Class I incisor relationshipwith good inter-incisor angle and adequate incisortorque and inclination and adequate posterior support.

It is vital to assess the smile line before the restoration; thisinclude the amount of vertical incisor exposure, the widthof smile, the lip length, the size of tooth, colour/shade oftooth. The gingival level of the lateral incisors tends to behigher than the central incisors because of bone resorptionin the missing lateral incisor areas. Hence this may affectthe aesthetic outcome of restorations.

While the gingival level of the final prosthesis in thiscase is not ideal, it was fortunate that the patient has alow lip line. Her smile line is adequately concealed thisdeficiency (Figure 11). The lower missing teeth wouldbe restored by dental implants in future.

5. Retention and StabilityAt the end of the orthodontic treatment, it is important toplan a retention and stability scheme for the patient. Thecontemporary practice normally tends to favour the

immediate restoration of the missing teeth after orthodontic treatment.15 A Vacuum-formed rigid retainerwas made immediately after debond. Having made theretainer, the bridge was then prepared and a provisional

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Orthodontics and Restorative Management of Hypodontia in an Adult: A Case Presentation

bridge was shaped according to the vacuum formed retainer. This temporary prosthesis functioned as part ofthe fixed retainer to maintain the stability of the arch post-orthodontically while waiting for final restorations.

Eventually, the upper anterior teeth were splinted by theEmpress II bridge from the central incisor to canine bilaterally (Figure 12 & 13). However, there is a possibility that a central diastema may open up inbetween the central incisors in the event of overloading inthe incisor area and a lack of posterior support. Because

of this, the patient was advised to wear the retainer nighttime for a prolong period of time. The patient was furtheradvised to restore the lower edentulous areas to maintainthe stability of posterior support.

In the lower arch, it is vital to have a tight fitting Vacuum-formed retainer so that the teeth are well supported and themolar would not tip into the edentulous space. Until suchtime when the lower edentulous space is restored with dental implants or fixed bridge, it is important for thepatient to wear the retainer full time.

Figure 11. The smile line showing adequate verticalincisor exposure and lateral width eliminating the lateral corridor appearance. The symmetry of the smilehas also been restored.

Figure 12. The arches had been levelled, teeth uprighted and spacesconsolidated. The missing upper laterals had been restored by twoEmpress II Bridges spanning from the central incisor to the caninebilaterally. On the side, there is a non-supported free and pontic.The lower missing teeth would be restored by dental implants infuture. Notice that the Empress II material has almost the sameradiographic appearance as the natural teeth. This is because theyhave similar optical refractivity index as the natural tooth.

Figure 13. The lateral Cephalographshows a nice Class I incisor relationship,good inter-incisor angle and adequateposterior support after the orthodontictreatment and the restoration of thebridge.

Figure 14 & 15. Comparison of smile line before and after the treatment. Noticethe smile is symmetrical now, the vertical incisor exposure is satisfactory andinter-canine width of smile is adequate. Patient is happy with the end result.

Before After

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Comparison of Smile lineBy comparing the smile line before and after the treatment, the smile is symmetrical after treatment. The vertical incisor exposure is satisfactory and inter-canine width of smile is adequate. It is worth noting that even the hair style and the make up haschanged after the change of a new smile. Patient is nowa happy and sweet lady with improved self-esteem.

CONCLUSION

Orthodontics and restorative treatment can do wonders in restoring missing teeth in patients withhypodontia. As has been noted in this case, patient hasdrastic improvement after treatment (Figure 14 & 15) andeven has an improved self-esteem.

REFERENCES

1. The American Heritage® Stedman's Medical Dictionary,1995. Houghton Mifflin Co.

2. Suarez BK, Spence MA. The genetics of hypodontia. J DentRes 1974;53:781-785.

3. Carter NE, Gillgrass TJ, Hobson RS, Jepson N, Meechan JG,Nohl FS, Nunn JH. The interdisciplinary management ofhypodontia: orthodontics Br Dent J 2003;194:361-366.

4. Butler PM. Studies of the mammalian dentition.Differentiation of the post-canine dentition. Proc Zoo Soc(Lond) 1939;109:1-36.

5. Hobkirk JA, Goodman JR, Jones SP. Presenting complaintsand findings in a group of patients attending a hypodontiaclinic. Br Dent J 1994;177:337-339.

6. Meon R. Hypodontia of the primary and permanent dentition.J Clin Paed Dent 1992;16:121-123

7. Schalk-vander Weide Y, Bosman F. Tooth size in relatives ofindividuals with oligodontia. Arch Oral Biol 1996;41:469-472.

8. Nunn JH, Carter NE, Gillgrass TJ, Hobson RS, Jepson NJ,Meechan JG, Nohl FS. The interdisciplinary management ofhypodontia: background and role of paediatric dentistry2003:194:245-251

9. Jepson NJ, Nohl FS, Carter NE, Gillgrass TJ, Meechan JG,Hobson RS, Nunn JH. The interdisciplinary management ofhypodontia: restorative dentistry 2003;194:299-304

10. McLaren E, Rifkin R. Macroesthetics: Facial and DentofacialAnalysis. J Calif Dent Assoc 2002;30:839-46

11. Dürer A. Vier Bucher von menschlicher Proportion, 1528.12. Levin E. Dental esthetics and the Golden Proportion. J

Prosthetic Dent 1978;40:244-252. 13. Chung L, Hobson R, Nunn J, Gordon P Carter N. An

analysis of the skeletal relationships in a group of young people with hypodontia J Orthod 2000;27:315-318.

14. Peck SKL, Kataja M, Site specificity of tooth agenesis insubjects with maxillary canine malpositions. Angle Orthod1996;66:473-476.

15. Thind b, Stirrups D, Larmour C, Mossey P Management ofhypodontia: Orthodontic considerations (II). QuintessenceInt 2005;36:345-53.


Dr. How Kim ChuanBDS (S’pore), MSc. Orthodontics (London),FDS RSC (England), FDS RCSEd (Edinburgh),MORTH RCS (England), MORTH RCSEd (Edinburgh)How’s Orthodontic and Specialist Clinic,Bangsar, Malaysia.Email: [email protected]

30

Non-extraction Orthodontic Treatment in Management of Moderately CrowdedClass II Division 2 Malocclusion: A Case ReportOthman SA MOrth RCS (Edinburgh), Lecturer, Department of Childrren’s Dentistry and Orthodontics, Faculty ofDentistry, University Of Malaya, 50603 Kuala Lumpur, Malaysia.

ABSTRACTA case report of a 13-year old male presented in his mixed dentition stage with a Class II division 2 incisor relationship on amild Class II skeletal base, complicated by an increased overbite, retroclined upper and lower incisors (bimaxillary retroclination) and moderate crowding in the upper and lower labial segments. Treatment was undertaken without extractionemploying an upper removable appliance with a flat anterior bite plane to correct the overbite, and an anterior screw to proclined the upper incisors while waiting for the eruption of the permanent teeth. Pre-adjusted edgewise fixed applianceswere placed in the lower arch, then in the upper arch to level and align the dentition, achieve Class I incisor relationship,reduced the interincisal angle and close residual spaces.

Key words:Orthodontics, Non-extraction, Class II division 2 malocclusion

INTRODUCTION

The definition of Class II division 2 malocclusionsby the incisor relationship is the lower incisor edges arepalatal to the cingulum plateau of the upper incisors.1 Theoverbite is increased and the upper incisors (and usuallythe lowers) are retroclined, with minimal overjet althoughit maybe increased. Characteristically, the lateral incisorsmay be proclined, mesially angulated, and mesiolabiallyrotated.2 Todd and Dodd2 reported that in the UnitedKingdom population, the incidence of Class II division 2malocclusions is 5 %. Other studies suggested 10 to 18 %.3

Currently the incidence in Malaysian population has notyet been studied.

The common method to relieve crowding in moderately to severely crowded upper and lower arches isby extraction. The reasons for elective extractions in orthodontics are for relief of crowding, overjet and overbite reduction, anchorage considerations, buccal segment relationship correction and also to retroclinedlower incisors for the correction of the Class III incisorrelationship. Several disadvantages have also been proposed. There are mandibular dysfunction,4 a less attractive facial appearance,5 longer or more difficult treatment, pain, anxiety and other possible adverse effectsof the actual extraction procedure.

Treatment of Class II division 2 malocclusions arebest managed with non-extraction approach especiallypatients with a low mandibular plane angle and deep

overbite, to avoid retraction of the incisors and protractionof the molars.6 Both of these movements will further deepen the overbite. In this case, a treatment of non-extraction for moderately crowded upper and lower segments in a Class II division 2 malocclusion will be presented.

CASE REPORTS

A 13-year old male presented at a new patientorthodontic clinic complained of crooked teeth of theupper and the lower arches. Clinical examination revealeda mild Class II skeletal base with average Frankfortmandibular planes angle. No facial asymmetry detectedand no TMJ clicking on opening and closing or on lateralexcursions. The lips were competent at rest and the lip linewas high. The oral hygiene was fair with a few localiseplaque deposits on intra-oral examination. The dentitionwas in a mixed dentition stage (Figure 1). Erupted teethpresented were;

6 E 4(p.e) 3(p.e) 2 1 1 2 C D E 6

7 6 5 4 3(p.e) 2 1 1 2 3(p.e) 4(p.e) 5(p.e) 6

(p.e – partially erupted)



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Othman

The upper and lower labial segments were moderatelycrowded with well align buccal segments. In occlusion, theincisor relationship was Class II division 2 with increasedoverbite and complete to teeth, and the overjet was decreased.The molar relationships were Class I. However, the upper second deciduous molars were still present at examination,and the molar relationships are expected to be Class II whenthe upper second deciduous molars exfoliated. This mesialdrift of the upper permanent first molars is for the closure ofthe leeway space following the eruption of the permanentcanines and premolars.

Radiographic examination on the dental panoramictomogram (Figure 2) showed normal development and thepresence of all permanent teeth. The root length and morphology of all the teeth was normal. Lateral cephalometric analysis (Table 1) confirmed that the patienthas a mild Class II skeletal base (ANB value: 5º). Themaxillary mandibular planes angle appears to be low butwas still within normal values. The upper and lower anterior face heights appear to be decreased although theface height ratio was slightly increased at 57%. The lowerincisors were retroclined at 82º to the mandibular plane

Figure 1. Pre-treatment intraoral photographs showing anterior view (in maximum intercuspation),right buccal view, left buccal view, maxillary occlusal view and mandibular occlusal view.

Figure 2. Pre-treatment dental panoramic tomogram showing the present of all permanent teeth.

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Non-extraction Orthodontic Treatment in Management of Moderately Crowded Class II Division 2 Malocclusion: A Case Report

and the upper incisors were also retroclined at 100º to themaxillary plane. This bimaxillary retroclination leads to anincreased interincisal angle. The lower incisor to APo lineand lower lip to Ricketts E Plane values were decreased.

Table 1. Pre-treatment cephalometric values.

Variable Pre-treatment Normal

SNA 81º 82º ± 3

SNB 76º 79º ± 3

ANB 5º 3º ± 1

Upper incisor to maxillary plane angle 100º 108º ± 5

Lower incisor to mandibular plane 82º 92º ± 5

Interincisal angle 155º 133º ± 10

Maxillary mandibular planes angle 23º 27º ±5

Upper anterior face height 46.5 mm

Lower anterior face height 61.5 mm

Face height ratio 57% 55%

Lower incisor to APo line -4.5 mm 0-2 mm

Lower lip to Ricketts E Plane -7.5 mm -2 mm

Sources of normal values: Jacobson (1975) Am J Orthod. 67:125-133.

Houston JWB, Stephens CD & Tulley WJ (1992)

A textbook of orthodontics. Wright, Oxford.

A treatment plan was formulated:1. Upper removable appliance with an anterior screw

to procline the upper incisors and a flat anterior bite plane for overbite correction.

2. Await eruption of all of the permanent teeth3. Lower pre-adjusted edgewise fixed appliance

(MBT™ prescription, 0.022” x 0.028” slot)4. Upper pre-adjusted edgewise fixed appliance

(MBT™ prescription, 0.022” x 0.028” slot)5. Bonded retainer on the lower labial segment from

lower right canine to left canine, and upper and lower removable vacuum-formed retainers.

Orthodontic treatments commenced in May 2003with upper removable appliance with an anterior screw anda flat anterior bite plane to procline the upper incisor andreduce the overbite (Figure 3). Lower fixed appliance wasfitted 6 months later with progression through light nickeltitanium wires (0.012”), up to 0.020” Australian stainlesssteel. In June 2004, the upper removable appliance treatment was stopped after changing the appliance twicein order to accommodate the changes in the inclination ofthe upper incisors. Upper fixed appliances was then fittedand also with the progression through light nickel titaniumwires, up to posted 0.019” x 0.025” stainless steel workingarchwire. The centre-line and the buccal segment corrections were done by starting the patient with class IIintermaxillary elastics, full time wear with different forceon the right and left side.

Lateral cephalometric radiograph and dentalpanoramic tomogram were taken one visit before debondto check the inclination of the upper and lower incisors and

Figure 3. Intraoral photographs showing maxillary occlusal view with the upper removable appliancefor the overbite and overjet corrections; anterior view, right buccal view and left buccal view withlower pre-adjusted edgewise fixed appliance with 0.012” nickel titanium archwire in-situ for initiallower arch alignment

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Othman

the root parallism. The active appliances were removedafter 2 years of treatment, and the patient provided withupper and lower vacuum-formed retainers for a further 9months. A bonded retainer was also fitted on the lowerright to left canines.

DISCUSSION

The treatment progress well with the patient proving to be co-operative during the removable and alsothe fixed appliances phase. However he struggled toachieve and maintain a very good standard of oral hygiene.Following comprehensive oral hygiene instruction andseveral visits to the hygienist, this has improved althoughthere was some deterioration towards the end of treatment.A trace of enamel decalcification (white spot) was visiblearound the upper anterior teeth after debond. The use of aweak fluoride solution or simply fluoride toothpaste causes the reversal of many white spot lesions in four to sixmonths were advised.7 Recent evidence suggested thatthere was no clinical advantage in using the combinationof the low fluoride formulated of mouthrinse and toothpaste,8 so the patient was instructed to use only fluoridated tooth paste to reduce the appearance of theenamel decalcification.

The patient was presented in the mixed dentitionphase and was still growing. Orthodontic treatment wascommenced early, not after the eruption of all the permanent teeth as growth will facilitate the overbitereduction.9 The overbite was corrected mainly by using anupper removable appliance with flat anterior bite plane.Anterior bite plane will release the upper and lower posterior occlusion. This will allow the lower posteriorteeth to erupt and remodelling of the alveolar bone takesplaced, hence reduced the overbite. The retroclined upperincisors were also corrected by using the removable appliance, by proclining them using anterior screw whichwas incorporated in the upper removable appliance.Adam’s clasps (0.7 mm-diameter stainless steel wire) wereplaced on the upper first molars and a Southend clasp (0.7mm-diameter stainless steel wire) on the upper centralincisors as retentive components. The other advantage ofthe upper removable appliance was it also facilitatedplacement of the lower fixed appliance at an early stage oftreatment to help level and align the lower arch (Figure 3).

It was planned that the patient will be treated bynon-extraction although the amount of crowding was moderate. Björk and Skieller10 stated that if possible, caseswith Class II division 2 should be treated non-extractionespecially in low angle cases as space closure is difficultand extraction will also result in further retroclination ofthe labial segment. Selwyn-Barnett11 also agreed thatextraction of the first premolars will lead to retraction ofthe labial segments during space closure and it will alsoposition the incisors too far lingually in relation to the supporting alveolar bone. For this patient, in order torelieve the moderate crowding in the upper and lower

arches, spaces were created by proclination of the retroclined upper and lower labial segments. This methodis controversial as Little et al.12 quoted that the originallower arch form should not be altered for stability purposes. The non-extraction treatment plan for thispatient was supported by Mills,13 where he stated that theproclination of the lower incisors was more likely to besuccessful in Class II division 2 cases where the incisaledges had apparently been held back by being, as it were,trapped by the cingulum of the upper incisors or by thesteeply rising anterior portion of the palate. It was alsosupported by Selwyn-Barnett.14 He claimed that the incisorcorrection was within the presenting envelope of the softtissue balance, hence no encroachment on the inner surfaceof the lower lip is emphasized.

Fixed appliance was fitted on the lower arch initially. The advantage of early levelling and aligning ofthe lower arch is overbite correction could be controlled bythe stiffer lower arch wire when starting fixed appliance onthe upper arch. Class II intermaxillary elastics were used tocorrect the buccal segment relationships and also as intraoral anchorage. This had the effect of proclining thelower incisors. A 0.019” x 0.025” stainless steel archwirewill procline the lower incisor when it is placed intoMBT™ prescription with 0.022” x 0.028” slot, especiallywith reversed curve of Spee due to the full expression ofthe torque.15,16,17 Therefore, to prevent further or excessiveproclination of the lower incisors, a lower 0.020”Australian stainless steel archwire was placed as the working arch wire for the lower arch. Further overbitereduction was done by placing the reversed curve of Speein the lower 0.020” Australian stainless steel archwire andincreased curve of Spee in the upper 0.019” x 0.025”stainless steel archwire (Figure 4).

Roth18 had developed special prescription in his own bracket prescription for Class II division 2 malocclusion. This malocclusion may require more torquein the upper incisor region and he recommended “SuperTorque” brackets. However the MBT™ prescriptionbracket system was chosen because it has more advantagescompared to Andrews and Roth prescriptions in treating aClass II division 2 malocclusion. These include:

• Even greater torque in the upper incisor region.• Reduced tip (mesial angulation) of the upper arch

teeth, thereby reducing the mesial movement of these teeth and hence the anchorage demands in the upper arch.

• Greater buccal root torque for the upper molars to prevent their palatal cusps from hanging down.

• Reduced lingual crown torque in the lower premolars and molars. This is to prevent, amongst other effects the tendency for the crowns of in particular the lower second molar from rolling lingually.

Lateral cephalometric radiograph and dentalpanoramic tomogram were taken 1 visit before debond. Itis more appropriate to take radiographs a month or two

34


before the completion of active treatment or beforedebond. This will allow the operator to check whether thetreatment targets have been achieved and any correctioncould still be done while patient is still wearing the fixedappliances, and also allow planning of retention.19

The pre-debond cephalometic analysis (Table 2)demonstrated a Class I skeletal base with a reduction in theSNA value by 3º and the SNB value by 1º during the treatment phase. This lead to a reduction in the ANB valuefrom 5º to 3º. The SNA reduction may be associated withthe upper incisor roots being torqued palatally, distalisingA point whilst the SNB reduction may be associated withthe lower incisors being proclined and the backwardgrowth rotation of the mandible, distalising B point. Therewas a clinically significant change in the lower anteriorface height, with an increase of 9 mm when compared tothe pre-treatment cephalometric analysis. The maxillarymandibular planes angle was also slightly increased; however the face height ratio remained unchanged. Therewas a marked improvement in the inclination of the inci-sors with a concomitant improvement in the interincisalangle. The lower incisors were proclined by 26º in relationto the mandibular base. The upper incisors were proclinedby 110º to the maxillary plane, a change of 10º from theirpre-treatment position. These changes have lead to adecrease in the interincisal angle by 38º, which isfavourable for the maintenance of the overbite correctionwhich was suggested by Houston.20 Houston20 quoted thatfor maximal chances of stability, the upper root centroidshould be at least 2 mm behind the lower incisor edge andthe inter-incisor angle is reduced as much as possibletoward 125º. The superimposition tracing of the pre-treatment and the pre-debond lateral cephalograms showedthat the position of the lower incisor edge had moved to be

in front of the upper root centroid. This favourable movement will increase the chance of stability.

Table 2. Pre-debond cephalometric values.

Variable Pre-debond Changes

SNA 78º -3º

SNB 75º -1º

ANB 3º -2º

Upper incisor to maxillary plane angle 110º +10º

Lower incisor to mandibular plane 108º +26º

Interincisal angle 117º -38º

Maxillary mandibular planes angle 25º +2º

Upper anterior face height 51.5 mm +5 mm

Lower anterior face height 70.5 mm +9 mm

Face height ratio 57.5% +0.5%

Lower incisor to APo line 3 mm +7.5 mm

Lower lip to Ricketts E Plane -8 mm -0.5 mm

Superimposition of the pre-treatment and the pre-debond lateral cephalograms, at the anterior cranial base(Figure 5), demonstrated significant vertical growth of thegeneral facial structures in the downward and slightlybackward direction. Maxillary superimposition (Figure 6),on the anterior surface of the zygomatic process,demonstrated a downward relative growth of the maxillawith no associated rotation. Mandibular superimposition(Figure 7) using Björk’s21 stable structures (mandibular

Figure 4. Mid-treatment intraoral photographs show upper 0.019” x 0.025” hooked stainless steel andlower 0.020” Australian stainless steel working archwires in-situ with Class II intermaxillary elastics.

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Othman

canal, lower third molar tooth germ and the inner cortex of the mental symphysis) demonstrated a significant downward growth with a slightly backward growth rotation. The tooth movements that occurred during treatment were extrusion of the upper and lower molars,palatal root torque of the upper incisors and marked proclination of the lower incisors.

The lower incisors appeared to be proclined and adecision was made to maintain them with a bonded retainer fitted from the lower right to left canines. This wasto ensure a stable antero-posterior and transverse positionof the lower segment.14 A removable vacuum-formed

retainer was also indicated in the upper and lower arches.The patient was instructed to wear this appliance at nighttime only for 9 months followed by part-time wear at leastuntil facial growth ceases, or forever as the only real guarantee that the teeth will remain aligned.

CONCLUSIONS

Overall, the treatment produced a good aestheticresult and the patient was very pleased (Figure 8). A ClassI molar relationship has been established with relatively

Figure 5. Overall superimposition of pre-treatment and pre-debond lateral cephalometrics registered on the anterior cranial base.

Pre-treatment

Pre-debond

Figure 6. Maxilla superimposition of pre-treatment and pre-debond lateral cephalometrics on the anterior surface of thezygomatic process of the maxilla.

Pre-treatment

Pre-debond

Figure 7. Mandibular superimposition of pre-treatment andpre-debond lateral cephalometrics on the mandibular canal,lower third molar tooth germ and the inner cortex of the mental symphsis.

Pre-treatment

Pre-debond

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good intercuspation and parallel roots. These factors,along with the position of the upper root centroid behindthe lower incisal edge, would suggest a good prognosis forstability. Clinician should be aware of the possibility oftreating moderately crowded dentition in Class II division2 malocclusion by non-extraction. However, the orthodontists should attempt to recognise, diagnose, andtreat these cases during the growth period to obtain optimalresults. Treatment as well as the mechanics that will beemployed must also be properly planned.

REFERENCES

1. British Standards Institutes. Glossary of Dental terms(BS4492) BSI London, 1983.

2. Todd JE, Lader D. Adult Dental Health, HMSO, London,1988.

3. Houston WJB. A Textbook of Orthodontics, 2nd edn. Wright:Oxford 1993.

4. Bowbeer GR. Saving the face and the TMJ – Part 4. FuncOrthod 1987;4:4-20.

5. Paquette DE, Beattie JR, Johnston LE Jr. A long term comparison of nonextraction and premolar extraction edgewise therapy in “borderline” Class II patients. Am JOrthod Dentofac Orthop. 1992;102:1-14.

6. Bishara SE. Class II malocclusions: diagnostic and clinicalconsiderations with and without treatment. Semin Orthod2006;12:11-24.

7. Zachrisson BU. JCO/Interviews Dr Bjorn U Zachrisson onExcellence in Finishing Part 2. J Clin Orthod 1986;19:536-56.

8. Willmot DR. White lesions after orthodontic treatment: doeslow fluoride make a difference? J Orthod. 2004;31:235-42.

9. Stephens CD, Houston WJB. Facial growth and lower premolar extraction space closure. Eur J Orthod 1985;7:157-62.

10. Björk A, Skieller V. Facial development and tooth eruption. An implant study at the age of puberty. Am JOrthod. 1972;62:339-83.

11. Selwyn-Barnett BJ. Rationale of treatment for Class II division 2 malocclusion. Br J Orthod 1991;18:173-81.

12. Little R, Riedel R, Artun J. An evaluation of changes inmandibular anterior alignment from 10 to 20 years postretention. Am J Orthod. 1988;93:423-28.

Figure 8. Post-treatment intraoral photographs showing anterior view (in maximum intercuspation),right buccal view, left buccal view, maxillary occlusal view and mandibular occlusal view.

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13. Mills JRE. The problem of overbite in Class II division 2malocclusion. Br J Orthod 1973;1:34-48.

14. Selwyn-Barnett BJ. Class II division 2 malocclusion: Amethod of planning and treatment. Br J Orthod 1996;23:29-36.

15. Sadowsky C, Sellke T. Management of overbite by controlling incisor and molar movements. Semin Orthod2000;6:43-49.

16. McLaughlin RP, Bennett JC, Trevisi HJ. Systemized orthodontic treatment mechanics. London: Mosby, 2001.

17. McLaughlin RP, Bennett JC, Trevisi HJ. Finishing with the preadjusted orthodontic appliance. Semin Orthod2003;9:165-83.

18. Roth RH. The Straight-Wire appliance – 17 years later. J ClinOrthod. 1987;21:632-42.

19. Isaacson KG, Thom AR, Jones ML, Barnett DP, Haines WF,Rose RJ. Orthodontic Radiology Guidelines. BritishOrthodontic Society, London, 2001.

20. Houston WJB. Incisor edge-centroid relationships and overbite depth. Eur J Orthod. 1989;11:139-43.

21. Björk A. Prediction of mandibular growth rotation. AngleOrthod. 1969;55:585-99.


Dr. Siti Adibah OthmanBDS (Malaya), DDS (Bristol), MOrth RCS (Edinburgh),Lecturer,Department of Children’s Dentistry and Orthodontics,Faculty of Dentistry, University of Malaya,50603 Kuala Lumpur, MalaysiaTel : 03-79674241,E-mail : [email protected],

[email protected]

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Randomised Clinical Trial: Comparing the Efficacy of Vacuum-formed andHawley Retainers in Retaining corrected tooth rotationsRohaya MAW MOrthRCSEd, Lecturer, Head of Department, Department of Orthodontics, Faculty of Dentistry,Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur, Malaysia.

Shahrul Hisham ZA Ph.D. (UMIST, Manchester), Lecturer, School of Bioscience and Biotechnology, Faculty of Scienceand Technology, Universiti Kebangsaan Malaysia, 43600 Bangi, Selangor, Malaysia.

Doubleday B Clinical Senior Lecturer, Glasgow Dental School, 378 Sauchiehall Street, Glasgow G2 3JZ, Scotland.

ABSTRACTRelapse is known as the return of corrected tooth towards their pre-treatment positions. Tooth rotation is one of the commonrelapse teeth due to stretching of the collagen fibres. Retention appliances or retainers are used at the end of the active phaseof orthodontic treatment to stabilize the aligned teeth, whilst the supporting tissues to adapt to the new position. The aim ofthe study was to determine whether there was any difference between the Hawley and Vacuum-formed retainers in terms oftheir efficacy in retaining orthodontically corrected tooth rotations. A randomised, prospective, controlled trial was done onconsecutively treated patients who had had at least an upper fixed appliance and allocated either an upper Hawley or Vacuum-formed retainer for nine months. Routine records were taken at pretreatment, posttreatment and postretention. The recurrence during retention of any corrected tooth rotations was determined from the measurements on study models. Theinvestigator who analyzed the study models was blind to the type of retainer that had been fitted and the stage of treatmentat which models had been taken. The result showed no statistically significant differences found between the number ofpatients with rotated teeth in the Vacuum-formed group compared to Hawley (p=0.7). The different in number of patients withcorrected tooth rotations at the end of treatment in the Vacuum-formed group and Hawley group also did not reached statistically significant level (p=0.89). However, there was a small, but statistically significant difference (p=0.04) in the proportion of patients in whom rotations of the teeth relapsed during retention. As the conclusion, the vacuum-formed retainer appears more efficient in preventing recurrence of teeth rotation after orthodontic correction and equally effective inmaintaining the alignment of the teeth after orthodontic treatment.

Key words:retainers, rotation, stability, clinical trial

INTRODUCTION

Rotated tooth position has been a problem fororthodontists to maintain the correction after active orthodontic movements. It has been proposed that orthodontic movement to correct rotated teeth results instretching of the collagen fibers and might be implicated inrotational relapse by pulling the teeth back toward their pretreatment position.1,2 This is due to considerable residual forces which remain in the tissues of the periodontium after tooth movement.1,3,4,5,6

Reitan1 also reported that reorganization of the periodontal ligament occurs over a 3 to 4 months periodafter active orthodontic appliances have been removed,whereas the gingival collagen-fiber network typicallytakes about 4 to 6 months to be remodeled. The elasticsupracrestal fibers may remain deviated for more than 232days, most markedly after correction of rotated teeth andspace closure. Gingival fiber surgery (circumferential

supracrestal fiberotomy) was advocated for the release ofsoft tissue tension and reattachment of the fibers in a passive orientation after orthodontic correction of toothrotation.2,7 Edwards in his study followed up 160 patientsprospectively, for up to 14 years post-treatment andshowed a significant difference in the irregularity indexbetween the group receiving circumferential supracrestalfiberotomy and the control group.8

However, Redlich et al. has questioned the theoryof stretched collagen fibers as the cause of rotationalrelapse.9 This is because when they analyzed the gingivaltissue samples obtained from rotated incisors in dogs, theyfound that the rotational forces caused significant changesin integrity and spatial arrangement of the gingival tissues,changes that are inconsistent with stretching. After fiberotomy, reorganization of the fibers similar to the control was evident. They concluded that rotational relapsemay actually originate in the elastic properties of thewhole gingival tissue rather than stretching of the gingivalfibers as previously believed.



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Rohaya / Shahrul Hisham / Doubleday

Retention of tooth movement has been advocated atthe end of an active orthodontic treatment due to potentialunstable tooth position. Several types of appliances havebeen used for the retention of post-treatment tooth position. Fixed or bonded retainer usually used in patientswith corrected rotation tooth position to avoid relapse.Bonded retainers consist of a length of orthodontic wire orKevlar (Ribbond) bonded to the teeth (usually from canineto canine) with acid-etch retained composite. Multistrandwire bonded to all teeth in the labial segment was used,where the irregular surface of the multistrand wires givethe advantage of increased mechanical retention for thecomposite without the need for the placement of retentiveloops.10 They also allow physiological movement of teethdue to their flexibility.11 However, fixed retainers may giveproblems especially in maintaining good oral hygiene asretainers may accumulate plaque and calculus.

Removable retainers such as Hawley retainer(Figure 1) is one of the most frequently used retentivedevice available to the clinical orthodontist. The palatal orlingual portion is usually constructed of acrylic and maycompletely cover palatal mucosa or may be constructed ina horseshoe shape contacting the lingual surfaces of theteeth and some of the palatal mucosa. A labial bow of around stainless steel 0.7mm wire is usually constructed tocontact the labial surface of four or six maxillary anteriorteeth. Speech interference and some adaptation time needed were common problems when using this type ofretainer due to palatal coverage.12 The retaining componentfor the anterior teeth in the Hawley type retainer, whichinvolves point contact of wire on the labial surface and amass of acrylic approximating the lingual surface wereclaimed to be insufficient to maintain alignment.13

Figure 1: An occlusal view of an upper Hawley retainer

Thermoplastic vacuum-formed retainer (Figure 2)is first described by Ponitz14 in 1971. It is made of thinthermoplastic material, adapted closely to the lingual,facial and occlusal surfaces of the teeth. The retainerserves as an aesthetic, comfortable, inexpensive and lesstime to fabricate alternative to the traditional fixed andremovable orthodontic retainers. Initially most vacuum-formed were made from material 1mm thickness. Animproved design introduced by Wang15 to afford maximumstiffness suggested using a 0.5mm thickness material,which reduced to 0.25 to 0.375mm after thermoforming.However the major drawbacks of the Vacuum-formedretainer were their tendency to cause openbite and theirlow durability.15

Figure 2: A frontal view of both arches with Vacuum-formed retainers

Sauget et al.16 in their study showed little change inocclusal contacts between debond and after 3 months ofretention with retainers. They concluded that the Vacuum-formed retainer holds teeth more firmly in their debondingposition as compared to the Hawley retainers that allowrelative vertical movement of the posterior teeth duringsettling. The vacuum-formed retainer was also said to bemore easily lost than traditional appliance because they aretransparent.17 Sheridan et al.13 however, have suggested away to reduce the likelihood of a Vacuum-formed retainerbeing lost by adding a coloured stripe along the lingualedge of the appliance. This will make it more visible whenout of the mouth.

There were 2 studies that have compared the efficacy of retainers in maintaining teeth after treatment.The comparison study between Hawley and Vacuum-formed retainer groups made was to compare the occlusalcontacts of teeth following retention.16 However,Littlewood et al.18 in their review in The CochraneCollaboration reported that the study did not assess theadverse effect on health, the survival of retainers andpatient’s satisfaction with the treatment. Comparison of theefficacy of both retainer groups also was done by measurements taken from study casts made prior, post-

40

Randomised Clinical Trial: Comparing the Efficacy of Vacuum-formed and Hawley Retainers in Retaining corrected tooth rotations

treatment and after six months of retention.17 The measurements made were the anterior crowding using‘Little Irregularity’ Index, overjet and overbite. However,there were several flaws in the study; the low numbers ofpatients; the poor randomization technique; questions overthe statistical analysis and the limited assessment ofocclusal changes.

A study was designed to investigate whether thereis any difference between Hawley and Vacuum-formedretainers in maintaining corrected tooth rotations with alarger sample size and using a prospective, stratified randomized controlled clinical trial. A rotation scoringsystem was used to detect relapse in corrected tooth rotations. The aim of the study was to compare the difference in efficacy of two types of retainers in retainingcorrected tooth rotations from measurements made onstudy dental casts taken pre-treatment, post-treatment andpost-retention. The null hypothesis is that there is no difference in efficacy between the Hawley and vacuum-formed retainers in maintaining corrected tooth rotationachieved during active treatment

MATERIAL AND METHOD

Sample

A total of 218 patients were recruited from two District General Hospitals. The inclusion criteria were: 1) consecutively treated patients who had either upper fixedor upper and lower fixed appliances; with and without aprior phase of functional appliance therapy and with orwithout extraction of teeth. 2) Patients prepared to weareither a Hawley or a Vacuum-formed retainer. The exclusion criteria were: 1) patients who had undergonesurgical repositioning of the jaws as part of their treatment,2) hypodontia treated by reopening spaces for prostheticreplacement of teeth, 3) patients with marked alveolarbone loss related to treated periodontal disease (now stabilized), who usually need permanent bonded retainers,4) cases that required substantial expansion of the upperarch, which necessitated the use of either rapid maxillaryexpansion or a quadhelix., 5) cleft lip and palate patients orpatients who presented with any craniofacial syndrome.Stratified randomization system was used to ensure thatthe patients in the two retainer groups were equivalentaccording to their original malocclusion and its rotationseverity. Once stratified, the patients were then randomly allocated one of the retainer types using anopaque envelope system containing either the letter H or Vthat selected by the third person who was not involved inthe study. The consort flow chart was made to show theprocess from the enrollment until analysis (Figure 3).

Retainer types

Type 1: A standard upper Hawley retainers, with aplain labial bow, Adam’s clasps on the first molars andcold-cured acrylic.

Type 2: A vacuum-formed retainer made fromEssix™ type C thermoplactic copolyester material (RaintreeEssix Inc., Ortho-Care (UK) limited) with a 0.5mm thicknessafter thermoformed, full-arch tooth coverage and the edgesextended about 2-3mm into labial gingival.

Retention regime

A standard protocol for retainer wear was used asfollows:

Hawley retainer: the patients were asked to wearthe retainer full time for the first 3 months, followed by 6months night time wear only.

Vacuum-formed retainer: the patients were asked towear the retainer full-time for one week, followed byevening and night-wear for three months and 6 months fornight time wear only. The total of retention time was 9months for both retainer types.

Methods of Measurement on study model

Rotations of the upper teeth (labial segment andpremolars) were measured using a protractor. Rotationswere either scored as present (i.e. teeth that were rotated15º or more from normal arch alignment) or absent.19 Forthe upper central incisors especially with V shaped arch,they were considered rotated disto-palatally if the anglebetween them was less than 90º (Diagram 1).

Diagram 1: The consideration of rotation of the uppercentral incisors

A) Rotation was not considered when angle between thecentral incisors is more than 90°

B) Rotation was considered when angle between the central incisors is less than 90°

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Figure 3: The Consort E-Flowchart

Assessed for eligibility(n-218)

Allocated to intervention Hawley(n=68)

Total Excluded (n=79)

Failed to attend for final impression (n=42)Failed to wear (n=20)Moved away (n=3)Other reasons (n=14)

Lost to follow-up (n=0)Discontinued intervention

(n=0)

Patient with rotation (n=40)Excluded from analysis (n=28)

(no rotation)

Allocated to intervention Vacuum-formed (n=71)

Lost to follow-up (n=0)Discontinued intervention

(n=0)

Patient with rotation (n= 44)Excluded from analysis (n=27)

(no rotation)

Randomized n=139

Enrollment

Allocation

Follow-Up

Analysis

42


Assessment of intra-examiner and inter-examiner agreement

Twenty-four study models were used to assessintra-examiner reproducibility and inter-examiner (author and co-author) reliability. The casts were chosen randomly for all three stages of treatment. Presences ofrotations were recorded twice with an interval of at least 3 weeks between. If the agreement between two measurements was high, it would indicate that intra-andinter-examiner measurement error was low.

Statistical analysis

Intra and inter-examiner agreement of presence ofrotations were assessed using Kappa statistics. The significance of the recurrence/relapse of rotation aftertreatment was determined by the Difference in Proportionstest.

RESULT

218 patients were originally recruited into the study,but only 139 patients completed all stages. 68 were fittedwith Hawley and 71 with Vacuum-formed retainers. The difference between the Hawley and Vacuum-formed retainer

groups in the number of patients with recurrence of toothrotation during retention was analyzed using the Differencein Proportions test. At the pre-treatment stage there were ahigher number of patients with rotated teeth in the Vacuum-formed group compared to Hawley but the difference did notreach a statistically significant level (p=0.7). The number ofpatients with corrected tooth rotations at the end of treatmentwere also more in the Vacuum-formed group compared toHawley group but again the difference did not reach a statistically significant level (p=0.89). Significantly higherproportion of patients was noted in the Hawley retainergroup that suffered a recurrence of tooth rotation duringretention (p=0.04) compared to the Vacuum-formed retainergroup (Table 1). It was also noted clinically that less rotationrecurrence for patient who worn Vacuum-formed comparedto Hawley retainers. The intra and inter-examiner agreementof the measurements of rotations on the study modelsanalysed using Kappa statistics showed very good agreementof intra-examiner (k= 0.82) and moderate agreement of inter-examiner (k= 0.47). Most of the disagreement involved theupper labial segment, which can be difficult to assess due toshape of their archform (i.e U or V). The disagreements werediscussed and a standardized protocol agreed upon whichwas to consider the teeth to be rotated disto-palatally if theangle between the upper incisor teeth was less than 90º.

Table 1. Comparison between the Hawley and Vacuum-formed retainers in retaining corrected tooth rotation

Hawley Vacuum-formed DIP p 95% CIgroup (n) group (n)

Pretreatment 40 44 -0.03 0.70 -0.19- 0.13

Corrected at the end of treatment 36 39 0.01 0.89 -0.005- 0.18

Rotations relapsed during retention 9 3 0.17 0.04* 0.01-0.34

n= number of subjects with one or more rotated teeth

DIP=Difference in Proportions

CI=Confidence Interval

*=Significant at p< 0.05

43


DISCUSSION

Relapse of tooth position has always been a greatchallenge to orthodontists around the world. Many studieshave been done to in the light of understanding the processof relapse and ways to minimize or event prevent relapse.These studies varied in their material and methods such asrelapse in extraction patients20 or non-extraction patients,21

comparing between extraction and non-extractionpatients22 by assessing the irregularity of mandibular incisors for a period between 10-20 years. The resultshowed that for extraction of first premolars, the crowdingin the mandibular incisor tend to worsen in the ‘well-aligned’ patients compared to moderate and severe crowding at the start of treatment.20 In the nonextractiontreatment, Little et al21 found that 89% of the postretentionrecords demonstrated clinically unsatisfied alignment ofthe mandibular incisors. Paquette et al22 found meanpostretention increase in the irregularity index of themandibular incisors for the extraction group (2.3mm) compared to nonextraction group (2.9mm). In these studies, there was no comparison of the retainer type thatwas worn. However the present study, comparison of tworetainers in maintaining tooth derotation was made. Thedifference in treatment approach (extraction or non-extraction) was included because the relapse was onlynoted if the correction done in treatment was not maintained.

In this study, tooth rotation was used to assessrelapse after completing orthodontic treatment.

Tooth rotation corrected during orthodontic treatment is known to be prone to relapse towards its pre-treatment position. There are two soft tissue periodontalentities that may influence the stability of teeth followingorthodontic tooth movement: (1) the supra alveolar groupof fibers – the interdental (transseptal) fibers running justsuperior to the alveolar crest and directly connecting adjacent teeth, and the gingival fibers originating in thecementum and terminating in the connective tissue of thegingival; and (2) the principal fibers of the periodontal ligaments.23

Edwards previously had shown that the attachedmarginal gingival was pulled along with the tooth as itrotated, under the influence of an orthodontic appliance.2

The gingival fibers remained attached to the tooth duringorthodontic rotation, which resulted in the displacement ofthe gingival in the direction of the tooth movement.Reorganization of the periodontal ligament occurs over a 3to 4 months period after treatment while the gingival collagen fiber network typically takes 4 to 6 months to beremodeled, the elastic supracrestal fibers remain deviatedfor more than 232 days.1,24,25

Permanent retention has been recommended tomaintain orthodontically corrected tooth rotations.10,26

However, fixed retainers require long-term maintenanceand can act as plaque retaining device which can predispose to caries and periodontal diseases. Partialdebonds of the wire may be left undetected by the patientand this can lead to relapse, enamel decalcification at thesite of bond failure.27 Furthermore, fixed retainers must besystematically monitored or recall for displacement andhygiene problems that induced by the accumulation ofplaque and calculus.13

The effectiveness on retention strategies used tostabilize tooth position after orthodontic braces in manystudies was evaluated.18 They concluded that it was notpossible to evaluate completely the effectiveness of different retention strategies due to a shortage of qualitystudies. In this study the Vacuum-formed retainer appearedto be significantly better in retaining orthodontically de-rotated teeth, although the numbers of rotated teethwere relatively small.

The Vacuum-formed retainer usually fabricated toadapt closely to the lingual, facial and occlusal surfaces ofthe teeth to retain tooth position.14 Adequate undercuts areremained in the dental casts during retainer fabrication toensure that the retainer does not slip easily over the teeth.28

They also promoted a patient-friendly method of long-term retention using the Vacuum-formed retainer, wherepatients were given responsibility for indefinite wear andthe retention was monitor routinely by phone. The Hawleytype of retainer, which has a retaining component for anterior teeth with a point contact of wire on the labial surface and a mass of acrylic approximating the lingualcervix was said to be insufficient in maintaining correctedtooth position.13 They also claimed that as the appliancebecomes loose with long-term wear, the mechanical constraints are lessened and teeth may shift.

The Vacuum-formed retainers also have otheradvantages in term of ease of fabrication, the speed ofinsertion, almost complete lack of need for adjustment,low cost and easier to remake if replacement is needed,14

compared to the Hawley retainer. The technicians involvedin the study claimed that the Vacuum-formed retainerstook half the time of the Hawley retainer fabrication tomake and about a third of a cost.

CONCLUSION

The results of this study suggest that the Vacuum-formed retainer appears better at retaining orthodonticallycorrected tooth rotations compared to the Hawley retainerwith same efficiency as Hawley retainer for a nine-monthperiod of retention.

44


REFERENCES

1. Reitan K. Tissue rearrangement during retention of orthodontically rotated teeth. Angle Orthod. 1959;29:105-13.

2. Edward J.G. A study of the periodontium during orthodonticrotation of teeth. Am J Orthod.1968;54:441-61.

3. Moss J.P. The soft tissue environment of teeth and jaws:an experimental and clinical study: Part 1. Br J Orthod.1980;7:127-37.

4. Moss J.P. The soft tissue environment of teeth and jaws.Experimental malocclusion: Part 2 and 3. Br J Orthod.1980;7(4):205-16.

5. Tanne K., Inoue Y., Sakuda M. Biochemical behavior of theperiodontium before and after orthodontic tooth movement.Angle Orthod. 1995;65(2):123-8.

6. King G.J., Keeling S.D. Orthodontic bone remodeling in relationto appliance decay. Angle Orthod. 1995;65(2):129-40.

7. Brain W.E. The effect of surgically transection of the freegingival fibres on the regression of orthodontically rotatedteeth in the dog. Am J Orthod.1969;55:50-70.

8. Edward J.G. A long- term prospective evaluation of the circumferential supracrestal fiberotomy in alleviating orthodontic relapse. Am J Orthod Dentofac Orthop.1988;93:380-7.

9. Redlich M., Rahamim E., Gaft A., Shochan S. The response of supraalveolar gingival collagen to orthodonticrotation movement in dogs. Am J Orthod Dentofac Orthop.1996;110:247-55.

10. Zachrisson B.U. The bonded lingual retainer and multiplespacing of anterior teeth. J Clin Orthod, 1983;17:838-44.

11. Artun J. Caries and periodontal reactions associated withlong-term use of different types of bonded lingual retainers.Am J Orthod. 1984;86(2):112-118.

12. Haydar B., Karabulut G., Ozkan S., Aksoy A.U, Ciger S.Effects of retainers on the articulation of speech. Am JOrthod Dentofacial Orthop.1996;110(5):535-40.

13. Sheridan J.J., LeDoux W., McMinn R. Essix retainers:Fabrication and supervision for permanent retention. J ClinOrthod. 1993;27(1):37-45.

14. Ponitz R.J. Invisible retainers. Am J Orthod. 1971;59(3):266-272.

15. Wang F. A new thermoplastic retainer. J Clin Orthod.1997;31:754-757.

16. Sauget E., Covell D.A., Jr., Boero R.P., Lieber W.S.Comparison of occlusal contacts with the use of Hawley andclear overlay retainers. Angle Orthod. 1997:67(3):223-30.

17. Lindauer S.J., Shoff R.C. Comparison of Essix and Hawleyretainers. J Clin Orthod. 1998;32(2):95-7.

18. Littlewood S.J., Millett D.T., Doubleday B., Bearn D.R.,Worthington H.V. Retention procedures for stabilizing toothposition after treatment with orthodontic braces (Review).The Cochrane Library. 2006; Issue 2.

19. Swanson W.D., Riedel R.A., D’Anna J.A. Postretentionstudy: incidence and stability of rotated teeth in humans.Angle Orthod. 1975;45(3):198-203.

20. Little RM, Wallen TR, Riedel RA. Stability and rekapse ofmandibular anterior alignment-first premolar extraction casestreated by traditional edgewise orthodontics. Am J Orthod.1981;80:349-65.

21. Little RM, Riedel RA, Stein A. Mandibular arch lengthincrease during the mixed dentition: postretention evaluationof stability and relapse. Am J Orthod Dentofacial Orthop.1990;97:393-404.

22. Paquatte DE, Beattie JR, Johnston LE. A long-term comparison of non-extraction and premolar extraction edgewise therapy in “borderline” Class II patients. Am JOrthod. Dentofacial Orthop. 1992;102:1-14.

23. Edward J .G. Soft-tissue surgery to alleviate orthodonticrelapse. Dent Clin North Am. 1993;37(2):205-25.

24. Reitan K. Clinical and histologic observations on toothmovement during and after orthodontic treatment. Am JOrthod.1967;53:721-45.

25. Reitan K. Principles of retention and avoidance of post-treatment relapse. Am J Orthod. 1969;55:776-790.

26. Lee R.T. The lower incisor bonded retainer in clinical practice: a three year study. Br J Orthod. 1981;8(1):15-8.

27. McNamara T.G., McNamara T., Sandy J.RA new approach toincisor retention the lingual spur retainer. Br J Orthod.1996;23(3):199-201.

28. Sheridan J.J., McMinn R., Le Doux W. Essix thermosealedappliances: various orthodontic uses. J Clin Orthod,1995;29(2):108-113.


Dr Rohaya Megat Abdul WahabBDS (Mal), MDentSci (Leeds), MOrthRCSEd,Lecturer & Head of Department,Department of Orthodontics,Faculty of Dentistry,Universiti Kebangsaan Malaysia,50300 Kuala Lumpur.Tel : 4040 5756/4040 5727Email: [email protected]

45

Dental Students’ Reflections: A Study of Video-triggered Reflections in Dentist-patient Communication Skill ClassAb Murat N Lecturer, Department of Community Dentistry, Faculty of Malaya, 50603 Kuala Lumpur, Malaysia.

ABSTRACTRecently, there has been a great interest in the use of reflective learning in dental education. A variety of teaching and learning techniques intended to engage students in reflection are either being used or are being developed. The aim of thisstudy is to examine the effectiveness of video-recording in triggering reflective behaviour among dental students when it isincorporated into the practical session of a dentist-patient communication skills class. A group of twelve third year dental students took part in this study. Their oral health interview sessions with a simulated patient were videotaped and the videotape was reviewed immediately. Students then were asked to write a critical incidents essay of their mock clinicalencounter. From the analysis of the essays, 3 major types of reflection on practice emerged: reflection on values, reflection onpractice and reflection on improvement. Majority of students commented that the reflective session made them aware of howeffective (or ineffective) their communication skills were and this prompted them to give more thoughts to their current practice. It is concluded that video-assisted reflection-on-action session may help to promote reflective behaviour thereby promoting acquisition of communication skills among dental students.

Key words:Reflective learning, dentist-patients communication skills, oral health interview

INTRODUCTION

Dental schools are in the business of preparingcompetent, caring and effective dental professionals. Aspart of the commitment to increase standards of service,schools are constantly challenged to develop and implement new techniques. However, as dental technologyadvances and the skills taught in dental schools are refined,what differentiates one professional from another is nolonger just dental competence and skill, but the ability tolisten and communicate effectively. It is, after all, throughcommunication that a dentist fosters the confidence andtrust that will ensure that the patient follows through withafter-care and comes back for further treatment. One pedagogical technique that has found favor in dentalschools of late is that of reflection.

Reflection is being increasingly recognized as acritical part of clinical practice. It is the process throughwhich individuals think about and evaluate their experience in order to come to new understandings andappreciation of their recent encounter.1 Boud et al2 definereflection as an important human activity in which peoplecapture their experiences, view them from a third person’sperspectives, think about them, and finally evaluate them.Boud’s conceptualization of reflection includes a numberof different process, including looking back on experiences, attending to feelings, recognizing values and

beliefs underlying actions and decisions, considering consequences and implications, exploring alternatives andreconsidering former views. Reflection is also often avehicle through which values or beliefs are challenged.3

Schon4 defines reflection in terms of action; namely reflection-in-action, which is when a practitionerlooks back on what he or she has done, and throughreflecting on it, learns lessons about what does or does notwork. Conversely reflection-on-action is a deliberate,conscious and public activity principally designed toimprove future action. Reflection-on-action is a naturalprocess of making sense of professional action. In additionto that, Ghaye and Ghaye5 describe reflection as a processof using and learning from experience.

In dental education, the process of reflection allowsstudents a chance to assimilate learning experiences andpossibly discover new solutions to problems. Reflectionalso allows the students a non-threatening evaluation of their own capabilities, while fostering a deeper understanding of the learning experiences. Most significantly perhaps, the new ideas and depth of meaningbrought about by the process endow the learner with amore insightful view of situations and problems they willface in the future.

A variety of approaches are used to promote suchreflective practices. The most common methods are journal writing, critical incident essays and reviews of



46

Dental Students’ Reflections: A Study of Video-triggered Reflections in Dentist-patient Communication Skill Class

audio and videotape recordings of one’s self in action. Inparticular, the use of video recordings has been shown toenhance the development of both general communicationskills and more specific consultation techniques amongstudents.6 Compared to more conventional education methods such as lectures and textbooks, the impact ofvideotaped feedback on students’ communication skills isreported to be more lasting.7 Encouragingly, Nilsen andBaerheim8 reported that the self esteem and confidence ofstudents were strengthened when video-based reviews oftheir performance were used.

In the field of nursing, Burnard9 and Minardi andRitter10 showed in different studies that video-taped recordings enhanced students’ ability to learn effectiveinterpersonal skills. In the field of dentistry, reflectionsthrough videotape feedback have also been shown to havea high impact on the modification of behavior patternsrelated to many aspects of clinical work, including technical skills.11

The aim of this study is to examine the efficacy ofvideo-recording in triggering reflective behaviour amongdental students when it is incorporated into the practicalsession of a dentist-patient communication skill class.

METHODS

Oral health interviewing is a skill introduced tothird year students of the Faculty of Dentistry in theUniversity of Malaya. This is part of a Behavioral Sciencecourse conducted by the Department of CommunityDentistry. One of the objectives of the course is to develop students’ ability to manage the psychosocialaspects of patient care. Lecturers involved in the conductof this course have been encouraged to videotape these students’ oral health interview sessions. However,logistical and technical problems have prevented this frombeing done in the past.

A group of twelve third year dentistry students consented to take part in the study. Each of the studentswas asked to see a “patient” and to interview her over aperiod of fifteen minutes, using a standard clinical pathway form as a guide.

The part of the “patient” was played by a volunteerand participants were given the impression that she was aforeigner with a relatively low level of education. Alltwelve participants interviewed the same patient. Theobjective of the interview was for the students to obtain abrief medical, dental and social history of the patient.

Videotapes of each student’s interview with the“patient” were reviewed immediately after the mock consultations. During this group review session, studentsobserved their own communication and interpersonalskills, as well as that of their peers. The researcher thenfacilitated an hour-long discussion during which studentswere prompted to reflect on their observations and suggestimprovements they could make to their communicationtechniques. No voice recording device was used during the

feedback session. At the end of the session, students werethen asked to write and submit a critical incidents essay oftheir mock clinical encounter.

These essays were subsequently reviewed and analyzed by the researcher for their common themes anddirect quotations were extracted where appropriate.

RESULTS

Three major themes emerged from an analysis ofthe critical incident essays: personal values, possibilitiesfor improvement and practice.

Reflection on values

In their reflections, students often mentioned theprofessionalism (or lack of professionalism) they demonstrated in their video-taped encounters. What concerned them most in this regard was whether theirbehaviors were in keeping with key values. The student’sconcerns coincided broadly with the clusters suggested byGhaye and Ghaye.5 They are:

i) A professional demeanor: Students were keenlyaware of the need to build good rapport with patients,and to come across to them as understanding, friendlyand approachable. Other aspects of maintaining a professional demeanor they mentioned were the needto be prepared, to look confident, to show enthusiasmand to be polite.

ii) Care and compassion: Students frequently mentionedbeing on the look-out for signs of caring, empathy,concern and active listening.

iii) A respect for human diversity: The students appearedmindful of the fact that patients had to be treated asequals and were to be valued as individuals. As one student put it, “Although the patient was a foreigner,I was neither prejudiced nor biased to her answers”.

Reflection on practice

During the feedback session, students were eager to identify the strengths and weaknesses of their current communication practices. One student said she had consciouslymaintained eye contact and smiled throughout the interview andwas heartened to see from the video that her non-verbal gestureswere effective in creating a climate of trust. After viewing thetapes, another student stressed the need to avoid using medicaljargon when communicating with the patient and emphasized theimportance of clarification: “I used simple layman’s terms so thatmy patient would understand my question. Sometimes, I repeated questions in different forms to clarify my intentions andto increase the patient’s understanding. I think this a good habitas it helps avoid misunderstandings that can occur when chartinga patient’s history”.

47

Ab Murat

Commenting on her failings, one student said,“I found that I did not let the patient know how concernedI was about her problem. I should make more of an effortto let the patient feel that I care….” Another student feltthat her unpreparedness made her nervous: “I…failed tokeep the conversation going smoothly as I was nervous.I’ve made that same mistake before in the clinic.”

Several students realized the importance of framingtheir questions appropriately. One participant said,“I realized that during the interview, I asked mostly directquestions which required ‘yes’ and ‘no’ answers. I failed toget the patient to elaborate on her problems.” As anotherstudent reflected on her actions, she said, “…I acceptedher answers, sometimes too quickly, and moved on to thenext question…”.

Reflection on improvement

Almost every student agreed that there was somemeasure of improvement that they could make on theirmethod of communication. One expressed the need to befully prepared before attending to patient: “I should bemore prepared. I should have read through the clinicalpathway form before attending to the patient as this wouldhave made our conversation move more smoothly”.

Another student had difficulty answering thepatient’s question and felt quite strongly about how shewould tackle such situations in the future: “The patientasked me a question that I could not answer but I did notdo anything about it. I should have told her that while Icouldn’t give a clear explanation at the time, I would getback to her the next time we met. This will let the patientknow that I care and increase the patient’s confidence inme.”

The experience was summed up by one member ofthe class as such: “I realized my weak points. This exercisehas given me a good deal to think about how I shouldimprove my skills. It is certainly a useful thing to thinkabout as I embark on my future career”.

DISCUSSION

In this study, only twelve participants wereinvolved. However, as this is a qualitative study, the number of participants involved was not of concern. Theresearcher solely analyzed the qualitative data, thus theinterpretation of the findings was subject to theresearcher’s biases.

This study was conducted in order to examine thenature of reflection brought about in dental students by theviewing of videotape recordings of their behavior in apatient-care situation. From the reflections that the students shared, it appears that the video feedback techniqueholds great promise as a means of helping learners reflect ontheir behaviour on a recent clinical encounter and at the sametime to operationalize their theoretical knowledge and makeit part of their professional practice.

Schon4 reports that when reflection is incorporated into professional education, it prevents students’ from repeatingthe bad habits they acquire. Indeed, the students who tookpart in the current study commented that it made them keenly aware of how they would deal with their mistakes,and how effectively (or ineffectively) they were able to communicate with the patient. As a result, this has promptedthem to give more thoughts to their current practice.

The outcomes of this effort appear also to be in linewith the findings of Kalwitzki et al.12 Kalwitzki and hiscolleagues studied the acceptance of video-based teachingin pediatric dentistry and reported that a considerable percentage of students had gained insights into neglectedbehavioral patterns and found some of their current practices to be inadequate. After watching video sequencesof themselves in action, the students in the study weremotivated to change their behavior

Many of the students made it a point to mention intheir critical incident essays that the video feedbackoffered them an opportunity to look back on their practiceand to plan for their own improvement. Similar to the findings of Strauss and Mofidi,13 the students felt that thevideo recordings offered them a chance to analyze howtheir values and attitudes relate to the ideals of the profession.

CONCLUSIONS

Although knowledge and technical competency arekey to the success of any dental student, dental schools arealso responsible for encouraging the acceptance of positivevalues. As the study shows, this can be furthered by effortsto provide opportunities for reflection. Judging from theoutcome of this effort, the University Malaya DentalFaculty would do well to incorporate reflection-on-actionformally into curriculum. It is clear that reflection hasgreat potential as a tool of meaningful learning and professional development.

REFERENCES:

1. Schon D. The reflective practitioner. How professionals thinkin action. New York: Basic Books; 1983

2. Boud D, Keogh R, Walker D. Reflection: Turning experienceinto learning: New York: Kogan Page; 1985.

3. Green C. Reflections on reflection: Students’ evaluation oftheir moving and handling education. Nurse Education inPractice. 2002;2,4-12.

4. Schon D. Educating the reflective practitioner. London:Jossey Bass; 1987.

5. Ghaye A and Ghaye K: Teaching and learning through critical reflective practice. David Fulton Publishers Ltd,London 1998.

6. Beckman HB. Frankel RM. The use of videotape in InternalMedicine training. J Gen Intern Med 1994;9;517-521.

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Dental Students’ Reflections: A Study of Video-triggered Reflections in Dentist-patient Communication Skill Class

7. Maguire P, Fairbann S, Fletcher C. Consultation skills ofyoung doctors: Benefits of feedback training in interviewingas students persist. Br Med J (Clin Res Ed) 1986;292;1573-1576.

8. Nilsen S, Baerheim A. Feedback on video recorded consultation in medical teaching: why students loathe andlove it – a focus-group based qualitative study. BMC MedEduc 2005;5:28.

9. Burnard P. Using video as reflective tool in interpersonalskills training. Nurse Educ Today 1991;11;143-146.

10. Minardi HA, Ritter S. Recording skills on videotape canenhance learning – a comparative study between nurse lecturers and nursing students. J Adv Nurs 1999;26;1318-1325.

11. Kalwitzki M. Self reported changes in clinical behaviour byundergraduate dental students after video-based teaching inpaediatric dentistry. Eur J Dent Educ 2005;9;108-114.

12. Kalwitzki M, Rosendahl R, Gottle R, Weiger R. Acceptance ofvideo-based teaching in paediatric dentistry by undergraduatedental students. Eur J Dent Educ 2003;7:66-71.

13. Mofidi M, Strauss R. Dental students’ reflections on theircommunity-based experiences: The use of Critical Incidents.J Dent Educ 2003;67;515-523.


Dr. Norintan Abdul Murat,Lecturer,Department of Community Dentistry,Faculty of Dentistry,University of Malaya,50603 Kuala Lumpur,Malaysia.Tel No : 03-7967 4866Fax No: 03-7967 4532Email : [email protected]

49

The Expert Says…

Qualitative investigation-: A partner in health research?Associate Professor Dr Raja Latifah Raja Jallaludin PhD (Malaya), Associate Professor of Community Dentistry,Community Dentistry, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia.

Dr Roslan Saub PhD (Toronto), Senior Lecturer of Community Dentistry, Faculty of Dentistry, University of Malaya,50603, Kuala Lumpur, Malaysia.

Why quantitative investigation?

Most dentists are familiar with the conventionalquantitative method in health research which has its rootsin the biomedical model of health. The model focuses onbiological agents in the aetiology of diseases and curativemethods as the key to health. The mind is considered separate from the body. Thus, many health studies aim at improving technical effectiveness and take on a reductionist approach whereby, data are converted to numbers. Quantitative studies (such as surveys and clinicaltrials) aim to test well-specified hypotheses concerningsome predetermined variables. These studies suitablyanswer questions such as whether? (e.g., whether an intervention did more good than harm), or how much?(e.g., how strongly a risk factor predisposes to a disease).

Why qualitative investigation?

More recently, with the advent of the“Psychosocial/Behavioural and Environmental” models inaddition to the traditional model, health is recognised to bemulti-dimension. The biological agent interacts with thewhole person/community within an environment (the placethe individual and community live, school, work, play andseek treatment). Addressing healthcare has become a complex issue and calls for a holistic approach and effective dialogue between all stakeholders in healthcare.Solving oral health problems therefore, requires more thana mechanistic and quantitative science. Dentists need togain insight into social, emotional and experiential phenomena in health care. Examples include inquiry aboutthe meaning of a healthy mouth to individuals and families, or the attitudes and behaviour of patients anddentists. Qualitative research questions tend not to ask"whether" or "how much" but rather to explore "what,""how," and "why”.

What is qualitative investigation?

Qualitative inquiries may have a variety of theory-generating aims. It may be to explore and describe socialphenomena (such as surveying diverse perspectives or giving voice to those not usually heard,1 to identify potentially important variables or concepts, to recognizepatterns and relationships, and to generate coherent theories and hypotheses. Qualitative reports do not typically generate "answers" but rather narrative accounts,explanations of phenomena, conceptual frameworks, andthe like. For example, Zainal Abidin (1997),2 examineddentist-patient relationship by exploring what patientsthought about their dentist. Dewar, Toros Posada & Dillon(2003)3 assessed the perceived challenges and need ofpatients with chronic pain. Another qualitative studyprobes why family members select certain processes fordiscontinuing life support.4 The data collected in qualitative investigations being narrative in naturedemands an astute researcher to inductively analyse forpatterns, linkages, competing themes and plausible explanations.

How do I collect data in qualitative investigation?

There are several techniques in qualitative investigations. One to one qualitative interviews are one ofthe most commonly used in qualitative inquiry. Unlikequantitative interview, qualitative interview only cover oneor two issue but in much greater detail. As such, there areno structured questions as in quantitative interviews.Usually the interviewer will have a core questions thatdefine the area to be covered. Further questions willemerge from the interview. Thus, the interviewers have tobe interactive and sensitive to the language and conceptsused by the interviewee so that they can go deeper on thetopic discussed. After each interview, analysis must be



50

The Expert Says…

made to identify concepts or themes that emerged. Samplewill be added on until the data reach a saturation point i.ewhen there are no more new themes or concepts emerged.This technique has been used by Saub & Jaafar (2001)5 inexploring the illness behaviour among the Orang Asli community.

Some researchers have used group interviews as away to collect data from several people simultaneously.One of these techniques is called focus groups. Focusgroups methods has been used in assessing health education messages, examining public understandings ofillness and of health behaviours, examining people experiences of disease and health services and exploringattitudes and needs of staff. The idea behind the focusgroups method is that group processes can help people toexplore and clarify their views in ways that would be lesseasily accessible in a one to one interview.6 In this techniques a group of people, 8-10 person are broughttogether to respond to questions on a topic of interest. The interview is led by a “moderator” who keeps therespondents focused on a particular topic. The participantsare encouraged to talk and to discuss among themselvesabout the topic. One of the advantages of this method isthat it also provides the researchers with many differentforms of communication that people use in day to dayinteraction, including jokes, anecdotes, teasing and arguing which tell us about what people know or experience. In this sense focus groups reach the parts othermethods cannot reach, revealing dimensions of understanding that often remain untapped by many moreconventional data collection techniques.

One of the problems with the focus groups is dominant participant. To avoid this problem, researcherhas designed a technique known as Nominal GroupTechnique (NGT). NGT is a structured procedure for gathering information from groups of people who haveinsight into a particular area of interest.7 This techniquecombines quantitative and qualitative data collection in agroup setting. As such, it is useful in the decision makingprocess. In this method, there are several steps need to befollowed. The process begins with the induction to thetopic of interest follow by silent generation of ideas inwriting (individual), listing of ideas on the flip chart,discussion of ideas on flip chart, ranking to select the “topten” ideas, voting on “top ten” ideas, discussion of vote,re-ranking and rating ‘top-ten’ items and conclusion ofnominal group.8

Observation is another method of data collection inqualitative inquiry. Observational technique involves systematic detailed observation of behaviour and talkthrough watching and recording what people do and say attheir natural setting. One of the advantages of this methodis it helps in overcoming the discrepancy between whatpeople say and what they actually do.9

Simple rules in qualitative investigationLet the participants talk; do not impose the researchervaluesListen and observe Use the participant vocabulary

Qualitative and quantitative investigations:A marriage?

Just as clinicians use complementary types ofinformation to draw clinical conclusions, complementaryresearch methods are often useful to examine differentaspects of a health problem.10,11,12 Qualitative studies offer arigorous alternative to "armchair hypothesizing" for areaswhere insight may not be well-established, or where conventional theories seem inadequate. Qualitative andquantitative studies each make useful contributions toknowledge in themselves. They may also be used in tandem-qualitative investigation to generate theories andidentify relevant variables, quantitative investigation to testthe implied hypotheses about relationships between those variables. Alternatively, qualitative and quantitativeapproaches can unfold concurrently within a research,informing each other during the analysis and interpretationphases, yielding findings that are broader in scope andricher in meaning than if only one approach were used.

Endnote

Qualitative investigation is growing in health services and health policy research. However, investigatorskeen on qualitative inquiry need to acquire the capacityand experience as the contributions of such an inquiry willnot be maximised unless the investigation techniques areapplied with rigour and creativity.

REFERENCES

1. Sofaer S. Qualitative methods: what are they and why usethem? Health Serv Res. 1999;34:1101-18.

2. Zainal Abidin, Z. Patient preferences for dentist communicationskills. Developing a conceptual model for the Malaysian Army.Masters in Community Dentistry thesis, University of Malaya1997.

3. DewarA., White., Toros Posada S., Dillon.Using NominalGroup Technique to assess chronic pain patients’ perceivedchallenges and needs to enhanced better targetes services in acommunity health region. Health Expectations, 2003;6:1, 44-52.

4. Tilden VP, Tolle SW, Garland MJ, Nelson CA. Decisionsabout life-sustaining treatment. Impact of physicians' behaviors on the family. Arch Intern Med. 1995;155:633-8.

5. Saub R, Jaafar N. A dental-anthropological study of healthand illness behaviour among Orang Asli of the Semai Tribe:The perspective of traditional healers. Medical Journal ofMalaysia 2001;56:401-407.

6. Kitzinger J. Introducing focus groups. British Medical Journal(International edition) 1995;311:299

51

Raja Latifah / Roslan

7. Moy, FM, Atiya AS. The use of nominal group technique inresearch. Malaysian Journal of Public Health Medicine2004;4:19-21.

8. Gallager M, Hares T, Spencer J, Bradshaw C, Webb I. Thenominal group technique: A research tool for general practice? Family Prac 1993;10:76-81

9. Mays N, Pope C. Observational method in medical setting.British Medical Journal (International Edition) 1995; 311:182 Stange KC, Zyzanski SJ. Integrating qualitative andquantitative research methods. Fam Med. 1989;21:448-51.

10. Stange KC, Zyzanski SJ. Intergrating qualitative and quantitative research methods. Fam Med. 1989;21:448-451

11. Goering PN, Streiner DL. Reconcilable differences: the marriage of qualitative and quantitative methods. Can JPsychiatry. 1996;41:491-7.

12. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34:1189-208.


Assoc. Prof. Dr. Raja Latifah Raja Jallaludin,PhD (Malaya)

Dr. Roslan Saub, PhD (Toronto)Department of Community DentistryFaculty of DentistryUniversity of Malaya50603, Kuala LumpurMalaysia.

52

Malaysian Dentists’ Opinion on Fixed Prosthodontics Teaching duringUndergraduate TrainingTandjung YRM MClinDent. Prosthodontics(Lon), Department of General Dental Practice and Oral MaxillofacialImaging, Faculty of Dentistry, University Of Malaya, 50603 Kuala Lumpur, Malaysia.

Morad SM Final Year Dental Student, Faculty of Dentistry, University Of Malaya, 50603 Kuala Lumpur, Malaysia.

Zakaria N Final Year Dental Student, Faculty of Dentistry, University Of Malaya, 50603 Kuala Lumpur, Malaysia.

Ibrahim N MSc Oral Diagnostic Science (Manchester), Department of General Dental Practice and Oral MaxillofacialImaging, Faculty of Dentistry, University Of Malaya, 50603 Kuala Lumpur, Malaysia.

ABSTRACTFixed prosthodontics curriculum is continuously reviewed and revised at various dental schools around the world. The purpose of this study was to identify whether fixed prosthodontics curriculum had adequately prepared students for prosthodontics treatment in general dental practice (GDP). Self-administered questionnaires were distributed amongst thedentists attending Asia Pacific Dental Congress (APDC) at the Putra World Trade Centre (PWTC), Kuala Lumpur in May2005. Pre-testing of the questionnaire was carried out amongst the lecturers at the Faculty of Dentistry, University of Malaya.A total of 150 questionnaires were distributed, 109 (73%) were returned. Collected data were analysed using StatisticalPackage for Social Science (SPSS) version 11. Approximately 50% of respondents stated that 14 topics of fixed prosthodontics were adequately emphasized during their undergraduate training. Implant supported fixed restoration wasthe most underemphasized topic. Both Malaysia and overseas trained dentists agreed that fixed and removable prosthodontics curriculum should be taught in integration.

Key words:prosthodontic, dental education, undergraduate, teaching

INTRODUCTION

An increased in patient’s awareness on oral healthand growing demands for aesthetic dentistry has requiredgeneral dental practitioners (GDPs) to be skilled in providing various types of prosthodontic treatments._Prosthodontic treatments namely crowns, fixed partialdentures and endodontic post/core were known to be themost common procedures performed by newly graduateddentists._

The current dental curriculum should thereforereact to these needs so that students are well equipped forgeneral dental practice. According to a survey done byMeskin and Brown_, they found that fixed prosthodonticteaching in undergraduate curriculum needed reassessmentto make it more relevant to general dental practice. Also,it has been estimated that more than millions of edentulousindividuals are in need of prosthodontic treatment in the21st century._ The importance for educators to persistentlyconducting surveys on prosthodontic curriculum and laboratory delegation has been emphasized.4

The aim of the present study is to examine whetherfixed prosthodontics curriculum had adequately prepared

student for prosthodontics treatment in GDP. The objectives of the study include:

• To survey on the relevance of prosthodontics teaching to current dental practice

• To determine preferable teaching methods i.e. conventional versus integration.

MATERIALS AND METHODS

The 27th Asia Pacific Dental Congress (APDC) washeld at the Putra World Trade Centre, Kuala Lumpur from25th to 29th of May 2005. It comprises of scientific and educational programmes delivered by various well-knownspeakers in various fields of dentistry.

Study Design

The study was a quantitative and cross-sectionalstudy carried out over a period of 4 days during the APDC.It was based on structured questionnaires and directly distributed to individuals.



53

Tandjung / Morad / Zakaria / Ibrahim

Sample and Sampling Technique

Study Population

All Malaysian dentists who received their undergraduate training in either local or overseas universities were the target group. The survey was conducted during APDC for convenience, ease of collection of questionnaire, time and cost effective. Otherforeign dentists (Japan, Indonesia etc) attending APDCwere excluded from answering the questionnaire.

Sampling Frame

There was no sampling frame in this study as allMalaysian dentists who attended the APDC were included.

Sample size

The sample size was not predetermined. The estimated sample of 150 dentists was expected during 4days data collection period.

The Survey Instrument

Questionnaire

A self-administered structured questionnaire wasformulated based on a review of the literatures.2,4

The questionnaire consisted of three sections:

1. Section A – to obtain socio-demographic information of the dentists;

2. Section B – this section was further subdivided into two parts which were:

• Part B1-to obtain some information on their syllabus of fixed prosthodontics teachingreceived during their undergraduate training.

• Part B2- to assess their concurrence teaching of fixed prosthodontics.

3. Section C – this section was also further subdivided into three parts which were:

• Part C1- to attain their current and anticipated scope of prosthodontics in their practice.

• Part C2- to appraise the dentists’ knowledge,skills and level of competency.

• Part C3- this was a double open-ended question requesting suggestions with regards to the opinion on improving the teaching of fixed prosthodontics curriculum and integration of fixed and removable prosthodontics.

The questionnaire was prepared in English and apilot study was conducted. A five point response scale(strongly underemphasized, underemphasized,adequately emphasized, overemphasized, stronglyoveremphasized) was used on section B1. Other responsescale (strongly disagree, disagree, somewhat agree,agree, strongly agree) was used in section B2, C1 and C2.

Pre-test

The questionnaire was pre-tested randomlyamongst the lecturers at the Faculty of Dentistry,University of Malaya. Some corrections were made basedon the feedback and comments given by the lecturers.

Data Collection

Letter to obtain authorization with a set of questionnaire and instructions were faxed to the organizingchairman of the APDC. The data collection was carriedout from 25th to 29th of May 2005 by distributing questionnaire randomly to the dentists attending APDC.Structured announcement was made by the master of ceremony ensuring only Malaysian dentists participated inthe study. 150 questionnaires were distributed within 4days and only 109 returned.

Data management and analysis

Data was checked for completeness and analyzedby computer using the Statistical Package for SocialScience software (SPSS) version 11. The data were analyzed according to the objectives of the study.Percentage and numeric value were reported in the analysis.

Confidentiality

All responses to the questionnaire were strictly confidential with no means of participants’ identification.Information acquired from the questionnaires were codedand entered into SPSS system.

RESULTS

Of the 150 questionnaires distributed, 109 (73%)were returned. The year of graduation ranged from 1956to 2005.

54

Malaysian Dentists’ Opinion on Fixed Prosthodontics Teaching during Undergraduate Training

SOCIODEMOGRAPHIC CHARACTERISTICS

Age and gender

Table 1 showed that female respondents constituted2/3 (68%) as compared to male respondents 1/3 (32%).Majority of respondents (40%) were between the age of 24to 33 years old

Table 1 Distribution of respondents by gender and agegroup.

VARIABLE N %

• Gender

1) Male 35 32

2) Female 74 68

• Age group

1) 24-33 years 44 40

2) 34-43 years 32 28

3) 44-53 years 28 26

4) 54-63 years 3 3

5) > 64 years 2 2

Total 109 100

Graduating country

The pie chart in Figure 1 demonstrated that therespondents were divided into Malaysia and overseas graduates (71% and 29%) respectively. Of the local graduates, a large proportion of the respondents (n=61)were from University of Malaya, five graduated fromNational University of Malaya (n=5), and the rest did notstate the institution they graduated from. On the otherhand, overseas graduates were from Indonesia, Singapore,India, Pakistan, Egypt, Australia and United Kingdom.

Practicing year

Practicing year was categorized into 4 groups,which was 1-10 years, 11-20 years, 21-30 years and 31years, and above. From Figure 2, it can be said that almosthalf of the respondents (47%) were in practice between 1-10 years. However, 24% of this group (1-10 years) wasfresh graduates (1-5 years in practice). The 11-20 yearsand 21-30 years groups contributed to 32% and 18%respectively. Only, small percentages (2%) of the respondents have been in practice for more than 31 years.

Sector joined

Figure 3 demonstrated that majority (62%) of therespondents were from government.

Figure 1 Country which the respondents graduating from

n = 109

Figure 2 Practicing Year

n = 109

Figure 3 Respondents’ Practice

n = 109

55


ASSESSMENT OF FIXED PROSTHODONTICS EDUCATION RECEIVED DURING UNDERGRADUATE COURSE

Fixed prosthodontics syllabus during undergraduatecourse

Table 2 summarised the topics that were found to be adequately emphasised. The three topics that adequately emphasised were principle of abutment selection, preparationand design, cementation procedures and materials and diagnosisand treatment planning (71%, 70% and 68% respectively).

Table 2. Topics of fixed prosthodontics that adequatelyemphasized

PERCENTAGETOPIC DISTRIBUTION

(%)

1. Diagnosis and treatment plan 68

2. Treatment options for vital teeth 64

3. Treatment options for endodontically treated teeth 64

4. Occlusion and interocclusalrecords 53

5. Soft tissue management 57

6. Principles of abutment selection,preparation and design 71

7. Provisional restorations 61

8. Impression materials and techniques 66

9. Mounting working casts 58

10. Fabrication techniques in crown and bridgework 58

11. Principles of framework design 53

12. Cementation procedures and materials 70

13. Maintenance and recall 62

n=77 (Malaysia graduates only)

There were only three topics that were underemphasized as listed in Table 3. Implant supportedfixed restoration was the most underemphasized topic contributing to the highest percentage (82%).

Table 3. Topics of fixed prosthodontics that under-emphasized

PERCENTAGETOPIC DISTRIBUTION

(%)

1. Management of combination cases (e.g. Ortho-restorative-perio) 53

2. Introduction to implant supported fixed restorations 82

3. Laboratory communication 60


Teaching of fixed prosthodontics during undergraduatecourse

Table 4: showed that a large number of respondentsagreed (47% and 44%) that teaching of fixed prosthodon-tics provided them with a sound basis for general practiceand initiated interest in future learning. Majority of therespondents disagreed that time allocation in learningprocess, lecture resources, current journals used and latestconcepts on fixed prosthodontics were sufficiently taught(32%, 33%, 33% and 35% respectively).

Table 4. Assessment of didactic learning

PERCENTAGE DISTRIBUTION

DIS- SOME- AGREEAGREE WHAT

AGREE

1) Provided a sound basis for general practice. 12 41 47

2) Initiated interest in future learning. 10 46 44

3) Sufficient time allocated 32 39 28

4) Sufficient lecture resources 33 46 21

5) Current journals used as extra references besides 33 47 20text books and lecture notes.

6) Latest concepts on fixed prosthodontics included 35 41 24during lectures and clinical sessions.


Table 5: showed that majority of the respondents(65%) agreed that the operative technique session or phantom head practices better prepared students for fixedprosthodontics tooth preparations than demonstrationmethods.

Table 5. Assessment of preclinical



AGREE

1) An operative technique session/phantom head prepares students for 8 26 65fixed prosthodontic tooth preparations


56


Table 6: A considerable number of respondents (46%)were uncertain that adequate time was given to complete therequirements during clinical years. About similar number ofthe respondents disagreed (39%) and somewhat agreed (38%)that they faced difficulties in integrating theoretical knowledgeinto clinical practice. When dealing with patient requiringinterdisciplinary management, 47% of respondents weresomewhat agreed that they have exposure to it.

Table 6. Assessment of clinical competency (when theywere student)

PERCENTAGE DISTRIBUTION (%)


AGREE

1) Exposure to new dental materials. 19 38 43

2) Exposed to various fixed prosthodontics procedures. 31 48 21

3) Adequate time given to complete clinical 28 46 26requirements on fixed prosthodontics.

4) Difficulties to integrate theoretical knowledge 39 38 23and clinical practice.

5) Exposure to diagnosis and treatment planning of patients requiring 31 47 22interdisciplinary management.

n= 77 (Malaysia graduates only)

Table 7: shows the current and anticipated scope ofprosthodontics in practice. Majority of the respondents(54%) disagreed that many partially edentulous patientsrequested for fixed prosthodontics treatment compared toremovable prosthodontics.

Table 7. Current and anticipated scope of prosthodonticsin practice



AGREE

1) Cases treated involved fixed prosthodontic treatment to some extent. 30 42 28

2) Many partially edentulous patients requested for fixed prosthodontic treatment as compared to removable prosthodontic. 54 24 22

n=109 (Malaysia and overseas graduates)

ASSESSMENT OF KNOWLEDGE, SKILLS ANDLEVEL OF COMPETENCY

Table 8: summarised the respondents’opinions on theirknowledge, skills and level of competency. Majority of therespondents (72%) agreed that by attending seminars,workshop and courses, current concepts of fixed prosthodontics can be updated. Nearly half (42%) of therespondents agreed that they were competent in providing various fixed prosthodontics treatment without supervision.Likewise, half of them (56%) agreed that their clinical skillshad improved after few years in practice.

Table 8. Assessment of knowledge, skills and level ofcompetency



AGREE

1) Update the current concepts by attending 3 25 72 seminars, workshop and courses.

2) Competent in providing various fixed prostho- 24 34 42dontics treatment without supervision.

3) Improved clinical skills on fixed prosthodontics 16 27 56after few years in practice.


Figure 4 demonstrated the respondents’ opinions toSection C3 item which were cross-tabulated based ongraduating countries. Majority of the Malaysia graduates(88%) and overseas graduates (90%) agreed that fixed andremovable prosthodontics teaching during undergraduatecourse should be integrated.

Figure 4. Integrated fixed and removable prosthodonticsteaching

n = 109

57


Future considerations for undergraduate fixedprosthodontic programme

The respondents’ opinions to improve the undergraduate fixed prosthodontic teaching were by:

1) Increasing clinical sessions with closed supervision.

2) Integrating multidisciplinary approach in treatment planning.

3) Teaching current techniques and latest materials in the field of fixed prosthodontic.

4) Encouraging students to perform various types of fixed prosthodontic procedures.

5) To conduct case discussions and presentations with students.

DISCUSSION

Fixed prosthodontics syllabus

The results of the present study found that theundergraduate fixed prosthodontics syllabuses have sufficiently prepared students for general dental practice.These results were similar to the findings of a study thatexplored the opinions of recent graduates and senior dental students of Indiana University School of Dentistry.5

The topics that were found to be adequately emphasized inthe previous study were almost similar to that of the present study. The three topics that were recognized to beunderemphasized were management of combination cases,introduction to implant-supported fixed prosthodonticsand laboratory communication.

Management of combination cases is an essentialtopic for teaching purposes as it involves multidisciplinarytreatment approach to restore the patient’s dentition togood health with optimal function and appearance. It hasbeen documented that graduate dental students faced difficulty in handling such cases due to limited knowledgeand exposure during undergraduate training.6 The inclusion of this topic in the lecture resources and case discussions may be vital in order to initiate understandingand improve students’ knowledge.

The increased demands for implant supported prostheses7 to some extent have brought to the attention ofdental educators’ on the need for the inclusion of basicimplants topic in the lecture resources. Besides, the present study has found that this topic was not taught andpoorly covered during undergraduate course. Ideally,undergraduate students should be instilled with soundknowledge on implants treatment. This is due to the factthat the initial examination and diagnosis are commonlymade by general practitioners or treating dentists.Therefore, it is important that the basic knowledge onimplants should be imparted so that patients could acquirethe best available treatment options for replacement ofmissing tooth.

Effective laboratory communication is anotheressential aspect in the fabrication of accurate and precisefit prosthesis. Knowing the proper way of communicatingwith the technicians may prevent miscommunicationresulting in various laboratory errors. This has been supported by a study done by Aquilino and Taylor.8 Theydemonstrated that inadequate interaction between dentistsand technicians resulted in poor quality prostheses.Therefore, it is important that students are taught on howto write clear instructions to technicians explaining thedesign of the prosthesis, materials and shade selected.9

Teaching of fixed prosthodontics

The present findings suggested that fixed prosthodontics education during undergraduate course hassufficiently provided a good foundation for general dentalpractice and initiated interest in future learning. Thesefindings were inconsistent with the surveys done in UnitedKingdom10 and Australia.11 These studies10,11 concluded thatdentists were inadequately prepared and encountered problems with crowns and bridgework. Nevertheless, amore recent study2 overruled this finding. It was noted thatalmost two thirds of the respondents were satisfied withboth didactic and clinical education they received duringundergraduate prosthodontics training. This showed thatthe emphasis in the teaching of fixed prosthodontics atundergraduate level is adequate. A sound basic knowledgeand interests in future learning amongst general practitioners not only resulted in an increase in the quantity but also the quality of fixed prosthodontic services in general dental practice.

Another factor that should be taken into account isthe time allocated for the teaching of fixed prosthodontics.This was found insufficient in the present study. As aresult, the students’ basic knowledge and interest in learning fixed prosthodontics may be negatively affected.It has been suggested that proper division of didactic andclinical teaching should be established. Apart from that,students should be given adequate time interval betweenthe stage of introducing, understanding and implementingnew concepts to clinical settings.3

Preclinical training (phantom head) has been shownto help in enhancing students’ manual dexterity,competency and became familiarized with technicalskills.12 This agrees with the present finding. Moreover,most respondents agreed that the practice on mannequinwas better compared to the traditional demonstrationmethod. Therefore, it can be recommended that every dental student should go through this training prior totreating patients.

The response to the clinical fixed prosthodonticsduring undergraduate course was markedly variable. Mostdentists agreed that the exposure to various prosthodonticsprocedures was insufficient. This could be due to the factthat only certain procedures were emphasised and practiced during undergraduate training. This finding supported the study on British dentists where they were

58


inadequately prepared for crown and bridgework.10 It istherefore suggested that students should be given moreopportunity to provide fixed prostheses in their training.Other than that, most of the respondents agreed that theyhad no difficulties in integrating theoretical knowledgeinto clinical practice.

Current and anticipated scope of prosthodontics practice

Due to its relatively low cost, removable partialdenture is still the treatment of choice for replacement ofmissing teeth particularly in government clinic. On theother hand, crown and bridges are more commonlyrequested in private clinics. In this study, it can be said thatremovable dentures were still highly demanded by partially edentulous patients. This finding was inconsistentwith the study carried out by MacNeil2 where the anticipated change in the demand for prosthodontics services was highest for single-tooth restoration and fixedpartial dentures. However, the present finding was not reliable as majority of the respondents were from the government hospitals. Therefore, their opinion could notrepresent the true population’s treatment needs anddemands for fixed and removable prosthodontics. This isdue to the fact that the treatment carried out at the dentalhospitals is mainly extractions and fillings. Fixed andremovable prosthodontics will only be performed by thespecialists. Therefore, the anticipated scope of fixedprosthodontics practice in Malaysia could not be based onthe findings of the present study.

Assessment of knowledge, skills and level of competency

Continual education is known to be an integral part ofprofessional life1. The respondents of the survey stronglyagreed on the importance of continual education in relation toimproving skills and the level of knowledge after graduation.By attending seminars, workshop and short courses, currentconcepts on fixed prosthodontics may be updated.

Conventional versus Integration fixed and removableprosthodontics

Conventional prosthodontics refers to the traditionmethod where there is a separation in the teaching of fixedand removable prosthodontics. The reason for that wasbecause the clinical skills required for both were significantly different.13 This teaching method was suggested to be effective as educators could concentrate oneach subject and reinforce the clinical skills. On the otherhand, integrated prosthodontics allows the teaching of fixed and removable prosthodontics concurrently.Furthermore, it has been shown that integrated fixed andremovable prosthodontics teaching offered a sound foundation for future professional learning and enhancedthe achievement of prosthodontic treatment goals.2,7

In the present study, there was a significant numberof respondents agreed that fixed and removable prosthodontics should be taught integrated. Integratedprosthodontics offered many advantages for instancedecreasing potential overlapping in the teaching and efficient usage of time allocated for both fixed and removable prosthodontic teaching.13

Some reasons given by the respondents for the integration were:

1) Most patients may require combined treatment approach. Integration may make this process easier as the treatment plan presented and approved by the same supervisor.

2) Students could understand complex treatment planning that requires both fixed and removable prosthodontics.

3) Crowned teeth can be used as abutment for removable prostheses.

It can be concluded that Malaysian dentists generally agreed that the integration of prosthodonticsteaching have adequately prepared them for general dentalpractice. On the other hand, conventional method mayresult in fragmentation of a coherent subject, creation ofcommunication barriers and lack of the interrelations inthe treatment planning.14 The present findings should beconsidered as a valuable reference throughout the curriculum review. Prosthodontics teaching should correspond with the current emergence in dental technology to ensure it benefits the students specificallyand the public generally.

CONCLUSIONS

Based on this study, the following conclusions canbe drawn:

1. Fixed prosthodontics syllabus in the undergraduate dental course was found to have adequately prepared the students for general dental practice.

2. Most Malaysian dentists preferred an integrated fixed and removable prosthodontics teaching.

ACKNOWLEDGEMENTS

We are highly indebted to Dr. S. Nagarajan,President of MDA for granting permission to conduct thestudy during the APDC. We would like to express ourdeepest gratitude to all the academic and supporting staffsat UM for their assistance and guidance.

59


REFERENCES

1) Christensen GJ. Are prosthodontics a vital part of dentistry?J Am Dent Assoc. 2002;133:647-648.

2) MacNeil MAJ, MacEntee MI. Opinions of dentists on integrated fixed and removable prosthodontic Curriculum, IntJ Prostho 1997;10:14 -18

3) Meskin L,Brown J. Prevalence and patterns of tooth loss inU.S. adult and senior populations. Int J Oral Implantol1988;5:59-60.

4) Goodacre JC,: review of the literature predoctoral fixedprosthodontics Education. J Prosthet Dent 1991;64:319-325.

5) Haug PS, Brown TD, Goodacre JC, Cerimele JB, .recentgraduates’ and current dental students’ evaluation of theirprosthodontic curriculum, J Prosthet Dent 1993;70:361-371.

6) Gerbert,: recent graduates’ evaluation of their dental schooleducation,J Dent Educ 1987;51:697-700.

7) Ong CT,: general dental practitioners’ perception of removable prosthodontics in the undergraduate curriculum.N Z Dent J 1999;95:80-82.

8) Aquilino SA, Taylor TD, prosthodontic laboratory and curriculum survey. Part III: Fixed prosthodontic laboratorysurvey. J Prosthet Dent 1984;52:879-885.

9) Smith GP, the responsibility of the dentist toward laboratoryprocedures in fixed and removable partial denture prosthesis.J Prosthet Dent 1963;13:295.

10) Silversin BJ, Shafer MS, Smales CF, Sheiham A, british dentist and final year British and United States students’opinions about their undergraduate Training. Brit Dent J1974;137:161-168.

11) Smales RJ, the Adelaide undergraduate dental curriculum:appraisal by recent graduates and final-year students. AustralDent J 1977;22:23-26.

12) Clancy JMS, Terry JL, Joyce FP, Lynn AJ, a comparison ofstudent performance in a simulation clinic and a traditionallaboratory environment : three-year results. J Dent Educ2002;66:1331-1337.

13) MacEntee MI, integration of fixed and removable prosthodontics in an undergraduate curriculum. J Dent Educ1981;45:204-206.

14) Atwood DA, practice of Prosthodontics: past, present andfuture, J Prosthet Dent 1969;21:393.

Author of correspondence:

Dr. Yeti Rosalina Muslim TandjungBDS (Adelaide), MClinDent. Prosthodontics (Lon)Department of General Dental Practice and OralMaxillofacial ImagingFaculty of Dentistry, University of Malaya50603 Kuala Lumpur.Tel: 603-7967 4895Email: [email protected]

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Aim And ScopeThe Malaysian Dental Journal covers all aspects of work in Dentistry and supporting aspects of Medicine. Interactionwith other disciplines is encouraged. The contents of the journal will include invited editorials, original scientific articles, case reports, technical innovations. A section on back to the basics which will contain articles covering basicsciences, book reviews, product review from time to time, letter to the editors and calendar of events. The mission is topromote and elevate the quality of patient care and to promote the advancement of practice, education and scientificresearch in Malaysia.

PublicationThe Malaysian Dental Journal is an official publication of the Malaysian Dental Association and is published half yearly (KDN PP4069/12/98)

Instructions to contributorsOriginal articles, editorial, correspondence and suggestion for review articles should be sent to:

Associate Professor Dr. Ngeow Wei Cheong,Editor, Malaysian Dental Journal

Malaysian Dental Association54-2, Medan Setia 2, Plaza Damansara

50490 Kuala Lumpur, Malaysia

Authors are requested to submit three copies of their typescript and illustration and also copy of their work in a file ona newly formatted 3.5 inch floppy disk. The editor cannot accept responsibility for any damage or loss of typescripts.The editorial currently is unable to support electronic submissions; apart from the use of e-mailing for correspondence.

A paper is accepted for publication on the understanding that it has not been submitted simultaneously to another journal in the English Language. Rejected papers will be returned to authors. The editor reserves the right to make editorial and literary corrections. Any opinion expressed or policies advocated do not necessarily reflect the opinion orpolicies of the editors.

CopyrightAuthors submitting a paper do so on the understanding the work has not been published before. The submission of themanuscript by the authors means that the authors automatically agree to sign exclusive copyright to the Editor and thepublication committee if and when the publication is accepted for publication. The copyright transfer agreement can bedownloaded at the MDA webpage (www.mda.org.my). A copy of the agreement must be signed by the principal authorbefore any paper can be published. We assure that no limitation will be put on your freedom to use material containedin the paper without requesting permission provide acknowledgement is made to the journal as the original source ofpublication.

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Ellis A, Moos K, El-Attar. An analysis of 2067 cases of zygomatico-orbital fractures. J Oral Maxillofac Surg1985;43:413-417.

Reference to books should be sent out as follows:Scully C, Cawson RA, Medical Problems in Dentistry 3rd edn. Wright 1993:175.

Tables. These should be double spaced on separate sheets and contain only horizontal rules. Do not submit tables as photographs. A short descriptive title should appear above each table and any footnotes, suitably identified below. Caremust be taken to ensure that all units are included. Ensure that each table is cited in the text.

IllustrationsLine illustration. All line illustrations should present a crisp black image on an even white background (127 mm x 173mm or 5 x 7 inches) or no larger than 203 mm x 254 mm or 8 x l0 inches.Photographic illustrations and radiographs. These should be submitted as clear lightly contrasted black and white prints(unmounted) sizes as above. Photomicrographs should have the magnification and details of the staining techniqueshown. Radiographs should be submitted as photographic prints carefully made to bring out the details to be illustrated,with an overlay indicating the area of importance.All illustration should be carefully marked (by label pasted on the back or by a soft crayon) with figure number and authorsname and the top of the figure should be indicated by an arrow. Never use ink of any kind. Do not use paper clips as thesecan scratch or mark illustrations. Caption should be typed, double spaced on separate sheets from the manuscript.Patient confidentiality. Where illustrations must include recognizable individuals living or dead and of whatever age,great care must be taken to ensure that consent for publication has been given. Otherwise, the patient’s eyes or any indentifiable anatomy should be covered.Permission to reproduce, borrowed illustration or table or identifiable clinical photographs. Written permission to repro-duce, borrowed material (illustrations and tables) must be obtained form the original publisher and authors and submitted with the typescript. Borrowed material should be acknowledged in the caption in this style. 'Reproduced bythe kind permission of...... (publishers) from /....(reference)'.

Page ProofsPage proofs are sent to the author for checking. The proofs with any minor corrections must be returned by fax or postto the editor within 48 hours of receipt.

Proprietary namesProprietary names of drugs, instruments etc. should be indicated by the use of initial capital letters.

Abbreviations and unitsAvoid abbreviations in the title and abstract. All unusual abbreviations should be fully explained at their first occurrencein the text. All measurements should be expressed in SI units. Imperial units are also acceptable.

OffprintsTen free offprints are supplied to the author. An offprint order form will be sent to the author with the page proof.

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MALAYSIAN DENTAL JOURNAL · Dr. Yap Yoke Yong Dr. Sharifah Tahirah Al-Junid Dr. Nurshaline Pauline...

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