Rehman Shahid

ORIGINAL ARTICLE Is Tooth Brushing Alone Sufficient? A Clinical Study Evaluating How Oral Hygiene is Improved with the Usage of Oral Rinse and Dental Flossing Along Conventional Tooth Brushing MUHAMMAD IMRAN1, REHMAN SHAHID2, DUR MOHAMMED LASHARI3 1 Assistant Professor of Community & Preventive Dentistry Demonstrator of Operative Dentistry, Nishtar Institute of Dentistry Multan 3 Associate Professor of Oral Biology Dental Section, Bolan Medical College Quetta Correspondence to: Dr. Rehman Shahid Email:-2 ABSTRACT Aim: To determine whether tooth brushing alone is sufficient or not beside the additional usage of CHX oral rinse and dental flossing to obtain maximum OHI scoring. Study Design:Descriptive study Place and Duration of Study: Nishtar Institute of Dentistry, Multan from 1stOctober 2017 to 31stMarch 2018. Methods: A total of 360 patients were included. These patients were divided in three major groups, A, B, and C. Each group was divided into 12 sub groups with each sub group having 10 patients. Complete history was taken of every patient. Group A was directed about the manual tooth brushing technique to continue it for four months. The group B was instructed tooth brushing along the oral rinse chlorhexidinegluconate 0.2% twice daily for four months. The third group C was given the instructions of tooth cleaning with manual tooth brushing, oral rinse and use of dental floss. First follow up was observed after two months and the second was at the end of fourth month. The oral hygiene index (OHI) was measured by Debris index and Calculus Index. Results:ANOVA shows the p<0.05. Tukey HSD equation gives the value of 0.6884.It connotes that any two means that are more than 0.6884 are significantly different.F statistic obtained is more than 3.46. So the null hypothesis is rejected describing the variance among the groups. Conclusion: It is evident that all three modes of applications contribute much oral hygiene. The patients in the community should be guided and made aware of all these oral hygiene measures in order to get the optimum results in the good oral hygiene. Keywords: Chlorhexidinegluconate (CHX), Dental floss, S mutans, Oral hygiene Index (OHI) INTRODUCTION Indeed whosoever purifies himself shall achieve success.(Al-A’la 87:14). Of course who obeyed the message of Holy Prophet (‫ﷺ‬ ), performed the prayers and praised the Allah (SWT) is candidate for Jannah. Islam emphasize on the cleanliness, both physical and spiritual. It has been an essential part of our faith. Being clean is a guarantee for good health. While we think of our body systems, the nature has created a unique system of cleaning in a beautiful harmony. The oral cavity is part of body that requires special attention to be paid for cleaning and perfectly hygienic. Our beloved Prophet Muhammad had a regular practice of using miswak for his blessed teeth before every salah. When the oral cavity is clean, the teeth would have less chances of caries and other associated diseases. In order to improve the oral health status it is necessary that proper oral hygiene methods and measurements should be the primary concern. Brushing the teeth is a common practice to keep the teeth health and clean and it plays an important role in the oral hygiene. No matter what the technique is applied while brushing, a key aspect is to keep the teeth clean and free of caries. Tooth brushing has been an object of research since long. Over the past few decades there has been a dramatic increase in the junk food leading to increased demand for tooth cleaning habits. ------------------------------------------------------------------------------Received on- Accepted on- 853 P J M H S Vol. 13, NO. 3, JUL – SEP 2019 It is known that a proper and recommended brushing technique is necessary for cleaning the teeth. Even the patients with regular brushing are usually found querulous lacking oral hygiene maintenance. Most of the people are unaware of the brushing method and they just do this by their own understandings and cacoethes making this practice is dime a dozen. Therefore, the patients and people of community should be advised the technique of tooth brushing that is recommended by the clinician. There are a number of brushing techniques that may be adopted according to the desire and need. These include Bass technique, Charter’s technique, vibratory technique, Stallman’s technique etc and many more. The objective is to make the teeth and gingiva clean. A good executed technique is beneficial. It helps cleaning all faces of teeth and gingiva. These faces include buccal, lingual, occlusal and the approximal surfaces. All these surfaces are required to be free of plaque and calculus. It is important to remember that there are some areas in the oral cavity which are difficult to clean and are in a difficult approach to the tooth brush. These are the approximal surfaces and also pits and fissures to some extent. Interdental brushes have been specially designed to overcome the problem and cleaning of the approximal parts. Moreover, dental floss has been devised to clean the interdental surfaces. It reduces the plaque and gingivitis or both efficiently more as compared to brushing alone.1 These floss threads are available in different forms like threaded, untwisted, waxed and non waxed. The purpose is same for all the materials. Various oral rinses have also been formulated to be used in Muhammad Imran, Rehman Shahid, Dur Mohammed Lashari conjunction with the brushing. The dental floss and oral rinse are usually not used commonly by the patients but their beneficial effects can’t be disregarded. They add much in good oral hygiene. The problem do exists in the malformed and mal aligned teeth where not only a particular tooth brushing technique is required but also the approach of adopting the brush in a gentle manner. For example the patients during orthodontic treatment may require special attention. The Propolis mouth may add beneficial effects in these patients2. The adjunctive therapies in addition to mechanical cleaning like anti plaque agents prevent plaque accumulation3. Clinical significance of essential oil mouth wash (Listerine) has also been reported as a positive adjunct to mechanical cleaning4. The dental plaque is bacterial colony. It is considered as major cause of gum inflammation i.e., gingivitis and periodontitis5. Therefore, plaque and calculus free teeth may contribute to improved oral hygiene. Table 1: Data obtained statistics MATERIALS AND METHODS Tukey HSD This study was conducted at Nishtar Institute of Dentistry, Multan from 1st October 2017 to 31st March 2018.A total of 360 patients were included. These patients were divided in three major groups, A, B, and C. Each group was divided into 12 sub groups with each sub group having 10 patients. Complete history was taken of every patient. At the beginning, complete scaling and polishing was done in order make a baseline start of the oral hygiene assessment. This procedure was performed in group segments on daily basis. After the completion of scaling and polishing, all the groups were instructed in simple words about the manual tooth brushing technique (Charter’s technique) and to continue it for four months. The group B was also instructed tooth brushing along the oral rinse chlorhexidine gluconate 0.2% twice daily for four months. The third group C was given the instructions of tooth cleaning with manual tooth brushing, oral rinse and use of dental floss. All the patients in three groups were given instructions about their respective cleansing mode. These instructions were including the brushing techniques and the use of dental floss. First follow up was after two months and the second was at the end of fourth month. The oral hygiene index (OHI) was measured by Debris index and Calculus Index. The mean of oral hygiene index was taken for each sub group in all three categories. After the expiry of four months the data was tabulated using SPSS 16 giving some interesting values. RESULTS The value of q is determined from the Tukey chart. The Df is 35 (within group) with 3 groups of treatments. It finds to be 3.4696 with alpha 0.05 in the Chart. By employing the values in Tukey HSD equation we get the value of 0.6884. It connotes that any two means that are more than 0.6884 are significantly different.F statistic obtained is greater than 3.46. So the null hypothesis is rejected suggesting that one or more treatments are significantly different. Further analysis of Tukey HSD test denotes the difference between the three sets of applications. The group C had the most favorable findings from the get-go. - Tooth brushing with oral rinse (CHX gluconate- Tooth brushing with oral rinse plus flossing- - - 81.9014 - 0.6524 0.4225 0.3427 0.9483 0.8077 0.6500 0.5854 0.9738 0.2332 0.1876 0.1690 0.1623 Tooth brushing Treatment Number Sum ∑xi Mean x¯ Sum of squares ∑x2i Sample variance s2 Sample Std. dev. S Std. dev. of mean SEx¯ Grand Total- Analysis of Variance (ANOVA) Sum of squares- Groups Between Within Total Df 2 33 35 Mean square- F statistic P Value 18.6204 < 0.00001 x¯A- x¯B=- =0.5325 x¯A-x¯C=- =1.6758 x¯B-x¯C=- =1.1433 DISCUSSION Tooth brushing with proper recommended technique is necessary for the clean oral cavity. This cleaning will be achieved when we employ the brushing in a prescribed way. The brushing of teeth includes cleaning of the teeth, gingiva, palate, tongue and associated soft tissues. All these are needed to be clean through tooth brushing. There are however, some adjunctive have been developed that add much contribution in the cleaning of the teeth. Traditionally, it has been argued that application of the dental floss, certain types of anti plaque agents and the oral rinses are of positive value. It has also been observed that the conventional brushing technique may sometimes not be appropriate for what it is meant for. Sometimes there might be an unambiguous relationship between the brushing and flossing or the use of oral rinse. The patient needs certain awareness about the application of the required techniques that are meant healthy cleaning of teeth. Inter dental areas are usually thought to be difficult to clean by the tooth brushing. This is especially because the approach of the tooth brush sometimes while cleaning is not applied in a correct way by the patient. It needs a little attention by the patient as well as by the dentist to create awareness and make patients learn the proper way of cleaning. The stagnation of food is more in the interdental areas, pits and fissures and certain morphologic variations that make the catch points on the tooth surface. While tooth brushing, every aspect of the tooth surface is considered. Chlorhexidine is considered the most effective in reducing the S-mutans as well as plaque.6Other herbal formulations of mouthwashes can also be used effectively as an alternate to chlorhexidine mouth wash7. Chlorhexidine mouth rinse has the anti bacterial effect which can last for three to four hours. The results obtained by Naiktari et al8 were statistically significant. Though the contradictory results were observed by Garcia et al9 P J M H S Vol. 13, NO. 3, JUL – SEP- Is Tooth Brushing Alone Sufficient? demonstrating that stannous fluoride dentifrices and peroxide gel are superior to the chlorhexidine mouth rinse in reducing the gingivitis. The antibiotic resistance is also a challenge for the prevention of certain diseases. Like its beneficial effects in other systemic diseases, it has also a major role in the oral cavity. Povidone Iodine (PVP-I) at concentration of 0.23% has shown to provide the protection against oropharyngeal infections in patients having high risk to oral and respiratory infections10. Other side of the coin is the adverse effect of the CHX gluconate is the increase mineral uptake in the biofilm in oral cavity. Thus it leads to the increase calculus formation. It has been observed and proved by the researchers. According to Sakayue et al11 the removal of the biofilm is necessary before CHX use in order to minimize the increase calculus formation as a adverse effect of the chlorhexidine mouthwash. A considerable amount of the literatures have been published that reflect different author’s investigations. Another study revealed anti plaque activity with CHX and herbal mouthwashes.12Luíset al13 reviewed that even the essential oil mouth rinses are more effective in reducing the inter-proximal plaque. Flossing 2-4 days a week is as beneficial as frequently employed flossing technique. The higher cases of periodontitis are due to old age, smoking and lack of regular dental checkups. In fact the dental floss is of much help in reducing the periodontitis, a preliminary work undertaken by Cepeda et al14. The correct tooth cleaning is necessary and the results of certain investigators are in accordance to those engaged by our study. A number of people have the faulty tooth cleaning techniques. Thus it should be emphasized that a proper awareness is mandatory for the good oral hygiene as pointed out by Naseem15. A dental floss impregnated with 2% chlorhexidine has more effectiveness in reducing the inter-proximal biofilms as compared to the conventional floss.16 Tooth brushing is essential for the oral health and thus preventing from caries and gingivitis. It may be recommended twice daily for two minutes regularly. Bain et al17 argues that both mechanical as well as manual tooth brushes are far better and advantageous. It has also been known that there are some damaging effects of the tooth brushing. Though it is necessary to clean the teeth but it is not uncommon to observe the damage done to the teeth due to excessive brushing especially in the old age. The abrasive material present in the tooth paste may result in the cervical abrasion and chipping of the enamel. It is therefore necessary that patient should be advised the correct brushing technique and the required frequency. Too much cleaning is harmful for the tooth structure18. CONCLUSION Tooth brushing is considered as an echt and integral part of good oral hygiene. It depends upon the technique of the brushing employed to get the optimum results. Meanwhile, the addition of the chlorhexidine (CHX) gluconate rinse adds much in reducing the plaque. A proper flossing technique also suits much to the patients improving their oral hygiene without a hitch. Thus, it evident from our study that all these three classic paradigms of oral hygiene 855 P J M H S Vol. 13, NO. 3, JUL – SEP 2019 improvement contribute bendigedig. Though in our study CHX exhibited remarkable results but it is not the only pebble on the beach. Further investigation with different oral rinses might show different OHI scoring. The patients in the community should be instructed and made aware of all these oral hygiene measures in order to get insouciant results on good oral hygiene. REFERENCES 1. Worthington HV, MacDonald L, Poklepovic Pericic T Home use of interdental cleaning devices, in addition to tooth brushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database Syst Rev 2019;4:CD-. Dehghani M, Abtahi M, Hasanzadeh N. Effect of Propolis mouthwash on plaque and gingival indices over fixed orthodontic patients. J ClinExp Dent 2019;11(3):e244-9. 3. Chapple ILC, Van der Weijden D, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J ClinPeriodontol2015;42(Suppl 16): S71–6. 4. Araujo MWB, Charles CA, Weinstein RB, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc 2015; 146: 610–22. 5. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis: group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 2005; 32(Suppl 6): 130–31. 6. Padiyar B,Marwah N,Gupta S. Comparative evaluation of effects of triphala, garlic extracts, and chlorhexidinemouthwasheson salivary streptococcus mutans counts and oral hygiene status. Int J ClinPediatr Dent2018;11(4):-. Vinod KS, Sunil KS, Sethi P. A novel herbal formulation versus chlorhexidine mouthwash in efficacy against oral microflora. J IntSocPrev Community Dent 2018;8(2):184-90. 8. Naiktari RS, Dharmadhikari C. Determining the antibacterial substantivity of Triphala mouthwash and comparing it with 0.2% chlorhexidinegluconateafter a single oral rinse: A crossover clinical trial. J Indian SocPeriodontol 2018;22(6):-. Garcia-Godoy C, Rothrock JPost-prophylaxis gingivitis prevention with two-step stannous fluoride dentifrice plus whitening gel sequence or chlorhexidinegluconatemouthrinse. Am J Dent 2018; 31:12-9. 10. Eggers M, Koburger-Janssen T In Vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens. Infect Dis Ther 2018;7(2):-. Sakaue Y, Takenaka S, Ohsumi T. The effect of chlorhexidineon dental calculus formation: an in vitro study. BMC Oral Health 2018;18(1):52. 12. Prasad KA,John S,Deepika V Anti-plaque efficacy of herbal and 0.2% chlorhexidinegluconate mouthwash: a comparative study. J IntOralHealth2015;7(8):-. Luís HS, Luís LS, Bernardo M Randomized controlled trial on mouth rinse and flossing efficacy on interproximal gingivitis and dental plaque. Int J Dent Hyg 2018;16(2):e73-8. 14. Cepeda MS, Weinstein R, Blacketer C Association of flossing/inter-dental cleaning and periodontitis in adults. J ClinPeriodontol 2017;44(9):-. Naseem S, Fatima SH, Ghazanfar H. Oral hygiene practices and teeth cleaning techniques among medical students. Cureus 2017;9(7):e1487. 16. Muniz FWMG, da Silva Lima H, Rösing CK, Efficacy of an unwaxeddental floss impregnated with 2% chlorhexidine on control of supragingival biofilm: a randomized, clinical trial. J InvestigClin Dent 2018;9(1):13-9. 17. Bain C, Sayed AA, Kaklamanos EG. Tooth brushing-Should We Advise Mechanical or Power Brushes? Results of an International Delphi Conference. J Contemp Dent Pract2018;19(10):-. Wiegand A, Schlueter N. The role of oral hygiene: does tooth brushing harm? Monogr Oral Sci2014;25:215-9. Original Article COMPLICATIONS AFTER POST AND CORE TREATMENT MUHAMMAD IMRAN 2 REHMAN SHAHID 3 MEHMOOD HUSSAIN 4 MUHAMMAD JAWAID 5 MOIN KHAN 1 ABSTRACT Rehabilitation of worn dentitions is a big challenge. To save badly damaged teeth after endodontic treatment, provision of post and core restoration is very effective treatment option. The aim of this study was to observe common complications associated with provision of post and core treatment for the badly damage tooth. In this study 95 patients reported to Oral Diagnostic Departments of Hamdard University Dental Hospital (HUDH), Karachi and Nishtar Institute of Dentistry (NID), Multan were randomly selected. Sixty two females and thirty three males were included in this study with age range from 18-47 years. After taking consent, patients were evaluated by using self designed proforma after six month from provision of post and core restorations. Statistical Package for Social Sciences (SPSS) version 16 was used for data analysis to find common complications linked with post and core restorations. The most frequent complain was gingivitis which was reported in 21 patients (22.1%) followed by loss of retention/ requirement of re cementation which was found in 15 (15.7%) patients respectively. Key Words: Endodontic treated tooth, complications, post and core restorations, post and core failure. INTRODUCTION With advent of aesthetics dentistry, every individual despite having compromised dentition wishes to have both functional and esthetically effective restorations in their mouth. It is difficult to restore tooth with conventional crown once sufficient tooth structure is lost. For restoration of such tooth multiple approaches can be employed.1 In many such cases restoration will be provided after completion of successful endodontic treatment. One of the very viable treatment options is post and core restorations. If following basic guide lines then post and core restorations can have longevity 1 2 3 4 5 Muhammad Imran, BDS, MCPS, Assistant Professor, Department of Community Dentistry, Nishtar Institute of Dentistry, Multan E-mail:-Cell:- Rehman Shahid, BDS, FCPS II Trainee, Lecturer, Department of Operative Dentistry, Nishtar Institute of Dentistry, Multan Mehmood Hussain, BDS, FCPS, Assistant Professor & Head Department of Prosthodontics, Hamdard College of Medicine & Dentistry, Karachi Muhammad Javaid, BDS, MDS Trainee, Lecturer Department of Operative Dentistry, Nishtar Institute of Dentistry, Multan Moin Khan, BDS, Lecturer Department of Prosthodontics, Hamdard College of Medicine & Dentistry, Karachi For Correspondence: Dr Mehmood Hussain, House No. A-695, Block H, North Nazimabad, Karachi E-mail:-Cell:- Received for Publication: May 10, 2015 Revised: August 15, 2015 Approved: August 21, 2015 of more than 20 years.2 Numerous varieties of posts depending upon type of material (metal, fiber post), shape of post (parallel or tapered), mode of action (active or passive) or mode of preparation (pre fabricated or custom made) are readily available, each having its characteristics advantages and disadvantages.3 Provision of specific type of post depends upon various factors like type of occlusion, presence of any parafunctional habit, location of tooth in the arch, amount of coronal structure remains after endodontic treatment, socioeconomic status.4 Radiographic assessment is also of significant value as it provides valuable information regarding root length, shape of canal, quality of root canal treatment, presence of any periapical pathology, periodontal status. All these factors have significant role on the success of post and core restorations.5 After placement of post, next step is core build up, numerous materials like glass ionomer materials including resin modified glass ionomer, cermet, amalgam, gold, composite are available on which preparation has been done for provision of crown.6 Provision of post reinforce the mechanical strength of the restored tooth, the onlay/ crown component protects the endodontically treated premolar from splitting under compressive loading while post will not only provide adequate retention but also protect the tooth from tensile (horizontal) stresses.7 Pakistan Oral & Dental Journal Vol 35, No. 3 (September 2015) 546 Complications after post and core treatment Provision of post is associated with many complains like caries, gingivitis, tooth fracture, post fracture, core fracture, prosthesis fracture, loss of retention and need for recementation. These problems must be properly evaluated and should be corrected accordingly.8 Diagnostic Departments of Hamdard University Dental Hospital, Karachi and Nishtar Institute of Dentistry, Multan were selected randomly for present study. The study was started in 2013 and was spread over 18 months. The aim of this study was to find out the common complications after provision of post and core restorations in patients visited Hamdard University Dental Hospital (HUDH), Karachi and Nishtar Institute of Dentistry (NID), Multan. After taking consent patients were advised to visit one week, one month and six months after provision of post and core restoration. Self designed proforma was used to record all relevant details after six months extra oral and intra oral examinations were carried out to find any complication linked with post and core restoration. METHODOLOGY Initially one hundred patients reported to Oral 14 13 13 12 11 12 Age Groups FREQUENCY 10 10 8 8 10-25 6 6 5 5 26-40 4 4 3 41-55 2 1 2 0 1 1 0 0 0 11 12 13 21 22 23 TEETH SELECTED FOR POST AND CORE Fig 1: Teeth selected in different age groups for Post and Core Treatment 9 9 FREQUENCY 8 8 Age Groups 7 7 6 6 5 5 10-25 4 4 3 3 2 2 26-40 2 2 1 1 1 0 0 1 41-55 0 Gingivitis Tooth Fracture Fracture of Core Fracture of Post Recementation COMPLICATIONS AFTER POST AND CORE TREATMENT Fig 2: Common Complications after Post and Core Treatment Pakistan Oral & Dental Journal Vol 35, No. 3 (September 2015) 547 Complications after post and core treatment As five patients did not visit on subsequent follow up visits, so they were excluded from the study. Therefore total ninety five patients were finally selected. Of the selected patients, 62 (65.2%) were females while 33 males (34.7%). Age of the patient varies from 18-47 years. Those patients who did not get any fixed prosthodontic treatment for the same tooth in past were included in this study. Those patients who have established uncontrolled diabetes or unable to maintain good oral hygiene due to local or systemic reasons were also excluded from the study. Statistical Package for Social Sciences (SPSS) version-16 was used to find common complications linked with post and core restorations. RESULTS The most frequent complain was gingivitis which was reported in 21 patients (22.1%) followed by loss of retention / requirement of re cementation which was found in 15 (15.7%) patients respectively. While in 06 (6.3%) patients post fracture was also reported. DISCUSSION Rehabilitation of anterior dentition often requires multidisciplinary approach, provision of post and core restoration followed by crown is still very effective treatment. Various factors like location of tooth, shape of root, root length, amount of coronal portion remains after tooth preparation have strong influence for the selection of particular type of post.9 In this study pre fabricated metal posts were used which is similar to the study conducted by Akbar.10 Similarly Memon et al also reported a case where they used prefabricated metal post to restore badly damaged tooth.11 In a study reported by Schmidlin et al12 majority of the patients (64%) were females while 24% males. These results are similar to the present study, as frequency of females and males were 62 (65.2%) 33 (34.7%) respectively. In this study all impressions were made with polysiloxane impression material which is similar to the study by Rashid where same impression material was used during provision of post and core restoration.13 In the study the most common complain was gingivitis (22.1%) which is similar to the results obtained in a result in a study by Jung RE et al14 where the frequency of gingivitis was 28.6%. this is contrast to the study conducted by De Backer H et al15 where caries (32%) was the most significant complain. Gbadebo et al16 reported 2.5% cases of decementation in their study while in this study, rate of decementation was 15.7% which was significantly higher. In this study all teeth are restored with porcelain fused to metal (PFM) crowns. Ratnakar et al17 in his survey found that majority of the endodontically treated were restored with PFM after placement of cast post. Fracture of post is also commonly associated complain after provision of post and core restoration. Various factors like material, type, shape, length, diameter of the post will determine the success of the post. In this study, 06 patients reported with complain of fracture of post. Pereira et al18 in their study also noticed that incidence of post fracture was increased when metal post was used. Fracture of tooth itself after provision of post and core restoration is also reported in the literature. In the present study three cases were reported having fracture of tooth. Use of prefabricated metal post enhanced the fracture of tooth as compare to the cast post system. This fact was also observed by Figueiredo et al19 in their study that incidence of tooth fracture was double if pre fabricated metal post was used in comparison to studies where cast metal post was used. The age of the patient is also a very critical factor in determination of successful post and core restoration. The need of recementation requirement was more in younger age group which is linked with presence of large number of teeth opposing arch and heavy masticatory forces which is generally low in older age group. In the present study 09 patients from younger age group were need recementation while for older age group recementation was done for only 01 patient. Mentink et al20 in their study reported that in 45% of the patients after 10 years required recementation. The cause of failure must be identified, complete assessment of the restoration, remaining tooth, patient’s functional and aesthetic demands are very critical in order to formulate a successful treatment plan.21 CONCLUSION To restore endodontically treated teeth with post and core restoration is linked with multiple complications. Every patient should be critically evaluated to minimize the incidence of various complications associated with post and core restoration. REFERENCES 1 Goyal MK, Goyal S, Hegde V, Balkrishana D, Narayana AI. Recreating an esthetically and functionally acceptable dentition: a multidisciplinary approach. Int J Periodontics Restorative Dent 2013; 33: 527-32. 2 Valderhaug J, Jokstad A, Ambjornsen E, Norheim PW. Assesment of the periapical and clinical status of crowned teeth over 25 years. J Dent 1997; 25: 97-105. 3 Wiskott HWA. Operative dentistry. Fixed Prosthodontics Principles and Clinics. 1st ed. Germany: Quintessence Publishing 2011; 289-338. Pakistan Oral & Dental Journal Vol 35, No. 3 (September 2015) 548 Complications after post and core treatment 4 Al-Omari WM, AM. The retention of cast metal dowels fabricated by direct and indirect techniques. J Prosthodont 2010; 19: 58-63. 14 Jung RE, Kalkstein O, Sailer I, Roos M, Hämmerle CH. A comparison of composite post buildups and cast gold post-and-corebuildups for the restoration of nonvital teeth after 5 to 10 years. Int J Prosthodont 2007; 20: 63-69. 5 Bateman G, Tomson P. Trends in Indirect Dentistry: 2. Post and Core Restorations. Dent Update 2005; 32: 190-98. 6 Al Ghadban A, Al Shaarani F. Antibacterial properties of amalgam and composite resin materials used as cores under crowns. Eur J Prosthodont Restor Dent. 2012 Jun; 20(2): 71-76. 15 De Backer H, Van Maele G, De Moor N, Van den Berghe L. An up to 20-year retrospective study of 4-unit fixed dental prostheses for the replacement of 2 missing adjacent teeth. Int J Prosthodont 2008; 21: 259-66. 7 Sharath Chandra SM. Sharonlay- A new onlay design for endodontically treated premolar. J Conserv Dent 2015; 18: 259-66. 16 Gbadebo OS, Ajayi DM, Oyekunle OO, Shaba PO. Randomized clinical study comparing metallic and glass fiber post in restoration of endodontically treated teeth. Indian J Dent Res 2014; 25: 58-63. 8 Jotkowitz A, Samet N. Rethinking ferrule – a new approach to an old dilemma. Br Dent J 2010; 209: 25-33. 9 Patil PG, Nimbalkar-Patil SP, Karandikar AB. Multidisciplinary treatment approach to restore deep horizontally fractured maxillary central incisor. J Contem Dent Pract 2014; 15: 112-15. 17 Ratnakar P, Bhosgi R, Metta KK, Aggarwal K, Vinuta S, Singh N. Survey on restoration of endodontically treated anterior teeth: a questionnaire based study. Int J Oral Health 2014; 6: 41-45. 10 Akbar I. Knowledge, attitudes and practice of restoring endodontically treated teeth by dentists in north of Saudi Arabia. Int J Health Sci 2015; 9: 41-49. 18 11 Memon MS, Khatri DR, Rehan F, Mirza D, Khan MY. Restoration of fractured maxillary central incisor of a young female patient. J Pak Dent Assoc 2006; 15: 104-06. Pereira JR, do Valle AL, Shiratori FK, Ghizoni JS, Bonfante EA. The effect of post material on the characteristic strength of fatigued endodontically treated teeth. J Prosthet Dent 2014; 112: 1225-30. 19 12 Schmidlin K, Schnell N, Steiner S, Salvi GE, Pjetursson B, Matuliene G, Zwahlen M, Brägger U, Lang NP. Complication and failure rates in patients treated for chronic periodontitis and restored with single crowns on teeth and/or implants. Clin Oral Implants Res 2010; 21: 550-57. Figueiredo FE, Martins-Filho PR, Faria-E-Silva AL. Do metal post-retained restorations result in more root fractures than fiberpost-retained restorations? A systematic review and meta-analysis. J Endod 2015; 41: 309-16. 20 Mentink AG, Meeuwissen R, Käyser AF, Mulder J. Survival rate and failure characteristics of all the metal post and core restoration. J Oral rehab 1993; 20: 455-61. 21 Beddis HP, Okechukwu N, Nattress BR. The last post: assessment of the failing post-retained crown. Dent Update 2014; 41: 386-88. 13 Saqib Rashid. Restoration of an extensively broken down Maxillary Molar with Cast Split Post and Core. A Case Report. J Pak D Assoc 2001; 10: 54-55. CONTRIBUTION BY AUTHORS 1 2 3 4 5 Muhammad Imran: Rehman Shahid: Mehmood Hussain: Muhammad Jawaid: Moin Khan: Collection of data & biostatistics. Collection of material for writing introduction. Data collection of patients, helped in writing introduction. Data collection of patients from Multan & bibliography writing. Biostatistics. Pakistan Oral & Dental Journal Vol 35, No. 3 (September 2015) 549 Original Article PATTERN OF ORAL HYGIENE MAINTENANCE AMONG PATIENTS SEEN AT TWO TERTIARY HOSPITALS SYED ABRAR ALI REHMAN SHAHID 3 MEHMOOD HUSSAIN 4 MUHAMMAD IMRAN 5 MOIN KHAN 1 2 ABSTRACT The study was conducted in two tertiary hospitals to observe frequency & duration of tooth brushing & their relation with incidence of caries, gingivitis & sensitivity. In this study total 1200 patients were selected randomly reported to Department of Operative Dentistry of both institutes. The duration of study was one year. Out of these 1200 patients 755 (62.91%) were male and 445 (37.08%) were female with age range from 15- 74 years. All patients were divided into three groups on the basis of their age, in group 1 age range was 15-25 years, in group 2 age range was 26-50 years while group 3 included patients of above 50 years. After taking consent from the patients a self designed questionnaire was used to get necessary details. Data compiling and statistical analysis was done by using SPSS – 20 & results were obtained. Brushing frequency and duration of brushing is better in group 2 followed by group 1 & 3 respectively. The rate of caries and gingivitis is also significantly higher in group 2 (50.8% & 40.4%) followed by group 1 (21.6% & 15%) and group 3 (1.8% & 2.5%) respectively. Key Words: Caries, gingivitis, sensitivity, frequency & duration of brushing. INTRODUCTION Good oral hygiene is one of the primary indicators of overall general health. In literature so much information is available on different methods to maintain good oral hygiene but unfortunately these methods are not properly practiced, as a result incidence of various oral health disorders are continuously increasing.1 1 2 3 4 5 Syed Abrar Ali, Assistant Professor & Head Department of Operative Dentistry, Hamdard College of Medicine & Dentistry, Karachi E-mail:-Cell:- Rehman Shahid, Lecturer Department of Operative Dentistry, Nishtar Institute of Dentistry, Multan Mehmood Hussain, Associate Professor & Head Department of Prosthodontics, Hamdard College of Medicine & Dentistry, Karachi Muhammad Imran, Assistant Professor, Department of Community Dentistry, Nishtar Institute of Dentistry Moin Khan, Lecturer Department of Prosthodontics, Hamdard College of Medicine & Dentistry, Karachi For Correspondence: Syed Abrar Ali, 359-B Block, Adamji Nagar, Karachi Email:-Cell:- Received for Publication: August 27, 2015 Revised: October 8, 2015 Approved: October 11, 2015 Pakistan Oral & Dental Journal Vol 35, No. 4 (December 2015) To maintain good oral hygiene proper tooth brushing is one of the simpler and easy way but still it is not properly practiced in our community. There are numerous brushing techniques like Bass, Stillmans, Leonard, Smith-Bell, Fones and Charters etc which are discussed in the literature. Each technique has its own advantages and disadvantages.2 Apart from brushing technique frequency of tooth brushing, total duration of tooth brushing, type of tooth brush, quality of tooth paste are also very significant factors in order to maintain good oral hygiene.3 Use of other cleansing aids like dental floss, interdental brushes, fluoride application and varnishes are also some significant factors in this regard.4 Faulty and irregular tooth brushing technique are directly related to increase incidence of various oral health disorders especially caries and gingivitis which will ultimately lead to loss of teeth.5 Bad oral hygiene not only affect the oral cavity but it can also contribute to other systemic diseases like cardiovascular diseases, prosthetic joint infections etc.6 This study was conducted to obtain information about frequency of tooth brushing and their relation with certain oral health problems in patients visited two different tertiary care hospitals. 645 Pattern of oral hygiene maintenance METHODOLOGY The study was conducted at Department of Operative Dentistry, Nishtar Institute of Dentistry, Multan and Department of Operative Dentistry, Hamdard University Dental Hospital, Karachi. The duration of this study was one year from 1st April 2014 to 31st March 2015. Total 1200 patients (600 from each institute) were selected randomly reported to Department of Operative Dentistry of both institutes. Out of these 1200 patients 755 (62.91%) were male and 445 (37.08%) were female with age range from 15-74 years. All patients were divided into three groups on the basis of their age, in group 1 age range was 15-25 years, in group 2 age range was 26-50 years while group 3 included patients of above 50 years. After taking consent from the patients a self designed questionnaire was used to get necessary details. Data collection and statistical analysis was done using SPSS – 20 and results were obtained. RESULTS Brushing frequency and duration of brushing is better in group 2 followed by group 1 and 3 respectively. The rate of caries and gingivitis is also significantly higher in group 2 (50.8% and 40.4%) followed by group 1 (21.6% and 15%) and group 3 (1.8% and 2.5%) respectively as shown in Table 1. DISCUSSION Good oral hygiene is a primary requisite for having better general health. There are numerous aids available for maintaining good oral hygiene. Using proper tooth paste with adequate brushing technique, brushing frequency and timing of brushing are important factors required for having good oral health.7 Parera et al8 reported that by using proper tooth paste with adequate brushing frequency are directly related with good oral hygiene. The incidence of caries and tooth loss was significantly higher in those individuals who did not brush their teeth properly. This is also found in this study. The brushing frequency and duration of brushing are the two most important factors for maintaining good oral hygiene. Peker et al9 observed in their study that brushing frequency and oral hygiene is better in young population as compared to the older population. The similar results were obtained in this study as well. The sample size of both studies were also same. Apart from manual tooth brush now days some special types of tooth brush like inter dental tooth brush, electrically operated tooth brushes are also available but their use is restricted in specific type of population. In this study, majority of the population used manual tooth brush. Field et al10 reported that in their study the use of both manual and electric tooth brush was effective in maintaining good oral hygiene. In this study, the incidence of brushing twice was 28.7% which closely matches with the study of Peeran et al11 conducted in Libian population. This is in contrast to the study of Ganss et al12 where frequency of brushing twice was 79.6%. Peterson et al13 noted in their study that frequency of tooth brushing is generally high in younger age groups as compared to older age group which is mainly due to high esthetics demand of younger population. Similar findings were also observed in this study. In the present study, 71.2% were doing tooth brushing for more than 2 minutes while 28.7% had duration of less than two minutes, while Albertsson et al14 noted in their study that duration of tooth brushing for more than 2 minutes was 41% and less than 2 minutes was 40.1%. The overall incidence of caries in this study was 74.3% which is significantly high, the incidence of caries in younger age group was 50.8% which is much higher than the elderly population which is only 1.8%. This result may be because of consumption of different variety of foods, faulty brushing technique, deposition of more secondary population in older population.. These findings were also noted by Chu et al15 where caries incidence is low in elderly population. This is in contrast to the study of Zubiene et al where incidence of caries was higher in older age group which was 25.6%.16 In the current study, 21.6% of the middle age group individuals had been found with carious teeth while TABLE 1: STATISTICS SHOWING FREQUENCY, DURATION OF TOOTH BRUSH, CARIES & GINGIVITIS IN DIFFERENT AGE GROUPS S. Age in No. years Brushing Frequency Brushing Time 1 2 3 Less than More than 2 min 2 min Gender M F Caries Gingivitis Sensitivity 1 15-25 210 138 42 80 310 203 187 260 180 95 2 26-50 480 169 90 215 524 509 230 610 485 121 3 Above 50 28 38 05 50 21 43 28 22 31 18 Pakistan Oral & Dental Journal Vol 35, No. 4 (December 2015) 646 Pattern of oral hygiene maintenance BRUSHING- FREQUENCY 500 400 - 210 200 138 15-25 Age - Age 90 100 38 28 80 50 42 21 5 Above 50 0 1 2 3 Less than 2 min Brushing Frequency More than 2 min Brushing Time Fig 1: Frequency & duration of brushing in different age groups Pattern of Caries, Gingivitis & Sensitivity in different age groups- Caries Gingivitis 15-25 Age 26-50 Age Sensitivity Above 50 Age Fig 2: Pattern of caries, gingivitis and sensitivity in different age groups Chen et al17 in their study found that incidence of caries in middle age group was 37.9%. The low frequency of brushing and faulty brushing technique will also affect the periodontal status of the existing dentition as well. In this study the incidence of gingivitis is 57.9% while Natto et al18 in their study conducted in population of Chad noted the incidence was 56.6% which is in close relation with this study. Darby et al noted in their study conducted on Australian population that the incidence of gingivitis was 28.4%.19 The incidence of sensitivity in the present study was 19.5% with higher incidence in younger age as compare to older age group, which is mainly due to deposition of Pakistan Oral & Dental Journal Vol 35, No. 4 (December 2015) secondary dentine and consumption of particular type of diet. The prevalence of hypersensitivity was 12.3% in the study conducted by Cunha et al20 in American population. Their results are also similar to this study where rate of hypersensitivity was low in elderly population. Sadaf et al21 in their study conducted in selected patients reported to tertiary care hospital of Karachi found the incidence of hypersensitivity was 38% which is significantly higher as compare to the current study. The study was conducted to observe the teeth brushing pattern both in terms of duration and frequency. With limitation of the sample size in this study, it was observed that in general oral health of our population 647 Pattern of oral hygiene maintenance is not adequate. There is an immense need to improve the oral health of our community by increasing the awareness about effects of good and poor oral hygiene on oral cavity as well as on general health. Regular educational programe for general public should be organized by the public and private organizations. Oral health care provider can also play a significant role in this regard.22 CONCLUSION In general the oral hygiene of the studied population is not adequate which is linked with decrease duration and low frequency of tooth brushing. Dentists can play a vital role in improvement of oral hygiene of the population. 10 Peker K, Bermek G. Oral health: locus of control, health behavior, self-rated oral health and socio-demographic factors in Istanbul adults. Acta Odontol Scand 2011; 69: 54-64. 11 Fjeld KG, Mowe M, Eide H, Willumsen T. Effect of electric toothbrush on residents'oral hygiene: a randomized clinical trial in nursing homes. Eur J Oral Sci 2014; 122: 142-48. 12 Peeran SW, Singh AJ, Alagamuthu G, Abdalla KA, Naveen Kumar PG. Descriptive analysis of toothbrushing used as an aid for primary prevention: a population-based study in Sebha, Libya. Soc Work Public Health 2013; 28: 575-82. 13 Ganss C, Schlueter N, Preiss S, Klimek J. Tooth brushing habits in uninstructed adults--frequency, technique, duration and force. Clin Oral investing 2009; 13: 203-8. 14 Petersen PE, Kandelman D, Arpin S, Ogawa H. Global oral health of older people call for public health action. Community Dent Health 2010; 27: 257-67. 15 Albertsson KW, van Dijken JW. Awareness of toothbrushing and dentifrice habits in regularly dental care receiving adults. Swed Dent J 2010; 34: 71-78. REFERENCES 1 Kidd E. Caries control from cradle to grave. Dent Update 2010; 37: 654-56. 16 2 Graetz C, Bielfeldt J, Wolff L, Springer C, El-Sayed KM, Sälzer S, Badri-Höher S, Dörfer CE. Toothbrushing education via a smart software visualization system. J Periodontol 2013; 84: 186-95. Chu CH, Ng A, Chau AM, Lo EC. Oral health status of elderly Chinese with dementia in Hong Kong. Oral Health Prev Dent 2015; 13: 51-57. 17 Zubiene J, Milciuviene S, Klumbiene J. Evaluation of dental care and the revalence of tooth decay among middle-aged and elderly population of Kaunas city. Stomatologija 2009; 11: 42-47. 3 Creeth JE, Gallagher A, Sowinski J, Bowman J, Barrett K, Lowe S, Patel K, Bosma ML. The effect of brushing time and dentifrice on dental plaque removal in vivo. J Dent Hyg 2009; 83: 111-16. 18 Chen X, Liu Y, Yu Q, Zheng L, Hong X, Yan F, Yu H. Dental caries status and oral health behavior among civilian pilots. Aviat Space Environ Med 2014; 85: 99- 1004. 4 Rogers HJ, Morgan AG, Batley H, Deery C. Why, what and how: caries control for erupting molars. Dent Update 2010; 42: 154-56. 19 Natto ZS, Petersen FF, Niccola Q. The oral health status and the treatment needs in Chad: a pilot study. Niger Postgrad Med J 2014; 21: 245-49. 5 Broadbent JM, Thomson WM, Boyens JV, Poulton R Dental plaque and oral health during the first 32 years of life. J Am dent Assoc 2011; 142: 415-26. 20 Darby I, Phan L, Post M. Periodontal health of dental clients in a community health setting. Aust Dent J 2012; 57: 486-92. 6 Worsley DJ, Marshman Z. Few studies addressing tooth brushing frequencu and periodontitits. Evid Based Dent 2015; 16: 15. 21 7 Mougeot FK, Saunders SE, Brennan MT, Lockhart PB. Associations between bacteremia from oral sources and distant-site infections: tooth brushing versus single tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119: 430-5. Cunha-Cruz J, Wataha JC, Heaton LJ, Rothen M, Sobieraj M, Scott J, Berg J. The prevalence of dentin hypersensitivity in general dental practices in the northwest United States. J Am Dent assoc 2013; 144: 288-96. 22 Sadaf D, Ahmad Z. Role of Brushing and Occlusal Forces in Non-Carious Cervical Lesions (NCCL). Int J Biomed Sci 2014; 10: 265-68. 8 Prado RL, Saliba NA, Garbin CA, Moimaz SA. Oral impacts on the daily performance of Brazilians assessed using a sociodental approach: analyses of national data. Braz Oral Res 2015; 29: 1-9. 23 Wu A, Switzer-Nadasdi R. The role of health behavior in preventing dental caries in resource-poor adults: a pilot intervention. J Tenn Dent Assoc 2014; 94: 17- 21. 9 Perera R, Ekanayake L. Tooth loss in Sri Lankan adults. Int Dent J 2011; 61: 7-11. CONTRIBUTION BY AUTHORS 1 2 3 4 5 Syed Abrar Ali: Rehman Shahid: Hasnain Abbas: Mehmood Hussain: Muhammad Imran: Wrote manuscript and examining patients. Collection of data. Examining patients. Assistance in inferences. Biostatistics. Pakistan Oral & Dental Journal Vol 35, No. 4 (December 2015) 648 ORIGINAL ARTICLE Tooth Morphology and Aesthetics While Smiling in Accordance to Golden Proportion 1 2 SHER MUHAMMAD , REHMAN SHAHID , MUHAMMAD ISMAIL SIDDIQUI 3 ABSTRACT Background: The anterior teeth have a great impact on personality. This is true because the anterior teeth are visible while smiling and talking. Moreover the aesthetics demand of the patients for anterior teeth while these are getting restored by the dentist, the restorative procedure may become a bit tricky needing a more handful of art and science that may fulfill the patient’s desires. Thus it is sometimes more challenging to materialize the outcome that the patient actually wants. The Golden proportion is the ratio that is found to exist between the maxillary anterior teeth while looking from the front. This ratio has been assumed to be an ideal proportion between the maxillary anterior teeth. It may be helpful while restoring the anterior teeth and evaluation of esthetics. Aim: To evaluate the existence of Golden proportions in outdoor patients coming at Nishtar Institute of Dentistry, Multan. Methods: This study was carried out at Nishtar Institute of Dentistry, Multan. A total 70 patients were selected aged between 25 to 35 years. Twenty patients were male and 50 were female. The size of anterior maxillary teeth while smiling was measured with the help of manual caliper. All the measurements were noted in accordance to Golden proportions. Results: Instead of golden proportion the ratio of 1.3 and 1.4 were more common i.e. 30% and 28.50% respectively among the patients. Conclusion: Golden proportion is not a common finding in the study group involving the local population. Key words: Golden proportion, Esthetics, Restorative intervention. INTRODUCTION The Holy Prophet (‫ )ﷺ‬said: "When you smile to your brother's face, it is charity". This is an authentic hadith. It is mentioned in Sunan al-Tirmidhi. There is enormous wisdom in the Holy Prophet’s (‫ )ﷺ‬words. A beautiful smile is the most attractive feature in the face. However beauty is not absolute and is extremely subjective. A smile may be an emotional gift or blessing, not a material one. It is a sign of joy and pleasure. It is a gift whose recreation is received by the heart. Smiling aids our mental as well as physical health. The neurotransmitters like dopamine, endorphins and serotonin are all released when a smile given across the face1. Indeed doctors have begun to incorporate smiling into their therapies. Smiling contributes to lowering blood pressure improved circulation and the beauty. It boosts the immune system. It works wherever stress and depression cause harm. Smiling relaxes us and improves our emotional stability. Aesthetics is derived ----------------------------------------------------------------------1 Assistant Professor, Oral Biology & Tooth Morphology, 3 Demonstrator, Senior Dental Surgeon, Department of Operative Dentistry, Nishtar Institute of Dentistry Multan Correspondence to Dr. Muhammad Ismail Siddiqui Email:-2 from the Greek word aisthetikos that means to sense perception2. It is the branch of philosophy concerned with the study of concepts like as beauty, taste, etc. Generally people are more conscious about their smile and thus aesthetic looks. If a patient has lost the anterior tooth/teeth, he is most conscious about his aesthetics or smile. In this way the patient may feel a psychological sense of being deprived and unable to talk or smile in an open way or according to desire. Thus a good aesthetics is somewhat a good smile that in turns dependent on the harmonious anterior teeth of face. It has also been observed that the patients that require the anterior teeth restorations take a keen interest in the outcome of the treatment and discuss all the procedure with the doctor before going to start as he uses all where withal. Thus it becomes somewhat more challenging to the doctor especially when the patient has missing or decayed teeth3. It all denotes that anterior teeth play a vital role in the personality and psychological attitude of the patient. An eloquent briefing to the patient about the treatment is sometimes more helpful. It is also to be noted that the congenitally missing laterals are accommodated making canines dissemble giving looks of laterals giving a good contribution to fetching aesthetics. The entire evocative treatment plan is to be is predetermined. If P J M H S Vol. 10, NO. 1, JAN – MAR- Tooth Morphology and Aesthetics While Smiling in Accordance to Golden Proportion the patient is satisfied from the treatment outcome the dentist may have a good cynosure. The size and shape of maxillary anterior teeth is of utmost importance while considering the aesthetics and the 4 smile . The length and width both are important for considering the restoration. There has been mesiodistal dimension and the incisogingival one. Both are to be kept in mind as how to restore in the most acceptable fashion. The width of the tooth matters most than the other dimensions5. The patient will be satisfied when all the restorative procedures coincide with the natural aesthetic looks. It was Mark Barr, an American mathematician who represented the Golden Ratio by using a Greek symbol Φ. The ideal proportion for aesthetics and symmetry was 6 found to be lie in the ratio of 0.618 to 1.0 . The Golden proportion is a constant Ratio between the larger and the smaller teeth. This ratio is approximately 1.618:1. According to this ratio the smaller anterior tooth is nearly 62% of the adjacent larger tooth. This proportion was first introduced by Euclid. While smiling the anterior teeth are visible. So the people are more conscious about their anterior teeth than posterior ones. The lost anterior teeth may compromise the smile and aesthetics. The main factors responsible for the aesthetics are the lip line, angulations of teeth, facial symmetry, incisal line and shade of teeth7. Special focus is also given when restoring these anterior teeth. A lot of restorative materials are available that are used to restore the lost tooth part for the conservation. Special consideration is given to match the excellence of aesthetics and a good harmony among all the anterior teeth. Since the aesthetics is of prime focus, the quality of restorative procedure as well as the material maters much. The objective of this study is to find out the natural proportions of the anterior teeth in comparison to golden proportion. MATERIALS AND METHODS This study was conducted at Nishtar Institute of Dentistry, Multan. Seventy patients were selected out of which fifty were females and twenty were males. Manual vernier calliper was used to measure the tooth dimensions in accordance with the Golden proportion. The width of maxillary incisors was made from the mesiodistal contact points. The width of canine was measured from the mesial contact point to the most distal point visible from front side. For the sake of good study finding and preventing any in accuracy, each measurement was taken thrice by the same operator. The width of larger central incisor was multiplied by 62 percent as compared to the smaller laterals and canines. The results were 282 P J M H S Vol. 10, NO. 1, JAN – MAR 2016 analyzed using SPSS version 20 at α=0.05. Various ratios of golden proportions were measured on the basis of sex. Inclusion criteria was followed as (a) normal healthy teeth with no dental anomaly or tooth size discrepancy, (b) no periodontal disease or gum recession, (c) no spacing or crowding of teeth, (d) no restorative treatment performed in anterior teeth under consideration, (e) no attrition, erosion or abrasion present and (f) no missing anterior teeth. RESULTS Instead of golden proportion the ratio of 1.3 and 1.4 were more common i.e. 30% and 28.5% respectively. The ratio of 1.5 and 1.6 were found 11.42% and 18.57% respectively. Among the ratio of 1.6 it was observed that females had more ideal relation of golden proportion i.e., 22% as compared to the males having 10%. The overall proportion of Golden proportion was 18.57%. The prevalence of Golden proportion in females was 22% and in males it was 10%. In males the ratio of 1.4 was 35% as compared to females having 28.5%. However, in females the ratio of 1.3 was more common i.e. 30% which was equal to males (Table 1). Table 1: Frequency and percentage of Golden proportion in the study group Ratio Male Female Total 1.1:1 1(5%) 1.42 1.2:1 2(10%) 5(10%) 10.0 1.3:1 6(30%) 15(30%) 30.0 1.4:1 7(35%) 13(26%) 28.5 1.5:1 2(10%) 6(12%) 11.42 1.6:1 2(10%) 11(22%) 18.57 DISCUSSION The dental and facial aesthetics has usually been defined in terms of macro and micro elements. Macro aesthetics correlates the interrelationships between the face, lips, gingiva, and teeth and the perception that these relationships usually present. Micro aesthetics involves the aesthetics of an individual tooth and the perception that the color and form are appealing. The dentolabial gingival relationship, which is considered a part of oral aesthetics, has traditionally been where treatment planning is initiated. This process begins by determining ideal maxillary incisal edge placement in the jaw. This is accomplished by understanding the incisal edge position relative to several different landmarks in the oral cavity. The following things are considered preliminary to determine ideal incisal edge position (a) the exact placement of maxillary incisors looking aesthetically pleasing, (b) the need for any restorative or orthodontic intervention required for aesthetics (c) Sher Muhammad, Rehman Shahid, Muhammad Ismail Siddiqui the proper dimensions of tooth display statically as well as dynamically and (d) tooth size, length and arch size all in accordance to facial symmetry. The relationship among the teeth, or arch form, involves the golden proportion and position of tooth width. Although it is aesthetically pleasing yet it seldom reflects natural tooth proportions. According to a study, the natural portions demonstrate a lateral incisor between 60 to 70 percent of the width of the central incisor, which is larger than the golden proportion6. However a rule guiding proportion is that the canine and all teeth distal should be perceived to occupy less visual space as we look from the frontal aspect. Another rule to help maintain proportions throughout the arch is 1-2-3-4-5; the lateral is 2/3 of the central and the canine is 4/5 of the lateral, with some latitude within those spaces. Finally, contact areas can be moved restoratively that may coincide the aesthetics outcomes. According to a study, the golden proportion was not found between perceived mesiodistal widths of maxillary central and lateral incisors and nor between perceived mesiodistal widths of maxillary lateral incisors and canines. In the majority of subjects, the width-to-height ratio of maxillary central incisor was within 75%-80%. Moreover there were no statistically significant differences in maxillary anterior teeth proportions between males and females. These results may serve as guidelines for treatment planning in restorative dentistry and periodontal surgery8. The aim of this study was to determine the prevalence of Golden proportion and recurring aesthetic dental proportions in individuals with attractive smiles attending the OPD at Nishtar Institute of Dentistry Multan. Seventy patients with natural dentition were selected out of which 20 were males and 50 were females aged 25-35. The smiles were analysed to evaluate the prevalence of Golden Proportion and obtained data was statistically analyzed. In a study of evaluation Golden Proportion, Recurring Aesthetic dental proportion (RED) proportion was present in 6.6% of population as opposed to golden proportion which was found in 0.6% of population. It was found that 70% RED was more prevalent than Golden Proportion in attractive as well as unattractive smiles.9 Our study demonstrates that the Golden proportion is not common in the local population. It was found to be more common in females than males attending the outdoor department of dental hospital. It is also to be noted that the tooth, arch size and the inter-arch relationships are all specific for a certain population thus having predilection for the certain population and the gender. In this way the Golden proportion may be variable10,11,12. According 13 to the research of Hasanreisoglu et al about the width of anterior teeth among Turkish population, it was found that the dimensions of the central incisors and canines had certain variations by gender without the Golden proportion. There has been no evidence pointing out that the golden proportion should be considered the ideal aesthetic standard when creating space for the 14. replacement of the missing lateral incisors 12 According to Gillen et al the golden proportion was rarely observed in his study group with 54 individuals only using dental casts to measure Golden proportion. Other studies have also shown that the frequency of the golden proportion in smiles was quite low15. The study of Woelfel16 also showed that Golden Proportion had not always been common phenomena and variations had been frequently observed. On the basis of results obtained in our study group and on the results from the different researches17,18. We may conclude that Golden Proportion should not be considered and ideal parameter for every case but rather a range. The work of Ahmed19 revealed that golden ratio can be a good starting point in order to obtain aesthetically acceptable results, however any ratio of 0.6-0.8 may be aesthetically acceptable. The golden ratio can be helpful to achieve aesthetic restorations of the maxillary central and lateral incisors. However, the golden ratio between the perceived widths of the maxillary lateral incisors to the canines does not seem to be decisive for an attractive smile and other factors should be considered17. According to de Castro et al18 the golden proportion was not often found in adjacent teeth shown in smiles in the sample 19 studied. Works of Mahshid et al also demonstrated that the golden proportion is not a common factor in aesthetic smiles. CONCLUSION Golden proportion is not a common finding in the study group. Although the Golden proportion is helpful for the felicity of the aesthetic restorations yet it should never be considered as a part and parcel for every aesthetic outcome. It might be good for one scenario but may remain superfluous for the next one. It would be better to think the Golden proportion as a range which might be adjusted according to both the patient’s as well as doctor’s judgment. REFERENCES 1. 2. Land RD. Neural correlates of conscious emotional experience. In: lane RD, Nadel L, eds. Cognitive neuroscience of emotion. New York: Oxford University Press, 2000; pp. 345–70. The Basics of Philosophy, http://www. Philosophy basics.com/ P J M H S Vol. 10, NO. 1, JAN – MAR- Tooth Morphology and Aesthetics While Smiling in Accordance to Golden Proportion 3. Curtis DA, Lacy A, Chu R, Richards D, Plesh O, Kasrovi P et al. Treatment planning in the 21st century: What’s new? Oral Health. 2003; 93(6):43-55. 4. Wolfart S, Brunzel S, Freitag S, Kern M. Assessment of dental appearance following changes in incisor angulation. Int J Prosthodont 2004; 17(2):150-4. 5. Ahmad I. Anterior dental aesthetics: Dental perspective. Br Dent J 2005; 199(3):135-41. 6. Ricketts RM. The biologic significance of the divine proportion and Fibonacci series. Am J Orthod 1982 May; 81(5):351-70. 7. Davis NC. Smile design. Dent Clin North Am 2007; 51(2):-. Sandeep N, Satwalekar P, Srinivas S, Reddy CS, Reddy GR, Reddy BA. An analysis of maxillary anterior teeth dimensions for the existence of golden proportion: clinical study. J Int Oral Health 2015; 7(9):18-21. 9. Meshramkar R, Patankar A, Lekha K, Nadiger R. A study to evaluate the prevalence of golden proportion and RED proportion in aesthetically pleasing smiles. Eur J Prosthodont Restor Dent 2013; 21(1):29-33. 10. Ahmad I. Anterior dental aesthetics: dental perspective. Br Dent J 2005; 199(3):-. Ricketts RM. The biologic significance of the divine proportion and Fibonacci series. Am J Orthod 1982; 81(5):351-70. 284 P J M H S Vol. 10, NO. 1, JAN – MAR 2016 12. Gillen RJ, Schwartz RS, Hilton TJ, Evans DB. An analysis of selected normative tooth proportions. Int J Prosthodont 1994; 7(5):410-7. 13. Hasanreisoglu U, Berksun S, Aras K, Arslan I. An analysis of maxillary anterior teeth: facial and dental proportions. J Prosthet Dent 2005; 94(6):530-8. 14. Bukhary SM, Gill DS, Tredwin CJ, Moles DR. The influence of varying maxillary lateral incisor dimensions on perceived smile aesthetics. Br Dent J 2007; 203(12):-. deCastro MV, Santos NC, Ricardo LH. Assessment of the “golden proportion” in agreeable smiles. Quintessence Int 2006;37(8):-. Smith SS, Buschang PH, Watanabe E. Interarch tooth size relationships of 3 populations: “does Bolton’s analysis apply?” Am J Orthod Dentofacial Orthop 2000; 117(2):-. Nikgoo A, Alavi K, Alavi K, Mirfazaelian A. Assessment of the golden ratio in pleasing smiles. World J Orthod 2009; 10(3):224-8. 18. de Castro MV, Santos NC, Ricardo LH. Assessment of the "golden proportion" in agreeable smiles. Quintessence Int 2006; 37(8):-. Mahshid M, Khoshvaghti A, Varshosaz M, Vallaei N. Evaluation of "golden proportion" in individuals with an aesthetic smile. J Esthet Restor Dent 2004; 16(3):18592. ORIGINAL ARTICLE Root and Canal Morphology of Human Primary Molars in a Local Population of Southern Punjab: an in vitro Study SHER MUHAMMAD1, REHMAN SHAHID2, MUHAMMAD ISMAIL SIDDIQUI3 ABSTRACT Background: The root canal is a procedure in which whole of the diseased pulp is removed and the canal is filled with an inert material. Therefore the success of root canal is mainly dependant on making the entire root canal system free of micro-organisms. Aim: To evaluate and asses the number of root canals and root curvatures present in primary maxillary and mandibular first molars that got extraction at Nishtar Institute of Dentistry, Multan. Methods: This prospective study was carried at Nishtar Institute of Dentistry Multan from June 2014 to August 2014. A total 60 primary molars were taken randamly out of that 30 were maxillary first molars and 30 were mandibular first molars. After extraction, the teeth were cleaned under running tap water to make them free of blood clots and debris. Ultrasonic scaler was used to remove the hard tissue attached to the teeth. The teeth were then put in glass container filled with the distilled water and the number, length and angulation of all the roots were measured. Access cavities were prepared using a fissure diamond bur (SF 12 Mani Japan) used in air turbine (NSK Japan) for penetration into the pulp chamber and Endo Z bur (E0152, 21mm Mani Japan) having non-cutting end for de-roofing. Results: Most of the teeth in the mandibular first molar had two roots. The two canals (90%) in the mesial root and one canal in the distal root (86.66%). The mean length of the mesial root was 8.99mm and mean angulation was 10.80o. The mean length of the distal root of mandibular molar was 7.10mm and the root angulation that of 8.10o .All the maxillary molars had three roots. Although a few had distobuccal and palatal roots fused yet the canals were completely separated. The mesiobuccal root of maxillary molar showed the maximum mean angulation of 18.740 followed by distobuccal and palatal having the mean angulation of 15.410 and 12.490 respectively. Conclusion: All the root canals of maxillary first molars are separated and the palatal canal being the longest one and straight. The mandibular first molars have two roots and three canals. The distal root being longer than mesial one. No specific aberrations were found. Keywords: Root canal, Root angulation, Zipping, Ledge, Perforation, Primary molars INTRODUCTION ` Dental caries is a very chronic bacterial disease leading to the disintegration of the organic and inorganic components of teeth. The destruction of the tooth tissue is due to the acid production. The deciduous teeth are the primary teeth present in the oral cavity during childhood. Primary teeth are considered essential in the development of the oral cavity. The permanent teeth replacements develop from the same tooth germs as the primary teeth, which provide guides for permanent teeth eruptions. Also the muscles of the jaw and the formation of the jaw bones depend on the primary teeth in order to maintain proper spacing for permanent teeth in oral cavity. The roots of primary teeth provide a salient --------------------------------------------------------------------1 Assistant Professor, Department of Oral Biology & Tooth Morphology, Nishtar Institute of Dentistry Multan, 2 Demonstrator, Department of Operative Dentistry, Nishtar Institute of Dentistry Multan., 3 Senior Dental Surgeon, Department of Operative Dentistry, Nishtar Institute of Dentistry, Multan Correspondence to Dr. Muhammad Ismail Siddiqui, Email:- feature, an opening for the senescence permanent teeth to erupt. The primary teeth are also mandatory for proper development of a child's speech and chewing of food. The tradition of throwing a baby tooth up into the sky to the sun or to Allah and asking for a better tooth to replace it is common in Middle Eastern countries (including Iraq, Jordan, Egypt and Sudan). It may have been originated in a pre-Islamic offering and certainly dates back to at least the 13th century, when Izz bin Hibat Allah Al Hadid mentions 1 it. In old Britain, lost teeth were commonly burnt to destroy them. This was partly for religious reasons connected with the Last Judgement and partly for fear of what might happen if an animal got them. A 2 rhyme might be said as a blessing. The treatment of primary and young permanent teeth is quite safe and predictable, that has been approached by a lot of research detailing the best clinical techniques helping the clinical practices. With sound clinical techniques and some rather extraordinary compounds, splendid can be done to save baby teeth. As always, treatment is based on assessment and diagnosis, though the diagnosis being much important, P J M H S Vol. 9, NO. 3, JUL – SEP- Root and Canal Morphology of Human Primary Molars in a Local Population of Southern Punjab especially in the case of primary teeth, may be decided by the state of the tooth at the time of examination and treatment. What’s necessary is a thorough knowledge and state-of-the art treatment techniques for the various stages of pulpal involvement for milk teeth with trauma and caries. The main object of the erudite clinician is to appease the patient regarding the specific treatment protocol whatsoever has been chosen. In the same way any failure in the desired treatment may be of much fractious both for the patient and clinician. The health of the permanent successors is somewhat dependant on the deciduous teeth. As we may say that deciduous teeth with caries control and well oral hygiene are a good indicator for the next coming sound and healthy permanent successors otherwise in the absence of any systemic disorder that affects bones and teeth. The main etiologic factor for dental diseases is the caries or the trauma leading to pulp exposure. In case of major pulp exposure, endodontics is indicated as sole treatment option in conjunction with the evaluation of the affected tooth prior to going for treatment. The patency of canals and root morphology is of prime importance while going for the endodontics. The main aim of this study is to evaluate and assess the root and canal morphology of extracted human primary mandibular and maxillary first molars. PATIENTS AND METHODS This prospective in vitro study was carried at Nishtar Institute of Dentistry Multan from June 2014 to August 2014. A total number of 60 extracted deciduous molar teeth were collected without having any sign of gross root resorption or fracture from the Department of Pedodontics, Nishtar Institute of Dentistry Multan. These teeth were meant for this study to investigate the root canals and morphology and were collected randomly after being extracted. The collected teeth were divided into two categories; category I - mandibular first molars (n=30) and category II - maxillary first molars (n=30). All the extracted teeth were cleaned to make them free of debris and blood clots by washing in running tap water. Ultrasonic scaler (Piezon, Japan) was used to remove any hard tissue like bony remnants or the calculus. All the surfaces were made clean free of debris. The collected teeth were then placed and stored at room temperature in a glass containers filled with distilled water. The number, length and angulation of the roots were then determined. The length of the roots was measured after pointing of the cervical and apical reference point on tracing paper to the nearest 1 mm using a 6 inch long scale. The measurement was rounded off to the nearest 1mm. The most constricted area was considered a cervical 1044 P J M H S Vol. 9, NO. 3, JUL – SEP 2015 3 point and the apex of the root was assumed as an apical reference point. Coronal root angulation was evaluated and assessed using a protractor. The angle was measured between a line perpendicular to 3 the cervical line and then a fabricating a tangent to the outer surface of the coronal part of each root on tracing paper. This method had been employed according to a study that was meant for root canal morphology of human primary molars3. As no clearing technique has been documented for deciduous teeth, so we modified the technique that 4,5 was meant for permanent teeth. Access cavities were prepared using a fissure diamond bur (SF 12 Mani Japan) used in air turbine (NSK Japan) for penetration into the pulp chamber. Then Endo Z bur (E0152, 21mm Mani Japan) having non-cutting end was used for de-roofing of all the extracted teeth. Two things are necessary for the proper finding to be assed. Firstly, the clean tooth surface and secondly, the disinfection. For both of these purposes, the teeth were placed and immersed for 24 hours in 5.25% sodium hypochlorite solution (Sultan Englewood, NJ USA). For making teeth decalcified, the teeth were again immersed in 6% hydrochloric acid (Merck, Darmstadt, Germany) for 24 hours first, and then washed under running tap water for one hour to flush out any debris remnants. After that it was followed by passage through different concentrations of ethyl alcohol for dehydration of the teeth. The sequence of ethyl alcohol concentrations used was 70%, 80%, 90%, and absolute ethanol. The teeth were immersed in each concentration for 5 hours. Clearing of the teeth was done by immersing them in a mixed solution of methyl salicylate and absolute ethanol for 5 hours, followed by immersion in methyl salicylate (Merck, Darmstadt, Germany) until the next step of procedure. India ink was injected into the root canals of the transparent teeth. In case of incomplete passing of dye into the canals, the suction was applied at the apical portion of teeth for a thorough distribution and flow of dye. After injecting the dye, the roots of the teeth were first examined under a magnifying glass (Lumagny, No. 7540, Hong Kong) at ×5 magnification and then under a stereomicroscope (Olympus, Tokyo, Japan) at X10 magnification for a better vision and thorough inspection. The canal type according to Vertucci’s classification, the root canal curvature (straight, curved or S-shaped) and root canal angulation were 6 determined. Statistical analysis was then applied to determine the frequency, mean, standard deviation and range for all two categories using the SPSS-20 version of software. RESULTS Sher Muhammad, Rehman Shahid, Muhammad Ismail Siddiqui All the mandibular molars had two roots i.e., one mesial and one distal. All the variants pertaining to the number of root canals, curvature of the canals and type according to the Vertucci’s has been mentioned in the table 1a and 1b. The mean length of the mesial root was found to be 8.99mm and mean o angulation was 10.80 . The mean length of the distal root was 7.10mm and the root angulation that of 8.10o. All the maxillary deciduous molars had three roots, i.e. mesiobuccal, distobuccal and palatal. Mostly the teeth had three separate roots. Only a small fraction i.e., 4(13.33%) had fused palatal and distobuccal roots. The mesiobuccal root was found to be the longest root with mean of 8.00 followed by palatal with mean of 7.54 and distobuccal having mean of 6.80. There was a small difference in lengths between the palatal and the distobuccal roots. The mesiobuccal root showed the maximum mean angulation of 18.740 followed by distobuccal and palatal having the mean angulation of 15.410 and 12.490 respectively (Tables 1-4). Table 1: Deciduous mandibular first molar data Variants No. Root Canal Number Mesial root 1 3 2 27 Distal root 1 26 2 4 Canal curvatures (mesial root) MB canal Straight 9 Curved 18 MI canal Straight 21 Curved 6 Mesial canal Straight 2 Curved 1 Canal curvatures (distal root) DB canal Straight 3 Curved 1 DL canal Straight 2 Curved 2 Distal canal Straight 16 Curved 10 Vertucci’s type of canal Mesial root Class IV 27 Class I 3 Distal root Class IV 4 Class I 26 % - - - - Table 2: Mean±SD of mandibular first molar Variants Range Root length Mesial root 7-10 mm Distal root 8-10 mm Root angulation Mesial root 3-17° Distal root 3-17° Table 3: Deciduous maxillary first molar data Variants No. Root Canal Number MB root 1 24 2 6 DB root 1 25 2 5 Palatal root 1 30 Canal curvatures MB canal Straight 4 Curved 26 DB canal Straight 6 Curved 22 S shaped 2 Palatal canal Straight 26 Curved 4 Vertucci’s type of canal MB root Class IV 6 Class I 24 DB root Class IV 5 Class I 25 Palatal root Class I 30 Table 4: Mean±SD of maxillary first molar Variants Range Root length MB root 8-10 mm DB root 5-10 mm Palatal root 5-11 mm Root angulation MB root 5-29° DB root 5-27° Palatal root 4-29° Mean±SD- %- - - Mean±SD-±-±5.39 DISCUSSION Different studies have been done to get an accurate root and canal morphology of deciduous teeth. These studies have used techniques like including radiography7 computed tomography4 and clearing7 Zoremchhingi et al4 have explored the root and canal morphology of primary molars in an Indian population using a CT scan technique. They found that it had P J M H S Vol. 9, NO. 3, JUL – SEP- Root and Canal Morphology of Human Primary Molars in a Local Population of Southern Punjab wide variations having certain complexities also. CBCT (cone beam computerized tomography) is a relatively new and effective technology, which provides a good image to add conventional radiography for assessing the variation in root canal 14 morphology of primary teeth. The prevalence of fused palatal and distobuccal roots in primary maxillary molars was common in Indians.4 Gupta and Grewal8 and investigated the root canal configuration of deciduous mandibular first molars in another Indian community using radiographic and clearing methods. Their investigation showed certain variations in the root canal morphology of these primary teeth. Their finding was a maximum of five root canals in a single specimen, and most of the specimens had four root 8 canals on average. Pulpotomy is the “partial pulp removal,” a technique, which has high successful rate of nearly 90%. It is used to treat the accidental, iatrogenic or carious pulp exposures. When the inflammation or infection is confined to the coronal area of the pulp, this technique is much beneficial to the patient. The procedure includes removal of the coronal portion of the pulp while at the same time preserving the vitality of the remaining root areas of the pulp. Pulpectomy is the procedure that involves complete removal of all the pulp tissue because of disease or trauma. If a child has tooth pain along with swelling of the gums or cheek, this requires the immediate clinician’s attention. A small hole is made to gain entry in pulp chamber with the help of high speed air turbine on the occlusal surface of the tooth. Its purpose is to drain the abscess or removal of necrotic pulpal tissue in order to give an immediate soothing effect to the patient without having any danger of further flare ups. This will remove all of infected tissue from the root canal/s completely. Root canal anatomy is the study of the pulp chamber and root canals through the sectioning of teeth. Both the pulp chamber and the roots contain the dental pulp. The smaller branches which are present laterally are termed as accessory canals. These are most frequently found near the root end (apex), but may be encountered anywhere along the root length. The total number of root canals per tooth depends on the number of the tooth roots present ranging from one to four, five or sometimes more in some cases. However sometimes there may be more than one root canal per root. Some teeth have a more variable internal anatomy than others. An unusual root canal shape, complex branching (especially the existence of horizontal branches), and multiple root canals are thought to be the main causes of root canal treatment failures. Tissue debris or biofilm remnants along such un-instrumented canal ways may lead to failure due to both inadequate disinfection, preparation of the canal and 1046 P J M H S Vol. 9, NO. 3, JUL – SEP 2015 the inability to properly obturate the root-canal space.4 Alternatively, the biofilm should always be removed with a proper disinfectant during root canal treatment. Therefore the main goal of the root canal is to make canals free of the microorganisms and the infected tissue9,10. The retention of the healthy primary dentition is a good indicator for proper 3,9,11 phonetics, spacing, mastication and esthetics . There are so many methods that may have been employed for the improvement of our knowledge regarding to the deciduous root morphology, canal configuration and investigation of various anomalies in the canals and roots. Unfortunately no method is currently devoid of some sort of demerits and limitations. These methods including the conventional radiography, computed tomography and filling the canals with certain materials to investigate the canals are being employed exclusively. The conventional periapical radiography is a two dimensional imaging of the tooth. That’s why the buccolingual root dimension still needs to be marked on the sample while in oral cavity the cone shift technique may be used to differentiate the buccal and lingual roots. The computed tomography is an excellent option for the different segments evaluation of the tooth in different planes but is an expensive one and requires special operatory training. In our study we have used the clearing technique which is inexpensive and reliable. Also there is minimal loss of the enamel. Most of the teeth in the mandibular first molar had two roots and two canals (90%) in the mesial root and one canal in the distal root (86.66%). This is in accordance to the studies conducted by Gupta and Grewal8 regarding the canal curvatures, 66.66% of the canals of the mesiobuccal side were curved while the ratio being lower in the mesiolingual canal being 22.22%. Although the roots of mesial portion were fused yet the canals were completely separated. All the canals in the mandibular molars followed the straight or the curved pattern. most of the canals in the distal roots were straight (61.53%). There was a broader distal canal which was much prominent in the pulp chamber. The distal root was longer as compared to the mesial roots. Since the curvatures in the canals may lead to perforations, zipping, elbow formation and ledge formation, a good knowledge of canal morphology and the root structure may provide 12 us convenience to avoid these problems. The maxillary molars had three canals with slight discrepancy of 20% and 16.66% with having two canals in the mesiobuccal and distobuccal canals respectively. Another finding was the canal curvature of S shaped in the distobuccal canal. 86.66% canals of the palatal roots were straight. The palatal roots found to be the longest roots having 5-11mm of length. both the palatal roots and distal root length of Sher Muhammad, Rehman Shahid, Muhammad Ismail Siddiqui the mandibular were more and in accordance with 3 the Zoremchhingi et al. The study so far done is also a good source for the morphology of second deciduous molars because the study of certain researchers say that external and internal anatomy of primary first molars are in close resemblance to that 13 of primary second molars. 4. 5. 6. CONCLUSION There has been a little evidence of variation in the root lengths of mandibular molars between mesial and distal roots, the distal root being longer than mesial ones. All the orifice openings are rounded or oval in shape without any band like shape. Palatal root canals are found to be longest as compared to mesiobuccal and distobuccal canals. It is common to have separated root canals even in fused canals. Most of the distobuccal and palatal canals were separated. The obtained data in our study may help clinicians improve sagacity to get a confident knowledge of the morphological variations of root canals in primary molars and to overcome problems related to cleaning, shaping and canal preparation during root canal procedures, and thus giving a helping opportunity for the management strategies for root canal treatment to perform in a better way. Further research in this respect may reticulate our clinical experience and broaden our knowledge. A good knowledge regarding the canal morphology, being a quintessential requirement may thus improve the outcomes of root canal preparation and endodontics. 7. 8. 9. 10. 11. 12. 13. REFERENCES 1. 2. 3. Al Hamdani M. Wenzel M. The worm in the tooth. Folklore 1966;77:60-64. Roud S. Penguin guide to the superstitions of Britain and Ireland. London: Penguin 2006. Zoremchhingi, Joseph T, Varma B, Mungara J. 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