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Background: The provision of dental care in Pakistan is limited, with less than 5% of the population having access to qualified dental practitioners. The lack of contextually relevant local dental guidelines further adds to the problem. We developed clinical practice guidelines (CPGs) and referral pathways to improve primary care for common oral diseases. Methods: Using the GRADE-ADOLOPMENT approach, recommendations from source guidelines (developed in Europe and the United States) were adopted (retained as is or with minor changes), adapted (modified according to the local context), or excluded (omitted due to lack of local relevance). The guidelines included diseases such as periodontitis, dental pain, intraoral swelling, and oral cavity malignancies. The end result was a set of locally relevant CPGs, which were then used to formulate referral pathways, with the incorporated suggestions being based on a thorough evidence review process. Results: We included four recommendations, three of which were adopted with minor modifications to the referral pathway. These changes focused on assessing potentially malignant oral conditions and counseling for risk factors. No content changes were needed for the CPGs of the other two disorders. We developed referral pathways for three specific oral conditions, detailing primary care physicians’ roles in diagnosis, initial treatment, and timely referral. Conclusion: Contextually relevant dental CPGs and referral pathways can improve patient outcomes in Pakistan. Our study produced four additional recommendations focused on risk factor counselling and mitigation, which could potentially reduce the burden of oral malignancies in our local population.

Limited mouth opening, which is also known as trismus or lockjaw, has a number of abeyant issues and its treatment depends on the major cause. The objective of this study is to figure out the common causes of limited mouth opening in Karachi and to ascertain the management approach for a patient with trismus. The level of awareness and skill amongst clinicians with reference to the management of patients with trismus has also been evaluated. About 300 dental clinicians were asked a group of questions by the help of a questionnaire. The survey was conducted amongst the public and private dental OPDs in Karachi. The questions have been asked to evaluate the level of awareness, diagnostic approach, and quality of management and care offered to the patients having trismus. The three most common causes of trismus according to the present study came out to be oral submucosal fibrosis (26.7%), infections (24.0%), and trauma (15.0%), respectively. The dentists have chosen different management approaches according to their field of specialization and case dependence such as physiological mouth opening exercises (50.7%), prescribing medications specially muscle relaxants (24.3%), incision on contracted oral mucosa (12.7%), correction of temporomandibular joint (TMJ) or bone deformity (7.7%), and intralesional corticosteroid therapy (4.7%). The study concluded that trismus can turn into a potentially life-threatening situation if misdiagnosed and managed improperly; therefore, special attention should be given to patients coming with any of the above-mentioned symptoms.

Abstract Desmoplastic fibroma (DF) is an uncommon bone tumor that originates from the mesenchymal tissue and despite being benign, exhibits aggressive behavior locally. The following report describes the case of a 7-year-old boy with a rapidly enlarging swelling on the right side of the mandible. After a thorough clinical examination, radiographic imaging, and histopathological analysis, the diagnosis of DF was confirmed. Treatment planning was formulated considering both the tumor’s tendency for local recurrence and the patient’s well-being. Due to the patient’s young age, segmental resection was not deemed appropriate, and an aggressive curettage and enucleation of the lesion followed by the bone graft was performed instead. The patient was kept under close follow-up for the first month of post-surgery and later reviewed after 3, 6, 9, and 12 months, respectively. Good bone healing was observed on radiographs. The patient did not show any signs of recurrence based on clinical or radiographic assessments and did not exhibit any neurosensory deficits as well.

We present a case of nasopalatine duct cyst in a 35-year-old female. The cyst was diagnosed based on the presence of only one clinical symptom and no obvious clinical signs, which is a relatively rare occurrence. However, the radiographic and histological presentation of this lesion was typical of a nasopalatine duct cyst. Therefore, this case report aims to highlight the variable presentations of the nasopalatine cyst, which is often misdiagnosed and treated as an endodontic infection. Key words: Nasopalatine cyst, Incisive canal cyst, Cone-beam computed tomography, Non-odontogenic cyst.

Background. The relationship of the root of the maxillary third molars and the maxillary sinus (MS) is an important predictor of the anticipated difficulty in extraction. The aim of this study was to assess the location of maxillary third molars to the inferior wall of the MS in a sample of Pakistani population evaluated using cone-beam computed tomography (CBCT) imaging and to assess if age or gender has any influence on third molar to MS distance. Methods. The CBCT scans of adult patients, carried out keeping image volume at 8 cm×8 cm, and the voxel size 0.2 and 0.1 mm. Images retrieved from the hospital database were included in the study. The relationship of root apices of maxillary third molar with the MS was assessed according to the vertical, horizontal and Winter’s classification. Descriptive statistics, t test and chi-square test of association were applied. Results. CBCT scans of 93 patients, 56 males and 37 females were evaluated. The mean age was 41.12±17.13 years. The mean distance of third molar roots to the MS wall was 2.38±1.54 mm for males and 1.86±1.04 mm for females, on the left and 2.67±1.81 mm for males and 2.58±1.54 mm in females, on the right side. Independent sample t test showed that there was no significant difference for third molar to sinus wall distance in the two genders. No significant difference was found between the two sides. Conclusion. In a sub-population of Pakistani adults, the mean distance between the roots of the upper third molar and MS wall is around 2 mm. Only 5% males and 8% females had their upper third molars roots protruding into the MS.

dental implants: a bibliometric analysis of 20 top cited articles. J Pak Med Assoc. PMID: 37427629.”1was published in June 2023. We believe that the reader has mixed up this paper with an earlier paper of ours, titled “A bibliometric analysis of the studies on dental implant failure. J Pak Med Assoc. PMID: 35202375.2 Dental implants have two types of failures: surgical (related to implant fixture, its placement techniques and bone biology etc.) and prosthetic (related to implant prosthesis, crown, abutment, other components, or technical issues arising from laboratory made implant prosthesis). The former paper was about identifying the top-cited publications on the surgical failures of implants whereas the latter bibliometrics related to the implant prosthetic complications. Regarding methodology of bibliometrics, the search terms we adopted for the first paper was “dental implant failure” whereas for the second paper, we employed “Prosthetic complication in dental implant” without using any Boolean operator. These key terms were searched in the abstracts using Web of Science, Google Scholar, and other electronic sources published in English language upto June 2021. We employed the option of “cited reference search” for ascertaining the number of citations. To review and synthesise the data, multiple parameters were explored. These included authors, journal, citation count, citation density, keywords and study design, and geographic and institutional affiliation of the first or corresponding authors. The country of literature emergence was determined by the address of the corresponding author. The details of methodology are already shared in the above-mentioned papers. Another important observation made by the reader was that the table 2 and table 3 displayed the same information that has already been shared in table 1. So why was it done? And that too in both the papers. The answer to this question is that although table 1 in both the papers displayed the primary bibliometric data but to stratify the data, based on author, institution, and the journal, table 2 was composed and to emphasize the study designs table 3 was made. That helped us to identify that there is just one clinical trial among top 30 cited papers on dental implant failures and more alarmingly, no randomized controlled trials in the list of top 20 cited papers on the implant prosthetic failures. Thus, table 2 and table 3 represented the subset of the data.

Hunter syndrome (mucopolysaccharidosis type II) has the highest reported prevalence of difficult tracheal intubation among the seven known types of mucopolysaccharidoses. Despite improved difficult airway guidelines and equipment, conventional approaches may fail in some cases. A 10-year-old child with Hunter syndrome, was scheduled for multiple dental extractions. On the first visit, failed intubation was declared as per Difficult Airway Society guidelines in the surgical day-care suite of our institute and the procedure was postponed. The case was then planned to be handled in the main operating room with additional preparation and input from the paediatric otolaryngologist for possible tracheostomy, paediatric intensive care for postoperative need for ventilation, and difficult airway resource faculty for an unconventional approach—videolaryngoscope combined with fibreoptic bronchoscope—which resulted in safe administration of anaesthesia. This case illustrates the importance of meticulous planning in the management of previously failed airway.

Objectives: To compare disease-free survival rates in oral squamous cell carcinoma patients initially attended to and referred by dentists versus other physicians. Methods: The systematic review was conducted after registration with the International prospective register of systematic reviews at the University of York, the United Kingdom, and comprised search on Medline, PubMed, Cochrane and CINAHAL Plus databases for studies published up to December 2021. The Population-Intervention-Comparison-Outcomes-Study criteria was used to search for studies involving patients diagnosed with oral squamous cell carcinoma receiving referrals by dentist or by other healthcare providers. Disease-free survival of patients was taken as the main outcome. Customized data collection proforma was used to record data in line with the Preferred Reporting Items in Systematic Reviews and Meta-Analysis guidelines. Data was subjected to systematic, qualitative review. Results: Of the 344 studies found, 8(2.3%) were analysed in detail. Patients referred by dentists ranged from 22.6% to 54%. Males comprised 53% to 70.3% of the sample. The highest number of referrals was made by primary physicians, ranging from 27.4% to 71.6%. Upto 67.6% cases were diagnosed with stage 1 and 2 oral cancer. The highest 5-year survival rate was 75% in a study where 59% patients were diagnosed at an early stage of disease. Conclusion: The relative scarcity of studies makes it impossible to draw an association between oral cancer survival rate and type of referral. Key Words: Oral squamous cell carcinoma, Cancer-free survival, Early detection, Referrals.

The purpose of this review was to explore the 20 most cited articles on prosthetic complications with dental implants. Identification of such articles could be helpful in prosthodontics residency programmes in devising the curriculum of essential reading material in implantology. The Institute for Scientific Information, Web of Science Database, and Google Scholar were used to identify the 20 top-cited articles published in journals from 1980 till June 2021. These articles were then evaluated according to the number of citations, authors, study design, publication year, and publishing journal. Descriptive statistics were computed for bibliometrics. It was observed that the citation count ranged from 6,391 to 315 (in descending order). The Toronto study is the most cited study on dental implant prosthetic complications. Prospective studies and systematic and narrative reviews were the predominant study designs used in the articles; however, alarmingly no randomised controlled trials were included in the list.

Dental implants offer a predictable solution for the replacement of missing dentition. This report describes the case of a patient who underwent dental implant surgery several years ago but due to negligence on the part of previous dentist, her implant pushed into the maxillary sinus. The patient presented with vague pain and swelling in the right maxillary region. Orthopantomogram (OPG) showed that the implant was lying in the right maxillary sinus which the patient had no clue of. It was decided to retrieve the implant and later restore the missing teeth for definitive function and aesthetics. However, at the time of surgery, the implant in question was missing from the anticipated position as it had migrated to the most posterior-superior compartment of the antrum making its retrieval difficult in the first attempt. Later, a maxillofacial surgeon carried out the retrieval. ---Continue

We aimed to explore the predictors of hospital length of stay for patients admitted and with maxillofacial injuries. Patients presenting with maxillofacial trauma were included. Poly-trauma involving neurosurgery and/ or needing orthopedics intervention were excluded. Logistic regression was applied to explore the predictors associated with the hospital stay of > 4 days. There were 241 patients with mean age 29.35 ± 12.5 years (age range 12-80 years). Mandibular fracture was the commonest observation 121(50.2%), followed by maxillary 48(19.9%), and zygomatic bone fracture 9 (3.7%). Road traffic accident 196 (81.3%) appears to be the most common etiology of maxillofacial injuries in the studied sample. The mean length of hospital stay among bone plating patients was 5.96 ±6.8 days compared to 4.15±6.2 days for ones treated without bone plating; p-value 0.05. It was concluded that longer length of stay is required in patients with more complex management including bone plates. Keywords: Maxillofacial injury; road traffic accident; bone plating; length of stay.

Oral and maxillofacial (OMF) surgery is a unique speciality. In many countries, OMFS is a dental speciality but the scope of its practice significantly overlaps with other specialities, including otolaryngology, head and neck surgery, plastic surgery, and orthopaedics. Thus, OMF surgery represents a true amalgamation of medical and dental specialities. There are different requirements of OMF residency training, which include a dental undergraduate training, medical training, or both. The training pathways for this speciality have evolved much in the last three decades and there is still no consensus over a single uniform path of becoming an OMF surgeon. An OMF surgeon deals with trauma, cysts, tumours and other pathologies of the maxilla, mandible, and zygomatic complex that need surgical correction. In addition to being a diverse speciality, ---Continue

The present report is comprised of five patients of panfacial fractures in which initially oral intubation was done that was later moved to retromolar area. This modification is an improvised approach that appears beneficial in surgeries requiring maxillo-mandibular fixation. Owing to low morbidity, the retromolar intubation should be considered as a preferred method to avoid tracheostomy.

Background: Tooth extraction is a common oral surgery procedure carried out mainly on outpatient basis. It is important to evaluate the risk factors which can lead to various complications after extraction of teeth. Normal healing of an extraction socket may be impaired by the presence of one or more factors. The objective of this study was to find out the effect of the medical conditions such diabetes, hypertension and smoking habit on the process of normal healing following dental extractions. Methodology: Patients reported for dental extraction in oral and maxillofacial surgery department at Baqai Dental College were divided into two groups. A control group and a disease group with systemic conditions like diabetes mellitus, hypertension and habit of smoking. All the extractions were performed under local anesthesia by the dental officers. SPSS version 17 was used to perform statistical analysis to identify the risk factors and possible relationships with the healing in extraction sockets. Results: In this study 88 females, 152 males participated. In healthy group there were 93 patients enrolled. In the healthy subjects (n = 93) 39.7% reported complications whereas in the diseased group (n = 147) the reported complications were 61.2% (Table 1). The percentages and number of patients are charted below according to complications. Table 2 is showing different complications and their percentages. Table 3 is showing disease patterns in both the groups and odds ratio which is greater than 4 in our study. Conclusions: The odds of complications among subjects with co-morbidities are four times that of same in the healthy subjects.

Abstract Dental extraction of abscessed or infected teeth before cardiac operation is frequently advocated to lower the risk of infections especially infective endocarditis. The scientific evidence that supports dental procedures before cardio-valvular surgery is however limited. The aim of the present paper was to explore whether there are any protocols for patients needing dental treatment before cardiac operations. Moreover, we have discussed the real life challenges encountered in the management of such patients. Continuous....

Objective: The aim was to systematically review indexed literature regarding the influence of a state of chronic hyperglycemia on guided bone regeneration (GBR). Material and methods: The addressed focused question was ''What is the influence of a state of chronic hyperglycemia on GBR?”. Databases were searched using different combinations of the following key words: “hyperglycemia”, “diabetes”, “guided bone regeneration”, “bone formation”. Full-texts of articles judged by title and abstract to be relevant were read and independently evaluated for the eligibility criteria. Letters to the editor, historic reviews, case reports, case-series and unpublished articles were excluded. Results: Ten experimental studies involving animal-models were included. Six studies were performed in rats and four studies were performed in rabbits. Total number of subjects ranged from 14 to 68 animals with a mean age range of 4 to 22 weeks. GBR was performed on maxillary, mandibular and parietal bones in one, one and eight studies respectively. Substances used for GBR included polytetrafluoroethylene (PTFE) membrane, titanium reinforced PTFE membrane, porous chitosan scaffold, methyl methacrylate hemispheres and titanium domes. Four studies showed comparable outcomes for new bone formation (NBF), among diabetics with GBR and healthy animals. Four out of five studies showed comparable outcomes in terms of NBF at follow up among animals in the diabetic and control-groups. Two studies showed comparable amounts of NBF in animals with poorly- and well-controlled diabetes after GBR. Conclusion: In animal-models with experimental diabetes, GBR is effective in inducing NBF; however, the effectiveness of GBR in patients with chronic hyperglycemic conditions (such as poorly controlled diabetes and prediabetes) warrants further studies.