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IAPHD NEWS
Year : 2014  |  Volume : 12  |  Issue : 4  |  Page : 330-356

Iaphd News


Date of Web Publication24-Dec-2014

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How to cite this article:
. Iaphd News. J Indian Assoc Public Health Dent 2014;12:330-56

How to cite this URL:
. Iaphd News. J Indian Assoc Public Health Dent [serial online] 2014 [cited 2019 May 25];12:330-56. Available from: http://www.jiaphd.org/text.asp?2014/12/4/330/147684





























DR. C. V. K. REDDY ENDOWMENT AWARD PG Category

Dr. Ishmeet Kaur

Swami Devi Dyal Hospital& Dental College, Barwali

Ethical and legal considerations in outreach programs


"All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence."

-Dr. Martin Luther King Jr

Community outreach programs vary widely with respect to size and scope, but almost always produce the same result, that is, bringing positive changes in the community. Outreach programs have emerged internationally in dental colleges over the past years. The Dental Council of India (DCI) has stated in a circular to principals of all dental schools in India (dated February 9, 2012) that, "the revision of the 5 year BDS curriculum to the four +1-year duration was done with clear intention of providing adequate clinical exposure to students during their internship period and as a part of this proposal, all dental institutions are required to setup Satellite Clinics to support a rural outreach dental program and to facilitate clinical exposure of interns." [1] Furthermore, as access to oral health care services in rural areas is limited, services provided in outreach programs based on felt needs of the community can uplift overall oral health status of the population significantly. [2]

IMPORTANCE OF ETHICAL AND LEGAL BEHAVIOR IN COMMUNITY INTERVENTIONS

Ethics is considered a standard of behavior and a concept of right and wrong beyond what the legal consideration is in any given situation. [3] Always acting ethically makes the outreach program more effective, cements the program organizers' standing in the community, allows the program to have a moral high ground and assures a good legal and professional stand. [4] In the absence of a pre-planned, defined protocol for invasive procedures and proper sterilization equipment, improper procedures performed at camps can lead to considerable harm to the patients. Furthermore, indiscriminate dumping of biomedical waste at the program site can have a detrimental effect on the environment and local residents. Avoiding such legal pitfalls makes an outreach program more acceptable to the community and ensures a warm welcome for future programs.

ETHICAL DILEMMAS

Decisions related to choice of treatment in an outreach program can be complex. Patients may have travelled a long way, sometimes on foot, to seek treatment, and it becomes necessary to choose therapies that can be completed quickly, to allow patients to return to their villages. Reduced availability of materials and equipment limits greatly the range of options that can be offered by a professional who often must perform treatments other than the ideal ones. [5]

A dentist is within his rights to refuse treatment to any patient so long as the reason for refusal is not based on race, religion or national origin. [6] However in a country like India, where the serpents of untouchability and casteism still rear their heads time and again, failure in effective communication can lead to disturbing arguments. The volatility of religious and caste-based issues in India mandates that all professionals deal carefully and professionally with such situations.

LEGAL ISSUES

The first and foremost thing every professional need to keep in mind is the dictum:

"Do no harm" (Hippocrates).

Some of the legal issues faced by healthcare professionals are consent, medical records, confidentiality, risk management, etc. [7] A practitioner is not entitled to treat a patient without consent. Such trespass is even considered assault in some cases. In order to give valid consent, the patient (or parent, in case of children) needs to understand, in broad terms, the nature and purpose of the procedure being proposed. [8] This can prove tricky in outreach programs in rural India, where consent of village chief or family head who takes decisions for members of his community/family needs to be sought first. It is a sad reality in these times of feminism, which often the father or a male member of the family takes decisions relating to the females' health, which makes the consent a debatable issue. [5]

Other legal issues arise when a professional fails to take thorough medical history, allows a patient to walk away after treatment in unfit condition, fails to sterilize dental instruments, uses out of date materials or drugs, fails to dispose of biomedical waste properly, etc. [9] All of these are easy to find in outreach programs, where sometimes due to the sheer number of patients, stress of working outside the dental setting and inexperience of some students, mistakes can happen.

RECOMMENDATIONS FOR ETHICAL AND LEGAL BEHAVIOUR IN OUTREACH PROGRAMMES

Being more aware of the community requirements and concerns, a public health dentist should play a key role in the execution of outreach programs. Considering this pivotal role played by public health dentists, it is necessary for them to be well versed with the code of ethics given by Public Health Leadership Society (2002) that is, respecting the individual's rights and diverse values, beliefs and cultures in the community. Institutions should ensure the professional competence of their employees and protect the confidentiality of individuals. [10]

In order to avoid legal complications, thorough record of the patients' treatment, resources and instruments used in the program must be maintained. [3,11] Since the access to emergency care is limited in remote areas, it becomes necessary to always carry first-aid kit and emergency drug kit. Also, appropriate provision should be made for ambulance and doctor on call, in case of any adverse event.

ADDRESSING COMPLAINTS

The confusion about inclusion of doctors under the Consumer Protection Act, 1986 was laid to rest by the landmark decision of the Supreme Court in 1996 that puts services of doctors for consideration under the purview of this act. [12] Complaints can be addressed to the DCI as it is responsible for the quality of dental practitioners and educational standards. [1] The public health department of all institutions should take responsibility for redressal of any complaints brought to them. By bridging the gaps in communication and dealing professionally with ethical and legal dilemmas, litigation can be avoided in most cases.

CONCLUSION

Even though outreach programs are one of the most effective measures to bring oral health care at the community's doorstep, many ethical and legal considerations need to be taken care of with sensitivity and professionalism. Always taking right moral stand can ensure the success of a well-planned outreach program.

Ishmeet Kaur

Swami Devi Dyal Hospital and Dental College,

Barwali, Makrana, India

Address for correspondence:

Dr. Ishmeet Kaur,

Swami Devi Dyal Hospital and Dental College,

Barwali, Makrana, India.

REFERENCES

1. Thanveer K, Ajithkrishnan CG, Harshal PB, Pal SR, Pulkit K. Student perspectives and opinions on their dental outreach posting experience at Vadodra, India. Indian J Dent Educ 2013;6:173-7.

2. Vashisth S, Gupta N, Bansal M, Rao NC. Utilization of services rendered in dental outreach programs in rural areas of Haryana. Contemp Clin Dent 2012;3:S164-6.

3. Booth KA, Whicker LG, Wyman TD, Pugh DJ, Thompson S. Medical Assisting. New York: The McGraw-Hill Companies, Inc.; 2009.

4. Community Tool Box: Ethical Issues in Community Interventions; 2014. Available from: http://www.ctb.ku.edu/en/table-of-contents/analyze/choose-and-adapt-community-interventions/ethical-issues/main. [Last accessed on 2014 Oct 11].

5. Rustichini F, Pradella F, Garatti S, Vitale G, Focardi M. Dentistry in humanitarian aid missions: Ethical and medical-legal aspects. J Forensic Odontostomatol Online 2013;31:162-4.

6. Dhanappa KB, Mn P, Ravi R, Mg J, Deshpande P, Biradar SM. Knowledge, attitudes and practice of healthcare ethics and law among dental graduates at the RV dental college, Bengaluru. J Contemp Dent Pract 2014;15:223-8.

7. University of Tennessee Health Science Center. Legal Issues in Health Care; 2007. Available from: https://www.uthsc.edu/Medicine/legaledu/. [Last accessed on 2014 Oct 10].

8. Morris CD. A commentary on the legal issues. Br Dent J 2004;196:139-40.

9. Singh P, Mizrahi E, Korb S. A five-year review of cases appearing before the General Dental Council's Professional Conduct Committee. Br Dent J 2009;206:217-23.

10. Bernheim RG, Melnick A. Principled leadership in public health: Integrating ethics into practice and management. J Public Health Manag Pract 2008;14:358-66.

11. Neta NB, Torres PF, Nogueira LT, Carvalho CM. Civil liability of dentists based on reports filed to the regional council of dentistry. Braz J Oral Sci 2011;10:109-12.

12. Thomas J. Ethical and legal issues in medical practice. Indian J Urol 2009;25:335-6.

IAPHD ENDOWMENT AWARD UG Category

FIRST PRIZE WINNER

Ms. Anita Precilla D'Souza

AB Shetty Dental College, Mangalore

INTEGRATION OF AYUSH INTO ORAL HEALTH CARE

Introduction


A good oral care is important to maintain oral health. Healthy mouth mirrors - a healthy body. There are five major diseases that plague the oral cavity, namely - Dental caries, Periodontitis, fluorosis, malocclusion and oral cancer. Prevalence of dental caries is approximately 45-50%, periodontal diseases 90%, malocclusion 30%, dental fluorosis 6% and oral cancer 14-16% of total body cancers. [1] Fortunately, they are all preventable. The standard Western medicine has proven itself time and again in preventing and treating these diseases, but they alter the oral micro biota and have undesirable side-effects. [2] Hence, the search for alternative products continued with a preference for traditional natural medicine over synthetic chemicals. So the term, Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) came up.

The main aim of AYUSH is prevention of oral diseases. Every sector of AYUSH talks about ways of prevention using traditional medicine. Since most of the medicines of AYUSH sector are made from medicinal plant materials, the Department has set up a National Medicinal Plants Board to promote the cultivation of medicinal plants and ensure sustained availability of quality raw material.

A separate National Policy on Indian Systems of Medicine and Homoeopathy is in place since 2002. [2]

BENEFITS OF AYURVEDA, YOGA AND NATUROPATHY, UNANI, SIDDHA AND HOMOEOPATHY

Ayurveda has been proven to be safe and effective, through several hundred to several 1000 years of use. For the treatment of oral disease, Ayurveda advocates procedures such as oral cleansing, extractions, excisions, flap surgeries, etc. Along with the treatment of orofacial diseases, Ayurveda recommends some daily use therapeutic procedures for the prevention of and maintenance of oral health. [3] These include:

  • Dant Dhavani-Chewing on herb stems is believed to cause attrition and leveling of biting surfaces, facilitates salivary secretion and has antibacterial and anticarious action.
  • Jivha Lekhana/Tongue scrapping-removes halitosis, Improves taste sensations and stimulates secretion of digestive enzymes.
  • Gandoosha/oil pulling prevents decay, oral malodor, bleeding gums, cracked lips, strengthens teeth, gums and jaw.
  • Tissue regeneration therapies use amla to strengthen the gum tissues.


Ayurvedic medications have stood the test of time and since time immemorial been used for various ailments. [3]

Substantial research has been conducted to look at the health benefits of yoga including postures (asanas), yoga breathing (pranayama) and meditation. Poor posture causes us to slouch forward, our skull then sits backward over our spine, and our mandible is moved forward leading to malocclusion.

Unani, Siddha and Homeopathy use the same natural substances as in Ayurveda and has been successful in treating most oral diseases.

LIMITATIONS

The benefits of AYUSH, being an ancient Indian system, provide health-care and longevity. However, with all these health benefits of AYUSH, we need to understand that this field, though existing for centuries, is still in its nascent stage. There are challenges such as standardizing the pricing for treatments and certification by recognized medical practitioners, which need to be addressed. There is not enough evidence based research in AYUSH; there are fewer hospitals that deal exclusively with AYUSH, let alone dental institutions. The available 3133 AYUSH hospitals and 22,975 AYUSH dispensaries in the states are inadequate to cater population of 119 crores in the country. The State Health expenditure for AYUSH is lower than 5% of the total health expenditure in most of the States. [2] There are much less staff and pharmaceuticals, which provide the medications. Besides this, the right amount of dosages, the duration of treatment and the possible side effects of these medications on the oral cavity are not very clearly explained.

FUTURE RECOMMENDATIONS

A study conducted in the US, reported the involvement of ayurvedic practitioners in treating oral diseases such as oral malodor, gingival or periodontal disease and toothache. [4] India, being the conceiver of this traditional medicine, should take steps toward strengthening and expansion of this sector.

Hence, for the practice of AYUSH to be continued, we need state of the art hospitals, dental clinics, equipment, professionals who have certified degrees in this field, medications and most importantly, more scientific research on this topic. The Indian Government developed the department of AYUSH with a view to provide focused attention to these fields. This department lays emphasis on the upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material and research and development in this field. The department of AYUSH should set up an oral health sector which allows for more improvised research by conducting randomized control trials and evidence-based research. The government should put in some infrastructure and provide enough manpower for the development of this field. There should be an increase in grant for conducting this research and for the development of any medications in this field.

In collaboration with the Dental Council of India, AYUSH should be incorporated into the existing Dental Curriculum. This should be enforced via Dental Universities and Institutions so that every BDS student graduates with sufficient knowledge on AYUSH, not just theoretically, but also on how to apply it practically. More public health centers should be set up by the government, and the people should be educated on the benefits of AYUSH. AYUSH information cell has been set up in Malaysia and is under-consideration for Trinidad and Tobago. [2] Hence, it aims at promoting awareness at a global scale.

CONCLUSION

Countries with a history of traditional medicine should support and integrate traditional medicine into national health systems in combination with national policy. Our government should evolve an Oral Health Policy, which incorporates this traditional medicine into everyday dental practice. Use of safe, quality products and practices must be ensured, based on available evidence and traditional medicine has to be acknowledged as a part of primary health care. Once this is achieved, AYUSH is sure to flourish to every corner of the country alongside western medicine to bring about an integrated approach in treating oral health concerns.

REFERENCES

1. Available from: http://www.mohfw.nic.in/WriteReadData/l892s/3817019010Refrence%20Manual.pdf.

2. Available from: http://www.performance.gov.in/sites/default/files/document/strategy/AYUSH.pdf.

3. Torwane NA, Hongal S, Goel P, Chandrashekar BR. Role of Ayurveda in management of oral health. Pharmacogn Rev 2014;8:16-21.

4. Brar BS, Norman RG, Dasanayake AP. Involvement of Ayurvedic practitioners in oral health care in the United States. J Am Dent Assoc 2012;143:1120-6.

Essay composed by:

Ms. Anita Precilla D'Souza


Final year BDS student

AB Shetty Memorial Institute of Dental Sciences

Deralakatte, Mangalore- 575018, Karnataka

E-mail: anita.tweets@gmail.com

IAPHD ENDOWMENT AWARD UG Category

SECOND PRIZE WINNER

Ms. Purvi lal

Narsinbhai Patel Dental College, Visnagar

INTEGRATION OF AYUSH INTO ORAL HEALTH CARE


Today's era is about advancement and modernization. The modernization has placed its foot in all zones of life, education, research technology, medical and dental fields. Nevertheless in the race of advancement we have left behind our tradition and culture.



NATURE IS OUR NURTURE

India is a land of cultures including its traditional culture of healing. In fact India is known for its alternative medicine across the world, example people across the globe come for the treatment in Kerala for its well-known Panchakarma therapy.

After Independence the government of India made efforts to recognize Ayurveda, Siddha, and Unani as being on par with allopathic biomedicine. More recently the government created the department of AYUSH that is, Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy to support research and development of traditional medicine and set standard and regulate the activity related to practice.

The World Health Organization has also recognized the important role of traditional medicine in developing countries.

Why not integrate it with oral health?

The various authenticated alternative medicine practiced in India are:

Acronymed (initialized) as AYUSH which means;

  • A - Ayurveda
  • Y - Yoga and Naturopathy
  • U - Unani
  • S - Sidhha
  • H - Homeopathy.


These mainly deal with using natural ingredients and therapy to promote health, they believe in the interaction between mind and body - Holistic Healing. There are so many families around the world who cannot afford even a simple dental treatment. For them, AYUSH is the best one, because it is easily available, low cost.

AYURVEDA - (SCIENCE OF LIFE) (2500 AND 500 BC)

Derived from Vedic science is the most ancient natural healing system of India. In this, the healing is done with the help of herbs and nature. The most important thing used in Ayurveda is herbs the most valued gift to mankind, which consists of medicinal properties. This reminds me a finest quote…

HERBS ARE MOTHER NATURE'S FINEST HEALERS

Various plants and natural products have been used for their pharmacological applications.

Herbs which have been used since time immerable have gained the attention of dentist (researcher) for their application in dentistry.



YOGA AND NATUROPATHY

'Yoga is the perfect way to be stree and work ourt at the same time'

- Shannon Elizabeth


Breathing exercises like pranayama have an effect on the various physiologic activities in our body and in turn have

a positive effect on our oral health. The various breathing exercises includes Sudharshan Kriya, Anulom Vilom, Nadi Shodhan, Kapalbhati, Udgeet, Sheetali and Bhastrika. The various actions of these breathing exercises are;

UNANI

Also known… Avicenna, popularly known as lbn-e-sina one of the greatest scholars of Unani Tibb (medicine) defined as…

According to Unani philosophy, the health and illness of a person depend upon the balance of the humors in the body. It believes that diseases can be kept at a bay by the use of clean and fresh water, breathing clean air and consuming fresh fruits likewise a balance should be maintained between the mind and the body so that the metabolic processess can take place easily.



SIDDHA

Which is the most ancient medical system developed by Siddhars. Even for them the medicinal source were plants and animals, naturally occurring minerals, including spiritual powers in their treatment.

The medicinal books of Siddha also recommend tooth powders for the condition where brushes were not recommended such as… in gingivitis, glossitis, paralysis, etc. Some of such tooth powders are….

  • Burnt bark of acacia and burnt almond shell are powered and mixed with salt which makes a good tooth powder.
  • Dried and powdered tender leaves of Melia azadirachta for, a good tooth powder.
  • Thriphala chooranam-kadukkai and thandrikkai in equal quantity are powdered and used as tooth powder, which clears the inflammation of gingival and strengthen the gingival.
  • Dries leaves of puthina is powdered and used for dental cleaning.
  • Kalnar parpam (calcium silicate) is a good tooth powder which strengthens the teeth.








HOMEOPATHY

It has gained entry in 18 th century, completely got assimilated in Indian culture.

Looking at all of the above systems, we can lastly say "nature is our nurture." Everything can be cured by just a touch of nature… all the above systems have the same source of medicine that is nature plants.

In the last few decades, there has been growing interest in alternative forms of therapy globally.

Recently with the notion to "GO GREEN" many researches are oriented towards use of herbs and natural therapy to cure oral disease and have also proved effect, thus it opens up a novel way to prevent oral problems. It the use of these herbs and its implication is made aware to the people we can see a better oral health in the future.

AYUSH deals with mind and body innervation used to enhance treatments such has support group medication, prayer, art, music, dance, relaxation, feedback, hypnosis and paranormal health remedies.

Dental treatment + concept of AYUSH-------

BETTER ORAL HEALTH

It plays a major role in promoting health and preventing disease.

The majority of India's people still receive medical services from indigenous practitioners who treated their patients according to the principles of three ancient systems of Indian medicines Ayurveda, Siddha, Unani. Thus by merging the contemporary and indigenous treatment for oral care a better results can be obtained.

Last but not the least AYUSH is like a boon to mankind…so save.

IAPHD ENDOWMENT AWARD UG Category

Third PRIZE WINNER

Ms. Arathi.P

M.S Ramiah Dental College, Bangalore

INTEGRATION OF AYUSH INTO ORAL HEALTH CARE


Oral cavity is the gateway to the body and closely linked to general health. Oral diseases are universal and widely prevalent. Recognizing the nature and burden of oral diseases, traditional medicine was incorporated in the World Health Organization (WHO) programs in 1976. In addition, some health administrators in the developing countries have recommended the inclusion of traditional healers in primary health care on the grounds that the healers know the sociocultural background of the people and that they are highly respected and experienced in their work. Also, countries like India and China have developed their traditional medicine to an internationally acceptable level.

The WHO has since urged developing countries of the world to utilize the resources of traditional medicine for achieving the goals of primary health care. This injunction stems round the various advantages of traditional medicine namely, low-cost, affordability, ready availability, accessibility and acceptability and perhaps low toxicity. The practitioners are ready sources of medical and dental manpower. It is also expected that in recognizing them, and hence utilizing the advantages, the various disadvantages of the practice can also be resolved. These include lack of adequate scientific proof, imprecise diagnosis and dosage, unstandardized medicines and occultic practices.

Despite the elaborate description in ancient Ayurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH) texts, oral health however is neglected in society. Oral diseases, as other noncommunicable diseases (NCD), are lifestyle related diseases and hence preventable to a great extent. For this, it is essential that information about various oral diseases, in terms of their causative factors, clinical presentation for early identification and prompt intervention to prevent complications be known, especially to practitioners of all streams of medicine and AYUSH. Medical Officers and various AYUSH doctors posted at various levels can prove to be a useful resource to provide oral health promotion and prevention, if properly motivated and trained. Moreover, they are very well trained in control and management of several NCD, which share common risk factors with oral and dental diseases.

Ayurveda is the ancient Indian system of health care and longevity. It involves a holistic view of man, his health, and illness. The natural phytochemicals could offer an effective alternative to antibiotics and represent a promising approach in prevention and treatment of dental infections. Antibacterial activity of some plant species like Melia azadirachta, Calotropis gigantea, Leucas aspera, Vitex negundo, and others have been tested. In India, plant wealth is greatly exploited for its therapeutic potential and medicinal efficacy to cure dental caries. The stem, bark, root and young fruits of Melia azadirachta are used as bitter, tonic, antiseptic, astringent, and antibacterial. In several indigenous tooth powders, toothpastes, toilet soaps, the extract from various parts of this tree is used. Azadirachta indica mouth wash is reported to inhibit the growth of Streptococcus mutans and carious lesions. Herbal compounds and chemical constituents exhibit antibacterial and antifungal properties, which may significantly delay the development of plaque, calculus, and caries. Some therapeutic approaches based on traditional Asian medicine have been reported to result in the successful treatment of such oral complaints as xerostomia, oral lichen planus, and glossodynia.

In homeopathy, hepar sulphuris is used for treatment of abscess. Belladonna is used in bruxism. Dry socket is treated by Ruta graveolens and trigeminal neuralgia by aconite. This discipline also advises the fluoridation of toothpaste.

Ayurveda recommends chewing sticks in the morning as well as after every meal to prevent diseases. Chewing sticks be obtained from fresh stems of neem. Chewing on these stems is believed to cause attrition. But facilitate salivary secretion and have an antibacterial action.

Saimbi et al. tested the antiplaque efficacy of neem extract, Ayurvedic tooth powders, and commercial toothpastes. Neem extract came out on top and commercial toothpastes were the last.

In southern India, mango leaf is widely used for cleaning teeth. A fresh mango leaf is washed, and the midrib is removed. It is rolled into a cylindrical pack and rubbed on the teeth. At the end, the midrib, which was first removed, is used as a tongue cleaner. Mangiferin a compound present in mango leaves had significant antibacterial property against certain strains of pneumococci, streptococci, staphylococci, and Lactobacillus acidophilus.

The miswak is a teeth cleaning twig made from a twig of the arak tree and features in Islamic hygiene jurisprudence. S. mutans and Lactobacillus are susceptible to miswak. Unless correct method of use is practiced, it could lead to gingival recession.

Oil pulling is a procedure that involves swishing oil in the mouth for oral and systemic health benefits. It prevent decay, oral malodor, bleeding gums, dryness of throat, cracked lips and for strengthening teeth, gums and the jaw. It can be done using oils like sunflower oil or sesame oil.

Gandusha and Kavala Graha are two primary oral cleansing techniques; specialized therapy to treat as well as to prevent oral diseases. These oral cleansing techniques benefit bad breath, loss of taste.

In Ayurveda, amla is considered a general rebuilder of oral health. Amla works well as a mouth rinse as a decoction. Bilberry fruit and hawthorn berry stabilize collagen, strengthening the gum tissue. Liquorice root promotes the anti-cavity action, reduces plaque, and has an antibacterial effect. Other examples include yellow dock root, alfalfa leaf, cinnamon bark, and turmeric root.

CONCLUSION

Countries with a history of traditional medicine should support and integrate traditional medicine into national health systems in combination with national policy. Use of safe, quality products and practices must be ensured, based on available evidence, and traditional medicine has to be acknowledged as part of primary health care. It is also required to ensure patient safety by upgrading the skills and knowledge of traditional medicine providers. Scientific validations of the dental health practices given above could justify their incorporation into modern dental care. Publicity of these techniques using appropriate media would benefit the general population by giving more confidence in the ancient practices, thus preventing tooth decay and loss.

Ms. Arathi. P,

IV Year Student,

Faculty of Dental Sciences,

M.S. Ramaiah Dental College,

Bengaluru, Karnataka, India

Address for correspondence:

P. Arathi, Faculty of Dental Sciences,

M. S. Ramaiah Dental College,

Bengaluru, Karnataka, India.




 

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