amir et al asian journal of dental and health sciences. 2022; 2(3):9-11 [9] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited effect of ph on pharmaceutical ingredients / drugs / chemicals md amir, md ashfaque alam, md fauwaz aftab, md gulam nabi, md sadre alam, dr. jagdeesh rathi, sonpal singh thakur* nri institute of pharmaceutical sciences, 1, sajjan singh nagar, opposite patel nagar, raisen road bhopal 462022, mp, india article info: _______________________________________ article history: received 03 july 2022 reviewed 21 aug 2022 accepted 27 aug 2022 published 15 sep 2022 _______________________________________ cite this article as: amir m, alam ma, aftab mf, nabi mg, alam ms, rathi j, thakur ss, effect of ph on pharmaceutical ingredients / drugs / chemicals, asian journal of dental and health sciences. 2022; 2(3):9-11 doi: http://dx.doi.org/10.22270/ajdhs.v2i3.17 _______________________________________ *address for correspondence: sonpal singh thakur, nri institute of pharmaceutical sciences, 1, sajjan singh nagar, opposite patel nagar, raisen road bhopal 462022, mp abstract ___________________________________________________________________________________________________________________ the word excipient is derived from the latin excipere meaning to except, which is simply explained as other than. pharmaceutical excipients are basically everything other than the active pharmaceutical ingredient. ideally, excipients should be inert, however, recent reports of adverse reactions have suggested otherwise. pharmaceutical excipients are substances other than the active pharmaceutical ingredient (api) that have been appropriately evaluated for safety and are intentionally included in a drug delivery system. solubility, which defines the liquid /solid equilibrium, is a key parameter to control a crystallization process. as the api is a weak acid (pka = 3.7), its solubility increases with the ph. on the basis of the experimental curve of solubility, a model was defined to fit the evolution of the solubility as a function of ph. in the case of this compound, studies revealed a weak influence of the temperature in comparison with the ph. so, the solubility of the compound is slightly impacted by the temperature. some experiments were carried out in order to compare the solubility of the api, at the same ph and temperature, for different concentrations of impurities found in the process. the results revealed a solubility increase in presence of acetic acid and a high solubility decrease in presence of sodium chloride. by carrying out experiments on common ions salts, the anion chloride cl− has been identified as the cause of the solubility decrease. keywords: solubility, api, impurity, ph introduction in pharmaceutical industries, the control of active pharmaceutical ingredient (api) crystal properties is necessary because these properties will define the pharmaceutical form of the medicine elaborated with the crystals. as the generation step of these crystals, the crystallization process has to be controlled 1,2. for this, one of the initial data needed is the solubility of the product in the mother solution. the api crystals are obtained by an acid-base precipitation. the ph is then the main parameter of the precipitation because it has a direct impact on the api solubility. the knowledge of the evolution of the solubility as a function of ph is then needed in order to control the precipitation. moreover, in the considered process, at the end of precipitation, the remaining solution in which crystals are suspended contains impurities such as sodium chloride and acetic acid. these impurities have an influence on the solubility of the api. as filtration and washing steps are necessary to purify crystals, the knowledge of the solubility is also paramount to determine the loss of product by dissolution during these steps 3, 4. definition of partition coefficient (pka) when a weak acid dissociates in solution according the scheme below (1), we can express the acid 1onization constant (ka) using equation (2). the negative logarithmic form of the acid 1onization constant (3) is more commonly used. rearrangement of equation (3) affords the hendersonhasselbalch equation (4). in a similar manner we can employ these equations for the conjugate acid forms of basic functional groups (5). ha + h2o ⇌ a + h3o + (1) ka= a h3o+ ha (2) pka = log10ka (3) ph=pka+log a ah (4) bh + + h2o ⇌ b + h3o + (5) material and methods chemicals sodium hydroxide molecular weight39.997g/mol chemical formulanaoh sodium chloride molecular weight58.44g/mol chemical formula – nacl hydrochloric acid molecular weight36.458 g/mol chemical formula –hcl open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i3.17 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd2 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd3 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd4 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd4 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd5 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3641858/#fd6 amir et al asian journal of dental and health sciences. 2022; 2(3):9-11 [10] ajdhs.com ammonium chloride molecular weight53.491g/mol chemical formula -nh4cl apparatus  ph meter  measuring cylinder-5ml  volumetric flask100ml  pipette-5ml  beaker100ml  glass rod experimental sodium hydroxide table 1: api solubility as a function of sodium hydroxide concentration, at 20°c naoh concentration (mol/l) solubility (mol/l) ph 0.00 0.0478 3.60 0.78 0.39997 3.57 0.95 0.395973 3.53 0.99 0.3799 3.50 1.21 0.4839 3.48 1.84 0.73597 3.44 2.65 1.05992 3.42 3.55 1.41989 3.40 sodium chloride table 2: api solubility as a function of sodium chloride concentration, at 20°c nacl concentration (mol/l) solubility (mol/l) ph 0.00 0.0477 2.60 0.68 0.0359 2.57 0.86 0.0326 2.53 0.98 0.0321 2.50 1.37 0.0273 2.48 1.95 0.0212 2.44 2.74 0.0153 2.42 3.42 0.0133 2.40 hydrochloric acid table 3: api solubility as a function of hydrochloric acid concentration, at 20°c hcl concentration (mol/l) solubility (mol/l) ph 0.00 0.2943 5.60 0.78 0.2843 5.57 0.89 0.3244 5.53 0.99 0.36093 5.50 1.38 0.5031 5.48 1.96 0.71451 5.44 2.75 1.00259 5.42 3.43 1.2578 5.40 ammonium chloride table 4: api solubility as a function of ammonium chloride concentration, at 20°c nh4cl concentration (mol/l) solubility (mol/l) ph 0.00 0.0497 4.60 0.79 0.0.225 4.57 0.89 0.4760 4.53 0.99 0.5295 4.50 1.38 0.73817 4.48 1.96 1.08442 4.44 2.75 1.47100 4.42 3.43 1.8347 4.40 results naoh is strong base, so this will produce 0.1 mol/l of oh ion solution. this will produce a ph of 13. to summarize, nacl decrease the solubility and reduce the activity of hydrogen ion, the net effect is a small reduction in ph (by about 0.01). the ph of the hydrochloric acid is 2 according to the given data which indicates that it is acidic in nature. the ph value of the solution will decrease (basically less than7) as the solution will become slightly acidic (ph value 4.5 to 6). conclusion this study focused on the main parameters influencing the solubility of an api. as it is a weak acid, it has been proven that the ph is the most important parameter and a model has been built to follow its evolution. the temperature revealed to be a less significant parameter but permitted to determine the enthalpy of dissolution of the api. finally, impacts of the process impurities have been characterized. considering the effects of hydration of ions, the presence of a kosmotropic anion explained the api solubility decrease observed. amir et al asian journal of dental and health sciences. 2022; 2(3):9-11 [11] ajdhs.com references 1. avdeef a. solubility of sparingly-soluble ionisable drugs. advanced drug delivery reviews, 2007; 59:568-590. https://doi.org/10.1016/j.addr.2007.05.008 2. carta r. solubilities of l-cystine, l-tyrosine, l-leucine and glycine in aqueous solutions at various ph and nacl concentrations. the journal of chemical & engineering data. 1996; 41:414-417. https://doi.org/10.1021/je9501853 3. granberg ra, rasmuson ac. solubility of paracetamol in binary and ternary mixtures of water plus acetone plus toluene. the journal of chemical & engineering data. 2000; 45:478-483. https://doi.org/10.1021/je990272l 4. leontidis e. hofmeister anion effects on surfactant self-assembly and the formation of mesoporous solids, current opinion in colloid & interface science. 2002; 7:81-91. https://doi.org/10.1016/s1359-0294(02)00010-9 https://doi.org/10.1016/j.addr.2007.05.008 https://doi.org/10.1021/je9501853 https://doi.org/10.1021/je990272l https://doi.org/10.1016/s1359-0294(02)00010-9 bairagi et al asian journal of dental and health sciences. 2023; 3(1):8-10 [8] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited evaluation of in-vitro anti-inflammatory activity of leaves of pongamia pinnata jyoti bairagi *, vivekanand katare, bharti chourey, abhilasha delouri, shivam nema vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india article info: _______________________________________ article history: received 17 dec 2022 reviewed 14 jan 2023 accepted 26 jan 2023 published 15 march 2023 _______________________________________ cite this article as: bairagi j, katare v, chourey b, delouri a, nema s, evaluation of in-vitro anti-inflammatory activity of leaves of pongamia pinnata, asian journal of dental and health sciences. 2023; 3(1):8-10 doi: http://dx.doi.org/10.22270/ajdhs.v3i1.33 _______________________________________ *address for correspondence: jyoti bairagi, vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india abstract ___________________________________________________________________________________________________________________ inflammation is a reaction of a living vascularised tissue to an injury. conventional or synthetic drugs used in the treatment of inflammatory diseases are inadequate, it sometimes have serious side effects. so, number of herbal medicines is recommended for the treatment of inflammation that has no side effects. pongamia pinnata, pierre (familyfabaceae) commonly known as karanja. the seed and seed oil of the plant have been reported to be effective in various inflammatory and infectious diseases such as leucoderma, leprosy, lumbago, muscular and articular rheumatism, cutaneous affection including herpes and scabies etc. in folk medicine and ayurveda, a traditional system of healing . anti-inflammatory activities of this plant for various parts have been reported in various models. this study examined the anti-inflammatory potential of a methanolic leaves extract of pongamia pinnata and reference drug declofenac sodium, invitro using heat-induced protein denaturation technique. the concentrations of the leave extract used were 50-250μg/ml. while diclofenac sodium were 50, 100, 150, 200 and 250μg/ml. both the diclofenac sodium and extract showed the ic50 values 18.36 and 82.24µg/ml respectively. it is concluded that the methanolic leaves extract of pongamia pinnata possess marked in vitro anti-inflammatory activity which is mediated possibly by flavonoids, tannins and alkaloids. this is a novel finding. further the results scientifically justify the use of leaves of pongamia pinnata in india traditional medicine to treat inflammation. keywords: inflammation, pongamia pinnata, fabaceae, heat-induced protein denaturation technique mail id: bairagijyoti01@gmail.com introduction inflammation is considered as a primary physiologic defense mechanism that helps body to protect itself against infections, burns, toxic chemicals, allergens or other noxious stimuli. an uncontrolled and persistent inflammation may act as etiological factor for many chronic illnesses1. non-steroidal anti-inflammatory drugs (nsaids) are widely used in the treatment of pain and inflammation. currently available nsaids are associated with unwanted side effects and have their own limitations. about 34-46% of the users of nsaids usually sustain some gastrointestinal damage due to inhibition of the protective cyclooxygenase enzyme in gastric mucosa2. hence there is a need for anti-inflammatory drugs with fewer side effects. plants have been an important source of medicine for 1000’s of years. herbal medicine is still the mainstay of therapy for about 75-80% of the whole population in developing countries for primary health care3. this is because of better cultural acceptability, affordability, better compatibility with the human body and fewer or no side effects, in addition, the last few years have seen a major increase in the use of herbal remedies in developed countries4. the long historical use of medicinal plants in many traditional medical practices, including experience passed from generation to generation, has demonstrated the safety and efficient value of traditional medicine5. world health organization encourages the inclusion of herbal medicines of proven safety and efficacy in the healthcare programs of developing countries because of the great potential they hold in combating various diseases6. many indian ethno botanic traditions propose a rich repertory of medicinal plants used by the population for the treatment, management and/or control of different types of pain7. however, there were not enough scientific investigations on the anti-inflammatory and analgesic activities conferred to these plants. one such plant from indian flora pongamia pinnata (fabaceae), a mediumsized glabrous tree, found throughout india and further distributed eastwards, mainly in the littoral regions of south eastern asia and australia . in the literature of india, different parts of this plant have been recommended as a remedy for various ailments. the seed and seed oil of this plant have been used for treating various inflammatory and infectious diseases such as leucoderma, leprosy, lumbago, muscular and articular rheumatism. the leaves are spicy, digestive, laxative, anthelmintic and cure piles, wounds and other inflammations. a liquid solution of the leaves is used as a medicated bath for relieving rheumatic pains and for cleaning ulcers in gonorrhea and scrofulous enlargement. root and seed extracts of pongamia pinnata have been reported to have anti-inflammatory activity8. hence, in the present study, anti-inflammatory activities of methanolic extracts of pongamia pinnata were evaluated using heat-induced protein denaturation technique. materials and methods plant material the leaves of plant pongamia pinnata were collected from local area of bhopal (m.p), india. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i1.33 bairagi et al asian journal of dental and health sciences. 2023; 3(1):8-10 [9] ajdhs.com chemical reagents all the chemicals used in this study were obtained from hi media laboratories pvt. ltd. (mumbai, india), sigma aldrich chemical co. (milwaukee, wi, usa), sd fine-chem. ltd. (mumbai, india) and srl pvt. ltd. (mumbai, india).all the chemicals used in this study were of analytical grade. extraction of plant material cold maceration method leaves of pongamia pinnata were collected, washed and rinsed properly. they were dried in shade and powdered mechanically. about 250gm of the leaves powder was macerated with petroleum ether and methanol and stored for 72 hours in ice cold condition for the extraction of phytochemicals. at the end of the third day extract was filtered using whatman no. 1 filter paper to remove all un-extractable matter, including cellular materials and other constitutions that are insoluble in the extraction solvent. the entire extract was concentrated to dryness using rotary flash evaporator under reduced pressure and stored in an air tight container free from any contamination until it was used. finally the percentage yields were calculated of the dried extracts9. assessment of in vitro anti-inflammatory activity by protein denaturation technique the reaction mixture (5ml) consisted of 0.2ml of egg albumin (from fresh hen’s egg ), 2.8ml of phosphate buffer saline (pbs,ph 6.4) and 2ml of varying concentrations of plant extract so that final concentrations become 50, 100, 150, 200,250µg/ml. similar volume of double distilled water served as control. then the mixture were incubated at (37±2)°c in incubator (universal) for 15 min and then heated at 70°c for 5 min. after cooling, their absorbance was measured at 660nm (systronic 2202) by using vehicle as blank. diclofenac -sodium at the final concentration of 50, 100, 150, 200, 250µ/ml was used as reference drug and treated similarly for determination of absorbance and viscosity10. the percentage inhibition of protein denaturation was calculated by using the following formula: % inhibition = 100 × (vt / vc -1) where, vt = absorbance of test sample, vc = absorbance of control. results and discussions the crude extracts so obtained after cold maceration extraction process were concentrated on water bath by evaporation the solvents completely to obtain the actual yield of extraction. the percentage yield of extraction is very important in phytochemical extraction in order to evaluate the standard extraction efficiency for a particular plant, different parts of same plant or different solvents used. the yield of extracts obtained from the leaves of the plants using petroleum ether and methanol as solvents are depicted in the table 1. results of in vitro antiinflammatory activity of diclofenac sodium standard and methanolic extract was given in table 2 using protein denaturation methods. table 1: results of percentage yield of leaves extracts s. no. solvent color of extract weight of plant material (gm) weight of extract (gm) % yield 1. petroleum ether dark green 180 4.32 2.4 2. methanol brown 160.71 10.68 1.29 table 2: effect of diclofenac sodium and pongamia pinnata methanolic extract on protein denaturation s. no. concentration (µg/ml) % inhibition diclofenac sodium methanolic extract 1 50 50.33738192 42.37516869 2 100 59.51417004 54.38596491 3 150 71.25506073 64.1025641 4 200 78.54251012 72.73954116 5 250 87.44939271 80.02699055 ic 50 18.36 82.24 conclusion in conclusion, this study shows, for the first time, in vitro antiinflammatory activity of methanolic leave extract of indian, pongamia pinnata and scientifically justify its use in india traditional medicine to treat inflammatory conditions. its antiinflammatory action is mediated by the synergistic action of flavonoids, tannins and purine and pseudo-alkaloids. furthermore. some studies have shown that the heat-induced protein denaturation test also indicated anti-rheumatoid arthritis activity in which case the results also suggest that pongamia pinnata may be useful to treat rheumatoid arthritis as well. references 1. kumar v, abbas ak, fausto n. in: robbins and cotran pathological basis of disease. 7th ed, philadelphia, elsevier saunders. 2004:4786. 2. rang hp, dale mm, ritter jm. anti-inflammatory and immunosuppressant drugs, chapter 14. flower rj; rang and dale’s pharmacology, 6th ed. elsevier publication. 2008; 226-45. https://doi.org/10.1016/b978-0-443-06911-6.50019-0 3. sangita k, shukla g, sambasiva rao a. the present status of medicinal plants-aspects and prospects. int j res pharm biomed sci 2011; 2:19-22. 4. karim a, sohail mn, munir s, sattar s. pharmacology and phytochemistry of pakistani herbs and herbal drugs used for https://doi.org/10.1016/b978-0-443-06911-6.50019-0 bairagi et al asian journal of dental and health sciences. 2023; 3(1):8-10 [10] ajdhs.com treatment of diabetes. int j pharmacol 2011; 7:419-39. https://doi.org/10.3923/ijp.2011.419.439 5. pattari ls, muchandi vn, haricharan kn, himabindu gm, tejaswi ch, ramanjaneyulu k, et al. study of analgesic acxtivity of litsea glutinosa (l.) ethanolic extract on swiss albino mice. int j pharm sci res 2010; 1:93-7. 6. who. general guidelines for methodologies on research and evaluation of traditional medicine who/edm/trm/2000. 1, geneva, switzerland, 2000. 7. soorya c, balamurugan s, ramya s, neethirajan k, kandeepan c, jayakumararaj r. physicochemical, admet and druggable properties of myricetin: a key flavonoid in syzygium cumini that regulates metabolic inflammations. journal of drug delivery and therapeutics, 2023; 11(4):66-63. https://doi.org/10.22270/jddt.v11i4.4890 8. bajpai vk, rahman a, shukla s, mehta a, shukla s, arafat sy, rahman mm, ferdousi z. antibacterial activity of leaf extracts of pongamia pinnata from india. pharmaceutical biology. 2009; 47(12):1162-7. https://doi.org/10.3109/13880200903019218 9. jha m, nema n, shakya k, ganesh n, sharma v. in vitro hepatoprotective activity of bauhinia variegata. pharmacologyonline. 2009; 3:114-8. 10. heendeniya sn, ratnasooriya wd, pathirana rn. in vitro investigation of anti-inflammatory activity and evaluation of phytochemical profile of syzygium caryophyllatum. journal of pharmacognosy and phytochemistry. 2018; 7(1):1759-63. https://doi.org/10.3923/ijp.2011.419.439 https://doi.org/10.22270/jddt.v11i4.4890 https://doi.org/10.3109/13880200903019218 extraction and phytochemical analysis verma et al asian journal of dental and health sciences. 2023; 3(1):11-14 [11] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited evaluation of antioxidant activity of trigonella foenum graecum seeds extract neha verma*, vivekanand katare, nisha kalme, abhilasha delouri, shivam nema vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india article info: _______________________________________ article history: received 09 dec 2022 reviewed 11 jan 2023 accepted 26 jan 2023 published 15 march 2023 _______________________________________ cite this article as: verma n, katare v, kalme n, delouri a, nema s, evaluation of antioxidant activity of trigonella foenum graecum seeds extract, asian journal of dental and health sciences. 2023; 3(1):11-14 doi: http://dx.doi.org/10.22270/ajdhs.v3i1.33 _______________________________________ *address for correspondence: neha verma, vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india abstract ___________________________________________________________________________________________________________________ in the current work, we completed a comprehensive assessment of the relative antioxidant activity in extracts from a few different medicinal plant species.the extracts' effectiveness at scavenging 1, 1diphenyl-2-picryl hydrazyl (dpph) radicals was assessed spectrophotometrically. the highest degree of radical scavenging was 52.54%, while the ic50 value was 93.54.trigonella foenum graecum extract demonstrates how the greater concentration of phytoconstituents chemicals leads to more powerful radical scavenging results. keywords: trigonella foenum graecum, antioxidant, dpph, phytochemical analysis mail id: nv132611@gmail.com introduction free radicals donate to more than one hundred disorders in humans counting atherosclerosis, arthritis, ischemia and reperfusion damage of numerous tissues, central nervous system injury, gastritis, cancer and aids. free radicals due to ecological pollutants, radiation, chemicals, toxins, profound fried and spicy foods as well as corporeal stress, cause exhaustion of immune system antioxidants, modify in gene expression and persuade abnormal proteins. oxidation development is one of the most imperative routs for producing free radicals in food, drugs and still living systems. catalase and hydroperoxides enzymes change hydrogen peroxide and hydroperoxides to nonradical forms and purpose as natural antioxidants in human body. owing to depletion of immune system natural antioxidants in dissimilar maladies, overwhelming antioxidants as free radical scavengers may be essential. at present available synthetic antioxidants similar to butylated hydroxy anisole (bha), butylated hydroxy toluene (bht), tertiary butylated hydroquinone and gallic acid esters, have been supposed to cause or punctual negative health effects. consequently, strong restrictions have been placed on their application and there is a trend to substitute them with naturally occurring antioxidants. furthermore, these synthetic antioxidants also show low solubility and reasonable antioxidant activity1,2. recently there has been an increase of interest in the therapeutic potentials of medicinal plants as antioxidants in dropping such free radical induced tissue injury. polyphenolic compounds with known properties which include free radical scavenging, inhibition of hydrolytic and oxidative enzymes and anti-inflammatory action3. a number of confirmations suggest that the biological actions of these compounds are related to their antioxidant activity4. an easy, rapid and sensitive method for the antioxidant screening of plant extracts is free radical scavenging assay using 1,1diphenyl-2-picryl hydrazyl (dpph) stable radical spectrophotometrically. in the occurrence of an antioxidant, dpph radical obtains one more electron and the absorbance decreases5. in particular, despite extensive use of wild plants as medicines in iran, the prose contains few reports of antioxidant activity and chemical composition of these plants. in current study, we carried out a systematic record of the relative free radical scavenging activity in selected medicinal plant species, which are being used traditionally: the seeds trigonella foenum graecum. in the longer term, plant species (or their active constituents) recognized as having high levels of antioxidant activity in vitro may be of value in the design of additional studies to unravel novel treatment strategy for disorders connected with free radicals induced tissue damage. besides well-known and traditionally used natural antioxidants from tea, wine, fruits, vegetables and spices, some natural antioxidant (e.g. rosemary and sage) are already exploited commercially either as antioxidant additives or a nutritional supplements6. also many other plant species have been investigated in the search for novel antioxidants7,8 but generally there is still a demand to find more information concerning the antioxidant potential of plant species. it has been mentioned the antioxidant activity of plants might be due to their phenolic compounds9. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i1.33 verma et al asian journal of dental and health sciences. 2023; 3(1):1-4 [12] ajdhs.com materials and methods selection, collection and processing of plant seeds of fenugreek were purchased from local retail market. the seeds were cleaned before drying it in oven at 50 °c for 24 h. then, the dried seeds were ground using a mill with ultra-centrifugal equipped with ring sieve owning trapezoid holes sized 0.5 mm. the moisture content of the seed was (5.51 ± 0.14% d.w basis). the powdered seeds were kept in dark airtight container before extraction. reagents and chemicals 2,2-diphenyl-1-picrylhydrazyl (dpph), methanol , ascorbic acid, potassium phosphate buffer-ph6.6 (dihydrogen phosphate , sodium hydroxide ), potassium ferricyanide , trichloroacetic acid , ferric chloride . extraction all the seeds are initially blended into coarse then into powder form. the powdered plant seeds were packed inside the soxhlet extractor and were successively extracted with petroleum ether, and methanol for 8-10 hours and 40-60oc temperature of the heating mantle were adjusted. the extracts so collected were distilled on a water bath at atmospheric pressure and the last traces of solvent were removed using vacuum. extracts were collected in air tight container10. qualitative phytochemical analysis of plant extract following standard methods by rani et al, 202111 the trigonella foenum graecum extract obtained was subjected to the preliminary phytochemical analysis. the extract was screened to spot the presence or absence of many active constituents like carbohydrates, glycosides, phenolic compounds, alkaloids, flavonoids, saponins, fats or fixed oils, protein, amino acid and tannins. activity (in-vitro anti-oxidant activity) dpph radical scavenging activity a) preparation of dpph reagent 0.1mm solution of 2,2-diphenyl-1-picrylhydrazyl (dpph) in methanol was prepared. b) preparation of sample/standard freshly 1 mg/ml methanol solution of extracts of trigonella foenum graecum standard was prepared. 1 mg of extracts/standard was taken with methanol to make 1mg/ml stock solution. different volume of extracts/standard (20 – 100μl) was taken from stock solution in a set of test tubes and methanol was added to make the volume to 1 ml. to this, 2 ml of 0.1mm dpph reagent was added and mixed thoroughly and absorbance was recorded at 517 nm after 30 minutes incubation in dark at room temperature. c) preparation of control for control, take 3 ml of 0.1mm dpph solution and incubated for 30 min at room temperature in dark condition. absorbance of the control was taken against methanol (as blank) at 517 nm12 .percentage antioxidant activity of sample/standard was calculated by using formula: % inhibition = [(ab of controlab of sample/ ab of control x 100] reducing power assay preparation of standard solution 3 mg of ascorbic acid was dissolved in 3 ml of distilled water/solvent. dilutions of this solution with distilled water were prepared to give the concentrations of 20, 40, 60, 80 and 100μg/ml. preparation of extracts of stock solutions of extracts of trigonella foenum graecum was prepared by dissolving 10 mg of dried extracts in 10 ml of methanol to give a concentration of 1mg/ml. then sample concentrations of 20, 40, 60, 80 and 100 μg/ml were prepared. protocol for reducing power according to this method, the aliquots of various concentrations of the standard and extracts of trigonella foenum graecum (20 to 100μg/ml) in 1.0 ml of deionized water was mixed with 2.5 ml of (ph 6.6) phosphate buffer and 2.5 ml of (1%) potassium ferricyanide. the mixture was incubated at 50°c in water bath for 20 min after cooling. aliquots of 2.5 ml of (10%) trichloroacetic acid were added to the mixture, which was then centrifuged at 3000 rpm for 10 min. the upper layer of solution 2.5 ml was mixed with 2.5 ml distilled water and a freshly prepared 0.5 ml of (0.1%) ferric chloride solution. the absorbance was measured at 700 nm in uv spectrometer (systronic double beam-uv-2201). a blank was prepared without adding extract. ascorbic acid at various concentrations (20 to 100μg/ml) was used as standard13. results table 1: percentage yield of trigonella foenum graecum extract s. no solvent color of extract weight of plant material (gms) weight of extract (gms) % yield 1 petroleum ether dark green 180 4.32 2.4 2 methanol green 164.71 10.68 6.484 verma et al asian journal of dental and health sciences. 2023; 3(1):1-4 [13] ajdhs.com table 2: qualitative phytochemical analysis phytoconstituents extracts pet. ether methanol alkaloids mayer +++ + dragendoff +++ + flavonoids lead acetate ferric chloride +++ +++ carbohydrates molish +++ +++ bendict + glycosides killer-lini ++ ++++ steroids salkowskis +++ libermanburchard +++ +++ protein and amino acids ninhydrin ++++ +++ biuret phenolic compounds and tannins ferric chloride gelatin +++ + lead acetate ++++ + terpenoids trim hill libermann-burchard +++ +++ saponins foam test +++ mercuric chloride +++ ++ note :-+++ very large quantity, +++ large quantity, +small quantity, absent table 3: dpph activity of ascorbic acid ascorbic acid concentration (µg/ml) absorbance (nm) % inhibition 20 0.447 46.97 40 0.353 58.12 60 0.235 72.12 80 0.137 83.74 100 0.069 91.81 control 0.843 ic50 24.34 figure 1: graph represents the percentage inhibition vs concentration of ascorbic acid table 4: dpph activity of trigonella foenum graecum extract trigonella foenum graecum concentration (µg/ml) absorbance (nm) % inhibition 20 0.49 16.9492 40 0.43 27.1186 60 0.38 35.5932 80 0.33 44.0678 100 0.28 52.5424 control 0.59 ic50 93.4568 figure 2: graph represents the percentage inhibition vs concentration of extract y = 0.5765x + 35.967 r² = 0.9929 0 10 20 30 40 50 60 70 80 90 100 0 20 40 60 80 100 120 y = 0.4407x + 8.8136 r² = 0.9985 0 10 20 30 40 50 60 0 20 40 60 80 100 120 verma et al asian journal of dental and health sciences. 2023; 3(1):1-4 [14] ajdhs.com table 5: reducing power activity of ascorbic acid concentration (µg/ml) absorbance (nm) 20 0.14 40 0.244 60 0.367 80 0.43 100 0.505 figure 3: graph represents the percentage inhibition vs concentration of ascorbic acid table 6: reducing power activity of trigonella foenum graecum extract concentration (µg/ml) absorbance (nm) 20 0.02 40 0.03 60 0.05 80 0.06 100 0.08 figure 4: graph represents the percentage inhibition vs concentration of extract conclusion the current study concluded that a trigonella foenum graecum seed which was purchased from local market of bhopal, madhya pradesh is rich source of phytochemicals. results showed the presence of alkaloids, amino acids, carbohydrates, flavonoids, phloba tannins and tannins in the seeds of trigonella foenum graecum. results of dpph assay showed that trigonella foenum graecum (100µg/ml) has about 52.54% scavenging activity. therefore, it is concluded from this preliminary study that trigonella foenum graecum can be used for isolation of important compounds with medicinal and pharmacological importance. references 1. barlow sm. toxicological aspects of antioxidants used as food additives. in food antioxidants, hudson bjf (ed.) elsevier, london, 1990; pp 253-307. https://doi.org/10.1007/978-94-0090753-9_7 2. branen al. toxicology and biochemistry of butylatedhydroxyanisol and butylatedhydroxytoluene. j. american oil chemists society, 1975; 5:5963. https://doi.org/10.1007/bf02901825 3. frankel e. nutritional benefits of flavonoids. international conference on food factors: chemistry and cancer prevention, hamamatsu, japan. abstracts, 1995; c62. 4. gryglewski rj, korbut r, robak j. on the mechanism of antithrombotic action of flavonoids. biochemical pharmacol, 1987; 36:317321. https://doi.org/10.1016/00062952(87)90288-7 5. koleva ii, van beek ta, linssen jph, de groot a, evstatieva ln. screening of plant extracts for antioxidant activity: a comparative study on three testing methods. phytochemical analysis, 2002; 13:8-17. https://doi.org/10.1002/pca.611 6. schuler p. natural antioxidants exploited commercially, in food antioxidants, hudson bjf (ed.). elsevier, london, 1990; pp 99170. https://doi.org/10.1007/978-94-009-0753-9_4 7. mantle d, eddeb f, pickering at. comparison of relative antioxidant activities of british medicinal plant species in vitro, j. ethnopharmacol. 2000; 72:4751. https://doi.org/10.1016/s0378-8741(00)00199-9 8. merghem m, dahamna s, in-vitro antioxidant activity and total phenolic content of ruta montana l. extracts, journal of drug delivery and therapeutics 2010; 10(2):69-75 https://doi.org/10.22270/jddt.v10i2.3919 9. cook nc, samman s. flavonoidschemistry, metabolism, cardioprotective effects, and dietary sources. nutritional biochemistry, 1996; 7:66-76. https://doi.org/10.1016/09552863(95)00168-9 10. dutta r, sharma mk, khan a, jha m. phytochemical and in vitro antioxidant assay of fumaria officinalis leaf extract. journal of advanced scientific research. 2020; 11(03):176-82. 11. rani d, kharkwal h, jha m, rai n. assessment of the total flavonoid, phenol, alkaloid content and sun protection factor in grewia abutilifolia leaf extract. journal of pharmaceutical research international.2021; 33(49a):42-51. https://doi.org/10.9734/jpri/2021/v33i49a33300 12. jha m, ganesh n, sharma v in vitro evaluation of free radical scavenging activity of pistia stratiotes. international journal of chemtech research 2010; 2(1):180-184 13. jha m, sharma v, nema n, hussain t. effect of the topical application of the extract of glycosmis pentaphylla on excisional wound model in mice. pharmacologyonline. 2009; 3:356-60. 0 0.1 0.2 0.3 0.4 0.5 0.6 0 20 40 60 80 100 120 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09 0 20 40 60 80 100 120 https://doi.org/10.1007/978-94-009-0753-9_7 https://doi.org/10.1007/978-94-009-0753-9_7 https://doi.org/10.1007/bf02901825 https://doi.org/10.1016/0006-2952(87)90288-7 https://doi.org/10.1016/0006-2952(87)90288-7 https://doi.org/10.1002/pca.611 https://doi.org/10.1007/978-94-009-0753-9_4 https://doi.org/10.1016/s0378-8741(00)00199-9 https://doi.org/10.22270/jddt.v10i2.3919 https://doi.org/10.1016/0955-2863(95)00168-9 https://doi.org/10.1016/0955-2863(95)00168-9 https://doi.org/10.9734/jpri/2021/v33i49a33300 fadjeri et al asian journal of dental and health sciences. 2023; 3(2):15-17 [15] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited chewing yam fruit (pachyrhizus erosus) as an effort to reduce index debris in elementary school children indrayati fadjeri1, afna dzulfaqor2, tedi purnama3 1,2,3 department of dental health, poltekkes kemenkes jakarta i, jakarta, indonesia article info: _______________________________________ article history: received 27 march 2022 reviewed 12 may 2023 accepted 30 may 2023 published 15 june 2023 _______________________________________ cite this article as: fadjeri i, dzulfaqor a, purnama t, chewing yam fruit (pachyrhizus erosus) as an effort to reduce index debris in elementary school children, asian journal of dental and health sciences. 2023; 3(2):15-17 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.41 _______________________________________ *address for correspondence: tedi purnama, department of dental health, poltekkes kemenkes jakarta i, indonesia abstract ___________________________________________________________________________________________________________________ oral health is an integral component of general health. the prevalence of dental caries in indonesia is around 90% of the 238 million indonesian population and the number of children aged 15 years and under who suffer from dental caries reaches 76.5%. eating fibrous foods such as fruits can help clean teeth, one of which is yam fruit. the purpose of this study was to determine the debris index score before and after eating yam in elementary school children. this research method is quasi experimental. this research was conducted with a population of 61 students obtained by using a total sampling technique. the instrument used in this study was a debris index examination sheet. results: before eating yam fruit, 3 students (4.9%) had good index debris criteria, 28 students (45.9%) moderate index debris criteria, 30 students (49, 9%) had bad index debris criteria (49, 2%) and after chewing yam fruit, 47 students (77%) had good debris index criteria, 14 students (23%) had moderate debris index criteria and there were no students with bad index debris criteria. the results of the paired sample test analysis obtained a p-value of 0.001. conclusion: chewing yam fruit can reduce index debris in elementary school children. keywords: chewing yam fruit, index debris, children introduction oral health is an integral component of general health. it is also becoming clear that the causes and risk factors for oral disease are often the same as those involved in common diseases. the health, well-being, education and development of children, families and society as a whole can be affected by oral health. although there have been considerable improvements in children's oral health in recent decades, rates of dental caries (tooth decay) are still one of the most common oral health problems in children worldwide. a sizeable population of children in developing countries is affected by tooth decay and most of the time their appropriate care is given last priority due to limited access to health services.1,2 the lack of availability and affordability of health services not only results in disease disorders but also increases the cost of treatment and care. until now, not a single country has stated that it has caries-free children.3 indonesian children under 12 years as much as 89% suffer from dental and oral diseases. this condition will affect their health status, growth process and even their future. in jakarta, 90% of children suffer from cavities and 80% suffer from gum disease. this figure is estimated to be more severe in regions and children from the middle to lower economic class.4,5 the prevalence of dental caries in indonesia is around 90% of the 238 million indonesian population and the number of children aged 15 years and under who suffer from dental caries reaches 76.5%. from the results of siagian's research it was found that 95% of elementary school children had poor dental and oral health, so they suffered from dental caries.6 many efforts have been made to maintain healthy teeth and mouth including mechanical, chemical, and modification between mechanical and chemical methods. one of them is by brushing your teeth, flossing (using dental floss), cleaning your tongue. chemically, namely avoiding foods that contain sucrose, but eating more fibrous and watery foods.7 eating fibrous foods such as fruits can help clean teeth, for example papaya, pineapple, watermelon, apples, yam, red guava are examples of fruits that are easy to find and can be consumed immediately fresh.8 yam fruit (pachyrhizus erosus) is a fruit that has a water content of 85.10% and 5.49% fiber by weight of the yam. the liquid contained in jicama such as isoflavones is used as an antioxidant and can reduce levels of bad cholesterol (ldl). the fiber in jicama has ingredients such as calcium phosphorus and vitamin c. yam requires chewing hard enough so that it can increase salivary secretion and can clean teeth from food debris naturally. chewing is a movement that will stimulate the release of saliva which contains antibacterial, glycoprotein compounds, calcium and fluoride in it. saliva produced from chewing movements can remove debris or food debris and neutralize acidic substances from food residues found in the pits and fissures of the tooth surface, but the tooth surface cannot be cleaned optimally only with saliva.9 in a study aritonang on the description of debris index before and after eating pears and jicama in grade iii open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.41 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.41&amp;domain=pdf fadjeri et al asian journal of dental and health sciences. 2023; 3(2):15-17 [16] ajdhs.com students at sd anastasia namo bintang pancur batu foundation, it was found that eating yam fruit was more effective than pears, which was shown through the results of the study, namely a decrease in debris index after eating pears was 0, while after eating jicama was 0.7.10 method and material the research design used was a quasi-experimental study with a one group pretest-posttest design. the research sample that will be used in this research is class v students at sdn 04 pagi tanjung barat, south jakarta, totaling 61 people. data collection was carried out on march 30-31 2022. the instrument for collecting debris data used index debris while the yam fruit given for consumption was 100 grams for each respondent. analysis of the data used in this study using spss with paired sample t test. result the results of the study were conducted on fifth grade students at sdn 04 pagi tanjung barat, south jakarta in 2022. data collection was carried out before and after chewing yam fruit by direct examination into the oral cavity of the students who were the samples. from the research conducted, the sample frequency distribution data is obtained as follows: table 1: frequency distribution of index debris criteria before chewing yam fruit index debris criteria frequency percentage good 3 4.9 moderate 28 45.9 bad 30 49.2 total 61 100 table 1 shows that index debris before chewing yam fruit obtained good index debris criteria of 3 people (4.9%), moderate index debris of 28 people (45.9%) and bad index debris of 30 people (49.2%) table 2: frequency distribution of index debris criteria after chewing yam fruit index debris criteria frequency percentage good 47 77.0 moderate 14 23.0 bad 0 0.0 total 61 100 table 2 shows that 47 students (77%) had good debris index after chewing yam fruit, 14 students (23%) had moderate index debris and there were no students with bad index debris. table 3: different test of debris index before and after chewing yam fruit debris index mean difference p-value pre-test 1.74 1.36 0.001 pos-test 0.38 table 3 shows that the results of the paired sample test analysis obtained a p-value of 0.001, meaning that chewing yam fruit can reduce index debris in elementary school children. discussion yam fruit (pachyrhizus erosus) is rich in various nutrients such as vitamin c and contains antibacterial compounds such as flavonoids, tannins, quinones, saponins, alkaloids and triterpenoids so that it is effective as a plaque cleanser in the oral cavity.1112 the water in yam can help the mouth secrete fluids naturally so that it can help the process of cleaning the mouth and teeth from dirt. with the water contained in this jicama will help provoke saliva in the mouth to appear and can work to keep teeth clean.13 hasil penelitian before chewing yam, 3 students (4.9%) had good index debris criteria, 28 students (45.9%) moderate index debris criteria, 30 students (49.2%) bad index debris criteria and after chewing yam found 47 students (77%) with good debris index criteria, 14 students (23%) with moderate index debris criteria and there were no students with bad index debris criteria, resulting in an increase in index debris criteria. the results of the paired sample test analysis obtained a p-value of 0.001, meaning that chewing yam fruit can reduce index debris in elementary school children. this is in line with research conducted by siahaan, there is a difference in the decrease in index debris before and after consuming yam fruit for good criteria of 0.15, for medium criteria of 0.77 and for bad criteria of 0.35. with a difference in debris index of all criteria is 1.27. then the research conducted by aritonang, 2019, there was a significant difference between the debris index before and after eating pears and jicama, that is, the initial dental debris index was in the bad category and after eating pears and jicama, the final debris index was in the moderate category.14 reinforced by research conducted by fitriyani, shows that the index debris score before chewing apples is 1.4 and after chewing apples is 0.9 so the difference is 0.5, while the index debris score before chewing yam fruit is 1 .6 and after chewing yam fruit is 0.8 so the difference is 0.8. so the difference in debris index of chewing yam fruit is higher than chewing apples. this means that this research is in line with the 3 previous studies. because yam (pachyrhizus erosus) is a fruit that has a water content of 85.10% and 5.49% of the fiber by weight of yam. yam requires chewing hard enough so as to increase salivary secretion and can clean teeth from food debris naturally. chewing is a movement that will stimulate the release of saliva with its content and fluoride in it. saliva produced from chewing movements can remove debris or food remnants and neutralize acidic substances from food residue found in the pits and fissures of the tooth surface, but the tooth surface cannot be cleaned optimally only with antibacterial saliva, glycoprotein compounds, calcium.15,9 conclusion based on the results of the research that has been done, it can be concluded that there is the chewing yam fruit can reduce index debris in elementary school children. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. fadjeri et al asian journal of dental and health sciences. 2023; 3(2):15-17 [17] ajdhs.com references 1. pudentiana rr, purnama t, tauchid sn, prihatiningsih n. knowledge of oral and dental health impacts the oral hygiene index simplified ( ohi-s ) of primary school children. indian j forensic med toxicol. 2021; 15(4):2179–83. 2. fadjeri i, budiarti r, purnama t. dental care interventions as efforts to reduce pufa index and improve nutritional status in children aged 9-12 years in orphanages. med leg updat. 2021; 21(1):366–71. 3. ramadhan a, cholil c, sukmana bi. hubungan tingkat pengetahuan kesehatan gigi dan mulut terhadap angka karies gigi di smpn 1 marabahan. dentino j kedokt gigi. 2016; 1(2):66–9. 4. zatnika. 89% anak derita penyakit gigi dan mulut. 2009; 5. hastuti s, andriyani a. perbedaan pengaruh pedidikan kesehatan gigi dalam meningkatkan pengetahuan tentang kesehatan gigi pada anak di sd negeri 2 sambi kecamatan sambi kabupaten boyolali. gaster. 2010; 7(2):624–32. 6. rahmawati i, hendrartini j, priyanto a. perilaku kesehatan gigi dan mulut pada anak sekolah dasar. ber kedokt masy. 2011; 27(4):180–6. 7. prasetyowati le, wahyuni sri. efektifitas buah semangka dan jambu biji terhadap nilai (ohis) pada anak usia 10-12 tahun. j anal kesehat. 2017; 5(1):483–9. 8. cahyati wh. konsumsi pepaya (carica papaya) dalam menurunkan debris index. kemas j kesehat masy. 2013; 8(2). 9. adrianton d, ramayanti s, nofika r. pengaruh mengunyah tebu (saccharum officinarum l.) dan bengkuang (pachyrhizus erosus) terhadap perubahan indeks debris pada anak umur 8-9 tahun di sd adabiah kota padang. andalas dent j. 2019; 7(2):87–93. https://doi.org/10.25077/adj.v7i2.140 10. aritonang dls. gambaran indeks debris sebelum dan sesudah mengunyah buah pir dan bengkuang pada siswa/siswi kelas iii sd yayasan anastasia namo bintang pancur batu. 2019; 11. supari ih. efektivitas antibakteri ekstrak biji bengkuang (pachyrrhizus erosus) terhadap pertumbuhan streptococcus mutans secara in vitro. pharmacon. 2016;5(3). 12. buckman es, oduro i, plahar wa, tortoe c. determination of the chemical and functional properties of yam bean (pachyrhizus erosus (l.) urban) flour for food systems. food sci nutr. 2018; 6(2):457–63. https://doi.org/10.1002/fsn3.574 13. diyatama nap, sugito bh, isnanto i. perbedaan efektivitas mengunyah buah apel dan buah semangka dalam menurunkan nilai debris indeks. j ilm keperawatan gigi. 2020; 1(2):14–20. https://doi.org/10.37160/jikg.v1i2.523 14. siahaan eg. gambaran mengkonsumsi buah bengkuang terhadap penurunan debris indeks pada siswa-siswi kelas iv sd negeri 067247 kecamatan medan tuntungan. 2020; 15. fitriyani n. gambaran efek mengunyah buah apel dan buah bengkuang terhadap penurunan debris indeks. 2019; https://doi.org/10.25077/adj.v7i2.140 https://doi.org/10.1002/fsn3.574 https://doi.org/10.37160/jikg.v1i2.523 dangi et al asian journal of dental and health sciences. 2022; 2(3):19-22 [19] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and health research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited development and characterization of tramadol hydrochloride rectal suppository nanci dangi, sunil k. jain, vivek jain, rupesh k. jain, pushpendra kumar khangar* adina institute of pharmaceutical sciences, nh86 lahadara naka bhopal road sagar, m.p., india article info: _______________________________________ article history: received 09 sep 2022 reviewed 28 oct 2022 accepted 11 nov 2022 published 28 nov 2022 _______________________________________ cite this article as: dangi n, jain sk, jain v, jain rk, khangar pk, development and characterization of tramadol hydrochloride rectal suppository, asian journal of dental and health sciences. 2022; 2(3):19-22 doi: http://dx.doi.org/10.22270/ajdhs.v2i3.29 _______________________________________ *address for correspondence: pushpendra kumar khangar, adina institute of pharmaceutical sciences, nh86a, lahdara, sagar, mp, 470001, india abstract ___________________________________________________________________________________________________________________ tramadol is a centrally acting analgesic drug. rectal administration of tramadol is useful in the treatment of post-operative pain or malignant pain in cases where it cannot be administered orally. rectal suppositories of tramadol hydrochloride were prepared using different bases and polymers and the effect of different additives on in vitro release of tramadol hydrochloride was studied. the agarbased suppositories were non-disintegrating/non-dissolving. all the prepared suppositories were evaluated for various physical parameters like weight variation, drug content and hardness. in vitro release study was performed by usp type i apparatus. addition of 10% w/w propylene glycol accelerates the release of tramadol hydrochloride significantly (p<0.05) as in a1, which may be due to decrease in the gel matrix of agar. in formulation a2, a3 addition of hpmc (1%, 3% w/w) and in formulation a3 and a4 addition of pvp (1%, 3% w/w) retards the release significantly (p<0.05), which may be due to increase in the viscosity and gel strength of the polymer matrix. hence, pvp, hpmc and similar polymers in higher concentration can be used to formulate sustained released suppositories. the sustained release suppositories can be prepared by addition of pvp, hpmc in agar-based suppositories. keywords: tramadol, rectal suppositories, pvp, hpmc, agar. mail id: pushpendra.rai16@gmail.com introduction rectal drug delivery has a number of advantages such as reduced hepatic first pass elimination of high clearance drugs, avoidance of gastric irritation associated with certain drugs in case of nausea, vomiting and when the patient is unconscious. rectal route of administration is specifically useful for infants and children who have difficulty in swallowing oral medicine. drug administered in suppository form can produce not only local effect but also systemic therapeutic action1. suppositories can be prepared by using lipophilic bases like cocoa butter or by hydrophilic bases such as pegs1-4. these suppositories melt or dissolve in body fluids and release the drug, but are unstable at higher temperature. agar has been recently used as base to produce non-disintegrating/ nondissolving suppositories, which are stable at higher temperature5,6. tramadol is a synthetic 4-phenyl-piperidine analogue of codeine. it is a centrally acting analgesic with a low affinity for mu opioid receptors (a class of opioid receptors with high affinity for enkephalins and betaendorphin but low affinity for dynorphins). it consists of two enantiomers, both of which contribute to its analgesic activity via different mechanisms. (+)tramadol and its metabolite (+)-o-desmethyltramodol (m1), produced by liver odemethylation, are agonists of the mu opioid receptor. (+)tramadol also inhibits serotonin reuptake whereas (-)tramadol inhibits norepinephrine reuptake, to enhance the inhibition of pain7,8. its use is indicated for the management of moderate to moderately severe pain including chronic pain and pain associated with molar extraction in adults9. tramadol is an effective and well-tolerated agent to reduce pain resulting from trauma, renal or biliary colic, and labor, and for the management of chronic pain of malignant or nonmalignant origin, particularly neuropathic pain. tramadol appears to produce less constipation and dependence than equianalgesic doses of strong opioids8. however, after intravenous and oral administration, peak concentrations are reached rapidly, and this has been associated with postoperative nausea and vomiting10. thus, this limits the use of tramadol as a postoperative analgesic, especially in day surgery. rectal administration of tramadol may be an alternative in this situation. it could be used at the same dose range as that of the oral form to maintain effective pain relief11. furthermore, it is useful in the treatment of post-operative pain or malignant pain in cases where oral administration is not possible12. in the present study attempts were made to formulate rectal suppositories of tramadol hydrochloride with bases, as the rectal route avoids first pass metabolism and side effects. materials and methods materials tramadol hydrochloride was obtained as a gift sample from sun pharmaceutical ltd. ahmedabad. hpmc and pvp were purchased from loba chemie pvt. ltd., mumbai. propylene glycol, methyl paraben and propyl paraben were purchased from s. d. fine chemicals pvt. ltd., mumbai, and all other chemicals used were of analytical grade and were used without any further chemical modification. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i3.29 dangi et al asian journal of dental and health sciences. 2022; 2(3):19-22 [20] ajdhs.com preformulation studies13, 14 physical characteristics by visual examination, the drug was identified for physical characters like colour, texture, odour etc. solubility solubility of the drug was determined by taking some quantity of drug (about 10 mg) in the 10 ml volumetric flasks separately and added the 10 ml of the solvent (water, ethanol, methanol, 0.1n hcl, 0.1n naoh, chloroform and 7.4 ph buffer) shake vigorously and kept for some time. note the solubility of the drug in various solvents (at room temperature). melting point a small quantity of powder was placed into a fusion tube. that tube was placed in the melting point determining apparatus (chemline) containing castor oil. the temperature of the castor oil was gradual increased automatically and read the temperature at which powder started to melt and the temperature when all the powder gets melted. ftir spectroscopy the concentration of the sample in kbr should be in the range of 0.2% to 1 %. the pellet is a lot thicker than a liquid film, consequently a decrease concentration in the sample is required (beer's law). for the die set that you'll be the usage of, about 80 mg of the mixture is wanted. too excessive of an attention causes typically difficulties to obtain clean pellets. ftir spectra of the samples were recorded over a spectral region from 4700 to 400 cm-1 using 20 scans with 4 cm-1 resolution. determination of λ max of tramadol hcl tramadol, 100 mg, was accurately weighted into a 100 ml volumetric flask, dissolved in phosphate buffer of ph 6.8 and the volume was made up with phosphate buffer of ph 6.8. pipette 1 ml of this solution into a 10 ml volumetric flask with phosphate buffer of ph 6.8 as the volume and marks it as stock. prepare an appropriate dilution to bring the concentration down to 2.5-17.5μg/ml. the resulting solution is scanned with a uv spectrophotometer (uv-1700 shimadzu corporation, japan) in the range of (200-400 nm) to determine the absorption maximum (λ max). concentration vs. absorbance was shown on a graph. preparation of tramadol hydrochloride rectal suppository agar suppositories were prepared by molding method15, dissolving methyl and propyl paraben in hot water and then drug along with other additives like propylene glycol, hpmc, pvp was added and mixed well. finally, agar was incorporated by maintaining the temperature at 75-80℃ and mixed thoroughly. the molten mass was poured into previously calibrated stainless-steel mould of 1g and allowed to set. the details of all formulations are tabulated in table 1. all the prepared suppositories were packed in polyethylene laminated foil pouches. table 1: formulations of tramadol hydrochloride rectal suppositories ingredients (%w/w) formulation codes a0 a1 a2 a3 a4 tramadol hydrochloride 5 5 5 5 5 agar 10 10 10 10 10 propylene glycol 10 10 10 10 methyl paraben 0.03 0.03 0.03 0.03 0.03 propyl paraben 0.02 0.02 0.02 0.02 0.02 hpmc 1 3 pvp 1 water qs 100 100 100 100 100 evaluation prepared suppositories were visually inspected. randomly selected suppositories were cut longitudinally and the surfaces were examined with naked eye. for determination of weight uniformity, twenty suppositories were weighed individually and the average weights were determined16. no suppositories should deviate from average weight by more than 5% except two, which may deviate by not more than 7.5%. the drug content for agar suppositories was determined by soaking individual suppository in water for 30 min, broken with spatula, vortexed for 5 min, filtered, diluted to 50 ml with distilled water, and then tramadol hydrochloride was estimated by shimadzu uv/visible spectrophotometer at 271 nm. the hardness of the prepared suppositories was tested using monsanto hardness tester. hardness test or breaking strength test was carried to determine the tensile strength of the suppositories to access whether they will be able to withstand the hazards of packing and transporting17. usp tablet disintegration apparatus was employed to measure the melting range of suppositories18. the time taken for the entire suppositories to melt/disperse was measured when immersed in water bath maintained at constant temperature of 37±0.50c. for in vitro dissolution studies an electrolab usp xxiii dissolution apparatus was used19. the dissolution medium was 900 ml of distilled water, maintained at 37±0.50c. the suppository was placed in the metal basket and maintained at 50 rpm. ten millilitres of sample was withdrawn at different intervals of time (10, 20, 30, 45, 60, 90, 120, 180, 240 min) and absorbance was measured at 271 nm. results and discussions the melting point of tramadol hydrochloride (pure drug) was found to be 180-183°c. tramadol hydrochloride was freely soluble in water, methanol and ethanol, soluble in chloroform and pbs 6.8. identification of tramadol hydrochloride was done by ftir spectroscopy with respect to marker compound. it was identified from the result of ir spectrum as per specification figure 1. the calibration curve of tramadol dangi et al asian journal of dental and health sciences. 2022; 2(3):19-22 [21] ajdhs.com hydrochloride was found to be linear in the concentration range of 2.5-17.5 µg/ml at 271nm figure 2. all the suppositories were free from pits, fissures and cracks. the longitudinal section of the suppositories was plain and clear. the results of different evaluation parameters are shown in table 2. the weight variation study for all the suppositories were found to be within the acceptable range of <5%, which indicates that calibration of mold was perfect. all the prepared suppositories showed uniformity in drug content and were within the permissible range (97% to 105%) indicating uniformity of drug dispersion in suppositories. the suppositories should have good mechanical strength for handling and transportation. all the suppositories were having good mechanical strength in the range of 1.50 to 2.00 kg/cm² showing optimum hardness. dissolution study of agar-based suppositories indicated that the suppository does not disintegrate, melt or dissolve in the dissolution medium but remains intact. the drug diffuses out from the hydrophilic matrix with time. it was observed that more than 50% of the drug was released from a0 formulation within 60 min. addition of 10% w/w propylene glycol accelerates the release of tramadol hydrochloride significantly (p<0.05) as in a1, which may be due to decrease in the gel matrix of agar. in formulation a2, a3 addition of hpmc (1%, 3% w/w) and in formulation a3, a4 addition of pvp (1%, 3% w/w) retards the release significantly (p<0.05), which may be due to increase in the viscosity and gel strength of the polymer matrix. hence, pvp, hpmc and similar polymers in higher concentration can be used to formulate sustained released suppositories table 3. figure 1: ft-ir spectrum of pure drug (tramadol hydrochloride) figure 2: wavelength maxima of tramadol hydrochloride in pbs 6.8 table 2: evaluation of suppositories for various parameters formulation code drug content* (%) weight variation ±sd (g) hardness* (kg/cm2) a0 97.55 1.008±0.04 1.50 a1 97.00 0.997±0.04 2.00 a2 98.10 0.998±0.03 2.00 a3 101.30 1.001±0.01 2.00 a4 105.00 1.002±0.02 2.00 dangi et al asian journal of dental and health sciences. 2022; 2(3):19-22 [22] ajdhs.com table 3: in vitro release of tramadol hydrochloride from suppositories time (min) % drug release a0 a1 a2 a3 a4 40 30 60 45 20 50 80 40 72 55 30 59 120 50 78 60 35 62 160 60 80 65 40 65 200 65 82 70 45 68 240 70 85 75 55 70 conclusion in conclusion, tramadol hydrochloride suppositories prepared using bases showed a rapid and almost complete release of the drug from their bases. rectal administration of tramadol in addition to oral and intravenous administration may be an alternative route for the treatment of pain. references 1. goodman do. pharmacokinetics: disposition and metabolism of drugs. in: munson pl, muller ra, breese gr. editors. principles of pharmacology, 1st ed. new york: chapman and hall; 2001. p. 47. 2. sanyal p, roy g. preparation and evaluation of suppositories of paracetamol. east pharma 2001; 49:95-7. 3. nair l, bhargava hn. comparison of in vitro dissolution and permeation of fluconazole from different suppository bases. drug develop ind pharm1999; 25:691-4. https://doi.org/10.1081/ddc-100102227 4. akala eo, adedoyn a, ogunbona fa. suppository formulations of amodiaquine: in vitro release characteristics. drug develop ind pharm 1991; 17:303-7. https://doi.org/10.3109/03639049109043827 5. kamlinder ks, deshpande sg, baichwal mr. studies on suppository bases: design and evaluation of sodium cmc and agar bases. indian drugs 1994; 31:149-54. 6. jayaprakash s, jawahar n, dhachina md, ramkanth s, mohamed anzar a, nagarajan m. design and evaluation of timed release matrix suppositories of indomethacin. pharm rev 2006; 4:100-2. 7. dayer p, collart l, desmeules j. the pharmacology of tramadol. drugs. 1994; 47(suppl):3-7. https://doi.org/10.2165/00003495199400471-00003 8. grond s, sablotzki a. clinical pharmacology of tramadol. clin pharmacokinet. 2004; 43:879-923. https://doi.org/10.2165/00003088-200443130-00004 9. micromedex healthcare series: document 2007. tramadol. available from: http://www.thomsonhc.com/ hcs/librarian/nd_pr/main/sbk/3/pfpui/7z16hw4. 10. petrone d, kamin m, olson w. slowing the titration rate of tramadol hcl reduces the incidence of discontinuation due to nausea and/ or vomiting: a double-blind randomized trial. j clin pharm ther. 1999; 24:115-23. https://doi.org/10.1046/j.13652710.1999.00203.x 11. mercadante s, arcuri e, fusco f, tirelli w, villari p, bussolino c, campa t, de conno f, ripamonti c. randomized double-blind, double-dummy crossover clinical trial of oral tramadol versus rectal tramadol administration in opioid-native cancer patients with pain. support care cancer. 2005; 13:702-7. https://doi.org/10.1007/s00520-004-0760-9 12. allen lv jr. compounding suppositories. part i: theoretical considerations. int j pharm compound. 2000; 4:289-93. 13. patel an, rai jp, jain dk, banweer ji. formulation, development and evaluation of cefaclor extended release matrix tablet. int j pharm pharm sci. 2012; 4(4):355-7. 14. jain p, nair s, jain n, jain dk, jain s. formulation and evaluation of solid dispersion of lomefloxacin hydrochloride. int j res pharm sci 2012; 3(4):604-608. 15. block lh. medicated topicals. in: gennaro ar. editors. remington: the science and practice of pharmacy. 21st ed. vol. 2. noida: lippincott williams and wilkins; 2005. p. 885-6. 16. british pharmacopoieal convention. british pharmacopoeia. vol. 2. london: h.m stationery offi ce; 1993. 17. coben lj, liberman ha. suppositories. in: lachman l, liberman ha, kanig jl, editors. theory and practice of industrial pharmacy. 3rd ed. mumbai: varghese publishing house; 1989. p. 580. 18. senthil kumaran k, thiruganasambantham p, viswanathan s, shree rammurthy m. development and evaluation of andrographolide (from andrographis paniculata) rectal suppositories. indian drugs 2002; 39:648-51. 19. hammouda ye, kasim na, nada ah. formulation and in vitro evaluation of verapamil hcl suppositories. int j pharm 1993; 89:111-117. https://doi.org/10.1016/0378-5173(93)90111-r https://doi.org/10.1081/ddc-100102227 https://doi.org/10.3109/03639049109043827 https://doi.org/10.2165/00003495-199400471-00003 https://doi.org/10.2165/00003495-199400471-00003 https://doi.org/10.2165/00003088-200443130-00004 https://doi.org/10.1046/j.1365-2710.1999.00203.x https://doi.org/10.1046/j.1365-2710.1999.00203.x https://doi.org/10.1007/s00520-004-0760-9 https://doi.org/10.1016/0378-5173(93)90111-r ahmed et al asian journal of dental and health sciences. 2022; 2(4):72-76 [72] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited physical assessment and formulation development of dome matrix controlled release tablet of diclofenac sodium sher ahmed*, ghulam mustafa shahwani, abdul gaffar, muhammad arsalan faculty of pharmacy, university of balochistan, quetta, pakistan article info: _______________________________________ article history: received 11 dec 2022 reviewed 26 jan 2023 accepted 07 feb 2023 published 25 feb 2023 _______________________________________ cite this article as: ahmed s, shahwani gm, gaffar a, arsalan m, physical assessment and formulation development of dome matrix controlled release tablet of diclofenac sodium, asian journal of dental and health sciences. 2022; 2(4):72-76 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.36 _______________________________________ *address for correspondence: sher ahmed, faculty of pharmacy, university of balochistan, quetta, pakistan abstract ___________________________________________________________________________________________________________________ in the last fifteen years where have significant acceleration in drug delivery research. in the early days of controlled release, development of pharmaceutical formulations was more idealized, with emphasis on the attainment of the illusive “zero-order release behavior”. when analyzing the swelling and release behavior of the dome matrix systems, it was demonstrated that the swelling behavior of the curved surfaces of the matrices strongly affected the drug release kinetics. the controlled release dome matrix tablets containing diclofenac sodium were prepared using a wet granulation process and polymers used xanthan gum, hpmc and eudragit. two different formulations were prepared; in first formulation the ratio was kept 60% active ingredient and 40% polymers subsequently in 2nd formulation 55% active ingredient 45% polymers. precompression test angle of repose, hausner’s ratio, bulk density, tapped density, car’s index were checked according to the specified standard procedure. all physical characteristics of dome tablets were analyzed. drug release pattern was also analyzed by using usp apparatus ii paddle method. the hardness, weight fluctuation, thickness, friability, drug content homogeneity, and in-vitro dissolution investigations of the manufactured controlled release tablets. all were examined and found within acceptable range. the f1 and f2 formulations performed well in tests and had a continuous drug release. the findings of this study showed that a polymer could be successfully used to formulate diclofenac sodium dome matrix tablets. the drug release was extended for 8 to 12 hours in all formulations using a drug to polymer ratio of 60:40, 55:45. the formulations are proved to have efficient drug release time. keywords: diclofenac sodium, dome matrix, eudragit, control release, xanthan gum. introduction in the last fifteen years there has been a significant acceleration in drug delivery research. in the early days of controlled release, development of pharmaceutical formulations was more idealized, with emphasis on the attainment of the illusive “zero-order release behavior”. recently, research has returned to a more realistic approach for solution of pharmaceutical application problems. thus, development of new pharmaceutical formulations is based on classical pharmaceutical technology (e.g., tablets, capsules, powders, fda approved excipients), appropriately designed for the achievement of prolonged release (typically up to 24 h) with controlled, but not necessarily constant release rates 1. formulations which might be capable of manipulate the discharge of drug have turn out to be a fundamental part of the pharmaceutical enterprise. mainly oral drug delivery has been the point of interest of pharmaceutical research for many years. this kind of drug shipping has been on the center of research due to its many benefits over conventional dosage. the focal point of this assessment is on matrix capsules because of their broadly use and ease of the system2. modified or controlled release oral drug shipping structures have, over the last few a long time, been shown to offer advantages over conventional structures 3. those consist of improved patient compliance 4, selective pharmacological motion; decreased aspect-impact profile and decreased dosing frequency 5. these structures might also therefore have a notably useful results in healing efficacy. managed release offers prolonged transport of medication and upkeep of plasma degrees inside a healing variety6. drug delivery has become an integral feature of novel therapeutic formulations. drug delivery systems (dds) allow the release of the necessary drug amount to the correct site and with the desirable kinetics. most oral drug delivery systems on the market are swell able or swelling matrices, i.e., monolithic systems triggered by the process of water transport in the polymer and the associated drug transport outwards. swell able matrices respond in the presence of water or biological fluids by changing dimensions and volume by water uptake, allowing the drug to diffuse out of the dosage form. the main component of the swell able matrix is a hydrophilic polymer, initially in its glassy state. when this matrix is in contact with the biological fluid, swelling occurs due to an abrupt change from a glassy to a rubbery state. the person polymer chains, at the start in the unperturbed country, soak up water so that their stop-to-give up distance and radius of gyration expand inside the new solvated nation. that is because of the decreasing of the everyday glass transition temperature of the polymer, determined by means of the swelling agent feature attention and depending on temperature and thermodynamic interactions of the polymer/solvent system 7. when analyzing the swelling and release behavior of the dome matrix systems, it was demonstrated that the swelling behavior of the curved surfaces of the matrices strongly open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.36 ahmed et al asian journal of dental and health sciences. 2022; 2(4):72-76 [73] ajdhs.com affected the drug release kinetics. indeed, the drug release from the convex base is faster and more linear than from the concave base. for further microscopic and molecular analysis, it is desirable to measure the dynamics of swelling evolution and, in particular, the front movement of this curved geometry that cannot be examined with the optical techniques previously used with the flat base matrix 8. material and methods equipment’s uv/vi’s spectrophotometer, tableting machine, hplc, dissolution apparatus, vernier caliper, disintegration apparatus, friabilator, hardness tester, usp 26 apparatus, hydroxypropyl methylcellulose (premium methocel k100m), ultrasound equipment, eudragit s 100, xanthan gum, mg state and acetone pre-formulation studies standard diclofenac sodium graph the standard curve of diclofenac sodium were drawn according to the standard procedure by using 100 mg of diclofenac sodium in 100 ml solvent (ph 6.7). this solution was further kept for 30 minutes complete dissolution and different dilutions made as per standard procedures. precompression. the pre-formulation studies will be conducted according to standard method as prescribed which comprised of angle of repose, hausner’s ratio, bulk density, tapped density, carr’s index according to the specified standard procedure procedure formulation development the active ingredient was kneaded in a motor and pestle and after kneaded this powder was pored through science no 125 and then mixed with polymers and ingredient. two different formulations were prepared, in first formulation the ratio was kept 60% active ingredient and 40% polymers subsequently in 2nd formulation 55% active ingredient 45% polymers. all the ingredients were mixed thoroughly for 15 minutes than with the help of tableting machine magnesium striate in acetone was used to lubricate the punches of the tableting machine to keep them from sticking.. the punches were shaped differently in four different shapes that was cylindrically flat base matrices, the second cylindrical matrix has a flat base, the third one has a convex base, and the fourth matrix has a concave base. physical characteristics of dome tablet weight variation test weight variation for tablets have been randomly selected and weighed individually with the help of an analytical stability. the average weights were determined and the proportion deviations from imply values had been calculated. the proportion weight version for each tablet was anticipated in keeping with the following formulation: % weight variation = (common weight-individual weight) / character weight × 100 surface area measurement surface area of the dome tablets were performed according to the specification of all formulation. drug release parameter by using usp apparatus ii paddle method. the rotation will be kept 75rpm and the temperature will be kept 75% and the medium will be filled upto 900ml. the samples will be collected accordingly to the different time intervals. mathematical interpretation for evaluation of the percentage release of dissolution compared with the standard were calculated by statistical formula. a= a.b.ceq. 1 fraction release = . a/a.b.c eq. ii hardness test hardness test was determined by using “monsanto” type hardness tester. the mean crushing strengths (hardness values) were determined. friability test for friability test, drugs were randomly selected, weighed and located into the friabilator chamber set at 25 rpm for 1 minute. the capsules had been weighed once more and the variations in weight have been calculated as the percentage friability. dissolution dissolution studies were performed according to usp monographs or standards. the basket rotation was kept 100/ rounds per minute and temperature maintained accordingly at 37 ± 0.1 0c. than the sample (5ml) were collected at time intervals specified, after that the samples were be examined by the help of uvvisible spectrophotometer. results standard diclofenac sodium graph the standard graph of diclofenac sodium (table 1) displays strong linearity, with r2 values of 0.1856 and 0. 0.1968 in 0.2 nhcl (fig. 1) and ph 6.7 buffer (fig. 2), under a maximum of 295 nm, demonstrating that it abides by lambert's "beer-law." table 1: standard diclofenac sodium graph conc. (mcg/ml) absorbance at 295nm 0.1 nhcl 6.7 ph buffer 5. 0.149 0.145 10. 0.218 0.238 15. 0.328 0.362 20. 0.438 0.443 25. 0.412 0.555 30. 0.505 0.661 35. 0.618 0.779 40. 0.760 0.848 45. 0.732 0.944 50. 1.309 1.021 r 2 0.1856 0.1968 ahmed et al asian journal of dental and health sciences. 2022; 2(4):72-76 [74] ajdhs.com 1.2 1 0.8 0.6 0.4 0.2 0 0 10 20 30 40 50 60 concentration(mcg/ml) figure 1: diclofenac sodium standard graph in 0.1 nhcl 1.2 1 0.8 0.6 0.4 0.2 0 0 10 20 30 40 50 60 concentration(mcg/ml) figure 2. diclofenac sodium standard graph in 6.7 ph buffer granule characterization the carr's index, bulk density, tapped density, drug content, and attitude of repose were used to characterise the matrix pill granules. angle of repose decreased to less than 35 degrees, and carr's index values for all batches of granules were less than 21, suggesting genuine flow ability and compressibility. for all of the batches, hausner's ratio was substantially lower than 1.25, indicating proper flow homes. in excess of 90% of all the granules of various formulations' medication content. y = 0.0199x + 0.0285 r 2 = of 0.1856 a b so rb a n c e a b so rb a n c e y = 0.0198x + 0.0493 r 2 = 0.1968 ahmed et al asian journal of dental and health sciences. 2022; 2(4):72-76 [75] ajdhs.com table 3: physical properties of precompression blend: formulations angle of repose (° ) bulk density (g/ml) tapped density (g/ml) carr’s index (%) hausner’s ratio f1 26.70 0.311 0.231 13.94 1.16 f2 27.34 0.305 0.410 14.43 1.17 5.4 matrix tablet physical evaluation: table four provides the effects of the matrix tablets' consistency of weight, hardness, thickness, friability, and medication content. due to the fact their weights various among 119.nine and 120.5 mg, all the capsules from unique batches met the legitimate requirements for weight uniformity. the matrix drugs' hardness numerous from 5.50 to 5. forty-five kg/cm, and their friability become much less than zero.38 percentage, displaying that they had been compact and difficult. the medicinal drugs' thickness ranged from three.22 to a few.37 mm. all the formulations met the medication's content material requirements, containing 95 to 99 percentage diclofenac sodium and precise drug homogeneity. cloth becomes discovered. as a result, all the bodily attributes of the organized capsules were located be nearly inside control. table 4: physical matrix tablets' evaluation f.code hardness (kg/cm2) † thickness (mm) ‡ weight (mg) ‡ friability (%) drug content * (%) f1 5.49 ±0.54 3.56±0.18 126.9±1.44 0.37 95.89±1.39 f2 5.45±0.41 3.07±1.27 131.5±0.52 0.38 99.76±0.79 all of the values cited in above desk taken mean ± well-known deviation (sd), n=three † all the values noted in above table taken mean ± general deviation (sd), n=6 ‡ all the values stated in above table taken suggest ± popular deviation (sd), n=20 0 5 10 15 20 25 30 angle of repose ( ° )bulk density (g/ml) tapped density (g/ml) carr’s index (%) hausner’s ratio physical properties of precompression blend f1 f2 0 20 40 60 80 100 120 140 hardness (kg/cm2) thickness (mm) weight (mg) friability (%) drug content(%) physical evaluation of matrix tablets f1 f2 ahmed et al asian journal of dental and health sciences. 2022; 2(4):72-76 [76] ajdhs.com theoretical release profile and dose calculations the dose that was calculated early than the necessary full dose for two times-day by day maintain release system of diclofenac sodium changed into found to be a 100 mg as well as its theoretical release profile is stated in table2. table 2: theoretical release profile of diclofenac sodium from sr tablets time (hours) cumulative % release 1 25.15 2 32.18 3 39.99 4 45.98 6 61.01 8 73.90 10 87.19 12 > 90 discussion one of the most cuttingedge sectors of controlled drug deliver y is oral medicine distribution such dosage forms offer a considerable benefit in terms of patient adherence at least a twofold reduction in dosing frequency is achieved with the extended release dosage form. when compared to the medicine delivered in an immediaterel ease (conventional) dose form. diclofenac sodium is an analgesic and anti-inflammatory medication. it is primarily utilized in the treatment of surgical inflammation and acute painit is a member of the class of painkillers known as nonsteroidal anti-inflammatory medicines (nsaids). inflammation is frequently treated with it, discomfort, acute gout, and ankylosing spondylitis, particularly in low back pain. for this reason, a therapeutic concentration of 100mg/day is required. the therapeutic dose must be maintained for at least 24 hours. because typical doses release the full medication in a matter of minutes therapeutic levels are only sustained for a brief period of time. requiring the administration of a second dose as a result, a diclofenac sodium sustained release formulation that releases the medicine over a 22-hour period is advantageous. the goal of this research is to develop and test diclofenac sodium extended-release dome matrix tablets. to improve the release, polymers such as 48 mg xanthan gum and 54 mg eudragit s100 were used to make the controlled release matrix tablet. conclusion the goal of this study was to prepare diclofenac sodiumcontrolled release dome matrix tablet formulation that would keep therapeutic levels of the drug constant for more than 12 hours. these types of formulation would be safer and continuous release which ultimately benefits the community in response to diseases. the controlled release dome matrix tablets containing diclofenac sodium are made using a wet granulation process and various grades of polymers xanthan gum, hpmc and eudragit. diclofenac sodium is an analgesic remedy. as a result, an attempt become made to hold the therapeutic awareness regular for an extended time. this was achieved with the aid of growing a drug shipping machine with a regulated launch. these managed launch dome matrix tablets had been in most cases designed to launch the drug for an extended time, i.e., 12 hours, and to absolutely launch the drug at the same time as fending off excessive dosage periodicity. the hardness, weight fluctuation, thickness, friability, drug content homogeneity, and in-vitro dissolution investigations of both formulations were within the acceptable range and the released rates were near 90% in 12 hours. the findings of this study showed that a polymer could be successfully used to formulate diclofenac sodium control release dome matrix tablets. the drug release mechanism of these formulations were checked and compared with other formulations, it was found that all these formulations were extended for 8 to 12 hours with different drug to polymer ratio of 60:40, 55:45. the formulations are proved to increased release time. as a result, it can be stated that diclofenac sodium in the form of a once-daily controlled release matrix tablet has a reasonable extended-release profile, suggesting that it may improve therapeutic efficacy. the drawbacks and restrictions of extended-release medications are overcome and removed by the new formulation. references 1. dimasi, j.a., et al., trends in risks associated with new drug development: success rates for investigational drugs. clinical pharmacology & therapeutics, 2010; 87(3):272-277. https://doi.org/10.1038/clpt.2009.295 2. powell, w.w., learning from collaboration: knowledge and networks in the biotechnology and pharmaceutical industries. california management review, 1998; 40(3):228-240. https://doi.org/10.2307/41165952 3. singh, b.n. and k.h. kim, floating drug delivery systems: an approach to oral controlled drug delivery via gastric retention. journal of controlled release, 2000; 63(3):235-259. https://doi.org/10.1016/s0168-3659(99)00204-7 4. rosenstock, i.m., understanding and enhancing patient compliance with diabetic regimens. diabetes care, 1985; 8(6):610-616. https://doi.org/10.2337/diacare.8.6.610 5. group, d.u.a., paroxetine: a selective serotonin reuptake inhibitor showing better tolerance, but weaker antidepressant effect than clomipramine in a controlled multicenter study. journal of affective disorders, 1990; 18(4):289-299. https://doi.org/10.1016/0165-0327(90)90081-i 6. kumari, a., s.k. yadav, and s.c. yadav, biodegradable polymeric nanoparticles based drug delivery systems. colloids and surfaces b: biointerfaces, 2010; 75(1):1-18. https://doi.org/10.1016/j.colsurfb.2009.09.001 7. colombo, p., et al., swellable matrices for controlled drug delivery: gel-layer behaviour, mechanisms and optimal performance. pharmaceutical science & technology today, 2000; 3(6):198-204. https://doi.org/10.1016/s1461-5347(00)00269-8 8. dahlberg, c., et al., polymer swelling, drug mobilization and drug recrystallization in hydrating solid dispersion tablets studied by multinuclear nmr microimaging and spectroscopy. molecular pharmaceutics, 2011; 8(4):1247-1256. https://doi.org/10.1021/mp200051e 0 20 40 60 80 100 1 2 3 4 5 6 7 8 c u m m u la ti ve % r el ea se time (hour) diclofenac sodium theoretical release profile from sr tablets https://doi.org/10.1038/clpt.2009.295 https://doi.org/10.2307/41165952 https://doi.org/10.1016/s0168-3659(99)00204-7 https://doi.org/10.2337/diacare.8.6.610 https://doi.org/10.1016/0165-0327(90)90081-i https://doi.org/10.1016/j.colsurfb.2009.09.001 https://doi.org/10.1016/s1461-5347(00)00269-8 https://doi.org/10.1021/mp200051e maurya et al asian journal of dental and health sciences. 2021; 1(1):14-18 [14] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2021 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a review on role of herbal antioxidants in periodontitis sheo datta maurya1, divya jain2, omji porwal3, ram chand dhakar4, r. jayakumararaj5 1 principal, sarvodaya college of pharmacy, azamgarh, india 2 srg hospital & medical college jhalawar, rajasthan, india 3 professor, department of pharmacognosy, faculty of pharmacy, tishk international university-erbil, kurdistan region, iraq 4 hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001 5 pg department of botany, government arts college, melur – 625106, madurai district, tn, india article info: _________________________________________ article history: received 07 november 2021 reviewed 14 december 2021 accepted 20 december 2022 published 25 december 2021 _________________________________________ cite this article as: maurya sd, jain d, porwal o, dhakar rc, jayakumararaj r, a review on role of herbal antioxidants in periodontitis, asian journal of dental and health sciences. 2021; 1(1):14-18 doi: http://dx.doi.org/10.22270/ajdhs.v1i1.1 abstract ___________________________________________________________________________________________________________________ periodontal disease or periodontitis is one of the common public health problems in the world and is most common reason of tooth loss in peoples. periodontitis is highly prevalent and can affect up to 90% of the world population. periodontitis is a gum infection that damages the soft tissues and bones present around tooth for support. herbs and their extracts have long been used as a therapy for various diseases in the world due to their safety & low cost. currently herbal medicines are preferred due to their low cost, high safety margin and wider range of medicinal activities. presence of excess free radicals results in oxidative damage of periodontal tissue. herbal antioxidant reduces the deleterious action of free radicals and improves the oral health and decrease of inflammatory levels of periodontium. thus, in this review we described the role of some herbal antioxidants as adjuvants for the management and treatment of periodontitis. keywords: periodontitis, herbal antioxidants, free radicals, periodontium *address for correspondence: dr. sheo datta maurya, principal, sarvodaya college of pharmacy, azamgarh, india email: meetshiv23@gmail.com introduction herbs and their extracts have long been used as a therapy for various diseases in the world due to their safety & low cost. currently herbal medicines are preferred due to their low cost, high safety margin and wider range of medicinal activities. periodontal disease or periodontitis is one of the common public health problems in the world and is most common reason of tooth loss in peoples. periodontitis is highly prevalent and can affect up to 90% of the world population. periodontitis is a gum infection that damages the soft tissues and bones present around tooth for support. the etiology is multifactorial with periodontopathogens forming a major crux in the initiation and progression of the disease. plaque build-up allows the growth of anaerobic bacteria 1 which eventually leads to the recruitment and activation of neutrophils. this further results in the upregulation of pro-inflammatory cytokines and also leads to the release of neutrophilic enzymes and ros. prolonged exposure of the connective tissue to these insults results in the degradation and subsequent loss of ligamentous support and alveolar bone, eventually leading to tooth loss. 2 presence of excess free radicals results in oxidative damage of periodontal tissue3. herbal antioxidant reduces the deleterious action of free radicals and improves the oral health and decrease of inflammatory levels of periodontium4. numerous studies have shown that the total antioxidant capacity in periodontitis patients is significantly lower when compared to healthy controls. 4, 5 thus, in this review we described the role of oxidative stress in periodontitis & role of herbal antioxidants as adjuvants for the management and treatment of periodontitis. role of oxidative stress in periodontitis it is well-established that oxidative stress is an important cause of cell damage associated with the initiation and progression of many chronic diseases 6-8. the results of the work carried out by ivan borges jr. et al showed an important correlation between oxidative stress biomarkers and periodontal disease9. open access review article doi: http://dx.doi.org/10.22270/ajdhs.v1i1.1 http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v1i1.1 mailto:meetshiv23@gmail.com maurya et al asian journal of dental and health sciences. 2021; 1(1):14-18 [15] ajdhs.com the exact mechanism of periodontitis development, including the prior agents or mediators involved, is not clear. periodontitis manifests itself as a multifactor phenomenon, including the generation of reactive oxygen species (ros) 9, 10. when periodontitis occurs, reactive oxygen species (ros), which are overproduced mostly by hyperactive neutrophils, could not be balanced by antioxidant defence system and cause tissues damage. this is characterized by increased metabolites of lipid peroxidation, dna damage and protein damage. local and systemic activities of antioxidants can also be influenced by periodontitis 11. the strong evidence linking reactive oxygen species to the pathological damages the soft tissues during periodontal disease rests on the presence of neutrophils infiltration as the main event in the host’s response to bacterial invasion 9, 12,13,14. furthermore, hydroxyl radical (•oh) is most active in damaging important molecules such as dna proteins and lipids, while hydrogen peroxide (h2o2), even not being considered a potent ros, is capable of crossing the nuclear membrane and also damaging the dna 15. quantitatively, the main source of superoxide anion (o2•−) and other ros responsible for initiation reactions is the respiratory chain. however, its presence in the periodontal soft tissue results first and foremost from the activation of phagocytes (neutrophils and macrophages), such as antibacterial agents 12, 13, 16. herbs used in periodontitis psidium guajava (guava) guava is a potential antioxidant owing to it is rich source of ascorbic acid. guava also has quercetin, polyphenols and carotenoids, which increase its antioxidant action and reduces the deleterious action of free radicals and improves the oral health and decrease of inflammatory levels of periodontium. 17, 18, 19 guava leaf extracts and essential oil from the stem have the ability to scavenge hydrogen peroxide, superoxide anion and inhibit the formation of hydroxyl radical 20, 21. the seed of guava contains glycosides, carotenoids, phenolic compounds having antimicrobial actions.22 results from study of h manohar sharma concluded that improvements in clinical and microbiological parameters showed that adjunctive use of locally delivered 3% p. guajava gel is effective in the management of chronic periodontitis. 23 figure 1: fresh fruits of psidium guajava (guava) study by varghese et al showed that guava mouth rinse fulfilled the requirement for an effective and useful oral care product with desirable substantivity and antibiofilm action. in addition, guava reduced the inflammation response in hgek-16 and may be a potential oral rinse for oral anti-inflammatory therapies. 24 rubia cordifolia (indian madder) r. cordifolia contain mollugin which has shown antiinflammatory action 25 results from study of baek et al showed that mollugin inhibited rankl-induced osteoclast differentiation and bone resorbing activity of mature osteoclasts. mollugin reduced the phosphorylation of signaling pathways activated in the early stages of osteoclast differentiation, including the mapk, apt, and gsk3β and inhibited the different genes associated with osteoclastogenesis such as osteoclastassociated receptor, tartrate resistant acid phosphatase, icam-1, cathepsin k, dc-stamp and oc-stamp. furthermore mice treated with mollugin showed significant restoration of lipopolysaccharideinduced bone loss as indicated by micro-computed tomography and histological analysis of femurs. 17, 26 results from study of mali et al concluded that arimedadi oil is equally effective to chlorhexidine gluconate as an adjunct to mechanical plaque control in prevention of plaque accumulation and gingivitis. arimedadi oil could be an effective and safe alternative to 2% chlorhexidine gluconate mouthwash due to its prophylactic and therapeutic benefits.27 figure 2: rubia cordifolia (indian madder) triphala triphala is an excellent herbal antioxidant that consists of powder of three fruits emblica officinalis, terminalia chebula and terminalia bellirica. ascorbic acid & polyphenolic contents in triphala are responsible for the antioxidant and radioprotective ability and reduce the oxidative stress by converting reactive oxygen free radicals to non-reactive products.28 t. chebula extract also has anticaries activity because it inhibits the growth and accumulation of s. mutans on the tooth surface. https://www.planetayurveda.com/library/manjistha-rubia-cordifolia/ maurya et al asian journal of dental and health sciences. 2021; 1(1):14-18 [16] ajdhs.com table 1: botanical description of triphala fruit 1 fruit 2 fruit 3 common name amla, amalaki black myrobalan, haritaki, harada belliric myrobalan, bibhitaki, bahera botanical name emblica officinalis terminalia chebula terminalia bellirica family phyllanthaceae combretaceae combretaceae chemical constituents ascorbic acid , gallic acid, and flavones ascorbic acid , gallic acid and tannic acid ascorbic acid, gallic acid, tannic acid, syringic acid and epicatechin figure 3: composition of triphala study by bajaj and tandon shown a significant progressive decrease in plaque scores from baseline till the end of 9 months in both triphala and chlorhexidine groups, whereas increase in plaque scores in negative control group. 29 results from study by desai et al. shown a significant reduction in periodontal indices in chlorhexidine and triphala groups who received scaling and root planing along with mouthwashes compared to a control group that received only scaling and root planing.30 pratibha mamgain et al carried out the comparative study of triphala and chlorhexidine in treatment of gingivitis. results from this study shows that triphala and ela decoction has similar efficacy as that of chlorhexidine in reducing dental biofilm buildup, gingivitis, and halitosis. it is easy to prepare, organic, and relatively economical compared with chlorhexidine. hence it can be used for effective plaque control, gingivitis control, and halitosis31 azadirachta indica (neem) azadirachta indica, commonly referred to as the neem plant. brushing with neem stick after every meal and chewing a neem leaves is recommended treatment for preventing gingivitis. it has shown several pharmacological action such as and anti-oxidant, antifungal antipyretic, antibacterial, antiinflammatory, antiviral, anticariogenic, antihelminthic, analgesic and anti-carcinogenic. several studies have shown that neem is used in the treatment of dental caries, gingivitis and periodontitis.32, 33, 34 regular brushing with neem-containing toothpaste will reduce the deposition of plaque, prevents caries, and enhances the immune response for overall oral health. frequent usage of mouthwash containing neem extract will lessen gingival problems, and also treats halitosis. 33 vennila et al used 10% neem oil as a local drug delivery system to evaluate the efficacy in the periodontal disease management. this study reported that clinical parameters showed statistically improved on the neem chip sites and presence of p. gingivalis strains were significantly reduced on the neem chip sites. hence, 10% neem oil local delivery system delivers desired effects on p. gingivalis. 32 botelho et al., in their experiments and trials concluded that azadirachta indica is highly efficacious in the treatment of periodontal disease thus exhibiting its biocompatibility with human periodontal fibroblast.33 based on the observations of singh et al, it can be concluded that chlorhexidine gluconate as well as neem gel can be effectively used as an adjunct to mechanical plaque control in prevention of plaque and gingivitis.34 conclusion presence of excess free radicals results in oxidative damage of periodontal tissue3. herbal antioxidants are preferred because they reduce the deleterious action of free radicals and improve the oral health and decrease of inflammatory levels of periodontium4. it is wellestablished that oxidative stress is an important cause of cell damage associated with the initiation and progression of many chronic diseases. 6, 7, 8 many scientific papers reported different application of herbal antioxidants in dentistry in the future; it would be of great interest to conduct clinical trials that would confirm the beneficial effect. many herbal drugs found suitable for the treatment of periodontal disease but further pharmacological studies are needed to find out and understand the possible toxic effects of herbal drugs in order to improve their biocompatibility. hence https://journals.sagepub.com/action/dosearch?target=default&contribauthorstored=mamgain%2c+pratibha maurya et al asian journal of dental and health sciences. 2021; 1(1):14-18 [17] ajdhs.com we can find out safe and effective herbs for the treatment of periodontal disease. conflicts of interest: the authors declare that there are no conflicts of interest in this paper. financial support and sponsorship: nil references 1. listgarten ma. pathogenesis of periodontitis. j clin periodontol 1986; 13:418-30. https://doi.org/10.1111/j.1600051x.1986.tb01485.x 2. laine ml, crielaard w, loos bg. genetic susceptibility to periodontitis. periodontol 2000 2012; 58:37-68 https://doi.org/10.1111/j.1600-0757.2011.00415.x 3. tóthová l, celec p, "oxidative stress and antioxidants in the diagnosis and therapy of periodontitis," frontiers in physiology, vol. 8, 2017. https://doi.org/10.3389/fphys.2017.01055 4. barbosa kbf, costa nmb, ralfenas rcg, de paula so, minim vpr, bressan j, "estresse oxidativo: conceito, implicações e fatores modulatórios," revista de nutrição, 2010; 23(4):629-643. https://doi.org/10.1590/s1415-52732010000400013 5. chapple il, mason gi, garner i, matthews jb, thorpe gh, maxwell sr, et al. enhanced chemiluminescent assay for measuring the total antioxidant capacity of serum, saliva and crevicular fluid. ann clin biochem 1997; 34:412-21 https://doi.org/10.1177/000456329703400413 6. matthews at, ross mk. oxyradical stress, endocannabinoids, and atherosclerosis. toxics 2015; 3:481-498. https://doi.org/10.3390/toxics3040481 7. fischer bm, voynow ja, ghio aj. copd: balancing oxidants and antioxidants. int j chron obstruct pulmon dis 2015; 10:261-76. https://doi.org/10.2147/copd.s42414 8. d'aiuto f, nibali l, parkar m, patel k, suvan j, donos n. oxidative stress, systemic inflammation, and severe periodontitis. j dent res 2010; 89:1241-6 https://doi.org/10.1177/0022034510375830 9. borges jr. i, moreira eam, filho dw, oliveira tbd, silva mbsd, frode ts, proinflammatory and oxidative stress markers in patients with periodontal disease. mediators of inflammation 2007; 1-5 article id 45794, https://doi.org/10.1155/2007/45794 10. waddington rj, moseley r, embery g, "reactive oxygen species: a potential role in the pathogenesis of periodontal diseases," oral diseases, 2000; 6(3):138-151. https://doi.org/10.1111/j.16010825.2000.tb00325.x 11. wang y, andrukhov o, rausch-fan x, oxidative stress and antioxidant system in periodontitis, front physiol. 2017; 8:910. https://doi.org/10.3389/fphys.2017.00910 12. kantarci a, oyaizu k, van dyke te, "neutrophil-mediated tissue injury in periodontal disease pathogenesis: findings from localized aggressive periodontitis," journal of periodontology, 2003; 74(1):66-75. https://doi.org/10.1902/jop.2003.74.1.66 13. katsuragi h, ohtake m, kurasawa i, saito k, "intracellular production and extracellular release of oxygen radicals by pmns and oxidative stress on pmns during phagocytosis of periodontopathic bacteria," odontology, 2003; 91(1):13-18. https://doi.org/10.1007/s10266-003-0022-1 14. a a io g u u, aliyev e, eren z s i s e g, keskiner i, yavuz u, "reactive oxygen species scavenging activity during periodontal mucoperiosteal healing: an experimental study in dogs," archives of oral biology, 2005; 50(12):1040-1046,. https://doi.org/10.1016/j.archoralbio.2005.03.012 15. takane m, suganon, iwasaki iwano hy, shimizu n, ito k, "new biomarker evidence of oxidative dna damage in whole saliva from clinically healthy and periodontally diseased individuals," journal of periodontology, 2002; 73(5):551554,. https://doi.org/10.1902/jop.2002.73.5.551 16. halliwell h, gutteridge jmc, "free radicals, other reactive species and disease," in free radicals in biology and medicine, pp. 617783, clarendon press, oxford, uk, 1998 17. ramesh a, varghese ss, jayakumar nd, malaiappan s, journal of intercultural ethnopharmacology, 2016 18. qian h, nihorimbere v. antioxidant power of phytochemicals from psidium guajava leaf. j zhejiang univ sci 2004; 5:676-83. https://doi.org/10.1631/jzus.2004.0676 19. dakappa ss, adhikari r, timilsina ss, sunita s. a review on the medicinal plant psidium guajava linn. (myrtaceae). j drug deliv ther 2013; 3:162-8. https://doi.org/10.22270/jddt.v3i2.404 20. ogunlana oe, ogunlana oo. in vitro assessment of the free radical scavenging activity of psidium guajava. res j agric biol sci 2008; 4:666-71. 21. chen hy, yeh gc. antioxidant activity and free radical-scavenging capacity of extracts from guava (psidium guajava l.) leaves. food chem 2007; 101:686-94. https://doi.org/10.1016/j.foodchem.2006.02.047 22. barbalho sm, farinazzi-machado fm, de alvares goulart r, brunnati ac, ottoboni am. psidium guajava (guava): a plant of multipurpose medicinal plants. med aromat plants. 2012; 1:104. 23. sharma hm, deepika pc, venkatesh mp, chandan s, shashikumar p, efficacy of 3% psidium guajava local drug delivery in the treatment of chronic periodontitis: a randomized controlled trial, 2021; 13(1):17-23 https://doi.org/10.4103/jioh.jioh_249_20 24. varghese j, ramenzoni ll, shenoy p, nayak uy, nayak n, attin t, schmidlin pr, in vitro evaluation of substantivity, staining potential, and biofilm reduction of guava leaf extract mouth rinse in combination with its anti-inflammatory effect on human gingival epithelial keratinocytes, materials 2019, 12, 3903; https://doi.org/10.3390/ma12233903 25. zhu zg, jin h, yu pj, tian yx, zhang jj, wu sg. mollugin inhibits the inflammatory response in lipopolysaccharide-stimulated raw264.7 macrophages by blocking the janus kinase-signal transducers and activators of transcription signaling pathway. biol pharm bull 2013; 36:399-406 https://doi.org/10.1248/bpb.b12-00804 26. baek jm, kim jy, jung y, moon sh, choi mk, kim sh, et al. mollugin from rubea cordifolia suppresses receptor activator of nuclear factorκb igand-induced osteoclastogenesis and bone resorbing activity in vitro and prevents lipopolysaccharide-induced bone loss in vivo. phytomedicine 2015; 22:27-35 https://doi.org/10.1016/j.phymed.2014.10.008 27. mali gv, dodamani as, karibasappa gn, vishwakarma p, jain vm, comparative evaluation of arimedadi oil with 0.2% chlorhexidine gluconate in prevention of plaque and gingivitis: a randomized clinical trial, j clin diagn res. 2016; 10(7):zc31-zc34. pmcid: pmc5020187 pmid: 27630949 https://doi.org/10.7860/jcdr/2016/19120.8132 28. deswal h, singh y, grover hs, bhardwaj a, verma s. curative effect of triphala in medical and dental sciences: a scientific review. innovare journal of health sciences. 2016; 4(2):1-4. 29. bajaj n, tandon s. the effect of triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. int j ayurveda res 2011; 2:29-36. https://doi.org/10.4103/0974-7788.83188 30. desai a, anil m, debnath s. a clinical trial to evaluate the effects of triphala as a mouthwash in comparison with chlorhexidine in chronic generalized periodontitis patient. indian j dent adv 2010; 2:243-7. 31. mamgain p, kandwal a, mamgain rk, comparative evaluation of triphala and ela decoction with 0.2% chlorhexidine as mouthwash in the treatment of plaque-induced gingivitis and halitosis: a randomized controlled clinical trial, journal of evidence-based complementary & alternative medicine. 2017; 22(3):468-472 https://doi.org/10.1177/2156587216679532 https://doi.org/10.1111/j.1600-051x.1986.tb01485.x https://doi.org/10.1111/j.1600-051x.1986.tb01485.x https://doi.org/10.1111/j.1600-0757.2011.00415.x https://doi.org/10.3389/fphys.2017.01055 https://doi.org/10.1590/s1415-52732010000400013 https://doi.org/10.1177/000456329703400413 https://doi.org/10.3390/toxics3040481 https://doi.org/10.2147/copd.s42414 https://doi.org/10.1177/0022034510375830 https://doi.org/10.1155/2007/45794 https://doi.org/10.1111/j.1601-0825.2000.tb00325.x https://doi.org/10.1111/j.1601-0825.2000.tb00325.x https://doi.org/10.3389/fphys.2017.00910 https://doi.org/10.1902/jop.2003.74.1.66 https://doi.org/10.1007/s10266-003-0022-1 https://doi.org/10.1016/j.archoralbio.2005.03.012 https://doi.org/10.1902/jop.2002.73.5.551 https://doi.org/10.1631/jzus.2004.0676 https://doi.org/10.22270/jddt.v3i2.404 https://doi.org/10.1016/j.foodchem.2006.02.047 https://doi.org/10.4103/jioh.jioh_249_20 https://doi.org/10.3390/ma12233903 https://doi.org/10.1248/bpb.b12-00804 https://doi.org/10.1016/j.phymed.2014.10.008 https://doi.org/10.7860/jcdr/2016/19120.8132 https://doi.org/10.4103/0974-7788.83188 https://doi.org/10.1177/2156587216679532 maurya et al asian journal of dental and health sciences. 2021; 1(1):14-18 [18] ajdhs.com 32. vennila k, elanchezhiyan s, ilavarasu s. efficacy of 10% whole azadirachta indica (neem) chip as an adjunct to scaling and root planning in chronic periodontitis: a clinical and microbiological study. indian j dent res. 2016; 27(1):15-21. https://doi.org/10.4103/0970-9290.179808 33. botelho ma, santos ra, martins jg, carvalho co, paz mc, azenha c, et al. efficacy of a mouthrinse based on leaves of the neem tree (azadirachta indica) in the treatment of patients with chronic gingivitis: a doubleblind, randomized, controlled trial. j med plant res. 2008; 2:341-6 34. vibha singh1, anjani kumar pathak2, kopal goel3, mahesh pal, evaluation of topical application of azadirachta indica (neem) in prevention of gingivitis: a randomized control trial, open journal of stomatology, 2019; 9(11):249-259 https://doi.org/10.4236/ojst.2019.911026 https://doi.org/10.4103/0970-9290.179808 https://doi.org/10.4236/ojst.2019.911026 dhakar et al asian journal of dental and health sciences. 2021; 1(1):19-23 [19] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2021 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited antioxidant potential of cordia dichotoma: a review ram chand dhakar1*, sunil kumar prajapati1*, sheo datta maurya3, vijay kumar tilak4, manas kumar das5, soumya das6, krishan kumar verma7*, nilesh jain 8 1 hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001 2 professor, institute of pharmacy, bundelkhand university, jhansi, india 3 principal, sarvodaya college of pharmacy, azamgarh, india 4 apex professional university, pasighat, arunachal pradesh-791102, india 5 director, orlean collge of pharmacy, 42-knowledge park-3, greater noida, u.p., india-201308 6 associate professor, niet (pharmacy institute), 19-knowledge park-2, greater noida, u.p., india-201308 7 professor, lloyd school of pharmacy, plot no 3, knowledge park-1, greater noida, u.p., india-201308 8 sagar institute of research technology & science-pharmacy, bhopal, india. article info: _________________________________________ article history: received 08 nov 2021 reviewed 18 dec 2021 accepted 21 dec 2021 published 25 dec 2021 _________________________________________ cite this article as: dhakar rc, prajapati sk, maurya sd, tilak vk, das mk, das s, verma kk, jain n, antioxidant potential of cordia dichotoma: a review, asian journal of dental and health sciences. 2021; 1(1):19-23 doi: http://dx.doi.org/10.22270/ajdhs.v1i1.6 abstract ___________________________________________________________________________________________________________________ many plants of genus cordia comprise of trees and shrubs are widely distributed in warmer regions and have been utilized in management of various diseases. many phytochemicals like flavonoids, alkaloids, terpenes, tannins, and glyceridess having different activities were screened and isolated from different parts of c. dichotoma. various important pharmacological properties including antiulcer, contraceptives, anti-inflammatory, anthelmintic, analgesic, anticancer, antioxidant, antimicrobial, hepatoprotective, antidiabetic and others have been well documented for this plant. c. dichotoma is a promising source of natural antioxidants which possess remarkable therapeutic action as inflammatory activity. in the present review, we have briefly reviewed the antioxidant potential of c. dichotoma that can be followed for future research on this plant for health benefits. keywords: cordia dichotoma, antioxidant, anti-inflammatory, flavonoids *address for correspondence: ram chand dhakar, hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001 introduction management of diseases with agents devoid of any side effects is still a big challenge to the researchers. there is increasing interest in natural medicine due to these reasons. plant species of the genus cordia are utilized for the treatment of various illnesses that affect many human systems. c. dichotoma is a tree of tropical and subtropical regions, commonly known as lasura in hindi and shleshmataka in sanskrit. various phytoconstituents like flavonoids, triterpenes, tannins, alkaloids and fatty acids possessing different bioactivities were isolated from different plant parts of c. dichotoma. many researchers reported various pharmacological applications of c. dichotoma such as anti-ulcer1, contraceptives2, anti-inflammatory3, 4, 5, 6 anthelmintic, analgesic, anticancer4,7, 8, antioxdant8,9, antimicrobial10, antifungal10, hepatoprotective11 and diuretic purposes and for treating digestive system, respiratory, urogenital, cardiac, vascular and blood disorders. c. dichotoma is a promising source of natural antioxidants which possess remarkable therapeutic action as inflammatory activity and may serve as food ingredients12, 13, 14, 15. thus objectives of the present review are to provide an overview of the uses of c. dichotoma as herbal antioxidant. open access review article doi: http://dx.doi.org/10.22270/ajdhs.v1i1.6 http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v1i1.6 dhakar et al asian journal of dental and health sciences. 2021; 1(1):19-23 [20] ajdhs.com figure 1: various parts of cordia dichotoma plant3 classification: kingdom: plantae; division: magnoliophyta; class: dicotyledons; subclass: astaridae; order: lamiales; family: boraginaceae; genus: cordia; species: c. dichotoma forst. distribution: c. dichotoma is a tree that found in tropical and subtropical regions. it grows in the sub-himalayan tract and outer ranges, ascending up to about 1500 m elevation. it is found in different types of forests ranging from the moist deciduous forests of the western ghats and tidal forests in mayanmar to the dry deciduous forest of rajasthan. in maharashtra, it grows in the moist monsoon forest also4. botanical description: c. dichotoma family boraginaceae is a small to moderate size deciduous tree with a short bole, short crooked trunk and spreading crown. the stem bark is grayish brown in color, longitudinally wrinkled or smooth. leaves are simple, entire and slightly dentate, ellipticallanceolate to broad ovate with the round and cordate base. these flowers are 25mm long, dull pinkish edible fruits with sticky flesh flowers are short-stalked, bisexual and white in color, appear in loose corymbose cymes.12 the fruit is a yellow or greenish-yellow shining globose or ovoid drupe seated in a saucer-like enlarged calyx (fig. 1). it turns black on ripening and the pulp gets viscid. the hard stone is 1-4 seeded. c. dichotoma as herbal antioxidant: free radicals are responsible for many diseases like arthritis, cancer, diabetes mellitus, aging, etc. herbal antioxidants have gained great importance in recent years as they are utilizing in the management of such diseases due to their ability to neutralize free radicals. as plants are the source of natural antioxidants, much attention has been gain to plants. currently, there has been an increased interest globally to identify antioxidant compound that has potent bioactivities and has low or no side effects. 17 oxidative stress is defined as an imbalance between the production of free radicals and the ability of the organism to counteract or detoxify their harmful effects through neutralization by antioxidants. as free radicals are very reactive species, their overproduction during oxidative stress can cause damage to all biological macromolecules, such as dna, proteins and lipids, thus leading to cell damage and subsequently, to the manifestation of pathological conditions as cardiovascular diseases, diabetes and inflammatory diseases 18. antioxidants are secondary molecules or metabolites that act as ros scavenger and activator of cellular antioxidative enzymes to prevent the damages induced by ros in biological system. hence, naturally occurring antioxidants from plant polyphenols are getting more attention in terms of practical usage as safe and potent bioactive compounds19. antioxidant activity of this plant may be attributed to presence of phenols, flavones, isoflavones, flavonoids, xanthones, alkaloids, anthraquinones, phytosterols, steroids, amino acids, anthocyanins, isothiocyanate dhakar et al asian journal of dental and health sciences. 2021; 1(1):19-23 [21] ajdhs.com indoles, coumarins lignans, catechins, and isocatechins etc20, 21, 22. many in vitro and in vivo studies on antioxidant activity of c. dichotoma are available in literature5,6,9,12,20,23,24. quercetin from c. dichotoma is a phytochemical with high antioxidant activity that has been shown to maintain blood pressure levels and thus improve cardiovascular function. quercetin can inhibit platelet aggregation, increase nitric oxide activity and improve endothelial function.20, 23 sharma et al studied the role of free radical scavenging activity of c. dichotoma seeds and leaves extract in degenerative disorders16. author state that these models demonstrate positive antioxidant activity in a concentration dependant manner and demonstrate that highest concentration exhibits highest (100 μg/ml) antioxidant activity. result concluded that antioxidant activity was more pronounced in leaves as compared to seeds. singh et al. were carried out a comparative study of methanolic extract of seeds and leaves of c. dichotoma for free radical scavenging potential in the management of degenerative disorders. antioxidant activity was more pronounce in methanolic extract of leaves as compared to seeds6. nariya et al evaluated the phenolic contents and antioxidant potential of methanolic and butanol extract of c. dichotoma bark. in the present study three in vitro models were used to evaluate antioxidant activity. the first two methods employed direct measurement of radical scavenging activity and in remaining one method evaluated the reducing power. c. dichotoma showed strong antioxidant activity by inhibiting dpph activity and reducing power activities when compared with standard l–ascorbic acid. in addition, both the extracts were found to contain a noticeable amount of total phenols, which play a key role in controlling oxidation. the results present study show that the extract can be used as an easily available source of herbal antioxidant. the chemicals present in the bark such as alkaloids, terpenoids, reducing sugars, flavonoids, proteins, steroids, and tannins may be responsible for such activity9. shuge et al carried out a study aiming to determine the phytochemical composition and antioxidant activity of air-dried c. dichotoma seeds. the results from this study indicate that c. dichotoma seeds are a rich source of polyphenolic compounds and amino acids, which can be used for quality assessment. results revealed that ethanolic extract of c. dichotoma seeds has good antioxidant capacity23. mahasweta et al examinated the antioxidant potential of c. dichotoma seeds. hentricontanol fraction (htf), hesperetin fraction (hf) and taxifolin fraction (tf) from the seeds of c. dichotoma showed promising dpph free radical scavenging activity at a concentration of 100 μg/ml5. table 1: reported work on antioxidant potential of cordia dichotoma s.n. source objective outcome ref 1 sharma et al 2007 to study the role of free radical scavenging activity of c. dichotoma seeds and leaves extract author state that these models demonstrate positive antioxidant activity in a concentration dependent manner. result concluded that antioxidant activity was more pronounced in leaves as compared to seeds 16 2 singh et al. 2010 to compared the methanolic extract of seeds and leaves of c. dichotoma for free radical scavenging potential both the extracts showed significant activity but antioxidant activity was more pronounce in methanolic extract of leaves as compared to seeds thus it can be used in the management of degenerative disorders 6 3 nariya et al 2011 phenolic contents were screened from methanolic and butanol extract of c. dichotoma bark to evaluate its antioxidant potential both extract showed strong antioxidant activity by inhibiting dpph activity and reducing power activities when compared with standard l–ascorbic acid. both the extracts were also found to contain a noticeable amount of total phenols, which play a key role in controlling oxidation. thus extracts can be used as an easily available source of herbal antioxidant. 10 4 rahman et al 2017 to evaluate anticancer activity of the methanolic extract of cordia dichotoma leaves (mecd) against a human prostate carcinoma cell line, pc3. results of this study confirm that mecd possesses antioxidant property due to presence of flavonoids in mecd and may be responsible for anti-cancer activity due to dual antioxidant and pro-oxidant properties. 25 5 ibrahim et al 2019 to investigate the chemical composition, antioxidant and the cdfpe showed a powerful effect in scavenging superoxide radicals and chelating metals ions as well 26 dhakar et al asian journal of dental and health sciences. 2021; 1(1):19-23 [22] ajdhs.com anti-tumor effects of c. dichotoma fruit pulp extract (cdfpe) as high reduction capability. results concluded that anti-tumor activity of cdfpe may be attributed due to phenols, flavonoids, tannins and glucouronic acid contents that are documented as an antioxidant, antiinflammatory, and antitumor agents. 6 hussain et al 2020 to stidy the antiinflammatory activity of c. dichotoma bark extract. the antioxidant activity was evaluated using dpph radical scavenging assay. in in vitro antioxidant activity, the methanolic extract of c. dichotoma exhibited good dpph radical scavenging activity. results of this study suggested that the antiinflammatory activity of c. dichotoma may be due to the presence of phenolic contents or plant flavonoids in the bark extract. 27 7 hussain et al 2020 to evaluate the antitumor and antioxidant activities of the methanol extract of cordia dichotoma (mecd) against ehrlich ascites carcinoma (eac) in swiss albino mice results of study concluded that the antitumor activity of mecd can be inferred from the increased life span of eac bearing mice which is due to its antioxidant activity 28 8 usmani et al 2021 to assessed the antioxidant activity of methanolic extract and different fractions of the seeds of cordia dichotoma maximum scavenging activity was exhibited by the methanolic extract with a low ic50 value. presence of phenolic compounds and flavonoids, which may be acting as the key factors responsible for the antioxidant activity. 29 9 swapna et al 2021 agnps of cordia dichotoma extract was fabricated to analyze their potential applications as antioxidant and biocidal agents phytomediated eco-friendly synthesized and structurally characterized agnps can act as antioxidants and exhibited antibacterial activity against gram-positive (staphylococcus aureus) and gram-negative (escherichia coli) pathogenic bacteria. 4 conclusion and future prospective over the past three decades, much scientific information has been accumulated regarding phytochemicals and pharmacology of c. dichotoma. however, this information has not been collectively discussed together, which is very important in understanding the therapeutic utility of this plant. various compounds like flavonoids, triterpenes, tannins, alkaloids and fatty acids possessing different bioactivities were isolated from different parts of this plant. the various pharmacological studies carried out with extracts of different parts indicates that the c. dichotoma possess analgesic, anti-inflammatory, antimicrobial, antiviral, wound healing, antidiabetic and antifertility activities. antioxidant activity was mainly attributed to the presence of flavonoids and phenolic compounds, which was confirmed by the ic50 data correlation in various reported work. due to the very long tradition using c. dichotoma for management of various diseases and also because of what is known today about its chemical constituents and biological activities, it seems to be worth the effort of exploring this plant further and such information may be used for further research work related to c. dichotoma and other traditional systems of medicine. financial support and sponsorship nil conflict of interest there are no conflicts of interest references 1. ganjare ab, nirmal sa, patil an. use of apigenin from cordia dichotoma in the treatment of colitis. fitoterapia 2011; 82:10521056. https://doi.org/10.1016/j.fitote.2011.06.008 2. bhattacharya p, saha a. evaluation of reversible contraceptive potential of cordia dichotoma leaves extract. rev. bras. farmacogn. 2013; 23:342-350. https://doi.org/10.1590/s0102695x2013005000020 3. jamkhande pg, barde sr, patwekar sl, tidke ps. plant profile, phytochemistry and pharmacology of cordia dichotoma (indian cherry): a review, asian pac j trop biomed 2013; 3:1009-1012. https://doi.org/10.1016/s2221-1691(13)60194-x 4. swapna g, rao bk. green synthesis and characterization of silver nanoparticles from stem bark extract of cordia dichotoma g. forst and evaluation of their antioxidant and antibacterial activities. pharmacognosy research. 2021; 13(3):158-164 https://doi.org/10.5530/pres.13.3.8 5. mahasweta r, kumar b, kumar n, patel a, kumar b. antioxidant activity of taxifolin obtained from methanolic extracts of c. dichotoma linn. seeds. int j pharm sci res 2014; 5:2896-2901. https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/flavonoid https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/tannin https://doi.org/10.1016/j.fitote.2011.06.008 https://doi.org/10.1590/s0102-695x2013005000020 https://doi.org/10.1590/s0102-695x2013005000020 https://doi.org/10.1016/s2221-1691(13)60194-x https://doi.org/10.5530/pres.13.3.8 dhakar et al asian journal of dental and health sciences. 2021; 1(1):19-23 [23] ajdhs.com 6. singh r, lawania rd, mishra a, gupta r. role of cordia dichotoma seeds and leaves extract in degenerative disorders. int. j pharm sci rev res 2010; 2:21-24 7. awad ab, chinnman m, fink cs, bradford pg. beta-sitosterol activates fas signaling in human breast cancer cells. phytomed 2007; 14:747-754. https://doi.org/10.1016/j.phymed.2007.01.003 8. consolacion yr, virgilio ej, mariquit mdlr, emelina hm, maria cst, robert b, et al. chemical constituents of cordia dichotoma g. forst., journal of applied pharmaceutical science 2015; 5 suppl 2:016-021 9. pankaj b. nariya, nayan r. bhalodia, vinay j. shukla, rabinarayan acharya, mukesh b. nariya, in vitro evaluation of antioxidant activity of cordia dichotoma (forst f.) bark, ayu 2013; 34:124128 https://doi.org/10.4103/0974-8520.115451 10. nariya pb, bhalodia nr, shukla vj, acharya rn. antimicrobial and antifungal activities of cordia dichotoma (forester f.) bark extracts. ayu 2011; 32:585-589. https://doi.org/10.4103/09748520.96138 11. thirupathi k, kumar ss, raju vs, ravikumar b, krishna dr, mohan gk. a review of medicinal plants of the genus cordia: their chemistry and pharmacological uses. j nat rem 2008; 8:1-10. 12. hussain n, kakoti bb, review on ethnobotany and phytopharmacology of cordia dichotoma journal of drug delivery and therapeutics 2013; 3(1):110-113 https://doi.org/10.22270/jddt.v3i1.386 13. prajapati sk, kar m, maurya sd, pandey r, dhakar rc, exploring phytochemicals and pharmacological uses of cordia dichotoma (indian cherry): a review, journal of drug delivery and therapeutics. 2017; 7(6):125-131 https://doi.org/10.22270/jddt.v7i6.1438 14. bouaziz a, djidel s, bentaher a, khennouf s, polyphenolic content, antioxidant and anti-inflammatory activities of melon (cucumis melo l. var. inodorus) seeds, journal of drug delivery and therapeutics. 2020; 10(2-s):22-26 https://doi.org/10.22270/jddt.v10i2-s.4022 15. laouicha s, senator a , kherbache a, bouriche h, total phenolic contents and antioxidant properties of algerian arbutus unedo l. extracts, journal of drug delivery and therapeutics. 2020; 10(3s):159-168 https://doi.org/10.22270/jddt.v10i3-s.4182 16. sharma a, bhardwaj s, mann as, jain a, kharya md. screening methods of antoxidant activity: an overview, phcog rev 2007; 2:232-238. 17. behera s, babu sm, ramani yr, choudhury pk, panigrahi r. phytochemical investigation and study on antioxidant properties of ocimum canum hydro-alcoholic leaf extracts, journal of drug delivery and therapeutics 2012; 2:122-128 https://doi.org/10.22270/jddt.v2i4.198 18. goutzourelas n , stagos d , spanidis y , liosi m , apostolou a , priftis a , haroutounian s, spandidos da , tsatsakis am, kouretas d, polyphenolic composition of grape stem extracts affects antioxidant activity in endothelial and muscle cell, molecular medicine reports, 2015; 12: 5846-5856. https://doi.org/10.3892/mmr.2015.4216 19. rahman mm, hossain ms , mostofa m g, ali khan m, ali r, mosaddik a, sadik m g, khurshid alam a , evaluation of anti-ros and anticancer properties of tabebuia pallida l. leave. clinical phytoscience, 2019; 5:17, 1389. https://doi.org/10.1186/s40816019-0111-5 20. ghosh r, deb p. a study on antioxidant properties of different bioactive compounds, journal of drug delivery and therapeutics 2014; 4:105-115 https://doi.org/10.22270/jddt.v4i2.772 21. killedar s, more h, mali s, nadaf s, salunkhe s, karade r. phytochemical screening and in vitro antioxidant potential of memecylon umbellatum burm leaf extracts, journal of drug delivery & therapeutics 2014; 4:30-35 https://doi.org/10.22270/jddt.v4i2.788 22. kaur c, kapoor hc. anti-oxidant activity and total phenolics content of some asian vegetables, int j food sci technol 2002; 37:153-61. https://doi.org/10.1046/j.1365-2621.2002.00552.x 23. shuge t, feng l, zhang x, upur h. phytochemical composition and antioxidant capacity of cordia dichotoma seeds, pak. j. pharm. sci 2014; 27:1123-1129 24. wang y, kazuhiro o, ryoji k, kazuo y. nat. medicines 1996; 50:367. 25. rhman ma, sahabjada, akhtar j, evaluation of anticancer activity of cordia dichotoma leaves against a human prostate carcinoma cell line, pc3, j tradit complement med. 2017; 7(3):315-321. pmcid: pmc5506664 pmid: 28725626 https://doi.org/10.1016/j.jtcme.2016.11.002 26. ibrahim ay, el-newary sa, ibrahim ge, antioxidant, cytotoxicity and anti-tumor activity of cordia dichotoma fruits accompanied with its volatile and sugar composition, annals of agricultural sciences, 2019; 64(1):29-37 https://doi.org/10.1016/j.aoas.2019.05.008 27. hussain n, kakoti bb, rudrapal m, rahman z, rahman m, chutia d, sarwa k. k. anti-inflammatory and antioxidant activities of cordia dichotoma forst,, biomed pharmacol j 2020; 13(4):20932099 https://doi.org/10.13005/bpj/2090 28. hussain n, kakoti bb, rudrapal m, junej ja, laskar ma, lal m, sarwa kk, anticancer and antioxidant activities of, cordia dichotoma forst, international journal of green pharmacy, 2020; 14(3):265-273. 29. usmani s, hussain a, wahab s, kushwaha p, khatoon s, arif m, prakash o, kama m, antioxidant potential of crude extract, flavonoid-rich fractions, and a new compound from the seeds of cordia dichotoma, indian journal of natural products and resources, 2021; 12(3):437-444 https://doi.org/10.1016/j.phymed.2007.01.003 https://doi.org/10.4103/0974-8520.115451 https://doi.org/10.4103/0974-8520.96138 https://doi.org/10.4103/0974-8520.96138 https://doi.org/10.22270/jddt.v3i1.386 https://doi.org/10.22270/jddt.v7i6.1438 https://doi.org/10.22270/jddt.v10i2-s.4022 https://doi.org/10.22270/jddt.v10i3-s.4182 https://doi.org/10.22270/jddt.v2i4.198 https://doi.org/10.3892/mmr.2015.4216 https://doi.org/10.1186/s40816-019-0111-5 https://doi.org/10.1186/s40816-019-0111-5 https://doi.org/10.22270/jddt.v4i2.772 https://doi.org/10.22270/jddt.v4i2.788 https://doi.org/10.1046/j.1365-2621.2002.00552.x https://doi.org/10.1016/j.jtcme.2016.11.002 https://doi.org/10.1016/j.aoas.2019.05.008 https://doi.org/10.13005/bpj/2090 yulita et al asian journal of dental and health sciences. 2022; 2(4):69-71 [69] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited significant caries (sic) index and distribution of regional origins for members of formed police unit (fpu) xi ita yulita1, tedi purnama1*, nurul hidayah2 1 department of dental health, poltekkes kemenkes jakarta i, jakarta, indonesia 2 dental nursing, lkok pusdokkes polri, jakarta, indonesia article info: _______________________________________ article history: received 06 oct 2022 reviewed 19 nov 2022 accepted 03 dec 2022 published 15 dec 2022 _______________________________________ cite this article as: yulita i, purnama t, hidayah n, significant caries (sic) index and distribution of regional origins for members of formed police unit (fpu) xi, asian journal of dental and health sciences. 2022; 2(4):69-71 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.31 _______________________________________ *address for correspondence: tedi purnama, department of dental health, poltekkes kemenkes jakarta i, indonesia abstract ___________________________________________________________________________________________________________________ indonesia's geographical conditions are very diverse. oral disease which is the most common global health problem is caries. an indicator of caries experience which includes decay, missing, filled criteria is dmf, the easiest and most frequently used method for epidemiological surveys of dental caries. to identify the subset of the population with high and very high dmf-t scores and to find individuals who are still susceptible to caries, the significant caries (sic) index is used as a complement to the average dmf-t value. this study aims to determine the description of the significant caries (sic) index and the distribution of regional origins of members of the formed police unit (fpu) in lkok pusdokkes polri jakarta by the year 2020. this research is descriptive study with a total sampling method of selecting samples. a the dmf-t score was 1157 with a mean dmf-t of 6.4 (high criteria), and sic index of 11.4 (very high criteria). respondents from the western region of indonesia had a dmf-t score of 465 and sic index of 11.34 (very high criteria). the dmf-t score for respondents from central region of indonesia was 155 and sic index 11.9 (very high criteria). respondents from eastern region of indonesia had dmf-t score of 76 and sic index 10.85 with (very high criteria). it can be concluded that respondents have dmf-t scores in the high criteria and sic index with very high criteria. based on the regions of origin of the respondents, sic score index in all three regions are of origin is included in the very high criteria with respondents from the central region of indonesia having the highest sic index compared to the other 2 regions. keywords: significant caries (sic) index, regions of origin of fpu xi member introduction diseases in the oral cavity have become a global health problem, everyone must have experienced poor oral health in their life. the disease most often found in the oral cavity is caries. most of dental caries that occurs in developing countries is not treated.1,2 in indonesia, the incidence of caries is increasing from year to year, even in the top ten major diseases.3 although efforts to prevent this disease have been promoted, they have not shown tangible results. the results of the 2018 basic health research stated that the largest proportion of dental problems in indonesia was damaged teeth/dental caries (45,3%), while the proportion of the population who received treatment by dental health personnel to solve dental problems was 10,2%.4 most people do not realize the importance of taking care of oral and dental health. the public's ignorance has resulted in decreased productivity due to the effects of pain that is felt. this is due to decreased dental support tissue. this dental caries later becomes a source of infection which can lead to several systemic diseases.5–7 the economic impact of dental caries is the weakening of community productivity. if children experience dental caries, then the child's development will be hampered so that it can reduce the level of intelligence of the child, which in the long term will have an impact on the quality of life of the community.5,8 according to who, the diagnosis of caries experience that meets the criteria for decay, missing, filled (dmf index) is the easiest and most frequently used method for epidemiological surveys of dental caries, because they can measure the health status of the oral cavity.9,10 although a decrease in the prevalence of dental caries has been observed in several countries, there is also a random distribution of dental caries in children within the age range of 12 years. in fact, some individuals aged 12 years have high and very high dmf-t scores while other individuals low or caries-free dmft rates.11,12 therefore, to identify the subset of the population with high and very high dmf-t rates, and to identify individuals who are still susceptible to caries, a new index called the significant caries (sic) index was introduced by brathall to be used as a attention to individuals who have a high caries value in each population. the value was obtained from the mean dmf-t scores in one third of the population with the highest caries score. this index is used as a complement to the mean dmf-t value.11,13 this study aims to determine the description of the significant caries (sic) index and the distribution regional origin of members of the formed police unit (fpu) xi in lkok pusdokkes polri jakarta method and material the method used is descriptive method. descriptive method is a research method conducted to describe a situation objectively. the form of implementation of descriptive research used is the type of survey. the population in this study were 182 members of the formed police unit (fpu) xi. from this number, 61 people (1/3 of the total population) with the highest dmf-t scores were determined to be used as research samples. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.31 yulita et al asian journal of dental and health sciences. 2022; 2(4):69-71 [70] ajdhs.com data collection was carried out at lkok pusdokkes polri jakarta on april to may 2020, the data was obtained from the medical records of members of the formed police unit (fpu) xi. to obtain the sic index, the steps taken are: 1) calculating the dmf-t score for each sample; 2) calculate the mean dmft; 3) determine the number of individuals included in 1/3 of the population with the highest dmf-t score; 4) summing the dmf-t scores; and 5) dividing the dmf-t score by the sample size of the 1/3 population. result this research was conducted in lkok pusdokkes polri jakarta in 2020 with targets members of the formed police unit (fpu) xi. the population in this study was the medical records of members of the formed police unit (fpu) xi with 182 respondents. the sampling technique used in this study was total sampling, which is a sampling technique in which the number of samples is the same as the population. the data used in this study are secondary data, obtained from the medical records of members of the formed police unit (fpu) xi by calculating the dmf-t score, grouping data with the same dmf-t score, calculating the mean dmf-t, determining the number of individuals who are included in 1/3 of the population takes the dmf-t data with the highest score, then divides it based on the value of 1/3 of the population so that the overall sic value is obtained. data collection was carried out on april to may 2020 at lkok pusdokkes polri jakarta. the data collection was carried out by researchers and assisted by an administrative officer of the lkok pusdokkes polri table 1: dmf-t scores on members of the police formed police unit (fpu) xi total (person) dmf-t mean dmf-t criteria 182 1157 6.4 high table 1 shows the dmf-t for members of the formed police unit (fpu) xi at lkok pusdokkes polri jakarta in 2020, from the total personnel of 182 people, the dmf-t score was 1157 with a mean dmf-t of 6.4 which was included in the high criteria. table 2: significant caries index (sic) for members of the formed police unit (fpu) xi total (person) dmf-t sic score criteria 61 694 11.4 very high table 2 shows the significant caries (sic) index for members of the formed police unit (fpu) xi at lkok pusdokkes polri jakarta in 2020. the number of respondents is 61 people which is 1/3 of the total population with the highest dmf-t score (1/3 x 182 people). the dmf-t score was 694 with a mean sic score of 11.4 which was included in the very high criteria. table 3: significant caries (sic) index of members of the formed police unit (fpu) xi based on region of origin region of origin total (person) dmf-t sic criteria western region of indonesia 41 465 11.34 very high central region of indonesia 13 155 11.9 very high eastern region of indonesia 7 76 10.85 very high total 61 696 table 3 shows that there were 41 respondents who came from the western region of indonesia with a dmf-t score of 465 and a sic score of 11.34 with very high criteria. respondents from the central region of indonesia are 13 people, have a dmf-t score of 155 and sic 11.9 with very high criteria, and respondents from the eastern region of indonesia have a dmf-t score of 76 and a sic of 10.85 with very high criteria. discussion from the results of the study, it can be seen that the total score of dmf-t in 182 members of the formed police unit (fpu) xi at lkok pusdokkes polri jakarta is 1157 with a mean dmf-t of 6.4 (high criteria). the results of this study are worse when compared to research conducted by jotlely et al (2017) which was conducted on papuan people aged 18-25 years, where the mean dmf-t score was 5.3 which was classified as a high criteria. however, when compared with the mean dmf-t results in the 2018 riskesdas national report according to job characteristics, the results of this study were better because in riskesdas 2018 the mean dmf-t score in the field of work of the national police (polri) is 7.7 (very high criteria).14 the significant caries index (sic) score of the formed police unit (fpu) xi at lkok pusdokkes polri jakarta is 11.4 with very high criteria. this result is worse when compared with the results of a study conducted by loyola et al. (2011 on adolescents and young adults in mexico aged 16-25 years. from loyola's research, it was found that the dmf-t score for the respondents was 4.04 and the prevalence of caries was 74.4%. based on caries severity, 48.8% of respondents had a dmft score > 3 and 24% of respondents had a dmft score > 6. the sic index is 8.64.15 the comparison of sic scores based on the regional origin of members of the formed police unit (fpu) xi at lkok pusdokkes polri jakarta showed that the mean sic score of respondents from the western region of indonesia is 11.4 with very high criteria, respondents from the central region of indonesia have a mean sic index of 11.9 with very high criteria, and respondents from the eastern region of indonesia have a mean sic score of 10.85 with very high criteria. from the calculation of the proportion of dental problems by province in the result of riskesdas 2018, it was found that the indonesian national figure for cavities is 45.3%, 19% of teeth lost due to extractions, and 4.1% of teeth had been filled due to cavities.4 these results are relevant to the results of this study where in the examination of the dmf-t index, the most commonly found be components are d (decay) compared to m (missing) and f (filling). from the comparison of data on respondents in the western, central and eastern regions of indonesia, both the dmf-t and sic scores indicate very high criteria. this shows that the location of the area does yulita et al asian journal of dental and health sciences. 2022; 2(4):69-71 [71] ajdhs.com not affect the level of tooth damage, but the dental health of individuals or communities is one of the factors that affect the health of these individuals or communities. to prevent the occurrence of dental caries and maintain good oral hygiene, a person needs to keep the teeth clean by regularly brushing his in the right way. correct brushing behavior refers to fdi word dental federation, which is the habit of brushing your teeth every day, at least twice a day, after breakfast and at night before going to bed. conclusion from the results of research conducted on members of the formed police unit (fpu) xi, it was concluded that: 1. the number of caries experience in respondents as measured by the dmf-t indicator shows a score with high criteria 2. from 1/3 of the population with the highest dmf-t score, the sic index was found to be in the very high criteria 3. if it based on the respondent's area of origin, the sic score was not too different in the three regions, each of which was included in the very high criteria. respondents from the central region of indonesia have the highest sic score compared to the other 2 regions. references 1. bratthall d. introducing the significant caries index together with a proposal for a new global oral health goal for 12‐year‐olds. int dent j. 2000; 50(6):378-84. https://doi.org/10.1111/j.1875595x.2000.tb00572.x 2. ramdiani d, yulita i, sasongko bg, purnama t. required treatment index (rti) pada pasien dewasa di klinik dokter gigi tjang riyanto cahyadi kota bogor. jdht j dent hyg ther. 2020; 1(2):5560. https://doi.org/10.36082/jdht.v1i2.128 3. campus g, solinas g, maidae c, castiglia p. the" significant caries index"(sic): a critical approach. 2003; 4. kemenkes ri. hasil utama riset k1. kemenkes ri. hasil utama riset kesehatan dasar tahun 2018. kementrian kesehat republik indones. 2018;1-100. esehatan dasar tahun 2018. kementrian kesehat republik indones. 2018; 1-100. 5. purnama t, fadjeri i, widiyastuti r. model mentoring teachers and parents as an efforts for brushing teeth behavior in preschool children. indian j forensic med toxicol. 2020; 14(4):3511-6. 6. achmad h, chandha mh, harun s, sudjarwo i, yunus m, rusdi rk, et al. prevalence of medically compromised children regarding dental caries and treatment needs in wahidin sudirohusodo hospital. j int dent med res. 2017; 10(3):915-20. 7. fadjeri i, budiarti r, purnama t. dental care interventions as efforts to reduce pufa index and improve nutritional status in children aged 9-12 years in orphanages. med leg updat. 2021; 21(1):366-71. 8. grytten j. payment systems and incentives in dentistry. community dent oral epidemiol. 2017; 45(1):1-11. https://doi.org/10.1111/cdoe.12267 9. mon a, maung kk, soe kk, aung st. study of dental caries status and oral health knowledge, attitude and practice (kap) among 15year-old schoolchildren in north okkalapa and tharyarwaddy townships. myanmar dent j. 2018;1. 10. steele j. the future for oral health surveillance. community dent oral epidemiol. 2012; 40:75-81. https://doi.org/10.1111/j.16000528.2012.00724.x 11. ditmyer m, dounis g, mobley c, schwarz e. inequalities of caries experience in nevada youth expressed by dmft index vs. significant caries index (sic) over time. bmc oral health. 2011; 11(1):1-10. https://doi.org/10.1186/1472-6831-11-12 12. an e-s, han j-h. the significant caries index of 12 years old in korean. j dent hyg sci. 2013; 13(1):91-6. 13. pudentiana rr, fadjeri i, priharti d, mariyati m. indeks dmf-t dan periodontitis pada pasien di klinik pertamedika yos sudarso jakarta utara. jdht j dent hyg ther. 2021; 2(1):6-11. https://doi.org/10.36082/jdht.v2i1.187 14. jotlely fb, wowor vns, gunawan pn. gambaran status karies berdasarkan indeks dmf-t dan indeks pufa pada orang papua di asrama cendrawasih kota manado. e-gigi. 2017; 5(2). https://doi.org/10.35790/eg.5.2.2017.17364 15. loyola-rodriguez jp, villa-chavez c, patiño-marin n, aradillasgarcia c, gonzalez c, de la cruz-mendoza e. association between caries, obesity and insulin resistance in mexican adolescents. j clin pediatr dent. 2011; 36(1):49-54. https://doi.org/10.17796/jcpd.36.1.e25411r576362262 https://doi.org/10.1111/j.1875-595x.2000.tb00572.x https://doi.org/10.1111/j.1875-595x.2000.tb00572.x https://doi.org/10.36082/jdht.v1i2.128 https://doi.org/10.1111/cdoe.12267 https://doi.org/10.1111/j.1600-0528.2012.00724.x https://doi.org/10.1111/j.1600-0528.2012.00724.x https://doi.org/10.1186/1472-6831-11-12 https://doi.org/10.36082/jdht.v2i1.187 https://doi.org/10.35790/eg.5.2.2017.17364 https://doi.org/10.17796/jcpd.36.1.e25411r576362262 viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [7] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district nankya viola1, esther kimono1, ndagire nuruh1 and *emmanuel ifeanyi obeagu2 1 school of nursing science, kampala international university, uganda 2 department of medical laboratory science, kampala international university, uganda article info: _______________________________________ article history: received 28 march 2022 reviewed 09 may 2023 accepted 27 may 2023 published 15 june 2023 _______________________________________ cite this article as: viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences. 2023; 3(2):7-14 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.39 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda email: emmanuelobeagu@yahoo.com abstract ___________________________________________________________________________________________________________________ in the absence of preventive measures hiv infected mothers transmit the infection to their babies during pregnancy delivery and breastfeeding. however, improving emtct service uptake and continuum of care still remains a significant impediment in the western region of uganda. the study was to explore factors hindering emtct service uptake among hiv positive women at comboni hospital kyamuhunga. a descriptive cross-section design was used and majorly simple random sampling was employed with a number of 36 respondents and interviewed response were analysed using spss version to determine the association between the independent and dependent variable. the findings of the study revealed that there are a range of factors that hinder hiv positive women on emtct service uptake, disclosure of hiv status with 77.7%, lack of partner and family support with 75%, dependence on partners with 80.6%, long waiting times at facility and no linkage to support groups with 33.3%and 47.2% respectively. in conclusion strengthening community awareness on the importance of emtct service uptake, improving on time management by health workers, engaging male involvement in emtct care, improve youth friendly services, empowering women, putting emphasis on disclosure of status and supporting young mothers is so crucial. keywords: elimination, mother to child transmission, hiv service uptake, hiv positive women introduction globally 90% of hiv infection in children is as result of mtct and this transmission occurs in 20-30% of hiv positive pregnant women during pregnancy, labour and breastfeeding 1. access to comprehensive hiv services reduces the risk of transmission to below 5% in communities that practice breastfeeding and to 2% in the communities that do not practice breastfeeding 2. poverty, lack of access to comprehensive hiv information and health care services, harmful cultural practices all contribute to new cases of mtct economically stable mothers are able to afford infant milk formulas and supplements’ in place of breast milk while poor mothers cannot, so poorer mothers are left with no option than to exclusively breastfeed their babies there by increasing the risk of hiv transmission through the breast milk and of which can lead to malnutrition if not breastfeed 3. sub-saharan africa the emtct service coverage remains <50% 1. increased vulnerability to hiv infection has been due to intimate partners violence, which is more common among young hiv positive mothers and those who are economically dependent on their male partners that is 10% in aged 15-20 years and 59% in older ones , women living with hiv experienced intimate partners violence were significantly less likely to start to adhere on art therapy and they had worse clinical outcomes than other hiv positive women 4-11. uganda hiv prevalence was associated with age and inversely associated with the level of education, the need for specific personnel for counselling, male partners involvement and availability of access for those who need treatment 12, pregnant adolescents faced a challenge of stigma, discrimination in health care settings. methodology study design and rationale the study adopted a descriptive cross-sectional design, it is descriptive because the researcher observed, described and documented aspect of situation, it is cross sectional because the study involved qualitative data collection at point of time. the rationale was to obtain detailed description of factors hindering emtct services. study area the study was conducted at comboni hospital found in western uganda. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.39 mailto:emmanuelobeagu@yahoo.com https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.39&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [8] ajdhs.com the study population the study targeted all hiv positive mothers attending emtct clinic at comboni hospital kyamuhunga during the month of data collection those willing to participate; mentally and physically capable. sample size determination the sample size was determined using formula developed by tora yamane in 1967 . which is stated as [ n= n/(1+ np2)]. where n sample size n study population p level of significance (0.05) [ n= n/(1+ np2)] n=40/(1+40*(0.05)2=40/1+0.1=40/1.1 n= 36 sampling procedure and rationale the study was carried out using probability sampling method particularly simple random sampling so as to reduce bias, the number of women present at the art clinic were enlisted, equal number of papers were assigned yes or no and folded then mixed in a box and each woman was given a chance to pick one. those who randomly picked yes were given papers to fill, one who picked no was not eligible to participate in the study and when sample size was not realised, another round of picking were assigned yes or no by those who were not seen selected in the first round. inclusion criteria the study included hiv positive mothers attending emtct clinic who were found at comboni hospital kyamuhunga during the study. only people willing to participate and who consented were included in the study. exclusion criteria all people who were unwilling to participate and those who did not consent, those that were mentally and physically incapable to stand the interview were excluded and those who withdrew after consenting. research instruments pretested structured questionnaires with close ended questions designed and distributed to the respondents who had consented to participate in the interview. the researcher conducted face to face interview with respondents who were requested to fill in their responses according to their understanding and will. in case the respondents did not understand english an interpreter helped in the translation of questions. data collection procedure the researcher got an introductory letter from the school which she presented to the hospital administrator who endorsed me to the in charge emtct clinic to give permission for data collection. the researcher introduced herself to the participants and explained to them the purpose of the research. questionnaires having serial number were given to respondents to fill and those who were not be able to read and write were guided by the research assistant. then the researcher checked through the filled questionnaires before leaving the data collection area to ensure their completeness. data analysis the data collected was analyzed using spss version 20, tabulated and presented inform of pie charts and tables using microsoft excel 2013. table 1: showing demographic characteristics of respondents n= 36 variable factor frequency percentage (%) age (years) 15-19 2 5.6 20-24 7 19.4 25-29 16 44.4 30 and above 12 33.3 religion christian-protestant 12 33.3 christian-catholic 17 47.2 moslem 5 13.9 adventist 2 5.6 marital status married 28 77.8 single 4 11.1 divorced 4 11.1 level of education never attended school 2 5.6 primary 14 38.9 secondary 15 41.7 tertiary institution 5 13.9 source: field data, august, 2019 viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [9] ajdhs.com according to the study findings in the table 1 above, results revealed that majority 16(44.4%) respondents belonged to the age group of 25 – 29 years while only 2(5.6%) respondents belonged to the age group of 15-19 meaning that the age group of 25-29 was 1.2 times more likely to be involved in the study. this revealed that majority of the respondents were mature enough and therefore gave reliable information about factors hindering emtct service uptake among hiv positive women. respondents were also asked about their religion and the responses were as shows below; results revealed that majority of the respondents, 17 (47.2%) respondents revealed that they were christian-catholic while the least number of the respondents were adventists and were set as the reference category. the adventist were set as reference category by a multinomial regression. more so, majority of the respondents, 28(77.8%) respondents were married while only 4 respondents were single and divorced as supported by 11.1%. it was therefore indicated that married respondents were 2 times more like to take part in the study than the single ones. respondents were also asked about their educational levels. most of the respondents revealed that they studied only secondary education as supported by 15 (41.7%) respondents while the least number of respondents 5 (13.9%) had tertiary level of education. it was therefore revealed that primary and secondary levels of education had more chances of being involved in the study to give reliable information. table 2: showing the socio-economic factors hindering emtct service uptake n= 36 variable frequency percentage (%) occupation business woman 13 36.1 house wife 8 22.2 civil servant 5 13.9 peasant farmer 10 27.8 financial supporter husband 29 80.6 relatives 7 19.4 family members 2 2 5.6 3 4 11.1 4 10 27.8 5 6 16.7 others 14 38.9 no of children 1 3 8.3 2 9 25.0 3 7 19.4 4 8 22.2 5 2 5.6 others specify 2 5.6 none 5 13.9 social support group yes 19 52.8 no 17 47.2 source: field data, august, 2019 according to the study findings in the table 2 above, results revealed that majority 13 (36.1%) respondents were business women while 5 (13.9%) were civil servants hence they have money for transport to access serves. more so, the respondents were asked to tell their financial supporters. it was therefore revealed that most of them were getting the support from their husbands as supported by 29 (80.6%) respondents while other were receiving their financial support from their relatives 7(19.4/%) meaning that they depend on their husbands for support. furthermore, it was revealed that majority 34 (83.4%) respondents had more than 4 family members. a least number of respondents 6, (16.7%) were having less than 4 family members. respondents were also asked about the number of children they had and majority of them had 2 children as supported by 9 (25.0%) respondents, 3 (8.3%) had only 1 child meaning those with large family spend much and are left out with less and therefore mis out appointments. the response from social support was also presented in the figure below viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [10] ajdhs.com figure 1: showing response about social support n=36 table 3: mothers were asked whether they interacted with health workers during health education services anc n=36 variable response frequency percentage (%) interact with health workers during anc? yes 32 88.9 no 4 11.1 health education services yes 33 91.7 no 3 8.3 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 3 above, results revealed that majority 34, (88.9%) respondents agreed with the question while only 4 (11.1%) respondents said that they do not interact with health workers. this showed that women get enough advice from health worker regarding anc. the results are shown in figure 2 below. figure 2: showing interaction with health workers during anc n=36 according to the study findings in the table 3 above, results revealed that majority 33 (91.7%) respondents agreed that they received health education services during anc while only 3 (8.3%) respondents said no to the question meaning that the information given was reliable and supported the study under investigation. the results above were also presented in a figure as show below. figure 3: showing health education services during anc n=36 table 4: showing whether mothers took long time waiting for services at the hospital n=36 response frequency percent (%) yes 12 33.3 no 24 66.7 total 36 100.0 source: field data, august, 2019 52.8 47.2 yes no 88.9 11.1 yes no 91.7 8.3 yes no viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [11] ajdhs.com according to the study findings in the table 4 above, results revealed that majority 24 (66.7%) respondents said that they were not taking long time waiting for services at the hospital while 12 (33.3%) respondents agreed that they were taking long time waiting for services at the hospital. this means that the hospital was doing its part not to delay patients for services. figure 4 below shows the response above. figure 4: showing whether they take long time waiting for services at the hospital n=36 table 5: showing the overall quality of services n=36 response frequency percent poor 1 2.8 fair 10 27.8 good 22 61.1 very good 3 8.3 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 5 above, results revealed that majority 22 (61.1%) respondents revealed that the services were good as supported by while only 1 respondent revealed that the services are poor and this showed that the overall quality of services were relatively good. table 6: showing whether mothers were satisfied with waiting time at the anc n=36 response frequency percent satisfied 11 30.6 moderately satisfied 12 33.3 unsatisfied 13 36..1 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 6 above, results revealed that majority 13 (36.1%) respondents were un satisfied while only 11 (30.6%) respondents revealed that they were satisfied with waiting time at the anc. the results therefore revealed that most of the people at the anc are not satisfied with waiting time meaning they spend there a lot of time. table 7: showing whether mother attended anc services n=36 attend anc services frequency percent yes 36 100.0 no 0 0.0 if yes to anc, where this facility comboni hospital 31 86.1 other public health facility (nyabubare health centre iv) 4 11.1 others (ishaka adventist hospital) 1 2.8 source: field data, august, 2019 according to the study findings in the table 7 above, results revealed that majority 31 (86.1%) respondents were receiving it from comboni hospital; others were receiving it from other public health facilities. the results therefore supported that the highest number of respondents attended their anc services at comboni hospital. the figure illustrates the results got from attendance of anc services. figure 5: showing attendance of anc services n=36 table 8: showing the 1st anc visit n=36 response frequency percent first trimester 5 13.9 second trimester 21 58.3 third trimester 10 27.8 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 8 above, results revealed that majority 21 (58.3%) respondents visited anc in their second trimester while 5 (13.9%) respondents received their anc services during their first trimester. this meant that most women do not attend anc during their first trimester which very risky towards their lives and the lives of their babies. the results are presented in table9 below. 33.3 66.7 yes no 86.1 11.1 2.8 comboni hospital nyabubare health centre ishaka adventist hospital viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [12] ajdhs.com table 9: showing times mothers attended anc for the last pregnancy n=36 times frequency percent once 4 11.1 twice 9 25.0 three times 13 36.1 more than three times 10 27.8 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 9 above, results revealed that majority 13 (36.1%) respondents revealed that they attended anc three times while only 4 (11.1%) respondents visited anc once meaning they do not complete the recommended number for anc visits. table 10: showing whether mothers received arvs during anc n=36 response frequency percent (%) yes 33 91.7 no 3 8.3 total 36 100.0 source: field data, august, 2019 according to the study findings in the table 10 above, results revealed that majority 33 (91.7%) respondents received arvs while 3 (8.3%) respondents disagreed with the statement meaning drugs are accessed and given. the results were also presented in a pie as indicated in figure9 below. figure 6: showing whether mothers received arvs during anc n=36 table 11: showing whether mothers’ partners attended anc with them n= 36 response frequency percent (%) yes 9 25.0 no 27 75.0 if yes, whether the partner knew hiv status yes 08 22.2% no 28 77.7% source: field data, august, 2019 according to the study findings in the table 11 above, results revealed that majority 27 (75.0%) respondents said that their partners do not attend anc with them while 9 (25.0%) respondents revealed that their partners attend anc with them meaning male involvement is poor and disclosure is a problem. table 12: showing whether mothers used family planning after delivery. n= 36 response frequency percent yes 24 66.7 no 9 25.0 no response 3 8.3 if yes which type injectaplan 14 38.9 implanon 5 13.9 jadalle 2 5.6 combines oral contraceptives 2 5.6 others (lactation amenoria) 4 11.1 no response 9 25.0 source: field data, august, 2019 according to the study findings in the table 12 above, results revealed that majority 24 (66.7%) respondents agreed that they use family planning after delivering while 3 (8.3%) did not respondent to the question. it was revealed from descriptive statistics that the respondents who said yes to the statement had 2 times of chances to be involved in the study as compared to the respondents who said no. figure 7: showing use of family planning after delivering n=36 in addition to the above, respondents were also asked on which type of family planning they use after delivery and the following were the responses. 14 (38.9%) respondents revealed that they were using injecta plan as their type of family planning giving a significance of 0.301 while only 4 respondents supported other types of family planning accounting for 11.1%. from the descriptive statistics, it was found out that injecta plan had 1.4 times chances of being used as compared to other methods of family planning. discussion in response to age brackets of the respondents, majority of the respondents, 16 (44.4%) belonged to the age group of 25 – 29 years. 91.7 8.3 yes no 24 9 3 yes no no response viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [13] ajdhs.com results revealed that majority of the respondents said that they studied only secondary education as supported by 15 (41.7%) respondents. it was therefore revealed that primary and secondary levels of education had more chances of being involved in the study than other levels of education. this finding suggests that educated women may be more knowledgeable about mtct of hiv and understand the benefits of testing for hiv during pregnancy. this finding reaffirms the results from other sub-saharan african countries showing that mothers with a secondary educational level or above are likely to be more knowledgeable about mother-tochild transmission 13. according to the first objective, majority number of the respondents were business women as supported by 13 (36.1%). type of business which is associated with household income is also significantly associated with a higher number of anc visits, and hence contributes to improved emtct service uptake. various studies support this finding. for instance, a systematic review of 28 studies in developing countries noted that household economic factors and women’s employment are critical factors in determining the use of anc services 14. more so, the respondents were asked to tell their financial supporters. it was therefore revealed that most of them were getting the support from their husbands as supported by 29 (80.6%) respondents. furthermore, it was revealed that majority of the families had more than 4 family members as indicated by a total of 34 (83.4%) respondents. respondents were asked whether they interact with health workers during anc and most of the respondents (34, (88.9%) agreed with the question. a big number of respondents 33 (91.7%) agreed that they received health education services during anc. the results showed that the information given was reliable and supported the study under investigation. the above results are in relation with the study conducted in vietnam explored comprehensive care and support programmes along with proper hiv/ aids education information provision needs to be carefully developed 15. it was revealed that majority of the respondents 24(66.7%) said that they were not taking long time waiting for services at the hospital this means that the hospital was doing its part not to delay patients for services. respondents were also asked how they rate the overall quality of services at the anc by the healthy workers. majority of the respondents revealed that the services were good as supported by 22 (61.1%) and this showed that the overall quality of services were relatively good. respondents were asked whether they satisfied with waiting time, 13 (36.1%) were unsatisfied therefore revealed that most of the people at the anc are not satisfied with waiting time meaning they spend there a lot of time. respondents were further asked where they attended their anc services. majority of them revealed that they were receiving it from comboni hospital as supported by 31 (86.1%). all the respondents revealed that they attended anc services. the results therefore supported that the highest number of respondents attended their anc services it was revealed that majority of the respondents 21 representing (58.3%) visited anc in their second trimester. this meant that most women do not attend anc during their first trimester which is very risky towards their lives and the lives of their babies. majority number of the respondents agreed that they received arvs during pregnancy as indicated by 33 respondents accounting for (91.7%). on the other hand, majority of the respondents revealed that their partners do not attend anc with them as indicated by 27 (75.0%). it was revealed that majority of the respondents 24 (66.7%) agreed that they use family planning after delivering. it was revealed from descriptive statistics that the respondents who said yes to the statement had 2 times of chances to be involved in the study as compared to the respondents who said no. amongst all the respondents. in addition to the above, respondents were also asked on which type of family planning they use after delivery and the following were the responses. 14 respondents accounting for (38.9% revealed that they were using injectaplan as their type of family planning method. from the descriptive statistics, it was found out that injectaplan had 1.4 times chances of being used as compared to other methods of family planning. conclusion a woman’s age was also factor to consider, women in age group 25-29 were significantly associated to emtct utilization and this could be because mothers in this age group have a high fertility rate and they are knowledgeable to the service provided to them. however, adolescent mothers were found not attending anc who belonged to the age group of 15-19. this could be because of stigma and poor youths friendly services. the study tested that women with secondary and tertiary level of education are more likely to utilize emtct. this was right because women who are educated know the importance of bearing a healthy baby who is not hiv infected. references 1. unaids global report on the aids epidemic 2013.geneva switzerland.joint united nations programme on hiv/aids 2017,21.22-000. 2. who.pmtct strategic vision 2010-1015:preventing mother-tochild-transmission of hiv to reach ungass and millennium development goals. 2010. 3. unaids. genevaunited nations programme on hiv revisiting the behavioural model and access to medical care; does it matterjournal of health social behaviour. 2016; 36:1-10. 4. omo-emmanuel uk, ochei kc, osuala eo, obeagu ei, onwuasoanya uf. impact of prevention of mother to child transmission (pmtct) of hiv on positivity rate in kafanchan, nigeria. int. j. curr. res. med. sci. 2017; 3(2):28-34. 5. obeagu ei, okwuanaso cb, edoho sh, obeagu gu. under-nutrition among hiv-exposed uninfected children: a review of african perspective. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 nov 23; 2(3):120-7. 6. obeagu ei, obeagu gu. an update on survival of people living with hiv in nigeria. j pub health nutri. 2022; 5(6):129. 7. odo m, obeagu ei, ochei kc, nkombe e, olusola-falae b, effa e, affirima b. intensified tb case finding in pmtct settings in nigeria should be reconsidered. int. j. adv. res. biol. sci. 2016; 3(2):85-92. 8. obeagu ei. a review of challenges and coping strategies faced by hiv/aids discordant couples. madonna university journal of medicine and health sciences issn: 2814-3035. 2023 jan 1; 3(1):7-12. 9. ifeanyi oe, obeagu gu. the values of prothrombin time among hiv positive patients in fmc owerri. international journal of current microbiology and applied sciences. 2015; 4(4):911-6. viola et al asian journal of dental and health sciences. 2023; 3(2):7-14 [14] ajdhs.com 10. obeagu ei, obeagu gu. an update on premalignant cervical lesions and cervical cancer screening services among hiv positive women. j pub health nutri. 2023; 6 (2). 2023; 141:1-2. 11. obeagu ei, obeagu gu, musiimenta e, bot ys, hassan ao. factors contributing to low utilization of hiv counseling and testing services. int. j. curr. res. med. sci. 2023; 9(2):1-5. 12. mbonye a, hansen, k, wamono,f, magunussen p. (2010).barriers to prevention of mother to child transmission of hiv services in uganda. journal of biosocial science. 2010; 42(2):271-283. https://doi.org/10.1017/s002193200999040x 13. merdekios b, adedimeji aa. effectiveness of interventions to prevent mother-to-child transmission of hiv in southern ethiopia. int j women’s health. 2011; 3:359–66. https://doi.org/10.2147/ijwh.s23124 14. patience aa, gordon a-n, sakyi k, charles kda, abor j. the socioeconomic determinants of maternal health care utilization in ghana. int j soc econ. 2011; 38:628–48. https://doi.org/10.1108/03068291111139258 15. gov..global aids response progress report 2,government of vietnam hanoi, vietnamguidelines on constraction of core indicators for monitoring the 2011 political declaration on hiv/aids vol jc2215e. 2012. https://doi.org/10.1017/s002193200999040x https://doi.org/10.2147/ijwh.s23124 https://doi.org/10.1108/03068291111139258 ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited prevalence of anaemia and associated factors in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district anslem ajugwo1,2 , robert unzi opigo2 and *emmanuel ifeanyi obeagu2 1 department of medical laboratory science, madonna university, elele campus, rivers state, nigeria 2 department of medical laboratory science, kampala international university, uganda article info: _______________________________________ article history: received 24 march 2022 reviewed 07 may 2023 accepted 23 may 2023 published 15 june 2023 _______________________________________ cite this article as: ajugwo a, opigo ru, obeagu ei, prevalence of anaemia and associated factors in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district, asian journal of dental and health sciences. 2023; 3(2):1-6 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.37 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda. email: emmanuelobeagu@yahoo.com abstract ___________________________________________________________________________________________________________________ the study was done to determine the prevalence of anaemia and its associated factors in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district. a cross-sectional study design was used. structured questionnaires were used to obtain socio-demographic, obstetric and other related anemia factors while blood samples were obtained for hemoglobin determination. data obtained were entered into excel and exported to spss version 25.0 for analysis. bivariate and multivariate analyses were performed to assess the factors associated with anaemia. the study results showed 11.7% prevalence of anaemia. taking iron supplement during pregnancy was significantly associated with anaemia among lactating mothers. the prevalence of anaemia among lactating mothers accessing services at health services at ishaka adventist hospital, bushenyi district was low (11.7%).taking iron supplement during pregnancy was significantly associated with anaemia among lactating mothers. keywords: anaemia, lactating mothers, pregnancy, ishaka adventist hospital introduction anaemia is the most common nutritional deficiency indicator and health status in the world affecting about one third of the global population 1-2. anaemia is never a diagnosis but occurs secondary to an underlying disease process. technically, anaemia is defined as a state in which an individual’s haemoglobin concentration (red cell mass) falls two standard deviations below the reference intervals in particular population (individuals of similar age, gender and geographical location) resulting into decreased oxygen-carrying capacity of red blood cells to the tissues 3. globally, a study conducted in india among lactating mothers found out that the prevalence of anaemia was 66.0% 4. a study in myanmar reported an anaemia prevalence rate of 60.3% in lactating mothers, with 20.3% of lactating mothers having severe anaemia 3. in africa, studies conducted in ethiopia in lactating mothers from 2011-2015 found out that the prevalence was 22.1% 5. another study in kenya concluded that lactating mothers whose haemoglobin levels were less than 12g/dl had prevalence of 43.8% 6. anaemia in lactating mother is common especially if the mother were anemic during their pregnancy. lactating mothers are vulnerable to anaemia morbidity due to their susceptibility to iron depletion during pregnancy and lactation as well as due to bad consequences of blood loss during their childbirth 7-11. anaemia in lactating mother has various adverse effects like decreased immunity which in turn results in delayed wound healing, and increased susceptibility to infections such as mastitis, ductitis and urinary tract infection and diminished quality or volume of the breast milk. it has also associated with reduction of global household income, cognitive impairment, impaired quality of life, and emotional instability as well as postpartum depression 12. these devastating impacts makeanaemiain lactating mothers to be one of the global health priority areas at the global level, especially in resource-limited areas 13. studies have shown that, although breast milk is not a good source of iron, the concentration of iron in breast milk is independent of maternal iron status. this indicates that the quality of breast milk is maintained at the expense of maternal stores. postpartum anaemia is highest in mothers who are anemic during pregnancy 14. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.37 mailto:emmanuelobeagu@yahoo.com https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.37&amp;domain=pdf https://orcid.org/0000-0002-2703-0045 https://orcid.org/0000-0002-4538-0161 ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [2] ajdhs.com the study was done to determine the prevalence of anaemia and its associated factors in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district methods and materials study design this was a hospital based cross-sectional study design which was conducted for a period of two months from 1st june 2022 to 1staugust 2022. study area this study was carried out in ishaka adventist hospital in bushenyi district. study population the study population included all lactating mothers accessing ishaka adventist hospital in ishaka, bushenyi district during the given period of the study. inclusion criteria this study included only lactating mothers accessing ishaka adventist hospital in ishaka, bushenyi district during the given period of the study. exclusion criteria this study excluded all non-lactating mothers, those who did not consent to take part in this study and those lactating mothers with history of illnesses and on iron supplementation. sample size determination the sample size of this study was determined using the formula by (keish et al,1965). this is illustrated as shown below. from where, n = sample size required p = prevalence of anaemiain lactating mothers among youths was 22.1% 5. z = the score on normal standard curve corresponding to a 95% (1.96) confidence level q=(1-p), proportion of those who do not have the disease. d = allowable error corresponding to 5% therefore, n = [(1.96)2 ×0.221 × 0.779] (0.05)2 n = 264.5 therefore 265samples were considered for the study sampling method simple random sampling technique was used to recruit until the required number is reached. data collection methods/instruments after obtaining an informed written consent, pretested structured questionnaire was used which was written in two versions i.e. english version and runyankole translated version for those who could not understand english. the questionnaire was validated and were used to collect information about variables that included demographic, obstetric factors and other anaemia related factors. whereas the prevalence of anaemia was collected using the blood sample sample collection for anaemia testing the venipuncture site was cleaned using a swab containing 70% isopropyl alcohol and using aseptic techniques, an appropriate vein was identified and hypodermic needle introduced into the vein. about 3-4mls of blood samples was collected into syringe and then transferred into a sterile container containing edta and then transported to the hematology laboratory for analysis. data analysis data was coded, entered into epi data version 7.2.4.0 and exported into spss version 25.0 for analysis. the data was computed to determine frequency and percentages and was presented inform of tables and figures at 95% confidence level. ethical consideration an introductory letter was sought from the dean, school of allied health sciences of kampala international universitywestern campus. this was taken to the medical director, ishaka adventist hospital, to seek permission to carry out the study. the medical director,then introduced the researchers to the medical laboratory scientists and who is also in charge of the haematology laboratory who allowed us to conduct the research. informed consent was sought first from the participants. participants were gotten from antenatal and postnatal clinic through the nursing officer in charge of antenatal and postnatal. privacy was guaranteed by interviewing each participant separately and ensuring that information collected does not contain individual identity so as to avoid a breach of confidentiality. all information obtained was treated with confidentiality and only for the purpose of this study. results table 1 shows that majority 128(48.3%) were aged 18-35 years, 219(82.5%) were married, the maternal education level was secondary with132 (49.8%) was secondary, the paternal education level was also secondary with 138 (52.1%), 166 (62.6%) were unemployed and lastly majority 143(54.0%) came from rural areas. ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [3] ajdhs.com table 1: demographic data of respondents variables frequency percent(%) age 18-25 years 128 48.3 26-35 years 112 42.3 ≥ 36 years 25 9.4 marital status single 25 9.5 married 219 82.5 divorced 21 8.0 maternal level of education primary 80 30.2 secondary 132 49.8 tertiary 48 18.1 never attended school 5 1.9 paternal level of education primary 60 22.6 secondary 138 52.1 tertiary 62 23.4 never attended school 5 1.9 occupation employed 99 37.4 unemployed 166 62.6 residence urban 122 46.0 rural 143 54.0 according to figure 1, 31 (11.7%) were anemic while 234 (87.9%) were not anemic. thus, the prevalence of anaemia among study participants is11.7%. figure 1: severity of anaemia in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district of the 31 anaemic mothers, many 16(51.6%) had anaemia classified as moderate, 11(35.5 had anaemia classified as mild (10-10.9 g/dl) and lastly 4(12.9%) had anaemia classified as severe. table 2: severity of anaemia in lactating mothers attending health services at ishaka adventist hospital, bushenyi district severity of anaemia frequency (n=31) percent (%) mild (10-10.9 g/dl) 11 35.5 moderate (7.0-9.9 g/dl) 16 51.6 severe (<7.9 g/dl) 4 12.9 31 234 11.7 87.9 0 50 100 150 200 250 anemic not anemic/normal frequency percent ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [4] ajdhs.com table 3: bivariate analysis of socio-demographic factors associated with anaemia in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district anaemia aor(95%ci) p-value anaemic not anaemic age 18-25 years 9 119 0.30(0.09-0.99) 0.049 26-35 years 17 94 0.72(0.23-2.19) 0.567 ≥ 36 years 5 20 1.00 marital status single 0 25 n/a married 31 185 n/a divorced 0 21 1.00 maternal level of education primary 10 70 0.57(0.06-5.64) 0.632 secondary 12 120 0.40(0.04-3.87) 0.429 tertiary 8 39 0.82(0.08-8.34) 0.87 never attended school 1 4 1.00 paternal level of education primary 9 46 0.78(0.08-7.84) 0.84 secondary 14 124 0.45(0.05-4.33) 0.49 tertiary 7 54 0.52(0.05-5.32) 0.58 never attended school 1 4 1.00 occupation employed 11 85 0.91(0.41-1.98) 0.803 unemployed 20 140 1.00 sex urban 13 108 0.84(0.39-1.79) 0.643 rural 18 125 1.00 table 4: bivariate analysis of obstetric factors associated with anaemia in lactating mothers accessing health services at ishaka adventist hospital, bushenyi district anaemia aor(95%ci) p-value anaemic not anaemic number of pregnancies have you ever carried one 12 81 0.79(0.31-2.01) 0.621 two 4 35 0.61(0.17-2.14) 0.440 three 6 69 0.46(0.16-1.39) 0.170 more than three 9 48 1.00 took iron supplement during pregnancy yes 19 186 0.40(0.18-0.88) 0.023 no 12 47 1.00 number of times you attend anc during your previous pregnancy no visit 1 13 0.47(0.06-3.77) 0.480 1-3 4 52 0.47(0.16-1.42) 0.182 4 and above 26 160 1.00 currently using contraceptive method yes 9 102 0.53(0.23-1.19) 0.123 no 22 131 1.00 period of breast feeding < 3 months 12 68 0.35(0.57-3.19) 0.491 ≥ 1 year 6 73 0.63(0.23-1.76) 0.378 3-9 months 13 92 1.00 number of birth ever had in the last five years once 17 118 0.89(0.33-2.42) 0.817 two 8 78 0.63(0.21-1.96) 0.426 three four 6 37 1.00 hiv status positive 1 31 0.21(0.03-1.63) 0.136 negative 30 199 1.00 are you pregnant yes 1 8 0.94(0.11-7.76) 0.952 no 30 225 1.00 ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [5] ajdhs.com table 5: multivariate analysis of factors associated with anaemiain lactating mothers accessing health services at ishaka adventist hospital, bushenyi district anaemia aor(95%ci) p-value anaemic not anaemic age 18-25 years 9 119 0.27(0.07-1.09) 0.066 26-35 years 17 94 0.79(0.23-2.69) 0.707 ≥ 36 years 5 20 1 number of pregnancies have you ever carried one 12 81 0.45(0.47-4.52) 0.517 two 4 35 1.01(0.218-4.69) 0.99 three 6 69 0.69(0.20-2.39) 0.56 more than three 9 48 1 took iron supplement during pregnancy yes 19 186 0.16(0.05-0.46) 0.001 no 12 47 1 number of times did you attend anc during your previous pregnancy no visit 1 13 0.19(0.02-2.11) 0.179 1-3 4 52 0.18(0.05-1.17) 0.055 4 and above 26 160 1 currently using contraceptive method yes 9 102 0.59(0.23-1.53) 0.284 no 22 131 1 hiv status positive 1 31 0.16(0.02-1.37) 0.095 negative 30 199 1 discussion in this study, the prevalence of anaemia among lactating mothers attending health services at ishaka adventist hospital, bushenyi district was 11.7%. this was low compared to 66.0% lactating mothers with anaemia according to a study done in india by [4], and anaemia prevalence rate of 60.3% in lactating mothers according to a study done in myanmar by (zhao et al.,2014).it was also low compared to 28.3% among 4658 ethiopian lactating mothers (liyew et al., 2020), rate of 43.8% among kenyan lactating mothers [6], a prevalence of (53.08%) in mozambique, (46.28%) in tanzania, and (19.33%) in rwanda. according lakew and colleagues, the lower prevalence of anaemia among lactating mothers may be due to the cultural norms of providing nutritional care to lactating mothers during the postpartum period. lactating mothers are encouraged to rest for 3–6 months and to eat a variety of foods 5. considerably, in ishaka and in communities surrounding it, cultural norms are almost extinct following the abolishment of kings in uganda. for over decades, ankole has no king and as result women in this region can now eat fish, chicken among other foods that were previously prohibited by culture. therefore, adoption of such foods that contain lots of iron could be the reason for low prevalence of anaemia among lactating mothers attending health services at ishaka adventist hospital, bushenyi district. regarding the severity of anaemia among lactating mothers, 51.6% had moderate form of anemia, 35.5% had mild form of anaemia and lastly 12.9% had severe form of anemia. in this study, taking iron supplement during pregnancy were significantly related to anaemia in lactating mothers. participants who took iron supplement during pregnancy were 84% less likely to be anaemic as compared to those who didn’t take iron supplement during pregnancy. this is supported by a study in bahir darethiopia 15, which showed that iron supplementation during pregnancy is negatively associated with having anaemia both for pregnant and lactating women. the possible explanation could be that, iron is the most important nutrient which is used for the formation of red blood cells and when it was taken during pregnancy it can have a probability of preventing anaemia during the lactation period as well. a study by carried out in ethiopia also revealed that lactating mothers who were taking modern contraceptives had a lower risk of having anaemia 5. conclusion in conclusion, the prevalence lactating mothers attending health services at ishaka adventist hospital, bushenyi district was low and its severity was commonly in moderate form. the risk of lactating mothers was seen to be significantly reduced with intake of iron supplement during pregnancy. references 1. ifeanyi oe. a review on nutritional anaemia. international journal of advanced multidisciplinary research. 2018; 5(4):11-5. 2. obeagu ei, bot ys, obeagu gu, alum eu, ugwu op. anaemia and risk factors in lactating mothers: a concern in africa. journal of innovative and applied research. 2023; 11(2):15-7. 3. zhao a, zhangy, li b, wang p, li j, xue. prevalence of anaemia and its risk factors among lactating mothers in myanmar. am j tropical medical hygiene. 2014; 90(5):963-967 https://doi.org/10.4269/ajtmh.13-0660 https://doi.org/10.4269/ajtmh.13-0660 ajugwo et al asian journal of dental and health sciences. 2023; 3(2):1-6 [6] ajdhs.com 4. singh ab, kandpal sd, chandra r. anaemia amongst pregnant and lactating women in district dehradun. indian journal of preventive and social medicine. 2009; 40:20-1. 5. lakew y, biadgilign s, haile d. anaemia prevalence and associated factors among lactating mothers in ethiopia: evidence from the demographic and health surveys. biomedical journal open. 2015; 5(4):e006001. https://doi.org/10.1136/bmjopen-2014-006001 6. ettyanga ga, oloob mla, saris whm. serum retinol, iron status and body composition of lactating women in nandi, kenya. annals of nutrition and metabolism. 2003 ; 47:276-83 https://doi.org/10.1159/000072400 7. julla bw, haile a, ayana g, eshetu s, kuche d, asefa t. chronic energy deficiency and associated factors among lactating mothers (15-49 years old) in offa woreda, wolayita zone, snnprs, ethiopia. world scientific research. 2018; 5:13-23. https://doi.org/10.20448/journal.510.2018.51.13.23 8. edward u, obeagu ei, okorie hm, vincent cc, bot ys. studies of serum calcium, inorganic phosphate and magnesium levels in lactating mothers in owerri. journal of pharmaceutical research international. 2021; 33(41b):209-16. https://doi.org/10.9734/jpri/2021/v33i41b32360 9. ibekwe am, obeagu ei, ibekwe ce, onyekwuo c, ibekwe cv, okoro ad, ifezue cb. challenges of exclusive breastfeeding among working class women in a teaching hospital south east, nigeria. journal of pharmaceutical research international. 2022; 27;34(46a):1-0. https://doi.org/10.9734/jpri/2022/v34i46a36371 10. obeagu ei. evaluation of effect of crude methanol tetrapleura tetraptera (tte) on hematological parameters of albino rats. j hematol thrombo dis. 2018;6(293):2. 11. ogomaka ia, obeagu ei. methods of breast feeding as determinants of malaria infections among babies in imo state, nigeria. breast. 2019; 2(01):17-24. 12. beard jl, hendricks mk, perez em. maternal iron deficiency anaemia affects postpartum emotions and cognition. journal of nutrition. 2005; 135:267-72. https://doi.org/10.1093/jn/135.2.267 13. kassebaum nj, jasrasaria r, naghavi m, wulf sk, johns n, lozano r. (2014).a systematic analysis of globalanaemiaburden from 1990 to 2010.blood. 2014; 123(5):615-24. https://doi.org/10.1182/blood-2013-06-508325 14. sserunjogi .l, scheut f, whyte sr. (2003).postnatal anaemia neglected problems and missed opportunities in uganda. health policy plan. 2003; 18:225-31. https://doi.org/10.1093/heapol/czg027 15. feleke be, feleke te. pregnant mothers are more anemic than lactating mothers, a comparative cross-sectional study, bahir dar, ethiopia. biomedical central hematology. 2018; 18(1):2. https://doi.org/10.1186/s12878-018-0096-1 https://doi.org/10.1136/bmjopen-2014-006001 https://doi.org/10.1159/000072400 https://doi.org/10.20448/journal.510.2018.51.13.23 https://doi.org/10.9734/jpri/2021/v33i41b32360 https://doi.org/10.9734/jpri/2022/v34i46a36371 https://doi.org/10.1093/jn/135.2.267 https://doi.org/10.1182/blood-2013-06-508325 https://doi.org/10.1093/heapol/czg027 https://doi.org/10.1186/s12878-018-0096-1 kushwaha et al asian journal of dental and health sciences. 2022; 2(4):35-39 [35] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited an overview on formulation and evaluation aspects of tablets neeta kushwaha1, anushree jain1, prateek kumar jain1, basant khare1*, yashwant singh jat2 1 adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 2 sardar patel college of pharmacy, villege-bangai, gulharia thana, gorakhpur, up 273013 article info: _______________________________________ article history: received 08 sep 2022 reviewed 10 nov 2022 accepted 29 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: kushwaha n, jain a, jain pk, khare b, jat ys, an overview on formulation and evaluation aspects of tablets, asian journal of dental and health sciences. 2022; 2(4):35-39 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.23 _______________________________________ *address for correspondence: basant khare, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ nothing in this world is stable and ever accepted. change is the requirement of nature for the sake of adaptability. however, the pharmaceutical world is also not far off from this change. technical advancement in pharma world also leads to the development of new dosages forms. this leads to the replacement of the older dosages forms with the newer once. but for the tablet dosages forms this replacement is substituted with modifications. on the top of it the availability of numerous evaluation parameters provides these new modifications in tablets a clear cut demonstration idea. tablets are defined as solid unit dosage form of medicaments intended for oral use. they became most popular as they were easy in preparation compared to any other type of dosage forms. but the major drawback exists in its manufacturing. if any minor problem occurs during their manufacturing then the whole batch of the unit should be discarded. it is necessary to avoid any sort of errors during its manufacturing and as a result evaluation of tablets is very important before dispatching of a batch. in the present study, we discussed about the manufacturing techniques and evaluation tests for tablets. keywords: tablets, solid unit dosage, compression method, indian pharmacopoeia, manufacturing, evaluations introduction oral solid dosage forms are administered for attaining a local therapeutic effect in the mouth, throat and digestive tract or for a systemic effect in the body after oral or gastrointestinal absorption. for preparing oral solid dosage forms, active ingredients and suitable excipients can be milled, dried, encapsulated, blended, granulated or tableted. various oral solid dosage forms such as tablets, capsules, lozenges, powders and granules etc. have been widely used for delivering active pharmaceutical ingredients (api) due to their convenience and consequent patient compliance1. tablet is the most widely used dosage form among the total available dosage forms because it is simple for administration, lower price of production and elegance2. tablets are a solid dosage form of medicaments with or without excipients which are prepared by compression method. according to the indian pharmacopoeia tablets are solid, flat or biconvex unit dosage form of a medicament alone or medicament along with excipients prepared by compressing technique. they may vary in its size shape and weight depending on the medicament and its mode of administration. tablets are said to be most widely used conventional dosage forms due to its variety of advantages and 70% of the medicaments were dispensed in tablet forms. most of the medicaments can be processed into tablets but there are some exceptions like medicaments with low density characters, hygroscopic and the medicaments which were not possible to administer3-7. tablet formulations which provide a unit dose which is either immediate drug release or modified release or is taste masked are some of the most popular and extensively explored aspects of oral solid dosage form development. tablet manufacturing (apart from the direct compression method) is a multistep process and hence is a complex process with many potential variables. the processes and parameters associated with tablet manufacture are still not fully understood. extensive research is ongoing to develop understanding in all areas of the tablet manufacturing process. numerous advances have been introduced to improve material attributes, engineering of manufacturing equipment and development of efficient analytical techniques. qualities by design-based formulation development approaches have been applied to reduce the variability in the processes to develop robust tablet dosage forms. in addition, new raw materials have been deployed to improve manufacturability and functionality of tablet formulations. these include the modification of existing excipients with enhanced purity or physical properties (e.g. particle size) and co processing with other materials to improve their performance in manufacturing processes. moreover, development and use of multi-functional materials provide lean manufacturing opportunities with significant economic impact. the last few years have seen the development of novel tableting technologies which improve machine performance. these advances in machine design aim to overcome limitations associated with conventional manufacturing approaches such as the denaturation of thermolabile active ingredients, material wastage, multiple processing steps and elevated costs due to protracted processing time, labour and maintenance of open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.23 kushwaha et al asian journal of dental and health sciences. 2022; 2(4):35-39 [36] ajdhs.com equipment. in addition, lean and continuous manufacturing concepts have been employed to ensure rapid, safe and efficient manufacturing operations. developments relating to engineering and machine design have also been implemented in the pharmaceutical industry. the concept of quality by design has been applied to enhance productivity by the application of novel process analytical technologies that track quality attributes of formulations. these also can document data as a function of input variables (materials and process) in a real time manner1. this manuscript aims to provide a comprehensive summary of numerous manufacturing technologies and evaluation parameters plays a major role to release any dosage form into the market. advantages  unit dosage forms with dose precision,  least content variability,  administration of accurate amounts of minute doses of a drug is possible,  economical of all oral dosage forms as its production doesn’t requires additional processing steps,  easy transportation,  sustain release of a drug can be achieved through enteric coating,  medicaments with bitter taste can be masked with coating technique (sugar coating),  tablet dosage form is stable when compared to all oral dosage forms. disadvantages  administration of drugs is not easy in case of children,  drugs with slow dissolution is not acceptable for tableting with good bioavailability,  medicaments with low density characters and amorphous in nature are difficult to compress,  hygroscopic nature of drugs is not acceptable for tablet compression. tablet manufacturing techniques8-12 direct compression the direct compression method is by far the most effective technique of tablet manufacturing. this technique is least tedious and hence is preferred over the other techniques. direct compression is the simplest and most economical method for the manufacturing of tablets because it requires less processing steps than other techniques such as wet granulation and roller compaction. however, most pharmaceutical active ingredients cannot be compressed directly into tablets due to lack of flow, cohesion properties and lubrication. therefore they must be blended with other directly compressible ingredients to manufacture satisfactory tablets. wet granulation wet granulation is a process of using a liquid binder to lightly agglomerate the powder mixture. the amount of liquid required to be properly adjusted, as over-wetting will cause the granules to be too hard and under-wetting will cause them to be too soft and friable. aqueous solutions have the advantage of being safer to deal with solvent-based systems but may not be suitable for drugs which are degraded by hydrolysis. dry granulation dry granulation requires drugs or excipients with cohesive properties. dry granulation is simpler than wet granulation, therefore the cost is reduced. this process is often used when the product to be granulated is sensitive to moisture and heat. dry granulation can be conducted on a tablet press using slugging tooling or on a roll press called a roller compactor. dry granulation often produces a higher percentage of fine granules, which can compromise the quality or create yield problems for the tablet. steps-by-step tablet manufacturing processes which are being utilized by various manufacturers are enlisted in table 1. evaluations of these tablets are being carried out by using various response variables. both preformulation and post formulation parameters are being evaluated to cement the effectiveness of formulated preparations. table 1: steps of tablet manufacturing processes wet granulation milling and mixing of drugs and excipients. preparation of binder solution. wet massing by addition of binder solution or granulating solvent. screening of wet mass followed by drying of the wet granules. screening of dry granules. blending with lubricant and disintegrant to produce running powder, compression of tablet dry granulation milling and mixing of drugs and excipients, compression into slugs or roll compaction, milling and screening of slugs and compacted powder, mixing with lubricant and disintegrant, compression of tablet direct compression milling and mixing of drugs and excipients, compression of tablet nanonization involves size reduction of drug to nanosize by milling the drug using a proprietary wet-milling technique. the nanocrystals of the drug are stabilized against agglomeration by surface adsorption on selected stabilizers, which are then incorporated cotton candy process involves the formation of matrix of polysaccharides by simultaneous action of flash melting and spinning. this candy floss matrix is then milled and blended with active ingredients and excipients after recrystallization and subsequently compressed to fdt. mass extrusion involves softening the active blend using the solvent mixture of water soluble polyethylene glycol, methanol and expulsion of softened mass through the extruder or syringe to get a cylindrical shape of the product into even segments using heated blade to form tablets. sublimation inert solid ingredients that volatilize rapidly like urea, camphor ammonium carbonate, ammonium bicarbonate, and hexamethylenetetramine were added to the other tablet ingredients and the mixture is compressed into tablets. the volatile materials were then removed via sublimation, which generates kushwaha et al asian journal of dental and health sciences. 2022; 2(4):35-39 [37] ajdhs.com porous structure. moulding water-soluble ingredients with a hydro alcoholic solvent is used and is molded into tablets under pressure lower than that used in conventional tablet compression. freeze drying/ lyophilization the drug is dissolved or dispersed in an aqueous solution of a carrier. the mixture is poured into the wells of the preformed blister packs. the trays holding the blister packs are passed through liquid nitrogen freezing tunnel to freeze the drug solution. then the frozen blister packs are placed in refrigerated cabinets to continue the freeze drying. finally the blisters are packaged and shipped. disintegrant addition involves the addition of superdisintegrants in optimum concentration to the formulation to achieve rapid disintegration/dissolution advances in tablet manufacturing processes tablet manufacturing routines involving advanced granulation approaches, hot melt extrusion, extrusion/spheronization, injection molding, spray drying, spray congealing, coprecipitation and nanotechnology-based approaches have been developed over a number of years to produce robust tablet formulations with improved performance characteristics. evaluation of tablets • appearance, • size and shape, • organoleptic properties, • uniformity of thickness, • hardness, • friability, • drug content uniformity, • weight variation test, • wetting time, • water absorption ratio, • in vitro dispersion time, • in vitro disintegration test, • in vitro dissolution studies, • two set of apparatus, • apparatus-1, • apparatus-2. appearance appearance is the first most required quality for the acceptance of tablet. general elegance and its identity play a major role for the consumer acceptance. acceptance of the appearance of batches of the tablet has been done based on the measurement of the following factors like size, color, shape, presence or absence of odor, taste etc13-18. size and shape size and shape of a tablet has been determined by its thickness. size and shape of table plays an important role in its patient compliance as the size of the tablet increases it is not much easier for its administration. micrometer is the devise which is used to determine the thickness of a tablet. it can be acceptable if the batch falls within the •±5% of standard deviation. organoleptic properties color should be distributed uniformly without appearance of any signs of mottling. colour of the tablet should be compared with the standard colour for comparison. uniformity of thickness to determine the uniformity of thickness random selection of tablets has to be done from each and every batch and need to measure its thickness independently. if the thickness of any single tablet varies then the batch containing that batch will not be dispatched into market (figure 1). hardness the ability of a tablet to withstand for mechanical shocks is known as hardness. pfizer hardness tester is the instrument which is used to determine the hardness of tablet. it is expressed in kg/cm2. take three tablets from each batch and hardness should be determined and the selection of tabled should be done randomly. then the mean and standard deviation values should be determined. friability roche friabilator is the equipment which is used for the determination of friability. it is expressed in percentage. note down the initial weight of the tablets individually (w initial). tablets are placed in a plastic chamber which revolves at 25 rpm and they are subjected to fall from a height of 6 inches in the friabilator for about 100 revolutions. then measure the weight of the tablet (w final) and observe any weight difference before tablet and after the friabilator processing (figure 2). limits: loss in weight less than 0.5 to 1% of the initial weight of the tablet should be considered as acceptable limits. percentage of friability is calculated as: f={(w initial)(w final)/ (w initial)}×100. kushwaha et al asian journal of dental and health sciences. 2022; 2(4):35-39 [38] ajdhs.com drug content uniformity initially weigh the tablet and then powder it. now the powdered tablet is transferred into a 100 ml volumetric flask and adds 0.1 n hcl up to mark. now filter the solution and discard first few ml of filtrate. take 10 ml of filtrate should be taken into a 50 ml volumetric flask and add 0.1 n hcl up to the mark and analysed spectrophotometrically at 274 nm and 234.5 nm. the concentration of the content of the drug (μg/ml) was calculated by using the standard calibration curve of the respective drug. drug content is calculated by using the below formula concentration of the drug in (μg/ml) × 100 × 50/10 × 1000 weight variation test random selection of 20 tablets from each batch should be done and note down the weight of the tablet individually and check for any variation in its weight. according to us pharmacopeias small variations in the weight is negligible and can be accepted. below is the acceptable limit of percentage deviation in weight variation. wetting time this method was performed to determine the wetting time of a tablet. a piece of tissue paper which is folded twice is kept in a petri dish containing 6 ml of water and place the tablet on the tissue paper. observe the time taken for complete wetting of the tablet. following procedure should follow three times (three trial) for each batch and standard deviation is also calculated from the obtained results. water absorption ratio a piece of tissue paper which is folded twice is kept in a petri dish (i.d.=6.5 cm) containing 6 ml of water and place the tablet on the tissue paper. observe the time taken for complete wetting of the tablet. thus wetted tablet was weighed. now the water absorption ratio r is calculated using the formula r=100 × wa –wb/wb wb is the weight of the tablet before absorption, wa is the weight of the tablet after absorption, following procedure should follow three times (three trial) for each batch and standard deviation is also calculated from the obtained results. in vitro dispersion time dispersion time of a tablet is determined by placing a tablet in 6 ml of 6.8 ph phosphate buffer and note down the time taken for complete dispersion of tablet. following procedure should be done for three tablets from each batch and in vitro dispersion time is calculated. standard deviation time is also determined from the obtained results. it is expressed in seconds. in vitro disintegration test disintegration is defined as the process of breakdown of tablet into small particles. disintegration time of a tablet is determined by using disintegration test apparatus as per ip specifications. place each tablet in each 6 tubes of the disintegration apparatus a then add a disc to each tube containing 6.8 ph phosphate buffer. the temperature of the buffer should maintain at 37±2°c and run the apparatus raised and lowered for 30 cycles per minute. note down the time taken for the complete disintegration of the tablet without any remitants (figure 3). conclusion tablet manufacturing and its evaluation has become the backbone of pharmaceutical research. from the various data sources it could be concluded that tablets have got uniqueness and power of adaptability. the tablets have shown vast changes in the last few decades or so both in manufacturing and evaluation. the advances in the evaluation techniques have proven to be both economical and time saving. from the number of manufacturing and evaluation parameters available the scope for the researchers also enhances and makes it possible for tablets to perfectly cement its place in this ever changing drug world. references 1. arshad ms, zafar s, yousef b, alyassin y, ali r, alasiri a, chang mw, ahmad z, elkordy aa, faheem a, pitt k. a review of emerging technologies enabling improved solid oral dosage form manufacturing and processing. advanced drug delivery reviews. 2021; 178:113840. https://doi.org/10.1016/j.addr.2021.113840 2. gaikwad ss, kshirsagar sj. review on tablet in tablet techniques. beni-suef university journal of basic and applied sciences. 2020; 9(1):1-7. https://doi.org/10.1186/s43088-019-0027-7 3. haritha b. a review on evaluation of tablets. j formul sci bioavailab 2017; 1: 107. 4. gautam sp, rai jp, billshaiya u, jain n, vikram p, jain dk. formulation and evaluation of mouth dissolving tablet of loperamide. international journal of pharmaceutical sciences and research. 2013; 4(5):1782. 5. patel an, rai jp, jain dk, banweer ji. formulation, development and evaluation of cefaclor extended release matrix tablet. int j pharm pharm sci. 2012; 4(4):355-7. 6. pandey sp, khan ma, dhote v, dhote k, jain dk. formulation development of sustained release matrix tablet containing metformin hydrochloride and study of various factors affecting dissolution rate. sch acad j pharm. 2019; 8(3):57-73. 7. jain p, nair s, jain n, jain dk, jain s. formulation and evaluation of solid dispersion of lomefloxacin hydrochloride. international journal of research in pharmaceutical sciences. 2012; 3 (4): 604608. 8. bi yx, sinnada h, yonezawa h. evaluation of rapidly disintegrating tablets by direct compression method, drug dev ind pharma 1999; 25: 571-581. https://doi.org/10.1081/ddc-100102211 9. ishikawa t, koizumi n, mukai b. pharmacokinetics of acetaminophen from rapidly disintegrating compressed tablet prepared using microcrystalline cellulose (ph-m-06) and spherical sugar granules. chem pharm bull 2001; 49: 230-32. https://doi.org/10.1248/cpb.49.230 10. shangraw rf. direct compression tableting, encyclopedia of pharmaceutical technology, vol-4, marcel dekker, usa, 2nd ed., 1988: 85-160. 11. suhel t., jain v., khangar p.k., jain r.k. formulation and evaluation of metformin hydrochloride sustained release tablet. https://doi.org/10.1016/j.addr.2021.113840 https://doi.org/10.1186/s43088-019-0027-7 https://doi.org/10.1081/ddc-100102211 https://doi.org/10.1248/cpb.49.230 kushwaha et al asian journal of dental and health sciences. 2022; 2(4):35-39 [39] ajdhs.com international journal of medical sciences and pharma research, 2022; 8(3), 28-32. https://doi.org/10.22270/ijmspr.v8i3.56 12. herbert l, lachman l, schwartz bj. chewable tablet pharmaceutical dosage forms: tablets. 1989; 2: 711-715. 13. valenta c, kast ce, harich i, bernkop-schnurch a. development and in vitro evaluation of a mucoadhesive vaginal delivery system for progesterone. j cont release 2001, 77: 323-332. https://doi.org/10.1016/s0168-3659(01)00520-x 14. yong cs, jung jh, rhee jd, kim ck, choi hg. physiological characterization and evaluation of buccal adhesive tablets containing omeprazole. drug dev ind pharm 2001, 27: 447-445. https://doi.org/10.1081/ddc-100104320 15. aburahma mh, el‐laithy hm, hamza ye. preparation and in vitro/in vivo characterization of porous sublingual tablets containing ternary kneaded solid system of vinpocetine with β‐ cyclodextrin and hydroxy acid. sci pharma 2010; 78: 363-379. https://doi.org/10.3797/scipharm.0912-04 16. kathiresan k, vijin p, moorthi c, manavalan r. formulation and evaluation of loratadine chewable tablets. res j pharm bio chem sci 2010; 2: 763-774. 17. jagdale s, gattani m, bhavsar d, kuchekar b, chabukswar a. formulation and evaluation of chewable tablets of levamisole. int j res pharma sci 2010; 1: 282-289. 18. mullarney mp, hancock bc, carlson gt, ladipo dd, langdon ba. the powder flow and compact mechanical properties of sucrose and three high-intensity sweeteners used in chewable tablets. int j pharma 2003; 257: 227-236. https://doi.org/10.1016/s03785173(03)00144-3 https://doi.org/10.22270/ijmspr.v8i3.56 https://doi.org/10.1016/s0168-3659(01)00520-x https://doi.org/10.1081/ddc-100104320 https://doi.org/10.3797/scipharm.0912-04 https://doi.org/10.1016/s0378-5173(03)00144-3 https://doi.org/10.1016/s0378-5173(03)00144-3 jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [14] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited an update on the recent emergence of candida auris monika jain1, anushree jain1, basant khare1, deepak kumar jain2, rubeena khan1, dolly jain*1 1 adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 2 sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 article info: _________________________________________ article history: received 10 jan 2022 reviewed 26 feb 2022 accepted 05 march 2022 published 15 march 2022 _________________________________________ cite this article as: jain m, jain a, khare b, jain dk, khan r, jain d, an update on the recent emergence of candida auris, asian journal of dental and health sciences. 2022; 2(1):14-19 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.11 _________________________________________ *address for correspondence: dolly jain, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ the incidence of invasive fungal infections (ifi) caused by unusual pathogens is on the rise, partly driven by the increased population of immunocompromised patients. the emerging multidrugresistant yeast pathogen candida auris (c. auris) has been a source of concern as an agent of healthcare-associated infections. c. auris is emerging multidrug-resistant yeast that causes serious invasive infections with high mortality. it was first discovered in 2009, and since then, individual cases or outbreaks have been reported from over 20 countries on five continents. controlling c. auris is challenging for several reasons: (1) it is resistant to multiple classes of antifungals, (2) it can be misidentified as other yeasts by commonly available identification methods, and (3) because of its ability to colonize patients perhaps indefinitely and persist in the healthcare environment, it can spread between patients in healthcare settings. the transmissibility and high levels of antifungal resistance that are characteristic of c. auris set it apart from most other candida species. a robust response that involves the laboratory, clinicians, and public health agencies is needed to identify and treat infections and prevent transmission. this review highlights epidemiology, pathogenesis, microbiological characteristics, clinical presentation, diagnostic challenges and treatment options of c. auris infections. infection prevention measures to prevent spread of c. auris and special measures during an outbreak situation have also been reviewed. rapid emergence of hospital onset c. auris is worrisome. early diagnosis of c. auris is essential for better outcomes and the implementation of infection prevention measures. lack of widespread awareness, absence of general availability of diagnostic testing methods, and limited options for treatment of c. auris infections make it a difficultto-treat pathogen. further studies are needed for better understanding of this emerging pathogen. keywords: fungal infection, candida, c. auris, candidemia, bloodstream infection email: dollyjain.btpc@gmail.com introduction candida species commonly colonizes the human mucosal and skin surfaces with potential to cause infections. disruption in host immunity increases the risk for development of opportunistic infections from candida. candidemia is recognized as the fourth most common cause of nosocomial bloodstream infections in the united states (us) associated with high morbidity and mortality rates (30%-40%)1. candida auris is emerging multidrug-resistant yeast that can cause invasive infections, is associated with high mortality, and can spread in healthcare settings. this yeast was first described in 2009 and has since been reported in over 20 countries on five continents. c. auris poses a global health threat for several reasons: 1. multidrug resistance is common, and a few isolates are resistant to all three of the main classes of antifungal drugs, severely limiting treatment options2. 2. c. auris is commonly misidentified in clinical laboratories. unless laboratories are aware of possible misidentification and have the ability to perform further evaluation, cases of c. auris could go undetected. 3. c. auris can be transmitted between patients in healthcare settings and cause healthcare-associated outbreaks. c. auris can colonize patients, especially on the skin, perhaps indefinitely, and persist for weeks in the healthcare environment. the lack of decolonization methods and suboptimal efficacy of some commonly used hospital environmental disinfectants compounds the challenge of controlling its spread. the genus candida comprises an array of phenotypically similar yet genetically highly divergent yeasts. c. auris differs markedly from common pathogenic candida species like candida albicans and candida glabrata. in healthcare settings, c. auris behaves more like transmissible bacterial multidrugresistant organisms (mdros), such as methicillin-resistant staphylococcus aureus (mrsa) and carbapenem-resistant enterobacteriacea (cre), than other candida species. unlike other candida infections, which are generally thought to result from autoinfection from host flora, c. auris can be transmitted between patients. unlike for most other candida species, for which transmission-based precautions are generally not required, c. auris requires implementation of specific infection control measures, much like those used for control of mrsa and cre. with itsmultidrug resistance, transmissibility and severe outcomes, c. auris has all the makings of a superbug. control of c. auris requires better understanding of the organism itself, vigilance and accurate identification, appropriate treatment and infection control measures, and a coordinated public health response. we review the emergence of c. auris, examining the global advent, biology, challenges of open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.11 jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [15] ajdhs.com identification, multidrug resistance, clinical manifestations, treatment, risk factors for infection, transmission, and control of c. auris. epidemiology incidence and prevalence the incidence of candida infections and causative candida species has varied with time and across geographic locations. until recently, the most common isolated species during nosocomial fungemia has been c. albicans, however with changing epidemiology, non-c. albicans has emerged as the predominant species in many countries1. candida glabrata is recognized as the most common cause of candidemia in the us while c. parapsilosis, c. tropicalis and c. krusei are common in other parts of the world1. the true incidence of c. auris fungemia and its global prevalence are poorly understood. this uncertainty is related to failure of conventional diagnostic methods to accurately identify c. auris and lack of global availability of diagnostic methods for its rapid identification3. few centers with diagnostic capabilities have estimated incidence and prevalence of c. auris fungemia at their healthcare facilities. prevalence of c. auris was rare prior to 2009 according to the investigation conducted on a pool of uncommon candida species included in the international antifungal surveillance program (sentry). of the 15,271 isolates reviewed from 4 continents between2004-2015, only four isolates were identified as c. auris4. however, since 2009 there has been a rapid and global emergence of c. auris. according to a single center study in sub-saharan africa from september 2010-june2013, candidemia attributed to 39% of nosocomial infections. during the study period, c. haemulonii, later reidentified as c. auris, was the most common cause of hospital-onset fungemia (38%) followed by c. albicans (27%)5. another study in multiple hospital systems in south africa highlighted the prevalence of c. auris-related candidemia to be 0.3%6. unfortunately, both these studies did not provide specific data on study period and total number of candidemia cases identified to understand the true impact of c. auris. a tertiary medical center in south america reported c. auris as the 6th most common cause of bloodstream infection in the hospital between march 2012-july 20137. an 18-month prospective study in indian icus reported 1400 candidemia cases. candida auris was identified as the 5th most common cause of icu-onset candidemia, discovered in 19 of 27 icus, with prevalence of 5.3% (n=74) 8. a random one-year screening for c. auris in patients admitted at a cardiothoracic center in london identified prevalence rateof 0.04% (1/2246 screened patients)9. overall, the prevalence of c. auris, predominantly nosocomial-onset, is rising globally. isolation of c. auris candida auris has been isolated from multiple body sites. first isolation of c. auris was from the external ear canal of a 70year-old woman in japan10. a multicenter surveillance study in korea (2004-2006) reported 15 specimens isolated from the ears of patients with chronic otitis media as closely related c. haemulonii species by sequence analysis, later re-identified as c. auris11. vaginal sample from a young woman in india identified c. auris as cause of vulvovaginitis12. candida auris has been described as the cause of fatal pericarditis in an indian patient with end stage liver disease13. first three cases of bloodstream infection from c. auris were reported from south korea in 200914. a fatal case of donor-derived c. auris infection was reported in a 71-year old lung transplant recipient in the us in 201715. currently, c. auris fungemia has been reported nearly from all continents except australia and antarctica. as awareness of c. auris has grown, novel isolates and previously unidentified candida isolates are increasingly being recognized as c. auris. according to the center for diseases control and prevention (cdc) in the united states, 86 isolates of c. auris have been identified in the us from infectious and non-infectious sources, mostly emerging from the east coast. biology and morphology the closest relatives of c. auris are c. ruelliae, c. pseudohaemulonii, candida duobushaemulonii, candida vulturna, c. heveicola, candida konsanensis, candida chanthaburiensis, c. haemulonii, and candida haemulonis var. vulnera16. c. auris is an ovoid to elongate budding yeast, which seldom forms rudimentary pseudohyphae and typically appears as pink, but sometimes white or red, colonies on chromagar candida or can2 chromogenic medium. this organism has a high tolerance for salinity and heat. its unique ability to grow at temperatures up to 42◦c16-20 and to grow in high salt conditions may help to distinguish c. auris from other candida species and aid laboratory isolation19. however, none of the phenotypic characteristics of c. auris are sufficient evidence for definitive identification. sequencing, mass spectrometry, or a vitek 2 version 8.01 are needed to accurately distinguish c. auris from closely related candida species. some strains of c. auris have been reported to form aggregations in culture, which may allow the organism to resist penetration by detergents, ultraviolet light, or other cleaning methods21. c. auris also forms biofilms, which provide a mechanism of adherence to surfaces. however, these biofilms are significantly thinner and less complex than those of c. albicans, primarily due to the rarity of pseudohyphae. c. auris may therefore have reduced ability to attach to surfaces like catheter material as compared to species that can form more robust biofilms22. in animal models, c. auris exhibits similar or slightly less virulence as c. albicans and candida tropicalis and greater virulence than the closely related species c. haemulonii23,24. its ability to form biofilms, produce phospholipase and proteinase, and secrete aspartic proteases as well as the presence of oligopeptide transporters and mannosyl transferases may explain some of the virulence seen with c. auris, though some of these characteristics have varied by strain25. aggregate-forming strains may be less virulent than strains without cell aggregations. despite these advances in our understanding of c. auris, much remains unknown about its cell biology and virulence characteristics. risk factors candida auris is a hospital-acquired pathogen causing infection in certain high-risk patient populations. the predisposing risk factors for c. auris infection are similar to other candidal species. patients with immunocompromising diseases (diabetes mellitus, malignancy, chronic kidney disease, neutropenia), concomitant bacteremia, broad spectrum antibacterial or antifungal therapy in prior 90 days, surgery within 90 days, presence of central venous catheters or urinary catheters, stay in intensive care unit (icu) and total parenteral nutrition (tpn) administration confer increased risk for acquiring c. auris26-28. till date, only one case-control study has been performed to determine specific risk factors predisposing to c. auris candidemia8. the study was conducted in the icus in india comparing c. auris (n=74) and non-auris (n=1087) fungemia cases. the multivariate analysis showed patients with respiratory illness, vascular surgery, antifungal exposure in prior 30-days and low apache ii score on admission had higher likelihood to develop icu-onset c. auris fungemia. multidrug resistance c. auris is a highly concerning pathogen because it can be resistant to multiple antifungal drugs, with some isolates resistant to all three major antifungal classes (azoles, jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [16] ajdhs.com polyenes, and echinocandins). the clinical and laboratory standards institute (clsi) and the european committee for antimicrobial susceptibility testing (eucast) have not established clinical susceptibility minimum inhibitory concentration (mic) breakpoints for c. auris. in the interim, cdc has proposed the following tentative breakpoints, conservatively based on those established for other species: ≥32 for fluconazole, ≥2 for amphotericin b (or ≥1.5 if using etest), ≥4 for anidulafungin and micafungin, and ≥2 for caspofungin29. in a collection of 54 isolates from india, pakistan, south africa, and venezuela, 93% of isolates were resistant to fluconazole, 35% were resistant to amphotericin b, and 7% were resistant to echinocandins using the following breakpoints: ≥32 for fluconazole, ≥2 for amphotericin b, and ≥8 for echinocandins. forty-one percent of isolates were resistant to at least two drug classes and two isolates were pan-resistant. in the largest study of c. auris resistance, on 350 isolates from india, 90% of isolates were resistant to fluconazole by the tentative breakpoints described above, 2% to anidulafungin, 2% to micafungin, and 8% to amphotericin b. in the united states, about 90% of isolates have been resistant to fluconazole, 30% have been resistant to amphotericin b, and 5% have been resistant to echinocandins29. public health england has reported that all uk isolates have been resistant to fluconazole, approximately 20% have been resistant to amphotericin b, and about 10% have been resistant to echinocandins30. taking data from around the world into account, c. auris has been generally resistant to fluconazole, and a substantial portion of isolates has been resistant to amphotericin b and echinocandins most other species of candida identified in clinical specimens exhibit high in vitro susceptibility to antifungal drugs. one of the other drugresistant candida of high concern has been c. glabrata, in which approximately 10% of isolates in the united states exhibit fluconazole resistance and 0–10% exhibit echinocandin resistance31,32. in comparison, the level of drug resistance observed in c. auris is unprecedented. molecular mechanisms underlying this resistance are currently under investigation. twelve erg11 mutations, which have been found in fluconazole-resistant but not wild-type c. albicans, have been found in c. auris33.three of these mutations have been directly linked to drug resistance in c. albicans, suggesting that they contribute to the resistance observed in c. auris as well34. efflux pump activity contributes to azole resistance in other candida species and may contribute to resistance in c. auris, though the extent of this contribution is unknown. none of these mechanisms alone can account for the high levels of resistance seen in c. auris, so multiple mechanisms are likely involved. elevated echinocandin mics are likely the result of fks mutations observed in c. auris isolates, such as the s639f mutation observed in isolates from india33.these mutations correspond to known mutations in other candida species, which have been directly linked to echinocandin resistance35. finally, while resistance to amphotericin b is rare in the most common candida species, it is observed in approximately 30% of us isolates of c. auris. though unconfirmed at this time, it is suspected that this is likely due to a reduction in ergosterol content in the cellular membrane-specifically a mutation in a gene involved in ergosterol biosynthesis36. clinical manifestations similar to other candida species, c. auris can cause severe invasive infections or colonize patients without infection. c. auris has been isolated from normally sterile body sites, including blood, bone, and cerebrospinal fluid, indicating invasive infection. infections may be severe, and persistently positive blood cultures for >5 days or recurrent candidemia in those with c. auris candidemia have been reported. c. auris candidemia is associated with mortality rates of about 30– 60%, depending on the setting . other clinical sources found in the course of routine patient care have been bile fluid, the ear, jejuna biopsy, ocular secretion, peritoneal fluid, pleural fluid, the respiratory tract, urine, vaginal fluid, and wounds; some of these represent sites of colonization rather than infection. patients can also be asymptomatically colonized with c. auris on the skin, nares, and other body sites37-39. diagnosis the under-recognition and delay in accurate diagnosis of c. auris species has been attributed to its misidentification by commercial biochemical methods (manual and automated). the conventional commercial diagnostic yeast identification systems such as vitek 2, bd phoenix and api20 are not able to identify or frequently misidentify c. auris isolates as one of the closely related candida species c. haemulonii, c. famata, c. catenulata, c. sake and rhodotorula glutinis40. molecular testing investigators have relied upon molecular methods to facilitate accurate identification of c. auris species. one of the most common methods described in multiple research studies and case reports was genomic dna extraction from the misidentified candida species followed by dna amplification and sequencing of the internal transcribed spacers (its) and d1/d2 regions of the ribosomal dna. these sequences were re-identified based on 98%-100% homology with c. auris isolate using genbank basic local alignment search tool (blast) from national center for biotechnology information (ncbi) database18,41. the its sequencing was also beneficial to define genomic diversity between c. auris and closely related candida isolates differentiating them into separate clades with bootstrap value of 99%18,42. rapid, efficient and successful identification of c. auris isolates was shown using msvitek and bruker microflex matrix-assisted laser desorption ionization time of flight mass spectrometry (maldi-tof) identification system43. however, caution is advised while using maldi-tof as not all devices include c. auris in the reference database44. during laboratory identification and validation of cdc panel containing c. auris, incorporation of research-use-only library containing c. auris resulted in accurate identification of c. auris isolates by both maldi-tof systems45. polymerase chain reaction (pcr) and real-time pcr assays have been developed targeting rdna region nucleotide sequences specific for c. auris. the assays showed rapid and accurate identification of c. auris similar to dna sequencing results46. the us cdc has provided guidance to healthcare facilities to suspect c. auris based on detection of misidentified candida species by standard testing method and for accurate identification of c. auris using diagnostic methods such as maldi-tof with updated database and dna sequencing. laboratories located in the us without capability to identify suspected candida isolates have an option to send samples to the cdc using state public health laboratories for further characterization. geographical link geographical clustering of c. auris isolates has been performed using genomic and proteomic analysis based on mutilocus sequence typing (mlst), maldi-tof ms and amplified fragment length polymorphism (aflp) typing42. among the analytic methods, m13 pcr fingerprinting and aflp is recognized as most efficient for strain typing and for geographical clustering helpful in epidemiological analysis42. the aflp typing grouped c. auris strains mainly into two clusters of indian and brazilian origin42. isolates from south african origin were randomly distributed among both clusters. c. auris isolates from india, brazil and south africa were clonal jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [17] ajdhs.com for the respective country of origin with 99%-100% nucleotide sequence similarity. a multicenter study in united kingdom (uk) performed rdna sequencing of 24 c. auris isolates, grouping the c. auris strains into three different lineages belonging to india/malaysia/kuwait, japan/korea and south african origin47. whole genome sequencing (wgs) of c. auris isolates showed genome size of 12.5mb similar to other candida species. the wgs helped establish independent emergence of c. auris isolates in different continents as the isolates differed by tens of thousands of single nucleotide polymorphisms (snps) between the geographic locations. the isolates from the us seem to be related to those from south asia (<60 snps apart) and south america (<150 snps apart), with no proven direct or indirect travel link48. treatment only three major classes of antifungal drugs are available to treat invasive fungal infections. c. auris poses a real treatment challenge because of high rates of antifungal drug resistance. as reported above, most c. auris isolates are resistant to fluconazole, the most widely available antifungal treatment for candidiasis. the alternatives, echinocandins and amphotericin b, are expensive and are not easily available in countries with more limited resources. amphotericin b is also known for causing severe side effects. although studies have reported therapeutic outcomes, no systematic study has assessed effectiveness of various antifungals against c. auris infections in humans. however, in a mouse model, micafungin wasmore efficacious at killing c. auris than fluconazole and amphotericin b. an in vitro study examining combinations of treatment with echinocandins and azoles found a synergistic interaction between micafungin and fluconazole and did not find any antagonistic interactions between micafungin or caspofungin and fluconazole or voriconazole. research is also being conducted on activity of new drugs like scy078, apx001a/apx001and cd101against c. auris, but these options are not yet available for clinical use in most settings. based on the most frequent resistance profiles, echinocandins are the recommended first-line treatment for most c. auris infections in adults. antifungal susceptibility testing is advised to inform treatment and patients should be closely monitored for treatment failure. acquired resistance while on treatment is a concern. echinocandin resistance has developed in patients with c. auris infection while receiving echinocandin treatment. for neonates and infants under 2 months of age, cdc recommends amphotericin b deoxycholate (1 mg/kg daily) as the first line treatment, with consideration of liposomal amphotericin b (5 mg/kg daily) if unresponsive to amphotericin b deoxycholate. echinocandin treatment in neonates and infants less than 2 months of age should only be considered in rare circumstances and only after checking that the central nervous system has not been affected. removal of catheters and lines and surgical debridement has been used alongside antifungal drugs when clinically indicated49-55. conclusion within less than a decade of its discovery, c. auris surpasses all candida species as the most difficult pathogen to identify and treat. poor practice of infection prevention measures and stewardship efforts may have led to rapid spread of drugresistant c. auris. lack of widespread awareness and recognition of this imminent fungal threat is likely to lead to significant consequences. further research is needed to understand the spread of this emerging pathogen and to develop better management strategies to combat this worrisome infection. references 1. mikulska m, del bono v, ratto s, et al. occurrence, presentation and treatment of candidemia. expert rev clin immunol. 2012; 8(8):755-65. https://doi.org/10.1586/eci.12.52 2. lockhart sr, etienne ka, vallabhaneni s et al. simultaneous emergence of multidrug-resistant candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses. clin infect dis. 2017; 64:134-140. https://doi.org/10.1093/cid/ciw691 3. centers for disease control and prevention. clinical alert to us healthcare facilities: global emergence of invasive infections caused by the multidrug-resistant yeast candida auris [internet] atlanta: cdc; 2017. 4. lockhart sr, etienne ka, vallabhaneni s, et al. simultaneous emergence of multidrug-resistant candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses. clin infect dis.2017; 64(2):134-40. https://doi.org/10.1093/cid/ciw691 5. okinda ek, castanheira m, njuguna a, et al. candidemia at a referral hospital in sub-saharan africa: emergence of candida auris as a major pathogen. european conference on clinical microbiology and infectious diseases: 2014: barcelona, spain[poster session] 6. magobo re, corcoran c, seetharam s, et al. candida auris-associated candidemia, south africa. emerg infect dis. 2014; 20(7):1250-1. https://doi.org/10.3201/eid2007.131765 7. calvo b, melo as, perozo-mena a, et al. first report of candida auris in america: clinical and microbiological aspects of 18 episodes of candidemia. j infect. 2016; 73(4):369-74. https://doi.org/10.1016/j.jinf.2016.07.008 8. rudramurthy sm, chakrabarti a, paul ra, et al. candida auris candidaemia in indian icus: analysis of risk factors. j antimicrob chemother. 2017; 72(6):1794-801. https://doi.org/10.1093/jac/dkx034 9. schelenz s, hagen f, rhodes jl, et al. first hospital outbreak of the globally emerging candida auris in a european hospital. antimicrob resist infect control. 2016; 5:35. https://doi.org/10.1186/s13756-016-0132-5 10. satoh k, makimura k, hasumi y, et al. candida auris sp. nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a japanese hospital. microbiol immunol. 2009; 53(1):41-4. https://doi.org/10.1111/j.1348-0421.2008.00083.x 11. kim mn, shin jh, sung h, et al. candida haemulonii and closely related species at 5 university hospitals in korea: identification, antifungal susceptibility, and clinical features. clin infect dis. 2009; 48(6):e57-61. https://doi.org/10.1086/597108 12. kumar d, banerjee t, pratap cb, et al. itraconazole-resistant candida auris with phospholipase, proteinase and hemolysin activity from a case of vulvovaginitis. j infect develop countries. 2015; 9(4):435-7. https://doi.org/10.3855/jidc.4582 13. khillan v, rathore n, kathuria s, et al. a rare case of breakthrough fungal pericarditis due to fluconazole-resistant candida auris in a patient with chronic liver disease. jmm case rep. 2014. https://doi.org/10.1099/jmmcr.0.t00018 14. lee wg, shin jh, uh y, et al. first three reported cases of nosocomial fungemia caused by candida auris. j clin microbiol. 2011; 49(9):3139-42. https://doi.org/10.1128/jcm.00319-11 15. azar mm, turbett se, fishman ja, et al. donor-derived transmission of candida auris during lung transplantation. clin infect dis. 2017. https://doi.org/10.1093/cid/cix460 16. sipiczki m, tap rm. candida vulturna pro tempore sp. nov., a dimorphic yeast species related to the candida haemulonis species complex isolated from flowers and clinical sample. int j syst evol microbiol. 2016; 66:4009-4015. https://doi.org/10.1099/ijsem.0.001302 17. sherry l, ramage g, kean r et al. biofilm-forming capability of highly virulent, multidrug-resistant candida auris. emerg infect dis. 2017; 23:328-331. https://doi.org/10.3201/eid2302.161320 https://doi.org/10.1586/eci.12.52 https://doi.org/10.1093/cid/ciw691 https://doi.org/10.1093/cid/ciw691 https://doi.org/10.3201/eid2007.131765 https://doi.org/10.1016/j.jinf.2016.07.008 https://doi.org/10.1093/jac/dkx034 https://doi.org/10.1186/s13756-016-0132-5 https://doi.org/10.1111/j.1348-0421.2008.00083.x https://doi.org/10.1086/597108 https://doi.org/10.3855/jidc.4582 https://doi.org/10.1099/jmmcr.0.t00018 https://doi.org/10.1128/jcm.00319-11 https://doi.org/10.1093/cid/cix460 https://doi.org/10.1099/ijsem.0.001302 https://doi.org/10.3201/eid2302.161320 jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [18] ajdhs.com 18. kathuria s, singh pk, sharma c et al. multidrug-resistant candida auris misidentified as candida haemulonii: characterization by matrix-assisted laser desorption ionization-time of flight mass spectrometry and dna sequencing and its antifungal susceptibility profile variability by vitek 2, clsi broth microdilution, and etest method. j clin microbiol. 2015; 53:18231830. https://doi.org/10.1128/jcm.00367-15 19. welsh rm, bentz ml, shams a, et al. survival, persistence, and isolation of the emerging multidrug-resistant pathogenic yeast candida auris on a plastic healthcare surface. j clin microbiol. 2017; 55:2996-3005. https://doi.org/10.1128/jcm.00921-17 20. ben-ami r, berman j, novikov a et al. multidrug-resistant candida haemulonii and c. auris, tel aviv, israel. emerg infect dis. 2017; 23:195-203. https://doi.org/10.3201/eid2302.161486 21. borman am, szekely a, johnson em. isolates of the emerging pathogen candida auris present in the uk have several geographic origins. med mycol. 2017; 55:563-567. https://doi.org/10.1093/mmy/myw147 22. larkin e, hager c, chandra j et al. the emerging pathogen candida auris: growth phenotype, virulence factors, activity of antifungals, and effect of scy078, a novel glucan synthesis inhibitor, on growth morphology and biofilm formation. antimicrob agents chemother. 2017; 61:e02396-16. https://doi.org/10.1128/aac.02396-16 23. borman am, szekely a, johnson em. comparative pathogenicity of united kingdom isolates of the emerging pathogen candida auris and other key pathogenic candida species. msphere. 2016; 1:e00189-16. https://doi.org/10.1128/msphere.00189-16 24. fakhim h, vaezi a, dannaoui e et al. comparative virulence of candida auris with candida haemulonii, candida glabrata and candida albicans in a murine model. mycoses. 2018; 61:377-382. https://doi.org/10.1111/myc.12754 25. chatterjee s, alampalli sv, nageshan rk, chettiar st, joshi s, tatu us. draft genome of a commonly misdiagnosed multidrug resistant pathogen candida auris. bmc genomics. 2015; 16:686. https://doi.org/10.1186/s12864-015-1863-z 26. chowdhary a, voss a, meis jf. multidrug-resistant candida auris: 'new kid on the block' in hospital-associated infections. j hosp infect. 2016; 94(3):209-12. https://doi.org/10.1016/j.jhin.2016.08.004 27. chowdhary a, anil kumar v, sharma et al. multidrug-resistant endemic clonal strain of candida auris in india. european j clin microbiol infect dis.2014; 33(6):919-26. https://doi.org/10.1007/s10096-013-2027-1 28. chowdhary a, sharma c, duggal s, et al. new clonal strain of candida auris, delhi, india. emerg infect dis. 2013; 19(10):1670-3. https://doi.org/10.3201/eid1910.130393 29. division of foodborne, waterborne and environmental diseases, national center for emerging and zoonotic infectious diseases, centers for disease control and prevention. recommendations for identification of candida auris. 2017; https://www.cdc.gov/fungal/candidaauris/recommendations.html. 30. bishop l, cummins m, guy r et al. guidance for the laboratory investigation, management and infection prevention and control for cases of candida auris. vol v 2.0. london: public health england. 2017. 31. vallabhaneni s, cleveland aa, farley mm et al. epidemiology and risk factors for echinocandin nonsusceptible candida glabrata bloodstream infections: data from a large multisite populationbased candidemia surveillance program, 2008-2014. open forum infect dis. 2015; 2:ofv163. https://doi.org/10.1093/ofid/ofv163 32. lockhart sr, iqbal n, cleveland aa et al. species identification and antifungal susceptibility testing of candida bloodstream isolates from population-based surveillance studies in two u.s. cities from 2008 to 2011. j clin microbiol. 2012; 50:3435-3442. https://doi.org/10.1128/jcm.01283-12 33. chowdhary a, prakash a, sharma c et al. a multicentre study of antifungal susceptibility patterns among 350 candida auris isolates (2009-17) in india: role of the erg11 and fks1 genes in azole and echinocandin resistance. j antimicrob chemother. 2018; 73:891-899. https://doi.org/10.1093/jac/dkx480 34. flowers sa, colon b, whaley sg, schuler ma, rogers pd. contribution of clinically derived mutations in erg11 to azole resistance in candida albicans. antimicrob agents chemother. 2015; 59:450-460. https://doi.org/10.1128/aac.03470-14 35. perlin ds. mechanisms of echinocandin antifungal drug resistance. ann n y acad sci. 2015; 1354:1-11. https://doi.org/10.1111/nyas.12831 36. pfaller ma, espinel-ingroff a, canton e et al. wild-type mic distributions and epidemiological cutoff values for amphotericin b, flucytosine, and itraconazole and candida spp. as determined by clsi broth microdilution. j clin microbiol. 2012; 50:2040-2046. https://doi.org/10.1128/jcm.00248-12 37. forsberg k, woodworth k, walters m, berkow el, jackson b, chiller t, vallabhaneni s. candida auris: the recent emergence of a multidrug-resistant fungal pathogen. med mycol. 2018; 0:1-12. https://doi.org/10.1093/mmy/myy054 38. al-siyabi t, al busaidi i, balkhair a, al-muharrmi z, al-salti m, al'adawi b. first report of candida auris in oman: clinical and microbiological description of five candidemia cases. j infect. 2017; 75:373-376. https://doi.org/10.1016/j.jinf.2017.05.016 39. rudramurthy sm, chakrabarti a, paul ra et al. candida auris candidaemia in indian icus: analysis of risk factors. j antimicrob chemother. 2017; 72:1794-1801. https://doi.org/10.1093/jac/dkx034 40. navalkele bd, revankar s, chandrasekar p. candida auris: a worrisome, globally emerging pathogen, expert rev anti-infect ther. 2017. https://doi.org/10.1080/14787210.2017.1364992 41. kim th, kweon oj, kim hr, et al. identification of uncommon candida species using commercial identification systems. j microbiol biotechnol. 2016; 26(12):2206-13. https://doi.org/10.4014/jmb.1609.09012 42. prakash a, sharma c, singh a, et al. evidence of genotypic diversity among candida auris isolates by multilocus sequence typing, matrix-assisted laser desorption ionization time-of-flight mass spectrometry and amplified fragment length polymorphism. clin microbiol infect. 2016; 22(3):277.e19. https://doi.org/10.1016/j.cmi.2015.10.022 43. girard v, mailler s, chetry m, et al. identification and typing of the emerging pathogen candida auris by matrix-assisted laser desorption ionisation time of flight mass spectrometry. mycoses. 2016; 59(8):535-8. https://doi.org/10.1111/myc.12519 44. candida auris interim recommendations for healthcare facilities and laboratories [internet] atlanta, cdc 2016. 45. mizusawa m, miller h, green r, et al. can multidrug-resistant candida auris be reliably identified in clinical microbiology laboratories. j clin microbiol. 2017; 55(2):638-40. https://doi.org/10.1128/jcm.02202-16 46. kordalewska m, zhao y, lockhart sr, et al. rapid and accurate molecular identification of the emerging multidrug resistant pathogen candida auris. j clin microbiol. 2017. https://doi.org/10.1128/jcm.00630-17 47. borman am, szekely a, johnson em. isolates of the emerging pathogen candida auris present in the uk have several geographic origins. med mycol. 2017. https://doi.org/10.1093/mmy/myw147 48. tsay s, welsh rm, adams eh, et al. notes from the field: ongoing transmission of candida auris in health care facilities united states, june 2016-may 2017. mmwr morb mortal wkly rep. 2017; 66(19):514-5. https://doi.org/10.15585/mmwr.mm6619a7 49. lepak aj, zhao m, berkow el, lockhart sr, andes dr. pharmacodynamic optimization for treatment of invasive candida auris infection. antimicrob agents chemother. 2017; 61:e0079117. https://doi.org/10.1128/aac.00791-17 https://doi.org/10.1128/jcm.00367-15 https://doi.org/10.1128/jcm.00921-17 https://doi.org/10.3201/eid2302.161486 https://doi.org/10.1093/mmy/myw147 https://doi.org/10.1128/aac.02396-16 https://doi.org/10.1128/msphere.00189-16 https://doi.org/10.1111/myc.12754 https://doi.org/10.1186/s12864-015-1863-z https://doi.org/10.1016/j.jhin.2016.08.004 https://doi.org/10.1007/s10096-013-2027-1 https://doi.org/10.3201/eid1910.130393 https://doi.org/10.1093/ofid/ofv163 https://doi.org/10.1128/jcm.01283-12 https://doi.org/10.1093/jac/dkx480 https://doi.org/10.1128/aac.03470-14 https://doi.org/10.1111/nyas.12831 https://doi.org/10.1128/jcm.00248-12 https://doi.org/10.1093/mmy/myy054 https://doi.org/10.1016/j.jinf.2017.05.016 https://doi.org/10.1093/jac/dkx034 https://doi.org/10.1080/14787210.2017.1364992 https://doi.org/10.4014/jmb.1609.09012 https://doi.org/10.1016/j.cmi.2015.10.022 https://doi.org/10.1111/myc.12519 https://doi.org/10.1128/jcm.02202-16 https://doi.org/10.1128/jcm.00630-17 https://doi.org/10.1093/mmy/myw147 https://doi.org/10.15585/mmwr.mm6619a7 https://doi.org/10.1128/aac.00791-17 jain et al asian journal of dental and health sciences. 2022; 2(1):14-19 [19] ajdhs.com 50. fakhim h, chowdhary a, prakash a et al. in vitro interactions of echinocandins with triazoles against multidrug-resistant candida auris. antimicrob agents chemother. 2017; 61:e01056-17. https://doi.org/10.1128/aac.01056-17 51. berkow el, angulo d, lockhart sr. in vitro activity of a novel glucan synthase inhibitor, scy-078, against clinical isolates of candida auris. antimicrob agents chemother. 2017; 61: e0043517. https://doi.org/10.1128/aac.00435-17 52. hager cl, larkin el, long l, zohra abidi f, shaw kj, ghannoum ma. in vitro and in vivo evaluation of the antifungal activity of apx001a/apx001 against candida auris. antimicrob agents chemother. 2018; 62:e02319-17. https://doi.org/10.1128/aac.02319-17 53. berkow el, lockhart sr. activity of cd101, a long-acting echinocandin, against clinical isolates of candida auris. diagn microbiol infect dis. 2018; 90:196-197. https://doi.org/10.1016/j.diagmicrobio.2017.10.021 54. choi hi, an j, hwang jj, moon sy, son js. otomastoiditis caused by candida auris: case report and literature review. mycoses. 2017; 60:488-492. https://doi.org/10.1111/myc.12617 55. lesho ep, bronsteinmz, mcgann p et al. importation, mitigation, and genomic epidemiology of candida auris at a large teaching hospital. infect control hosp epidemiol. 2018: 39:53-57. https://doi.org/10.1017/ice.2017.231 https://doi.org/10.1128/aac.01056-17 https://doi.org/10.1128/aac.00435-17 https://doi.org/10.1128/aac.02319-17 https://doi.org/10.1016/j.diagmicrobio.2017.10.021 https://doi.org/10.1111/myc.12617 https://doi.org/10.1017/ice.2017.231 jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [33] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited novel drug delivery systems: an overview sameeksha jain*, meena kirar, mahima bindeliya, lucky sen, madhur soni, md shan, arpana purohit, prateek kumar jain adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _________________________________________ article history: received 21 jan 2022 reviewed 26 feb 2022 accepted 09 march 2022 published 15 march 2022 _________________________________________ cite this article as: jain s, kirar m, bindeliya m, sen l, soni m, shan m, purohit a, jain pk, novel drug delivery systems: an overview, asian journal of dental and health sciences. 2022; 2(1):33-39 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.14 _________________________________________ *address for correspondence: sameeksha jain, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ the performance of an existing medicinal molecule in terms of patient compliance, safety, and efficacy can be greatly enhanced by evolving it from a traditional form to a unique delivery mechanism. an old medication molecule can be given new life as a novel drug delivery system. the limitations of the conventional drug delivery methods are addressed by the innovative drug delivery system, which is a novel method of drug administration. a significant improvement in the ability to release a drug at a specified spot and rate is possible with a novel drug delivery system that is properly developed. pharmaceutical companies are working to create novel drug delivery systems in order to give medications to patients effectively and with fewer side effects. the fundamentals of novel drug delivery systems, as well as their various varieties, are covered in this article. the scientific requirements to be incorporated in novel drug delivery systems, such as nanoparticles, microemulsions, matrix systems, solid dispersions, liposomes, solid lipid nanoparticles, and so on, can be met by modern phytopharmaceuticals research, though, by determining pharmacokinetics, mechanism of action, site of action, required precise dose, etc. keywords: novel drug delivery system, conventional drug delivery, pharmaceutical companies, pharmacokinetics. email; sameejain888@gmail.com introduction the way a medicine is administered can significantly affect how effective it is. concentrations above or below this range may be hazardous or fail to yield any therapeutic benefit for some medications, which have an optimal concentration range within which maximum benefit is obtained1. the very gradual improvement in the effectiveness of treating serious diseases, on the other hand, has indicated an increasing need for a multidisciplinary approach to the delivery of medicines to targets in tissues. this led to the development of fresh concepts for managing the pharmacokinetics, pharmacodynamics, non-specific toxicity, immunogenicity, biorecognition and effectiveness of medications. these innovative approaches-often referred to as drug delivery systems (dds)-combine polymer science, pharmaceutics, bioconjugate chemistry and molecular biology. various drug delivery and drug targeting systems are now being developed to reduce drug degradation and loss, to prevent negative side effects, to boost medication bioavailability, and to raise the percentage of the drug accumulating in the necessary zone1. previously simply a pipe dream or at most a potential, controlled and novel drug delivery is now a reality. pharmaceutical and other experts have conducted considerable and rigorous study in this area of drug development during the past 15 years. soluble polymers, microparticles comprised of insoluble or biodegradable, natural and synthetic polymers, cells, cell ghosts, lipoproteins, liposomes, and micelles are examples of drug carriers. the carriers can be engineered to slowly degrade, react to stimuli (such changes in temperature or ph), and even be targeted (e.g., by conjugating them with specific antibodies against certain characteristic components of the area of interest). the capacity to steer a drug-loaded system to a specific location is known as targeting. to address the intended areas for drug release, two main processes can be identified: (i) passive and; (ii) active targeting1 the preferential accumulation of chemotherapeutic drugs in solid tumors as a result of the increased vascular permeability of tumor tissues in comparison to healthy tissue is an example of passive targeting. surface functionalization of drug carriers with ligands that are specifically recognized by receptors on the surface of the cells of interest is a method that might enable active targeting. this might enable more exact targeting of the location of interest because ligand-receptor interactions can be quite selective. any drug delivery system may be defined as a system comprising of: a) drug formulation b) medical device or dosage form/technology to carry the drug inside the body c) mechanism for the release the formulation of the medicine into an appropriate form, such as a crushed tablet for oral administration or a solution for intravenous administration, is a traditional drug delivery open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.14 jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [34] ajdhs.com method. it has been discovered that these dose forms have significant drawbacks, including greater dosage requirements, decreased effectiveness, toxicity, and negative side effects. to fulfill the demands of the healthcare industry, new drug delivery systems have been developed or are being developed to get around the drawbacks of the traditional drug delivery systems. these systems fall under the categories of targeted medication delivery systems and controlled drug release systems. the therapeutic benefits of these new systems include:  increased medication effectiveness and site-specific delivery  reduced toxicity and side effects  enhanced convenience  effective therapies for diseases that were once incurable  potential applications for prevention  better adherence from the patient. drug delivery methods don't have a standardized definition that is widely accepted. it is presumable that it is based on the two fundamental factors of route of entry (a) and dosage form (b). any component of (a x bcartesian )'s product is considered a drug delivery mechanism. such a definition suggests that this group contains a sizable number of individuals. carrier based drug delivery system a) liposomes b) nanoparticles c) microspheres d) monoclonal antibodies e) niosomes f) resealed erythrocytes as drug carriers transdermal drug delivery systems a) sonophoresis  supramolecular delivery systems  variable release delivery systems b) osmotic pump c) microencapsulation drug delivery carriers micellar solutions, vesicle and liquid crystal dispersions, as well as nanoparticle dispersions made up of tiny particles with a diameter of 10–400 nm, all hold considerable potential as colloidal drug carrier systems. the objective when creating these formulations is to produce systems with ideal drug loading and release characteristics, a long shelf life, and low toxicity2. the medicine that has been integrated affects the system's microstructure and may even change it as a result of molecular interactions, particularly if the drug has amphiphilic and/or mesogenic features. pharmaceutical carriers for drug delivery applications, micelles created by the selfassembly of amphiphilic block copolymers (5-50 nm) in aqueous solutions are of great interest. drugs can be delivered at concentrations that are greater than their intrinsic water solubility by becoming physically trapped in the center of block copolymer micelles. additionally, the hydrophilic building pieces have the ability to make hydrogen bonds with their watery environment and create a solid shell around the micellar core. as a result, the hydrophobic core's contents are effectively shielded against hydrolysis and enzymatic deterioration. additionally, the corona might inhibit the reticuloendothelial system from recognizing the micelles, leading to their preliminary removal from the bloodstream. amphiphilic block copolymers' ability to easily adjust their chemical composition, total molecular weight, and block length ratios, which enables control over the size and shape of the micelles, is a final characteristic that makes them appealing for drug delivery applications. the stability of the associated micelles can be improved as a result of functionalizing block copolymers with cross linkable groups. block copolymer micelles can be substituted with certain ligands to activate a wider variety of sites with considerably higher selectivity3. liposomes vesicles called liposomes might have a lot, a little, or only one phospholipid bilayer inside of them. polar medicinal molecules can be encapsulated due to the liposomal core's polar nature. according to their affinity for phospholipids, amphiphilic and lipophilic compounds are solubilized within the phospholipid bilayer. niosomes are produced when nonionic surfactants participate in the bilayer synthesis rather than phospholipids. in the hydrophobic region of vesicle membranes, channel proteins can be inserted without losing their functionality, operating as a size-selective filter that only permits passive diffusion of tiny solutes like ions, nutrients, and antibiotics. as a result, pharmaceuticals that are enclosed in nanocages functionalized with channel proteins are efficiently shielded from proteolytic enzymes' premature breakdown. the drug molecule, however, is able to diffuse through the channel, driven by the concentration difference between the interior and the exterior of the nanocage4-8. dendrimers dendrimers are symmetrical macromolecules with nanometer-sized, highly branching, monodisperse structures. a central core, branching units, and terminal functional groupings make them up. the environment of the nanocavities and, subsequently, their solubilizing capabilities are determined by the core together with the internal units, whilst the solubility and chemical behavior of these polymers are determined by the exterior groups. attaching targeting ligands to the dendrimers' exterior surfaces influences the efficiency of targeting, and functionalizing the dendrimers with polyethylene glycol chains increases their stability and protects them from the mononuclear phagocyte system. the characteristics of both the liquid and solid states are combined in liquid crystals. they are capable of taking on various geometries and can incorporate aqueous medicinal solutions in alternative polar and non-polar layers (i.e., a lamellar phase) 9, 10. nanoparticles nanoparticles are in the solid form and can be either amorphous or crystalline, with sizes ranging from 10 to 200 nm for nanospheres and nanocapsules. they have the capacity to adsorb and/or encapsulate a medication, shielding it from enzymatic and chemical deterioration. given their uses in the controlled release of drugs, the ability to target specific organs or tissues, the ability to carry dna in gene therapy, and the ability to deliver proteins, peptides, and genes orally, biodegradable polymeric nanoparticles have received a lot of attention recently as potential drug delivery devices11. jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [35] ajdhs.com grouping of nanomaterials: a) nanowiresglowing silica nano wire is wraped around a single stand of human hair. it looks delicate. it is about five times smaller than virus applications for nano wires include the early sensing of breast and ovarian malignancies. a) nanocantileverthis tiny carbon cantilever's honeycomb mesh serves as the fly's eye's surface. beams with a single end anchored are known as cantilevers. they serve as sensors in the nano realm, perfect for identifying the presence of incredibly small compounds in biological fluid. b) nanoshellsgold-coated hollow silica spheres make up nanoshells. in order for the shells to target certain shells, such as cancer cells, scientists can attach antibodies to the surfaces of the shells. one day, polymers holding drugs will also be incorporated into nanoshells. c) quantum dotsquantum dots, which are tiny semiconductor particles, can act as markers for specific types of cells or substances in the body. they are able to achieve this because the type of cadmium employed in their cores affects the wavelengths of radiation that they release. cadmium telluride is used for the far infrared and near infrared, cadmium sulphide for the ultraviolet to blue, and cadmium selinide for the majority of the visible spectrum. d) nano poresapplications for cancer research and treatment involve nanopores. they are holes that have been engineered into particles that are so small that dna molecules can flow through them one strand at a time, enabling extremely accurate and effective dna sequencing. drug producers can control the pace of drug diffusion in the body by incorporating nanopores into the surface of pill capsules that are just a little bit larger than the molecules of the medication. e) gold nanoparticlesthe transmission electron microscopy image of these nanoparticles reveals that they have a solid core. in order to create super sensitive detection methods for dna and protein markers connected to various types of cancer, including breast and prostate cancer, researchers at north western university are employing gold particles. f) nanotubes carbon atoms are arranged in hollow cylinders called nanotubes. additionally, they can be filled with liquid and sealed to create test tubes or prospective drug delivery systems. carbon nanotubes it is possible to modify carbon nanotubes so they circulate easily inside the body. both covalent and non-covalent bonds are capable of carrying out these alterations. changes can lengthen or shorten the duration that blood circulates through the body. when carbon nanotubes are altered to be soluble in aqueous bodily fluids, their toxicity is minimal. they easily access the cells. larger than normal cells and showing leaking, cancer cells are found in tumors. large molecules that move slowly can enter cancer cells and build up there. animal investigations have shown that carbon nanotubes carrying active substances are capable of doing this. researchers have also using carbon tubes to deliver prodrugs, or precursors to active pharmaceutical ingredients. as in: cisplatin12-16. microspheres microspheres are naturally biodegradable powders made of proteins or synthetic polymers that flow freely and preferably have a particle size of less than 200 m. polymers are the materials utilized to create microspheres. they are classified into two types 1. synthetic polymers 2. natural polymers synthetic polymers are divided into two types. a. non-biodegradable polymers  poly methyl methacrylate (pmma)  glycidyl methacrylate  epoxy polymers b. biodegradable polymers  lactides, glycolides & their co polymers  poly alkyl cyano acrylates  poly anhydrides synthetic polymers a possible medication carrier for parenteral as well as other ophthalmic, oral preparations is poly alkyl cyano acrylates. a good carrier for narcotic antagonist, anti-cancer drugs including cisplatin, cyclo phosphamide, and doxorubicin is poly lactic acid. co-polymers of poly lactic acid and poly glycolic acid have been used in the formulation of sustained release formulations for antimalarial medications as well as for many other medications. it has been explored to increase the precorneal residence duration for ocular administration using poly anhydride microspheres (40 m). timolol maleate is packaged in poly adipic anhydride for ocular administration. functional microspheres are those made of poly acrolein. since the surfacial free cho groups over the poly acrolein can react with the nh2 group of the protein to create schiff's base, they do not need any activation steps. when delivered parenterally, non-biodegradable drug carriers have the potential to cause long-term carrier toxicity because they stay in the body after the drug has been fully released. parenteral applications are better suited for biodegradable carriers that break down in the body to non-toxic breakdown products since they do not raise the issue of carrier toxicity. natural polymers natural polymers obtained from different sources like proteins, carbohydrates and chemically modified carbohydrates. proteins: albumin, gelatin, and collagen carbohydrates: agarose, carrageenan, chitosan, starch chemically modified carbohydrates: polydextran, poly starch. gelatin microspheres are an effective means of transporting substances that can alter biological responses, such as interferon, to phagocytes. starch is a type of carbohydrate. it is mostly composed of the glucopyranose unit, which upon hydrolysis produces d-glucose. it has a lot of free oh groups because it is a poly saccharide. numerous active chemicals can be integrated into and made active on the surface of microspheres using these free oh groups. a deacylated form of chitin is chitosan. due to its charge, the effect of chitosan has been taken into consideration. at neutral and alkaline ph levels, it is insoluble, although it combines with other salts to produce salts. chitosan's amino groups protonate during breakdown, resulting in a positively charged polymer 17-19. resealed erythrocytes as drug carriers the most numerous cells in the human body, erythrocytes, may be used as a drug delivery vehicle. erythrocytes can be loaded with a number of chemically and physiologically active jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [36] ajdhs.com chemicals utilizing a variety of chemical and physical techniques, and they are biocompatible, biodegradable, have very long circulation half lifetimes, and all of these characteristics. erythro = red and cytes = cell erythrocyte is red cell. erythrocyte is biconcave discs, anucleate filled with hemoglobin (hb), a protein that functions in gas transport. it contains the plasma protein spectrin. healthy adult male=4.5millions/µml healthy adult female=4.8million/ µml immature rbc are called “reticulocytes20.” erythrocytes properties of resealed erythrocyte of novel drug delivery carriers: 1) a regulated release of the medicine is required at the target spot. 2) it must be the proper size and form and be able to flow through capillaries. and drug leakage should be kept to a minimum. 3) it should have a low harmful effect and be biocompatible. 4) it should be able to transport a variety of medications. 5) it must have distinct physicochemical characteristics that enable identification of the intended target size. 6) after the medicine has been released at the chosen site, the degradation product of the carrier system should be biocompatible. the two should be physically and chemically compatible. 7) the carrier system must to be noticeably stable when being stored. advantage: 1) they are biodegradable by nature because they are a natural component of the body. 2) chemical drug modification is not necessary for the trapping of drugs. 3) drug entrapment does not necessitate chemical alteration of the target material. 4) they can be directed towards diseased tissue or organs and have non-immunogenic activity. 5) they extend the drug's systemic action. 6) it is simple to isolate erythrocytes, and more medication can be contained in a smaller volume of cells. 7) they are able to focus the medication on the reticuloendothelial system. 8) they make it easier for eukaryotic cells to incorporate protein and nucleic acid by infusing the cells with rbc. disadvantage: 1) they have a limited potential as carrier to nonphagocyte target tissue. 2) possibility of clumping of cells and dose dumping may be there21. drug loaded erythrocytes one of the expanding and potential systems for the delivery of medications and enzymes is this one. erythrocytes can be filled with a range of biologically active chemicals and are biocompatible, biodegradable, have a long circulation half-life, and all of these characteristics. by obtaining blood samples from the target organism and separating the erythrocytes from the plasma, carrier erythrocytes are prepared. the term "resealed erythrocytes" refers to the carriers produced when cells are ruptured and drugs are trapped inside of them utilizing a variety of physical and chemical techniques. when administered again, the drug targets the reticulo-endothelial system through the sluggish circulation of the drug-loaded erythrocytes22-25. niosomes the non-ionic surfactant span-60, which forms vesicles in niosomes, is often stabilized by the addition of cholesterol and a little amount of an anionic surfactant like dicetyl phosphate. both niosomes and liposomes have an equivalent ability to transport drugs and do so more effectively than free drugs do. niosomes are preferred to liposomes because they have higher chemical stability and are more cost-effective. niosomes that generate surfactants are biocompatible, nonimmunogenic, and degradable. drugs with higher bioavailability than free drugs, such as nimesulide, flurbiprofen, piroxicam, ketoconazole, and bleomycin, are more effective when they are incorporated into niosomes26. transdermal drug delivery system transdermal medication delivery is the application of selfcontained, discrete dosage forms to intact skin in order to administer drugs to the bloodstream at a controlled rate. an essential component of new drug delivery systems, the transdermal drug delivery system (tdds) has become wellestablished27,28. the transdermal route is an intriguing choice for delivery because it is practical and secure.  the advantages of administering medications through the skin to produce systemic effects include: avoiding first pass metabolism  preventing gastro intestinal compatibility issues  predictable action with a long duration  enhancing pharmacological and physiological responsiveness  therapy can be stopped at any time with ease.  increased patient compliance as a result of the removal of multiple dosing  the profile possess the capacity for self-management  to improve therapeutic efficacy sonophoresis a technique called sonophoresis uses ultrasonic radiation to dramatically accelerate the absorption of topical substances (transdermal delivery) into the epidermis, dermis, and skin appendages. low molecular weight medications and macromolecules can be quickly and conveniently delivered into the skin using sonophoresis. it is a localized, non-invasive, convenient technique. sonophoresis is thought to improve medication delivery mechanically by altering the skin tissue in a mixture of heat, chemical, and mechanical ways. for sonophoresis, ultrasound has been employed at a range of frequencies between 20 khz and 16 mhz, with intensities up to 3w/cm2. percutaneous absorption is known to be affected by ultrasound parameters including treatment duration, intensity, and frequency, with the latter being the most significant. because ultrasound waves produce microvibrations in the skin's epidermis and boost the overall kinetic energy of the molecules making up topical medicines, jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [37] ajdhs.com sonophoresis occurs. the cavitation, micro-streaming, and heating caused by the ultrasound most likely improve drug delivery. by successfully treating digital polyarthritis with hydrocortisone ointment plus ultrasound in 1954, fellinger and schmid first described ultrasound-mediated transdermal delivery of essential chemicals. in hospitals, sonophoresis is frequently utilized to administer medications through the skin. by combining the medications with a coupling agent (gel, cream, or ointment), pharmacists are able to deliver ultrasonic energy from the ultrasound transducer to the skin. thus, applying ultrasound to the skin makes it more permeable (a process known as sonophoresis) and makes it possible to transfer numerous chemicals both into and through the skin. physical therapy also uses sonophoresis. interstitial fluid samples can be extracted for analysis using reverse ultrasound technology. sonophoresis is therefore being researched as a method of pulling substances like glucose out of the skin in addition to its impact on delivering compounds into the skin2933. mucoadhesive drug delivery systems the situation in which two materials, at least one of which is biological in nature, are kept together for a long time by interfacial forces is known as bioadhesion. in the field of pharmaceutical sciences, the phenomenon is known as mucoadhesion when the sticky connection is to mucus or a mucous membrane. mucoadhesive polymers have the potential to considerably extend the residence time of sustained release delivery systems on mucosal membranes. this potential has been demonstrated in drug delivery systems for the eyes, nose, mouth, and vagina. additionally, there has always been a lot of interest in the development of oral mucoadhesive delivery systems because those that can adhere to certain gastrointestinal (gi) segments would have a number of benefits34-38. supramolecular drug delivery systems an intermolecular non-covalent binding contact holds two or more molecular units together and organizes them into a supramolecular system. in addition to serving as models for understanding natural supramolecular self-assembly and molecular recognition, supramolecular structures involving macrocyclic compounds have also generated a great deal of interest as starting points for the development of novel nanomaterials for use in electronics, biomedicine, and pharmaceutical applications35. osmotically controlled drug delivery systems these systems use osmotic pressure as their driving force in order to deliver the medicine in a regulated manner. the most intriguing and well-liked method of drug delivery among all the available technologies is osmotic. osmotic systems have been the subject of extensive research, and various patents have also been made public. alza was a leader in the development of osmotic drug delivery systems, and it currently holds the majority of the patents examined as well as various products based on the osmotic principle. these methods can be employed for parenteral as well as oral administration. gastro-intestinal therapeutic methods include oral osmotic systems. implantable pumps are used for parenteral osmotic medication delivery. osmotic pumps come in a variety of shapes and sizes, according to reports in the literature but in general they can be divided in oral and implantable systems39-43. microencapsulation the method of microencapsulation involves surrounding or coating tiny droplets or particles of liquid or solid substance with a continuous film made of polymeric materials. first, the gelatin coacervation process was used to prepare gelatin spheres for the microencapsulation technique, which was developed by bungen burg de jon and kan in 1931. the controlled drug delivery system has been utilized to lessen the drawbacks of traditional therapy and to increase a specific medicine's therapeutic effectiveness. the active substance must be delivered to the target tissue at the ideal rate in order to have the greatest therapeutic efficacy, while also producing the least amount of toxicity and side effects possible. the microencapsulation technique aids in the transformation of liquids into solids, alteration of colloidal and surface properties, protection of the environment, and regulation of the release characteristics of various coated materials. in contrast to microencapsulation, which uses tiny coated particles to create a wide range of dosage forms, macropakaging techniques can achieve some of these features. innovative drug delivery methods were developed with the goal of optimizing bioavailability by changing the drug's blood concentration's bioavailability. medicine therapy can be enhanced with sustained and controlled release products, which is a common objective over non sustained and controlled release with the same drug. microencapsulated products (micro particles) are the small entities that have an active agent know as the core material surrounded by a shell known as the coating material or embedded into a matrix structure. most microparticle shells are of organic polymers, but waxes and lipids are also used. generally the size of the microencapsulated products (microparticles) is considered as larger than 1 micrometer and up to 1000 micrometers in diameter. commercially available microparticles contained 1090% w/w core. a number of core materials can be encapsulated like that live cells, adhesives, flavors, agrochemicals, enzymes, pharmaceuticals. the microencapsulation technology helps to regulate the release characteristics of various coated materials as well as the conversion of liquids into solids, adjustment of colloidal and surface properties, and environmental protection. techniques for macropakaging can accomplish some of these properties, as opposed to microencapsulation, which employs microscopic coated particles to produce a variety of dose forms. innovative drug delivery techniques have been created with the intention of improving bioavailability by altering the drug's bioavailability at different blood concentrations. a shared goal over non sustained and controlled release with the same drug is to improve medicine therapy with sustained and controlled release products. the more recent finding in pharmaceutical research is that the rate at which a drug is released from the dosage form can be used to alter how quickly it is absorbed. the sustained action, sustained release, prolonged action, delayed action, and timed release medications are all included in the controlled released dose forms. this has been accomplished by creating novel pharmacological entities, finding new polymeric materials useful for extending the duration of drug release, improving patient safety, and increasing therapeutic efficacy44. novel drug delivery system: in herbal formulations the creation of innovative drug delivery systems (ndds) for herbal medicines has received a lot of interest during the last few decades. idealistically, the innovative carriers should meet two requirements. the medicine should first be delivered over the course of treatment at a rate determined by the body's needs. second, it should direct the herbal drug's active ingredient to the place of action. none of these can be satisfied by conventional dosage forms, including prolonged-release dosage forms. bioactive and plant extracts have been used to create a number of innovative herbal formulations, including jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [38] ajdhs.com liposomes, phytosomes, nanoemulsions, microspheres, transferosomes, and ethosomes45-52. references 1. reddy pd, swarnalatha d. recent advances in novel drug delivery systems. int j pharmtech res., 2010; 2(3):2025-2027. 2. muller cc. physicochemical characterization of colloidal drug delivery systems such as reverse micelles, vesicles, liquid crystals and nanoparticles for topical administration. eur j pharm biopharm., 2004; 58(2):343-356. https://doi.org/10.1016/j.ejpb.2004.03.028 3. http://www.azonano.com/oars.asp 4. sharma a, sharma us. liposomes in drug delivery: progress and limitations. int j pharm., 1997; 154(2):123-140. https://doi.org/10.1016/s0378-5173(97)00135-x 5. lau jr, geho wb, snedekar gh. inventors; sdg inc, an ohio corporation, assignee; targeted liposomal drug delivery system. us patent 20100209492. 2010 aug 19. 6. takagi a, yamashita n, sonobe t. inventors; astellas pharma inc tokyo, assignee; intracellular drug delivery improving liposomes. us patent 20070286898. 2007 dec 13. 7. lau jr,geho wb, snedekar gh. inventors; targeted liposomal drug delivery system. us patent 20070104777. 2007 may 10. 8. zhang y, luo b, iyer l. inventors; liposomal delivery vehicle for hydrophobic drugs. us patent 20070014845. 2007 jan 18. 9. yamauchi h, morita h, kikuchi h. inventors; daiichi pharmaceuticals co.ltd, assignee; liposomes and liposomal dispersion. us patent 20020182248. 2002 dec 5. 10. verma rk, garg s, current status of drug delivery technologies and future directions. pharm tech on-line. 2001; 25(2):1-14. 11. torchilin vp. structure and design of polymeric surfactant-based drug delivery systems. j control release. 2001; 73:137-72. https://doi.org/10.1016/s0168-3659(01)00299-1 12. turos e, cormier r, kyle de. inventors; university of south florida fl, assignee; polyacrylate nanoparticle drug delivery. us patent 20100278920. 2010 nov 4. 13. sung h, liang h, tu h. inventors; nanoparticle for protein drug delivery. us patent 20090155374. 2009 june 18. 14. jacobson gb, zare rn, markides ke, shinde rr. inventors; encasulated nanoparticle for drug delivery. us patent 20080095856. 2008 apr 24. 15. lobl tj, schloss jv, nagy ai, pananen je. inventors; neurosystec corporation, valencia ca, assignee; nanoparticle drug formulation. us patent 20080145439. 2008 june 19. 16. singh an, mahanti b, bera k. novel drug delivery system & it's future: an overview. int j pharm engin., 2021; 9(2):1070-1088. 17. wu d, chu cc, carozza j. inventors. injectable microspheres. us patent 20110151004. 2011 june 23. 18. sah hk, inventor; sk chemicals co ltd kr. assignee; method for producing microspheres loaded with drugs and microspheres loaded with drugs produced thereby. us patent 20090318569. 2009 dec 24. 19. shah s. novel drug delivery carrier: resealed erythrocytes, int j pharma biosci., 2011; 2(1):394-406. 20. raut d, sakhare r, dadge k, halle pd. resealed erythrocytes drug delivery: a review, int j pharm chem., 2013; 2:193-205. 21. gupta a, mishra ak, bansal p, kumar s, gupta v, singh r, kalyan gs. cell based drug delivery system through resealed erythrocytea review. int j pharm sci drug res., 2010; 2(1):23-30 22. magnani m, rossi l, biagiotti s, bioanchi m. inventors; drug delivery system. us patent 20120141540. 2012 june 7. 23. grimald s, lisi a, cinti c. inventors; cnr conciglio nazionale delle ricerche roma, assignee; us patent 20110262415. 2011 oct 27. 24. yang vc, kwon ym, chung hs, yang aj. inventors; erythrocyte encapsulated laspaginase for enhanced acute lymphoblastic leukemia therapy. us patent 20100284982. 2010 nov 11. 25. madhar nvs, saini a. niosomes: a novel drug delivery system. int j res pharm chem., 2011; 1(3):498-511. 26. alcantor n, williams ec, toomey r. inventors; university of south florida,fl, assignee; niosome hydrogel drug delivery systems. us patemt 20100068264. 2010 mar 18. 27. arunachalam a, karthikeyan m, vinay kumar d. et al., transdermal drug delivery system: a review. curr pharm res., 2010; 1(1):7081. https://doi.org/10.33786/jcpr.2010.v01i01.015 28. sharma b, saroha k, yadav b. sonophoresis: an advanced tool in transdermal drug delivery system. int j curr pharm res., 2011; 3(3):89-97. 29. easterbrook tj, gosden e, meyer e. inventors; transdermal drug delivery device. us patent 20110190716. 2011 aug 4. 30. tang j. inventor; stabilised transdermal drug delivery system. us patent 20110182949. 2011 july 28. 31. nisato g, baret jc. inventors; koninklijke philips electronics n.v, nc, assignee; transdermal drug delivery patch. us patent 20100222751. 2010 june 10. 32. heiati h, weimann l. inventor; pharmapatch llc, san diego ca, assignee; multiple nozzle transdermal drug delivery system. us patent 20100143448. 2010 sept 2. 33. vinod kr, reddy r, banji d, reddy v, sandhya s. critical review on mucoadhesive drug delivery systems. hygeia j drugs med., 2012; 6(1):7-28. 34. yoon hj, jang wd. polymeric supramolecular systems for drug delivery. j mater chem., 2010; 2:211-222. https://doi.org/10.1039/b910948j 35. zerbe hg, paiement n. inventor; oral mucoadhesive dosage form. us patent 20110028431. 2011 feb 3. 36. sambasivam m. inventor; convatec technologies inc, nv, assignee; ostomy devices with mucoadhesives. us patent 2010010064. 2010 apr 22. 37. david ae, zhang r, park yj, yang ajm, yang vc. inventors; mucoadhesive vescicles for drug delivery. us patent 20090232899. 2009 sept 17. 38. gupta s, singh rp, sharma r, kalyanwat r, lokwani p. osmotic pumps: a review. int j comprehen pharm., 2011; 6(1):1-8. 39. patel h, patel u, kadikar h, bhimani b, daslaniya d, patel g. a review on osmotic drug delivery system. int res j pharm., 2012; 3(4):88-94. 40. nghiem t, jackson g. inventors; biovail laboratories international s.r.l., assignee; multiparticulate osmotic delivery system. us patent 20090004281. 2009 jan 1. 41. patel hb. inventor; reliant pharmaceuticals inc., assignee; oral osmotic drug delivery system. us patent 20080248114. 2008 oct 9. 42. kidane a, bhatt pp. inventors; osmotic drug delivery system. us patent 20070254032. 2007 nov 1. 43. kumar a, sharma p, banik a. microencapsulation as novel drug delivery system. int pharm sci., 2011; 1(1):1-7. 44. saraf as. applications of novel drug delivery system for herbal formulations. fitoterapia. 2010; 81:680-689. https://doi.org/10.1016/j.fitote.2010.05.001 45. he zf, liu dy, zeng s, ye jt. study on preparation of ampelopsin liposomes. j chine mat med., 2008; 33(1):27-30. 46. rane s, prabhakar b. influence of liposome composition on paclitaxel entrapment & ph sensitivity of liposomes. indian j phys ther res., 2009; 1(3):914-917. 47. godin b, touitou e. mechanism of bacitricin permeation enhancement through the skin & cellular membrane from an https://doi.org/10.1016/j.ejpb.2004.03.028 https://doi.org/10.1016/s0378-5173(97)00135-x https://doi.org/10.1016/s0168-3659(01)00299-1 https://doi.org/10.33786/jcpr.2010.v01i01.015 https://doi.org/10.1039/b910948j https://doi.org/10.1016/j.fitote.2010.05.001 jain et al asian journal of dental and health sciences. 2022; 2(1):33-39 [39] ajdhs.com ethosomal carrier. j control release. 2004; 94(2-3):365-379. https://doi.org/10.1016/j.jconrel.2003.10.014 48. youfang c, xianfu l, hyunjin p, richard g. artemisnin nanoparticles. nanomed nanotechnol biol med., 2009; 5:316-322. 49. shimada s. composition comprising nanoparticle ginkgo biloba extract with the effect of brain function activation. us patent 8105637; 2012 jan 31. 50. bhattacharya s. phytosomes: emerging strategy in delivery of herbal drugs & nutraceuticals. pharma times. 2009; 41(3):9-12. 51. wu jh, yen fl, lin lt, tsai tr, lin cc, et al., preparation, physicochemical characterization & antioxidant effects of quercetin nanoparticle. int j pharm.. 2008; 346:160-168. https://doi.org/10.1016/j.ijpharm.2007.06.036 52. sampath kumar kp, bhowmik d, chiranji b, chandira m, tripathi kk. innovations in sustained release drug delivery system and its market opportunities. j chem pharm res., 2010; 2(1):349-360 https://doi.org/10.1016/j.jconrel.2003.10.014 https://doi.org/10.1016/j.ijpharm.2007.06.036 khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [20] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited an overview of lassa fever, an rising old world haemorrhagic viral disease basant khare1, dolly jain1, sameeksha jain1, monika jain1, pushpendra kumar khangar2, deepak kumar jain3* 1 adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 2 adina institute of pharmaceutical sciences, nh86a, lahdara, sagar, mp, 470001 3 sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 article info: _________________________________________ article history: received 10 jan 2022 reviewed 22 feb 2022 accepted 06 march 2022 published 15 march 2022 _________________________________________ cite this article as: khare b, jain d, jain s, jain m, khangar pk, jain dk, an overview of lassa fever, an rising old world haemorrhagic viral disease, asian journal of dental and health sciences. 2022; 2(1):20-26 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.12 _________________________________________ *address for correspondence: deepak kumar jain, sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 abstract ___________________________________________________________________________________________________________________ lassa fever is an acute immunosuppressive illness of increasing public health concern causing severe morbidity and significant mortality especially in epidemic cases. lassa fever is an acute viral zoonotic illness caused by lassa virus, an arenavirus known to be responsible for a severe haemorrhagic fever characterised by fever, muscle aches, sore throat, nausea, vomiting, chest and abdominal pain. the virus exhibits persistent, asymptomatic infection with profuse urinary virus excretion in the ubiquitous rodent vector, mastomys natalensis. lassa fever is endemic in west africa and has been reported from sierra leone, guinea, liberia, and nigeria. the virus replicates through a strategy known as the ambisense, where two rna strands code for genes in both the sense and antisense direction that is rapid and demonstrate temporal control in replication. different diagnostic tests for the virus are available, which range from viral culture to serological and molecular diagnostic tests. there is an urgent need to develop drugs and vaccines against the virus because the world health organization (who) has identified lassa virus as one of the viruses that is likely to cause a future epidemic, although a research is ongoing to evaluate lassa virus vaccine immunogenicity in the cba/j-ml29 mouse model. this review gives an overview on the structure, replication cycle, pathogenesis and diagnosis of the virus. keywords: lassa fever, lassa virus, arenavirus, replication, pathogenesis, diagnosis email: jaindeepak2022@gmail.com introduction lassa virus (lasv) is first described in the 1950s1 but not identified until 1969 in jos, nigeria2, 3. the virus causes lassa fever that is hemorrhagic in nature, which is severe and fatal. it affects 2-3 million people annually4,5 and has been known to be endemic in benin republic in 2014, ghana in 2011, guinea, liberia, and mali in 2009, sierra leone, and nigeria3,4,6, but probably exists in other west african countries as well4. it is a reemerging virus with a select agent, which requires biosafety level 4-equivalent containment7. it is endemic in west african countries including sierra leone, the republic of guinea, nigeria, and liberia, where cases of the infection is between 300,000 and 500,000 yearly resulting in 5000 deaths annually4,8,9. about 80% infected with the virus are asymptomatic and 1 in 5 infection results in severe disease, where the virus affects several organs such as the liver, spleen, and kidneys10. the virus is harbored by the multimammate rats of the genus mastomys and transmitted to mans through primary aerosols of the rat’s urine, close contact with urine, feces, saliva, or ingestion of contaminated foods of the rat11. lasv is also spread through contaminated hospital equipment but interestingly, it cannot be contracted by humans to humans only via bodily fluids contacts12. findings have reported the presence of the virus in seminal fluids up to 3 months after infection of the virus. research to show that lassa virus can be gotten via sexual intercourse has not been reported but there are speculations that lasv might possibly be used for bioterrorism, so it is now being studied at greater lengths13,14. due to the variability of the clinical course of the disease, detection of the disease in affected patients has been challenging. when presence of the virus is confirmed in a locality, quick isolation of infected patients, good infection prevention and control practices, and rigorous contact tracing can help halt epidemicity15. epidemiology lasv is a single-stranded rna virus of the arenaviridae family. first identified in 1969 in nigeria, lassa fever is now endemic in west africa including nigeria, sierra leone, guinea, liberia, benin, ghana and mali and has spread to neighboring countries (figure 1). in some areas, 10%-16% of people admitted to hospitals every year have lasv. cases have also been identified in germany, the netherlands, sweden, the usa, the uk and japan, largely imported after travel in west africa. the long incubation period of lasv (~7–10 days) makes it one of the most commonly exported vhfs to countries outside its endemic range16. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.12 mailto:jaindeepak2022@gmail.com khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [21] ajdhs.com figure 1 geographic distribution of lassa fever in west africa, adapted from emergencies-lassa fever, who, geographic distribution of lassa fever in west african affected countries, 1969-2018 lassa virus structure lassa virus is an envelope, single-stranded, bisegmented rna virus belonging to the arenaviridae family. like other arenaviruses, lassa virus lacks a conventional negative-strand coding arrangement and the isolates of the virus differ in their genetic, serologic and pathogenic characteristics17-19. lassa virus is spherical in shape and measures between 70 and 150 nm in diameter (figure. 2). it has a smooth surface envelope with t-shaped spikes measuring 7-10 nm and built with glycoprotein. the envelope encloses the genome which has helical nucleocapsid measuring between 400 and 1300 nm in length20,21. often the interior contains electron dense granule identified as the host cell ribosome from where the name “arena” was derived meaning sandy22. lassa virus can be inactivated in ultraviolet, gamma irradiation, heating from 56100oc and ph range between 5.5 and 8.5. chemical agents like 0.5% sodium hypocorite, 0.5% phenol and 10% formalin are good inactivants against the virus23,24. the single-stranded arenavirus genome consists of a small (s) and a large (l) rna fragment, sizes 3.4 and 7 kb, respectively and the srna encodes the viral glycoprotein precursor protein (gpc) and the nucleoprotein (np), while the lrna encodes the viral polymerase and a small, zinc-binding (z) protein25. new methods for full-length srna amplification are facilitating research efforts on the identification and molecular analysis of new arenaviruses or arenavirus strains26. the sequencing of lassa virus srna has enabled the identification and molecular characterization of four lassa virus strains. these include: the strain josiah, originating from sierra leone, the strain nigeria and strain lp27,28, both from nigeria and the strain av imported into germany by a traveler who had visited ghana, côte d’ivoire, and burkina faso. sequencing of srna of lassa virus indicated a considerable genetic variation among the strains of the virus, however, phylogenetically, strain av appears to be the most closely related to strain josiah from sierra leone. figure 2 structure of lassa virus replication of lassa virus the first step in viral replication is adsorption on cell surface receptors that are found to be widely distributed and highly conserved molecules29. the glycoprotein of the spikes is responsible for the interactions with cell surface receptors30. the next step is the penetration of the virus, then deproteinisation, and finally liberation of rna genome into the infected host cytoplasm where both replication and transcription take place. during the process, the cell nucleus provides capped cellular mrna for priming transcription, and the nuclear membranes provide structural support. it has been observed that the 5’ end of the s derived subgenomic mrnas extend beyond the end of the genomic rna template and thelength of such an extension varies between 1 and 7 nucleotides and terminate at 5’ cap structure31. the initiation khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [22] ajdhs.com of replication and transcription starts from the terminus of the template. as the rna polymerase rails on the template to add new nucleotides that will form polynucleotide of the new strand, the first two slip back on the template to create nontemplated nucleus, a process peculiar to arenaviruses. after biosynthesis of macro-molecules, the virions are assembled through a process not yet understood. matured virions are released through budding from the plasma membrane of acutely infected cells. reservoir mastomys natalensis multimammate rodents are the most common rodent across the african continent, found predominantly in rural areas and human dwellings. these rodents show persistent lasv infection but are largely unaffected by the disease and shed the virus in their excrement. seroprevalence has been reported to be as high as 60%-80% in m. natalensis populations. more recently, other rodent species including hylomyscus pamfi and mastomys erythroleucus have been shown to host lasv. transmission to humans occurs primarily through contact with infected rodent urine or faeces; handling and consumption of infected rodents is also a pathway to infection. airborne transmission may occur from aerosolised rodent excretions (dust) during cleaning activities. m. natalensis rodents readily colonise human areas where food is stored, contributing a significant risk for spillover, especially in communities with poor sanitation or crowded living conditions. human-to-human transmission is less common, but lasv can be spread through direct contact with bodily secretions of persons infected with lassa fever, presenting a higher risk for healthcare and humanitarian personnel, who increases with progression of disease and increasing viral load. there are suspected sexual transmission risks, as lasv can be detected in semen for 3 months past symptomatic infection16. pathogenesis the lassa virus is well-known to cause lassa fever32. its symptoms include flu-like illness characterized by fever, general body weakness, cough, tonsillitis, headache and gastrointestinal disorders. hemorrhagic manifestations are other features of lassa fever, which include vascular permeability10. the virus pathogenesis is still unclear, but it has been shown that the virus chiefly target the antigenpresenting cells (mainly dendritic cells) and endothelial cells33. lassa virus infects most tissues in the human body when gained entry. it starts with the mucosa, intestine, lungs, and urinary system, and then moves to the vascular system. there are findings that the viral agent can prevent a host’s innate immune system by np activity34. usually, when a microbe penetrates a host, the innate defense system detects the pathogen-associated molecular patterns (pamps) and aggravates the response of the immune system. one of themechanisms identifies double-stranded rna that is only produced by negative-sense viral agents35. in the cytoplasm, dsrna receptors, such as melanoma differentiation-associated gene 5 (mda-5) and retinoic acid-inducible gene i (rig-i), detects dsrnas and facilitates ignaling pathways that results in the translocation of interferon regulatory factor 3 (irf-3) and other transcription factors to the nuclear material9. translocated transcription factors enhance expression of interferons 𝛂 and 𝛃, and secreted interferons facilitate antiviral responses including adaptive immunity. np encoded in the viral agent is important in the replication and transcription of the virus, but it also stops host innate ifn response by inhibiting translocation of irf-3. np of the virus is reported to have an exonuclease activity to only dsrnas12. double-stranded rna exonuclease activity of the np leads to counteract ifn responses by digesting the pamp that leads to the evasion of host immune responses. the recent understanding of the pathogenesis of the viral fever does not involve the chain of functions that take place during development of the disease state and leads to mortality of severed ill patients36. the high death and truly dramatic course of the disease state, the pathological findings do not give the bench that would explain the mechanism of disease progression and the cause of mortality by the viral agent5,8. development of the cellular immune response failure, which would control dissemination of lasv is indicated by high serum titers of the virus, together with dispersed replication in tissues and lack of neutralizing antibodies that could lead to the fatal lassa fever development6,37. patientscheck physically after fever onset usually depicts facial oedema, bilateral conjunctival hemorrhages, purulent pharyngitis, and abdominal disorders5. pathological changes physically may include pulmonary oedema, ascites, pleural effusions, and hemorrhagic signs in the gastrointestinal mucosa while examination under the microscope reveals splenic necrosis, hepatocellular necrosis, adrenocortical necrosis and apoptosis, mild mononuclear interstitial myocarditis without myocardial fiber necrosis, alveolar oedema with capillary blockage and mild interstitial pneumonitis, lymph nodal sinus histiocytosis with mitoses, gastrointestinal mucosal petechiae, renal tubular injury, lymph nodal sinus histiocytosis with mitoses, and interstitial nephri. more often, lesions of lassa fever in man happen in the hepatic cells5,8. there are four major characteristic hepatitis of lasv, which is derived: i. focal cytoplasmic degeneration of hepatocytes related to phagocytosed apoptotic fragments. ii. distribution of multifocal hepatocellular necrosis randomly. iii. monocytic reaction to necrotic hepatocytes. iv. hepatocellular mitoses. the physical impacts do not happen uniformly in all cases, rather in some instances can be observed simultaneously. the virus fever is not associated with coagulation dysfunction, for example, decrease in the coagulation factors and disseminated intravascular coagulation (dic) have been revealed in infected subjects. more so, moderate thrombocytopenia with importantly damaged functionality of thrombocytes is reported in severe lassa fever subjects7,37. one significant mechanism involved in the pathogenesis of lassa fever is infection-triggered induction of uncontrolled cytokine expression, which looks like what is seen in sepsis9. in this subject that died from hemorrhagic shock and multi-organ failure, the proinflammatory cytokines, tumor necrosis factor α (tnf-α), and interferon γ (ifn-γ) rises to extremely high level just before death. in a related study, no increase of both cytokine levels was reported in the checked fatal cases of the virus fever, and it is suggestive that the levels of ifn-γ and tnf-α are either elevated only in a fraction of patients or during a limited period that would involve frequent sampling for assay12,35. virus-induced immunosuppression may be involved in a severe lassa fever pathogenesis where the lasv infection fails to trigger macrophages (mp) and monocytederived dendritic cells (dc) of human. human-infected dc with the naturally nonpathogenic mopeia virus induces stronger cd4 and cd8 t-cell responses when compared with those infected with lasv5,8. infected dc fail to secrete proinflammatory cytokines, do not upregulate costimulatory molecules, such as cd40, cd80, and cd86, and poorly induce proliferation of t cells. downregulation of immune responses due to infection by lasv has been depicted in vitro, and it is also in consonance with findings of clinical reports demonstrating that the virus fever fatal outcome relates with low levels interleukin (il) 8 and ifn inducible protein 10 (ip10) in the system14. khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [23] ajdhs.com diagnosis the signs and symptoms of lassa fever may be difficult to distinguish from diseases that are common in the tropics such as severe malaria, typhoid fever, yellow fever and other viral haemorrhagic fevers38-40, but diagnosis can be assisted with simple laboratory support but definitive diagnosis requires testing that is available only in highly specialized laboratories42. as the symptoms of lassa fever are so varied and nonspecific, clinical diagnosis is often difficult especially early in the course of infection. hence, to make accurate diagnosis of lassa fever, clinical manifestation, epidemiological data and result of laboratory findings should be taken into consideration. laboratory investigation: lassa fever is diagnosed by detection of lassa antigen, antibodies, or virus isolation techniques. in the laboratory, the virus can be isolated using laboratory animals such as albino mice, guinea pigs, vero cell or african green mon keys. albino mice inoculated intracerebrally die between 3 and 5 days. lassa fever virus causes conspicuous cytopathic effect on confluent monolayer of vero cell culture within 96 h. the antigens to be used for viral isolation can be obtained from the patients blood, urine, pleural fluid, throat swab and in case of death, pathological materials from liver, kidney, spleen and heart41. the virus can be seen under electron microscope using specimens obtained from infected persons. although virus isolation remains the most sensitive, it is still uniquely a research tool. the classical method to detect lassa virus is inoculation of vero cells with serum, cerebrospinal fluid (csf), throat washing, pleural fluid or urine of the patient. specimen for laboratory analysis should be collected as soon as possible from the patient suspected of having the infection. lassa virus is infectious by aerosol and the human and rodent specimens should be processed with appropriate precautions in biosafety level iv laboratories 42. the specific diagnosis is readily made by the isolation and identification of the virus. this is usually done by the inoculation of blood from the patient into vero cell cultures. virus antigen can be detected by enzymelinked immunosorbent assays (elisa) using lassa virus-specific antibodies. these tests are easy to handle and rapid, and can be performed with inactivated specimens, which is advantageous in the field if sophisticated equipment is not available. results should be mentioned as soon as they are ready to help in monitoring the prognosis of the disease. the indirect fluorescent-antibody (ifa) test has traditionally been employed in the laboratory diagnosis of acute lassa virus infection43,44. although the interpretation of ifa results is complicated by the presence of ifa during both acute and convalescent stages of infection and by the subjective nature of the assay, the appearance of ifa antibody early in the course of lassa infection may be useful in identifying patients with poor prognosis. however, due to lack of specificity in populations in non-endemic areas45 the technique has been largely replaced by elisa for lassa virus antigen and lassa virus-specific immunoglobulin m (igm) and g (igg) antibodies46-48. a thorough evaluation of the lassa virus elisa on field-collected samples to assess its true sensitivity and specificity was performed in sierra leone and guinea in west africa49. in the study, isolation of virus as detected by immunofluorescent stains for viral antigen along with a positive reverse transcription-pcr (rt-pcr) test on the isolate wasemployed as the “gold standard” test of lassa virus infection. the results showed that the combined elisa ag/igm assay was highly sensitive and specific for the diagnosis of lassa fever and the antigen detection assay offered a particular advantage in providing early diagnosis as well as prognostic information. from this research, the technique appeared to be a better diagnostic tool for lassa virus infection compared to other serological techniques. although the rt-pcr assays are very sensitive, their applicability in the west african countries where lassa fever is endemic is limited by issues of strain variation, cross contamination, lack of qualified personnel, inadequate facilities and expense50,51. another valuable diagnostic tool is the rapid diagnostic immunoblot assay (rdia) for lassa fever. unfortunately, its usefulness is limited by its low capacity to provide prognostic information and also its low sensitivity. differential diagnosis: lassa haemorrhagic fever must be differentiated from other febrile diseases like ebola (marburg) haemorrhagic fever, malaria, diphtheria, legionella, yellow fever, congo-haemorrhagic fever, etc. lassa fever virus has a peculiar natural reservoir rodent host (m. natalensis). it is very imperative that clinical assessment be combined with specific laboratory diagnosis to adequately identify the lassa fever virus in order to commence early treatment which is paramount to the survival of infected individual52. useful prevention/control measures lassa fever transmission is enhanced by cohabitation of m. natalensis species of rodent with humans in their residences in the affected areas having access to water and food items in the household. these rats are also prepared and consumed as delicacies by many inhabitants of west african region53,54. therefore, any control/preventive measures to be adopted must take cognizance of routes and mechanism of transmission of lassa fever. the following measures are imperative in curtailing the regular epidemic outbreak and spread of lassa fever in sub-saharan region of africa. these include:  observance of general hygiene including personal and environmental hygiene by the populace.  since lassa fever transmission is associated with infected mouse (m. natalensis), therefore, every household needs to device all means geared towards preventing rats from having any contact with foods, water and utensils utilized by the household. this may be achieved by: -covering of foods and water meant for human consumption regularly. foods should be kept in tightly sealed containers. -readyto-eat food item (such as gari) should not be spread in the open or by the roadside where rats can have access to it.  public enlightenment campaign about lassa fever should be conducted regularly in areas where the disease is prevalent.  every community should be counseled to avoid foods and other items contaminated with rat’s excretions and secretions.  people should be admonished to kill and destroy rats in and around the house, shops or market places.  foods and water should be boiled adequately before consumption.  encourage members of the community to always attend healthcare centre nearest to them for medical attention when they are sick or have had contact with contaminated environment.  all persons suspected of lassa virus infection should be admitted to isolation facilities and promptly attended to with utmost care. -hospital workers should take universal precautions and protective measures when attending to such patients. -every body fluids and excreta produced bysuch patients should be handled with care and properly disposed of. khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [24] ajdhs.com  early detection of the disease and aggressive treatment (such as the use of intravenous ribavirin) 55 is important for the survival of infected patient.  healthcare workers should be sensitized about the need to adopt universal preventive measures in their routine hospital procedures to limit the transmission and acquisition of lassa virus infection and indeed all infectious diseases in hospital setting.  governments at all levels (national, state and local) should demonstrate political will in mobilizing logistics and necessary materials and financial support to aid adequate management and effective control of lassa fever.  more diagnostic and treatment centres for lassa fever should be established at various regions of each country endemic for lassa fever.  development of effective vaccine against lassa fever (which has reached advanced stage with positive results in animal trials) 56 is crucial in checkmating the spread of lassa fever. treatment ribavirin the antiviral drug is effective in the treat ment of lassa fever, but only if administered early in the course of illness57. in a study of lassa fever in sierra leone, west africa, it was observed that patients with a high risk of death who were treated for 10 days with intravenous ribavirin, begun within the first six days after the onset of fever, had a casefatality rate of 5% (1 of 20) (p = 0.0002 by fisher’s exact test), while patients whose treatment began seven or more days after the onset of fever had a case fatality rate of 26% (11 of 43) (p = 0.01). the study confirmed the efficacy of ribavirin in the treatment of lassa fever and that it should be used at any point in the illness, as well as for post-exposure prophylaxis. because of its expense, need for intravenous administration, potential toxicity and teratogenicity, empiric therapy with ribavirin is undesirable58-60. in a remote area of eastern sierra leone, west africa, brief episodes of rigors were reported in patients receiving ribavirin. however, the occurrence or number of rigors in an individual patient was not associated with sex, age, weight, volume of loading dose, cumulative dose, and administration of other drugs and use of intravenous lines or heparin traps. the report indicated slowing the infusion rate, generated no further episodes and concluded that epidemiologic techniques are important tools in rapid assessment of unexpected events particularly when conducting trials in remote locations. supportive treatment is often necessary and includes fluid replacement, blood transfusion, administration of paracetamol, phylometadione, ringer lactate, haemocoel quinine and broad spectrum antibiotics61. conclusion/recommendations lassa fever has emerged as one of the most prevalent, immunosuppressive and highly fatal haemorrhagic fevers endemic in sub-saharan africa particularly west and central africa. transmission of the disease is influenced by cohabitation of reservoir rodent (m. natalensis) with human population and poor environmental hygiene common in most parts of the region resulting in regular outbreak of the disease and fatality. currently, there are no clinically certified vaccines against lassa fever which limits the scope of control/preventive measures against lassa fever. hence, there is need to intensify public educational or enlightenment program in all affected areas on the useful control measures against lassa fever. the stakeholders need to prioritize the intervention, support and deterrent program and speed up the process leading to production of effective vaccine to checkmate the menace of lassa fever outbreak and associated morbidity and mortality. references 1. tomori o, fabiyi a, sorungbe a, smith a, mccormick jb. viral hemorrhagic fever antibodies in nigerian populations. american j trop med hyg., 1988;38:407-410. https://doi.org/10.4269/ajtmh.1988.38.407 2. troup jm, white ha, fom almd, carey de. an outbreak of lassa fever on the jos plateau, nigeria, in january-february 1970. american j trop med hyg., 1970;19:695-696. https://doi.org/10.4269/ajtmh.1970.19.695 3. echioya du, hass m, olshlager s, becker-ziaja b, chukwu coo, coker j, et al. lassa fever, nigeria, 2005-2008. emerg infect dis., 20101; 6(6):1040-1041. https://doi.org/10.3201/eid1606.100080 4. world health organization. who calls for early diagnostic tests for lassa fever. geneva, switzerland: world health organization; 2016. 5. centers for disease control and prevention. 2017. lassa fever, signs and symptoms. archived 9 july 2017 at the wayback machine. 6. ogbu o, ajuluchukwu e, uneke cj. lassa fever in west african subregion: an overview. j vec bor dis., 2007; 44(1):1-11. 7. samuel d. lassa fever what you need to know. 2017. 8. dongo ae, kesieme eb, iyamu ce, okokhere po, akhuemokhan oc, akpede go. lassa fever presenting as acute abdomen: a case series. virol j., 2013; 10:124. https://doi.org/10.1186/1743422x-10-123 9. hastie km, bale s, kimberlin cr, saphire eo. hiding the evidence: two strategies for innate immune evasion by hemorrhagic fever viruses. curr opin virol., 2012; 2(2):151-156. https://doi.org/10.1016/j.coviro.2012.01.003 10. ne y, walker dh. pathogenesis of lassa virus. viruses. 2012; 4(12):2031-2048. https://doi.org/10.3390/v4102031 11. qi x, lan s, wang w, schelde lm, dong h, wallat gd, ly h, liang y, dong c. cap binding and immune evasion revealed by lassa nucleoprotein structure. nature. 2010; 468:779-783. https://doi.org/10.1038/nature09605 12. flatz l, rieger t, merkler d, bergthaler a, regen t, schedensack m, et al. t cell-dependence of lassa fever pathogenesis. plos pathogens. 2010; 6:ee1000836. https://doi.org/10.1371/journal.ppat.1000836 13. donaldson ri. the lassa ward: one man's fight against one of the world's deadliest diseases. new york, ny: st. martin's press, kindle edition; 2009. 14. branco lm, grove jn, boisen ml, shaffer jg, goba a, fullah m, momoh m, grant ds, garry rf. emerging trends in lassa fever: redefining the role of immunoglobulin m and inflammation in diagnosing acute infection. virol j., 2011; 8:478. https://doi.org/10.1186/1743-422x-8-478 15. national institute of allergy and infectious diseases. niaid emerging infectious diseases/pathogens. bethesda, md: national institute of allergy and infectious diseases; 2016. 16. mazzola lt, kelly-cirino c.diagnostics for lassa fever virus: a genetically diverse pathogen found inlow-resource settings bmj glob health. 2019; 4:e001116. https://doi.org/10.1136/bmjgh2018-001116 17. bowen md, peters cj, nichol st. phylogenetic analysis of the arenaviridae: patterns of virus evolution and evidence for cospeciation between arenaviruses and their rodent hosts. mol phylogenet evol., 1997; 8:301-16. https://doi.org/10.1006/mpev.1997.0436 18. jahrling pb, frame jd, smith sb, monson mh. endemic lassa fever in liberia. iii. characterization of lassa virus isolates. trans r soc https://doi.org/10.4269/ajtmh.1988.38.407 https://doi.org/10.4269/ajtmh.1970.19.695 https://doi.org/10.3201/eid1606.100080 https://doi.org/10.1186/1743-422x-10-123 https://doi.org/10.1186/1743-422x-10-123 https://doi.org/10.1016/j.coviro.2012.01.003 https://doi.org/10.3390/v4102031 https://doi.org/10.1038/nature09605 https://doi.org/10.1371/journal.ppat.1000836 https://doi.org/10.1186/1743-422x-8-478 https://doi.org/10.1136/bmjgh-2018-001116 https://doi.org/10.1136/bmjgh-2018-001116 https://doi.org/10.1006/mpev.1997.0436 khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [25] ajdhs.com trop med hyg., 1985; 79:374-9. https://doi.org/10.1016/00359203(85)90386-4 19. ruo sl, mitchell sw, kiley mp, roumillat lf, fisherhoch sp, mccormick jb. antigenic relatedness between arenaviruses defined at the epitope level by monoclonal antibodies. j genet virol., 1991; 72:549-55. https://doi.org/10.1099/0022-1317-723-549 20. auperin dd, mccormick jb. nucleotide sequence of the lassa virus (josiah strain) s genome rna and amino acid sequence comparison of the n and gpc proteins to other arenaviruses. virol., 1989; 168:421-5. https://doi.org/10.1016/00426822(89)90287-0 21. auperin dd, sasso dr, mccormick jb. nucleotide sequence of the glycoprotein gene and intergenic region of the lassa virus s genome rna. virol., 1986; 154:155-67. https://doi.org/10.1016/0042-6822(86)90438-1 22. mccormick jb. arenaviruses. in: fields bn, knipe dm editors. fields virology. new york: raven press 1990; p.1245-67. 23. mccormick jb. epidemiology and control of lassa fever. curr top microbiol immunol., 1987; 134:69-78. https://doi.org/10.1007/978-3-642-71726-0_3 24. gunther s, emmerich p, laue t, kuhle o, asper m, jung a, grewing t, termeulen j, schmitz h. imported lassa fever in germany: molecular characterization of a new lassa virus strain. emerg infect dis., 2000; 6(5):466-76. https://doi.org/10.3201/eid0605.000504 25. lozano me, posik dm, albarino cg, schujman g, ghiringhelli pd, calderon g, sabattini m, romanowski v. characterisation of arenaviruses using a family-specific primer set for rt-pcr amplification and rflp analysis. its potential use for detection of uncharacterised arena viruses. virus res., 1997; 49:79-89. https://doi.org/10.1016/s0168-1702(97)01458-5 26. clegg jc, wilson sm, oram jd. nucleotide sequence of the s rna of lassa virus (nigerian strain) and comparative analysis of arena virus gene products. virus res., 1991; 18:151-64. https://doi.org/10.1016/0168-1702(91)90015-n 27. termeulen j, koulemou k, wittekindt t, windisch k, strigl s, conde s, et al. detection of lassa virus antinucleoprotein immunoglobulin g (igg) and igm antibodies by a simple recombinant immunoblot assay for field use. j clin microbiol., 1998; 36:3143-8. https://doi.org/10.1128/jcm.36.11.3143-3148.1998 28. demby ah, chamberlain j, brown dw, clegg cs. early diagnosis of lassa fever by reverse transcription-pcr. j clin microbiol., 1994; 32:2898-903. https://doi.org/10.1128/jcm.32.12.28982903.1994 29. southern pj. arenaviridae: the viruses and their replication. in: fields bn, knipe dm, howley pmeditors. fields virology. philadelphia:lippencott-raven, paraven 1996; p. 1505-19. 30. burns jw, buchmeier mj. glycoproteins of the arenaviruses. in: salvato ms editor. the arenaviridae. new york: plenum press 1993; p. 17-35. https://doi.org/10.1007/978-1-4615-3028-2_2 31. auperin dd, galinski m, bishop dh. the sequences of the n protein gene and intergenic region of the s rna of pichinde arenavirus. virology 1984; 134:208-19. https://doi.org/10.1016/00426822(84)90286-1 32. centers for disease control and prevention. lassa fever. archived 23 september 2016 at the wayback machine; 2016. 33. rojek jm, kunz s. cell entry by human pathogenic arenaviruses. cell microbiol., 2008;10(4):828-835. https://doi.org/10.1111/j.1462-5822.2007.01113.x 34. mahanty s, hutchinson k, agarwal s, mcrae m, rollin pe, pulendran b. cutting edge: impairment of dendritic cells and adaptive immunity by ebola and lassa viruses. j immunol., 2003;170(6):2797-2801 https://doi.org/10.4049/jimmunol.170.6.2797 35. baize s, kaplon j, faure c, pannetier d, georges-courbot mc, deubel v. lassa virus infection of human dendritic cells and macrophages is productive but fails to activate cells. j immunol., 2004; 172(5):2861-2869. https://doi.org/10.4049/jimmunol.172.5.2861 36. hensley l, smith m, geisbert j, fritz e, daddario-dicaprio k, larsen t, geisbert t. pathogenesis of lassa fever in cynomolgus macaques. virol j., 2011; 8:205. https://doi.org/10.1186/1743422x-8-205 37. richmond jk, baglole dj. lassa fever: epidemiology, clinical features, and social consequences. bmj. 2003; 327:1271-1275. https://doi.org/10.1136/bmj.327.7426.1271 38. yadav r, jha m, prasad s, jat d, jain dk. mayaro virus (mayv) disease: past, present and future. j pharm biol sci., 2022; 10(1):716. 39. khatri s, dhanoriya c, jain dk. zika virus (zikv) disease: past, present and future. j drug deliv therap., 2018; 8(6-s):320-327. https://doi.org/10.22270/jddt.v8i6-s.2076 40. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech j pharma sci., 2018:7 (4):1-25. 41. cummins d. lassa fever. br j hosp med., 1990; 43(3): 186-8, 190 & 192. 42. update on lassa fever in west africa. who wkly epidemiol rec., 2005; 10(11):86-7. 43. mccormick jb, king ij, webb pa, johnson km, o'sullivan r, smith es, trippel s, tong tc. a casecontrol study of the clinical diagnosis and course of lassa fever. j infect dis,. 1987; 155:445-55. https://doi.org/10.1093/infdis/155.3.445 44. wulff h, lange jv. indirect immunofluorescence for the diagnosis of lassa fever infection. bull who., 1975; 52:429-36. 45. vanderwaals fw, pomeroy kl, goudsmit j, asher dm, gajdusek dc. hemorrhagic fever virus infections in an isolated rainforest area of central liberia. limitations of the indirect immunofluorescence slide test for antibody screening in africa. trop geogr med., 1986; 38:209-14. 46. ivanov ap, tkachenko ea, vander groen g, butneko am, konstantinov ok. indirect enzyme-immunoassay for the laboratory diagnosis of lassa and ebola hemorrhagic fevers. vopr virusol., 1986; 2:186-90. 47. jahrling pb, niklasson bs, mccormick jb. early diagnosis of human lassa fever by elisa detection of antigen and antibody. lancet. 1985; i:250-2. https://doi.org/10.1016/s0140-6736(85)91029-3 48. niklasson bs, jahrling pb, peters cj. detection of lassa virus antigens and lassa virus-specific immunoglobulins g and m by enzyme-linked immunosorbent assay. j clin microbiol., 1984; 20:239-44. https://doi.org/10.1128/jcm.20.2.239-244.1984 49. bausch dg, rollin pe, demby ah, coulibaly m, kanu j, conteh as, wagoner kd, mcmullan lk, bowen md, peters cj, ksiazek tg. diagnosis and clinical virology of lassa fever as evaluated by enzyme-linked immunosorbent assay, indirect fluorescentantibody test, and virus isolation. j clin microbiol., 2000; 38(7):2670-757. https://doi.org/10.1128/jcm.38.7.26702677.2000 50. lunkenheimer k, hufert ft, schmitz h. detection of lassa virus rna specimens from patients with lassa fever by using the polymerase chain reaction. j clin microbiol., 1990; 28:2689-92. https://doi.org/10.1128/jcm.28.12.2689-2692.1990 51. trappier sg, conaty al, farrar bb, auperin dd, mccormick jb, fisher-hoch sp. evaluation of the polymerase chain reaction for diagnosis of lassa virus infection. am j trop med hyg. 1993; 49:214-21. https://doi.org/10.4269/ajtmh.1993.49.214 52. fleischer k, kohler b, kirchner a, schmid j. lassa fever (article in german). med klin., 2000; 95(6):340-5. https://doi.org/10.1007/pl00002133 53. mccormick, j.b. a prospective study of the epidemiology and ecology of lassa fever. j infect dis., 1987; 155:437-441. https://doi.org/10.1093/infdis/155.3.437 54. federal ministry of health, (fmh). lassa fever update federal ministry of health abuja, federal capital territory. april, 2016. https://doi.org/10.1016/0035-9203(85)90386-4 https://doi.org/10.1016/0035-9203(85)90386-4 https://doi.org/10.1099/0022-1317-72-3-549 https://doi.org/10.1099/0022-1317-72-3-549 https://doi.org/10.1016/0042-6822(89)90287-0 https://doi.org/10.1016/0042-6822(89)90287-0 https://doi.org/10.1016/0042-6822(86)90438-1 https://doi.org/10.1007/978-3-642-71726-0_3 https://doi.org/10.3201/eid0605.000504 https://doi.org/10.1016/s0168-1702(97)01458-5 https://doi.org/10.1016/0168-1702(91)90015-n https://doi.org/10.1128/jcm.36.11.3143-3148.1998 https://doi.org/10.1128/jcm.32.12.2898-2903.1994 https://doi.org/10.1128/jcm.32.12.2898-2903.1994 https://doi.org/10.1007/978-1-4615-3028-2_2 https://doi.org/10.1016/0042-6822(84)90286-1 https://doi.org/10.1016/0042-6822(84)90286-1 https://doi.org/10.1111/j.1462-5822.2007.01113.x https://doi.org/10.4049/jimmunol.170.6.2797 https://doi.org/10.4049/jimmunol.172.5.2861 https://doi.org/10.1186/1743-422x-8-205 https://doi.org/10.1186/1743-422x-8-205 https://doi.org/10.1136/bmj.327.7426.1271 https://doi.org/10.22270/jddt.v8i6-s.2076 https://doi.org/10.1093/infdis/155.3.445 https://doi.org/10.1016/s0140-6736(85)91029-3 https://doi.org/10.1128/jcm.20.2.239-244.1984 https://doi.org/10.1128/jcm.38.7.2670-2677.2000 https://doi.org/10.1128/jcm.38.7.2670-2677.2000 https://doi.org/10.1128/jcm.28.12.2689-2692.1990 https://doi.org/10.4269/ajtmh.1993.49.214 https://doi.org/10.1007/pl00002133 https://doi.org/10.1093/infdis/155.3.437 khare et al asian journal of dental and health sciences. 2022; 2(1):20-26 [26] ajdhs.com 55. mccormick, j.b., king, i.j., webb, p.a., scribner, c. l., graven, r.b., johnson, k.m, elliott, l.h., belmont-williams, r. lassa fever: effective therapy with ribavirin. n engl j med., 1986; 314:20-26. https://doi.org/10.1056/nejm198601023140104 56. mocroft a, kirk o, barton se, dietrich m, proenca r, colebunders r, pradier c. anaemia is an independent predictive marker for clinical prognosis in hiv infected patients from across europe, eurosida study group. aids. 1999: 13(8):943-950. https://doi.org/10.1097/00002030-199905280-00010 57. jahrling pb, hesse ra, eddy ga, johnson km, callis rt, stephen el. lassa virus infection of rhesus monkeys: pathogenesis and treatment with ribavirin. j infect dis., 1980; 141:580-9. https://doi.org/10.1093/infdis/141.5.580 58. mccormick jb, king ij, webb pa, scribner cl, craven rb, johnson km, elliott lh, belmont-williams r. lassa fever: effective therapy with ribavirin. new eng j med., 1986; 314:20-6. https://doi.org/10.1056/nejm198601023140104 59. fisher-hoch sp, gborie s, parker l, huggins j. unexpected adverse reactions during a clinical trial in rural west africa. antivir res., 1992; 19:139-47. https://doi.org/10.1016/0166-3542(92)90073e 60. kochhar dm. effects of exposure to high concentrations of ribavirin in developing embryos. pediatr infect dis., 1990; 9:s88s90. https://doi.org/10.1097/00006454-199009001-00008 61. holmes gp, mccormick jb, trock sc, chase ra, lewis sm, mason ca, et al. lassa fever in the united states. investigation of a case and new guidelines for management. new engl j med., 1990; 323:1120-3. https://doi.org/10.1056/nejm199010183231607 https://doi.org/10.1056/nejm198601023140104 https://doi.org/10.1097/00002030-199905280-00010 https://doi.org/10.1093/infdis/141.5.580 https://doi.org/10.1056/nejm198601023140104 https://doi.org/10.1016/0166-3542(92)90073-e https://doi.org/10.1016/0166-3542(92)90073-e https://doi.org/10.1097/00006454-199009001-00008 https://doi.org/10.1056/nejm199010183231607 lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited effervescent tablets: everything you need to know vineeta devi lodhi1, arvind singh jadon2, jyoti sen3, prateek kumar jain1, bhupendra singh thakur1, basant khare1, anushree jain1* 1 adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 2 school of studies in pharmaceutical science, jiwaji university, gwalior, madhya pradesh, india-474001 3 svn institute of pharmaceutical science, sagar, madhya pradesh, india-470001 article info: _______________________________________ article history: received 03 sep 2022 reviewed 21 october 2022 accepted 01 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: lodhi vd, jadon as, sen j, jain pk, thakur bs, khare b, jain a, effervescent tablets: everything you need to know, asian journal of dental and health sciences. 2022; 2(4):1-8 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.18 _______________________________________ *address for correspondence: anushree jain, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ oral dosage forms are the most popular way of taking medication, despite having some disadvantages compared with other methods like risk of slow absorption of the medicament, which can be overcome by administering the drug in liquid form, therefore, possibly allowing the use of a lower dosage. however, instability of many drugs in liquid dosage form limits its use. effervescent technique can be used as alternate to develop a dosage form which can accelerate drug disintegration and dissolution, is usually applied in quick release preparations. along with the development of new pharmaceutical technique, effervescent tablets are more and more extensively to adjust the behavior of drug release, such as in sustained and controlled release preparations, pulsatile drug delivery systems, and so on. in this review we have discussed about formulation, evaluation, advantages of effervescent tablets and also demonstrated the new applying of effervescent technique in effervescent tablets. keywords: effervescent tablets. carbon tablet, effervescent granules. mail id: anushree1595@gmail.com introduction oral drug delivery has been known for decades as the most widely utilized route of administered among all the routes that have been employed for the systemic delivery of drug via various pharmaceutical products of different dosage forms. the reasons that the oral route achieved such popularity may be in part attributed to its ease of administration.1-2 oral sustained drug delivery system is complicated by limited gastric residence times (grts). rapid gi transit can prevent complete drug release in the absorption zone and reduce the efficacy of the administered dose. effervescent tablets are becoming increasingly popular in a variety of sectors including supplements and pharmaceutical use due to the ease in which they can be consumed. effervescent tablets are designed to break in contact with liquid such as water or juice, often causing the tablet to dissolve into a solution.3-5 effervescent tablet delivery system these buoyant delivery systems utilize matrices prepared with swellable polymers such as methocel or poly saccharides, e.g., chitosan, and effervescent components, e.g., sodium bicarbonate and citric or tartaric acid or matrices containing chambers of liquid that gasify at body temperature.6-8 flotation of a drug delivery system in the stomach can be achieved by incorporating a floating chamber filled with vacuum, air or an inert gas. gas can be introduced into the floating chamber by the volatilization of an organic solvent (e.g. ether or cyclopentane) or by the co2 produced as a result of an effervescent reaction between organic acids and carbonate–bicarbonate salts.9 the matrices are fabricated so that upon arrival in the stomach, carbon dioxide is liberated by the acidity of the gastric contents and is entrapped in the jellified hydrocolloid. this produces an upward motion of the dosage form and maintains its buoyancy. a decrease in specific gravity causes the dosage form to float on the chyme.10 recently a multiple-unit type of floating pill, which generates carbon dioxide gas, has been developed. the system consisted of sustainedrelease pills as seeds surrounded by double layers. the inner layer was an effervescent layer containing both sodium bicarbonate and tartaric acid. the outer layer was a swellable membrane layer containing mainly polyvinyl acetate and purified shellac. moreover, the effervescent layer was divided into two sub layers to avoid direct contact between sodium bicarbonate and tartaric acid. sodium bicarbonate was contained in the inner sublayer and tartaric acid was in the outer layer. when the system was immersed in a buffer solution at 37°c, it sank at once in the solution and formed swollen pills, like balloons, with a density much lower than 1 g/ ml. the reaction was due to carbon dioxide generated by neutralization in the inner effervescent layers with the diffusion of water through the outer swellable membrane layers. the system was found to float completely within 10 min and approximately 80%remained floating over a period of 5 hr irrespective of ph and viscosity of the test medium. while the system was floating, a drug (pamino open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.18 lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [2] ajdhs.com benzoic acid) was released. a variant of this approach utilizing citric acid (anhydrous) and sodium bicarbonate as effervescing agents and hpc-h grade as a release controlling agent has also been reported. in vitro results indicated a linear decrease in the ft of the tablets with an increase in the amount of effervescing agents in the range of 10– 20%. attempts have also been made to develop sr floating tablets using a mixture of sodium bicarbonate, citric acid and chitosan.11-12 figure 1: an effervescent tablet in a glass of water effervescent or carbon tablets are tablets which are designed to dissolve in water, and release carbon dioxide.13 they are products of compression of component ingredients in the form of powders into a dense mass, which is packaged in blister pack, or with a hermetically sealed package with incorporated desiccant in the cap. to use them, they are dropped into water to make a solution. the powdered ingredients are also packaged and sold as effervescent powders or may be granulated and sold as effervescent granules. generally powdered ingredients are first granulized before being made into tablets.14 effervescent tablets are designed to break in contact with liquid such as water or juice, often causing the tablet to dissolve into a solution. this makes effervescent tablets the preferred choice of many, including people who are taking tablets medicinally as well as a dietary supplement.15 reason to choose effervescent tablets over regular tablets effervescent tablets are becoming increasingly popular in a variety of sectors including supplements and pharmaceutical use due to the ease in which they can be consumed. the following are some reasons to choose effervescent tablets over regular tablets,16-19 pleasant taste compared to regular tablets effervescent tablets are so popular due to the fact they can be dissolved in a liquid such as water or fruit juice, meaning that they often taste better than regular tablets. conventional tablets dissolve slowly which can result in reduced absorption rates, effervescent tablets, in contrast, dissolve quickly and completely, meaning you get the full benefit from the ingredients. distributed more evenly conventional tablets dissolve gradually in the stomach once ingested and can sometimes only partially dissolve which can lead to irritation in some cases. the benefit of effervescent tablets is that they dissolve completely and evenly meaning that localised concentrations of the ingredients cannot occur. this means not only a better taste but also less chance of irritation and a more efficient means of ingesting the ingredients. increased liquid intake effervescent tablets provide the nutritional benefits intended, but in addition to this they also increase liquid intake. this can be especially beneficial if you are dehydrated or ill and not ingesting as much fluid as usual. effervescent tablets can be a fantastic way of rehydrating as well as reaping the benefits you are taking the tablets for whether this is a dietary supplement, herbally or medicinally. easy alternative to regular tablets they can be a great alternative for those who may have trouble swallowing either due to illness or age. older individuals may have difficulty swallowing but need to take medication or supplements on a regular basis and in this respect, effervescent tablets can be a lot easier than having to swallow a tablet. in addition to this, they can be a great way of ingesting medicine for individuals with sore throats or medical issues that make swallowing difficult and so are a viable alternative to regular tablets. simple and easy to measure effervescent tablets are easily dissolved into water or a liquid of your choice and then after a while are consistent, well mixed and ready to drink. traditional tablets or powders, however, need to be measured and stirred in repeatedly to avoid an inconsistent drink with lumpy bits. even with stirring and measuring it is common to have an inconsistent drink with lumpy bits and an odd taste and this is where effervescent tablets are more efficient. simply drop them in and they dissolve fully and evenly ensuring you get all the benefits of the tablet, as well as being able to comfortably drink it. to sum up effervescent tablets are becoming increasingly popular and it is easy to see why. they provide a much more efficient way of taking supplements or medication due to being distributed evenly and much more quickly than regular tablets. in addition to this, they taste better as can be added to water or a liquid drink of your choice as well as being easier to take for people who may find it difficult to swallow. all these factors combine to make effervescent tablets a very popular choice for those taking tablets for either dietary supplementation or medicinal reasons. mechanism of effervescence as per revised definition proposed to us fda, effervescent tablet is a tablet intended to be dissolved or dispersed in water before administration. effervescent tablets are uncoated tablets that generally contain acid or acid salts (citric, tartaric, malic acid or any other suitable acid or acid anhydride) and carbonates or bicarbonates (sodium, potassium or any other suitable alkali metal carbonate or hydrogen carbonate), which react rapidly in the presence. of water by releasing carbon dioxide. due to liberation in co2 gas, the dissolution of api in water as well as taste masking effect is enhanced.20-21 the reaction between citric acid and sodium bicarbonate & tartaric acid and sodium bicarbonate, which results in liberation of carbon dioxide shown as follows, lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [3] ajdhs.com c6h8o7.h2o+3nahco3 (aq) → na3c6h5o7 + 4h2o + 3co2 (g) ↑ citric acid + sodium bicarbonate → sodium citrate + water + carbon dioxide c4h6o6 + 2 nahco3→ na2c4h4o6 + 2h2o + 2co2 (g) ↑ tartaric acid + sodium bicarbonate → sodium tartrate + water + carbon dioxide figure 2: mechanism of effervescence fundamentals of effervescent effervescent tablets are designed to release carbon dioxide upon contact with water, promoting their disintegration. within a couple of minutes the tablets completely dissolve and the drug becomes available in solution. the generation of carbon dioxide is a result of the chemical reaction that occurs between a carbonate or bicarbonate salt (e.g., sodium bicarbonate) and a weak organic acid (e.g., citric or tartaric acid) in the presence of water. due to the high content of carbonate salt, upon the ingestion of the drug solution, the gastric ph is temporarily elevated, resulting in fast gastric emptying. this in turn promotes drug absorption from the upper small intestine, which is the primary site for drug absorption. in doing so, higher drug bioavailability and a faster onset of action can usually be achieved. as such, effervescence has been found to be useful to formulate medicines that are difficult to digest, medicines that induce stomach or esophageal irritation (e.g., aspirin), and medicines that are moistureor ph-sensitive (e.g., antibiotics or medicines of large doses that are impossible to swallow, such as those containing more than 2 g of drug) or to obtain a rapid onset of action (e.g., analgesics).22-24 effervescence consists of a soluble organic acid and an alkali metal carbonate salt, one of which is often the api. carbon dioxide is formed if this mixture comes into contact with water. typical examples of the acids and alkalis used include: citric acid tartaric acid malic acid fumaric acid adipic acid sodium bicarbonate sodium carbonate sodium sesquicarbonate potassium bicarbonate potassium carbonate advantages of effervescent tablets25 fast onset of action no need to swallow tablet. good stomach and intestinal tolerance. more portability. improved palatability. superior stability. more consistent response. incorporation of large amounts of active ingredients. accurate dosing. improved therapeutic effect. in remote areas, especially where parenteral forms are not available due to prohibitive cost, lack of qualified medical staff, effervescent tablets could become an alternative. disadvantages of effervescent tablets unpleasant taste of some active ingredients. larger tablets requiring special packaging materials. relatively expensive to produce due to large amount of more or less expensive excipients and special production facilities. clear solution is preferred for administration, although a fine dispersion is now universally acceptable. formulation methodologies26-28 wet granulation the most widely used process of agglomeration in pharmaceutical industry is wet granulation. wet granulation process simply involves wet massing of the powder blend with a granulating liquid, wet sizing and drying. important steps involved in the wet granulation mixing of the drug(s) and excipients. preparation of binder solution. mixing of binder solution with powder mixture to form wet lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [4] ajdhs.com mass. drying of moist granules. mixing of screened granules with disintegrant, glidant, and lubricant. advantages permits mechanical handling of powders without loss of mix quality. improves the flow of powders by increasing particle size and sphericity. increases and improves the uniformity of powder density. limitation of wet granulation the greatest disadvantage of wet granulation is its cost. it is an expensive process because of labor, time, equipment, energy and space requirements. loss of material during various stages of processing. dry granulation in dry granulation process the powder mixture is compressed without the use of heat and solvent. it is the least desirable of all methods of granulation. the two basic procedures are to form a compact of material by compression and then to mill the compact to obtain a granules. two methods are used for dry granulation. the more widely used method is slugging, where the powder is recompressed and the resulting tablet or slug are milled to yield the granules. the other method is to recompress the powder with pressure rolls using a machine such as chilosonator. rollar compaction the compaction of powder by means of pressure roll can also be accomplished by a machine called chilsonator. unlike tablet machine, the chilsonator turns out a compacted mass in a steady continuous flow. the powder is fed down between the rollers from the hopper which contains a spiral auger to feed the powder into the compaction zone. like slugs, the aggregates are screened or milled for production into granules. use: use in the production of directly compressible excipients, the compaction of drugs and drug formulations, the granulation of inorganic materials, the granulation of dry herbal material and the production of immediate/sustained release formulations. advancement in granulations steam granulation it is modification of wet granulation. here steam is used as a binder instead of water. its several benefits includes higher distribution uniformity, higher diffusion rate into powders, more favorable thermal balance] during drying step, steam granules are more spherical, have large surface area hence increased dissolution rate of the drug from granules, processing time is shorter therefore more number of tablets are produced per batch, compared to the use of organic solvent water vapour is environmentally friendly, no health hazards to operators, no restriction by ich on traces left in the granules, freshly distilled steam is sterile and therefore the total count can be kept under control, lowers dissolution rate so can be used for preparation of taste masked granules without modifying availability of the drug. melt granulation / thermoplastic granulation here granulation is achieved by the addition of moldable binder. that is binder is in solid state at room temperature but melts in the temperature range of 50 – 80˚c. melted binder then acts like a binding liquid. there is no need of drying phase since dried granules are obtained by cooling it to room temperature. evaluation of effervescent tablet pre-compression parameters:29-32 angle of repose (θ) angle of repose is defined as the maximum angle possible between the surface of a pile of the powder and horizontal plane. the frictional force in a loose powder or granules can be measured by angle of repose. it is an indicative of the flow properties of the powder. tan θ = h / r θ = tan-1 (h/r) where, θ is the angle of repose, h is height of pile. r is radius of the base of pile the powder mixture was allowed to flow through the funnel fixed to a stand at definite height (h). the angle of repose was then calculated by measuring the height & radius of the heap of powder formed. care was taken to see that the powder particles slip & roll over each other through the sides of the funnel. relationship between angle of repose and powder flow property. table 1: angle of repose as an indication of powder flow properties angle of repose (degrees) type of flow <20 excellent 20-30 good 30-34 passable >40 very poor flow rate flow rate of a powder has been defined as the rate at which the particular mass emerges through the office of funnel of a suitable diameter. the flow rate for granules of each formulation was determined by pouring accurately weighed quantities of granules in funnel with an orifice of 8 mm diameter. the time required for the complete granule mass to emerge out of the orifice was recorded using a stopwatch. the flow rate was calculated from following equation: bulk density the bulk density was obtained by dividing the mass of a powder by the bulk volume in cm3. the sample of about 50 cm3 of powder, previously been passed through a standard sieve no. 20, was carefully introduced into a 100 ml graduated cylinder. the cylinder was dropped at 2-second intervals onto a hard wood surface three times from a height of 1 inch. the bulk density of each formulation was then obtained by dividing the weight of sample in grams by the final volume in cm3 of the sample contained in the cylinder. it was calculated by using equation below: df = m/vp where, df = bulk density, m = weight of samples in grams, vp = final lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [5] ajdhs.com volumes of granules in cm3 tapped density the tapped density was obtained by dividing the mass of a powder by the tapped volume in cm3. the sample of about 50 cm3 of powder previously been passed through a standard sieve no. 20, is carefully introduced into a 100 ml graduated cylinder. the cylinder was dropped at 2-second intervals onto a hard wood surface 100 times from a height of 1 inch. the tapped density of each formulation was then obtained by dividing the weight of sample in grams by the final tapped volume in cm3 of the sample contained in the cylinder. it was calculated by using equation given below: do= m/vp where, do= bulk density, m = weight of samples in grams, vp = final volumes of granules in cm3 carr’s index an indirect method of measuring powder flow from bulk densities was developed by carr. the percentage compressibility of a powder was a direct measure of the potential powder arch or bridge strength and stability. carr’s index of each formulation was calculated according to equation given below: where, df = fluff or poured bulk or bulk density, do = tapped or consolidated bulk density. table 2: carr’s index as an indication of powder flow carr’s index (%) type of flow 5-15 excellent 12-16 good 18-21 fair to passable 23-35 poor 33-38 very poor >40 extremely poor evaluation of effervescent tablets weight variation weight variation was determined to know whether different batches of tablets have uniformity. weighed 20 tablets individually, calculated the average weight and compared the individual tablet weights to the average. the tablets meet the test if not more than two tablets are outside the % limit and none of the tablet differ by more than two times the % limit.33-34 table 3: weight variation specification ip/bp limit usp 80mg or less 10% 130mg or less morethan80mgor less than 250mg 7.5% 130mg to 324 mg 250mg or more 5% more than 324mg tablet thickness and diameter thickness and diameter of tablets were important for uniformity of tablet size. thickness and diameter were measured using vernier calipers. tablet hardness the resistance of tablets to shipping or breakage under conditions of storage, transportation and handling before usage depends on its hardness. the hardness of tablet of each formulation was measured by monsanto hardness tester. the hardness was measured in items of kg/cm2. hardness or tablet crushing strength is the force required to break a tablet in a diametric compression. the force is measured in kg and the hardness of about 3-5 kg/cm2 is considered to be satisfactory for uncoated tablets.35 friability (f) friability of the tablet determined using roche friabilator. this device subjects the tablet to the combined effect of abrasion and shock in a plastic chamber revolving at 25 rpm and dropping a tablet at a height of 6 inches in each revolution. pre weighted sample of tablets was placed in the friabilator and were subjected to the 100 revolutions. tablets were dusted using a soft muslin cloth and reweighed. usp limit is 0.5 to 1%.36 the friability (f) is given by the formula measurement of effervescence time a single tablet is placed in a beaker containing 200 ml of purified water at 20 °c ± 1 °c. whenever a clear solution without particles is obtained effervescence time has finished. the mean of three measurements of each formulation is to be reported.37 determination of effervescent solution ph of solution is determined with one tablet in 200 ml of purified water at 20 ± 1 °c by using ph meter, immediately after completing the dissolution time. repeat experiment 3times for each formulation. measurement of co2 content one effervescent tablet solved in 100 ml of 1n sulphuric acid solution and weight changes were determined after dissolution end. the obtained weight difference is shown the amount (mg) of co2 per tablet. reports the averages of 3determinations. evaluation of the water content 10 tablets of each formulation are dried in a desiccators containing of activated silica gel for 4 hours. water content of 0.5% or less is acceptable. uniformity of content 10 tablets were selected randomly. each tablet was transferred into a 50ml volumetric flask, dissolved and diluted to 50 ml with phosphate buffer ph 6.8. one ml of this solution was diluted to 100 ml with phosphate buffer ph 6.8. the amount of drug present in each tablet was determined by uv spectroscopy at 246 nm. standard limit for uniformity of content is ip: active less than 10mg or 10%, bp:active less than 2 mg or 2%, usp:active less than 25mg or 25%. lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [6] ajdhs.com 10 tabs limit nmt 1 tab deviate 85 – 115% & none outside 75 – 125% of the avg value/ip/bp/usp (relative standard deviation less than or equal to 6%), if 2 or 3 individual values are outside the limits 85 – 115% of the avg value, & none outside 75 – 125% repeat for 20 tablets. determination of the equilibrium moisture content three desiccators are prepared containing saturated salt solutions of potassium nitrate (for creation 90% rh, at 18 °c), sodium chloride (for creation 71% rh, at 18 °c) and sodium nitrite (for creation 60% rh, at 18 °c). three tablets of each formulation are placed in desiccators. then, the equilibrium moisture content is determined by karl fischer method and the autotitrator device in the first day and after 7day.38 in-vitro disintegration time the process of breakdown of a tablet into smaller particles is called as disintegration. the in-vitro disintegration time of a tablet was determined using disintegration test apparatus as per i.p. specifications. (ph-6.8) maintained at37°±2°c as the immersion liquid. the assembly should be raised and lowered between 30 cycles per minute in the phosphate buffer (ph-6.8) maintained at 37°±2°c. the time in seconds taken for complete disintegration of the tablet with no palpable mass remaining in the apparatus was measured and recorded. standard limit for disintegration time is within 3 min in water at 250c ± 10c (ip) and 15 – 250c (bp). dissolution studies the release rate of atorvastatin from mouth dissolving tablets was determined using usp dissolution testing apparatus ii (paddle type). the dissolution medium used was 900 ml of phosphate buffer ph 6.8 which was maintained at 37±0.50c. the paddle speed was kept at 50 rpm throughout the study. five ml of samples was withdrawn at every 5 minutes interval and diluted to 10ml then 5ml of fresh dissolution media maintained at the same temperature was replaniced. the samples were analysed spectrophotometrically at 246nm using phosphate buffer ph 6.8 as blank. the raw dissolution data was analyzed for calculating the amount of drug released and percentage cumulative drug released at different time intervals.39 release kinetic modeling of effervescent tablets in recent years, drug release from pharmaceutical dosage forms has been the subject of intense and profitable scientific developments. whenever a new dosage form is developed form is developed, it is it is necessary to ensure that drug release occurs in an appropriate manner. the quantitative analysis of the values obtained in release tests is easier when mathematical formulas that express the release results as a function of some of the dosage forms characteristics are used. in some cases, these mathematic models are derived from the theoretical analysis of the occurring process. drug dissolution from dosage forms has been described by kinetic models in which the dissolved amount of drug (q) is a function of the test time, t or q=f (t). some analytical definitions of the q (t) function are commonly used, such as zero order, first order, higuchi and korsmeyer–papas.32,36-40 in-vitro dissolution has been recognized as an important pharmaceutical dosage form can influence the release element in drug development. under certain conditions it kinetic be used as a surrogate for the assessment of bioequivalence. several theories / kinetics models describe drug dissolution from immediate and modified release dosage forms. there are several models to represent the drug dissolution profiles where ft is a function of t (time) related to the amount of drug dissolved from the pharmaceutical dosage system. in most cases, with tablets, capsules, coated forms or prolonged release forms that theoretical fundament does not exist and sometimes a more adequate empirical equations used. a water-soluble drug incorporated in a matrix is mainly released by diffusion, while for a low water-soluble drug the selferosion of the matrix will be the principal release mechanism. to accomplish these studies the cumulative profiles of the dissolved drug are t more commonly used in opposition to their differential profiles. to compare dissolution profiles between two drug products model dependent (curve fitting), statistical analysis and model independent methods can be used.41 zero order kinetics drug dissolution from dosage forms that do not disaggregate and release the drug slowly can be represented by the following equation wo-wt= kt where, wo is the initial amount of drug in the dosage form, wt is the initial amount of drug in the dosage form at time(t) , k is the proportionality constant, dividing this equation by and simplify ft=kot where ft= 1-(wt-wo) and ft represents the fraction of drug dissolved in time t and ko the zero order of release constant. this relation can be used to describe the modified release dosage form; the following relation can, in simple way to express this model qt = qo + kot where, qt is the amount of drug dissolved in time t. qo is the amount of drug in the solution. first order kinetics gibaldi and feldman first proposed the application of this model to drug dissolution studies in 1967 and later by wagner in 1969. the dissolution phenomena of solid particles in a liquid media implies a surface action, as can be seen by the noyeswhitney equation. dc/dt= k (cs-c) where, c is the concentration of the solute in time t, cs is the solubility in the equilibrium at expression temperature k is the first order proportionality higuchi model higuchi developed several theoretical models to study the release of water soluble and low soluble drops incorporated in the matrixes. the drug particles dispersed in a uniform matrix behaving as the diffusion media, the relation obtained was the following: ft = q= d(2c-cs) cst where, q is the amount of drug released in time t, per unit area, c is the drug initial concentration, cs is the drug solubility in the matrix media, d is the diffusivity of the drug molecules (diffusion constant in matrix). dq = cdh – ½ (csdh) but, in accordance to the first law (dq/dt = dc/h) higuchi in 1962 proposed the following equation, for the case lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [7] ajdhs.com in which the drug is dissolution. in general way it is possible to resume the highuchi model to the following expression (generally known as the simplified higuchi model). ft = kht 1/2. where kh is the highuchi dissolution constant treated sometimes in a different manner by different authors and theories. higuchi describes drug release as a diffusion process based on fick’s law, square root time dependent. korsmeyer – peppas model korsmeyer et al., in 1983 was developed a simple, semi empirical model, relating exponentially the drug release to the elapsed time (t). ft = atn a – is a constant incorporating structural and geometric characteristics of the drug dosage from, n is the release exponent, indicate of the drug release mechanisms and the of drug). if drug release occurs under perfect sink condition, the following initial and boundary conditions, boundary conditions can be assumed, t=0-d/2<x<d/z c=c0 t>0. x=+d/z= -d/z c=c1 c0-is the initial drug concentration in the device. c1 -is the concentration of drug at the polymer water interface. in the diffusion is the main drug release mechanism, a graphic representation the drug amount released, in the referred conditions, versus the square root of time should originate a straight line. table 4: mathematical models used to describe drug release mechanism s.no. mathematical model equation 1. zero order qt=qo=kot 2. first order in q = in qo + k1t 3. higuchi qt=kh√t 4. korsmeyer-peppas qt/q∞=kktn conclusion effervescence is defined as the evolution of gas bubbles from a liquid as a result of a chemical reaction. for medicinal use, effervescent tablets have specific characteristics that allow rapid adsorption of the intended drug. in this manner, a medication can be absorbed easily and effectively if it dissolves easily in water and is present at a sufficient dose. common acids utilized for effervescent reactions are citric, malic, tartaric, adipic and fumaric acids. citric acid is most commonly used for this application, which also adds a citruslike taste to the products. tartaric, adipic and fumaric acids are usually used in small amounts, due to their low water solubility. we can conclude that effervescent tablets are used to simplify the handling of doses, provide optimal compatibility, promote superior and rapid absorption, increase a patient’s liquid intake and circumvent the difficulty of swallowing large pills. references 1. gharti kp, thapa p, budhathoki u, bhargava a, formulation and in vitro evaluation of floating tablets of hydroxypropyl methylcellulose and polyethylene oxide using ranitidine hydrochloride as a model drug, journal of young pharmacists, 2009; 4(4):201-208. https://doi.org/10.4103/0975-1483.104363 2. singh bn, kim kh, floating drug delivery systems: an approach to oral controlled drug delivery via gastric retention, journal of controlled release, 2000; (63):235-59. https://doi.org/10.1016/s0168-3659(99)00204-7 3. deepali dw, madhav ms, jain ds, gastroretentive floating microspheres: a review, international journal of pharmacy &technology, 2011; 3(4):1783-1799. 4. singh lp, rajesh ks, umalkar dg, chauhan vk, rana vk, vasava ks, floating effervescent tablet : a review, journal of pharmaceutical and biomedical sciences, 2011; 5(11):1-6. 5. agyilirah ga, green m, ducret r, banker gs, evaluation of the gastric retention properties of a cross-linked polymer coated tablet versus those of a non-disintegrating tablet, international journal of pharmaceutics, 1991; 75:241-47. https://doi.org/10.1016/0378-5173(91)90198-w 6. mohrle r, liberman l, schwartz l. pharmaceutical dosage form, vol. 1, marcel decker inc., new york, 2005; 285292. 7. lachman l, liberman ha, kanig jl. the theory and practice of industrial pharmacy. 3rd ed. philadelphia: lea and febiger; 1986. 8. swarbrick j, boylan jc. encyclopaedia of pharmaceutical technology. new york: marcel dekker; 2002 9. harald s, effervescent dosage, pharmaceutical technology europe, 2003; 15(4):25-28. 10. srinath kr. formulation and evaluation of effervescent tablets of paracetamol. international journal of pharmaceutical research & development. 2011; 3(3):76104. 11. indian pharmacopoeia, government of india ministry of health and family welfare. delhi: controller of publications 1996; 2: 35, 448, 554. 12. howard ca, lloyd a, nocholas and popovich. effervescent granules"8th edition pharmaceutical dosage from and drug delivery. international student edition.-2000, 172-178. 13. dixit n, maurya sd, sagar bps, sustained release drug delivery system, indian journal of research in pharmacy and biotechnology, 2013; 1(3): 305-310. 14. shimodaira s, quality verification of dendritic cell-based cancer vaccine. pharm anal acta, 2016; 7:467. https://doi.org/10.4172/2153-2435.1000465 15. hassali ma. role of pharmacists in health based nongovernmental organizations ngo: prospects and future directions, pharm anal acta. 2016; 7:467. 16. vergeire dg. usefulness of cost effectiveness: evidence versus applicability. pharm anal acta, 2016; 7:456. 17. wang c, application of in vitro models in developmental neurotoxicity and pharmaceutics research, journal of molecular pharmaceutics & organic process research, 2015; 3:122-128.. 18. lyubchenko yl, nanoimaging for molecular pharmaceutics of alzheimer's and other neurodegenerative disorders, journal of molecular pharmaceutics & organic process research, 2013; 1:107-111. https://doi.org/10.4172/jmpopr.1000e107 19. skalkz bn, note on the "molecular pharmaceutics and organic process". journal of molecular pharmaceutics & organic process research, 2013; 1:104-110. 20. foldvari m, nanopharmaceutics innovations in gene therapy: moving towards non-viral and non-invasive delivery methods. j nanomedine biotherapeutic discovery. 2014; 4:135. https://doi.org/10.4103/0975-1483.104363 https://doi.org/10.1016/s0168-3659(99)00204-7 https://doi.org/10.1016/0378-5173(91)90198-w https://doi.org/10.4172/2153-2435.1000465 https://doi.org/10.4172/jmpopr.1000e107 lodhi et al asian journal of dental and health sciences. 2022; 2(4):1-8 [8] ajdhs.com 21. maurya sd, rawal rk, jha s, chauhan ps, kumar a, drug loaded beads: current status, american journal of pharm tech research, 2013; 3 (1): 331-337. 22. sallam a, bioequivalence of two oral formulations of modafinil tablets in healthy male subjects under fed and fasting conditions. journal of bioequivalence availability. 2015; 7:63-67. 23. agatonovic ks, biorelevant dissolution studies of pioglitazone hcl immediate release tablets and the determination of an in vitro in vivo correlation, journal of bioequivalence availability, 2015; 7:086-089. 24. abdul as, formulation, evaluation and mathematical modeling of clopidogrel bisulphate & aspirin immediate release bilayer tablets, pharmaceutca anal acta, 2012; 3:194. 25. biswas d and halquist m, using biorelevant in vitro models testing to characterize release of non-oral dosage forms as another tool for safety. journal of pharmacovigilance, 2016; 4:153-160. https://doi.org/10.4172/2329-6887.1000e153 26. bhattacharjee j. mass drugs administration in india a failure story. epidemiology, sunnyvale, 2016; 6:252. https://doi.org/10.4172/2161-1165.1000252 27. swain s and beg s. emergence in the lipid-based nanostructured systems for optimizing oral delivery of drugs. pharmaceutical regulatory affairs, 2016; 5:157-163. 28. kokardekar rr, development and evaluation of sustained release microspheres of glibenclamide by emulsion solvent evaporation method. clinical pharmacology and biopharmaceutics, 2014; 3:127. https://doi.org/10.4172/2167-065x.1000127 29. cho sk. the synergistic effects of pioglitazone on the glucose lowering action of metformin in relation to oct1 and gluts m rna expression in healthy volunteer. clinical pharmacology and biopharmaceutics, 2015; 3:129. 30. asati s, jain s, choubey a, bioadhesive or mucoadhesive drug delivery system: a potential alternative to conventional therapy, journal of drug delivery and therapeutics 2019; 9(4-a):858-867 31. mahale mm, saudagar rb, microsphere: a review, journal of drug delivery and therapeutics 2019; 9(3-s):854-856. 32. patil js, novel tubercular therapeutic agents: need of the day, advance pharmacoepidemiology and drug safety, 2015; 4:137. 33. obara t, prevalence, determinants, and reasons for the nonreporting of adverse drug reactions by pharmacists in the miyagi and hokkaido regions of japan, advance pharmacoepidemiology and drug safety, 2015; 4:191. 34. teoh bc, et al. perceptions of doctors and pharmacists towards medication error reporting and prevention in kedah, malaysia: a rasch model analysis. advpharmacoepidemiol drug saf. 2015; 4:192. 35. united states pharmacopeia 31/national formulary 26. rockville md usa: united states pharmacopeial convention; 2008. 36. yanze fm, duru c, jacob m, a process to produce effervescent tablets: fluidized bed dryer melt granulation. drug development & industrial pharmacy, 2000; 26(11):1167-76. https://doi.org/10.1081/ddc-100100988 37. simona b, tanja r, using different experimental designs in drug excipient compatibility studies during the preformulation development of a stable solid dosage formulation, acta chimica slovenica, 2010; 57:895-903. 38. larry la and stephan wh, pharmaceutical dosage form: tablets 3rd edition vol. 1: 465. 39. aboud hm, elbary a, ali aa, enhanced dissolution of meloxicam from orodispersible tablets prepared by different methods, bulletin of faculty of pharmacy, cairo university, 2012; 50:89-97. https://doi.org/10.1016/j.bfopcu.2012.07.001 40. ahmed i, aboul-einien m, in vitro and in vivo evaluation of a fast disintegrating lyophilized dry emulsion tablet containing griseofulvin, european journal of pharmaceutical sciences. 2007; 32:58-68. https://doi.org/10.1016/j.ejps.2007.05.114 41. more s, gavali k, doke o, kasgawade p, gastroretentive drug delivery system, journal of drug delivery and therapeutics 2018; 8(4):24-35 https://doi.org/10.22270/jddt.v8i4.1788 https://doi.org/10.4172/2329-6887.1000e153 https://doi.org/10.4172/2161-1165.1000252 https://doi.org/10.4172/2167-065x.1000127 https://doi.org/10.1081/ddc-100100988 https://doi.org/10.1016/j.bfopcu.2012.07.001 https://doi.org/10.1016/j.ejps.2007.05.114 https://doi.org/10.22270/jddt.v8i4.1788 jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [48] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited contemporary trends in dental implants sanyam jain, sani soni, shivani lodhi, rubeena khan *, anushree jain, basant khare, bhupendra singh thakur, prateek kumar jain adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 13 sep 2022 reviewed 08 nov 2022 accepted 27 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: jain s, soni s, lodhi s, khan r, jain a, khare b, thakur bs, jain pk, contemporary trends in dental implants, asian journal of dental and health sciences. 2022; 2(4):48-54 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.25 _______________________________________ *address for correspondence: rubeena khan, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ a high number of patients have one or more missing tooth and it is estimated that one in four world subjects over the age of 74 have lost all their natural teeth. many options exist to replace missing teeth but dental implants have become one of the most used biomaterial to replace one (or more) missing tooth over the last decades. therefore, the use of dental implants is also a common practice. although research on dental implant designs, materials and techniques has increased in the past few years and is expected to expand in the future, there is still a lot of work involved in the use of better biomaterials, implant design, surface modification and functionalization of surfaces to improve the long-term outcomes of the treatment. this paper provides a brief history and evolution of dental implants. it also describes the types of implants that have been developed, and the parameters that are presently used in the design of dental implants. finally, it describes the trends that are employed to improve dental implant surfaces, and current technologies used for the analysis and design of the implants. keywords: dental implants, history, design, surfaces, osseointegration, biopolymers. introduction in our society of appearance, teeth must be white and the dentition harmonious. teeth participate primarily as one of the main attributes of smile. when decayed, grey or blackish, they can scare and must be hidden. today, patients are still suffering from this evil of another age confining to archaism. total edentulism is the ultimate degree of the parodontal disease and is still observed nowadays1. a poorly treated decay, a genetic alteration of enamel or dentine (e.g., amelogenesis or dentinogenesis imperfecta) and a trauma are sufficient to lose a tooth. fortunately, in most cases, a solution exists for a tooth replacement such as bridge, dental implant, pivot tooth or denture. the solution depends of the local conditions of the dental status and also of the financial aspect of the treatment. uncemented endosseous implants have become a most valuable alternative to dental prostheses supported by remaining teeth or adjacent oral soft tissues. the method started in the late sixties. during the last decades, metallic implants have become the most frequently used treatment. titanium is one of the most commonly used biomaterial in oral and maxillo-facial surgery. excellent clinical results have been obtained with threaded titanium implants by pioneer workers2-4. after more than four decades, dental implantology is now a well-recognized therapeutic advance in the treatment of partial or complete teeth loss5. the technique is reliable and suppresses the use of fixed or removable dentures, which invariably alter the supportive adjacent teeth after a short or medium period. the sustainability of dental implantology is primarily based on the overall analysis of the patient’s clinical situation (periodontal condition, occlusion, available bone volume, general health condition) and the appropriate adaptation of surgicalprosthetic options. the threaded implants currently available meet strict criteria of manufacturing and surgical procedures for their bone fixation and adaptability are now done according to specific prosthetic concepts. the pre-implant bone site is the most important point to consider in its ability to favor the implant osseointegration (i.e., primary bone anchorage of this metallic biomaterial) and its long-term stability. however, a reduced bone volume (constantly observed in the edentulous patient) impairs the placement of implants1; this has led to develop bone grafting techniques and the use of synthetic biomaterials6. statistics provided by the american association of oral and maxillofacial surgeons show that 69% of adults ages 35 to 44 have lost at least one permanent tooth to an accident, gum disease, a failed root canal or tooth decay. furthermore, by age 74, 26% of adults have lost all of their permanent teeth7. therefore, the use of dental implants reveals that about 100,000-300,000 dental implants are placed per year, which approximates the numbers of artificial hip and knee joints placed per year8. research on dental implant designs, materials and techniques has increased in the past few years and is expected to expand in the future9 due to the recent growth of the global market for dental implants and the rising in the demand for cosmetic dentistry. historical overview the history of dental implants can be traced back to ancient egypt, where carved seashells and/or stones were placed into human jaw bone to replace missing teeth. other documented open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.25 jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [49] ajdhs.com examples of early implants are those fabricated from noble metals and shaped to recreate natural roots10. dental implants have a history of several centuries starting with the early civilizations more than 2,000 years ago in south and north america and regions of the middle asia and mediterranean. archeological findings have indicated that these civilizations replaced missing teeth using carved stone, shells, bones and gold11. around 1930s, archaeological excavations in honduras revealed that the mayan civilization had the earliest known examples of dental implants, dating from about 600 ad, when a fragment of mandible with implants was found. the specimen had three pieces of shells carved into tooth shapes placed into the sockets of three missing lower incisor teeth. later on, it was also observed that there was compact bone formation around two of the implants12,13. in the middle ages, dental implantation was performed by using allografts and xenografts. however, this practice didn’t become very popular, since it was identified as the reason for infectious diseases and even deaths12,14. modern dental implant history starts during world war ii when in the years of service in the army, dr. norman goldberg thought about dental restoration using metals that were used to replace other parts of the body. later on in 1948, in association with dr. aaron gershkoff, they produced the first successful sub-periosteal implant13. this success formed the foundation of implant dentistry in which they were pioneers in teaching techniques in dental schools and dental societies around the world13. one of the most important developments in dental implantology occurred in 1957, when a swedish orthopedic surgeon by the name of peringvar branemark began studying bone healing and regeneration and discovered that bone could grow in proximity with the titanium (ti), and that it could effectively be adhered to the metal without being rejected15. therefore, brånemark called this phenomenon ‘osseointegration’, and he carried out many further studies using both animal and human subjects. in 1965, he placed the first ti dental implants into a 34-year-old human patient with missing teeth due to severe chin and jaw deformities. branemark inserted four ti fixtures into the patient’s mandible, and several months later he used the fixtures as the foundation for a fixed set of prosthetic teeth4. the dental implants served for more than 40 years, until the end of the patient’s life. branemark published many studies on the use of ti implants, and between 1978 and 1981, he cofounded a company for the development and marketing of dental implants. branemark’s discovery had such a profound impact in dentistry that to the present day, over 7 million branemark system implants have now been placed and hundreds of other companies produce dental implants15,16. in may of 1982, branemark presented the results of his 15 years of human and animal research at the toronto conference on osseointegration in clinical dentistry, and shortly after the conference, researchers from the united states were trained in branemark’s methods in sweden. in 1982, the us food and drug administration approved the use of ti dental implants, and in 1983, dr. matts andersson developed the procera (nobel biocare, zurich, switzerland) computer-aided design and computer-aided manufacturing (cad/cam) method of high precision, repeatable manufacturing of dental crowns. recent progress in the past century has focused on materials and techniques to improve quality and anchorage17 and after the mid-1980s, other important developments in dental implantology have been focused in the esthetic restorations. the development of modern ceramics started in 1992; and from that time on, dental implant companies, have incorporated ceramic surface treatments and ceramic-like elements to implants with the purpose of further enhancing osseointegration18. today, approximately 450,000 osseointegrated dental implants are being placed every year, with an expectation of 95% success rate (in the case of single tooth replacement with an implant supported crown), with minimum risks and associated complications12. the dental implants the vast majority of implants that have been placed in patients all over the world in 2015 have a similar shape: a hollow supporting screw that receives, in a second time, a supraprosthetic device. there are numerous variations in the overall shape of the implants (e.g., a rounded or pointed apex; more or less spaced threads, cylindrical or conical body) (figure 1). the surface quality of an oral implant is one of the essential features for a successful early clinical outcome. the manufacturers have developed a number of specific processes to improve the rate of osseo-integration and the long-term biomechanical anchorage of the implant on the bone matrix. implants with a rough surface have a better osseo-integration, evaluated by histomorphometric parameters, than the original machined titanium implant of nobel biocare, which had a smooth surface19. roughness results in a better interlocking between the implant and bone on growth by increasing the developed surface at the micrometer scale. however, an excess of roughness, especially in the upper threads can increase peri-implantitis as well as ionic leakage20. it is generally accepted that a moderate roughness of 1-2µm is the most suitable condition21,22. several methods have been proposed by the manufacturers to produce a rough surface on a dental implant23. titanium plasma-spraying the method uses a plasma torch under argon (hot titanium powder is explosive in the air) to project titanium particles onto the surface of the implant. they fuse and constitute a layer more or less uniform. however, some inconveniences have been described with filaments of metals, an increased risk of wear debris and the leakage of metal ions24. particle blasting and acid etching blasting the implant surface with hard ceramic particles (corundum) at high velocity causes numerous impacts and tears at the material surface creating irregularities. however, the surface is made by defects with acute angles and can retain impacted foreign particles. for these reasons, an additional acid treatment using strong acids such as hf, hcl and hno3 is usually done after the blasting step. this produces a very typical rough surface with the appearance of waves and valleys, a condition that favor osseo-integration25. other treatments can also induce surface irregularities such as sodium fluoride since titanium can be attacked by halogens. anodization of the implant surface anodization can produce micro or nano-textured rough surfaces. this causes an increase in the passivation layer of titanium oxide associated with pores26. coatings several coating methods have been also proposed to modify the roughness and improve cell attachment27. hydroxy-apatite can be deposed by plasma-spraying but the layer tends to delaminate, leading to implant failure in mid-term studies28. these implants are nowadays abandoned. similar problems were also encountered with coatings made of other orthophosphate calcium salts. biomimetic calcium phosphate have also been electro-deposited or created by immersion in synthetic body fluids (gel-sol technique) 29.whatever the mechanisms used to induce a surface roughness, this favors fibronectin deposition, cell attachment and spreading as evidenced by in vitro and in vivo studies30,31. jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [50] ajdhs.com placement methods the placement of a dental implant can be done under local or general anaesthesia; the local anaesthesia being the most commonly used in daily practice. the implantation protocols are totally painless regardless of the maxillary or mandibular location. occurrence of intra-operative pain is the result of incomplete anaesthesia or an iatrogenic act. although occurring in the oral cavity which contains many of saprophytic bacteria, the asepsis protocol must be strict and similar to the general rules of surgery with the use of sterile implant packages and sterile drapes to cover the patient. ct scans are necessary to ensure a correct implant placement in bone at distance from nerves or vessels which would be a source of complication. the principle for an implant placement is based on the use of calibrated drills with increasing size until the width of the implant is obtained. depending of the bone density, drilling is more or less intensive. this step ends with a control of locking the implant on the bone with a torque wrench. indeed, a residual mobility will not permit the stability of the implant and it will be necessary to remove it. at the end of surgery, two possibilities exist: (i) bury the implant on bone for several months under the sutured gingiva. proponents of this method consider that such a quiescent condition is more favorable without mechanical stress, risk of infection or epithelial invasion. (ii) other authors prefer to immediately place the implant collar inside the oral environment by fixing a cover screw at the top of the implant until the impression procedure. overall, there is no consensus on the superiority of either of these two methods. as mentioned above, the concept of osseo-integration is defined by the tolerance into the living bone of a foreign and inert body (the titanium implant) which will provide a sustainable and stable bone anchor. an x-ray follow-up must confirm the absence of peri-implant osteolysis (appearing as a radiolucent edging around the implant).osteolysis is also associated with a painful inflammatory reaction and implant mobility. this situation requires removal of the implant as soon as possible to limit the expansion of the peri-implant osteolysis of the alveolar bone. as previously mentioned, the surgical protocol is now no more strictly based on the branemark’s concepts pro-posed thirty years ago. the timing for loading the implant has raised a considerable amount of articles and can be done in several ways. it has been advocated that after implant placement, the surgical site should be left undisturbed for4 to 5 months to allow a good wound healing between the implant and the bone. this period is in accordance with bone cell physiology: osteoblasts elaborate woven bone rapidly to ensure the primary bone anchorage and this bone (being of poor quality) is secondarily remodelled and replaced by lamellar bone which possesses a better quality. more recently, other authors have proposed the concept of immediate loading of the implant to support provisional fixed crowns or prosthesis32,33. immediate loading is the placement of a temporary prosthesis on the implants just after the implant placement. the benefit of this protocol is to immediately correct the tooth loss and to favor maturation of the gingival tissues at the implant’s base. the obvious disadvantage of this procedure is that loaded implants are exposed to the chewing force immediately after implantation, a situation that may delay osseo-integration. this protocol is not the subject of a consensus and the exact definition of immediate loading may vary from same-day implant loading to a shortly-delayed loading (usually three days to one week), making published results difficult to compare. figure 1: different types of dental implants proposed by several companies implant requirements and design since the use of dental implants has a long history, there are many factors that have been recognized as critical for the successful performance of the implants9. one of the most important factors is biocompatibility; which not only involves compatibility of the material with the tissue but its ability to perform a specific function. therefore, this property is not dependent just on the physical, chemical and mechanical properties of the material, but also by the application in which the material is used. in the case of dental implants, the biocompatibility of materials is evaluated by studying the direct interactions between the implant and the tissues, which is a measurement of the degree of osseointegration34. in order to improve osseointegration; therefore long-term success of the implants, the following variables are critical and should be considered in the design of dental implants include biomaterials composition, implant width length and geometry, biomechanical factors, surface characteristics, medical status of the patient, bone quality and surgical technique35. jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [51] ajdhs.com 1. biomaterials the biomaterials used for manufacturing dental implants include metals, ceramics, carbons, polymers, and combinations of these. polymers are softer and more flexible than the other classes of biomaterials. they also present with low mechanical strength, which makes them prone to mechanical fractures during function under high loading forces. polymeric materials were reported to have very little application in implant dentistry and were only used to fabricate shockabsorbing components placed between the implant and the suprastructure35. ti, including alloy ti-6al-4v (ti-6 aluminum-4 vanadium), is the first modern material used for dental implants, and it is still one of the most used in contemporary dental implants. commercially pure ti is a light metal with excellent biocompatibility, relatively high stiffness and high resistance to corrosion. however, when exposed to air, a surface oxide is formed and this layer of oxide determines the biological response. this oxide layer is a dynamic interface that acts as platform for the apposition of bone matrix35. other metals have been used for osseointegration, including zirconium, gold and ti-aluminumvanadium alloys. these alloys may strengthen the implant but have been shown to have relatively poor bone-to-implant contact. bioceramics such as hydroxyapatite are also used because although their low strength, excellent biocompatibility, and capacity to integrate with hard tissue and living bone8. besides their brittle nature, hydroxyapatite, tricalcium phosphate, and aluminum oxide ceramics are currently used as plasma-sprayed coatings onto a metallic core. this results in union of the implant with the host tissue35. 2. implant design a wide variety of different sizes and shapes of implants have evolved to fit current surgical concepts and improve patient treatment. continuous research has revealed that subtle changes in shape, length, and width of the implants could influence success rates36. length implant length and diameter have an influence on the stress distribution at the bone-implant interface, as well as on success rates37. implant length is the dimension from the platform to the apex of implant9. implant length varies from 620 millimeters. the most common length employed is between 8-15 millimeters36. research in implant dentistry has shown that longer implants guarantee better success rates and prognosis; and that shorter implants have statistically lower success rates due to reduced stability, which can be explained in terms of less bone to implant contact and smaller implant surface36. however, short or narrow implants are preferred for the prosthetic solution of the extremely resorbed alveolar bone areas38. diameter the diameter of the implant is measured from the widest point of a thread to the opposite point on the implant and typically ranges from 3 to 7 mm; although narrower diameter implants can be used in small spaces. for clinical applications, physicians select implant diameter depending on the patient’s bone quantity and quality to yield optimal stability and to prohibit over-instrumentation. for example, wider implants allow for interaction with a larger amount of bone. ivanoff et al39 concluded from animal studies that larger diameter implants are more stable in removal torque tests, and that they may be more useful in the clinical setting since there is a larger contact area with cortical bone. in addition, it has been shown in mechanical simulations that larger diameter implants can resist larger vertical loads40. using fea, it was determined that the implant diameter was much more important in stress dissipation than implant length, especially in cortical bone41, though other groups have reported that the length of the implant was more important in controlling stress distribution in the cancellous bone42. based off of the literature, implant lengths ranging from 8 mm to 12 mm are used clinically. geometry one of the main concerns in terms of design is the shape of the implant, since the geometry affects the interaction between the bone and implant, the surface area, the distribution of forces to the bone and the stability of the implant. therefore, commercial dental implants are classified into different groups according to their shape. the main types of implants are cylindrical, conical, stepped, screw-shaped, and hollow cylindrical. several studies revealed that conical implant surfaces or surfaces with geometric discontinuities resulted in higher stresses than smoother shapes such as cylindrical or screw-shaped. for this reason, the cylindrical screw threaded implants are the most commonly used9,10. threads as mentioned before, threads are incorporated into implants in order to improve initial stability, enlarge implant surface area, distribute stress favorably while minimizing the amount of extreme adverse stresses to the bone-implant interface. the thread profile is characterized by the depth, pitch (number of threads per unit length), flank angle, the top radius of curvature, and the straight part at the bottom of the thread1. different modifications in thread patterns such as microthreads near the neck of the implant, macrothreads on the mid-body, and variety of altered pitch threads have been employed to accentuate the effect of threads and induce a desired biomechanical behavior34,43. 3. biomechanical factors dental implants are primarily anchored in bone by means of mechanical interlocking1; therefore, implant stability is considered to play a fundamental role in successful osseointegration. it has been found an implant failure rate of 32% for implants with inadequate initial stability. as mentioned above, major contributors to dental implant stability are the design parameters such as length, diameter, geometry and threads have important effects on biomechanical stability, load transfer mechanisms and either success or failure of implants. other factors that affect the stability are the material properties and the quality and quantity of surrounding bone. masticatory forces acting on dental implants can also result in undesirable stress within the surrounding jawbone, and this can cause bone rejection and eventual failure of the implant8. moreover, bone resorption can be activated by surgical trauma or bacterial infection, as well as by the design parameters used42,43. 4. surface characteristics when a material is placed in the body, there will be a biological response that will be mediated by the interaction of the implant through its surface. micro-level features are included to impart osseointegration or direct bone to implant contact at the micro level44. at the points of contact between cells and biomaterials there is an exchange of information leading to activation of specific genes and remodeling. the first step in this response involves the adsorption of specific proteins, lipids, sugar, and ions that can activate cells mechanisms to induce either acceptance or rejection of the implant by determining which and how many cells populate the surface45,46. therefore, a high percentage of bone-implant contact is necessary to create sufficient anchorage of the implant, which jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [52] ajdhs.com is a determinant factor in osseointegration. two of the most important factors that affect the quality and speed of osseointegration are the physical and chemical nature of the surface of the implant. these properties also have an effect on the maintenance of soft tissue and surrounding bone around the implant. in order to increase the success rate of dental implants, research has focused on the control of surface properties such as morphology, topography, roughness, chemical composition, surface energy, residual stress, the existence of impurities, thickness of ti oxide film, and the presence of metallic and nonmetallic compounds on the surface. these properties profoundly influence the osseous and tissue response to the implant by either increasing or decreasing healing times and osseointegration37. research has shown that osteoblastic cells adhere more quickly to rough surfaces than to smooth surfaces1. this property can also produce orientation and guide locomotion of specific cell types and has the ability to directly affect cell shape and function47. there are two broad types of chemical alterations: 1) addition of inorgainic phases (e.g., hydroxyapatite or calcium phosphates) and 2) addition of organic phases (growth factors). in both cases, the goal is to impart direct bone to implant contact. the addition of inorganic phases such as calcium phosphates imparts osteoconductive properties to the implant48,49. coating ti implants with calcium phosphates increases the speed at which bone formation occurs and also serves to span a gap between bone and the implant50,51. ti implants are typically coated with hydroxyapatite using plasmaspraying to form an inorganic film. though this coating serves to increase osteoinduction, the bond between the film is a limiting factor in the efficacy of inorganic coatings; the micronsized film can delaminate or loosen and release large particles, causing implant failure18. secondly, the addition of organic molecules or bioactive molecules also influences the surrounding cells. for those reasons most commercial dental implants have a microroughened surface (0.5-1μm) obtained by techniques such as grit-blasting and/or acid-etching54. although many studies have demonstrated the importance of roughness in osseointegration, there is no standard for the roughness of dental implants1. however, many animal studies support that bone ingrowth into macro rough surfaces (23μm) enhances the interfacial and shear strengths. surface roughness can also induce orientation and guide locomotion of cells and has the ability to directly affect cell shape and function52,53. contraindications they are now well identified and classified. general contraindications are psychiatric disorders, severe cardiovascular troubles, hematological malignancies and ongoing therapeutic trials. a special attention is given to patients receiving intravenous amino-bisphosphonates for a malignant disease. due to the high risk of inducing an osteonecrosis of the jaw, scientific societies and health agencies consider that dental implants are prohibited in these particular cases. however, bisphosphonate treatment for other metabolic bone disease such as osteoporosis is not a contraindication and recommendations should be care-fully followed. local contraindications are represented by an absent oral hygiene, a massive bone loss and occlusal disorders. smoking is a discussed contraindication: it has been shown that a significantly higher percentage of implant failures may occur in smokers (particularly at the maxilla) 54-56 but smoking do not preclude implant placement; smokers should be informed that they are more at risk for peri-implantitis. limits and complications of dental implants the limits of implantology derive from careful analysis of the contraindications but nowadays, there are fewer and fewer taboos. as an example, a limited bone volume is typical of the evolution and adaptation of the therapeutic strategies. at the beginning of implantology, a minimum of bone volume was required for the placement of the fixtures. the development of new grafting techniques was proposed to overcome the problem of bone insufficiency. during the1990s, filling or apposition grafts were extensively developed at the maxilla or the mandible after having harvested a bone autograft at the skull or iliac bone. the history of sinus lift is characteristic of the huge amount of progress made with bone grafts. in this technique, a bone autograft is added between the jaw and the olfactory epithelium covering the maxillary sinus (schneider’s membrane).after healing, an increased bone volume is obtained allowing the placement of the implants after 6 to 9 months. the use of biomaterials as bone substitute has led to the development of this protocol by eliminating the first surgical time (harvesting of the autograft). this led to a more easy and reliable technique ensuring a high level of success and a better anchorage of the implant with prosthetic devices. at that time, the most recommendable biomaterial to use for making a sinus lift is beta tricalcium phosphate (β-tcp), which is gradually resorbed and induces bone osteoconduction. in the past, implant placement was a source of infectious complications and had a reputation of an ill-fitting. since 3-4 decades, implant outfits are the rule, explaining the interest of dentists and maxillo-facial surgeons for these techniques. the present complications are mainly infectious. after nearly four decades of implant practice, it is possible to observe a bone lesion, termed peri-implantitis, which can threaten the implant holding. this leads to a peri-implant osteolysis associated with an inflammation of soft tissues. bone loss occurs around the implant as a saucer defect and its progression is non-linear and accelerated by risk factors (tobacco, poor oral hygiene). removal of the implant before the bone loss is too pronounced may represent a preventive and conservative action to protect the bone volume. fractures of the prosthetic elements are not rare and can be easily corrected. however, it should be noted that iatrogenic complications are not uncommon. they can be due to a surgical fault, after a poor x-ray analysis, a defective positioning of the implant, the fracture of an instrument, the compression or section of the inferior alveolar nerve, the migration of an implant in the maxillary sinus or the lack of a global therapeutic evaluation. these cases usually have medico-legal consequences. the lifetime of dental implants is exceedingly high, generally in the order of two decades if the protocols are correctly followed. the percentage of complications (loss of implants) remains low because, usually less than 5% in the first 5 years for the majority of authors57. conclusion at the end of the 20th century, a major advance in the treatment of tooth loss is represented by the discovery of dental implants. although implantology has not the same importance that other surgical techniques concerned with lifethreatening diseases, the correction of a dental deficit influences the physiological and psychological condition of the patients and improves their quality of life. rigorous manufacturing processes, the recognition of an operative consensus and the numerous prosthetic adaptations available have really accomplished a technological revolution. the technique remains; however, poorly known among all the other organ grafts but its therapeutic value is now well admitted. references 1. bodic f, hamel l, lerouxel e, baslé mf, chappard d. bone lossand teeth. joint bone spine 2005; 72:215-21. https://doi.org/10.1016/j.jbspin.2004.03.007 https://doi.org/10.1016/j.jbspin.2004.03.007 jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [53] ajdhs.com 2. adell r, lekholm u, rockler b, brånemark pi. a 15-year study of osseo-integrated implants in the treatment of the edentulous jaw. int j oral surg 1981; 10:387-416. https://doi.org/10.1016/s0300-9785(81)80077-4 3. albrektsson t, brånemark p-i, hansson h-a, lindström j. osseointegrated titanium implants: requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. acta orthopaedica 1981; 52:155-70. https://doi.org/10.3109/17453678108991776 4. brånemark pi, zarb ga, albrektsson t. tissue integrated prostheses. chicago: quintessence int; 1985. 5. guillaume b. les implants dentairestechniquesprescriptions advantages. ellebore; 2011. 6. guillaume b. autogreffe, xénogreffe et allogreffe: utilisa-tion clinique. in: guillaume b, audran m, chappard d, editors.tissu osseux et biomatériaux en chirurgie dentaire. paris:quintessence int; 2014. p. 337-66. 7. oral and maxillofacial surgeons: the experts in face, mouth and jaw surgery [internet]. rosemont (il): american association of oral and maxillofacial surgeons. available from: http://www.aaoms.org/conditions-and-treatments/dentalimplants. 8. gupta a, dhanraj m, sivagami g. status of surface treatment in endosseous implant: a literary overview. indian j dent res 2010; 21:433-8. https://doi.org/10.4103/0970-9290.70805 9. seth s, kalra p. effect of dental implant parameters on stress dis¬tribution at bone-implant interfaces. inter j sci res 2013; 2:121-4. 10. lee jh, frias v, lee kw, wright rf. effect of implant size and shape on implant success rates: a literature review. j prosthet dent 2005; 94:377-81. https://doi.org/10.1016/j.prosdent.2005.04.018 11. digiallorenzo d. history of dental implants [internet]. colleg¬eville (pa): lanap & implant center of pennsylvania. available from: http://www.perioimplants.us/history-of-dentalimplants.html. 12. sullivan rm. implant dentistry and the concept of osseointegration: a historical perspective. j calif dent assoc 2001; 29:737-45. 13. history [internet]. chicago (il): american academy of implant dentistry. available from: http://www.aaid.com/about/history.html. 14. dental implants: histroy of dental implants [internet]. [place un¬known]: manoimplantai. available from: http://www.manoimplantai.lt/dantu-implantai/dantu-implantuistorija/?lang=en. 15. find out who was responsible for starting dental implant history [internet]. [place unknown]: dental-health-advice. available from: http://www.dental-health-advice.com/dental-implanthistory.html. 16. dental implant history [internet]. albufeira: cris piessens clinic. available from: http://www.crispiessensclinic.com/implant_history.html. 17. rethman mp. introduction & historical perspectives on dental im¬plants. chicago: hu-friedy; 2010:1-4. 18. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech journal of pharmaceutical sciences. 2018; 7(4):1-25. 19. grizon f, aguado e, huré g, baslé mf, chappard d. enhancedbone integration of implants with increased surface roughness:a longterm study in the sheep. j dent 2002; 30:195-203. https://doi.org/10.1016/s0300-5712(02)00018-0 20. patel ns, jain dk, nagar h, patel a, chandel hs. evaluation of analgesic and antipyretic activity of tridax procumbens leaves extract. rguhs j pharm sci. 2011; 1(3):226-31. https://doi.org/10.5530/rjps.2011.3.9 21. albrektsson t, wennerberg a. the impact of oral implants pastand future, 1966-2042. j can dent assoc 2005; 71:327. 22. khatri s, dhanoriya c, jain dk. zika virus (zikv) disease: past, present and future. journal of drug delivery and therapeutics. 2018; 8(6-s):320-7. https://doi.org/10.22270/jddt.v8i6-s.2076 23. yadav r, jha m, prasad s, jat d, jain dk. mayaro virus (mayv) disease: past, present and future. j pharm biol sci. 2022; 10(1):716. 24. browne m, gregson p. effect of mechanical surface pretreat-ment on metal ion release. biomaterials 2000; 21:385-92. https://doi.org/10.1016/s0142-9612(99)00200-8 25. cochran d, schenk r, lussi a, higginbottom f, buser d. boneresponse to unloaded and loaded titanium implants with asandblasted and acid-etched surface: a histometric study inthe canine mandible. j biomed mater res 1998; 40:1-11. https://doi.org/10.1002/(sici)1097-4636(199804)40:1<1::aidjbm1>3.0.co;2-q 26. sul y-t, johansson c, albrektsson t. which surface propertiesenhance bone response to implants? comparison of oxidizedmagnesium, tiunite, and osseotite implant surfaces. int jprosthodont 2005; 19:319-28. 27. roy m, bandyopadhyay a, bose s. induction plasma sprayednano hydroxyapatite coatings on titanium for orthopaedic anddental implants. surf coat technol 2011; 205:2785-92. https://doi.org/10.1016/j.surfcoat.2010.10.042 28. liao h, fartash b, li j. stability of hydroxyapatite-coatingson titanium oral implants (imz). clin oral implants res1997; 8:6872. https://doi.org/10.1111/j.1600-0501.1997.tb00009.x 29. peltola t, pätsi m, rahiala h, kangasniemi i, yli-urpo a. calciumphosphate induction by sol-gel-derived titania coatings on tita-nium substrates in vitro. j biomed mater res 1998; 41:50410. https://doi.org/10.1002/(sici)10974636(19980905)41:3<504::aid-jbm22>3.0.co;2-g 30. degasne i, baslé mf, demais v, huré g, lesourd m, grolleaub, et al. effects of roughness, fibronectin and vitronectin onattachment, spreading, and proliferation of human osteoblast-like cells (saos2) on titanium surfaces. calcif tissue int1999; 64:499-507. https://doi.org/10.1007/s002239900640 31. mustafa k, wroblewski j, lopez bs, wennerberg a, hul-tenby k, arvidson k. determining optimal surface roughnessof tio2 blasted titanium implant material for attach-ment, proliferation and differentiation of cells derived fromhuman mandibular alveolar bone. clin oral implants res2001; 12:515-25. https://doi.org/10.1034/j.1600-0501.2001.120513.x 32. chiapasco m, gatti c, rossi e, haeflige w. implantretainedmandibular overdentures with immediate loading. clin oralimplants res 1997; 8:48-57. https://doi.org/10.1111/j.16000501.1997.tb00007.x 33. ericsson i, nilson h, lindh t, nilner k, randow k. immediatefunctional loading of brånemark single tooth implants. clin oralimplants res 2000; 11:26-33. https://doi.org/10.1034/j.1600-0501.2000.011001026.x 34. vidyasagar l, apse p. dental implant design and biological effects on bone-implant interface. stomatologija 2004; 6:51-4. 35. triplett rg, frohberg u, sykaras n, woody rd. implant ma¬terials, design, and surface topographies: their influence on osseointegration of dental implants. j long term eff med implants 2003; 13:485-501. https://doi.org/10.1615/jlongtermeffmedimplants.v13.i6.50 36. searson lj. history and development of dental implants. in: narim l, wilson hf, eds. implantology in general dental practice. london, chicago: quintessence publishing co; 2005:19-41. 37. guan h, van staden r, loo yc, johnson n, ivanovski s, meredith n. influence of bone and dental implant parameters on stress distribution in the mandible: a finite element study. int j oral maxillofac implants 2009; 24:866-76. 38. mandhane ss, more ap. a review: evaluation of design parameters of dental implant abutment. inter j emerging sci eng 2014; 2:64-7. https://doi.org/10.1016/s0300-9785(81)80077-4 https://doi.org/10.3109/17453678108991776 https://doi.org/10.4103/0970-9290.70805 https://doi.org/10.1016/j.prosdent.2005.04.018 https://doi.org/10.1016/s0300-5712(02)00018-0 https://doi.org/10.5530/rjps.2011.3.9 https://doi.org/10.22270/jddt.v8i6-s.2076 https://doi.org/10.1016/s0142-9612(99)00200-8 https://doi.org/10.1002/(sici)1097-4636(199804)40:1%3c1::aid-jbm1%3e3.0.co;2-q https://doi.org/10.1002/(sici)1097-4636(199804)40:1%3c1::aid-jbm1%3e3.0.co;2-q https://doi.org/10.1016/j.surfcoat.2010.10.042 https://doi.org/10.1111/j.1600-0501.1997.tb00009.x https://doi.org/10.1002/(sici)1097-4636(19980905)41:3%3c504::aid-jbm22%3e3.0.co;2-g https://doi.org/10.1002/(sici)1097-4636(19980905)41:3%3c504::aid-jbm22%3e3.0.co;2-g https://doi.org/10.1007/s002239900640 https://doi.org/10.1034/j.1600-0501.2001.120513.x https://doi.org/10.1111/j.1600-0501.1997.tb00007.x https://doi.org/10.1111/j.1600-0501.1997.tb00007.x https://doi.org/10.1034/j.1600-0501.2000.011001026.x https://doi.org/10.1615/jlongtermeffmedimplants.v13.i6.50 jain et al asian journal of dental and health sciences. 2022; 2(4):48-54 [54] ajdhs.com 39. ivanoff cj, sennerby l, johansson c, rangert b, lekholm u. in¬fluence of implant diameters on the integration of screw implants. an experimental study in rabbits. int j oral maxillofac surg 1997; 26:141-8. https://doi.org/10.1016/s09015027(05)80837-9 40. shemtov-yona k, rittel d, levin l, machtei ee. effect of den¬tal implant diameter on fatigue performance. part i: mechanical behavior. clin implant dent relat res 2012. https://doi.org/10.1111/j.1708-8208.2012.00477.x 41. himmlová l, dostálová t, kácovský a, konvicková s. influence of implant length and diameter on stress distribution: a finite element analysis. j prosthet dent 2004; 91:20-5. https://doi.org/10.1016/j.prosdent.2003.08.008 42. baggi l, cappelloni i, di girolamo m, maceri f, vairo g. the influence of implant diameter and length on stress distribution of osseointegrated implants related to crestal bone geometry: a three-dimensional finite element analysis. j prosthet dent 2008; 100:422-31. https://doi.org/10.1016/s0022-3913(08)60259-0 43. lan th, du jk, pan cy, lee he, chung wh. biomechanical analysis of alveolar bone stress around implants with different thread designs and pitches in the mandibular molar area. clin oral investig 2012; 16:363-9. https://doi.org/10.1007/s00784-0110517-z 44. stanford cm. surface modifications of dental implants. aust dent j 2008; 53(suppl 1):s26-33. https://doi.org/10.1111/j.18347819.2008.00038.x 45. kumar k, ramesh bhat tr, harish pv, sameer vk, gangaiah m. nanobiotechnology approaches to design better dental implant materials. trends biomater artif organs 2011; 25:30-3. 46. palmquist a, omar om, esposito m, lausmaa j, thomsen p. ti¬tanium oral implants: surface characteristics, interface biology and clinical outcome. j r soc interface 2010; 7(suppl 5):s515-27. https://doi.org/10.1098/rsif.2010.0118.focus 47. bonfante ea, marin c, granato r, suzuki m, hjerppe j, witek l, et al. histologic and biomechanical evaluation of aluminablasted/acid-etched and resorbable blasting media surfaces. j oral implan¬tol 2012; 38:549-57. https://doi.org/10.1563/aaid-joid-10-00105 48. dohan ehrenfest dm, coelho pg, kang bs, sul yt, albrektsson t. classification of osseointegrated implant surfaces: materials, chemistry and topography. trends biotechnol 2010; 28:198-206. https://doi.org/10.1016/j.tibtech.2009.12.003 49. yuan h, yang z, li y, zhang x, de bruijn jd, de groot k. os¬teoinduction by calcium phosphate biomaterials. j mater sci mater med 1998; 9:723-6. https://doi.org/10.1023/a:1008950902047 50. søballe k. hydroxyapatite ceramic coating for bone implant fixa¬tion. mechanical and histological studies in dogs. acta orthop scand suppl 1993; 255:1-58. https://doi.org/10.3109/17453679309155636 51. barrère f, van der valk cm, meijer g, dalmeijer ra, de groot k, layrolle p. osteointegration of biomimetic apatite coating applied onto dense and porous metal implants in femurs of goats. j biomed mater res b appl biomater 2003; 67:655-65. https://doi.org/10.1002/jbm.b.10057 52. ota-tsuzuki c, datte ce, nomura ka, gouvea cardoso la, shibli ja. influence of titanium surface treatments on formation of the blood clot extension. j oral implantol 2011; 37:641-7. https://doi.org/10.1563/aaid-joi-d-09-00125.1 53. ahn sj, leesungbok r, lee sw. histomorphometric analysis and removal torque of small diameter implants with alternative surface treatments and different designs. j oral implantol 2010; 36:263-72. https://doi.org/10.1563/aaid-joi-d-09-00052 54. bain ca, moy pk. the association between the failure of dentalimplants and cigarette smoking. int j oral maxillofac implants1993; 8:609-15. 55. moy pk, medina d, shetty v, aghaloo tl. dental implant failurerates and associated risk factors. int j oral maxillofac implants2005; 20:569-77. 56. karoussis i, salvi g, heitz-mayfield l, brägger u, hämmerle c,lang n. history of treated periodontitis and smoking as risksfor implant therapy. int j oral maxillofac implants 2009; 24:39-68. 57. guillaume b. dental implants: a review. morphologie. 2016 dec 1; 100(331):189-98. https://doi.org/10.1016/j.morpho.2016.02.002 https://doi.org/10.1016/s0901-5027(05)80837-9 https://doi.org/10.1016/s0901-5027(05)80837-9 https://doi.org/10.1111/j.1708-8208.2012.00477.x https://doi.org/10.1016/j.prosdent.2003.08.008 https://doi.org/10.1016/s0022-3913(08)60259-0 https://doi.org/10.1007/s00784-011-0517-z https://doi.org/10.1007/s00784-011-0517-z https://doi.org/10.1111/j.1834-7819.2008.00038.x https://doi.org/10.1111/j.1834-7819.2008.00038.x https://doi.org/10.1098/rsif.2010.0118.focus https://doi.org/10.1563/aaid-joi-d-10-00105 https://doi.org/10.1563/aaid-joi-d-10-00105 https://doi.org/10.1016/j.tibtech.2009.12.003 https://doi.org/10.1023/a:1008950902047 https://doi.org/10.3109/17453679309155636 https://doi.org/10.1002/jbm.b.10057 https://doi.org/10.1563/aaid-joi-d-09-00125.1 https://doi.org/10.1563/aaid-joi-d-09-00052 https://doi.org/10.1016/j.morpho.2016.02.002 soesilo et al asian journal of dental and health sciences. 2023; 3(1):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited apicoectomy for periapical lesion treatment after post endodontic failure on first maxillary premolar (case study) diana soesilo *, fani pangabdian, yongki hadinata wijaya, sinta puspita conservative dentistry departement, universitas hang tuah, surabaya, jl. arif rahman hakim 150, surabaya, jawa timur, indonesia article info: _______________________________________ article history: received 02 jan 2023 reviewed 05 feb 2023 accepted 14 feb 2023 published 15 march 2023 _______________________________________ cite this article as: soesilo d, pangabdian f; wijaya yh, puspita s, apicoectomy for periapical lesion treatment after post endodontic failure on first maxillary premolar (case study), asian journal of dental and health sciences. 2023; 3(1):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v3i1.38 _______________________________________ *address for correspondence: soesilo, diana; conservative dentistry departement, universitas hang tuah, surabaya, jl. arif rahman hakim 150, surabaya, jawa timur, indonesia abstract ___________________________________________________________________________________________________________________ introduction. factors that cause failure of endodontic therapy include incomplete cleaning and shaping of root canals and unhermetic obturation. endodontic failure can lead to periapical lesions. apicoectomy is one of endodontic surgery treatment choice to preserving the tooth with endodontic treatment failure. aim. the aim of this report was to show that in cases of failure of root canal treatment could be treat without extraction, however there was an alternative treatments such as apicoectomy that could be used to preserve the tooth and its function in the oral cavity.case. a male 32 years old patient came to dentist with persistent pain on upper left first premolar. the tooth had been endodontically treated for ten years. clinical examination tooth #24 had porcelain fused to metal on it, percussion test (+), bite test (+), pain on palpation. radiographic examination showed that tooth #24 had fabricated post without gutta percha obturation on apical third. there was 3 mm round periapical lesion on the distal side of the tooth. procedure apicoectomy and retrograde filling with mineral trioxide aggregate (mta) and bone graft was performed to eliminate that periapical lesion. conclusion apicoectomy is one of main choice to preserve post endodontic tooth with periapical lesion and post core crown on it, as long as possible in oral cavity keywords : apicoectomy, periapical lesion, post endodontic treatment failure introduction purpose of root canal treatment is cleaning the pulp tissue or microorganisms contained in the root canal system so that root canal filling can be carried out properly and periapical tissue repair occurs.1 the causes of root canal treatment failure are many, including incomplete obturation, root perforation, external root resorption, periradicular periodontal lesions, overfilling, residual root canal, periapical cysts, broken instruments in the root canal, perforation of the base of the nasal foramen and coronal leakage.2 as a result of failure of root canal treatment could cause apical lesions. most periapical lesions (more than 90%) are classified as granulomas, radicular cysts or abscesses. there is clinical evidence that the larger the size of the lesion, the more likely it is a radicular cyst. however, some extensive lesions may be granulomas or abscesses. a definitive diagnosis can only be confirmed by histological analysis.3 recommended treatment for large periapical lesion is endodontic surgical treatment because conventional root canal treatment of nonvital teeth with widespread periapical lesions has a high failure rate.1,4 endodontic surgery indications are persistent pain and a root canal system that cannot be filled orthogradically. apicoectomy or apical resection is a procedure to reduce the root tip of the tooth with periapical curettage, which is indicated in post-root canal treatment teeth with developing periapical inflammation. the inflammation that develops can be characterized by symptomatic complaints in the patient and a wider periapical radiolucent area than before root canal treatment was started. apicoectomy is usually followed by retrograde filling to seal the root canal ends.5 aim of this report was to show that in cases of failure of root canal treatment could be treat without extraction, however there was an alternative treatments such as apicoectomy that could be used to preserve the tooth and its function in the oral cavity case report a male 32 years old patient came to conservative dentistry specialist with persistent pain on upper left first premolar. tooth #24 had been treated with conventional endodontic treatment for 10 years, however for the past three months patient felt continous and persistent dull pain.pain increased when chewing food. clinical examination tooth #24 had porcelain fused to metal on it, percussion test (+), bite test (+), pain on palpation (fig 1).radiographic examination showed that tooth #24 had fabricated post without gutta percha obturation on apical third. there was 3 mm round periapical lesion on the distal side of the tooth (fig. 2). open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i1.38 soesilo et al asian journal of dental and health sciences. 2023; 3(1):1-4 [2] ajdhs.com fig 1. clinical examination tooth #24 fig 2. radiographic examination tooth #24 after the patient signed the informed consent, the surgical area was disinfected using iodine. infiltration anesthesia was performed on the posterior superior alveolar nerve and the nasopalatine nerve with lidocaine 2%. incision was done with semilunar flap design (fig 3) located at the apical region of the tooth using a #15 scalpel blade pressed right against the periosteum of the alveolus bone, then the flap was opened using a raspatorium (fig 4) fig 3. incision with semilunar flap design fig 4. flap was opened with rasparatorium cortical bone was removed around the root tip of tooth #24 with a form bone bur and irrigated with saline. after that, the reduction was continued with a fissure-shaped bone bur so that the periapical area was opened and a clear view was obtained to the apex area of tooth #24. extraction of the lesion, enucleation, and curettage were performed at the tip of the tooth root with irrigation using saline. the apex of tooth #24 was resected and smoothed with a horizontal carbide fissure bur in the buccal palatal direction (fig 5) fig 5. apex of tooth #24 was resected and smoothed with a horizontal carbide fissure bur root canal was prepared retrogradely using ultrasonic in the middle with a depth of 2 mm to place the mta (mineral trioxide aggregate) material. the operating area was irrigated with saline until the operating area was clean. the mta filler was stirred until homogeneous and then applied to the prepared and condensed parts (fig 6). bone graft was applied to the affected area (fig 7). fig 6. mta was applied retrogradely on resected root canal figure 7: bone graft was applied on affected area after repositioning the flap, the suturing procedure was performed using an atraumatic needle with silk thread (fig 8). prescription of antibiotics (clindamycin 300 mg, taken twice a day for 5 days), analgesics (cataflam 50 mg taken twice a day for 3 days), and it is recommended to always maintain oral hygiene. patients were given control instructions 1 week postoperatively to remove suturing thread. afer suturing removal, the patient moved to another city so unfortunatelly we couldn’t follow up our surgery treatment. fig 8. flap reposition with suturing procedure soesilo et al asian journal of dental and health sciences. 2023; 3(1):1-4 [3] ajdhs.com discussion the success of root canal treatment is obtained from good root canal preparation and filling, especially in the apical third. the filling must be hermetic so that there is no empty space so that microorganisms cannot live there.6 the cause of the failure of root canal treatment in this case showed that the obturation of the root canal was lost when gutta-percha was taken in the fabricated post manufacturing process. failure of root canal treatment can be overcome by root canal retreatment or surgical endodontic treatment. root canal retreatment aims to repair pathological damage caused by failure of previous root canal treatment.4 apicoectomy is one of alternative treatment in cases of failure of conventional endodontic treatment. in the case report of pedroche, et. al the patient had retreatment with conventional endodontic treatment on the maxillary left molar but the patient still felt persistent pain and on radiographic examination there was a periapical lesion at the mesiobuccal root apex. after apicoectomy treatment and then control after 7 months, it showed on clinical examination and radiography the fistula had healed.7 another comparative case was the case report by irwandana,. et al which showed endodontic treatment failure because of an overfilling root canal filling on the maxillary right incisor and the presence of a radicular cyst around the tooth. the treatment was apicoectomy with retrograde filling using mineral trioxide aggregate (mta). after 6 months, on clinical examination there was no lumps on the palatum and on radiographic examination the lesion had shrunk. 8 cavity preparation at the apical tip of tooth #24 was performed for placement of retrograde filling material using mta. retrograde placement of the filling material should be prepared at the apical end in a direction parallel to the occlusal plane until the tip of the gutta-percha is visible. mta has many advantages, which is it has excellent biocompatibility, has a bactericidal effect with a ph of 12.5, is non-cytotoxic, and is non-mutagenic.9 the ingredients contained in mta are calcium silicate, bismuth oxide, calcium carbonate. calcium sulfate, and calcium aluminate. mixing mta with water will form amorphous calcium oxide crystals consisting of 49% phosphate, 33% calcium, 6% silica, 3% chloride, and 2% carbon.6,10 witasari, et. al analized inflammatory reaction of the pulp tissue with direct pul pcapping agents calcium hydroxide, mta, and portland cement for 7, 14, 42 and 90 days. on day 42, calcium hydroxide showed an inflammatory reaction whereas the mta and portland cement materials reaction have been seen since day 7th. this could be assumed that the work system mta and portland cement induced tissue faster than calcium hydroxide. this was consistence with the statement that the mta had effects that work faster in forming the hard tissue than calcium hydroxide.11 bonegraft administration in this case aimed to accelerate bone healing. giving bone grafts to the surgical site, in addition to accelerating healing, also induced host cells to form lost bone.11 the process of bone formation or osteogenesis involves osteoblasts or progenitor cells present in the graft material and osteoinduction, the ability of bonegraft material to stimulate the formation of a scaffold or scaffold for host stem cells to grow, in the process of osteoinduction many growth factors influence the change of host stem cells into osteoblasts. growth factors that play a role in this process include platelet-derived growth factors (pdgfs), fibroblast growth factors (fgfs) and transforming growth factor-β (tgfs-β). these four materials serve as basic properties in the formation of new bone which occurs in direct parallel with the interconnections between bones.12 the use of bone substitution materials such as bone graft is an alternative to regenerate damaged bone tissue. bone graft is one of the scaffolds that plays a role in tissue engineering for bone tissue regeneration. it is necessary to design a bone graft as an appropriate and appropriate scaffold so that new bone growth can be generated. regeneration of bone tissue requires various factors between the appropriate scaffold design with mechanical strength, porosity, speed of degradation involving the release of appropriate molecular signals, biocompatible materials are the alloys needed in regenerating bone tissue so that bone defects can be restored.13 bone graft material selection depend on its biocompatibility, bioresistability, sterility, structural integrity, and adequate porosity for the growth of new blood vessels, compressive strength, cost factor, and ease of manipulation of the material.14 suturing was performed using an atraumatic needle with silk thread by sewing the flap to its original position. the purpose of flap repositioning is that the wound can be completely closed, and to prevent secondary infection during the wound healing process.15 conclusion treatment of tooth 24 with a diagnosis of previously treated teeth with dental granuloma could be performed with endodontic surgery. the use of mta material in this case was the right choice and bone graft application was needed for alveolar bone regeneration. conflict of interest there was no conflict of interest between authors refferences 1. torabinejad m, fouad af, shahbang s, endodontic principles and practice, 6th ed, elsevier, 2021. p. 61-78 2. karamifar k, tondari a, saghiri ma. endodontic periapical lesion : an overview on the etiology, diagnosis, and current treatment modalities. eur enod j, 2020; 5(2):54-67 https://doi.org/10.14744/eej.2020.42714 3. shailaja s, suresh bs, endodontic microflora -a review, j oral health comm dent, 2014; 8 (3):160-5 https://doi.org/10.5005/johcd-8-3-160 4. gopikhrisna v, grossman's endodontic practice, 14th ed, wolter kluwer health india, 2021. p. 426-428 5. fabbro m, corbella s, sequeira-byron p, tsesis i, royen e, lolato a, taschieri s, endodontic procedures for treatment of periapical lesions, cochrane database syst rev, 2016; 10:cd005511 https://doi.org/10.1002/14651858.cd005511.pub3 6. berman lh, hargreaves km, cohen's pathway of the pulp, 12th ed, elsevier, 2021. chapter 9 7. pedroche lo, barbier n, tomazinho fsf ulbrich lm, leonardi dp, sicuro sm, apicoectomy after conventional endodontic treatment failure: case report, rsbo, 2021; apr-jun 10(2):182187. https://doi.org/10.21726/rsbo.v10i2.918 8. irwandana pw, kristianti y, apicoectomy of maxillary central incisor after root canal treatment with periapical lesions, mkgk, 2016; 2(3):143-149 9. rawtiya m, verma k, singh s, mta-based root canal sealers. journal of orofacial research. 2013; 3:16-21 https://doi.org/10.5005/jp-journals-10026-1057 10. priyanka sr, a literature review of root-end filling materials, iosr-jdms, 2013; 9(4):20-25. https://doi.org/10.9790/08530942025 11. witasari jeh, muryati u, dewi a, the inflammatory reaction of pulp tissue with calcium hydroxide, mta, and portland cement, https://doi.org/10.14744/eej.2020.42714 https://doi.org/10.5005/johcd-8-3-160 https://doi.org/10.1002/14651858.cd005511.pub3 https://doi.org/10.21726/rsbo.v10i2.918 https://doi.org/10.5005/jp-journals-10026-1057 https://doi.org/10.9790/0853-0942025 https://doi.org/10.9790/0853-0942025 soesilo et al asian journal of dental and health sciences. 2023; 3(1):1-4 [4] ajdhs.com odonto dental journal, 2017; 4(2):114-121 https://doi.org/10.30659/odj.4.2.114-121 12. liu tj, jn zhou, lh guo, impact of different regenerative techniques and materials on the healing outcome of endodontic 516 surgery: a systematic review and meta-analysis. international endodontic journal, 2021; 54:536-555. https://doi.org/10.1111/iej.13440 13. mahanani, es, the characteristic of scaffold design for bone regeneration : a literature review, odonto dental journal, vol 9 special issue april 2022: 16-23 https://doi.org/10.30659/odj.9.0.16-23 14. zhao rusin, ruijia yang, paul rc, zohaib k, amin s, jithendra r, bonegrafts and subtitutes in dentistry: a review of current trend and developments, molecules, 2021; 26:3007 https://doi.org/10.3390/molecules26103007 15. kolk a, handschel j, drescher w, current trends and future prespective of bone substitute material from space holder to innovative biomaterial, j cranio maxillofacial surgery, 2013; 40:706-7018 https://doi.org/10.1016/j.jcms.2012.01.002 16. koshak h, dental suturing material and technique, global journal of otolarynology, 2017; 12(2):27-37 https://doi.org/10.19080/gjo.2017.12.555833 https://doi.org/10.30659/odj.4.2.114-121 https://doi.org/10.1111/iej.13440 https://doi.org/10.30659/odj.9.0.16-23 https://doi.org/10.3390/molecules26103007 https://doi.org/10.1016/j.jcms.2012.01.002 https://doi.org/10.19080/gjo.2017.12.555833 nagar et al asian journal of dental and health sciences. 2023; 3(1):5-7 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited evaluation of antioxidant activity of rosa indica linn divya nagar*, vivekanand katare, shreeram sen, abhilasha delouri, shivam nema vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india article info: _______________________________________ article history: received 13 dec 2022 reviewed 16 jan 2023 accepted 23 jan 2023 published 15 march 2023 _______________________________________ cite this article as: nagar d, katare v, sen s, delouri a, nema s, evaluation of antioxidant activity of rosa indica linn , asian journal of dental and health sciences. 2023; 3(1):5-7 doi: http://dx.doi.org/10.22270/ajdhs.v3i1.34 _______________________________________ *address for correspondence: divya nagar, vivekanand college of pharmacy, shikandrabad, bhopal, mp, 462044, india abstract ___________________________________________________________________________________________________________________ plants have served human beings as a natural source for treatments and therapies from ancient times, amongst them medicinal herbs have gain attention because of its wide use and less side effects. in the recent years plant research has increased throughout the world and a huge amount of evidences have been collected to show immense potential of medicinal plants used in various traditional systems. rosa indica symbol of godness and beauty known for various healing power, has astringent, sedative, antiinflammatory and antidepressant qualities. the aim of the present study was to evaluate in vitro antioxidant activities of leaves of rosa indica. the in vitro antioxidant activity of methanolic extract of the leave part was assessed against dpph free radical scavenging assay methods using standard protocols. the activities of methanolic leave part extract against dpph assay method were concentration dependent with ic 50 values of ascorbic acid and extracts 24.34 and 62.66μg/ml respectively. the diverse array of phytochemicals present in the plant thus suggests its therapeutic potentials which may be explored in drug manufacturing industry as well as in traditional medicine. keywords: antioxidant activity, rosa indica, dpph assay method, methanolic extract mail id: dnagar217@gmail.com introduction indian medicinal plants are considered a vast source of several pharmacologically active principles and compounds, which are commonly used in home remedies against multiple ailments1. reactive oxygen species (ros) are highly reactive molecules which may be both important mediators of some physiological functions and also potential prooxidants. imbalance between ros generation and antioxidant capacity induces a condition known as oxidative stress which may play a major role in the initiation and progression of numerous pathologies including cardiovascular dysfunction associated with vascular disease, hyperlipidemia, diabetes mellitus, hypertension and ischemia/reperfusion injury. the potential damage caused by an excess of ros is controlled by a series of antioxidant defence mechanisms and among them, a key protective role is played by the antioxidant enzymes gluthatione (gsh) peroxidase, superoxide dismutase (sod) and gsh reductase2. several herbal secondary metabolites such as flavonoid have been found to protect cells from oxidative damage3. these compounds have been evidenced to stabilize rbc membrane by scavenging free radicals and reducing lipid peroxidation4,5. rosa indica belongs to family rosaceae is an erect or climbing shrubs, deciduous or evergreen and have a wide range of biological activities, multiple health issues like intestinal diseases, as inflammatory agents and as well as for: diarrhoea, constipation, gallstones, gallbladder ailments, lower urinary tract, kidney disorders, fluid retention (dropsy or oedema), gout, back and leg pain (sciatica), high cholesterol, weight loss, high blood pressure, fever, increasing immune function during exhaustion, increasing blood flow in the limbs increasing urine flow and quenching thirst6. the present study was focused to evaluate the anti oxidant activity of leaves of rosa indica by using dpph free radical scavenging assay methods. materials and methods plant material the leaves of plant rosa indica were collected from local area of bhopal (m.p), india. chemical reagents all the chemicals used in this study were obtained from hi media laboratories pvt. ltd. (mumbai, india), sigma aldrich chemical co. (milwaukee, wi, usa), sd fine-chem. ltd. (mumbai, india) and srl pvt. ltd. (mumbai, india).all the chemicals used in this study were of analytical grade. extraction of plant material cold maceration method leaves of rosa indica were collected, washed and rinsed properly. they were dried in shade and powdered mechanically. about 200gm of the leaves powder was macerated with petroleum ether and methanol and stored for 72 hours in ice cold condition for the extraction of phytochemicals. at the end of the third day extract was filtered using whatman no. 1 filter paper to remove all un-extractable matter, including cellular materials and other constitutions that are insoluble in the extraction solvent. the entire extract was concentrated to dryness using rotary flash evaporator under reduced pressure and stored in an air tight container free from any contamination until it was used. finally the percentage yields were calculated of the dried extracts7. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i1.34 nagar et al asian journal of dental and health sciences. 2023; 3(1):5-7 [6] ajdhs.com dpph free radical scavenging assay dpph scavenging activity was measured by modified method8. dpph scavenging activity was measured by the spectrophotometer. stock solution (6 mg in 100ml methanol) was prepared such that 1.5 ml of it in 1.5 ml of methanol gave an initial absorbance. decrease in the absorbance in presence of sample extract at different concentration (20-100µg/ml) was noted after 15 minutes. 1.5 ml of dpph solution was taken and volume made till 3 ml with methanol, absorbance was taken immediately at 517 nm for control reading. 1.5 ml of dpph and 1.5 ml of the test sample of different concentration were put in a series of volumetric flasks and final volume was adjusted to 3 ml with methanol. three test samples were taken and each processed similarly. finally the mean was taken. absorbance at zero time was taken for each concentration. final decrease in absorbance was noted of dpph with the sample at different concentration after 15 minutes at 517 nm. the percentage inhibition of free radical dpph was calculated from the following equation: % inhibition = [(absorbance of control absorbance of sample)/absorbance of control] × 100%. though the activity is expressed as 50% inhibitory concentration (ic50), ic50 was calculated based on the percentage of dpph radicals scavenged. the lower the ic50 value, the higher is the antioxidant activity. results and discussions the crude extracts so obtained after cold maceration extraction process were concentrated on water bath by evaporation the solvents completely to obtain the actual yield of extraction. the percentage yield of extraction is very important in phytochemical extraction in order to evaluate the standard extraction efficiency for a particular plant, different parts of same plant or different solvents used. the yield of extracts obtained from the leaves of the plants using petroleum ether and methanol as solvents are depicted in the table 1. table 1: results of percentage yield of leaves extracts s. no. solvent colour of extract weight of plant material (gm) weight of extract (gm) % yield 1. petroleum ether dark green 100.21 0.425 0.424 2. methanol dark green 96.17 4.08 4.24 antioxidant activity of the samples was calculated through dpph assay. % inhibition was calculated as an indicative of antioxidant potency. the higher the % inhibition the better the activity. ascorbic acid was taken as standard and the values were comparable with concentration ranging from 20µg/ml to 100µg/ml. a dose dependent activity with respect to concentration was observed table 2 & figure 1, 2. table 2: % inhibition of ascorbic acid and methanolic extract using dpph method figure 1: dpph radical scavenging activity of ascorbic acid y = 0.5765x + 35.967 r² = 0.9929 0 10 20 30 40 50 60 70 80 90 100 0 20 40 60 80 100 120 s. no. concentration (µg/ml) % inhibition ascorbic acid methanolic extract 1 20 46.97 43.2900433 2 40 58.12 53.1385281 3 60 72.12 65.4761905 4 80 83.74 72.9437229 5 100 91.81 84.7402597 ic 50 24.34 62.66 nagar et al asian journal of dental and health sciences. 2023; 3(1):5-7 [7] ajdhs.com figure 2: dpph radical scavenging activity of extract conclusion it can be concluded that from present investigation the observed level of phytoconstituents revealed that rosa indica is a rich source of antioxidant compounds proved by in vitro studies. currently available synthetic antioxidants are suspected to cause or prompt negative health effects, hence strong restrictions have been placed on their application and there is a trend to substitute them with naturally occurring antioxidants. further phytochemical studies are also required to isolate and characterize active ingredients that are responsible for its in vivo antioxidant activity and to explore the existence of synergism if any, among the compounds. references 1. chatopadhyay i, biswas k, bandhopadhyay u, banerjee rk. turmeric and curcumin: biological actions and medicine of applications. curr sci 2004; 87:44. 2. zawadzka-bartczak e, kopka l, gancarz a. antioxidative enzyme profiles in fighter pilots. aviat space environ med 2003; 74:654658 3. kumar s, pandey a. chemistry and biological activities of flavonoids: an overview. sci world j 2013; 1-16. https://doi.org/10.1155/2013/162750 4. yu l. free radical scavenging properties of conjugated linoleic acids. j agric food chem 2001; 49:3452-3546. https://doi.org/10.1021/jf010172v 5. ebrahimzadeh m, nabavi s, nabavi s, eslami b. antihemolytic and antioxidant activities of allium paradoxum. cent eur j biol 2010; 5:338-345. https://doi.org/10.2478/s11535-010-0013-5 6. baser khc, altinas a, kurkcuoglu m. a review of the history, ethnobotany and modern uses of rose petals, rose oil, rose water and other rose products. herbal gram. 2013; 96:40–53. 7. jha m, nema n, shakya k, ganesh n, sharma v. in vitro hepatoprotective activity of bauhinia variegata. pharmacologyonline. 2009; 3:114-8. 8. merghem m, dahamna s, in-vitro antioxidant activity and total phenolic content of ruta montana l. extracts, journal of drug delivery and therapeutics 2010; 10(2):69-75. https://doi.org/10.22270/jddt.v10i2.3919 y = 1.0669x 0 20 40 60 80 100 120 0 20 40 60 80 100 120 series1 linear (series1) https://doi.org/10.1155/2013/162750 https://doi.org/10.1021/jf010172v https://doi.org/10.2478/s11535-010-0013-5 https://doi.org/10.22270/jddt.v10i2.3919 patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [12] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited formulation and evaluation of sustained release solid dispersed nifedipine microcapsules ayushi patel, rupesh kumar jain, vivek jain, pushpendra kumar khangar* adina institute of pharmaceutical sciences, nh86a, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 03 sep 2022 reviewed 24 oct 2022 accepted 08 nov 2022 published 23 nov 2022 _______________________________________ cite this article as: patel a, jain rk, jain v, khangar pk, formulation and evaluation of sustained release solid dispersed nifedipine microcapsules, asian journal of dental and health sciences. 2022; 2(3):12-18 doi: http://dx.doi.org/10.22270/ajdhs.v2i3.21 _______________________________________ *address for correspondence: pushpendra kumar khangar, adina institute of pharmaceutical sciences, nh86a, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ conventional drug delivery system for treating the angina and hypertension are not much effective as the drug do not reach the site of action in appropriate amounts. thus potent and guarded therapy of this angina and hypertension disorder using specific drug delivery system is a challenging task to the pharmaceutical professionals. the study was aimed at increase the solubility of poorly soluble drug nifedipine and formulating it in sustained release dosage form. solid dispersion of drug was prepared using poly vinyl pyrrolidone (pvp) as inert hydrophilic carriers by solvent evaporation technique. a 17-fold increase in dissolution rate of nifedipine was observed with solid dispersion prepared with pvp (k30). sustained release microcapsules of nifedipine were formulated using eudragit rs 100 as a polymer, acetone as polymer solvent for eudragit rs100, n-hexane as a non-solvent, liquid paraffin vehicle, with solid dispersion of nifedipine as core by emulsion solvent evaporation method and modified emulsion solvent evaporation method. microcapsules from all the batches were found to discrete, spherical and free flowing and % entrapment efficiency was found to be in range of 96.01% to 97.87%. all the batches of microcapsules showed sustained release curve in ph 7.4 phosphate buffer up to 12hours with maximum release up to 97.22% after 12hrs was found to be in b2. sem studies of the microcapsules showed the surface topography states that prepared microspheres were spherical in shape. shiny and uniform covered surface with polymer. keywords: nifedipine, poly vinyl pyrrolidone, solid dispersion, microcapsules, emulsion solvent evaporation method introduction hypertension is one of the most common cardiovascular diseases, which have become the leading cause of death for human1, 2. successful treatment of hypertension in clinical practice means maintenance of blood pressure at a normal physiological level. in long-term therapy for the treatment of hypertension, the antihypertensive drugs have to be taken for life. in general, conventional formulations of the antihypertensive drugs need to be administered twice or three times a day to achieve effective therapeutic concentration, which results in marked blood pressure fluctuations and poor patient compliance. however, the formulations of drug sustained (controlled) release delivery systems have many advantages including reduced frequency of administration and fluctuation in plasma drug concentration, maintained stable blood pressure and improved patient compliance3,4. therefore, the oral drug sustained (controlled) release delivery systems for the treatment of hypertension are an ideal solution. nifedipine is a calcium channel blocker of the dihydropyridine type which is mainly used for the treatment of hypertension and angina pectoris. nifedipine is a suitable candidate for cr administration due to its short elimination half-life of 2-4 hrs, its rapid and complete drug absorption over the entire gastrointestinal tract, despite its low water solubility and the relationship between drug plasma concentrations and blood pressure reduction. the importance of reduced peak plasma levels in order to avoid adverse effects such as reflex tachycardia has also been demonstrated5. numerous attempts have been made to modify the dissolution characteristic of drug to attain more rapid and complete absorption6-8. solid dispersion is one of the techniques which are originally used to enhance the dissolution rate of poorly water-soluble drugs using inert hydrophilic carriers9. the enhancement in the dissolution rate is obtained by one or a combination of the following mechanism: eutectic formation, increased surface area of the drug due to precipitation in the carrier, formation of true solid solution, improved wettability due to close contact with a hydrophilic carrier, precipitation as a metastable crystalline form or a decrease in substance crystallinity. the type of solid dispersion formed depends on both the carrier-drug combination and the method of manufacture10. hydrophilic polymers like polyethylene glycols (peg) 11-13. polyvinyl pyrrolidone (pvp) 14,15 and hydroxyl propyl methyl cellulose (hpmc) 16 are among the popular carriers commonly used to prepare solid dispersions. being freely soluble in water, these polymers are mainly used as excipients, to enhance the dissolution rate of drugs17, 18. pluronic f-68 is being used as a newer material for preparation of solid dispersion to enhance the dissolution rate of poorly water soluble nifedipine19. the aim of this study is to improve the solubility of the poorly water soluble drug nifedipine by preparing solid dispersions using various hydrophilic carriers and using optimized solid dispersion to open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i3.21 patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [13] ajdhs.com fabricate microcapsules for sustained release delivery of the drug with better bioavailability. materials and methods materials nifedipine was obtained from cipla ltd. mumbai, india. polyvinyl pyrrolidone k30 was obtained as a gift from blessings pharmaceuticals nagpur, india. eudragit rs 100 was obtained as a gift from rohm pharma gmbh, germany. liquid paraffin was obtained from shaw wallace, india. methanol, acetone was purchased from loba chemicals, india. other reagents/chemicals were of ar/gr grade and purchased locally. method preformulation study20-22 solubility solubility study was conducted to determine the effect of different buffers on the drug. an excess amount of drug was dispersed in 5 ml of distilled water, methanol, acetone, phosphate buffer solution (ph 6.8 and 7.4), 0.1n hcl, in glass stoppered tubes respectively, all the glass tubes were closed with stopper and covered with cellophane membrane to avoid solvent loss. tubes were kept in water bath shaker at 37°c for 24 hrs. as the samples attain equilibrium, they were subjected for centrifugation at 3000 rpm for about 5 minutes. after completion of centrifugation the samples get separated, then supernatant liquid is filtered through membrane filter and then analyzed by uv spectrophotometer at 238nm respectively. melting point determination melting point of nifedipine was determined by open capillary method. determination of partition coefficient 25 mg of nifedipine with aqueous phase and n-octanol was taken in three separating funnels. the separating funnels were shaken for 2 hrs in a wrist action shaker for equilibration. two phases were separated and the amount of the drug in aqueous phase was analyzed spectrophotometrically. the partition coefficient of the drug in phases was calculated. determination of λmax a solution of nifedipine containing the concentration 10µg/ml was prepared in phosphate buffer 7.4 ph and uv spectrum was taken using shimadzu (uv-1800) double beam spectrophotometer. the solution was scanned in the range of 200400 nm. preparation of standard calibration curve of nifedipine 100mg of drug was accurately weighed and dissolved in 100ml phosphate buffer 7.4 ph in 100 ml volumetric flask, to make (1000μg/ml) standard stock solution (1). then 10 ml stock solution (1) was taken in another 100 ml volumetric flask to make (100μg/ml) standard stock solution (2), then again 0.5, 1, 1.5, 2, 2.5 and 3.0 ml of stock solution (2) was taken in another 10 ml volumetric flask and then final concentrations were prepared 5, 10, 15, 20, 25 and 30μg/ml with distilled water. the absorbance of standard solution was determined using uv/vis spectrophotometer (shimadzu uv1800) at 238nm. linearity of standard curve was assessed from the square of correlation coefficient (r2) which determined by least-square linear regression analysis. ftir spectroscopy the concentration of the sample in kbr should be in the range of 0.2% to 1 %. the pellet is a lot thicker than a liquid film, consequently a decrease concentration in the sample is required (beer's law). for the die set that you'll be the usage of, about 80 mg of the mixture is wanted. too excessive of an attention causes typically difficulties to obtain clean pellets. ftir spectra of the samples were recorded over a spectral region from 4700 to 400 cm-1 using 20 scans with 4 cm-1 resolution. preparation of solid dispersions all procedures of experiments were performed in darken conditions for avoidance nifedipine light deprivation physical mixtures procedure nifedipine and polymer pvp-k30 taken in various concentrations like (1:2, 1:4, 1:6, and 1:8) 23. solid dispersions procedure using solvent evaporation technique, nifedipine as well as pvp k-30 uniformly dissolved in methanol taking various concentrations like (1:2, 1:4, 1:6, 1:8 and 1:10) after wards at 400c the solvent evaporated. resultant solid dispersed material passed through 100 meshes sieve. solid dispersion evaluation estimation solubility procedure the solubility study carried out for pure nifedipine, prepared physical mixtures and solid dispersions using thermostatic shaker water bath. concentrated saturated solutions in 0.1 n hcl shake for 96 hrs at 370c. at end solutions were removed filtered diluted drug concentration was found by spectrophotometrically at 238 nm23, 24. estimation of nifedipine precisely weighted nifedipine samples were hauling out into methanol then extracts diluted using buffer solution (ph–7.4). resultant extract analysed for nifedipine spectrophotometrically at 238 nm against buffer solution (ph 7.4) used blank solution. the method followed beers lamberts law in concentration range of 1-10μg/ml23, 24. solid dispersions in vitro dissolution studies performed using (type ii) usp xxiv dissolution test apparatus using the media 0.1 n hcl 900ml dissolution medium for 1 hr, at 50 rpm and 370c10c temperatures. 5ml of samples taken at different time intervals and 5ml of same dissolution medium added to maintain sink condition. withdrawn aliquots suitably diluted and analysed at 238 nm using u.v. spectrophotometer. the percent release of nifedipine calculated and graph plotted against time23, 24. formulation of microcapsules two techniques used to prepare microcapsules. emulsion solvent evaporation (ese) and modified emulsion solvent evaporation (mese). in each case of this techniques, eudragit rs 100 as a polymer, acetone as polymer solvent for eudragit rs100, n-hexane as a nonsolvent, liquid paraffin vehicle, in following a1, a2 and b1, b2 batches using 1:2 and 1:4 core to coat ratios for each25. emulsion solvent evaporation method (ese) polymer dissolved in 15ml acetone. solid dispersed nifedipine added into polymeric solution with agitation. then obtained mixture transpired drop wise by syringe having needle size (15guage,2.5 inch) to the dispersion media containing liquid paraffin 100ml, containing polysorbate ( tween 80) (1%) w/w contained beaker study stirring at 600 rpm. at 250c200c patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [14] ajdhs.com (room temperature) until solvent acetone completely evaporated. lastly liquid paraffin separated by decantation and filtration procedure. collected microcapsules washed using n-hexane for removal of traces of vehicle. the prepared microcapsules then dried at room temperature25, 26. modified emulsion solvent evaporation method (mese) this technique was same as ese method. difference is that when addition of polymeric solution in over after 10-15min nhexane was poured to vehicle phase. acetone to hexane ratio 3:2. produced microcapsules processed like a process given for ese method25,26. evaluation of microcapsules27-30 drug content determination from precisely weighted sample nifedipine haul out inside methanol, and then aliquots marked up using buffer solution (ph-7.4). resultant extract analysed for nifedipine spectrophotometrically at 238nm against buffer solution (ph 7.4) used blank solution. technique pursued beers lamberts law within 1-10μg/ml concentration range. encapsulation efficiency sieved microcapsules (50 mg) were grounded in a mortar and the drug content was extracted in ph 7.4 phosphates buffer. after suitable dilution of the sample, the drug content was analyzed spectrophotometrically at a wavelength of 238nm. every batch of microcapsule was analyzed in a triplicate. particle size particle size determined using sieve shaker, using different range of standard sieve and the quantity failed on different sieves were noted measured and standard (avg) diameter of the particle was calculated. invitro dissolution the dissolution studies performed using (type ii) usp xxiv dissolution rate test apparatus in 0.1 n hcl for 2 hrs followed by ph 7.4 900ml dissolution medium containing 20% methanol at 50 rpm and 370c, temperature up to 12 hrs. 5ml of samples taken at different time intervals and 5ml of same dissolution medium added to maintain sink condition. withdrawn aliquots diluted and analysed spectrophotometrically on 238 nm using u.v. spectrophotometer. nifedipine percent release calculated and graph plotted against time. accelerated stability study the microcapsules from the selected and optimized batch were studied for stability and kept under the accelerated conditions of temperature and moisture (humidity) for the period of six months. these microspheres stability was studied at temperature 40°c and humidity 75% rh conditions. every sample separately weighed and enclosed by aluminium foils and sealed in black pvc bottle and kept in specified conditions at humidity chamber for six months. the formulations were checked for physical changes also analysed for dissolution study. scanning electron microscopy (sem) study microcapsules mounted directly on scotch double adhesive tape analysed under scanning electron microscope sem model, s-410 operated at 15k sem thickness of 100% using hitachi vacuum at 15 kv. results and discussion the nifedipine is found to be soluble in methanol, chloroform, freely soluble in phosphate buffer (ph 7.4) and practically insoluble in ethanol and distilled water. the melting point of nifedipine was 170 ºc -174ºc and λ max of nifedipine was found to be 238nm by using u.v. spectrophotometer (shimadzu uv1800). the calibration curve of nifedipine was found to be linear in the concentration range of 5-30µg/ml at 238nm figure 1. the partition coefficient of nifedipine was found to 0.562 in octanol: water. identification of nifedipine was done by ftir spectroscopy with respect to marker compound. it was identified from the result of ir spectrum as per specification figure 2. as concerned with solubility of the solid dispersions, it was found that drug, polymer ratios (1:8) shown enhanced solubility than other batches. prepared whole batches of physical-mixture represented reduced solubility of drug and discharge than solid dispersions. batch of solid dispersions composed 1:8 shown more discharge of drug. the pure nifedipine was shown 9.2% released within one hr. the enhanced drug dissolution is because of wetting ability enhanced also solubilization effect of polymer near diffusion level, another parameter is expansion of nifedipine solubilization through solid dispersion is due to the amorphous structure of nifedipine, no aggregation, particle size reduction in solid dispersions. nifedipine solubility from dispersion was enhanced as extent of pvp k-30 increased up to 1:8, after increase in concentration of pvp decreased the dissolution. reason might be that high polymer proportions cause’s difficulty in leaching to drug during dissolution table 1 & 2. the drug content of all physical mixture lies between 8.50 to 32.49 % and for solid dispersions it was 8.20 to 31.69 % table 3 & 4. dissolution profile of physical mixture and solid dispersions was given in table 5 & 6. the microencapsulating efficiency determined by using drug content of microcapsules and formula. nifedipine amount for total batches perceived in uniform quantity. the higher percentage of 97.87% entrapment efficiency was found in batch b2 when compare to other formulation table 7. an in vitro dissolution rate study was done for whole batches of microcapsules. batch a1 shown 78% drug release up to 12 hrs, batch a2 (94.012%) and batch b1 shown 82.32 % drug release and batch b2 (98.22%) showed highest percentage of drug release up to 12 hrs. this study reveals as the polymer amount raised the drug release retarded. the drug released by erosion of coating material. in mese methodology, hexane added which is miscible in acetone as well as liquid paraffin. little bit amount of hexane get miscible with liquid paraffin increases attraction of liquid paraffin to acetone leads in an enhanced extent of solvent evaporation figure 3. the microcapsules from the selected and optimized batch (b2) were studied for stability and kept under the accelerated conditions like raised temperature and moisture up to period of six months. the results revealed no marked alterations in physical appearance and drug releasing properties figure 4. the surface topography states that prepared microspheres were spherical in shape. shiny and uniform covered surface with polymer figure 5. patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [15] ajdhs.com figure 1: wavelength maxima of nifedipine figure 2: ft-ir spectrum of pure drug (nifedipine) table 1: solubility study of physical mixture carrier concentration of nifedipine in physical mixture (µg/ml) 1:2 1:4 1:6 1:8 1:10 pvp(k30) 7.483 7.882 9.905 9.563 8.963 table 2: solubility study of solid dispersion polymer concentration of nifedipine in solid dispersion (µg/ml) 1:2 1:4 1:6 1:8 1:10 pvp (k30) 12.321 14.516 15.65 17.898 15.762 pure nifedipine: solubility found to be 8.94 µg per ml table 3: nifedipine %yield physical mixture sr. no. nifedipine: povidone theoretical yield mg % physical mixture practical yield % 1. 1:2 33.33 32.49 2. 1:4 20 19.53 3. 1:6 14.28 13.03 4. 1:8 11.11 10.24 5. 1:10 9.09 8.50 patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [16] ajdhs.com table 4: nifedipine %yield solid dispersions sr. no. nifedipine: povidone theoretical solid dispersions practical 1. 1:2 33.33 31.69 2. 1:4 20 19.23 3. 1:6 14.28 12.56 4. 1:8 11.11 10.04 5. 1:10 9.09 8.20 table 5: dissolution profile of physical mixture time min nifedipine povidone (1:2) povidone (1:4) povidone (1:6) povidone (1:8) povidone (1:10) 0 0 0 0 0 0 0 10 0.89 1.53 2.62 3.92 5.03 5.5 20 1.92 3.89 5.01 6.03 7.12 8.12 30 2.85 4.56 8.05 8.12 10.9 9.98 40 5.06 8.21 11.12 12.52 15.56 15.78 50 7.36 10.72 14.31 15.62 18.52 18.21 60 9.29 13.91 17.17 19.06 22.06 22.56 table 6: solid dispersions dissolution profiles time min nifedipine povidone (1:2) povidone (1:4) povidone (1:6) povidone (1:8) povidone (1:10) 0 0 0 0 0 0 0 10 0.65 7.53 9.52 13.87 15.72 12.56 20 1.82 13.9 19.25 26.52 32.52 28.57 30 2.2 19.8 28.82 35.21 48.25 43.56 40 5.06 28.06 39.56 49.72 63.21 59.15 50 7.3 35.72 49.25 61.82 78.92 72.76 60 9.2 43.57 59.52 75.21 96.31 87.65 table 7: drug content and entrapment efficiency sample % drug content % of entrapped pure drug 99.97 ------ a1 10.89 96.01 a2 8.79 96.69 b1 10.76 96.84 b2 8.89 97.87 patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [17] ajdhs.com figure 3: cumulative % drug release of all batches figure 4: cumulative % drug release study of optimized formulation at accelerated conditions figure 5: microcapsules batch b2 at 15kv 50x conclusion extended release dosage forms of nifedipine are difficult to formulate due to its poor solubility. approach of solid dispersion was employed in which hydrophilic carriers like pvp were used. pvp markedly enhanced the dissolution rate of nifedipine. ir studies also indicated no chemical interaction between nifedipine and excipient. thus, solid dispersion was then microencapsulated using different material using emulsion solvent evaporation method and modified emulsion solvent evaporation method. microcapsules formulated were found to be spherical and discrete as seen in sem photomicrographs and were also having good encapsulating efficiency. nifedipine release up to 97.22% after 12hrs was observed. references 1. akinboboye o, idris o, akinkugbe o. trends in coronary artery disease and associated risk factors in sub-saharan africans. j hum hypertens. 2003; 17(6):381-7. https://doi.org/10.1038/sj.jhh.1001562 2. okpechi ig, rayner bl. impact of recent landmark clinical trials on hypertension treatment. clin investig. 2011; 1(8):1141-54. https://doi.org/10.4155/cli.11.97 https://doi.org/10.1038/sj.jhh.1001562 https://doi.org/10.4155/cli.11.97 patel et al asian journal of dental and health sciences. 2022; 2(3):12-18 [18] ajdhs.com 3. barakat ns, almurshedi as. design and development of gliclazideloaded chitosan microparticles for oral sustained drug delivery: in-vitro/in-vivo evaluation. j pharm pharmacol. 2011; 63(2):16978. https://doi.org/10.1111/j.2042-7158.2010.01214.x 4. sousa e silva jp, lobo js, bonifácio mj, machado r, falcão a, soaresda-silva p. in-vivo evaluation of prolonged release bilayer tablets of anti-parkinson drugs in göttingen minipigs. j pharm pharmacol. 2011; 63(6):780-5. https://doi.org/10.1111/j.20427158.2011.01278.x 5. derakhshandeh k, soleymani m. formulation and in vitro evaluation of nifedipine-controlled release tablet: influence of combination of hydrophylic and hydrophobic matrix forms. asian j pharm. 2010; 4(4):185-193. https://doi.org/10.4103/09738398.76739 6. lin sl, menig j, lachman l. interdependence of physiological surfactant and drug particle size on the dissolution behavior of water-insoluble drugs. j pharm sci. 1968; 57(12):2143-8. https://doi.org/10.1002/jps.2600571225 7. kornblum ss, hirschaorn jo. dissolution of poorly water-soluble drugs. j pharm sci. 1970; 56:606-614. https://doi.org/10.1002/jps.2600590506 8. parrot el. milling of pharmaceutical solids. j pharma sci. 1974; 63:813-820. https://doi.org/10.1002/jps.2600630603 9. chiou wl, riegelman s. pharmaceutical application of solid dispersion systems. j pharma sci.1971; 60:1281-1302. https://doi.org/10.1002/jps.2600600902 10. serajuddin atm. solid dispersion of poorly water-soluble drugs: early promises, subsequent problems and recent breakthroughs. j pharm sci. 1999; 88:1058-1066. https://doi.org/10.1021/js980403l 11. sheen p, khetarpal vk, cariola cm, rowlings ce. formulation studies of poorly water soluble drug in solid dispersion to improve bioavaibility. int j pharm. 1995; 118:221-227. https://doi.org/10.1016/0378-5173(94)00366-d 12. sahu v, jadon as, jain n, yadav r, jain pk, khare b, jain a, review on microspheres as drug carriers for controlled drug delivery. international journal of medical sciences and pharma research, 2021; 7(2):1-9 https://doi.org/10.22270/ijmspr.v7i2.53 13. mooter vg, augustijns p, blaton n, kinget r. physico-chemical characterization of solid dispersion of temazepam with polyethylene glycol 6000 and pvp k30. int j pharm. 1998; 164:6780. https://doi.org/10.1016/s0378-5173(97)00401-8 14. tantishaiyakul v, kaewnopparat n, ingkataworn ws. properties of solid dispersion of piroxicam in polyvinylpyrrolidone k-30. int j pharm. 1996; 143:59-66. 11. https://doi.org/10.1016/s03785173(96)04687-x 15. torrado s, torrado jj, cadorniga r. preparation dissolution and characterization of albendazole solid dispersion. int j pharm. 1996; 140:247-250. https://doi.org/10.1016/03785173(96)04586-3 16. ho h, su h, tsai t, sheu m. the preparation and characterization of solid dispersion on pellets using a fluidized bed system. int j pharm. 19996; 139:223229. https://doi.org/10.1016/03785173(96)04594-2 17. perng cy, kearney as, patel k, palepu nr, zuber g, et al. investigation of formulation approaches to improve the dissolution of sb-210661, a poorly water soluble 5-lipoxygenase inhibitor. int j pharm. 1998; 176:31-38. https://doi.org/10.1016/s0378-5173(98)00296-8 18. nair r, gonen s, hoag sw. influence of polyethylene glycol and povidone and the polymorphic transformation and solubility of carbamazepine. int j pharm. 2002; 240:11-16. https://doi.org/10.1016/s0378-5173(02)00083-2 19. mehta ka, kislalioghu ms, phuapradit w, malick w, shah nh. multi unit controlled release systems of nifedipine and nifedipine: pluronic f68 solid dispersions: characterization of release mechanism. drug dev ind pharm. 2002; 28:275-286. https://doi.org/10.1081/ddc-120002843 20. nagarajan k, rao mg. formulation and dissolution studies of solid dispersions of nifedipine. indian journal of novel drug delivery 2010; 2:96-98. 21. more cg, dabhade ps, jain np, aher bo. solubility and dissolution enhancement of gliclazide by solid dispersion technique. int j pharm chem anal. 2015; 2(2):51-8.. 22. vo cl, park c, lee bj. current trends and future perspectives of solid dispersions containing poorly water-soluble drugs. eur j pharm biopharm. 2013; 85(3):799-813. https://doi.org/10.1016/j.ejpb.2013.09.007 23. chowdary kpr, ramesh s. microencapsulation of solid dispersed nifedipine-pvp system. indian drugs. 1995; 32 (10):477483. 24. arias mj, gines jm, moyano jr, rabasco am. dissolution properties and in vivo behaviour of triamterene in solid dispersions with polyethylene glycols. pharmaceutica acta helvetiae. 1996; 71(4):229-35. https://doi.org/10.1016/s0031-6865(96)00017-9 25. nokhodchi a, farid d. microencapsulation of paracetamol: by various emulsion techniques using cellulose acetate phthalate. pharm tech north america. 2002; 26(6):54-60. 26. wu pc, huang yb, chang js, tsai mj, tsai yh. design and evaluation of sustained release microspheres of potassium chloride prepared by eudragit®. eur j pharm sci. 2003; 19(23):115-22. https://doi.org/10.1016/s0928-0987(03)00069-1 27. gautam sp, rai jp, billshaiya u, jain n, vikram p, jain dk. formulation and evaluation of mouth dissolving tablet of loperamide. int j pharm sci res. 2013; 4(5):1782. 28. patel an, rai jp, jain dk, banweer ji. formulation, development and evaluation of cefaclor extended release matrix tablet. int j pharm pharm sci. 2012; 4(4):355-7. 29. pandey sp, khan ma, dhote v, dhote k, jain dk. formulation development of sustained release matrix tablet containing metformin hydrochloride and study of various factors affecting dissolution rate. sch acad j pharm. 2019; 8(3):57-73. 30. jain p, nair s, jain n, jain dk, jain s. formulation and evaluation of solid dispersion of lomefloxacin hydrochloride. int j res pharm sci 2012; 3(4):604-608. https://doi.org/10.1111/j.2042-7158.2010.01214.x https://doi.org/10.1111/j.2042-7158.2011.01278.x https://doi.org/10.1111/j.2042-7158.2011.01278.x https://doi.org/10.4103/0973-8398.76739 https://doi.org/10.4103/0973-8398.76739 https://doi.org/10.1002/jps.2600571225 https://doi.org/10.1002/jps.2600590506 https://doi.org/10.1002/jps.2600630603 https://doi.org/10.1002/jps.2600600902 https://doi.org/10.1021/js980403l https://doi.org/10.1016/0378-5173(94)00366-d https://doi.org/10.22270/ijmspr.v7i2.53 https://doi.org/10.1016/s0378-5173(97)00401-8 https://doi.org/10.1016/s0378-5173(96)04687-x https://doi.org/10.1016/s0378-5173(96)04687-x https://doi.org/10.1016/0378-5173(96)04586-3 https://doi.org/10.1016/0378-5173(96)04586-3 https://doi.org/10.1016/0378-5173(96)04594-2 https://doi.org/10.1016/0378-5173(96)04594-2 https://doi.org/10.1016/s0378-5173(98)00296-8 https://doi.org/10.1016/s0378-5173(02)00083-2 https://doi.org/10.1081/ddc-120002843 https://doi.org/10.1016/j.ejpb.2013.09.007 https://doi.org/10.1016/s0031-6865(96)00017-9 https://doi.org/10.1016/s0928-0987(03)00069-1 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [24] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2021 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited development and evaluation of aceclofenac liposomes gurleen kaur* , zaquiyya naaz, kapil kumar , deepak teotia department of pharmaceutics, global institute of pharmaceutical education and research, kashipur244713, uttarakhand, india article info: _________________________________________ article history: received 17 nov 2021 reviewed 11 dec 2021 accepted 18 dec 2021 published 25 dec 2021 _________________________________________ cite this article as: kaur g, naaz z, kumar k, teotia d, development and evaluation of aceclofenac liposomes, asian journal of dental and health sciences. 2021; 1(1):24-32 doi: http://dx.doi.org/10.22270/ajdhs.v1i1.8 abstract ___________________________________________________________________________________________________________________ this review gives concise information about the application of dendrimers as drug delivery carrier in the field of drug delivery. due to their unique architecture these have improved physical and chemical properties. due to their terminal groups these show high solubility, miscibility and reactivity. dendrimers have well defined size, shape, molecular weight and monodispersity. these properties make the dendrimers a suitable carrier in drug delivery application. dendrimers are unimolecular miceller in nature and due to this enhances the solubility of poorly soluble drugs. their compatibility with dna, heparin and polyanions make them more versatile. dendrimers, also referred as modern day polymers, they offer much more good properties than the conventional polymers. due to their multivalent and mono disperse character dendrimers have stimulated wide interest in the field of chemistry biology, drug delivery, gene therapy and chemotherapy. self-assembly produces a faster means of generating nanoscopic functional and structural systems. but their actual utility in drug delivery can be assessed only after deep understanding of factors affecting their properties and their behaviour in vivo. keywords: dendrimers, drug targeting, nanoscale carriers. *address for correspondence: gurleen kaur, department of pharmaceutics, global institute of pharmaceutical and research, kashipur 244713, uttarakhand, india orcid id: https://orcid.org/0000-0001-7753-6880 introduction: the liposomes are specifically targeted drug delivery system which helps to carry the drug at a specific site and shows its therapeutic effect. over the past few decades, liposomes have received widespread attention as a carrier system for therapeutically active compounds, due to having a specialized characteristic such as the capability to incorporate both hydrophilic as well as in hydrophobic drugs, low toxicity, good compatibility, lack of immune system activation and targeted delivery of a bioactive compound to the site of action.1 liposomes are colloidal vesicular structures composed of one and more than one lipid bilayer surrounding an equal number of aqueous compartments. generally, liposomes are simple, small microscopic vesicle structures that incorporate both the type of drug either it is hydrophilic and lipophilic.2 the main aim of any drug delivery system is to minimize toxicity and increase its effectiveness, safety, target specificity, and target ability at a particular site. the liposomes are so formed to targeting and site-specific delivery of a drug, to increase the circulation, time of drug and release slowly for the extended action of a drug, drug protective from degradative enzymes. the liposomes are directly delivered to the drug at a targeted site of action and provide maximum therapeutic efficacy and help to prevent the drug from any degradation and protect the body from any inappropriate and adverse drug reaction.3,4 liposomes provide a wide range of attention, it provides a targeted carrier for many drugs such as anticancer, antidepressant, anti-asthmatic, anti-fungal and also helps to deliver the drug at a targeted site. due to their phospholipid bilayer structure, liposomes can easily cross the drug from the bloodbrain barrier (bbb) in the case of the hydrophilic nature of anti-depressant drugs.5,6 the structure of phospholipid is amphipathic in nature, due to this it helps to incorporate water-soluble drug as well as a lipid-soluble drug as well as lipid-soluble drug. the tail of lipophilic is repelled by the water and the head of hydrophilic is repelled by the lipid.7 liposomes play a major role in the pharmaceutical industry, cosmetic and dermatologist and carry both hydrophilic and lipophilic drugs and entrap the drug by liposomes and target the drug at a specific-organs. due to their structure, liposomes also help to prevent the drug from oxidation. liposome helps to penetrate the dermatological preparation into the deeper skin.8 the objective of this delivery system is to target the drug at specific site during the time period of treatment as to produce the stable, efficacious and safe delivery system of aceclofenac to overcome complications related to oral route by formulating the liposomes of aceclofenac for topical use. aceclofenac used in the pain induced by rheumatoid arthritis and osteoporosis, which reduce the level of pge2 in synovial fluid & suppresses the production from blood polymorphonuclear leukocytes (mononuclear leukocytes). this delivery system is used in open access research article doi: http://dx.doi.org/10.22270/ajdhs.v1i1.8 http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v1i1.8 https://orcid.org/0000-0001-7753-6880 https://orcid.org/0000-0001-7753-6880 https://orcid.org/0000-0003-0481-7109 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [25] ajdhs.com study because of their specialized characteristics and helps to incorporate the aceclofenac efficiently and used as topically and ultimately reduce the oral side effects of aceclofenac.9 figure 1: liposome10 materials and method: materials aceclofenac was received as a gift sample from s. p pharma, chandigarh india. lecithin, methanol, cholesterol, mannitol, and chloroform were taken from the global institute of pharmaceutical education and research institute kashipur laboratory. all other materials and chemicals used were of either pharmaceutical or analytical grade. method: preparation of topical drug-loaded aceclofenac liposomes was prepared by the thin-film hydration method. in this method, 3gm of mannitol powder and cholesterol in 3%, 2%, 4%, and 5% were placed in 250ml rbf and held at a temper e f d f ed eed f f -30 min in a rotatory evaporator.11 aceclofenac (50mg) and lecithin with a ratio of 0.1:1, 0.1:2, 0.1:3 and 0.1:4 was dissolved in methanol and chloroform in the ratio of 1:4 v/v and add 0.5ml aliquot of the above organic solution were introduced in rbf containing mannitol and cholesterol at 37⸰c. after drying a second aliquot (0.5ml) of the solution was added and then dried, a thin film is formed on the surface of rbf and placed in a desiccator overnight and the sieved with 100 mesh. the aceclofenac-loaded liposomes were prepared and mentioned as f1, f2, f3, and f4.12 composition of different formulation: formulation code drug (mg) chloroform (ml) methanol(ml) lecithin(gm) mannitol(gm) cholesterol (%) f1 50 4 1 1 3 3% f2 50 4 1 2 3 2% f3 50 4 1 3 3 4% f4 50 4 1 4 3 5% figure 2: lipid film hydration method13 pre-formulation studies pre-formulation study related to drug is necessary to develop the effective and safe dosage form. it is the first step to form any dosage form. it is also helping to shows the compatibility between excipients and drug and also finds out the physical and chemical characteristic. pre-formulation study is necessary to develop the:  safe and effective use of drug.  compatibility study of drug with different excipients.  to find the release kinetics.14 physical appearance of drug is also observed, its color, odour, taste. organoleptic properties:  color: powder of white crystalline  odour odourless  taste: tasteless  solubility: water insoluble, in acetone soluble freely and solubilise in alcohol. angle of repose it is done to check the flow property of powder. it is range from 0 to 90 degree. in this method, glass funnel is used.15 tan ɵ – h/r whereas, ɵ =angle of repose hheap height r heap radius kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [26] ajdhs.com relation b/w flowability and angle of repose angle of repose flowability <20 excellence 20 to 30 good 30 to 40 passable >40 very poorly bulk density it depends on size of particle, its shape and adhering tendency. for this, a powder mass is taken in 10ml measuring cylinder. and then, filling was done; cylinders dropped at the surface from one inch height in 2sec interval. the bulk density determination calculated by: pb = m/vb whereas, pbbulk dens. mpowder wt. tapped density in this, sample is taken in measuring cylinder and tapped and then calculated by following method. pt = m/vt whereas, pt = tapped density m= powder weight vt = tapped density carr’s compressibility index: this method is used for determining weight uniformity. ’ i dex = b de i y – tapped density/tapped density ×100 car’s compressibility index percentage compressibility description of flow 5 to15 excellence 12 to 16 good 18 to 21 fairly 23 to 28 poorly 28 to 35 poorly 35 to 38 very poorly greater than 40 extreme poorly solubility analysis the solubility of aceclofenac was done by using a different solvent. in this method, an amount of solvent taken in a testtube after that drug also added in it and left overnight for the complete solubilization. on the next, solution was sonicated for some time after that a small amount of solution is pipette out around 0.1ml and further dilutions were prepared by using this. after a several dilutions were prepared, absorbance was determined with different concentration by using uv spectrophotometer with the blank solution. by using the calibration curve, amount of dissolve drug was calculated.16 determination of melting point in this method, the melting point of aceclofenac was determined to check the purity of drug. at which temperature, a substance starts melts known as melting point. it is carried out by m.p apparatus, in this drug filled in capillary and one ended of the capillary sealed with the help of flame and attached with thermometer. note the time at which drug starts melts. moisture content determination formulation was allowed to content of moisture study by infra-red moisture balance by placing liposomes for 10 minutes in 105⸰c. calibration curve preparation: calibration curve of aceclofenac prepared in po43buffer 6.8. calibration curve preparation in phosphate buffer 6.8 in this method, 10mg of aceclofenac powder were dissolved in 10ml of po43buffer having 6.8 ph to produce 1000ug/ml. after that several dilutions were prepared by using the above solution having 0.5ml, 1ml, 2ml, 3ml, 4ml was taken and diluted with phosphate buffer 6.8 up to 100ml. the prepared dilutions were analysed by uvspectrophotometer at 273nm. 17 compatibility studies of drugexcipients: ftir study ftir studies were done for determining compatibility b/w drug and excipients. this study was performed by using the saturated potassium bromide. drug sample were prepared with kbr pellets i.e., 2mg sample in 200mg kbr with a hydrostatic force for 5.2n cm-2 for 3 minutes. development of aceclofenac liposomes by thin film hydration tech. in this, a specified lipid &drug amount were dissolved with chloroform in an rbf. after that, evaporation of solvents takes ce d ce he hi fi by ed ci g he e e. t ce’ solvent was removed by using vacuum by storing the flask overnight and then film was hydrated with phosphate buffer 6.8.18 result: flow property of aceclofenac powder s.no properties of powder f1 f2 f3 f4 1 angle of repose 31.5±0.02 31.2±0.10 30.1±0.07 31.4±0.04 2 bulk density(gm/ml) 0.65±0.05 0.66±0.05 0.68±0.03 0.62±0.01 3 tapped density 0.72±0.09 0.74±0.11 0.78±0.07 0.73±0.05 4 ’ i dex 9.76±0.06 9.75±0.08 9.72±0.06 9.8±0.06 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [27] ajdhs.com organoleptic properties of aceclofenac s.no properties results 1. physical appearance white crystalline powder 2. odor odorless 3. taste tasteless 4. solubility practically insoluble in water, freely soluble in acetone, soluble in alcohol (95%) 5. melting point 149-153◦c 6 moisture content 0.6% solubility: the solubility study of aceclofenac performed and result observed in the form of calibration curve. calibration of aceclofenac in methanol s.no concentration(µg/ml) absorbance(nm) 1. 2 0.049±0.02 2. 4 0.086±0.04 3. 6 0.0139±0.012 4. 8 0.198±0.010 5. 10 0.246±0.14 6. 12 0.298±0.016 calibration curve of aceclofenac in methanol compatibility study: compatibility study was done to determine the interaction of drug with excipients. the peak of aceclofenac and peak of aceclofenac and mannitol is almost similar. so, the sample of aceclofenac properties matched with the standard value.13 ftir spectra of api aceclofenac ftir spectra of aceclofenac and mannitol ftir spectra interpretation functional group (wave number cm) o-h c-h c=o nh2 p=o s-or aceclofenac 3399.78 3317.18 2941.64 613.08 1788.78 1718.70 1577.92 1247.99 1146.76 844.85 881.81 aceclofenac +mannitol 3276.24 2833.83 3028.41 2994.23 1770.71 1718.70 1579.75 1145.75 896.00 848.71 calibration curve of aceclofenac in methanol y = 2x 2 r2 = 1 0 2 4 6 8 10 12 14 16 0 1 2 3 4 5 6 7 8 9 concentration a b s o rb a n c e kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [28] ajdhs.com characterization of liposomes of aceclofenac batch code yield (%) entrapment efficiency (%) f1 56.37±0.003 95±0.05 f2 60.23±0.06 85±0.03 f3 65.46±0.04 89.45±0.07 f4 62.45±0.07 79.15±0.02 comparison of entrapment efficiency of different liposomes of aceclofenac in vitro cumulative percent drug release profile of aceclofenac of batch f1 to f4 time(hour) f1 f2 f3 f4 0 0 0 0 0 1 37±0.007 34±0.06 27±0.05 18±0.02 2 48±0.002 37±0.07 32±0.003 22±0.019 3 51±0.03 42±0.05 35±0.01 24±0.002 4 64±0.014 52±0.02 41±0.012 27±0.005 5 67±0.020 58±0.04 46±0.008 46±0.09 percentage of drug released from liposomes of aceclofenac of batch f1 to f4 release kinetic study kinetic study of formulation f1 time (hour) square root of time log time cumulative percent drug release log cumulative percent drug release % ara log cumulative % drug remaining 1 1 0 37 1.56 63 1.79 2 1.4 0.30 48 1.68 52 1.71 3 1.7 0.47 51 1.70 49 1.69 4 2 0.60 64 1.80 36 1.55 5 2.2 0.69 67 1.82 33 1.51 0 50 100 150 200 f1 f2 f3 f4 % e n tr ap m en t ef fi ci en cy batch code % drug entrapment efficiency of liposomes of aceclofenac of batch f1 to f4 yield % entrapment efficiency 0 10 20 30 40 50 60 70 80 0 1 2 3 4 5 6 c u m u la ti v e % d r u g r el ea se time in hours in vitro cumulative % drug release of liposomes of aceclofenac of batch f1 to f4 f1 f2 f3 f4 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [29] ajdhs.com kinetic study of formulation f2 time (hour) square root of time log time cumulative percent drug release log cumulative percent drug release % ara log cumulative % drug remaining 1 1 0 34 1.53 66 1.81 2 1.4 0.30 37 1.56 63 1.79 3 1.7 0.47 42 1.62 58 1.76 4 2 0.60 52 1.71 48 1.68 5 2.2 0.69 58 1.76 42 1.62 kinetic study of formulation f3 time (hour) square root of time log time cumulative percent drug release log cumulative percent drug release % ara log cumulative % drug remaining 1 1 0 27 1.43 73 1.86 2 1.4 0.30 32 1.50 68 1.83 3 1.7 0.47 35 1.54 65 1.81 4 2 0.60 41 1.61 59 1.77 5 2.2 0.69 46 1.66 54 1.73 kinetic study of formulation f4 time (hour) square root of time log time cumulative percent drug release log cumulative percent drug release % ara log cumulative % drug remaining 1 1 0 18 1.25 82 1.91 2 1.4 0.30 22 1.34 78 1.89 3 1.7 0.47 24 1.38 76 1.88 4 2 0.60 27 1.43 73 1.86 5 2.2 0.69 46 1.66 54 1.73 drug release kinetic with model fitting formulation code r2 n value best fit model mechanism of release zero order first order higuchi matrix f1 0.987 0.9875 0.9676 0.4407 first order non-fickian diffusion f2 0.9811 0.888 0.9703 0.3836 first order non-fickian diffusion f3 0.9886 0.9301 0.8807 0.3923 first order non-fickian diffusion f4 0.9298 0.9341 0.8929 0.5859 zero order fickian diffusion kinetic release model of zero order release 0 10 20 30 40 50 60 70 80 0 1 2 3 4 5 6 % c u m u la ti v e d r u g r el ea se time(hr) f1 f2 f3 f4 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [30] ajdhs.com kinetic release model of first order release kinetic release model of higuchi release kinetic release model of korsmeyer peppas release discussion: preformulating studies: preformulating study of aceclofenac was done by placing the following test: -i.e., melting point, solubility, flow property was done according to i.p. physical appearance: the organoleptic properties of liposome were observed by physical and visual method, properties were matched with the standard drug and the prepared aceclofenac liposomes were sticky in appearance. solubility: aceclofenac is freely soluble in acetone, soluble in alcohol (95%) and practically insoluble in water. aceclofenac liposome solubility matched with the standard drug. melting point: the melting point of aceclofenac liposomes was found to be 150◦c and the standard range is 149-153◦c. flow property of aceclofenac  angle of repose: it was found to be 31.5, it indicates the powder is passable.  bulk density: it was found to be 0.65 having good flow property.  tapped density: it was found to be 0.72. preparation of calibration curve the calibration curve of aceclofenac was plotted in phosphate buffer having ph 6.8 and the graph was plotted between concentration (x-axis) and absorbance (y-axis). the results of calibration curve of aceclofenac were shown in figure 16. table 10 shows the absorbance of aceclofenac standard 0 20 40 60 80 100 0 1 2 3 4 5 6 lo g % a r a time(hr) f1 f2 f3 f4 0 20 40 60 80 0 0.5 1 1.5 2 2.5 % c u m u la ti v e d r u g r el ea se square root of time f1 f2 f3 f4 0 0.5 1 1.5 2 0 0.2 0.4 0.6 0.8 lo g % c r time (hr) f1 f2 f3 f4 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [31] ajdhs.com solution containing 10-50 µg/ml of drug in phosphate buffer ph 6.8. in vitro drug release studies of liposome in vitrodrug release study was carried out in usp xiii dissolution test apparatus type ii. in this, a temperature was set at 37◦c ±5◦c and set at 50rpm. phosphate buffer of 1000 ml and set for 12 hours. release of drug at different time interval has been analyzed by uv spectrophotometer at 274 nm. compatibility study compatibility study of drug and excipient was done by ftir method. the peak of alone aceclofenac and peak of aceclofenac with excipients was almost same but a little different due to presence of excipients. there was no appearance or disappearance of peaks found in the drug-lipid mixture which confirms the absence of any chemical interaction between the drug and excipients. release kinetics: drug release kinetic model are used to illustrate the drug release mechanism. for this various model are used like zero order, first order, higuchi, korsmeyer peppas model to obtain the value of r2 and n-value for the determination of best fit model. r2 value was compared for all the formulation which shows the best fit model and by noticing n value which is from korsmeyer peppas model. release mechanism was described by an equation.19 mt/m∞ = n followed by standard release mechanism n value release mechanism 0.5 fickian diffusion 0.5<n<1 non-fickian diffusion 1 supercase ⅱ transport the observed data of kinetic model shows the best fit model for prepared aceclofenac liposomes was determined by regression coefficient (r2) in all formulation. the highest r2 value determine the best fit model, the observed data shows the first order release in f1, f2 and f3 formulation it shows the drug release is dependent on concentration and in f4 it shows zero order release i.e., the drug release is independent of concentration. formulation f1, f2 & f3 shows the non-fickian diffusion and f4 shows the fickian diffusion which means f1, f2 & f3 is anomalous drug release as it is erosion-controlled release rate and diffusion release rate. the best formulation is f4 formulation because the drug release is independent of concentration. entrapment efficiency: the drug entrapment efficiency of liposomes formulations is given in table 12. the loading efficiency calculated for all liposome from batch f1 to f4 ranged from 79.15 to 95%. for this, it is clear that drug entrapment efficiency changed by changing the ratio of excipients. the highest loading efficiency was found for the f1 formulation is 95% and f3 is 89.45 determination of ph: the ph of prepared aceclofenac liposomes was found to be 5 which is matched with the ph of skin so, the aceclofenac liposomes was prepared successfully and have good therapeutic effect. conclusion in this study, it has been concluded that the formulation of aceclofenac liposomes provides the sustained action of drug. the aceclofenac liposomes were successfully formulated by using cholesterol, mannitol and chloroform for topical use. in this, the polymer used as a carrier for aceclofenac drug release.20 the aceclofenac liposomes have a capability to penetrate the lipoidal structure easily and produce a prolonged action. when the aceclofenac given orally, it will produce the gastrointestinal complication so, to overcome this, the topical preparation of aceclofenac liposomes can be formulated; it is used in the treatment of rheumatoid arthritis, osteoarthritis and ankylosing spondylitis.21 from the above experiments, it has been concluded that: i) different pre-formulation studies were done on the sample of aceclofenac. ii) the liposome of aceclofenac prepared by using different excipients such as methanol, chloroform, mannitol, lecithin, etc. the liposome of aceclofenac has been prepared by the thin film hydration method and the rotary film evaporator equipment were used.22 the prepared aceclofenac liposomes to be a novel drug approach for treating the arthritis through transdermal route in which drug can permeate through skin and also show a sustained action. the prepared formulation was found to have better bioavailability, analgesic activity and antiinflammatory action as compared to existing formulations of the mentioned drug.23 according to the results obtained from this study, it was concluded that the aceclofenac liposome were successfully prepared to obtain ointment. aceclofenac ointment showed good ph value, spreadability, good entrapment efficiency. the kinetic study was also performed for the prepared aceclofenac liposomes and the observed data of kinetic model shows the bestfit model for prepared aceclofenac liposome was determined by regression coefficient (r2) in all formulation. the best model of formulation f4 shows zero order release because the drug release is independent of concentration and it shows the fickian diffusion.24 therefore, it was concluded that the formulation could be very promising alternative for the topical or transdermal treatment. conflict of interest: the authors have no conflicts of interest regarding this investigation. acknowledgement: authors acknowledges to global institute of pharmaceutical education and research for all support and encouragement for writing this research article. references: 1. kong f, zhou, ge, liu, wang, zhou. mannosylated liposomes for targeted gene delivery. international journal of nanomedicine. 2012; 1079. https://doi.org/10.2147/ijn.s29183 2. liu q, boyd bj. liposomes in biosensors. analyst, 2012; in press. 2021. 3. allison, anthony c., and gregory. gregoriadis. liposomes in biological systems. chichester: john wiley & sons, ltd., 1980. print. 4. deamer d. from "banghasomes" to liposomes: a memoir of alec bangham, 1921-2010. the faseb journal. 2010; 24(5):1308-1310. https://doi.org/10.1096/fj.10-0503 5. chioma e. formulation and evaluation of etodolac niosomes by modified ether injection technique. universal journal of pharmaceutical research. 2016; 1(1):1-6. https://doi.org/10.22270/ujpr.v1i1.r1 https://doi.org/10.2147/ijn.s29183 https://doi.org/10.1096/fj.10-0503 https://doi.org/10.22270/ujpr.v1i1.r1 kaur et al asian journal of dental and health sciences. 2021; 1(1):24-32 [32] ajdhs.com 6. anwar w, dawaba hm, afouna mi, samy am. screening study forformulation variables in preparation and characterization of candesartan cilexetil loaded nanostructured lipid carriers. universal journal of pharmaceutical research 2019; 4(6):8-19. https://doi.org/10.22270/ujpr.v4i6.330 7. singh b, mehta g, kumar r, bhatia a, ahuja n, katare o. design, development and optimization of nimesulide-loaded liposomal systems for topical application. current drug delivery. 2005; 2(2):143-153. https://doi.org/10.2174/1567201053585985 8. andhale a varsha, patil priyanka r, dhas ahuja u, chauhan priyanka d, desai seema v, liposomes an emerging tool in drug carrier system. international journal of pharmacy and technology. 2016; 8(1): 1098811011. 9. nwobodo nn, adamude fa, dingwoke ej, ubhenin a. formulation and evaluation of elastic liposomes of decitabine prepared by rotary evaporation method. universal journal of pharmaceutical research 2019; 4(3):1-5. https://doi.org/10.22270/ujpr.v4i3.267 10. dua j.s. et. al. liposomes: methods of preparation and application: international journal of pharmaceutical studies and research. 2012; 4:14-20. 11. mishra h, chauhan v, kumar k, teotia d. a comprehensive review on liposomes: a novel drug delivery system. journal of drug delivery and therapeutics. 2018; 8(6):400-404. https://doi.org/10.22270/jddt.v8i6.2071 12. john df, yunus aa, chigbo uj, paul us, ikenna e. tolnaftate loaded liposomes-design, and in-vitro evaluation. universal journal of pharmaceutical research 2016; 1(2): 29-31. https://doi.org/10.22270/ujpr.v1i2.r6 13. subhash chandran m.p, prasbh g.r jaghatha t, aswathy b.s, remya s.b. an overview on liposomal drug delivery system. international journal of pharmaceutical and phytopharmcological research. 2019; 9(2):61-69. 14. elsaied eh, dawaba hm, ibrahim esa, afouna mi. effect of pegylated edge activator on span 60 based nanovesicles: comparison between myrj 52 and myrj 59. universal journal of pharmaceutical research 2019; 4(4):1-8. https://doi.org/10.22270/ujpr.v4i4.290 15. nagasany venkatesh dhandapani. liposomes as novel drug delivery system: a comprehensive review, int j, res. pharm sci, 4(2):187-193. 16. kulkarni k, priyanka r, yadav jd, vaidya ka. liposomes a novel drug delivery system. international journal of current pharmaceutical research. 2011; 3(2):10-18. 17. sharma a. liposomes in drug delivery: progress and limitations. international journal of pharmaceutics. 1997; 154(2):123-140. https://doi.org/10.1016/s0378-5173(97)00135-x 18. shaheen sm, ahmed frs, hossen mn, ahmed m, amran ms, anwarul-islam m, liposome as a carrier for advanced drug delivery. pakistan journal of biological sciences. 2006; 9(6):1181-1191. https://doi.org/10.3923/pjbs.2006.1181.1191 19. ugochukwu ae, nnedimkpa oj, rita no. preparation and characterization of tolterodine tartrate proniosomes. universal journal of pharmaceutical research 2017; 2(2):1-3. https://doi.org/10.22270/ujpr.v2i2.r1 20. mishra h, kaur g, kumar k, teotia d. formulation and evaluation of liposomes of indomethacin. journal of advanced scientific research, 2019; 10(4):180-185. 21. akbarzadeh a, rezaei-sadabady r, davaran s, joo s, zarghami n, hanifehpour y et al. liposome: classification, preparation, and applications. nanoscale research letters. 2013; 8(1). https://doi.org/10.1186/1556-276x-8-102 22. mathur p, mathur ck, mathur k. oral drug delivery of insulin in diabetes mellitus: an attractive alternate to overcome invasive route. universal journal of pharmaceutical research 2018; 3(6): 45-48. https://doi.org/10.22270/ujpr.v3i6.221 23. jadhav m, gaikwad r, kshirsagar n, nagarsenker m, samad a. formulation and evaluation of long circulating liposomal amphotericin b: a scinti-kinetic study using99mtc in balb/c mice. indian journal of pharmaceutical sciences. 2011; 73(1):57. https://doi.org/10.4103/0250-474x.89757 24. riaz mohammad. liposomes preparation methods. pakistan journal of pharmaceutical sciences.1991; 19(1):65-77. https://doi.org/10.22270/ujpr.v4i6.330 https://doi.org/10.2174/1567201053585985 https://doi.org/10.22270/ujpr.v4i3.267 https://doi.org/10.22270/jddt.v8i6.2071 https://doi.org/10.22270/ujpr.v1i2.r6 https://doi.org/10.22270/ujpr.v4i4.290 https://doi.org/10.1016/s0378-5173(97)00135-x https://doi.org/10.3923/pjbs.2006.1181.1191 https://doi.org/10.22270/ujpr.v2i2.r1 https://doi.org/10.1186/1556-276x-8-102 https://doi.org/10.22270/ujpr.v3i6.221 https://doi.org/10.4103/0250-474x.89757 ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited compressive review on role of ich guidelines in registration of pharmaceutical products paramlal ahirwar, basant khare*, prateek kumar jain, anushree jain, rubeena khan, bhupendra thakur adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 03 july 2022 reviewed 21 aug 2022 accepted 27 aug 2022 published 15 sep 2022 _______________________________________ cite this article as: ahirwar p, khare b, jain pk, jain a, khan r, thakur b, compressive review on role of ich guidelines in registration of pharmaceutical products, asian journal of dental and health sciences. 2022; 2(3):1-8 doi: http://dx.doi.org/10.22270/ajdhs.v2i3.16 _______________________________________ *address for correspondence: mr . basant khare, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ the international conference on harmonization (ich) of technical requirements is a unique project for registration of pharmaceutical products which are intended for human use. this brings together the regulatory authorities of europe, japan and united states and experts from the pharmaceutical industry in the three regions to discuss scientific and technical aspects of product registration.the purpose is to make recommendations on ways to achieve greater harmonization in the interpretation and application of technical guidelines and requirements for product registration in order to reduce or obviate the need to duplicate the testing carried out during the research and development of new medicines.the objective of such harmonization is a more economical use of human, animal and material resources and the elimination of unnecessary delay in the global development and availability of new medicines whilst maintaining safe guards on quality, safety and efficacy and regulatory obligations to protect public health. it creates a venue that allows all key pharmaceutical regulatory authorities and industry stakeholders the opportunity to be more actively involved in pharmaceutical harmonization work. it aimed at the standardization of requirements and format along with the content of regulatory documentation and brings down the pressure on the price of medicines by enabling greater economies of scale and a labelled regulatory playing field. this paper is an effort to provide the detailed information about ich guidelines. keywords: international conference on harmonization, product registration, medicines, pharmaceutical e-mail: basant.khare08@gmail.com introduction the international council for harmonisation of technical requirements for pharmaceuticals for human use (ich) 1 is a unique project in bringing together the regulatory authorities and pharmaceutical industry to discuss scientific and technical aspects of drug registration. since its inception in 1990, ich has gradually evolved, to respond to the increasingly global face of drug development. harmonisation leads to a more sensible use of human, animal and other resources, the elimination of unnecessary delay in the global development, and availability of new medicines while maintaining safeguards on calibre, welfare, efficacy, and regulatory obligations to protect public health. harmonisation can be achieved through the development of ich guidelines via a process of scientific consensus with regulatory and industry experts working side-by-side. the basic key to the success of this process is the commitment of the ich regulators to implement the final guidelines. the mission of ich is to make recommendations towards achieving greater harmonisation in the interpretation and application of technical guidelines and requirements for pharmaceutical product registration and the maintenance of such registrations. it also monitors and update harmonised technical requirements leading to a greater mutual acceptance of research and development data. ich helps to facilitate the adoption of new or improved technical research and development approaches which update or replace current practices. it helps to develop policy for the ich medical dictionary for regulatory activities terminology (meddra) 2 whilst ensuring the scientific and technical maintenance, development and dissemination of meddra as a standardised dictionary which facilitates the sharing of regulatory information internationally for medicinal products used by humans. its objectives are, thus, as follows:  more efficient and effective use of human, animal and material resources  reduce the development times and unwanted delays of drugs  end duplicate clinical trials  facilitate the concurrent launch of new drug in different countries, across all three ich members  create guidelines to ensure that the highest level of safety, quality and efficacy is applied to drug development, with an eye towards globalization. structure of ich 3  ich assembly  ich management committee  meddra management committee  ich secretariat the ich assembly works in bringing together all members and observers of the ich association as the overarching governing body of ich. it takes decisions on particular matters such as on the adoption of ich guidelines, open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i3.16 ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [2] ajdhs.com admission of new members and observers, and the ich association’s work plans and budget. member representatives appointed by the assembly are supported by ich coordinators who represent each member to the ich secretariat on a daily basis. the ich management committee (mc) is that body which supervises the operational aspects of ich on behalf of all members, including administrative and financial matters and oversight of the working groups (wgs).the meddra management committee (mc) has responsibility for providing direction of meddra, ich’s standardised medical terminology. the meddra mc is responsible for managing, supporting, and facilitating the maintenance, development, and dissemination of meddra. the ich secretariat is responsible for day-to-day management of ich, coordinating ich activities as well as providing support to the assembly, the mc and working groups. the ich secretariat also provides support to the meddra mc. the ich secretariat is located in geneva, the development of a new harmonised guideline and its implementation (the formal ich procedure) involves 5 steps 4 (figure1). ich guidelines objective of ich is to increase international harmonization of technical requirements to ensure that safe, effective, and higher quality medicines are developed and registered in the most efficient and cost effective manner. ich has developed over 45 harmonized guidelines.there are four major categories into which the ich guidelines are divided. quality those relating to chemical and pharmaceutical quality assurance. safety those relating to in vitro and in vivo preclinical studies. efficacy those relating to clinical studies in human subject 5. figure 1: flow chart showing ich harmonization process ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [3] ajdhs.com guidelines the present study is an attempt to provide detailed information about ich on the basis of literature. quality stability testing the objective of stability study 6 is to provide proof on how the quality of drug substance or drug product changes with time under the effect of a variety of environmental factors such as temperature, humidity and light and recommended storage conditions, re-test periods and shelf-life to be established. the choice of test conditions depends on climatic conditions in the areas of eu, japan and usa. drug substance information on the stability of the drug substance is an integral part of the systematic approach to stability evaluation. stress study of the drug substance can help identify the degradation products which can in turn help establish the degradation pathways and validate the stability indicating power of the analytical procedures used 7. the nature of the stress study will depend on the individual drug substance and the type of drug product used. stress study is to be carried out on a single batch of the substance. it should include the effect of temperature, humidity. the study should also evaluate the susceptibility of the drug substance to hydrolysis across a wide range of ph values when in solution or suspension. photostability study should be an integral part of stress testing 8. the standard conditions for photo stability studies are described in ich q1b 9. data from formal stability studies should be provided on at least three batches. the batches should be manufactured to a pilot scale by the same route as used earlier and using a method of manufacture and procedure that simulates the final process for production batches. the stability studies should be conducted on the drug substance packed in final packing. specification is a list of tests, reference to analytical procedures and proposed acceptance criteria, which are addressed in ich guideline q6a and q6b. additionally, specification for degradation of products in a drug substance is discussed in q3a. stability studies include study of those of attributes of the drug substance that are susceptible to change during storage and are likely to affect quality, safety and efficacy. the study should cover, as appropriate, the physical, chemical, biological and microbiological attributes. validated stability-indicating analytical procedures should be applied whether and to what extent replication should be performed will depend on the results from validation studies 10. study frequency for long-term studies, frequency of testing should be sufficient to establish the stability profile of the active pharmaceutical product (api). for apis with a proposed retest period or shelf-life of at least 12 months, the frequency of testing at the long-term storage condition should normally be in every three months over the first year, in every six months over the second year, and annually thereafter throughout the proposed re-test period or shelflife.at the accelerated storage condition, a minimum of at least three time points, including the initial and final time points (e.g. 0, 3 and 6 months), from a six months study is recommended. when a testing at the intermediate storage condition is required as a result of significant change at the accelerated storage condition, a minimum of four time points, including the initial and final time points (e.g. 0, 6, 9 and 12 months), from a 12-month study is recommended. storage conditions in general, an api should be evaluated under storage conditions (with appropriate tolerances) that test its thermal stability and, if applicable, its 91 sensitivity to moisture. the storage conditions and the lengths of studies chosen should be sufficient to cover storage and shipment. storage condition tolerances are defined as the acceptable variations in temperature and relative humidity of storage facilities for stability studies. in the rare case of any api of non-biological origin being intended for storage in a freezer, the re-test period or shelf-life should be based on the long-term data obtained at the long-term storage condition. in the absence of an accelerated storage condition for apis intended to be stored in a freezer, testing on a single batch at an elevated temperature (e.g. 5°c± 3°c or 25°c ±2°c or 30°c ± 2°c) for an appropriate time period should be conducted to address the effect of short-term excursions outside the proposed label storage condition, e.g. during shipping or handling. apis intended for storage below -20 °c should be treated on a case-bycase basis. evaluation the purpose of the stability study is to establish and evaluating the stability information including, as appropriate, results of the physical, chemical, biological and microbiological tests, a re-test period applicable to the other batches of the api manufactured under similar circumstances. the degree of discrepancy of an individual batch affects the conviction that a future production batch will remain within specification throughout the assigned re-test period. on-going stability studies the stability of the api should be monitored on the basis of continuous and appropriate programme that will permit the detection of any stability issue (e.g. changes in levels of degradation products). the on-going stability programme is required to monitor the api and to determine that the api remains, and can be expected to remain, within specifications under the storage conditions indicated on the label, within the re-test period in all future batches. the ongoing stability programme should be described in a written protocol and the results are presented in a formal report. ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [4] ajdhs.com the protocol for an on-going stability programme should extend to the end of the re-test period and shelf-life and should include the following parameters:  number of batches and batch sizes, if applicable;  relevant physical, chemical, microbiological and biological test methods;  acceptance criteria;  reference to test methods;  description of the container closure system(s);  testing frequency; description of the storage conditions (standardized conditions for long-term testing as described in these guidelines, and consistent with the api labelling, should be used); other applicable parameters specific to the api. validation validation of an analytical procedure is the process by which it is established, by laboratory studies so that the performance characteristics of the procedure meet the requirements for the intended analytical applications. method validation provides an assurance of reliability during normal use, and is sometime referred to as the process for providing documented evidence that the method does what it is intended to do 11. ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [5] ajdhs.com repeatability repeatability is termed as the use of the analytical procedure within a laboratory over a hort period of time using the same analyst with the same equipment. it should be evaluated using a minimum of nine determinations covering the specified range for the procedure (i.e., three concentrations and three replicates of each concentration or using a minimum of six determinations at 100% of the test concentration) reproducibility reproducibility indicates the precision between laboratories (collaborative studies, usually applied to standardisation of methodology). it is usually demonstrated by means of an inter-laboratory trial 12, 13. • specificity: specificity is the ability to measure accurately and specifically the analyte of interest in the presence of other components that may be expected to be present in the. • linearity: it is a mathematical relationship or function which means that it can be graphically represented as a straight line. it can be established initially by visual examination of a plot of signals as a function of analyte concentration of content. it is suggested to have a minimum of five concentration levels, along with certain minimum specified ranges. for performing the assay, the minimum specified range is from 80% -120% of the target concentration. • detection limit and quantitation limit: the detection limit refers to the lowest concentration of an analyte in a sample that can be detected but cannot quantify. the quantitation limit refers to the lowest concentration of an analyte in a sample that can be determined with acceptable precision and accuracy under the stated operational conditions of the analytical procedures. good manufacturing practices good manufacturing practices (gmp) is a part of quality assurance (qa) which ensures that products are consistently produced and controlled in accordance with the quality standards that are appropriate for their intended use and as required by the marketing authorization 14. gmp guidelines provide minimum requirements for pharmaceutical or a food product manufacturer to assure that the products are of high quality and do not pose any risk to the consumer. additionally, gmp has issued guidelines for the achievement of consistent product quality, with interpretation and individual variations being accepted. gmp implemented in the united states by the us fda, under section 501(b) of the 1938 food, drug, and cosmetic act (21 uscs § 351). the regulations use the phrase “current good manufacturing practices” (cgmp) and it describes the guidelines 15. pharmacopoeia a pharmacopoeia is a legally binding collection of standards and quality specifications for medicines used in a country or region 16. within the pharmacopoeia, a quality specification is a set of appropriate tests that will confirm the identity and purity of the product, ascertain the strength (or amount) of the active substance and, when needed, the performance characteristics. reference substances that are used in testing help to ensure the quality, strength and purity of the drugs. a pharmacopoeia covers the information regarding the pharmaceutical starting materials, excipients, intermediates and finished pharmaceutical products (fpps). details of general requirements may also be provided on important subjects related to drugs quality, such as analytical methods, microbiological purity, dissolution testing, or stability. the modern pharmacopoeia points out certain quality specifications for active pharmaceutical ingredients (apis), fpps and general requirements. the existence of such specifications and requirements is necessary for the proper functioning or regulatory control of medicines production 17. ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [6] ajdhs.com quality guidelines ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [7] ajdhs.com ahirwar et al asian journal of dental and health sciences. 2022; 2(3):1-8 [8] ajdhs.com conclusion the ich is a major global undertaking to affect the harmonization of regulatory requirements in the 3 major regions involved. the creation of the ich – the international conference of harmonization, was fuelled by trade reasons, to even out the competition between markets and end the aforementioned stagnation. ich was created to deliver health care technology providers a common, almost global regulatory framework for them to develop their products. the ich’s work is far from over, as more and more regulatory scrutiny is demanded from manufacturers and investigators and more pressure is applied to pharmaceutical companies to increase data transparency, who look up for ich’s guidance. references 1. ich quality implementation working group, international conference on harmonisation of technical requirements for registration of pharmaceuticals for human use. geneva: ich secretariat; 2011. 2. meddra [internet]. meddra; 2019. available from: http://www.meddra.org 3. rahi s, rana a. role of ich guidelines in registration of pharmaceutical products. international journal of drug regulatory affairs. 2019; 7(4):14-27. https://doi.org/10.22270/ijdra.v7i4.365 4. van der laan jw, degeorge jj, editors. global approach in safety testing: ich guidelines explained. berlin: springer; 2013. https://doi.org/10.1007/978-1-4614-5950-7 5. somvanshi y, satbhai p. ich guidelines and main focus on stability guidelines for new formulation and dosage forms. world j pharm rese. 2015; 4(10):561-78. 6. pokharana m, vaishnav r, goyal a, shrivastava a. stability testing guidelines of pharmaceutical products. journal of drug delivery and therapeutics. 2018; 8(2):169-75. https://doi.org/10.22270/jddt.v8i2.1564 7. ich q1a (r2). stability testing guidelines: stability testing of new drug substances and products. ich steeringcommittee [internet]. london: emea; 2003. 8. welankiwar a, saudagar s, kumar j, barabde a. photostability testing of pharmaceutical products. int. res. j. pharm. 2013; 2:115. https://doi.org/10.7897/2230-8407.04904 9. somvanshi y, satbhai p. ich guidelines and main focus on stability guidelines for new formulation and dosage forms. world j pharm rese. 2015; 4(10):561-78. 10. yadav c, vaishnav r, goyal a. aspects of pharmaceutical process validation: a review. international journal of pharmacy and pharmaceutical research. 2018; 14(1):55-66. 11. validation of analytical procedures: text and methodology q2 (r1), ich harmonised tripartite guidelines, international conference on harmonisation of technical requirements for registration of pharmaceuticals for human use; 2005. 12. ravisankar p, navya cn, pravallika d, sri dn. a review on step-bystep analytical method validation. iosr j pharm. 2015; 5(10):719. 13. romanach. r.j, paternia as. theory of sampling in pharmaceutical manufacturing. impublications com. 2015; (5):67-70. https://doi.org/10.1255/tosf.61 14. chaudhari v, yadav v, verma p, singh a. a review on good manufacturing practice (gmp) for medicinal products. pharmatutor. 2014; 2(9):8-19. 15. shukla a, vishnoi g, das dr. current good manufacturing guidelines for medicinal product. journal of drug delivery and therapeutics. 2016; 6(2):57-61. https://doi.org/10.22270/jddt.v6i2.1201 16. soni nr. specifications for starting materials, intermediates and finished products. pharmatutor. 2016; 4(11):21-6. 17. ich quality implementation working group, international conference on harmonisation of technical requirements for registration of pharmaceuticals for human use. [internet]. geneva 20, switzerland: ich secretariat; 2011. https://doi.org/10.22270/ijdra.v7i4.365 https://doi.org/10.1007/978-1-4614-5950-7 https://doi.org/10.22270/jddt.v8i2.1564 https://doi.org/10.7897/2230-8407.04904 https://doi.org/10.1255/tosf.61 https://doi.org/10.22270/jddt.v6i2.1201 rajak et al asian journal of dental and health sciences. 2022; 2(4):64-68 [64] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited review on toxicity of antihypertensive drugs devraj rajak, deepali sahu, anushree jain, rubeena khan, basant khare, prateek kumar jain, bhupendra singh thakur* adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 13 sep 2022 reviewed 08 nov 2022 accepted 25 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: rajak d, sahu d, jain a, khan r, khare b, jain pk, thakur bs, review on toxicity of antihypertensive drugs, asian journal of dental and health sciences. 2022; 2(4):64-68 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.28 _______________________________________ *address for correspondence: bhupendra singh thakur, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ adverse drug reactions are common and pose a serious health problem, limiting treatment options, causing compliance issues, and even leading to therapy discontinuation. hypertension is a chronic disease that is regarded as a major risk factor for cardiovascular disease. to achieve a target blood pressure in an individual patient, a wide range of anti-hypertensive agents are available as single or combination therapy, whereas combination therapy increases the risk of developing adverse drug reaction. hypertensive patients frequently have coexisting disease conditions such as hyperlipidemia, impaired glucose metabolism, and renal impairment, which increase the risk of cardio vascular morbidity and mortality. when treating hypertensive patients, comprehensive management of both hypertension and concomitant cardio vascular disease risk factors is essential. some of the rare and serious adverse drug reactions that occurred in patients treated with these drugs included betablockers causing psoriasis, calcium channel blockers causing gingival hyperplasia, peripheral oedema, angiotensin converting enzyme inhibitors causing ankle oedema, and thiazide diuretics causing hyponatremia and hyperglycemia. asymptomatic hypertension is more common and necessitates lifelong treatment with antihypertensive agents, predisposing to adverse drug events.in order to improve treatment outcomes and reduce morbidity and mortality associated with adverse drug reactions, healthcare professionals must monitor adverse drug reactions in patients taking antihypertensive drugs. keywords: adverse drug reactions, hypertension, hyperlipidemia, glucose metabolism introduction hypertension is a chronic disease that is regarded as a major public health issue and a significant cardiovascular risk factor when the systolic blood pressure is greater than 140 mmhg and the diastolic blood pressure is greater than 90 mmhg1-2. according to the global burden of disease study, hypertension is the third most preventable cause of death in the world and the second most common condition in westernized countries3. in the year 2000, it was also discovered that the world had 1 billion people with hypertension, with the number expected to rise to 1.56 billion by 2025. hypertension becomes more common with age and is a treatable risk factor for stroke, ischemic heart disease, renal insufficiency, and dementia4,5. although public awareness of hypertension diagnosis has grown, improvements in cardiovascular disease rates have not kept pace6. despite numerous guidelines emphasising the importance of achieving optimal blood pressure control in high-risk patients such as diabetics, only about 29% of hypertensive patients have blood pressure under control to a target of 140/90 mmhg6-10. a wide range of antihypertensive medications are currently available for the treatment of hypertension11. thiazide diuretics, beta blockers, long acting calcium channel antagonists, angiotensin converting enzyme inhibitors, and angiotensin ii receptor blockers have all been shown to improve outcomes12-14. adverse drug reactions are regarded as one of the leading causes of death. adrs are estimated to account for 6% of hospital admissions, with 615% of hospitalised patients experiencing serious adrs15. antihypertensive medications are frequently associated with adverse drug reactions, which can limit treatment options and decrease patient compliance, thereby impairing blood pressure control. different discontinuation rates for different classes of antihypertensive medications were thought to be related to their different rates of adverse symptoms16-19. typically, two or more antihypertensive medications are required to achieve blood pressure control; however, increasing the number of antihypertensive medications in a regimen may result in even more adverse effects20. in light of the potential side effects of antihypertensive drugs, we have highlighted some of the potential adverse drug reactions caused by antihypertensive medications in this article. beta blockers triggered negative effects beta blockers are a type of antihypertensive agent that is widely used to treat both cardiovascular and noncardiovascular diseases such as hypertension, ischemic heart disease, arrhythmias, heart failure, hyperthyroidism, glaucoma, and anxiety disorders21. they should be used in conjunction with calcium channel blockers if used to treat vasospastic angina pectoris. beta blockers are classified into three types: older beta nonspecific agents (e.g., propanolol); 1 specific agents (e.g., atenolol, metoprolol, and bisoprolol); and beta blockers with additional properties (e.g. carvedilol and nebivolol). beta blockers work by blocking either 1 receptor (cardio selective) or 2 receptors (non -cardio selective). the newer beta blockers produce better central aortic blood pressure control than older beta blockers, particularly carvedilol, which has better tolerability and outcome than open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.28 rajak et al asian journal of dental and health sciences. 2022; 2(4):64-68 [65] ajdhs.com older agents22. when used alone or in combination with diuretics, beta blockers have a negative impact on glucose and lipid metabolism. as a result, beta blockers are not recommended as first-line therapy in the elderly or when hypertension is complicated by other diseases such as diabetes mellitus or abnormal glucose tolerance23. the most common adverse effects of these drugs fall into two categories: a) those caused by known pharmacological consequences, such as bronchospasm, heart failure, prolonged hypoglycemia, bradycardia, heart block, intermittent claudication, and raynaud's phenomenon; and b) those caused by unknown pharmacological consequences. b) other reactions that do not seem to be caused by adrenergic receptor blockade, such as unusual occulo-muco cutaneous reactions and the possibility of oncogenesis24. according to one study, long-term hypertension and beta blocker use may be risk factors developing psoriasis25. beta blocker induced psoriasis psoriasis is a common autoimmune inflammatory skin disease that affects approximately 2-3% of the us population and over 125 million patients globally26-28. it is distinguished by t-cellmediated keratinocyte hyperproliferation and inflammatory processes that are based on a complex genetic background26,27. smoking, alcohol consumption, trauma, infections, endocrine factors, stressful life events, and exposure to drugs such as beta blockers, angiotensin converting enzyme inhibitors (acei), antimalarials, non steroidal anti-inflammatory drugs (nsaid), lithium, interferons, and acute withdrawal of systemic or potent topical corticosteroids29-33 are all potential risk factors. several case control and cross-over studies show that beta blockers are a major aggravating factor in patients with psoriasis vulgaris who are hospitalized34-37. mechanism the mechanism for psoriasis exacerbation with blocker use is thought to be related to a blockade in the activation of the messenger system of cyclic adenosine 3' 5'-cyclic monophosphate, which results in decreased intracellular calcium concentrations, which causes an accelerated proliferation of keratinocytes or polymorph nuclear leukocytes, both of which may play a role in inducing psoriasis37-40. management beta blockers are widely used and have a good track record of safety. in the case of blockers that have caused psoriasis, switching from one to the other results in the reintroduction of psoriasis-like skin lesions. as a result, an alternative class of antihypertensive medication must be chosen. thiazide diuretics or calcium channel blockers can be used as first-line treatment for hypertension, according to new antihypertension guidelines. traditional therapeutic agents such as topical and systemic drugs can be recommended for the treatment of drug-induced psoriasis. emollients can be beneficial if psoriasis is only present in a few areas41-44. calcium channel blockers induced adverse effects calcium channel blockers (ccbs) are a diverse class of drugs that are the most commonly used antihypertensive medications. ccbs exert their therapeutic effects by binding to l-type calcium channels found on vascular smooth muscles, cardiac myocytes, and cardiac nodal tissues, which prevent calcium ions from passing through cell membranes. ccbs cause relaxation of vascular smooth muscles and vasodilation through this blockage, resulting in a reduction in heart rate and a decrease in conduction velocity within the heart. despite well-known side effects, such as flushing, headache, or palpitation with dhps, constipation with verapamil, and gingival enlargement and ankle oedema with nifedipine. ccbs are well tolerated45-48. gingival enlargement gingival enlargement is a proliferative fibrous gingival lesion that causes aesthetic and functional issues. more than 20 prescription medications are currently linked to gingival enlargement, and they can be broadly classified into three groups: anticonvulsants, calcium channel blockers (ccb), and immunosuppressants. both patients and clinicians may be concerned about drug-induced gingival hyperplasia the prevalence of ccb-induced gingival overgrowth is unknown. although several studies have been conducted to investigate this question, the results from previous studies range from 20% to 83%, with diltiazem and amlodipine providing estimates of 74% and 3.3%, respectively. males are 3.3 times more likely than females to experience overgrowth49-53. management because drug-induced gingival overgrowth has not been reported with any of these drugs, the most effective treatment for these lesions is discontinuation of the offending medication and substitution with another class of antihypertensive such as beta blockers, diuretics, or acei. another option is to replace the ccb medication with one that has a lower risk of causing gingival enlargement (e.g. verapamil, isradipine). if changing the regimen is not an option, the lesions should be managed surgically or nonsurgically [54-59]. peripheral oedema oedema is the accumulation of fluid in intracellular tissue caused by an abnormal increase in interstitial fluid volume, which results in decreased plasma oncotic pressure, increased capillary permeability, or lymphatic obstruction. because of its dose-dependent nature, the frequency of peripheral oedema with ccb therapy varies widely in the literature, ranging from 5% to as high as 70%. ankle oedema is more common in the dihydropyridine (dhp) group of ccbs, though lacidipine and lecanidipine may cause it less frequently than nifedipine and amlodipine. this is more common in women and is associated with upright posture, age, and the selection and dosage of ccb diltiazem, anon-dhpagent,seems to be associated with lowest incidence of ankle edema60-63. mechanism of ccb induced oedema the increased capillary hydrostatic pressure caused by greater dilation of pre-capillary vessels than post-capillary vessels causes ccb-induced oedema. this effect is mediated by resistance vessels being more sensitive to ccb-induced reductions in myogenic vascular reactivity than capacitance vessels61. management the standard treatment for ccb-induced oedema is to discontinue therapy and replace it with an alternative class of antihypertensive, such as thiazide diuretics, aceis, or arbs. some studies have also shown that switching from dihydropyridine ccb to non-dihydropyridine ccbs like verapamil or diltiazem reduces oedema. ccb-related peripheral oedema may not be physiologically corrected, and it is recommended that diuretics be prescribed to patients solely for the purpose of correcting the oedema state61. angiotensin-converting enzyme inhibitors induced angio-oedema in all stages of symptomatic heart failure caused by impaired left ventricular systolic function, ace inhibitors have rajak et al asian journal of dental and health sciences. 2022; 2(4):64-68 [66] ajdhs.com consistently shown beneficial effects on mortality, morbidity, and quality of life ace inhibitors work by preventing the production of angiotensin-ii, a potent vasoconstrictor and growth promoter, as well as increasing the concentrations of the vasodilator bradykinin by preventing its degradation. ace inhibitors are typically started at a low dose and gradually increased to the highest tolerated maintenance dose. dry cough, dizziness, deterioration in renal function, hypotension, and angio-oedema are all side effects of ace inhibitors. the use of ace inhibitors has increased significantly in recent years, and more adverse reactions, including severe angiooedema of the upper airways and even death due to asphyxiation, have been reported. angio-oedema is a sudden, asymmetric swelling of the skin or mucous membrane caused by a transient increase in endothelial permeability, resulting in plasma extravasation. angioedema caused by ace inhibitors is typically characterised by oedematous skin that is slightly red and is not accompanied by urticaria. angiooedema is most commonly found in the oro-facial and/or perioral areas, as well as the upper airways. angio-oedema caused by ace inhibitors can affect 0.1% to 0.5% of patients taking the drug64-68. mechanism of ace induced angio-oedem the mechanism is still unknown. one theory is that bradykinin, which is normally degraded by kinase-ii/ace, is involved. in patients receiving acei, bradykinin degradation is inhibited, resulting in bradykinin accumulation in tissues. plasma bradykinin levels have been shown to rise up to 12fold during angioedema attacks66,67. management (1)discontinue ace inhibitor/arb immediately. (2) airway management, fluid replacement therapy, and vital sign monitoring should all be initiated as soon as possible. (3) bradykinin receptor antagonist i catibint has been used as an effective treatment option in severe cases involving the upper airways or gi tract. (4) corticosteroids66-67, epinephrine 1:1000 (0.3-0.5ml). thiazide diuretics induced hyponatremia diuretics are currently recommended as first-line therapy for the treatment of hypertension in all age groups by the seventh report of the joint national commission (jnc) on prevention, detection, evaluation, and treatment of high blood pressure. diuretics are classified into three types, each of which plays an important role in the treatment of most hypertensive patients. during the course of thiazide diuretic treatment, type ii diabetes, low serum cholesterol levels, and hyperuricemia (gout) may occur.in a few patients, hypokalemia may develop on low-dose thiazide diuretics, prompting a diagnosis of primary aldosteronism, which can be managed with the addition of potassium sparing drugs (spirinolactone, eplerenone), achieving effective hypertension control and correcting hypokalemia without the need for extensive diagnostic assessment of adrenalictomy69-71. mechanism thiazide diuretics interfere with sodium chloride cotransport in the distal convoluted tubule. as a result, sodium excretion increases while free water excretion decreases, resulting in hyponatraemia72. management (1)stop using thiazide diuretics. (2) regulardiet(usuallysupplementedwithpotassium) (3) restrictingwaterintake (4) if the hyponatremia is severe or symptomatic, furosemide and isotonic saline should be administered73. thiazide diuretic induced hyperglycemia diabetes is a major risk factor for cardiovascular disease. hyperglycemia is a more common and severe adverse effect of thiazide diuretics than other classes of antihypertensive agents74. mechanism of thiazide induced hyperglycemia low serum potassium has been implicated in the pathogenesis of diuretic-induced hyperglycemia. it is critical to understand that serum potassium levels do not always correlate with intracellular potassium stores. as a result, while serum potassium levels may be normal, intracellular potassium deficiency persists, reducing endogenous insulin release and causing hypoglycemia75. management patients with diuretic-induced hyperglycemia are frequently diagnosed with type ii diabetes and prescribed oral antidiabetic medications. because hypertension is more common than diabetes, and because thiazide diuretics are used to treat hypertension, thiazide-induced hyperglycemia is very common. as a result, some authors believe that using thiazide diuretics to treat hypertension is both safe and effective. the complication of high glucose levels is reversible and thus insignificant76. conclusion to achieve recommended bp targets quickly and rigorously, but with good tolerability and sustained patient adherence, there is a need for safe, effective, and simple therapies to treat hypertension. the use of combination therapy as first-line treatment will help more patients achieve bp goals more quickly, and fixed dose combinations allow for simple but flexible dosing. because the current review is concerned with the adr profile of antihypertensive agents, it may be useful in selecting appropriate medicines for hypertensive patients, improving patient adherence with therapy by selecting medicines with lower adr profiles, and reducing unnecessary economic burden to patients due to unwanted effects of the therapy.it is important to remember that most adrs will go away once the offending agent is stopped or the dosage is reduced. as a result, monitoring of adverse effects from antihypertensive medications, particularly those of a serious nature, is required. as a result, physicians, clinical pharmacists, and other health care professionals should report any life-threatening complications or hospitalizations (initial or extended) associated with antihypertensive drugs. references 1. raghu kumar v, raghu ram v, guru prasad b, mohanta g.p and manna p.k: a study of adverse drug reactions due to antihypertensive drugs in a tertiary care teaching hospital. international journal of pharmacy and life sciences 2011; 2:767772. 2. aellig hw: adverse reactions to world health organisation preventing chronic diseases: a vital investment. geneva, switzerland: who; 2005. 3. murray cj, lopez ad: mortality by cause for eight regions of the world: global burden of disease study. lancet 1997; 349: 12691276. https://doi.org/10.1016/s0140-6736(96)07493-4 4. michel joffres et al., hypertension prevalence, awareness, treatment and control in national surveys from england, the usa and canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study. british medical journal 2013; 3:e003423. https://doi.org/10.1136/bmjopen-2013-003423 5. peter lloydsherlock, john beard, nadia minicuci, shah ebrahim and somnathchatterji.:hypertension among older adults in lowand middle-income countries: prevalence, awareness and control. https://doi.org/10.1016/s0140-6736(96)07493-4 https://doi.org/10.1136/bmjopen-2013-003423 rajak et al asian journal of dental and health sciences. 2022; 2(4):64-68 [67] ajdhs.com international journal of epidemiology 2014; 1-13. https://doi.org/10.1093/ije/dyt215 6. the sixth report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. archives of internal medicine 1997; 157:24132446. https://doi.org/10.1001/archinte.1997.00440420033005 7. 1999 world health organisationinternational society of hypertension guidelines for the management of hypertension. guidelines subcommittee.journal of hypertension 1999; 17:151183. https://doi.org/10.1097/00004872-199917020-00001 8. kaplan nm: guidelines for the management of hypertension. canadian journal of cardiology 2000; 16:1147-1152. 9. ramsay l et al., guidelines for the management of hypertension: report of the third working party of the british hypertension society. journal of human hypertension 1999; 13:569-592. https://doi.org/10.1038/sj.jhh.1000917 10. scottish intercollegiate guidelines network. hypertension in older people.a national clinical guideline. 2001. sign publication no. 49. 11. dabhadesuhas, bhosle deepak, atrekavita: review on pharmacovigilance study of telmisartan in hypertension patients. asian journal of pharmaceutical and clinical research 2013; 6:1720. 12. collins r, macmahon s: blood pressure, anti-hypertensive drug treatment and the risk of stroke and of coronary heart disease. british medical bulletin 1994; 50:272298. https://doi.org/10.1093/oxfordjournals.bmb.a072892 13. neal b, mac mahon s and chapman n: effects of ace inhibitors, calcium antagonists and other blood pressurelowering drugs: results of prospectively designed overuse of randomised trials. blood pressure lowering treatment trialists' collaboration. lancet 2000; 355:1955-1964. https://doi.org/10.1016/s01406736(00)03307-9 14. zia al sabbah, aijazmansoor, upendrakaul: angiotensin receptor blockers-advantages of the new sartans. journal of the association of physicians of india 2013; 61:464470. 15. hussain a, aqil m, alam m.s, khan m.r, kapur p and pillai k.k: a pharmacovigilance study of antihypertensive medicines at south delhi hospital. indian journal of pharmaceutical sciences 2009; 71:338-341. https://doi.org/10.4103/0250-474x.56018 16. degliesposti e, sturani a and di martino n: long term persistence with anti-hypertensive drugs in new patients. journal of human hypertension 2002; 16:439-444. https://doi.org/10.1038/sj.jhh.1001418 17. degliesposti l, degliesposti e and valpiani g: a retrospective, populationbased analysis of persistence with anti-hypertensive drug therapy in primary care practice in italy. clinical therapeutics 2002; 24:13471357. https://doi.org/10.1016/s0149-2918(02)80039-x 18. monana m, bohn rl, gurwitz jh, glynn rj, levin r and avorn j: the effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a populationbased study in the elderly. american journal of hypertension 1997; 10:697-704. https://doi.org/10.1016/s08957061(97)00056-3 19. ross sd, akhras ks, zhang s, rozinsky m and nalysnyk l: discontinuation of anti-hypertensive drugs due to adverse events: a systematic review and meta-analysis. pharmacotherapy 2001; 21:940-953. https://doi.org/10.1592/phco.21.11.940.34520 20. allhat officers and co-ordinators for the allhat collaborative research group. major outcomes in high-risk hypertensive patients randomized to angiotensinconverting enzyme inhibitor or calcium channel blocker vs diuretic: the anti-hypertensive and lipid lowering treatment to prevent heart attack trial. the journal of the american medical association.2002; 288:2981-2997. https://doi.org/10.1001/jama.288.23.2981 21. lionel f, baker: triggering psoriasis: the role of infections and medications. clinics in dermatology 2007; 25:606615. https://doi.org/10.1016/j.clindermatol.2007.08.015 22. jeffery. martin: hypertension guidelines: revisiting the jnc 7 recommendations. the journal of lancaster general hospital 2008; 3:91-97. 23. treatment with antihypertensive drugs. jsh guidelines.hypertension research.2009; 32:33-39. https://doi.org/10.1038/hr.2008.5 24. william h. frishman: beta-adrenergic blockers, adverse effects and drug interactions. journal of american heart association 1988; 11:ii 21ii 29. https://doi.org/10.1161/01.hyp.11.3_pt_2.ii21 25. joanna lyford: hypertension and beta-blockers may raise risk of psoriasis. the pharmaceutical journal 2014; 293. 26. jain m, jain a, khare b, jain dk, khan r, jain d. an update on the recent emergence of candida auris. asian journal of dental and health sciences. 2022; 2(1):14-9. https://doi.org/10.22270/ajdhs.v2i1.11 27. kormeili t, lowe nj, yamauchi ps: psoriasis: immunopathogenesis and evolving immune-modulators and systemic therapies; u.s. experiences. british journal of dermatology 2004; 151:3-15. https://doi.org/10.1111/j.1365-2133.2004.06009.x 28. thao nguyen, jashin j wu: relationship between tumour necrosis factorα inhibitors and cardiovascular disease in psoriasis: a review. the permanente journal 2014; 18:4954. https://doi.org/10.7812/tpp/13-092 29. brauchli y.b, jick s.s, curtin f and meier c.r: association between beta blockers, other antihypertensive drugs and psoriasis: population-based casecontrol study. british journal of dermatology 2008; 158:1299-1307. https://doi.org/10.1111/j.1365-2133.2008.08563.x 30. jat d, thakur n, jain dk, prasad s, yadav r. iris ensata thunb: review on its chemistry, morphology, ethno medical uses, phytochemistry and pharmacological activities. asian journal of dental and health sciences. 2022; 2(1):1-6. https://doi.org/10.22270/ajdhs.v2i1.9 31. tsankov n, kasandjieva j and drenovska k: drugs in exacerbation and provocation of psoriasis. clinics in dermatology 1998; 16:333-51. https://doi.org/10.1016/s0738-081x(98)00005-4 32. naldi l, parazzini f, peli l, chatenoud l and cainelli t: dietary factors and the risk of psoriasis. results of an italian case-control study.british journal of dermatology 1996; 134:101-106. https://doi.org/10.1046/j.1365-2133.1996.d01-734.x 33. naldi l et al., cigarette smoking, body mass index and stressful life events as risk factors for psoriasis: results from an italian casecontrol study. journal of investigative dermatology 2005; 125:6167. https://doi.org/10.1111/j.0022-202x.2005.23681.x 34. steinkraus v, steinfath m and mensing h: beta adrenergic blocking drugs and psoriasis. journal of the american academy of dermatology 1992; 27:266-267. https://doi.org/10.1016/s01909622(08)80738-4 35. halevy s, livni e: psoriasis and psoriasiform eruptions associated with propranolol the role of an immunological mechanism. archives of dermatological research 1991; 283:472-473. https://doi.org/10.1007/bf00371785 36. cohen ad, bonneh dy, reuveni h, vardy da, naggan l and halevy s: drug exposure and psoriasis vulgaris: casecontrol and casecrossover studies. actadermatovenereologica 2005; 85:299-303. https://doi.org/10.1080/00015550510032823 37. khatri s, dhanoriya c, jain dk. zika virus (zikv) disease: past, present and future. journal of drug delivery and therapeutics. 2018; 8(6-s):320-7. https://doi.org/10.22270/jddt.v8i6-s.2076 38. yadav r, jha m, prasad s, jat d, jain dk. mayaro virus (mayv) disease: past, present and future. j pharm biol sci. 2022; 10(1):716. 39. obrien m, koo j: the mechanism of lithium and beta blocking agents in inducing and exacerbating psoriasis. journal of drugs in dermatology 2006; 5:426-432. https://doi.org/10.1093/ije/dyt215 https://doi.org/10.1001/archinte.1997.00440420033005 https://doi.org/10.1097/00004872-199917020-00001 https://doi.org/10.1038/sj.jhh.1000917 https://doi.org/10.1093/oxfordjournals.bmb.a072892 https://doi.org/10.1016/s0140-6736(00)03307-9 https://doi.org/10.1016/s0140-6736(00)03307-9 https://doi.org/10.4103/0250-474x.56018 https://doi.org/10.1038/sj.jhh.1001418 https://doi.org/10.1016/s0149-2918(02)80039-x https://doi.org/10.1016/s0895-7061(97)00056-3 https://doi.org/10.1016/s0895-7061(97)00056-3 https://doi.org/10.1592/phco.21.11.940.34520 https://doi.org/10.1001/jama.288.23.2981 https://doi.org/10.1016/j.clindermatol.2007.08.015 https://doi.org/10.1038/hr.2008.5 https://doi.org/10.1161/01.hyp.11.3_pt_2.ii21 https://doi.org/10.22270/ajdhs.v2i1.11 https://doi.org/10.1111/j.1365-2133.2004.06009.x https://doi.org/10.7812/tpp/13-092 https://doi.org/10.1111/j.1365-2133.2008.08563.x https://doi.org/10.22270/ajdhs.v2i1.9 https://doi.org/10.1016/s0738-081x(98)00005-4 https://doi.org/10.1046/j.1365-2133.1996.d01-734.x https://doi.org/10.1111/j.0022-202x.2005.23681.x https://doi.org/10.1016/s0190-9622(08)80738-4 https://doi.org/10.1016/s0190-9622(08)80738-4 https://doi.org/10.1007/bf00371785 https://doi.org/10.1080/00015550510032823 https://doi.org/10.22270/jddt.v8i6-s.2076 rajak et al asian journal of dental and health sciences. 2022; 2(4):64-68 [68] ajdhs.com 40. ockenfels hm et al., tyrosine phosphorylation in psoriasis t-cells is modified by drugs that induce or improve psoriasis. dermatology 1995; 191:217-225. https://doi.org/10.1159/000246549 41. drs m keefe, hamlet n w and rebecca e i kerr: psoriasis is a side effect of beta blockers. british medical journal 1987; 295: 1352. https://doi.org/10.1136/bmj.295.6609.1352-a 42. o'brian m, koo j: the mechanism of lithium and beta blocker agents in inducing an exacerbating psoriasis. journal of drugs in dermatology 2006; 5:426-433. 43. hypertension: clinical management of primary hypertension in adults. nice guidelines. 2011. 44. tsankov n, irena a and kasandjieva j: drug-induced psoriasis: recognition and management. american journal of clinical dermatology 2000; 1: 159-165. https://doi.org/10.2165/00128071200001030-00003 45. peter trenkwalder: anti-hypertensive treatment with calcium channel blockers: pharmacological pornography or useful intervention? nephrology dialysis transplantation 2004; 19:17-20. https://doi.org/10.1093/ndt/gfg431 46. harikrishnamakani md, sripal bangalore md, mha, jorge romero md, omar wever-pinzon md, franz h. messerli md: effect of reninangiotensin system blockade on calcium channel blocker-associated peripheral edema. the american journal of medicine 2011; 124:128135. https://doi.org/10.1016/j.amjmed.2010.08.007 47. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech journal of pharmaceutical sciences. 2018; 7(4):1-25. 48. livada r and shiloah j: calcium channel blocker-induced gingival enlargement. journal of human hypertension 2014; 28:0-14. https://doi.org/10.1038/jhh.2013.47 49. shetty ak, shah hj, patil ma and jhota kn: idiopathic gingival enlargement and its management. journal of indian society of periodontology 2010; 14:263-265. https://doi.org/10.4103/0972124x.76935 50. vishakha grover, anoopkapoor and marya cm: amlodipine-induced gingival hyperplasia. journal of oral health and community dentistry 2007; 1:19-22. https://doi.org/10.5005/johcd-1-1-19 51. murat sucu, murat yucc and vedatdavutoglu: amlodipine-induced massive gingival hypertrophy. canadian family physician 2011; 57:436-437. 52. ellis js, seymour ra, steele jg, robertson p, butler tj and thomason jm: prevalence of gingival overgrowth induced by calcium channel blockers: a community-based study. journal of periodontology 1999; 70:63-67 https://doi.org/10.1902/jop.1999.70.1.63 53. pristant lm and herman w: calcium channel blocker induced gingival overgrowth. the journal of clinical hypertension 2002; 4:310-311 https://doi.org/10.1111/j.1524-6175.2002.01095.x 54. lucas rm, howell lp, wall ba: nifedipineinduced gingival hyperplasia. a histochemical and ultrastructural study.journal of periodontology 1985; 56:211-215. https://doi.org/10.1902/jop.1985.56.4.211 55. barclay s, thomason jm, idle jr, seymour ra: the incidence and severity of nifedipine induced gingival over growth. journal of clinical periodontology 1992; 19:311314. https://doi.org/10.1111/j.1600051x.1992.tb00650.x 56. duncan mr, berman b: stimulation of collagen and glycosaminoglycan production in cultured human adult dermal fibroblast by recombinant human interleukin-6. journal of investigative dermatology 1991; 97:686-689. https://doi.org/10.1111/1523-1747.ep12483971 57. gautam sp, rai jp, billshaiya u, jain n, vikram p, jain dk. formulation and evaluation of mouth dissolving tablet of loperamide. international journal of pharmaceutical sciences and research. 2013; 4(5):1782. 58. patel an, rai jp, jain dk, banweer ji. formulation, development and evaluation of cefaclor extended release matrix tablet. int j pharm pharm sci. 2012; 4(4):355-7. 59. torpet la, kragelund c, reibel j and nauntofte b: oral adverse drug reaction to cardiovascular drugs. critical reviews in oral biology and medicine 2004; 15:28-46. https://doi.org/10.1177/154411130401500104 60. katheryn p, traues md and james s. edema: diagnosis and management. american academy of family physicians 2013; 88:102110. 61. domenic a. sica: calcium channel-related peripheral oedema; can it be resolved? the journal of clinical hypertension 2003; 5:291-295. https://doi.org/10.1111/j.1524-6175.2003.02402.x 62. messerli fh and groossman e: pedal oedema-not all dihydropyridine calcium antagonist are created equal. american journal of hypertension 2002; 15:1019-1020. https://doi.org/10.1016/s08957061(02)03087-x 63. sirker a, missouris cg and macgregor g: dihydropyridine calcium channel blockers and peripheral side effects. jounal of human hypertension 2001; 15:745746. https://doi.org/10.1038/sj.jhh.1001248 64. rajeev kumar, ramji sharma, khemrajbairwa, ram kumar roy, arun kumar and atulbaruwa: modern development in ace inhibitors. der pharmacia lettre 2010; 2:388-419. 65. pandey sp, khan ma, dhote v, dhote k, jain dk. formulation development of sustained release matrix tablet containing metformin hydrochloride and study of various factors affecting dissolution rate. sch acad j pharm. 2019; 8(3):57-73. 66. jain p, nair s, jain n, jain dk, jain s. formulation and evaluation of solid dispersion of lomefloxacin hydrochloride. int j res pharm sci 2012; 3(4):604-608. 67. upendra kaul, aijaz mansoor and zia al sabbah: angiotensin receptor blockers-advantages of the new sartans. journal of the association of physicians of india 2013; 61:464470. 68. philip babatundeadebayol and olutayo christopher alebiosu: ace-i induced angioedema: a case report and review of literature 2009; 2: 7181. https://doi.org/10.4076/1757-1626-2-7181 69. sharabi y, illan r, kamari y, cohen h, nadler m, grossman e and messerli fh: diuretic induced hyponatraemia in elderly hypertensive women. journal of human hypertension 2002; 16:631-635. https://doi.org/10.1038/sj.jhh.1001458 70. domenic a. sica: diuretics related side effects: development and treatment. the journal of clinical hypertension 2004; 6:532-540. https://doi.org/10.1111/j.1524-6175.2004.03789.x 71. lawrence r. krakoff: diuretics for hypertension. american heart association 2005; 112:127-129. https://doi.org/10.1161/circulationaha.105.570192 72. patel ns, jain dk, nagar h, patel a, chandel hs. evaluation of analgesic and antipyretic activity of tridax procumbens leaves extract. rguhs j pharm sci. 2011; 1(3):226-31. https://doi.org/10.5530/rjps.2011.3.9 73. kyu sig hwang and gheun-ho kim: thiazide-induced hyponatremia. electrolyte blood press 2010; 8:51-57. https://doi.org/10.5049/ebp.2010.8.1.51 74. anil k. mandal, linda m. hiebert: is diuretic-induced hyperglycemia reversible and inconsequential? journal of diabetes research and clinical metabolism 2012; 1:1-4. https://doi.org/10.7243/2050-08661-4 75. padwal r, laupacis: a antihypertensive therapy and incidence ot type 2 diabetes. diabetes care 2004, 27:247255. https://doi.org/10.2337/diacare.27.1.247 76. halderman jh, elahi d, anderson dk, raizes gs, tobin jd, shocken d, andres r: prevention of glucose intolerance of thiazide diuretics by maintenance of body potassium. diabetes 1983, 32:106-111. https://doi.org/10.2337/diabetes.32.2.106 https://doi.org/10.1159/000246549 https://doi.org/10.1136/bmj.295.6609.1352-a https://doi.org/10.2165/00128071-200001030-00003 https://doi.org/10.2165/00128071-200001030-00003 https://doi.org/10.1093/ndt/gfg431 https://doi.org/10.1016/j.amjmed.2010.08.007 https://doi.org/10.1038/jhh.2013.47 https://doi.org/10.4103/0972-124x.76935 https://doi.org/10.4103/0972-124x.76935 https://doi.org/10.5005/johcd-1-1-19 https://doi.org/10.1902/jop.1999.70.1.63 https://doi.org/10.1111/j.1524-6175.2002.01095.x https://doi.org/10.1902/jop.1985.56.4.211 https://doi.org/10.1111/j.1600-051x.1992.tb00650.x https://doi.org/10.1111/j.1600-051x.1992.tb00650.x https://doi.org/10.1111/1523-1747.ep12483971 https://doi.org/10.1177/154411130401500104 https://doi.org/10.1111/j.1524-6175.2003.02402.x https://doi.org/10.1016/s0895-7061(02)03087-x https://doi.org/10.1016/s0895-7061(02)03087-x https://doi.org/10.1038/sj.jhh.1001248 https://doi.org/10.4076/1757-1626-2-7181 https://doi.org/10.1038/sj.jhh.1001458 https://doi.org/10.1111/j.1524-6175.2004.03789.x https://doi.org/10.1161/circulationaha.105.570192 https://doi.org/10.5530/rjps.2011.3.9 https://doi.org/10.5049/ebp.2010.8.1.51 https://doi.org/10.7243/2050-0866-1-4 https://doi.org/10.7243/2050-0866-1-4 https://doi.org/10.2337/diacare.27.1.247 https://doi.org/10.2337/diabetes.32.2.106 jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited iris ensata thunb: review on its chemistry, morphology, ethno medical uses, phytochemistry and pharmacological activities diksha jat1, niharika thakur2, deepak kumar jain3*, shilpi prasad4, rajni yadav5 1 oriental college of pharmacy, raisen rd, patel nagar, bhopal, mp, 462022 2 truba institute of pharmacy, karond bypass rd, gandhi nagar, bhopal, mp, 462038 3* sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 4 siddhi vinayaka institute of technology and sciences, mangla, bilaspur, cg, 495001 5 dept. of pharmacology, faculty of pharmacy, kalinga university, naya raipur, cg, 492101 article info: _________________________________________ article history: received 03 jan 2022 reviewed 21 feb 2022 accepted 04 march 2022 published 15 march 2022 _________________________________________ cite this article as: jat d, thakur n, jain dk, prasad s, yadav r, iris ensata thunb: review on its chemistry, morphology, ethno medical uses, phytochemistry and pharmacological activities, asian journal of dental and health sciences. 2022; 2(1):1-6 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.9 _________________________________________ *address for correspondence: deepak kumar jain, sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 abstract ___________________________________________________________________________________________________________________ medicinal plants are mainly used as herbal medicine and play an essential role in primary health care, ethno-medicine system and production of appropriate drugs. due to this multi-usage, trade network demand for the different medicinal species can extend to national as well as international boundaries. as only little studies are done on this plant, the purpose of current review is to make accessible up-todate information on, botany, morphology, ecological biodiversity, therapeutic uses, phytochemistry and pharmacological activities on diverse parts of iris ensata thunb. the plant iris ensata thunb belongs to the family iridaceae. it has been praised by the physicians of all times as a panacea and is broadly used in a huge number of disases. it heals up the chronic ulcers and absess, useful in insect bite, burns, vitiligo, weakness of muscles, itching and dandruff. it is emmenagogue, anti-inflammatory, anti orchitis, used in cold cough, in all humours, pneumonia, dyspnoea. the egesta accumulated in the chest are attenuated and resolved by irsa, it is emetic and purgative. ibne sina recommends its efficacious actions in strengthening the wisdom and intellect, cures head injuries skull bone fractures, phlegmic and hot swelling. ibne baitar quoted that it is useful in tooth ache, dyspnoea, spleenomegaly, rigidity of uterus, flatulence, it is abortifacient, anti tussive. the fermentation with sosan is benifecial in endometritis, adenitis and hard swelling. its efficacy in dyspnoea, asthma, thorasic pain, hydropes, jaundice, haemorrhoids, liver complaints, and sciatica. root of iris ensata thunb are reach source of glycosides steroids, resins, proteins, phenolic compounds and also tannins. flowers of this plant also contains anthocyanin 5-0-glucosyltransferase (r2) and anthocyanin-flavone e.g. malvidine 3kgac5g, petunidine 3kgac5c, delphinidine 3rgac5g, petunidine(r2) . the epigeal parts of this plant contain mangiferin(r) and leteolin c-glycosides. this review highlights the traditional, ethnobotanical, phytochemical, pharmacological information available on iris ensata, which might be helpful for scientists and researchers to find out new chemical entities responsible for its claimed traditional uses. keywords: iris ensata thunb, phytochemistry, pharmacological activity, ayurveda, medicinal uses email: jaindeepak2022@gmail.com mobile: 09424036795 introduction plant diversity is an important segment for biological diversity and is also useful for successful regulation of the ecosystem. plants are performing as important ingredients in nature and are used in multifold directions among the human beings1. from the ancient time, herbal medicines have been used for the welfare of mankind as medicines to cure the series of diseases. new drugs of plant derivation are crucial because they are cheap, have little side effects and in accordance with who, about 80% of the world population are still depends mainly on plant based drugs2,3. as of now, it is well established that medicinal plants serve as lead molecules in modern medicines and nutraceuticals because of their derived phytoconstituents4. iris l., commonly known as iris, are perennial plant growing from creeping rhizomes (rhizomatous irises) in temperate region (1000-3000 m altitude) or, they can also grow in drier climates, from bulbs (bulbous irises) belonging to the iridaceae a family placed under the order asparagales5. almost cosmopolitan in distribution, it is one of the most important and prized group of plants in horticulture and floriculture. plants of genus iris comprise over 3000 species in the world of which twelve species are reported in india6 but most commonly iris species found in india are iris croceae, iris ensata, iris germanica, iris hookerian, iris kumaonensis and iris kashmiriana specially found in himalayan regions. medicinal plants belongs to this genus has been named irsa in iranian traditional medicine. iris is a genus of variety of species of flowering plants with showy flowers. several cultures have used species of iridaceae as food, ornamental, condimental, or medicinal plants. the navajo, the largest native american tribe of north america used decoctions of iris missouriensis as an emetic7. pieces of the rhizome of the same species were used to relieve toothaches8 or earaches9.the mashed roots of iris versicolor were applied to wounds, presumably as an antiseptic10 and the infusions of dry roots of the same species were used to calm pain. sisyrinchium acre was used in hawaii in different ways. leaves or leaf-sap were open access review article doi: http://dx.doi.org/10.22270/ajdhs.v2i1.9 http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.9 mailto:jaindeepak2022@gmail.com http://dx.doi.org/10.22270/ajdhs.v2i1.9 jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [2] ajdhs.com used as a dye, to give the blue color to tattoos. the use of the leaves, macerated with salt, sugar and other spices was recommended to clean the skin and cure skin diseases11. iris ensata was used in india as anthelmintic and diuretic, and, mixed with other species, to treat venereal diseases12. therefore, in this study, the ethno pharmacological review of iris ensata was carried out aimed at providing a detailed précis of the botany, ethnomedicinal uses, pharmacological activities and chemical composition of the species. research methodology to recognize pertinent information on the botany, medicinal uses, phytochemistry and biological activities of c. latifolium, a review was compiled based on scientific literature from various sources including google scholar, web of science, scifinder, scopus, science direct, pubmed, scielo, springerlink, google patents, espacenet, biomed central (bmc) and medline. the keywords used for recognition of relevant data included dissimilar scientific name and synonyms, common english names and the terms: biological activities, medicinal uses, ethnobotany, ethnopharmacology, medicinal, pharmacology, phytochemistry and therapeutic value, c. latifolium, irsa, sosun, marjal, iris. further literatures were obtained from books, book chapters, theses, websites and conference proceedings. phytoconstituents and biological activities of iris plants the intensive phytochemical investigations of various species of iris have resulted in the isolation of variety of secondary metabolites. approximately more than three hundred compounds have been reported from the genus iris which flavonoids13, isoflavones (irigenin, nigricin, irisflorentin, iriskumaonin, irilon, iriflogenin, etc.) 14 and their glycosides; cglucosyl xanthones15, quinines16 , triterpenoids17, stilbene glycosides18. other groups of secondary metabolite recorded in the family are saponins, fructans, non-protein amino acids, sterols and bufadienolides. some individual metabolites are of economic importance. the sesquiterpene α -irone from iris florentina l. is valued for its characteristic scent of violets and is used in perfumery. the yellow carotenoid-like pigment crocein from styles of crocus sativus is employed as a food colorant. again, the isoflavones iridin is a major component of orris root, obtained from the rhizome of iris florentina, and still used in perfumery. here, attention will be mainly focused on the more recent survey of phenolic patterns in the family, which covered 255 species from 57 genera19. the rhizomes of irises also contain carbohydrates, fatty oil, organic acids, tannins and essential oil, which is used in perfumery and cosmetics20,21, while the leaves are a source of ascorbic acid and vitamins18. iris plants have immense medicinal importance and tremendous pharmacological potential and biological roles have been reported. the peeled and dried rhizomes of iris species, collectively known as rhizome iridis enjoyed popularity due to their emetic, cathartic, diuretic stimulant and expectorant properties22. the dried rhizomes of iris has been used in folk medicine of european countries as a diaphoretic for bronchitis, in dental practice-in order to accelerate teething in infants; as anti-inflammatory for the treatment of pancreatic and salivary glands and the vegetative neurosis23.the rhizomes of iris hookeriana exhibit significant anthelminthic activity against gastrointestinal nematodes of sheep. extracts of iris species in general possess strong total antioxidant, effective reducing power and exhibit free radical scavenging, metal chelating activities and inhibition of lipid peroxidation24. powder of roots of iris songarica, mixed with curd is used to cure diarrhea25.these species have been introduced as diuretic and expectorant at low doses and as a strong purgative and emetic in high doses. it has been reported that irsa is useful for pulmonary, asthma, liver and uterus diseases as well as hemorrhoid and gripe26. the iris essential oil has expectorant properties17, 21. the isoflavone rich dietary consumption is reported to reduce risk of cancer particularly breast and prostate cancer27, 28. the role of isoflavones in cancer27, 29, osteoporosis, cardiovascular diseases and menopausal symptoms in addition to their antioxidant30, antimicrobial31 [31], anti-inflammatory and estrogenic activities27, 32. iris ensata the plant iris ensata belongs to the family iridaceae. it is known by several names in the vernacular language, they are hindi irsa, sosun; kashmiri marjal, unarjal; urdu irsa; english -iris. japanese iris or japanese water iris is a rhizomatous beardless perennnial iris that grows in slowly expanding clumps to 2-4′ tall. rhizomes creeping, stout, prostrate. leaves ensiform, 25-70 cm long, straight, tough with prominent midrib, margins scarious, apex acuminate, base dark purple. aerial stem tufted, short, 20-100 cm high, stout or slender, bearing a single terminal or lateral head; spathes 3, unequal, lanceolate, 4-7.5 cm long, 1-3 flowered, veins distinct, raised; basal spathe shorter, apex usually acute; apical spathe longer, apex usually obtuse. flowers lilac or reddish purple; pedicel 1.5-3.5 cm long. falls and standards often with purplish veins, stalked. perianth tube absent or very short; blade of falls rhomboidly ovate, entire, shorter than the claw, molted yellow at centre; standards erect, oblanceolate. stamens about 3.5 cm long; anthers purple. ovary cylindric; style purple, 5cm long. capsule ellipsoid, 6ribbed, beaked. seeds reddish-brown, semi orbicular, flat33, 34. flowering period: may-july altitudinal range: 1600-2600 m chromosome number: 2n = 24 distribution: kashmir scientific classification kingdom: plantae (unranked): angiosperms (unranked): monocots order: asparagales family: iridaceae genus: iris subgenus: limniris species: iris ensata binomial name: iris ensata thunb synonyms: iris kaempferi siebold ex lem. figure 1 iris ensata http://www.popflock.com/learn?s=taxonomy_(biology) http://www.popflock.com/learn?s=monocots http://www.popflock.com/learn?s=binomial_nomenclature http://www.popflock.com/learn?s=synonym_(taxonomy) jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [3] ajdhs.com phytoconstituents and medicinal properties iris ensata (irsa) is the supreme one among its comrade drugs used in respiratory ailments. it has been praised by the physicians of all times as a panacea and is broadly used in a huge number of disases. dioscorides, cited by razi, it heals up the chronic ulcers and absess, useful in insect bite, burns, vitiligo, weakness of muscles, itching and dandruff. it is emmenagogue, anti-inflammatory, anti orchitis, used in cold cough, in all humours, pneumonia, dyspnoea. the egesta accumulated in the chest are attenuated and resolved by irsa, it is emetic and purgative. razi quotes galen (199 a.d.) in his book the container (alhawi) that it has emmenagogue, anti tussive, anti-epileptic, astringent, regenerative and anti pleuritic actions, it is useful in pneumonia, pneumothorax, eclampsia, palpitation, chill, liver pain and spermatorrhoes. ibn-e-masewaih describes the white sosan as hot phlegmic pains of nerves and uterus are cured, maseeh reported its efficacy in headache, the poultice for ulcers and wounds, vitiligo itch, baldness, nerve injuries and redness of skin35-37. ibne sina recommends its efficacious actions in strengthening the wisdom and intellect, cures head injuries skull bone fractures, phlegmic and hot swelling. ibne baitar quoted that it is useful in tooth ache, dyspnoea, spleenomegaly, rigidity of uterus, flatulence, it is abortifacient, anti tussive. the fermentation with sosan is benifecial in endometritis, adenitis and hard swelling. antaki (1597 a.d.) states its efficacy in dyspnoea, asthma, thorasic pain, hydropes, jaundice, haemorrhoids, liver complaints, and sciatica. its clyster is employed in all aforesaid disorders. dymock (1890) reported that a century back it is used in asthma, cough, fever, dyspnoea and skin diseases38. root of iris ensata thunb are reach source of glycosides steroids, resins, proteins, phenolic compounds and also tannins. flowers of this plant also contains anthocyanin 5-0-glucosyltransferase (r2) and anthocyaninflavone e.g. malvidine 3kgac5g, petunidine 3kgac5c, delphinidine 3rgac5g, petunidine(r2) . the epigeal parts of this plant contain mangiferin(r) and leteolin c-glycosides39. reported activity of iris ensata yabuya et al., (2001): reported malvidin and petunidin 3-(pcoumaroyl)rhamnosyl glucoside-5-glucosides as well as nonacylated 3-rhamnosylglucoside-5-glucoside of these anthocyanidins were detected as major anthocyanins in cyanic flowers of iris ensata. enzyme extracts from flower buds of this plant catalyzed the transfer of the p-coumaroyl moiety from p-coumaroyl-coa to both the anthocyanidin 3rhamnosylglucoside and 3-rhamnosylglucoside-5-glucoside to form the anthocyanidin 3-(p-coumaroyl) rhamnosylglucoside and 3-(p-coumaroyl) rhamnosylglucoside-5-glucoside, at a ratio of ca. 1 to 4, respectively. the activities of this enzyme were also examined for various cyanic and acyanic cultivars, in addition to the characterization of the pcoumaroyltransferase. the sequence of acylation and 5glucosylation in the anthocyanin biosynthesis of this plant is discussed40. yabuya et al., (2002): characterized anthocyanin 5-oglucosyltransferase in flowers of iris ensata containing malvidin and petunidin 3-(pcoumaroyl)rhamnosylglucoside5-glucosides as well as nonacylated 3-rhamnosylglucoside-5glucoside of these anthocyanidins as major anthocyanins. enzyme extracts from flower buds catalyzed the transfer of the glucosyl moiety from udp-glucose to the 5position of anthocyanidin 3-rhamnosylglucoside to form the anthocyanidin 3-rhamnosylglucoside-5-glucoside, but not to the anthocyanidin 3-glucoside and 3-(pcoumaroyl)rhamnosylglucoside. in addition to the characterization of the 5-o-glucosyltransferase, the activities of this enzyme were also examined for various cyanic and acyanic cultivars. the sequence of 5-o-glucosylation and pcoumaroylation in the anthocyanin biosynthesis in this plant is discussed in detail41. boltenkov and zarembo (2005); tested the differentiation and morphogenetic capacity of floral organs of iris ensata, i. setosa, and i. sanguinea cultured in vitro. organogenesis through direct formation of shoots from explants, callogenesis, and floral organogenesis were demonstrated in i. ensata callus culture in vitro. these processes depended on the plant species and on the content of phytohormones in the medium. adventitious shoots proved to develop on the basal part of the perianth tube and on the apical part of the ovary, while roots were not formed. direct organogenesis was induced by the following phytohormones: α-naphthylacetic acid and 6benzylaminopurine for i. ensata and 2,4dichlorophenoxyacetic acid and 6-benzylaminopurine for i. setosa and i. sanguinea; while callogenesis was induced by 2,4dichlorophenoxyacetic acid. the obtained data indicate that development of adventitious structures from iris floral organs requires the presence of 6-benzylaminopurine in the growth medium42. inoue et al., (2006): characteristics such as flower form, size and color of outer and inner perianths, anthocyanins in outer perianths, size, color and fertility of pollen and self-fertility of diploid and tetraploid lines regenerated via protoplast culture of iris fulva were examined and compared with those of the diploid wild line. among these characteristics, flower forms, inner and outer perianth sizes of the tetraploid lines were noticeable, because these lines had upward flower forms and bigger flowers than diploid lines. furthermore, reciprocal crosses between diploid or tetraploid lines of i. fulva and i. ensata and those of i. fulva and i. laevigata were performed. three seedlings were obtained from the cross of tetraploid i. fulva diploid i. laevigata through embryo rescue. one of them was identified as the interspecific hybrid between tetraploid i. fulva and i. laevigata by flow cytometoric (fcm), cytological and molecular (rapd) analyses. this is the first report on production of hybrids from these lines. i. fulva has unique brown flowers, and this trait could be very useful for flower color breeding of i. laevigata which lacks this color. therefore, the hybrid of i. fulva (4) i. laevigata may be the best available gene source for brown color breeding of this species43. yan et al., (2010): reported severe mosaic disease was observed on iris ensata thunb. in spring 2008, in hangzhou, china and it was found to be widely distributed in that region. detection of viruses by electron microscopy resulted in the occurrence of a potyvirus in most symptomatic seedlings. sequencing 1745 nucleotides of the 3 -terminal region of the genome of the typical viral isolate revealed that it was a new isolate of iris severe mosaic potyvirus (ismv), tentatively named ismv-phz .this strain shared high nucleotide identity with ismv. phylogenetic analysis also showed that this isolate clustered with iris severe mosaic potyvirus (ismv) and onion yellow dwarf virus (oydv) into a monophyletic group, and was closest in similarity to ismv. the divergence of potyvirusinfecting iris species had a higher degree of relevance with natural host but not with the region from which it was isolated. this is the first report of ismv isolated from i. ensata in china44. ahmad et al., (2012): reported the extracts of dried root of iris ensata thunb were screened for their effects on hypoglycmic and antihyperglycemic activities in normal rabbits and stz induced diabetic rabbits. the plant root extracts exhibited antihyperglycaemic effect in glucose loaded rabbits. oral admisntration of iris ensata root for 21 days significantly reduced blood glucose level in stz induced diabetic rabbits and in normal rabbits. the study reveals for jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [4] ajdhs.com the first time the antihyperglycemic and hypoglycemic activities of iris ensata root on rabbits45. wani et al., (2012): reports the antibacterial activity of different extracts of five different iris plant species growing in kashmir himalayas. water, methanol and hexane extracts of the rhizome of iris croceae, iris ensata, iris germanica, iris hookeriana and iris kashmiriana were prepared and screened for phytochemical studies and antibacterial activities against five bacterial strains including both gram positive and gram negative. the different extracts of these species showed broad spectrum antibacterial activity with methanol extract showing highest zone of inhibition followed by hexane and aqueous extracts. the phytochemical analysis of the different extracts of these five species revealed the presence of flavonoids, isoflavonoids, glycosides and tannins, while as alkaloids were absent in these plant species46. xiao et al., (2012): reported microsatellite primers were developed in iris ensata (iridaceae) to provide polymorphic markers for further studies into population genetics. thirteen polymorphic microsatellite loci were isolated from i. ensata. these loci were successfully amplified in two natural populations of i. ensata from eastern china (longwangshan, zhejiang province) and northeastern china (jinchuan, jilin province). there was no significant linkage disequilibrium found for any pair of loci. these loci contained between two and 12 alleles per locus across all 48 individuals of i. ensata. the number of alleles per locus varied from two to 10 at the population level and the observed and expected heterozygosities ranged from 0.167 to 0.958 and from 0.284 to 0.853, respectively. these loci showed high levels of polymorphism and could be used to study the population genetic structure, genetic relationships, and phylogeography of i. ensata47. kitahara et al., (2014): reported six anthocyanins were isolated from the flowers of the nagai line of iris ensata thunb. they were identified as petunidin and malvidin 3-obeta-[(4"'-z-p-coumaroyl-alpha-rhamnopyranosyl)-(1-->6) beta-glucopyranoside]-5-o-beta-glucopyranosides (1 and 3) and their e-forms (2 and 4), and petunidin and malvidin 3-orutinoside-5-o-glucosides (5 and 6). though the e-form of petunidin 3-o[(4"'-p-coumaroylrhamnosyl)-(1-->6)glucoside]-5-o-glucoside has been reported, its z-form was found for the first time. the presence of zand e-forms of malvidin 3-o-[(4'''-p-coumaroylrhamnosyl)(1-->6)glucoside]-5-o-glucoside is also reported for the first time. fifty-one cultivars of nagai line and their wild form (i. ensata var. spontanea) were divided into four anthocyanin patterns, i.e. 1) the presence of 1-4, 2) the presence of 2 and 4, 3) the presence of 5 and 6, and 4) no anthocyanin48. haleem et al., (2015): study was designed to standardize herbal drug-irsa. irsa (iris ensata) belong to the family iridaceae, its root is used in respiratory diseases such as asthma, cough, diphtheria and pneumonia. an effort has been made to carry out the physicochemical and phytochemical studies of plant. i. ensata was standardized on physicochemical parameters as extractive values: pet. ether (2.9%), di-ethyl ether (4.58%), chloroform (2.20%), acetone (3.54%), alcoholic (10.03%), aqueous (14.13%); solubility: water (9.44 %) & alcohol (1.16 %); moisture contents (3.45 %), total ash values (6.93%), ph of 1% (6.76) & 10% solution (6.16) and loss on drying (5.3%). phytochemical analysis revealed the presence of almost all the phyto-constituents in the test drug sample i.e. alkaloid, flavonoids, glycoside, carbohydrate, tannin, protein, amino acids, starch and resins38. mirza et al., (2015): reported to conduct a clinical trial for cervicitis management with irsa. irsa was given in the form of majoon, 10 gm in two divided doses after menses for 15 days for three cycles. extract of irsa (10ml) was prepared and used locally in the form of humool (pessary) od after menses for 15 days for three cycles. all the patients were assessed by subjective parameters and per speculum examination once in fifteen days for three cycles. low backache was relieved in 16 (53.3%) patients, lower abdominal pain was relieved in 21 (72.4%) patients and dyspareunia was relieved in 12 (85.7%). after the completion of the treatment 9 (100%) patients had shown improvement in abnormal vaginal odour. relief in pruritis vulvae was observed in 20 (80%) patients. dysuria was relieved in 19 (86.4%) patients. all the patients i.e. 30 (100%) complained of vaginal discharges. after the completion of treatment 13 (43.3%) recovered completely and on per speculum examination 30 (100%) patients had cervical discharge at the beginning of trial. after the completion of treatment 15 (50%) had shown improvement. cervical swab culture was positive in 5 (16.7%) patients at the beginning of trial. after the completion of treatment 4 (80%) patients had shown improvement. the study revealed that the test drug is effective. so, the trial drug can be recommended to manage it49. kim et al., (2016): this study was aimed to evaluate the in vitro effects of medicinal herb extracts (mhes) on ruminal fermentation characteristics and the inhibition of protozoa to reduce methane production in the rumen. a fistulated hanwoo was used as a donor of rumen fluid. the mhes (t1, veratrum patulum; t2, iris ensata var. spontanea; t3, arisaema ringens; t4, carduus crispus; t5, pueraria thunbergiana) were added to the in vitro fermentation bottles containing the rumen fluid and medium. total volatile fatty acid (tvfa), total gas production, gas profiles, and the ruminal microbe communities were measured. the tvfa concentration was increased or decreased as compared to the control, and there was a significant (p≤0.05) difference after 24 h incubation. ph and ruminal disappearance of dry matter did not show significant difference. as the in vitro ruminal fermentation progressed, total gas production in added mhes was increased, while the methane production was decreased compared to the control. in particular, arisaema ringens extract led to decrease methane production by more than 43%. in addition, the result of real-time polymerase chain reaction indicted that the protozoa population in all added mhes decreased more than that of the control. in conclusion, the results of this study indicated that mhes could have properties that decrease ruminal methanogenesis by inhibiting protozoa species and might be promising feed additives for ruminants50. guoa and wilson (2018): investigated before anthesis, older floral organs enclose younger ones forming a bud, within which the shape and relative size of floral organs are largely determined. the floral diversity in iris, including sepal ornamentation, limited development of petals or sepals in some species and presence of petaloid style branches in all but one species, provides a unique opportunity to compare organ development within the confined space of a bud. using transverse serial sections, light microscopy and measurement software, we investigated floral packing geometry (relative size and spacial relationships of floral organs) in seven species focusing on five species where we studied changes across three developmental stages. in this study, we found that floral packing geometries are diverse even among species with similar floral organ morphologies. the “filling law” proposed for vegetative buds is not applicable during floral bud development with empty space increasing as bud size increased for each of the five species that were examined. other key findings include the presence of space between anther thecae in some species, the enlargement of sepal outgrowths and petal margins into space between thecae, differences in the relative growth of anthers versus petaloid jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [5] ajdhs.com style branches and the curvature of connectives, petals and style branches in some species. this study clarifies the integration of floral bud growth and illustrates a largely ignored yet important aspect of flower development: coordinated growth of floral organs within the bud51. uniyal et al., (2018): reported in this study, t. asahii was procured from mtcc and its sensitivity was checked against different solvents (methanol, ethanol, acetone, and chloroform) of iris ensata, a medicinal plant. zone of inhibition and mic were evaluated using agar well diffusion assay and tube dilution broth assay. ketoconazole and nystatin b were used as positive controls. phytochemical screening was done to determine the phytochemicals present in the plant. the methanol extract was found to be most effective compared to other solvent extracts and positive controls. phytochemicals play a major role in this anti trichosporon activity52. luo et al., (2018): reported in 2016, a severe leaf spot disease was found on iris ensata thumb. in nanjing, china. the symptom was elliptical, fusiform, or irregularly necrotic lesion surrounded by a yellow halo, from which a small-spored alternaria species was isolated. the fungus was identified as alternaria iridiaustralis based on morphological characteristics. the pathogenicity tests revealed that the fungus was the causal pathogen of the disease. phylogenic analyses using sequences of its, gpd, endopg, and rpb2 genes confirmed the morphological identification. this study is the first report of a. iridiaustralis causing leaf spots on i. ensata in china53. conclusions the iris species (iridaceae) have long been utilized to treat several diseases around the globe. interestingly, different species have been used in treating the same disease. as highlighted in the present review, the immense medicinal value of the indian iris ensata is a signal of their remarkable potential globally. the plant iris ensata has rich potential to treat many disorders among human society. it has multiple ethno medicinal uses as reported by many researchers. scientific reports on its enormous phyto constituents and pharmacological application of iris ensata showing its wide range of ethno medicinal uses. based on the above utility and valuation to treat certain disorders this plant should not be overexploited, much spread for maintaining their existence for coming future. references 1. patel dk. crinum asiaticum linn: a medicinal herb as well as ornamental plant in central india. int j environ sci nat res. 2017; 6(1):555678. https://doi.org/10.19080/ijesnr.2017.06.555678 2. tambe da, chaudhari tb, chaudhari s. analgesic activity of caralluma adscendens roxb. (aerial parts). int j pharm res dev. 2010; 7:10-4. 3. alves rr, rosa il. why study the use of animal products in traditional medicines. j ethnobiol ethnomed. 2005; 1:5. https://doi.org/10.1186/1746-4269-1-5 4. ncube ns, afolayan aj, okoh ai. assessment techniques of antimicrobial properties of natural compounds of plant origin: current methods and future trends. afr j biotech. 2008; 7(12):1797-806. https://doi.org/10.5897/ajb07.613 5. stevens pf. angiosperm phylogeny website. 2001. http://www.mobot.org/mobot/research/apweb/ 6. bhattacharjee sk. handbook of medicinal plants. 1998; 1921919245. 7. vestal b, paul a. the ethno botany of the ramah navaho. papers of the peabody museum of american archaeology and ethnology.1952; 40(4):1-94. 8. nickerson gs. some data on plains and great basin indian uses of certain. native plants. tebiwa.1966; 9(1):45-51. 9. train a, percy b, henrichs jr, archer wa. medicinal uses of plants medicinal by indian tribes of nevadawashington dc. u.s. department of agriculture. 1941; 89-90. https://doi.org/10.5962/bhl.title.82312 10. raymond a, marcel t. notes ethno botaniques sur les tetedeboule de manouan. contributions de l' institut botaniquel' universite de montreal. 1945; 55:113-134. 11. speck fg, hassrick rb, carpenter es. rappahannock herbals, folklore and science of cures. proceedings of the delaware county institute of sci.1942; 10:7-55. 12. chopra rn, nayar sl, chopra ic. glossary of indian medicinal plants (including the supplement). council of scientific and industrial research, new delhi. 1996. 13. tsukasa t, ootani s. flavonoids of the genus iris; structures, distribution and function: review. ann tsukuba bot gard. 1998; 17: 147-183. 14. wang h, cui y, zhao c. flavonoids of the genus iris (iridaceae). mini rev med chem. 2010; 10(7): 643-661. https://doi.org/10.2174/138955710791384027 15. kukula-koch w, sieniawska e, widelski j, urjin o, głowniak p, skalickawozniak k. major secondary metabolites of iris spp. phytochem rev. 2013; 12(4): 1-32. https://doi.org/10.1007/s11101-013-9333-1 16. rahman au, choudhary mi, alam mn, ndognii po, badarchiin t, purevsuren g. two new quinones from iris bungei. chem pharm bull (tokyo). 2000; 48(5):738-739. https://doi.org/10.1248/cpb.48.738 17. kovalev vn, mikhailenko oa, vinogradov ba. aromatic compounds and terpenoids of iris hungarica. chem nat comp. 2014; 50:161162. https://doi.org/10.1007/s10600-014-0900-5 18. khare cp. indian medicinal plants. berlin, heidelberg: springerverlag; 2007. 836. https://doi.org/10.1007/978-0-387-70638-2 19. williams ca, harborne jb, colasante m. flavonoid and xanthone pattems in bearded. iris species and the pathway of chemical evolumeution in the genus. biochem syst ecol. 1997; 25:309-325. https://doi.org/10.1016/s0305-1978(97)00008-2 20. roger b, jeannot v, fernandez x, cerantola s, chahboun j. characterisation and quantification of flavonoids in iris germanica l. and iris pallida lam. resinoids from morocco. phytochem anal. 2012; 23(5):450-455. https://doi.org/10.1002/pca.1379 21. lawless j. the illustrated encyclopedia of essential oils. publ. element books ltd., reissue edition; 1995. 256. 22. steinegger e, hansel r. lehrbuch der pharmacognosy and phytopharmazie. 4th edition new york: springer verlag: 252. 1988. https://doi.org/10.1007/978-3-662-08318-5 23. adams m, berset c, kessler h. medicinal herbs for the treatment of rheumatic disorders -a survey of european herbals from the 16th and 17th century j ethnopharmacol. 2009; 121:343-359. https://doi.org/10.1016/j.jep.2008.11.010 24. nadaroglu h, demir y, demir n. antioxidant and radical scavenging properties of iris germanica. pharma chem. 2003; 41:409-415. https://doi.org/10.1007/s11094-007-0089-z 25. ali s, mathew b. iridaceae no. 202. in si ali, m qaiser editor flora of pakistan. karachi & st. louis: department of botany university of karachi and missouri botanical press: 2000; 2005-2012. 26. mirheidar mm, tehran ag. daftar nashar farhang-e-islami. 1996; 6:326-32. 27. agarwal vk, thappa rk, agarwal sg, dhar kl. phytochem. 1984; 23:1342-1343. https://doi.org/10.1016/s0031-9422(00)80460-4 28. jang ds, cuended m, parolus ad, kardon lbs, kawanishi k, farnsworth nr. potential cancer chemopreventive constituents of the leaves of macaranga triloba. phytochem. 2004; 65:345-350. https://doi.org/10.1016/j.phytochem.2003.10.026 https://doi.org/10.19080/ijesnr.2017.06.555678 https://doi.org/10.1186/1746-4269-1-5 https://doi.org/10.5897/ajb07.613 https://doi.org/10.5962/bhl.title.82312 https://doi.org/10.2174/138955710791384027 https://doi.org/10.1007/s11101-013-9333-1 https://doi.org/10.1248/cpb.48.738 https://doi.org/10.1007/s10600-014-0900-5 https://doi.org/10.1007/978-0-387-70638-2 https://doi.org/10.1016/s0305-1978(97)00008-2 https://doi.org/10.1002/pca.1379 https://doi.org/10.1007/978-3-662-08318-5 https://doi.org/10.1016/j.jep.2008.11.010 https://doi.org/10.1007/s11094-007-0089-z https://doi.org/10.1016/s0031-9422(00)80460-4 https://doi.org/10.1016/j.phytochem.2003.10.026 jat et al asian journal of dental and health sciences. 2022; 2(1):1-6 [6] ajdhs.com 29. ososki al, kennelly ej. phytoestrogens: a review of present state of research. phytother res. 2003; 17:845-869. https://doi.org/10.1002/ptr.1364 30. pietrzak bl, hendrich ab, zugaj j, michalak k. metabolic odemethylation does not alter the influence of isoflavones on the biophysical properties of membranes and mrp1-like protein transport activity. arch biochem biophys. 2005; 433:428-434. https://doi.org/10.1016/j.abb.2004.10.004 31. wollenweber e, stevens jf, klimo k, knauft j, frank n, gerhauser c. cancer chemopreventive in vitro activities of isoflavones isolated from iris germanica. planta med. 2003; 69:15-20. https://doi.org/10.1055/s-2003-37030 32. piette pg. flavonoids as antioxidants. j nat prod. 2000; 63:10351042. https://doi.org/10.1021/np9904509 33. akhter c, khuroo aa, malik ah, dar gh. a taxonomic appraisal of genus iris l. (iridaceae) in kashmir himalaya, india. iran j bot.2013; 19(1):116-123. 34. kirtikar kr, basu b.d. indian medical plant with illustration. second edition 2001; 9:3398. 35. kiritikar kr, basu bd. indian medicinal plants. international book distributers (dehradun) vo. i: 1996; 2460-2461. 36. najmul g. khazainul advia. published by idara kitabul shifa, new delhi: 2001; 305-306. 37. baitar i. al-jamiul-mufridat-ul-advia-wa-ulaghzia. urdu translation. part.i. ccrum (new delhi): 1999; 177-179. 38. haleem a, latif a, rauf a, siddiqui n, rehman s. physicochemical and phytochemical standardization of irsa (iris ensata thunb.). int j res develop pharm life sci. 2015; 4(3):1498-1505. 39. www.ibismedical.com/503-523,1972. 40. yabuya t, yamaguchi m, fukui y, katoh k, imayama t, ino i. characterization of anthocyanin p-coumaroyltransferase in flowers of iris ensata. plant sci. 2001; 160:499-503. https://doi.org/10.1016/s0168-9452(00)00417-9 41. yabuya t, yamaguchi m, imayama t, katoh k, ino i. anthocyanin 5o-glucosyltransferase in flowers of iris ensata. plant sci. 2002; 162:779-784. https://doi.org/10.1016/s0168-9452(02)00021-3 42. boltenkov ev, zarembo ev. in vitro regeneration and callogenesis in tissue culture of floral organs of the genus iris (iridaceae). biol bull. 2005; 32(2):138-142. https://doi.org/10.1007/s10525-0050020-7 43. inoue k, kato t, nobukuni a, kunitake h, yabuya t. characterization of tetraploid plants regenerated via protoplast culture of iris fulva and their crossability with japanese irises. sci horticul. 2006; 110:334-339. https://doi.org/10.1016/j.scienta.2006.07.025 44. yan s, qin z, jin l, chen j. a new isolate of iris severe mosaic virus causing yellow mosaic in iris ensata thunb. j nanosci nanotechnol. 2010; 10:726-730. https://doi.org/10.1166/jnn.2010.1901 45. ahmad w, suresh dk, khan m, khalid s. effect of aqueous extract of iris ensata thunb root on normal and streptozotocin induced diabetic rabbits. adv pharmacol toxicol. 2012; 13(2):19-25. 46. wani sh, amin a, rather ma, parray ja, parvaiz q, qadri ra. antibacterial and phytochemical screening of different extracts of five iris species growing in kashmir. j pharm res. 2012; 5(6):3376-3378. 47. xiao y, hu y, liu h, chen x. isolation and characterization of polymorphic microsatellites in iris ensata (iridaceae) american j bot. 2012; e498-e500. https://doi.org/10.3732/ajb.1200266 48. kitahara k, murai y, bang sw, kitajima j, iwashina t, kaneko y. anthocyanins from the flowers of nagai line of japanese garden iris (iris ensata). nat prod commun. 2014; 9(2):201-4. https://doi.org/10.1177/1934578x1400900216 49. mirza s, naaz sa, alim sm, rahman a. analgesic, anti-inflammatory and anti-microbial activities of irsa(iris ensata): a clinical study on the patients of iltehabe unqur-rehm (cervicitis). int j pharm pharma res. 2015; 3(4):66-72. 50. kim et, hwang sh, lee sm, lee sj, lee d, lee sk, et al., effects of medicinal herb extracts on in vitro ruminal methanogenesis, microbe diversity and fermentation system. asian australas. j anim sci. 2016; 29(9):1280-1286. https://doi.org/10.5713/ajas.16.0053 51. guoa j, wilson ca. organization, available space and organ morphology within floral buds of iris (iridaceae). flora. 2018; 249:67-76. https://doi.org/10.1016/j.flora.2018.10.001 52. uniyal v, bhatt rp, saxena s. antifungal activity of iris ensata against trichosporon asahii causing invasive trichosporonosis. int j life sci scienti res.2018; 4(2):1644-1648. https://doi.org/10.21276/ijlssr.2018.4.2.4 53. luo h, tao yq, fan wy, oh sk, lu hx, deng jx. identification and characterization of alternaria iridiaustralis causing leaf spot on iris ensata in china. mycobiol. 2018; 46(2):168-171. https://doi.org/10.1080/12298093.2018.1454007 https://doi.org/10.1002/ptr.1364 https://doi.org/10.1016/j.abb.2004.10.004 https://doi.org/10.1055/s-2003-37030 https://doi.org/10.1021/np9904509 https://doi.org/10.1016/s0168-9452(00)00417-9 https://doi.org/10.1016/s0168-9452(02)00021-3 https://doi.org/10.1007/s10525-005-0020-7 https://doi.org/10.1007/s10525-005-0020-7 https://doi.org/10.1016/j.scienta.2006.07.025 https://doi.org/10.1166/jnn.2010.1901 https://doi.org/10.3732/ajb.1200266 https://doi.org/10.1177/1934578x1400900216 https://doi.org/10.5713/ajas.16.0053 https://doi.org/10.1016/j.flora.2018.10.001 https://doi.org/10.21276/ijlssr.2018.4.2.4 https://doi.org/10.1080/12298093.2018.1454007 akinpelu et al asian journal of dental and health sciences. 2023; 3(2):18-22 [18] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited histopathological and biochemical effect of vitamin c and d on phosphine-induced hepatotoxicity in wistar rats moronkeji akinpelu1, solomon matthias gamade2 , frederick akinbo3, temidayo daniel adeniyi1, adebowale funmilola elizebeth4 and emmanuel ifeanyi obeagu5 * 1 department of medical laboratory science, faculty of allied health sciences, university of medical sciences, ondo state, nigeria 2 department of medical laboratory science, faculty of allied health sciences, bingham university karu, nasarawa state, nigeria 3 department of medical laboratory science, faculty of basic medical sciences, university of benin, edo state, nigeria 4 department of medical laboratory science, achievers university owo, ondo state, nigeria 5 department of medical laboratory science, kampala international university, uganda article info: _______________________________________ article history: received 02 april 2022 reviewed 08 may 2023 accepted 27 may 2023 published 15 june 2023 _______________________________________ cite this article as: akinpelu m gamade sm, akinbo f, adeniyi td, elizebeth af, obeagu ei, histopathological and biochemical effect of vitamin c and d on phosphine-induced hepatotoxicity in wistar rats, asian journal of dental and health sciences. 2023; 3(2):18-22 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.40 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda email: emmanuelobeagu@yahoo.com abstract ___________________________________________________________________________________________________________________ background: aluminum phosphide is becoming a very common agent for self-poisoning. the lack of specific antidote for phosphide poisoning has aroused the current interest of research. objectives: this study aimed to investigate the possible protective effect of vitamin c and d in phosphine-induced hepatotoxicity in wistar rats. methods: in this experimental study, 20 wistar rats were randomly divided into five groups ( n = 12). group i was apparently normal control group. groups ii-v were induced with 2.5 mg/kg alp. groups ii was without further treatment while groups iii-iv received vitamin c at 100mg/kg/bw and vitamin d at 10mg/kg/bw. group v was coadministered with vitamin c at 100mg/kg/bw and vitamin at 10mg/kg/bw. the treatments lasted for 28 days. results: the results showed that vitamin c and d (p<0.05) increased antioxidant capacity. combined active constituents of the vitamin c and vitamin d raised the gpx antioxidant activities when compared to the phosphine poisoned group treated individually with vitamin c and d. the combined activities of vitamin c and vitamin d showed the highest antioxidant effect as compared with the control conclusion: the combined activities of vitamin c and d supplementation improved the antioxidant defense system and histology of the liver in phosphine poisoning. keywords: metal phosphide, carotene, liver cell damage, poison introduction the agricultural revolution and the growing use of pesticides in improving agricultural produce have brought their share of downsides in the form of pesticide poisoning1. about 300,000 deaths worldwide occur annually as a result of pesticide poisoning2,3. additionally, self-intoxication accounts for more than 33% of suicides worldwide4. aluminum phosphide (alp) is the most common pesticides used for the safe storage and transportation of grains especially in asian, middle eastern, and african countries5,6. unfortunately, considering several health outcomes, it is becoming a very common agent for selfpoisoning7,8,9. in nigeria, alp is sold in the form of a tablet, granules, or powder as phostoxin, justoxin, cejphos, multiphos, force toxin. when it is, metal phosphides generate toxic phosphine gas when ingested or inhaled by humans as a result of the stomach's diluted acid content, causing multisystem toxicity10,11. the easy availability of alp and it growing use for both agricultural and non-agricultural purposes is a public concern due to increasing number of suicide cases12. vitamin d is essential for a wide range of non-classical functions and its deficiency has been linked to several chronic disorders including diabetes and cardiovascular disease13. it has been reported to inhibit iron-dependent lipid peroxidation and its antioxidant properties are compared to that of the anticancer medication tamoxifen14. vitamin d uptake has shown to prevent destruction of hepatocytes secondary to phosphine-induced lipid peroxidation15. although there no available report, some experimental studies suggested that vitamin c and carotene could ameliorate the effects of oxidative phosphine16, 17. the lack of specific antidote for aluminum phosphide poisoning has aroused our interest. this study aimed to investigate the possible protective effect of vitamin c and d in phosphine-induced hepatotoxicity in male wistar rats. methodology the study was approved by the biomedical research and ethics committee of the ministry of agriculture and forestry, akure, ondo state, nigeria (mnr/v384/9). the experimental animals were handled following the international humane open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.40 mailto:emmanuelobeagu@yahoo.com https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.40&amp;domain=pdf https://orcid.org/0000-0002-7631-8782 https://orcid.org/0000-0002-4538-0161 akinpelu et al asian journal of dental and health sciences. 2023; 3(2):18-22 [19] ajdhs.com animal care standards18. twenty (20) inbred wistar rats weighing 180±20g were used and maintained under the standard husbandry condition (between 22-25°c, 12 hours light and 12 hours dark) in the animal house. animals were fed ad libitum. chemicals and reagents superoxide peroxide and glutathione peroxide reagents were purchased from the r and d system in minneapolis, minnesota, in the united states. commercial enzyme-linked immunosorbent test (elisa) kits for tumour necrosis factoralpha (tnf-α) and interleukin 6 (il-6) were purchased from creative diagnostics in shirley, new york, 11967, usa. from stock chemicals of analytical grade, haematoxylin and eosin (h&e), pbs solution, and 10 percent neutral buffer formalin were prepared. drugs aluminum phosphide (arysta life science south africa pty ltd) was purchased in lagos nigeria. partan-c vitamin c tablet manufactured by kunimed pharmachem limited, lagos nigeria, and health aid vitamin d 1000iu produced by health aid plus limited, nigeria. experimental design twenty (20) adult male wistar rats obtained from the animal holding of the department of anatomical sciences, university of medical sciences, ondo state were randomly allotted into five groups consisting of four rats each. each of the test groups was exposed to aluminum phosphide at a standard dosage of 2.5 mg/kg/body weight. group i was the apparently normal control group group ii was induced with 2.5 mg/kg alp without further treatment group iii was the alp-exposed group administered with vitamin c at 100mg/kg/bw group iv was the alp-exposed group administered with vitamin d at 10mg/kg/bw group v was the alp-exposed group co-administered with vitamin c at 100mg/kg/bw and vitamin at 10mg/kg/bw respectively. the treatments lasted for 28 days. induction of hepatotoxicity two and a half percent solution of the alp was prepared and used to induce phosphine toxicity via an orogastric tube. necropsy upon completion of the experiment, the wistar rats were euthanized and the liver of the rats was carefully excised and immediately transferred in 10% neutral buffered formalin for adequate fixation followed by histological processing for microscopic studies while the liver samples for biochemical analysis were rinsed in freshly prepared 0.1 mol/l phosphatebuffered saline (pbs, ph 8.0), followed by homogenisation and centrifuged at 3000 revolutions per minute for 20 min at 4°c. the supernatant obtained was preserved at -80°c for the estimation of biochemical analytes. histopathological study upon completion of fixation in 10% neutral buffered formalin. the liver was processed for light microscopic study using an automatic tissue processor machine (thermo scientific spin tissue processor, stp120, frankfurt, germany). the tissues were dehydrated in graded alcohol concentrations, cleared in two changes of xylene, infiltrated in two changes of wax bath, and lastly embedded in paraffin wax. olympus binocular light research microscope was used to histologically assess the thin sections of 4 microns stained with haematoxylin and eosin (h&e). micrographs were taken with a kodak digital camera (kodak easyshare c183). biochemical analysis the activity of superoxide dismutase (sod) was determined by the method of misra et al19. while glutathione (gpx) activity was assayed according to rahman et al20. levels of interleukin-6 (il-6) and tumour necrosis factor-alpha (tnfα) were evaluated using sandwich elisa kit protocols described by the manufacturer. statistical analysis the data were analysed using statistical software for social sciences (spss) 23.0 version. data were presented using mean standard deviation (mean sd) for all quantitative values, and one-way analysis of variance (anova) was used for comparisons between the groups. quantitative values of p<0.05 were considered statistically significant. results biochemical findings table 1 showed the immunomodulatory effect of vitamin c and d on il-6 and tnf-α. regarding the gpx and sod activities, il-6 and tnf-α levels were significantly (p<0.00001) reduced compared to the control group. however, combined active constituents of alp+vit.c &vit d raised the gpx antioxidant activities when compared to the phosphine poisoned group treated individually with vitamin c and d. combined activities of vit.c &vit d showed the highest antioxidant effect as compared with the control (table 1). table 1: immunomodulatory effect of il-6 and tnf-α parameter normal control positive control (alpinduced animals) alp+vit. c (100 mg/kg/bw) alp+vit. d (10 mg/kg/bw) alp+vit.c &vit d. sod ( u/mg) 36.89±0.27 2.90±0.09 2.08±0.02 2.10±0.03 2.58±0.18 gpx ( µmoles ) 116.92±0.63 39.90±0.36* 39.56±0.42* 34.95±0.22* 43.29±0.88* il-6 27.62±0.24 123.24±7.06* 231.29± 3.53* 224.73±9.38* 234.7±2.29* tnf alpha 217.32±1.07 525.52±3.74* 473.76±8.98* 570.86±19.73* 491.23±2.97* values were expressed as mean value ± standard deviation (sd).*mean values were significantly different compared to the normal control at p≤ 0.05.#mean values were significantly different compared with the control akinpelu et al asian journal of dental and health sciences. 2023; 3(2):18-22 [20] ajdhs.com 0 100 200 300 400 500 600 tnf alpha normal control alp alp+vit.100mg/kg alp+10mg/kg alp+100mg vit c+vit d 10 mg/kg 0 50 100 150 200 250 glutathione peroxidase il6 normal control alp alp+vit c 100mg/kg alp+vit d 10mg/kg alp+vit c 100mg+vit d 10mg/kg figure 1: immunomodulatory effect of vitamin c and d on alp poisoning histopathological result alp-induced liver normal control liver alp +vit. c 100 mg/kg figure 1: histological representation of normal liver cells showed a central vein (red arrow) and radiating chords of hepatocytes (black arrow) with sinusoids devoid of congestion. alp-induced liver exhibited hepatocyte vacuolation (black arrow), sinusoidal congestion (blue arrow), and nuclear fragmentation (green arrow). alp-induced liver administered with vit. c 100 mg/kg illustrated regenerative changes (pyknotic nuclei) characterized by reduced congestion in the sinusoidal space and the absence of nuclear fragmentation of hepatocytes. (h&e. x 400). alp +vit. d 10 mg/kg alp +vit. c 100 +vit. d 10 mg/kg figure 3: histological representation of alp-induced liver administered with vit. d 10 mg/kg showed interstitial hemorrhage (green), and pyknotic nuclei (blue) which is suggestive of reparation changes. alp-induced liver treated with vit. c +vit. d showed apparently normal liver cells with a significant reduction in sinusoidal congestion. (h&e. x 400). akinpelu et al asian journal of dental and health sciences. 2023; 3(2):18-22 [21] ajdhs.com discussion hepatic damage is a major cause of death due to phosphine poisoning21. to date, there is no substantial treatment for the several cases reported22. this study aimed to investigate the immunohistopathological effect of vitamin c and d in aluminium phosphide poisoning. the present study showed that alp-induced liver exhibited hepatocyte vacuolation, sinusoidal congestion, and nuclear fragmentation. consistent with our result, previous studies has reported hepatocyte vacuolation, sinusoidal congestion, fatty liver changes, centrilubolar necrosis, and destruction of nucleolus of hepatocytes in phosphinepoisoning22,23. haghi et al 24 concisely discussed the mechanisms of hepatocyte phosphineinduced cytotoxicity, highlighting the production of reactive hydroxyl radicals, induction of cellular hypoxia, and free radical-mediated injury in addition to the inhibition of cytochrome c-oxidase and other essential cellular enzymes25,26,27. vitamin c administration at a dose of 100 mg/kg exhibits a recovery in the alp-induced hepatotoxicity with reparation features suggestive of regenerative changes. in addition, the sinusoidal congestion subsided with no evidence of nuclear fragmentation in the group. interstitial haemorrhage and the presence of pyknotic nuclei were seen in the liver of the alp-induced toxicity in rats administered vitamin d at a dose of 10mg/kg. the liver of the alp-exposed rats co-administered with vitamin c and d appeared apparently normal with a significant reduction in the sinusoidal congestion. according to the present study, phosphine decreases sod and gpx activities in the liver tissue and this effect is slightly inhibited by the concurrent administration of vitamins c and d. documented evidence abound, antioxidant supplements especially vitamin c and vitamin d relieve the body of stress associated with phosphine poisoning28. studies have also revealed that vitamin c enhance the strength of the antioxidant defense system by increasing the antioxidant capacity and controlling reactive oxygen species29. vitamin d reduces ros and pro-inflammatory cytokines possibly by improving cellular glutathione levels30,31. conclusion in conclusion, our finding showed that the combination of vit c and vit d supplementation improved the antioxidant defense system and improved the histopathology of the liver in phosphine poisonng and reduces oxidative stress. references 1. garg kk. review of aluminum phosphide poisoning. int j med sci public health 2020; 9(7):392-400. 2. eddleston m, phillips mr. self poisoning with pesticides. br. med. j. 2004; 328:42-4. https://doi.org/10.1136/bmj.328.7430.42 3. hashemi-domeneh, b., zamani, n., hassanian-moghaddam, h., rahimi, m., shadnia, s., erfantalab, p., & ostadi, a. a review of aluminium phosphide poisoning and a flowchart to treat it. arhiv za higijenu rada i toksikologiju, 2016; 67(3):183-193. https://doi.org/10.1515/aiht-2016-67-2784 4. toussi, a. g. successful treatment of aluminum phosphide; is it possible? asia pacific journal of medical toxicology, 2017; 6(3):90-96. 5. hasabo g. aluminum phosphide, a serious killer in egypt. journal of forensic, toxicology and medicolegal analysis. 2015; 1(1):6-7. 6. u. hackenberg, chronic ingestion by rats of standard diet treated with aluminium phosphide, toxicol. appl. pharmacol. 1972; 23:147-158. https://doi.org/10.1016/0041-008x(72)90214-1 7. mehrpour o, singh s: rice tablet poisoning: a major concern in iranian population. hum exp toxicol 2010; 29:701-702. https://doi.org/10.1177/0960327109359643 8. shadnia s, soltaninejad k: spontaneous ignition due to intentional acutealuminum phosphide poisoning. j emerg med. 2009; 40:179181. https://doi.org/10.1016/j.jemermed.2009.05.028 9. singh, i. dewan, a.n. pandey, s. tyagi, spectrum of unnatural fatalities in chandigarh zone of north-west india a 25 years autopsy study from a tertiary care hospital, j. clin. forensic med. 2003; 10:145-152. https://doi.org/10.1016/s13531131(03)00073-7 10. moghadamnia aa, abdollahi m: an epidemiological study of poisoning in northern islamic republic of iran. east mediterr health j. 2002; 8:88-94. https://doi.org/10.26719/2002.8.1.88 11. a.t. proudfoot, aluminium and zinc phosphide poisoning, clin. toxicol. 2009; 47:89-100. https://doi.org/10.1080/15563650802520675 12. bajpai sr: aluminium phosphide poisoning: management and prevention. j indian acad forensic med 2010; 32:352-354. 13. mokhtari, z., hekmatdoost, z., & nourian, m. antioxidant efficacy of vitamin d. journal of parathyroid disease. 2017; 5(1):11-16. http://www.jparathyroid.com. 14. wiseman h. vitamin d is a membrane antioxidant. ability to inhibit iron-dependent lipid peroxidation in liposomes compared to cholesterol, ergosterol and tamoxifen and relevance to anticancer action. febs lett 1993; 326:285-288. https://doi.org/10.1016/0014-5793(93)81809-e 15. a.j. christophers, s. singh, d.j. goddard, dangerous bodies: a case of fatal aluminium phosphide poisoning, med. j. aust. 2002; 176:403. https://doi.org/10.5694/j.1326-5377.2002.tb04471.x 16. halvaei z, tehrani h, soltaninejad k, abdollahi m, shadnia s. vitamin e as a novel therapy in the treatment of acute aluminum phosphide poisoning. turk j med sci 2017; 47:795-800. https://doi.org/10.3906/sag-1512-6 17. bresm, m. h. a., & habeeb, m. h. h. effect of vitamin d3 on some antioxidant parameters in chilled semen in awassi ram. archives of razi institute. 2022; 78(2):721-727. https://doi.org/10.22092/ari.2022.359482.2433 . 18. hau, j., & van hoosier, g. handbook of laboratory animal science, second edition: essential principles and practices. in j. jann hau and gerald l. van hoosier (ed.), handbook of laboratory animal science, second edition: essential principles and practices (second, vol. 2). 2002. crc press. https://doi.org/10.1201/9781420040913 19. misra hp and fridovich i. the role of superoxide anion i the autoxidation of epinephrine and a simple assay for superoxide dismustase. the journal of biological chemistry. 1972; 247(10):3170-3175. https://doi.org/10.1016/s00219258(19)45228-9 20. rahman i., kode a., biswas s. assay for quantitative determination of glutathione and glutathione disulfide levels using enzymatic recycling method. nat protoc. 2002; 1(6):3159-65. https://doi.org/10.1038/nprot.2006.378 21. n.s. nath, i. bhattacharya, a.g. tuck, d.i. schlipalius, p.r. ebert, mechanisms of phosphine toxicity, j. toxicol. 2011; 2011:494168 https://doi.org/10.1155/2011/494168 22. ali akbar moghadamnia. an update on toxicology of aluminum phosphide. daru journal of pharmaceutical sciences. 2012; 20:25 http://www.darujps.com/content/20/1/25. https://doi.org/10.1186/2008-2231-20-25 23. saleki s, ardalan fa, javidan-nejad a. liver histopathology of fatal phosphine poisoning. forensic sci int 2007; 166:190-3. https://doi.org/10.1016/j.forsciint.2006.05.033 24. haghi aminjan, h., abtahi, s. r., hazrati, e., chamanara, m., jalili, m., & paknejad, b. targeting of oxidative stress and inflammation through ros/nf-kappa b pathway in phosphine-induced https://doi.org/10.1136/bmj.328.7430.42 https://doi.org/10.1515/aiht-2016-67-2784 https://doi.org/10.1016/0041-008x(72)90214-1 https://doi.org/10.1177/0960327109359643 https://doi.org/10.1016/j.jemermed.2009.05.028 https://doi.org/10.1016/s1353-1131(03)00073-7 https://doi.org/10.1016/s1353-1131(03)00073-7 https://doi.org/10.26719/2002.8.1.88 https://doi.org/10.1080/15563650802520675 https://doi.org/10.1016/0014-5793(93)81809-e https://doi.org/10.5694/j.1326-5377.2002.tb04471.x https://doi.org/10.3906/sag-1512-6 https://doi.org/10.22092/ari.2022.359482.2433 https://doi.org/10.1201/9781420040913 https://doi.org/10.1016/s0021-9258(19)45228-9 https://doi.org/10.1016/s0021-9258(19)45228-9 https://doi.org/10.1038/nprot.2006.378 https://doi.org/10.1155/2011/494168 http://www.darujps.com/content/20/1/25 https://doi.org/10.1186/2008-2231-20-25 https://doi.org/10.1016/j.forsciint.2006.05.033 akinpelu et al asian journal of dental and health sciences. 2023; 3(2):18-22 [22] ajdhs.com hepatotoxicity mitigation. life sciences. 2019; 232(6):116607. https://doi.org/10.1016/j.lfs.2019.116607 25. abdollahi, m., & mehrpour, o. aluminum phosphide. in encyclopedia of toxicology: third edition (third edit, vol. 1). elsevier. 2014. https://doi.org/10.1016/b978-0-12-3864543.00467-x 26. neki, n. s., shergill, g. s., singh, a., kaur, a., nizami, s., singh, t., & pannu, j. s. recent advances in management of aluminium phosphide poisoning. journal of punjab academy of forensic medicine and toxicology. 2017; 17(1):53-56. https://doi.org/10.22192/ijcrms.2017.03.04.011 27. karimani, a., mohammadpour, a. h., zirak, m. r., rezaee, r., megarbane, b., tsatsakis, a., & karimi, g. antidotes for aluminum phosphide poisoning an update. toxicology reports, 2018; 5(7):1053-1059. https://doi.org/10.1016/j.toxrep.2018.10.009 28. wahba ns, ghareib sa, abdel-ghany rh, abdel-aal m, alsemeh ae. vitamin d3 potentiates the nephroprotective effects of metformin in a rat model of metabolic syndrome: role of ampk/sirt1 activation and dpp-4 inhibition. canadian journal of physiology and pharmacology. 2021; 99:685-697. https://doi.org/10.1139/cjpp-2020-0435 29. tagliaferri s, porri d, de giuseppe r, manuelli m, alessio f, cena h. the controversial role of vitamin d as an antioxidant: results from randomised controlled trials. nutrition research reviews. 2019; 32:99-105. https://doi.org/10.1017/s0954422418000197 30. schroten nf, ruifrok wp, kleijn l, et al. short-term vitamin d3 supplementation lowers plasma renin activity in patients with stable chronic heart failure: an open-label, blinded end point, randomized prospective trial (vitd-chf trial). american heart journal. 2013; 166:357-364. e352. https://doi.org/10.1016/j.ahj.2013.05.009 31. mastali vp, hoseini r, azizi m. the effect of short-term vitamin d on the antioxidant capacity following exhaustive aerobic exercise. afri health sci. 2023; 23(1):584-91. https://doi.org/10.4314/ahs.v23i1.61 https://doi.org/10.1016/j.lfs.2019.116607 https://doi.org/10.1016/b978-0-12-386454-3.00467-x https://doi.org/10.1016/b978-0-12-386454-3.00467-x https://doi.org/10.22192/ijcrms.2017.03.04.011 https://doi.org/10.1016/j.toxrep.2018.10.009 https://doi.org/10.1139/cjpp-2020-0435 https://doi.org/10.1017/s0954422418000197 https://doi.org/10.1016/j.ahj.2013.05.009 https://doi.org/10.4314/ahs.v23i1.61 vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited herbal products for gynecological disorders harshna vishwakarma*, sakshi patel, sahil chouksey, sachin lodhi, rituraj kurmi, prakhar nema *adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _________________________________________ article history: received 03 march 2022 reviewed 21 april 2022 accepted 04 may 2022 published 15 june 2022 _________________________________________ cite this article as: vishwakarma h, patel s, chouksey s, lodhi s, kurmi r, nema p, herbal products for gynecological disorders, asian journal of dental and health sciences. 2022; 2(2):1-8 doi: http://dx.doi.org/10.22270/ajdhs.v2i2.15 _________________________________________ *address for correspondence: harshna vishwakarma, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ herbal products are often used as an alternative to pharmacological therapy. menopausal symptoms and gynecological disorders (such as premenstrual syndrome and dysmenorrhea) are the indications where pharmacological therapy may have serious adverse events; hence many women prefer to use herbal products to help with these symptoms. here, we reviewed plants and derived products, which are commonly used for the abovementioned indications, focusing on clinical data, safely profile and whether or not their use is justified. we noted that limited data are available on the use of some plants for alleviating the symptoms of menopause and gynecological disorders. while black cohosh (cimicifuga racemose) and red clover (trifolium pretense) were consistently shown to help reduce menopausal symptoms in clinical studies, currently available data do not fully support the use of fenugreek (trigonella foenum-graecum), hops (humulus lupulus), valerian (valeriana officinalis), and soybean (glycine max and glycine soja) for this indication. for premenstrual syndrome and premenstrual dysphoric disorder, chaste tree (vitex agnus-castus) shows effectiveness, but more clinical studies are needed to confirm such effect upon the use of evening primrose (oenothera biennis). keywords: menopause; dysmenorrhea; premenstrual syndrome; gynecological disorders; herbal products; medicinal plants. email: vishwakarmaneelu679@gmail.com introduction women often seek help for various gynecological disorders. most commonly, these are premenstrual syndrome, dysmenorrhea, and menopausal symptoms. often, they prefer alleviation of symptoms with herbal products over pharmacological therapy 1. this is especially the case with, e.g., hormone replacement therapy in menopause, as this therapy bears the possibility for serious adverse events, such as breast cancer 2. premenstrual syndrome is characterized by irritability, tension, depressed mood, breast tenderness and bloating in the weeks before menstruation 3. these symptoms are severe in 5–8% of women. typical pharmacological therapies include analogues of gonadotropin releasing hormone, estradiol, contraceptives and serotonin reuptake inhibitors. dysmenorrhea is the occurrence of painful cramps of the uterus 4. here, we will focus on primary dysmenorrhea, which is present due to menstruation as opposed to secondary dysmenorrhea, which can have different underlying reasons, such as endometriosis, pelvic inflammatory disease, ovarian cysts, and adenomyosis, to name a few 5. typical therapies for primary dysmenorrhea are contraceptives, progestins and non-steroidal anti-inflammatory drugs 4. menopause occurs approximately one year after the last menstruation cycle, which stops due to the gradual decrease in ovarian function 6. the mean age of women entering menopause is 51 years. the transition period, characterized by the cessation of ovarian function, is called perimenopause and starts several years prior to menopause. women entering perimenopause and menopause experience several symptoms, which are assessed by different criteria. kupperman menopausal index is often used to measure the intensity of menopausal symptoms (hot flashes, excessive sweating, sleep disturbances, irritability, depressive mood, attention deficit disorder, joint and bone pain, headache, arrhythmias, paresthesia) assessed on a 1 through 4 scales 7. other similar assessments are done with the greene climacteric scale, or the menopause rating scale 8. pharmacological treatments for these symptoms include hormone replacement therapy, selective serotonin reuptake inhibitors and selective serotonin-norepinephrine reuptake inhibitors 6, 9-11. herbal plants for the treatment of gynecological disorders fenugreek (trigonella foenum-graecum l) fenugreek or trigonella foenum-graecum l. is a member of the fabaceae family. it is grown in the mediterranean, northern africa and indian peninsula to be used as a herb, spice, or in traditional medicine. fenugreek is an annual plant, which grows up to the height of 60 cm, has trifoliate leaves and white to yellow flowers. fenugreek seeds grow in thin pods, which are about 15 cm long, and are a part of plant which is commonly used in formulations, such as powder, dry extract or soft extract 12, 13. the seeds are golden yellow and contain polysaccharides (24–25% galactomannans), 0.016% essential oil, 0.6–1.7% saponins (from diosgenin, yamogenin, tigogenin, and others), sterols (β-sitosterol), flavonoids (orientin, isoorientin, isovitexin) and other secondary metabolites (protoalkaloids, trigonelline, choline) 12. a wide array of versatile compounds contained in fenugreek seeds is the reason that many health effects have been attributed to this plant. these include antidiabetic, antihyperlipidemic, antiobesity, anticancer, anti-inflammatory, antioxidant, antifungal, antibacterial, galactagogue activities, and to help with climacteric and period problems 13. in this review, we open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i2.15 vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [2] ajdhs.com concentrate on the alleviation of menopausal symptoms and dysmenorrhea. diosgenin and yamogenin are steroidal sapogenins, which are obtained after the acid hydrolysis of fenugreek seeds. they are of interest for the pharmaceutical industry due to the possibility to synthesize oral contraceptives and steroid hormone drugs from them, and due to their own pharmacological activity. another compound with the activity on the endocrine system is the alkaloid trigonelline, which is a phytoestrogen, as it activates the estrogen receptor (er) 13. another set of compounds, which might play a role in alleviating menopausal symptoms and are contained in fenugreek, are flavonoids. not only trigonelline, but also fenugreek extract showed the ability to bind to er in a competitive er binding assay and to have agonist activity on this receptor in a transactivation gene reporter assay 13, 14. furthermore, fenugreek extracts upregulated the expression of the estrogen-responsive gene and induced proliferation of estrogen dependent breast cell line mcf-7 14. another study showed the antiproliferative effect of fenugreek extract on several breast cancer cell lines, including mcf-7 cells 15. the same cell line was used for subcutaneous implantation in female mice where diosgenin (which is present in fenugreek seed) inhibited tumor growth 13, 16. extract preparation and active compound content may thus be the underlying reason for different results in these studies. fenugreek extract was shown to improve sexual function in women in a randomized placebo-controlled study, where increased plasma 17βestradiol was measured, possibly due to increased aromatase conversion of testosterone to 17β-estradiol 13, 17. in a placebo controlled study on 101 women, fenugreek extract helped with dysmenorrhea symptoms during menstruation 13. duration of pain was decreased and reduction of systemic a more than 20% reduction in hot flashes, night sweats, insomnia, and more than 30% improvement of depression 18, 19. increases in serum 17β-estradiol, free testosterone and progesterone were observed, and decreases in folliclestimulating hormone and steroid hormone-binding globulin. authors speculated that this indicates the phytoestrogenic effect of fenugreek and an establishment of hormonal balance in postmenopausal women upon taking fenugreek extracts 19. in terms of safety and possible interactions, fenugreek is generally safe, but patients taking antidiabetic drugs should monitor their blood sugar regularly 13. fenugreek can cause digestive disorders and allergic reactions 12. it should not be taken during pregnancy due to uterine stimulatory and abortifacient activities. moreover, non-clinical data suggest embryo-lethal effects, testicular toxicity and decreased thyroid hormone levels 12 symptoms, such as fatigue, headache and nausea, was observed 20. a study from 2006, where postmenopausal women were given 6 g of fenugreek seed powder for eight weeks revealed improvement of hot flashes and night sweats after four weeks 21. hops (humulus lupulus l) there are three main species in the genus humulus (cannabaceae): humulus lupulus l., h. scandens (lourr.) merr. and h. yunnanensis hu. 22. humulus lupulus l. is native to central europe; however, today it is naturalized throughout the northern temperate regions. it is a perennial and dioecious climbing plant with a herbaceous stem which can reach 10 m. male small flowers are organized in clusters. the female inflorescences are cones that contain foliaceous bracts and socalled glandular trichomes in the lupulin glands containing essential oil (constituents: β-myrcene, β-caryophyllene, αhumulene, β-farnesene, α-selinene, β-selinene, humulene epoxides, β-bisabolol, 2-methyl-3-buten-2ol, a.s.o.), prenylated acylphloroglucinols (α-acids: humulone = hu, its derivatives, and β-acids: lupulones), prenylated flavanones (isoxanthohumol = ix, 6-prenylnaringenin = 6pn, 8prenylnaringenin = 8pn), chalcones (xanthohumol = xh, desmethylxanthohumol), triterpenes, flavonols, and tannins 23. xh is the main chalcone in the lupulin glands (0.1–1% of cone dry weight) 24. although ix, 6pn and 8pn are present in different varieties of hops 25, some authors theorized these derivatives could be partly decomposition products emerging during drying and storage 26. female inflorescence of hop is important for the production of beer. moreover, there is a pharmacopoeial drug monograph used for the quality check during the production of herbal teas or herbal preparations (comminuted or powdered herbal drug; liquid extract (der 1:1), extracted with ethanol 45% v/v; liquid extract (der 1:10), extracted with sweet wine; tincture (ratio of herbal substance to extraction solvent 1:5), extracted with ethanol 60% v/v; and dry extract (der 4-5:1), extracted with methanol 50% v/v). they are all mentioned in a category of traditional herbal medicinal products, used for the relief of mild symptoms of mental stress and to aid sleep 27. increased interest in therapeutic use of hops dates back to the end of the last century when it was discovered that hops contains prenylflavonoids which are thought to be phytoestrogens. milligan and colleagues isolated estrogenic 8pn by bioassayguided fractionation of hops extracts 28. it has long been traditionally believed that hops has strong estrogenic activity, e.g., in women, harvesting hops by hand, who started menstruating two days after the hops harvesting began. koch and heim claimed that the estrogenic activity of hops corresponds to the presence of the equivalent of 20–300 g 17β-estradiol/g 29. red clover (trifolium pratense l) red clover or trifolium pretense l. is a member of the fabaceae family. it is native to europe, asia and africa, and has been introduced to every other continent 30. it is grown in terrestrial and wetlands, and is used for pasturage, hay and silage for the livestock 31. it is a herbaceous, perennial plant, which grows up to 80 cm tall. the leaves are trifoliate (compounded typically of three leaflets) and alternate. the flowers are pink to red or white in color. red clover at the flowering stage contains isoflavones formononetin, biochanin a, daidzein and genistein in cumulative concentrations of 5.4– 8.1 mg/g of dry matter, where formononetin and biochanin a contribute 51% and 40% of the weight, respectively 32. leaves contribute to 73.9% of the total isoflavone content, while stems contribute 17.6% and flowers approximately 9% 32. in addition, glycitein and prunetin can also be found in red clover in smaller amounts 8. isoflavones act as phytoestrogens, as they activate ers by binding to two isoforms: to estrogen receptor β (erβ) with higher affinity and to estrogen receptor α (erα) with lower affinity 8. this may, in turn, lead to a reduction of gonadotropin-releasing hormone, folliclestimulating hormone, and luteinizing hormone levels 33. additionally, isoflavones are thought to have antioxidant properties, to inhibit tyrosine kinases, and affect ion transport 8. breeding problems of sheep herds in australia in 1940s, which fed on clover, brought attention to possible hormonal effects of this plant 34. many clinical studies were conducted to determine whether red clover could be used to help with menopausal symptoms due to its putative estrogenic activity. a recent (2021) systematic review and meta-analysis by kanadys et al. presented randomized controlled trials on the use of red clover extract inmenopause 8. the effectiveness of red clover isoflavone extracts on the relief of hot flashes and menopausal symptoms in periand postmenopausal women was assessed. eight trials out of 107 potentially relevant randomized controlled trials passed the quality criteria and were included in comparisons. in most of these trials, 40–80 mg of red clover isoflavone extract was given to participants per day. a meta-analysis revealed a reduction in the hot vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [3] ajdhs.com flashes frequency, by 1.73 hot flashes per day. the menopausal symptoms were alleviated upon treatment with red clover isoflavone extract according to kupperman menopausal index and menopause rating scale, but not according to greene climacteric scale. the red clover isoflavone extract was more effective in women experiencing more than five hot flashes per day, in doses higher than 80 mg of the extract per day, and when the content of biochanin a was higher. red clover is likely safe when used as a supplement to relieve menopausal symptoms 33. no significant side effects were seen upon a year of use of such supplements. however, due to its estrogenic activity, patients on hormone replacement therapy or contraceptives, and patients with a history of hormone-dependent cancers should pay special attention to any adverse events. due to coumarin in red clover, it could have an effect on platelet aggregation; therefore special care is needed if used concomitantly with anticoagulants 34. overall, clinical studies support the use of a red clover isoflavone extract for women suffering from menopausal symptoms. red clover supplements are considered safe for this indication. valerian (valeriana officinalis l) valeriana genus (caprifoliaceae) is comprised of 289 species. the most important one, valeriana officinalis l. (valerian), is known under at least 22 synonyms. it grows naturally in europe and western asia, and was introduced to north america. it prefers moist locations, but can also be found in drier soils. morphology of valerian is very diverse. in the second year of growth, the plant produces a round, furrowed and hollow flowering stem, 80–120 cm tall and branched at the top. the pale green (upper side) lanceolate feathery leaves grow either from one feathered shape or from 9 to 21 finely serrated leaflets. leaves are attached in pairs to either side of the stem. the stems terminate in umbels bearing many branches and tiny white and pale pink flowers. valerian has a robust rhizome with many secondary roots and stolons. the european pharmacopoeia requires as a pharmaceutical material dried, whole or fragmented underground parts of valerian (valeriana officinalis l. s.l.), including rhizome surrounded by the roots and stolons (valerianae radix, 35) or dried, cut underground parts of valerian, including rhizome, roots and stolons (valerianae radix minutata,). this use in folk medicine has been translated into official therapy, which is confirmed by the existence of a european herbal monograph 36. here, we can find indications “for the relief of mild nervous tension and sleep disorders“ in the well-established use category, and “for relief of mild symptoms of mental stress and to aid sleep“ in the traditional use category. the use of valerian root for nervous disorders during menopause is mentioned only by usmanghani et al. (1997) 37. soybean (glycine max (l.) merr and glycine subsp soja (siebold & zucc.) h. ohashi) wild soybean or glycine soja is an annual or perennial climbing herb from the legume family (fabaceae). it is native in eastern asia, russian far east, eastern china, korean peninsula and japan. wild soybean is not to be mistaken for widely cultivated domesticated soybean or glycine max. in contrast to domesticated soybean, wild soybean has dormant seeds. they are about 1.8–2.5 mm wide, 2.5–4.0 mm long, ellipsoid shape and black in color. domestic soybean has less genetic diversity and is more susceptible to damage from climatic changes, while wild soybean is more resilient due to2.8. soybean (glycine max (l.) merr. and glycine subsp. soja (siebold & zucc.) h. ohashi) wild soybean or glycine soja is an annual or perennial climbing herb from the legume family (fabaceae). it is native in eastern asia, russian far east, eastern china, korean peninsula and japan. wild soybean is not to be mistaken for widely cultivated domesticated soybean or glycine max. in contrast to domesticated soybean, wild soybean has dormant seeds. they are about 1.8–2.5 mm wide, 2.5–4.0 mm long, ellipsoid shape and black in color 38-41. domestic soybean has less genetic diversity and is more susceptible to damage from climatic changes, while wild soybean is more resilient due to its widespread presence in diverse climates and could consequently be a good resource for creating improved genetic variants of domesticated soybean 42. wild soybean beans contain a wide range of compounds, among them saponins and isoflavones (e.g., daidzein, 6-hydroxy-daidzein, daidzein glycosides, genistein, genistein glycosides, glycitein, and glycitein glycosides), trypsin inhibitors, and twice the amount of α-linolenic acid in triglycerides as domesticated soybean 40. glycoside forms of the three aglycons may be β-glucosides, 6”-o-malonylglucosides and 6”-o-acetyl-glucosides. isoflavonoid content in domesticated soybean per gram soybeans is up to: 516 µg daidzin, 1079 µg genistin, 177 µg glycitin, 768 µg malonyldaidzin, 158 µg malonylglycitin, 2446 µg malonylgenistin, 265 µg genistein. a better absorption was shown for aglycone isoflavonoids than the glycoside forms in humans. soy isoflavones are of particular interest in the pharmaceutical industry. they mimic estrogen and are thus classified as phytoestrogens, and have antioxidant properties 43-45. the estrogenic properties of some isoflavones are also the basis for the hypothesis that soy could act as a hormone replacement therapy and thus help alleviate menopausal symptoms. the typical isoflavone ingestion through supplements intended for the relief of menopausal symptoms is 35–150 mg/day. among soy isoflavones, genistein is the most potent with regard to er binding, followed by daidzein. namely, genistein binds to erβ with 30 times lower affinity than 17β-estradiol, and to erα with a 10,000 times lower affinity. this raises a question of whether soy isoflavones could act as selective er modulators, i.e., exert estrogenic effects in some tissues, but none or antiestrogenic effects in other tissues 44-48. black cohosh (actaea racemosa l/cimicifuga racemosa (l) nutt) black cohosh or cimicifuga racemosa syn. actaea racemosa is a perennial and is endemic to the eastern united states and canada. this plant belongs to the family ranunculaceae. it forms up to 2 m of creeping rhizomes. it has elongated fringed divided leaves 49. inflorescences of small, white flowers in the form of long clusters appear at the end of branched stems from may to august. the rhizome is used as a herbal drug for medicinal purposes. native american tribes living in the area of growth of this plant have traditionally used it for centuries 49, 50. common names for this herb are black cohosh, macrotys, rattle weed and black snake root. in some european countries, the herbal preparations of black cohosh rhizome are marketed as herbal medicines with proven use to relieve menopausal symptoms, e.g., hot flashes. in the united kingdom, black cohosh is a traditional drug for the symptomatic relief of rheumatic pain 50, 51. there are three groups of compounds in black cohosh that are responsible for its pharmacological action: phenolic compounds, including ferulic acid, isoferulic acid and caffeic acid derivatives, cycloartane triterpene glycosides (actein, 26-deoxyactein) and phenylpropanoids. the phytoestrogenic flavonoid formononetin was also found in early studies of the constituents of this plant 52, but this was confirmed in neither the raw herb nor the standardized extracts in later studies 49. despite numerous research efforts, we do not know the exact composition or function of this plant. the preparations of black cohosh are standardized to the triterpene glycoside content of 26-deoxyactein. other important triterpene glycosides are actein and cimicifugoside (aglycone cimegenol) 49. a black cohosh extract contains many triterpene glycosides 53, but there is no direct evidence that vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [4] ajdhs.com these are the main active ingredients in relieving menopausal symptoms, especially hot flashes 50. the efficacy of black cohosh extract in reducing hot flashes may be attributed to the binding and modulation of key central nervous system receptors for thermoregulation, mood, and sleep (e.g., receptors for serotonin, dopamine, γ-aminobutyric acid (gaba), µ-opioids). it also affects the improvement of metabolism in the brain and its overall activity 54, 55. the extract contains active ingredients that act as partial agonists of the serotonin receptors (also known as 5-ht or 5hydroxytryptamine receptors), which are located in the hypothalamus and are associated with thermoregulation. from the 75% ethanol extract standardized to 5.6% triterpene glycosides, the compound nωmethyl serotonin was isolated, which could be the main active ingredient of the extract. another mode of action of the rhizome extract could be via triterpenoids (especially 23-oacetylshengmanol-3-o-dxylopyranoside) through modulation of gabaa receptors. the triterpenoid deoxyactein has also been associated with beneficial effects in osteoporosis by influencing osteoclast growth and differentiation and mineralization 56, 59. chaste tree (vitex agnus-castus l) chaste tree or vitex agnus-castus l. is a deciduous shrub or a small tree of the lamiaceae family, native to areas stretching from the mediterranean to northern india. it grows to a height of 6 m. it has pale violet panicular inflorescences that ripen into brown fruits with a characteristic, aromatic and peppery aroma 60, 61. the fruits have been used traditionally for their emmenagogue, lactagogue, vulnerary, carminative, antihelmintic and anti-inflammatory properties 62, while in terms of rational phytotherapy, they are considered herbal substances most frequently used in the treatment of premenstrual syndrome 61. v. agnus-castus is also believed to have been used by monks as an anaphrodisiac, to diminish their sex drive, hence the common names monk’s pepper, chaste tree and chasteberry 61. phytochemical compounds of the fruit include volatile compounds (essential oil), flavonoids and other phenolic compounds, iridoids, ketosteroids and diterpenoids 62, 63. in 2016, an lc/ms method for differentiation between the chaste tree and two related species popular in japan, v. rotundifolia and v. trifolia, was described, based on the identification of chastol and epichastol diterpenoids proposed to be marker compounds in chaste tree fruits 64, 65. according to the european pharmacopeia 66, whole, ripe and dried fruits are used as an herbal substance (agni casti fructus). casticin, also known as vitexicarpin, which is a methoxylated flavonol, is defined to a minimum of 0.08% content in the dried herbal substance. in addition, the extract of chaste trees (agni casti fructus extractum siccum) is prepared from the herbal substance by a suitable procedure using ethanol (40–80%, v/v) and must conain a minimum of 0.1% casticin (dried herbal substance) 66. evening primrose (oenothera biennis l) evening primrose or oenothera biennis l. is a biennial plant that grows to between 30 and 150 cm in height. it is native to central america, from where it spread first to north america and europe. it grows today in regions with a moderate climate all over the world. the plant was named after the pleasant spectacle that unfolds every evening at dusk, when its yellow flowers open. however, they only last until the following day. fruits are up to 4 cm long and contain numerous small seeds 67, 68. the plant’s stem and leaf juices and poultices were used by native americans dermally to treat skin inflammation, bruises and minor wounds, while the leaves were used internally for gastrointestinal disorders and sore throats 69. today, the seed oil is well-known, particularly in alternative treatments, for use in inflammatory conditions such as atopic dermatitis, eczema and rheumatoid arthritis, and women’s conditions, which are described in the following sections. the seeds of evening primrose contain approx. 20% of oil (triglycerides), which is yellow to greenish-yellow when unrefined, with a typical odor. linoleic acid is a highly predominant fatty acid (typically ~70%) followed by γlinolenic acid (typically ~10%) 67. both belong to the group of polyunsaturated omega-6 fatty acids. the european pharmacopeia specifies limits for individual fatty acids, i.e., palmitic (4–10%), stearic (1–4%), oleic (5–12%), linoleic (65– 85%), γ-linolenic (7–14%) and α-linolenic (max 0.5%) acids, as well as unsaponifiable matter (max. 2.5% determined on 5 g of oil) [34]. due to the high oxidative instability of the oil, it is important that manufacturers ensure the peroxide value of max. 10.0 (or max. 5.0 if intended for use in parenteral preparations 34. regulatory accepted in the european union is the use of oil obtained from two oenothera species, o. biennis l. and o. lamarckiana l., in the form of a traditional herbal medicinal product for the symptomatic relief of itching in acute and chronic dry skin conditions, exclusively based upon long-standing use 70. the mechanism of action of oenothera oil is attributed to the effects of omega-6 fatty acids on immune cells and the synthesis of prostaglandins, cytokines and cytokine mediators 69. it is also assumed that low levels of prostaglandin e1 in women with premenstrual syndrome lead to increased sensitivity to luteal phase prolactin 71. research studies and findings which proposed a possible connection between premenstrual syndrome, prolactin levels, prostaglandins and γ-linolenic acid, an essential fatty acid precursor of prostaglandin e1, originate from the early 1980s 72, 73, including first clinical studies showing success in the treatment with oenothera oil, for premenstrual syndrome 74 and mastalgia 75. data showed that women with premenstrual syndrome have the inability to convert linoleic acid to γlinolenic acid due to a decreased activity of the delta-6 desaturase enzyme 76, 82, in addition to hormonal disbalance 71. cerin et al. 71 investigated hormonal status (progesterone, estradiol, prolactin, cortisol, aldosterone) and cholesterol, triglyceride, lipoprotein, magnesium and calcium levels, and glucose tolerance in the follicular and luteal phases of the menstrual cycle in women diagnosed with premenstrual syndrome vs. symptom-free controls. the parameters were found to be similar in both groups, except for aldosterone which was lower in the follicular and luteal phases, and cholesterol which was higher in the follicular phase in women with premenstrual syndrome. in the same study, the effect of oenothera oil was also evaluated in a randomized, doubleblind crossover design, but no effects were found for any of the biochemical parameters. commiphora wightii a therapeutic flowering plant known by many common names, including guggulu, guggul, and gugal, commiphora wightii is a member of the burseraceae family. although it can also be found in central asia, guggul is most frequently found in northern india. guggul extract, also known as gugulipid, is a frequent ingredient in ayurvedic and herbal remedies. guggul contains a variety of therapeutic essential oils, gum extracts, and resinous compounds. the study demonstrated that guggul reduces the dhea-induced pcos in the ovarian follicles, which is a key factor in minimizing morphological abnormalities. as a result, the hormonal fluctuations return to normal. the study also shown that the dhea-induced pcos profile, which includes the hormones fsh, lh, progesterone, estrogen andtestosterone, experienced a sharp rise in hormone levels. elevated glucose levels were also observed28.for the purpose of raising awareness, promoting the use of guggul as a nutritional/dietary supplement, and determining the safety of usein humans, the national institute of health environmental sciences nominated the gum guggul to extract for examination of vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [5] ajdhs.com the toxicological parameters and characterization. gum guggul has been shown to provide advantages for female reproductiveorgans andhormonal balance 81. table 1: commonly used plants in relieving menopausal symptoms plant species, drug part active compounds biological activities/supposed mechanism of action black cohosh (cimicifuga racemosa) rhizome phenolic compounds (ferulic acid, isoferulic acid and caffeic acid derivatives, cycloartane triterpene glycosides (actein, 26-deoxyactein, cimicifugoside)) and phenylpropanoids, possibly phytoestrogenic flavonoid formononetin, nω-methylserotonin, 23-oacetylshengmanol-3-o-dxylopyranoside [52,56,27] • modulation of key central nervous system receptors for thermoregulation, mood, and sleep (e.g., receptors for serotonin, dopamine, γaminobutyric acid (gaba), µ-opioids) [54, 55] • improvement of metabolism in the brain and its overall activity [54,55] • modulating osteoclast growth and differentiation and mineralization [58, 59] chaste tree (vitex agnus-castus) fruit volatile compounds (essential oil), flavonoids and other phenolic compounds, iridoids, ketosteroids, chastol and epichastol diterpenoids [62– 65] methoxylated flavonol casticin, (also known as vitexicarpin) [66] • binding to dopamine receptors followed by a decreased release of prolactin [77,78] • involvement of serotoninergic system has been proposed [79] • decreased serum prolactin levels [80] evening primrose (oenothera biennis) seed 20% of oil (triglycerides) containing linoleic acid, γlinolenic acid, palmitic acid, stearic acid, oleic acid, αlinolenic acid, unsaponifiable matter [66,67] • modulation of the immune response and the synthesis of prostaglandins, cytokines and cytokine mediators [69] fenugreek (trigonella foenum-graecum) seed polysaccharides (24–25% galactomannans), 0.016% essential oil, secondary metabolites (protoalkaloids, trigonelline, choline), 0.6–1.7% saponins (from diosgenin, yamogenin, tigogenin, and others), sterols (β-sitosterol), and flavonoids (orientin, isoorientin, isovitexin) [12] • activation of the estrogen receptor (er) [13] • upregulation of the expression of estrogen responsive genes [14] • proliferation of estrogen-dependent breast cells as well as antiproliferative effect on several cell lines [13-16] • increased plasma 17β-estradiol [13,17,19] • increased free testosterone and progesterone [19] • decreased in follicle stimulating hormone and steroid hormone binding globulin [19] hops (humulus lupulus) inflorescence essential oil (constituents: β-myrcene, βcaryophyllene, α-humulene, β-farnesene, α-selinene, β-selinene, humulene epoxides, β-bisabolol, 2-methyl3-buten-2-ol, a.s.o.), prenylated acylphloroglucinols (α-acids: humulone, its derivatives, and β-acids: lupulones), prenylated flavanones (isoxanthohumol, 6-prenylnaringenin, 8-prenylnaringenin), chalcones (xanthohumol, desmethylxanthohumol), triterpenes, flavonols, and tannins [23] • estrogenic effect [28,29] red clover (trifolium pratense) stem, leaf, flower isoflavones formononetin, biochanin a, daidzein and genistein, glycitein and prunetin [8,32] • activation of the ers by binding to two isoforms: to estrogen receptor β (erβ) with higher affinity and to estrogen receptor α (erα) with lower affinity [8] • reduction of gonadotropin releasing hormone, follicle stimulating hormone, and luteinizing hormone levels [32] • antioxidant activity, inhibition of tyrosine kinases and modulation of ion transport [8] soybean (glycine max and glycine soja) seed saponins and isoflavones (e.g., daidzein, 6-hydroxydaidzein, daidzein glycosides, genistein, genistein glycosides, glycitein, and glycitein glycosides), trypsin inhibitors, and twice the amount of α-linolenic acid as domesticated soybean [40] glycoside forms of the three aglycons may be β-glucosides, 6 00-o-malonylglucosides and 6 00-o-acetyl-glucosides [43] • estrogenic effect–genistein binds to erβ with 30 times lower affinity than 17β-estradiol, and to erα with a 10,000 times lower affinity [44,45] • antioxidant activity [45] vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [6] ajdhs.com conclusions based on this review, we noted limited data are available on the use of some plants for alleviating the symptoms of menopause and gynecological disorders. while black cohosh and red clover were consistently shown to help reduce menopausal symptoms in clinical studies, currently available data do not fully support the use of fenugreek, hops, valerian, and soybean for this indication. for premenstrual syndrome and premenstrual dysphoric disorder, chaste tree shows effectiveness, but more clinical studies are needed to confirm such effect upon the use of evening primrose. references 1. nedrow a, miller j, walker m, nygren p, huffman lh, nelson hd. complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. archives of internal medicine. 2006; 166(14):1453-65. https://doi.org/10.1001/archinte.166.14.1453 2. marjoribanks j, farquhar c, roberts h, lethaby a. long term hormone therapy for perimenopausal and postmenopausal women. cochrane database of systematic reviews. 2012(7). https://doi.org/10.1002/14651858.cd004143.pub4 3. yonkers ka, o'brien ps, eriksson e. premenstrual syndrome. the lancet. 2008; 371(9619):1200-10. https://doi.org/10.1016/s0140-6736(08)60527-9 4. bernardi m, lazzeri l, perelli f, reis fm, petraglia f. dysmenorrhea and related disorders. f1000research. 2017; 6. https://doi.org/10.12688/f1000research.11682.1 5. dawood my. dysmenorrhea. clinical obstetrics and gynecology. 1990; 33(1):168-78. https://doi.org/10.1097/00003081199003000-00023 6. greendale ga, lee np, arriola er. the menopause. the lancet. 1999; 353(9152):571-80. https://doi.org/10.1016/s01406736(98)05352-5 7. kupperman hs, blatt mh, wiesbader h, filler w. comparative clinical evaluation of estrogenic preparations by the menopausal and amenorrheal indices. the journal of clinical endocrinology & metabolism. 1953; 13(6):688-703. https://doi.org/10.1210/jcem13-6-688 8. kanadys w, barańska a, błaszczuk a, polz-dacewicz m, drop b, kanecki k, malm m. evaluation of clinical meaningfulness of red clover (trifolium pratense l.) extract to relieve hot flushes and menopausal symptoms in peri-and post-menopausal women: a systematic review and meta-analysis of randomized controlled trials. nutrients. 2021; 13(4):1258. https://doi.org/10.3390/nu13041258 9. orleans rj, li l, kim mj, guo j, sobhan m, soule l, joffe hv. fda approval of paroxetine for menopausal hot flushes. new england journal of medicine. 2014; 370(19):1777-9. https://doi.org/10.1056/nejmp1402080 10. cheema d, coomarasamy a, el-toukhy t. non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidencebased review. archives of gynecology and obstetrics. 2007; 276(5):463-9. https://doi.org/10.1007/s00404-007-0390-9 11. handley ap, williams m. the efficacy and tolerability of ssri/snris in the treatment of vasomotor symptoms in menopausal women: a systematic review. journal of the american association of nurse practitioners. 2015; 27(1):54-61. https://doi.org/10.1002/2327-6924.12137 12. westferry c, wharf c. committe on herbal medicinal products (hmpc). european medicines agency science medicines health. 2010. 13. nagulapalli venkata kc, swaroop a, bagchi d, bishayee a. a small plant with big benefits: fenugreek (trigonella foenum‐graecum linn.) for disease prevention and health promotion. molecular nutrition & food research. 2017; 61(6):1600950. https://doi.org/10.1002/mnfr.201600950 14. sreeja s, anju vs, sreeja s. in vitro estrogenic activities of fenugreek trigonella foenum graecum seeds. indian journal of medical research. 2010; 131(6):814. 15. shabbeer s, sobolewski m, anchoori rk, kachhap s, hidalgo m, jimeno a, davidson ne, carducci m, khan sr. fenugreek: a naturally occurring edible spice as an anticancer agent. cancer biology & therapy. 2009; 8(3):272-8. https://doi.org/10.4161/cbt.8.3.7443 16. srinivasan s, koduru s, kumar r, venguswamy g, kyprianou n, damodaran c. diosgenin targets akt‐mediated prosurvival signaling in human breast cancer cells. international journal of cancer. 2009; 125(4):961-7. https://doi.org/10.1002/ijc.24419 17. rao a, steels e, beccaria g, inder wj, vitetta l. influence of a specialized trigonella foenum‐graecum seed extract (libifem), on testosterone, estradiol and sexual function in healthy menstruating women, a randomised placebo controlled study. phytotherapy research. 2015; 29(8):1123-30. https://doi.org/10.1002/ptr.5355 18. purohit a, jain s, nema p, jain dk, vishwakarma h, jain pk, a comprehensive review on tailoring an herbal approach for treatment of poly cystic ovarian syndrome, asian journal of dental and health sciences. 2022; 2(1):27-32. https://doi.org/10.22270/ajdhs.v2i1.13 19. hakimi s, mohammad alizadeh s, delazar a, abbasalizadeh f, bamdad mogaddam r, siiahi mr, mostafa garabagi p. probable effects of fenugreek seed on hot flash in menopausal women. journal of medicinal plants. 2006; 5(19):9-14. 20. khanna a, john f, das s, thomas j, rao j, maliakel b, im k. efficacy of a novel extract of fenugreek seeds in alleviating vasomotor symptoms and depression in perimenopausal women: a randomized, double‐blinded, placebo‐controlled study. journal of food biochemistry. 2020; 44(12):e13507. https://doi.org/10.1111/jfbc.13507 21. thomas jv, rao j, john f, begum s, maliakel b, krishnakumar im, khanna a. phytoestrogenic effect of fenugreek seed extract helps in ameliorating the leg pain and vasomotor symptoms in postmenopausal women: a randomized, double-blinded, placebocontrolled study. pharmanutrition. 2020; 14:100209. https://doi.org/10.1016/j.phanu.2020.100209 22. the plant list: search results for humulus. available online: http://www.theplantlist.org/tpl1.1/search?q=humulus. 23. bocquet l, sahpaz s, hilbert jl, rambaud c, rivière c. humulus lupulus l., a very popular beer ingredient and medicinal plant: overview of its phytochemistry, its bioactivity, and its biotechnology. phytochemistry reviews. 2018; 17(5):1047-90. https://doi.org/10.1007/s11101-018-9584-y 24. stevens jf, taylor aw, deinzer ml. quantitative analysis of xanthohumol and related prenylflavonoids in hops and beer by liquid chromatography-tandem mass spectrometry. journal of chromatography a. 1999; 832(1-2):97-107. https://doi.org/10.1016/s0021-9673(98)01001-2 25. stevens jf, ivancic m, hsu vl, deinzer ml. prenylflavonoids from humulus lupulus. phytochemistry. 1997; 44(8):1575-85. https://doi.org/10.1016/s0031-9422(96)00744-3 26. chadwick lr, nikolic d, burdette je, overk cr, bolton jl, van breemen rb, fröhlich r, fong hh, farnsworth nr, pauli gf. estrogens and congeners from spent hops (humulus l upulus). journal of natural products. 2004; 67(12):2024-32. https://doi.org/10.1021/np049783i 27. werner rd, merz ad. committee on herbal medicinal products (hmpc). 28. milligan sr, kalita jc, heyerick a, rong h, de cooman l, de keukeleire d. identification of a potent phytoestrogen in hops (humulus lupulus l.) and beer. the journal of clinical endocrinology & metabolism. 1999; 84(6):2249-. https://doi.org/10.1210/jcem.84.6.5887 29. koch w, heim g. östrogene hormone in hopfen und bier. med. wchnschr. 1953; 95:845. https://doi.org/10.1001/archinte.166.14.1453 https://doi.org/10.1002/14651858.cd004143.pub4 https://doi.org/10.1016/s0140-6736(08)60527-9 https://doi.org/10.12688/f1000research.11682.1 https://doi.org/10.1097/00003081-199003000-00023 https://doi.org/10.1097/00003081-199003000-00023 https://doi.org/10.1016/s0140-6736(98)05352-5 https://doi.org/10.1016/s0140-6736(98)05352-5 https://doi.org/10.1210/jcem-13-6-688 https://doi.org/10.1210/jcem-13-6-688 https://doi.org/10.3390/nu13041258 https://doi.org/10.1056/nejmp1402080 https://doi.org/10.1007/s00404-007-0390-9 https://doi.org/10.1002/2327-6924.12137 https://doi.org/10.1002/mnfr.201600950 https://doi.org/10.4161/cbt.8.3.7443 https://doi.org/10.1002/ijc.24419 https://doi.org/10.1002/ptr.5355 https://doi.org/10.22270/ajdhs.v2i1.13 https://doi.org/10.1111/jfbc.13507 https://doi.org/10.1016/j.phanu.2020.100209 https://doi.org/10.1007/s11101-018-9584-y https://doi.org/10.1016/s0021-9673(98)01001-2 https://doi.org/10.1016/s0031-9422(96)00744-3 https://doi.org/10.1021/np049783i https://doi.org/10.1210/jcem.84.6.5887 vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [7] ajdhs.com 30. trifolium pratense l. plants of the world online, kew science. available online: http://www.plantsoftheworldonline.org/taxon/ urn:lsid:ipni.org:names:523575-1. 31. trifolium pratense (red clover): go botany. available online: https://gobotany.nativeplanttrust.org/species/trifolium/ pratense. 32. lemežienė n, padarauskas a, butkutė b, cesevičienė j, taujenis l, norkevičienė e, mikaliūnienė j. the concentration of isolavones in red clover (trifolium pratense l.) at lowering stage. zemdirbysteagriculture. 2015; 102(4). https://doi.org/10.13080/za.2015.102.057 33. nelsen j, ulbricht c, barrette ep, mac ds, tsouronis c, rogers a, basch s, hashmi s, bent s, basch e. red clover (trifolium pratense) monograph: a clinical decision support tool. journal of herbal pharmacotherapy. 2002; 2(3):49-72. https://doi.org/10.1080/j157v02n03_06 34. messina m, mejia sb, cassidy a, duncan a, kurzer m, nagato c, ronis m, rowland i, sievenpiper j, barnes s. neither soyfoods nor isoflavones warrant classification as endocrine disruptors: a technical review of the observational and clinical data. critical reviews in food science and nutrition. 2022; 62(21):5824-85. https://doi.org/10.1080/10408398.2021.1895054 35. european medicines agency (ema); committee on herbal medicinal products (hmpc). ema/hmpc/150848/2015, corr. european union herbal monograph on valeriana officinalis l., flos; ema: amsterdam, the netherlands; hmpc: london, uk, 2016; 31:1-9. 36. hoberg e, orjala j, meier b, sticher o. diterpenoids from the fruits of vitex agnus-castus. phytochemistry. 1999; 52(8):1555-8. https://doi.org/10.1016/s0031-9422(99)00181-8 37. usmanghani k, saeed a, alam mt. indusyunic medicine: traditional medicine of herbal animal and mineral origin in pakistan. department of pharmacognosy, faculty of pharmacy, university of karachi; 1997. 38. glycine max subsp. soja (siebold & zucc.) h.ohashi. plants of the world online, kew science. available online: http: //www.plantsoftheworldonline.org/taxon/urn:lsid:ipni.org:name s:920989-1. 39. wang kj, li xh, zhang jj, chen h, zhang zl, yu gd. natural introgression from cultivated soybean (glycine max) into wild soybean (glycine soja) with the implications for origin of populations of semi-wild type and for biosafety of wild species in china. genetic resources and crop evolution. 2010; 57(5):747-61. https://doi.org/10.1007/s10722-009-9513-4 40. kuroda y, kaga a, tomooka n, yano h, takada y, kato s, vaughan d. qtl affecting fitness of hybrids between wild and cultivated soybeans in experimental fields. ecology and evolution. 2013; 3(7):2150-68. https://doi.org/10.1002/ece3.606 41. xu z, ren t, marowa p, you x, lu x, li y, zhang c. establishment of a cultivation mode of glycine soja, the bridge of phytoremediation and industrial utilization. agronomy. 2020; 10(4):595. https://doi.org/10.3390/agronomy10040595 42. nawaz ma, lin x, chan tf, ham j, shin ts, ercisli s, golokhvast ks, lam hm, chung g. korean wild soybeans (glycine soja sieb & zucc.): geographic distribution and germplasm conservation. agronomy. 2020; 10(2):214. https://doi.org/10.3390/agronomy10020214 43. murphy pa, barua k, hauck cc. solvent extraction selection in the determination of isoflavones in soy foods. journal of chromatography b. 2002; 777(1-2):129-38. https://doi.org/10.1016/s1570-0232(02)00342-2 44. european medicines agency (ema); committee on herbal medicinal products (hmpc). ema/hmpc/220598/2016. assessment report on glycine max (l.) merr., lecithinum; ema: amsterdam, the netherlands; hmpc: london, uk, 2017; 31: 2-27. 45. izumi t, piskula mk, osawa s, obata a, tobe k, saito m, kataoka s, kubota y, kikuchi m. soy isoflavone aglycones are absorbed faster and in higher amounts than their glucosides in humans. the journal of nutrition. 2000; 130(7):1695-9. https://doi.org/10.1093/jn/130.7.1695 46. khare b, jain d, jain m, jain d, khangar pk, jain dk. an overview of lassa fever, an rising old world haemorrhagic viral disease, asian journal of dental and health sciences. 2022; 2(1):20-26. https://doi.org/10.22270/ajdhs.v2i1.12 47. skledar dg, tvrdý v, kenda m, zega a, pour m, horký p, mladěnka p, dolenc ms, mašič lp. applicability of the oecd 455 in-vitro assay for determination of hera agonistic activity of isoflavonoids. toxicology and applied pharmacology. 2020; 386:114831. https://doi.org/10.1016/j.taap.2019.114831 48. messina m. soy and health update: evaluation of the clinical and epidemiologic literature. nutrients. 2016; 8(12):754. https://doi.org/10.3390/nu8120754 49. pizzorno e, murray mt. a textbook of natural medicine,(4thedn). churchill livingstone, an imprint of elservier inc. 2013; 355. 50. european medicines agency (ema); committee on herbal medicinal products (hmpc). ema/hmpc/48744/2017 assessment report on cimicifuga racemosa (l.) nutt., rhizome; ema: amsterdam, the netherlands; hmpc: london, uk, 2017; 44: 1-64. 51. european medicines agency (ema); committee on herbal medicinal products (hmpc). ema/hmpc/48745/2017 european union herbal monograph on cimicifuga racemosa (l.) nutt., rhizoma; ema: amsterdam, the netherlands; hmpc: london, uk, 2017; 44: 1-8. 52. kennelly ej, baggett s, nuntanakorn p, ososki al, mori sa, duke j, coleton m, kronenberg f. analysis of thirteen populations of black cohosh for formononetin. phytomedicine. 2002; 9(5):461-7. https://doi.org/10.1078/09447110260571733 53. he k, zheng b, kim ch, rogers l, zheng q. direct analysis and identification of triterpene glycosides by lc/ms in black cohosh, cimicifuga racemosa, and in several commercially available black cohosh products. planta medica. 2000; 66(07):635-40. https://doi.org/10.1055/s-2000-8619 54. reame ne, lukacs jl, padmanabhan v, eyvazzadeh ad, smith yr, zubieta jk. black cohosh has central opioid activity in postmenopausal women: evidence from naloxone blockade and pet neuroimaging studies. menopause (new york, ny). 2008; 15(5):832. https://doi.org/10.1097/gme.0b013e318169332a 55. rhyu mr, lu j, webster de, fabricant ds, farnsworth nr, wang zj. black cohosh (actaea racemosa, cimicifuga racemosa) behaves as a mixed competitive ligand and partial agonist at the human μ opiate receptor. journal of agricultural and food chemistry. 2006; 54(26):9852-7. https://doi.org/10.1021/jf062808u 56. powell sl, go decke t, nikolic d, chen sn, ahn s, dietz b, farnsworth nr, van breemen rb, lankin dc, pauli gf, bolton jl. in vitro serotonergic activity of black cohosh and identification of n ω-methylserotonin as a potential active constituent. journal of agricultural and food chemistry. 2008; 56(24):11718-26. https://doi.org/10.1021/jf803298z 57. cicek ss, khom s, taferner b, hering s, stuppner h. bioactivityguided isolation of gabaa receptor modulating constituents from the rhizomes of actaea racemosa. journal of natural products. 2010; 73(12):2024-8. https://doi.org/10.1021/np100479w 58. cui g, leng h, wang k, wang j, zhu s, jia j, chen x, zhang w, qin l, bai w. effects of remifemin treatment on bone integrity and remodeling in rats with ovariectomy-induced osteoporosis. plos one. 2013; 8(12):e82815. https://doi.org/10.1371/journal.pone.0082815 59. choi em. deoxyactein stimulates osteoblast function and inhibits bone‐resorbing mediators in mc3t3‐e1 cells. journal of applied toxicology. 2013; 33(3):190-5. https://doi.org/10.1002/jat.1733 60. nema p, jain s, vishwakarma h, purohit a, jain pk. a complete review on aromatherapy: a complementary alternative medication therapy with recent trend. international journal of medical sciences and pharma research, 2021; 7(4): 1-7. https://doi.org/10.13080/z-a.2015.102.057 https://doi.org/10.13080/z-a.2015.102.057 https://doi.org/10.1080/j157v02n03_06 https://doi.org/10.1080/10408398.2021.1895054 https://doi.org/10.1016/s0031-9422(99)00181-8 https://doi.org/10.1007/s10722-009-9513-4 https://doi.org/10.1002/ece3.606 https://doi.org/10.3390/agronomy10040595 https://doi.org/10.3390/agronomy10020214 https://doi.org/10.1016/s1570-0232(02)00342-2 https://doi.org/10.1093/jn/130.7.1695 https://doi.org/10.22270/ajdhs.v2i1.12 https://doi.org/10.1016/j.taap.2019.114831 https://doi.org/10.3390/nu8120754 https://doi.org/10.1078/09447110260571733 https://doi.org/10.1055/s-2000-8619 https://doi.org/10.1097/gme.0b013e318169332a https://doi.org/10.1021/jf062808u https://doi.org/10.1021/jf803298z https://doi.org/10.1021/np100479w https://doi.org/10.1371/journal.pone.0082815 https://doi.org/10.1002/jat.1733 vishwakarma et al asian journal of dental and health sciences. 2022; 2(2):1-8 [8] ajdhs.com 61. schulz v, hänsel r, blumenthal m, tyler ve. rational phytotherapy: a reference guide for physicians and pharmacists. springer science & business media; 2004; 15. https://doi.org/10.1007/978-3-662-09666-6 62. certo g, costa r, d'angelo v, russo m, albergamo a, dugo g, germanò mp. anti-angiogenic activity and phytochemical screening of fruit fractions from vitex agnus castus. natural product research. 2017; 31(24):2850-6. https://doi.org/10.1080/14786419.2017.1303696 63. chen sn, friesen jb, webster d, nikolic d, van breemen rb, wang zj, fong hh, farnsworth nr, pauli gf. phytoconstituents from vitex agnus-castus fruits. fitoterapia. 2011; 82(4):528-33. https://doi.org/10.1016/j.fitote.2010.12.003 64. masada s. authentication of the botanical origin of western herbal products using cimicifuga and vitex products as examples. journal of natural medicines. 2016; 70(3):361-75. https://doi.org/10.1007/s11418-016-1006-0 65. oshima n, masada s, suzuki r, yagi k, matsufuji h, suenaga e, takahashi y, yahagi t, watanabe m, yahara s, iida o. identification of new diterpenes as putative marker compounds distinguishing agnus castus fruit (chaste tree) from shrub chaste tree fruit (viticis fructus). planta medica. 2016; 82(01/02):147-53. https://doi.org/10.1055/s-0035-1558089 66. european directorate for the quality of medicines (edqm). european pharmacopoeia (ph. eur.), 10th ed.; council of europe: strasbourg, france, 2019. 67. vishwakarma h, thakur k, purohit a, jain s, nema p, jain pk. a herbal approach for the treatment of kidney stone. international journal of medical sciences and pharma research, 2022; 8(1): 1-9. 68. oenothera biennis l. plants of the world online, kew science. available online: http://www.plantsoftheworldonline.org/taxon/ urn: lsid: ipni.org: names: 172755-2. 69. qureshi a, jain pk, shrivastava a, jain s, nema p, jain h. evaluation of antidepressant activity of aqueous and ethanolic extracts of glycyrrhiza glabra. asian journal of pharmaceutical education and research, 2022; 11(2): 84-92. 70. european medicines agency (ema); committee on herbal medicinal products (hmpc). ema/hmpc/753041/2017 european union herbal monograph on oenothera biennis l. or oenothera lamarckiana l., oleum; ema: amsterdam, the netherlands; hmpc: london, uk, 2018; 44:1-6. 71. cerin a, collins a, and bm, eneroth p. hormonal and biochemical profiles of premenstrual syndrome: treatment with essential fatty acids. acta obstetricia et gynecologica scandinavica. 1993; 72(5):337-43. https://doi.org/10.3109/00016349309021108 72. horrobin df. the role of essential fatty acids and prostaglandins in the premenstrual syndrome. the journal of reproductive medicine. 1983; 28(7):465-8. 73. brush mg, watson sj, horrobin df, manku ms. abnormal essential fatty acid levels in plasma of women with premenstrual syndrome. american journal of obstetrics and gynecology. 1984; 150(4):363-6. https://doi.org/10.1016/s0002-9378(84)80139-8 74. puolakka j, mäkäräinen l, viinikka l, ylikorkala o. biochemical and clinical effects of treating the premenstrual syndrome with prostaglandin synthesis precursors. the journal of reproductive medicine. 1985; 30(3):149-53. 75. pye jk, mansel re, hughes le. clinical experience of drug treatments for mastalgia. the lancet. 1985; 326(8451):373-7. https://doi.org/10.1016/s0140-6736(85)92506-1 76. massil hy, o'brien ps. approach to the management of premenstrual syndrome. clinical obstetrics and gynecology. 1987; 30(2):443-52. https://doi.org/10.1097/00003081-19870600000024 77. hoberg e, orjala j, meier b, sticher o. diterpenoids from the fruits of vitex agnus-castus. phytochemistry. 1999; 52(8):1555-8. https://doi.org/10.1016/s0031-9422(99)00181-8 78. wuttke w, jarry h, christoffel v, spengler b, seidlova-wuttke d. chaste tree (vitex agnus-castus)-pharmacology and clinical indications. phytomedicine. 2003; 10(4):348-57. https://doi.org/10.1078/094471103322004866 79. marjoribanks j, brown j, o'brien pm, wyatt k. selective serotonin reuptake inhibitors for premenstrual syndrome. cochrane database of systematic reviews. 2013(6). https://doi.org/10.1002/14651858.cd001396.pub3 80. kilicdag eb, tarim e, bagis t, erkanli s, aslan e, ozsahin k, kuscu e. fructus agni casti and bromocriptine for treatment of hyperprolactinemia and mastalgia. international journal of gynecology & obstetrics. 2004; 85(3):292-3. https://doi.org/10.1016/j.ijgo.2004.01.001 81. purohit a, jain s, nema p, jain dk, vishwakarma h, jain pk. a comprehensive review on tailoring an herbal approach for treatment of poly cystic ovarian syndrome. asian journal of dental and health sciences, 2022; 2(1): 27-32. 82. jain s, purohit a, nema p, vishwakarma h, jain pk. a brief review on nutraceuticals and its application. asian journal of dental and health sciences, 2022; 2(1): 7-13. https://doi.org/10.1007/978-3-662-09666-6 https://doi.org/10.1080/14786419.2017.1303696 https://doi.org/10.1016/j.fitote.2010.12.003 https://doi.org/10.1007/s11418-016-1006-0 https://doi.org/10.1055/s-0035-1558089 https://doi.org/10.3109/00016349309021108 https://doi.org/10.1016/s0002-9378(84)80139-8 https://doi.org/10.1016/s0140-6736(85)92506-1 https://doi.org/10.1097/00003081-198706000-00024 https://doi.org/10.1097/00003081-198706000-00024 https://doi.org/10.1016/s0031-9422(99)00181-8 https://doi.org/10.1078/094471103322004866 https://doi.org/10.1002/14651858.cd001396.pub3 https://doi.org/10.1016/j.ijgo.2004.01.001 meena et al asian journal of dental and health sciences. 2021; 1(1):10-13 [10] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2021 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited application of moringa oleifera in dentistry raghunandan meena1, sunil kumar prajapati2, rajendra nagar3, omji porwal4, teena nagar5, vijay kumar tilak6, r. jayakumararaj 7, rajeshwar kamal kant arya8, ram chand dhakar*9 1 professor, department of general medicine, jhalawar medical college, jhalawar, rajasthan, india 2 professor, institute of pharmacy, bundelkhand university, jhansi, india 3 associate professor, department of paediatrics, jhalawar medical college, jhalawar, rajasthan, india 4 professor, department of pharmacognosy, faculty of pharmacy, tishk international university-erbil, kurdistan region, iraq 5 associate professor, department of gynaecology, jhalawar medical college, jhalawar, rajasthan, india 6 apex professional university, pasighat, arunachal pradesh-791102, india 7 pg department of botany, government arts college, melur – 625106, madurai district, tn, india 8 assistant professor, deparment of pharma sciences, kumaun university nainital, india 9 hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001 article info: _________________________________________ article history: received 07 nov 2021 reviewed 13 dec 2021 accepted 18 dec 2021 published 25 dec 2021 _________________________________________ cite this article as: meena r, prajapati sk, nagar r, porwal o, nagar t, tilak vk, jayakumararaj r, arya rkk, dhakar rc, application of moringa oleifera in dentistry, asian journal of dental and health sciences. 2021; 1(1):10-13 doi: http://dx.doi.org/10.22270/ajdhs.v1i1.5 abstract ___________________________________________________________________________________________________________________ all part of the moringa tree is useful in some way and people depends on it for their livelihood. oral diseases persist to be a major health problem all over the world. various microorganisms are found to be the possible pathogens responsible for the oral diseases. the leaves of the moringa tree are an excellent source of nutrients like minerals, protein and vitamins (a and c). moringa tree has approximately 46 antioxidants and it is one of the cheapest sources of natural anti-oxidants. antioxidants supply the free atoms needed by the human body and mitigate the effect of free radicals. m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids which possess antibacterial effects. moringa oleifera has high mineral and protein content and has been previously investigated for its potential in treating different oral soft tissue diseases. present review summarises the various application of moringa oleifera in the field of dentistry. keywords: moringa oleifera, anti-oxidants, oral diseases, dentistry *address for correspondence: ram chand dhakar, hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001. email: dhakar_rc@yahoo.co.in introduction moringa oleifera is the most widely cultivated pantropical species of a monogeneric family, the moringaceae, which is native to the sub-himalayan tracts of india, pakistan, bangladesh and afghanistan. moringa oleifera is known by such regional names as benzolive, drumstick tree, kelor, marango, mlonge, mulangay, nébéday, saijhan, and sajna.1. virtually every part of the tree is beneficial in some way and both rural and urban people depend on it for their livelihood. in developing tropical countries, moringa trees have been used to combat malnutrition, especially among infants and nursing mothers 2,3. the leaves of the moringa tree are an excellent source of nutrients like minerals, protein and vitamins (a and c) 4, 5, 6, moringa has approximately 46 antioxidants and is one of the most powerful sources of natural anti-oxidants. anti-oxidants supply the free atoms needed by the human body and mitigate the effect of free radicals. m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids which possess antibacterial effects. open access review article doi: http://dx.doi.org/10.22270/ajdhs.v1i1.5 http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v1i1.5 https://orcid.org/0000-0001-8250-8489 meena et al asian journal of dental and health sciences. 2021; 1(1):10-13 [11] ajdhs.com figure 1: various parts of moringa oleifera 7-14 moringa oleifera in dentistry moringa has approximately 46 antioxidants and is one of the most powerful sources of natural anti-oxidants. anti-oxidants supply the free atoms needed by the human body and mitigate the effect of free radicals. m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids which possess antibacterial effects hence it can be used as safe and cheap plant antimicrobial agent. the extract from leaves of moringa oleifera has high mineral and protein content and its historic reputation as a traditional medicine for different diseases has been previously investigated for its potential in treating different oral soft tissue diseases 15, 16. moringa oleifera extract contains the highest values of calcium and phosphate that are required for the remineralization process. therefore moringa oleifera extract is investigated by younis et al for its ability to treat induced enamel lesion.17 scanning electron microscopy revealed that leaves extract of moringa oleifera loaded-varnish groups iv & v showed the most re-establishment of normal enamel architecture. elemental analysis of the treated surfaces of groups iv and v showed the surfaces treated by moringa oleifera leaf extract loaded-varnish groups had significantly higher ca, p, and o deposition than the fluoride varnish group. leaves extract of moringa oleifera might be considered as a biomimetic material which having capacity to guiding enamel tissue remineralization.17 hanaa elgamily et al carried out a study to assess the antibacterial and antifungal potentials of different parts of moringa oleifera plant using different extraction methods in attempts to formulate natural dental remedies from this plant. the different extracts of different parts of moringa oleifera showed an antibacterial effect against staphylococcus aureus and streptococcus mutans growth. the novel toothpaste of ethanolic leaves extract has antimicrobial and antifungal potential effects all selected strains.18 based on the results of the study by risnayanti anas et al, it can be concluded that there is an increase in the amount of calcium in the teeth after the application of moringa oleifera based paste and casein phosphopeptide-amorphous calcium phosphate (cppacp) application. moringa oleifera based paste and cppapp are effective to increasing calcium levels in teeth compared to the pre-test group.19 dental caries is closely related with cariogenic biofilm, an oral biofilm containing a high proportion of streptococcus mutans 20. generally, oral biofilm is structurally and functionally organized and contains a balance of normal flora and pathogenic bacteria like s. mutans 21. su-kyung jwa has investigated the antimicrobial effects of the m. oleifera leaf extracts on s. mutans and formation of cariogenic biofilm. extract from m. oleifera leaves was derived using distilled water (dw) and ethyl alcohol (etoh). s. mutans susceptibility assays were performed for each extract. cariogenic biofilm was formed with or without dw and etoh extract, and cariogenic biofilm was treated with both extracts. both extracts showed antimicrobial activity against s. mutans and inhibited formation of cariogenic biofilm. 22 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7522384/#bib6 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7522384/#bib7 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6779079/#b11-pnfs-24-308 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6779079/#b13-pnfs-24-308 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 meena et al asian journal of dental and health sciences. 2021; 1(1):10-13 [12] ajdhs.com table 1: application of moringa oleifera in dentistry s.n. author objective of study application ref 1 rao p k, et al 2011 to assess the antibacterial activity of isolated compounds from m. oleifera against selected oral bacteria all the isolated compounds from m. oleifera were active against streptococcus mutans (mtcc 497), streptococcus salivarius, lactobacillus fermentum, streptococcus anginosus, streptococcus gordonii, lactobacillus acidophilus. 23 2 hanaa elgamily et al 2016 to assess the antibacterial and antifungal potentials of different parts of moringa oleifera for dental remedies, experimental toothpaste exhibited higher mean inhibition than the mouthwash against staphylococcus aureus, streptococcus mutans and only the toothpaste revealed antifungal effect against candida albicans 18 4 carranza j b, 2017 to identify the secondary compounds of three varieties of moringa oleifera lam. extracts namely; native, chinese, and yard long malunggay using phytochemical analysis the extracts of moringa varieties contain flavonoids, alkaloids and tannins that are known to have antimicrobial and anti-inflammatory properties; thus, these have potential natural components in the manufacture of toothpastes 24 5 su-kyung jwa et 2019 to investigate the antimicrobial effects of the m. oleifera leaf extracts extracts showed antimicrobial activity against s. mutans and inhibited formation of cariogenic biofilm 22 6 piasti sopandani et al 2020 to assess the antibacterial effect of m. oleifera extract as an irrigation solution against e. faecalis m. oleifera extract solution at concentrations of 75% and 100% is as effective as 5.25% naocl against e. faecalis 25 7 mahassen m farghaly et al 2020 to formulate a nontoxic mouthwash from moringa oleifera moringa extract showing antibacterial and antiplaque effect will be used 26 8 younis sh 2020 to assess the effect of leaves extract of moringa oleifera loaded-varnish groups iv & v on enamel moringa leaf extract loaded-varnish groups had significantly higher ca, p, and o deposition than the fluoride varnish group. leaves extract of moringa oleifera might be considered as a biomimetic material which having capacity to guiding enamel tissue remineralization 17 9 anas r et al 2021 to study the effectiveness of paste based moringa oleifera to increase calcium levels human tooth results of this research showed that moringa oleifera paste has higher calcium level compared to pre-test groups and moringa oleifera paste can be effective in increasing calcium levels of human teeth 19 10 nawal aidaros et al 2021 to investigate and compare the effect of green tea, black tea and moringa oleifera on artificially demineralized enamel and dentin in dentin, the highest mean value was found in moringa oleifera. study concluded that moringa tree enhanced the remineralization process and thus, might be considered as an effective natural remineralizing agents 27 11 buakaew et al 2021 moringa oleifera and azadirachta indica were assessed for oral healthcare and gingivitis adjunctive treatment author state that accumulative reduction percentages of both staphylococcus spp. and candida spp. were found and indicated that the herbal mouthwashes reduced gingival index and plaque index and showed potential as oral healthcare products 28 conclusion m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids which possess antibacterial effects hence it can be used as safe and cheap plant antimicrobial agent. the extract from leaves of moringa oleifera has high mineral and protein content. as traditional medicine it has potential in treating different oral soft tissue diseases. study by nawal aidaros et al concluded that moringa oleifera enhanced the remineralization process of demineralized enamel and dentin, and thus, might be considered as an effective natural remineralizing agent27. further research on moringa oleifera needed to exploit the pharmacological uses for management and prevention of oral disease. https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 meena et al asian journal of dental and health sciences. 2021; 1(1):10-13 [13] ajdhs.com references 1 dhakar rc, maurya sd, pooniya bk, bairwa n, gupta m, s. moringa: the herbal gold to combat malnutrition. chron young sci 2011; 2:119-25. https://doi.org/10.4103/2229-5186.90887 2. dahot mu, memon ar, nutritive significance of oil extracted from moringa oleifera seeds. j pharm univ kar 1985; 3:75-80 3. ram j. moringa a highly nutritious vegetable tree, tropical rural and island/ atoll development experimental station (triades), technical bulletin. 1994; 2. 4. abrams b, duncan d, hertz piccioto i. a prospective study of dietary intake and acquired immune deficiency syndrome in hiv seropositive homosexsual men. j acquir immune defic syndr 1993; 8:949-58. 5. anwar f, bhanger mi. analytical characterization of moriga oleifera seed oil growth in temperate region of pakistan. j agric food chem 2003; 51:655863. https://doi.org/10.1021/jf0209894 6. prakash ao. ovarian response to aqueous extract of moringa oleifera during early pregnancy in rats. fitoterapia 1988; 59:8996 7. gopalan, c, rama bv, balasubramanian sc. nutritive value of indian foods. hyderabad, india: (national institute of nutrition), 1971 8. fuglie, lowell j, editor. the miracle tree—moringa oleifera: natural nutrition for the tropics. training manual. 2001. dakar, senegal: church world service; 2002. 9. price ml. “the moringa tree.” educational concerns for hunger organization (echo) technical note. 1985 (revised 2002). may 2002. 10. de saint sauveur, armelle. “moringa exploitation in the world: state of knowledge and challenges.” development potential for moringa products. dar es salaam, tanzania, international workshop; 2001. https://doi.org/10.1007/bf02887070 11. morton jf. “the horseradish tree, moringa pterygosperma (moringaceae)-a boon to arid lands?” econ bot 1991; 5:318-33. 12. indian gyan. the source for alternative medicines and holistic health. home remedies for common ailments. 2002. 13. bakhru hk. foods that heal: the natural way to good health. south asia, south asia books; 1995. 14. new crop resource online program (newcrop). “moringa oleifera lam.” 1998. purdue u. jan. 2005. 15. el-sharkawy r.t., el-kammar h.a., obeid r.f., bdelkhalek a.a. effects of moringa oleifera aqueous leaf extract on submandibular salivary glands of diabetic albino rats. egypt. dent. j. 2018; 64(issue 2-april):1293– 1303. https://doi.org/10.21608/edj.2018.77385 [google scholar] 16. elkammar hala, obeid raneem f., radwa t.e. 2019. potential therapeitic effect of moringa oleifera on tongue; pp. 2–8. (june) [google scholar] 17. younis sh, obeid rf, ammar mm, subsurface enamel remineralization by lyophilized moringa leaf extract loaded varnish, heliyon. 2020; 6(9):e05054. 10.1016/j.heliyon.2020.e05054 pmcid: pmc7522384 pmid: 33015394 18. elgamily h, moussa a, elboraey a, el-sayed h, al-moghazy m, abdalla a. microbiological assessment of moringa oleifera extracts and its incorporation in novel dental remedies against some oral pathogens. open access maced j med sci. 2016; 4(4):585-90. https://doi.org/10.3889/oamjms.2016.132 19. anas r, mattulada ik, akbar fh, indriany l, asmah n, irawati e, utama md, effectiveness of paste based moringa oleifera to increase calcium levels human tooth (in vitro), nat. volatiles & essent. oils, 2021; 8(4):15193-15201 20 lee sh, kim yj. a comparative study of the effect of probiotics on cariogenic biofilm model for preventing dental caries. arch microbiol. 2014; 196:601–609. doi: https://doi.org/10.1007/s00203-014-0998-7 . 21 marsh pd. microbial ecology of dental plaque and its significance in health and disease. adv dent res. 1994; 8:263–271. doi: https://doi.org/10.1177/08959374940080022001 22. jwa sk. efficacy of moringa oleifera leaf extracts against cariogenic biofilm. prev nutr food sci. 2019; 24(3):308-312. doi: https://doi.org/10.3746/pnf.2019.24.3.308 23. rao pk, rao db, kiran c, et al. in vitro antibacterial activity of moringa oleifera against dental plaque bacteria. journal of pharmacy research 2011; 4(3):695-742 24. carranza jb, molina pg, ortañez jjr, et al. flavonoids, alkaloids and tannins of three varieties of horse radish (moringa oleifera lam.) extracts: potential components of toothpastes. international scholars conference proceeding 2017; 5(1):30-3. 25. piasti s, ongki ib, taufiq a, sadono dm, antibacterial effects of moringa oleifera leaf extract against enterococcus faecalis in vitro. scientific dental journal, 2020; 4(1):16-20. doi: https://doi.org/10.4103/sdj.sdj_43_19 26. mahassen m farghaly, shahinaz g elashiry, anticariogenic effect of moringa oleifera mouthwash compared to chlorhexidine mouthwash clinicaltrials.gov identifier: nct04575948. 27. aidaros n, mosallam r, farouk h, effect of green tea, black tea and moringa oleifera on remineralization of artificially demineralized enamel and dentin: an in-vitro microhardness analysis, advanced dental journal, 2021; 3(1):24-34 https://doi.org/10.21608/adjc.2020.34873.1072 28. buakaew w, sranujit rp, noysang c, sangouam s, suphrom n, thongsri y, potup p, usuwanthim k. evaluation of mouthwash containing citrus hystrix dc., moringa oleifera lam. and azadirachta indica a. juss. leaf extracts on dental plaque and gingivitis. plants. 2021; 10(6):1153. https://doi.org/10.3390/plants10061153 https://doi.org/10.4103/2229-5186.90887 https://doi.org/10.1021/jf0209894 https://doi.org/10.1007/bf02887070 https://doi.org/10.21608/edj.2018.77385 https://scholar.google.com/scholar_lookup?journal=egypt.+dent.+j.&title=effects+of+moringa+oleifera+aqueous+leaf+extract+on+submandibular+salivary+glands+of+diabetic+albino+rats&author=r.t.+el-sharkawy&author=h.a.+el-kammar&author=r.f.+obeid&author=a.a.+bdelkhalek&volume=64&issue=issue+2-april&publication_year=2018&pages=1293-1303& https://scholar.google.com/scholar?q=elkammar+hala+obeid+raneem+f.+radwa+t.e.+potential+therapeitic+effect+of+moringa+oleifera+on+tongue+(june)+2019+2+8+ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7522384/ https://dx.doi.org/10.1016%2fj.heliyon.2020.e05054 https://www.ncbi.nlm.nih.gov/pubmed/33015394 https://doi.org/10.3889/oamjms.2016.132 https://doi.org/10.1007/s00203-014-0998-7 https://doi.org/10.1177/08959374940080022001 https://doi.org/10.3746/pnf.2019.24.3.308 https://doi.org/10.4103/sdj.sdj_43_19 https://clinicaltrials.gov/ct2/show/nct04575948 purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [27] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a comprehensive review on tailoring an herbal approach for treatment of poly cystic ovarian syndrome arpana purohit1*, sameeksha jain1, prakhar nema1, deepak kumar jain2, harshna vishwakarma1, prateek kumar jain1 1 adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 2 sun institute of pharmaceutical education & research (siper), bhatpura road, lahar, bhind, mp, 477445 article info: _________________________________________ article history: received 13 jan 2022 reviewed 26 feb 2022 accepted 07 march 2022 published 15 march 2022 _________________________________________ cite this article as: purohit a, jain s, nema p, jain dk, vishwakarma h, jain pk, a comprehensive review on tailoring an herbal approach for treatment of poly cystic ovarian syndrome, asian journal of dental and health sciences. 2022; 2(1):27-32 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.13 _________________________________________ *address for correspondence: arpana purohit, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ the review gives a brief about poly cystic ovarian syndrome (pcos) and the symptoms related to the disease. around 2.2 to 26% of cases of pcos are present globally. the disorder generally occurs in the reproductive age group of women. the review has a mention of few herbs which can be used to correct the diseased condition. the various herbs have a positive effect on the diseased condition and can be used to cure symptoms like hypothyroidism, hyperplasia, obesity, diabetes, menorrhagia, sleep disturbances, cardiovascular problems, hyperlipidemia, hirsutism, infertility, irregular menstrual cycle, etc. the herbs included in the review include bauhinia variegata useful in hormone imbalance, phyllanthus emblica, terminalia bellirica, terminalia chebula, and commiphora wightii are used to regulate the hormones, cinnamon cassia acts as an anti-oxidant, tribulus terrestris improves reproductive dysfunction, hypericum perforatum regulates depression, commiphora myrrha prevents menorrhagia, nigella sativa controls cholesterol, saraca asoca has estrogenic action, asparagus racemosus promotes folliculogenesis, tinospora cordifolia regulates menstrual flow, ocimum sanctum as an anti-oxidant. the plants taken had a positive effect on women with pcos without causing any side effects. the natural herbs used for the treatment of pcos did not have any side effects and treated the diseased condition naturally. this review aims to understand the natural plants available for the treatment of the disease naturally. the herbs can be used individually or can be used in combination. keywords: poly cystic ovarian syndrome, herbal medicine, herbs, natural plants email: tanuprht@gmail.com introduction one of the most prevalent disorders that affect both the metabolic and reproductive systems is polycystic ovary syndrome (pcos). the main symptoms of pcos are hyperandrogenism, persistent an ovulation and irregular menstrual periods 1, 2. there is no one effective treatment for this illness since its pathophysiology is still unclear, despite the fact that it likely has epigenetic roots3, 4. for pcos, various pharmaceutical therapies have been suggested. although they have drawbacks including side effects, low patient compliance with long-term pharmaceutical therapies, low efficacy, and occasionally contraindications, complementary treatments can be a good substitute1-5. a complex but frequent condition known as polycystic ovarian syndrome typically affects females in the reproductive age group. nearly 70% of women who struggle with ovulation due to this condition develop sub fertility. the polycystic ovarian syndrome hinders the ovaries from functioning normally because the ovaries have cysts on them. obesity or increased weight, high blood pressure, diabetes, dysfunctional lipid profiles, dandruff on the scalp or oily skin, dark patches on the neck and underarms, chronic pelvic pain, acne, increased levels of male hormones causing hair thinning and baldness in the male pattern, excessive hair growth on the body and face, and, in the case of women, menstruation are some of the underlying symptoms of this disorder9. improper metabolism of estrogen, androgen, and the generation of regulated amounts of androgen are the main underlying causes of pcos in females 10. women have been reported to have low-grade inflammation and insulin resistance. pcos is negatively impacted by some circumstances, including dietary modifications, lifestyle adjustments, and exposure to some environmental contaminants. it may cause major health concerns if left untreated. additionally, it directly affects fertility11. the most popular pcos treatment options available today are oral contraceptives. they work by lowering blood levels of free androgens and preventing the release of gonadotropins12. letrozole, an aromatase inhibitor, and clomiphene citrate, a non-steroidal selective estrogen receptor modulator (serm), are frequently used to induce ovulation. although there is accumulating evidence that letrozole has superior efficacy and safety for the mother and fetus13, 14, clomiphene citrate is still the first-line medication. insulin resistance, a crucial component of the rotterdam criteria, is treated with metformin in pcos patients. overall, treating insulin resistance and hyperandrogenism enhances metabolic, reproductive, and hormonal processes14. in recent years, the usage of complementary therapies has grown, and currently, 40% of individuals benefit from them15, 16. a neuroendocrine characteristic of pcos includes increased luteinizing hormone secretion frequency, luteinizing hormone serum concentration rise, luteinizing hormone amplitude increase, and ratio of lh/fsh increase17. the development of pcos is also brought open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.13 purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [28] ajdhs.com on by the interaction of numerous environmental and genetic variables. it is typically found in obese, less active or exercisechallenged women with a family history of pcos. ovarian cysts are among the symptoms that are employed in the therapy of the disorder, along with the absence of ovulation and excessive testosterone levels. the presence of any cysts can be determined using ultrasound techniques. the diagnosis of the illness can also be made using a number of additional factors, such as hypothyroidism, hyperplasia, and increased blood prolactin levels18. according to recent studies, there is currently little to no cure for pcos. the only way to address the condition is to slightly alter your lifestyle, such as through exercise and weight loss. the regularity of the menstrual cycle can be maintained with the use of birth control pills, as can skin issues like acne and excessive hair growth. additionally, a variety of methods can be employed to cure acne and remove body hair19. lifestyle modification is the current treatment for pcos corresponding to pharmacological interventions. to overcome this condition, modifications are to be made in the lifestyle such as proper exercise, diet, and also loss of weight. agents that lower insulin, certain anti-androgens, and progestinestrogen in combination comes under the category of pharmacological intervention. this category of treatment causes various problems and side-effects as they are expensive. the side effects can be gain of weight, irregular menstrual cycle, gastrointestinal problems, and also insulin resistance20.therefore, at present, lifestyle modification and diet alterations are the major concern for the abovementioned gynecological diseases. also, more and more patients are opting for herbal treatment. this review defines the few natural herbs used for the treatment and their role in the treatment of complications related to pcos as described in table 1. table 1 herbs used in the treatment of associated pcos complications herb used for treatment symptom/complication associated with pcos  tribulus terrestris reproductive dysfunction  cinnamon cassia  ocimum sanctum anti-oxidant  bauhinia variegata hormonal imbalance  phyllanthus emblica,  terminalia bellirica,  terminalia chebula, and  commiphora wightii regulation of hormones  hypericum perforatum depression & mood swings  commiphora myrrha menorrhagia  nigella sativa cholesterol  saraca asoca estrogenic action  tinospora cordifolia regulation of menstrual flow  asparagus racemosus folliculogenesis herbs in the treatment of pcos hypericum perforatum the plant known as st. john's wort, hypericum perforatum, is a member of the hypericaceae family. many nations employ st. john's wort as a medicinal plant. tipton weed, goat weed, and enola weed are some of the other names for st. john's wort. the herb was advised by greek physicians to cure menstruation disturbances21. there are various situations in which the patient's psychological discomfort or psychology could influence the course of treatment or reduce the likelihood of successful outcomes22. any factor that contributes to negative stress or sadness has no beneficial effects on ovarian function or treatment. patients today have more faith in and desire in using natural herbs for therapy and the safe, effective, and natural method of healing. in order to achieve a synergistic impact or to assist the treatment for better results, patients with ovarian dysfunctions and pcos are now utilizing alternative medicine23. in general, women who are of reproductive age utilize st. john's wort extracts, which are widely recognized as synthetic medications that modulate serotonin24, 25. mild depression and mood fluctuations are frequent side effects of pcos; such mild to moderate depression is treated with st. john's wort26. commiphora wightii a therapeutic flowering plant known by many common names, including guggulu, guggul, and gugal, commiphora wightii is a member of the burseraceae family. although it can also be found in central asia, guggul is most frequently found in northern india. guggul extract, also known as guggulipid, is a frequent ingredient in ayurvedic and herbal remedies. guggul contains a variety of therapeutic essential oils, gum extracts, and resinous compounds27. the study demonstrated that guggul reduces the dhea-induced pcos in the ovarian follicles, which is a key factor in minimizing morphological abnormalities. as a result, the hormonal fluctuations return to normal. the study also shown that the dhea-induced pcos profile, which includes the hormones fsh, lh, progesterone, estrogen and testosterone, experienced a sharp rise in hormone levels. elevated glucose levels were also observed28. for the purpose of raising awareness, promoting the use of guggul as a nutritional/dietary supplement, and determining the safety of use in humans, the national institute of health environmental sciences nominated the gum guggul to extract for examination of the toxicological parameters and characterization. gum guggul has been shown to provide advantages for female reproductive organs and hormonal balance29. tribulus terrestris the medicinal plant is a member of the zygophyllaceae family and belongs to the genus tribulus; there are about 20 species in this family. tribulus terrestris, tribulus cistoides, and tribulus alatus are the three principal species found in india30. the medicinal herb utilized in both ayurveda and western medicine is gokhru, one of the three species31. gokhru is utilized industrially for the creation of feed-based additives and medicinal formulations due to its saponin concentration32. the herb contains a variety of compounds, including glycosides, flavonoids, alkaloids, etc.; these compounds are rich in biological significance when taken as a dry extract of the therapeutic plant. according to recent study investigations, the medicinal herb is thought to have an impact and enhance female sexual dysfunction and reproduction. gokhru is seen as a potential alternative therapy for polycystic ovarian disease. using a strong gokhru extract, ovarian activity can be restarted after cysts in the ovaries have been eliminated. it is thought that the medicinal extract affects pcos-affected women's folliculogenesis. the mechanism, however, is still not understood33. herbal medicines are used more frequently than synthetic ones since they have fewer side effects, are more affordable, and are beneficial to the health. they can also be taken for a longer period of time. gokhru is thought to be an ovarian stimulant and a fertility purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [29] ajdhs.com tonic with an impact on women with pcos. as a result, it is a preferred herb for pcos34. asparagus racemosus in conventional ayurvedic medicine, shatavari is a herb used for medicinal purposes that is a member of the asparagaceae family. women utilize the remedy plant for infertility, menstrual cycle control, ovarian follicle formation, and healthy functioning. the plant is thought to contain phytoestrogen, a type of natural plant-based estrogen that helps women's reproductive systems recover. in cases of hyperinsulinemia, it also aids in the body's regulation of insulin35. there was a shatavari effect in young women with pcos. according to a study, the plant is thought to boost the hormone that stimulates the formation of new follicles, increasing folliculogenesis. according to numerous studies36, the weight of the ovaries may also grow. it is also regarded as the herb of choice for issues related to menstruation. shatavari has a number of ingredients that aid in the treatment of issues associated to menstruation, such as menorrhagia, or painful menstrual bleeding, irregular flow, etc. the principal component of shatavari, saponin, aids in maintaining uterine mobility and is hence helpful in reducing unpleasant premenopausal bleeding37. infertility is one of the issues that women deal with. because it promotes folliculogenesis, the herb is useful in the treatment of infertility issues. it gets the womb ready and lowers the likelihood of miscarriages. the roots of shatavari are frequently utilized during abortions to assist the uterine muscles grow stronger38. nigella sativa a plant of significant therapeutic value that can be found all throughout the nation is nigella sativa, also known as kalaunji or black cumin and belonging to the ranunculaceae family. all traditional medical systems, such as ayurveda, unani, siddha, etc., use herbs. the kalaunji plant plays a significant part in the oil and seed portion and is utilized in practically all types of medicine. many illnesses and medical disorders are treated with kalaunji. according to islamic literature39, it is well known to be a curative drug. according to numerous researches, black cumin is thought to be actively employed in the treatment and management of polycystic ovarian syndrome in female patients. women with pcos are thought to have a higher risk of developing cholesterol. kalaunji was therefore seen to have impacted nearly all the metrics, according to the investigations. however, high-density lipoprotein and cholesterol were the main effects. while raising the body's ldl levels, black cumin modulates cholesterol and hdl levels. it has a favorable impact on the lipid profile because of choleretic activity, as was seen in the case of kalaunji. additionally, it's thought that kalaunji's decrease of appetite results in a hypolipidemic profile40. cinnamon cassia the bark of the dalchini tree has been used all over the world as both traditional and modern medicine with a variety of uses in addition to as a spice for cooking. cinnamon trees may be found all over the world, and the dalchini has at least 250 species that have been documented to date41,42. insulin resistance and signs of hyperinsulinemia have been identified in women with pcos. women were shown to have greater levels of insulin resistance than controls. hyperandrogenism and insulin resistance are the main causes of irregular menstruation and anovulation in women. synthetic medications like metformin have helped to address the problem to some extent. they do, however, have gastrointestinal side effects. therefore, pre-clinical and clinical studies on the natural herb dalchini revealed a sensitizing effect. the herb's polyphenols have the ability to increase insulin-dependent glucose metabolism, which changes how glucose is transported. according to the study, dalchini can be used to treat pcos in women since it reduces irregularities in the menstrual cycle and offers efficient treatment without side effects. when compared to a placebo group, the study also reveals that the herb's extract can be utilized to treat irregular menstrual cycles and ovulation43. according to the study, cinnamon extract acts as an antioxidant and enhances lipid profile. as a result, pcos-affected women experience fewer side effects and risk factors44. bauhinia variegata in the tropical and temperate areas of india, there is a tree known as bauhinia variegata or kanchanar, which has been used for many centuries in the ayurveda. kanchanar guggul is the form of kanchanar that is used to treat pcos. it works well to cure a variety of ailments, including pcos, uterine cysts, various joint issues, and hormone imbalances. guggul is known as "guggulu" in sanskrit, and it signifies "to protect from diseases." the purpose of guggul is to boost the lymphatic system's performance as well as the body's ability to rid itself of pollutants. varuna, black pepper, long pepper, a kwath of triphala, pure guggul resin, cardamom, and cinnamon are among the herbs included in kanchanar guggul45. triphala: emblica officinalis, terminalia beletica, terminalia chebula the term "triphala" refers to a combination or mixture of the three fruits amla, haritaki, and baheda. triphala is used to treat pcos because it has anti-inflammatory properties in addition to being an antioxidant and a natural source of vitamin c. triphala also has cleansing and purifying properties that aid in the treatment of pcos. the radicals that triphala scavenges are superoxide and diphenylpicrylhydrazyl. as a result, it has anti-inflammatory properties. free radical scavenging is a characteristic of phenolic compounds, which are found in triphala extracts. by affecting hormone regulation, these chemicals primarily serve to alleviate the issue of menstrual irregularities46. according to ayurveda, "tridoshic rasayana" is a therapeutic agent that affects the three constitutional energies of vata, pitta, and kapha. it has balancing and rejuvenating effects on these energies. triphala is thought to be a combination of vatta, pitta, and kapha according to ayurveda, making it well-balanced and detoxifying. in an old ayurvedic source, triphala is referred to as a tridoshic rasayana, a medicinal substance with rejuvenating and balancing effects on the three humors, or constitutional elements, of vata, pitta, and kapha. amla is chilly in nature, but harad, baheda, and ama have warm energies. because it combines all three, triphala is balanced and effective as a remedy for internal cleaning and detoxification47. saraca asoka leguminosae is the family that the ashoka tree belongs to. the tree's dry bark contains tannins, catechol, and other substances that contain calcium. the asoka tree includes a number of important ions, such as phosphate, sodium, calcium, and magnesium. treatment for pcos, irregular menstruation patterns, uncontrolled profuse bleeding, uterine spasms, mild to severe discomfort, and dysmenorrhea are the main uses of ashoka bark. asoka is regarded as one of the best uterine tonics because it combats irregular menstrual cycles and miscarriage situations. antimenorrhagia or excessive bleeding is treated with the herb. women with pcos and other uterine disorders use both the flower and the bark parts of the plant. uterine hemorrhage can also be treated using asoka's stem. additionally, the oxytocin activity of the herb is said to have thickened the endometrium, the innermost layer of the uterus, helping to prevent uterine diseases. the ashoka is purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [30] ajdhs.com thought to behave similarly to estrogen, promoting healthy uterine function and reducing excessive bleeding. in cases of severe menstrual bleeding, it functions as an astringent. additionally, it induces the uterine muscles to contract. additionally, uterine fibroid and menorrhagia in pcos cases are mentioned in the studies48. ocimum sanctum the main medical applications of the sacred herbal plant tulsi are the management of obesity and hypoglycemia49. because of its anti-androgenic qualities, it is used to treat polycystic ovarian syndrome. it controls obesity and reduces testosterone production50. the body does not use the androgens since the appropriate ovulation process does not occur. unused androgens are the cause of hirsutism and the acne issue. tulsi's function is to maintain and utilize androgen levels appropriately. additionally, it has antioxidant properties51. tinospora cordifolia the scientific name for the family member guduchi is tinospora cordifolia. a medicinal herb known as menispermaceae has a variety of therapeutic benefits, including hypoglycemia, anti-inflammatory, anti-stress, and ovarian balance. the pant uses the stem portion. guduchi's primary use is in the management of pcos. the primary contributors to tissue inflammation are insulin disturbances and ovarian cysts. guduchi is thought to have antiinflammatory properties. it serves to naturally strengthen immunity. women who have pcos develop insulin resistance, which aids in overcoming that resistance. this plant also regulates menstruation flow46. all body tissues are regenerated by guduchi, and it also aids in increasing immunity and metabolism52. commiphora molmol commiphora molmol, also known as commiphora myrrha, is a member of the genus commiphora, which is regarded as having the most species diversity among all the genera of flowering plants and is descended from the family burseraceae. myrrha is known as "murr" in arabic, which means "bitter"; according to the unani school of medicine, "murr" refers to an oleo gum resin that is extracted from the tree's bark. alkaloids, glycosides, volatile oil, saponins, terpenoids, steroids, bitter principle, and others are some of the main phytochemical components of commiphora myrrha53.myrrha is mostly responsible for amenorrhea, or the absence of menstruation. to help the menstrual cycle, myrrh is coupled with iron-rich foods. menorrhagia, which is characterized as a medical disease with copious and protracted bleeding throughout the menstrual period, is another function of myrrh in pcos. myrrh stops excessive blood loss during irregular and protracted bleeding. the resin may also act as an emmenagogue to increase blood flow when there is a uterine irregularity. several uterine infections are treated with oleo-gum resin54. any obstruction in the path of the uterus is one of the herb's most crucial functions, and it also plays a part in brief and irregular periods. it encourages controlling menstrual bleeding55. future aspects of pcos using herbal treatment the disorder known as polycystic ovarian syndrome has a number of long-term, chronic health issues. on the long-term impact of pcos on a woman's health, little research has been done to date. according to numerous studies, pcos can cause women to have a variety of side effects, including mood fluctuations, weight gain, diabetes, heart disease, and miscarriage. choosing the best treatments for women going through the postmenopausal stage is still a challenge. numerous studies indicate that women with pcos had higher bone mineral densities. to understand the health hazards associated with women's aging, more research is needed. identifying the relevant risk factors and genetic alterations both play a crucial role56. a few herbs that can be used to cure polycystic ovarian syndrome naturally and without any negative side effects are listed in the review. the long-term use of synthetic medications is linked to a number of negative side effects; as a result, the symptoms of pcos gradually start to disappear. it is advised to use natural products over the long term57. conclusion according to the review, continuous usage of synthetic medications may result in negative effects. on the other hand, herbal medications are secure and offer therapeutic activity without any negative side effects when used for a long period of time. a number of herbs can be taken singly or in combination to reduce pcos risk factors. additionally, it was shown that combining a few herbs results in a synergistic impact. it is more common to see the pharmacological action in combination than as a single component. a number of market concoctions combine a number of plants, and each herb enhances the pharmacological effects of the others. consequently, choosing the right herbs and their interactions is equally crucial. there are several herbal products offered for pcos, including well-known manufacturers like himalaya, patanjali, dabur, baidyanath, etc. all these marketed preparations have herbal drugs or a combination of herbal drugs. references 1. eshre tr. asrm-sponsored pcos consensus workshop group. revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. fertil steril., 2004; 81(1):19-25. https://doi.org/10.1016/j.fertnstert.2003.10.004 2. ozcan dag z, alpua m, isik y, buturak sv, tulmac ob, turkel y. the evaluation of temperament and quality of life in patients with polycystic ovary syndrome. gynecol endocrinol., 2017; 33(3):2503. https://doi.org/10.1080/09513590.2016.1254610 3. celik o, acbay o. effects of metformin plus rosuvastatin on hyperandrogenism in polycystic ovary syndrome patients with hyperlipidemia and impaired glucose tolerance. j endocrinol investig., 2012; 35(10):905-10. 4. norman rj, dewailly d, legro rs, hickey te. polycystic ovary syndrome. lancet. 2007; 370(9588):685-97. https://doi.org/10.1016/s0140-6736(07)61345-2 5. helvaci n, yildiz bo. oral contraceptives in polycystic ovary syndrome. minerva endocrinol., 2014; 39(3):175-87. 6. seaman he, de vries cs, farmer rd. venous thromboembolism associated with cyproterone acetate in combination with ethinyloestradiol (dianette): observational studies using the uk general practice research database. pharmacoepidemiol drug saf., 2004; 13(7):42-36. https://doi.org/10.1002/pds.896 7. messinis ie. ovulation induction: a mini review. hum reprod., 2005; 20(10):2688-97. https://doi.org/10.1093/humrep/dei128 8. tannus s, burke yz, kol s. treatment strategies for the infertile polycystic ovary syndrome patient. womens health (lond)., 2015; 11(6):901-12. https://doi.org/10.2217/whe.15.40 9. dayani siriwardene sa, karunathilaka lp, kodituwakku nd, karunarathne ya. clinical efficacy of ayurveda treatment regimen on sub fertility with poly cystic ovarian syndrome (pcos). ayu. 2010; 31(1):24-27. https://doi.org/10.4103/0974-8520.68203 10. patelanuradha j, thakor ap. prospective use of tephrosia purpureain remedial treatment of pcos: study in wistar rat. int res j biol sci., 2012; 1(3):1-6. https://doi.org/10.1016/j.fertnstert.2003.10.004 https://doi.org/10.1080/09513590.2016.1254610 https://doi.org/10.1016/s0140-6736(07)61345-2 https://doi.org/10.1002/pds.896 https://doi.org/10.1093/humrep/dei128 https://doi.org/10.2217/whe.15.40 https://doi.org/10.4103/0974-8520.68203 purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [31] ajdhs.com 11. latha st, prasanna jl, rani mj, divya k, babu ams. a review on natural remedies for prevailing polycystic ovarian disorder. indo am j pharm., 2015; 5(10):3307-3315. 12. franik s, kremer ja, nelen wl, farquhar c. aromatase inhibitors for subfertile women with polycystic ovary syndrome. cochrane database syst rev., 2014; 2:cd010287. https://doi.org/10.1002/14651858.cd010287.pub2 13. balen ah, morley lc, misso m, franks s, legro rs, wijeyaratne cn, et al. the management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global who guidance. hum reprod update., 2016; 22(6):687-708. https://doi.org/10.1093/humupd/dmw025 14. abu hh. twenty years of ovulation induction with metformin for pcos; what is the best available evidence? reprod biomed online., 2016; 32(1):44-53. https://doi.org/10.1016/j.rbmo.2015.09.015 15. lunny ca, fraser sn. the use of complementary and alternative medicines among a sample of canadian menopausal-aged women. j midwifery womens health., 2010; 55(4):335-43. https://doi.org/10.1016/j.jmwh.2009.10.015 16. barnes pm, bloom b, nahin rl. complementary and alternative medicine use among adults and children; united states. natl health stat report. 2007. 17. mobeen h, afzal n, kashif m. polycystic ovary syndrome may be an autoimmune disorder. scientifica (cairo). 2016; 4071735. https://doi.org/10.1155/2016/4071735 18. balaji s, amadi c, prasad s, bala kasav j, upadhyay v, singh ak, surapaneni km, joshi a. urban rural comparisons of polycystic ovary syndrome burden among adolescent girls in a hospital setting in india. biomed res int., 2015; 158951. https://doi.org/10.1155/2015/158951 19. choudhary k, singh r, garg a, verma n, purohit a, deora d. an updated overview of polycystic ovary syndrome. int j biol sci., 2019; 7(3):1-13. https://doi.org/10.22159/ijms.2019.v7i3.34248 20. nowak da, snyder dc, brown aj, demark-wahnefried w. the effect of flaxseed supplementation on hormonal levels associated with polycystic ovarian syndrome: a case study. curr top nutraceutical res., 2007; 5(4):177-181. 21. belwal t, devkota hp, singh mk, sharma r. chapter 3.40 st. john's wort (hypericumperforatum), nonvitamin and nonmineral. nutritional supplements; academic press, 2019, pp. 415-432. https://doi.org/10.1016/b978-0-12-812491-8.00056-4 22. mitsi c, efthimiou k. infertility: psychological-psychopathological consequences and cognitive-behavioural interventions. psychiatriki., 2014; 25(4) :293-302. 23. o'reilly e, sevigny m, sabarre ka, phillips kp. perspectives of complementary and alternative medicine (cam) practitioners in the support and treatment of infertility. bmc complement altern med., 2014; 14:394. https://doi.org/10.1186/1472-6882-14-394 24. rayburn wf, gonzalez cl, christensen hd, stewart jd. effect of prenatally administered hypericum (st john's wort) on growth and physical maturation of mouse offspring. am j obstet gynecol., 2001; 184(2):191-195. https://doi.org/10.1067/mob.2001.108339 25. canning s, waterman m, orsi n, ayres j, simpson n, dye l. the efficacy of hypericumperforatum (st john's wort) for the treatment of premenstrual syndrome: a randomized, doubleblind, placebo-controlled trial. cns drugs. 2010; 24(3):207-225. https://doi.org/10.2165/11530120-000000000-00000 26. insulite health pcos. herbal remedies for pcos. available from: https://pcos.com/herbal-remedies/. 27. sing dc, dhyani s, kaur ga. critical review on guggulu[commiphorawightii(arn.) bhand.] & its miraculous medicinal uses. int j ayurveda pharma res., 2015; 3(1):1-9. 28. kavitha a, narendra ba, kumar sm, kiran vs. evaluation of effect of commiphora wightii in dehydroepiandrosterone (dhea) induced polycystic ovary syndrome (pcos) in rats. pharma tutor., 2016; 4(1):47-55. 29. rani r, mishra s. phytochemistry of guggul (commiphorawightii): a review. asian j res chem., 2013; 6(4): 415-426. 30. evans wc, evans d, trease ge. a taxonomic approach to the study of medicinal plants and animal derived drugs. in: trease and evans pharmacognosy, 15th; wb saunders: edinburgh, new york, 2002. 31. duke j, duke pk, cellier jl. duke handbook of medicinal herbs, 2nd; united states, 2002. https://doi.org/10.1201/9781420040463 32. kostova i, dinchev d. saponins in tribulusterrestris-chemistry and bioactivity. phytochem rev., 2005; 4:111-137. https://doi.org/10.1007/s11101-005-2833-x 33. abadjieva d, kistanova e. tribulus terrestris alters the expression of growth differentiation factor 9 and bone morphogenetic protein 15 in rabbit ovaries of mothers and f1 female offspring. plos one., 2016; 11(2):e0150400. https://doi.org/10.1371/journal.pone.0150400 34. singh pp, krishna a. anti-hyperglycaemic activity of tribulusterrestrisfruit extract restores metabolic imbalance in letrozole induced -pcos mice. int j pharmacogn phytochem., 2019; 11(4):304-311. 35. pachiappan s, matheswaran s, saravanan pp, gayathiri m. medicinal plants for polycystic ovary syndrome: a review of phytomedicine research. int j herb., 2017; 5(2):78-80. 36. kalia v, jadav an, bhuttani kk. in vivo effect of asparagus racemosus on serum gonadotrophin levels in immature female wistar rats. 2nd world congress of biotech; devision of herbal medicine: nbri: lucknow, 2003, p. 40. 37. gaitondé bb, jetmalani mh. antioxytocic action of saponin isolated from asparagus racemosus willd (shatavari) on uterine muscle. arch int pharmacodyn ther., 1969; 179(1):121-129. 38. sharma k, bhavnagar m. asparagus racemosus (shatavari): a versatile female tonic. int j phar., 2011; 2(3):855-863. 39. ahmad a, husain a, mujeeb m, khan sa, najmi ak, et al., a review on therapeutic potential of nigella sativa: a miracle herb. asian pac j trop biomed., 2013; 3(5):337-352. https://doi.org/10.1016/s2221-1691(13)60075-1 40. sheeraz m. rational approach towards the role of kalawnji (nigella sativa linn) in marz-eakyas khusyatur rehm (polycystic ovarian syndrome)-a review. indo am j pharm., 2018; 8(5):1089-1096. 41. sangal a. role of cinnamon as beneficial antidiabetic food adjunct: a review adv appl sci res., 2011; 2(4):440-450. 42. vangalapati m, prakash s. a review on pharmacological activities and clinical effects of cinnamon species. res j pharm biol chem sci., 2012; 3(1): 653-663. 43. kort dh, lobo ra. preliminary evidence that cinnamon improves menstrual cyclicity in women with polycystic ovary syndrome: a randomized controlled trial. am j obstet gynecol., 2014; 211(5):487.e1-487.e6. https://doi.org/10.1016/j.ajog.2014.05.009 44. borzoei a, rafraf m, niromanesh s, farzadi l, narimani f, doostan f. effects of cinnamon supplementation on antioxidant status and serum lipids in women with polycystic ovary syndrome. j tradit complement med., 2017; 8(1):128-133. https://doi.org/10.1016/j.jtcme.2017.04.008 45. netmeds. kanchanar guggulu: this ayurvedic formulation treats hormonal imbalance. available from: https://www.netmeds. com/health-library/post/kanchanar-guggulu-this-ayurvedicformulation-treats-hormonal-imbalance 46. khandelwal r, nathani s. an ayurvedic approach to pcos: a leading cause of female infertility. int j ayurveda res., 2016; 1(3):77-82. 47. chouhan b, ramesh k, mita k, ramamurthy a, nathani s. triphala: a comprehensive ayurvedic review. int j res ayurveda pharm., 2013; 4(4): 612-617. https://doi.org/10.7897/2277-4343.04433 https://doi.org/10.1002/14651858.cd010287.pub2 https://doi.org/10.1093/humupd/dmw025 https://doi.org/10.1016/j.rbmo.2015.09.015 https://doi.org/10.1016/j.jmwh.2009.10.015 https://doi.org/10.1155/2016/4071735 https://doi.org/10.1155/2015/158951 https://doi.org/10.22159/ijms.2019.v7i3.34248 https://doi.org/10.1016/b978-0-12-812491-8.00056-4 https://doi.org/10.1186/1472-6882-14-394 https://doi.org/10.1067/mob.2001.108339 https://doi.org/10.2165/11530120-000000000-00000 https://doi.org/10.1201/9781420040463 https://doi.org/10.1007/s11101-005-2833-x https://doi.org/10.1371/journal.pone.0150400 https://doi.org/10.1016/s2221-1691(13)60075-1 https://doi.org/10.1016/j.ajog.2014.05.009 https://doi.org/10.1016/j.jtcme.2017.04.008 https://doi.org/10.7897/2277-4343.04433 purohit et al asian journal of dental and health sciences. 2022; 2(1):27-32 [32] ajdhs.com 48. aruljothi r, thiruthani m. review of saraca asoca for uterine tonic in traditional siddha medicine. int j curr res chem pharm sci, 2019; 6(6):1-3. 49. satapathy s, das n, bandyopadhyay d, mahapatra sc, sahu ds, meda m. effect of tulsi (ocimum sanctum linn.) supplementation on metabolic parameters and liver enzymes in young overweight and obese subjects. indian j clin biochem., 2017; 32(3):357-363. https://doi.org/10.1007/s12291-016-0615-4 50. pachiappan s, matheswaran s, saravanan pp, gayathiri m. medicinal plants for polycystic ovary syndrome: a review of phytomedicine research. int j herb., 2017; 5(2):78-80. 51. khanage sg, subhash ty, bhaiyyasaheb ir. herbal drugs for the treatment of polycystic ovary syndrome (pcos) and its complications. pharm res., 2019; 2(1):5-13. 52. healthy living. saraca asoca bark. available from: https://healthyliving.natureloc.com/wpcontent/uploads/2016/08/ashoka-bark4. 53. https://cdn.shopify.com/s/files/1/0058/0252/4783/articles/stjohns-wort-hypericum-perforatum-primaryv2.jpg?v=1567803563 54. fahad t, ismath s. phytochemical & therapeutic potentials of murrmakki (commiphor amyrrha). indian j appl res., 2018; 8(9):102-104. 55. there's an eo for that. treat pcos naturally using essential oils. available from: https://www.theresaneoforthat.com/treat-pcosnaturally-using-essential-oils. 56. barthelmess ek, naz rk. polycystic ovary syndrome: current status and future perspective. front biosci (elite ed.)., 2014; 6:104-119. https://doi.org/10.2741/e695 57. ghani u, batool a, rafeeq h, naeem m. advancement and future directions towards herbal treatment for various diseases. saudi j med pharm sci., 2019; 5(11):931-941. https://doi.org/10.36348/sjmps.2019.v05i11.003 https://doi.org/10.1007/s12291-016-0615-4 https://doi.org/10.2741/e695 https://doi.org/10.36348/sjmps.2019.v05i11.003 haryani et al asian journal of dental and health sciences. 2023; 3(3):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited motivation and dental health self-care behavior with adolescent quality of life using ohip-14 wiworo haryani*, diani sulistiawati, etty yuniarly department of dental health, health polytechnic of yogyakarta, yogyakarta, indonesia article info: _______________________________________ article history: received 04 june 2023 reviewed 27 july 2023 accepted 23 august 2023 published 15 september 2023 _______________________________________ cite this article as: haryani w, sulistiawati d, yuniarly e, motivation and dental health self-care behavior with adolescent quality of life using ohip-14, asian journal of dental and health sciences. 2023; 3(3):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.45 _______________________________________ *address for correspondence: wiworo haryani, department of dental health, health polytechnic of yogyakarta, yogyakarta, indonesia. abstract ___________________________________________________________________________________________________________________ background: the prevalence of dental and oral disease in indonesia is still high (57.6%) and the most cases are dental caries and periodontal disease. adolescents during puberty are prone to oral health problems, so they need attention from dental and oral health care programs. preventive measures against dental and oral diseases need to be carried out in adolescents so that there are no disturbances in function, activity, and work productivity which will affect quality of life. technological developments require innovation to detect oral health-related quality of life (ohrqol) in adolescents early. objective: to determine the relationship between motivation and dental health self-care behavior with the quality of life of adolescents using the oral health impact profile-14 or ohip-14 questionnaire. method: this type of research is observational analytic with a cross sectional design. the research location is at the junior high school in the sleman regency area. the sample was 100 teenagers aged 12-15 years. the sampling technique was carried out using purposive sampling. the data analysis used was bivariate analysis using chi-square correlation to determine the relationship between motivation and dental health behavior and quality of life in adolescents. results: there is a significant relationship between motivation and quality of life (p=0.004; or=4.74). adolescents with low motivation have a tendency to have a low quality of life 4.74 times compared to adolescents with high motivation. there is a significant relationship between dental health self-care behavior and quality of life (p=0.041; or= 5.47). adolescents with bad behavior tend to have a lower quality of life 5.47 times compared to adolescents with good dental health behavior. conclusion: there is a relationship between motivation and dental health self-care behavior and quality of life in adolescents. keywords: motivation, behavior, quality of life of adolescents introduction quality of life is recognized as an important part of health and is considered in the assessment of therapy and wellness programs. quality of life evaluates perceived health from a multidimensional perspective including physical, psychological, social, and environmental aspects.1 quality of life related to oral health is called oral health-related quality of life or ohrqol.2,3 adolescents are one of the groups at high risk of having health problems. in dental and oral health, this threat can be avoided by preventing dental and oral diseases.4 oral health has an impact on the quality of life of adolescents, and the ohrqol measurement instrument that is often used is the oral health impact profile-14 (ohip-14) which contains 14 dimensions of quality of life. the ohip-14 concept measures various aspects of oral health, for example psychological, physical and social aspects. a high ohip-14 score will always equate to a negative impact on ohrqol.5 pain and psychological discomfort are the ohip-14 dimensions most frequently reported as impacting ohrqol in adolescents. 6 several studies say there is a relationship between motivation for dental care and quality of life in medical students and based on the ohip-14 dimensions it was found that good quality of life is highest for functional limitations, social disabilities and obstacles. stated that gender, location of residence, region, only child status, parental education, frequency of carbohydrate consumption, self-perception of oral health status, visits to the dentist in the last 12 months, knowledge, age, and the dmft index were related to ohrqol.7,8 ohrqol measurements are currently still carried out using questionnaires such as the oral impact on daily performance (oidp).9,10 child perceptions questionnaire (cpq).11,12, the oral health impact profile-14 (ohip-14).1,5 a preliminary study on students of smpn gamping in sleman regency in 2021 showed that the prevalence of dental caries and periodontal disease in students was still high with a dmft index of 4.6 and a low periodontal status of 65%. based on this description and in line with the dental health department's research roadmap for 2019-2023, the researchers argue that the need for dental assistants to detect ohrqol includes motivation and self-care behavior for dental health using ohip-14 in adolescents. method and material this type of research is analytic observational with a cross sectional design. the sample is adolescents aged 12-15 years with a total of 100 children. the sampling technique was carried out by purposive sampling. influence variables consist of dental care motivation, and dental health self-preservation behavior. the affected variables consist of quality of life. the research instrument was the ohip-14 questionnaire and the scale used was ordinal. quality of life is measured using the oral health impact profile-14 (ohip-14) including the dimensions of functional limitations, physical pain, psychological discomfort, physical disability, psychological open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.45 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.45&amp;domain=pdf haryani et al asian journal of dental and health sciences. 2023; 3(3):1-4 [2] ajdhs.com disability, social disability, and handicap. factors related to oral health include sociodemographic characteristics (gender, maternal education, parental occupation), motivation, knowledge, behavior, oral hygiene, and experience of dental caries. the data analysis used was bivariate analysis using chisquare correlation to determine the relationship between motivation and dental health behavior with the quality of life of adolescents. result and discussion table 1: frequency distribution based on respondent characteristics variable n % age 12 years 4 4.0% 13 years 78 78.0% 14 years 18 18.0% gender man 36 36.0% women 64 64.0% mother's education elementary school 6 6.1% junior high school 13 13.1% senior high school 42 42.4% college 38 38.4% parents' job government employees 26 26.0% private 43 43.0% farmers / traders 4 4.0% laborer 12 12.0% etc 9 9.0% doesn't work 6 6.0% based on the results of research on junior high school adolescents in the sleman regency, yogyakarta aged 12-15 years, it was found that out of 100 adolescents it was known that most were 13 years old, 78 (78.0%). most of the teenagers are women 64 (64.0%). the mother's highest level of education is senior high school 42 (42.4%). most parents' work is private 43 (43.0%). wu et al. stated that gender, parental education, self-perception of oral health status, knowledge, age, and the dmft index are related to ohrqol.8 table 2: frequency distribution of knowledge, motivation, behavior, and quality of life variable mean sd n % dental care motivation 4.76 0.51 motivation low (<5) 20 20.0% high (≥5) 80 80.0% dental health self-care behavior 4.42 1.26 behavior not good (<4) 10 10.0% good (≥4) 90 90.0% total quality of life score 24.59 6.42 quality of life low (<23) 46 46.0% high (≥23) 54 54.0% table 2 shows that the average dental care motivation score is 4.76, based on the median cut off, it was found that the majority of teenagers had dental care motivation in the high category of 80 (80.0%). motivation for dental care is influenced by attitudes, behavior and knowledge about teeth.13 high motivation can affect dental and oral health in adolescents. motivation also influences adolescent awareness to treat damage to their teeth, so they are able to maintain dental and oral health which includes efforts to overcome it, and are able to instill healthy behavior from an early age.14 dental health care behavior obtained an average of 4.5 and based on the median cut off, it was found that most adolescents had dental health self-care behavior in the high category of 90 (90.0%). more than half of the quality of life of haryani et al asian journal of dental and health sciences. 2023; 3(3):1-4 [3] ajdhs.com adolescents is in the high category (54.0%). oral health behavior is one of the factors that causes gingivitis in adolescents aged 12-15 years.15 table 3: results of analysis of motivation and oral health behavior with quality of life in adolescents quality of life low (<23) high (≥23) p or n % n % motivation low (<5) 15 32.6% 5 9.3% 0.004* 4.74 high (≥5) 31 67.4% 49 90.7% behavior not good (<4) 8 17.4% 2 3.7% 0.041* 5.47 good(≥4) 38 82.6% 52 96.3% table 3 shows the p-value of motivation with quality of life of 0.0004 (p<0.05). the p-value of knowledge with quality of life is 0.0001 (p<0.05). the p-value of behavior with quality of life is 0.041 (p<0.05). this shows that there is a relationship between motivation and dental health behavior on the quality of life in adolescents. this is in line with the research by zuhriza et al. shows that the higher the motivation for dental care, the better the quality of life, this is because the level of knowledge can influence a person's behavior towards oral diseases. dental and oral health knowledge is very important in supporting behavior to maintain dental and oral hygiene and health.7 awareness to take advantage of medical services is increasing which encourages motivation to visit dental health services, so as to reduce dental health problems in adolescents. health problems in the oral cavity and are serious can cause a decrease in the quality of life of individuals. quality of life related to oral health is called oral health-related quality of life or ohrqol.2 ohrqol is a person's assessment of the impact of dental and oral health problems that can affect the quality of life related to oral health in adolescents, the higher the dental health problems, the worse the quality of life.16 conclusion based on the research results, it can be concluded that there is a significant relationship between motivation (p = 0.004) and dental health self-care behavior (p = 0.041) and quality of life. this shows that there is a relationship between motivation and dental health behavior on the quality of life in adolescents. the higher the motivation for dental care, the better the quality of life. dental health problems that can affect the quality of life related to oral health in adolescents, the higher the dental health problems, the worse the quality of life. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. ethical clearance this research has received a certificate of appropriate research ethics from the yogyakarta health research ethics commission no.dp.04.03/e-kepk.1/243/2023 dated 27 february 2023. references 1. sobouti f, armin m, akhtari sar, moosazadeh m, dadgar s. quality of life based on oral health impact profile among adolescents undergoing fixed orthodontic appliances. int j pediatr. 2020; 8(12):12651-7. 2. friedlander l, berdal a, boizeau p, licht ba, manière m-c, picard a, et al. oral health related quality of life of children and adolescents affected by rare orofacial diseases: a questionnaire-based cohort study. orphanet j rare dis. 2019; 14(1):1-13. https://doi.org/10.1186/s13023-019-1109-2 pmid:31164137 pmcid:pmc6549379 3. molania t, malekzadeh shafaroudi a, taghavi m, ehsani h, moosazadeh m, haddadi a, et al. oral health-related quality of life (ohrqol) in cardiovascular patients referring to fatima zahra hospital in sari, iran. bmc oral health. 2021; 21(1):1-9. https://doi.org/10.1186/s12903-021-01756-0 pmid:34380490 pmcid:pmc8356446 4. portero de la cruz s, cebrino j. oral health problems and utilization of dental services among spanish and immigrant children and adolescents. int j environ res public health. 2020; 17(3):738. https://doi.org/10.3390/ijerph17030738 pmid:31979248 pmcid:pmc7036804 5. fernandes c, colussi prg, piardi cc, weidlich p, rösing ck, muniz fwmg. oral health-related quality of life and associated factors in institutionalized adolescents: a census study. j heal sci. 2020; 22(2):113-9. https://doi.org/10.17921/24478938.2020v22n2p113-119 6. drachev sn, brenn t, trovik ta. oral health-related quality of life in young adults: a survey of russian undergraduate students. int j environ res public health. 2018; 15(4):719. https://doi.org/10.3390/ijerph15040719 pmid:29641464 pmcid:pmc5923761 7. zuhriza ra, wulandari dr, skripsa th, prabowo yb. hubungan motivasi perawatan gigi terhadap kualitas hidup terkait kesehatan gigi (oral health related quality of life-ohrqol) mahasiswa fakultas kedokteran universitas diponegoro. e-gigi. 2021; 9(2):145-51. https://doi.org/10.35790/eg.9.2.2021.33890 8. wu hj, cheng ml, zhang cz, xu mr, gao xl, du s, et al. associated factors of oral health-related quality of life in chinese adolescents aged 12-15 years. chin j dent res. 2021; 24(2):105-12. 9. alwadi mam, vettore mv. contextual income inequality and adolescents' oral-health-related quality of life: a multi-level analysis. int dent j. 2019; 69(6):463-71. https://doi.org/10.1111/idj.12504 pmid:31278752 pmcid:pmc9379052 10. prasertsom p, kaewkamnerdpong i, krisdapong s. conditionspecific oral health impacts in thai children and adolescents: findings from the national oral health-related quality of life https://doi.org/10.1186/s13023-019-1109-2 https://doi.org/10.1186/s12903-021-01756-0 https://doi.org/10.3390/ijerph17030738 https://doi.org/10.17921/2447-8938.2020v22n2p113-119 https://doi.org/10.17921/2447-8938.2020v22n2p113-119 https://doi.org/10.3390/ijerph15040719 https://doi.org/10.35790/eg.9.2.2021.33890 https://doi.org/10.1111/idj.12504 haryani et al asian journal of dental and health sciences. 2023; 3(3):1-4 [4] ajdhs.com survey. asia pacific j public heal. 2020; 32(1):49-56. https://doi.org/10.1177/1010539519899774 pmid:31955590 11. maroneze mc, ardenghi dm, brondani m, unfer b, ardenghi tm. dental treatment improves the oral health‐related quality of life of adolescents: a mixed‐methods approach. int j paediatr dent. 2019; 29(6):765-74. https://doi.org/10.1111/ipd.12548 pmid:31278821 12. de stefani a, bruno g, irlandese g, barone m, costa g, gracco a. oral health-related quality of life in children using the child perception questionnaire cpq11-14: a review. eur arch paediatr dent. 2019; 20:425-30. https://doi.org/10.1007/s40368-01900418-8 pmid:30762210 13. lendrawati l, ervan d, iryani d. hubungan pemeliharaan kesehatan gigi dengan status karies gigi siswa kelas 1 smp 1 muhammadiyah kecamatan padang timur kota padang. andalas dent j. 2015; 3(1):1-9. https://doi.org/10.25077/adj.v3i1.30 14. asnita bs, rawati s. gambaran karies yang tidak dirawat dengan kualitas hidup pada siswa/i kelas vii smp negeri 31 medan. j ilm pannmed. 2017; 12(12):21-2. https://doi.org/10.36911/pannmed.v12i2.9 15. fan w, liu c, zhang y, yang z, li j, huang s. epidemiology and associated factors of gingivitis in adolescents in guangdong province, southern china: a cross-sectional study. bmc oral health. 2021; 21(1):1-9. https://doi.org/10.1186/s12903-02101666-1 pmid:34134691 pmcid:pmc8207589 16. utami s, prasepti di. hubungan status karies gigi dengan oral health related quality of life pada mahasiswa. insisiva dent j. 2019; 8(2):46-52. https://doi.org/10.18196/di.8207 https://doi.org/10.1177/1010539519899774 https://doi.org/10.1111/ipd.12548 https://doi.org/10.1007/s40368-019-00418-8 https://doi.org/10.1007/s40368-019-00418-8 https://doi.org/10.25077/adj.v3i1.30 https://doi.org/10.36911/pannmed.v12i2.9 https://doi.org/10.1186/s12903-021-01666-1 https://doi.org/10.1186/s12903-021-01666-1 https://doi.org/10.18196/di.8207 rajpoot et al asian journal of dental and health sciences. 2022; 2(4):55-58 [55] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited review on molecular modelling in chemistry education itendra singh rajpoot, hemant patel, rahul singh thakur, basant khare, anushree jain, prateek kumar jain, bhupendra singh thakur* adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 11 sep 2022 reviewed 06 nov 2022 accepted 23 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: rajpoot is, patel h, thakur rs, khare b, jain a, jain pk, thakur bs, review on molecular modelling in chemistry education, asian journal of dental and health sciences. 2022; 2(4):55-58 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.26 _______________________________________ *address for correspondence: bhupendra singh thakur, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ molecular models derived from results of quantum-chemical calculations present an important category of didactic instruments in chemistry education. these models can be used especially as tools for supporting the students’ understanding by visual learning, which can adequately address complexity of many chemical topics, incorporate appropriate didactic principles, as well as utilize the benefits brought up by the actual information technology. the proposed molecular models are non-trivial examples of didactic application of computational chemistry techniques in illustration of electron interactions in amidic group, namely the interaction of the free electron pair on the nitrogen atom with the carbonyl group and also the interaction of atoms in the amide group with other surrounding atoms in the molecule. by these molecular models it is possible to explain acid-base properties of amides applying knowledge of electron density distribution in the molecules and the resulting electrostatic potential. presentation of the structure and properties of the amides within education is important also for the reason that amidic functions are involved in many important natural substances (e.g. proteins, peptides, nucleic acids or alkaloids), synthetic macromolecular substances (e.g. silon) or pharmaceutical preparations (e.g. paracetamol). this paper investigated the effect of using different types of models while teaching organic chemistry on student understanding of new concepts and the spatial structure of new molecules, as well as preference of a particular model type and illustrates the possibilities of computer-assisted molecular modelling in supporting chemistry teaching and learning. keywords: molecular models, acidity, amides, basicity, electrostatic potential introduction chemical concepts are abstract by nature and therefore challenging to illustrate in an understandable way. the triple mode of representation brings more challenge to chemistry learning on the macro level, the submicroscopic level and the symbolic level1. at the macro level one can see and observe chemical phenomena. the submicroscopic level justifies and illustrates the visible properties of a substance with atoms, molecules and ions (for example with molecular modelling). the symbolic level shows the macro level and micro level phenomena using chemical symbols, formulas and equations. it is important that teachers understand the threefold relationship so that it can be conveyed to their students2. while a teacher moves smoothly from one level to another, a student might be confused and get a fragmented vision of chemistry. according to gabel (1999), the primary barrier in understanding chemistry is that chemistry instruction occurs predominantly on the most abstract level, the symbolic level. the unobservable submicroscopic level, in which phenomena and concepts are difficult to be combined with the students' perceptions and the living environment, produces also problems for students 3. therefore students need to use different models, analogies or computer graphics to make invisible into visible4. since models and modelling are essential in chemical thinking and in the development of scientific knowledge they should also be included in chemical education. students should: learn about the nature of models and their usage as thinking tools; learn about the scope and the limitations of specific chemical models; be encouraged to use multiple models for a given phenomenon5. visualizations help students to build mental models when learning about difficult concepts and submicroscopic level phenomena. that is why the students' visualisation skills, spatial ability particularly, should be developed. computer-based molecular modelling has helped a variety of learners to improve their visualisation skills and helped them to understand the concept of the model, three-dimensional molecular structure and chemical bonds6. molecular modelling software and computerassisted learning materials enable new learning environments where chemistry concepts and phenomena can be viewed and perceived in a new manner. at the same time computerassisted methods create new approaches enabling challenging chemistry topics to be clarified and simplified. virtual models and visualisations can be modified according to the needs of teaching and learning7. computer-based molecular modelling provides a tool for teaching and learning in order to support the visualisation of chemical phenomena and the development of chemistry teaching8-11. the computer enables to perceive things through visual experience which helps memorise things and improves learning outcomes9. according to the experiences of finnish school teachers, computer-based molecular modelling helps teachers to illustrate and students to learn difficult concepts in chemistry in a new way, it develops students’ visualisation skills and makes students interested in chemistry12. finnish school teachers have used molecular modelling to illustrate the spatial structure of molecules, isomerism, atomic and molecular orbitals, chemical bonds, electron density, ir-spectroscopy, energy and its open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.26 rajpoot et al asian journal of dental and health sciences. 2022; 2(4):55-58 [56] ajdhs.com changes in chemical processes and chemical reactions. molecular modelling can also be applied to biochemistry, biology and biotechnology education. according to pernaa, aksela and lundell (2009) 10, high school teachers experienced that molecular modelling supports the drawing of conclusions and the understanding of three-dimensional structures and it provides added value for teaching of orbitals, chemical bonds and biomolecules. teachers and students generally have positive attitudes towards molecular modelling8, 12. the teacher has an important role in the success and effectiveness of teaching chemistry through computerbased molecular modelling, because the use of modelling programs should not remain merely as a funny trick, instead working with a computer should be tied into teaching. the instructions and questions direct the learner's interest and activities in order to support learning tasks as well as it is possible and to train higher-order thinking skills13. the current learning theories highlight learning as a socially interactive process based on the students’ experiences. by using computer-based molecular modelling it is possible to support the understanding of scientific concepts, practice different learning skills and to motivate students to investigate in an authentic research environment9. there are commercial molecular modelling programs e.g. spartan (www.wavefun.com) and hyperchem (www.hyper.com), and free programs e.g. chemsketch (www.acdlabs.com), arguslab (www.arguslab.com), symyx draw (www.symyxdraw.en.softonic.com), avogadro (www.avogadro.en.softonic.com) and marvinsketch (www.chemaxon.com). edumol (www.edumol.fi) is an open, web-based environment for molecular modelling and visualisation. findings indicate that molecular modelling has helped students to understand concepts in molecular geometry and bonding8 as well as in model concept, isomerism and functional groups14. in the ongoing doctoral study, the meaningful teaching model for covalent bonds (as opposed to rote learning) is being developed. brief history of the development of molecular models the history of models15-18 can be traced back to plato (482347 bc), who conceived of the four elementssoil, water, air and fire. nothing much happened in terms of model development until in 1808 dalton published the new system of chemical philosophythe first substantial discourse on atomic theory. at the same year malus discovered polarized light. wollaston related it to tetrahedron, but noted that "it is perhaps too much to hope that the geometrical arrangement of primary particles will ever be perfectly known". in 1811 dalton had a set of models of atoms and simple diatomic molecules constructed to help illustrate his ideas. in 1815 biot observed several organic compounds that enable light polarization and realized that the rotation of light was due to a property of the individual molecule. in 1848 pasteur found that crystals can be separated into two types, and in solution they rotated the plane of polarized light equally, but in opposite directions. this discovery could not be explained at that time due to lack of a proper model. the next indication of actual model construction was by kekule in 1867, who proposed the tetrahedral structure of carbon bonds. in 1874 van’t hoff used modelstetrahedra joined at the apex, sides or faces to describe the optical isomers of tartaric acid, which raised widespread objection. sachse was one of the few chemists who around 1890 used molecules to make predictions, and predicted the ‘boat’ and ‘chair’ forms of cyclohexane. during 1900-1920 the use of ball-and-stick models became more widespread. in 1934 stuart developed space-filling models that gave precise indications of the van der waals radii of the atoms in a molecule. these were preferred over the earlier type, and opened the ‘golden age’ of molecular models. in 1947 pitzer computed the energy barrier to carbon-carbon bond in butane. later, pitzer and hazel, who won nobel prize in chemistry, demonstrated the axial and equatorial chair form of cyclohexane ring. space filling models were considered an indispensable tool for organic chemists during the next 30 years and enabled the prediction of structural conformations, strereochemistry, reactivity and physical properties. most notable was the double helix structure of dna proposed by watson and creek in 1953, who later won nobel prize in chemistry. models in science and science education modeling and simulation are used in research and education to describe, explain and explore phenomena, processes and abstract ideas. scientists, engineers and science educators use models to concretize, simplify and clarify abstract concepts, as well as to develop and explain theories, phenomena and rules. a model is considered useful if it is simpler than the natural object that it represents. an important value of models in science and science education is their contribution to visualization of complex ideas, processes and systems. a virtue of a good model is that it stimulates its creators and viewers to pose questions that take us beyond the original phenomenon to formulate hypotheses that can be examined experimentally19,20. experimentation, however, is rarely presented as a way of developing, interpreting or evaluating explanatory models for the investigated phenomenon21. benzvi and genut (1998) 22 recommended teaching high school students about interconnections of history and philosophy of science on one hand and the usefulness and limitations of scientific models, such as the periodic table, on the other hand. gilbert and boulter (1998) 23 distinguish between target systems, mental models, expressed models, consensus models and teaching models. other researchers underscored the need for models as enablers of students’ mental transformation from two-dimensional to three dimensional representations2426. one of the problems that arise while using concrete models is that insufficient emphasis is placed on the fact that models are theory-based simulations of reality. the theory of molecular structure is a kind of intellectual model27. harrison and treagust (1996) 28 claimed that the use of term "model" is a source of considerable semantic variation for science students and teachers. models are often oversimplified and therefore cannot tell humans all they may wish to know about the real physical system that is being modeled. teachers and students should, therefore, be made aware of the fact that models, employed in a variety of research, study and design contexts, are not complete representations of the realities they are supposed to represent29. applied to chemistry, physical ball and stick models derived from polystyrene spheres and plastic straws are not merely enlargements of the molecules they are intended to represent. these are analogue models that are used to explain new and abstract concepts. some of the properties are similar to aspects of the target they are representing. for example, the relative diameter of the spheres represents the size of the different atoms. other aspects, however, are not reflected in the model. for example, in a ball-and-stick model type, all sticks (straws) are of equal length, while "real" molecular bond lengths are not. other analog models focus on different properties of the molecule, thereby creating multiple ways of representing the same molecule. teachers frequently use just one type of model, limiting students' experience with models and causing their model perceptions to be partially or completely inadequate. computerized molecular modelling the use of concrete molecular models (made of plastic, wood and/or metal) to illustrate phenomena in chemistry teaching rajpoot et al asian journal of dental and health sciences. 2022; 2(4):55-58 [57] ajdhs.com has been widespread for a relatively long time30. the choice of model type has an impact on the image students create concerning the ways in which particles are shaped and how they function in the "real" world from a scientific viewpoint. simulating different model types quickly and efficiently is achieved in a computerized environment, of which theoretical chemists, experimentalists and educators are taking advantage. information technology helps relieving presentday researchers and students from the laborious task of data collection and enables them to engage in creative thinking and problem solving. nakhleh and krajcik (1994) 31 investigated how different levels of information presented by various technologies affect secondary students’ understanding of acid, base and ph concepts. they found that students using microcomputer-based laboratories exhibited a positive shift in their concept map scores, indicating greater differentiation and integration of their knowledge. the development of computerized molecular modeling (cmm) made traditional models less favorable in the late 1960’s. not only are computers capable of drawing and manipulating molecules in three dimensions. they are also powerful tools for predicting molecular spatial structure through energy minimization calculations based on quantum mechanics. these capabilities have opened the way for advanced research in chemistry, resulting, among other things, winning nobel prize in chemistry (1998). among the advantages of using information technology in science education are the options of providing for individual learning, simulation, graphics, and the demonstration of models of the micro and macro world32. computer aided instruction enables students to solve a variety of problems while carrying out their own research at their own pace. the use of computerized models places more emphasis on the creation of mental models by students and their use to make prediction23. students need more experience with models as intellectual tools that provide contrasting conceptual views of phenomena, and more discussion of the roles of models in the service of scientific inquiry. raghavan & glaser (1995) 33 recommend that science educators become less concerned with the presentation of facts and concentrate on showing the centrality of models in research and education. however, most educators use a limited number of static models, and do not emphasize the way in which models are created, their essential role in science learning, or their advantages and limitations. williamson and abraham (1995) 34 studied the effect of computer animations on college student mental models of chemical phenomena. animations were used in two treatment situations: as a supplement in large group lectures and as both the lecture supplement and an assigned individual activity. both treatments increased the students’ understanding. they attributed the improvement to the superior formation of dynamic mental models of chemical processes that were made possible by the computer animation. (a) (b) (c) figure 1 (a) hand-made primitive cubic unit cell; (b) hand-made body centered cubic unit cell; (c) hand-made face centered cubic unit cell. rajpoot et al asian journal of dental and health sciences. 2022; 2(4):55-58 [58] ajdhs.com conclusion interpretation of symbols, as well as understanding the particulate nature of matter and spatial structures are essential skills students need for solving problems in organic chemistry. however, model perception and understanding the spatial structure of organic molecules has been a source of difficulty for many chemistry students. a computerized molecular modeling (cmm)-based collaborative learning environment has been shown to be an effective means to overcome certain learning difficulties in chemistry. references 1. johnstone a h. the development of chemistry teaching: a changing response to a changing demand. journal of chemical education.1993; 70(9):701-705. https://doi.org/10.1021/ed070p701 2. gabel d. improving teaching and learning through chemistry education research: a look to the future. journal of chemical education.1999; 76(4):548-554. https://doi.org/10.1021/ed076p548 3. hinton m e, nakhleh mb. student's microscopic, macroscopic and symbolic representations of chemical reactions. the chemical educator.1999; 4(4):1-29. https://doi.org/10.1007/s00897990325a 4. barnea n, dori y j. computerized molecular modeling as a tool to improve chemistry teaching. journal of chemical information and computer sciences.1996; 36(4):629-636. https://doi.org/10.1021/ci950122o 5. justi r, gilbert jk. models and modelling in chemical education. in j. k. gilbert, o. de jong, r. justi, d. f. treagust, & j. h. van driel (eds.), chemical education: towards research-based practice.2002; pp. 4768. https://doi.org/10.1007/0-306-47977-x_3 6. barnea n. teaching and learning about chemistry and modelling with a computer managed modelling system. in j. k. gilbert, & c. j. boulter (eds.), developing models in science education. 2000; pp. 307-323. https://doi.org/10.1007/978-94-010-0876-1_16 7. jalonen e, lundell j, aksela m. molekyylimallinnus lukion kemian opetuksessa. (molecular modelling in the chemistry teaching of upper secondary school). in m. aksela & m. montonen (eds.), uusia lähestymistapoja kemian opetukseen perusopetuksesta korkeakouluihin. 2007; 148-154. 8. barnea n, dori yj. computerized molecular modeling as a tool to improve chemistry teaching. journal of chemical information and computer sciences 1996; 36(4): 629-636. https://doi.org/10.1021/ci950122o 9. lundell j, aksela m. molekyylimallinnus kemian opetuksessa, osa 1: molekyylimallinnus ja kemian opetus, dimensio. 2003; 67(5):47-49. 10. pernaa j, aksela m, lundell j. kemian opettajien käsityksiä molekyylimallinnuksen käytöstä opetuksessa. (finnish school teachers' views about the usage of molecular modelling in teaching). in m. aksela & j. pernaa (eds.), arkipäivän kemia, kokeellisuus ja työturvallisuus kemian opetuksessa perusopetuksesta korkeakouluihin: iv valtakunnalliset kemian opetuksen päivät. 2009; 195-204. 11. jain m, jain a, khare b, jain dk, khan r, jain d. an update on the recent emergence of candida auris. asian journal of dental and health sciences. 2022; 2(1):14-9. https://doi.org/10.22270/ajdhs.v2i1.11 12. aksela m, lundell j. computer-based molecular modelling: finnish school teachers' experiences and views. chemistry education research and practice. 2008; 9:301-308. https://doi.org/10.1039/b818464j 13. aksela m, lundell j. kemian opettajien kokemuksia tietokoneavusteisesta molekyylimallinnuksesta. (finnish school teachers' experiences about computer-based molecular modelling). in m. aksela & m. montonen (eds.), uusia lähestymistapoja kemian opetukseen perusopetuksesta korkeakouluihin. 2007; 226-247. 14. dori yj, barak m. virtual and physical molecular modeling: fostering model perception and spatial understanding. educational technology and society. 2001; 4(1): 61-74. 15. walton a. a review of the use of both skeletal and space-filling models. progress in stereochemistry. 1968; 4:335-336. 16. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech journal of pharmaceutical sciences. 2018; 7(4):1-25. 17. hardwicke aj. using molecular models to teach chemistry. part 1: modeling molecules. school and science review. 19995; 77:59-64. 18. clarke fh. new skeletal space-filling models: a model of an enzyme active site. journal of chemical education. 1997; 54:230-235. https://doi.org/10.1021/ed054p230 19. toulmin s. the philosophy of science: an introduction. new york: harper and row.1953. 20. bagdonis as, salisbury df. development and validation of models in instructional design. educational technology. 1994; 34:26-32. 21. tamir p. traning teachers to teach effectively in the laboratory. science education. 1989; 73:59-69. https://doi.org/10.1002/sce.3730730106 22. ben-zvi n. genut s. uses and limitations of scienctific modls: the perioduc table as an inductive tool. international journal of science education. 1998; 20; 351-360. https://doi.org/10.1080/0950069980200307 23. gilbert jk, boulter cj. learning science through models and modeling. in fraser bj and tobin, kg (eds). international handbook of science education. kluwer academic publisher, dordrecht/boston/london. 1998; 53-66. https://doi.org/10.1007/978-94-011-4940-2_4 24. baker rs, talley hl. visualization skills as a component of aptitude for chemistry a construct validation study. journal of research in science teaching. 1974; 11: 95-97. https://doi.org/10.1002/tea.3660110203 25. barak m, dori yj. model perception and understanding the spatial structure of organic molecules by high school chemistry students. science teacher's education toward the new millenium, technion, haifa, israel. 1999. 26. eliot jk, hauptman a. different dimensions of spatial ability. studies in science education. 1981; 8:4566. https://doi.org/10.1080/03057268108559886 27. hammond gs, osteryoung j, crawford th, gray hb. models in chemical science. benjamin inc., 2nd edition, menlo park, ca.1972. 28. harrison ag, treagust df. mental models. science education. 1996; 80:508534. https://doi.org/10.1002/(sici)1098237x(199609)80:5<509::aid-sce2>3.0.co;2-f 29. osborne rj, gilbert jk. the use of models in science teaching. the school and science review. 1980; 62:57-67. 30. peterson qr. some reflections on the use and abuse of molecular models. journal of chemical education. 1970; 47(1):24-29. https://doi.org/10.1021/ed047p24 31. nakhleh mb, krajcik sj. influence of levels of information as presented by different technologies on students' understanding of acid, base and ph concepts. journal of research in science teaching. 1994; 31:10771096. https://doi.org/10.1002/tea.3660311004 32. dori yj, hameiri m. the mole environment study ware: applying multidimensional analysis to quantitative chemistry problems. international journal of science education. 1998; 20:317-333. https://doi.org/10.1080/0950069980200305 33. raghavan k, glaser r. model based analysis and reasoning in science: the mars curriculum. science education. 1995; 79:37-61. https://doi.org/10.1002/sce.3730790104 34. williamson vm, abraham mr. the effects of computer animation on the particulate mental models of college chemistry students. journal of research in science teaching. 1995; 32:521-534. https://doi.org/10.1002/tea.3660320508 https://doi.org/10.1021/ed070p701 https://doi.org/10.1021/ed076p548 https://doi.org/10.1007/s00897990325a https://doi.org/10.1021/ci950122o https://doi.org/10.1007/0-306-47977-x_3 https://doi.org/10.1007/978-94-010-0876-1_16 https://doi.org/10.1021/ci950122o https://doi.org/10.22270/ajdhs.v2i1.11 https://doi.org/10.1039/b818464j https://doi.org/10.1021/ed054p230 https://doi.org/10.1002/sce.3730730106 https://doi.org/10.1080/0950069980200307 https://doi.org/10.1007/978-94-011-4940-2_4 https://doi.org/10.1002/tea.3660110203 https://doi.org/10.1080/03057268108559886 https://doi.org/10.1002/(sici)1098-237x(199609)80:5%3c509::aid-sce2%3e3.0.co;2-f https://doi.org/10.1002/(sici)1098-237x(199609)80:5%3c509::aid-sce2%3e3.0.co;2-f https://doi.org/10.1021/ed047p24 https://doi.org/10.1002/tea.3660311004 https://doi.org/10.1080/0950069980200305 https://doi.org/10.1002/sce.3730790104 https://doi.org/10.1002/tea.3660320508 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2021 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited dendrimers as drug delivery carriers in the dentistry sunil kumar prajapati1*, vijay kumar tilak2, ram chand dhakar3 , krishan kumar verma4*, vikrant saluja5, r. jayakumararaj 6, rajeshwar kamal kant arya7, manas kumar das8, soumya das9 1 professor, institute of pharmacy, bundelkhand university, jhansi, india 2 apex professional university, pasighat, arunachal pradesh-791102, india 3 hospital pharmacy, srg hospital & medical college jhalawar, rajasthan, india-326001 4 professor, lloyd school of pharmacy, plot no 3, knowledge park-1, greater noida, u.p., india-201308 5 associate professor, faculty of pharmaceutical sciences, pcte group of institutes, ludhiana, india 6 pg department of botany, government arts college, melur – 625106, madurai district, tn, india 7 assistant professor, deparment of pharma sciences, kumaun university nainital, india 8 director, orlean collge of pharmacy, 42-knowledge park-3, greater noida, u.p., india-201308 9 associate professor, niet (pharmacy institute), 19-knowledge park-2, greater noida, u.p., india-201308 article info: _________________________________________ article history: received 03 nov 2021 reviewed 11 dec 2021 accepted 19 dec 2021 published 25 dec 2021 _________________________________________ cite this article as: prajapati sk, tilak vk, dhakar rc, verma kk, saluja v, r jayakumararaj, arya rkk, , das mk, das s, dendrimers as drug delivery carriers in the dentistry, asian journal of dental and health sciences. 2021; 1(1):1-9 doi: http://dx.doi.org/10.22270/ajdhs.v1i1.3 abstract ___________________________________________________________________________________________________________________ this review gives concise information about the application of dendrimers as drug delivery carrier in the field of drug delivery. due to their unique architecture these have improved physical and chemical properties. due to their terminal groups these show high solubility, miscibility and reactivity. dendrimers have well defined size, shape, molecular weight and monodispersity. these properties make the dendrimers a suitable carrier in drug delivery application. dendrimers are unimolecular miceller in nature and due to this enhances the solubility of poorly soluble drugs. their compatibility with dna, heparin and polyanions make them more versatile. dendrimers, also referred as modern day polymers, they offer much more good properties than the conventional polymers. due to their multivalent and mono disperse character dendrimers have stimulated wide interest in the field of chemistry biology, drug delivery, gene therapy and chemotherapy. self-assembly produces a faster means of generating nanoscopic functional and structural systems. but their actual utility in drug delivery can be assessed only after deep understanding of factors affecting their properties and their behaviour in vivo. keywords: dendrimers, drug targeting, nanoscale carriers. *address for correspondence: dr. sunil kumar prajapati, professor, institute of pharmacy, bundelkhand university, jhansi email:drsunilprajapati@gmail.com introduction dendrimers are class of well-defined hyper branched synthetic polymer systems, which can be conjugated to various chemical species, such as detection agents, imaging agents, targeting components, biomolecules, pharmaceutical/ therapeutic agents, radio ligands, affinity ligands, for various bioanalytical applications1. the term “dendrimer” arise from two greek words; “dendron” meaning tree and “meros” meaning part. a typical dendrimer structure consists of three basic components: a multi-functional central core moiety where other molecules can be trapped 2, 3, branched units that emanates from the central core and external capping�groups. the highly regular branching units are organized in layers called “generations”, and represent the repeating monomer unit of these synthetic macromolecules 4. therefore, dendrimers can be synthesized from simple branched monomer units, in a precise and controlled fashion from trunk to branch and to leaf “surface groups”. the three-dimensional structure of dendrimers gives them a variety of unique properties, such as nanoscaled globular shape, welldefined functional groups at the periphery, hydrophobic or hydrophilic cavities in the interior and extremely low polydispersity 5, and thus a wide range of potential applications. the precise control over the distribution of drugs is highly valuable to abolish the typical drawbacks of traditional medicine. in recent years, improved pharmacokinetics, biodistribution and controlled release of the drug to the specific targeted site has been achieved with polymer based drug delivery6 unlike traditional polymers, dendrimers have received considerable attention in biological applications due to their high water solubility,7 biocompatibility,8 polyvalency9 and precise molecular weight.4 these open access review article doi: http://dx.doi.org/10.22270/ajdhs.v1i1.3 http://jddtonline.info/ https://orcid.org/0000-0001-8250-8489 http://dx.doi.org/10.22270/ajdhs.v1i1.3 mailto:drsunilprajapati@gmail.com http://dx.doi.org/10.22270/ajdhs.v1i1.3 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [2] ajdhs.com features make them an ideal carrier for drug delivery and targeting applications. for investigating dendrimers as drug delivery vehicles, their biopermeability across the biological membranes should be considered. figure 1: schematic representation of the dendrimer structure1 table 1: various dendrimer based marketed products for drug delivery, therapy and diagnosis name of product type company use ref priostar peham/pea starpharma targeted diagnostic and therapeutic delivery for cancer 10, 11 starburst pamam dow chemical targeted diagnostic and therapeutic delivery for cancer 12 stratus cs pamam dade behring cardiac marker 13 astramol® ppi starpharma 14 taxotere nd sanofi aventis anticancer drug delivery superfect pamam qiagen gene transfection 15,16 alert ticket pamam us army research lab. anthrax detection 17 nd: not define, peham: poly (etherhydroxylamine), pea: poly (esteramine), pamam: polyamidoamine, ppi: poly (propylene imine), hiv: human immunodeficiency virus, stds: sexually transmitted diseases application of dendrimers in drug delivery for dentistry the development of dendrimer based efficient drug delivery systems has attracted a great deal of attention over the last few years. unlike traditional polymers, dendrimers can be obtained in precise molecular weights even at high generations, which as previously highlighted can provide a reproducible pharmacokinetic behavior. this feature makes them ideal candidates for drug delivery applications. 18, 19 pamam dendrimers loaded with calcium and phosphate ions and have been used experimentally to prevent tooth decay. the loaded pamam dendrimer was effective for prolonged release of calcium and phosphate at low ph, with neutralization of the acidic environment and inhibition of dental caries..20 many potential uses of dendrimer hydrogels (dh) as a drug delivery system in periodontics and implants dentistry as they allow clinicians to customize drug release kinetics, mechanical properties, and in-situ gelling for specific clinical applications. 21 dendrimer-based dental composites have attracted attention because of the higher cross-link density, decreased water sorption and solubility, improved mechanical properties, and higher resin melting temperature. 22, 23 triclosan, an effective antimicrobial agent encapsulated into the pamam dendrimer resulted in the solubilization of tcn, thus slow release of the drug and improved efficacy. 24 pamam dendrimer loaded with different metronidazole concentrations showed prolonged release of the drug, thus proved to be a suitable vehicle for the delivery of antimicrobial drugs at the target site. hence, it has a relevant application in periodontal therapy. 25 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [3] ajdhs.com table 1: reported work on dendrimers as drug delivery carrier in dentistry18 source type of dendrime r generation objective methodical approach outcome ref (dodiuk -kenig et al., 2004) pamam dendrimer to check the adhesive properties of hyper-branched and dendritic polymers in acrylate-based dental composite commercial hyperbranched polyesteramide, two dendripolyamides and pamam dendrimer  compressive strength of dental composite with 0.3 wt% hyperbranched polyesteramide improved the from 253 ± 20mpa to 386 ± 20mpa  the same composite showed reduction in linear shrinkage from 2.4 ± 0.2% to 1.5 ± 0.2 %  improved bond durability and shear bond strength with the above composition 26 (paul et al., 2006) methyl methacryla te dendrimer to enhance the composite properties in dental additive highly branched, globular 2,3dihydroxybenzyl motif to achieve multi-methacrylate dendritic additive  compared to control, addition of 0.5% multi-methacrylate dendritic additive showed 21–35% increase in flexural strength  flexural strength increased with higher molecular weight dendrimers  increase in additive concentration could not have positive effect on flexural strength 27 (gardin er et al., 2008) pamam dendrimer g3 incorporation of triclosan in dendrimer to enhance solubility π-π stacking between g3 dendrimer and the amino acid, phenylalanine to enhance solubility  solubilization of triclosan increased with increasing concentration of dendrimer due to ionisation effect  solubility of triclosan showed to improve with π-π stacking between dendrimer and phenylalanine at 1:21 ratio  the increase in solubility could to reflected by change in ph 24 (kim et al., pamam dendrimer g5 modified g5 dendrimer could g5 dendrimer with rgd ligand  western blot analysis suggested increase in 28 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib78 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib80 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib95 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib108 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [4] ajdhs.com 2010) bind to dental pulp cell to increase odontogenic potential vascular endothelial growth factor, matrix extracellular phosphoglycoprotein, dentin sialoprotein and matrix protein through jnk pathway  application of g5rgd showed enhanced mineralization as evidenced by von kossa assay (eichler et al., 2011) pamam dendrimer g5 pamam dendrimer could modify adsorption/desorp tion behaviour of human saliva compared to selfassembled monolayers grafted surface surface of the periodontitis model grafted with pamam-nh2  covalently bound pamam depicted decreased adherence of streptococcus gordonii in absence of saliva  same approach of repelling bacteria was observed even after saliva conditioning  substitution of pamam lowers the amount of absorbed protein 29 (li et al., 2013) pamam dendrimer g3 and g4 restorative substitution with pamam in human hard tissues to mimic the functions of noncollagenous proteins to promote mineralization carboxyl (-cooh) terminated g3 and g4 pamam dendrimers to substitute noncollagenous proteins on dentine surface  monodispersed characteristics and steric hindrance property were reported advantageous  bioinspired mineralization process in dentine environment was facilitated by g4 dendrimer  dendritic structure could be a potential restorative material for biomineralized hard tissue 30 dung th et al. 2013 pamam dendrimer g5 to study the sustained release of metronidazole an antibacterial and antiprotozoal drug a series of dendrimer g5pluronic f127 nanofilms (at 1:10, 1:20 and 1:30 mole ratios), loaded with various percent of metronidazole dendrimers showed prolonged release of the drug, thus proved to be a suitable vehicle for the delivery of antimicrobial drugs at the target site. 25 (bengazi et al., 2014) methyl methacryla te to investigate the degree of utilization of the commercial dendrimers of different methyl  following heat induced polymerization, there 31 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib112 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib113 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib105 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [5] ajdhs.com dendrimer methyl methacrylate monomers in different dendrimer conjugated resins methacrylate units (12 in d12 and 24 in d24) were incorporated in dental resin were 65% and 62% degree of conversion for d12 and d24, respectively  residual monomer contents were 1.0% and 1.5%, respectively for d12 and d24  following photo polymerization, degree of conversion decreased with increase in methyl methacrylate proportion and thus increase in residual monomer content  heat induced polymerization method was suggested as best method with degree of conversion and residual monomers (galli et al., 2014) poly(epsilo n-lysine) dendron g3 dendritic approach to titanium surfaces could improve differentiation of osteoblastic cells and the activation of wnt/b-catenin signalling phosphoserinetethered poly(epsilon-lysine) dendrons in endosseous implants  dendrons showed increased expression of two osteoblastic markers, alkaline phosphatase and osteocalcin in primary bone marrow cells and murine osteoblastic mc3t3 cells  osteoclastogenesis opposing protein osteoprotegerin was found to get expressed significantly higher  wnt target genes, wisp-2 and b-catenin were also showed increased expression 32 (lin et al., 2017) pamam dendrimer application of dendrimer functionalized with nanohydroxyapatite in dentin tubule occlusion modification of nanohydroxyapatite with cooh-terminated pamam dendrimer  dendrimer functionalized nanohydroxyapatite found to crosslink with collagen fibres  therefore, effective dental tubule occlusion reported  superior value of microhardness was observed with modified nano33 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib106 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib74 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [6] ajdhs.com hydroxyapatite (tao et al., 2017) pamam dendrimer g4 determination of dentin remineralization extent with pamam dendrimer pamam-oh, pamam-cooh, pamam-nh2 coated dentin  dentin coated with pamam containing different functional groups showed increased hardness of dentin, reduced loss of mineral and lesion depth, with higher remineralization capability  lower mineral loss and lesion depth with higher dentin tubule blocking effect was shown by pamamcooh, pamamnh2 than pamam-oh  effects of pamamcooh, pamamnh2 dentin remineralization were comparable 34 (xiao et al., 2017) pamam dendrimer g3 development of bioactive multifunctional composite (bmc) via nanopar ticles of amorphous calcium phosphate, 2methacryloyloxyethyl phosphorylcholine, dimethylaminohexadecyl methacrylate and silver nanoparticles for class v restoration investigation of bmc with pamam dendrimer on remineralization of demineralized root dentin in a cyclic artificial saliva/lactic acid environment for the first time bmc complex mixture with nanoparticles of amorphous calcium phosphate, 2methacryloyloxyethyl phosphoryl-choline, dimethylaminohexadecyl methacrylate and silver nanoparticles and bmc with pamam dendrimer  pamam with bmc showed superior dentin mineralization characteristics  the hardness of the dentin increased enough to match healthy root dentin  pamam with bmc induced complete and effective root dentin remineralization in an acid challenge environment 35 (ge et al., 2017) pamam dendrimer g3 the anti-caries effect and mechanical properties of the modified adhesive in biofilm regulation and remineralization pamam and dimethylaminodode cyl methacrylate in biofilm adhesive  addition of pamam and dimethylaminododec yl methacrylate in adhesive showed no adverse effecton dentin bond strength 36 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib75 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib76 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6820096/#bib77 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [7] ajdhs.com capabilities  the modified adhesive with 1% pamam and 5% dimethylaminododec yl methacrylate showed anti-biofilm properties and developed a healthier biofilm to reduce the chances of dental caries  remineralization capabilities of the modified adhesive was found to have similarity with 1% pamam modified adhesive el-aziz khater et al 2018 pamam dendrimer to evaluate the remineralizing effect of pamam dendrimer, gluteraldehyde and their combination on demineralized dentin luteraldehyde was applied to the demineralized dentin, group (iii), (n=10): a combination of pamam dendrimer and gluteraldehyde all treatment materials used were effective in increasing dentin microhardness and produced micromorphological changes of the dentin surface in 37 k. liang et al 2019 pamam dendrimer ca delivery to prevent tooth decay dendrimers loaded with calcium and phosphate ions  the loaded pamam dendrimer was effective for prolonged release of calcium and phosphate at low ph, with neutralization of the acidic environment and inhibition of dental caries 20 nicholas yesbeck 2021 pamam dendrimer g5 to prolong the release kinetics of antibiotics dendrimer hydrogels were synthesized from pamam and peg diacrylate to contain cefazolin  dendrimer hydrogels is a promising platform for long-term release of cefazolin in-vitro 21 ramyaa shri k et al 2021 pamam dendrimer to develop pamam dendrimer to enhance the antibacterial activity entrapping dexamethasone into the dendrimer's cavities was done to ensure a slow release of the drug  pamam dendrimer's functionalization to silver nanoparticles to protect the nanoparticles from aggregating and reducing its cytotoxicity without affecting the antibacterial properties 22 conclusion pamam dendrimer has shown to have marked prospective to be used as biomimetic biomaterial for remineralisation of enamel.18 addition of dendrimers has shown significant enhancement of mechanical properties of adhesive systems and reduction in polymerization shrinkage of dental composites. it also causes improvement in shear strength and better bonding durability of adhesive systems 26, 27. besides drug delivery, dendrimers have been found to have a great emphasis in gene delivery, boron neutron capture therapy, pdt and as magnetic resonance imaging contrast agents. boosting of commercial applications of prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [8] ajdhs.com dendrimer technology will provide strength for its usefulness in future. conflict of interests the authors declare that there is no conflict of interests references 1. prajapati sk, maurya sd, das mk, tilak vk, verma kk, dhakar rc. dendrimers in drug delivery, diagnosis and therapy: basics and potential applications. journal of drug delivery and therapeutics, 2016; 6(1):67-92. https://doi.org/10.22270/jddt.v6i1.1190 2. dwivedi dk, singh ak, dendrimers: a novel carrier system for drug delivery, journal of drug delivery and therapeutics 2014; 4(5):1-6 https://doi.org/10.22270/jddt.v4i5.968 3. d'emanuele a, jevprasesphant r, penny j, attwood d. the use of a dendrimer-propranolol prodrug to bypass efflux transporters and enhance oral bioavailability. j control release 2004; 95:5447-53. https://doi.org/10.1016/j.jconrel.2003.12.006 4. tomalia da, birth of a new macromolecular architecture: dendrimers as quantized building blocks for nanoscale synthetic polymer chemistry. prog polym sci 2005; 30:294-324. https://doi.org/10.1016/j.progpolymsci.2005.01.007 5. boas u, jørn bolstad christensen, heegaard pmh, "dendrimers in medicine and biotechnology: new molecular tools", 2006, 62-70 https://doi.org/10.1039/9781847552679-00062 6. allen tm, cullis pr. drug delivery systems: entering the mainstream. science 2004; 303:1818-22. https://doi.org/10.1126/science.1095833 7. soto-castro d, cruz-morales ja, ramírez apan mt, guadarrama p. solubilization and anticancer-activity enhancement of methotrexate by novel dendrimeric nanodevices synthesized in one-step reaction. bioorg chem 2012; 41-2:13-21. https://doi.org/10.1016/j.bioorg.2012.01.002 8. duncan r, izzo l. dendrimer biocompatibility and toxicity. adv drug deliv rev 2005; 57:2215-37. https://doi.org/10.1016/j.addr.2005.09.019 9. patton dl, cosgrove sweeney yt, mccarthy td, hillier sl. preclinical safety and efficacy assessments of dendrimer-based (spl7013) microbicide gel formulations in a nonhuman primate model. antimicrob agents chemother 2006; 50:1696-700. https://doi.org/10.1128/aac.50.5.1696-1700.2006 10. tolia gt, choi hh. the role of dendrimers in topical drug delivery. pharm technol 2008; 32:88-98. 11. swanson dr, huang b, abdelhady hg, tomalia da. unique steric and geometry induced stoichiometries observed in the divergent synthesis of poly (ester-acrylate/amine) (pea) dendrimers. new j chem 2007; 31:1368-78. https://doi.org/10.1039/b700193m 12. tomalia da, fréchet jm. discovery of dendrimers and dendritic polymers: a brief historical perspective. j polym sci a polym chem 2002; 40:2719-28. https://doi.org/10.1002/pola.10301 13. tomalia da, rookmaker m. poly (propylene imine) dendrimers. polymer data handbook. newyork: oxford university press; 2009. 14. singh p. dendrimers and their applications in immunoassays and clinical diagnostics. biotechnol appl biochem 2007; 48:1-9. https://doi.org/10.1042/ba20070019 15. hill sw, heidecker g. transfection of hematopoetic cells in suspension using an activated-dendrimer reagent. in qiagen news. sect. 1998; 8-10. 16. liu h, wang h, yang w, cheng y. disulfide cross-linked low generation dendrimers with high gene transfection efficacy, low cytotoxicity, and low cost. j am chem soc 2012; 134:17680-7. https://doi.org/10.1021/ja307290j 17. spangler bd. inventor biosensors utilizing dendrimer-immobilized ligands and there use thereof patent. united states patent 7138121. 2006. 18 bapat ra, dharmadhikari s, chaubal tv, amin mcim, bapat p, gorain b, choudhury h, vincent c, kesharwani p, the potential of dendrimer in delivery of therapeutics for dentistry. heliyon. 2019; 5(10):e02544. pmcid: pmc6820096 pmid: 31687479 https://doi.org/10.1016/j.heliyon.2019.e02544 19 parajapati sk, maurya sd, das mk, tilak vk, verma kk, dhakar rc, potential application of dendrimers in drug delivery: a concise review and update, journal of drug delivery andtherapeutics. 2016; 6(2):71-88 https://doi.org/10.22270/jddt.v6i2.1195 20 liang k, wang s, tao s, xiao s, zhou h, wang p, cheng l, zhou x, int. j. oral sci. 2019, 11:15. https://doi.org/10.1038/s41368-019-0048-z 21 nicholas yesbeck, a thesis submitted in partial fulfilment of the requirements for the degree of master of science in dentistry at virginia commonwealth university. 5 jan 2021. https://scholarscompass.vcu.edu/etd/6541 22 ramyaa shri k, subitha p, srinivasan n, ramachandran m, shoba n, fabrication of dexamethasone-silver nanoparticles entrapped dendrimer collagen matrix nanoparticles for dental applications. biointerface research in applied chemistry. 2021; 11(6):14935 -14955 https://doi.org/10.33263/briac116.1493514955 23 jaymand m.; lotfi m.; lotfi r. functional dendritic compounds: potential prospective candidates for dental restorative materials and in situ re-mineralization of human tooth enamel. rsc advances 2016; 6:43127-43146 https://doi.org/10.1039/c6ra05722e 24 gardiner j., freeman s., leach m., green a., alcock j., d'emanuele a. pamam dendrimers for the delivery of the antibacterial triclosan. j. enzym. inhib. med. chem. 2008; 23:623-628. https://doi.org/10.1080/14756360802205257 [pubmed] [google scholar] 25 dung th, do lt, yoo h. pamam dendrimer generation 5pluronic f127 nanofilm as a matrix for local metronidazole release. j biomed nanotech. 2013; 9(7):1286-92 https://doi.org/10.1166/jbn.2013.1534 26 dodiuk-kenig h., lizenboim k., eppelbaum i., zalsman b., kenig s. the effect of hyper-branched polymers on the properties of dental composites and adhesives. j. adhes. sci. technol. 2004; 18:1723-1737. https://doi.org/10.1163/1568561042708304 27 paul n.m., bader s.j., schricker s.r., parquette j.r. 2,3branching benzyl ether dendrimers for the enhancement of dental composites. react. funct. polym. 2006; 66:16841695. https://doi.org/10.22270/jddt.v6i1.1190 https://doi.org/10.22270/jddt.v4i5.968 https://doi.org/10.1016/j.jconrel.2003.12.006 https://doi.org/10.1016/j.progpolymsci.2005.01.007 https://doi.org/10.1039/9781847552679-00062 https://doi.org/10.1126/science.1095833 https://doi.org/10.1016/j.bioorg.2012.01.002 https://doi.org/10.1016/j.addr.2005.09.019 https://doi.org/10.1128/aac.50.5.1696-1700.2006 https://doi.org/10.1039/b700193m https://doi.org/10.1002/pola.10301 https://doi.org/10.1042/ba20070019 https://doi.org/10.1021/ja307290j https://doi.org/10.1016/j.heliyon.2019.e02544 https://doi.org/10.22270/jddt.v6i2.1195 https://doi.org/10.1038/s41368-019-0048-z https://doi.org/10.33263/briac116.1493514955 https://doi.org/10.1039/c6ra05722e https://doi.org/10.1080/14756360802205257 https://www.ncbi.nlm.nih.gov/pubmed/18821252 https://scholar.google.com/scholar_lookup?journal=j.%c2%a0enzym.+inhib.+med.+chem.&title=pamam+dendrimers+for+the+delivery+of+the+antibacterial+triclosan&author=j.+gardiner&author=s.+freeman&author=m.+leach&author=a.+green&author=j.+alcock&volume=23&publication_year=2008&pages=623-628& https://doi.org/10.1166/jbn.2013.1534 https://doi.org/10.1163/1568561042708304 prajapati et al asian journal of dental and health sciences. 2021; 1(1):1-9 [9] ajdhs.com https://doi.org/10.1016/j.reactfunctpolym.2006.07.003 [google scholar] 28 kim j.k., shukla r., casagrande l., sedgley c., nör j.e., baker j.r. differentiating dental pulp cells via rgd-dendrimer conjugates. j. dent. res. 2010; 89:1433-1438. https://doi.org/10.1177/0022034510384870 [pubmed] [google scholar] 29 eichler m., katzur v., scheideler l., haupt m., geisgerstorfer j., schmalz g. the impact of dendrimer-grafted modifications to model silicon surfaces on protein adsorption and bacterial adhesion. biomaterials. 2011; 32:9168-9179. https://doi.org/10.1016/j.biomaterials.2011.08.063 [pubmed] [google scholar] 30 li j., yang j., li j., chen l., liang k., wu w. bioinspired intrafibrillar mineralization of human dentine by pamam dendrimer. biomaterials. 2013; 34:6738-6747 https://doi.org/10.1016/j.biomaterials.2013.05.046 [pubmed] [google scholar] 31 bengazi f., lang n.p., canciani e., viganò p., velez j.u., botticelli d. osseointegration of implants with dendrimers surface characteristics installed conventionally or with piezosurgery®. a comparative study in the dog. clin. oral implant. res. 2014; 25:10-15. https://doi.org/10.1111/clr.12082 [pubmed] [google scholar] 32 galli c., piemontese m., meikle s.t., santin m., macaluso g.m., passeri g. biomimetic coating with phosphoserinetethered poly(epsilon-lysine) dendrons on titanium surfaces enhances wnt and osteoblastic differentiation. clin. oral implant. res. 2014; 25:e133-e139. https://doi.org/10.1111/clr.12075 [pubmed] [google scholar] 33 lin x., xie f., ma x., hao y., qin h., long j. fabrication and characterization of dendrimer-functionalized nanohydroxyapatite and its application in dentin tubule occlusion. j. biomater. sci. polym. ed. 2017; 28:846-863. https://doi.org/10.1080/09205063.2017.1308654 [pubmed] [google scholar] 34 tao s., fan m., xu h.h.k., li j., he l., zhou x. the remineralization effectiveness of pamam dendrimer with different terminal groups on demineralized dentin in vitro. rsc adv. 2017; 7:54947-54955. https://doi.org/10.1039/c7ra11844a [google scholar] 35 xiao s., liang k., weir m.d., cheng l., liu h., zhou x. combining bioactive multifunctional dental composite with pamam for root dentin remineralization. mater. (basel, switzerland) 2017; 10:89. https://doi.org/10.3390/ma10010089 [pmc free article] [pubmed] [google scholar] 36 ge y., ren b., zhou x., xu h.h.k., wang s., li m. novel dental adhesive with biofilm-regulating and remineralization capabilities. mater. (basel, switzerland) 2017; 10:26. https://doi.org/10.3390/ma10010026 [pmc free article] [pubmed] [google scholar] 37 el-aziz khater a., niazy m., el-aziz gad n. the effect of poly amido amine dendrimer, gluteraldehyde and their combination on the micro hardness and micromorphology of demineralized dentin. al-azhar dental journal for girls, 2018; 5(4):341-347. https://doi.org/10.21608/adjg.2018.20019 https://doi.org/10.1016/j.reactfunctpolym.2006.07.003 https://scholar.google.com/scholar_lookup?journal=react.+funct.+polym.&title=2,3-branching+benzyl+ether+dendrimers+for+the+enhancement+of+dental+composites&author=n.m.+paul&author=s.j.+bader&author=s.r.+schricker&author=j.r.+parquette&volume=66&publication_year=2006&pages=1684-1695& https://doi.org/10.1177/0022034510384870 https://www.ncbi.nlm.nih.gov/pubmed/20929719 https://scholar.google.com/scholar_lookup?journal=j.%c2%a0dent.+res.&title=differentiating+dental+pulp+cells+via+rgd-dendrimer+conjugates&author=j.k.+kim&author=r.+shukla&author=l.+casagrande&author=c.+sedgley&author=j.e.+n%c3%b6r&volume=89&publication_year=2010&pages=1433-1438&pmid=20929719& https://doi.org/10.1016/j.biomaterials.2011.08.063 https://www.ncbi.nlm.nih.gov/pubmed/21906807 https://scholar.google.com/scholar_lookup?journal=biomaterials&title=the+impact+of+dendrimer-grafted+modifications+to+model+silicon+surfaces+on+protein+adsorption+and+bacterial+adhesion&author=m.+eichler&author=v.+katzur&author=l.+scheideler&author=m.+haupt&author=j.+geis-gerstorfer&volume=32&publication_year=2011&pages=9168-9179&pmid=21906807& https://doi.org/10.1016/j.biomaterials.2013.05.046 https://www.ncbi.nlm.nih.gov/pubmed/23787113 https://scholar.google.com/scholar_lookup?journal=biomaterials&title=bioinspired+intrafibrillar+mineralization+of+human+dentine+by+pamam+dendrimer&author=j.+li&author=j.+yang&author=j.+li&author=l.+chen&author=k.+liang&volume=34&publication_year=2013&pages=6738-6747&pmid=23787113& https://doi.org/10.1111/clr.12082 https://www.ncbi.nlm.nih.gov/pubmed/23231427 https://scholar.google.com/scholar_lookup?journal=clin.+oral+implant.+res.&title=osseointegration+of+implants+with+dendrimers+surface+characteristics+installed+conventionally+or+with+piezosurgery%c2%ae.+a+comparative+study+in+the+dog&author=f.+bengazi&author=n.p.+lang&author=e.+canciani&author=p.+vigan%c3%b2&author=j.u.+velez&volume=25&publication_year=2014&pages=10-15& https://scholar.google.com/scholar_lookup?journal=clin.+oral+implant.+res.&title=osseointegration+of+implants+with+dendrimers+surface+characteristics+installed+conventionally+or+with+piezosurgery%c2%ae.+a+comparative+study+in+the+dog&author=f.+bengazi&author=n.p.+lang&author=e.+canciani&author=p.+vigan%c3%b2&author=j.u.+velez&volume=25&publication_year=2014&pages=10-15& https://doi.org/10.1111/clr.12075 https://www.ncbi.nlm.nih.gov/pubmed/23210635 https://scholar.google.com/scholar_lookup?journal=clin.+oral+implant.+res.&title=biomimetic+coating+with+phosphoserine-tethered+poly(epsilon-lysine)+dendrons+on+titanium+surfaces+enhances+wnt+and+osteoblastic+differentiation&author=c.+galli&author=m.+piemontese&author=s.t.+meikle&author=m.+santin&author=g.m.+macaluso&volume=25&publication_year=2014&pages=e133-e139& https://scholar.google.com/scholar_lookup?journal=clin.+oral+implant.+res.&title=biomimetic+coating+with+phosphoserine-tethered+poly(epsilon-lysine)+dendrons+on+titanium+surfaces+enhances+wnt+and+osteoblastic+differentiation&author=c.+galli&author=m.+piemontese&author=s.t.+meikle&author=m.+santin&author=g.m.+macaluso&volume=25&publication_year=2014&pages=e133-e139& https://doi.org/10.1080/09205063.2017.1308654 https://www.ncbi.nlm.nih.gov/pubmed/28325103 https://scholar.google.com/scholar_lookup?journal=j.%c2%a0biomater.+sci.+polym.+ed.&title=fabrication+and+characterization+of+dendrimer-functionalized+nano-hydroxyapatite+and+its+application+in+dentin+tubule+occlusion&author=x.+lin&author=f.+xie&author=x.+ma&author=y.+hao&author=h.+qin&volume=28&publication_year=2017&pages=846-863&pmid=28325103& https://doi.org/10.1039/c7ra11844a https://scholar.google.com/scholar_lookup?journal=rsc+adv.&title=the+remineralization+effectiveness+of+pamam+dendrimer+with+different+terminal+groups+on+demineralized+dentin+in+vitro&author=s.+tao&author=m.+fan&author=h.h.k.+xu&author=j.+li&author=l.+he&volume=7&publication_year=2017&pages=54947-54955& https://doi.org/10.3390/ma10010089 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5344620/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5344620/ https://www.ncbi.nlm.nih.gov/pubmed/28772450 https://scholar.google.com/scholar_lookup?journal=mater.+(basel,+switzerland)&title=combining+bioactive+multifunctional+dental+composite+with+pamam+for+root+dentin+remineralization&author=s.+xiao&author=k.+liang&author=m.d.+weir&author=l.+cheng&author=h.+liu&volume=10&publication_year=2017&pages=89& https://doi.org/10.3390/ma10010026 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5344622/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5344622/ https://www.ncbi.nlm.nih.gov/pubmed/28772391 https://scholar.google.com/scholar_lookup?journal=mater.+(basel,+switzerland)&title=novel+dental+adhesive+with+biofilm-regulating+and+remineralization+capabilities&author=y.+ge&author=b.+ren&author=x.+zhou&author=h.h.k.+xu&author=s.+wang&volume=10&publication_year=2017&pages=26& https://doi.org/10.21608/adjg.2018.20019 sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [26] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited relationship between family history, diet and sedentary behavior with the incidence of diabetes mellitus ace sudrajat, maharani romadhona, santa manurung*, suratun, nelly yardes, dewi lusiani, tin hartini health polytechnic of jakarta iii, indonesia article info: ______________________________________ article history: received 30 march 2022 reviewed 09 may 2023 accepted 28 may 2023 published 15 june 2023 ______________________________________ cite this article as: sudrajat a, romadhona m, manurung s, suratun, yardes n, lusiani d, hartini t, relationship between family history, diet and sedentary behavior with the incidence of diabetes mellitus , asian journal of dental and health sciences. 2023; 3(2):26-31 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.42 _______________________________________ *address for correspondence: santa manurung, health polytechnic of jakarta iii, indonesia abstract ________________________________________________________________________________________________________________________ diabetes mellitus (dm) is a degenerative disease that is a public health problem throughout the world. diabetes mellitus has become one of four non-communicable diseases that will cause around 6.7 million people to die in 2021. currently, the number of cases and prevalence of diabetes mellitus continues to increase. there are several risk factors that can cause diabetes mellitus, including family history, food patterns and sedentary behavior. this study aims to determine the relationship between family history, diet and sedentary behavior on the incidence of diabetes mellitus. the population in this study were all patients aged 4575 years who were treated at the chronic disease management program (prolanis), public health rebo district market center. samples were taken as many as 68 respondents with a purposive sampling technique. the data was collected using a questionnaire and then analyzed using the chi square test. the results showed that there is a relationship between family history (p-values = 0.003 with or = 5.061), diet (p-values = 0.002 with or = 5.667) and sedentary behavior (p-values = 0.011). with or value = 3829) with the incidence of diabetes mellitus keywords: family history, food patterns, sedentary behavior, diabetes mellitus, incidence introduction diabetes mellitus (dm) is one of the degenerative diseases that affect the health of individuals worldwide. diabetes mellitus is a metabolic disorder caused by hyperglycemia (increased blood sugar levels) that occurs due to decreased insulin secretion, impaired insulin metabolism, or both. this makes blood sugar in the blood unable to be utilized by the body's cells as energy resulting in hyperglycemia.1,2 diabetes mellitus is one of the four non-communicable diseases which will cause around 6.7 million deaths in 2021. currently, diabetes mellitus continues to increase every year. according to a report by the international diabetes federation (idf), the number of people with diabetes mellitus worldwide in 2021 has reached 537 million. it is estimated that the number of people with diabetes mellitus in indonesia will continue to increase in 2045 to 28.6 million sufferers. indonesia is the only country in southeast asia on the list. thus, indonesia has a significant contribution to the incidence of diabetes mellitus in southeast asia.3 according to the 2018 basic health research, the incidence of diabetes mellitus in indonesia according to doctors' diagnoses at the age of ≥ 15 years has increased to 2%. this figure represents that there was an increase in cases of diabetes mellitus previously in 2013, which was 1.5%. meanwhile, the prevalence of diabetes mellitus based on blood sugar examination results in 2018 increased in percentage from 6.9% to 8.5%. dki jakarta has the highest incidence of diabetes mellitus at 3.4%.4 according to data the author obtained from the pasar rebo district health center, the number of people with diabetes mellitus during the julydecember 2021 period was 3,038 sufferers. diabetes mellitus is the second most common disease in the pasar rebo health center. one of the risk factors that cause diabetes mellitus is a family history of diabetes mellitus. judging from the results of research conducted by irwan et al it is said that individuals with a family history of diabetes mellitus, especially parents and siblings, are at higher risk of developing diabetes mellitus than someone who has no family history. in addition, there are other studies which explain that if one of the two parents suffers from diabetes mellitus, there is a 15% risk of suffering from diabetes. however, if both parents have diabetes mellitus, the risk of developing diabetes mellitus increases to 75%.5,6 diet can also contribute to the occurrence of diabetes mellitus. diet is the accuracy and consistency of the patient in controlling the type, amount and frequency of eating. a person can be said to have a healthy diet if they follow dietary guidelines such as type, amount and frequency. conversely, if someone does not do less than these three indicators, then the eating pattern of people with diabetes mellitus will be bad. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.42 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.42&amp;domain=pdf sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [27] ajdhs.com based on the results of research conducted, it was found that someone who has a bad diet is twice as likely to suffer from diabetes mellitus compared to those who have a healthy diet. this unhealthy eating pattern is about people who often eat foods high in calories, fat and cholesterol, such as fast food.1,7,8 the results of the 2018 basic health research stated that there was an increase in the number of people who were less active, including sedentary behavior, namely by 33.5%, compared to 26.1% in 2013. sedentary behavior is a risky behavior that can cause metabolic syndrome, namely coronary heart disease, diabetes mellitus, and stroke. based on the results of a research study conducted by yusfita, explaining that someone who engages in sedentary behavior ≥ 6 hours per day has a 16 times greater risk of metabolic syndrome, one of which is diabetes mellitus, compared to people who engage in sedentary behavior < 6 hours per day.4,9–11 based on the description above, the researcher is interested in proving that there is a correlation between family history, diet, and sedentary behavior on the incidence of diabetes mellitus at the pasar rebo district health center, east jakarta city. methods and materials the research used an analytic observational study and used a cross sectional design. the population in this study were all polyprolanis patients at the pasar rebo district health center. the sample calculation in this study used a simple size application with the results of 68 respondents consisting of patients who suffer from diabetes mellitus and do not suffer from diabetes mellitus. the sampling technique used was purposive sampling. the research began in mid-may 2022 at the pasar rebo district health center. data collection was carried out by collecting primary data in the form of questionnaires given to respondents and secondary data in the form of patient visit data. the questionnaires used in this study were the food frequency questionnaire (ffq) and the sedentary behavior questionnaire (sbq). prior to conducting the research, the researcher obtained ethical approval from the health research ethics committee of the poltekkes kemenkes jakarta iii and obtained the ethic number lb.02.02/kepk/029/2022. data analysis was carried out in a univariate manner, namely to explain data on the characteristics of the respondents (age, gender, education level, occupation) and research variables (family history, diet, sedentary behavior). bivariate analysis was conducted to determine the relationship between the independent variables and the dependent variable. processing with chi square statistical test. results and discussion table 1 shows that most of the respondents are in the middle adult range (45-65 years) (77.9%), where the majority of respondents are female (61.8%). as for the educational level of the majority of the respondents, the majority of respondents had basic education, and in the employment category, most of the respondents did not work (57.4%). table 1: characteristics of respondents characteristics frequency % age 45-65 53 77.9 >65 15 22.1 gender male 26 38.2 female 42 61.8 level of education basic education 30 41.1 higher education 38 55.9 employment work 29 42.6 no work 39 57.4 based on table 2, it can be seen that most of the respondents were patients with diabetes mellitus (66.2%), where the majority of respondents had a family history of diabetes mellitus (54.4%). as for the eating patterns of the majority of respondents, the majority of respondents had unhealthy eating patterns (52.9%), and the sedentary behavior of most respondents had sedentary behavior ≥ 6 hours/day (60.3%). table 2: frequency distribution based on research variables characteristics frequency % incidence of diabetes mellitus yes 23 33.8 no 45 66.2 family history of diabetes mellitus yes 30 44.1 no 38 55.9 dietary habit good 32 47.1 bad 36 52.9 sedentary behavior < 6 hours/day 24 39.7 ≥ 6 hours/day 41 60.3 sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [28] ajdhs.com table 3: relationship of respondent characteristics with the incidence of diabetes mellitus variable incidence of diabetes mellitus p-value or (ci95%) yes no total f % f % f % age 45-65 22 41.5 31 58.5 53 100 0.012 9.935 >65 1 6.7 14 93.9 15 100 (1.215-81.21) gender male 14 53.8 12 46.2 26 100 0.006 4.279 female 9 21.4 33 78.6 42 100 (1.273-12.43) level of education basic education 16 46.7 14 33.3 30 100 0.003 0.198 higher education 7 18.4 31 81.6 38 100 (0.006-0.527) employment work 15 51.7 14 48.3 29 100 0.007 0.241 no work 8 20.5 31 79.5 39 100 (0.083-0.699) in this study it was found that the average age of the respondents was mostly in the middle adult age range (45-60 years) (57.4%). however, almost all of the respondents in the late adult age range (> 65 years) suffered from diabetes mellitus (93.9%). the results showed that there was a relationship between age and the incidence of diabetes mellitus (p-value = 0.012). the results of this study are in line with research conducted by riris and siregar, namely that there is a relationship between age and the incidence of diabetes mellitus (p-value = 0.001). likewise with the research conducted by arania et al, that there is a relationship between age and the incidence of diabetes mellitus (p-value = 0.032 <0.05), where a person aged > 45 years has a 5.6 times greater risk of suffering from diabetes mellitus. referring to the research by setyorogo and trisnawati (2013), that at the age of more than 50 years, most patients suffer from diabetes mellitus due to lifestyle factors. at that age began to occur increased glucose intolerance. the aging process causes a decrease in the ability of pancreatic β cells to produce insulin accompanied by lifestyle impacts in adolescents and productive ages, thereby increasing the risk of suffering from diabetes mellitus. in addition, in older individuals, there is a 35% decrease in mitochondrial activity in muscle cells. this is related to an increase in fat content in the muscles by 30% and triggers insulin resistance. there is another theory that suggests that as we get older, the ability of the tissues to take up glucose in the blood decreases. this is what causes diabetes mellitus to occur more in people aged over 40 years. the assumption of the researchers based on the results of the study is that the older you get, the greater the risk of suffering from diabetes mellitus.12–14 the results showed that there was a relationship between gender and the incidence of diabetes mellitus (p-value = 0.006), where female respondents had a 4.297 times greater risk of suffering from diabetes mellitus than male respondents. in this study it was known that the majority of respondents were female (61.8%). these results are in line with research conducted by rosita et al, that there is a relationship between gender and the incidence of diabetes mellitus (p-value = 0.012). the main cause of the large number of women affected by diabetes mellitus is because women gain weight more easily. in addition, women experience a decrease in the hormone estrogen, especially during menopause. the hormones estrogen and progesterone have the ability to increase insulin response in the blood. at the age of menopause, insulin response will decrease due to low estrogen and progesterone hormones. however, there are other opinions which state that people with male sex are more at risk of suffering from diabetes mellitus. musdalifah and nugroho's research, explains that this difference in risk is caused by the amount of fat in the body, in which men accumulate a lot of fat around the abdomen, causing central obesity which is more at risk of causing metabolic disorders, in other words, men are more at risk for diabetes. the researcher's assumption based on the research results is that gender can influence the occurrence of diabetes mellitus in a person. women have a greater risk of suffering from diabetes mellitus than men. however, this returns to each individual, if a person has a bad lifestyle, such as eating sweet foods and rarely exercising, both women and men have the same risk of developing diabetes mellitus.15,16 in this study it was known that most of the respondents had primary education (55.9%). the results showed that there was a significant relationship between education level and the incidence of diabetes mellitus (p-value = 0.003), where respondents with a basic education level had a 0.198 times greater risk of suffering from diabetes mellitus than respondents with a higher education level. these results are based on research by arania et al, that the level of learning is associated with the incidence of diabetes, with a relative value of -0.304, a negative value is obtained, which means that the higher the level of education, the lower the incidence of diabetes.13 this phenomenon is also based on the research of pahlawati et al. (2019), that there is a relationship between grade grade and the incidence of diabetes mellitus with a pvalue of 0.002. education is one of the efforts to develop personality and abilities inside and outside of school and lasts a lifetime. education affects the learning process, the higher a person's education, the easier it is for that person to receive information, both from other people and from the mass media, the more information that comes in, the more knowledge one gets.17,18 irwan also argues that there is an attachment between people with a higher level of education where they are more able to accept themselves as sick if they experience sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [29] ajdhs.com symptoms related to an illness compared to groups of people who have lower education. it is also indicated that people with higher levels of education seek help from the health team more quickly than people with lower social status. from the description above, the researchers assume that the level of education greatly influences the incidence of diabetes mellitus. those with basic education are more at risk of suffering from diabetes mellitus than those with higher education, because someone with higher education has better knowledge about diabetes mellitus and its effects on health so they have awareness to take better care of their health.5 in this study it is known that most of the respondents do not work (60.3%). the results showed that there was a significant relationship between work and the incidence of diabetes mellitus (p-value = 0.007), where respondents who worked had a 0.241 times greater risk of suffering from diabetes mellitus than respondents who did not work. these results are in line with research conducted by r. mahmud (2018), that there is a relationship between work and the incidence of diabetes mellitus (p-value = 0.003). research conducted by cahyaningrum and sugiharti, also argues that there is a relationship between work and the incidence of diabetes mellitus (p-value = 0.04). based on research by hanif et al. entitled gender specific epidemiology of diabetes states that a person's job affects the level of physical activity which affects health so that he is at risk of suffering from diabetes mellitus. someone who doesn't work, such as housewives, unemployed, and retirees, spends more time at home so they have less movement and can trigger obesity. this can lead to insulin resistance because the body's tissues are less sensitive to the effects of insulin. thus, blood sugar levels in cells increase. the researcher's assumption based on the research results is that work has a significant relationship with the incidence of diabetes mellitus. someone who does not work has a greater risk of suffering from diabetes mellitus than those who work.19,20 table 4: relationship of research variables with the incidence of diabetes mellitus variable incidence of diabetes mellitus p-value or (ci95%) yes no total f % f % f % family history of diabetes mellitus yes 16 53.3 14 46.4 31 100 0.006 5.061 no 7 18.8 31 81.6 37 100 (1.702-15.04) dietary habit good 17 53.1 15 46.9 32 100 0.003 5.667 bad 6 16.7 30 83.3 36 100 (1.852-17.33) sedentary behavior < 6 hours/day 14 51.9 13 48.1 24 100 0.011 3.829 ≥ 6 hours/day 9 22.0 32 78.0 41 100 (1.331-11.01) the results showed that there was a significant relationship between family history and the incidence of diabetes mellitus (p-value = 0.003), where respondents who had a family history had a 5.061 times greater risk of developing diabetes mellitus than respondents who did not have a family history. the results of this study are in line with research conducted by irwan, genetic factors are associated with the incidence of diabetes mellitus with a p-value = 0.000. in this research it is also said that someone who has a family history has a 4 times greater risk of suffering from diabetes mellitus.5 a family history of diabetes mellitus is closely related to genetics and is thought to affect pancreatic beta cells, insulin action, and glucose metabolism. people who have a history of diabetes mellitus in the family have a 1.093 times greater chance of suffering from type 2 diabetes mellitus than people who do not have a history of diabetes mellitus in the family, the family in question is father, mother and siblings.21,22 gene inheritance mainly occurs from the mother's side while in the womb. however, because the genes of the child and his siblings come from the mother and father, even if the father has dm, the risk of a child suffering from dm is still there. the risk of getting dm from a mother is 10-30% greater than a father with dm. if a sibling suffers from dm, the risk of suffering from dm is 10% and 90% if the sufferer is an identical twin.6 there is another opinion which says that family history is closely related to the incidence of type 2 diabetes mellitus, this is inseparable from environmental habits. for example, parents with healthy eating habits tend to pass them on to the next generation. unhealthy eating habits accompanied by infrequent physical activity are more at risk of experiencing high sugar levels, so they are at risk of developing type 2 diabetes mellitus when they are at productive age or the elderly.23 unlike previous studies, cahyaningrum and sugiharti stated that family history had no relationship with the incidence of diabetes mellitus (p value = 0.117).19 wardiah and emilia explain that diabetes mellitus can occur in individuals who have a family history of diabetes, but do not rule out the possibility for individuals who do not have a family history. individuals who do not have a family history of diabetes may suffer from diabetes mellitus if their lifestyle deviates, such as frequently consuming foods high in sugar and fat and rarely doing physical activity. from the description above, researchers assume that there is a relationship between family history and the incidence of diabetes mellitus. however, it is possible for someone who has no family history to suffer from diabetes mellitus, because diabetes mellitus can be influenced by other risk factors such as unhealthy diet and lack of physical activity.24 the results of this study indicate that there is a significant relationship between diet and the incidence of diabetes sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [30] ajdhs.com mellitus (p-value = 0.002). where it is known that most of the respondents in this study had a bad diet (57.1%). so it can be seen that respondents who have a bad diet have a tendency to suffer from diabetes mellitus. this finding is in line with research conducted by isnaini and ratnasari, that there is a relationship between diet and the incidence of diabetes mellitus at the wangon i public health center with p = 0.031. in a study conducted by hariawan et al, it was also stated that there was a relationship between diet and the incidence of diabetes mellitus (p-value = 0.023). in this study it was found that most of the respondents often consumed foods containing carbohydrates.22,25 suprapti in his research stated that someone who has a frequent carbohydrate diet has a risk 4 times higher than those who have a rare carbohydrate diet. carbohydrate intake that exceeds the need will further increase blood sugar and cannot be controlled within normal limits. in carrying out its functions, the body needs energy obtained from potential energy in the form of chemical energy stored in food ingredients. the energy will be released after experiencing metabolic processes in the body. carbohydrates are foods that can meet energy needs. carbohydrates will be absorbed by the body in the form of glucose in the process of metabolism. in this metabolic process, insulin is needed to enter glucose and other nutrients into cells to be used as fuel and become energy. if insulin is lacking or cells are resistant to insulin, blood sugar levels will increase.26,27 diet is defined as a person's accuracy in controlling the type, amount and frequency of food to maintain health. diet is a modifiable risk factor and is closely related to diabetes mellitus. people who cannot control their eating patterns will be more susceptible to disease than people who are careful in consuming food. in accordance with the guidelines issued by perkeni (2021), the recommended carbohydrate intake for dm patients is 45-68% of total calories in food. adjusting eating patterns such as a healthy diet with balanced nutrition is very important for controlling blood sugar, but people with diabetes mellitus still often consume foods or drinks high in carbohydrates. it is important for people with diabetes mellitus to start consuming less food or drinks that are high in carbohydrates by reducing the amount and frequency, for example someone who usually drinks tea (3-4 times a day) should reduce tea consumption (1-2 times a day). this should also be applied to rice intake and other eating habits.24 based on the description above, researchers assume that diet greatly influences the occurrence of diabetes mellitus. someone who has a bad diet is more at risk of suffering from diabetes mellitus than those who have a good diet. in this study it was found that the majority of respondents (68.8%) performed sedentary behavior < 6 hours/day. the results showed that there was a relationship between sedentary behavior and the incidence of diabetes mellitus (pvalue = 0.011). respondents who engage in sedentary behavior ≥ 6 hours/day have a 3.829 times greater risk of developing diabetes mellitus compared to respondents who engage in sedentary behavior < 6 hours/day. the results of this study are in line with research conducted by irwan et al that sedentary behavior carried out for ≥ 6 hours/day is associated with diabetes mellitus with a p-value = 0.000.5 in addition, research conducted by yanti also obtained the same results as this study, namely that there was a significant relationship between sedentary behavior and the incidence of diabetes mellitus at the fish market health center in bengkulu city in 2016 with p-values = 0.049. someone who is physically active for 150 to 300 minutes per week, will probably engage in sedentary behaviors such as sitting for several hours a day at work or during their leisure time. according to henson et al, those who do not do much physical activity and have high sedentary behavior have twice the risk of developing type 2 diabetes mellitus. the effect of physical activity is directly related to increasing the speed of muscle glucose recovery (how much muscle takes glucose from the bloodstream). blood). when doing physical activity, the muscles use glucose stored in the muscles and if glucose is reduced, the muscles fill the void by taking glucose from the blood. this will result in a decrease in blood glucose thereby increasing blood glucose control. therefore, lack of physical activity will cause an increase in blood sugar levels so that it can cause diabetes mellitus.28–30 physical activity is any bodily movement produced by skeletal muscles that requires energy. activities such as spending a lot of time watching tv and lying down make the energy in the body not much used, meanwhile the energy that comes from food continues to increase. this causes an imbalance between incoming energy and used energy. excess energy can lead to excess body weight (obesity). according to the indonesian ministry of health, central obesity is a risk factor that can cause chronic diseases including diabetes mellitus. the researcher's assumption based on the results of the study is that sedentary behavior that is carried out ≥ 6 hours can cause diabetes mellitus. if this behavior is carried out continuously it can cause various diseases such as diabetes mellitus, cardiovascular disease, obesity and so on. for this reason, it is important to do physical activity such as exercising for 30-45 minutes 3-5 days a week so that blood sugar levels can be controlled.31 conclusion based on the results of the study, it was found that there was a relationship between age (p-value = 0.012), gender (p-value = 0.003), education (p-value = 0.003) and occupation (p-value = 0.003) and the incidence of diabetes mellitus. in addition, it was also found that there was a relationship between family history (p-value = 0.003), diet (p-value = 0.002), and sedentary behavior (p-value = 0.011) with the incidence of diabetes mellitus. it is hoped that the results of this study can be used as a guideline for health services in order to further improve counseling or health education for patients with diabetes mellitus. references 1. association ad. diagnosis and classification of diabetes mellitus. diabetes care. 2013; 36(suppl 1):s67. https://doi.org/10.2337/dc13-s067 2. manurung s. educational model: anti-stroke gymnastics on compliance and health status of patients hypertension. asian j pharm res dev. 2022; 10(4):9-15. https://doi.org/10.22270/ajprd.v10i4.1161 3. federation id. idf diabetes atlas, tenth. international diabetes; 2021. 4. kementerian kesehatan ri. laporan nasional riset kesehatan dasar 2018. riskesdas. 2018;614. 5. irwan fa, bialangi s. hubungan riwayat keluarga dan perilaku sedentari terhadap kejadian diabetes melitus. jambura j helath sci res. 2021; 3(1). https://doi.org/10.35971/jjhsr.v3i1.7075 6. diabetes uk. diabetes in the uk 2010: key statistics on diabetes. london diabetes uk. 2010; 7. chairani r, satriadi a. application of family nursing care in patients with hypertension: a case study. asian j pharm res dev. 2022; 10(2):48-52. https://doi.org/10.22270/ajprd.v10i2.1118 8. nguyen ct, pham nm, lee ah, binns cw. prevalence of and risk factors for type 2 diabetes mellitus in vietnam: a systematic review. asia pacific j public heal. 2015; 27(6):588-600. https://doi.org/10.1177/1010539515595860 9. riskesdas ri. riset kesehatan dasar tahun 2013. badan penelit dan pengemb kesehat kementrian kesehat ri. 2013; https://doi.org/10.2337/dc13-s067 https://doi.org/10.22270/ajprd.v10i4.1161 https://doi.org/10.35971/jjhsr.v3i1.7075 https://doi.org/10.22270/ajprd.v10i2.1118 https://doi.org/10.1177/1010539515595860 sudrajat et al asian journal of dental and health sciences. 2023; 3(2):26-31 [31] ajdhs.com 10. bozkurt b, aguilar d, deswal a, dunbar sb, francis gs, horwich t, et al. contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the american heart association. circulation. 2016; 134(23):e535-78. https://doi.org/10.1161/cir.0000000000000450 11. yusfita yl. hubungan perilaku sedentari dengan sindrom metabolik pada pekerja. indones j public heal. 2018; 13(2):14355. https://doi.org/10.20473/ijph.v13i2.2018.145-157 12. siregar ird. karakteristik individu dan perilaku berisiko terhadap kejadian dm tipe ii. j ilm kesehat. 2018; 17(02):3-9. https://doi.org/10.33221/jikes.v17i02.264 13. arania r, triwahyuni t, esfandiari f, nugraha fr. hubungan antara usia, jenis kelamin, dan tingkat pendidikan dengan kejadian diabetes mellitus di klinik mardi waluyo lampung tengah. j med malahayati. 2021; 5(3):146-53. https://doi.org/10.33024/jmm.v5i3.4200 14. trisnawati sk, setyorogo s. faktor risiko kejadian diabetes melitus tipe ii di puskesmas kecamatan cengkareng jakarta barat tahun 2012. j ilm kesehat. 2013; 5(1):6-11. 15. rosita r, kusumaningtiar da, irfandi a, ayu im. hubungan antara jenis kelamin, umur, dan aktivitas fisik dengan diabetes melitus tipe 2 pada lansia di puskesmas balaraja kabupaten tangerang. j kesehat masy. 2022; 10(3):364-71. https://doi.org/10.14710/jkm.v10i3.33186 16. musdalifah m, nugroho ps. hubungan jenis kelamin dan tingkat ekonomi dengan kejadian diabetes melitus di wilayah kerja puskesmas palaran kota samarinda tahun 2019. borneo student res. 2020; 1(2):1238-42. https://doi.org/10.22437/jkmj.v2i1.6535 17. pahlawati a, nugroho ps. hubungan tingkat pendidikan dan usia dengan kejadian diabetes melitus di wilayah kerja puskesmas palaran kota samarinda tahun 2019. borneo student res. 2019; 1(1):1-5. https://doi.org/10.33761/jsm.v14i1.78 18. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta. 2010; 200:26-35. 19. cahyaningrum ed, sugiharti rk. the relationship between obesity and physical activity to the incidence of diabetes mellitus in ledug, kembaran, banyumas, central java. in: 1st international conference on community health (icch 2019). atlantis press; 2020. p. 137-43. https://doi.org/10.2991/ahsr.k.200204.031 20. hanif aam, shamim aa, hossain mm, hasan m, khan msa, hossaine m, et al. gender-specific prevalence and associated factors of hypertension among elderly bangladeshi people: findings from a nationally representative cross-sectional survey. bmj open. 2021; 11(1):e038326. https://doi.org/10.1136/bmjopen-2020-038326 21. biondi b, kahaly gj, robertson rp. thyroid dysfunction and diabetes mellitus: two closely associated disorders. endocr rev. 2019; 40(3):789-824. https://doi.org/10.1210/er.2018-00163 22. isnaini n, ratnasari r. faktor risiko mempengaruhi kejadian diabetes mellitus tipe dua. j kebidanan dan keperawatan aisyiyah. 2018; 14(1):59-68. https://doi.org/10.31101/jkk.550 23. nuraisyah f, ruliyandari r, matahari r. riwayat keluarga diabetes tipe ii dengan kadar gula darah. j kebidanan dan keperawatan'aisyiyah. 2020; 16(2):253-9. https://doi.org/10.31101/jkk.1356 24. wardiah w, emilia e. faktor risiko diabetes mellitus pada wanita usia reproduktif di wilayah kerja puskesmas langsa lama kota langsa, aceh. j kesehat glob. 2018; 1(3):119. https://doi.org/10.33085/jkg.v1i3.3975 25. hariawan h, fathoni a, purnamawati d. hubungan gaya hidup (pola makan dan aktivitas fisik) dengan kejadian diabetes melitus di rumah sakit umum provinsi ntb. j keperawatan terpadu (integrated nurs journal). 2019; 1(1):1-7. https://doi.org/10.32807/jkt.v1i1.16 26. suprapti d. hubungan pola makan, kondisi psikologis, dan aktivitas fisik dengan diabetes mellitus pada lansia di puskesmas kumai. j borneo cendekia. 2020; 2(1):1-23. https://doi.org/10.54411/jbc.v2i1.85 27. veridiana nn, nurjana ma. hubungan perilaku konsumsi dan aktivitas fisik dengan diabetes mellitus di indonesia. bul penelit kesehat. 2019; 47(2):97-106. https://doi.org/10.22435/bpk.v47i2.667 28. yanti dwirf. hubungan perilaku sedentari dan pola makan dengan kejadian diabetes melitus di puskesmas pasar ikan kota bengkulu tahun 2016. universitas dehasen bengkulu; 2016. 29. henson j, dunstan dw, davies mj, yates t. sedentary behaviour as a new behavioural target in the prevention and treatment of type 2 diabetes. diabetes metab res rev. 2016; 32:213-20. https://doi.org/10.1002/dmrr.2759 30. sari n, purnama a. aktivitas fisik dan hubungannya dengan kejadian diabetes melitus. wind heal j kesehat. 2019; 368-81. https://doi.org/10.33368/woh.v0i0.213 31. kemenkes ri. tetap produktif, cegah, dan atasi diabetes melitus. pus data dan inf kementrian kesehat ri. 2020; https://doi.org/10.1161/cir.0000000000000450 https://doi.org/10.20473/ijph.v13i2.2018.145-157 https://doi.org/10.33221/jikes.v17i02.264 https://doi.org/10.33024/jmm.v5i3.4200 https://doi.org/10.14710/jkm.v10i3.33186 https://doi.org/10.22437/jkmj.v2i1.6535 https://doi.org/10.33761/jsm.v14i1.78 https://doi.org/10.2991/ahsr.k.200204.031 https://doi.org/10.1136/bmjopen-2020-038326 https://doi.org/10.1210/er.2018-00163 https://doi.org/10.31101/jkk.550 https://doi.org/10.31101/jkk.1356 https://doi.org/10.33085/jkg.v1i3.3975 https://doi.org/10.32807/jkt.v1i1.16 https://doi.org/10.54411/jbc.v2i1.85 https://doi.org/10.22435/bpk.v47i2.667 https://doi.org/10.1002/dmrr.2759 https://doi.org/10.33368/woh.v0i0.213 umar et al asian journal of dental and health sciences. 2023; 3(3):33-36 [33] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited determination of relationship of birth order position and intelligent quotient among students of college of medicine and allied health sciences, federal university dutse mikail isyaku umar1,2, ni'imah rabiu el-yakub1, ibrahim ahmad atiku1, abba ishaq1, musa abubakar3 and *emmanuel ifeanyi obeagu4 1 department of human anatomy, federal university dutse, igawa state, nigeria 2 department of human anatomy, kampala international university uganda. 3 department of human anatomy, bayero university kano, kano state, nigeria. 4 department of medical laboratory science, kampala international university, uganda. article info: _______________________________________ article history: received 29 june 2023 reviewed 07 august 2023 accepted 24 august 2023 published 15 september 2023 _______________________________________ cite this article as: umar ms, el-yakub nr, atiku ia, ishaq a, abubakar m, obeagu ei, determination of relationship of birth order position and intelligent quotient among students of college of medicine and allied health sciences, federal university dutse, asian journal of dental and health sciences. 2023; 3(3):33-36 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.51 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda. abstract ___________________________________________________________________________________________________________________ the present study is aimed at finding the relationship of birth order position and intelligence quotient among students of college of medicine and allied health sciences in federal university dutse, jigawa state. a total number of 250 students which comprise 124 males and 126 females were assessed using questionnaires. data was analyzed using “spss statistics version 20”. the variable measurements were presented as mean ± sd. the differences between the two groups that is males and females were compared by using “independent sample t-test”. the correlation between the variables were found using pearson’s and partial correlation. values of p < 0.05 were deemed as level of significant. the present study shows negative or no relationship between birth order position and intelligent quotient in the population study. independent sample t-test for sexual dimorphism of the variables shows that no significant difference. keywords: relationship, birth order position, intelligent quotient, students introduction intelligence has been defined in a variety of ways ranging from the ability to acquire and apply knowledge and skills 1. intelligence is a general mental capability that, among other things, involves the ability to reason, plan, solve problems, comprehend complex ideas, think abstractly, learn quickly and learn from experience 2. intelligence is also defined as one’s capacity for logic, abstract thought, clear understanding, selfawareness, communication, learning, memory, emotional knowledge, planning, creativity and ability to accurately solve problems 3. intelligence is not merely book learning, a narrow academic skill, good grades, or test-taking smarts 4. rather, it reflects a broader and deeper capability for understanding our surroundings; ‘catching on,’ ‘making sense,’ of things or figuring out what to do. intelligence is the ability to think rationally, learn effectively, understand complex ideas, and adapt to the environment 5. human intelligence is the intellectual capability of humans, which is marked by complex cognitive facts and high levels of motivation and self-awareness 6. human intelligence, is a mental quality that consists of the abilities to learn from experience, adapt to new situations, understand and handle abstract concepts, and use knowledge to manipulate man’s environment 7. iq (the intelligence quotient) is the quantification of an individual’s intelligence relative to peers of a similar age or a range of characteristics 8. iq is one of the most heritable psychological traits, and an individual’s score on a modern iq test is a good predictor of many life outcomes, including educational and career success, health, longevity, and even happiness 9. open access research article http://dx.doi.org/10.22270/ajdhs.v3i3.51 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.51&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 umar et al asian journal of dental and health sciences. 2023; 3(3):33-36 [34] ajdhs.com materials and methods study area the study was conducted at dutse local government area of jigawa state. college of medicine and allied health sciences, federal university dutse, jigawa state was chosen as the study area. study population a total number of 250 students were selected comprising both genders students from all departments across the college. sampling method random sampling method was adopted in this study that comprises 250 numbers of different birth ordinal positions. out of the questionnaires distributed, all were retrieved and the information contained in each questionnaire was analyzed and presented in a table. the remaining questionnaires were returned either unfilled or uncompleted. the population size was determined using the formula; where, n=minimum sample size n=total number of population e=coefficient error ethical approval an introductory letter of approval was obtained from research and ethics committee of human anatomy department, federal university dutse. the informed consents of the participated students were signed by the school managements on behalf of the students. inclusion criteria subjects that are students from college of medicine and allied health sciences exclusion criteria subjects that are not students from college of medicine and allied health sciences. materials birth order position assessment questionnaire intelligence quotient test questionnaire methodology assessment of birth order position the birth order position of the students was accessed by the use of birth order position assessment questionnaire. the participants of the study were personally enlightened before they were given the questionnaire. they were briefed regarding the nature and objectives of the study. intelligence quotient test the intelligence quotient test was accessed by using iq test questions which involves making the subjects to respond to a set of questions on a questionnaire. the questionnaire consists of two parts: a and b part. a consist of space for bio data like sex, age, level etc. while b consists of space for birth order position, iq score and set of intelligence quotient test questions designed at the ultimate iq test book. the questions were marked and recorded. statistical analysis independent t-test was used the find the difference between the means. partial and pearson’s correlations were used to find the strength of the relationship between the variable. level of significance was deemed acceptable at p<0.005. statistical package for service solution (spss) version 20.0 was used for analysis. results table 1 shows the descriptive statistics for level, no. of siblings, order of birth, and iq score of both males and females. the minimum and maximum level of both subjects were 1 and 4 respectively, the minimum and maximum number of siblings were 0 and 17 respectively, also the minimum and maximum iq score where 1 and 20 respectively. the minimum and maximum order of birth were 1 and 12 respectively. the mean value of order of birth was 3±1.975. the average value of iq score was 9.19±3.657. table 2 shows the difference in iq score of male and female subjects, the male subjects had a slightly higher mean score of 9.23±3.92 than their female counterparts with mean score of 9.14±3.393. also, there was no significant statistical difference in the iq score (p=0.844). table 3a & b shows the relationship between the iq and birth order for male and female subjects respectively. when level variable was controlled, there was no statistically significance correlation between iq and birth order (p=0.009) and (p=0.046) respectively. also, the tables show the relationship between iq and level in both male and female subjects, there is no statistically significant correlation between the two variables (p=0.155) and (p=0.708) respectively. and also, there is no statistically significant relationship between level and order of birth (p=0.264) and (p=0.857) respectively. table 1: descriptive statistics of level, number of siblings, order of birth, and iq score statistic minimum statistic maximum statistic mean statistic std. dev. statistic kurtosis statistic std. error level 250 1 4 2.34 1.151 -1.431 0.307 no. of siblings 249 0 17 5.66 2.756 0.869 0.307 order of birth 250 1 12 3 1.975 3.339 0.307 iq score 250 0 20 9.19 3.657 0.222 0.307 valid n (list wise) 249 umar et al asian journal of dental and health sciences. 2023; 3(3):33-36 [35] ajdhs.com table 2: difference in the iq score of male and female subjects male female n mean±sd n mean±sd t p iq score 124 9.23±3.92 126 9.14±3.39 0.196 0.844 order of birth 124 2.86±1.95 126 3.14±1.99 -1.121 0.263 iq=intelligence quotient n=number of subjects sd=standard deviation correlation is significant at p<0.05 table 3a & b: pearson’s correlation of the study variables male control variables correlations r p no control iq score order of birth -0.160 0.075 iq score level -0.129 0.155 order of birth level 0.101 0.264 level is controlled iq score order of birth -0.149 0.099 female control variables correlations r p no control iq score order of birth -0.041 0.650 iq score level 0.034 0.708 order of birth level 0.016 0.857 level is controlled iq score order of birth -0.041 0.646 iq= intelligence quotient correlation is significant at 0.005 level of significance. discussion the current findings show that there was no significant relationship between iq and birth order position. contrary to the paper published by belmont and marolla in 1973, which says within each family size (i) firstborns always scored better on the raven than did later borns; and (ii) with few inconsistencies, there was a gradient of declining scores with rising birth order, so that firstborns scored better than second borns, who in turn scored better than thirdborns, and so forth 10. research has shown that there is no significant relationship between the iq and birth order position, and there is no difference between male and female subjects in terms of iq and birth order position that can be detected. in the average score of the present study the male subjects have a slightly high average iq score of 9.23±3.92 than their female counterparts with the average score of 9.14±3.39 but no statistically significance difference between iq and birth order position of male and female subjects. it was observed from the study that birth order position has negative relationship with intelligence quotient (iq) with a significance p<0.001. the reason for this may be due to the issue of confounding variables, which if not properly taken into account, can produce biased estimates of the effects. second is the issue of design choice, that is, whether a birth order study uses a between-versus a within-family design. previous research and theory (e.g., sulloway 11 suggests that the most important potential confounds in birth order research are sibship size, parental socio-economic status (ses), family structure, age, and gender. if not properly accounted for, these factors may lead to biased estimates of the links between birth order, personality and intelligence 1213. conclusion there was no statistically significant relationship between birth order position and intelligent quotient (iq). sexual dimorphism was absent in the study population. references 1. sternberg rj. successful intelligence: a broader view of who's smart in school and in life. the international schools journal. 1997; 17(1):19. 2. legg s, hutter m. a collection of definitions of intelligence. frontiers in artificial intelligence and applications. 2007; 157:17. 3. drigas as, papoutsi c. a new layered model on emotional intelligence. behavioral sciences. 2018; 8(5):45. https://doi.org/10.3390/bs8050045 pmid:29724021 pmcid:pmc5981239 4. smithey fulmer i, barry b. the smart negotiator: cognitive ability and emotional intelligence in negotiation. international journal of conflict management. 2004; 15(3):245-72. https://doi.org/10.1108/eb022914 https://doi.org/10.3390/bs8050045 https://doi.org/10.1108/eb022914 umar et al asian journal of dental and health sciences. 2023; 3(3):33-36 [36] ajdhs.com 5. maftoon p, sarem sn. the realization of gardner's multiple intelligences (mi) theory in second language acquisition (sla). journal of language teaching and research. 2012; 3(6):1233. https://doi.org/10.4304/jltr.3.6.1233-1241 6. leary mr, buttermore nr. the evolution of the human self: tracing the natural history of self‐awareness. journal for the theory of social behaviour. 2003; 33(4):365-404. https://doi.org/10.1046/j.1468-5914.2003.00223.x 7. legg s, hutter m. a collection of definitions of intelligence. frontiers in artificial intelligence and applications. 2007; 7:157:17. 8. purcell pl, shinn jr, davis ge, sie kc. children with unilateral hearing loss may have lower intelligence quotient scores: a meta‐ analysis. the laryngoscope. 2016; 126(3):746-54. https://doi.org/10.1002/lary.25524 pmid:26452077 pmcid:pmc4755927 9. almlund m, duckworth al, heckman j, kautz t. personality psychology and economics. inhandbook of the economics of education 2011; 4:1-181). elsevier. https://doi.org/10.1016/b978-0-444-53444-6.00001-8 10. belmont l, marolla fa. birth order, family size, and intelligence. science, 1973; 182(4117):1096-1101. http://www.jstor.org/stable/1737007 https://doi.org/10.1126/science.182.4117.1096 pmid:4750607 11. sulloway fj. born to rebel: birth order, family dynamics, and creative lives. new york: pantheon/vintage. 1996. 12. ernst c, angst j. birth order: its influence on personality. new york: springer-verlag. 1983; https://doi.org/10.1007/978-3-64268399-2_4 13. rodgers jl,thompson vd. toward a general framework of family structure: a review of theory-based empirical research. population and environment, 1986; 8:143-172. https://doi.org/10.1007/bf01263072 https://doi.org/10.4304/jltr.3.6.1233-1241 https://doi.org/10.1046/j.1468-5914.2003.00223.x https://doi.org/10.1002/lary.25524 https://doi.org/10.1016/b978-0-444-53444-6.00001-8 http://www.jstor.org/stable/1737007 https://doi.org/10.1126/science.182.4117.1096 https://doi.org/10.1007/978-3-642-68399-2_4 https://doi.org/10.1007/978-3-642-68399-2_4 https://doi.org/10.1007/bf01263072 jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [26] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited immunostimulants: concepts, types and functions prince jain, pratik darji, bhupendra singh thakur, anushree jain, prateek kumar jain, basant khare* adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 06 sep 2022 reviewed 11 nov 2022 accepted 28 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: jain p, darji p, thakur bs, jain a, jain pk, khare b, immunostimulants: concepts, types and functions, asian journal of dental and health sciences. 2022; 2(4):26-34 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.22 _______________________________________ *address for correspondence: basant khare, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ the proper functioning of human immune system is essential for organism survival against infectious, toxic and oncogenic agents. the concept of immunomodulation was proposed by edward jenner, while working on polio vaccine in 1796. a brawny, fine-functioning immune system is the keystone of excellent health. immune replies are the consequence of an effectual interaction among innate (natural and non-specific) and acquired (adaptive and specific) components of the immune system. inequity or failure of the immune systems is connected with a variety of chronic illness counting allergies, autoimmune diseases, cancers and furthers. immunomodulators are natural or synthetic materials that regulate the immune system and induce innate and adaptive defense mechanisms. these substances are classified into two types, immunostimulants and immunosuppressants. immunostimulants can enhance body's resistance against various infections through increasing the basal levels of immune response. these agents could increase the oxidative activity of neutrophils, augment engulfment activity of phagocytic cells and stimulate cytotoxic cells as necessary defense mechanisms. the researchers classified the immunostimulants using their origin and mode of action such as bacterial products, complex carbohydrates, vaccines (antigens and adjuvants), cytokines, immunoenhancing drugs, nutritional factors, animal extracts, and plant extracts. the link between immune system with diet, exercise, sleep, stress, microbial exposure, alcohol, water, hygiene are found to influence the immune response to a greater extent. immunostimulants and some immunity enhancing nutrients improve the functioning of the immune system. in addition, some preventive measures such as healthy diet or proper nutrition, moderate exercise, sound sleep, drinking adequate water, subclinical exposure to microbes and managing stress, good hygiene, are altogether capable of boosting the immune system. in this review, the concepts, types and functions of immunostimulants will be described as a therapeutic approach against different diseases. keywords: immunomodulators, immunostimulants, adjuvant, mechanism, immune system. introduction humans and other vertebrates reside in a world that is occupied by a huge range of pathogenic microbes and toxic substances that menace normal homeostasis; and immunity is a specialized form of host defense mechanism that works particularly in relation to the causes and prevention of diseases1. manifestation of disease due to the pathogen depends on its virulence and capability of the immune system; and to achieve resistance against disease, the most important is strengthening the immune system2. if the immune system fails become under or over active, or hits the wrong target it can vent a variety of adverse consequences. under-activity of the immune system lead to loss the defensive mechanism against infections; extreme immune failure results hiv disease, certain cancer, etc. whereas over-activity can lead to autoimmune diseases, including arthritis, inflammatory bowel disease, inflammatory lung disease, connective tissue disease, autoimmune endocrine diseases, multiple sclerosis, etc. so, proper understanding and strictly regulating the immune system has become mandatory. two main compounds are able to enhance immune responses including adjuvants and immunostimulants. an adjuvant is a substance combined with an antigen for increasing its immune response, but an immunostimulant can induce the immune response without injection with an antigen3. there are several types of stimulants with different mechanisms and functions such as bacterial products, complex carbohydrates (e.g., glucans, schizophyllan, scleroglucan, lentinan, statolon, bestatin, acemannan), vaccines, immunoenhancing drugs (e.g., levamisole, isoprinosine, fluoroquindone, avridine, polyribonucleotides), nutritional factors (e.g., vitamins, carotenoids, lipids, trace elements, selenium), animal extracts (e.g., chitosan from shrimp), cytokines (e.g., macrophage activating factor, interferon, interleukin-2, tumor necrosis factor), and plant extracts (e.g., lectins, mitogens such as phytohemagglutinin, concanavalin a) 4. two main approaches were determined to evaluate the efficiency of an immunostimulant such as in vivo protection against pathogens, and in vitro assay of cellular and humoral immune mechanisms. in vitro tests should be performed before in vivo experiments to clarify the basic mechanisms responsible for the protection. in vitro immunostimulant evaluation is usually based on some parameters such as serum lysozyme, complement, total leucocyte count, monocyte/lymphocyte/granulocyte count, antibody titers, phagocytosis, respiratory burst and leucocyte proliferation4. immunomodulation can be either specific or non-specific. specific immunomodulation is limited to a single antigen such as vaccination, whereas non-specific immunomodulation leads to a further change in immune response both in innate and adaptive immunity causing altered host reactivity to many various antigens5. immune system open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.22 jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [27] ajdhs.com the immune system consist of a complex network of specialized cells, tissues, molecules and biological processes within an organism that watches out the continually to protect it against attacks by foreign antigens or invaders (basically microbes-infection causing organisms such as bacteria, viruses, parasites, and fungi or any injury, and disease) 6. the different organs of human immune system are shown in figure 1. some of the potentially infectious agents includes: (a) viruses, which are sub-microscopic non-living entities that replicates only inside the host cells (living organism) and often results in serious diseases. examples include influenza virus, human immunodeficiency virus (hiv), herpes simplex virus (hsv, which can cause cold sores or genital ulcers), a newly discovered virus named coronavirus (causes infection in the upper respiratory tract). (b) bacteria are single celled microbes capable of causing disease when get entry into the body through water, air, soil and also through physical contact. examples include staphylococcus and streptococcus that cause acute infections such as abscesses and sore throats, escherichia, salmonella that cause food poisoning and mycobacteria that cause chronic infections such as tuberculosis and leprosy. (c) fungi, eukaryotic, nonphototrophic organisms with rigid cell walls, they can be unicellular or multicellular. examples include aspergillus that causes allergic disease, candida that causes thrush, cryptococcus that causes meningitis and meningo-encephalitis in patients with hiv infection and aids. (d) parasites, which are eukaryotic organisms that live off other organisms, or host, to survive. some are them are single-celled protozoa that cause diseases for example, malaria; others are large, multicellular organisms (metazoa) example, worms that can be seen with the naked eye. in order to prevent disease, the immune system must able to scan, recognize and attack the foreign invaders by distinguishing self from non-self substances2. self-molecules are those components that belongs to an organism's body which the immune system can distinct from foreign substances. autoimmunity is an immune response in opposed to its own healthy cells and tissues, which may lead to various diseases7. non-self-molecules are those recognized components that do not belong to an organism’s body, they are foreign invaders. one example of non-self-molecules is antigens that cause the immune system to promote the generation of antibodies against it and then combine specifically with them to induce an immune response8. innate and adaptive immunity defence against infection is divided into two main forms namely innate immunity and adaptive immunity. its components are shown in figure 2. some of the differences between innate and adaptive immunity are shown in table 1. innate immunity innate immunity regarded as the first line of defense from both external and internal attack, also known as natural or native immunity. it is a nonspecific and antigen-independent defensive mechanism which responds immediately and within minutes or hours of meeting an antigen9. its host defense mechanisms are encoded as their mature form by the germline gene of the host1. this type of immune response is lack in memory to recognize the pathogen, if the same pathogen invades for second time as they cannot generate that immunologic memory. innate immunity consists of two major components: humoral (include complement cells) and cellular (includes neutrophils, macrophages, adnatural killer cells). figure 1: organs of the human immune system jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [28] ajdhs.com figure 2: flowchart of basic components of human immune system the defensive barriers of innate immunity are of four types:  anatomical barriers e.g., skin and mucous membrane, the epithelial cell layers offers tight junction so there is tight cell to cell contact, the mucus layers over the respiratory, gastrointestinal and genitourinary tract, and when foreign particles are inhaled, the mucus layer get contaminated which are constantly discarded by the epithelial cilia.  physiological barriers e.g., temperature, low ph and chemical mediators  endocytic and phagocytic cells (neutrophils, macrophages), dendritic cells, natural killer (nk) cells and other innate lymphoid  inflammatory barriers e.g., a series of events occurs in inflammation process that plays an important role to destroy or inactivate microbes. adaptive immunity adaptive immunity is also known as specific or acquired immunity which means the resistance acquired by human during their lifetime. it is antigen-dependent and antigenspecific defensive mechanism and, thus delays the time of the antigen to get expose and to produce the maximal response. the advantage of adaptive immunity is their capacity to generate memory which permits the host to elicit a more rapid, stronger and efficient immune response against consecutive exposure to the antigen10. this type of immunity provides the basis for effectual immunization facing infectious diseases. the two major components of adaptive immunity are humoral (comprises of antibodies formed by b lymphocytes) and cellular (mediated by t lymphocytes). b lymphocytes and t lymphocytes are two kind of lymphocytes found in this type of immunity that impart long lasting immunity against specific antigens by proliferating into memory cells. lymphocytes are generated from the bone marrow and the type that mature in bone marrow turns into b lymphocytes whereas the type that leave the bone marrow and migrate to thymus gland get mature into t lymphocytes and based on ‘cluster of differentiation’ (cd) molecules on their surface they acquire certain genetic and immune surface characteristics which determines their different functions11. b lymphocytes are responsible for formation of specific antibodies by differentiating into plasma cells while t lymphocytes get activated in presence of appropriate antigens presented by macrophages like apc and histocompatibility complex (mhc). the function of b lymphocytes are like military intelligence system, they find out the target and organise defensive action, while t lymphocyte perform like soldiers, they destroy the invading substance identified by the intelligence system i.e. b lymphocytes12. antigen specific receptors are encoded by genes that are assembled by somatic rearrangement of germline gene to form intact t cell receptor (tcr) and immunoglobulin (b cell antigen receptor; ig) genes. millions of different antigen receptors are formed from the collection of a few hundred germ-line-encoded gene elements assembly of antigen receptors, each of which are potentially unique and antigen specific1. the advantage of this diverseness of receptors helps adaptive immunity to identify any kind of pathogen13. they are of two types i.e., naturally acquired adaptive immunity and artificially acquired adaptive immunity. naturally acquired adaptive immunity: in naturally acquired active adaptive immunity, antigens enter the body naturally then the bodies develop antibodies and specialized lymphocytes whereas in naturally acquired passive adaptive immunity, antibodies passes from mother to foetus/infant through placenta/mother’s milk. naturally acquired active adaptive immunity lives longer than naturally acquired passive adaptive immunity. artificially acquired adaptive immunity: in artificially acquired active adaptive immunity, antigens are introduced into the body through the use of vaccines then the bodies generate antibodies and specialized lymphocytes against it whereas in artificially acquired passive adaptive immunity, preformed antibodies in immune serum are introduced into the body by injection. artificially acquired active adaptive immunity lives longer than artificially acquired passive adaptive immunity but, when there is very less time to develop active immunity then passive type is more effective as it can prevent the infection in any stage and its process is rapid. jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [29] ajdhs.com table 1: differences between innate and adaptive immunity feature innate immunity adaptive immunity cells involved dendritic leukocyte, natural killer cells, mast cell, granulocytes/ macrophages, basophils, etc killer cd8+ t-cells, helper cd4+ t-cells, bcells, antigen presenting cells, etc. molecules involved cytokines, complement cells, interferon, acute phase reactants/ proteins antibodies, cytokines receptors germline encoded no somatic rearrangement non-clonal distribution encoded in gene segments somatic rearrangement necessary clonal distribution action time immediate effector activation delayed effector activation response rapidly occurs (0-6 h ours) occurs over days to weeks order of defense it is the first line of defense of immune system action against pathogens that are able to evade or overcome innate immune defense immunological memory none confer immunological memory types of immune response inflammation, complement mediated killing, phagocytosis antibodies generation, microbial destruction by helper t cells and cytotoxic t cells subsequent exposure immune response does not get alter on repeated exposure immune response get improves with subsequent exposure reason behind immune evasion caused by pathogenic virulence caused by mutation of the recognized antigen allery or hypersensitivity reaction none immediate and delay hypersentivity potency lower higher physioanatomicalcal barriers skin, mucous membranes, temp, ph, chemicals, etc lymph nodes, spleen, mucosal associated lymphoid tissue functions (a) recruiting immune cells to site of infection; (b) activation of complement cascade to identify antigens; (c) identification & removal of foreign substances present in organs, tissues, blood and lymph; (d) activation of adaptive immune system through antigen presentation; (e) acting as physical & chemical barrier to infectious agents. (a) recognition of specific “nonself” antigens during the process of antigen presentation; (b) generation of responses that are tailored to maximally eliminate specific pathogens or infected cells; (c) development of immunological memory, through memory b cells and memory t cells. functioning of immune system the immune system comprised of cells and proteins that uphold the body from the foreign invaders14. these cells emanate from the pluripotent stem cells of bone marrow. of the two pathways (i) the myeloid pathway, in presence of il3, becomes excited giving rise to the production of platelets, erythrocytes, monocytes and granulocytes. (ii) the lymphoid pathway, in presence of il-7, becomes excited giving rise to the production of innate and adaptive lymph cells (lymphocytes). the pathways distinction relies on the chemical signals in the surrounding area15,16. when pathogens invade the host body, innate immunity provides the first line of defense. leukocytes like dendritic cells, monocytes, neutrophils, macrophages, eosinophils, mast cells, are allowed by the pattern recognition receptor (prrs) to detect and react rapidly towards a large population pathogen which is structurally similar, known as pathogen associated molecular patterns (pamps). an example of these is the components of bacterial cell wall like lipopolysaccharides (lps) and doublestranded ribonucleic acid17. the binding of prps with pamps triggers the release of cellular messenger called cytokines (e.g. interleukin) and causes inflammatory reaction. inflammation leads to vasodilation, increased vascular permeability and cellular infiltration due to which the microbial cells get destroyed. other cells, like natural killers are the critical members of innate immunity as they able to pursue and kill a vast number of pathogens along with malignant cells. all the cells of immune system are capable to suppress or induce inflammation by communicating one another over direct cell contact or through generation of cytokines. again a complex systems of proteins known as the complement system also induces inflammatory response that aid to fight infection. this type of immunity also aid to remove dead cells or foreign substances from different organs, blood and lymph13. the adaptive response takes over when the innate immune response becomes ineffective to eliminate pathogen. in adaptive immunity at first antigen presenting cell (apc) like macrophages and dendritic cells recognizes, engulfs and process the antigen; and displays the specific part of antigen jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [30] ajdhs.com on its surface then present it to tcells. t-cells receptors are there that bind with the specific antigenic sites and triggers proliferation and differentiation processes in lymphoid tissues2. there are two classes of t-cells namely, helper t-cells and cytotoxic t-cells which can be discriminate by their presence of some molecules on their surface like cd4+ and cd8+ respectively. t-helper cells aid the immune response in recognition of antigen and then activate other t and b-cells by secreting cytokines whereas cytotoxic t-cells aid the immune response by killing pathogen infected cells or tumor cells. one other class of t-cells, known as suppressive t-cells are able to secret suppressive cytokines that can inhibit the actions of other t-cells. antigen binding and helper t-cell can trigger the differentiation process of b-cells into plasma cells and secret antibodies which circulate in the blood and causes destruction or inactivation of the antigen18. immunostimulants immunostimulants (or immune stimulants) are biologically active substances obtained from natural or synthetic sources with different chemical characteristics and mechanism of action that modulate the immune system of host to increase resistance against various infections [19]. they interact with specific receptors and cellular components of innate and adaptive response to modulate the immune response. they used during suppressed immunity condition like cancer disease, aids, sars etc. to improve the host’s resistance19. concept of immunostimulant immunostimulants known as immunostimulators are attractive substances that activate the immune system of humans and animals for prevention of diseases and improvement of the body’s natural resistance to various viral and bacterial infections. these biologically active substances are the products derived from natural sources or synthetically made with different chemical properties and mechanisms of action. in general, immunostimulants induce synthesis of specific antibodies and cytokines for treatment of infectious diseases. two major groups of immunostimulants contain a) specific immunostimulants acting as antigen for stimulation of immune responses (e.g., vaccines), and b) non-specific immunostimulants without antigenic properties enhancing immune responses to other antigens (e.g., adjuvants and nonspecific immunostimulators). moreover, immunostimulants were classified based on their origin and mode of action20. functions of immunostimulants immunostimulants activate different elements of the immune system in humans and animals. they develop the non-specific immunotherapy and immunoprevention by stimulating the major factors of the immune system including phagocytosis, properdin and complement systems, protective secretory iga antibodies, αand γ-interferon release, tand b-lymphocytes, synthesis of specific antibodies and cytokines, and synthesis of pulmonary surfactant. there are several reasons for using the immunostimulants in the control of various infectious diseases including: a) antibiotic resistance of the bacteria; b) allergic reactions to antibiotics; c) immunosuppressive effects of antibiotics; and d) poor effects of the antibiotics in viral infections19. figure 3 shows some types of immunostimulants and their general functions. figure 3: schematic representation of some types of immunostimulants and their general functions types of immunostimulants for simplification, we divided the types of immunostimulants as 7 groups such as bacterial products, complex carbohydrates, vaccines (antigens and adjuvants), cytokines, immunoenhancing drugs, plant extracts, and animal extracts as mentioned below: immunostimulatory drugs a few immunostimulatory drugs (endogenous immunostimulants or synthetic immunostimulants) have been developed to induce humoral or cellular immune responses or both of them against bacterial or viral infections, jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [31] ajdhs.com immunodeficiency diseases, and cancer. they were classified as follows: a) levamisole (ergamisol): levamisole is a synthetic drug inducing b and t lymphocytes, monocytes, and macrophages. it was used in adjuvant therapy with 5-fluorouracil after surgical resection in patients with duke’s stage c colon cancer. its disadvantages are allergy, nausea, flu, and muscle pain. levamisole has been successfully used in combination with polymers for treatment of dermatologic disorders. for example, it was combined with cimetidine for treating recalcitrant warts, and with prednisolone for treating aphthous ulcers of the mouth21,22. b) thalidomide: thalidomide or immunoprin (c13h10n2o4) is an immunomodulatory drug. thalidomide could decrease circulating tnf-α in patients with erythema nodosum leprosum. in contrast, it increased tnf-α in hiv-seropositive patients. furthermore, its therapeutic effects were determined in severe rheumatoid arthritis and angiogenesis21. c) isoprinosine (inosiplex/ imunovir): isoprinosine (c52h78n10o17) is a combination of inosine, acetamidobenzoic acid, and dimethylaminoisopropanol. isoprinosine could enhance the levels of cytokines including il-1, il-2, and ifn-γ. it increased the proliferation of lymphocytes against mitogenic or antigenic stimuli. moreover, isoprinosine augmented active t-cells and induced t-cell surface markers on prothymocytes. it was used to treat herpes simplex infections, epstein-barr, and measles viruses. its disadvantages are minor cns depressant, transient nausea, and increased level of uric acid in serum and urine21. d) immunocynin: immunocynin is a stable form of haemocynin, a copper-containing protein, found in molluses and arthropods. it was used to treat urinary bladder cancer with poor side effects such as rare-mild fever21. e) bestatin: bestatin, a dipeptide [(2s, 3r)-3-amino-2 hydroxy-4-phenylbutanoyl]-l-leucine, is an immunostimulant with low toxicity which binds to the cell surface of lymphocytes and macrophages and enhances both humoral and cellular immune responses. it is a leucine aminopeptidase and aminopeptidase-b inhibitor. bestatin possesses antitumor activity and also increase the antitumor activity of bleomycin and adriamycin. bestatin efficiently prevented the metastasis of p388 leukemia when the antibiotic was constantly injected after tumor inoculation23. the dipeptide was immunorestorator in the elderly and cancer patients and hivinfected subjects. it stimulated granulocytopoiesis and thrombocytopoiesis in vitro and could restore them in myelohypoplastic man24. bacterial products the immunostimulatory effects of bacteria and bacterial products are due to the release of cytokines. live bacillus calmette-guerin (bcg) is an attenuated, live culture of the bacillus of calmette and guerin strain of mycobacterium bovis. its mechanism of action includes: a) induction of a granulomatous reaction at the site of administration, and b) prevention and treatment of carcinoma types. furthermore, bcg enhances both b and t cell-mediated responses leading to phagocytosis and resistance to infection. its disadvantages are hypersensitivity, fever, shock, and immune complex disease21. recombinant cytokines several interferons and interleukins are suggested to stimulate effective immune responses. interferons could be obtained from trout leucocytes after stimulation with mitogens. it was able to cause an in vitro resistance against pancreatic necrosis virus in trout cells. in mammalian, low doses of interferon could induce stable positive results without side effects. on the other hand, vaccination of animals with the recombinant il-2 against different infections increased the protective effects. however, il-2 was a very toxic compound in high doses causing side effects such as fever and diarrhea. the purified cytokines showed unsatisfactory results in clinical trials, because the immune responses were produced by a mixture of cytokines generated by the immune cells, but not against a single cytokine. thus, the enhancers of nonspecific cytokine synthesis may improve immune responses and solve this problem4. thus, recombinant cytokines are produced recently in different expression systems (e.g., plants) and used in clinical trials such as interferons, tnf-α and il-225. complex carbohydrates several types of the complex carbohydrates were described as follows: a) glucans: an important class of immunostimulants is the β(1→3)-linked chain of glucose units. the main chain has β(1→6)-branched glucose units. the β-glucans were obtained from highly conserved structural components of cell walls in fungi, algae, yeast, and have a broad range of molecular weights from 5 to 200 kda. the length and frequency of these branches vary depending on different sources. β-glucan was used to stimulate anti-tumor mechanisms (e.g., increased macrophage activity) and to enhance host resistance to a variety of microbial pathogens in mammalian. glucan might also be helpful to prevent the carcinogenic effects of aflatoxin. β-glucan was consideredas a stimulator of cellular immunity. indeed, mammalian macrophages or monocytes have specific receptors for βglucans and produce mediators such as cytokines (e.g., il-1, il-9, tnf-α) and prostaglandins in the presence of glucans26, 27. in japan, the β-glucans such as lentinan derived from the shiitake mushroom and polysaccharide-k derived from coriolus versicolor were licensed as anti-cancer drugs28. lentinan could induce protective th1 immune responses to control the proliferation of malaria parasites red blood cells by stimulating maturation of dcs, increasing the expression of mhcii, cd80/cd86, tolllike receptors (tlr2/tlr4) and the level of il-12, and preventing the adverse effects of tregs29,30. the main roles of glucans were detected in cancer treatment, infection immunity, stress reduction, and restoration of damaged bone marrow. a mixture of polysaccharides isolated from the cell walls of saccharomyces cerevisiae named as zymosan could potently stimulate macrophages and induce the release of cytokines from neutrophils. indeed, β-glucan in zymosan was identified as its effective component for non-specific immunomodulation. in addition, β-glucan could reverse myelosuppression generated by chemotherapeutic drugs via targeting the c3 fragment of complement and circulating antibodies. the recent studies have shown that daily therapy with soluble or insoluble β-glucan led to a 70%-95% reduction in tumor size. indeed, after the binding of antibodies on the surface of cancer cells, c3 fragments of complement could coat the cancer cells. then, β-glucan-primed cells, such as blood neutrophils, macrophages, and nk cells specifically recognized these complement-antibody complexes and killed the tumor cells. in fact, the cooperation of β-glucan with anti-tumor antibodies is an effective approach in combination therapy28. b) trehalose: trehalose dimycolate (tdm), muramyl dipeptide (mdp), and lipopolysaccharides (lps) as the bacterial products promote the production of antibody, stimulate activation of lymphocytes, and elicit specific immunity against different bacterial infections. trehalose dimycolate, a glycolipid present in the cell wall of mycobacteria is a potent immunostimulant that limits tumor growth and enhances resistance against bacterial, parasitic, and viral infections. it can interact with membranes due to its amphipathic properties. tdm primes murine macrophages to jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [32] ajdhs.com generate nitric oxide (no) and to develop anti-tumoral activity. as an adjuvant, tdm enhances both cellular and humoral immunity, but elicits a stronger cellular response. tdm could induce potent immune responses against malaria antigens in mice as compared to groups immunized with malarial antigens and freund’s adjuvant. the reports showed that the protective effect of tdm is reduced in macrophagedepleted mice injected with silica particles indicating the role of macrophages. t lymphocytes were not necessary for tdm to prime peritoneal macrophages. trehalose diesters could induce il-12p40 and ifn-γ mrna31,32. c) prebiotics: prebiotics are indigestible fibers that increase beneficial gut commensal bacteria resulting in improvement of the host's health. prebiotics, such as fructooligosaccharide, mannanoligosaccharide, inulin, or β-glucan, are called immunosaccharides. they directly enhance innate immune responses including phagocytic activation, neutrophil activation, activation of the alternative complement system, and increased lysozyme activity. immunosaccharides directly activate the innate immune system by interacting with pattern recognition receptors (prr) expressed on innate immune cells. they can also associate with microbe associated molecular patterns (mamps) to activate innate immune cells. indeed, probiotics activate the innate immune system in two ways: a) by directly stimulating the innate immune system and b) by enhancing the growth of commensal microbiota33. immunostimulants used in vaccines vaccines contain a wide range of immunostimulants. for example, an adjuvant heat-labile enterotoxin from escherichia coli (lt), administered as an immunostimulant (lt-is) patch on the skin may further enhance immune responses to influenza vaccine in the elderly34. also, the immune activation mediated by lt-is improved the potency of generating alzheimer's disease (ad)-specific vaccination responses as an adjuvant in the clinical trial35. co-administration of a potent adjuvant in is patches containing heat-labile enterotoxin from e. coli placed on the skin at the site of dna vaccination significantly increased anti-influenza antibody immune response36. adjuvants enhance and modulate immune responses to antigens. this is important when the purified antigens do not elicit the effective innate or adaptive immune systems. adjuvants are different in the types and levels of immune responses. expected advantages of adjuvants contain stronger immune priming, effective immune responses in lowresponse populations (e.g., the elderly or immunocompromised patients), the use of smaller amounts of the antigen, and safety profile37. new adjuvants have already applied to more efficient influenza vaccines, as well as vaccines targeting hepatitis b (hbv) and human papillomavirus (hpv) 38. on the other hand, cpg oligonucleotides and imiquimod drugs (an antiviral agent) could activate dendritic cells, induce in situ maturation and migration of dcs, and augmented both humoral and cellular immune responses39. the unmethylated cpg motif in bacterial dna was identified as a b-cell stimulating adjuvant, and synthetic oligodeoxynucleotides (odns) containing the cpg motifs were shown to induce potent therapeutic activities in different infections and tumor animal models. imiquimod was topically used for patients with anogenital warts as well as basal-cell carcinoma. the studies indicated that cpg odns and imiquimod (resiquimod) drugs act as synthetic ligands for tlr9 and tlr7, respectively, and both stimulate efficiently dc maturation39. plant-derived immunostimulants natural plant product promote various activities such as antistress, growth promotion, appetite stimulation, immunostimulation, aphrodisiac and antimicrobial properties, due to the active substances such as alkaloids, flavanoids pigments, phenolics, terpenoids, steroids, and essential oils. medicinal plants have been known as immunostimulants, growth promoters, immune enhancers, where they act as antibacterial and antiviral agents to the host immune system. unfortunately, the mechanisms were not understood40. some medicinal plants were described as following: a) ocimum sanctum (tulsi): leaves of o. sanctum containing water-soluble phenolic compounds and various other constituents may act as an immunostimulant. leaves extract of o. sanctum affected both specific and nonspecific immune responses. it stimulated both antibody response and neutrophil activity5,41. b) phyllanthus emblica (amla): p. emblica has antioxidant, anti-fungal, anti-microbial, and antiinflammatory activities. amla fruit pulp contains a large amount of vitamin c as an immunostimulant5,41. c) azadirachta indica (neem): a. indica possesses antihuman immunodeficiency virus, anti-tumor, and antimicrobial activities. azadirachtin, a triterpenoid derived from a. indica, enhanced respiratory burst activities, the leukocyte count and the primary and secondary antibody responses against srbc (sheep erythrocytes) in tilapia5,41. d) solanum trilobatum (purple fruited pea eggplant): the herbal extract of s. trilobatum possesses a broad spectrum of antibiotic, antibacterial and anticancer activities. a study showed that the water-soluble fraction of s. trilobatum significantly enhanced the production of reactive oxygen and decreased the percentage of mortality following a challenge with aeromonas hydrophila5,41. e) eclipta alba (bhringraj): e. alba possesses several medicinal properties. the methanol extracts of e. alba significantly increased the phagocytic index, antibody titer and wbc count in mice5,41. f) zingiber officinale (ginger): the extracts of z. officinale contain polyphenol compounds which have a high antioxidant activity. moreover, it showed a significant increase in proliferation of neutrophils, macrophages, and lymphocytes, as well as it enhanced phagocytic, respiratory burst, lysozyme, bactericidal and antiprotease activities5,41. g) echinacea (purple coneflowers) and allium sativum (garlic): echinacea and a. sativum improved the gain in body weight, survival rate and resistance against challenge infection of aeromonas hydrophila. both compounds developed resistance to cold stress during the winter season5,41. h) camellia sinensis (green tea): green tea extracts possess biological activity including antioxidant, antiangiogenesis, and anti-proliferative activities that are related to the prevention and treatment of various forms of cancer5,41. i) aloe vera: oral administration of a. vera could enhance the specific and non-specific immune responses and increase lysozyme activity, serum bactericidal potency, and the total protein and igm levels5,41. j) cynodon dactylon (bermuda grass): the antiviral activity of c. dactylon was confirmed to prevent white spot syndrome virus (wssv) infection with no mortality and no signs of wsd (white spot disease) 5,41. k) achyranthes aspera (prickly chaff flower): a. aspera showed both specific and non-specific immunity revealed by higher levels of serum antibody and also serum antiproteases in fish. moreover, the level of serum globulin and rna/dna ratio of the spleen were also significantly enhanced in the fish fed with a. aspera5,41. jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [33] ajdhs.com m) nyctanthes arbortristis (night-flowering jasmine): n. arbortristis possesses hepatoprotective, anti-leishmanial, antiviral and antifungal activities. the extract of n. arbortristis significantly enhanced serum lysozyme, complement activities and cellular reactive oxygen species (ros), reactive nitrogen intermediate (rni) and myeloperoxidase (mpo) production5,41. n) fermented vegetable product (fvp): the phagocytic activities, the activity of lysozyme, and superoxide generation of peritoneal leukocytes enhanced in fish fed with the fvp supplemented diet5,41. o) saffron: saffron, a spice derived from the flower of crocus sativus, is rich in carotenoids. carotenoids are lipophilic molecules accumulating in lipophilic compartments including lipoproteins and/or membranes. two main natural carotenoids of saffron, crocin, and crocetin, are responsible for its color42. saffron and its components were suggested as promising candidates for cancer prevention43. the mechanisms underlying cancer chemopreventive activities of carotenoids contain modulation of carcinogen metabolism, regulation of cell growth and cell cycle progression, inhibition of cell proliferation, antioxidant activity, immune modulation, enhancement of cell differentiation, stimulation of cell-tocell gap junction communication, apoptosis and retinoid dependent signaling. the immunomodulatory activity of saffron was determined on driving toward th1 and th2 limbs of the immune system42. carotenoids increase the proliferative response of t and b lymphocytes to mitogens, the activity of natural killer cells, the number and activity of cytotoxic t-cells, macrophage tumor-killing activity and also induce the secretion of tnf-α in an animal model. these effects are involved in preventing tumor growth, killing tumors and lowering tumor burden. different carotenoids were used as main phytonutrients to inhibit the development of tumors in vitro and in vivo44. for example, a single treatment with crocin significantly decreased tumor size in a mouse model43. animal originated immunostimulants there are some immunostimulants derived from animals. for example, chitin and chitosan are the non-specific immunostimulators which are protective against infections for a short time. also, fermented products of chicken egg (ef203) containing immunoactive peptides showed immunomodulatory effects when administered orally to rainbow trout, oncorhynchus mykiss. fish treated with ef203 displayed an increased resistance to both natural and experimental β-haemolytic streptococcal infection41. moreover, chitosan, the deacetylated derivative of chitin, has shown strong anti-microbial activity depending on its degree of deacetylation and molecular weight. both oligomers of chitin and chitosan were effective in enhancing the migratory activity of macrophages. furthermore, chitosan could activate the production of cytokines such as il-1β, tnf-α, and reactive oxygen intermediates to promote the defense system against microbial infections45. on the other hand, glycated chitosan (gc) as an immunoadjuvant was used in combination with phototherapy for cancer treatment in animal models. in vitro studies also showed that after incubation of gc with macrophages, it could significantly stimulate the secretion of tnf-α46. conclusion immunomodulators are divided into several groups including physiological products, cytokines, host defense peptides, microbial products, probiotics, synthetic chemical compounds, herbal products, adjuvants, and polysaccharides. immunostimulants represent a promising class of drugs for the treatment of infectious disorders and cancer. herbal extracts and animal originated product have a potential application as an immunostimulant, because they can be easily obtained, are not expensive and act against a broad spectrum of pathogens. most of the herbs and herbal extracts can be given orally, which is the most convenient method of immunostimulation in a dose dependent approach. recently, carbohydrate-based immunostimulants that target toll-like receptor 4 (tlr-4) and cluster of differentiation 1d (cd1d) receptors as vaccine adjuvants are underway. also, the incorporation of immunostimulants into nanomaterials has shown a novel approach to enhance the immunostimulation properties. however, further studies are needed to identify effective immunostimulants without adverse side effects and determination of their mechanism of action. references 1. chaplin dd. overview of the immune response. j allergy clin immunol. 2015; 125:1-41. 2. meagher mw. immune system structure and function. encyclopedia of health psychology. 2014; 1-9. 3. carter d, reed sg. role of adjuvants in modeling the immune response. curr opin hiv aids. 2010; 5 (5):409-13. https://doi.org/10.1097/coh.0b013e32833d2cdb 4. galeotti m. some aspects of the application of immunostimulants and a critical review of methods for their evaluation. j appl ichthyol. 1998; 14 (3-4): 189-99. https://doi.org/10.1111/j.14390426.1998.tb00641.x 5. dhama k, saminathan m, jacob ss, singh m, karthik k, amarpal, tiwari r, sunkara lt, malik ys, singh rk. effect of immunomodulation and immunomodulatory agents on health with some bioactive principles, modes of action and potent biomedical applications. int j pharmacol. 2015; 11 (4):253-90. https://doi.org/10.3923/ijp.2015.253.290 6. schultz kt, grieder f. structure and function of the immune system. toxicol pathol. 1987; 15(3):262-264. https://doi.org/10.1177/019262338701500301 7. rajasekaran a, venkatasubramanian g, berk m, debnath m. mitochondrial dysfunction in schizophrenia: pathways, mechanisms and implications. neurosci biobehav rev. 2015; 48:10-21. https://doi.org/10.1016/j.neubiorev.2014.11.005 8. marshall js, warrington r, watson w, kim hl. an introduction to immunology and immunopathology. allergy, asthma clin immunol. 2018; 14:49-59. https://doi.org/10.1186/s13223-0180278-1 9. cruvinel wdm, júnior dm, antônio j, araújo p, tieko t, catelan t. fundamentals of innate immunity with emphasis on molecular and cellular mechanisms of inflammatory response. bras j rheumatol. 2010; 50(4):434-461. https://doi.org/10.1590/s0482-50042010000400008 10. marshall js, warrington r, watson w, kim hl. an introduction to immunology and immunopathology. allergy, asthma clin immunol. 2011; 7:1-8. https://doi.org/10.1186/1710-1492-7-s1s1 11. nielsen hg. exercise and immunity. in: current issues in sports and exercise medicine. 2016. p. 121-42. available from: https://www.intechopen.com/books/advanced-biometrictechnologies/liveness-detection-in-biometrics. 12. advances in exercise immunology uq espace. available from: https://espace.library.uq.edu.au/view/uq:145869. 13. turvey se, broide dh. innate immunity. j allergy clin immunol. 2010; 125:24-32. https://doi.org/10.1016/j.jaci.2009.07.016 14. sattler s. the role of the immune system beyond the fight against infection. 1003rd ed. london: springer international publishing; 2017. p. 3-14. https://doi.org/10.1007/978-3-319-57613-8_1 15. john h humphrey ssp. evolution of the immune system. encycl br. 2020; 1-3. https://doi.org/10.1097/coh.0b013e32833d2cdb https://doi.org/10.1111/j.1439-0426.1998.tb00641.x https://doi.org/10.1111/j.1439-0426.1998.tb00641.x https://doi.org/10.3923/ijp.2015.253.290 https://doi.org/10.1177/019262338701500301 https://doi.org/10.1016/j.neubiorev.2014.11.005 https://doi.org/10.1186/s13223-018-0278-1 https://doi.org/10.1186/s13223-018-0278-1 https://doi.org/10.1590/s0482-50042010000400008 https://doi.org/10.1186/1710-1492-7-s1-s1 https://doi.org/10.1186/1710-1492-7-s1-s1 https://doi.org/10.1016/j.jaci.2009.07.016 https://doi.org/10.1007/978-3-319-57613-8_1 jain et al asian journal of dental and health sciences. 2022; 2(4):26-24 [34] ajdhs.com 16. travis j. on the origin of the immune system. science. 2009; 324(5927):580-582. https://doi.org/10.1126/science.324_580 17. panda s, ding jl, alerts e. natural antibodies bridge innate and adaptive immunity. j immunol. 2015; 194:13-20. https://doi.org/10.4049/jimmunol.1400844 18. janeway ca jr, travers p wm. immuno biology: the immune system in health and disease. 5th ed. new york: garland science; 2001. 1-884 pp. 19. petrunov b, nenkov p, shekerdjiisky r. the role of immunostimulants in immunotherapy and immunoprophylaxis. biotechnol & biotechnol eq. 2007; 21(4):454-63. https://doi.org/10.1080/13102818.2007.10817494 20. labh sn, shakya sr. application of immunostimulants as an alternative to vaccines for health management in aquaculture. int j fish aquat st. 2014; 2 (1):153-6. 21. patil us, jaydeokar av, bandawane dd. immunomodulators: a pharmacological review. int j pharm pharm sci. 2012; 4 (1):30-6. 22. biswajit d, suvakanta d, chandra cr, jashabir c. an overview of levamisole hydrochloride with immunostimulant activity. am j pharm health res. 2014; 2(4):1-9. 23. jain m, jain a, khare b, jain dk, khan r, jain d. an update on the recent emergence of candida auris. asian journal of dental and health sciences. 2022; 2(1):14-9. https://doi.org/10.22270/ajdhs.v2i1.11 24. mathe g. bestatin, an aminopeptidase inhibitor with a multipharmacological function. biomed pharmacoter. 1991; 45:49-54. https://doi.org/10.1016/0753-3322(91)90122-a 25. sirko a, vanek t, gora-sochacka a, redkiewicz p. recombinant cytokines from plants. int j mol sci. 2011; 12 (6):3536-52. https://doi.org/10.3390/ijms12063536 26. sahoo pk, mukherjee sc. effect of dietary β-1, 3 glucan on immune responses and disease resistance of healthy and aflatoxin b1induced immunocompromised rohu (labeo rohita hamilton). fish shellfish immunol. 2001; 11 (8):683-95. https://doi.org/10.1006/fsim.2001.0345 27. madrigal-bujaidar e, morales-gonzález ja, sánchezgutiérrez m, izquierdo-vega ja, reyes-arellano a, álvarezgonzález i, pérezpasten r, madrigal-santillán e. prevention of aflatoxin b1-induced dna breaks by β-d-glucan. toxins (basel). 2015; 7 (6):2145-58. https://doi.org/10.3390/toxins7062145 28. vetvicka v. glucan-immunostimulant, adjuvant, potential drug. world j clin oncol. 2011; 2 (2):115-9. https://doi.org/10.5306/wjco.v2.i2.115 29. zhou ld, zhang qh, zhang y, liu j, cao ym. the shiitake mushroom-derived immuno-stimulant lentinan protects against murine malaria blood-stage infection by evoking adaptive immune-responses. int immunopharmacol. 2009; 9(4):455-62. https://doi.org/10.1016/j.intimp.2009.01.010 30. sajeevan tp, philip r, bright singh is. dose/frequency: a critical factor in the administration of glucan as immunostimulant to indian white shrimp fenneropenaeus indicus. aquaculture. 2009; 287(3):248-52. https://doi.org/10.1016/j.aquaculture.2008.10.045 31. parant m, audibert f, parant f, chedid l, soler e, polonsky j, lederer e. non-specific immunostimulant activities of synthetic trehalose-6, 6'-diesters (lower homologs of cord factor). infect immun. 1978; 20 (1):12-9. https://doi.org/10.1128/iai.20.1.1219.1978 32. oswald ip, dozois cm, petit jf, lemaire g. interleukin-12 synthesis is a required step in trehalose dimycolate-induced activation of mouse peritoneal macrophages. infect immun. 1997; 65 (4):13649. https://doi.org/10.1128/iai.65.4.1364-1369.1997 33. jat d, thakur n, jain dk, prasad s, yadav r. iris ensata thunb: review on its chemistry, morphology, ethno medical uses, phytochemistry and pharmacological activities. asian journal of dental and health sciences. 2022; 2(1):1-6. https://doi.org/10.22270/ajdhs.v2i1.9 34. frech sa, kenney rt, spyr ca, lazar h, viret jf, herzog c, glück r, glenn gm. improved immune responses to influenza vaccination in the elderly using an immunostimulant patch. vaccine. 2005; 23 (7):946-50. https://doi.org/10.1016/j.vaccine.2004.06.036 35. davtyan h, ghochikyan a, hovakimyan a, petrushina i, yu j, flyer d, madsen pj, pedersen lo, cribbs dh, agadjanyan mg. immunostimulant patches containing escherichia coli lt enhance immune responses to dnaand recombinant proteinbased alzheimer's disease vaccines. j neuroimmunology. 2014; 268 (12):50-7. https://doi.org/10.1016/j.jneuroim.2014.01.002 36. mkrtichyan m, ghochikyan a, movsesyan n, karapetyan a, begoyan g, yu j, glenn gm, ross tm, agadjanyan mg, cribbs dh. immunostimulant adjuvant patch enhances humoral and cellular immune responses to dna immunization. dna cell biol. 2008; 27 (1): 19-24. https://doi.org/10.1089/dna.2007.0639 37. garçon n, leroux-roels g, cheng wf. understanding modern vaccines: perspectives in vaccinology. elsevier bv. 2011; 1: 89113. https://doi.org/10.1016/j.pervac.2011.05.004 38. pasquale ad, preiss s, da silva ft, garçon n. vaccine adjuvants: from 1920 to 2015 and beyond. vaccines (basel). 2015; 3 (2):32043. https://doi.org/10.3390/vaccines3020320 39. mizumoto n, gao j, matsushima h, ogawa y, tanaka h, takashima a. discovery of novel immunostimulants by dendritic-cell based functional screening. blood. 2005; 106 (9):3082-9. https://doi.org/10.1182/blood-2005-03-1161 40. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech journal of pharmaceutical sciences. 2018; 7(4):1-25. 41. bairwa mk, jakhar jk, satyanarayana y, reddy ad. animal and plant originated immunostimulants used in aquaculture. j nat prod plant resour. 2012; 2(3):397-400. 42. bolhassani a, khavari a, bathaie sz. saffron and natural carotenoids: biochemical activities and anti-tumor effects. biochim biophys acta. 2014; 1845:20-30. https://doi.org/10.1016/j.bbcan.2013.11.001 43. khavari a, bolhassani a, alizadeh f. chemoimmunotherapy using saffron and its ingredients followed bye7-nt (gp96) dna vaccine generates different anti-tumor effects against tumors expressing the e7 protein of human papillomavirus. arch virol. 2015; 160(2): 499-508. https://doi.org/10.1007/s00705-014-2250-9 44. bolhassani a. cancer chemoprevention by natural carotenoids as an efficient strategy. anticancer agents med chem. 2015; 15(8):1026-31. https://doi.org/10.2174/1871520615666150302125707 45. mastan sa. use of immunostimulants in aquaculture disease management. int j fish aquat st. 2015; 2(4):277-80. 46. chen wr, sarker a, liu h, naylor mf, nordquist re. effects of immunostimulants in phototherapy for cancer treatment. biophotonics and immune responses iv. 2009; 71780a. https://doi.org/10.1117/12.808019 https://doi.org/10.1126/science.324_580 https://doi.org/10.4049/jimmunol.1400844 https://doi.org/10.1080/13102818.2007.10817494 https://doi.org/10.22270/ajdhs.v2i1.11 https://doi.org/10.1016/0753-3322(91)90122-a https://doi.org/10.3390/ijms12063536 https://doi.org/10.1006/fsim.2001.0345 https://doi.org/10.3390/toxins7062145 https://doi.org/10.5306/wjco.v2.i2.115 https://doi.org/10.1016/j.intimp.2009.01.010 https://doi.org/10.1016/j.aquaculture.2008.10.045 https://doi.org/10.1128/iai.20.1.12-19.1978 https://doi.org/10.1128/iai.20.1.12-19.1978 https://doi.org/10.1128/iai.65.4.1364-1369.1997 https://doi.org/10.22270/ajdhs.v2i1.9 https://doi.org/10.1016/j.vaccine.2004.06.036 https://doi.org/10.1016/j.jneuroim.2014.01.002 https://doi.org/10.1089/dna.2007.0639 https://doi.org/10.1016/j.pervac.2011.05.004 https://doi.org/10.3390/vaccines3020320 https://doi.org/10.1182/blood-2005-03-1161 https://doi.org/10.1016/j.bbcan.2013.11.001 https://doi.org/10.1007/s00705-014-2250-9 https://doi.org/10.2174/1871520615666150302125707 https://doi.org/10.1117/12.808019 jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [9] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a review on herbal cosmetics and cosmeceuticals sameeksha jain*, mahima trivedi, manoj raikwar, maniram lodhi, meer yousuf ali, arpana purohit, prakhar nema adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 21 sep 2022 reviewed 29 october 2022 accepted 20 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: jain s, trived mi, raikwar m, lodhi m, ali ma, purohit a, nema p, a review on herbal cosmetics and cosmeceuticals, asian journal of dental and health sciences. 2022; 2(4):9-16 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.19 _______________________________________ *address for correspondence: sameeksha jain, adina college of pharmacy, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ human beings have been using herbs for different purpose like food, medicine, beautifying. the word cosmetic was derived from the greek word “kosm tikos” meaning having the power, arrange, skill in decorating. the natural herbs and their products when used for their aromatic value in cosmetic preparation are termed as herbal cosmetics. the increased demand for the natural product has created new avenues in cosmeceuticals market. the herbal cosmetics have been the first choice of the customers, for being more potent, easily available and thought to be less side effective. herbal cosmetics are fastest growing field of personal care products. cosmeceuticals is the fastest growing segment of the personal care products these are cosmetic preparations which contain biologically active principles or ingredients of plant origin. in recent years there is an increased demand for the use of herbs in cosmetics due to their mild action and less toxic in nature and they are found to be more effective. the desire of good looking and to be beautiful gave a huge market for the herbal cosmetics. now a days desire to be look younger than original age, to be look beautiful, fresh, charming and fair have directly increased the demand of herbal cosmetics as well as of the cosmeceuticals in the market. hence the review overlooks on the use of herbal cosmetics and cosmeceuticals. it also describes about herbs as cosmetics. numerous herbal plants are available naturally; they having different chemical constituents used in cosmetics preparations. this review is based on focusing on the cosmeceuticals intended to enhance the health and beauty of skin. keywords: herbal cosmetics, cosmeceuticals, herbs, skin care, skin cosmetics, tooth cosmetics, hair cosmetics. introduction now-a-days the usefulness of herbs in the cosmeceutical production has been extensively increased in personal care system and there is a great demand for the herbal cosmetics. cosmetics are the substances is to be applied to the human body for cleansing, beautifying, promoting attractiveness, and altering the appearance without affecting the body's structure or functions. the word cosmetic was derived from the greek word “kosm tikos” meaning having the power, arrange, skill in decorating 1. the origin of cosmetics was associated with hunting, fighting, religion and superstition and later associated with medicine. various synthetic compounds, chemicals, dye are proved to cause various skin diseases having numerous side effects. thus we are using herbal cosmetics as much as possible. the basic idea of skin care cosmetic lies deep in the, ayurveda and unani and homeopathic system of medicine. the herbs should have variety of properties like anti-oxidant, anti-inflammatory, antiseptic, emollient, anti-seborrhatic, antikerolytic activity and anti-bacterial etc cosmetics are developed to reduce wrinkles, fight acne and to control oil secretion. for various types of skin ailments formulations like skin protective, sunscreen, anti-acne, anti-wrinkle and antiaging are designed using varieties of materials, either natural or synthetic 2. the skin and hair beauty of individuals depends on the health, habits, routine job, climatic conditions and maintenance. the skin due to excessive exposure to heat will dehydrate during summer and causes wrinkle, freckles, blemishes, pigmentation and sunburns. the extreme winter cause damages to the skin in the form of cracks, cuts, maceration and infections 3. cosmetics are an extremely various and diversified set of product including creams, powders, perfumes, lotions, washing products, and the wide sector of decorative cosmetics or makeup. natural substances are extensively used in the preparations of cosmetics, and there is an ever growing interest in the understanding of their mechanisms of action, in order to achieve a more sophisticated targeted design of skin care products. the demand of herbal medicines is increasing rapidly due to their skin friendliness and lack of side effects. the best thing of the herbal cosmetics is that it is purely made by the herbs and shrubs and thus is side-effects free. the natural content in the herbs does not have any side effects on the human body instead provide the body with nutrients and other useful minerals 4. compared to other beauty products, natural cosmetics are safe to use. they are hypo-allergenic and tested and proven by dermatologists to be safe to use anytime, anywhere. since they are made of natural ingredients, people don’t have to worry about getting skin rashes or experience skin itchiness. in the 21st century natural cosmetic is about developing “new skin care concept based on the perfect synergy between nature and technology, between the purest bioactive ingredients and premium performance innovation.” natural cosmetic philosophy is “believe in the synergy of nature, in its simplest form, along with the most complex open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.19 jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [10] ajdhs.com technology.” modern natural cosmetic products are free from potentially harmful substances and help promote our looks without damaging our skin. the present study collect the details of herbal plants were used in different cosmetics discusses the constituents and its activities in cosmetics preparations. cosmeceuticals is the fastest growing segment of the personal care products, these are cosmetics products which contains biologically active principles and ingredients of plant origin. to study the functions and efficacy of naturally derived ingredients for the use in cosmetics, a new branch of science is developed known as “cosmetic phytognosy” which deals with biochemical properties of plant derived ingredients to be use in herbal cosmetics. according to drug and cosmetic act 1940, describes as, any article or preparation intended to rubbed, poured, sprinkled or sprayed on or introduced to or applied to any part of human body for cleaning, perfuming, beautifying, promoting, attractiveness or altering the appearance and includes any article intended for use as component of cosmetics. the use of natural herbs ingredients in personal and health care product has been emerged for its better experiences. recent researchers proves that herbs while being more effective as they mild and soothing. potent synthetic preparation and chemicals, though effective, constitute a toxic burden to human body. herbal cosmetics, referred as products formulated by various natural herbal ingredients are used in as base in preparation of effective herbal cosmetic. herbs do not produce instant cures. they offer a way to put the body in proper tune with nature 5. the demand of herbal medicines is increasing rapidly due to their skin friendliness and lack of side effects. the best thing of the herbal cosmetics is that it is purely made by the herbs and shrubs and thus is side-effects free. the natural content in the herbs does not have any side effects on the human body; instead provide the body with nutrients and other useful minerals 6. the term cosmeceuticals was first used by raymond reed founding member of u.s society of cosmetics chemist in 1961. he actually used the word to brief the active and science based cosmetics. the above term was further used by dr albert kligman in the year 1984 to refer the substances that have both cosmetic and therapeutic benefits 7. cosmeceuticals are cosmetic-pharmaceutical hybrids intended to enhance health and beauty through ingredients that influence the skin's biological texture and function 8. advantages of herbal cosmetics over synthetic 9 1. naturally available herbal cosmetics are made by herbs which are easily available from nature; they are free from all the harmful synthetic chemicals. although herbal cosmetics prepared by naturally available plant parts and plant extracts, they may as effective as synthetic product. e.g. aloe-vera gel and coconut oil. they also consist of natural nutrients like vitamin e, vitamin c that beautify skin and provide nourishment to the skin. for example, aloe vera is an herbal plant species belonging to liliaceae family and is naturally and easily available 10. there are number of consumers concerned about toxic synthetic chemicals, mineral oils which is may use as ingredients in many cosmetics. they demand more natural products with traceable and more natural ingredients, free from harmful chemicals and effectiveness 11. 2. safer to use as compared to synthetic products, herbal cosmetics are safe to use. they are less allergenic, non toxic, tested and proven by dermatologists to be safe to use. since they are made of natural ingredients. 3. less side effects the synthetic beauty products can irritate your skin, and cause rashesh on skin. sometime they might block skin pores and make skin dry or oily. with herbal cosmetics, we need not worry any adverse reactions. the natural ingredients used assure no side effects; it can apply on the skin assurely. for example herbal cosmetics are free from parabens that are the most widely used preservative in cosmetics and can penetrate the skin 12. and are suspected of interfering with hormone function (endocrine disruption) 13. 4. economical to use natural cosmetics are not that expensive. in fact, some of these products are more affordable than synthetic ones. they are offered at discounted prices and are sold for a cheap price during sales. just need to survey enough to look for great deals. an estimate of who demonstrates about 80% of world population depends on natural products for their health care, because of side effects inflicted and rising cost of modern medicine. world health organization currently recommends and encourages traditional herbal cures in natural health care programs as these drugs are easily available at low cost and are comparatively safe 14 . cosmeceuticals ‘cosmeceuticals’ is fastest growing segment of the beauty industry. cosmeceuticals are cosmetic-pharmaceutical products intended to improve the health and beauty of the skin by providing a specific result, ranging from acnecontrol, sun protection to anti-wrinkle, anti-agening effects. they are skin protecting as well as skin glowing agent 15. cosmeceuticals are future generation of skin care. they are the advances made within the world of dermatological products and the new backbone in skincare. cosmeceutical are typically cosmetic pharmaceutical hybrids intended to enhance the health and beauty of skin. some cosmeceuticals are naturally-derived while others are synthetic, but all contain functional ingredients with therapeutic, diseasefighting or healing properties 16 raymond reed, founder of u.s. society of cosmetic chemist, created the concept of “cosmeceutical” was popularized by american dermatologist. the synthetic beauty products can irritate your skin, and cause pimples. they might block your pores and make your skin dry or oily. with natural cosmetics, one need not worry about these. the natural ingredients used assure no side effects; one can apply them anytime, anywhere. for example herbal cosmetics are free from parabens that are the most widely used preservative in cosmetics and can penetrate the skin. cosmetic preparation is divided into 3 categories solid: face powder, talcum powder, compact powder semisolid: cream, ointment, liniments liquid: lotion, hair oil, shampoo, mouthwashes, sprays etc 17. how to use herbs in earlier time, herbs were used for both medicinal purposes as well as for beautification .these had been used in both forms, i.e. fresh form & dried form .these can be used by mashing & directly applying to the body with or without using other ingredients. in fact in earlier times these were used this way only. but nowadays, their extracts, decoctions, infusion, tinctures, steam distillates etc. there are a few manufacturer of herbal in india. herbs can be used in the form of following. jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [11] ajdhs.com infusions: these are basically strong teas of herbs and can be prepared either in china clay pots or stainless steel vessels .aluminium vessels should not be used as these can taint infusions. decoctions: these are prepared by boiling the herb with water. extracts and tinctures: extracts are generally prepared with hydro alcoholic solvents with high percentage of alcohol. flower waters: flower waters are made in the same way as infusions. the same proportions of herbs and water can be used 18,19. raw materials generally used in herbal cosmetics oils, waxes, gums, hydrophillic colloids, colours, perfumes, protective agents, bleaching agents, preservatives, antioxidants and other auxillary agents20, 21. 1. oils: oils are derived from vegetable and mineral sources, and are used in cosmetics. examples of vegetable oils are almond oil, arches oil, castor oil, olive oil and coconut oil. examples of mineral oils are light and heavy paraffin. a) almond oil: it is a fixed oil obtained by expressing the seeds of prunes amygdalus, family rosaceae, the oil is pale yellow in colour, with a characteristic odour. the active principles are mainly the mixture of glycoside with oleic acid, linoleic acid, myristic and palmitic acid. it has an emollient action, so it is used in the preparation of creams and lotions. b) arachis oil: this is also a fixed oil obtained from the seeds of the aarchishypogea belonging to the family leguminoseae. the oil is pale yellow in colour, with a faint nutty odour. refined groundnut oil is colourless, with active principles like oleic. linoleic acid and asmall amount of other acids. at 3°c, it is cloudy, at a lower temperature, it solidifies. it is used in the preparation of hair oils and brilliantines. c) castor oil: oil is obtained from the seeds ofricinuscommunis belonging to the family, euphorbiaceae. it has a slight odour; the oil is either yellow in colour or colourless. it consists of a mixture of glycosides, in which 80% of ricinoleic acid is the major constituent. at 0° c it forms a clear liquid. it is used as an emollient, in the preparation of lipsticks, hair oils, creams and lotions. d) olive oil: this oil is obtained from the fruit of the oleaeuropea, belonging to the family, oleaceae. the oil is either pale yellow or greenish yellow in colour, it has a slight odour. it consists of the glycerides of oleic acid, palmitic, linoleic, stearic and myristic acids. at a lower temperature, it is solid or partly solid. it has emollient, soothing properties. it is used in the manufacturing of creams, lotions and bath oils 22. e) coconut oil: this oil is obtained from the dried solid part of the endosperm of the coconut cocosnucifera, family palmea. it is a white or pearl-white unctuous mass in winter and colourless in summer. f) light liquid paraffin: it consists of a mixture of hydrocarbons in the form of an oily liquid which has no colour or odour. viscosity and weight per ml (0.83-0.87g) are both low in light liquid paraffin. it is used in the manufacture of bath oils, hair oils, brilliantines, lotions and creams, due to its better spreadibility. i) heavy liquid paraffin: it is composed of a mixture of hydrocarbons in the form of a colourless and odourless oily liquid. due to its soothing effect on the skin, it is used in creams, lotions, brilliantines, hair oils and bath oils. heavy liquid paraffin is obtained from petroleum. 2. waxes: waxes are the esters resulting from the condensation of high molecular straight chain fatty acids with high molecular straight chain monohydric alcohol of the methanol series. they are used in cosmetics as a base, along with oils and fats. example: lipsticks. commonly used waxes are briefly discussed below. a) beeswax: it is a purified wax separated from the honeycomb of bees, apismellifera which belong to the family, apidae. beeswax is composed of 70% ester myricylpalmitate. it is yellowish brown in colour, solid, with a honey-like odour. under cold conditions it becomes brittle; when bleached, it becomes yellowish-white solid with a faint characteristic odour. the melting point of beeswax is 62°c-65°c. beeswax helps in the incorporation of water to form an emulsion. b) carnauba wax: this is obtained from the leaves of the brazilian wax palm, copernicacerifera, which belongs to the palmae family. carnauba wax is available in various grades. the highest grade is light-brown to pale-yellow in colour. it is in the form of moderately coarse powder or flakes, with a characteristic bland odour. the melting range of this wax is 81°c -86°c. it is a hard wax and is used in the manufacture of candles, wax varnishes, leather and furniture polishes. c) paraffin wax: it is derived by the distillation of petroleum. it is a mixture of solid hydrocarbons consisting mainly of nparaffins and, to some extent, their isomers. so, it also called hard paraffin wax. physically, the paraffin wax is colourless, odourless or a white, translucent, wax-like solid, which is slightly greasy to touch. paraffin wax melts at 50°c57°c. d) spermaceti: it is a solid wax obtained from the head, blubber and ear case of the sperm whole, physestercolodon, which belongs to the physeteridae family. it consists mainly of cetylpalmitate and cetyimyristate spermaceti in a solid wax, which is a translucent crystalline, pearly-white, unctuous mass with little odour and taste. it melts at a specific gravity of about 0.94. spermaceti is also available synthetically and is composed of a mixture of esters of saturated fatty alcohols and saturated fatty acids. synthetic spermaceti is available as white to off-white translucent flakes with a crystalline structure and a pearly lustre. the melting range of synthetic spermaceti is 43°c-47°c. 3. colours: colours have been used in cosmetics, since time immemorial, by human beings. basically, the desire to buy a cosmetic product is controlled by three senses, namely, sight, touch and smell. so color is one of the most important ingredients of cosmetic formulations. color is a visual sensation which can be caused by a definite wavelength or a group of wavelengths by an object through one or more of the following phenomena emission, refection, refraction or transmission. natural colours such as cochineal, saffron and chlorophyll are discussed in brief here. 23 a) cochineal: cochineal is a red dyestuff derived from the dried female insect, dactilopiuscoccus, which belongs to the coccidae family. carminic acid is the main colouring constituent in cochineal. on crystallization, carminic acid forms red needles and at 130°c, the needles darken and also carbonize at 250°c. for the preparation of caramine, the cochineal is extracted with water. alum is added to this solution to precipitate the red aluminium salt called carmine lake. b) saffron: it consists of the stigmas and tops of the styles of the plant, crocus sativa, which belongs to the iridaceae family. it is a perennial plant grown in jammu and kashmir in india. saffron powder is yellowish and is easily soluble in water, so it is used as aflavouring and colouring agent in food jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [12] ajdhs.com preparations. saffron contains a number of carotenoids crocin is an important natural saffron carotenoid. picrocrocin is a colorless bitter glycoside responsible for saffron's characteristic odour. c) chlorophyll: it is the natural green pigment, found abundantly in nature. it is the component that is responsible for photosynthesis. d) rose: it is obtained by the steam distillation process from the flower petals of rosmarinas officinalis which belongs to the labiatae family. for obtaining rose oil, the blossoms are collected before they open, a little before sunrise. e) jasmine essential oil: obtained from the flowers of jasminum grandiflorum which belongs to the oleaceae family, the oil is obtained by the solvent extraction method and its essence is used in the perfumery industry. f) lavender: it is obtained from the flowers and stalk of lavandula officinals which belongs to the labiatae family. g) tuberose: the nickname of the tuberose is "mistress of the night". the oil is a brown, viscous liquid with a sweet, heavy and sensuous scent. h) geranium: this oil is obtained from the flowers, leaves and stalks of the pelargonium graveolens, which belongs to the geranigceae family. its essence is obtained by the distillation process, from the flowers and stems of the plant. the geranium is known as geranium bourbon. i) champa: it is obtained from the flowers of the micheliachampaka.'yhecolour of the flower is yellow to deep orange. j) cinnamon: cinnamon oil is obtained from the different parts of the cinnamon tree its leaves, bark and roots. cinnamon zeylanicum belongs to the family, lauraceae. the oil obtained from the bark is most valuable. the oil has a warm, spicy and sweet character. k) neroli: it is an essential oil obtained through the distillation process from the flower of the bitter orange tree. it can be stored in amber-coloured bottles in the refrigerator. l) clove: it contains essential oils, obtained from the buds of the eugincacarryophylus, which belongs to the family, myrataceae. m) ambrette: ambrette seeds contain oil; it can be obtained by using the expression method. the oil is rich; it is sweet, floral and musky in nature. the oil can be used as an anti-aging agent. n) sandalwood: it is obtained by the steam distillation process from the hard wood of santalurn album belonging the family, sundalaceae. in most perfumes, it is used as a fixative agent. 4. protective agents: in the formulation of creams, silicones act as protective agents; a combination of silicones with other barrier agents like petroleum jelly beeswax, paraffin etc can produce excellent barrier creams. a) bleaching agents the most commonly used bleaching agents are given below. mercury compounds: mercuric chloride (hgcl), red mercuric oxide (hgo) and ammoniated mercury are examples of mercury compounds that can be used, for their skin bleaching effects. currently, the use of mercury compounds is prohibited in cosmetics. b) hydroquinones: they are mostly used as bleaching agents for temporarily lighting skin at a concentration of 1.5%-2%. in the case of 5% concentration, redness and burning may be produced. reverse action of hydroquinones takes place on exposure to sunlight. if the cosmetics containing hydroquinone are discontinued, then too, a similar effect can be observed. c) catechol and its derivatives: catechol exhibits skin lighting effect to an extent. 4isopropy catechol has been found to be among the most potent de-pigmenting agents. they can produce irritation and a sensitization reaction at concentrations of 3% or more. d) ascorbic acid and its derivatives: ascorbic acid does not seem to be very effective as a de-pigmenting agent, but its use has been found to be safe. it is mostly used in skin bleaching creams, which contain hydroquinone as a stabilizer (antioxidant). ascorbyloleate used in skin bleaching cream for bleaching freckles in human skin is used at a concentration of 3% and 5%. 5. oxidizing agents: hydrogen peroxide has been used as an oxidizing agent in skin bleach creams. sometimes, zinc peroxide is also used in anhydrous ointments such as bleaching agents, although the properties of zinc peroxide have been not proved. 6. opaque covering agents: various cosmetic products which contain white or pale pigments like titanium dioxide, zinc oxide, talc, kaolin, bismuth etc. can provide a temporary but remarkable change in the colour of the skin. 7. preservatives: these are the agents who are used to prevent spoilage of cosmetic products. they are products of the oxidation of oils and fats and also the growth of microorganisms. most cosmetic preparations, especially those containing water are likely to deteriorate if preservatives are not added. properties of preservatives  an ideal preservative must possess the following attributes; 1. it should be compatible with the formulation. 2. soluble to the extent needed to achieve an effective concentration. 3. stable enough to provide a sustained antimicrobial effect. 4. colourless and odourless or nearly so. 5. non-irritant and non allergic in the concentrations used. examples organic acids: benzoic acid, formic acid alcohols: ethyl alcohol, isopropyl alcohol aldehydes: formaldehyde, cinnamic aldehyde phenolics: cresol, phenol esters: methyl p-hydroxy benzoate, ethyl p-hydroxy benzoate mercury: thiomersol, nitromersol surface active agents:benzalkonium chloride, cetylpyridinium chloride miscellaneous compounds: ethyl vanillin and vanillin 8. antioxidants: natural antioxidants like tocopherols present in fats and oils are destroyed during therefining process. hence, the addition of antioxidants is essential to avoid the rancidity of fats and oils in cosmetics due to oxidative deterioration. some of the common antioxidants used in cosmetic preparation are. amines: purins and lecithin phenols: gallic acid, methyl gallate jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [13] ajdhs.com quinones:tocopherols, hydroxychromans esters: di-lauryl thiopropionate organic acids: ascorbic acid alcohols: sorbitol and mannitol 24. herbs used in cosmetics/cosmeceuticals there are numerous herbs available naturally having different uses in cosmetic preparations for skincare, hair care and as antioxidants, perfumes as follows. 1. skin care ➢ coconut oil: coconut oil is excellent as a skin moisturizer and softener. coconut oil is derived from the fruit or seed of the coconut palm tree cocos nucifera, family arecaceae which contains about 6065% of the oil. coconut oil contains a high amount of glycerides of lower chain fatty acids. the melting point of coconut oil is 24 to 25°c (75-76ºf) and thus can be used easily in liquid or solid forms and is often used in cooking and baking. ➢ olive oil: this oil is a fixed oil extracted from the fruits of olea europaea, family oleaceae. the major constituents are triolein, tripalmitin, trilinolein, tristearate, monosterate, triarachidin, squalene, βsitosterol and tocopherol. it is used as skin and hair conditioner in cosmetics like lotions, shampoos etc. it is a potent fatty acid penetration enhancer. ➢ aloe vera: aloe vera is an herbal plant species belonging to family liliaceae. it is an ingredient in many cosmetics because it heals, moisturizes, and softens skin. simply cut one of the aloe vera leaves to extract the soothing gel 6. aloe vera contains amino acids like leucine, isoleucine, saponin glycosides that provide cleansing action, vitamins a,c,e,b, choline, b12 and folic acid and provide antioxidant activity. ➢ green tea: the tea plant (camellia sinensis) has been cultivated in asia for thousands of years 15. the 4 major polyphenolic catechins present in green tea leaves are (2)epicatechin (ec), egc, (2)-ec-3-gallate, and egcg, which is the most abundant. it was found that green tea extracts or an individual green tea polyphenol (gtpp), especially epigallocatechin (egc)-3-gallate (egcg), inhibited two-stage chemical carcinogenesis (eg, induced by 7,12-dimethylbenz(a)anthracene [dmba] and 12-otetradecanoylphorbol 13-acetate [tpa]), and photocarcinogenesis (induced by uvb). ➢ calendula: calendula officinalis is reported to have a remarkable antioxidant activity, antiinflammatory activity and wound healing activity. a previous study demonstrated that the essential oil of calendula consists mainly of α-thujene, α-pinene, 1,8-cineole, dihydrotagetone and t-muurolol 25. ➢ turmeric: it is a deep yellow-to-orange powder that comes reduce the number of ultraviolet b (uvb)induced sunburn. it is skin protecting agent as well as antiseptic in nature. ➢ multani mitts (fullers earth): it is mother nature’s own baby powder. clay was one of the earliest substance to be used as a beauty mask to draw oils from the skin, natural moisturizers for hairs, teeth, gums, and hairs, toremove pimple marks, treatment on sunburn, helps unclog pores, to cleans the skin of flakes and dirt. ➢ oat (avena sativa): oat oil is rich in antioxidants and natural emollient property. it also use in many lotions, creams and facial oils. ➢ chandan: it was used as scrubs and face packs that were applied on face to remove dead cells. regenerate growth of new cells and gives a young look. it also use as detanning agent in sunburn treatment. ➢jojoba oil: it is a mixture of long chain, linear liquid wax esters extracted from the seeds of the desert shrub simmondsia chinenesis, and belonging to the family simmondsiaceae. jojoba oil is easily refined to remove any odour, colour it is oxidatively stable, and is often used in cosmetics as a moisturizer and as carrier oil for exotic fragrances 26. ➢rhodiola rosea: it is commonly known as golden root, roseroot, aaron's rod, arctic root, king's crown, lignum rhodium, belonging to the family crassulaceae. traditional folk medicine used r. rosea to increase physical endurance, work productivity, longevity, resistance to high altitude sickness, and to treat fatigue, depression, anemia, impotence, gastrointestinal ailments, infections, and nervous system disorders 27. ➢carrot: it is obtained from the plant daucus carota belonging to the family apiaceae. it is a valuable herb since ages as due to its richness in vitamin a along with other essential vitamins. carrot seed oil is used as anti-aging, revitalizing and rejuvenating agent. the carrot gets its characteristic and bright orange colour from β-carotene, and lesser amounts of α-carotene and γ-carotene. α and βcarotenes are partly metabolized into vitamin a in humans 28. 2. hair care ayurveda has numerous natural medications in dandruff treatment wherein the most common herbs include neem, kapoor (naphthalene), and henna, hirda, behada, and amalaki, magic nut, bringaraj, rosary pea, sweet flag, cashmere tree and mandor. ➢ henna: henna comes from the plant lawsonia inermis family lythraceae, which contain a dye molecule called lawsone, which when processed produces henna powder. besides lawsone other constituents present are gallic acid, glucose, mannitol, fats, resin (2%), mucilage and traces of an alkaloid. leaves yield hennatannic acid and an olive oil green resin, soluble in ether and alcohol. lawsone edible fruit. it is highly praised both for its high vitamin c content and for the precious oil, which is extracted from its seeds and pulp and used as a treatment for hair and scalp problems. it is used in eye syndromes, hair loss, and children ailments etc. ➢ shikakai: acacia concinna linn. (leguminosae) is a medicinal plant that grows in tropical rainforests of southern asia. the fruits of this plant are used for washing hair, for improving hair growth, as an expectorant, emetic, and purgative. the powder of acacia concinna linn shows the presence of saponins, alkaloid, sugar, tannin, flavanoids, anthraquinone glycosides. ➢ amla: amla is the fruit of a small leafy tree (emblica officinalis), which grows throughout india and yields an characteristics. there are mainly four species of roses for oil production. these are rosa damascena mill., r. gallica l., r. moschata herrm. and r. centifolia l. rose oil and rose water have many therapeutic effects. rose oil helps soothe the mind and heals depression, grief, nervous stress and tension. it also helps to heal wound and skin health. ➢ hibiscus: a red colour obtained from the extract of hibiscus sabdariffa family malvaceae. hibiscus consist of calcium, phosphorus, iron vitamin b1 used to stimulate thicker hair growth and prevent premature greying of hair. jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [14] ajdhs.com ➢ walnut: juglance regia family juglandaceae, leaves are used in traditional medicine for external applications such as eczema, loss of hair, scalp itching, peeling and dandruff. ➢neem: neem or margosa is a botanical relative of mahogany. it is belonging to the family meliaceae. the common treatment for the dandruff is neem as it produces antifungal, antibacterial, pain-relieving, and anticompounds that would treat dandruff 31. 3. antioxidants ➢ tamarind: tamarind or tamarindus indica l. of the fabaceae, subfamily caesalpinioideae consists of amino acids, fatty acids and minerals of tamarind plant parts. the most distinguished characteristic of tamarind is its sweet acidic taste due to tartaric acid. besides being a rich source of sugars, tamarind fruit is also an excellent source of vitamin b and contain minerals, exhibit high antioxidant capacity that appear to be associated with a high phenolic content, and thus can be an important food source. ➢carrot: it is obtained from the plant daucus carota belonging to the family apiaceae. it is a valuable herb since ages as due to its richness in vitamin a along with other essential vitamins. carrot seed oil is used as anti-aging, revitalizing and rejuvenating agent. the carrot gets its characteristic and bright orange colour from β-carotene, and lesser amounts of α-carotene and γ-carotene. α and βcarotenes are partly metabolized into vitamin a in humans 28. ➢ vitamin c: vitamin c is necessary for the hydroxylation of proline, procollagen, and lysine. vitamin c improves the changes caused by photo damage. vitamin c has been used effectively to stimulate collagen repair, thus removing some of the effects of photo-aging on skin. ➢ vitamin e: (alpha-tocopherol) is the major lipophilic antioxidant in plasma membranes and tissues. the term vitamin e collectively refers to 30 naturally occurring molecules (4 tocopherols and 4 tocotrienols), all of which exhibit vitamin e activity. its major role is generally considered to be the arrest of chain propagation and lipid peroxidation by scavenging lipid peroxyl radicals, hence protecting the cell membrane from destruction. 4. essential oils ➢ rose oil: roses are widely referred to as the world’s favorite flower in part due to their vast diversity in plant habitat and floral characteristics. there are mainly four species of roses for oil production. these are rosa damascena mill., r. gallica l., r. moschata herrm. and r. centifolia l. rose oil and rose water have many therapeutic effects. rose oil helps soothe the mind and heals depression, grief, nervous stress and tension. it also helps to heal wound and skin health. ➢ eucalyptus oil: there are around 700 different species of eucalyptus in the world, of which at least 500 produce a type of essential oil. it is produced by steam distillation from the leaves of eucalyptus species (e. cinerea f. muell., e. baueriana f. muell., e. smithii r. t. baker, e. bridgesiana r. t. baker, e. microtheca f. muell., e. foecunda schau., e. pulverulenta sims, e. propinqua deane and maiden, e. erythrocorys f. muell.) etc. they are widely used in the preparation of liniments, inhalants, cough syrups, ointments, toothpaste and also as pharmaceutical flavors. 5. oral care ➢ meswak (salvadora persica): chewing stick have been widely used in the indian subcontinent, meswak, a derivative from arak tree, is used by many people in different cultures as a traditional toothbrush for oral hygiene. it is suitable for cleansing teeth, comparatively cheap, it’s also found its way into the dentifrices in the recent years as antiplaque and antigingivitis agent. it is believed that chewing on these stem facilitate salivary secretions which possibly help in oral cleaning and plaque. ➢ red clover (trifolium pratense): red clover mouthwash is healing for irritated and diseased gums. after making red clover tea, prepare an ointment from the strained blossoms and leaves. rub the ointment, which has antibiotic properties, on gums that are abcessed from sore or root canal therapy or other dental procedure. ➢ peppermint oil: peppermint contain menthol as a volatile oil, methyl acetate, tannic acid, and vitamin c. pepperm bint oil is used to relieve toothache by soaking a cotton ball in the oil and placing it in cavity or rubbing it on the tooth. peppermint mouthwash can be used to relieve gum inflammation. applications of herbal products in cosmetics herbal skin care products: lavender silk soaps, lotions creams, body powder,lavender herbal body powder, skin care creams 32-35. herbal hair care cosmetics: henna (lawsoniainermis), amla (emblicaofficinalis), shikakai (acacia concinna), brahmi (bacopamonnieri), bhringraj (eclipta alba), guar gum (cyamopsistetragonolobus. herbal lip care cosmetics: herbal lipsticks, herbal lip gloss, herbal lip balm, herbal lip plumper herbal eye care cosmetics: eye make up, eyeshadows, eye gloss, liquid eye liners creams: aloe moisturizing hand cream, rich face and hand cream, herbal moisturizers herbal oils: herbal oils are effective for baldness, falling of hair, thinning of hair, dandruff, and irritation & itching of scalp, patchy baldness, and maintenance of fine head of hair herbal perfumes &fragrances: citrus fragrance: the light, fresh character of citrus notes (bergamot, orange, lemon, petitgrain, mandarin etc.) is often combined with more feminine scents (flowers, fruits and chypre). chypre fragrance: based on a woody, mossy and flowery complex, sometimes with aspects. chypre fragrances smell slightly dry, not very sweet 35-40. results and discussion in this study prove effective and safe, when used as a moisturizer with absence of adverse reaction. the herbal plants like coconut oil, sunflower oil, jojoba oil, olive oil, aloe vera. coconut oil is excellent as a skin moisturizer and softener. a study shows that extra virgin coconut oil is effective and safe when used as a moisturizer, with absence of adverse reactions. a study found that coconut oil helped prevent protein loss from the wet combing of hair when used for fourteen hours. human sebum and jojoba oil are virtually identical. sebum protects and moisturizes the skin and hair but is stripped away by chemicals, pollutants, sun and the aging process, resulting in dry skin and hair. jojoba oil replenishes what skin and hair loss and restores them to their natural ph balance. carrot seed oil is used as antiaging, revitalizing and rejuvenating agent. herbs are rich in vitamins, they have anti-aging, revitalizing and rejuvenating agent. the herbs like rhodiola rosea, carrot, jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [15] ajdhs.com and gingko. r. rosea is rich in phenolic compounds, known to have strong antioxidant properties. herbs produce anti-fungal, anti-bacterial and pain relieving that can treat dandruff, henna, neem. lawsone isolated from the leaves of l.inermis has shown significant antifungal, antibiotic effect. the common treatment for the dandruff is neem as it produces antifungal, antibacterial, pain-relieving, and anticompounds that would treat dandruff. the plants produce anti-septic, anti-inflammatory, antioxidant, insect repellent, help in wound healing and skin protection. green tea, calendula, turmeric, shikakai, rose oil. it was found that green tea extracts or an individual green tea polyphenol (gtpp), especially epigallo catechin (egc)-3gallate (egcg), inhibited two-stage chemical carcinogenesis (e.g., induced by 7,12-dimethylbenz(a) anthracene [dmba] and 12-o-tetra-decanoylphorbol 13acetate [tpa]), and photo carcinogenesis (induced by uvb). rose oil helps soothe the mind and heals depression, grief, nervous stress and tension. it also helps to heal wound and skin health. herbs have vitamins and other constituents. they provide nutrition to hair and also cause darkening of hair. amla, eucalyptus oil. antioxidant: different vitamins like vitamin b and vitamin c which provide antioxidant and photo aging on the skin. tamarind, vitamin c, vitamin e. vitamin c has been used effectively to stimulate collagen repair, thus removing some of the effects of photo-aging on skin. vitamin e is generally considered to be the arrest of chain propagation and lipid per oxidation by scavenging lipid peroxyl radicals, hence protecting the cell membrane from destruction. conclusion there are numerous herbs available naturally having different uses in cosmetic preparations for skincare, hair care and as antioxidants. the current review highlights importance of herbal cosmetics, the herbs used in them and their advantages over the synthetic counterparts. herbal cosmetics are the preparations containing phytochemical from a variety of botanical sources, which influences the functions of skin and provide nutrients necessary for the healthy skin or hair. there is common belief that chemical based cosmetics are harmful to the skin which increase the awareness among consumers for herbal products. herbal cosmetics are prepared, using one or more herbal ingredients to treat different skin ailments and for the beautification. the cosmeceuticals are the agent that protects skin and gives nourishment to the skin which may produce from the herbal drug which are stated in present review. the cosmetic products are the best option to reduce skin problems such as hyper pigmentation, skin wrinkling, skin ageing and rough skin texture etc. the demand of herbal cosmetic is rapidly expanding. hence the herbal cosmetics have the most advantageous over the synthetic cosmeceuticals due to its effectiveness. the present study revealed that herbal cosmetics are very safe and does not produce any toxic and adverse reactions compare to marketed cosmetics products. we suggest that, we use herbal cosmetics in future, we will avoid skin problems. references 1. sumit k, vivek s, sujata s, ashish b. herbal cosmetics: used for skin and hair. inven j. 2012; 2012:1-7. 2. joshi ls, pawar ha. herbal cosmetics and cosmeceuticals: an overview. nat prod chem res. 2015; 3(2):170. https://doi.org/10.4172/2329-6836.1000170 3. jain s, purohit a, nema p, vishwakarma h, jain pk. intelligent or smart polymers: advance in novel drug delivery. j drug deliv ther. 2022; 12(5):208-216. https://doi.org/10.22270/jddt.v12i5.5578 4. larsson sc, bergkvist l, naslund i, rutegard j, wolk a. vitamin a, retinol, and carotenoids and the risk of gastric cancer: a prospective cohort study. am j clin nutr. 2007; 85(2):497-503. https://doi.org/10.1093/ajcn/85.2.497 5. pandey s, meshya n, viral d. herbs play an important role in the field of cosmetics, int j pharm tech res. 2010; 2: 632-639. 6. gediya sk, mistry rb, patel uk, blessy m, jain hn. herbal plants: used as cosmetics, j nat prod plant resour. 2011; 1: 24-32. 7. saha r. cosmeceuticals and herbal drugs: practical uses, int j pharm res sci. 2012; 3:59-65. 8. sharma hd, paramesh r. trends in aging and skin care: ayurvedic concepts. j ayurveda integr med. 2010; 1:110-113. https://doi.org/10.4103/0975-9476.65081 9. nema p, jain s, vishwakarma h, purohit a, jain pk. a complete review on aromatherapy: a complementary alternative medication therapy with recent trend. int j med sci pharm res.2021; 7(4):1-7. https://doi.org/10.22270/ijmspr.v7i4.28 10. akinyele bo, odiyi ac. comparative study of the vegetative morphology and the existing taxonomic status of aloe vera. j plant sci. 2007; 2: 558-563. https://doi.org/10.3923/jps.2007.558.563 11. escamilla m, ferre a, hidalgo c, fuentes n, kaps r, et al. revision of european ecolabel criteria for soaps, shampoos and hair conditioners. joint res cen europ commi. 2012; 1-40. 12. u.s. food and drug administration, "parabens". 13. suzuki d. the "dirty dozen" ingredients investigated in the david suzuki foundation survey of chemicals in cosmetics. backgrounder. 2010:1-5. 14. sharma a, shanker c, tyagi lk, singh m, rao chv. herbal medicine for market potential in india : an overview. acad j plant sci. 2008; 1: 26-36. 15. kuroda y, hara y, antimutagenic and anticarcinogenic activity of tea polyphenols. mutat res rev mutat res.1999; 436:69-97. https://doi.org/10.1016/s1383-5742(98)00019-2 16. wanjari n, waghmare j. a review on latest trend of cosmeticscosmeceuticals. int j pharm res rev. 2015; 4:45-51. 17. devi n, kumar a, garg a, hussain a, khathuriya r. a review on herbal cosmetics. edi. ist, cbs publisher, 257-290. 18. united state pharmacopoeia drug information: drug information for the health care professional, vol. 1, 27th ed. greenwood village, co: thomson micromedex, 2007; 2514-2517. 19. vimladevi m. text book of cosmetics; edition (2005); cbs publishers & distributor; page no. 29, 67, 88, 101, 253. 20. kokate ck, purohit ap, goyal sb. pharmacognosy. nirali prakashan, pune, 29 eduition, 2004; 167-250. 21. trease eg, evans cw. pharmacognosy, elbs publisher, usa. 12th edition, 1985, 383-413, 488-509. 22. torkelson ra. the cross name index to medicinal plant, volume 4 crc press, 1999; 1571. 23. asolkar lv, kakkar kk, chakre oj. second supplement to glossary of indian medicinal plant with active principles, part 1, publication information directorate, new delhi, 2 edition, 1992; 47. 24. chatterjee a, prakashi cs. the treatse of indian medicinal plants, vol.5, national institute of science communication, new delhi, 1997; 36. 25. okoh oo, sadimenko ap, asekeen ot, afolayan aj. the effects of drying on the chemical components of essential oils of caledula officinalis l. african j biotechnol, 2008; 7:1500-1502. https://doi.org/10.3923/jas.2007.3806.3810 26. rabasco aam, gonzalez rml. lipids in pharmaceutical and cosmetic preparations. grasas y aceites. 2000; 51:74-96. https://doi.org/10.3989/gya.2000.v51.i1-2.409 https://doi.org/10.4172/2329-6836.1000170 https://doi.org/10.22270/jddt.v12i5.5578 https://doi.org/10.1093/ajcn/85.2.497 https://doi.org/10.4103/0975-9476.65081 https://doi.org/10.22270/ijmspr.v7i4.28 https://doi.org/10.3923/jps.2007.558.563 https://doi.org/10.1016/s1383-5742(98)00019-2 https://doi.org/10.3923/jas.2007.3806.3810 https://doi.org/10.3989/gya.2000.v51.i1-2.409 jain et al asian journal of dental and health sciences. 2022; 2(4):9-16 [16] ajdhs.com 27. brown rp, gerbarg pl, ramazanov z. rhodiola rosea: a phytomedical overview. herbal gram. j am botl coun. 2002; 56:40-52. 28. strube m. naturally occurring antitumourigens: carotenoids except β-carotene. iv. nordic council of ministers; 1999. 29. dixit sn, srivastava hs, tripathi rd. the antifungal antibiotic from leaves of lawsonia inermis and some aspects of its mode of action. indian phy. 1980; 31:131-133. 30. jain s, purohit a, nema p, vishwakarma h, jain pk. a brief review on nutraceuticals and its application. asian j dental health sci.2022; 2(1):7-13. https://doi.org/10.22270/ajdhs.v2i1.10 31. chaudhary g, goyal s, poonia p, lawsonia inermis linnaeus: a psychopharmacological review. int j pharm sci drug res. 2010; 2:91-98. 32. anand n, aquicio jm, anand a. antifungal properties of neem (azadirachta indica) leaves extract to treat hair dandruff. int. j. sci. res. 2010; 2:244-252. 33. wallis te. text book of pharmacognosy, 5 th edition, cbs publisher and distributer, new delhi, 2003; 214-215, 368-369. 34. jain s, purohit a, nema p, vishwakarma h, qureshi a, jain p. pathways of targeted therapy for colorectal cancer. j drug del ther.2022; 12(5):217-221. https://doi.org/10.22270/jddt.v12i5.5602 35. qureshi a, jain pk, shrivastava a, jain s, nema p, jain h. evaluation of antidepressant activity of aqueous and ethanolic extracts of glycyrrhiza glabra. asian j pharm edu res. 2022; 11(2):84-92. 36. taylor ve, brady rl, robbers ej, pharmacognosy, 8 th edition, lea febiger, usa, 1981; 57-77. 37. shivanand p, nilam m, viral d. herbs play an important role in the field of cosmetics. international journal of pharmtech research. 2010; 2(1):632-9. 38. jain s, kirar m, bindeliya m, sen l, soni m, shan m, purohit a, jain pk, novel drug delivery systems: an overview. asian j dental health sci. 2022; 2(1):33-39. https://doi.org/10.22270/ajdhs.v2i1.14 39. purohit a, jain s, nema p, jain dk, vishwakarma h, jain pk. a comprehensive review on tailoring an herbal approach for treatment of poly cystic ovarian syndrome. asian j dental health sci. 2022; 2(1):27-32. https://doi.org/10.22270/ajdhs.v2i1.13 40. vishwakarma h, thakur k, purohit a, jain s, nema p, jain pk. a herbal approach for the treatment of kidney stone. int j medical sci pharma res.2022; 8(1):1-9. https://doi.org/10.22270/ijmspr.v8i1.29 https://doi.org/10.22270/ajdhs.v2i1.10 https://doi.org/10.22270/jddt.v12i5.5602 https://doi.org/10.22270/ajdhs.v2i1.14 https://doi.org/10.22270/ajdhs.v2i1.13 https://doi.org/10.22270/ijmspr.v8i1.29 sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [40] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a comprehensive review: transdermal drug delivery system: a tool for novel drug delivery system sadab, sarad sahu, shubham patel, rubeena khan*, basant khare, bhupendra singh thakur, anushree jain, prateek kumar jain adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 11 sep 2022 reviewed 06 nov 2022 accepted 24 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: sadab, sahu s, patel s, khan r, khare b, thakur bs, jain a, jain pk, a comprehensive review: transdermal drug delivery system: a tool for novel drug delivery system, asian journal of dental and health sciences. 2022; 2(4):40-47 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.24 _______________________________________ *address for correspondence: rubeena khan, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ in the recent decade, skin delivery (topical and transdermal) has gained an unprecedented popularity, especially due to increased incidences of chronic skin diseases, demand for targeted and patient compliant delivery and interest in life cycle management strategies among pharmaceutical companies. transdermal drug delivery system was presented to overcome the difficulties of drug delivery especially oral route. transdermal drug delivery refers to a means of delivering drugs through the surface of the skin for local or systemic treatment. the drug functions after absorption through the skin into the systemic circulation via capillary action at a certain rate. transdermal patches are now widely used as cosmetic, topical and transdermal delivery systems. these patches represent a key outcome from the growth in skin science, technology and expertise developed through trial and error, clinical observation and evidence-based studies that date back to the first existing human records. a transdermal patch is a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through skin and into the bloodstream. an advantage of a transdermal drug delivery route over other types of delivery system such as oral, topical, intravenous (i.v.), intramuscular (i.m.), etc. is that the patch provides a controlled release of the medication into the patient, usually through either a porous membrane covering a reservoir of medication or through body heat melting thin layers of medication embedded in the adhesive. the main disadvantage to transdermal delivery systems stems from the fact that the skin composition offers very effective barrier that allow only small molecule based drugs to penetrate the skin and pass through the barrier. sildenafil citrate (sld) is a selective cyclic guanosine monophosphate-specific phosphodiesterase type 5 inhibitor used for the oral treatment of erectile dysfunction and more recently, it has been used for the treatment of pulmonary arterial hypertension and the enhancement of uteroplacental perfusion in case of fetal growth retardation. the challenges facing the oral administration of the drug include poor bioavailability and short duration of action that requires frequent administration. the main objective of transdermal drug delivery system is to deliver drugs into systemic circulation through skin at predetermined rate with minimal inter and intrapatient variations. keyword: skin delivery, transdermal drug delivery, oral rout, sildenafil citrate, pulmonary arterial hypertension introduction oral route is the most popular route of drug delivery system but it has some disadvantages including first pass metabolism, drug degradation in gastrointestinal tract due to enzymes, ph etc. to overcome these problems, a novel drug delivery system was developed by chien in 1992, banker in 1990, guy in 1996 based on transdermal patches meant for transdermal delivery1. transdermal drug delivery system (tdds) refers to a route of drug delivery through the skin to achieve local or systemic therapeutic action. it is one of the focus areas of research for the third-generation pharmaceutical preparations, next only to oral medication and injection2. the reasons lie in the administration route of the drug, which is convenient, easy to use, non-invasive, and also improves patient compliance3. it also reduces the fluctuation of the drug concentration in the blood, provides steady plasma levels and fewer chances of overdose and easy detection of the drug4,5. at the same time, it evades problems associated with oral delivery such as the effect of the gastrointestinal environment (ph, enzymatic activity, drug and food interaction) on the drug efficacy and the ‘first pass effect’ (the rapid uptake and metabolism of an agent into inactive compounds by the liver, immediately after enteric absorption and before it reaches the systemic circulation). they are available in different sizes & having more than one ingredient. once they apply on unbroken skin they deliver active ingredients into systemic circulation passing via skin barrier. a transdermal patch containing high dose of drug inside is retained on the skin for prolonged period of time and enters into blood circulation via diffusion process. transdermal drug delivery systems are used in various skin disorders, also in the management of angina pectoris, pains, smoking cessation & neurological disorders such as parkinson’s disease6,7. transdermal drugs will continue to gain popularity along with further improvements to improve safety and efficacy. a further major step forward will be the production of patches delivering peptide and even protein substances including insulin, growth open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.24 sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [41] ajdhs.com hormone, and vaccines8. transdermal patches can be categorized into three categories first generation, second generation, and third generation. first generation transdermal patches they are the first set of patches and have been used much in clinics. the transdermal patch design consists of a drug in a reservoir that is enclosed on one side with impermeable backing and an adhesive, which contacts the skin8. however, due to certain limitations, not all drugs with suitable properties can be delivered. the first generation transdermal patches are limited primarily to the outermost skin barrier that is stratum corneum. hence, the drugs should be of low molecular weight, lipophilic, and efficient at low doses. second generation transdermal patches the second generation transdermal patches consists of advanced system that allows increased the skin permeability, reduced damage to the deeper tissues and better transport into the skin. however, enhancement methods developed in this generation, such as chemical enhancers, non-cavitation ultrasound and iontophoresis experienced difficulty in balancing between increased permeation through stratum corneum and at the same time protection of tissues at the deeper level. chemical enhancers disrupt the highly ordered bilayer of the stratum corneum by inserting amphiphilic molecules to help in better permeation. this leads to skin irritation. similarly, iontophoresis involves administration of drugs into the stratum corneum under low voltage current. it mainly provides an electrical driving force for transport across stratum corneum. it does not disturb the skin barrier, thus, can be used for delivery of small molecules that carry a charge and some macromolecules up to a few daltons. rate of drug delivery can be controlled using a microprocessor. in noncavitation ultrasound, the pressure gradients and oscillation associated with ultrasound emerges to be responsible for passage of drug through the skin by disrupting stratum corneum and thereby increasing the permeability. the effects of ultrasound have been limited to small lipophilic molecules. it has been limited due to its associated tissue heating, which can damage the deeper tissue9. third generation transdermal patches the third generation of transdermal delivery system involves targeted approach of disruption of stratum corneum while protecting deeper tissues intact. novel chemical enhancers, electroporation, cavitational ultrasound, microneedles, thermal ablation and microdermabrasion are few newer techniques that deliver macromolecules, including therapeutic proteins and vaccines, across the skin in human clinical trials10. skin the skin is the largest and most visible organ of the body. the skin covers a total surface area of approximately 1.5-2 m2 and is the barrier between human body and the external environment11. many of its functions include temperature regulation, immunity from microorganisms, maintaining electrolyte balance, as well as protection from physical injuries, chemical agents, and ultraviolet radiation12,13. in addition, skin is also an important avenue for absorption of drugs and exerting their efficacy. the skin is composed of epidermis, dermis, and subcutaneous tissue, and contains appendages (such as hair follicles, sebaceous glands, sweat glands), blood vessels, lymphatic vessels, nerves, etc. the epidermis can be divided into five layers from the inside to the outside, namely the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum (sc) (figure 1) 13,14. the properties of sc are quite different from those of the other layers, with the overall structure composed of inactive keratinocytes and intercellular lipids that form a ‘brick and mortar’ model, in which, the proteinrich keratinocytes serve as the bricks and the intercellular lipids serve as the mortar15,16. sc is the main factor determining the skin barrier, and also the major obstacle limiting the rate of percutaneous absorption even though the thickness is only 10-20 µm17,18. there are two routes of transdermal permeation of drugs. one is through the natural channel of skin appendages. these channels are hydrophilic and have a diameter of few microns. owning to the fact that the average follicular orifice area on the human skin surface is only about 0.1% of the total surface area19, it is not the primary pathway of percutaneous absorption. the second route is through the penetration of the epidermis, to enter the dermis through the sc and the deeper epidermis, being absorbed in the body circulation by the capillaries. as for the penetration of drugs and passing through the sc, two pathways exist,namely, the transcellular route, through which substances infiltrate the keratinocytes and intercellular lipids, and subsequently pass through and are transported. the drug needs to diffuse through hydrophilic and hydrophobic areas, and therefore, it may not be applicable to most drugs. the second and most likely route taken by drugs when penetrating the sc is via a tortuous pathway through the lipids surrounding the keratinocytes, known as the intercellular route20. mechanism of action of transdermal patch a typical transdermal patch consists of an adhesive layer which sticks on to the skin, a semi solid to liquid drug is smeared between the layers of drug releasing membranes which are exclusively semipermeable in nature. an outermost clear backing protects overall patch during application. a transdermal patch when applied to skin, establishes a good connection between the skin and semi permeable membrane figure 2. a slow and a sustained flow of drug occurs from drug reservoir of the patch to the skin via drug release membrane by simple diffusion/ osmosis process through percutaneous drug delivery system21. advantages of transdermal drug delivery  transdermal drug delivery enables the avoidance of gastrointestinal absorption with its associated pitfalls of enzymatic and ph associated deactivation.  avoidance of first pass metabolism.  the lack of peaks in plasma concentration can reduce the risk of side effects, thus drugs that require relatively consistent plasma levels are very good candidate for transdermal drug delivery.  as a substitute for oral route.  the patch also permit constant dosing rather than the peaks and valley in medication level associated with orally administered medication.  rapid notifications of medication in the event of emergency as well as the capacity to terminate drug effects rapidly via patch removal.  avoidance of gastro intestinal incompatibility.  convenience especially notable in patches that require only once weekly application, such a simple dosing regimen can aid in patient adherence to drug therapy.  minimizing undesirable side effects. sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [42] ajdhs.com  provide utilization of drug with short biological half lives, narrow therapeutic window.  avoiding in drug fluctuation drug levels.  inter and intra patient variation.  termination of therapy is easy at any point of time.  provide suitability for self administration.  they are non invasive, avoiding the inconvenience of parentral therapy.  the activity of drugs having a short half life is extended through the reservoir of drug in the therapeutic delivery system and its controlled release.  it is of great advantages in patients who are nauseated or unconscious.  transdermal patches are better way to deliver substances that are broken down by the stomach aids, not well absorbed from the gut, or extensively degraded by the liver.  transdermal patches are cost effective. figure 1: schematic representation of the different skin layers figure 2: different layers of transdermal patch with mechanism of action22 disadvantages of transdermal drug delivery  transdermal drug delivery system cannot deliver ionic drugs.  it cannot achieve high drug levels in blood.  it cannot develop for drugs of large molecular size.  it cannot deliver drugs in a pulsatile fashion.  it cannot develop if drug or formulation causes irritation to skin.  possibility of local irritation at site of application.  may cause allergic reaction.  sufficient aqueous and lipid solubility, a log p (octanol/ water) between 1 and 3 is required for permeate to transverse stratum corneum and underlying aqueous layer.  only potent drugs are suitable candidates for transdermal patch because of the natural limits of drug entry imposed by the skin’s impermeability. sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [43] ajdhs.com  long time adherence is difficult23-28. basic components of tdds  polymer matrix/drug  reservoir drug  permeation enhancer  adhesive  backing film  liner  plasticizer polymer matrix29-38 it is very important component in tdds and control the release of drug from patch.  they should not produce any toxic effect either alone (or) with other excipients in tdds formulation.  they shouldn’t expensive one and it should be easily manufactured.  they should have good stability and more compatibility with drugs and other components of system.  the polymers used in tdds should be stable. the cross linked poly ethylene glycol, eudragit, ethyl cellulose, poly vinyl pyrolidine and hydroxyl propyl methyl cellulose are commonly used as matrix formers in tdds. the polymers like eva, poly urethane and silicone rubber are used as rate controlling membrane. table 1 list of polymers used in tdds natural polymers synthetic elastomer synthetic polymer cellulose derivative, gelatin, shellac, starch, waxes, gums, natural rubber, chitosan etc. poly butadiene, hydrin rubber, poly iso butylenes, silicon rubber, nitrile, acronitryle, neoprene, butyl rubber etc pva, poly vinyl chloride, polyethylene, pvp, poly acrylate etc. drug reservoir the selection of drug is based on its properties like physiochemical as well as biological properties.  drug should have higher first pass metabolism.  drugs having narrow therapeutic window.  drugs with short half life.  drugs with frequent dosing.  low molecular weight moieties (<1000 dalton)  drugs with low dose (mg/day).  low melting point substances (<200⁰c)  drugs having affinity with both lipophilic and hydrophilic phases.  drugs without any dermatological effect are suitable for formulation as transdermal patch. permeation enhancers these are the substances which are reversibly changes the structure of stratum corneum and increase the permeation of drug from skin to blood stream. they are two types 1) chemical enhancers [accelerants, absorption promoters (or) permeation enhancers] they act by increasing drug permeability by reversible damage to stratum corneum and to increase partition coefficient of drug. table 2 list of chemical enhancers used in tdds chemical enhancers examples solvents water, methanol, ethanol, propylene glycol, di-methyl acetamide terpenes menthol, cardamom oil, cinnamon oil, 18-cineol, carvone pyrolidine n-methyl 2pyrolidine, axone sulfoxides dms, didecyl sulfoxides fatty acids & esters oleic acid, linoleic acid, lauric acid, capric acid surfactants anionicsls, decodecyl methyl, sulfomide non-ionicpluronic f127, pluronic f68, bile saltssodium taurocholate, sodium deoxy cholatte amides dimethyl acetamide, dimethyl formamide miscellaneous phosphor lipids, amino acid derivatives, enzymes, urea sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [44] ajdhs.com physical enhancers the following physical techniques have been used for enhancing the permeability of drug through skin.  ionotophoresis  electrophoresis  sonophoresis  by using micro needles  magnetophoresis  by using laser radiation adhesive  it is used to affix the patch on the skin.  it should be adhere onto the skin with light pressure applied by finger.  it should be easily removed from the skin surface without leaving any residue. it should not produce any irritation.  it should have excellent contact with the skin.  it should be compatible with other components in formulation.  it should allow permeation of drug freely from the patch e.g. polyacrylates, polyisobutylenes and silicone derivatives. backing laminate  it is used to protect the patch from outer environment.  it should be chemically resistant.  it should not allow permeation of components in the patch.  it should have optimal elasticity, flexibility and tensile strength.  it should have low water vapour transition rate.  if a drug incorporated into a liquid (or) gel in the formulation, the backing material should be heat stable to allow fluid, the tight packing of drug reservoir (form-fill seal process). e.g. vinyl, poly ethylene and poly ester film liner it is used to protect the patch during the storage.  it is removed during application of patch on skin.  it should be chemically inert.  it consists of two layers, one is base layer and other is release coating layer. the base layer may be occlusive (e.g. poly ethylene, poly vinyl chloride). the release coat layer made up of silicon (or) teflon.  the polyester foil and metallized laminate are also used as release liner. plasticizer  it is used to provide plasticity to transdermal patch.  it is also chemically inert and compatible with all other ingredients in the formulation.  some of the plasticizer also acts as a permeation enhancer. major transdermal systems single-layer drug-in-adhesive: the adhesive layer of this system also contains the drug. in this type of patch the adhesive layer not only serves to adhere the various layers together, along with the entire system to the skin, but is also responsible for releases of the drug. the adhesive layer is surrounded by a temporary liner and a backing39. multi-layer drug-in-adhesive: the multi-layer drug-in adhesive patch is similar to the single-layer system in that both adhesive layers are also responsible for release of the drug. the multi-layer system is different however as it adds another layer of drug-in-adhesive, usually separated by a membrane (but not in all cases). this patch also has a temporary liner-layer and a permanent backing40. reservoir: unlike the single-layer and multi-layer druginadhesive systems the reservoir transdermal system has a separate drug layer. the drug layer is a liquid compartment containing a drug solution or suspension separated by the adhesive layer. this patch is also backed by the backing layer. in this type of system the rate of release is zero order41. matrix: the matrix system has a drug layer of a semisolid matrix containing a drug solution or suspension. the adhesive layer in this patch surrounds the drug layer partially overlaying it42. vapour patch: in this type of patch the adhesive layernot only serves to adhere the various layers together but also to release vapour. the vapour patches are new on the market and they release essential oils for up to 6 hours. the vapour patches release essential oils and is used in cases of decongestion mainly. other vapour patches on the market are controller vapour patches that improve the quality of sleep43. various methods for preparation of tdds asymmetric tpx membrane method: a prototype patch can be fabricated using a heat sealable polyester film with a concave of 1 cm diameter will be used as the backing membrane. drug sample is dispensed into concave membrane, covered by tpx {poly(4-methyl-1-pentene)} asymmetric membrane, and sealed by an adhesive. circular teflon mould method: in this method, solutions containing polymers in various ratios are used in an organic solvent. calculated amount of drug is dissolved in half the sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [45] ajdhs.com quantity of same organic solvent. enhancers in different concentrations are dissolved in the other half of the organic solvent and then added. di-n butyl phthalate is added as a plasticizer into drug polymer solution. the total contents are stirred for 12 h and poured into circular teflon mould. the moulds are placed on a leveled surface and covered with inverted funnel to control solvent vaporization in a laminar flow hood model with an air speed of 0.5 m/s. the solvent is allowed to evaporate for 24 h. the dried films are stored for another 24 h at 25±0.5°c in a desiccators containing silica gel before evaluation to eliminate aging effects. mercury substrate method: in this method, drug is dissolved in a polymer solution along with plasticizer. the above solution is stirred for 10-15 min to produce a homogenous dispersion and poured onto a leveled mercury surface, covered with inverted funnel to control solvent evaporation. “ipm membranes” method: in this method, drug is dispersed in a mixture of water and propylene glycol containing carbomer 940 polymer and stirred for 12 h in magnetic stirrer. the dispersion is to be neutralized and made viscous by the addition of triethanolamine. buffer ph 7.4 can be used in order to obtain solution gel, if the drug solubility in aqueous solution is very poor. the formed gel will be incorporated in the ipm membrane. “evac membranes” method: in this method, drug is dispersed in a mixture of water and propylene glycol containing carbomer 940 polymer and stirred for 12 h in magnetic stirrer. the dispersion is neutralized and made viscous by the addition of triethanolamine. buffer ph 7.4 can be used in order to obtain solution gel, if the drug solubility in aqueous solution is very poor. the formed gel will be incorporated in the ipm membrane. aluminium backed adhesive film method: aluminium backed adhesive film method is a suitable one when loading dose is greater than 10mg. for preparation of the same, chloroform is a solvent of choice because most of the drugs as well as adhesives are soluble in chloroform. the drug is dissolved in chloroform and adhesive material will be added to the drug solution and dissolved. a custom made aluminium former is lined with aluminium foil and the ends blanked with tightly fitting cork blocks. preparation of tdds by using proliposomes: the proliposomes are prepared by carrier method using film deposition technique. the proliposomes are prepared by taking 5mg of mannitol powder in a 100 ml round bottom flask which is kept at 60-70°c temperature and the flask is rotated at 80-90 rpm and dried the mannitol at vacuum for 30 min. after drying, the temperature of the water bath is adjusted to 20-30°c. drug and lecithin are dissolved in a suitable organic solvent mixture; a 0.5 ml aliquot of the organic solution is introduced into the round bottomed flask at 37°c, after complete drying second aliquot (0.5 ml) of the solution is to be added. after the last loading, the flask containing proliposomes are connected in a lyophilizer and subsequently drug loaded mannitol powders proliposomes) are placed in a desiccator over night and then sieved through 100 mesh. the collected powder is transferred into a glass bottle and stored at the freezing temperature until characterization. free film method: in this method, free film of cellulose acetate isprepared by casting on mercury surface. a polymer solution (2% w/w) is prepared using chloroform. plasticizers are to be incorporated at a concentration of 40% w/w of polymer weight. five ml of polymer solution was poured in a glass ring which is placed over the mercury surface in a glass petri dish. the rate of evaporation of the solvent is controlled by placing an inverted funnel over the petri dish. the film formation is noted by observing the mercury surface after complete evaporation of the solvent. the dry film is separated out and stored between the sheets of wax paper in desiccator until use. free films of different thickness can be prepared by changing the volume of the polymer solution44-50. future of transdermal drug delivery system future aspects in transdermal drug delivery system include administration of drugs meant for transdermal delivery through liposomes, niosomes and micro emulsions. aim of this development is to improve delivery of drug that has low inherent solubility in most of classical formulation excipients. a wide range of potential drugs for delivery like steroids, antifungal, antibacterial, interferon, methotrexate, local anesthetics are formulated for transdermal delivery. the market for transdermal patches has been estimated to increase in future and has recently experienced annual growth of at rate of 25%. this figure will increase in future as novel devices emerge and list of marketed transdermal drug increases. transdermal delivery of analgesics is likely to continue to increase in popularity as there are further improvements in design. research is being performed to increase safety and efficacy. to improve practical matters such as the experience for the wearer of the patch, and also to provide more precise drug delivery associated with increased duration of action. other potential improvements include improved transdermal technology that utilizes mechanical energy to increase drug flux across the skin either by altering the skin barrier or increasing the energy of the drug molecules. after the successful design of patches using iontophoresis, various modesof ‘active’ transdermal technologies are being investigated for different drugs. these include electroporation (short electrical pulses of high voltage to create transient aqueous pores in the skin), sonophoresis (uses low frequency ultrasonic energy to disrupt the stratum corneum), and thermal energy (uses heat to make the skin more permeable and to increase the energy of drug molecules). magnetic energy, magnetophoresis, has been investigated as a means to increase drug flux across the skin. the transdermal patch may be an underutilized tool for management of acute and chronic pain. with improved delivery and a wider range of analgesics, we expect the popularity and applicability of this modality to deliver drugs to increase. in current scenario, transdermal route of drug delivery system in comparison with oral treatment is the most successful innovative research area in new drug delivery system, with around 40% of the drug delivery candidate products under clinical trials related to transdermal or dermal system. the transdermal drug delivery systems have been designed as an alternative, safest and easy route for systemic drug delivery. the systemic drug administration through skin holds several advantages such as maintaining constant drug level in blood plasma, less number of side effects, and improvement of bio availability by circumventing hepatic firstpass metabolism and increase patient compliance with respect to drug regime used for treatment. in recent times, skin is considered as a safest port for drug administrationto provides continuous drug release into systemic circulation51. conclusion transdermal drug delivery is a painless, convenient, and potentially effective way to deliver regular doses of many medications. wide range of drugs can be delivered improved drug uptake minimal complications and side effects low cost and easy to use. transdermal route of drug delivery system has been one of the advanced modes of drug delivery with sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [46] ajdhs.com safety and good efficacy. there has been a lot of improvement in the process of transdermal route of drug delivery since its beginning years of 1981 to the current advancements till 2022. this tdds review articles provide valuable information regarding the transdermal drug delivery systems and the process of preparation of transdermal patches as a ready reference for the research scientist who is involved in tdds. references 1. sharma n. a brief review on transdermal patches. organic & medicinal chem. 2018; 7(2):1-5. 2. hao y, li w, zhou xl, et al., j. biomed. nanotechnol. 2017; 13:15811597. https://doi.org/10.1166/jbn.2017.2474 3. b. barry, j. control release 6 (1987) 85-88. https://doi.org/10.1016/0168-3659(87)90066-6 4. h. marwah, t. garg, a.k. goyal, et al., drug deliv. 23 (2016) 564-578. https://doi.org/10.3109/10717544.2014.935532 5. jain m, jain a, khare b, jain dk, khan r, jain d. an update on the recent emergence of candida auris. asian journal of dental and health sciences. 2022; 2(1):14-9. https://doi.org/10.22270/ajdhs.v2i1.11 6. kesarwani a, yadav ak, singh s, hemendra gautam, haribansh n singh, et al. a review-theoretical aspects of transdermal drug delivery system. bulletin of pharmaceutical research 2013; 3(2):78-89. 7. sampath kumar kp, bhowmik d, chiranjib b, chandira rm. a reviewtransdermal drug delivery systema novel drug delivery system and its market scope and opportunities. international journal of pharma and bio sciences 2010; 1(2). 8. venkatraman s, gale r. skin adhesives and skin adhesion 1. transdermal drug delivery systems. biomaterials 1998; 19(13):1119-36. https://doi.org/10.1016/s01429612(98)00020-9 9. khatri s, dhanoriya c, jain dk. zika virus (zikv) disease: past, present and future. journal of drug delivery and therapeutics. 2018; 8(6-s):320-327. https://doi.org/10.22270/jddt.v8i6-s.2076 10. mathews l, roy a. management of pain using transdermal patchesa review. asian j pharm clin res, 2016; 9(6):32-35. https://doi.org/10.22159/ajpcr.2016.v9i6.13775 11. trommer h, neubert rh, skin pharmacol physio. 2006; 19:106121. https://doi.org/10.1159/000091978 12. yasin z.a.m., lbrahim f, n.n. rashid, et al., curr pharm biotechnol. 2017; 18:864-876. https://doi.org/10.2174/1389201019666171219105920 13. ventrelli l, strambini lm, barillaro g, adv. healthcare mater. 2015; 4:2606-2640. https://doi.org/10.1002/adhm.201500450 14. pandey sp, khan ma, dhote v, dhote k, jain dk. formulation development of sustained release matrix tablet containing metformin hydrochloride and study of various factors affecting dissolution rate. sch acad j pharm. 2019; 8(3):57-73. 15. c. kodiweera, y. yang, a. l. bunge, j pharm. sci. 2017; 17:11311142. https://doi.org/10.1016/j.xphs.2017.12.011 16. khatri s, jain dk. autism spectrum disorder (asd): past, present and future. cibtech journal of pharmaceutical sciences. 2018; 7(4):1-25. 17. cevc g, vierl u, j control release 2010; 141:277-299. https://doi.org/10.1016/j.jconrel.2009.10.016 18. armengot-carbo m, hernandez-martin a, torrelo a, actas dermosifiliogr. 2015; 106:86-95. https://doi.org/10.1016/j.ad.2013.10.019 19. jain p, nair s, jain n, jain dk, jain s. formulation and evaluation of solid dispersion of lomefloxacin hydrochloride. int j res pharm sci 2012; 3(4):604-608. 20. erdo f, hashimoto n, karvaly g, et al., j. control release 2016; 233:147-161. https://doi.org/10.1016/j.jconrel.2016.05.035 21. dhadwal a, sharma dr, pandit v, ashawat ms, kumar p, cubosomes: a novel carrier for transdermal drug delivery, journal of drug delivery and therapeutics 2010; 10(1):123-130 https://doi.org/10.22270/jddt.v10i1.3814 22. available at: http://painrelief.co.in/tr-ansdermal-patches/typesof-tdp/. accessed on: 28 aug, 2016. 23. yadav v. transdermal drug delivery system: review. int. j pharm sci. res. 2012;3(2):376-382. 24. dhiman s, thakur gs, rehni ak. transdermal patches: a recent approach to new drug delivery system. int. j pharmacy pharm sci. 2011; 3(5):26-34. 25. sharma rk, keleb e, mosa eb, aljahwi aaz. transdermal drug delivery systemdesign and evaluation. int. j advances pharm sci. 2010; 1:201-211. 26. sandhu p, bilandi a, kataria s, middha a. transdermal drug delivery system (patches), applications in present scenario. int. j res. pharm chem. 2011; 1(4):1139-1151. 27. patel d, chaudhary sa, parmar b, bhura n. transdermal drug delivery system: a review. the pharm innovation. 2012; 1(4):6675. https://doi.org/10.31638/ijprs.v1.i1.00018 28. jalwal p, jangra a, dhaiya l, sangwan y, saroha r. a review on transdermal patches. pharm res. j. 2010; 3:139-149. 29. verma prp and iyer ss. transdermal delivery of propranolol using mixed grades of eudragit: design and in vitro and in vivo evaluation. drug dev ind pharm. 2000; 26:471-6. https://doi.org/10.1081/ddc-100101257 30. gautam sp, rai jp, billshaiya u, jain n, vikram p, jain dk. formulation and evaluation of mouth dissolving tablet of loperamide. international journal of pharmaceutical sciences and research. 2013; 4(5):1782. 31. chung sj. future drug delivery research in south korea. j controlled. release. 1999; 62:73-9. https://doi.org/10.1016/s0168-3659(99)00025-5 32. gordon ra and peterson ta. four myths about transdermal drug delivery. drug delivery technology. 2003; 3:1-7. 33. williams ac and barry bw. penetration enhancers, advanced drug delivery reviews. 2004; 56:603-18. https://doi.org/10.1016/j.addr.2003.10.025 34. karande p, jain a, ergun k, kispersky v and mitragotri s. design principles of chemical penetration enhancers for transdermal drug delivery, proceedings of the national academy of sciences of the united states of america. 2005; 102:4688-93. https://doi.org/10.1073/pnas.0501176102 35. walters ka. transdermal drug delivery systems in:swarbick k., boylan j.c, eds. encyclopedia of pharmaceutical technology. new york, marcel dekker inc. 1997; 253-293. 36. kumar a, transferosome: a recent approach for transdermal drug delivery, journal of drug delivery and therapeutics 2018; 8(5s):100-104 https://doi.org/10.22270/jddt.v8i5-s.1981 37. foco a, hadziabdic j and becic f. transdermal drug delivery systems. med arch. 2004; 58: 230-4. 38. rao pr and diwan py. permeability studies of cellulose acetate free films for transdermal use: influence of plasticizers. pharm acta helv. 1997; 72:47-51. https://doi.org/10.1016/s00316865(96)00060-x 39. barry bw., the lpp theory of skin penetration enhancement. maturitas. 1998; 29: 165-85. 40. ghafourian t, zandasrar p, hamishekar h, nokhodchi a, the effect of penetration enhancers on drug delivery through skin: a qsar study. j control release.2004; 99: 113-25. https://doi.org/10.1016/j.jconrel.2004.06.010 41. montia d, saettone mf, giannaccini b, angeli dg, enhancement of transdermal penetration of dapiprazole through hairless mouse skin. j control release.1995; 33: 71-7. https://doi.org/10.1016/0168-3659(94)00079-a https://doi.org/10.1166/jbn.2017.2474 https://doi.org/10.1016/0168-3659(87)90066-6 https://doi.org/10.3109/10717544.2014.935532 https://doi.org/10.22270/ajdhs.v2i1.11 https://doi.org/10.1016/s0142-9612(98)00020-9 https://doi.org/10.1016/s0142-9612(98)00020-9 https://doi.org/10.22270/jddt.v8i6-s.2076 https://doi.org/10.22159/ajpcr.2016.v9i6.13775 https://doi.org/10.1159/000091978 https://doi.org/10.2174/1389201019666171219105920 https://doi.org/10.1002/adhm.201500450 https://doi.org/10.1016/j.xphs.2017.12.011 https://doi.org/10.1016/j.jconrel.2009.10.016 https://doi.org/10.1016/j.ad.2013.10.019 https://doi.org/10.1016/j.jconrel.2016.05.035 https://doi.org/10.22270/jddt.v10i1.3814 https://doi.org/10.31638/ijprs.v1.i1.00018 https://doi.org/10.1081/ddc-100101257 https://doi.org/10.1016/s0168-3659(99)00025-5 https://doi.org/10.1016/j.addr.2003.10.025 https://doi.org/10.1073/pnas.0501176102 https://doi.org/10.22270/jddt.v8i5-s.1981 https://doi.org/10.1016/s0031-6865(96)00060-x https://doi.org/10.1016/s0031-6865(96)00060-x https://doi.org/10.1016/j.jconrel.2004.06.010 https://doi.org/10.1016/0168-3659(94)00079-a sahu et al asian journal of dental and health sciences. 2022; 2(4):40-47 [47] ajdhs.com 42. bharadwaj s, gupta gd, sharma vk. topical gel: a novel approach for drug delivery. j chem. bio. phy. sci. 2012; 2(2): 856-867. 43. sharma n, parashar b, sharma s, mahajan u. blooming pharma industry with transdermal drug delivery system. indo global j pharm. sci. 2012; 2(3): 262-278. https://doi.org/10.35652/igjps.2012.33 44. darwhekar g, jain dk, paditar vk. formulation and evaluation of transdermal drug delivery system of clopidogrel bisulfate. asi. j. pharmacy life sci. 2011; 1(3): 269-278. 45. berner b, john va. pharmacokinetic characterization of transdermal delivery system. j. clin. pharmaco. 1994; 26(2): 121134. https://doi.org/10.2165/00003088-199426020-00005 46. arunachalam a, karthikeyan m, kumar vd, prathap m, sethuraman s, ashutoshkumar s, manidipa s. transdermal drug delivery system: a review. current pharma res. 2010; 1(1):70-81. https://doi.org/10.33786/jcpr.2010.v01i01.015 47. kumar sr, jain a, nayak s. development and evaluation of transdermal patches of colchicine. der pharmacia lettre. 2012; 4(1): 330-343. 48. patel, d., sunita, a., parmar b., bhura n., transdermal drug delivery system: a review. the pharma innovation. 2012; 1(4): 66-75. https://doi.org/10.31638/ijprs.v1.i1.00018 49. nair ss, chitosan-based transdermal drug delivery systems to overcome skin barrier functions, journal of drug delivery and therapeutics 2019; 9(1):266-270 https://doi.org/10.22270/jddt.v9i1.2180 50. das, u. s., pande k.h., an overview of diabetes mellitus, world journal of pharmacy and pharmaceutical sciences. 2013; 2(1): 161-178. 51. dhiman sonia (2011) transdermal patches: a recent approch to new drug delivery system. international journal of pharmacy and pharm 3(5). https://doi.org/10.35652/igjps.2012.33 https://doi.org/10.2165/00003088-199426020-00005 https://doi.org/10.33786/jcpr.2010.v01i01.015 https://doi.org/10.31638/ijprs.v1.i1.00018 https://doi.org/10.22270/jddt.v9i1.2180 putri rindharso et al asian journal of dental and health sciences. 2024; 4(2):14-16 [14] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited portable dental chair innovation in improving operator comfort rahmaisynta putri rindharso *, bedjo santoso, lanny sunarjo, endah aryati eko ningtyas master of applied dental therapist poltekkes kemenkes semarang, indonesia article info: _____________________________________________ article history: received 19 march 2024 reviewed 28 april 2024 accepted 21 may 2024 published 15 june 2024 _____________________________________________ cite this article as: putri rindharso r, santoso b, sunarjo l, aryati eko ningtyas e, portable dental chair innovation in improving operator comfort, asian journal of dental and health sciences. 2024; 4(2):14-16 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.77 _____________________________________________ *address for correspondence: rahmaisynta putri rindharso, master of applied dental therapist poltekkes kemenkes semarang, indonesia abstract _________________________________________________________________________________________________________________ objective: to produce a suitable portable dental chair innovation and its effective application in improving operator comfort. materials and methods: this study was an r&d type with a pre-experimental design. sampling was done using purposive sampling with a total of 30 dental therapists across all primary health centers in the banjarbaru city. the independent variable was the portable dental chair innovation, and the dependent variable was operator comfort. results: the use of portable dental chair innovation provides convenience in dental health services regarding operator comfort, which is sometimes suboptimal, as well as limitations in features for complex dental care. technical and logistical issues such as equipment damage and lack of resource availability can also be challenging. therefore, innovation in the production of portable dental chairs is crucial. technological advancements can improve ergonomics, efficiency, and equipment quality, addressing the increasing market demand for mobile and flexible dental care. thus, this innovation not only provides solutions to existing problems but also expands access to quality dental care for more people, resulting in a positive impact on overall dental health sector. conclusion: portable dental chair innovation is suitable and effectively applied to improve operator comfort. keywords: dental therapists, portable dental chair, operator comfort introduction oral health services are efforts aimed at improving oral health, preventing and treating diseases, and restoring oral health for individuals, families, groups, or communities comprehensively, integrative, and qualitatively. optimal oral health services require adequate equipment, one of which is a portable dental chair. a portable dental chair is a type of dental unit that can be moved, easily stored, folded, and carried according to needs, suitable for providing dental health services in remote areas or areas that are difficult to reach by health facilities. dental health services using portable dental chairs are mainly chosen because of the mobility and flexibility they offer, allowing dental health service providers to easily carry and use this equipment in various locations, such as primary care in remote areas. another advantage is the more affordable cost of obtaining and maintaining portable dental chairs compared to larger and more advanced fixed dental chairs. portable dental chairs may not provide all the comfort features offered by fixed dental chairs but still serve as an efficient solution in situations where mobility, flexibility, and the ability to provide dental care in different locations are priorities. the use of portable dental chairs provides convenience in dental health services, one of which is the sometimes suboptimal comfort for operators, as well as limitations in features for complex dental care. technical and logistical issues such as equipment damage and resource availability can also be challenging. therefore, innovation in the production of portable dental chairs is crucial. technological advancements can improve ergonomics, efficiency, and equipment quality, addressing the increasing market demand for mobile and flexible dental care. thus, this innovation not only provides solutions to existing problems but also expands access to quality dental care for more people, resulting in a positive impact on the overall dental health sector. materials and methods in this study, the participants were 30 dental therapists from all primary health centers in banjarbaru city. data collection duration was one month. questionnaires were printed and distributed directly to dental therapists and summarized using tables with ratings using a likert scale. the questionnaire was created by researchers considering the purpose of this study. the main focus of this research is the innovation of making portable dental chairs that can improve comfort for operators. the questionnaire includes operator comfort, ergonomic support, ease of equipment accessibility, and the strength of materials of the portable dental chair innovation. data collected from respondents through completed questionnaires were kept confidential and anonymous. product results researchers innovated the production of portable dental chairs that are easily transportable, equipped with adjustable headrests, footrests, and body rests, as well as tables and lamps, while still focusing on operator comfort to support the effective and efficient provision of dental health services. 1. equipment specifications a. overall chair height = 93 cm b. chair height from the bottom = 47 cm open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.77 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.77&amp;domain=pdf putri rindharso et al asian journal of dental and health sciences. 2024; 4(2):14-16 [15] ajdhs.com c. chair width = 39 cm d. length of chair to footrest = 85 cm e. backrest height = 43 cm f. headrest designed to be soft and adjustable g. table length = 48 cm h. table width = 30 cm 2. attributes of portable dental chairs are as follows: a. frame made of round iron pipe material b. portable/foldable c. cushioned with foam on the head, back, seat, and footrest d. foam covered with synthetic leather fabric e. additional small table on the left side f. lightweight yet sturdy and easy to carry results: this study is an innovation study of making portable dental chairs with equipment testing using expert validation questionnaires. expert validation was conducted to obtain data used as the basis for testing the feasibility of using portable dental chair innovations. expert validation was carried out by experts consisting of 4 individuals, namely dentists, dental nurses, psychologists, and electromedical experts. expert validation was conducted to obtain data used as the basis for testing the feasibility of using portable dental chair models. the feasibility test results by experts can be seen in the following table: table of results of expert validation test on the use of portable dental chair model number respondent *score criteria 1 expert 1 95% very suitable 2 expert 2 77,5% 3 4 expert 3 expert 4 80% 87,5% mean 85% the table above shows that the assessment results through the likert scale show an average score of 85% with the criteria very suitable, indicating that the portable dental chair model can be tested as a product. table of interclass correlation coefficient test results by experts on the use of portable dental chair model variable average category p-value portable dental chair 0.904 high 0.001. variable mean category p-value dental chair portable 0,904 high 0,001 *interclass correlation coefficient test the table above shows that the test results of the equipment feasibility by expert validators averaged 0.904, indicating a high category with a p-value of 0.001, indicating that the portable dental chair is highly suitable in supporting dental health service activities. the study was conducted on 30 dental therapists working in all primary health centers in banjarbaru city. research results: table of equipment use test on operator comfort aspect variable statistics conventional school chair portable dental chair p-value operator comfort. *mann whitney test the table above shows that the operator comfort aspect towards the use of conventional school chairs in dental health services was 5.90, whereas in the use of portable dental chairs, it was 13.7 with a delta δ value of 7.87. the statistical test results show that the p-value is 0.000 (< 0.05), meaning that the use of portable dental chairs has a more effective compared to conventional school chairs. discussion: discomfort in healthcare services, including discomfort experienced by healthcare professionals during examinations or treatments without comfortable chairs, is indeed an important issue. the physical health and comfort of healthcare professionals not only affect the quality of care provided to patients but also impact their mental and physical well-being. comfortable chairs not only allow healthcare professionals to work more efficiently and with better concentration but also can help prevent injuries or fatigue caused by non-ergonomic positions over long periods. furthermore, the physical comfort of healthcare professionals can also affect their job satisfaction, which in turn can influence staff retention and the quality of service provided. based on the information gathered and field interviews conducted, it was found that one of the obstacles in dental healthcare services is the lack of dental chairs that provide comfort for operators. to date, there have been no innovations from health centers or schools in creating healthcare tools that support operator comfort. the desired solution is a portable dental chair equipped with a headrest, table, light, and adjustable footrest to make operators feel comfortable. innovative tools in the form of portable dental chairs are highly necessary to support healthcare activities, given the importance of comfort in preventing back injuries in operators performing counselling, examinations, and procedures. therefore, the researchers developed a tool innovation to improve operator comfort in the form of a portable dental chair data collection through expert validation conducted by several experts in the fields of health and technology revealed that the average tool feasibility test result from expert validators was 0.904, indicating a high category with a p-value of 0.001, variable statistic conventional school chair dental chair portable p-value operator comfort a. mean+sd 5,90+1,561 13,77+1,736 0,000 b. delta δ 7,87 putri rindharso et al asian journal of dental and health sciences. 2024; 4(2):14-16 [16] ajdhs.com showing that the portable dental chair is highly feasible in supporting dental healthcare activities. validation by experts was carried out to determine the level of suitability of a tool effectively. tool assessment can be reviewed and evaluated by experts in their respective fields according to predetermined indicators. the statistical test results show that the p-value is 0.000 (<0.05), meaning that the use of the portable dental chair provides a more effective level of operator comfort compared to conventional school chairs in dental healthcare services. in dental healthcare services, operator comfort is crucial to maintaining optimal service quality. portable dental chairs that support operator comfort play a crucial role in ensuring that service procedures can be performed with high efficiency and accuracy. operators often have to work in awkward positions and require high focus for extended periods. therefore, in this study, portable dental chairs have provided ergonomic support, such as soft cushions and proper supports for the back, arms, and head, to help reduce fatigue and tension that may occur during service procedures. according to a study by al wazni et al. (2015) 8, ergonomic chair designs can minimize the risk of injury and improve operator comfort the lightweight and easily movable mobility of portable dental chairs can assist operators in providing dental care in various locations or different environments. this can reduce physical and mental fatigue on operators. according to a study conducted by monametsi et al. (2019) 9, high mobility in portable dental chairs can improve the efficiency and comfort of operator work in dental healthcare services in remote areas. conclusion: based on the research findings, it can be concluded that the innovation of portable dental chairs is feasible and its application effectively improves operator comfort. this is evidenced by the average result of expert validation tests of 0.904, indicating tool feasibility in the high category with a pvalue of 0.001. the innovation of portable dental chairs is more effective in improving operator comfort compared to conventional school chairs, as evidenced by a p-value of 0.000 (<0.05). references 1. jkg, aceh. evaluasi pelayanan program usaha kesehatan gigi sekolah ( ukgs ) di wilayah kerja puskesmas baiturrahman kota banda aceh. 2019;3:151-168. 2. suwarmiyati s, abi ma. rancang bangun alat monitoring pada dental unit berbasis esp32 cam. j teknol elekterika. 2020;4(1):35. https://doi.org/10.31963/elekterika.v4i1.2806 3. permenkes ri. peraturan menteri kesehatan republik indonesia nomor 89 tahun 2015 tentang upaya kesehatan gigi dan mulut. j teknosains. 2015;44(8):53. 4. makansi n, rousseau j, bedos c, et al. domiciliary dentistry clinics: a multiple case study in the province of quebec, canada. bmc health serv res. 2021;21(1):1-12. https://doi.org/10.1186/s12913-021-06788-4 pmid:34526032 pmcid:pmc8442809 5. gupta s, hakim m, patel d, et al. reaching vulnerable populations through portable and mobile dentistry — current and future opportunities. dent j. 2019;7(3). https://doi.org/10.3390/dj7030075 pmid:31374831 pmcid:pmc6784459 6. pratamawawi. dasar-dasar keselamatan pasien pada praktik dokter gigi. universitas brawijaya malang; 2019. 7. aprilisa n g. model april’s mophie (motion graphic video) terhadap upaya peningkatan keterampilan menggosok gigi pada anak tunagrahita kategori sedang. published online 2023:1-17. 8. al wazni, y., hamdan, m., & mansour m. ergonomic evaluation of portable dental chair units. int j mech eng appl. published online 2015:111-118. 9. monametsi, n. p., sibanda, m., & nemathaga lh. ergonomic challenges of using portable dental chairs in limpopo province, south africa. south african dent j. published online 2019:246-251. https://doi.org/10.31963/elekterika.v4i1.2806 https://doi.org/10.1186/s12913-021-06788-4 https://doi.org/10.3390/dj7030075 jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [7] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a brief review on nutraceuticals and its application sameeksha jain, arpana purohit, prakhar nema, harshna vishwakarma, prateek kumar jain adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _________________________________________ article history: received 07 jan 2022 reviewed 23 feb 2022 accepted 04 march 2022 published 15 march 2022 _________________________________________ cite this article as: jain s, purohit a, nema p, vishwakarma h, jain pk, a brief review on nutraceuticals and its application, asian journal of dental and health sciences. 2022; 2(1):7-13 doi: http://dx.doi.org/10.22270/ajdhs.v2i1.10 _________________________________________ *address for correspondence: sameeksha jain, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ because of their putative safety, nutraceuticals have sparked tremendous interest. nutraceuticals are nutritional supplements that are used to improve health, postpone aging, prevent disease and support the healthy functioning of the human body. nutraceuticals are currently gaining popularity due to their nutritional and medicinal properties. they are classified as dietary supplements or herbal bioactive substances based on their source. herbal nutraceuticals aid in the maintenance of health and the promotion of optimal health, longevity, and quality of life. nutraceuticals have demonstrated encouraging results in the treatment of a variety of ailments, including cancer, neurological diseases, cardiovascular disease, and others. the current review provides an overview of several bioactive substances that operate as nutraceuticals (carbohydrates, lipids, edible flowers, alkaloids, medicinal plants, etc.) and their involvement in health benefits. focus on the need for appropriate diets, health issues associated with failure to adhere to known healthy eating models, development of new nutraceuticals/functional foods/food supplements with novel health benefits, elucidation of mechanisms of action of these products, and to define and understand the analytical, formulation, and regulatory aspects of nutraceuticals. the use of nutraceuticals in the prevention of certain diseases has also been addressed. keywords: nutraceutical, dietary supplements, herbal bioactive compounds, application email; sameejain888@gmail.com introduction stephen l. defelice, founder and chairman of the foundation of innovation medicine, invented the term in 1989 as a combination of the words nutrition and pharmaceutical. nutraceuticals are products produced from food resources that are claimed to provide additional health advantages in addition to the fundamental nutritional content present in foods. depending on the jurisdiction, items may promise to prevent chronic diseases, promote health, slow the aging process, extend life expectancy, or support the structure or function of the body1. nutraceuticals are biologically active compounds found in food that have properties similar to both nutrition and medications. nutraceuticals are natural bioactive or chemical compounds that, in addition to serving as a nutritional supplement, have health-promoting, diseasecuring, or preventative qualities. nutraceuticals are supplements that contain lipids, vitamins, carbohydrates, proteins, minerals, or other essential ingredients. nutraceuticals have been found to be potential agents in the treatment of a variety of maladies, including cardiovascular disease2, 3, diabetes 4, 5, atherosclerosis6, 7, cancer8,9 and neurological disorders10,11. the causes for the trend toward nutraceuticals are as follows12-16. 1. a growing proportion of customers are concerned about rising healthcare prices. 2. people who are dissatisfied with pharmaceutical agents for health promotion are turning to nutraceuticals to improve their health and prevent chronic disease. 3. health care providers realize that our excessively processed food supply, which is derived from crops farmed with chemical fertilizers, pesticides, herbicides, and frequently genetically engineered seeds, lacks the nutrients required for optimal health. 4. people who believe in prevention rather than cure. 5. people suffering from chronic ailments who have found no relief from allopathic medication. 6. patients with limited financial resources. bioactive compounds as nutraceuticals bioactive chemicals are found in trace amounts in foods, particularly fruits, vegetables, whole grains, and so on. they have a wide range of therapeutic possibilities and provide numerous health advantages in addition to basic nutritional value. bioactive chemicals are classified into two types based on their origins: herbal sources and dietary supplements (table. 1). table 1 bioactive ingredients herbal bioactive ingredients dietary supplements 1. anthraquinones 1. charbohydrates 2. alkaloids 2. proteins 3. tannins 3. lipids 4. carotenoids 4. vitamins 5. flavonoids 5. probiotics 6. bitters 6. prebiotics 7. essential oil 7. mushroom open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i1.10 jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [8] ajdhs.com herbal bioactive ingredients therapeutic plants herbs have received a lot of attention over the years because of their diverse array of scents and flavors, which make them useful not only as medicines but also in cooking. herbal bioactive substances found in herbs, such as carotenoids, coumarins, flavonoids, lignans, phthalates, plant sterols, polyphenols, saponins, sulphides, and terpenoids, are a significant category of nutraceuticals17,18. alkaloids alkaloids are a unique family of substances that play crucial functions in the biological processes of animals, plants, and microorganisms. it is a heterocyclic chemical molecule with nitrogen that is used in pharmacology, medicine, and ecology19. since alkaloids have potent physiological effects when they interact with much cellular and molecular level of organisms, they have been widely used as curative medications in the pharmaceutical industry20. alkaloids can occasionally be exceedingly harmful in small concentrations and are soluble in organic solvents21. in the pharmaceutical business, alkaloids from plants are widely used as antimalarial (quinine and chloroquinine), anti-cancer (vinblastine, vincristine, and taxol), and blood circulation (in the brain) boosting drugs (vincamine) 22, 23. the most of us love a cup of black tea or coffee, which include the pharmacologically active alkaloids theophylline and caffeine, respectively, and are essential components of the human diet24. long pepper (piper longum l.) and pepper (piper nigrum l.), which both contain the alkaloid piperine, are additional often used spices in indian cuisine as well as many other cuisines25. capsicum peppers like chili and red pepper (capsicum annuum l.), bird pepper or tabasco (capsicum frutescens l.), peruvian pepper (capsicum bac catum l.), aji pepper (capsicum chinese jacq.), and rocoto pepper (capsicum chinense jacq.) are some other plants that contain significant amounts of alkaloid (capsicum pubescens ruizet pav.). according to research, piperine has significant physiological activity and is not harmful26. saponins steroid saponins can be obtained from a wide range of plants, microorganisms, and animals27. aubergines (solanum aethiopicum l.), capsicum peppers (capsicum annuum), ginseng (panax ginseng), and yucca (yucca schidigera) are a few typical medicinal plants that contain saponins28. saponins are essential for a variety of pharmacological processes, such as hypoglycemic activity, lowering of ldl cholesterol and serum cholesterol, inhibition of cancer cell growth, stimulation of the cell-mediated immune system, antioxidant activity, antifungal activity, neurotrophic and neuroprotective activity, and viricidal effects29. tannins these are a collection of substances that include phenolic and polyphenolic chemicals. they function as astringents in our body by causing tissues to contract and structural proteins in the mucosa and skin to shrink. the prevention of lipid peroxidation, the production of super-oxides, and the completion of free radical scavenging activity are additional roles for tannins30-32. tannins are used to treat ulcerative colitis because they have a number of beneficial health features, including anti-inflammatory, antibacterial, antileishmanial, immunomodulatory, analgesic, antilymphocytic, neuroprotective, antidiarrheal, and antihy pertensive actions33,34. legumes with tannin have been utilized as nutritional feed for livestock to protect it against parasites such gastrointestinal worms35. bitters they are a combination of bitter-tasting chemicals that are present in many herbs. yarrow (achilles mille folium), chamomile (matricaria chamomilla), horehound (marrubium vulgare), peppermint (mentha piperita), rue (ruta), milk thistle (silybum marianum), and dandelion are among common herbs that contain significant quantities of bitter (taraxacum). bitter compounds primarily affect the digestive system, which in turn causes the stomach to release digestive enzymes. additionally, it facilitates the flow of bile from the liver, increasing appetite and facilitating better nutritional absorption from food36. patients with symptoms like gallbladder issues, liver issues, poor appetite, gastritis, sluggish bowel, and symptoms after the flu are typically advised to take bitters [37]. other pharmacological advantages of bitters include their ability to treat cancer, to calm the nervous system, and to have antibacterial, antioxidant, antiinflammatory, and anti-diabetic properties38. despite their disagreeable taste, the beneficial effects of bitters begin in the mouth itself, therefore oral use is required for the optimum results. some of the bitters described in indian ayurveda are guduchi (tinospora cordifolia), manjista (rubia cordifolia), and neem (azadirachta indica), as well as turmeric (curcuma longa) and rubia cordifolia. because of their predilection for the liver and spleen, they are widely utilized to treat ailments39. carotenoids carotenoids can be made by bacteria, fungus, algae, and plants. carotenoids are responsible for the orange, yellow, and red colors that can be seen in fruits, vegetables, and seafood40. animals must obtain carotenoids through dietary intake and metabolize them in order to use them for physiological processes because they are unable to produce them on their own41. carotenes have crucial roles in biology as antioxidants, membrane fluidic regulators, and auxiliary light-harvesting components of photosynthetic systems42. apricots (prunus armeniaca) and broccoli are good sources of ß-carotene and lutein, while carrots and tomatoes are excellent sources of ßcarotene and lycopene, pumpkin (cucurbita spp.) is a good source of ß-carotene, ß-cryptoxanthin, lutein, and zeaxanthin, and green leafy vegetables offer both lutein and ßfew carotenoids (about 50 out of the 600 discovered) have provitamin a activity, and the three most significant ones are carotene, ß-carotene, and ß cryptoxanthin43,44. thus, eating these carotenoids can help us from developing significant eye conditions. carotenoids serve as antioxidants and improve oxidative stress resistance in all species45. they also have anticancer properties46. flavonoids in nature, flavonoids can be found as glycosides and antioxidants. vegetables such as broccoli, green pepper, kale, onion, spinach, and tomato; fruits such as orange, grapefruit, apple, and grape; herbs such as citrus grandis, hypericum perforatum, and sophora japonica; and soybeans are major sources of flavonoids47. flavonoids have a protective impact against coronary heart disease in addition to having antiviral, antiallergic, anticholinesterase, anticancer, and antioxidant properties48. a variety of products containing flavonoids are either being researched and developed or are already being sold as functional foods and/or dietary supplements. the adme property of flavonoids in animals has received less attention in published research, which makes it harder to anticipate the biological effects of flavonoids. this restricts the use of them as possible food sources49. jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [9] ajdhs.com essential oils the following plant components can be used to make essential oils: buds, bark, fruits, flowers, herbs, leaves, roots, seeds, twigs, and wood50. they may be extracted using techniques like solvent or steam extraction since they are a naturally occurring combination of aromatic chemicals. a subcritical water extraction technique has also been used to extract essential oils from thymbraspicata leaf material51. these volatile oils typically contain a distinctive aroma and are a blend of terpenes, aldehydes, esters, ketones, phenolic chemicals, and aldehydes. significant levels of terpenoids are found in essential oils, which have antiseptic and antibacterial properties52 and stimulate the body's natural defense mechanisms against a number of infectious disorders. it has beneficial effects on and is anti-cancer, anti-inflammatory, and antispasmodic (yarrow and chamomile) on the heart and circulatory system (rosemary, ginger, and thyme) 53. anthraquinones a variety of molecules with different biological characteristics are included in anthraquinones54. as a result of their stimulation of muscle contraction, they frequently have a laxative effect. aloe vera (aloe barbadensis miller), cascara (rhamnus purshianus), dock (rumex crispus), rhubarb (rheum palmatum), and senna are among the numerous plant species that contain high concentrations of anthraquinones (senna alexandrina). researchers have found that the hydroxyanthra quinone found in aloe vera, aloe-emodin, has the ability to limit the proliferation of a variety of tumor cell lines, including lung cancer cells55, hepatoma cells, and leukemia cells56. similar to this, rheum rhabarbarum's emodin and rhein also have anticancer effects57. a particular in-vivo and in-vitro anti-neuroectodermal tumor property of the anticancer drug aloe-emodin has been reported58. aloe's latex contains significant amounts of anti-inflammatory anthraquinones, which are known for their ability to heal and stop pain. anthraquinone has been found to be produced not just by plants but also by marine life. two anthraquinones (lupinacidin a and galvaquinone b) with anti-tumor capabilities were recently found in sea anemone from easter island, and a new analysis by a group of researchers in germany suggested that it might be used as a nutraceutical59. dietary supplements probiotics probiotics, or helpful microorganisms, which improve human health, are the subject of rising research. when administered in the proper dose, probiotics are a culture of live microorganisms (which can be a single or mixed culture) that have therapeutic benefits for the recipient (fao and who, 2006). russian immunologist elie metchnikoff made observations and hypothesized that the consumption of fermented milk, which contains beneficial lactobacillus bacteria, is the cause of the healthy and long lives of bulgarian peasants. probiotics are a result of these observations. years later, it is evident that bacteria are not just static colonists but rather dynamic, symbiotic co-residents in our bodies60. some modern ailments, such as the increase in inflammatory and allergy disorders, are caused by a decrease in the consumption of helpful microbes as compared to our ancient ancestors61. lactobacillus, bifidobacterium and saccharomyces cerevisiae are the three bacterial species that are most frequently used to make commercial probiotics. consuming probiotics has been shown to enhance immune defense against pathogens, suppress auto-immune responses, shorten the duration of infectious diarrhea, increase gastrointestinal tolerance to antibiotics, improve treatment of women with bacterial vaginosis, lessen symptoms of irritable bowel syndrome, and decrease the incidence of dental caries62. prebiotics prebiotics are food ingredients that, in little amounts, promote the growth of helpful bacteria, whose, when colonized by the host, has a good impact on the health of the host63. prebiotics can be thought of as food for the different bacterial species that inhabit the inside of humans and are essential to their health and wellbeing. probiotic bacteria like lactobacillus and bifidobacterium are among the microbes that use prebiotic fiber as a substrate and consume it. in order to ascertain prebiotic fermentation characteristics in a variety of hosts, including humans, prebiotic compounds often undergo a wide range of in-vivo and in-vitro testing. the examined fermentation parameters are often linked to healthy colon function and metabolism64, 65. numerous food items that contain fermentable fiber are available for human nutrition66. a substance's potential to ferment may be the only consideration for selecting it as a prebiotic67. some studies, however, believe that this shouldn't be used as the only criterion because food matrices are diverse and have a variety of metabolic and nutritional advantages68. when determining if a substance is a prebiotic, it's also important to consider the fermentation products, which may be advantageous or harmful66. the two most popular sources of prebiotics at the moment are resistant starch and fructans. proteins proteins are key constituents of food as they have or ganoleptic properties especially texture, tissue building, a valuable source of nutrition, and possess various other health benefits. in order to enhance the development of healthy, novel and safe foods, the use of the plant-derived nutrients is increasing as it is beneficial from both economic and environmental perspectives69. similarly, there is an increasing demand for plant proteins for applications in food matrices to improve the nutritional and health profiles of these food products. one of the modern-day examples is the use of legume proteins as food ingredients that have been traditionally used for derivation of oils and fats. amongst legumes, lupin (lupinus albus l.) is the richest source of protein, its protein content is equivalent to soybean, almost 35% of its dry weight70. recently, interest in dietary proteins from seed has emerged around the globe for their nutritional role. they possess various therapeutic activities, such as hypoglycaemic, hypolipidemic, anti-cancer and anti-obesity activities71,72. therefore, plant proteins possess a vital role in the improvement of human health. apart from this egg protein, which is considered as an essential source of proteins in a balanced diet, also possesses health benefits, such as anti�cancer, antihypertensive, antimicrobial, antioxidant, im�munomodulatory, and protease inhibitor activities73. protein isolate has been prepared using by-products of waste generated during the milling process of pigeon pea. this protein isolate has been reported as a good source of nutraceuticals and also as an encapsulating material with bioactive properties74. carbohydrates it is the most widely distributed nutritional class, and it plays an important role in the human body. carbohydrate molecules in the dietary matrix range from complicated to tiny. according to dietary standards, carbohydrates should account for at least 5% of total calories ingested in a balanced diet75. carbohydrates help with human physiology and metabolic activity. it aids in the prevention of a number of chronic diseases, including cancer, cardiovascular disease, diabetes, jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [10] ajdhs.com obesity, and gastrointestinal disorders. starchy carbs are an important source of energy and help keep the digestive tract healthy. untapped research potential exists in the application of bioactive carbohydrates in functional meals76. inulin (fructans), fructose, as well as other oligosaccharides, for example, promote the growth rate measures how fast of health-promoting bacteria such as bifidobacteria, which can limit the proliferation of potentially hazardous anaerobic microbes in the gut and act as immunomodulators77. chitosan and chitin have been used as functional dietary additives, with possible anti-obesity activity78. according to study conducted, consuming carbs together with a suitable amount of protein has a good impact on the gut bacteria count, which has numerous benefits in humans79. as a result, the utilization of carbohydrates as a nutraceutical offers great promise for human health. lipids lipids are a broad category of compounds that share the trait of being soluble in organic solvents but insoluble in water. initially, it was assumed that consuming dietary fats causes weight gain and other health concerns. recent technologies, however, combine the beneficial effects of fatty acids with triacylglycerol molecules to increase the nutritional value of lipids. structured fats play an obvious function in lowering the caloric value of the diet to which they are added, as well as providing certain medical benefits. the link between lipid nutrition and stereospecific fatty acid position suggests that acidolysis could be used to improve the nutrition profiles of triacylglycerols. because of such advantages of lipid isolation, more research is required for cost-effective lipid manufacturing. according to one investigation, kelp is an alternate source of nutraceuticals80. take control®, becel proactiv, and flora proactiv by unilever, cooksmart® by procter & gamble, danacol® by danone, and others81 are some of the prominent nutraceuticals on the market that include large levels of phytosterols, phytostanols, and their fatty acid esters. aside from these items, new study indicates that flaxseed is a good source of lipids and could be used as a nutraceutical. it is projected that eating flaxseed reduces the chance of cancer and cardiovascular disease, relaxes artery smooth muscles, and lowers cholesterol levels82. vitamins due to their anti-oxidant properties, vitamins can be used as nutraceuticals and play a significant part in maintaining human health. these nutraceutical items may be helpful to people on special diets and smokers who are prone to vitamin deficiencies. lack of food intake, poor body absorption, and insufficient use are causes of vitamin insufficiency. as their nutrient profiles contain adequate concentrations of the b complex vitamins (b1, b2, and b12), vitamins with antioxidant properties (such as vitamin c and e), provitamins a and e, and carotenoids, seaweeds are a rich source of vitamins83. it has a beneficial effect on lung and cervical malignancies and aids in the decrease of cases of death brought on by cerebrovascular illnesses84. red algae are a rich source of vitamin b12, which is typically insufficiently prevalent in vegan diets (porphyra sp.). people who consume vitamin c-rich diets often have a lower chance of acquiring stomach cancer than patients who consume regular diets85. according to a study, the combination of shilajit and b-complex vitamins is effective in preventing alzheimer's disease86. for the treatment of dry eye symptoms, it is advantageous to employ oral supplementation of nutraceuticals containing vitamins, minerals, omega-3 fatty acids, and antioxidants87. as a result, vitamins have a lot of potential, and adding them to the diet as a nutraceutical is good for people's health. mushrooms humans have recently exploited mushrooms for both culinary and medicinal purposes. its applications have grown to include cosmeceuticals, nutraceuticals, and medicines. around 2000 of the approximately 12000 diverse species of mushrooms are suitable for human consumption88. around 35 different species are commercially produced throughout the world (agaricus bisporus is the most common species41, while 200 different wild species are used for therapeutic purposes89. fruiting bodies contain between 50 and 65 percent carbohydrates and 20 to 30 grams of unsaturated fatty acids per kilogram of dry mass90. in addition to polysaccharides (ßglucans), peptides, minerals, unsaturated fatty acids, dietary fiber, terpenes, glycoproteins, alcohols, and antioxidants, edible mushrooms also contain other active ingredients91. because ergothioneine, selenium, vitamin b1 and vitamin d2 are highly bioavailable when consumed, mushrooms are regarded as great functional foods. mushrooms are pharmaceutically significant for boosting the immune system to treat and prevent life-threatening disorders such cerebral stroke, cancer, heart disease, and hypertension because they contain unique biologically active compounds. the antibacterial, anti-diabetic, anti-tumor, anti-fungal, antiinflammatory, antithrombotic, antiviral, and hypolipidemic effects of mushrooms are among their other qualities92,93. application of nutraceuticals for more than 20 years, researchers have been attempting to link phytochemicals with potential health advantages. research shows that consuming fruits and vegetables lowers the incidence of esophageal, stomach, lung, endometrial, oral cavity, pancreatic, pharyngeal, and colon disorders94. the main phytochemicals that play a role in disease prevention are allium compounds; beta carotene, dietary fibers, flavonoids, folic acid, d-limonene, dithiolthiones, indole-3-carbinol, inositol hexaphosphate, iso flavones, isothiocyanates, lutein, lycopene, phytosterols, selenium, saponin heart and blood vessel problems are referred to as cardiovascular diseases (cvd). low intake of fruits and vegetables is associated with increased risk of cvd95. numerous studies have documented the beneficial effects of a diet high in fruits and vegetables on the prevention of cvd. for the prevention and treatment of cvd, nutraceuticals in the form of minerals, vitamins, dietary fibers, antioxidants, and omega-3 polyunsaturated fatty acids are recommended together with physical activity. the likelihood of vascular disease is decreased by polyphenols because they alter cellular communication and metabolism 96. additionally, flavonoids are crucial for preventing cvd. they prevent platelet aggregation by inhibiting angiotensinconverting enzyme and cyclooxygenase enzymes97. one of the main public health issues nowadays is cancer. carotenoids have antioxidant properties and are helpful in preventing cancer. lycopene and other carotenoids like it provide a protective role against cancer98. by reducing oxidative stress and dna damage, lycopene-rich fruits and vegetables have an anti-cancer impact99. tomatoes, pink grapefruit, guava, water melon, and papaya all contain lycopene. apples contain pectin, a soluble fiber that has been shown to be protective against prostate cancer by preventing cancer cells from sticking to healthy cells in the body. natural phenolic substances with anticancer properties include gallic acids, curcumin, ferulic acid, and caffeic acid97. an extract of curcuma longa called curcumin has been found to have anti-inflammatory, antioxidative, and anti-carcinogenic properties. obesity is a global health issue that is linked to a number of serious illnesses, jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [11] ajdhs.com including cancer, congestive heart failure, hypertension, angina pectoris, hyperlipidemia, osteoarthritis, respiratory issues, and renal vein thrombosis. the eating of high-fat foods is one of the key contributors to obesity. the potential of nutraceuticals to help manage obesity is now being studied. nutraceuticals with putative anti-obesity benefits include capsaicin conjugated linoleic acid, momordica charantia, citrus aurantium, and psyllium fiber97, 100. herbal stimulants that help with weight loss include ephedrine, caffeine, chitosan, and green tea. conclusion nutraceuticals are a different source of all-natural treatments that not only treat but also prevent a wide range of fatal illnesses. they are in demand because they are more affordable and accessible than prescription medications. longterm study is necessary to understand the function that nutraceuticals play in health and how diseases are treated. it is also necessary to conduct more study on how nutraceuticals affect disease activity and pathogenesis. it is necessary to conduct research on how bioactive compounds interact with other food components and how this interacts with their ability to act as drugs. in addition, depending on the type and quantity of bioactive compounds added to the food products, sensory qualities such as look, body, flavor, color, and texture may also be impacted. this will have an impact on how well the product functions as a whole. the microbial instability of these functional elements when they are incorporated into the food matrix is another obstacle that needs to be overcome. to boost the acceptability of these products in the global marker, clinical studies must be conducted more quickly, precisely, and uniformly. references 1. singh j, sinha s. classification, regulatory acts and applications of nutraceuticals for health: a review. int j pharm biol sci., 2012; 2(1):177-187. 2. ashwlayan v, nimesh s. nutraceuticals in the management of diabetes mellitus. pharm pharmacol int j., 2018; 6:114-120. https://doi.org/10.15406/ppij.2018.06.00166 3. aquila g, marracino l, martino v, calabria d, campo g, caliceti c, rizzo p. the use of nutraceuticals to counteract atherosclerosis: the role of the notch pathway. oxid med cell longev., 2019; 5470470. https://doi.org/10.1155/2019/5470470 4. mcclements dj. nutraceuticals: superfoods or superfads. in future foods. copernicus chem., 2019; 167-201. https://doi.org/10.1007/978-3-030-12995-8_6 5. sarris j, byrne gj, stough c, bousman c, mischoulon d, murphy j, et al., nutraceuticals for major depressive disorder-more is not merrier: an 8-week double-blind, randomised, controlled trial. j affect disord., 2019; 245:1007-1015. https://doi.org/10.1016/j.jad.2018.11.092 6. hussain sa, panjagari nr, singh rr, patil gr. potential herbs and herbal nutraceuticals: food applications and their interactions with food components. crit rev food sci nutr., 2015; 55(1):94122. https://doi.org/10.1080/10408398.2011.649148 7. dureja h, kaushik d, kumar v. developments in nutraceuticals. indian j pharmacol., 2003; 35(6):363-372. 8. https://www.globenewswire.com/newsrelease/2019/01/29/17 06747/0/en/global-nutraceuticals-market 9. http://publication.assocham.tv/data/product-file/88. 10. sharma a, kumar p, sharma p, shrivastav ba. comparative study of regulatory registration procedure of nutraceuticals in india, canada and australia. int j pharm qual assur., 2013; 4(4):6166. 11. smarta rb. paradigm shift from pharmaceuticals to nutraceuticals, nuffoods spectrum. 2017. 12. maxwell j, smith d, brewster m, eggleton s. food as pharma as wellness products evolve, the distinction between food and medicine blurs. r&c worlds express. 2012. 13. biotech for wellness: driving successful r & d and licensing in nutraceuticals through new business models and collaboration, research and markets, 2010. 14. kumar p, kumar n, tushar o. nutraceuticalscritical supplement for building a healthy india, world j pharm pharma sci., 2016; 5(3):579-594. 15. olaiya co, soetan ko, esan a. the role of nutraceuticals, functional foods and value added food products in the prevention and treatment of chronic diseases m. 1, african j food sci., 2016; 10(10):185-193. https://doi.org/10.5897/ajfs2015.1402 16. sosnowska b, penson p, banach m. the role of nutraceuticals in the prevention of cardiovascular disease. cardiovasc diagn ther., 2017; 7(1):s21-s31. https://doi.org/10.21037/cdt.2017.03.20 17. roy a, jauhari n, bharadvaja n. medicinal plants as a potential source of chemopreventive agents. anticancer plants: natural products and biotechnological implements; springer, 2018;109139 https://doi.org/10.1007/978-981-10-8064-7_6 18. kapoor vk, dureja j, chadha r. herbals in the control of ageing. drug discov today. 2009; 14(19-20):992-998. https://doi.org/10.1016/j.drudis.2009.06.014 19. debnath b, singh ws, das m, goswami s, singh mk, maiti d, manna k. role of plant alkaloids on human health: a review of biological activities. mater.today chem., 2018; 9:56-72. https://doi.org/10.1016/j.mtchem.2018.05.001 20. sottorff i, künzel s, wiese j, lipfert m, preuke n, sonnichsen fd, imhoff jf. antitumor anthraquinones from an easter isl and sea anemone: animal or bacterial origin. mar. drugs, 2019; 17(3):154. https://doi.org/10.3390/md17030154 21. kumar s. alkaloidal drugs-a review. asian j pharm sci., 2014; 4(3): 2014. 22. isah t. anticancer alkaloids from trees: development into drugs. pharmacogn rev., 2016; 10(20):90-99. https://doi.org/10.4103/0973-7847.194047 23. alasvand m, assadollahi v, ambra r, hedayati e, kooti w, peluso i. antiangiogenic effect of alkaloids. oxid med cell longev., 2019; 2019:9475908. https://doi.org/10.1155/2019/9475908 24. aniszewski t. alkaloids-secrets of life: aklaloid chemistry, biological significance, applications and ecological role; elsevier, 2007. 25. gorgani l, mohammadi m, najafpour gd, nikzad m. piperine-the bioactive compound of black pepper: from isolation to medicinal formulations. compr rev food sci food saf., 2017; 16(1):124-140. https://doi.org/10.1111/1541-4337.12246 26. srinivasan k. black pepper and its pungent principle-piperine: a review of diverse physiological effects. crit rev food sci nutr., 2007; 47(8):735-748. https://doi.org/10.1080/10408390601062054 27. podolak i, galanty a, sobolewska d. saponins as cytotoxic agents: a review. phytochem rev., 2010; 9(3):425-474. https://doi.org/10.1007/s11101-010-9183-z 28. moreira r, pereira dm, valentão p, andrade pb. pyrrolizidine alkaloids: chemistry, pharmacology, toxicology and food safety. int j mol sci., 2018; 19(6): 1668. https://doi.org/10.3390/ijms19061668 29. ding x, zhang w, li s, yang h. the role of cholesterol metabolism in cancer. am j cancer res., 2019; 9(2):219-227. 30. ying w, sevigny mb, chen y, swanson ra. poly(adpribose) glycohydrolase mediates oxidative and excitotoxic neuronal death. proc natl acad sci usa, 2001; 98(21):12227-12232. https://doi.org/10.1073/pnas.211202598 https://doi.org/10.15406/ppij.2018.06.00166 https://doi.org/10.1155/2019/5470470 https://doi.org/10.1007/978-3-030-12995-8_6 https://doi.org/10.1016/j.jad.2018.11.092 https://doi.org/10.1080/10408398.2011.649148 https://doi.org/10.5897/ajfs2015.1402 https://doi.org/10.21037/cdt.2017.03.20 https://doi.org/10.1007/978-981-10-8064-7_6 https://doi.org/10.1016/j.drudis.2009.06.014 https://doi.org/10.1016/j.mtchem.2018.05.001 https://doi.org/10.3390/md17030154 https://doi.org/10.4103/0973-7847.194047 https://doi.org/10.1155/2019/9475908 https://doi.org/10.1111/1541-4337.12246 https://doi.org/10.1080/10408390601062054 https://doi.org/10.1007/s11101-010-9183-z https://doi.org/10.3390/ijms19061668 https://doi.org/10.1073/pnas.211202598 jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [12] ajdhs.com 31. bors w, michel c. chemistry of the antioxidant effect of polyphenols. ann n y acad sci., 2002; 957(1):57-69. https://doi.org/10.1111/j.1749-6632.2002.tb02905.x 32. wei l, chuncheng y, huafeng z, rugang y. preparation of aloeherbs health beverage. food sci china, 2004; 25:207-209. 33. roy a, bharadvaja n. effect of various culture conditions on shoot multiplication and gc-ms analysis of plumbago zeylanica accessions for plumbagin production. acta physiol plant., 2018; 40(11):190. https://doi.org/10.1007/s11738-018-2766-9 34. roy a, bharadvaja n. establishment of root suspension culture of plumbago zeylanica and enhanced production of plumbagin. ind crops prod., 2019; 137:419-427. https://doi.org/10.1016/j.indcrop.2019.05.007 35. hoste h, sotiraki s, mejer h, heckendorn f, maurer v, thamsborg s. alternatives to synthetic chemical antiparasitic drugs in organic livestock farming in europe. organic farming, prototype for sustainable agricultures; springer: dordrecht, 2014; 149-169. https://doi.org/10.1007/978-94-007-7927-3_8 36. dhingra d, michael m, rajput h, patil rt. dietary fibre in foods: a review. j food sci technol., 2012; 49(3):255-266. https://doi.org/10.1007/s13197-011-0365-5 37. liao h, banbury lk, leach dn. antioxidant activity of 45 chinese herbs and the relationship with their tcm characteristics. evid based complement alternat med., 2008; 5(4):429-434. https://doi.org/10.1093/ecam/nem054 38. mcmullen mk, whitehouse jm, towell a. bitters: time for a new paradigm. evid based complement altern med., 2015; 670504. https://doi.org/10.1155/2015/670504 39. manohar sr, paul r, priya s. a brief review of synonyms and properties of guduci (tinospora cordifolia (thunb.) miers) from selected nighantus (ayurvedic drug lexicons). phcog j., 2018; 10(6s) https://doi.org/10.5530/pj.2018.6s.2 40. sugawara t, yamashita k, asai a, nagao a, shiraishi t, imai i, hirata t. esterification of xanthophylls by human intestinal caco-2 cells. arch biochem biophys., 2009; 483(2):205-212. https://doi.org/10.1016/j.abb.2008.10.007 41. okada t, nakai m, maeda h, hosokawa m, sashima t, miyashita, k. suppressive effect of neoxanthin on the differentiation of 3t3-l1 adipose cells. j oleo sci., 2008; 57(6):345-351. https://doi.org/10.5650/jos.57.345 42. umeno d, tobias av, arnold fh. diversifying carotenoid biosynthetic pathways by directed evolution. microbiol mol biol rev., 2005; 69(1):51-78. https://doi.org/10.1128/mmbr.69.1.5178.2005 43. tang g, russell rm. carotenoids as provitamin a. carotenoids; birkhäuser basel, 2009; 149-172. https://doi.org/10.1007/978-37643-7501-0_8 44. carrillo-lopez a, yahia em, ramirez-padilla gk. bioconversion of carotenoids in five fruits and vegetables to vitamin a measured by retinol accumulation in rat livers. am j agric biol sci., 2010; 5(2):215-221. https://doi.org/10.3844/ajabssp.2010.215.221 45. yeum kj, aldini g, russell rm, krinsky ni. antioxidant/pro-oxidant actions of carotenoids. carotenoids; birkhäuser basel, 2009; 235268. https://doi.org/10.1007/978-3-7643-7501-0_12 46. linnewiel-hermoni k, khanin m, danilenko m, zango g, amosi y, levy j, sharoni y. the anti-cancer effects of carotenoids and other phytonutrients resides in their combined activity. arch biochem biophys., 2015; 572:28-35. https://doi.org/10.1016/j.abb.2015.02.018 47. chao pdl, hsiu sl, hou yc. flavonoids in herbs: biological fates and potential interactions with xenobiotics. yao wu shi pin fen xi, 2002; 10(4):23-28. 48. panche an, diwan ad, chandra sr. flavonoids: an overview. j nutr sci., 2016; 5e47. https://doi.org/10.1017/jns.2016.41 49. prasad r, prasad sb. a review on the chemistry and biological properties of rutin, a promising nutraceutical agent. asian j pharm sci., 2019; 5(s1): 1-20. https://doi.org/10.31024/ajpp.2019.5.s1.1 50. brenes a, roura e. essential oils in poultry nutrition: main effects and modes of action. anim feed sci technol., 2010 158(1-2):1-14. https://doi.org/10.1016/j.anifeedsci.2010.03.007 51. ozel mz, gogus f, lewis ac. subcritical water extraction of essential oils from thymbra spicata. food chem., 2003; 82(3):381-386. https://doi.org/10.1016/s0308-8146(02)005587 52. bansod s, rai m. antifungal activity of essential oils from indian medicinal plants against human pathogenic aspergillus fumigatus and a. niger. world j med sci., 2008; 3(2):81-88. 53. christaki e, bonos e, giannenas i, florou-paneri p. aromatic plants as a source of bioactive compounds. agriculture, 2012; 2(3):228243. https://doi.org/10.3390/agriculture2030228 54. srinivas g, babykutty s, sathiadevan pp, srinivas p. molecular mechanism of emodin action: transition from laxative ingredient to an antitumor agent. med res rev., 2007; 27(5):591-608. https://doi.org/10.1002/med.20095 55. lee hz, hsu sl, liu mc, wu ch. effects and mechanisms of aloeemodin on cell death in human lung squamous cell carcinoma. eur j pharmacol., 2001; 431(3):287-295. https://doi.org/10.1016/s0014-2999(01)01467-4 56. yeh ft, wu ch, lee hz. signaling pathway for aloe emodininduced apoptosis in human h460 lung nonsmall carcinoma cell. int j cancer, 2003; 106(1):26-33. https://doi.org/10.1002/ijc.11185 57. huang q, lu g, shen hm, chung mc, ong cn. anticancer properties of anthraquinones from rhubarb. med res rev., 2007; 27(5):609630. https://doi.org/10.1002/med.20094 58. elsohly ma, gul w, avula b, khan ia. determination of the anthraquinones aloe-emodin and aloin-a by liquid chromatography with mass spectrometric and diode array detection. j aoac int., 2007; 90(1):28-42. https://doi.org/10.1093/jaoac/90.1.28 59. sottorff i, künzel s, wiese j, lipfert m, preußke n, sönnichsen fd, imhoff jf. antitumor anthraquinones from an easter island sea anemone: animal or bacterial origin. mar drugs, 2019 17(3):154. https://doi.org/10.3390/md17030154 60. eckburg pb, bik em, bernstein cn, purdom e, dethlefsen l, et al., diversity of the human intestinal microbial flora. science, 2005; 308(5728):1635-1638. https://doi.org/10.1126/science.1110591 61. guarner f, bourdet-sicard r, brandtzaeg p, gill hs, mcguirk p, van eden w, versalovic j, weinstock jv, rook ga. mechanisms of disease: the hygiene hypothesis revisited. nat clin pract gastroenterol hepatol., 2006; 3(5):275-284. https://doi.org/10.1038/ncpgasthep0471 62. kechagia m, basoulis d, konstantopoulou s, dimitriadi d, gyftopoulou k, skarmoutsou n, fakiri em. health benefits of probiotics: a review. isrn nutr., 2013; https://doi.org/10.5402/2013/481651 63. markowiak p, śliżewska k. effects of probiotics, prebiotics, and synbiotics on human health. nutrients, 2017; 9(9):1021. https://doi.org/10.3390/nu9091021 64. tokunaga t. novel physiological function of fructooligosaccharides. biofactors, 2004; 21(1-4):89-94. https://doi.org/10.1002/biof.552210117 65. forchielli ml, walker wa. the role of gut-associated lymphoid tissues and mucosal defence. br j nutr., 2005; 93(s1):s41-s48. https://doi.org/10.1079/bjn20041356 66. priebe mg, vonk rj, sun x, he t, harmsen hj, welling gw. the physiology of colonic metabolism. possibilities for interventions with preand probiotics. eur j nutr., 2002 41(1 suppl. 1): i2-i10. https://doi.org/10.1007/s00394-002-1101-8 https://doi.org/10.1111/j.1749-6632.2002.tb02905.x https://doi.org/10.1007/s11738-018-2766-9 https://doi.org/10.1016/j.indcrop.2019.05.007 https://doi.org/10.1007/978-94-007-7927-3_8 https://doi.org/10.1007/s13197-011-0365-5 https://doi.org/10.1093/ecam/nem054 https://doi.org/10.1155/2015/670504 https://doi.org/10.5530/pj.2018.6s.2 https://doi.org/10.1016/j.abb.2008.10.007 https://doi.org/10.5650/jos.57.345 https://doi.org/10.1128/mmbr.69.1.51-78.2005 https://doi.org/10.1128/mmbr.69.1.51-78.2005 https://doi.org/10.1007/978-3-7643-7501-0_8 https://doi.org/10.1007/978-3-7643-7501-0_8 https://doi.org/10.3844/ajabssp.2010.215.221 https://doi.org/10.1007/978-3-7643-7501-0_12 https://doi.org/10.1016/j.abb.2015.02.018 https://doi.org/10.1017/jns.2016.41 https://doi.org/10.31024/ajpp.2019.5.s1.1 https://doi.org/10.1016/j.anifeedsci.2010.03.007 https://doi.org/10.1016/s0308-8146(02)00558-7 https://doi.org/10.1016/s0308-8146(02)00558-7 https://doi.org/10.3390/agriculture2030228 https://doi.org/10.1002/med.20095 https://doi.org/10.1016/s0014-2999(01)01467-4 https://doi.org/10.1002/ijc.11185 https://doi.org/10.1002/med.20094 https://doi.org/10.1093/jaoac/90.1.28 https://doi.org/10.3390/md17030154 https://doi.org/10.1126/science.1110591 https://doi.org/10.1038/ncpgasthep0471 https://doi.org/10.5402/2013/481651 https://doi.org/10.3390/nu9091021 https://doi.org/10.1002/biof.552210117 https://doi.org/10.1079/bjn20041356 https://doi.org/10.1007/s00394-002-1101-8 jain et al asian journal of dental and health sciences. 2022; 2(1):7-13 [13] ajdhs.com 67. blaut m. relationship of prebiotics and food to intestinal microflora. eur j nutr., 2002; 41(1 suppl. 1):i11-i16. https://doi.org/10.1007/s00394-002-1102-7 68. slavin j. why whole grains are protective: biological mechanisms. proc nut. soc., 2003; 62(1):129-134. https://doi.org/10.1079/pns2002221 69. lonnie m, hooker e, brunstrom jm, corfe bm, green ma, watson aw, et al., protein for life: review of optimal protein intake, sustainable dietary sources and the effect on appetite in ageing adults. nutrients, 2018; 10(3):360. https://doi.org/10.3390/nu10030360 70. melini f, melini v, luziatelli f, ruzzi m. current and forwardlooking approaches to technological and nutritional improvements of gluten-free bread with legume flours: a critical review. compr rev food sci food saf., 2017; 16:1101-1122. https://doi.org/10.1111/1541-4337.12279 71. das l, bhaumik e, raychaudhuri u, chakraborty r. role of nutraceuticals in human health. j food sci technol., 2012; 49(2):173-183. https://doi.org/10.1007/s13197-011-0269-4 72. drewnowski a, dwyer j, king jc, weaver cm. a proposed nutrient density score that includes food groups and nutrients to better align with dietary guidance. nutr rev., 2019; 77(6):404416. https://doi.org/10.1093/nutrit/nuz002 73. réhault-godbert s, guyot n, nys y. the golden egg: nutrition al value, bioactivities, and emerging benefits for human health. nutrients, 2019; 11(3):684. https://doi.org/10.3390/nu11030684 74. tapal a, vegarud ge, sreedhara a, kaul tp. nutraceutical protein isolate from pigeon pea (cajanus cajan) milling waste by product: functional aspects and digestibility. food funct., 2019; 10(5):2710-2719. https://doi.org/10.1039/c8fo01933a 75. galanakis cm. nutraceutical and functional food components, effects of innovative processing techniques, 1st ed.; elsevier inc., b.v., 2017. https://doi.org/10.1016/b978-0-12-805257-0.000016 76. slavin j, carlson j. carbohydrates. adv nutr., 2014; 5(6):760-761. https://doi.org/10.3945/an.114.006163 77. lattimer jm, haub md. effects of dietary fiber and its components on metabolic health. nutrients, 2010; 2(12):1266-1289. https://doi.org/10.3390/nu2121266 78. hayes m, carney b, slater j, brück w. mining marine shellfish wastes for bioactive molecules: chitin and chitosan-part a: extraction methods. biotechnol j., 2008; 3(7):871-877. https://doi.org/10.1002/biot.200700197 79. hayes m, tiwari bk. bioactive carbohydrates and peptides in foods: an overview of sources, downstream processing steps and associated bioactivities. int j mol.sci., 2015; 16(9):2248522508. https://doi.org/10.3390/ijms160922485 80. tomova a, bukovsky i, rembert e, yonas w, alwarith j, barnard nd, kahleova h. the effects of vegetarian and vegan diets on gut microbiota. front nutr., 2019; 6:47. https://doi.org/10.3389/fnut.2019.00047 81. misurcova l, ambrozova j, samek d. seaweed lipids as nutraceuticals. advances in food and nutrition research; academic press, 2011; 64:339-355. https://doi.org/10.1016/b978-0-12387669-0.00027-2 82. kumar s, sharma b, bhadwal p, sharma p, agnihotri n. lipids as nutraceuticals: a shift in paradigm. therapeutic foods; academic press, 2018; 51-98. https://doi.org/10.1016/b978-0-12-8115176.00003-9 83. skrovankova s. seaweed vitamins as nutraceuticals. advances in food and nutrition research; academic press, 2011; 64:357-369. https://doi.org/10.1016/b978-0-12-387669-0.00028-4 84. hoang bv, lee j, choi ij, kim yw, ryu kw, kim j. effect of dietary vitamin c on gastric cancer risk in the korean population. world j gastroenterol., 2016; 22(27):6257-6267. https://doi.org/10.3748/wjg.v22.i27.6257 85. carrasco-gallardo c, farías ga, fuentes p, crespo f, maccioni rb. can nutraceuticals prevent alzheimer's disease? poten tial therapeutic role of a formulation containing shilajit and com plex b vitamins. arch med res., 2012; 43(8):699-704. https://doi.org/10.1016/j.arcmed.2012.10.010 86. gatell-tortajada j. oral supplementation with a nutraceutical formulation containing omega-3 fatty acids, vitamins, minerals, and antioxidants in a large series of patients with dry eye symptoms: results of a prospective study. clin interv aging, 2016; 11:571-578. https://doi.org/10.2147/cia.s98102 87. aghajanpour m, nazer mr, obeidavi z, akbari m, ezati p, kor nm. functional foods and their role in cancer prevention and health promotion: a comprehensive review. am j cancer res., 2017; 7(4):740-769. 88. rathore h, prasad s, sharma s. mushroom nutraceuticals for improved nutrition and better human health: a review. pharma nutrition, 2017; 5(2):35-46. https://doi.org/10.1016/j.phanu.2017.02.001 89. aida fmna, shuhaimi m, yazid m, maaruf ag. mushroom as a potential source of prebiotics: a review. trends food sci technol., 2009; 20(11-12):567-575. https://doi.org/10.1016/j.tifs.2009.07.007 90. arora s, tandon c, tandon s. evaluation of the cytotoxic effects of cam therapies: an in vitro study in normal kidney cell lines. sci. world j., 2014 https://doi.org/10.1155/2014/452892 91. rahi dk, malik d. diversity of mushrooms and their metabolites of nutraceutical and therapeutic significance. j mycol., 2016. https://doi.org/10.1155/2016/7654123 92. chaturvedi vk, agarwal s, gupta kk, ramteke pw, singh mp. medicinal mushroom: boon for therapeutic applications. 3 biotech., 2018; 8(8):334. https://doi.org/10.1007/s13205-0181358-0 93. badalyan sm, barkhudaryan a, rapior s. recent progress in research on the pharmacological potential of mushrooms and prospects for their clinical application. medicinal mushrooms; springer: singapore, 2019; 1-70. https://doi.org/10.1007/978981-13-6382-5_1 94. bradbury ke, appleby pn, key tj. fruit, vegetable, and fiber intake in relation to cancer risk: findings from the european prospective investigation into cancer and nutrition (epic). am j clin nutr, 2014; 100(suppl): 394s-398s. https://doi.org/10.3945/ajcn.113.071357 95. rafieian-kopaei m. medicinal plants and the human needs. j herbmed pharmacol., 2012; 1(1):1-2. 96. asgary s, sahebkar a, afshani mr, keshvari m, haghjooyjavanmard s, rafieian-kopaei m. clinical evaluation of blood pressure lowering, endothelial function improving, hypolipidemic and antiinflammatory effects of pomegranate juice in hypertensive subjects. phytother res., 2014; 28(2):193-199. https://doi.org/10.1002/ptr.4977 97. nasri h, baradaran a, shirzad h, rafieian-kopaei m. new concepts in nutraceuticals as alternative for pharmaceuticals. int j prev med., 2014; 5(12):1487-1499. 98. willis ms, wians fh. the role of nutrition in preventing prostate cancer: a review of the proposed mechanism of action of various dietary substances. clin chim acta., 2003; 330(1-2):5783. https://doi.org/10.1016/s0009-8981(03)00048-2 99. shirzad m, kordyazdi r, shahinfard n, nikokar m. does royal jelly affect tumor cells. j herbmed pharmacol., 2013; 2(2):45-48. 100. de freitas junior lm, de almeida eb. medicinal plants for the treatment of obesity: ethnopharmacological approach and chemical and biological studies. am j transl res., 2017; 9(5):2050-2064. https://doi.org/10.1007/s00394-002-1102-7 https://doi.org/10.1079/pns2002221 https://doi.org/10.3390/nu10030360 https://doi.org/10.1111/1541-4337.12279 https://doi.org/10.1007/s13197-011-0269-4 https://doi.org/10.1093/nutrit/nuz002 https://doi.org/10.3390/nu11030684 https://doi.org/10.1039/c8fo01933a https://doi.org/10.1016/b978-0-12-805257-0.00001-6 https://doi.org/10.1016/b978-0-12-805257-0.00001-6 https://doi.org/10.3945/an.114.006163 https://doi.org/10.3390/nu2121266 https://doi.org/10.1002/biot.200700197 https://doi.org/10.3390/ijms160922485 https://doi.org/10.3389/fnut.2019.00047 https://doi.org/10.1016/b978-0-12-387669-0.00027-2 https://doi.org/10.1016/b978-0-12-387669-0.00027-2 https://doi.org/10.1016/b978-0-12-811517-6.00003-9 https://doi.org/10.1016/b978-0-12-811517-6.00003-9 https://doi.org/10.1016/b978-0-12-387669-0.00028-4 https://doi.org/10.3748/wjg.v22.i27.6257 https://doi.org/10.1016/j.arcmed.2012.10.010 https://doi.org/10.2147/cia.s98102 https://doi.org/10.1016/j.phanu.2017.02.001 https://doi.org/10.1016/j.tifs.2009.07.007 https://doi.org/10.1155/2014/452892 https://doi.org/10.1155/2016/7654123 https://doi.org/10.1007/s13205-018-1358-0 https://doi.org/10.1007/s13205-018-1358-0 https://doi.org/10.1007/978-981-13-6382-5_1 https://doi.org/10.1007/978-981-13-6382-5_1 https://doi.org/10.3945/ajcn.113.071357 https://doi.org/10.1002/ptr.4977 https://doi.org/10.1016/s0009-8981(03)00048-2 boy et al asian journal of dental and health sciences. 2023; 3(4):8-10 [8] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the effectiveness of using apples and papayas in reducing the debris index score in children with mild mental retardation hendry boy*, muhammad al faridho, yesi nurmawi department of dental health, health polytechnic jambi, indonesia article info: _____________________________________________ article history: received 21 september 2023 reviewed 03 november 2023 accepted 27 november 2023 published 15 december 2023 _____________________________________________ cite this article as: boy h, faridho ma, nurmawi y, the effectiveness of using apples and papayas in reducing the debris index score in children with mild mental retardation, asian journal of dental and health sciences. 2023; 3(4):8-10 doi: http://dx.doi.org/10.22270/ajdhs.v3i4.54 abstract _________________________________________________________________________________________________________________ one of the supporting factors causing dental caries is debris or leftover food around the teeth. the fiber and water content of apples can stimulate the speed of salivary secretion and neutralize acidic substances in the mouth and also have an effect on reducing the debris index. consumption of fresh fruit rich in vitamins and minerals and water can encourage self-cleaning of the teeth, papaya is a plant source of vitamins, minerals and water. the aim of the study was to determine the effectiveness of using apples and papayas in reducing the debris index score in mildly mentally retarded children at slbn 2 jambi city. the type of research used in this study was quasiexperimental while the research design used was two group pre-test and post-test debris index observed twice, namely before treatment and after treatment with a total sample of 32 people with a total sampling technique. based on the results of the study there was a significant difference in the average debris index between before and after chewing apples p value 0.000 and papayas p value 0.000. there is a significant difference in the average difference in debris index reduction between the use of apples compared to papayas with a p value of 0.000. keywords: apple, papayas, debris indeks, mildly mentally retarded *address for correspondence: hendry boy, department of dental health, health polytechnic jambi, indonesia introduction health is one of the elements of a prosperous society, namely achieving the right to a healthy life for all levels of society through a health system that can guarantee community protection from various risks that can affect health as well as the availability of quality, affordable health services and equitable distribution of health services. health as an investment to produce a healthy and productive population as human resources for sustainable development and global competitiveness.1–3 dental and oral health are parts of body health that cannot be separated from each other. a healthy mouth allows individuals to talk, eat, and socialize without pain, discomfort, or embarrassment. teeth are a part of the body that functions for chewing, speaking and maintaining the shape of the face.4,5 one of the contributing factors that causes dental caries is debris or leftover food around the teeth. debris is a soft material found on the surface of teeth consisting of a layer of biofilm, white material and food debris. debris has quite a big influence on the caries process. debris index is a score of debris attached to the surface of the determining tooth. this debris index measurement is carried out to measure the tooth surface that is covered with debris.6–8 according to the world health organization (who), dental and oral health problems are increasing every year, as evidenced by the results of the 2018 basic health research, dental and oral health problems have doubled compared to 2013, namely 25.9% to 57.6 %. as many as 20 provinces have a prevalence of dental and oral problems above the national problem.9,10 clinically, the level of oral hygiene is assessed using the oral hygiene index simplified criteria. this criterion is assessed based on the condition of soft deposits or debris and tartar or calculus. most food residues are liquefied by bacterial enzymes and disappear 5-30 minutes after eating, but it is possible that some may still remain on the surface of the teeth and mucous membranes. chewing fibrous fruit such as apples, watermelon, guava and papaya can help clean teeth. apart from that, fruit also has the ability to self-clean the oral cavity. physiologically, fibrous foods will encourage saliva secretion, thereby helping to clean food residue stuck to the surface of the teeth.11–13 the fiber and water content of apples can stimulate the speed of saliva secretion and neutralize acidic substances in the mouth and also have an effect on reducing the debris index. apart from containing lots of fiber and water, apples also contain flavonoids which function as anti-bacterials in the mouth.8 consuming fresh fruit rich in vitamins, minerals, fiber and water can encourage self-cleaning of teeth, thereby reducing the surface area of dirt and ultimately preventing dental caries. papaya is a plant source of vitamins, minerals, fiber and contains enzymes that are useful for digestion.14 mentally retarded children are children whose intelligence is below average and are classified as children who can be trained. the existing limitations and abilities possessed by mentally retarded children give rise to various problems, one of which is difficulty in caring for their dental health.15 based on observations at slbn 2 jambi city, it was found that many mentally disabled children do not regularly consume open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i4.54 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i4.54&amp;domain=pdf boy et al asian journal of dental and health sciences. 2023; 3(4):8-10 [9] ajdhs.com fibrous foods such as fruit and vegetables. this is one of the factors in children's limited abilities and lack of knowledge about the importance of consuming fruit and vegetables with fiber. apples and papayas both contain fiber and water, where the fiber in apples is higher than in papayas, while the water content in papayas is higher than in apples. method and material the type of research used in this research is quasi experiment. the research design used was two group pretest and posttest. the debris index was observed twice, namely before treatment and after treatment. the sampling technique used a total sampling of 32 mildly mentally disabled children in slbn 2 jambi city. the research was carried out in may 2023 on mentally disabled children at slbn 2 jambi city. the measuring instrument used in this research is the debris index (di) and the research materials are apples and papaya which have been weighed weighing 100 grams and packaged in plastic. the stages of data collection were carried out as follows: all samples were first given biscuits with the aim of equalizing the condition of their oral cavity, then the first measurement was carried out on all samples. after the first measurement, the samples were divided into two groups, the first group consumed apples and the second group consumed fruit. papaya, both groups received fruit with the same weight, namely 100 grams and finally, after both sample groups had eaten the fruit, a second measurement would be carried out again. data analysis for effectiveness before and after chewing apples and chewing papaya was carried out by the wilcoxon test. the effectiveness of chewing apples and papaya in reducing the debris index score using mann whitney so that later it can be seen whether there is a difference between chewing apples and chewing papaya in reducing the debris index score. result table 1: debris index score before and after chewing apples and papaya group mean sd p value apples pre-test 2,113 0,3862 0,001 post-test 0,431 0,2056 papaya pre-test 2,088 0,3263 0,001 post-test 1,094 0,0929 based on table 1, it shows that a different average value was obtained for the apple group before 2.113 and after 0.431. in the papaya fruit group, the average value before and after was 2,088 and 1,094. this means that it indicates there is a difference in the average debris index score before and after chewing apples and papaya in children with mild mental retardation at slbn 2 jambi city with a p value of 0.001. table 2: effectiveness of using apples and papaya in reducing debris index scores variable n mean rank sd p value apples 16 23,53 0,4647 0,001 papaya 16 9,47 based on table 2, after carrying out the mann-whitney statistical test, it was obtained that the mean rank decrease in the debris index score was higher for the use of apples than papaya, namely 23.53 compared to 9.47. statistically there is a significant difference between the effectiveness of using apples and papaya in reducing debris index scores in children with mild mental retardation in slbn 2 jambi city (p=0.001). discussion based on the research results, before chewing the apple, the average value was 2.113 in the apple group, after chewing the apple, the average value was 0.431, based on the wilcoxon test, the significance value was 0.001 < 0.05. this means that there is a difference between the pre-test and post-test in the apple group. based on the results of statistical tests, it was found that the lowest debris index value before chewing an apple was 1.5 and the highest debris index value was 2.8. meanwhile, after chewing an apple, the debris index value was the lowest, namely 0.1 and the highest debris index value, namely 1.0. it can be seen that there is a decrease in the debris index value of the sample after chewing the apple, which also shows that the dental hygiene of the sample has increased. the factor that causes a decrease in dental hygiene after chewing apples is that the fruit consumed contains fiber which can control debris mechanically, because the chewing process directly causes a cleaning effect.16,17 the fiber and water content of apples can stimulate the speed of saliva secretion and neutralize acidic substances in the mouth and also have an effect on reducing the debris index.8,18 primary prevention in children who are at high risk of caries is that eating more fibrous and watery vegetables and fruit will cleanse and stimulate saliva secretion so that dental caries can be prevented.19,20 based on data analysis before chewing the papaya, the average value was 2,088, after chewing the papaya the average value was 1,094, based on the wilcoxon test, the significance value was 0.001 < 0.05. this means that there is a difference between the pre-test and post-test in the papaya group. it can be concluded that the papaya fruit group also experienced a decline. based on the results of statistical tests, it was found that the lowest debris index value before chewing papaya fruit was 1.5 and the highest debris index value was 2.6. meanwhile, after chewing papaya, the debris index value was the lowest, namely 1.0 and the highest debris index value, namely 1.3. this also shows a decrease in the debris index of the papaya fruit group, but the decrease is quite low because the fiber content in papaya fruit is lower than in apples but the water content in papaya fruit is higher. papaya contains quite highwater content which can help produce more saliva which can have a selfcleaning effect on the teeth (self-cleansing effect).21 boy et al asian journal of dental and health sciences. 2023; 3(4):8-10 [10] ajdhs.com based on the results of the mann-whitney statistical test, the mean rank value for the apple group was 23.53 and the mean rank for the papaya group was 9.47, and a significance value of 0.001 < 0.05 was obtained. this means that there is a significant difference between the initial and final debris index values in the apple group (which received treatment by chewing apples) and the papaya group (which received treatment by chewing papaya). this shows the effectiveness of using apples and papaya in reducing the debris index score. there is an increase in dental hygiene in mildly mentally disabled children in slbn 2 jambi city, between apples and papaya in reducing the debris index score, apples are more effective in reducing the debris index score. the results of this research are in accordance with the statement by penda, et al, that apples can reduce the debris index effectively. apples contain high concentrations of tannin which can prevent tooth decay caused by plaque buildup. the fiber content in apples can help clean food debris stuck to the teeth, because apples are a fibrous fruit so chewing apples can be called a natural toothbrush. eating or consuming apples by biting and chewing the apple can stimulate saliva in the mouth. apples can also be used as a medium to clean and freshen the mouth. this is because apples contain tannin, a substance that functions to clean and freshen the mouth so that it can prevent tooth decay and gum disease.22–24 conclusion from the results of the research and discussion regarding the effectiveness of using apples and papaya in reducing debris index scores in mildly mentally disabled children in slbn 2 jambi city, it can be concluded that there is a significant difference in the average difference in debris index reduction between the use of apples compared to papaya. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. references 1. organization wh. health systems resilience toolkit: a who global public health good to support building and strengthening of sustainable health systems resilience in countries with various contexts. 2022; 2. erlyn p, hidayat b, cahyo a, saksono h. investment in human resources to increase achievement levels of sustainable development. j bina praja j home aff gov. 2022;14(1):135-46. https://doi.org/10.21787/jbp.14.2022.135-146 3. huang y-k, chang y-c. oral health: the first step to sustainable development goal 3. j formos med assoc. 2022;121(7):1348-50. https://doi.org/10.1016/j.jfma.2021.10.018 pmid:34732302 4. re pr, purnama t, tauchid sn, prihatiningsih n. knowledge of oral and dental health impacts the oral hygiene index simplified (ohis) of primary school children. indian j forensic med toxicol. 2021;15(4):2179-83. 5. scheid rc, weiss g. woelfel's dental anatomy. jones & bartlett publishers; 2020. 6. nurilawaty v, purnama t, zahra mf. carbohydrate diet during the covid-19 pandemic (case study: 4 th grade students of elementary school 02 meruya utara, west jakarta). int res j pharm med sci. 2021;4(4):37-40. 7. øilo m, bakken v. biofilm and dental biomaterials. materials (basel). 2015;8(6):2887-900. https://doi.org/10.3390/ma8062887 pmcid:pmc5455733 8. hartari n, lendrawati l, ristiono b. perbandingan efektivitas mengunyah buah apel (malus sylvestris mill) dan buah semangka (citrullus lanatus) sebagai self-cleansing terhadap perubahan indeks debris pada siswa kelas vii smpn 30 kota padang. andalas dent j. 2021;9(2):60-6. https://doi.org/10.25077/adj.v9i2.175 9. kemenkes ri. hasil utama riskesdas 2018. jakarta kemenkes ri. 2018; 10. riskesdas. riset kesehatan dasar; badan penelitian dan pengembangan kesehatan kementerian kesehatan ri tahun2010. lap nas 2010. 2013;1-446. 11. musa n. the relationship between oral hygiene status and dental caries was assessed using icdas ii criteria. j dent med public heal. 2021;1(1):23-33. 12. andriani a, wilis r, liana i, keumala cr, mardelita s, zahara e. the effect of dental health education and the total quality management approach on the behavior of dental and oral health maintenance and the status of the oral hygiene index simplified in elementary school students in aceh besar. open access maced j med sci. 2021;9(f):47-51. https://doi.org/10.3889/oamjms.2021.5576 13. nurjannah n, herijulianti e, putri mh. ilmu pencegahan penyakit jaringan keras dan jaringan pendukung gigi. jakarta egc. 2012; 14. mandalika wc, wicaksono da, leman ma. pengaruh konsumsi pepaya (carica papaya) dalam menurunkan indeks debris pada anak usia 10-12 tahun di sdn 103 manado. e-gigi. 2014;2(2). https://doi.org/10.35790/eg.2.2.2014.5778 15. agustiningsih aa. pelatihan menggosok gigi untuk meningkatkan kemampuan bina diri anak tunagrahita sedang di slb. j pendidik khusus. 2016;9(1):1-10. 16. kidd eam, fejerskov o. essentials of dental caries. oxford university press; 2016. https://doi.org/10.1093/oso/9780198738268.001.0001 17. sihombing kp, irma s, manta r, tiurlan sr. comparing the effect of pineapple fruit and star fruit to reduce the dental plaque in children aged 10-12 years: a cross sectional study. int j gastroenterol. 2020;4(1):11-4. https://doi.org/10.11648/j.ijg.20200401.13 18. sulistyanti ad, kamelia e, miko h, ambarwati t, setiana r. chewing royal gala apples on the formation of plaque and ph saliva in grade vi students of sdit assunnah cirebon. jdht j dent hyg ther. 2021;2(1):27-33. https://doi.org/10.36082/jdht.v2i1.214 19. zafar n, ali a, imtiaz s, afzal my, nazir u, sikandar m, et al. the role of nutrition in tackling dental caries. pure appl biol. 2020;9(4):2233-49. https://doi.org/10.19045/bspab.2020.90239 20. van loveren c, lingström p. diet and dental caries. dent caries dis its clin manag. 2015;3:136-7. 21. syifa n, utami nk, nurwati b, ulfah r, habibah ss. effect of consuming papaya fruit (carica papaya) on ph saliva in students class x and xi madrasah aliyah (ma) puteri al-amin martapura, indonesia. in: international conference on health sciences. 2021. p. 58-61. 22. penda pac, kaligis shm. perbedaan indeks plak sebelum dan sesudah pengunyahan buah apel. e-gigi. 2015;3(2). https://doi.org/10.35790/eg.3.2.2015.9631 23. braud a, symoneaux r, patron c, brasse c, forgerit v, lourtioux f, et al. how oral health and food sensory properties impact oral comfort during consumption of apples: a comparative approach in seniors and young adults. j texture stud. 2019;50(4):271-84. https://doi.org/10.1111/jtxs.12450 pmid:31145468 24. zainur ra, trawijaya a, cahyati sa. the effect of apples as selfcleansing to reduce plaque scores on madrasah ibtidaiyah tarbiyah islamiyah students palembang. in: first international conference on health, social sciences and technology (icohsst 2020). atlantis press; 2021. p. 13-6. https://doi.org/10.21787/jbp.14.2022.135-146 https://doi.org/10.1016/j.jfma.2021.10.018 https://doi.org/10.3390/ma8062887 https://doi.org/10.25077/adj.v9i2.175 https://doi.org/10.3889/oamjms.2021.5576 https://doi.org/10.35790/eg.2.2.2014.5778 https://doi.org/10.1093/oso/9780198738268.001.0001 https://doi.org/10.11648/j.ijg.20200401.13 https://doi.org/10.36082/jdht.v2i1.214 https://doi.org/10.19045/bspab.2020.90239 https://doi.org/10.35790/eg.3.2.2015.9631 https://doi.org/10.1111/jtxs.12450 srinivasam et al asian journal of dental and health sciences. 2024; 4(1):4-8 [4] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited knowledge, self-perception, attitude of halitosis among students in chengalpet: a questionnaire study naveena srinivasam * , nethra devi , nandhitha ravichandran , nithya sree thurkkaram , pavithra rajamurthi , dr. lakshmiganthan , dr. aneez karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india article info: _____________________________________________ article history: received 11 december 2023 reviewed 04 january 2024 accepted 16 january 2024 published 15 march 2024 _____________________________________________ cite this article as: srinivasam n, devi n, ravichandran n, thurkkaram ns, rajamurthi p, lakshmiganthan, aneez, knowledge, self-perception, attitude of halitosis among students in chengalpet: a questionnaire study, asian journal of dental and health sciences. 2024; 4(1):4-8 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.66 _____________________________________________ *address for correspondence: naveena srinivasam, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india abstract _________________________________________________________________________________________________________________ aim: to measure self-perception, knowledge, and awareness of halitosis among students studying in karpaga vinayaga educational groups materials and methods: in this study, total of 240 participants who are students of karpaga vinayaga educational group were recruited. a questionnaire was created online using google forms, and the link was sent to the participants through different social media platforms such as whatsapp and emails. their responses were recorded. result: a widespread issue that affects people all over the world, halitosis or bad breath, has social and psychological as well as medical repercussions. there is ample evidence that halitosis is common everywhere in the world. our study found that the self-perception of poor breath is significantly influenced by age. most of the respondents in our study did not report to dentist for having bad breath. instead, they tried to solve by using chewing gums, mouth wash and sweets. this gave us the conclusion that they lack knowledge about the cause and management plan. conclusion: oral malodour is generally poorly understood in all of its facets. therefore, it is important to promote increased public awareness and education. to lessen this issue, regular visits to dentists and other healthcare providers should be promoted. it should be stressed that dentists have a responsibility to educate and advise their patients about oral malodour, and dental students should receive enough training in handling this problem by organising dental camps, lectures should be provided to students so as to improve knowledge about halitosis14 keywords: halitosis, awareness, self-perception, bad breath, oral malodor introduction: halitosis is a broad word for an unpleasant smell in the mouth that is difficult to remove as a result of poor oral hygiene. halitosis comes from the latin word “halitus” meaning breath and the greek word “osis” which means abnormal or disease. bad odour from inhaling is known as halitosis. the offensive smell brought on by the emission of volatile sulphur compounds (vscs) as a result of gram-negative bacteria's activity during decay1. there are three different types of halitosis: true halitosis, pseudo halitosis, and halitophobia2. although the exact source of halitosis is still unknown, food scraps left in the mouth are the most common cause. halitosis is a problem that has an impact on social, medical, and psychological facets of life. the extra-oral factors can include breathing issues, digestive tract issues, sinus issues, diabetes, renal issues, and sometimes drug reactions3. foods with onion, garlic, pepper, smoking, drinking alcohol, and morning bad breath are all temporary causes of odour. bad breath, if present, often results in decreased self-esteem and avoidance behaviours, especially in social settings.4 certain substances are widely used by the general public to reduce or eliminate odours, such as toothpaste, mouthwash, chewing gum, floss, etc most of the time, a person with bad breath doesn’t even know they have bad breath because they are not aware of it. improving oral hygiene practices has been shown to decrease bad breath and improve self-esteem and confidence.5 the lack of self-awareness about halitosis results in carelessness to treat it. this study is conducted to assess the knowledge, awareness, self-perception and cause of halitosis materials and methods in this study, total of 240 participants who are students of karpaga vinayaga educational group were recruited. the duration of data collection was one month. a questionnaire was created online using google forms, and the link was sent to the participants through different social media platforms such as whatsapp and emails. their responses were recorded. a questionnaire that was created based on another study was modified to take the goals of the current study into account. our study's main focus was on the knowledge, self-perception, and attitude toward halitosis among students studying in karpaga vinayaga educational group utilizing validated instruments. secondarily, demographic factors such as age, gender, and educational attainment were evaluated. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.66 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.66&amp;domain=pdf https://orcid.org/0009-0008-4453-641x https://orcid.org/0009-0002-4157-2841 https://orcid.org/0009-0006-3361-6620 https://orcid.org/0009-0004-3425-9157 https://orcid.org/0009-0008-2381-752x https://orcid.org/0000-0002-0723-6820 https://orcid.org/0000-0002-0869-5615 srinivasam et al asian journal of dental and health sciences. 2024; 4(1):4-8 [5] ajdhs.com the survey comprised two parts: 1) demographic inquiries and 2) in-depth questions examining the participants' selfperception of halitosis and their understanding of the causes and remedies for oral malodour and their attitude towards halitosis. the questionnaire included questions about their oral health, oral hygiene practices underlying medical conditions, personal habits (smoking and alcohol consumption), whether or not the person believes they have bad breath, how long they have been aware of it, where they first noticed it, steps to minimize it, dental procedures and the existence of dry mouth. students who are studying mbbs, engineering, nursing and other paramedical courses in karpaga vinayaga educational groups were included in this study. dental students of karpaga vinayaga educational groups were excluded in this study. the data collected from the respondents via the completed questionnaires was kept private and anonymous. result: this study is the first questionnaire study done among medical, engineering, nursing, paramedical students in karpaga vinayaga institution, chengalpet regarding self-perception, knowledge and attitude of halitosis among students in karpaga vinayaga educational group. in this study 240 students had participated in which 125 students were medical, 79 students were engineering ,12 students were nursing and 24 students were paramedical the mean age of students participating in the study was 22.5 years among them 69.2% were females and 30.8% were males. the number of answers given for each question in the questionnaire was calculated and the percentage of correct answers for each question were calculated for the entire sample. in response to questions about halitosis, 15.8% said they have halitosis ,52.8% said they did not, 31.7% said they have while eating onion and garlic. predominately 71.3% of participants have no coatings on tongue, 13.3% of participants have coatings in their tongue and 15.4% of are not aware of coatings in their tongue. majority of the participants don’t have any medical problems and 5.4% participants have medical problems. among them 90.8% of participants are didn’t take any medications and 9.2% of participants are under medications. of those with halitosis, the majority knew they had it from “days ago” (62.1%),19.6% for “month ago” and 18.3% for a “year ago” among them 78.3% of participants are not mouth breather, 8.8% are mouth breather and 12.9% of participants are not sure about mouth breathing. of the participants, 30 % noticed they have bad breath and 70% said they don’t have bad breath. among them 87.5% didn’t had an examination for bad breath and 12.5% of participants had an examination for bad breath. majority of participants 78.8% don’t have bleeding gums and 21.3% of participants have bleeding gums. about 37.1% of participants selected mouthwash as a halitosis reducing measure.25.4% of participants selected nothing, 23.8% of participants selected chewing gums, 13.3% of participated selected they avoid certain foods to avoid halitosis. regarding to personal habits 88.8% of participants are nonsmoker and 11.3% are smoker. 88.8% of participants are nonalcoholic and 11.3% are alcoholic. approximately 88.3% of the participants did not go to dentist for a checkup due to foul smell and 11.7% said they go to the dentist for halitosis. in terms of dental hygiene, 65.4% said improper brushing and diet is one of the causes for bad breath and 34.6% said that’s not the cause for halitosis. majority of participants brush their teeth once a day around 70.4% and 29.6% said that they brush their teeth twice a day. about tongue cleaner 55% of participants doesn’t use tongue cleaner and 45% of participants uses tongue cleaner. regarding deposits in teeth 41.7% of participants don’t have deposits in teeth, 20.4% of participants have deposits in teeth and 37.9% of participants were not sure about deposits in teeth. majority of participants don’t know they have halitosis or not (47.9%) ,32.5% of participants answered that they just know they have bad breath,15% of participants said that someone told them they have halitosis and 4.5% of participants came to know through non-verbal communications of other people. individuals reported with bad breath about 52.1% of participants felt uneasy whenever need to talk,45% of participants hesitate to talk to people,16.3% of participants don’t like to meet other people and 6.3% of participants said other people avoid them .77.5% of participants are not aware of tests used to detect halitosis and 22.5% of participants are aware of tests used to detect halitosis. among 240 participants 56.3% of people are not willing to go for treatment for halitosis and 43.8% of people are willing to go for treatment of halitosis discussion: a widespread issue that affects people all over the world, halitosis or bad breath, has social and psychological as well as medical repercussions. there is ample evidence that halitosis is common everywhere in the world.6 our study found that the self-perception of poor breath is significantly influenced by age. younger folks may be more conscious of their breath since they participate in more social events than older adults, which could be one explanation for this.7 however, our study found no evidence that education level was a significant factor in determining one’s poor breath. this is in contrast to earlier research that found poorer self-perception of halitosis is associated with lower levels of education.8 brushing the tooth at least twice a day has been the followed protocol to maintain keep the optimum oral hygiene. majority reported brushing their teeth regularly, but many brushed only once that may cause halitosis. even if oral hygiene is good yet they develop halitosis, then the cause will be the coated tongue.9 this may be the reason why students in this study with minimal tongue cleaner users reported bad breath. most of the respondents in our study did not report to dentist for having bad breath. instead, they tried to solve by using chewing gums, mouth wash and sweets.10this gave us the conclusion that they lack knowledge about the cause and management plan. organoleptic score is the gold standard method of measuring halitosis. in this study the students participated have not undergone these methods, instead they evaluated. by their own and some came to know while they interacted with other people. some systemic illnesses are known to cause bad breath which is a rare scenario in our study. systemic conditions like diabetes, tonsilitis, sinusitis, stomach problems cause halitosis.11 this correlation was found minimally in our study but some are affected with pcod, wheezing and ulcer. improper breathing like mouth breathing may lead to bad breath12 where 21 individuals were mouth breathers and suggested to be a cause of bad breath. smoking was found among 27 participants in this study. in previous study, it was reported that individuals use smoking as management tool. flossing has also been an auxiliary method to maintain oral hygiene along with brushing and using mouth wash.13 in our study we questioned about the use of mouthwash and most of them were using it regularly and occasionally. diet also plays a role in the halitosis. in this study some of them mentioned they had bad breath while eating onion, garlic. one of this study’s strength is the usefulness of a validated tool. however, the study had limitations because the assessment of poor breath was done without a clinical examination and instead based on self-perceived data. those students who said that they did not have halitosis, it is not clear that they did were free from it or because of that they were afraid to say confusion. srinivasam et al asian journal of dental and health sciences. 2024; 4(1):4-8 [6] ajdhs.com table 1: demographic data of respondents (n=240) age n(%) 17-19 years 20.1% 20-22 years 57.2% 23-25 years 20.4% 26-28 years 2.3% gender males 30.8% females 69.2% course mbbs 52.1% engineering 32.9% nursing 5% paramedical 10% table 2: oral hygienic status frequency % how often do you brush your teeth? once 169 70.4% twice 71 29.6% do you use mouth wash? yes 62 25.8% no 127 52.9% occasionally 51 21.3% do you use tongue cleaner? yes 108 45% no 132 55% do you have deposits on your teeth? yes 49 20.4% no 100 41.7% may be 91 37.9% are there any coating on your tongue? yes 32 13.3% no 171 71.3% may be 37 15.4% do you have bleeding gums? yes 51 21.3% no 189 78.8% srinivasam et al asian journal of dental and health sciences. 2024; 4(1):4-8 [7] ajdhs.com table 3: perception and knowledge towards halitosis do you have bad breath? % yes 38 15.8% no 126 52.5% sometimes while eating onion, garlic 76 31.7% how do you know do you have bad breath? i don’t know 115 47.9% i just know 78 32.5% someone told me 36 15% nonverbal communication of other people 11 4.6% do you think improper brushing and diet is one of the cause for bad breath? yes 157 65.4% no 83 34.6% did you consult any dentist because of your bad breath? yes 28 11.7% no 212 88.3% are you aware of the test used to detect bad breath? yes 54 22.5% no 186 77.5% are you willing to under go treatment for bad breath? yes 105 43.8% no 135 56.3% conclusion: the current study discovered that a very small percentage of participants self-reported having halitosis, a much higher proportion said that their stench bothered those around them. the majority of respondents said that instead of treating the underlying cause of foul breath, they would disguise it. oral malodour is generally poorly understood in all of its facets. therefore, it is important to promote increased public awareness and education. to lessen this issue, regular visits to dentists and other healthcare providers should be promoted. it should be stressed that dentists have a responsibility to educate and advise their patients about oral malodour, and dental students should receive enough training in handling this problem1by organising dental camps, lectures should be provided to students so as to improve knowledge about halitosis14. financial support and sponsorship nil conflicts of interest there are no conflicts of interest references 1. saleem mkm, lal a, masood s, ghandhi d, sitai aa, ahmed n. perception of halitosis among general population. j bahria uni med dental coll. 2021; 11(1):35-39 https://doi.org/10.33279/jkcd.v11i01.162 2. özen me, aydin m. subjective halitosis: definition and classification. j n j dent assoc [internet]. 2015;86(4):20-4. 3. yamunadevi a, selvamani m, mohan kumar k, basandi p, madhushankari g. halitosis an overview: part-i -classification, etiology, and pathophysiology of halitosis. j pharm bioallied sci. 2015;7(6):339 https://doi.org/10.4103/0975-7406.163441 pmid:26538874 pmcid:pmc4606616 4. sedky na. perceived impact of halitosis on individual's social life and marital relationship in qassim province, ksa. j am sci. 2015;11(3). 5. setia s, pannu p, gambhir r, galhotra v, ahluwalia p, sofat a. correlation of oral hygiene practices, smoking and oral health conditions with self perceived halitosis amongst undergraduate dental students. j nat sci biol med.2014;5(1):67. https://doi.org/10.4103/0976-9668.127291 pmid:24678201 pmcid:pmc3961956 6. bakhshi m, tofangchiha m, bakhtiari s. prevalence of self-perceived halitosis, demographic factors and oral health care among defined groups of dental students in iran. j int oral heal. 2018;10(4):187 https://doi.org/10.4103/jioh.jioh_153_18 7. alzoubi fq, karasneh ja, daamseh nm. relationship of psychological and oral health statuses with self-perceived halitosis in a jordanian population: a cross-sectional study.bmc oral health. 2015;15(1):89. https://doi.org/10.1186/s12903015-0078-7 pmid:26227389 pmcid:pmc4520075 8. al-ansari jm, boodai h, al-sumait n, al-khabbaz ak, al-shammari kf, salako n. factors associated with self-reported halitosis in kuwaiti patients. j dent. 2006;34(7):444-9. https://doi.org/10.1016/j.jdent.2005.10.002 pmid:16309815 9. gonçalves ac de s, martins mcn, paula bl de, weckwerth ph, franzolin s de ob, silveira emv. a new technique for tongue brushing and halitosis reduction: the x technique. j appl oral sci. 2019;1:27:e20180331 https://doi.org/10.1590/1678-77572018-0331 pmid:30970113 pmcid:pmc6442830 https://doi.org/10.33279/jkcd.v11i01.162 https://doi.org/10.4103/0975-7406.163441 https://doi.org/10.4103/0976-9668.127291 https://doi.org/10.4103/jioh.jioh_153_18 https://doi.org/10.1186/s12903-015-0078-7 https://doi.org/10.1186/s12903-015-0078-7 https://doi.org/10.1016/j.jdent.2005.10.002 https://doi.org/10.1590/1678-7757-2018-0331 https://doi.org/10.1590/1678-7757-2018-0331 srinivasam et al asian journal of dental and health sciences. 2024; 4(1):4-8 [8] ajdhs.com 10. tarakji b, al-waeli h, alhadithy t, darwazeh a, hammad m. prevalence and awareness of halitosis in a sample of jordanian population. j int soc prev community dent. 2014;4(6):178. https://doi.org/10.4103/2231-0762.149033 pmid:25625076 pmcid:pmc4304056 11. torsten m, gómez-moreno g, aguilar-salvatierra a. drug related oral malodour (halitosis): a literature review. eur rev med pharmacol sci. 2017;21(21):4930-4. 12. bollen cm, beikler t. halitosis: the multidisciplinary approach. int j oral sci. 2012;4(2):55-63. https://doi.org/10.1038/ijos.2012.39 pmid:22722640 pmcid:pmc3412664 13. aylikci b, çolak h. halitosis: from diagnosis to management. j nat sci biol med. 2013;4(1):14. https://doi.org/10.4103/09769668.107255 pmid:23633830 pmcid:pmc3633265 14. goel s, chaudhary g, kalsi d s, bansal s, mahajan d. knowledge and attitude of indian population toward "self-perceived halitosis". indian j dent sci 2017;9:79-83 https://doi.org/10.4103/ijds.ijds_15_17 https://doi.org/10.4103/2231-0762.149033 https://doi.org/10.1038/ijos.2012.39 https://doi.org/10.4103/0976-9668.107255 https://doi.org/10.4103/0976-9668.107255 https://doi.org/10.4103/ijds.ijds_15_17 nethra devi et al asian journal of dental and health sciences. 2023; 3(4):4-7 [4] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited granuloma pyogenicum in an extraction site: an unusual case report nethra devi* , naveena srinivasam , saravanan thalaimalai karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india article info: _____________________________________________ article history: received 04 september 2023 reviewed 18 october 2023 accepted 13 november 2023 published 15 december 2023 _____________________________________________ cite this article as: devi n, srinivasam n, thalaimalai s, granuloma pyogenicum in an extraction site: an unusual case report, asian journal of dental and health sciences. 2023; 3(4):4-7 doi: http://dx.doi.org/10.22270/ajdhs.v3i4.60 abstract _________________________________________________________________________________________________________________ pyogenic granuloma also known as granuloma pyogenicum is a typical, acquired, benign vascular lesion of the skin and mucous membranes. it can occasionally present intravascularly or subcutaneously. this report discusses the case of pyogenic granuloma in a 25-year-old male in extraction site in lower left back tooth region. keywords: pyogenic granuloma, lobular capillary hemangioma, benign neoplasm, hyperplastic lesion. *address for correspondence: nethra devi l, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india. introduction: one of the most frequently occurring benign mucocutaneous lesions is pyogenic granuloma which is also known as lobular capillary hemangioma 1. it is believed that this soft tissue tumor of the oral cavity, is reactive rather than malignant in nature 2,3. from clinical point of view, pyogenic granuloma is present as a solitary nodule or sessile collagenous papule with a smooth or lobulated surface. lesions become less vascular as they become mature, and clinically it is more pink and 4,5. the marginal gingiva is the most frequently observed site, but lesions have also been reported on the palate, buccal mucosa, tongue, and lips6. the preferred method of treatment for these lesions has always been complete surgical excision with sub-periosteal curettage. plaque, swollen restorations, etc. are examples of potential irritating elements that must be similarly eliminated to prevent recurrence 7. this article includes a case of pyogenic granuloma present in extraction site in the lower left back tooth region. case report: a 25-year-old male patient reported to the department of oral medicine and radiology, karpaga vinayaga institute of dental sciences, chengalpattu district, tamil nadu, india. the patient’s chief complaint was pain in his left lower back tooth region for past 1 month. history revealed tooth extraction in left lower back tooth region before 2 years. growth which is initially small in size and gradually increased to the present size for past 1 month. pain is present which is dull throbbing, intermittent and non-radiating in nature. aggravated by mastication and relieved by medications. spontaneous bleeding was present. figure1: front view on extra-oral examination, there was no evidence of external swelling, no palpable lymph node in submental and submandibular region and no evident of pus discharge or bleeding. on intra-oral examination, presence of single well-defined growth of size 2x2 cm is seen in relation to 37 region. it is roughly oval in shape and sessile in nature extending anteriorly distal aspect of 36, posteriorly mesial aspect of 38, superiorly along the alveolar mucosa and inferiorly along the lower left buccal vestibule ( fig.2 ). no secondary changes were seen. on palpation, all inspectory findings are confirmed with respect to number, site, size, shape and extent. it is non-tender, fibrous in consistency with bleeding discharge. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i4.60 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i4.60&amp;domain=pdf https://orcid.org/0009-0002-4157-2841 https://orcid.org/0009-0008-4453-641x https://orcid.org/0009-0009-1983-5458 nethra devi et al asian journal of dental and health sciences. 2023; 3(4):4-7 [5] ajdhs.com figure 2: intra oral photograph histopathological examination section studied show a polypoidal lesion lined by ulcerated stratified squamous epithelium with underlying stroma showing lobules of proliferating capillary sized blood vessels lined by plump endothelial cells with interstitial lymphoplasmacytic infiltrate. (fig.3) figure 3: histopathology radiographic examination intra oral periapical examination reveals radiolucency in relation to 37. it also reveals vertical bone loss and widening of periodontal in relation to 36. ( fig.4 ) figure 4: radiographic image treatment: patient positioned 2% lignocaine with adrenaline administered as left inferior alveolar nerve block. extraction of 36 done under local anaesthesia and a tissue of size 1x2 cm excised and placed in formalin container for histopathological study (fig.5). bone filing done. granulomatous tissue removed. saline irrigation done. suturing done with 3-0 silk. hemostasis achieved. (a) (b) figure 5(a) surgical excision of the lesion (b) extracted 36 nethra devi et al asian journal of dental and health sciences. 2023; 3(4):4-7 [6] ajdhs.com (a) (b) figure 6: post op image (a) day 1 (b) day 7 discussion: a pyogenic granuloma is an inflammatory hyperplasia that develops when connective tissue reacts excessively to a localized small injury or any underlying irritation8. dental calculi, poor oral hygiene, an unidentified illness, and overcontoured restorations are all potential sources of irritation 7,8. pyogenic granulomas can develop anywhere on the body's surface. they are most common around the fingers and toes. pyogenic granulomas in the oral cavity have a strong predilection for the gingiva, with interdental papillae being the most frequent site in 70% of cases9. vilmann et al. claim that only 15% of pyogenic granulomas are found on the alveolar portion, with the majority of them being found on the marginal gingiva 10. the second decade of life is when pyogenic granuloma most frequently occurs, according to studies by zain rb et al. among singaporean communities 11. a smooth or lobulated exophytic lesion with a pedunculated or sessile base is the most common clinical manifestation of pyogenic granuloma. the size of a pyrogenic granuloma can range from a few millimeters to several centimeters, but it rarely exceeds 2.5 cm12,13. it bleeds readily, grows quickly, and is typically asymptomatic and painless. due to the masticatory trauma, the surface is frequently covered in fibrin, ulcerated, and friable. the surface color varies from pink to red or purple depending on how old the lesion is. while older pgs contain more collagen, younger pgs have more vascularity and hyperplastic granulation tissue13. since they infect minor trauma sites during the healing process, bacteria like streptococci and staphylococci may be involved in the etio-pathogenesis of this lesion. as a result, there may be an increase in vascular growth and tumor-like hyperplasia.12,15 the histopathological examination consists of numerous thinwalled arterial channels visible inside an edematous connective tissue matrix9,16. sometimes, these vessels are grouped into lobular aggregates, and some pathologists need this lobular arrangement to make a diagnosis. moreover, there is a mixed cellular infiltration that is rather dense. the underlying stratified squamous epithelium is typically deteriorated or ulcerated in large sections, and the ulcer edge may have a primitive dysplastic look. it can also be atrophic or hyperplastic9,16. the majority of vascular tumors, such as haemangiomas, oral fibromas, peripheral giant cell granulomas, and peripheral ossifying fibromas, as well as neoplastic lesions, such as kaposi sarcoma, metastatic carcinoma, and other malignant tumors, are included in differential diagnosis17. there have been some reports of drug-induced gingival hypertrophy among nifedipine users. drug-induced gingival enlargement is a generalized fibrotic event that affects a significant section of upper and lower gingiva and has a pebbly surface. it is pale-pink in color13. with respect to treatment, powell mentioned using a nd yag laser to remove this lesion because there were fewer chances of bleeding than with previous surgical methods.18 in a case study by kocaman et al., bleeding time and operating time were decreased during surgery when nd:yag laser was utilized to treat pg. additionally, postoperative hemostasis was accomplished quickly, and no scars or discomfort were seen19. according to a report by fekrazad et al., who used an er:yag laser for the excision of pg, co2 and er:yag lasers aids in better cutting than nd:yag and diode lasers because of their high water absorption, less penetration, and reduced coagulation20. but as of right now, the majority of reports recommend using surgical excision as the preferred treatment. it is advised to do curettage of the underlying tissue following lesion excision, performing an excision with 2 mm margins in the periphery and at a depth that will include periosteum. additionally, it is necessary to remove any foreign objects, calculi, or restorations that may be connected to the development of pyogenic granulomas.21 pyogenic granuloma recurrence following excision is a known hazard. re-excision of such lesions may be required due to the pyogenic granuloma recurrence rate, which is reported to be 16% of treated lesions15. pyogenic granuloma can be effectively treated if the right diagnosis and course of action are taken. a meticulous approach to the lesion's therapy also aids in preventing its recurrence. conclusion literature on oral pyogenic granulomas is extensive. however, the occurrence on the extraction site is very rare. since tooth extraction is a common dental procedure, professionals should be aware that pyogenic granuloma can also develop from an extraction socket. a practitioner may misinterpret this reactive lesion for a more serious one due to lack of awareness about its atypical location. histopathology validates its innocuous nature, making it easy to overcome. conflicts of interest: none. references [1] shiradhonkar a, thakur r, jangid m, kasare n, kurien vt, khan s. management of oral pyogenic granuloma: a case report. int healthc res j. 2022;6(4):cr1-cr4 https://doi.org/10.26440/ihrj/0604.07549 [2] ramirez. k, bruce g: carpenter. wpyogenic granuloma: case report in a 9-year-old girl. general dentistry 2002, 50(3):280-1. [3] nevile bw, damm dd, allen cm, bouquot je: oral and maxillofacial pathology second edition. w.b. saunders co; 2004:444-449. https://doi.org/10.26440/ihrj/0604.07549 nethra devi et al asian journal of dental and health sciences. 2023; 3(4):4-7 [7] ajdhs.com [4] svirsky j: oral pyogenic granuloma. 2007 [http://www.emedi cine]. (10 pages), web med accessed mar 10, 2007 [5] regezi ja, sciubba , james j, jordan richors ck: oral pathology, clinical pathologic correlation fourth edition. sanders company; 2003:115-76. [6] andrikopoulou m, chatzistamou i, gkilas h, vilaras g, sklavounou a. assessment of angiogenic markers and female sex hormone receptors in pregnancy tumor of the gingiva. j oral maxillofac surg. 2013;71(8):1376-81. https://doi.org/10.1016/j.joms.2013.03.009 pmid:23623199 [7] carla gadea rosa, andrea cartagena lay, andreé cáceres la torre. oral pyogenic granuloma diagnosis and treatment: a series of cases. revista odontológica mexicana 2017;21 (4): e244-e252 https://doi.org/10.1016/j.rodmex.2018.01.015 [8] sosa l, ramírez d, palacios mf, arteaga s, dávila l. granuloma piógeno reporte de un caso. acta odontológica venezolana (in english) 2010;48:1-12. [9] patil k, mahima v g, lahari k. extragingival pyogenic granuloma.indian j dent res 2006;17:199-202 https://doi.org/10.4103/0970-9290.29864 pmid:17217217 [10] vilmann a, vilmann p, vilmann h. pyogenic granuloma: evaluation of oral conditions. br j oral maxillofac surg 1986; 24(5): 37682 https://doi.org/10.1016/0266-4356(86)90023-9 pmid:2945586 [11] zain r, khoo s, yeo j. oral pyogenic granuloma clinical analysis of 304 cases. singapore dent j 1995; 20(1): 8-10. [12] pushpendra kumar verma , ruchi srivastava, h.c. baranwal, t.p. chaturvedi, anju gautam , amit singh. pyogenic granuloma hyperplastic lesion of the gingiva: case reports. the open dentistry journal, 2012, 6, 153-156 https://doi.org/10.2174/1874210601206010153 pmid:23091574 pmcid:pmc3474946 [13] dimitrios andreadis, ioanna lazaridi, eleftherios anagnostou, athanasios poulopoulos, prashanth panta, shankargouda patil. diode laser assisted excision of a gingival pyogenic granuloma: a case report clinics and practice 2019; 9:1179, 69-72 https://doi.org/10.4081/cp.2019.1179 pmid:31579498 pmcid:pmc6755259 [14] rai s, kaur m, bhatnagar p. laser: a powerful tool for treatment of pyogenic granuloma. j cutan aesthet surg 2011;4:144-7 https://doi.org/10.4103/0974-2077.85044 pmid:21976910 pmcid:pmc3183723 [15] jafarzadeh h, sanatkhani m, mohtasham n. oral pyogenic granuloma: a review. j oral sci 2006;48:167-75 https://doi.org/10.2334/josnusd.48.167 pmid:17220613 [16] neville bw, damm dd, allen cm, bouquot je: oral and maxillofacial pathology, 2nd ed. elsevier, philadelphia, pages 44749,2002. [17] scully c. oral and maxillofacial medicine. the basis of diagnosis and treatment. 2nd ed. london: elsevier; 2008. pp. 367. [18] amirchaghmaghi m, falaki f, mohtasham n, mozafari pm. extragingival pyogenic granuloma: a case report. cases j. 2008;1:71. https://doi.org/10.1186/1757-1626-1-371 pmid:19055747 pmcid:pmc2614954 [19] kocaman g, belduz n, erdogan c, et al. the use of surgical nd:yag laser in an oral pyogenic granuloma: a case report. j cosmet laser ther 2014;16:197-200. https://doi.org/10.3109/14764172.2014.910078 pmid:24689434 [20] fekrazad r, nokhbatolfoghahaei h, khoei f, kalhori k. pyogenic granuloma: surgical treatment with er:yag laser. j lasers med sci 2014;5:199-205 [21] rosa cg, lay ac, torre ac. oral pyogenic granuloma diagnosis and treatment: a series of cases. rev odontol mex. 2017;21:24452. https://doi.org/10.1016/j.rodmex.2018.01.015 https://doi.org/10.1016/j.joms.2013.03.009 https://doi.org/10.1016/j.rodmex.2018.01.015 https://doi.org/10.4103/0970-9290.29864 https://doi.org/10.1016/0266-4356(86)90023-9 https://doi.org/10.2174/1874210601206010153 https://doi.org/10.4081/cp.2019.1179 https://doi.org/10.4103/0974-2077.85044 https://doi.org/10.2334/josnusd.48.167 https://doi.org/10.1186/1757-1626-1-371 https://doi.org/10.3109/14764172.2014.910078 https://doi.org/10.1016/j.rodmex.2018.01.015 ahirwar et al asian journal of dental and health sciences. 2022; 2(4):59-63 [59] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to pharmaceutical and medical research copyright © 2022 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited review on qsar using anticancer drug hemant ahirwar, gabbar kurmi, rubeena khan, basant khare, anushree jain, prateek kumar jain, bhupendra singh thakur* adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 article info: _______________________________________ article history: received 17 sep 2022 reviewed 09 nov 2022 accepted 24 nov 2022 published 15 dec 2022 _______________________________________ cite this article as: ahirwar h, kurmi g, khan r, khare b, jain a, jain pk, thakur bs, review on qsar using anticancer drug, asian journal of dental and health sciences. 2022; 2(4):59-63 doi: http://dx.doi.org/10.22270/ajdhs.v2i4.27 _______________________________________ *address for correspondence: bhupendra singh thakur, adina college of pharmacy, adina campus rd, lahdara, sagar, mp, 470001 abstract ___________________________________________________________________________________________________________________ new drug discovery has been acknowledged as a complicated, expensive, time-consuming, and challenging project. it has been estimated that around 12 years and 2.7 billion usd, on average, are demanded for a new drug discovery via traditional drug development pipeline. how to reduce the research cost and speed up the development process of new drug discovery has become a challenging, urgent question for the pharmaceutical industry. computer-aided drug discovery (cadd) has emerged as a powerful and promising technology for faster, cheaper and more effective drug design. recently, the rapid growth of computational tools for drug discovery, including anticancer therapies, has exhibited a significant and outstanding impact on anticancer drug design, and has also provided fruitful insights into the area of cancer therapy. in this work, we discussed the qualitative structure activity relationship, a computer-aided drug discovery process with a focus on anticancer drugs. keywords: new drug discovery, computer-aided drug discovery, the qualitative structure activity relationship, anticancer introduction up to now, cancer remains a global and serious public health challenge. it is estimated that there are more than 200 different types of cancer, generally named according to the tissue where the cancer was recognized for the first time. cancer is considered to be one of the significant causes for death in the 21st century and the most critical obstacle for the increase of global life expectancy. according to an analysis by the world health organization (who) in 2015, cancer is the second leading cause of death for patients younger than 70 years old in 91 countries and the third or fourth leading cause of death among 22 other countries1. moreover, a global increase of 18.1 million new cancer cases and 9.6 million cancer-related deaths have been reported in a previous study2, especially 70% of the death caused by cancer occur in lowincome and middle-income countries. the fast growth of the cancer incidence and mortality has turned out to be global health challenges. how to reduce the cancer-related death rate has attracted significant attention from the government, society, medical industry, as well as scientific communities, expecting the rapid development of effective and safe drugs for cancer treatment. despite of the impressive progress in biotechnologies and further understandings of the disease biology, the development of new, practical and innovative small molecule drugs remains an arduous, time consuming and expensive project, which requires collaborations from many expertise in multidisciplinary fields, including medicinal chemistry, computational chemistry, biology, drug metabolism, clinical research, etc. furthermore, it has been illustrated that the successful discovery and development of a new drug costs 12 years, and expensive investment3. thus, novel drug development strategies with a reduced cost of time and money, as well as an enhanced efficiency are in high demand, which would contribute to a significant improvement in global health and life expectancy. since the successful development of hiv protease inhibitor viracept in the usa in 1997, which was the first drug design fully driven by its target structure4, computational methods have served as an essential tool in drug discovery projects and have been a cornerstone for new drug development approaches. this makes the drug developmental process faster and cheaper. recently, the fast growth in computational power, including massively parallel computing on graphical processing units (gpus), the continuous advances in artificial intelligence (ai) tools5,6, have translated fundamental research into practical applications7 in the drug discovery field. this attracted considerable attention for their outstanding performance on providing new promising perspectives and solutions to overcome life threatening diseases. in this review, we aim at providing an overview of qsar-method and anti-cancer therapy discovery in particular. we reviewed some of the most representative examples and clarified fundamental principles by exploring studies on anticancer drug designs with the help of qsar methods. anti-cancer drug target prediction human contains approximately 30,000 genes, among which around 6,000 to 8,000 sites are estimated as potential pharmacological targets. however, less than 400 encoded open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v2i4.27 ahirwar et al asian journal of dental and health sciences. 2022; 2(4):59-63 [60] ajdhs.com proteins have been proved to be effective for drug development until now8,9. cancer, compared to many other human diseases, now has a plethora of potential molecular targets for therapeutic development10. traditional drug discovery mainly follows the paradigm of "one molecule one target one disease", without considering the interactions between drugs and proteins. however, an important fact that many complex diseases are relevant to a variety of target proteins11-13 has been overlooked. furthermore, unexpected drug functions derived from off-targets are accidental and uncontrollable activities because of the ‘poly pharmacological’ properties of certain drugs, which might result in undesirable side effects. those are particularly pronounced for cancer drugs. on the other hand, there are some positive examples that benefit from the different pathways targeted by one given molecule. for example, sildenafil (viagra) was developed to treat angina, but now it is used for erectile dysfunction therapy14. there are several drugs, including anticancer drugs, whose corresponding target proteins (both primary and nontarget) remain yet unidentified or unknown15. furthermore, some attractive and potentially effective cancer targets remain outside of the scope of pharmacological regulation. some of these targets such as phosphatases, transcription factors, and ras family members have been described as undruggable, as they lack effective enzymatic active sites10. to make the full use of known drugs to treat new indications, the characterization of all potential new ligand binding sites has been illustrated as a key point in drug repositioning and repurposing. therefore, new and highly qualitative bioinformatic target prediction methods are required for the accurate prediction of drug targets. up to now, a wide range of drug target interactive web servers has been established, providing a series of drug-target databases and prediction tools. moreover, various computational approaches have been used to study potential interactions between proteins and drugs. in particular, network-based models and ml-based models have emerged as important tools. a review by chen et al. summarizes several available computational models for this application13. interestingly, a method proposed by campillos et al. that uses the similarity of drug side effects to determine whether multiple drugs could interact with the same target proteins attracted our attention16. based on this research, takarabe et al. took advantage of the us fda’s adverse event reporting system (aers) to define the pharmacological similarity of all potential medicines and developed a novel system to predict large-scale interactions between unknown drug targets15. notably, aers was employed to predict interactions between drugs and targets for the first time. in 2010, klipp et al. summarized several available computational models for network-based drug-target prediction17. moreover, various biological data settings, including structures of bioactive compounds, sequences of target proteins, and information of ligand-target interactions, have been combined. a series of machine learning-based approaches have been demonstrated as efficient tools in detecting relationships among drug structures and corresponding target proteins from a large amount of data, such as supervised learning method18, bipartite graph learning method19, bipartite local model20and so on. a recent review by mayr et al. compared the predictive performance of deep learning with other prediction approaches for multiple drug targets in the comparative studies of composite target prediction methods. as a result, feed-forward neural networks were identified with better performance in drug target prediction than other methods21. as above, since a large number of compounds and vigorous efforts are abandoned and wasted due to the off-target effects during the classical drug development procedure, a greatly enhanced development of target prediction in new drug exploration exhibited attractive advantages and further expansion in this area are still highly desirable. quantitative structure activity relationship qsar (quantitative structure activity relationship) is a ligand-based approach that relies on analyzing the biological activities of drugs using various molecular descriptors (mds) or fingerprints (fps). these models mathematically describe how the activities response to the targets according to the ligand's structural characteristics. qsar was obtained by calculating the correlations between the properties of the ligand binding agent and the biological activity measured by experiments. different ml and deep learning (dl) approaches have also been applied to develop qsar models22: including support vector machine (svm), random forest (rf), polynomial regression (pr), multi linear regression (mlr), artificial neural network (ann). unlike the pharmacophore models, qsar models can measure biological activities quantitatively and can even find positive or negative effects according to certain characteristics of the molecule on its activity. qsar has been applied to many other molecular design purposes, such as predicting the new molecule analog activity, optimizing lead, and predicting new structural leads in drug discovery. in the classical 2d-qsar approaches, the biological activity is related to physical and chemical features consisting of steric, electronic, and hydrophobic characters of drugs, and the relationships are represented as mathematical equations23. more advanced 3d-qsar approaches, such as comparative molecular field analysis24 and molecular similarity indexes in a comparative analysis25, are based on the force field calculations. the structural information of molecules is needed, and developed models are represented in 3d contour maps facilitating the visualization and interpretation successful stories of computational drug discovery qsar methods have proved to play an essential role in modern drug discovery. since computational methods could cover almost all stages of the drug discovery pipeline, the applications of qsar methods in anticancer drug discoveries have shown great advantages in terms of the required investment, resources, and time. more recently, qsar methods have become a potent and powerful tool in several successful cases of anticancer drug development. herein, we list several successful applications of qsar methods for small molecule drugs, which have been applied to cancer treatment or are at later stages in the clinical trial. in a study of alomori et al., four oxidovanadium(iv) complexes have been synthesized and characterized by several spectroscopic methods. the ir spectra suggested that the ligands have bidentate coordination mode to the vanadium ion. in addition, the molar conductance, epr, magnetic moment values, and electronic data support a square pyramidal structure for all complexes. computational studies were applied to demonstrate the optimization geometry and essential quantum parameters and confirm their biological efficiency. the metal complexes showed a square-pyramidal geometry arrangement around the metal ion which was agreeable with experimental results. the form coordination bonds length presented strength bonded between oxidovanadium(iv) and the investigated ligand to form stable complexes. the bioactivity study was varied and involved dna-binding, molecular docking, qsar, and cytotoxicity analyses. dna binding results revealed two behaviors for the synthesized oxidovanadium(iv) complexes with an increase in ct-dna concentration, hyperchromic with electrostatic or grooves binding modes and hypochromic signifying an intercalation binding mode. molecular docking results showed that the [vo (ctz)2] 2h2o complex exhibited significant interaction with colon cancer (3ig7) protein with good selectivity. qsar study has given significant information ahirwar et al asian journal of dental and health sciences. 2022; 2(4):59-63 [61] ajdhs.com on biological activity by using the mlr method. qsar model showed a good correlation between the predicted and the experimentally observed inhibitory activities. the results of validation indicate that the generated qsar model possessed a high predictive power (r2 = 0.97). based on the molecular docking and qsar results, [vo(ctz)2] 2h2o was selected and tested for its inhibitory activity against colon cancer cell line (hct116). the selected complex showed higher anticancer activity than the standard cisplatin chemotherapy drug26. in an another research qsar and qaar studies have been conducted on diverse benzamide-derived hdac3 inhibitors as the first initiative to explore the designing strategies of higher active and selective hdac3 inhibitors over hdac1 and hdac2. qsar models reveal that molecular size and shape along with the steric effect should have to be optimized to achieve higher hdac3 inhibition. qaar models reflect that modification/substitution at the benzamide scaffold should be optimized in such a way so that these molecules possess lower steric bulk along with nonpolar features for achieving higher hdac3 selectivity over hdac1 and hdac2. however, the importance of spiro hydrophobic cap group, as well as electron withdrawing fluorine group at the benzamide scaffold, should be well-accounted for retaining higher hdac3 selectivity over hdac1. moreover, less polar and less hydrophobic benzamides are preferred for hdac3 selectivity over hdac2. this detailed structural exploration will surely unveil a new vista of designing highly potent and selective benzamide-based hdac3 inhibitors that may be a crucial weapon to battle against a variety of cancers27. ahirwar et al asian journal of dental and health sciences. 2022; 2(4):59-63 [62] ajdhs.com an example of qsar studies, to design new molecules with anticancer activity, two 3d qsar models was developed: comfa (q2 = 7.32, r2 = 9.92) and comsia (q2 = 7.32, r2 = 9.92) based on 42 pyrazole derivatives. the results obtained for both models were satisfactory and validated by reliable methods. all the newly designed molecules respect the different drug-likeness rules (lipinski, veber, ghose, egan, muegge, and admet prediction). moreover, molecular docking studies results on egfr receptor indicated that the interaction results of the designed compounds t1-t5 in the cavity of the egfr receptor (1 m17) show more type and the number of interactions (hydrogen bond interaction) compared to erlotinib as reference inhibitors of egfr. together, these results facilitate and guide the design and synthesis of novel and more potent pyrazole derivatives with anticancer activity28. conclusion cancer has become a tangible threat to human health. about 9.6 million people are estimated to die from the various forms of cancer each year, according to a statistic report. cancer has become the second-largest disease that causes human death. however, developing a new drug molecule costs 12 years and 2.7 billion usd on average. the drug development for cancer even becomes more complicated, especially considering the molecular pharmacology is still not well understood. hence, the discovery and development of new drugs is considered very expensive and time-consuming. in this respect, computational methods could be constructive for performing different tasks including protein-interaction network analysis, drug target prediction, binding site prediction, virtual screening, and many others. all these innovative methods could considerably facilitate the anti-cancer drug discovery. in recent years, with the advance of ai, more sophisticated methods, such as qsar, retro-synthetic routine plan, drug scaffold generation, drug binding affinity predictions, were developed. the useful predictions generated by qsar models combined with experimental validations could further speed up the anti-cancer drug development. references 1. yan b, yang w, han x, han l. crystal structures and antitumor activity evaluation against gastric carcinoma of two novel coordination polymers. main group chemistry. 2019; 18(3):239246. https://doi.org/10.3233/mgc-180748 2. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer journal for clinicians. 2018; 68(6):394-424. https://doi.org/10.3322/caac.21492 3. kapetanovic i. computer-aided drug discovery and development (caddd): in silico-chemico-biological approach. chemicobiological interactions. 2008; 171(2):165-176. https://doi.org/10.1016/j.cbi.2006.12.006 4. kaldor sw, kalish vj, davies jf, shetty bv, fritz je, appelt k, tatlock jh. viracept (nelfinavir mesylate, ag1343): a potent, orally bioavailable inhibitor of hiv-1 protease. journal of medicinal chemistry. 1997; 40(24):3979-3985. https://doi.org/10.1021/jm9704098 5. chan hs, shan h, dahoun t, vogel h, yuan s. advancing drug discovery via artificial intelligence. trends in pharmacological sciences. 2019; 40(8):592-604. https://doi.org/10.1016/j.tips.2019.06.004 6. yan b, yang w, han x, han l. crystal structures and antitumor activity evaluation against gastric carcinoma of two novel coordination polymers. main group chemistry. 2019; 18(3):239246. https://doi.org/10.3233/mgc-180748 7. zhavoronkov a, ivanenkov ya, aliper a, veselov ms, aladinskiy va, aladinskaya av, aspuru-guzik a. deep learning enables rapid identification of potent ddr1 kinase inhibitors. nature biotechnology. 2019; 37(9):1038-1040. https://doi.org/10.1038/s41587-019-0224-x 8. drews j. drug discovery: a historical perspective. science. 2000; 287(5460):1960-1964. https://doi.org/10.1126/science.287.5460.1960 9. chen x, yan cc, zhang x, zhang x, dai f, yin j, zhang y. drug-target interaction prediction: databases, web servers and computational models. briefings in bioinformatics. 2016; 17(4):696-712. https://doi.org/10.1093/bib/bbv066 10. lazo js, sharlow er. drugging undruggable molecular cancer targets. annual review of pharmacology and toxicology. 2016; 56:23-40. https://doi.org/10.1146/annurev-pharmtox-010715103440 11. hopkins al. network pharmacology: the next paradigm in drug discovery. nature chemical biology. 2008; 4(11):682-690. https://doi.org/10.1038/nchembio.118 12. yamanishi y, araki m, gutteridge a, honda w, kanehisa m. prediction of drug-target interaction networks from the integration of chemical and genomic spaces. bioinformatics. 2008; 24(13):i232-i240. https://doi.org/10.1093/bioinformatics/btn162 13. rajak h, patel v, jain dk, dewangan pk, sharma pc, veerasamy r, gupta ak, dangi js. structure-activity relationships among novel 1, 3, 4-oxadiazole analogues for their anti-inflammatory activity. current research in pharmaceutical sciences. 2012; 03:142-148. 14. ghofrani ha, osterloh ih, grimminger f. sildenafil: from angina to erectile dysfunction to pulmonary hypertension and beyond. nature reviews drug discovery. 2006; 5(8):689-702. https://doi.org/10.1038/nrd2030 https://doi.org/10.3233/mgc-180748 https://doi.org/10.3322/caac.21492 https://doi.org/10.1016/j.cbi.2006.12.006 https://doi.org/10.1021/jm9704098 https://doi.org/10.1016/j.tips.2019.06.004 https://doi.org/10.3233/mgc-180748 https://doi.org/10.1038/s41587-019-0224-x https://doi.org/10.1126/science.287.5460.1960 https://doi.org/10.1093/bib/bbv066 https://doi.org/10.1146/annurev-pharmtox-010715-103440 https://doi.org/10.1146/annurev-pharmtox-010715-103440 https://doi.org/10.1038/nchembio.118 https://doi.org/10.1093/bioinformatics/btn162 https://doi.org/10.1038/nrd2030 ahirwar et al asian journal of dental and health sciences. 2022; 2(4):59-63 [63] ajdhs.com 15. takarabe m, kotera m, nishimura y, goto s, yamanishi y. drug target prediction using adverse event report systems: a pharmacogenomic approach. bioinformatics. 2012; 28(18):i611i618. https://doi.org/10.1093/bioinformatics/bts413 16. campillos m, kuhn m, gavin ac, jensen lj, bork p. drug target identification using side-effect similarity. science. 2008; 321(5886):263-266. https://doi.org/10.1126/science.1158140 17. klipp e, wade rc, kummer u. biochemical network-based drugtarget prediction. current opinion in biotechnology. 2010; 21(4):511-516. https://doi.org/10.1016/j.copbio.2010.05.004 18. srivastava n, hinton g, krizhevsky a, sutskever i, salakhutdinov r. dropout: a simple way to prevent neural networks from overfitting. the journal of machine learning research. 2014; 15(1):1929-1958. 19. li x, chen h. recommendation as link prediction in bipartite graphs: a graph kernel-based machine learning approach. decision support systems. 2013; 54(2):880-890. https://doi.org/10.1016/j.dss.2012.09.019 20. yıldırım ma, goh ki, cusick me, barabási al, vidal m. drug-target network. nature biotechnology. 2007; 25(10):1119-1126. https://doi.org/10.1038/nbt1338 21. mayr a, klambauer g, unterthiner t, steijaert m, wegner jk, ceulemans h, hochreiter s. large-scale comparison of machine learning methods for drug target prediction on chembl. chemical science. 2018; 9(24):5441-5451. https://doi.org/10.1039/c8sc00148k 22. mendenhall j, meiler j. improving quantitative structure-activity relationship models using artificial neural networks trained with dropout. journal of computer-aided molecular design. 2016; 30(2):177-189. https://doi.org/10.1007/s10822-016-9895-2 23. hansch c, fujita t. additions and corrections-ρ-ς-π analysis. a method for the correlation of biological activity and chemical structure. journal of the american chemical society. 1964; 86(24):5710-5710. https://doi.org/10.1021/ja01078a623 24. cramer rd, patterson de, bunce jd. comparative molecular field analysis (comfa). 1. effect of shape on binding of steroids to carrier proteins. journal of the american chemical society. 1998; 110(18):5959-5967. https://doi.org/10.1021/ja00226a005 25. klebe g, abraham u, mietzner t. molecular similarity indices in a comparative analysis (comsia) of drug molecules to correlate and predict their biological activity. journal of medicinal chemistry. 1994; 37(24):4130-4146. https://doi.org/10.1021/jm00050a010 26. alomari fy, sharfalddin aa, abdellattif mh, domyati d, basaleh as, hussien ma. qsar modeling, molecular docking and cytotoxic evaluation for novel oxidovanadium (iv) complexes as colon anticancer agents. molecules. 2022; 27(3):649. https://doi.org/10.3390/molecules27030649 27. adhikari n, amin sa, trivedi p, jha t, ghosh b. hdac3 is a potential validated target for cancer: an overview on the benzamide-based selective hdac3 inhibitors through comparative sar/qsar/qaar approaches. european journal of medicinal chemistry. 2018; 157:1127-1142. https://doi.org/10.1016/j.ejmech.2018.08.081 28. singh a, patel vk, jain dk, sharma pc, gupta ak, sharma ak, rajak h. histone deacetylase inhibitors: current status in treatment of leukemia. current research in pharmaceutical sciences. 2013; 03 (04):102-107 https://doi.org/10.1093/bioinformatics/bts413 https://doi.org/10.1126/science.1158140 https://doi.org/10.1016/j.copbio.2010.05.004 https://doi.org/10.1016/j.dss.2012.09.019 https://doi.org/10.1038/nbt1338 https://doi.org/10.1039/c8sc00148k https://doi.org/10.1007/s10822-016-9895-2 https://doi.org/10.1021/ja01078a623 https://doi.org/10.1021/ja00226a005 https://doi.org/10.1021/jm00050a010 https://doi.org/10.3390/molecules27030649 https://doi.org/10.1016/j.ejmech.2018.08.081 emini et al asian journal of dental and health sciences. 2023; 3(2):23-25 [23] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited leaflet media as an effort to increase knowledge of dental health maintenance in elementary school students emini1, lola amalia2, tedi purnama3* 1,2,3 department of dental health, health polytechnic jakarta i, jakarta, indonesia article info: ___________________________________________ article history: received 29 march 2022 reviewed 12 may 2023 accepted 28 may 2023 published 15 june 2023 ___________________________________________ cite this article as: emini, amalia l, purnama t, leaflet media as an effort to increase knowledge of dental health maintenance in elementary school students, asian journal of dental and health sciences. 2023; 3(2):23-25 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.44 _______________________________________ *address for correspondence: tedi purnama, department of dental health, health polytechnic jakarta i, jakarta, indonesia abstract ________________________________________________________________________________________________________________________ knowledge can be increased through health promotion. in terms of the age at which children are susceptible to disease, counseling is especially aimed at groups prone to dental and oral health problems, namely elementary school-aged children. leaflet media is the right media to increase the knowledge of fourth grade students where students can already read. this study aims to analyze the effectiveness of dental and oral health maintenance knowledge before and after being given counseling using leaflet media to class iv students at sdn sawangan 07 depok in 2022. the research design used was quasi-experimental. the sampling technique with a total sample of 36 students. data was collected by filling out pre-test and post-test questionnaires given to class ivb students. data analysis used paired sample test. the results of the study before being given counseling about dental health maintenance using leaflet media had a good level of knowledge category of 25 people with a percentage of 69%, the level of knowledge in the sufficient category was 5 people with a percentage of 14%, and the level of knowledge in the poor category was 6 people with a percentage of 17%. the results of the study after being given counseling about maintaining dental health with leaflet media, most of the respondents had a good level of knowledge, 29 people with a percentage of 81%, the level of knowledge in the sufficient category was 7 people with a percentage of 19%, and no students were included in the poor category. the results of the paired sample test analysis obtained a p-value of 0.000. conclusion: leaflet media is effective in increasing knowledge about maintaining oral health in elementary school students. keywords: leaflet media, knowledge, dental health, elementary school students introduction dental and oral health is part of overall health. maintaining good and correct dental and oral health will certainly greatly support the realization of optimal dental and oral health. dental and oral diseases that affect many children and adults are caries or cavities.1–3 based on data from basic health research the prevalence of dental caries in indonesia is still quite high, seen in 2018 the prevalence of dental caries in the 5-9 years age category reached 54.0% and the 10-14 years age group was 41.4%. the population of school children aged 6-12 years reaches 40-50% of the general community, so dental and oral health education efforts to target school children are a top priority.4–6 one of the main factors affecting oral health is behavior. behavior that can affect the development of caries is about how to maintain healthy teeth and mouth, so that behavior is greatly influenced by knowledge. behavior that is based on correct knowledge will last longer than behavior that is not based on knowledge, including knowledge about how to maintain proper dental health which will greatly affect the incidence of caries.7–9 knowledge can be increased through health promotion. in terms of the age at which children are susceptible to disease, counseling is especially aimed at groups prone to dental and oral health problems, namely elementary school-aged children. one form of effort to minimize existing morbidity rates is preventive action through health promotion activities. counseling is an example of efforts to prevent dental and oral health problems, because this activity can increase public knowledge and awareness to maintain health and improve health status. dental and oral health promotion is a process of providing information that arises on the basis of dental and oral health needs that aim to produce good dental and oral health and improve living standards. in promoting dental and oral health, individuals gain experience or information through various media for promoting dental and oral health. the media is one thing that needs attention in carrying out health promotion.10–12 the media used in this research is leaflet media. this media includes print media in the form of sheets which have the function of conveying health information or messages through folded sheets. information content can be in sentences or pictures, or a combination. leaflet sheets are simply folded and then given an attractive design and use simple language to make it easy for readers to understand. media leaflets are generally placed in public places and are easily visible. this is due to the characteristics of the leaflet media which are specifically designed to be read quickly by the recipient. research hadju, shows that there is an influence of counseling through the media of leaflets on increasing knowledge of dental and oral health with an average pre-test score of 3.91 and an average post-test score of 6.21 from the results of the research he conducted on students – 49 grade v students at sd negeri 18 mandonga, kendari city. another study by nubatonis also proved leaflet media could significantly increase the knowledge, attitudes and dental and oral hygiene of elementary school students.13–15 open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.44 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.44&amp;domain=pdf emini et al asian journal of dental and health sciences. 2023; 3(2):23-25 [24] ajdhs.com method and material the research design used was a quasi-experimental study with a one group pretest-posttest design. the aim of the study was to analyze the effectiveness of dental health maintenance knowledge before and after counseling using leaflet media for fourth grade students at sdn sawangan 07 depok. the research was conducted in april 2022. the sample is the object that is examined and is considered to represent the entire population. the sample used is the total sampling method, which is a sampling technique where the number of samples is the same as the population.16 the sample used in this study was 36 students in grade ivb at sdn sawangan 07 depok. the instruments used in this study were informed consent sheets (statements of consent), questionnaires (pretest and posttest) to obtain data about knowledge of dental and oral health care, and leaflets containing material about dental and oral health care. the stages of the research were carried out in several stages, first conducting introductions and explaining the research to respondents; conduct a pretest on respondents before counseling is carried out to find out knowledge about maintaining dental and oral health by using a questionnaire and filling in is limited to 10 minutes; distributing leaflets; explain the contents of the leaflet while conducting counseling for 15 minutes; leaflets are given as student self-learning; the last week after doing a posttest to find out knowledge about maintaining oral and dental health after being given dental health education using leaflet media. analysis of the data used in this study using spss with paired sample t test. result measuring knowledge of dental and oral health care before being given counseling using leaflet media, given a pretest questionnaire with a total of 12 questions. table 1: frequency distribution of knowledge of dental and oral health maintenance before counseling using leaflet media knowledge frequency percentage good 25 69 sufficient 5 14 poor 6 17 total 36 100 based on table 1, the level of knowledge of dental and oral health maintenance of respondents before counseling using leaflet media had a good level of knowledge category of 25 people with a percentage of 69%, sufficient category of 5 people with a percentage of 14%, and poor category of 6 people with a percentage of 17%. table 2. frequency distribution of knowledge of dental and oral health maintenance after counseling using leaflet media knowledge frequency percentage good 29 81 sufficient 7 19 poor 6 17 total 36 100 based on table 2, the level of knowledge of dental and oral health after being given counseling with leaflet media, most of the 36 respondents had a good level of knowledge, 29 people with a percentage of 81%, the sufficient category was 7 people with a percentage of 19%, and no students entered the poor category. table 3: different test of debris index before and after counseling using leaflet media knowledge of dental and oral health mean difference p-value pre-test 8.6 1.6 0.000 pos-test 10.2 based on table 3, the average knowledge of dental and oral health maintenance before being given counseling using leaflet media has an average value of 8.6 and the average knowledge after being given counseling using leaflet media has an average value of 10.2, with p=0.000, meaning that the leaflet media is effective in increasing knowledge of dental and oral health care for elementary school children discussion the results of the research conducted regarding the description of knowledge of dental and oral health maintenance before and after being given counseling using leaflet media for class ivb students at sdn sawangan 07 depok, there was a change in students' knowledge before and after being given counseling using leaflet media about maintaining dental and oral health, the data obtained was that there was increase in knowledge in the good category, before counseling there were 25 students with a percentage of 69%, after being given counseling with leaflet media to 29 students with a percentage of 81%, then there was an increase in the sufficient category before being given counseling there were 5 students with a percentage of 14%, after being given counseling there were 7 students with a percentage of 19%, and a decrease in the less category before being given counseling there were 6 students with a percentage of 17%, after being given counseling there were no students who were included in the less category. the results of the paired sample t test obtained a value of p = 0.000, meaning that leaflet media is effective in increasing knowledge of dental and oral health maintenance in elementary school children. the results of this study indicate that there is an increase in the knowledge of respondents before and after being given counseling about dental and oral health maintenance using leaflet media. this is because counseling with leaflet media has the advantage that it is easier to attract attention and stimulate children's understanding. counseling with leaflet media can also make children see interesting pictures simultaneously related to the material provided.12 then according to research conducted by nubatonis shows that leaflet media can effectively increase children's knowledge. this was reinforced by research conducted by nubatonis, the results of which showed that there were significant differences in knowledge and attitudes assessed by pretest and posttest between the two elementary school groups using leaflet media. these results prove that dental health education interventions through leaflet media can increase changes in students' knowledge and attitudes in maintaining dental and oral hygiene.15 from this description, when compared with the results of research conducted by imelda regarding the effect of leaflet media counseling on dental and oral hygiene knowledge of fifth grade students at supat 1 public elementary school in 2021. based on the results of his research before counseling (pretest) that the average score average 8.3 and the average emini et al asian journal of dental and health sciences. 2023; 3(2):23-25 [25] ajdhs.com value after counseling (posttest) is 15.3 meaning that there is a significant difference in the level of knowledge of children from children before counseling compared to after counseling with leaflet media. while the results of the study were obtained for class ivb students at sdn sawangan 07 depok in 2022, that the average score before counseling using leaflet media (pretest) was 8.6 and the average score after counseling (posttest) was 10.2. it can be concluded that from this research there is a similarity, namely an increase in the average value of respondents' knowledge before counseling (pretest) and after counseling (posttest) with leaflet media. and the difference is the results of the numbers obtained before and after counseling. conclusion based on the results of the research that has been done, it can be concluded that there is the leaflet media is effective in increasing knowledge of dental and oral health care for elementary school children acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. references 1. re pr, nurbayani s, atmasumarta t, lestari tr, purnama t. the effect of pop up book media on increasing dental health knowledge in elementary school children. asian j pharm res dev. 2022; 10(2):6-9. https://doi.org/10.22270/ajprd.v10i2.1112 2. fadjeri i, budiarti r, purnama t. dental care interventions as efforts to reduce pufa index and improve nutritional status in children aged 9-12 years in orphanages. med leg updat. 2021; 21(1):366-71. 3. ramdiani d, yulita i, sasongko bg, purnama t. required treatment index (rti) pada pasien dewasa di klinik dokter gigi tjang riyanto cahyadi kota bogor. jdht j dent hyg ther. 2020; 1(2):5560. https://doi.org/10.36082/jdht.v1i2.128 4. kementerian kesehatan ri. laporan nasional riset kesehatan dasar 2018. riskesdas. 2018; 614. 5. wirata in, gede agung aa. perbedaan tingkat pengetahuan tentang pemeliharaan kesehatan gigi dan mulut siswa sdn 2 singapadu kaler sebelum dan sesudah dilakukan penyuluhan. j kesehat gigi (dental heal journal). 2016; 4(2):72-7. 6. maryam h, isnanto i, mahirawatie ic. determinants of nutritional status in the dental health status of school age children: systematic literature review. jdht j dent hyg ther. 2021; 2(2):62-71. https://doi.org/10.36082/jdht.v2i2.336 7. ngatemi, purnama t, rahmadhani nm. dental health education with zoom meeting application during the covid-19 pandemic: is it effective? int j multidiscip res anal. 2021; 3:5. https://doi.org/10.47191/ijmra/v4-i12-17 8. widiyastuti r, awaliah m, et al. instagram social media as an effort to increase dental health knowledge. int j multidiscip res anal. 2022; 05(12):3465-8. https://doi.org/10.47191/ijmra/v5-i12-22 9. tanjung mfa. hubungan perilaku kesehatan gigi dengan kejadian karies gigi pada anak di kelurahan pasar baru kecamatan sei tualang raso kota tanjung balai tahun 2020. j heal sci physiother. 2021; 3(2):26-31. 10. cooper am, o'malley la, elison sn, armstrong r, burnside g, adair p, et al. primary school‐based behavioural interventions for preventing caries. cochrane database syst rev. 2013; (5). https://doi.org/10.1002/14651858.cd009378.pub2 11. ngatemi n, purnama t. counseling with tooth brushing demonstration method as an effort to improve tooth brushing skills and the status of dental and oral hygiene in early childhood at school. med leg updat. 2021; 21(1):684-7. 12. papilaya ea, zuliari k. perbandingan pengaruh promosi kesehatan menggunakan media audio dengan media audio-visual terhadap perilaku kesehatan gigi dan mulut siswa sd. e-gigi. 2016; 4(2). https://doi.org/10.35790/eg.4.2.2016.14261 13. sholiha n, purwaningsih e, hidayati s. pengetahuan tentang kebersihan gigi dan mulut dengan penggunaan media leaflet pada siswa sekolah dasar. j ilm keperawatan gigi. 2021; 2(3):593-602. 14. hadju l. pengaruh penyuluhan melalui media leaflet terhadap peningkatan pengetahuan kesehatan gigi dan mulut pada siswa kelas v di sd negeri 18 mandonga kota kendari. miracle j public heal. 2020; 3(1):33-8. https://doi.org/10.36566/mjph/vol3.iss1/136 15. nubatonis mo, ayatulah mi. promosi kesehatan gigi dengan menggunakan media leaflet terhadap pengetahuan, sikap, status kebersihan gigi dan mulut. j kesehat gigi. 2019; 6(2):147-56. https://doi.org/10.31983/jkg.v6i2.5493 16. notoatmodjo s. metodologi penelitian kesehatan. jakarta: rineka cipta; 2010 https://doi.org/10.22270/ajprd.v10i2.1112 https://doi.org/10.36082/jdht.v1i2.128 https://doi.org/10.36082/jdht.v2i2.336 https://doi.org/10.47191/ijmra/v4-i12-17 https://doi.org/10.47191/ijmra/v5-i12-22 https://doi.org/10.1002/14651858.cd009378.pub2 https://doi.org/10.35790/eg.4.2.2016.14261 https://doi.org/10.36566/mjph/vol3.iss1/136 https://doi.org/10.31983/jkg.v6i2.5493 rusmali et al asian journal of dental and health sciences. 2023; 3(3):5-9 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the effect of dental caries incidence rate (dmf-t), dental and oral hygiene status (ohi-s) on adolescent tooth brushing behavior based on the area of residence on the river coast and highlands in tayan hilir district in 2023 rusmali, miftah tri abadi, mery sartika department of dental health, health polytechnic of pontianak, indonesia article info: _______________________________________ article history: received 12 june 2023 reviewed 05 august 2023 accepted 26 august 2023 published 15 september 2023 _______________________________________ cite this article as: rusmali, abadi mt, sartika m, the effect of dental caries incidence rate (dmf-t), dental and oral hygiene status (ohi-s) on adolescent tooth brushing behavior based on the area of residence on the river coast and highlands in tayan hilir district in 2023, asian journal of dental and health sciences. 2023; 3(3):5-9 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.46 _______________________________________ *address for correspondence: rusmali, department of dental health, health polytechnic of pontianak, indonesia. abstract ___________________________________________________________________________________________________________________ concerning oral health in sanggau district is still quite high, the results of an initial survey in tayan hilir district on mtsn3 children used a questionnaire on 42 respondents. the results obtained are as follows, knowledge about dental and oral health is good (54.8%, and moderate (45.2%). this study aims to describe and analyze the influence of the incidence of dental caries (dmf-t), the status of dental and oral hygiene ( ohi-s) on tooth brushing behavior of young men based on their area of residence on the river coast and highlands in tayan hilir district, sanggau regency.the tools used were a questionnaire with cross sectional, correlate spearman and kendall's test and regression, with univariate, bivariate analysis, multivariate the results showed that the incidence of dental caries (dmf-t) was 32.3%, oral hygiene status (ohi-s) was 48%. river (54.5%), types of food consumed on average non-cariogenic types every day (61.1%), the age of most respondents aged 13 years (40.4%), the incidence of caries (dmf-t) is influenced by status dental and oral hygiene (ohi-s) by (r=15.7%), influenced by tooth brushing behavior by (r=15%), influenced by living area by (r=8.8%), influenced by type of food ( r=6.3%), and influenced by age (r=6.5%). dental and oral hygiene status (ohi-s) affected the incidence of dental caries (dmf-t) by (r=16.4%), influenced tooth brushing behavior by (r=15%), affected area of residence (r=9, 9%), affecting the type of food consumed every day non cariogenic type (r = 9%), as well as influencing age (r = 21.3%). overall the incidence of dental caries (dmf-t) is influenced by oral hygiene status (ohi-s), and vice versa, including the type of food consumed daily and age. the significance value is 0.00 <0.05 with the number (r) close to 1, so it can be concluded that the effect is perfect. keywords: dmf-t, ohi-s, toothbrushing behaviour, place of residence introduction efforts to provide dental health services are aimed at groups prone to dental and oral health problems, such as pregnant women, nursing mothers, toddlers, preschool age and schoolage children. the group of school-age children is one of the vulnerable groups, because these school-age children have habits and behaviors that are less supportive of dental and oral health. knowledge is fundamental and very important for cultivating a person's habits to be able to change attitudes and behavior. knowledge can be obtained directly or indirectly both planned and without planning, whether through formal or informal education processes, because knowledge is a predisposing factor of attitudes and behavior.1,2 based on the 2020 tayan hilir district profile, the topography or living areas of tayan hilir district are generally located in river coastal areas or hilly and swampy highlands which are flowed by several rivers such as the kapuas river and tributaries of the sembesut river. cempedak river, semendok river, segelam river, mata burik river and tayan river. local culture (social sciences) states that different topography can cause differences in light intensity, humidity, air pressure and air temperature. high-altitude topography will also affect living creatures in receiving oxygen and air pressure, so it will affect a person's health status.3 the results of research conducted by researchers in 2020, regarding empowering people by directly reading personal hygiene books to maintain oral hygiene with a sample of children from sdn 01 semanget village and sdn 08 nekan village, which had a very positive impact. the difference in value between the control and intervention groups before and after receiving treatment by reading personal hygiene books on how to maintain oral hygiene. there was a difference in value of 49.4% between the intervention group and the control group and a siq value of 0.00 <0.05. this means that providing knowledge by directly empowering respondents will be better and very significant than just using lectures and regular question and answer. based on these problems, the researcher wants to describe the results of the analysis of the effect of the incidence of dental caries (dmf-t), dental and oral hygiene status (ohi-s) on the teeth brushing behavior of young men based on the area of residence on the river coast or highlands in tayan hilir district, sanggau in 2023. method and material this study used a survey method with observation to collect data on the incidence of dental caries (dmf-t), dental and oral hygiene status (ohi-s), on the toothbrushing behavior of young women based on the area of residence on the river open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.46 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.46&amp;domain=pdf rusmali et al asian journal of dental and health sciences. 2023; 3(3):5-9 [6] ajdhs.com coast or highlands. the tools used are questionnaires, spearmant kendalls test and regression. the total number of respondents was 198 people. the subjects of this study are especially young men aged between 12 and 25 years and who live in coastal areas or highlands in tayan hilir district, sanggau regency in 2023. the research was carried out in tayan hilir district, with the location of the schools in the coastal area of the river or highlands in the village of tayan hilir district, sanggau regency. the time provided adjusts to the academic calendar, so that the secondary and premier data collection schedules are also adjusted, data collection can be carried out between friday saturday. the analysis used is univariate, bivariate, multivariate, the test used is regression to find the magnitude of the effect while corelate is to find out whether there is no correlation or perfect correlation. the data is displayed in the form of a frequency distribution table. result table 1: frequency distribution based on respondent characteristics, dental caries incidence rate (dmft), dental and oral hygiene status (ohi-s), tooth brushing behavior and types of food that are often consumed every day variable n % age 12 years 16 16.7 13 years 80 40.4 14 years 50 25.3 15 years 21 10.6 16 years 17 8.6 17 years 11 5.6 18 years 1 0.5 19 years 2 1 domicile river coast 108 54.5 plateau 90 45.5 dental caries incidence rate (dmft) very low (0.0-1.1) 56 28.3 low (1.1-2.6) 29 14.6 medium (2.7-4.4) 64 32.3 height (4.5-6.5) 31 15.7 very high (> 6.6) 18 9.1 dental and oral hygiene status (ohi-s) good 94 47.5 moderate 95 48 bad 9 4.5 tooth brushing behavior 1x a day 33 16.7 2x a day 134 67.7 3x a day 26 13.1 > 3x a day 5 2.5 type of food cariogenic 77 38.9 non cariogenic 121 61.1 table 1 shows that the most dominant average age is 13 years 40.4% and 14 years 25.3%. it can be seen that the average area of residence for young men on the river coast is 54.5% and that in the highlands is 45.5%. the average incidence of dental caries (dmft) is in the moderate category, 32.3%. the average oral hygiene status (ohi-s) was moderate 48% and good 47.5%. the average tooth brushing behavior of young women is 67.7% twice a day and the average number of young men consuming cariogenic types of food is 38.9% while non-cariogenic types are 61.1%. rusmali et al asian journal of dental and health sciences. 2023; 3(3):5-9 [7] ajdhs.com table 2: correlation test analysis results correlation r siq. r dmf-t vs ohi-s 0.147 0.03 0.157 tooth brushing behavior 0.57 521 0.150 domicile 0.061 390 0.088 age 0.065 372 0.77 types of food 0.067 282 0.063 table 2 shows that the influence of the number of dental caries incidents (dmf-t) on ohi-s status is very perfect because the r value is close to 1 and is also very significant because the p value = 0.03 <0.05. table 3: regression test analysis results correlation r siq. r ohi-s vs dmf-t 0.147 0.03 164 tooth brushing behavior 0.57 0.36 150 domicile 0.061 0.58 099 age 0.065 0.00 213 types of food 0.067 0.21 211 table 3 shows that the effect of status (ohi-s) on the dmf-t number is 16.4% and is very perfect because the r value is close to 1. it is also very significant because the siq value. 0.03<0.05. likewise with the magnitude of the age of 21.3% and is very perfect because the value of r is close to 1 is also very significant because the value of p = 0.00 <0.05. discussion the incidence of dental caries (dmf-t) is in the moderate category of 64 (32.3%), this shows that teenagers need to pay special attention to increasing knowledge, taking preventative action against existing cases to prevent and avoid further damage. from tooth decay so that it does not interfere with future activities. tooth decay will greatly affect activities and even interfere with school activities, as well as disrupting appetite which can result in malnutrition due to lack of intake that can be absorbed by the body, thus special attention needs to be paid to changing attitudes and behavior among teenagers so that the number of cases increases. dental and oral health continues to improve with age. it is also necessary to pay attention to why, because today's teenagers will continue to grow and develop.4,5 this growth and development will be disrupted or become a separate problem for adolescents, when they later enter the world of work, if the teeth are not treated comprehensively, it can result in these adolescents being unable to enter the world of work due to toothache, for example. in the world of work, if this happens, the company or place where youth work will lose a number of production due to absence from work. for the growth and development that can occur in adolescents where there is a lot of damage to the teeth, it will result in difficulty eating because it hurts. if the toothache persists, it can cause you to be lazy about eating, which can lead to a lack of nutritional intake in the body. the lack of nutritional intake will affect the organs in the body, and if this continues without improving the nutritional intake of these adolescents they can be malnourished or even anemia. if malnutrition or anemia continues without adequate nutritional support, something even worse can happen, namely stunting. what young men can do is to carry out simple promotive, preventive and curative activities, with the aim of changing attitudes and behavior through increased knowledge.6–8 knowledge is a very important domain for changes in one's attitude and behavior, moreover this knowledge has been instilled from an early age. based on the opinion of several experts, if we reach 40 years of age, we must have a minimum of 28 teeth. preventive activities that can be carried out are closing fissures using glass ionomer (gi) materials, or cleaning tartar if tartar is present. while the curative action that can be done is in the form of fillings with the art technique, using composite materials or other tooth-colored filling materials. the influence of tooth brushing habits can reduce the plaque index and ph of saliva, according to triswari & pertiwi, this habit needs to be instilled as early as possible especially in children who have the potential to damage their teeth more, so it is necessary to instill the habit from an early age, so that this habit will carry over until adulthood.9 based on the results of research from wijayanti & rahayu, it is stated that getting used to brushing your teeth is the main action in efforts to improve dental and oral health. knowledge is a very important domain in shaping a person's actions (overt behavior).10 according to written research experience by handayani and ratnaningsih in rusmali that behavior based on knowledge will be more lasting than behavior that is not based on knowledge. knowledge is justified true belief, which means confirming the truth of a belief based on observation.11 the dental and oral hygiene status (ohis) of respondents in this study was in the moderate criteria, namely 95 (48%). dental and oral hygiene status (ohi-s) is an indicator of dental and oral health in terms of hygiene. efforts to keep your teeth and mouth healthy and clean are necessary, you have to go to the nearest dental and oral health service facility, whether it is a health center, hospital or private service clinic, at least twice a year to have it checked according to recommendations. this status is the result of combining the debris index (di) and calculus index (ci) values. if these values are combined, a person's dental and oral hygiene status will be depicted. this status can be included in the good criteria if the value is 0.01.0, the medium criteria if the combined value is 1.13.0 and the worst is if the combined value is ranging from 3.1-6.0. rusmali et al asian journal of dental and health sciences. 2023; 3(3):5-9 [8] ajdhs.com teeth with a lot of tartar will cause buildup on the teeth and make the oral cavity smelly. if a large amount of tartar is not cleaned for a long time, it can cause the teeth to become loose. the degree of mobility of the teeth will cause the mouth to feel painful when chewing while eating and drinking, as a result the teeth are an indication for extraction. teeth should stay in a person's oral cavity longer, with good teeth the digestive process in the digestive tract will still be good.12–14 based on research results from wijayanti & rahayu, it is stated that getting used to brushing your teeth is the main action in efforts to improve dental and oral health. teeth are healthy and clean if the teeth do not have cavities, when used they do not feel painful, there is no tartar, the color of the gums is pink. the best way to do this is to brush your teeth properly and regularly.10 according to arianto, factors related to dental and oral hygiene maintenance behavior (ohi-s) and oral hygiene maintenance attitudes (ohis) have a value of p=0.018, knowledge of maintenance behavior with a value of p=0.044, maintenance actions dental and oral hygiene (ohis) p = 0.013. or=1,749 value. oral hygiene status (ohis) affects the dmf-t rate of 16.4% and the siq. 0.03 <0.05, this value shows that the influence of dental and oral hygiene is very large and very significant in influencing the occurrence of cavities.15 the behavior of adolescents in brushing their teeth on average with a frequency of 2x a day is 67.7%. however, the 2x a day must be adjusted according to the time such as: why do you brush your teeth after breakfast, because after you have breakfast your mouth will have a rest period so you don't chew food while someone is active. thus, during rest, acidogenic germs will not metabolize cariogenic food waste in the oral cavity, so that the process of demineralization or shedding of the tooth enamel layer does not occur. brushing your teeth before going to bed at night, because when we sleep with a clean oral cavity, we can avoid the demineralization process mentioned above. a person's behavior or habit of brushing their teeth properly and regularly, which is done every day, can have an influence on the occurrence of dental caries of (r = 0.570 = 57.0%) and the siq value. 0.000 < 0.05. the behavioral factor turns out to have a very large influence, reaching 57.0%, behavior is a habit and is usually carried out every day by someone.16 behavior does not mean it cannot be changed, but it can be done even though it takes time because it depends on the person's wishes. according to covey in the book the seven habbits, this habit can be quickly adopted if it is started from childhood, so that later when an adult someone is used to these positive things. these habits require knowledge, so knowledge is a very important domain for behavior change to occur. human behavior is an action that is influenced by several factors such as custom, emotion, ethics and others. activities can be interpreted in a broad form, therefore these activities can be observed directly or indirectly, human behavior is a form of emotion that is stimulated from outside.17 the behavior of indonesian children in maintaining dental and oral health is still very low, dental care is considered not very important even though it is very useful in supporting health and appearance. this behavior arises from children's lack of knowledge about the importance of maintaining healthy teeth.18,19 it was recorded that behavior from the results of this research had a 15% influence on tooth brushing behavior. behavior can change once there is knowledge. so it is necessary to cultivate habits from an early age. the average respondent who became the research sample was 40.4% aged 13 years and 25.3% aged 14 years, according to who the youth category is between 12 years and 25 years old. this means that teenagers who are currently the sample in this study can still be guided and directed on how to maintain healthy teeth and mouths to stay healthy. nurwati said that one of the factors that influences the occurrence of dental caries is age.20 it turns out that age can also affect the occurrence of one's dental caries, the magnitude of the influence of the age scale for the occurrence of dental caries is (r = 0.107 = 10.7%), meaning that it is also necessary to pay attention to it because it has quite a large effect. tooth decay is strongly influenced by age, as evidenced by the results of this study showing the magnitude of the influence of age is 21.3% and is very significant. siq value. 0.00 <0.05, meaning that a person's age has a very significant influence on the occurrence of cavities, it is possible that at the age of 13 he is still unstable or indeed his knowledge is still limited, especially about maintaining healthy teeth and mouth. the average area where respondents live is along the river coast, 108 (54.5%), where they live may also have an influence on the occurrence of cavities, the status of dental hygiene and so on, although it is less significant, it is strongly correlated, namely (0.61 %). this means that people who live on the coast of rivers or highlands can have an influence on the occurrence of dental caries. a living area is a place that shows that we live there, a living area is not just a living area because topographically there are differences in the reception of light, oxygen, etc., these differences in reception can affect the reception of oxygen (o2), for example, including a person's level of pain. this different acceptance will of course also affect a person's level of pain. the coastal area of the river is synonymous with lots of water, lots of fish etc. this assumption makes us think that in river coastal areas the teeth will definitely be in the good category, apart from consuming lots of fish, by eating lots of fish it is also hoped that the calcium levels will be sufficient to meet the needs of a person's bone and tooth growth. however, rivers are currently starting to be disrupted both in terms of function and usefulness, rivers could be polluted by home industry waste or large-scale industrial waste such as factories, meaning that rivers could be polluted by industrial waste. a plateau is possible due to calcium levels obtained from the use of artificial well water if this water is consumed daily, as well as sources of vitamins and minerals as well as calcium obtained for daily needs. based on the results of this research, it turns out that people living in highland areas can influence the occurrence of caries or cavities. efforts that we can make are to increase knowledge through education about dental and oral health. the next step that can be taken is to apply high doses of flour to prevent the process of demineralization by germs on tooth enamel. it is hoped that the promotive and preventive efforts carried out will help prevent the occurrence of cavities. regarding the area of residence, it also includes the food consumed, according to ramayanti & purnakarya in rusmali et al stated that the role of food in the incidence of dental caries really needs to be paid attention to, because the type of food is cariogenic along with microorganisms, teeth as (host) and time change the ph very quickly. saliva reaches 5.5 and can drastically cause demineralization. microorganisms can convert sugars such as glucose, especially sucrose, very effectively, because they have a more efficient ability to grow acidogenic microorganisms. apart from that, there is a deficiency of several vitamins and minerals which can lead to dental caries such as deficiencies of vitamins a, b, c and d, ca, phosphorus, fluorine and zinc, therefore preventive measures are needed at primary, secondary or tertiary stages. geographical differences greatly influence individual health, such as clinical and sub-clinical infections, namely intestinal infections, diarrhea, environmental enteropathy, worm infections, ari, etc. the cultural factor of food is a basic human need, so it must be fulfilled and if the fulfillment is inadequate it will result in malnutrition or even stunting.21 rusmali et al asian journal of dental and health sciences. 2023; 3(3):5-9 [9] ajdhs.com the type of food consumed daily can influence the occurrence of dental caries, whether it is cariogenic or non-cariogenic. of course, the type of food is very influential for people who frequently consume it, especially the type of cariogenic food, the type of cariogenic food is the type of food that sticks together easily when consumed and tastes sweet. even though it is already known that this type of cariogenic food is a favorite for germs in our oral cavity to reproduce. this type of cariogenic food is metabolized by germs to become acid. this acid will dissolve (demineralize) the outer layer of the teeth, namely the enamel, until cavities occur. what can be done to prevent the demineralization process by germs is by brushing your teeth. brushing your teeth is a real form of activity to break the chain of metabolism by germs. microorganisms can convert sugars such as glucose, especially sucrose, very effectively, because they have a more efficient ability to grow acidogenic microorganisms. apart from that, there is a deficiency of several vitamins and minerals that can lead to dental caries, such as deficiencies of vitamins a, b, c and d, ca, phosphorus, fluor and zinc. in this study, 61.1% of teenagers usually consumed noncariogenic foods. this figure of 61.1% may be related to the income of the students' parents, because students are also found living in private special school dormitories. however, the dental caries rate reached 32.3% and the dental and oral hygiene status was 48%, each in the moderate category. this means that non-cariogenic eating habits do not absolutely influence the incidence of cavities or oral hygiene. teenagers who usually consume non-cariogenic foods are 61.1%. this figure of 61.1% may be related to the income of the students' parents, because students are also found living in private special school dormitories. however, the dental caries rate reached 32.3% and the dental and oral hygiene status was 48%, each in the moderate category. this means that noncariogenic eating habits do not absolutely influence the incidence of cavities or oral hygiene. therefore, preventive measures are needed at primary, secondary or tertiary stages. conclusion the conclusion of this study is that the incidence of dental caries (dmf-t) has a significant effect on oral hygiene status (ohi-s). in addition, ohi-s status also has a significant effect on the incidence of dental caries (dmf-t) and age. references 1. graca sr, albuquerque ts, luis hs, assuncao va, malmqvist s, cuculescu m, et al. oral health knowledge, perceptions, and habits of adolescents from portugal, romania, and sweden: a comparative study. j int soc prev community dent. 2019; 9(5):470. https://doi.org/10.4103/jispcd.jispcd_194_19 pmid:31620380 pmcid:pmc6792312 2. dewi igac, wirata in. gambaran karies gigi sulung dan tingkat pengetahuan orang tua terhadap pemeliharaan kesehatan gigi dan mulut pada anak pra sekolah di tk sila chandra iii batubulan tahun 2017. j kesehat gigi (dental heal journal). 2018; 6(1):22-8. 3. cooper mw, brown me, hochrainer-stigler s, pflug g, mccallum i, fritz s, et al. mapping the effects of drought on child stunting. proc natl acad sci. 2019; 116(35):17219-24. https://doi.org/10.1073/pnas.1905228116 pmid:31405971 pmcid:pmc6717288 4. purnama t, rasipin sb, suwondo a, fatmasari d. tedi's behavior change model as an efforts for brushing teeth behaviour in preschool children. int j allied med sci clin res. 2019; 7(3):71522. 5. liu j, zhang ss, zheng sg, xu t, si y. oral health status and oral health care model in china. chin j dent res. 2016; 19(4):207-15. 6. fadjeri i, budiarti r, purnama t. dental care interventions as efforts to reduce pufa index and improve nutritional status in children aged 9-12 years in orphanages. med leg updat. 2021; 21(1):366-71. 7. gupta a, khandelwal r, kapil u. interrelationship between dental health status and nutritional status among elderly subjects in india. j fam med prim care. 2019; 8(2):477. https://doi.org/10.4103/jfmpc.jfmpc_353_18 pmid:30984658 pmcid:pmc6436255 8. achmad w. social reality stunting prevention in cianjur district. j eduhealth. 2022; 13(02):467-77. 9. triswari d, pertiwi ad. pengaruh kebiasaan menyikat gigi sebelum tidur malam terhadap skor indeks plak dan ph saliva. insisiva dent j maj kedokt gigi insisiva. 2017; 6(2):1-8. https://doi.org/10.18196/di.6282 10. wijayanti hn, rahayu pp. membiasakan diri menyikat gigi sebagai tindakan utama dalam upaya peningkatan kesehatan gigi dan mulut pada anak. j pemberdaya masy mandiri indones. 2019; 1(2). https://doi.org/10.35473/jpmmi.v1i1.19 11. rusmali r. indek's dmf-t dengan kejadian anemia pada remaja putri berdasarkan status gizi. dent ther j. 2019; 1(2):87-94. https://doi.org/10.31965/dtj.v1i2.451 12. kramer a, splieth c. health promotion through structured oral hygiene and good tooth alignment. gms hyg infect control. 2022; 17. 13. hailu fa, hailu ya, hailu ta. dental anatomy and physiology of human tooth and the consequences of pathogenic microbiota on the oral cavity. j clin case stud rev reports. 2020; 2(5):1-7. https://doi.org/10.47363/jccsr/2020(2)147 14. singh p. oral health knowledge, practice, oral hygiene status and attitude of dhanuks of bapu nagar basti, lucknow. asian man (the)-an int j. 2016; 10(1):89-95. https://doi.org/10.5958/09756884.2016.00011.6 15. arianto a. faktor-faktor yang berhubungan dengan perilaku pemeliharaan kebersihan gigi dan mulut di kelurahan wonoharjo kabupaten tanggamus. j anal kesehat. 2019; 7(2):744-8. https://doi.org/10.26630/jak.v7i2.1204 16. hagman j, wide u, werner h, hakeberg m. oral health and oral health behavior in young adults with caries disease. bdj open. 2021; 7(1):28. https://doi.org/10.1038/s41405-021-00084-3 pmid:34333512 pmcid:pmc8325684 17. laraswati n, mahirawatie ic, marjianto a. peran ibu dalam menjaga kesehatan gigi anak prasekolah dengan angka karies di tk islam al-kautsar surabaya. j ilm keperawatan gigi. 2021; 2(1). 18. purnama t, rasipin r, santoso b. pengaruh pelatihan tedi's behavior change model pada guru dan orang tua terhadap keterampilan menggosok gigi anak prasekolah. qual j kesehat. 2019; 13(2):75-81. https://doi.org/10.36082/qjk.v13i2.80 19. vishwanathaiah s. knowledge, attitudes, and oral health practices of school children in davangere. int j clin pediatr dent. 2016; 9(2):172. https://doi.org/10.5005/jp-journals-10005-1358 pmid:27365943 pmcid:pmc4921891 20. nurwati b. hubungan karies gigi dengan kualitas hidup pada anak sekolah usia 5-7 tahun. j skala kesehat. 2019; 10(1):41-7. https://doi.org/10.31964/jsk.v10i1.164 21. rusmali r, abadi mt, sartika m, kristianto j, yulita i. kejadian karies gigi kebersihan mulut terhadap perilaku menyikat gigi remaja putri berdasarkan daerah tinggal. j heal sains. 2023; 4(1):134-45. https://doi.org/10.46799/jhs.v4i1.662 https://doi.org/10.4103/jispcd.jispcd_194_19 https://doi.org/10.1073/pnas.1905228116 https://doi.org/10.4103/jfmpc.jfmpc_353_18 https://doi.org/10.18196/di.6282 https://doi.org/10.35473/jpmmi.v1i1.19 https://doi.org/10.31965/dtj.v1i2.451 https://doi.org/10.47363/jccsr/2020(2)147 https://doi.org/10.5958/0975-6884.2016.00011.6 https://doi.org/10.5958/0975-6884.2016.00011.6 https://doi.org/10.26630/jak.v7i2.1204 https://doi.org/10.1038/s41405-021-00084-3 https://doi.org/10.36082/qjk.v13i2.80 https://doi.org/10.5005/jp-journals-10005-1358 https://doi.org/10.31964/jsk.v10i1.164 https://doi.org/10.46799/jhs.v4i1.662 noviani et al asian journal of dental and health sciences. 2023; 3(3):14-18 [14] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited stair poster media as an effort to improve the dental health behavior of elementary school children nita noviani1, ngatemi2, indrayati fadjeri3, tedi purnama4*, sekar restuning5 1,2,3,4 department of dental health, health polytechnic of jakarta i, jakarta, indonesia 5 department of dental health, health polytechnic of bandung, bandung, indonesia article info: _______________________________________ article history: received 11 august 2023 reviewed 18 august 2023 accepted 12 september 2023 published 15 september 2023 _______________________________________ cite this article as: noviani n, ngatemi, fadjeri i, purnama t, restuning s, stair poster media as an effort to improve the dental health behavior of elementary school children, asian journal of dental and health sciences. 2023; 3(3):14-18 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.48 _______________________________________ *address for correspondence: tedi purnama, department of dental health, health polytechnic of jakarta i, jakarta, indonesia. abstract ___________________________________________________________________________________________________________________ the prevalence rate of dental caries has experienced an increasing trend from year to year, so that the condition of dental and oral health problems in indonesia is still worrying, especially for elementary school children. the high number of dental health problems is caused by many factors, one of which is the low level of dental health maintenance behavior. promotive and preventive measures are needed to prevent dental and oral health problems, namely by providing dental and oral health education. poster media is a medium or prop/tool that can be used to convey messages from communicators to the audience. staircase poster media is a development of general poster media, this media is designed for the sequence/stages of maintaining dental health which are attached to the school steps. objective: this research is to analyze the effectiveness of stair poster media in improving the dental health behavior of elementary school children. method: this research used a non-equivalent control group quasiexperimental design. the research sample was 125 people taken using purposive sampling technique. the intervention group was given dental health education using posters, while the control group was given dental health education using filpchart. data were tested using wilcoxon test analysis, namely a pre-post design, while to compare the means of the treatment and control groups, the mann whitney test was used. results: the results of the test of differences in knowledge, attitudes and actions of brushing teeth show that the p-value between the intervention group and the control group is 0.000 (p <0.05), meaning that there is a difference between the values of knowledge, attitudes and actions of brushing teeth after dental health education with children's poster media. steps and dental health education with filpchart. conclusion: dental health education using stair poster media is more effective in increasing the knowledge, attitudes and actions of brushing teeth in elementary school children compared to dental health education using flipcharts keywords: stair poster, media, dental health, behavior introduction dental and oral health problems can have an impact on a person's quality of life, because teeth have a function in speaking, chewing and appearance. the health of a child's teeth and mouth will affect their growth and development. tooth decay in children can cause pain, thereby reducing appetite, and incomplete breakdown of food in the mouth, which interferes with the absorption of nutrients needed by the human body, thus causing malnutrition in children. in addition, children are a vulnerable age group because at that time the milk teeth begin to fall out one by one and are replaced by permanent teeth. newly erupted permanent teeth are immature and therefore easily damaged, they only grow once in a lifetime, so they need to be cared for and cared for to avoid dental problems. if children neglect to keep their teeth and mouth clean, this will increase the risk of plaque forming on the surface of the teeth which can cause dental caries and periodontal disease.1–4 the results of the 2018 basic health research stated that the prevalence of caries according to the characteristics of ages 59 years in indonesia was 92.6% and ages 10-14 years was 73.4% with the proportion of damaged, cavities or diseased teeth in the 5-9 years age group being 54%, and the aged 1014 years is 41.4%. gum problems and/or abscesses increased 11% for ages 5-9 years, and 11.3% for gum problems and/or abscesses at ages 10-14 years. this data shows that the dental and oral diseases most suffered by children are dental caries and periodontal disease. one of the causes of these two diseases is behavioral factors.5,6 people's behavior that ignores dental and oral health care causes dental and oral health problems. this is based on a lack of knowledge about the importance of maintaining oral health. budiharto's research, knowledge, attitudes and actions are forms of behavior. children's behavior regarding maintaining dental health includes knowledge, attitudes and actions aimed at preventing plaque accumulation as a cause of caries and periodontal disease.7–9 efforts to improve behavior include promoting dental health, which places more emphasis on vulnerable groups of school children. the school environment is an extension of the family in laying the foundation for healthy living behavior for school children. health promotion is an effort to increase a person's knowledge and abilities through practical techniques or instructions with the aim of influencing human behavior both individually and in community groups to increase awareness of the importance of health so as to change their behavior into healthy living behavior.10,11 dental health promotion cannot be separated from the media open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.48 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.48&amp;domain=pdf noviani et al asian journal of dental and health sciences. 2023; 3(3):14-18 [15] ajdhs.com because through the media, the messages conveyed can be more interesting and understood. posters are an outreach medium in the form of printed media with images and delivered using the lecture method. posters have often been used as an outreach medium and are able to increase the target's knowledge from not knowing to knowing and ultimately wanting to change behavior.10,12,13 step poster media is a development of mini poster media. staircase posters are an effective graphic medium for presenting certain messages, in the form of a series/steps containing pictures or writing about maintaining dental health which are then attached to the steps. material and method the research design used was a quasi-experimental study with a pretest-posttest control group design. the aim of the study was to analyze the effectiveness of stair poster media in improving the dental health behavior of elementary school children. the research was conducted in june to august 2023 at sdn 02 pangkalanjati and sdn 02 cinere, cinere district, depok city. the research sample was 125 students, with a purposive sampling technique. the intervention group was given dental health education using posters as a medium for 64 students, while the control group was given dental health education using filcharts as many as 61 students. data collection was carried out on each group on day 1, carrying out a pre-test to measure knowledge, attitudes and actions of brushing teeth, then education was provided according to the planned intervention. on the 3rd day, dental health education was conducted and on the last day, on the 21st day, a post-test was carried out to determine changes in elementary school children's knowledge, attitudes and teeth brushing actions. the instruments used in this study were a knowledge and attitude questionnaire and a tooth brushing checklist to measure the act of brushing your teeth. data analysis used the wilcoxon test, namely a pre-post design, while to compare the means of the treatment and control groups, the mann whitney test was used. result table 1: frequency distribution based on respondent characteristics variable intervention control n % n % age 10 years 13 20,3 16 26,2 11 years 43 67,2 38 62,3 12 years 8 12,5 7 11,5 total 64 100 61 100 gender man 34 53,1 34 55,7 women 30 46,9 27 44,3 total 64 100 61 100 table 1 shows that the ages of children in the intervention and control groups have the same proportion, most of whom are 11 years old and male. table 2: data normality test variable groups intervention control knowledge pre-test 0,000 0,000 knowledge post-test 0,000 0,000 attitudes pre-test 0,001 0,000 attitudes post-test 0,000 0,000 actions of brushing teeth pre-test 0,000 0,000 actions of brushing teeth post-test 0,000 0,000 table 2 shows the results of the normality test for knowledge, attitudes and actions of brushing teeth in the intervention and control groups with an abnormal distribution, because the p-value < 0.05, the non-parametric test was continued, using the wilcoxon test, namely a pre-post design, while to compare the means. from the treatment and control groups, mann whitney was used. noviani et al asian journal of dental and health sciences. 2023; 3(3):14-18 [16] ajdhs.com table 3: test the effectiveness of knowledge, attitudes and actions of brushing teeth before and after intervention in the intervention and control groups groups knowledge attitudes actions mean+ sd p-value mean+ sd p-value mean+ sd p-value intervention pre-test 5,08+ 1,238 0.000 39,36+5,214 0.000 4,67+1,183 0.000 post-test 8,81+ 0,889 43,45+2,889 9,16+0,597 control pre-test 5,62+ 1,157 0.763 40,41+2,877 0.188 4,69+1,041 0.285 post-test 5,61+ 1,130 40,52+2,826 4,75+0,960 table 3 shows the results of the data effectiveness test before and after being given dental health education using posters as media, showing the knowledge p-value of the intervention group was 0.000, the p-value of attitude was 0.000 and the p-value of the action of brushing teeth was 0.000 (p < 0.05) means that dental health education using posters as media is effective in increasing knowledge, attitudes and actions of brushing teeth in elementary school children. the control group's p-value for knowledge was 0.763, the attitude p-value was 0.188 and the p-value for the action of brushing teeth was 0.285, meaning that dental health education using flipcharts was not effective in increasing the scores of knowledge, attitudes and actions of brushing teeth in elementary school children. table 4: test differences in knowledge, attitudes and actions of brushing teeth before and after intervention in the intervention and control groups groups knowledge attitudes actions mean p-value mean p-value mean p-value intervention 8,81 0.000 43,45 0.000 9,16 0.000 kontrol 5,61 40,52 4,75 table 4 shows the results of the difference test in knowledge, attitudes and actions of brushing teeth, showing that the p-value between the intervention group and the control group is 0.000 (p <0.05), meaning that dental health education using children's posters is more effective in increasing knowledge, attitudes and actions of brushing teeth. compared to the control group. discussion efforts to improve dental and oral health include promotive, preventive, curative and rehabilitative efforts. one promotional effort to improve people's behavior is through an educational process regarding the importance of maintaining healthy teeth and mouth. for children aged 6-12 years, this is the age where children are in the transition period or mixed dentition period, namely the period of change between deciduous teeth (children) to permanent teeth (adults). at this age, children still lack behavior in terms of maintaining dental and oral hygiene, resulting in the potential for damage to dental tissue in the form of caries.9,14,15 behavior that is based on correct knowledge will greatly influence the incidence of children's dental and oral health problems. knowledge is the result of knowing about an object that a person obtains through the senses and is mostly obtained from the eyes and ears. a person has the ability to reexpress the knowledge he knows in the form of an answer to a stimulus in the form of a question, either verbally or in writing. dental and oral health knowledge is all the data an individual has to understand what oral disease is, how the disease arises, and understand protective measures. this knowledge will lead to changes in behavior that guide individuals to make changes in everyday life.7,16,17 knowledge can be increased through health promotion. health promotion is an action or activity aimed at increasing the abilities or activities of individuals, groups and communities in terms of knowledge, attitudes and skills to achieve the best healthy living standards. promoting health in elementary school age is an ideal time to practice motor skills and improve cognition. children's attention spans are short, so they need training that is fun and motivating. using attractive integrated media for health promotion can increase knowledge and change behavior.18–20 dental health education as an effort to provide knowledge about dental health basically emphasizes aspects of dental health which are closely related to targeted daily efforts in maintaining dental health, so that the selection of education material is prioritized regarding efforts to maintain dental and oral health, where efforts are common and common. by students and adults in general is brushing their teeth and efforts to control themselves in consuming food and being selective in choosing types of food that are good and that can facilitate tooth decay. the selection of extension materials and extension priorities must consider the magnitude of the impact of the problem/material to be presented.11,21,22 health promotion media is a tool used in health promotion so that targets understand the information conveyed. media that promote health must be regulated based on the principle that humans receive or capture information obtained through the five senses. the choice of media is one of the factors that can influence the promotion of oral health, the media can foster children's motivation and attention to learning, and the meaning of the information conveyed will be clearer, so that children can understand and better understand the learning objectives.8,23,24 the media used by researchers in conducting research is poster media which is a development of mini poster media. staircase posters are an effective graphic medium for presenting certain messages, in the form of a series/steps containing pictures or writing about maintaining dental health which are then attached to the steps. in this study, researchers made two packages of stair posters which were displayed on all the school stairs with material on 9 tips for maintaining healthy teeth and steps for brushing your teeth properly. noviani et al asian journal of dental and health sciences. 2023; 3(3):14-18 [17] ajdhs.com based on the results of the data effectiveness test before and after being given dental health education using poster posters, the knowledge p-value of the intervention group was 0.000, the p-value of attitude was 0.000 and the p-value of the action of brushing teeth was 0.000 (p <0.05) this means that dental health education using posters as media is effective in increasing the knowledge, attitudes and actions of brushing teeth in elementary school children. the p-value of the control group on knowledge is 0.763, the p-value of attitude is 0.188 and the p-value of the action of brushing teeth is 0.285, meaning that dental health education using flipcharts is not effective in increasing the scores of knowledge, attitudes and actions of brushing teeth in elementary school children. the results of different tests also show that knowledge, attitudes and actions of brushing teeth show that the p-value between the intervention group and the control group is 0.000 (p <0.05), so it can be interpreted that dental health education using children's poster media is more effective in increasing knowledge, attitudes and actions of brushing. teeth compared to dental health education with flipcharts. this is because education using posters as media has the advantage of attracting children's attention more easily and stimulating children's understanding. counseling with posters on stairs can also make children see interesting pictures at the same time related to the material provided, where every day when children go to school when they enter the classroom on the 2nd floor, they are sure to read it every day, giving rise to a response and motivation in them to follow the material in stair poster media. with the hope that the child's emotional response will emerge, the child will eventually become enthusiastic or motivated to want to take part in the next activity. stimulus-organismresponse (sor) theory of behavior change which says that the cause of behavior change depends on the stimulus or stimuli given.25 so it can be interpreted that the staircase poster media can stimulate children to know more about maintaining dental health, especially brushing their teeth. this is in line with research by jumilah et al. proves that there is an increase in dental and oral health knowledge in saigon village public elementary school students after being exposed to posters for 7 and 14 days. wayudi's research states that poster media is effective in increasing students' attitudes and intentions to act in maintaining dental health. another study by sukarsih et al showed that there was an increase in knowledge of how to brush teeth at high criteria before being given counseling by 29.41% to 82.35% after being given counseling using poster media. there was an increase in skills on how to brush teeth with good criteria by 25% to 86.76% after being given counseling on how to brush teeth using poster media..26–28 conclusion based on the results of the study, it can be concluded that the dental health education using stair poster media is more effective in increasing the knowledge, attitudes and actions of brushing teeth in elementary school children compared to dental health education using flipcharts. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. ethical clearance this research has received a certificate of appropriate research ethics from the yogyakarta health research ethics commission no.dp.04.03/e-kepk.2/773/2023 references 1. nurhamidah n, ramadhan es, asmawati a, juni j. hubungan status kesehatan gigi dan mulut dengan prestasi belajar siswa/i sd negeri 2 sangga beru kecamatan gunung meriah kabupaten aceh singkil. j kesehatan gigi. 2016; 3(2):35-40. https://doi.org/10.31983/jkg.v3i2.1776 2. sari ek, ulfiana e, rachmawati pd. pengaruh pendidikan kesehatan gosok gigi dengan metode permainan simulasi ular tangga terhadap perubahan pengetahuan, sikap, dan aplikasi tindakan gosok gigi anak usia sekolah di sd wilayah paron ngawi. indones j community heal nurs. 2012; 1(1). 3. papilaya ea, zuliari k. perbandingan pengaruh promosi kesehatan menggunakan media audio dengan media audio-visual terhadap perilaku kesehatan gigi dan mulut siswa sd. e-gigi. 2016; 4(2). https://doi.org/10.35790/eg.4.2.2016.14261 4. rifki a, hermina t. perbedaan efektifitas menyikat gigi dengan metode roll dan horizontal pada anak usia 8 dan 10 tahun di medan. cakradonya dent j. 2016; 8(1):11-6. 5. ri k. hasil utama riskesdas 2018. jakarta kemenkes ri. 2018; 6. purnama t, rasipin n. tedi's behavior change model to improving brushing teeth behavior parents. j appl heal manag technol. 2020; 2(1):1-12. https://doi.org/10.31983/jahmt.v2i1.5475 7. purnama t, fadjeri i, widiyastuti r. model mentoring teachers and parents as an efforts for brushing teeth behavior in preschool children. indian j forensic med toxicol. 2020; 14(4):3511-6. 8. ngatemi; lestari sy, purnama t. pillow book media as dental health promotion in preschool children: is it effective? int j drug res dent sci. 2022; 4(1):7-13. 9. budiharto j. pengantar ilmu perilaku kesehatan pendidikan kesehatan gigi. jakarta egc. 2010; 18-20. 10. notoatmodjo. promosi kesehatan dan perilaku kesehatan, edisi revisi. jakarta: rineka cipta; 2012. 11. pudentiana rr re, subandini sl. pendidikan kesehatan gigi. jakarta: egc; 2019. 12. palupi dn, widyastomo jw. efektifitas media poster dengan flanelgraf terhadap pengetahuan kesgilut ibu hamil desa klampok singosari malang. e-prodenta j dent. 2019; 3(1):187-95. https://doi.org/10.21776/ub.eprodenta.2019.003.01.2 13. siregar r. efektifitas penyuluhan dengan media poster terhadap peningkatan pengetahuan tentang kebersihan gigi pada siswa/i kelas iii dan iv di sdn 104186 tanjung selamat kecamatan sunggal tahun 2014. j ilm pannmed (pharmacist, anal nurse, nutr midwivery, environ dent. 2014; 9(2):166-9. https://doi.org/10.36911/pannmed.v9i2.315 14. sumantri d, lestari y, arini m. pengaruh perubahan tingkat pengetahuan kesehatan gigi dan mulut pada pelajar usia 7-8 tahun di 2 sekolah dasar kecamatan mandiangin koto selayan kota bukittinggi melalui permainan edukasi kedokteran gigi. andalas dent j. 2013; 1(1):39-48. https://doi.org/10.25077/adj.v1i1.12 15. purnama t, ngatemi n, sofian r, kasihani nn, re pr, nurbayani s. model 5 days gosgi sebagai upaya pembentukan kemandirian menggosok gigi anak usia dini di sekolah. qual j kesehat. 2020; 14(1):19-24. https://doi.org/10.36082/qjk.v14i1.96 16. norfai n, rahman e. hubungan pengetahuan dan kebiasaan menggosok gigi dengan kejadian karies gigi di sdi darul muâ€tm minin kota banjarmasin tahun 2017. din kesehat j kebidanan dan keperawatan. 2017; 8(1):212-8. 17. rad m, shahravan a, haghdoost aa. oral health knowledge, attitude, and practice in 12-year-old schoolchildren in iran. j int soc prev community dent. 2015; 5(5):419. https://doi.org/10.31983/jkg.v3i2.1776 https://doi.org/10.35790/eg.4.2.2016.14261 https://doi.org/10.31983/jahmt.v2i1.5475 https://doi.org/10.21776/ub.eprodenta.2019.003.01.2 https://doi.org/10.36911/pannmed.v9i2.315 https://doi.org/10.25077/adj.v1i1.12 https://doi.org/10.36082/qjk.v14i1.96 noviani et al asian journal of dental and health sciences. 2023; 3(3):14-18 [18] ajdhs.com https://doi.org/10.4103/2231-0762.165926 pmid:26539396 pmcid:pmc4606608 18. notoatmodjo s. promosi kesehatan: teori dan aplikasi. jakarta: rineka cipta; 2012. 19. kurniawan a, putri rm, widiani e. pengaruh promosi kesehatan terhadap pengetahuan dan sikap tentang perilaku hidup bersih dan sehat kelas iv dan v sekolah dasar. nurs news j ilm keperawatan. 2019; 4(1). https://doi.org/10.47317/dmk.v1i1.138 20. tandilangi m, mintjelungan c, wowor vns. efektivitas dental health education dengan media animasi kartun terhadap perubahan perilaku kesehatan gigi dan mulut siswa sd advent 02 sario manado. e-gigi. 2016; 4(2). https://doi.org/10.35790/eg.4.2.2016.13503 21. puspitawati y, ulliana u, sulistiani s, fadliyah nk, nurwanti w. dental health promotion using fliphchart media on knowledge of elementary school student. jdht j dent hyg ther. 2022; 3(1):215. https://doi.org/10.36082/jdht.v3i1.486 22. nurilawaty v, purnama t, zahra mf. carbohydrate diet during the covid-19 pandemic (case study: 4 th grade students of elementary school 02 meruya utara, west jakarta). int res j pharm med sci. 2021; 4(4):37-40. 23. hanif f, prasko p. perbedaan pengaruh penyuluhan menggunakan media video dan boneka tangan terhadap peningkatan pengetahuan kesehatan gigi dan mulut pada siswa sekolah dasar. j kesehat gigi. 2018; 5(2):1-6. https://doi.org/10.31983/jkg.v5i2.3854 24. re pr, nurbayani s, atmasumarta t, lestari tr, purnama t. the effect of pop up book media on increasing dental health knowledge in elementary school children. asian j pharm res dev. 2022; 10(2):6-9. https://doi.org/10.22270/ajprd.v10i2.1112 25. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta. 2010; 200:26-35. 26. jumilah j, jauhari ah, ridha a. efektifitas media poster terhadap peningkatan pengetahuan tentang kesehatan gigi (studi pada siswa-siswi kelas v sd negeri di kelurahan saigon). jumantik. 2017; 1(02). 27. wahyudi dt. media poster terhadap peningkatan sikap dan niat untuk bertindak kesehatan gigi. jpk j penelit kesehat. 2015; 5(1):24-7. 28. sukarsih s, silfia a. peningkatan pengetahuan dan ketrampilan menyikat gigi dengan media poster pada murid madrasah diniyah takmiliyah al-banat kabupaten muaro jambi. j binakes. 2020; 1(1):33-8. https://doi.org/10.35910/binakes.v1i1.370 https://doi.org/10.4103/2231-0762.165926 https://doi.org/10.47317/dmk.v1i1.138 https://doi.org/10.35790/eg.4.2.2016.13503 https://doi.org/10.36082/jdht.v3i1.486 https://doi.org/10.31983/jkg.v5i2.3854 https://doi.org/10.22270/ajprd.v10i2.1112 https://doi.org/10.35910/binakes.v1i1.370 pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [45] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the challenges of chronic wound care and management pallav dave * regulatory compliance analyst, louisville, ky, 40223, usa article info: _____________________________________________ article history: received 03 january 2024 reviewed 20 february 2024 accepted 04 march 2024 published 15 march 2024 _____________________________________________ cite this article as: dave p, the challenges of chronic wound care and management, asian journal of dental and health sciences. 2024; 4(1):45-50 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.70 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky, 40223, usa abstract _________________________________________________________________________________________________________________ chronic wounds are a significant healthcare challenge across the world. they affect approximately 2.21 per 1000 people making them a prevalent challenge that needs to be addressed. the prevalence of these wounds is also growing as the population ages. various underlying factors such as medical conditions, poor nutrition, diabetes, vascular disease, arterial disease, prolonged pressure, neuropathy, chronic venous insufficiency, and being overweight or obese are contributing to the increasing prevalence of chronic wounds. addressing chronic wounds is vital. they are a significant healthcare burden that affects the overall quality of life and contributes to the loss of function. chronic wounds are also painful, which makes them a difficult experience for patients. with the increasing morbidity and mortality attributed to chronic wounds, it is important to ensure treatment interventions are effective to achieve positive outcomes. however, achieving positive outcomes is a challenge because of the existing challenges that impede proper wound care and management. identifying the challenges that make it difficult to manage chronic wounds effectively is vital to ensure positive outcomes in management. the aim of this review is to identify the challenges that affect chronic wound care and management. keywords: chronic wounds, ulcers, wound care, wound management, treatment interventions introduction chronic wounds refer to wounds that do not progress through the normal healing process as other wounds. as a result, they remain open for longer periods of time. these wounds are a significant challenge to healthcare systems affecting about 2.21 people per 1000 across the world.1 in the us alone, chronic wounds affect more than 2.5% of the population or 10.5 million people.2 the incidence of chronic wounds is increasing. in the us, about 1% of the population has an active or healed venous ulcer.3 pressure sores are also a significant burden to the population. another one million of the 30 million people who live with diabetes develop an ulcer every year.3 the burden of these wounds is projected to increase in the coming years as the aging population increases. elderly people tend to be disproportionately affected by chronic wounds.2,4 factors such as underlying medical conditions, poor nutrition, increased risk of falls, and the likelihood of undergoing surgery can explain why this population is disproportionately affected.5 in the general population, chronic wounds can be attributed to a number of factors. some of these factors include diabetes, vascular disease, arterial disease, prolonged pressure, neuropathy, chronic venous insufficiency, and being overweight or obese.4,6 addressing the burden of chronic wounds is vital. they are a significant health burden that contributes significantly to lower quality of life and inability to perform daily functions.7 individuals with chronic wounds are prone to infections with a recurrence rate of up to 70% making it even more difficult for patients.4 another feature of these wounds is inflammation which means they cause a great deal of pain to the affected patients. chronic wounds also contribute to the morbidity and mortality burden. according to jupiter et al.8 a diabetic ulcer is associated with 40% mortality rate five years after its occurrence. chronic wounds also contribute significantly to disabilities. 85% of all amputations are attributed to ulcers while diabetic ulcers contribute to 75% of all lower limb amputations.9 the high morbidity and mortality rates attributed to chronic wounds despite the therapeutic interventions that are available for managing these wounds explain why they are a significant health burden. chronic wounds are also attributed to a significant financial burden.10 the difficulty in treating them, the high recurrence rate, and the persistent infections are some of the factors that contribute significantly to the financial burden of treating chronic wounds. identifying the challenges attributed to chronic wound care and management is vital to their management. by identifying these challenges, it becomes easier to put interventions in place that can improve patient health outcomes. the aim of this review is to provide an overview of the challenges that are encountered in the care of chronic wounds. the review begins by providing a brief overview of chronic wounds including their classification and pathophysiology. it goes ahead to discuss the challenges that are encountered in the management of these wounds before providing a brief overview of measures that can be taken to ensure success is achieved when it comes to chronic wound care and management. classification of chronic wounds classifying chronic wounds is vital for the provision of adequate care. classifying these wounds allows for adequate care and treatment interventions.11 chronic wounds are mainly classified in three main ways. they include vascular ulcers, diabetic ulcers, and pressure ulcers.4 open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.70 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.70&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [46] ajdhs.com vascular ulcers vascular ulcers can either occur as venous or arterial ulcers. venous ulcers are the most common type of presenting wound.12 they result from chronic venous insufficiency or venous hypertension and mostly occur in the lower extremity.6 venous ulcers typically present as shallow wounds and normally occur following venous reflux or obstruction.13 venous ulcers can be attributed to a number of risk factors. some of these risk factors are venous disease, old age, obesity, heart disease, arterial disease, insufficiency of the superficial, perforating, or deep veins of the legs, and deep venous thrombosis.13,14 arterial ulcers emerge because of impaired tissue perfusion more so the reduced supply of blood to the lower limb.13 reduced perfusion leads to ischemia or reduced blood flow making it hard to deliver nutrients which leads to the death of body tissue.15 it is this reduced blood flow and subsequent death of the body tissue that leads to the occurrence of an ulcer. arterial ulcers occur on the distal extremities and present as deep wounds where the tendon or bone is exposed.16 arterial ulcers are mostly attributed to atherosclerotic disease.17 other risk factors that cause arterial ulcers include diabetes, vasculitis, thromboangiitis, hypertension, smoking, advanced age, obesity, and hyperlipidaemia. 15-17 diabetic ulcers diabetic foot ulcers mostly affect people who are living with type 2 diabetes. diabetic ulcers mainly occur when diabetes is not well controlled. in the us, diabetic foot ulcers affect an average of 1.6 million people annually.18 several factors increase the risk of developing diabetic ulcers. they include peripheral neuropathy, arterial insufficiency, poor glycemic control, foot deformities, calluses, lack of proper foot care, and poor circulation.15,16, 19,20 patients with peripheral neuropathy are particularly at a high risk of developing diabetic foot ulcers. this is because they have reduced sensory awareness because of sensory neuropathy. as a result of this reduced sensory awareness, they are less likely to feel pressure, heat, or injury.21 in normal people, sensory awareness leads to pain and discomfort. however, when it is reduced, pain and discomfort go unnoticed for a long time which increases the risk of developing an injury or formation of an ulcer. this explains why peripheral neuropathy is a significant risk factor for diabetic foot ulcers. diabetic ulcers develop in three stages. in the first stage, a callus is formed because of neuropathy. neuropathy normally affects the nerves interfering with sensations and causing their impairment.22 the impairment of nerves results in what is known as sensory neuropathy. sensory neuropathy leads to loss of senses and contributes to ongoing trauma.19 neuropathy can also occur as motor neuropathy. motor neuropathy causes damage to motor nerves.19 it also affects the ability of an individual to coordinate movements which leads to physical deformity of the foot, hammerhead toes and claws, and charcot’s foot.22 neuropathy also presents as autonomic neuropathy. autonomic neuropathy causes the deportation in functions of the sebaceous and sweat glands in the foot.22 as a result, it makes the skin around the foot dry making it easier to form fissures. a combination of these factors and the continuous trauma to the callus is what results in subcutaneous hemorrhage and eventually the development of an ulcer.21,23 diabetic ulcer is also attributed to severe atherosclerosis. atherosclerosis develops when the basement membranes of capillaries thicken leading to vascular compromise.19 inadequate blood flow makes the wound heal slowly which leads to necrosis and gangrene.22 pressure ulcers chronic wound ulcers are also classified as pressure ulcers (pus). pressure ulcers occur when there is prolonged pressure over a bony prominence normally lasting 2 to 6 hours.4 the sustained pressure or compression of the soft tissues makes it difficult for the tissue to get the needed blood flow (ischemia) resulting in tissue death (necrosis) or damage.24,4 there are four mechanisms that result in pus. one is sustained high interphase pressure, loss of elasticity in aged skin, the friction that leads to superficial erosions and blisters, and excess skin moisture because of exposure to fluids such as urine, sweat, wound drainage, and fecal matter over a prolonged period of time.16 pressure ulcers are attributed to several risk factors. key among these factors is limited mobility.16 limited mobility or impaired sensation increases the risk of developing pus because of the difficulty the tissue has in getting the needed blood flow.24 basically, individuals who have limited mobility are likely to experience reduced blood flow to the tissue. individuals who are at risk include those who are sedated, and frail, those who have undergone surgery and are not able to move, and those with spinal cord injuries.24 other risk factors that contribute to the development of pus are skin changes that occur naturally with age, cognitive impairment, lower extremity edema, rheumatoid arthritis, and diabetes.4,16 skin changes that occur with age increase the risk of developing pus because of the thinning of the epidermis and dermis. challenges in the care and management of chronic wounds addressing chronic wounds is vital because of the burden they cause in healthcare systems. however, addressing chronic wounds is not easy. despite the advances that have been made in managing chronic wounds, the challenges of proper wound care and management still remain. various challenges contribute to poor wound healing leading to chronic wounds. to understand these factors, it is important to understand how a wound heals. wound healing occurs in four phases. they are hemostasis, inflammation, proliferation, and remodelling.4 hemostasis is the first phase and it occurs after the injury.4 the main characteristics of this phase are vasoconstriction and blood clotting.25 vasoconstriction and clotting play a critical role in preventing blood loss. they also play a crucial role in providing the provisional matrix for cell migration into the wound a process known as chemotaxis. chemotaxis marks the beginning of the inflammatory phase. the inflammatory phase is the second phase. the stage normally lasts about seven days.4 in this stage, phagocytic cells such as neutrophils, macrophages, and lymphocytes help in the healing process.4 neutrophils help to clear the invading microbes and cellular debris from the wound area. it does this by releasing reactive oxygen species (ros) and protases which helps to prevent contamination by bacteria and clear cellular debris.26 macrophages are additional cells that help in the healing process. macrophages are formed when blood monocytes arrive at the site of the wound and differentiate. macrophages help in wound healing by removing bacteria and nonviable tissue. they release cytokines which facilitates an inflammatory response. cytokines recruit and activate leukocytes, fibroblasts, keratinocytes, and endothelial cells that help to repair damaged blood vessels and promote tissue regeneration.26 the proliferation phase does not occur at a particular time and overlaps with the inflammatory phase. tissue granulation is one of the characteristics of this phase.4 it also involves the formation of new blood vessels a process known as angiogenesis and epithelialization with fibroblasts and epithelial cells occurring at this stage. these cells play a crucial role in supporting capillary growth, helping in collagen formation, and formation of granulation tissue over the site of the wound. re-epithelialization occurs when epithelial cells migrate from the wound periphery and adjacent edges of the pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [47] ajdhs.com wound.4,26 a thin superficial layer of epithelial cells is laid down over the wound before a more durable layer is laid over time. the remodelling phase occurs once the wound has closed. the duration of this phase varies but starts at around three weeks and can last up to 1 year.4,27 unlike other wounds, chronic wounds do not heal in a normal and timely manner. according to wallace et al.27 wounds take an average of 4 to 6 weeks to heal. however, for chronic wounds, the process takes longer and they are even likely to reoccur after a certain period of time. in most instances, these wounds stall at the inflammation phase.4 some of the common characteristics of chronic wounds are the excess presence of cytokines, proteases, ros, and senescent cells. chronic wounds can be attributed to a number of factors. they include bacterial colonization, impaired collagen production, altered cellular response, ischemia, reperfusion injury and hypoxia.27 chronic wounds also occur when failure to achieve complete reepithelialization happens.4 an additional factor that affects healing is bacterial biofilm. bacterial biofilm occurs in up to 90% of these wounds.1 vestby et al.28 define bacterial biofilm as membranous tissue that is created by a bacteria community that is attached to the wound bed. as a result, they are polymicrobial in nature. bacteria biofilm occurs as a result of disruptions that occur in the skin microenvironment.29,30 they affect the wound healing process because they cause slow tissue repair and make the wounds non-responsive to treatment by making it difficult for antibiotics to penetrate the wound.31 several underlying factors can contribute to impaired wound healing. some of these factors are the presence of chronic conditions such as diabetes, comorbidities, poor nutrition, smoking, and local factors such as tissue edema, oxygenation, dehydration, pressure, and infection.26,27,32 systematic factors such as age, stress and obesity, can also affect the wound healing process.26 addressing the factors that contribute to impaired wound healing is vital to achieving positive outcomes. however, this still remains a challenge with a large proportion of the population continuing to suffer from wounds. access and delivery of care are still a significant barrier that makes it difficult to manage chronic wounds.32 in most cases, chronic wounds are not given specialized care because they are not considered an actual disease.5 the care is fragmented with different healthcare providers using different treatment strategies based on their experiences and views.33 one challenge posed by fragmented care is the lack of coordination and poor communication among care providers. the end result of this is poor quality of care and poor patient outcomes. taking a multidisciplinary approach can help to address the fragmentation and improve care outcomes. research documents the importance of a multidisciplinary approach in managing chronic wounds because of their complex nature.4,5,7,34,35 mahmoud and gould,5 recommend establishing a center of excellence that can promote a multidisciplinary approach to chronic wound healing. having a center of excellence can also ensure there are systematic care protocols in place to ensure standard wound care. sen,6 recommends using different care professionals in the management of chronic wounds. for instance, physical therapists can use different treatment regimens including edema management, debridement, positioning, and mobility improvement to improve care outcomes for patients with chronic wounds.6 occupational therapists, on the other hand, can improve outcomes for wound care using treatment regimens such as edema management, positioning, wheelchair management, and toileting programs. therefore, employing a multidisciplinary approach can lead to positive outcomes and improve patient outcomes. chronic wound care and management although managing chronic wounds is a complex process, positive outcomes are possible with proper treatment regimens and management techniques. an assessment of the wound and the patient should be done to ascertain the underlying areas of concern before any type of treatment is commenced. frykberg and banks,4 recommend an assessment to identify any underlying areas of concern that need to be addressed to ensure favorable outcomes are attained. after assessing the patient and identifying all underlying areas of concern, a holistic approach to managing the patient should be taken to ensure positive outcomes. healthcare providers should not focus on the wound alone. instead, they should focus on the patient as a whole including addressing all the underlying comorbidities and the factors associated with the wound.34 without addressing the underlying factors and comorbidities, it becomes difficult to achieve positive outcomes because they contribute to the likelihood of developing chronic wounds. for instance, nutrition is one of the factors that is constantly mentioned as affecting wound healing.36 without proper nutrition support, positive outcomes of chronic wounds are less likely to be achieved.37 for diabetic patients, it is important to control for hyperglycemia and manage neuropathy.4 in patients that have pressure ulcers, there is a need to optimize patient mobility and redistribute the pressure to prevent friction.34 applying compression for patients with venous ulcers to improve blood flow is also necessary.38 therefore, employing a holistic approach and management for patients with chronic wounds other than treating the wound alone is likely to lead to positive outcomes. after conducting a wound assessment and all the necessary interventions, wound bed preparation should begin. wound bed preparation is crucial in chronic wound management because it accelerates endogenous healing and ensures the therapeutic measures applied are effective.34,39 using the tissue, infection/inflammation, moisture imbalance, epithelial edge advancement (time) concept can optimize wound bed preparation and lead to positive outcomes.4 each component should be taken it account to improve the likelihood of positive wound care. debridement is one of the most critical components of wound care. it helps to accelerate the healing process which explains why it is a critical component of care.4 debridement entails the removal of non-viable wound components and tissue.3 it also includes the removal of necrotic tissue, biofilm, and slough. necrotic tissue and biofilm are known to impair the healing process by prolonging the inflammation phase of wound healing.40 debridement can be done in various ways with the most common methods being surgical, ultrasonic, hydrosurgical, mechanical, and autolytic debridement.41,34 surgical debridement also known as sharp debridement is a common method of debridement and is considered the most effective.41,42 it is done using scalpels, curettes, scissors, or tissue nippers. a topic, local, or general anesthesia may also be applied. effective debridement is considered vital in chronic wound care. if debridement is not done as expected, it can slow wound healing significantly. another important aspect that should be considered is offloading. offloading is mainly applied in treating diabetic foot ulcers and is done to reduce mechanical stress on the wound.43 offloading is considered a standard for care for diabetic ulcers and is known to lead to successful outcomes.4,44, 45reducing pressure from wounds helps to accelerate the healing process. in diabetic ulcers, total contact cast (tcc) is regarded as the gold standard for offloading because it enhances pressure redistribution.46,47 tcc is also considered instrumental because can help to reduce edema.46 pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [48] ajdhs.com an additional aspect of chronic wound management that should be considered is infection control. according to eriksson et al.3 it is important to assume all chronic wounds are infected with bacteria to provide the necessary level of care that is needed. assessing whether the wound is infected is vital. this can be done by carrying out a swab on the wound to determine if there is a presence of bacteria that can hinder healing.3 however, although swabs are considered important, it is vital to note that not all bacteria hinder healing. as a result, routine swab on all chronic wounds is not recommended.34 to know which wounds to conduct a swab on, clinical diagnosis is recommended.34 diagnosis can be done using quantitative biopsy.34 using appropriate method to conduct biopsy is vital ensure safety and an accurate diagnosis. after diagnosing whether the wound is infected, infection control can begin. various measures are recommended in infection control of infected wounds. the first is using cleansing agents and topical antimicrobials that can aid in healing.40 different agents can be used to cleanse wounds including normal saline or tap water and dilute vinegar 0.5% acetic acid.40 topical antimicrobials are considered vital in the management of chronic wounds and are preferred over systematic antimicrobials. they are used for treating wounds that are superficially infected. they are considered vital in managing these wounds because they directly target the bacteria.40 the food and drug administration (fda) recommends minocycline and gentamycin for topical treatment but caution needs to be applied because of the high risk of developing antimicrobial resistance.40 as such, eriksson et al. recommend limiting treatment using topic antimicrobials to two weeks to prevent resistance. dressing is also a vital part of wound care. according to eriksson et al.3 wound dressings perform different functions in wound care and this should be considered when selecting the appropriate dressing. for instance, some dressings are for protection while others are for managing moisture. some dressings help with pain management while others help with offloading. choosing the appropriate dressing is vital in aiding with wound healing. for instance, moisture-retentive dressings help to balance moisture by absorbing moisture while still keeping the wound moist.40,48,49 examples of moisture-retentive therapies that can used in wound dressing are hydrofibers, acrylics, alginates, hydrocolloids, films, and micronized collagen among others.3,4,50 all these dressings have different advantages and disadvantages and this should be taken into account when providing care. other advanced therapies can also be considered in the care and management of chronic wounds. examples of such therapies include negative pressure wound therapy, hyperbaric oxygen therapy, bioengineered therapies, acellular therapies, and stem cell therapies.4,51,52,53 all these therapies have been shown to have different levels of success when it comes to the management of chronic wounds. choosing the right type of therapy depending on the wound being treated and the underlying needs of the patient is what determines the level of success that will be achieved in treating chronic wounds. therefore, it is imperative for healthcare professionals involved in chronic wound management and care to select the right type of therapy to ensure success and positive outcomes are achieved. strengths and limitations of the review findings from this review offer a comprehensive discussion on chronic wound care and management. it includes challenges that are experienced in chronic wound care and various management/treatment approaches that can be used to achieve positive outcomes. understanding the challenges healthcare providers face in the management of chronic wounds can help to identify appropriate strategies that can be used to enhance positive clinical outcomes. chronic wounds still remain a prevalent challenge and as the population ages, the problem is not likely to go away soon. therefore, it is imperative to understand the challenges encountered in the care and management of chronic wounds and different treatment/management strategies that can be applied to increase the likelihood of positive outcomes and a better quality of life. this review has some limitations. it does not follow a rigorous data extraction process and only includes articles that the author considers appropriate to inform this research. determining the quality of sources included in this review was also difficult because a quality assessment was not done. conclusion managing chronic wounds is still a significant challenge. despite advances in interventions to treat these wounds, they pose a significant challenge to healthcare systems around the world. the difficulty of managing chronic wounds stems from their complexity. underlying factors such as diabetes, poor nutrition, comorbidities, infection, tissue edema, and pressure contribute to the complexity of managing chronic wounds. addressing these factors is vital in achieving positive outcomes when it comes to treatment of chronic wounds. addressing these factors requires a multidisciplinary approach that involves different healthcare professionals. it also requires a holistic approach to care that ensures the underlying factors that are contributing to impaired wound healing are addressed. underlying factors that contribute to impaired wound healing can be addressed by conducting patient and wound assessments. after conducting a wound assessment wound bed preparation should commence. other crucial management strategies that should be applied to enhance wound healing are debridement, offloading, infection control, and proper dressing. advanced therapies such as hyperbaric oxygen therapy and negative pressure wound therapy should be applied as appropriate. references 1. martinengo l, olsson m, bajpai r, et al. prevalence of chronic wounds in the general population: systematic review and metaanalysis of observational studies. annals of epidemiology. 2019; 29:8-15. https://doi.org/10.1016/j.annepidem.2018.10.005 pmid:30497932 2. sen ck. human wound and its burden: updated 2022 compendium of estimates. advances in wound care. 2023;12(12):657-70. https://doi.org/10.1089/wound.2023.0150 pmid:37756368 3. eriksson e, liu py, schultz gs, et al. chronic wounds: treatment consensus. wound repair and regeneration. 2022;30(2):156-71. https://doi.org/10.1111/wrr.12994 pmid:35130362 pmcid:pmc9305950 4. frykberg rg, banks, j. challenges in the treatment of chronic wounds. advances in wound care. 2015; 4(9): 1-23. https://doi.org/10.1089/wound.2015.0635 pmid:26339534 pmcid:pmc4528992 5. mahmoudi m, gould lj. opportunities and challenges of the management of chronic wounds: a multidisciplinary viewpoint. chronic wound care management and research. 2020; 7:27-36. https://doi.org/10.2147/cwcmr.s260136 6. sen ck. human wound and its burden: updated 2020 compendium of estimates. advances in wound care. 2021;10(5):281-92. https://doi.org/10.1089/wound.2021.0026 pmid:33733885 pmcid:pmc8024242 7. franks pj, barker j, collier m, et al. management of patients with venous leg ulcers: challenges and current best practice. journal of wound care. 2016 ;25(sup6):s1-67. https://doi.org/10.12968/jowc.2016.25.sup6.s1 pmid:27292202 https://doi.org/10.1016/j.annepidem.2018.10.005 https://doi.org/10.1089/wound.2023.0150 https://doi.org/10.1111/wrr.12994 https://doi.org/10.1089/wound.2015.0635 https://doi.org/10.2147/cwcmr.s260136 https://doi.org/10.1089/wound.2021.0026 https://doi.org/10.12968/jowc.2016.25.sup6.s1 pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [49] ajdhs.com 8. jupiter dc, thorud jc, buckley cj, shibuya n. the impact of foot ulceration and amputation on mortality in diabetic patients. i: from ulceration to death, a systematic review. international wound journal. 2016;13(5):892-903. https://doi.org/10.1111/iwj.12404 pmid:25601358 pmcid:pmc7950078 9. järbrink k, ni g, sönnergren h, et al. the humanistic and economic burden of chronic wounds: a protocol for a systematic review. systematic reviews. 2017;6:1-7. https://doi.org/10.1186/s13643-016-0400-8 pmid:28118847 pmcid:pmc5259833 10. järbrink k, ni g, sönnergren h, schmidtchen a, pang c, bajpai r, car j. prevalence and incidence of chronic wounds and related complications: a protocol for a systematic review. systematic reviews. 2016;5:1-6. https://doi.org/10.1186/s13643-016-0329y pmid:27609108 pmcid:pmc5017042 11. mostow en. diagnosis and classification of chronic wounds. clinics in dermatology. 1994;12(1):3-9. https://doi.org/10.1016/0738081x(94)90251-8 pmid:8180943 12. bowers s, franco e. chronic wounds: evaluation and management. american family physician. 2020;101(3):159-66. 13. nelson ea, adderley u. venous leg ulcers. bmj clinical evidence. 2016. 14. valencia ic, falabella a, kirsner rs, eaglstein wh. chronic venous insufficiency and venous leg ulceration. journal of the american academy of dermatology. 2001; 44(3):401-24. https://doi.org/10.1067/mjd.2001.111633 pmid:11209109 15. kirsner rs, vivas ac. lower-extremity ulcers: diagnosis and management. british journal of dermatology. 2015;173(2):37990. https://doi.org/10.1111/bjd.13953 pmid:26257052 16. singer aj, tassiopoulos a, kirsner rs. evaluation and management of lower-extremity ulcers. new england journal of medicine. 2017;377(16):1559-67. https://doi.org/10.1056/nejmra1615243 pmid:29045216 17. grey je, enoch s, harding kg. abc of wound healing: venous and arterial leg ulcers. bmj. 2006;332(suppl s4). https://doi.org/10.1136/bmj.332.7537.347 pmid:16470058 pmcid:pmc1363917 18. voelker r. what are diabetic foot ulcers?. jama. 2023;330(23):2314. https://doi.org/10.1001/jama.2023.17291 pmid:37976071 19. oliver ti, mutluoglu m. diabetic foot ulcer. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk537328/ 20. jeffcoate wj, harding kg. diabetic foot ulcers. the lancet. 2003;361(9368):1545-51. https://doi.org/10.1016/s01406736(03)13169-8 pmid:12737879 21. boulton aj. the diabetic foot. medicine. 2015;43(1):33-37. https://doi.org/10.1016/j.mpmed.2014.10.006 22. noor s, zubair m, ahmad j. diabetic foot ulcer-a review on pathophysiology, classification and microbial etiology. diabetes & metabolic syndrome: clinical research & reviews. 2015;9(3):1929. https://doi.org/10.1016/j.dsx.2015.04.007 pmid:25982677 23. armstrong dg, boulton aj, bus sa. diabetic foot ulcers and their recurrence. new england journal of medicine. 2017;376(24):2367-75. https://doi.org/10.1056/nejmra1615439 pmid:28614678 24. mervis js, phillips tj. pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation. journal of the american academy of dermatology. 2019;81(4):881-90. https://doi.org/10.1016/j.jaad.2018.12.069 pmid:30664905 25. monika p, chandraprabha mn, rangarajan a, waiker pv, chidambara murthy kn. challenges in healing wound: role of complementary and alternative medicine. frontiers in nutrition. 2022;8:791899. https://doi.org/10.3389/fnut.2021.791899 pmid:35127787 pmcid:pmc8811258 26. guo sa, dipietro la. factors affecting wound healing. journal of dental research. 2010;89(3):219-29. https://doi.org/10.1177/0022034509359125 pmid:20139336 pmcid:pmc2903966 27. wallace ha, basehore bm, zito pm. wound healing phases. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk470443/ 28. vestby lk, grønseth t, simm r, nesse ll. bacterial biofilm and its role in the pathogenesis of disease. antibiotics. 2020;9(2):59. https://doi.org/10.3390/antibiotics9020059 pmid:32028684 pmcid:pmc7167820 29. costerton jw, cheng kj, geesey gg, ladd ti, nickel jc, dasgupta m, marrie tj. bacterial biofilms in nature and disease. annual reviews in microbiology. 1987;41(1):435-64. https://doi.org/10.1146/annurev.mi.41.100187.002251 pmid:3318676 30. wu h, moser c, wang hz, høiby n, song zj. strategies for combating bacterial biofilm infections. international journal of oral science. 2015;7(1):1-7. https://doi.org/10.1038/ijos.2014.65 pmid:25504208 pmcid:pmc4817533 31. clinton a, carter t. chronic wound biofilms: pathogenesis and potential therapies. laboratory medicine. 2015;46(4):277-84. https://doi.org/10.1309/lmbnswkui4jpn7so pmid:26489671 32. sen ck. human wounds and its burden: an updated compendium of estimates. advances in wound care. 2019;8(2):39-48. https://doi.org/10.1089/wound.2019.0946 pmid:30809421 pmcid:pmc6389759 33. corbett lq. wound care nursing: professional issues and opportunities. advances in wound care. 2012;1(5):189-93. https://doi.org/10.1089/wound.2011.0329 pmid:24527304 pmcid:pmc3839022 34. falcone m, de angelis b, pea f, scalise a, stefani s, tasinato r, zanetti o, dalla paola l. challenges in the management of chronic wound infections. journal of global antimicrobial resistance. 2021;26:140-7. https://doi.org/10.1016/j.jgar.2021.05.010 pmid:34144200 35. brown-maher t. multidisciplinary approach to chronic wound care: our 2-year newfoundland and labrador experience. journal of cutaneous medicine and surgery. 2009;13(3_suppl):s26-8. https://doi.org/10.2310/7750.2009.00006 pmid:19480748 36. gould l, abadir p, brem h, et al. chronic wound repair and healing in older adults: current status and future research. wound repair and regeneration. 2015;23(1):1-3. https://doi.org/10.1111/jgs.13332 pmid:25753048 pmcid:pmc4582412 37. molnar ja, underdown mj, clark wa. nutrition and chronic wounds. advances in wound care. 2014;3(11):663-81. https://doi.org/10.1089/wound.2014.0530 pmid:25371850 pmcid:pmc4217039 38. ren sy, liu ys, zhu gj, liu m, shi sh, ren xd, hao yg, gao rd. strategies and challenges in the treatment of chronic venous leg ulcers. world journal of clinical cases. 2020;8(21):5070. https://doi.org/10.12998/wjcc.v8.i21.5070 pmid:33269244 pmcid:pmc7674718 39. sibbald rg, elliott ja, persaud-jaimangal r, goodman l, armstrong dg, harley c, coelho s, xi n, evans r, mayer do, zhao x. wound bed preparation 2021. wound healing southern africa. 2021;14(2):52-62. https://doi.org/10.1097/01.asw.0000733724.87630.d6 pmid:33739948 pmcid:pmc7982138 40. powers jg, higham c, broussard k, phillips tj. wound healing and treating wounds: chronic wound care and management. journal of the american academy of dermatology. 2016; 74(4):607-25. https://doi.org/10.1016/j.jaad.2015.08.070 pmid:26979353 41. attinger ce, bulan ej. debridement: the key initial first step in wound healing. foot and ankle clinics. 2001;6(4):627-60. https://doi.org/10.1111/iwj.12404 https://doi.org/10.1186/s13643-016-0400-8 https://doi.org/10.1186/s13643-016-0329-y https://doi.org/10.1186/s13643-016-0329-y https://doi.org/10.1016/0738-081x(94)90251-8 https://doi.org/10.1016/0738-081x(94)90251-8 https://doi.org/10.1067/mjd.2001.111633 https://doi.org/10.1111/bjd.13953 https://doi.org/10.1056/nejmra1615243 https://doi.org/10.1136/bmj.332.7537.347 https://doi.org/10.1001/jama.2023.17291 https://www.ncbi.nlm.nih.gov/books/nbk537328/ https://doi.org/10.1016/s0140-6736(03)13169-8 https://doi.org/10.1016/s0140-6736(03)13169-8 https://doi.org/10.1016/j.mpmed.2014.10.006 https://doi.org/10.1016/j.dsx.2015.04.007 https://doi.org/10.1056/nejmra1615439 https://doi.org/10.1016/j.jaad.2018.12.069 https://doi.org/10.3389/fnut.2021.791899 https://doi.org/10.1177/0022034509359125 https://www.ncbi.nlm.nih.gov/books/nbk470443/ https://doi.org/10.3390/antibiotics9020059 https://doi.org/10.1146/annurev.mi.41.100187.002251 https://doi.org/10.1038/ijos.2014.65 https://doi.org/10.1309/lmbnswkui4jpn7so https://doi.org/10.1089/wound.2019.0946 https://doi.org/10.1089/wound.2011.0329 https://doi.org/10.1016/j.jgar.2021.05.010 https://doi.org/10.2310/7750.2009.00006 https://doi.org/10.1111/jgs.13332 https://doi.org/10.1089/wound.2014.0530 https://doi.org/10.12998/wjcc.v8.i21.5070 https://doi.org/10.1097/01.asw.0000733724.87630.d6 https://doi.org/10.1016/j.jaad.2015.08.070 pallav dave asian journal of dental and health sciences. 2024; 4(1):45-50 [50] ajdhs.com https://doi.org/10.1016/s1083-7515(02)00010-4 pmid:12134576 42. attinger ce, bulan e, blume pa. surgical debridement: the key to successful wound healing and reconstruction. clinics in podiatric medicine and surgery. 2000;17(4):599-630. https://doi.org/10.1016/s0891-8422(23)01152-7 pmid:11070797 43. lazzarini pa, jarl g, gooday c, et al. effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review. diabetes/metabolism research and reviews. 2020; 36:e3275. https://doi.org/10.1002/dmrr.3275 pmid:32176438 pmcid:pmc8370012 44. cavanagh pr, bus sa. off-loading the diabetic foot for ulcer prevention and healing. journal of the american podiatric medical association. 2010;100(5):360-8. https://doi.org/10.1016/j.jvs.2010.06.007 pmid:20804932 45. elraiyah t, prutsky g, domecq jp, tsapas a, nabhan m, frykberg rg, firwana b, hasan r, prokop lj, murad mh. a systematic review and meta-analysis of off-loading methods for diabetic foot ulcers. journal of vascular surgery. 2016;63(2):59s-68s. https://doi.org/10.1016/j.jvs.2015.10.006 pmid:26804369 46. armstrong dg, nguyen hc, lavery la, van schie ch, boulton aj, harkless lb. off-loading the diabetic foot wound: a randomized clinical trial. diabetes care. 2001; 24(6):1019-22. https://doi.org/10.2337/diacare.24.6.1019 pmid:11375363 47. fife ce, carter mj, walker d. why is it so hard to do the right thing in wound care?. wound repair and regeneration. 2010;18(2):154-8. https://doi.org/10.1111/j.1524475x.2010.00571.x pmid:20163568 48. fonder ma, lazarus gs, cowan da, aronson-cook b, kohli ar, mamelak aj. treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. journal of the american academy of dermatology. 2008;58(2):185-206. https://doi.org/10.1016/j.jaad.2007.08.048 pmid:18222318 49. powers jg, morton lm, phillips tj. dressings for chronic wounds. dermatologic therapy. 2013;26(3):197-206. https://doi.org/10.1111/dth.12055 pmid:23742280 50. han g, ceilley r. chronic wound healing: a review of current management and treatments. advances in therapy. 2017;34:599610. https://doi.org/10.1007/s12325-017-0478-y pmid:28108895 pmcid:pmc5350204 51. wu sc, marston w, armstrong dg. wound care: the role of advanced wound-healing technologies. journal of the american podiatric medical association. 2010;100(5):385-94. https://doi.org/10.7547/1000385 pmid:20847352 52. orgill dp, bayer lr. update on negative-pressure wound therapy. plastic and reconstructive surgery. 2011;127:105s-15s. https://doi.org/10.1097/prs.0b013e318200a427 pmid:21200280 53. kosaric n, kiwanuka h, gurtner gc. stem cell therapies for wound healing. expert opinion on biological therapy. 2019;19(6):57585. https://doi.org/10.1080/14712598.2019.1596257 pmid:30900481 https://doi.org/10.1016/s1083-7515(02)00010-4 https://doi.org/10.1016/s0891-8422(23)01152-7 https://doi.org/10.1002/dmrr.3275 https://doi.org/10.1016/j.jvs.2010.06.007 https://doi.org/10.1016/j.jvs.2015.10.006 https://doi.org/10.2337/diacare.24.6.1019 https://doi.org/10.1111/j.1524-475x.2010.00571.x https://doi.org/10.1111/j.1524-475x.2010.00571.x https://doi.org/10.1016/j.jaad.2007.08.048 https://doi.org/10.1111/dth.12055 https://doi.org/10.1007/s12325-017-0478-y https://doi.org/10.7547/1000385 https://doi.org/10.1097/prs.0b013e318200a427 https://doi.org/10.1080/14712598.2019.1596257 pallav dave asian journal of dental and health sciences. 2024; 4(2):21-25 [21] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited social media and the risk of poor mental health among young adults pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 18 april 2024 reviewed 16 may 2024 accepted 31 may 2024 published 15 june 2024 _____________________________________________ cite this article as: dave p, social media and the risk of poor mental health among young adults, asian journal of dental and health sciences. 2024; 4(2):21-25 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.74 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ social media platforms have become an integral part of people’s lives in the last decade. as a prominent fixture in young people’s lives, social platforms have allowed them to share their experiences and connect with peers. however, using these platforms excessively can become problematic. research has linked problematic use of social sites to more risk of having mental health issues. some of the common mental health problems reported include depression, anxiety, loneliness, social media-related fatigue, unhappiness, and increased risk of alcohol use. different reasons contribute to the increased risk of developing mental health problems because of excessive use of these platforms. they are sedentary behavior, poor sleep patterns, cyberbullying and victimization, multitasking, and internalizing online experiences. others have a high risk of developing mental disorders because they neglect important aspects of their lives such as real-life social interactions. addressing these factors can lower individual’s risk of developing mental health issues. besides, some studies have shown that there is a link between using social platforms and positive mental health more so for individuals struggling with mental problems. social sites can be used to provide social support for young individuals experiencing mental problems. individuals can use these problems to share about their life struggles with mental issues. they can also use these platforms to obtain help and resources. therefore, the aim of this review is to explore how social media increases the risk of mental problems among young adults. keywords: social media, depression, anxiety, loneliness, social support, problematic/excessive social media use introduction the last decade has seen social media become an integral part of individual’s lives more so young adults. social media platforms such as facebook, instagram, youtube, x formerly known as twitter, and tiktok have become popular tools for social interaction more so for youths and young adults. according to pew research center, approximately 7 in 10 americans use sites such as instagram, snapchat, and tiktok being some of the most famous platforms with a large following by young adults.1 the growth in popularity of such platforms among young adults can be attributed to a number of factors. key among them is the ability to use the platform to communicate, share messages, co-create, and exchange digital content including photos and videos.2,3 social media also plays a role in creating and shaping young people’s experiences. for most young adults, these platforms provide a means for people to interact with others which is crucial in forming their identities online.4 however, despite the significance of these platforms in shaping the experience of most young people, some scholars believe it is like a double-edged sword. doubleedged sword in the sense that it allows young people to express their feelings and receive social support, and also contributes to an increased risk of having mental health issues and other psychological problems.5,6,7,8,9,10 research has also shown that individuals who live with different mental disorders use social platforms more than the general population.11,12 the high use of social platforms in this population could be attributed to a number of factors including as a platform to seek information, as a mechanism to give and receive social support, or as a mechanism to cope. whichever the case, social platforms cannot be disregarded pertaining to its contribution to mental health. therefore, this review seeks to explore the role of social media as a problematic aspect when it comes to mental health in young adults. particularly, the review explores how these platforms are contributing to the risk of having mental health issues among young adults. mental health among young adults mental health disorders remain one of the most significant problems affecting the adult population. the world health organization estimates that 1 in every 8 individuals which is approximately 970 million of the world population live with a mental health disorder. among the adult population, young adults are one of the groups that is adversely affected by mental health problems.13 according to the national institute of mental health, about 57.8 million adults in the us suffer from mental health disorders with young adults being one of the groups that is mostly affected.14 according to the data, young adults aged 18 to 25 years had the highest prevalence of mental illness at 33.7%. adults aged 26 to 49 years accounted for 28.1% and those aged 50 years and older were 15%.14 young adults were also the most affected by serious mental illness. serious mental illness in this case is a mental illness that results in severe functional impairment. of the 14.1 million adults who were diagnosed with serious mental illness in 2021, 11.4% of these were young adults aged 18 years to 25. the number was higher than the 7.1% that was reported among adults aged 26 to 49 years and 2.5% in adults aged 50 years and older.14 issues related to mental problems are a major area of concern reported among young adults. if not addressed, mental health open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.74 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.74&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):21-25 [22] ajdhs.com problems can lead to severe impairment and significantly affect functioning. the global burden of disease study that was conducted in 2019 reported mental health disorders contribute significantly to years lived with disability (yld).15 based on the study, the number of ylds contributed significantly to the burden of mental health disorders with 125.3 million ylds. mental health disorders also contributed significantly to disability-adjusted life-years (dalys) with the numbers increasing from 80.8 million in 1999 to 125.3 million in 2019.15 some of the main mental health disorders affecting young adults are major depressive disorders, anxiety disorders, mood disorders, and alcohol use disorders.16 addressing mental disorders affecting young adults is vital. in addition to contributing significantly to mental challenges and physical functioning, mental disorders also affect overall health and social well-being. however, addressing mental disorders can be challenging because of the complexities involved. this is particularly the case where social media is involved. the growing use of social platforms in young adults’ lives can be problematic more so when it comes to problematic behaviors such as addiction. addiction can be a fueling factor for mental health problems. social media addiction can lead to increased isolation and loneliness with real-life social contracts leading to challenges such as depression. considering the challenges that mental health causes in young adults, there is a need to explore how these platforms contribute to increased risk of mental health issues. social media and mental health the advent of social media has seen an increase in the number of people affected by mental health issues. some studies have reported that using social platforms excessively increases individual’s risk of having mental problems. other studies have reported that social platforms use leads to positive outcomes when it comes to mental health. although the results on the impact of social platforms are mixed, evidence suggests that the quantity of exposure is what really matters. mere exposure is not regarded as harmful. however, constant exposure is seen as a catalyst factor for mental issues.17 according to a scoping review by mccrory et al. the time individuals spend using highly visual social platforms impact their mental health.18 some studies report that people who spend more time on these platforms report a greater sense of social connection and acceptance. other studies reported that individuals who spend more time on social media had higher levels of loneliness and depression.18 similarly, another study by shensa et found using social platforms in a manner that was problematic made people be at a higher risk of developing depression.8 problematic use of social platforms in this case refers to the amount of time people spent on these sites. other measures that were used to determine problematic social media usage were having an uncontrollable urge to use the platforms, logging in social sites as way to forget one’s problems, using social sites to an extent that it was problematic to one’s job and studies, trying to cut down social sites usage without having much success, and being restless when asked to stop using social platforms.8 the findings from this nationally representative study were similar to those by primack et al.9 according to primack et al. increased social sites usage was associated with both depression and anxiety.9 the more time one spent on social sites increased their risk of having depression and anxiety symptoms.9 individuals who used 7 to 11 platforms reported more likelihood of experiencing depression and anxiety.9 the risk of developing anxiety was high because of the fear of missing out. the fear made individuals check social platforms on a regular basis contributing to anxiety. lin et al. also established increased odds of depression among young adults who reported high usage of social sites than those who reported using less time of social platforms per day even after controlling for factors such as age, sex, and race.19 in addition to depression and anxiety, social platforms leads to risk of having other mental problems. social media use led to a decline in individual’s subjective well-being.20 in this case, two components were used to measure the participants' subjective well-being namely how they felt from moment to moment and how satisfied they were with their lives.20 the study established that the more people used facebook the worse they felt. consistent use over a period of two weeks led to lower levels of life satisfaction over time. another study found that facebook led to decrease in mood.21 the reason why facebook was associated with a decrease in mood is because individuals judged the site as less useful, less meaningful, and more of a waste of time.21 these perceptions are what could have led to a decrease in mood. other mental problems that are associated with social media use are fatigue, loneliness, unhappiness, and increased risk of alcohol use.22 depression seems to be the most commonly reported mental disorder in individuals who have problematic social platforms use. reasons why social media increases the risk of mental health different plausible explanations have been given as to why social platforms increases the risk of having mental challenges. one of the reasons is because it is a sedentary behavior. as a sedentary behavior, social media increases the risk of health problems including mental issues. research has found that leading a sedentary lifestyle increases the risk of mental problems.23,24,25 lack of physical activity is always associated with poor mental well-being with individuals that have lower levels of exercise being known to lead to poor mental health outcomes.26 when it comes to excessive use of social platforms, engaging in physical activity becomes a problem. because of the considerable amount of time spent on these platforms, engaging in any form of physical activity becomes difficult which explains why leading a sedentary lifestyle leads to mental problems. in addition to being a sedentary behavior, excessive social media use affects sleep patterns risking mental health issues. research has found that poor and inadequate sleep leads to mental issues and well-being more so the risk of developing depression in young people.27 inadequate sleep has also been linked to mental distress in adults with 6 hours of sleep and less being shown to increase the likelihood of developing mental distress.28 problematic media use increases the risk of inadequate sleep and chronic sleep deprivation. the use of electronic devices near bedtime is common among young people. in some instances, the use may be problematic leading to inadequate sleep. according to a systematic review by alonzo et al. significant association between excessive use, poor mental outcomes, and poor sleep quality was reported.29 poor sleep quality led to negative mental health.29 similar findings were established by yu et al.30 the study found that excessive social use, poor sleep quality, and poor outcomes were associated. some of the reasons why social media use was associated with poor sleep quality was because the sites were interactive platforms which increased mental stimulation and subsequent poor sleep. besides, prolonged use of social sites before bedtime affected sleep onset. the mental stimulation did not create a conducive environment for sleep. it also reduced the overall period of sleep duration. an additional reason why social media use has been associated with increased depressive symptoms is because individuals who spend most of their time on these plaforms tend to neglect other important aspects such as real-life social interactions.8 spending a lot of time on social platforms can make individuals have fewer face-to-face interactions which can affect their social pallav dave asian journal of dental and health sciences. 2024; 4(2):21-25 [23] ajdhs.com well-being. some studies have reported decreased levels of social interaction and social support in real life for individuals who use these platforms excessively.31,32 social interactions play a crucial role when it comes to providing support and subsequent well-being. although social platforms can provide support, face-to-face interactions play a key role when it comes to keeping the social connection. despite being an avenue for social support and interaction, these platforms may not fill the void the user may be seeking to fill which is why it can lead to more feelings of exclusion.9 lower levels of social support and exclusion can lead to lower levels of social satisfaction and subsequent depression. the way individuals internalize their online experiences is also vital when it comes to social platforms use and increased risk of mental issues. people internalize experiences differently. some people tend to over-analyze situations which can lead to feelings of depression and sadness. others can engage in excessive self-comparison which can lead to low mood. according to a study done by chou et al. facebook use had an impact on how people perceived other individuals’ lives.33 for instance, positive messages and happy pictures were perceived as doing better in life. individuals may engage in selfcomparison with others based on these pictures and messages which lead to feelings of sadness for feeling unaccomplished. use of social platforms has also been associated with a greater risk of internalizing problems.34 internalizing social experiences can increase the risk of mental problems. it can lead to increased sadness and the likelihood of developing depression. cyberbullying and victimization on social platforms are other emerging threats that are being reported by young people following the increasing use of these sites. the increasing incidences of cyberbullying on social media are being facilitated by a number of key factors more so the anonymity these platforms offer.35 unlike face-to-face interactions, these platforms provides bullies with more anonymity. bullies can hide behind their online personas and recruit others to facilitate the bullying. cyberbullying and victimization have been linked to mental challenges more so among young people. some researchers have found that cyberbullying on social media affects an individual’s well-being. according to giumetti and kowalski, cyberbullying on these platforms among youths and young adults affects well-being.10 it contributes to psychological distress, suicidal ideation, and lower levels of life satisfaction. viner et al. also found that frequent use of these platforms increased the risk of mental issues.36 the association between using social platforms and mental problems could also be attributed to online multitasking. technology has encouraged multitasking with people using multiple screens at the same time.37 some studies have found that multitasking on different online platforms increases the risk of mental issues. according to becker et al., media multitasking was a predicting factor for self-reported depression and social anxiety.38 this was even after controlling for factors such as personality and overall media use. similar findings were established by li and fan et al. who found media multitasking to lead to increased risk of depression and anxiety among college students.39 multitasking was also shown to increase the risk of depression, narcissism, mania, antisocial disorder, paranoid disorder, and compulsive disorder.37 online multitasking also affects an individual’s attention span. it is highly disruptive which makes it difficult to concentrate. poor concentration can affect different aspects of an individual’s life such as work and school leading to poor performance. poor performance in these aspects can lead to psychological distress. although a link has been made between excessive social media use and mental problems, there are some studies that show that it has the opposite effect. according to deters and mehl, posting facebook status updates decreased loneliness.7 it decreased loneliness because it made people feel more connected and in touch with their friends on a daily basis. social media was also seen as a tool of social support for sexual minority and heterosexual youth.6 for marginalized youth, social media can be used for mental health interventions. social media offers an opportunity to establish supportive resources for young people struggling with mental challenges.5 additionally, social media can be used to provide online peer support among individuals with mental illness and promote engagement and retention in mental health services.40 online discourses about mental illness can be beneficial. social media platforms can provide an avenue for people struggling with mental health problems to open up about their struggles and connect with people going through similar struggles. such interactions can have positive outcomes for individuals struggling with mental issues. evidently, the findings on the impact of social media on mental health are mixed. some studies have found that excessive social media usage increases the risk of mental issues more so depression and anxiety while others find social media usage leads to positive mental health in terms of social support.18, 41 therefore, whether these platforms are responsible for leading to mental issues is still an area of contention. the link between social platforms and mental health problems is not straightforward. different factors contribute to the association which means that controlling for these factors can lead to a positive social experience on these sites. for instance, the association between excessive social media use, poor quality sleep, and poor mental problems can be addressed by using social media responsibly and avoiding it before bedtime. avoiding multitasking can also lead to positive mental health outcomes. other aspects that can be controlled include being more physically active, having face-to-face interaction, and internalizing experiences in a positive manner. controlling for these factors while using social platforms can lead to a positive experience. for instance, using these sites as a source of peer support for those struggling with mental health problems can improve people’s experiences. social platforms are allso increasingly being used as a source of information. positioning these sites to offer mental health information and resources to those struggling with mental health issues can lead to positive outcomes. mental health clinicians can also use these sites to reach out to people struggling with mental health problems. however, caution is needed to avoid misguiding information that may have negative consequences. conclusion as highlighted in this review, social media sites have become an integral aspect of people’s lives today more so young adults. in some instances, social media use has been problematic with excessive use increasing the risk of mental health. some of the common mental health disorders associated with excessive use of social platforms are depression, anxiety, loneliness, social media-related fatigue, unhappiness, and increased risk of alcohol use. several factors increase the risk of developing mental health disorders for individuals using social media excessively. some of these factors include sedentary behavior, poor sleep patterns, cyberbullying and victimization, multitasking, and internalizing online experiences. others have a high risk of developing mental health problems because they neglect important aspects of their lives such as real-life social interactions. however, the link between use of social platforms and increased risk of mental health is not straightforward. although there are associations, some studies have found social media to have a positive effect on mental health. using social sites to seek support and share lived experiences with mental problems has been shown to have a positive effect. social platforms can also be used to seek information and as a source of peer support. all these are crucial for individuals struggling pallav dave asian journal of dental and health sciences. 2024; 4(2):21-25 [24] ajdhs.com with mental health issues. however, social media needs to be used in a way that it does not become problematic. excessive use has a negative effect. other than leading to addiction, it can increase the risk of developing mental problems. therefore, there is a need to use social media responsibly to minimize negative effects on mental health. references 1. auxier, b, anderson, m. social media use in 2021. pew research center. 2021. available from: https://www.pewresearch.org/internet/2021/04/07/socialmedia-use-in-2021/ 2. wong a, ho s, olusanya o, antonini mv, lyness d. the use of social media and online communications in times of pandemic covid19. journal of the intensive care society. 2021;22(3):255-60. https://doi.org/10.1177/1751143720966280 pmid:34422109 pmcid:pmc8373288 3. ahmed ya, ahmad mn, ahmad n, zakaria nh. social media for knowledge-sharing: a systematic literature review. telematics and informatics. 2019;37:72-112. https://doi.org/10.1016/j.tele.2018.01.015 4. berryman c, ferguson cj, negy c. social media use and mental health among young adults. psychiatric quarterly. 2018;89:30714. https://doi.org/10.1007/s11126-017-9535-6 pmid:29090428 5. fergie g, hunt k, hilton s. social media as a space for support: young adults' perspectives on producing and consuming usergenerated content about diabetes and mental health. social science & medicine. 2016;170:46-54. https://doi.org/10.1016/j.socscimed.2016.10.006 pmid:27750067 pmcid:pmc5115652 6. ceglarek pj, ward lm. a tool for help or harm? how associations between social networking use, social support, and mental health differ for sexual minority and heterosexual youth. computers in human behavior. 2016;65:201-9. https://doi.org/10.1016/j.chb.2016.07.051 7. dave p. the correlation between stigma and mental health disorders in people living with hiv/aids. journal of drug delivery and therapeutics, 2024;14(3):227-33. https://doi.org/10.22270/jddt.v14i3.6490 8. shensa a, escobar-viera cg, sidani je, bowman nd, marshal mp, primack ba. problematic social media use and depressive symptoms among us young adults: a nationally-representative study. social science & medicine. 2017;182:150-7. https://doi.org/10.1016/j.socscimed.2017.03.061 pmid:28446367 pmcid:pmc5476225 9. dave p, reducing disparities in pain management in primary care, asian journal of hospital pharmacy, 2024;4(2):28-33 10. giumetti gw, kowalski rm. cyberbullying via social media and well-being. current opinion in psychology. 2022;45:101314. https://doi.org/10.1016/j.copsyc.2022.101314 pmid:35313180 11. naslund ja, aschbrenner ka, bartels sj. how people with serious mental illness use smartphones, mobile apps, and social media. psychiatric rehabilitation journal. 2016;39(4):364. https://doi.org/10.1037/prj0000207 pmid:27845533 pmcid:pmc5125865 12. brunette mf, achtyes e, pratt s, stilwell k, opperman m, guarino s, kay-lambkin f. use of smartphones, computers and social media among people with smi: opportunity for intervention. community mental health journal. 2019;55:973-8. https://doi.org/10.1007/s10597-019-00431-7 pmid:31175518 pmcid:pmc7534532 13. world health organization. mental disorders. 2022. https://www.who.int/news-room/fact-sheets/detail/mentaldisorders 14. national institute of mental health. mental illness. 2023. https://www.nimh.nih.gov/health/statistics/mental-illness 15. gbd 2019 mental disorders collaborators. global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the global burden of disease study 2019. the lancet psychiatry. 2022;9(2):137-50. https://doi.org/10.1016/s22150366(21)00395-3 pmid:35026139 16. gustavson k, knudsen ak, nesvåg r, knudsen gp, vollset se, reichborn-kjennerud t. prevalence and stability of mental disorders among young adults: findings from a longitudinal study. bmc psychiatry. 2018;18:1-5. https://doi.org/10.1186/s12888018-1647-5 pmid:29530018 pmcid:pmc5848432 17. davila j, hershenberg r, feinstein ba, gorman k, bhatia v, starr lr. frequency and quality of social networking among young adults: associations with depressive symptoms, rumination, and corumination. psychology of popular media culture. 2012;1(2):72. https://doi.org/10.1037/a0027512 pmid:24490122 pmcid:pmc3907111 18. mccrory a, best p, maddock a. the relationship between highly visual social media and young people's mental health: a scoping review. children and youth services review. 2020;115:105053. https://doi.org/10.1016/j.childyouth.2020.105053 19. lin ly, sidani je, shensa a, radovic a, miller e, colditz jb, hoffman bl, giles lm, primack ba. association between social media use and depression among us young adults. depression and anxiety. 2016; 33(4):323-31. https://doi.org/10.1002/da.22466 pmid:26783723 pmcid:pmc4853817 20. kross e, verduyn p, demiralp e, et al. facebook use predicts declines in subjective well-being in young adults. plos one. 2013 aug 14;8(8):e69841. https://doi.org/10.1371/journal.pone.0069841 pmid:23967061 pmcid:pmc3743827 21. sagioglou c, greitemeyer t. facebook's emotional consequences: why facebook causes a decrease in mood and why people still use it. computers in human behavior. 2014;35:359-63. https://doi.org/10.1016/j.chb.2014.03.003 22. zubair u, khan mk, albashari m. link between excessive social media use and psychiatric disorders. annals of medicine and surgery. 2023;85(4):875-8. https://doi.org/10.1097/ms9.0000000000000112 pmid:37113864 pmcid:pmc10129173 23. dave p., the role of pharmacists in opioid addiction management. asian journal of dental and health sciences, 2024;4(1):51-56. https://doi.org/10.22270/ajdhs.v4i1.71 24. hoare e, milton k, foster c, allender s. the associations between sedentary behaviour and mental health among adolescents: a systematic review. international journal of behavioral nutrition and physical activity. 2016;13:1-22. https://doi.org/10.1186/s12966-016-0432-4 pmid:27717387 pmcid:pmc5055671 25. zink j, belcher br, imm k, leventhal am. the relationship between screen-based sedentary behaviors and symptoms of depression and anxiety in youth: a systematic review of moderating variables. bmc public health. 2020;20:1-37. https://doi.org/10.1186/s12889-020-08572-1 pmid:32272906 pmcid:pmc7147040 26. harris ma. the relationship between physical inactivity and mental wellbeing: findings from a gamification-based communitywide physical activity intervention. health psychology open. 2018;5(1):2055102917753853. https://doi.org/10.1177/2055102917753853 pmid:29372067 pmcid:pmc5774736 27. qiu j, morales-muñoz i. associations between sleep and mental health in adolescents: results from the uk millennium cohort study. international journal of environmental research and public health. 2022;19(3):1868. https://doi.org/10.3390/ijerph19031868 pmid:35162890 pmcid:pmc8835146 28. blackwelder a, hoskins m, huber l. effect of inadequate sleep on frequent mental distress. preventing chronic disease. 2021;18:200573. https://doi.org/10.5888/pcd18.200573 pmid:34138697 pmcid:pmc8220958 https://doi.org/10.1177/1751143720966280 https://doi.org/10.1016/j.tele.2018.01.015 https://doi.org/10.1007/s11126-017-9535-6 https://doi.org/10.1016/j.socscimed.2016.10.006 https://doi.org/10.1016/j.chb.2016.07.051 https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1016/j.socscimed.2017.03.061 https://doi.org/10.1016/j.copsyc.2022.101314 https://doi.org/10.1037/prj0000207 https://doi.org/10.1007/s10597-019-00431-7 https://doi.org/10.1016/s2215-0366(21)00395-3 https://doi.org/10.1016/s2215-0366(21)00395-3 https://doi.org/10.1186/s12888-018-1647-5 https://doi.org/10.1186/s12888-018-1647-5 https://doi.org/10.1037/a0027512 https://doi.org/10.1016/j.childyouth.2020.105053 https://doi.org/10.1002/da.22466 https://doi.org/10.1371/journal.pone.0069841 https://doi.org/10.1016/j.chb.2014.03.003 https://doi.org/10.1097/ms9.0000000000000112 https://doi.org/10.22270/ajdhs.v4i1.71 https://doi.org/10.1186/s12966-016-0432-4 https://doi.org/10.1186/s12889-020-08572-1 https://doi.org/10.1177/2055102917753853 https://doi.org/10.3390/ijerph19031868 https://doi.org/10.5888/pcd18.200573 pallav dave asian journal of dental and health sciences. 2024; 4(2):21-25 [25] ajdhs.com 29. alonzo r, hussain j, stranges s, anderson kk. interplay between social media use, sleep quality, and mental health in youth: a systematic review. sleep medicine reviews. 2021;56:101414. https://doi.org/10.1016/j.smrv.2020.101414 pmid:33385767 30. yu dj, wing yk, li tm, chan ny. the impact of social media use on sleep and mental health in youth: a scoping review. current psychiatry reports. 2024:1-6. https://doi.org/10.1007/s11920024-01481-9 pmid:38329569 pmcid:pmc10948475 31. meshi d, ellithorpe me. problematic social media use and social support received in real-life versus on social media: associations with depression, anxiety and social isolation. addictive behaviors. 2021;119:106949. https://doi.org/10.1016/j.addbeh.2021.106949 pmid:33934007 32. lopes ls, valentini jp, monteiro th, costacurta mc, soares lo, telfar-barnard l, nunes pv. problematic social media use and its relationship with depression or anxiety: a systematic review. cyberpsychology, behavior, and social networking. 2022;25(11):691-702. https://doi.org/10.1089/cyber.2021.0300 pmid:36219756 33. chou ht, edge n. "they are happier and having better lives than i am": the impact of using facebook on perceptions of others' lives. cyberpsychology, behavior, and social networking. 2012;15(2):117-21. https://doi.org/10.1089/cyber.2011.0324 pmid:22165917 34. riehm ke, feder ka, tormohlen kn, crum rm, young as, green km, pacek lr, la flair ln, mojtabai r. associations between time spent using social media and internalizing and externalizing problems among us youth. jama psychiatry. 2019;76(12):126673. https://doi.org/10.1001/jamapsychiatry.2019.2325 pmid:31509167 pmcid:pmc6739732 35. hamm mp, newton as, chisholm a, shulhan j, milne a, sundar p, ennis h, scott sd, hartling l. prevalence and effect of cyberbullying on children and young people: a scoping review of social media studies. jama pediatrics. 2015;169(8):770-7. https://doi.org/10.1001/jamapediatrics.2015.0944 pmid:26098362 36. viner rm, gireesh a, stiglic n, et al. roles of cyberbullying, sleep, and physical activity in mediating the effects of social media use on mental health and wellbeing among young people in england: a secondary analysis of longitudinal data. the lancet child & adolescent health. 2019;3(10):685-96. https://doi.org/10.1016/s2352-4642(19)30186-5 pmid:31420213 37. rosen ld, whaling k, rab s, carrier lm, cheever na. is facebook creating "idisorders"? the link between clinical symptoms of psychiatric disorders and technology use, attitudes and anxiety. computers in human behavior. 2013;29(3):1243-54. https://doi.org/10.1016/j.chb.2012.11.012 38. becker mw, alzahabi r, hopwood cj. media multitasking is associated with symptoms of depression and social anxiety. cyberpsychology, behavior, and social networking. 2013;16(2):132-5. https://doi.org/10.1089/cyber.2012.0291 pmid:23126438 39. li s, fan l. media multitasking, depression, and anxiety of college students: serial mediating effects of attention control and negative information attentional bias. frontiers in psychiatry. 2022;13:989201. https://doi.org/10.3389/fpsyt.2022.989201 pmid:36061274 pmcid:pmc9433771 40. naslund ja, bondre a, torous j, aschbrenner ka. social media and mental health: benefits, risks, and opportunities for research and practice. journal of technology in behavioral science. 2020;5:24557. https://doi.org/10.1007/s41347-020-00134-x pmid:33415185 pmcid:pmc7785056 41. keles b, mccrae n, grealish a. a systematic review: the influence of social media on depression, anxiety and psychological distress in adolescents. international journal of adolescence and youth. 2020;25(1):79-93. https://doi.org/10.1080/02673843.2019.1590851 https://doi.org/10.1016/j.smrv.2020.101414 https://doi.org/10.1007/s11920-024-01481-9 https://doi.org/10.1007/s11920-024-01481-9 https://doi.org/10.1016/j.addbeh.2021.106949 https://doi.org/10.1089/cyber.2021.0300 https://doi.org/10.1089/cyber.2011.0324 https://doi.org/10.1001/jamapsychiatry.2019.2325 https://doi.org/10.1001/jamapediatrics.2015.0944 https://doi.org/10.1016/s2352-4642(19)30186-5 https://doi.org/10.1016/j.chb.2012.11.012 https://doi.org/10.1089/cyber.2012.0291 https://doi.org/10.3389/fpsyt.2022.989201 https://doi.org/10.1007/s41347-020-00134-x https://doi.org/10.1080/02673843.2019.1590851 ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [19] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited relationship between facial musculinity and digit ratio (2d:4d) among hausa taxi and tricycle drivers in kano metropolis, niger isyaku ibrahim1, anas ibrahim yahaya2, mikail isyaku umar3,4, muhammad alhaji buba1 and *emmanuel ifeanyi obeagu5 1 human anatomy department, faculty of basic medical sciences, yusuf maitama sule university kano, nigeria. 2 anatomy department, faculty of basic medical sciences, bayero university kano, nigeria. 3 department of human anatomy, federal university, dutse, jigawa state, nigeria. 4 department of human anatomy, kampala international university, uganda 5 department of medical laboratory science, kampala international university, uganda. article info: _______________________________________ article history: received 19 june 2023 reviewed 27 july 2023 accepted 21 august 2023 published 15 september 2023 _______________________________________ cite this article as: ibrahim i, yahaya ai, umar mi, buba ma, obeagu ei, relationship between facial musculinity and digit ratio (2d:4d) among hausa taxi and tricycle drivers in kano metropolis, niger, asian journal of dental and health sciences. 2023; 3(3):19-29 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.49 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda abstract ___________________________________________________________________________________________________________________ studies have recognized an association between 2d: 4d ratios and testosterone-dependent traits. the aim of the present study is to determine the relationship of 2d: 4d and facial masculinity. four hundred and two (402) subjects were selected from the two association in kano state (tsaya da kafarka taxi drivers association and tricycle operators association kano (toakan), using random sampling methods, the age range of the participants between 18-50 years. the lengths of the 2nd and 4th digits were determined by a direct method of measurement. photographic approaches were used to capture the face, facial masculinity was derived from facial distances (captured image face). we use several approaches of measuring facial masculinity to study the association with digit ratio. the data were expressed as mean ± sd, pearson correlation was used to quantify the relationships between the 2d: 4d and facial masculinity. none of the facial masculinemeasures correlated with both right and left 2d:4d ratios. keywords: facial masculinity, 2d:4d (digit ratio), photographic methods, correlation introduction studies have established an association between 2d: 4d ratios and testosterone-dependent characters. this investigation found such a relationship in the right but not the left hand 1. the fourth digit is the ring finger of the human hand and it is located between the little finger and middle finger while the index finger is the first finger, and it is second digit of the human hand. the index finger is situated between the middle and the thumb finger and usually the most skilled and sensitive finger of the hand but show that males have relatively shorter index finger than the ring finger 2. the relative of the 2nd and 4th digits lengths (2d:4d) is a sexually dimorphic trait in which males have an affinity to have shorter 2nd digits relative to 4th digits than in females 3. this showed that digit ratio (2d:4d) is standby marker of prenatal testosterone 3. distinct digit ratio (2d:4d) values remain comparatively stable across development 4. a study indicated the indirect signal that e (estrogen) stimulates the growth of the second finger whereas t (testosterone) excites prenatal growth of the fourth finger. a low 2d: 4d ratio might act as a marker for a uterine environment high in t and low in e, and such a ratio is more commonly seen in males. similarly, a high 2d: 4d ratio may aid as a marker for a uterine environment low in t and high in e, more commonly found in females 1. the study between the digit ratios in two-year-old children and the levels of prenatal testosterone and estrogen in the amniotic fluid for the period of their prenatal development the outcome shows that low 2d:4d correlates with high concentrations of prenatal testosterone in comparative to estrogen 5. initial exposure to higher levels of t is expected to produce more male-like characteristics (masculinization) and less female characteristics (defeminisation) 6, whereas less exposure to t is expected to produce more female characteristics (defeminisation) and fewer male-like characteristics (masculinization). facial distances are influenced highly by factors such as sex, age, genetic factors and environmental 7,8. testosterone (t) distressed several facial features, and in adolescent males, a high testosterone-to-oestrogen (t/e) ratio is thought to simplify the lateral growth of the chin, mandibles, cheekbones, the lengthening of the lower face and the frontward growth of the bones of the eyebrow ridges leading to a more robust face shape 9. in the pubertal female, the upshot of oestrogen (e) leads to a more gracile facial shape with, less robust jaws, filled lips and great eyebrows 9. masculinity is related to males’ testosterone (t) exposure during puberty 10. t open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.49 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.49&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [20] ajdhs.com exposure during development produces several variations in the male body, such as the increase of secondary sexual characteristics and greater musculoskeletal development 10. nevertheless, t exposure stimuli both human male behaviour 11 and their physical appearance 12. females and males have different growth trajectories that diverge at puberty for bi-zygomatic width and not for upper facial height, leading to a width-to-height facial dimorphism (larger ratio in men than in women) that is independent of sex difference and enlarged body size 13. facial masculinity founded on a single trait is the eye-mouth-eye (eme) angle. researchers’ deliberation that eme is a sexually dimorphic trait, significantly lesser in males 14, even though this sexual dimorphism is vague 15. this measure only shows a slight correlation with inter-pupillary distance and upper face height even though both features define this angle. certain studies have shown that women and men differ in restricted face shape at several regions, though particularly at the lower jaw 16,17. some of these variances are apparent from an early age. male nose width, as model, is significantly greater from about age eight 18. other methods of measuring masculinity integrate several measures of sexually dimorphic features in an index. index 1 simply by adds up standardised measures of cheekbone prominence (upper facial width/lower facial width) and lower face length 19. some index usually employed adds five facial measures that show dimorphic differences between sexes (eye length, lower face height/face height, cheekbone prominence, face width/lower face height and mean eyebrow height, all of them divided by interpupillary distance) 20. this index yields higher values when these features are more masculine (smaller eyes, smaller eyebrow distance, smaller cheekbone prominence, smaller face width and larger lower face). they engaged three measures that were significantly different between sexes: nose width (nw, larger in men), upper lip height (ulh, lower in men) and lower lip height (llh, lower in men). all their measures were summarised as an interpupillary distance percentage. facial indices of masculinity were not associated with 2d:4d 21. the 2d:4d and shape of the face differs depending on hormonal presence earlier to the onset of puberty, which gives the characteristics of masculinity 22. research found no significant association between 2d:4d and perceptual and structural facial masculinity. these studies calculated different indices of structural masculinity, using principal components analysis of the relative locations of facial landmarks. though this technique may produce indices that accurately reflect structural masculinity such indices will, by nature, be averages of masculinity. a face with a combination of highly masculine and feminine characteristics may receive a score that suggests average masculinity. therefore, it remains possible that 2d:4d is associated with localized differences in face shape, i.e., differences that occur at specific regions of the face (such as the nose or jaw). growth spurts at puberty further increase sex differences, particularly at the mandible 23. the aim of the present study is to determine the relationship of 2d: 4d and facial masculinity. however, in the present research, we look the relationship between a different set of measures of masculinity employed by different scholars and digit ratio to determine how different facial masculinity correlate with digit ratio and find out the hypothesis of association between facial masculinity with 2d:4d ratio, which support to the effects of prenatal androgens (as indicated by 2d:4d) on facial masculinity and femininity similarly, in the previous research there was inconsistency with regards to the relationship of 2d:4d with facial anthropometrics as reported. materials and methods study location the present study was conducted in kano state of nigeria. the rainfall in this part of the country is less than 100cm, with long dry season that begins from october and end at april. the rainy season is shorter which is just for five months and the temperature is between 2427ºc and can be as high as 38ºc. kano is the most populous state in nigeria, with a population of 9,383,682 million people. the urban area of the state covers 137 km2 and comprises of six local government areas (lgas), tarauni ,kano municipal, , fagge, dala, gwale, and nassarawa with a population of 2,163,225 at the 2006 nigerian census 24, 25. study population four hundred and two (402) subjects were selected from the male taxi and tricycle drivers within the urban area of the state. seemingly healthy male taxi and tricycle drivers whose face and fingers were free from any inflammation, pathological changes, or deformity within the age range of 18-50 years who was hausa up to the level of 2 grandparents. ethical approval and informed consent before the commencement of the research, ethical approval was sought from the ethical committee of the bayero university kano college of health science at aminu kano teaching hospital, kano. informed consents were sought from the participants. methodology measurement of the digit lengths and determination of 2d: 4d the lengths of the 2nd and 4th digits were determined using a direct method of measurement. following manning and tailor (manning & taylor, 2001), the participants were asked to remove rings and the lengths of the 2nd and 4th digits were measured directly (using vernier calipers accurate to 0.01 mm) on the ventral surfaces of both right and left hands from the basal crease of the digit to its tip. every digit was measured twice, and the average was taken. when there was a crowd of creases at the base of the digit, the most proximal crease was considered. digit lengths measured (in mm) were computed for determination of the 2d: 4d by dividing the 2nd digit length by the 4th digit length (plates i). plate i: photograph showing the landmarks for measurement of 2d and 4d digits ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [21] ajdhs.com photographs the photographic set up comprises of a tripod, supporting a digital camera. the tripod was used for modification of height of the camera that allows the optical axis of the lens to be maintained in a horizontal position during the recording. in order to obtain the photographs (frontal), individuals were asked to sit and look directly at the camera in front of them 26 keeping an upright and normal posture, with both arms free along the body. this position corresponds to the broca’s natural head position 27, 28. each participant was asked to ease with both hands hanging beside the trunk. the participants were positioned on a line marked on the floor. the participants were photographed with a nikon d40 digital camera at 1.00 m and in front of a standard white background, while posing in a neutral facial expression. the subjects had to look into the lens of the camera with their lips relaxed so that the front view profile was taken in the natural head position before every recording. the operative ensured that the subjects’ neck, ear and forehead, were clearly visible and their lip in restfulness. the tripod helped to avoid undesirable movements of operator and camera while taking photographs 29. before taking the face, the operator ensured that glasses (if worn) had been removed and the participant’s neck, ears, and forehead, were clearly visible during the process 30. after the images were captured, they were downloaded to a private computer and stored in jpeg format for processing and analyses. processing and analyses the captured facial images were imported into a software, bioanalyser (a software developed using microsoft visual basic version 6). the database was customized with land marks 30 that was used in the study. the software was used to compute all the linear dimension and angles. facial landmarks identification standard anatomical landmarks and reference points were recognised according to prior works 31-34 and were recognized using bioanalyzer (a software developed using microsoft visual basic version 6) for frontal facial analysis. plate ii: landmarks used for facial measurements 33. key: al; alar, ch; cheilion en; endocanthion, ex; exocanthion, gn; gnathion, go; gonion, ls; labiale superious, li; labiale inferious, n; nasion, pi; palpebrale inferious, ps; palpebrale superious, sn; subnasale, st; stomium, tr; trichion, zy; zygon, ft: frontotemporale. facial measures of masculinity the facial measures of masculinity used in the present study include the following: 1. facial width to upper face height ratio (fwhr): this was measured as a ratio of the distance between left and right zygions (bizygomatic width) and upper facial height (a distance between nasion and prosthion) (plate iii) 35. plate iii: upper facial height and width with their associated landmarks 35. key: a= facial width b= special face height c= facial width height ratio 2. upper lip height (ulh), lower lip height (llh) and nose width (nw): these measurements were expressed as percentage of interpupillary distance (which is a distance measured from the centre of the right pupil to the centre of the left pupil.). the upper lip height was determined as the vertical distance between the stomion and the labiale superius, and lower lip height as the vertical distance between the stomion and the labiale inferius. nose width was measured as the horizontal distance between the left and right alares (plate iv) as reported in the previous study. a b c ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [22] ajdhs.com plate iv: upper lip height (ulh), lower lip height (llh) and nose width (nw). key: al: alare st: stomion ls: labiale superior li: labial inferior 3. index i: this was determined as the sum of special face length/face height and cheek-bone prominence (plates v). the special face length (sfh) was measured as a distance from the pupils (corresponding to nasion) to the tip of the chin (gnathion) as a proportion of the total face length (fh). cheek-bone prominence was calculated as a ratio of the width of the face at cheekbone (bizygomatic width) (ufw) divided by the width of the face at the level of the mouth (bigonion) (lfw) 36. plate v: special face length/face height and cheek-bone prominence 36 key: sfh: special face height fh: face height ufw: upper face width lfw: lower face width n: nasion gn: gnathion zy: zygion go: gonion tr: trachion 4. index ii: this was determined as sum of eye length, special face height/face height and cheekbone prominence, face width/special face height and mean eyebrow length (plate vi), all of them divided by interpupillary distance. the eye length (el) was measured by distance between the right and left exocanthion minus the distance between the right and left endocanthion divided by two (eye length = d1 – d2/2). 2. special face height (sfh)/ face height (fh) was measured as the distance of the face from the pupils to the tip of the chin over distance of the face from the hairline to the tip of the chin d8/ d7. the cheek bone prominence (ufw/lfw) was measured as the distance between the left and right zygion ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [23] ajdhs.com (bizygomatic width) over the width of the face at the level of the mouth, d3/ d6. face width (ufw)/special face height (sfh) was measured as the distance between the left and right zygion (bizygomatic width) over height which was measured as the distance of the face from the pupils to the tip of the chin. mean eye brown height (mebl) was measured as the sum right eye brow length (distance from the right outer eye brow border to the right inner eyebrow border d9) and left eye brow length (distance from the left inner eye brow border to the left outer eyebrow border d10) divided by two (2) 17.. ( ) ( ) ( ) plate vi. lower face length, cheek-bone prominence, eye length, and lower face height/face height, face width/lower face height and mean eyebrow length with their associated landmarks 17. key: d 1 = distance between right and left exocanthion d 2 = distance between right and left endocanthion d 3 = upper face width (ufw) d 4 = nose width d 5 = mouth width, d 6 = lower face width (lfw) d 7 = face height (fh) d 8 = special face height (sfh) d 9 = right eye brow length d 10 = left eye brow length 5. index iii: this was determined as sum of facial width to upper face height ratio (fwhr), upper lip height (ulh), lower lip height (llh) and nose width (nw), special face length/face height (sfh/fh) and cheek-bone prominence (ufw/lfw), eye length (el), face width (ufw)/special face height (sfh) and mean eyebrow length (mebl), all of them divided by interpupillary distance (ipd). ( ) ( ) ( ) measurement error direct measurements of facial features for measurement error analyses, a direct facial anthropometry was adopted 34. this involved asking a participant to sit with his head in natural head position. a digital vernier caliper was then used to measure the facial linear dimension of face directly (plate: vi). this helped in the determination of the factor to be used for real size measurements of the photographs. the factor was 0.50 which was obtained by dividing actual size measurement with actual pixel of the image measurement. precision of measurements to calculate precision, the technical error of measurement was determined, a set of two measurements were taken with each method. these measurements were matched using technical error of measurement (tem). this allowed assessment of random error. the tem (also called the ‘‘method error statistic’’) is a standard-deviation−like estimate of error magnitude expressed in the original units of measurement. it can be used to generate both intra and inter-observer precision estimates. when there are two measurements involved, the formula for tem 37 is as follows: absolute tem = ∑di2/2n where ∑d2 = summation of deviations (the difference between the 1st and 2nd measurements) raised to the second power, n = a number of volunteers measured, i= the number of deviations the absolute tem was expressed as percentages as follows. relative tem = absolute tem/ vav × 100 ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [24] ajdhs.com where vav = variable average value, is the arithmetic mean of the mean between both measurements obtained (1st and 2nd measurements) of each volunteer for the same variable. this procedure was performed for each of the n participants and the n averages obtained and was summed up and divided by n (total of a number of participants) 38. the percentage scores were divided into five precision categories: scores less than 1% was deemed ‘‘excellent,’’ scores ranging from 1% to 3.9% were deemed ‘‘very good,’’ scores ranging from 4% to 6.9% were deemed ‘‘good,’’ scores ranging from 7% to 9.9% were deemed ‘‘moderate,’’ and scores exceeding 10% were deemed ‘‘poor 39. strength of measurements (r) the r was computed to demonstrate the strength of the relationship (similarities) between two measurements. intraclass correlation (icc) was used for this purpose. the values for the reliability coefficient ranged from 0 to 1, where icc< 0 indicated ‘‘no reliability” and 0.6 to <0.8 indicated substantial reliability, and 1 indicated almost perfect reliability 40. the interval between two measurements was at least one week. 30 randomly selected records were used for this evaluation. those dimensions with many differences between the first and the second measurements were discarded. statistical analyses the data were expressed as mean ± sd, frequency, and percentages. pearson correlation was used to quantify the relationships between the facial masculinity and digit ratio. the analyses were carried out using spss version 20. p < 0.05 was considered as level significance results table 1 shows assessment of technical error of measurements (tem) in linear facial dimensions. it was observed that special face height showed the least tem (1.65%) whereas philtrum length showed higher value (9.66%). the rest of the facial measurements were also within the acceptable level of tem no variables was greater than 10%. therefore, all measurements were retained. table 1: assessment of measurement error in linear facial dimension variables n vav tem rtem% zy1_zy2 30 105.16 1.98 1.88 n_pr 30 64.94 1.84 2.83 tr_gn 30 186.74 4.20 2.25 al1_al2 30 46.10 3.21 6.97 n_gn 30 108.40 1.79 1.65 go1_go2 30 111.82 2.00 1.79 ex1_en1 30 27.52 1.29 4.70 ex2_en2 30 28.23 1.46 5.17 en1_en2 30 38.82 2.03 5.22 ls_st 30 11.28 0.71 6.33 st_li 30 11.59 0.99 8.53 ebo_ebi 30 43.05 1.04 2.42 ex1_ex2 30 95.02 2.14 2.25 sn_gn 30 63.28 5.16 8.15 g_sn 30 61.67 1.40 2.27 sn_ls 30 14.67 1.42 9.66 n_sn 30 45.77 2.74 5.98 st_gn 30 37.95 1.16 3.05 ls_li 30 21.79 1.33 6.10 ps1_pi1 30 10.81 0.65 5.99 table 2 shows another method of the assessment of error in the facial dimensions. the higher single measured intra class correlation (icc) was found in philtrum length (sn-ls) and the lowest values found in nose width (al_al). the rest of the measurements were greater than 0.89. ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [25] ajdhs.com table 2: intra-class correlation (icc) measurements of facial dimensions s/n variable measuremant n icc 1 zy1_zy2 single measures 30 0.944 average measures 0.971 2 n_pr single measures 30 0.950 average measures 0.975 3 tr_gn single measures 30 0.931 average measures 0.964 4 al1_al2 single measures 30 0.714 average measures 0.833 5 n_gn single measures 30 0.970 average measures 0.985 6 go1_go2 single measures 30 0.953 average measures 0.976 7 ex1_en1 single measures 30 0.850 average measures 0.919 8 ex2_en2 single measures 30 0.794 average measures 0.885 9 en1_en2 single measures 30 0.744 average measures 0.854 10 ls_st single measures 30 0.810 average measures 0.895 11 st_li single measures 30 0.759 average measures 0.863 12 ebo_ebi single measures 30 0.812 average measures 0.896 13 ex1_ex2 single measures 30 0.938 average measures 0.968 14 rcp_lcp single measures 30 0.921 average measures 0.959 15 sn_gn single measures 30 0.946 average measures 0.972 16 g_sn single measures 30 0.958 average measures 0.979 17 sn_ls single measures 30 0.823 average measures 0.903 18 n_sn single measures 30 0.767 average measures 0.868 19 st_gn single measures 30 0.940 average measures 0.969 20 ls_li single measures 30 0.878 average measures 0.935 21 ps1_pi1 single measures 30 0.711 average measures 0.831 ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [26] ajdhs.com table 3 shows the descriptive statistics of the derived facial measures of masculinity of the study population. it was observed that averaged facial width to height ratio was 1.71±0.19. upper lip height (ulh) was 15.86±3.16mm, lower lip height (llh) was 16.53±3.21 and nose width (nw) was 68.51±5.33. all the three measures were rendered as percentage of interpupillary distance. upper lip height (ulh) was lower than lower lip height (llh). averaged cheek-bone prominence was 0.96±0.06. for the index i, ii and iii were measured as 1.55±0.07, 1.09±0.07 and 108.36 ±11.35, respectively. table 3: descriptive statistics of the derived facial measures of masculinity of the study population parameters minimum maximum mean ± sd fwhr. 1.00 2.74 1.71±0.19 al1_al2:ipd % 53.75 84.02 68.51±5.33 zy1_zy2 /n_gn (fwshr) 0.70 1.30 1.00±0.07 zy1_zy2 /n_gn:ipd 0.00 0.02 0.01±0.00 n_gn/tr_gn (sfhfhr) 0.50 1.00 0.59±0.04 n_gn/tr_gn:ipd 0.00 0.01 0.01±0.00 zy1_zy2/go1_go2 (cbp) 0.75 1.24 0.96±0.06 zy1_zy2/go1_go2: ipd 0.00 0.02 0.01±0.00 ls_sti :pd% 8.20 26.39 15.86±3.16 st_li:ipd% 6.53 25.47 16.53±3.21 ebo_ebi 32.51 58.68 42.60±4.61 ebo_ebi:inp 0.49 1.00 0.62±0.05 el 21.69 43.29 30.18±3.65 el:inp 0.00 0.56 0.43±0.04 rcp_lcp 53.38 90.17 69.46±6.59 index i 1.32 2.00 1.55±0.07 index ii 0.88 1.27 1.09±0.07 index iii 74.63 143.21 108.36 ±11.35 table 4 shows descriptive statistics of digit lengths, digit ratio of the study population. the mean value for 2dright was 72.18±4.86mm, lower than the 4dright, which was 74.09±5.08mm, similar to the left digit. the mean value of 2dr: 4dr was 0.98±0.04 which was the higher than 2dl: 4dl with mean value of 0.96±0.05. table 4: descriptive statistics of digit lengths, digit ratio parameters (mm) minimum maximum mean ± sd 2dr 55.65 87.21 72.18±4.86 4dr 54.47 88.00 74.09±5.08 2d:4dr 0.83 1.13 0.98±0.04 2dl 52.86 87.45 72.15±4.83 4dl 57.14 90.42 75.10±5.33 2d:4dl 0.84 1.11 0.96±0.05 table 5 shows correlation between different derived facial parameters (measures of masculinity), digit length and ratios. it was observed that facial width to height ratio (fwhr) showed significant negative correlation with 2dr, 4dr, 2dl and 4dl. nose width/ special face height (czzy1_zy2/n_gn:ipd) showed significant negative correlation with 2dr, 4dr and 2dl and 4dl. cheek-bone prominence interpupillary distance (zy1_zy2:go1_go: ipd) showed significant negative correlation with 2dr, 4dr and 4dl. it was noted that eyebrow length (ebi_ebi) showed significant positive correlation with 2dr, 4dr, 2dl and 4dl. finally, eye length (el) showed significant positive correlation with 2dr, 4dr, 2dl and 4dl, while index iii was positively correlated with 2dl only. ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [27] ajdhs.com table 5: pearson’s correlation between derived facial parameters (measures of masculinity) with digit length and ratios parameters (mm) 2dr 4dr 2d:4dr 2dl 4dl 2d:4dl fwhr. -0.161** -0.148** -0.014 -0.137** -0.120* -0.022 al1_al2:ipd% 0.092 0.07 0.025 0.07 0.052 0.019 zy1_zy2 /n_gn -0.124* -0.110* -0.022 -0.123* -0.052 -0.095 zy1_zy2 /n_gn:ipd -0.175** -0.160** -0.024 -0.174** -0.115* -0.077 n_gn/tr_gn 0.09 0.069 0.027 0.085 0.03 0.075 n_gn/tr_gn:inp -0.064 -0.059 -0.01 -0.063 -0.061 -0.004 zy1_zy2:go1_go2 -0.067 -0.095 0.043 -0.084 -0.075 -0.008 zy1_zy2:go1_go2: ipd -0.143** -0.151** 0.012 -0.152** -0.127* -0.029 ls_st:ipd% -0.022 0.017 -0.054 0.032 0.025 0.016 st_li:ipd% 0.048 0.043 0.014 0.081 0.057 0.039 ebo_ebi 0.150** 0.155** -0.01 0.136** 0.143** -0.016 ebo_ebi:ipd -0.015 -0.025 0.013 -0.049 -0.041 0.003 el 0.112* 0.106* 0.007 0.141** 0.115* 0.025 el:ipd -0.02 -0.01 -0.017 0.01 0.017 -0.021 right eme -0.042 -0.056 0.021 -0.02 -0.032 0.016 left eme -0.036 -0.018 -0.028 -0.037 0.007 -0.064 total eme -0.048 -0.047 -0.003 -0.035 -0.016 -0.027 index i -0.007 -0.042 0.051 -0.024 -0.047 0.035 index ii -0.036 -0.037 -0.002 -0.044 -0.03 -0.016 index iii 0.082 0.082 -0.001 0.100* 0.081 0.026 *p< 0.05, **p <0.01 discussion from this study, the measurements were found to be reproducible with a negligible error for the intra observer errors estimated. this was based on the acceptable level of tem reported in the previous study 39. the icc of the measurements have fallen within the prescribed limits as in oliveira et al.41. this has made the results more robust and reliable. the minimal error of measurement observed in the present study will be have less influence in the interpretation of the results in the context of the global data. similarly, this may provide more opportunities to compare results using different methodologies. since, the facial morphometric quantified using photogrammetric methods has proved to be similar to what was obtained using direct anthropometry with the acceptable methods level of error. the main objective of this research was to examine different approaches of measuring facial masculinity in order to standardise the method employed to compute this feature. to achieve this aim, we have engaged several methods of measuring facial masculinity. we studied how these different measures are related to digit ratio. however, as facial masculinity has been previously linked to different variables based on sex hormone activities right from intra-uterine life, we expected at least some of the masculinity measurements to correlate with digit ratio. our main concern is to explain which of the different measurement methods are more suitable to analyse the association between masculinity and digit ratio. in the present study no significant correlation was observed between the 2d:4d with indices of masculinity. the absence of the correlation may also be attributed to influences of several confounding factors such latitude and techniques of finger length measurement on 2d:4d as suggested in the literature 42. contrary to the present study, it was reported that weak but significant negative correlations exist between 2d: 4d ratios and both masculinity and dominance, supporting their argument that high prenatal testosterone levels serve to ‘organize’ male facial features to subsequently reflect dominance and masculine characteristics at puberty 43. but this is based on the opposite sex rated facial masculinity, facial dominance, and facial attractiveness. it is therefore imperative to explain the possible reasons of the discrepancy between present finding and literature 43 due to the fact that a face with a mixture of highly masculine and feminine characteristics may receive a score that suggests average masculinity. therefore, it remains possible that 2d:4d is correlated with localized differences in face shape, meaning differences that occur at specific regions of the face (such as the nose or jaw). studies have shown that men and women differ in localized face shape at several regions, particularly at the lower jaw 44. hence, the subjects rated in the above study v may be have more of feminine facial characteristics. conclusion the main objective of this research was to examine different approaches of measuring facial masculinity but none of the facial masculinemeasures correlated with both right and left 2d:4d ratios. we therefore recommend further study should be carried out on different population and also among different ethnic group and larger sample sizes should also be used in order to explore more on the relationship between facial anthropometry with digit ratio. ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [28] ajdhs.com acknowledgments i must acknowledge the approval to conduct the study from these two noble associations in kano state, tsaya da kafarka taxi drivers association kabuga and tricycle operators association kano (toakan). i would like to express my sincere and special appreciation to my mentor dr a. i. yahaya for his guidance, advice, support. references 1. manning jt. digit ratio: a pointer to fertility, behaviour and health. new brunswick, nj: rutgers university press. 2002. 2. burriss rp, little ac, nelson ec. 2d:4d and sexually dimorphic facial characteristics. archives of sexual behavior, 2007; 36(3):377–384. https://doi.org/10.1007/s10508-006-9136-1 3. manning jt, scutt d, wilson j, lewis-jones di. the ratio of 2nd to 4th digit length: a predictor of sperm numbers and concentrations of testosterone, luteinizing hormone and oestrogen. human reproduction, 1998; 13:3000–3004. https://doi.org/10.1093/humrep/13.11.3000 4. mcintyre mh, ellison pt, lieberman de, demerath e, towne b. the development of sex differences in digital formula from infancy in the fels longitudinal study. proceedings of the royal society b: biological sciences, 2005; 272:14731479. https://doi.org/10.1098/rspb.2005.3100 5. lutchmaya s, baron-cohen s, raggatt p, knickmeyer r, manning jt. 2nd to 4th digit ratios, fetal testosterone and estradiol. early human development, 2004; 77: 22–28. https://doi.org/10.1016/j.earlhumdev.2003.12.002 6. mazur a, booth a. testosterone and dominance in men. in behavioral and brain sciences, 1998; 21:353-363. https://doi.org/10.1017/s0140525x98001228 7. angulu r, tapamo jr, adewumi ao. age estimation via face images: a survey. in eurasip journal on image and video processing, 2018; 42:3-35 https://doi.org/10.1186/s13640-0180278-6 8. anas iy. the influence of age, sex and facial size on facial asymmetry in hausa population of kano and kaduna states, nigeria. journal of anatomy and physiological studies, 2019; 3:001005. 9. enlow dh. essential of facial growth. saunders company; philadelphia, 1996; 281-293. 10. sisk cl, zehr jl.pubertal hormones organize the adolescent brain and behavior. in frontiers in neuroendocrinology, 2005; 26:163– 174. https://doi.org/10.1016/j.yfrne.2005.10.003 11. schulz km, zehr jl, sales-ramirez ky, sisk cl. testosterone programs adult social behavior before and during, but not after adolescent. endocrinology, 2009; 150: 3690-3698. 12. zitzmann m, nieschlag e. testosterone levels in healthy men and the relation to behavioural and physical characteristics: facts and constructs. in european journal of endocrinology, 2001; 144:183– 197. https://doi.org/10.1530/eje.0.1440183 13. weston em, friday ae, liò p. biometric evidence that sexual selection has shaped the hominin face. plos one, 2007; 2:1–8. https://doi.org/10.1371/journal.pone.0000710 14. danel d, pawlowski b. eye-mouth-eye angle as a good indicator of face masculinization, asymmetry, and attractiveness (homo sapiens). journal of comparative psychology, 2007; 121:221–225. https://doi.org/10.1037/0735-7036.121.2.221 15. van s, sprengers e. hand grip strength in relation to morphological measures of masculinity, fluctuating asymmetry and sexual behaviour in males and females. in sex hormones, 2012; 293–306. https://doi.org/10.5772/25880 16. hennessy rj, mclearie s, kinsella a, waddington jl. facial surface analysis by 3d laser scanning and geometric morphometrics in relation to sexual dimorphism in cerebral-craniofacial morphogenesis and cognitive function. in journal of anatomy, 2005; 207:28593. https://doi.org/10.1111/j.14697580.2005.00444.x 17. penton-voak is, jones bc, little ac, baker s, tiddeman b, burt dm, perrett di. symmetry, sexual dimorphism in facial proportions and male facial attractiveness. proceedings of the royal society b: biological sciences, 2001; 268(1476):1617–1623. https://doi.org/10.1098/rspb.2001.1703 18. nute sj, orth m, moss jp, orth d. three-dimensional facial growth studied by optical surface scanning. journal of orthodontics, 2000; 27:31–38. 19. scheib je, gangestad sw, thornhill r. facial attractiveness, symmetry and cues of good genes. proceedings of the royal society b: biological sciences, 1999; 266(1431):1913–1917. https://doi.org/10.1098/rspb.1999.0866 20. pound n, penton-voak is, surridge ak. testosterone responses to competition in men are related to facial masculinity. proceedings of the royal society b: biological sciences, 2009; 276:153–159. https://doi.org/10.1098/rspb.2008.0990 21. koehler n, simmons lw, rhodes g. how well does second-tofourth-digit ratio in hands correlate with other indications of masculinity in males? proceedings of the royal society of london, series b, 2004; 271:s296–s298. https://doi.org/10.1098/rsbl.2004.0163 22. meindl k, windhager s, wallner b, schaefer k. second-to-fourth digit ratio and facial shape in boys: the lower the digit ratio, the more robust the face. proceedings of the royal society b: biological sciences, 2012; 279(1737):2457-2463. https://doi.org/10.1098/rspb.2011.2351 23. snodell f, nanda rs, currier gf. a longitudinal cephalometric study of transverse and vertical craniofacial growth. american journal of orthodontics and dentofacial orthopedics, 1993; 104:471–483. 24. iloeje np. a new geography of nigeria. new revised edition. longman nigeria plc.2001; 200. 25. barau as. the great attractions of kano. research and documentation publications. research and documentation directorate. government house kano, 2007; 33-0. 26. moorrees cfa. natural head position-a revival. american journal of orthodontics and dentofacial orthopedics, 1994; 105(5):512513. https://doi.org/10.1016/s0889-5406(94)70014-1 27. ferrario vf, sforza c, miani a, tartaglia g. craniofacial morphometry by photographic evaluations. american journal of orthodontics and dentofacial orthopedics, 1993; 103(4): 327-37. https://doi.org/10.1016/0889-5406 (93)70013-e 28. meiyappan n, tamizharasi s, sen-thilkumar kp, janardhanan k. natural head position: an overview. dental science, 2015; 7(6):424:427. 29. morosini i, de a, c, peron a, p, l, m., correia k, r, moresca r. study of face pleasantness using facial analysis in standardized frontal photographs. dental press journal of orthodontics, 2012; 17(5): 24-34. https://doi.org/10.1590/s2176-94512012000500005 30. reddy m, ahuja n, raghav p, kundu v, mishra va. computerassisted angular photogrammetric analysis of the soft tissue facial profile of north indian adults. the journal of indian orthodontic society, 2011; 45(3):119-123. https://doi.org/10.5005/jp-journals-10021-1021 31. farkas lg. anthropotry of the head and face (l. g. farkas (ed.); 2nd ed.). raven press,1994. new york: raven press, 1994; 3–56. 32. porter jp, olson kl.anthropometric facial analysis of the african american woman. archives of facial plastic surgery : official publication for the american academy of facial plastic and reconstructive surgery, inc. and the international federation of facial plastic surgery societies, 2001; 3:191–7. https://doi.org/10.1001/archfaci.3.3.191 33. gibelli d, mapelli a, obertovà z, poppa p, gabriel p, ratnayake m et al. age changes of facial measurements in european young adult males: implications for the identification of the living. homo journal of comparative human biology, 2012; 63(6):451–458. https://doi.org/10.1016/j.jchb.2012.08.002 34. adamu lh, ojo sa, danborno b, adebisi ss, taura mg. sex determination using facial linear dimensions and angles among https://doi.org/10.1007/s10508-006-9136-1 https://doi.org/10.1093/humrep/13.11.3000 https://doi.org/10.1098/rspb.2005.3100 https://doi.org/10.1016/j.earlhumdev.2003.12.002 https://doi.org/10.1017/s0140525x98001228 https://doi.org/10.1186/s13640-018-0278-6 https://doi.org/10.1186/s13640-018-0278-6 https://doi.org/10.1016/j.yfrne.2005.10.003 https://doi.org/10.1530/eje.0.1440183 https://doi.org/10.1371/journal.pone.0000710 https://doi.org/10.1037/0735-7036.121.2.221 https://doi.org/10.5772/25880 https://doi.org/10.1111/j.1469-7580.2005.00444.x https://doi.org/10.1111/j.1469-7580.2005.00444.x https://doi.org/10.1098/rspb.2001.1703 https://doi.org/10.1098/rspb.1999.0866 https://doi.org/10.1098/rspb.2008.0990 https://doi.org/10.1098/rsbl.2004.0163 https://doi.org/10.1098/rspb.2011.2351 https://doi.org/10.1016/s0889-5406(94)70014-1 https://doi.org/10.1016/0889-5406 https://doi.org/10.1590/s2176-94512012000500005 https://doi.org/10.5005/jp-journals-10021-1021 https://doi.org/10.1001/archfaci.3.3.191 https://doi.org/10.1016/j.jchb.2012.08.002 ibrahim et al asian journal of dental and health sciences. 2023; 3(3):19-29 [29] ajdhs.com hausa population of kano state, nigeria. egyptian journal of forensic sciences, 2016; 6(4):459–467. 35. carré jm, mccormick cm. in your face: facial metrics predict aggressive behaviour in the laboratory and in varsity and professional hockey players. proceedings of the royal society b: biological sciences, 2008; 275(1651):2651–2656. https://doi.org/10.1098/rspb.2008.0873 36. sanchez-pages s, rodriguez-ruiz c, turiegano e. facial masculinity: how the choice of measurement method enables to detect its influence on behaviour. plos one, 2014; 9(11). https://doi.org/10.1371/journal.pone.0112157 37. aldridge k, boyadjiev sa, capone gt, deleon vb, richtsmeier jt. precision and error of three-dimensional phenotypic measures acquired from 3dmd photogrammetric images. american journal of medical genetics, 2005; 138:247-53. https://doi.org/10.1002/ajmg.a.30959 38. perini ta, oliveira gl, dos santos oj, palha de of.technical error of measurement in anthropometry. revista brasileira de medicina do esporte, 2005; 11:86–90. https://doi.org/10.1590/s151786922005000100009 39. weinberg sm, scott nm, neiswanger k, brandon ca, marazita ml. digital three-dimensional photogrammetryevaluation of anthropometric precision and accuracy using a genex 3d camera system. cleft palate craniofacial journal 2004; 41(5):507–18. 40. landers r. computing (icc) as intraclass estimates correlations of interrater reliability in spss. the winnower, 2015; https://doi.org/10.15200/winn.143518.81744 41. oliveira fd, lima rt, daruge j, andrea s, silveira d. sexual dimorphism in brazilian human skulls: discriminant function analysis.” journal of forensic odontostomatology, 2012; 30(2):26– 33. 42. manning jt, fink b, neave n, caswell n. photocopies yield lower digit ratios (2d:4d) than direct finger measurements. archives of sexual behavior, 2005; 34:329-333. https://doi.org/10.1007/s10508-005-3121-y 43. neave n, laing s, fink b, manning jt. second to fourth digit ratio, testosterone and perceived male dominance. proceedings of the royal society b: biological sciences, 2003; 270:2167–2172. https://doi.org/10.1098/rspb.2003.2502 44. hennessy rj, baldwin pa, browne dj, kinsella a, waddington jl. frontonasal dysmorphology in bipolar disorder by 3d laser surface imaging and geometric morphometrics: comparisons with schizophrenia. schizophrenia research, 2010; 122:63-71 https://doi.org/10.1016/j.schres.2010.05.001 https://doi.org/10.1098/rspb.2008.0873 https://doi.org/10.1371/journal.pone.0112157 https://doi.org/10.1002/ajmg.a.30959 https://doi.org/10.1590/s1517-86922005000100009 https://doi.org/10.1590/s1517-86922005000100009 https://doi.org/10.15200/winn.143518.81744 https://doi.org/10.1007/s10508-005-3121-y https://doi.org/10.1098/rspb.2003.2502 https://doi.org/10.1016/j.schres.2010.05.001 fadjeri et al asian journal of dental and health sciences. 2023; 3(3):42-46 [42] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited storgi media as an effort to improve dental health behavior in orphanage children indrayati fadjeri1, tedi purnama2*, eliati sri suharja3, widi nurwanti4 1,2 department of dental health, health polytechnic of jakarta i, jakarta, indonesia 3 department of dental health, health polytechnic of tasikmalaya, tasikmalaya, indonesia 4 department of dental health, puskesad dental health academy, jakarta , indonesia article info: _______________________________________ article history: received 05 august 2023 reviewed 19 august 2023 accepted 13 september 2023 published 15 september 2023 _______________________________________ cite this article as: fadjeri i, purnama t, suharja es, nurwanti w, storgi media as an effort to improve dental health behavior in orphanage children, asian journal of dental and health sciences. 2023; 3(3):42-46 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.53 _______________________________________ *address for correspondence: tedi purnama, department of dental health, health polytechnic of jakarta i, jakarta, indonesia. abstract ___________________________________________________________________________________________________________________ background: orphanage children can also be classified as one of the groups that are vulnerable to dental disease, this is due to a lack of dental health maintenance behavior due to low socioeconomic status. to improve dental and oral health maintenance behavior, dental health promotion can be done with interesting and appropriate media. storgi media is one of the outreach media that is integrated with tooth brushing facilities in the form of toothbrush lockers. objective: the research aims to analyze the effectiveness of storgi media as an effort to improve dental health behavior in orphanage children. method: this research used a quasi-experimental design with a pretest and posttest control group design. the research sample was 50 children from orphanages taken using purposive sampling technique. the intervention group was given dental health education using storgi media, while the control group was given dental health education using flipcharts. the data was tested using paired sample t-test/wilcoxon analysis, namely a pre-post design, while to compare the means of the treatment and control groups, the independent t-test/mann whitney test was used. results: the results of the test of differences in knowledge, attitudes and actions of brushing teeth show that the p-value between the intervention group and the control group is 0.000 (p <0.05), meaning that there is a difference between the values of knowledge, attitudes and actions of brushing teeth after dental health education with children's storgi media and dental health education with filpchart. conclusion: dental health education using storgi media is more effective in increasing the knowledge, attitudes and actions of brushing teeth in in orphanage children keywords: storgi, media, dental health education, behavior, orphanage introduction dental and oral diseases remain a significant health problem throughout the world. dental caries and periodontal disease affect almost 100% of the population worldwide. in indonesia, the results of basic health research in 2018 reported that the prevalence of the indonesian population who had dental and oral health problems was 57.6%. nelwan's research on children from orphanages showed that the prevalence of dental caries was 69.7%. so it could be interpreted that children in orphanages have higher levels of caries than children in general.1–3 the problem of the high prevalence of dental caries is caused by a lack of knowledge and awareness about the importance of maintaining oral health. maintaining dental and oral health is a form of health behavior. an overview of behavior regarding dental health can be seen from the 2018 riskesdas results showing that the behavior of brushing teeth correctly among the population aged 3 years in indonesia reached 2.8%. the results of community service carried out by ngatemi et al also proved that 83 children (64.0%) had poor knowledge of dental health care (83 children (64.0%), 36 children (27.6%) had moderate criteria and 11 children (8.4%) had good criteria.2,4,5 behavior is influenced by the presence or absence of health infrastructure as a supporting factor. difficulty in accessing communities in disadvantaged areas is one of the factors that influences community behavior.6–8 the level of education and socio-economic level also influence dental and oral health behavior, that is, the lower a person's educational and economic level, the lower the dental and oral health behavior will be. dental and oral health maintenance behavior in rural areas is lower than in urban areas. underdeveloped areas are rural areas where the basic facilities and infrastructure in the area are still inadequate or non-existent, causing obstacles to the growth or development of people's lives in the economic and educational fields. based on these data, it is necessary to make efforts to improve dental and oral health. efforts to maintain dental and oral health in children in orphanages through dental health education.9–11 dental health education in schools is the first step in preventing dental problems. one of the health education efforts is through outreach efforts to increase knowledge and attitudes in maintaining dental health. success in providing dental health education to school children cannot be separated from educational methods and the important role of the media.12,13 health education is an educational activity carried out by spreading messages, instilling confidence, so that people are not only aware, know and understand, but are also willing and able to carry out recommendations related to health. health education is identical to health education because both are oriented towards changing behavior. success in providing open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.53 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.53&amp;domain=pdf fadjeri et al asian journal of dental and health sciences. 2023; 3(3):42-46 [43] ajdhs.com dental health education to school children cannot be separated from educational methods and the important role of the media.8,14 learning media is a tool used to help convey information from teachers to students. providing health education material is easier to convey if you use media that can attract attention. through the correct method and use of appropriate teaching aids, the material presented in the counseling will be easily accepted by the target audience. delivery of material is more effective if it is delivered in a pleasant atmosphere and methods that attract students' attention.13,15 storgi media is an innovation in education media that is integrated between education media and tooth brushing facilities in the form of toothbrush lockers. this really helps improve the dental health behavior of children in orphanages who have limited access and facilities for maintaining oral health. method and material the research design used was a quasi-experimental study with a pretest-posttest control group design. the aim of the study was to analyze the effectiveness of storgi media as an effort to improve dental health behavior in orphanage children. this research was carried out from june to july 2023 in 4 orphanages located in cilandak district, south jakarta and cinere district, depok city. the sample used in this research was 50 respondents consisting of 25 people for the intervention group carried out at the mizan amanah orphanage, karang tengah and cilandak, south jakarta, while for the control group there were 25 people at the mizan amanah orphanage, cinere and pangkalanjati, depok city. the intervention data collection stage begins with a pretest where all orphanage children fill out a knowledge and attitude questionnaire and brush their teeth before being given the intervention. the intervention group was given dental health education using storgi media, while the control group was given dental health education using flipcharts. children filled out a knowledge and attitude questionnaire and performed the same action of brushing their teeth after 10 days. the data was tested using paired sample t-test/wilcoxon analysis, namely a pre-post design, while to compare the means of the treatment and control groups, the independent t-test/mann whitney test was used. result table 1: frequency distribution based on respondent characteristics variable intervention control n % n % age 8 years 4 16,0 3 12,0 9 years 3 12,0 4 16,0 10 years 6 24,0 5 20,0 11 years 1 4,0 2 8,0 12 years 5 20,0 6 24,0 13 years 6 24,0 5 20,0 total 25 100 25 100 gender man 11 44,0 13 52,0 women 14 56,0 12 48,0 total 25 100 25 100 table 1 shows that the majority of respondents in the intervention group were 13 years old (24.0%) and female, while in the control group the majority were 12 years old (24.0%) and male. table 2: mean knowledge, attitudes and actions of brushing teeth in the intervention and control groups variable intervention control pre-test post-test pre-test post-test knowledge mean 57,20 94,40 57,20 58,00 sd 11,00 7,118 9,363 10,00 attitudes mean 41,20 46,84 40,00 40,24 sd 3,948 2,528 3,162 3,099 actions mean 45,20 89,20 52,80 53,20 sd 11,94 10,77 11,37 11,80 table 2 shows that the mean value of knowledge has increased, in the intervention group it increased from 57.20 to 94.40 while in the control group it increased from 57.20 to 58.00. the mean attitude value increased, in the intervention group it increased from 41.20 to 46.84 and in the control group it increased from 40.00 to 40.24. the mean score for brushing teeth increased, in the intervention group from 45.20 to 89.20, while in the control group there was an increase from 52.80 to 53.20. fadjeri et al asian journal of dental and health sciences. 2023; 3(3):42-46 [44] ajdhs.com table 3: data normality test variable groups intervention control knowledge pre-test 0,000 0,005 knowledge post-test 0,000 0,042 attitudes pre-test 0,454 0,166 attitudes post-test 0,016 0,327 actions pre-test 0,005 0,006 actions post-test 0,000 0,006 table 3 shows the results of the normality test for knowledge and actions of brushing teeth in the intervention and control groups, the distribution is not normal, because the p-value is <0.05, then the non-parametric test is continued, while for attitudes in the intervention and control groups the distribution is normal, because the p-value is > 0.05 then continue with parametric testing. table 4: test the effectiveness of knowledge, attitudes and actions before and after intervention in the intervention and control groups groups knowledge* attitudes** actions* mean+ sd p-value mean+ sd p-value mean+ sd p-value intervention pre-test 57,20+ 11,00 0.000 41,20+3,948 0.000 45,20+11,94 0.000 post-test 94,40+ 7,118 46,84+2,528 89,20+10,77 control pre-test 57,20+ 9,363 0.317 40,00+3,162 0.425 52,80+11,37 0.655 post-test 58,00+ 10,00 40,24+3,099 53,20+11,80 * wilcoxon ** paired sampel t-test table 4 shows the results of the data effectiveness test before and after being given dental health education using posters as media, showing the knowledge p-value of the intervention group was 0.000, the p-value of attitude was 0.000 and the p-value of the action of brushing teeth was 0.000 (p < 0.05) means that dental health education using storgi media is effective in increasing knowledge, attitudes and actions of brushing teeth in children in orphanages. the control group's p-value for knowledge was 0.317, the attitude p-value was 0.425 and the p-value for the action of brushing teeth was 0.655, meaning that dental health education using flipcharts was not effective in increasing the knowledge, attitudes and actions of brushing the teeth of children in orphanages. table 5: test differences in knowledge, attitudes and actions before and after intervention in the intervention and control groups groups knowledge* attitudes** actions* mean p-value mean p-value mean p-value intervention 94,40 0.000 46,84 0.000 89,20 0.000 kontrol 58,00 40,24 53,20 * mann whitney ** t-independen table 5 shows the results of the test of differences in knowledge, attitudes and actions of brushing teeth, showing that the p-value between the intervention group and the control group is 0.000 (p <0.05), meaning that dental health education using storgi media is more effective in increasing knowledge, attitudes and actions of brushing teeth compared to control group. discussion dental and oral health behavior is influenced by various factors. one of them is a lack of knowledge about dental and oral health. knowledge is a very important domain for the formation of a person's behavior. behavior is formed from knowledge which then stimulates attitudes and actions. the research results showed that the average knowledge of respondents before the intervention was 57.20, including the poor category. lack of knowledge about dental and oral health can be a major factor in low behavior, because behavior is formed from knowledge which then stimulates attitudes and actions. factors that influence knowledge include educational and socio-economic levels.16–18 low socio-economic conditions also influence knowledge about maintaining oral health. those with low social conditions have less awareness and knowledge of the importance of maintaining oral health.10 the results of research on respondents' knowledge are in line with respondents' attitudes before the dental health education intervention, which was also included in the poor category with an average of 41.20. attitudes are formed due to stimulation from knowledge. knowledge, thoughts, beliefs and emotions play a very important role in determining attitudes. poor attitudes are caused by poor knowledge, so that respondents' attitudes are included in the category of lacking in maintaining dental and oral health due to the respondent's lack of knowledge about maintaining dental and oral health. attitudes are greatly influenced by other people, especially fadjeri et al asian journal of dental and health sciences. 2023; 3(3):42-46 [45] ajdhs.com people who are considered important, especially parents. where children in orphanages already have parents, this could be the cause of the lack of attitudes of respondents regarding maintaining oral health.4,19,20 the results of research on the action of brushing teeth before dental health education from respondents were also included in the poor category with an average of 45.20. the overall results of research on respondents' teeth brushing actions are in line with research on respondents' knowledge and attitudes which are included in the poor category. this is in accordance with the theory which states that the actions a person takes are based on their attitudes. a lack of attitude will result in a lack of action.19 health promotion is an action or activity aimed at increasing the abilities or activities of individuals, groups and communities in terms of knowledge, attitudes and skills to achieve the best healthy living standards. promoting health in children is an ideal time to practice motor skills and improve cognition. children's attention spans are short, so they need training that is fun and motivating. using attractive integrated media for health promotion can increase knowledge and change behavior.21–23 dental health education as an effort to provide knowledge about dental health basically emphasizes aspects of dental health which are closely related to targeted daily efforts in maintaining dental health, so that the selection of education material is prioritized regarding efforts to maintain dental and oral health. the selection of extension materials and extension priorities must consider the magnitude of the impact of the problem/material to be presented.12,24,25 the choice of media is one of the factors that can influence the promotion of oral health, the media can foster motivation and attention to learning and the meaning of the information conveyed will be clearer, so that children can understand and better understand the learning objectives.26,27 this storgi media is designed to make it easier for orphanage children to maintain dental health, especially brushing their teeth. promotion of dental health through storgi media is used because storgi media is an education media that is integrated between education media and tooth brushing facilities in the form of toothbrush lockers, meaning that it combines toothbrush lockers and their contents in the form of brushes, toothpaste and mouthwash glasses with learning media in the form of health care posters. teeth, especially about brushing teeth in one medium. this really helps improve the dental health behavior of children in orphanages who have limited access and facilities for maintaining oral health. the results of the study showed that there was a significant increase in the value of knowledge (p=0.000), attitude (p=0.000) and the act of brushing teeth (p=0.000) after being given dental health education using storgi media, compared to the group that was only given education using flipcharts. this shows that storgi media is more effective in improving dental health behavior which can prevent caries in children in orphanages. according to rama et al's statement, behavior is influenced by attitudes and also requires facilities. to translate attitudes into real form (action), supporting factors such as facilities are needed.19 existing facilities in the respondent's environment are inadequate. facilities for maintaining oral health in an orphanage environment include tools and places for brushing teeth. this is also a supporting factor in the low level of dental health care taken by respondents. purnama et al stated that by providing toothbrush storage facilities in the form of brushes, toothpaste and personal mouthwash cups, brushing your teeth becomes more precise.28 conclusion based on the results of the study, it can be concluded that the dental health education using storgi media is more effective in increasing the knowledge, attitudes and actions of brushing teeth in in orphanage children acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. ethical clearance the study was conducted after obtaining approval from the ethics committee of the health polytechnic of yogyakarta no.dp.04.03/e-kepk.1/725/2023. references 1. hamid a, wijaya d, sulaiman z, ismalayani i. kualitas hidup anak usia 3-5 tahun dengan early chilhood caries yang tidak ditangani. j kesehatan gigi. 2019;6(1):14-18. https://doi.org/10.31983/jkg.v6i1.3824 2. kemenkes ri k. hasil utama riskesdas 2018. jakarta kemenkes ri. 2018; 3. nelwan jj. faktor-faktor yang mempengaruhi tingginya kasus karies gigi pada anak panti asuhan yataama al-firdausi di wilayah kerja puskesmas ngesrep tahun 2011. j kesehatan gigi (dental health journal). 2015;3(2):106-112. 4. purnama t, rasipin r, ngatemi n. tedi's behavior change model to improving brushing teeth behavior parents. j appl heal manag technol. 2020;2(1):1-12. https://doi.org/10.31983/jahmt.v2i1.5475 5. ngatemi n, lestari sy, karmawati ia, yulita i, budiarti r, kristianto j, et al. pemeliharaan kesehatan gigi dan gerakan 3m (menjaga jarak, memakai masker, mencuci tangan) pada masa pandemi covid-19 di panti asuhan dan panti jompo. gemakes j pengabdi kpd masy. 2021;1(1):29-34. 6. budiharto j. pengantar ilmu perilaku kesehatan pendidikan kesehatan gigi. jakarta egc. 2010;18-20. 7. hiremath ss. textbook of preventive and community dentistry. elsevier india; 2011. 8. notoatmodjo. promosi kesehatan dan perilaku kesehatan, edisi revisi. jakarta: rineka cipta; 2012. 9. budisuari ma, oktarina o, mikrajab ma. hubungan pola makan dan kebiasaan menyikat gigi dengan kesehatan gigi dan mulut (karies) di indonesia. bul penelit sist kesehat. 2010;13(1):21306. 10. rama s, suwargiani aa, susilawati s. perilaku anak sekolah dasar daerah tertinggal tentang pemeliharaan kesehatan gigi underdeveloped area elementary school children's behaviour towards dental health care. j kedokt gigi univ padjadjaran. 2017;29(2). https://doi.org/10.24198/jkg.v29i2.18574 11. nurhidayat o. perbandingan media power point dengan flip chart dalam meningkatkan pengetahuankesehatan gigi dan mulut. unnes j public heal. 2012;1(1). 12. pudentiana rr re, subandini sl. pendidikan kesehatan gigi. jakarta: egc; 2019. 13. arsyad a. media pembelajaran. jakarta: pt raja grafindo persada; 2011. 14. anwar i. pengembangan bahan ajar. bahan kuliah online direktori upi bandung. 2010; 15. daryanto d. media pembelajaran. bandung: nurani sejahtera; 2011. 16. re pr, tauchid sn, purnama t. determinants of tooth brushing behavior in sixth grade elementary school students in lebak https://doi.org/10.31983/jkg.v6i1.3824 https://doi.org/10.31983/jahmt.v2i1.5475 https://doi.org/10.24198/jkg.v29i2.18574 fadjeri et al asian journal of dental and health sciences. 2023; 3(3):42-46 [46] ajdhs.com bulus sub-district, south jakarta. int res j pharm med sci. 2021;4(4):41-41. 17. silaban s. prevalensi karies gigi geraham pertama permanen pada anak umur 8-10 tahun di sd kelurahan kawangkoan bawah. egigi. 2013;1(2). https://doi.org/10.35790/eg.1.2.2013.3147 18. newacheck pw, hung yy, jane park m, brindis cd, irwin jr ce. disparities in adolescent health and health care: does socioeconomic status matter? health serv res. 2003;38(5):123552. https://doi.org/10.1111/1475-6773.00174 pmid:14596388 pmcid:pmc1360944 19. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta. 2010;200:26-35. 20. worang ty, pangemanan dhc, wicaksono da. hubungan tingkat pengetahuan orang tua dengan kebersihan gigi dan mulut anak di tk tunas bhakti manado. e-gigi. 2014;2(2). https://doi.org/10.35790/eg.2.2.2014.5777 21. notoatmodjo s. promosi kesehatan: teori dan aplikasi. jakarta: rineka cipta; 2012. 22. kurniawan a, putri rm, widiani e. pengaruh promosi kesehatan terhadap pengetahuan dan sikap tentang perilaku hidup bersih dan sehat kelas iv dan v sekolah dasar. nurs news j ilm keperawatan. 2019;4(1). https://doi.org/10.47317/dmk.v1i1.138 23. tandilangi m, mintjelungan c, wowor vns. efektivitas dental health education dengan media animasi kartun terhadap perubahan perilaku kesehatan gigi dan mulut siswa sd advent 02 sario manado. e-gigi. 2016;4(2). https://doi.org/10.35790/eg.4.2.2016.13503 24. puspitawati y, ulliana u, sulistiani s, fadliyah nk, nurwanti w. dental health promotion using fliphchart media on knowledge of elementary school student. jdht j dent hyg ther. 2022;3(1):215. https://doi.org/10.36082/jdht.v3i1.486 25. nurilawaty v, purnama t, zahra mf. carbohydrate diet during the covid-19 pandemic (case study: 4 th grade students of elementary school 02 meruya utara, west jakarta). int res j pharm med sci. 2021;4(4):37-40. 26. hanif f, prasko p. perbedaan pengaruh penyuluhan menggunakan media video dan boneka tangan terhadap peningkatan pengetahuan kesehatan gigi dan mulut pada siswa sekolah dasar. j kesehat gigi. 2018;5(2):1-6. https://doi.org/10.31983/jkg.v5i2.3854 27. ngatemi; lestari sy, purnama t. pillow book media as dental health promotion in preschool children: is it effective? int j drug res dent sci. 2022;4(1):7-13. 28. purnama t, ngatemi n, sofian r, kasihani nn, re pr, nurbayani s. model 5 days gosgi sebagai upaya pembentukan kemandirian menggosok gigi anak usia dini di sekolah. qual j kesehat. 2020;14(1):19-24. https://doi.org/10.36082/qjk.v14i1.96 https://doi.org/10.35790/eg.1.2.2013.3147 https://doi.org/10.1111/1475-6773.00174 https://doi.org/10.35790/eg.2.2.2014.5777 https://doi.org/10.47317/dmk.v1i1.138 https://doi.org/10.35790/eg.4.2.2016.13503 https://doi.org/10.36082/jdht.v3i1.486 https://doi.org/10.31983/jkg.v5i2.3854 https://doi.org/10.36082/qjk.v14i1.96 obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [26] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the vital role of blood transfusions during pregnancy: a comprehensive review *emmanuel ifeanyi obeagu 1 and getrude uzoma obeagu 2 1 department of medical laboratory science, kampala international university, uganda, 2 school of nursing science, kampala international university, uganda, article info: _____________________________________________ article history: received 21 december 2023 reviewed 18 january 2024 accepted 17 february 2024 published 15 march 2024 _____________________________________________ cite this article as: obeagu ei, obeagu gu, the vital role of blood transfusions during pregnancy: a comprehensive review, asian journal of dental and health sciences. 2024; 4(1):26-31 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.58 _____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda, 0000-0002-4538-0161 abstract _________________________________________________________________________________________________________________ pregnancy is a remarkable yet complex physiological state that can be accompanied by various complications, including obstetric hemorrhage and severe anemia, which significantly affect maternal and fetal health. blood transfusions serve as crucial interventions to manage these complications and mitigate potential risks. this comprehensive review synthesizes the pivotal role of blood transfusions during pregnancy, encompassing their indications, benefits, risks, and advancements in transfusion medicine. exploring the multifaceted landscape of transfusions in addressing obstetric challenges, anemia, and other maternal conditions, this article underscores the paramount importance of timely and appropriate transfusion interventions to safeguard the health and well-being of both mother and child. through an in-depth analysis of current knowledge and emerging trends, this review aims to provide a holistic understanding of the significance of blood transfusions in optimizing outcomes during pregnancy. keywords: blood transfusions, pregnancy, maternal health, hemorrhage, anemia, obstetrics, fetal health, transfusion medicine introduction pregnancy is a transformative journey characterized by remarkable physiological changes to support the growth and development of the fetus. however, this period can also be fraught with potential complications that challenge maternal health and the well-being of the unborn child. among these complications, obstetric hemorrhage and severe anemia stand as significant contributors to maternal morbidity and mortality worldwide.1-6 obstetric hemorrhage, often unpredictable and rapid in onset, remains a leading cause of maternal mortality globally, accounting for approximately one-quarter of all pregnancy-related deaths. additionally, anemia, prevalent among pregnant individuals due to increased blood volume demands and physiological changes, poses risks to both maternal and fetal health. addressing these challenges effectively requires comprehensive strategies, and blood transfusions emerge as indispensable lifesaving interventions.7-12 the administration of blood and blood products has revolutionized obstetric care, providing a crucial lifeline in managing acute blood loss, correcting anemia, and mitigating complications during pregnancy and childbirth. while the primary focus of blood transfusions is to stabilize maternal conditions, their impact extends to ensuring the optimal growth and development of the fetus.13-14 this paper aims to provide a comprehensive overview of the importance of blood transfusions during pregnancy. it will delve into the indications, benefits, and risks associated with transfusions in obstetric care. furthermore, it will explore advancements in transfusion medicine, including emerging techniques and strategies, emphasizing their impact on maternal and fetal outcomes. understanding the critical role of blood transfusions in pregnancy is essential not only for healthcare providers but also for policymakers and the broader community. by elucidating the significance of timely and appropriate transfusion interventions, this review aims to underscore the necessity of a multidisciplinary approach and continued advancements in transfusion practices to ensure the optimal health and well-being of pregnant individuals and their babies. indications for blood transfusions during pregnancy obstetric hemorrhage obstetric hemorrhage, characterized by excessive bleeding during pregnancy, childbirth, or the postpartum period, stands as a critical indication for blood transfusions. it represents a major cause of maternal morbidity and mortality globally. various factors contribute to obstetric hemorrhage, including uterine atony, placental abnormalities, trauma, and surgical complications. managing obstetric hemorrhage effectively often necessitates prompt and targeted interventions, with blood transfusions playing a pivotal role in stabilizing the patient and preventing severe complications.15-23 postpartum hemorrhage resulting from uterine atony, a failure of the uterus to contract effectively after childbirth, is one of the most common causes of excessive bleeding. transfusions are often open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.58 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.58&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 https://orcid.org/0000-0002-1373-9571 obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [27] ajdhs.com required when conventional measures like uterotonic medications fail to control bleeding.24-30 conditions such as placenta previa or placental abruption may lead to significant bleeding, requiring transfusions to address acute blood loss and maintain adequate perfusion to vital organs. in cases of obstetric trauma during childbirth or surgical complications, such as uterine rupture or severe lacerations, immediate transfusions may be necessary to stabilize the patient and restore blood volume.31-34 transfusion protocols for obstetric hemorrhage involve rapid assessment, identification of the bleeding source, and simultaneous resuscitative measures. timely administration of blood products, including packed red blood cells, fresh frozen plasma, platelets, and sometimes clotting factors, is essential to replace lost blood volume and correct coagulopathies.35-38 furthermore, a multidisciplinary approach involving obstetricians, hematologists, anesthesiologists, and blood bank specialists is crucial in optimizing transfusion therapy for obstetric hemorrhage. the aim is not only to prevent maternal complications but also to ensure the preservation of fetal wellbeing during these critical moments. benefits and risks of blood transfusions in pregnancy blood transfusions during pregnancy carry both potential benefits and risks, necessitating careful consideration and individualized management based on the specific clinical circumstances. understanding these aspects is crucial in optimizing maternal care while minimizing potential complications. benefits: blood transfusions serve as life-saving interventions in cases of obstetric hemorrhage, trauma, or severe postpartum hemorrhage, effectively restoring blood volume and preventing hypovolemic shock.39-41 pregnant individuals may experience anemia due to factors such as iron deficiency, hemoglobinopathies, or other underlying conditions. transfusions can rapidly replenish red blood cells and improve oxygen-carrying capacity, mitigating the risks associated with severe anemia for both the mother and the fetus.42-45 timely transfusions help prevent complications related to inadequate tissue perfusion, organ dysfunction, and coagulopathies, reducing the risk of maternal morbidity and mortality.46 risks: adverse reactions to transfusions, including febrile reactions, allergic reactions, hemolytic reactions, and transfusion-related acute lung injury (trali), pose risks to the recipient. proper blood typing, cross-matching, and screening for antibodies are essential to minimize these risks.47 despite stringent screening protocols, there remains a minimal risk of transmitting infectious agents through blood transfusions, including viruses (such as hiv, hepatitis b and c) and bacteria. blood banks follow strict guidelines to minimize this risk. transfusions can trigger immune responses leading to alloimmunization, where the recipient's immune system forms antibodies against transfused blood components. this may complicate future transfusions or pregnancies, potentially affecting fetal health in subsequent pregnancies.48 rapid administration of large volumes of blood products can result in fluid overload, especially in individuals with compromised cardiac function, leading to pulmonary edema and exacerbating pre-existing conditions. to mitigate these risks and optimize benefits, healthcare providers must weigh the indications for transfusion against the potential complications. individualized patient assessment, close monitoring, adherence to transfusion protocols, and ensuring compatibility and safety of blood products are critical in minimizing risks associated with transfusions during pregnancy. the decision to administer blood transfusions during pregnancy should involve a thorough risk-benefit analysis, considering the urgency of the situation, the patient's clinical status, and potential alternatives. careful monitoring for adverse reactions and appropriate posttransfusion care are imperative to ensure optimal outcomes for both the pregnant individual and the developing fetus. advances in transfusion medicine and pregnancy transfusion medicine has witnessed significant advancements, revolutionizing approaches to blood product administration and transfusion strategies in obstetric care. these innovations aim to enhance safety, efficacy, and outcomes for pregnant individuals facing complications requiring blood transfusions.49-50 improved understanding of blood component therapy has enabled more precise and tailored transfusion approaches. specific components such as packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate can be administered based on individual patient needs, optimizing hemostasis and minimizing unnecessary transfusions.51 rapid point-of-care testing methods have evolved, enabling timely assessment of coagulation parameters and hemoglobin levels. these advancements facilitate prompt decision-making in managing obstetric hemorrhage and anemia, allowing for targeted and personalized transfusion therapy.52 enhanced collaboration between transfusion medicine specialists and maternal-fetal medicine experts has led to improved understanding of the impact of transfusions on both maternal and fetal outcomes. this interdisciplinary approach considers the unique needs of both the pregnant individual and the developing fetus, ensuring comprehensive and balanced care.53 implementation of pathogen reduction technologies in blood products has significantly reduced the risk of transfusion-transmitted infections. these technologies employ various methods to inactivate pathogens while preserving the integrity and functionality of blood components, enhancing the safety profile of transfusions.54 patient blood management (pbm) programs have gained prominence, focusing on optimizing patient outcomes by minimizing unnecessary transfusions, reducing exposure to blood products, and promoting alternative strategies such as iron supplementation, erythropoiesis-stimulating agents, and hemostatic agents.55 research into immunomodulation techniques aims to mitigate adverse immune reactions and alloimmunization in transfusion recipients. strategies to induce immune tolerance to prevent alloimmunization are being explored, potentially impacting future transfusion and pregnancy outcomes.56 ongoing research into blood substitutes and alternative oxygencarrying solutions aims to develop safer alternatives to traditional blood transfusions, reducing the risks associated with allogeneic blood products. these advances underscore the dynamic nature of transfusion medicine in pregnancy. implementing these innovations requires ongoing research, multidisciplinary collaboration, and adherence to evolving best practices. by embracing these advancements, healthcare providers can optimize transfusion therapy, ensuring safer and more effective care for pregnant individuals facing obstetric complications that necessitate blood transfusions. impact on maternal and fetal health the impact of blood transfusions on maternal and fetal health during pregnancy is multifaceted and warrants careful consideration, as these interventions directly influence the well-being of both the pregnant individual and the developing fetus. obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [28] ajdhs.com maternal health: blood transfusions play a crucial role in stabilizing maternal conditions during obstetric hemorrhage. prompt administration of blood products helps restore blood volume, ensuring adequate tissue perfusion and mitigating the risk of maternal morbidity and mortality. severe anemia in pregnancy poses risks to maternal health, including fatigue, cardiac strain, and impaired oxygen delivery to tissues. transfusions can rapidly address anemia, improving maternal well-being and reducing the risk of complications. transfusions help prevent or mitigate complications associated with hypovolemia, inadequate oxygenation, and coagulopathies, reducing the risk of organ dysfunction and improving overall maternal outcomes.57 fetal health: maternal blood transfusions enhance oxygen-carrying capacity, ensuring improved oxygen delivery to the placenta and subsequently to the developing fetus. this is particularly beneficial in cases of maternal anemia, optimizing fetal growth and development. while transfusions primarily focus on maternal stabilization, their effects extend to the fetus. timely interventions can indirectly mitigate potential fetal complications resulting from maternal distress due to hemorrhage or anemia.58 balancing maternal and fetal well-being optimizing maternal health through transfusions is crucial for ensuring a favorable intrauterine environment for the developing fetus. however, healthcare providers must carefully weigh the benefits of transfusions for the mother against potential risks to the fetus, considering factors such as gestational age, indications for transfusion, and the overall health status of both the mother and the fetus.59 monitoring fetal well-being during and after transfusions through techniques like fetal heart rate monitoring and ultrasound assessments is vital. multidisciplinary collaboration between obstetricians, hematologists, neonatologists, and other specialists ensures comprehensive care, aiming to minimize risks to the fetus while addressing maternal health concerns.6061 understanding the interconnectedness of maternal and fetal health in the context of blood transfusions during pregnancy underscores the importance of individualized care, close monitoring, and informed decision-making to optimize outcomes for both the mother and the unborn child. ethical and societal perspectives ethical and societal perspectives surrounding blood transfusions during pregnancy are integral aspects that influence decision-making, healthcare delivery, and patient outcomes. respecting the autonomy of pregnant individuals in decision-making regarding transfusions is crucial. healthcare providers must ensure that individuals are adequately informed about the risks, benefits, and alternatives to transfusions, considering religious, cultural, and personal beliefs that may impact their acceptance of this intervention.62 the ethical principles of beneficence (doing good) and nonmaleficence (avoiding harm) guide healthcare professionals in balancing the benefits of transfusions for maternal health against potential risks to both the mother and the fetus. striking this balance requires a careful evaluation of the clinical situation while prioritizing the well-being of both patients.62 religious beliefs and cultural norms significantly influence attitudes toward blood transfusions during pregnancy. certain religious groups have prohibitions or reservations against blood transfusions, necessitating respectful dialogue, and alternative approaches to care that align with patients' beliefs. ensuring equitable access to transfusion services is essential. socioeconomic factors, geographical location, and healthcare disparities may affect access to timely transfusions. efforts to provide access to safe and culturally sensitive transfusion services are imperative to prevent adverse maternal and fetal outcomes. legal frameworks govern healthcare decisions, including transfusions during pregnancy. healthcare providers must adhere to established guidelines, ensuring patient safety and respecting patient rights, including the right to refuse treatment based on religious or personal beliefs. public awareness and education campaigns are vital to dispel misconceptions, increase awareness about the importance of blood transfusions in pregnancy, and foster understanding and support within communities. this helps address stigmas or fears surrounding transfusions and encourages informed decision-making. ethical considerations in research involving transfusions during pregnancy involve safeguarding the rights and wellbeing of pregnant participants. ethical research practices ensure that advancements in transfusion medicine benefit pregnant individuals without undue risks. navigating these ethical and societal considerations demands a patient-centered approach that respects cultural diversity, promotes patient autonomy, and upholds ethical principles while delivering optimal healthcare. collaboration among healthcare providers, ethicists, community leaders, and policymakers is crucial in developing inclusive policies and practices that respect patients' beliefs while ensuring the best possible care outcomes for pregnant individuals requiring blood transfusions. future directions future directions in blood transfusions during pregnancy are poised to bring about significant advancements in maternal and fetal care. advances in technology and understanding of individual patient factors (such as genetics, immunology, and hemodynamics) may lead to tailored transfusion approaches. precision medicine principles could enable customized transfusion therapies based on specific patient needs, minimizing risks and optimizing outcomes. ongoing research aims to further reduce the risks associated with transfusions, including efforts to enhance blood safety, prevent transfusion reactions, and develop alternative transfusion products or strategies that minimize immunological responses. research into non-blood alternatives, such as synthetic oxygen carriers, hemoglobin-based oxygen carriers, and oxygen therapeutics, continues to advance. these alternatives aim to provide oxygen-carrying capacity without the risks associated with traditional blood transfusions. strategies to modulate the immune response and prevent alloimmunization posttransfusion are under exploration. novel techniques may aim to induce immune tolerance, reducing the risks of adverse reactions and sensitization in pregnant individuals. advancements in point-of-care testing technologies are expected to further improve the rapid assessment of hemoglobin levels, coagulation parameters, and immunological responses. this will facilitate real-time decision-making and personalized transfusion interventions. integration of telemedicine and remote consultation services could enhance access to expert guidance in managing obstetric complications necessitating transfusions, especially in underserved or remote areas lacking immediate access to specialized care. continued research focusing on the long-term maternal and fetal outcomes following blood transfusions during pregnancy is essential. studying the potential effects on subsequent pregnancies, immune sensitization, and overall health of both mother and child will provide valuable insights. further exploration into ethical dilemmas, cultural sensitivities, and religious perspectives regarding blood transfusions in pregnancy is critical. policies and practices obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [29] ajdhs.com should evolve to respect diverse beliefs while ensuring optimal care. the future of transfusion medicine in pregnancy lies in advancing safety, efficacy, and individualized care. collaborative efforts among researchers, healthcare providers, policymakers, and communities will drive these advancements, shaping the landscape of maternal-fetal medicine and transfusion practices for improved outcomes and patientcentered care. continued innovation and research in these areas will further refine and enhance transfusion therapies for pregnant individuals facing obstetric challenges. recommendations recommendations concerning blood transfusions during pregnancy encompass a multifaceted approach aimed at optimizing care, ensuring patient safety, and improving outcomes. encourage the establishment of multidisciplinary teams comprising obstetricians, hematologists, anesthesiologists, neonatologists, and transfusion specialists. collaborative efforts ensure comprehensive care, facilitating timely decision-making and optimal management of pregnant individuals requiring blood transfusions. develop evidencebased protocols and clinical guidelines specific to blood transfusions during pregnancy. these guidelines should encompass indications, dosing, monitoring, and adverse event management, ensuring standardized and safe practices across healthcare settings. emphasize patient-centered communication and informed consent processes. healthcare providers should engage in open discussions with pregnant individuals, respecting their beliefs, preferences, and concerns regarding transfusions. providing clear, understandable information aids in informed decision-making. offer continuous education and training programs for healthcare professionals involved in obstetric care. these programs should focus on transfusion protocols, ethical considerations, cultural competency, and advancements in transfusion medicine, enhancing the quality of care provided to pregnant patients. ensure equitable access to safe and culturally sensitive transfusion services, especially in underserved or remote areas. addressing healthcare disparities and ensuring access to timely transfusions can significantly impact maternal and fetal outcomes. encourage and support research endeavors focusing on transfusion medicine in pregnancy. research initiatives should explore alternative transfusion strategies, long-term outcomes, immunomodulation techniques, and safety measures to continually improve transfusion practices and minimize risks. develop policies that balance patient autonomy, safety, and ethical considerations surrounding transfusions during pregnancy. these policies should respect diverse cultural and religious beliefs while prioritizing maternal and fetal wellbeing. foster public awareness campaigns highlighting the importance of blood transfusions in pregnancy. promote community support, dispel myths, and encourage dialogue to increase acceptance and understanding of transfusions among diverse populations. by implementing these recommendations, healthcare systems can enhance the quality of care provided to pregnant individuals, ensure patient safety, and improve outcomes associated with obstetric complications requiring blood transfusions. continuous evaluation and adaptation of practices based on emerging evidence and ethical considerations are essential to advancing transfusion medicine in the context of pregnancy. conclusion the significance of blood transfusions during pregnancy cannot be overstated in safeguarding the health and well-being of both the pregnant individual and the developing fetus. obstetric complications such as hemorrhage and severe anemia pose substantial risks, necessitating prompt and effective interventions, where blood transfusions play a pivotal role. striking a balance between optimizing maternal health and ensuring fetal well-being remains a core challenge. this balance necessitates a personalized, patient-centered approach that respects individual beliefs, preferences, and cultural considerations. multidisciplinary collaboration, evidencebased protocols, and continuous advancements in technology and research are critical to evolving transfusion practices, minimizing risks, and improving outcomes. ultimately, the comprehensive understanding and application of advancements in transfusion medicine during pregnancy underscore the commitment to providing optimal care. by embracing emerging knowledge, fostering collaboration, and advocating for patient-centered approaches, we pave the way for continued advancements that ensure the well-being of pregnant individuals and their babies, embodying the essence of compassionate and evidence-based obstetric care. acknowledgements not applicable authors contribution all the authours were involved in conceptualisation, methodology, visualization, validation, drafting and editing of the article funding source no fund was received to write this paper conflict of interest the authors declare that they have no conflict interests. ethical clearance not applicable references 1. obeagu ei, agreen fc. anaemia among pregnant women: a review of african pregnant teenagers. j pub health nutri. 2023; 6 (1). 2023;138. links/63da799664fc860638054562/anaemia-amongpregnant-women-a-review-of-african-pregnant-teenagers.pdf. 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. links/5710fae108ae846f4ef05afb/erythropoietin-in-theanaemias-of-pregnancy-a-review.pdf. 3. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-8. links/608a6728a6fdccaebdf52d94/assessmentof-haematological-changes-in-pregnant-women-of-ido-ondo.pdf. 4. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. http://irmhs.com/index.php/irmhs/article/view/111. 5. jakheng sp, obeagu ei. seroprevalence of human immunodeficiency virus based on demographic and risk factors among pregnant women attending clinics in zaria metropolis, 1nigeria. j pub health nutri. 2022;5(8):2022;137. https://6317a6b1acd814437f0ad268/seroprevalence-of-humanimmunodeficiency-virus-based-on-demographic-and-risk-factorsamong-pregnant-women-attending-clinics-in-zaria-metropolisnigeria.pdf https://doi.org/10.9734/sajrm/2022/v13i230295 6. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university https://6317a6b1acd814437f0ad268/seroprevalence-of-human-immunodeficiency-virus-based-on-demographic-and-risk-factors-among-pregnant-women-attending-clinics-in-zaria-metropolis-nigeria.pdf https://6317a6b1acd814437f0ad268/seroprevalence-of-human-immunodeficiency-virus-based-on-demographic-and-risk-factors-among-pregnant-women-attending-clinics-in-zaria-metropolis-nigeria.pdf https://6317a6b1acd814437f0ad268/seroprevalence-of-human-immunodeficiency-virus-based-on-demographic-and-risk-factors-among-pregnant-women-attending-clinics-in-zaria-metropolis-nigeria.pdf https://6317a6b1acd814437f0ad268/seroprevalence-of-human-immunodeficiency-virus-based-on-demographic-and-risk-factors-among-pregnant-women-attending-clinics-in-zaria-metropolis-nigeria.pdf https://doi.org/10.9734/sajrm/2022/v13i230295 obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [30] ajdhs.com journal of medicine and health sciences issn: 2814-3035. 2022;2(2):1-9. 7. villa ch, anselmo ac, mitragotri s, muzykantov v. red blood cells: supercarriers for drugs, biologicals, and nanoparticles and inspiration for advanced delivery systems. advanced drug delivery reviews, 2016; 106, 88-103. https://doi.org/10.1016/j.addr.2016.02.007 pmid:26941164 pmcid:pmc5424548 8. ross pt. risking reproduction reproductive health among women with sickle cell disease. wayne state university. 2013. 9. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci, 2016; 3(3), 10-8. 10. obeagu ei, agreen fc. anaemia among pregnant women: a review of african pregnant teenagers. j pub health nutri. 2023; 6 (1), 138. 11. obeagu ei, ogunnaya fu. pregnancyinduced haematological changes: a key to marternal and child health. european journal of biomedical, 2023; 10(8), 42-3. 12. obeagu ei, hassan ao, adepoju oj, obeagu gu, okafor cj. evaluation of changes in haematological parameters of pregnant women based on gestational age at olorunsogo road area of ido, ondo state. nigeria. journal of research in medical and dental science, 2021; 9(12), 462-4. https://doi.org/10.9734/jpri/2022/v34i12a35546 13. kelly se. the maternal-foetal interface and gestational chimerism: the emerging importance of chimeric bodies. science as culture, 2012; 21(2), 233-257. https://doi.org/10.1080/09505431.2011.628014 14. sharma s, banerjee s, krueger pm, blois sm. immunobiology of gestational diabetes mellitus in post-medawar era. frontiers in immunology, 2022; 12, 758267. https://doi.org/10.3389/fimmu.2021.758267 pmid:35046934 pmcid:pmc8761800 15. osborne c, kolakowski m, lobenstine d. pre-and perinatal massage therapy: a comprehensive guide to prenatal, labor and postpartum practice. jessica kingsley publishers. 2021. 16. gamde ms, obeagu ei. iron deficiency anaemia: enemical to pregnancy. european journal of biomedical, 2023; 10(9), 272-275. 17. obeagu ei, hassan ao, adepoju oj, obeagu gu, okafor cj. evaluation of changes in haematological parameters of pregnant women based on gestational age at olorunsogo road area of ido, ondo state. nigeria. journal of research in medical and dental science. 2021;9(12):462-. https://doi.org/10.9734/jpri/2022/v34i12a35546 18. obeagu ei, ikpenwa jn, chukwueze cm, obeagu gu. evaluation of protein c, protein s and fibrinogen of pregnant women in owerri metropolis. madonna university journal of medicine and health sciences, 2022; 2(1): 292-298. 19. obeagu ei. comparative study of serum iron and hemoglobin levels of cord blood of normal neonates and that of maternal blood in federal medical centre owerri. journal of clinical and laboratory research, 2021;4(1): 2768-0487. 20. anyiam af, obeagu ei, obi e, omosigho po, irondi ea, arinzeanyiam oc, asiyah mk. abo blood groups and gestational diabetes among pregnant women attending university of ilorin teaching hospital, kwara state, nigeria. international journal of research and reports in hematology, 2022; 5(2), 113-121. 21. obeagu ei. gestational thrombocytopaenia. j gynecol women's health, 2023; 25(3), 556163. https://doi.org/10.19080/jgwh.2023.25.556163 22. jakheng spe, obeagu ei. seroprevalence of human immunodeficiency virus based on demographic and risk factors among pregnant women attending clinics in zaria metropolis, nigeria. j pub health nutri. 2022; 5 (8), 137. https://doi.org/10.9734/sajrm/2022/v13i230295 23. obeagu ei, gamade sm, obeagu gu. the roles of neutrophils in pregnancy. int. j. curr. res. med. sci, 2023; 9(5), 31-35. 24. orefice r. immunology and the immunological response in pregnancy. best practice & research clinical obstetrics & gynaecology, 2021; 76, 3-12. https://doi.org/10.1016/j.bpobgyn.2020.07.013 pmid:33191116 25. robertson sa, care as, moldenhauer lm. regulatory t cells in embryo implantation and the immune response to pregnancy. the journal of clinical investigation, 2018;128(10), 4224-4235. https://doi.org/10.1172/jci122182 pmid:30272581 pmcid:pmc6159994 26. burton gj, fowden al, thornburg kl. placental origins of chronic disease. physiological reviews, 2016; 96(4), 1509-1565. https://doi.org/10.1152/physrev.00029.2015 pmid:27604528 pmcid:pmc5504455 27. chighizola cb, lonati pa, trespidi l, meroni pl, tedesco f. the complement system in the pathophysiology of pregnancy and in systemic autoimmune rheumatic diseases during pregnancy. frontiers in immunology, 2020; 11, 2084. https://doi.org/10.3389/fimmu.2020.02084 pmid:32973817 pmcid:pmc7481445 28. robinson dp, klein sl. pregnancy and pregnancy-associated hormones alter immune responses and disease pathogenesis. hormones and behavior, 2012; 62(3), 263-271. https://doi.org/10.1016/j.yhbeh.2012.02.023 pmid:22406114 pmcid:pmc3376705 29. okorie hm, obeagu ei, obarezi hc, anyiam af. assessment of some inflammatory cytokines in malaria infected pregnant women in imo state nigeria. international journal of medical science and dental research, 2019; 2(1), 25-36. 30. emeka-obi or, ibeh nc, obeagu ei, okorie hm. evaluation of levels of some inflammatory cytokines in preeclamptic women in owerri. journal of pharmaceutical research international, 2021; 33(42a), 53-65. https://doi.org/10.9734/jpri/2021/v33i42a32384 31. ifeanyi oe, vincent ccn, ugochi cmj. studies on some cytokines of apparently healthy nigerian women aged 10-40 years. int. j. curr. res. med. sci, 2019; 5(12), 24-30. 32. obeagu ei, okoroiwu il, obeagu gu. relationship between thrombopoietin and interleukin 3: a review. int j curr res chem pharm. sci, 2022; 9(1), 7-13. 33. obeagu ei, muhimbura e, kagenderezo bp, nakyeyune s, obeagu gu. an insight of interleukin-6 and fibrinogen: in regulating the immune system. j biomed sci, 2022; 11(10), 83. 34. ifeanyi o, uzoma o, amaeze a, ijego a, felix c, ngozi a, ... chinenye k. maternal expressions (serum levels) of alpha tumour necrosis factor, interleukin 10, interleukin 6 and interleukin 4 in malaria infected pregnant women based on parity in a tertiary hospital in southeast, nigeria. journal of pharmaceutical research international, 2020; 32(23), 35-41. https://doi.org/10.9734/jpri/2020/v32i2330786 35. obeagu e, felix ce, mtb o, chikodili um, nchekwubedi cs, chinedum ok. studies on some cytokines, cd4, iron status, hepcidin and some haematological parameters in pulmonary tuberculosis patients based on duration of treatment in southeast, nigeria. african journal of biological sciences, 2021; 3(1), 146156. https://doi.org/10.33472/afjbs.3.1.2021.146-156 36. obeagu ei, amedu go, okoroiwu il, okafor cj, okun o, ochiabuto om, ukeekwe co. evaluation of plasma levels of interleukin 6 and iron status of football players in a nigerian university. journal of pharmaceutical research international, 2021; 33(59b), 383-388. https://doi.org/10.9734/jpri/2021/v33i59b34393 37. obeagu ei, obeagu gu, guevara mec, okafor cj, bot ys, eze gc, ... uwakwe os. evaluation of plasma levels of interleukin 6 and iron of volleyball players based on heights and weight of a nigerian university students. asian journal of medicine and health, 2022; 20(10), 147-152. https://doi.org/10.9734/ajmah/2022/v20i1030515 38. macpherson aj, de agüero mg, ganal-vonarburg sc. how nutrition and the maternal microbiota shape the neonatal immune system. nature reviews immunology, 2017; 17(8), 508-517. https://doi.org/10.1038/nri.2017.58 pmid:28604736 https://doi.org/10.1016/j.addr.2016.02.007 https://doi.org/10.9734/jpri/2022/v34i12a35546 https://doi.org/10.1080/09505431.2011.628014 https://doi.org/10.3389/fimmu.2021.758267 https://doi.org/10.9734/jpri/2022/v34i12a35546 https://doi.org/10.19080/jgwh.2023.25.556163 https://doi.org/10.9734/sajrm/2022/v13i230295 https://doi.org/10.1016/j.bpobgyn.2020.07.013 https://doi.org/10.1172/jci122182 https://doi.org/10.1152/physrev.00029.2015 https://doi.org/10.3389/fimmu.2020.02084 https://doi.org/10.1016/j.yhbeh.2012.02.023 https://doi.org/10.9734/jpri/2021/v33i42a32384 https://doi.org/10.9734/jpri/2020/v32i2330786 https://doi.org/10.33472/afjbs.3.1.2021.146-156 https://doi.org/10.9734/jpri/2021/v33i59b34393 https://doi.org/10.9734/ajmah/2022/v20i1030515 https://doi.org/10.1038/nri.2017.58 obeagu et al asian journal of dental and health sciences. 2024; 4(1):26-31 [31] ajdhs.com 39. garcía-roa m, del carmen vicente-ayuso m, bobes am, pedraza ac, gonzález-fernández a, martín mp, ... gutiérrez l. red blood cell storage time and transfusion: current practice, concerns and future perspectives. blood transfusion, 2017; 15(3), 222. 40. obeagu ei, babar q, obeagu gu. allergic blood transfusion reaction: a review. int. j. curr. res. med. sci. 2021; 7(5):25-33. 41. obeagu ei, oshim io, ochei kc, obeagu gu. iron and blood donation: a review. int. j. curr. res. med. sci. 2016; 2(10):16-48. 42. okoroiwu il, obeagu ei, elemchukwu q, ochei kc, christian gs. frequency of transfusion reactions following compatible cross matching of blood: a study in owerri metropolis. international journal of current research and academic review. 2015; 3(1):155-60. 43. ogar co, okoroiwu hu, obeagu ei, etura je, abunimye da. assessment of blood supply and usage pre-and during covid-19 pandemic: a lesson from non-voluntary donation. transfusion clinique et biologique. 2021; 28(1):68-72. https://doi.org/10.1016/j.tracli.2020.10.004 pmid:33080420 pmcid:pmc7836417 44. brand a. immunological complications of blood transfusions. la presse médicale, 2016; 45(7-8), e313-e324. https://doi.org/10.1016/j.lpm.2016.06.024 pmid:27499223 45. montgomery ra, tatapudi vs, leffell ms, zachary aa. hla in transplantation. nature reviews nephrology, 2018; 14(9), 558570. https://doi.org/10.1038/s41581-018-0039-x pmid:29985463 46. neal md, raval js, triulzi dj, simmons rl. innate immune activation after transfusion of stored red blood cells. transfusion medicine reviews, 2013; 27(2), 113-118. https://doi.org/10.1016/j.tmrv.2013.01.001 pmid:23434246 47. tormey ca, hendrickson je.transfusion-related red blood cell alloantibodies: induction and consequences. blood, the journal of the american society of hematology, 2019; 133(17), 1821-1830. https://doi.org/10.1182/blood-2018-08-833962 pmid:30808636 pmcid:pmc6484385 48. johnsen j. pathogenesis in immune thrombocytopenia: new insights. hematology 2010, the american society of hematology education program book, 2012(1): 306-312. https://doi.org/10.1182/asheducation.v2012.1.306.3798320 pmid:23233597 49. remy ke, hall mw, cholette j, juffermans np, nicol k, doctor a. pediatric critical care blood research network (blood net). mechanisms of red blood cell transfusion-related immunomodulation. transfusion, 2018; 58(3), 804-815. https://doi.org/10.1111/trf.14488 pmid:29383722 pmcid:pmc6592041 50. alegre ml, lakkis fg, morelli ae. antigen presentation in transplantation. trends in immunology, 2016; 37(12), 831-843. https://doi.org/10.1016/j.it.2016.09.003 pmid:27743777 pmcid:pmc5135637 51. davenport rd. an introduction to chemokines and their roles in transfusion medicine. vox sanguinis, 2009; 96(3), 183-198. https://doi.org/10.1111/j.1423-0410.2008.01127.x pmid:19076338 52. brown cj, navarrete cv. clinical relevance of the hla system in blood transfusion. vox sanguinis, 2011; 101(2), 93-105. https://doi.org/10.1111/j.1423-0410.2011.01474.x pmid:21535436 53. leventhal js, schröppel b. toll-like receptors in transplantation: sensing and reacting to injury. kidney international, 2012; 81(9), 826-832. https://doi.org/10.1038/ki.2011.498 pmid:22297675 54. hendrickson je, tormey ca. understanding red blood cell alloimmunization triggers. hematology 2014, the american society of hematology education program book, 2016(1), 446451. https://doi.org/10.1182/asheducation-2016.1.446 pmid:27913514 pmcid:pmc6142457 55. sarkesh a, sorkhabi ad, ahmadi h, abdolmohammadi-vahid s, parhizkar f, yousefi m. aghebati-maleki l. allogeneic lymphocytes immunotherapy in female infertility: lessons learned and the road ahead. life sciences, 2022; 299, 120503. https://doi.org/10.1016/j.lfs.2022.120503 pmid:35381221 56. aguilar-nascimento je, zampieri-filho jp, bordin j o. implications of perioperative allogeneic red blood cell transfusion on the immune-inflammatory response. hematology, transfusion and cell therapy, 2021; 43: 58-64. https://doi.org/10.1016/j.htct.2020.03.003 pmid:32532624 pmcid:pmc7910182 57. vamvakas ec, blajchman ma. deleterious clinical effects of transfusion-associated immunomodulation: fact or fiction? blood, the journal of the american society of hematology, 2001; 97(5), 1180-1195. https://doi.org/10.1182/blood.v97.5.1180 pmid:11222359 58. tormey ca, hendrickson je. transfusion-related red blood cell alloantibodies: induction and consequences. blood, the journal of the american society of hematology, 2019; 133(17): 1821-1830. https://doi.org/10.1182/blood-2018-08-833962 pmid:30808636 pmcid:pmc6484385 59. gonzalez ca, gonzalez s. fetal and neonatal allo-immune response. transfusion and apheresis science, 2020; 59(5): 102945. https://doi.org/10.1016/j.transci.2020.102945 pmid:32958398 60. brown jb, neal md, guyette fx, peitzman ab, billiar tr, zuckerbraun bs, sperry j. l. design of the study of tranexamic acid during air medical prehospital transport (staamp) trial: addressing the knowledge gaps. prehospital emergency care, 2015; 19(1), 79-86. https://doi.org/10.3109/10903127.2014.936635 pmid:25076119 pmcid:pmc4623322 61. yusoff sm, bahar r, hassan mn, noor nhm, ramli m, shafii nf. prevalence of red blood cell alloimmunization among transfused chronic kidney disease patients in hospital universiti sains malaysia. oman medical journal, 2020; 35(5): e177. https://doi.org/10.5001/omj.2020.95 pmid:33083035 pmcid:pmc7538639 62. day jd, cockrell c, namas r, zamora r, an g, vodovotz y. inflammation and disease: modelling and modulation of the inflammatory response to alleviate critical illness. current opinion in systems biology, 2018; 12, 22-29. https://doi.org/10.1016/j.coisb.2018.08.008 pmid:30886940 pmcid:pmc6420220 https://doi.org/10.1016/j.tracli.2020.10.004 https://doi.org/10.1016/j.lpm.2016.06.024 https://doi.org/10.1038/s41581-018-0039-x https://doi.org/10.1016/j.tmrv.2013.01.001 https://doi.org/10.1182/blood-2018-08-833962 https://doi.org/10.1182/asheducation.v2012.1.306.3798320 https://doi.org/10.1111/trf.14488 https://doi.org/10.1016/j.it.2016.09.003 https://doi.org/10.1111/j.1423-0410.2008.01127.x https://doi.org/10.1111/j.1423-0410.2011.01474.x https://doi.org/10.1038/ki.2011.498 https://doi.org/10.1182/asheducation-2016.1.446 https://doi.org/10.1016/j.lfs.2022.120503 https://doi.org/10.1016/j.htct.2020.03.003 https://doi.org/10.1182/blood.v97.5.1180 https://doi.org/10.1182/blood-2018-08-833962 https://doi.org/10.1016/j.transci.2020.102945 https://doi.org/10.3109/10903127.2014.936635 https://doi.org/10.5001/omj.2020.95 https://doi.org/10.1016/j.coisb.2018.08.008 geeth deepika kottai gandhi et al. asian journal of dental and health sciences. 2024; 4(2):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the distal pole-alternative to conventional distal shoe space maintainer: a case report geeth deepika kottai gandhi 1* , jonathan vasantha rajan pt 2 , dinesh nandakumar gopalan 3 1 reader, csi college of dental sciences and research, madurai, india 2 private, practitioner 3 reader, best dental college, madurai, india article info: _____________________________________________ article history: received 29 march 2024 reviewed 23 april 2024 accepted 09 may 2024 published 15 june 2024 _____________________________________________ cite this article as: kottai gandhi gp, pt gvr, gopalan dn, the distal pole-alternative to conventional distal shoe space maintainer: a case report, asian journal of dental and health sciences. 2024; 4(2):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.75 _____________________________________________ *address for correspondence: geeth deepika kottai gandhi, reader, csi college of dental sciences and research, madurai, india abstract _________________________________________________________________________________________________________________ aim and background: a major clinical challenge for pedodontist is space maintenance in primary dentition associated with the premature loss of primary teeth. when a primary second molar is lost prematurely, it is the distal shoe appliance (dsa) most widely used and proved to be the effective tool in guiding the permanent first molar into its proper place. case description: the sole purpose of this case report is to describe briefly the clinical management of unilateral extensively carious primary mandibular second molar with a modified distal shoe space maintainer which we named it as “distal pole” which is highly inevitable to prevent space loss and following malocclusion development in later stages. clinical significance: the prime importance in pediatric dentistry is preserving the primary teeth in the dental arch until their physiological exfoliation time however there are certain conditions which are challenging at times where extraction seems unavoidable. keywords: distal shoe, space maintenance, e space, deciduous dentitions introduction the prime importance in pediatric dentistry is preserving the primary teeth in the dental arch until their physiological exfoliation time however there are certain conditions which are challenging at times where extraction seems unavoidable due to extensive dental caries or trauma. when a primary second molar is lost prematurely, it is the distal shoe appliance (dsa) most widely used and proved to be the effective tool in guiding the permanent first molar into its proper place. the distal shoe space maintainer was first introduced by gerber1 and modified by croll2,3 indications and contra-indications of this space maintainer were discussed in detail by hicks4 who chose fabrication of a cast gold appliance. modifications like appliances with attachments which are soldered to stainless steel crowns or bands were also clinically acceptable. brill5 in the year 2002 described chairside fabrication of a distal shoe space maintainer which can be delivered immediately after the extraction of the poor prognosed primary second molar showed a high success rate if the patient was cooperative. it has also been proved that early loss of primary second molars and the absence of eruption guidance for erupting permanent molars results in a higher reduction of arch length which is measured about 8mm in each maxillary quadrant and about 4-6 mm in each mandibular quadrant.6 hence the use of distal shoe space maintainer in early loss of primary second molar is highly inevitable to prevent space loss and following malocclusion development in later stages. based on the eruption pattern, upper arch molar teeth erupt distally and buccally whereas in lower arch, it is mesially and lingually which proved that special attention should be given while fabricating the design for this space maintainer.7 however there are some contraindications which should also be taken into consideration. these include, absence of adequate number of abutments (loss of multiple teeth), highly uncooperative child and/or parents, congenital absence of permanent first molar, systemic conditions such as diabetes mellitus which interferes with wound healing and cardiac anomalies which require prophylactic antibiotics regime prior to dental procedure.4 in these conditions, the pediatric dentist is left with only two choices before considering giving this appliance that include: regaining the lost space after the eruption of permanent first molar and the usage of a fixed or removable appliance that neither penetrate the tissues but applies pressure on the ridge immediately mesial to the unerupted permanent first molar.6 the sole purpose of this case report is to describe briefly the clinical management of unilateral extensively carious primary mandibular second molar with a modified distal shoe space maintainer which we named it as “distal pole” appliance fabrication the first step in the appliance fabrication is the appropriate selection of band which can be done directly from the mouth or indirectly after taking an impression followed by cast pouring. in this case we had plans to place the loop component open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.75 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.75&amp;domain=pdf https://orcid.org/0000-0002-8548-0108 https://orcid.org/%200000-0002-4064-7314 https://orcid.org/0000-0003-2397-6965 geeth deepika kottai gandhi et al. asian journal of dental and health sciences. 2024; 4(2):1-4 [2] ajdhs.com to the stainless steel crown since the adjacent tooth was pulpally treated. the loop component in this design consisted of two parts namely horizontal and vertical. horizontal part maintains the mesio-distal dimension of the extracted primary second molar and the vertical part actually serves as a pole of guidance for the erupting permanent first molar. horizontal part of the loop follows the residual alveolar ridge and the vertical part extends into the extracted socket till it reaches 1 mm beyond the mesial marginal ridge of the erupting permanent first molar. the free ends of the loop were then approximated and soldered to the stainless steel crown of adjacent tooth. case report a 5 years old boy reported to my clinic in the month of december 2022 with a chief compliant of pain and frequent swelling in the lower left back region for a brief period of time. he has non-contributory medical history. clinical examination revealed a grossly decayed primary mandibular left second molar and pulpally involved mandibular left first molar. a radiovisiography of the same teeth had been taken which showed the extensively decayed and mesial root resorption in primary second molar and dental caries involving the mesial pulp horn of primary mandibular first molar. (figure 1) we planned to proceed with pulpectomy for primary first molar followed by stainless steel placement and extraction of primary second molar followed by modified dsa which is soldered with ssc of primary first molar. before cementation, a rvg was taken to determine the relationship of intragingival extension with mesial surface of the permanent molar. (figure 2) final cementation is done with type – 1 glass ionomer luting cement (gc fuji, tokyo, japan). (figure 3) post extraction, post cementation and oral hygiene maintenance instructions were given to the patient as well as his parents. recalling and reviewing visits has been given every 3 months to check the integrity of the appliance and the eruption status of permanent molar. follow up after one year showing the ideal eruption of lower left permanent first molar without any clinical signs of mesial drift (figure 4) figure 1: pre-operative radiovisiograph figure 2: immediate post cementation radiovisiography showing the tip of the distal pole just reaching beyond the mesial marginal ridge of unerupted lower left permanent first molar geeth deepika kottai gandhi et al. asian journal of dental and health sciences. 2024; 4(2):1-4 [3] ajdhs.com figure 3: immediate post cementation image figure 4: follow up after one year showing the ideal eruption of lower left permanent first molar without any clinical signs of mesial drift discussion premature loss of multiple primary molars is a potential challenge for the pedodontists to manage and preserve the arch integrity. in this case of premature loss of primary second molar before the eruption of permanent first molar, it is mandatory to provide a distal shoe appliance which serves as a space maintainer as well as guides the eruption. since the conventional distal shoe has its own disadvantages, modified distal shoe has been adopted in this case which favours simple design with minimal adjustment, high stability & strength and patient acceptance. this unilateral modified distal shoe appliance is considered as a short-term appliance for eruption guidance.8 in such situations, if they left untreated, the first permanent molar would definitely migrate mesially and proficient space loss would occur evidently which could possibly result in a need for active therapy. active appliances also have some complications and patients and their parents should have full cooperation. however, it is desirable to have an affordable method that requires a moderate level of patient cooperation geeth deepika kottai gandhi et al. asian journal of dental and health sciences. 2024; 4(2):1-4 [4] ajdhs.com that can guide the eruption of permanent first molars towards their correct position in the dental arch. for this purpose, the use of modified distal shoe appliance would be suggested as the treatment plan. benefitting from the anchorage provided by the remaining teeth in the dental arch, a fixed, bilateral appliance with an intra-alveolar extension was fabricated, which was capable of guiding the eruption of the first permanent molar into its proper position. by placing this appliance, space loss due to mesial drifting of the permanent first molar could be prevented. moreover, this appliance would be more easily tolerated by children due to its fixed nature, simplicity, and optimal stability compared to removable appliances. however, this design has some shortcomings as well, including its difficult fabrication, relatively high cost, and non-functionality.9 in uncooperative children, this appliance is preferred to removable alternatives. modified distal shoe space maintainer is considered a short-term appliance that will be replaced with other appliances depending on the eruption of the first permanent molars and permanent incisors. in contrast to our case, gujjar et al9 & dhindsa and pindat10 used uniform appliances that did not have the potential of chairside adjustability and the whole appliance was fabricated in a laboratory. the current appliance was fabricated by soldering a part of the gerber-type distal shoe to confer chair-side adjustability to the appliance. however, the appliance could be adjusted easier and more precise. movement of the distal blade in the tube enables and ensures the correct position of the intra-alveolar extension of the appliance. following the complete eruption of the first permanent molar or observing any interference with the eruption of permanent incisors, the appliance must be replaced with other types of space maintainers depending on the clinical conditions of patients. research works conducted by anegundi and his colleagues proposed that the horizontal u-loops space maintainers with an extended vertical arm length which can be easily adjustable against the mesial tipping movement of the first permanent molar.11 there are various other studies that have reported many designs of the conventional appliances effectively modified for premature loss of multiple primary molars with inadequate abutments.12,13,14 in our case study, we presented a simple method distal pole being soldered to the stainless steel crown (similar to crown and loop space maintainer) of pulpally treated first primary molar. following which a custom-made stainless-steel wire was used for the horizontal and vertical parts of the distal shoe; moreover, sscs have a perfect contour and shape easily adapts to the anatomy of first primary molars. our case study also showed the healthy gingival tissue around distal shoe appliance and the abutments after more than a year; also the appliance did not intervene or impede the eruption of the first permanent molars. when considering the oral hygiene maintenance after the appliance insertion is of great importance to maintain healthy gingival conditions, especially of the fixed appliance whose vertical arm extends into the gingival tissue. fluoridated toothpaste will greatly help with plaque removal and caries prevention in such kids. an interdental brush or end tuft brush will prove to clean underneath the wires as well as the abutments. parents were equally advised to provide assistance in oral cleaning, especially for young children who are in their developmental stages where their fine motor skills are yet to develop. also, this appliance has an added advantage of fabricating in the same visit as the extraction of the hopeless primary second molar and can be done in a very cost-effective manner compared to other appliances that included lab expenses and frequent visits subsequently. moreover, after the eruption of permanent first molar, conversion of this distal shoe appliance to a band and loop maintainer is quite easy and simple which can be done without the need of local anaesthesia & cumbersome procedures. hence this appliance serves as a valuable and effective asset to the paediatric dentist in space management and eruption guidance. conclusion to conclude, the placement of modified distal shoe appliance preserves the integrity of dental arch and prevents space loss following the early loss of several primary molars in the cases that the use of conventional distal shoe appliance is not possible. however, regular patient follow-ups are critical for the success of this contemporary treatment plan. references 1. gerber we. facile space maintainer. j am dent assoc 1964;69:6914. https://doi.org/10.14219/jada.archive.1964.0387 pmid:14212036 2. croll tp. an adjustable intra-alveolar wire for distal extension space maintenance: a case report. j pedod 1980;4:347-53. 3. croll tp, sexton tc. distal extension space maintenance: a new technique. quintessence int 1981;12:1075-80. 4. hicks ep. treatment planning for the distal shoe space maintainer. dent clin north am 1973;17:135-50. https://doi.org/10.1016/s0011-8532(22)00765-0 pmid:4508940 5. brill wa. the distal shoe space maintainer chairside fabrication and clinical performance. pediatr dent 2002;24:561-5. 6. managing the developing occlusion. in: bell ra, dean ja, mcdonald re, avery dr. mc donald and avery dentistry for the child and adolescent. 9th ed. saint louis: mosby; 2011. 550613. https://doi.org/10.1016/b978-0-323-05724-0.50031-x 7. muthu ms, kumar s. paediatric dentistry: principles and practice. 2nded. elsevier india. 2011. p.312-3. 8. foster td. a textbook of orthodontics. oxford: philadelphia: blackwell; distributed by j.b> lippincott, 1975. 9. gujjar kr, indushekar kr, amith hv, sharma sl. modified distal shoe appliance--fabrication and clinical performance. j dent child (chic). 2012 sep-dec;79(3):185-8. 10. dhindsa a, pandit ik. modified willet's appliance for bilateral loss of multiple deciduous molars: a case report. j indian soc pedod prev dent. 2008 sep;26(3):132-5. https://doi.org/10.4103/09704388.43196 pmid:18923227 11. anegundi r, banerjee s, patil s, trasad v. a modification of distal shoe appliance for premature loss of primary second molarcomparison with willet's appliance: report of four cases. int j pedod rehabil 2019; 4: 84-7. https://doi.org/10.4103/ijpr.ijpr_9_19 12. somwanshi yi, katre an, jawdekar am. modified distal shoe appliance for multiple loss of first and second primary molars. j clin diagn res 2016; 10:zj03-zj4. https://doi.org/10.7860/jcdr/2016/17686.8660 pmid:27891494 pmcid:pmc5121832 13. bhat pk, navin hk, idris m, christopher p, rai n. modified distal shoe appliance for premature loss of multiple deciduous molars: a case report. j clin diagn res 2014; 8: zd43-5. https://doi.org/10.7860/jcdr/2014/9796.4759 pmid:25302284 pmcid:pmc4190811 14. bora a, saha r, datta p, kundu g. bilateral long span fixed distal shoe space maintainer: a case report. int j dent sci innov res2019; 2: 625-29. https://doi.org/10.14219/jada.archive.1964.0387 https://doi.org/10.1016/s0011-8532(22)00765-0 https://doi.org/10.1016/b978-0-323-05724-0.50031-x https://doi.org/10.4103/0970-4388.43196 https://doi.org/10.4103/0970-4388.43196 https://doi.org/10.4103/ijpr.ijpr_9_19 https://doi.org/10.7860/jcdr/2016/17686.8660 https://doi.org/10.7860/jcdr/2014/9796.4759 sun et al asian journal of dental and health sciences. 2023; 3(4):1-3 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited facial nerve paralysis after dental extraction chia earn sun1*, irfan mohamad 2, khairul bariah noh3, fei ming ong 4 1 kpj healthcare university, lot pt 17010, persiaran seriemas utama, kota seriemas, 71800 nilai, negeri sembilan, malaysia. 2 department of otorhinolaryngology, head & neck surgery, school of medical sciences, universiti sains malaysia, kubang kerian, 15200 kota bharu, kelantan, malaysia. 3 department of otorhinolaryngology, head & neck surgery, hospital sultanah bahiyah, km 6, jln langgar, bandar, 05460 alor setar, kedah, malaysia. 4 bagan specialist centre, jalan bagan 1, taman bagan, 13400 butterworth, pulau pinang, malaysia. article info: _____________________________________________ article history: received 06 september 2023 reviewed 09 october 2023 accepted 02 november 2023 published 15 december 2023 _____________________________________________ cite this article as: sun ce, mohamad i, noh kb, ong fm, facial nerve paralysis after dental extraction, asian journal of dental and health sciences. 2023; 3(4):1-3 doi: http://dx.doi.org/10.22270/ajdhs.v3i4.59 abstract _________________________________________________________________________________________________________________ parotitis is inflammation of the parotid gland caused by infection, either virus or bacteria. facial nerve palsy with an associated parotid mass should always be investigated for underlying neoplasm. facial nerve palsy is an unusual symptom of inflammation of the parotid gland. we report two cases of unilateral facial paralysis associated with acute parotitis. the patients experience ipsilateral facial paralysis, accompanied by additional symptoms that varied between cases. infective causes of facial nerve palsy usually have good prognosis. keywords: parotid gland, facial nerve, facial paralysis; parotitis, neoplasm *address for correspondence: chia earn sun, kpj healthcare university, lot pt 17010, persiaran seriemas utama, kota seriemas, 71800 nilai, negeri sembilan, malaysia. introduction facial paralysis due to parotid pathology is almost always associated with malignant lesion of the gland. although there has been reported facial nerve palsy secondary to benign parotid gland pathology such as benign tumours, sarcoidosis and parotid cysts, the incidence of facial nerve palsy secondary to infective pathology of the parotid gland is exceedingly rare1,2. case summary case 1 a 36-year-old gentleman presented with one-week history of right parotid swelling and pain. he also complained of right sided facial nerve palsy for 5 days. he had history of dental procedure done 2 weeks prior to his symptoms. no preceding upper respiratory tract symptoms. he has no odynophagia, dysphagia or respiratory compromise. there was no fever. clinical examination revealed diffuse swelling over right parotid which was erythematous and tender. there was no trismus. intraoral examination was unremarkable. no pus on milking of stenson duct. no medialization of lateral pharyngeal wall. no neck nodes were palpable. there was presence of right-sided facial nerve palsy, with house-brackmann grade iii. other cranial nerves were intact. otoscopy examination were unremarkable. pure tone audiometry showed normal hearing bilaterally. topodiagnostic test revealed absent ipsilateral stapedial reflex, normal schimer test bilaterally. flexible endoscopic examination was unremarkable. a clinical diagnosis of acute right parotitis was made. he was treated with intravenous co-amoxiclav, oral methylcobalamin, tablet prednisolone, artificial eye drops and advised on eye care. right-sided facial swelling and pain resolved in response to antibiotic. he was discharged after 3 days of hospitalization and completed total 10 days of antibiotics and tapering dose of prednisolone. follow-up outpatient visit at one month showed improvement of right sided facial nerve palsy house-brackman grade ii and resolved right parotid swelling. facial nerve palsy resolved completely at subsequent follow-up 6 months post initial presentation. figure 1. right facial nerve palsy at initial presentation. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i4.59 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i4.59&amp;domain=pdf sun et al asian journal of dental and health sciences. 2023; 3(4):1-3 [2] ajdhs.com case 2 a 58-year old gentleman with underlying diabetes mellitus presented with two-day history of right parotid swelling, restricted mouth opening and reduced oral intake. he had a dental procedure done about a week prior to initial presentation. he denied odynophagia, dysphagia or airway symptoms. there was no history of preceding upper respiratory tract infection or fever. initial clinical assessment showed diffuse, tender swelling over right parotid region. overlying skin is warm and erythematous. he also had trismus with mouth opening of one finger-breadth. intra-oral examination revealed bulging of the right peritonsillar region. no neck nodes palpable. further flexible nasopharyngo-laryngoscopy examination showed right peritonsillar bulge with slight extension of the right lateral pharyngeal wall. cranial nerves were intact on initial assessment. otoscopy examination was unremarkable. contrast-enhanced computed topography of the neck revealed small collection inferior to right alveolar process of right maxillary bone, swollen right masseter and right parotid glands. diagnosis of acute peritonsillar abscess with acute parotitis was made. incision and drainage was done over right peritonsillar region, which drained 10cc of pus. pus culture and sensitivity showed mixed growth of 1 gram positive cocci and 2 gram negative rods. he was treated with intravenous cefuroxime and metronidazole. on day 6 of admission, patient developed rightsided facial nerve palsy, house-brackmann grade iii. other cranial nerves were intact. fine needle aspiration cytology done over right parotid swelling showed benign salivary acini, no malignant cell seen. right sided facial swelling and pain resolved with antibiotics, with improved mouth opening and good oral intake. he completed 2 weeks of intravenous antibiotics. he was referred for facial exercises. on his follow-up outpatient visit at one month, right parotid swelling resolved, with persistent right facial nerve paralysis house-brackmann grade ii. discussion inflammation of salivary gland such as parotitis is usually caused by salivary stasis. predisposing factors include sialolithiasis, duct stricture, dehydration, poor oral hygiene, immunosuppression, diabetes mellitus, autoimmune disorders and congenital sialectasis3. in both patients, there was a history of dental procedure prior to presentation, suggesting dental origin of infection. poor oral hygiene was predisposing factors in both patients. index patient in the second case had underlying diabetes mellitus. acute suppurative sialadenitis commonly involved the parotid glands as the serous property of the saliva has less antimicrobial activity, as compared to the mucinous saliva of the submandibular gland. common organisms that are responsible for sialadenitis include staphylococcus aureus followed by streptococcus viridans, and anaerobes4. in the second case, pus culture showed mixed growth of a grampositive cocci and 2 gram negative rods. majority of the patient presented with acute onset of local pain and swelling, erythema, trismus, usually accompanied by fever, malaise and poor oral intake. clinical examination will reveal tenderness, warmth and induration of the overlying skin. in parotid abscess, fluctuancy may not be elicited due to the overlying capsule formed by the fascia superficial to it1. bimanual palpation occasionally demonstrates pus from stenson duct opening4. in the first case, the patient came with typical presentation of right acute parotitis with involvement of facial nerve, which was unusual. both parotid swelling and facial paralysis responded well to antibiotics. the second patient presented with acute right peritonsillar abscess with inflammation of ipsilateral parotid gland. facial paralysis developed later at day 6 of admission. fine needle aspiration was thus essential to exclude possibility of parotid neoplasm, in which cytology revealed benign salivary acini. computed tomography did not show parotid neoplasm. facial nerve palsy secondary to parotitis is extremely rare. in cases where facial nerve palsy is associated with parotid pathology, malignant neoplasm of the gland has to be highly suspicious especially high grade mucoepidermoid carcinoma and adenoid cystic carcinoma of parotid because of perineural invasion4. other than that, benign conditions of the parotid gland such as warthin tumour, and sarcoidosis has also been shown to affect the facial nerve3. the etiology of facial nerve paralysis in acute parotitis remains unknown. involvement of the facial nerve has been suggested to be secondary to compression of the seventh nerve in association with local inflammation; perineuritis due to the virulence of the offending organisms or ischemic neuropathy arising from the local toxic effects of infection1,2,5. clinical approach should begin with a full history and clinical examination. detailed examination of the head and neck and cranial nerves should be done to exclude any malignancy. acute signs of infection such as redness, tenderness and warmth with documented fever should be treated with intravenous antibiotics. if there is a purulent discharge, swab for culture and sensitivity has to be taken to determine the offending organism and its antibiotic sensitivity. for our second patient, pus culture grew mixed growth of 1 gram positive and 2 gram negative rods. other adjuvant measures include sialogouges, hydration and good oral hygiene are advocated3 when diagnostic doubt exists, patients should be investigated for an underlying neoplasm. imaging is indicated in patients who do not respond to medical therapy or if there is suspicion of underlying malignancy4. ultrasound scan is the initial imaging modality of choice for the assessment of parotid gland, as it is able identify any collection, mass or calculi; and will be able to detect features of malignant lesion such as irregular shape, speculated or ill-defined margin, heterogeneous echotexture, punctate calcification and vascularization6. further imaging modalities such as ct (computed tomography) or mri (magnetic resonance imaging) will be needed if there is further suspicion of malignancy to see the extension of tumour, any nodal metastasis and for staging purpose. further evaluation of a parotid mass can be done by means of fine needle aspiration, biopsy or histological evaluation of the mass by surgical excision4. in our cases, the patient responded to initial medical treatment and the parotid swelling resolved rapidly. the first patient showed complete resolution of facial paralysis. as for the second patient, further follow-up visit at one month showed persistent facial nerve paralysis despite resolution of his right parotid swelling. conclusion facial nerve palsy accompanying benign parotid pathology is uncommon. acute parotitis causing facial nerve palsy is even rare. in cases of facial nerve palsy associated with parotid swelling, malignancy has to be excluded. infective causes of facial nerve palsy have a good prognosis, with likely resolution of the facial nerve palsy. conflict of interest: there is no conflict of interest in this work. sun et al asian journal of dental and health sciences. 2023; 3(4):1-3 [3] ajdhs.com patient’s consent: verbal consent was obtained from patient in agreement of data publication. what is new in this case report compared to previous literature? parotitis/ infective pathology is an unusual cause of facial nerve palsy. we highlighted the possibility of dental origin of infection progressing to involve parotid and other neck spaces. learning points and implications to patients full examination of the head and neck and relevant investigations must be undertaken to rule out the possibility of malignancy. management of patient should be focused on treating the underlying cause to reduce perineural inflammation. references 1. mohamad i, ahmad mz, mohamad h. parotid abscess with facial nerve paralysis in a young healthy female. bangladesh j otorhinolaryngol. 2011;17(2):147149. https://doi.org/10.3329/bjo.v17i2.8858 2. alam m, hasan s, hashmi s, singh p. facial palsy due to parotid abscess: an unusual complication. turk arch otorhinolaryngol. 2017;54(4):168-171. https://doi.org/10.5152/tao.2016.1671 3. lowe e, singh c, birdi s. what lies beneath a facial nerve palsy? case report of a facial palsy caused by non-suppurative parotitis. case studies in surgery. 2016;2(4):17-21. https://doi.org/10.5430/css.v2n4p17 4. hajiioannou j, florou v, kousoulis p et al. reversible facial nerve palsy due to parotid abscess int j surg case rep. 2013;4(11):10211024. https://doi.org/10.1016/j.ijscr.2013.08.016 5. pitz cc, duurkens va, goossens dj, et al. tetraplegia after a tracheal resection procedure. chest. 1994;106(4):1264-5. https://doi.org/10.1378/chest.106.4.1264 6. wu s, liu g, chen r, guan y. role of ultrasound in the assessment of benignity and malignancy of parotid masses. dento maxillo facial radiology. 2012;41(2):131–135. https://doi.org/10.1259/dmfr/60907848 https://doi.org/10.3329/bjo.v17i2.8858 https://doi.org/10.5152/tao.2016.1671 https://doi.org/10.5430/css.v2n4p17 https://doi.org/10.1016/j.ijscr.2013.08.016 https://doi.org/10.1378/chest.106.4.1264 https://doi.org/10.1259/dmfr/60907848 ezema et al asian journal of dental and health sciences. 2023; 3(2):32-36 [32] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited evaluation of biochemical parameters of patients with type 2 diabetes mellitus based on age and gender in umuahia godfrey ogochukwu ezema1, ndukaku yusuf omeh1, simeon egbachukwu1, ejiofor c. agbo2, adachukwu pauline ikeyi3 and emmanuel ifeanyi obeagu4* 1 department of biochemistry, michael okpara university of agriculture, umudike, abia state, nigeria. 2 department of medical laboratory services, federal medical centre, umuahia, abia state, nigeria. 3 department of science technology, institute of management and technology, enugu, nigeria. 4 department of medical laboratory science, kampala international university, uganda. article info: _______________________________________________ article history: received 07 april 2022 reviewed 11 may 2023 accepted 27 may 2023 published 15 june 2023 ________________________________________________ cite this article as: ezema go, omeh ny, egbachukwu s, agbo ec, ikeyi ap, obeagu ei, evaluation of biochemical parameters of patients with type 2 diabetes mellitus based on age and gender in umuahia, asian journal of dental and health sciences. 2023; 3(2):32-36 doi: http://dx.doi.org/10.22270/ajdhs.v3i2.43 ____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda email: emmanuelobeagu@yahoo.com abstract ________________________________________________________________________________________________________________ diabetes mellitus is a major public health issue. the study was done to determine the changes in some biochemical parameters between type 2 diabetes mellitus patients and apparently healthy adults in umuahia. the fasting blood glucose was significantly higher in females than in males in the diabetic population. the table revealed a significantly (p<0.05) higher levels of serum total cholesterol, trialytglycerol, ldl-cholesterol, in females than males, except low hdl cholesterol (p<0.05) compared to male matched patients. glycated haemoglobin was significantly (p<0.05) higher in female than male. creatinine was significantly (p<0.05) higher in male. urea was also significantly (p<0.05) higher in female. potassium was significantly (p<0.05) higher in females. bicarbonate was significantly (p<0.05) lower in female.the study showed a significantly (p<0.05) higher levels of total cholesterol, trialyglycerol, ldlcholesterol in patient’s aged between 5774years, except low hdl-cholesterol (p<0.05) compared to those aged between 40-56years. fasting blood glucose and hbaic were significantly (p<0.05) higher in age limit 57-74years than 40-56years. urea and creatinine were significantly (p<0.05) low in patients aged 57-74years when compared to age 40-56years. however, hdl concentration was significantly (p<0.05) high in the 40-56years when compared to 57-74years.elevated levels of triglyceride (tg), total cholesterol (tc), and glycated haemoglobin (glyc.hb) and reduced levels of hd. keywords: type 2 diabetes mellitus, lipid profile, kidney function, liver function, glycated haemoglobin, fasting blood sugar. introduction diabetes mellitus (dm) is a group of metabolic diseases characterized by high blood glucose. it is a carbohydrate metabolic disorder characterized by elevated blood glucose 1-4. frequently it is a consequence of deficient insulin secretion, insensitivity or both 5. in 2013, the global estimate of diabetics was about 382 million, amounting to a prevalence of 8.3%. north america and the caribbeans had the higher prevalence of 11% or 37 million people with diabetes, followed by the middle east and north africa with a prevalence of 9.2% or 35 million diabetics 6. the incidence of known cases as reported is essentially the same for men and women except among the elderly and generally increases with age. the prevalence of diabetes rises from about 6% in people aged 45-64years to 12% in those aged 65years and above 7. in the older group, more women than men are diagnosed with disease each year, with relatively higher risk in non-whites 8. three million two hundred thousand diabetes related deaths are reported annually, 8,700 deaths per day or 6 deaths each minute 8. in the african continent, prevalence was estimated to be 3 million in 1994 and 7.1 million in 2000. this figure is expected to rise by 2030 to 18.6 million 6. the prevalence of 23.4% was reported among oil workers in port harcourt nigeria 9. diabetes as one of the five leading causes of death in most countries poses financial implication on the sector and patients. world health organization (who) estimated that as at 2007 diabetes alone accounted for $215-375 billion on cost 7. diabetes mellitus can be classified into 3 broad groups namely; type 1 diabetes mellitus (formally called insulin dependent diabetes mellitus, iddm) characterized by lack of insulin production due to autoimmune destruction of pancreatic beta cells and constitute 5-10% of cases. type 2 (formally called non-insulin dependent diabetes mellitus, niddm) is characterized by impaired insulin action which accounts for 90-95% of diabetes mellitus 10. the third category gestational diabetes is a form of glucose intolerance during pregnancy which resolves after the mother has given birth 11. diabetes can be associated with many complications. nephropathy, neuropathy, retinopathy and cardiovascular diseases which are the most commonly encountered episodes 12. type 2 diabetes, the most common type is characterized by disorder of insulin resistance and insulin secretion, either of which may be the predominant feature. the important point is that insulin secretion does not cease when the disease develops but may be inadequate for the purpose for which it is secreted. there is usually too much glucose to be metabolized for the amount of insulin present. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i2.43 mailto:emmanuelobeagu@yahoo.com https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i2.43&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 ezema et al asian journal of dental and health sciences. 2023; 3(2):32-36 [33] ajdhs.com materials and methods sample collection and processing the blood samples were collected in the morning from subjects after overnight fasting from the left or right superficial vein of median cubital vein at cubital fossa by vein puncture. a tourniquet was applied at mid upper arm. the area of the suitable vein was cleansed with cotton wool soaked in 70% alcohol. a ten-milliliter syringe with needle was used. nine milliliters of blood samples were collected from both the diabetic patients and control subjects and dispensed into the separate test tubes. an aliquot (2ml) of each sample was taken into a fluoride oxalate test tube for fasting blood glucose. a volume (7ml) of each sample was taken into a plain test tube for electrolytes, urea and creatinine(s/e/u/cr) and lipid profiles estimations. each sample bottle was labeled with the subject’s/patient’s name, date and serial number, placed mouth up in a rack and stored in freezer until used. the blood samples for s/e/u/cr and lipid profiles were allowed to clot at room temperature and centrifuged at 1,500 revolutions per minute (rpm) for 5 minutes to separate the serum from whole blood. estimation of plasma glucose plasma glucose was estimated by the glucose oxidaze method described by trinder (1969). the reagent kit used was manufactured by randox laboratories limited ardmore, diamond road, united kingdom. procedure test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter of glucose reagent was dispensed into each tube. ten microliters each of distilled water, standard, plasma and control were dispensed into the respective tubes. the contents of each tube were properly mixed and incubated for 10 minutes at room temperature. the absorbances of the standard, test and control were read on a spectrophotometer against a reagent blank at 540 nm within 30 minutes. estimation of glycated haemoglobin glycated hemoglobin was measured using nyocardhbalcboronate affinity assay method described by jeppson et al. (2002). procedure the reagent i (ri) was equilibrated at room temperature before use. five micro liters (5ul) of whole blood was added to the test tube with 20ul ri/reagent. it was wellmixed and then incubated for 2 minutes. it was then mixed to obtain a homogenous suspension twenty-five micro liters (25ul) of the reaction mixture was applied to a test device (td) by holding the pipette approximately 0.5cm above the test well. the content of the pipette was then emptied quickly into the middle of the test well. the reaction mixture was allowed to soak completely into the membrane. twenty-five (25ul) microliters of the washing solution/reagent 2 mixture were applied to the test device (td). the washing solution was also allowed to soak completely into the membrane by allowing it to stand for ten minutes. the test result was read within five minutes using the nycocard reader ii. estimation of serum sodium serum sodium was estimated by colorimetric method of henry et al. (1974). the reagent kit was manufactured by obour industrial company, cairo, egypt. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter of sodium reagent was dispensed into each tube. ten microliters (10ul) each of standard, serum and control was dispensed into the respective tubes. the contents of each tube were thoroughly mixed and incubated at room temperature for 5 minutes and the absorbance of the standard, test and control samples read against reagent blank on a spectrophotometer at 630nm. estimation of serum potassium serum potassium was estimated by the turbidimetrictetra pheylborate (tpb) method hillman (1967). the reagent kit was manufactured by obour industrial company, cairo, egypt. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter of potassium reagent was dispensed into each tube. twenty microlitres (20ul) of standard, sample and control were dispensed into the respective reaction tubes. the contents of each tube were thoroughly mixed and incubated at 370c for 3minutes and their absorbances read against reagent blank at 578nm. estimation of serum chloride serum chloride was estimated by the mercuric chloride method of schonfeld [13]. the reagent kit was manufactured by agape diagnostics, switzerland. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter of chloride reagent was dispensed into each tube. tenmicrolitres (10ul) of standard, sample and control were dispensed into the respective reaction tubes. the contents of each were thoroughly mixed and incubated at 37 c for a minute and their absorbances read against reagent blank at 505nm. estimation of serum bicarbonate serum bicarbonate was estimated by spectrophotometric method of norris [14]. the reagent kit was manufactured by chema diagnostica monsano-italy. procedure clean test tubes were placed in a rack and labeled blank, standard, test and control respectively. one milliliter of bicarbonate reagent was dispensed into each tube. ten microlitres (10ul) each of water, standard, serum and control were dispensed into the respective reaction tubes. the contents of each tube were thoroughly mixed and incubated at 37 c for 2 minutes. estimation of serum creatinine serum creatinine was estimated by the buffered kinetic jaffe reaction without deproteinization method of bowers and wong 15. the reagent kit was manufactured by obour industrial company cairo, egypt. creatinine clean tubes were placed in a rack and labelled standard, test and control respectively. one milliliter of creatinine reagent was dispensed into each tube. one hundred microlitres (100ul) each of standard, test and control reagents were dispensed into the respective tubes. the contents of each tube were properly mixed. after 30 seconds, the respective ezema et al asian journal of dental and health sciences. 2023; 3(2):32-36 [34] ajdhs.com absorbances (ai) of the standard, test and control tubes were read. exactly 2 minutes later, the absorbances (a2) of the standard, test and control tubes respectively were read again. a2-a1=a specimen or a standard estimation of serum urea serum urea was estimated by the urease method of wheatherburn 16. the reagent kit was manufactured by chema diagnostica, italy. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter of urea reagent a was dispensed into each test tube. ten microlitres (10ul) each of distilled water, standard, test control was dispensed into the respective tubes. the contents of each tube were thoroughly mixed and incubated at 370c for 5 minutes. next, one milliliter of urea reagent b was dispensed into the each of the tubes. the contents were mixed and incubated at 370c for 5 minutes. the absorbances of the standard (ac), test(ax) and control(av) were read against a reagent blank at 600nm. estimation of serum cholesterol serum cholesterol was estimated by the cholesterol oxidase peroxidase method of arntz 17. the reagent kit was manufactured by agape diagnostics, switzerland. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter (1ml) of cholesterol working reagent was dispensed into each tube. ten microlitres (10ul) each of standard, test and control reagent was dispensed into the respective tubes. the contents were mixed and incubated for 5minutes at 37˚c. the absorbance of each tube was read at 540nm against a reagent blank. cholesterol cone (mg/dl)= absorbance of test or control ×200 absorbance of standard estimation of serum triacylglycerol serum triacylglycerol was estimated by the glycerol -3 phosphate oxidase-tops method of schettler and nussel(1975). the reagent kit was made by agape diagnostics, switzerland. procedure clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one milliliter (1ml) of triacylglycerol reagent was dispensed into each tube. ten microliters(10ul) of standard, test and control reagents were dispensed into each tube mixed and incubated for 5 minutes at 370c. change in absorbance was measured at 546nm against a reagent blank for each sample. estimation of hdl-cholesterol serum hdl –cholesterol was estimated by the precipitation. the reagent kit was made by agape diagnostics, switzerland procedure 1. precipitation clean test tube was placed in a rack and 30ul of hdl reagent and 30ul of test sample added to the tube. the content was mixed, well, allowed to stand for 10 minutes at room temperature, mixed again and centrifuged for 10 minutes at 4000 rpm. after centrifugation, the clear supernatant was separated from the precipitate within one hour using a pasteur pipette. hdl cholesterol concentration was determined using cholesterol reagent. 2. hdl cholesterol determination three clean test tubes were placed in a rack and labelled blank, standard, test and control respectively. one thousand microliters (1000ul) of cholesterol reagent were dispensed into each tube. fifty mircoliters (50ul) of hdl standard and the hdl supernatant were dispensed into standard and test tubes respectively. the contents were mixed incubated for 5 minutes at 37c. the absorbances of the standard and test samples were measured at 630nm against a reagent blank. statistical analysis the data generated were analyzed using statistical software spss version 16.0. students ttest was used for analysis of difference between means for two groups at p<0.05 level of significance. pearson correlations were conducted to determine associations among different variables. result biochemical parameters between males and females in table 1, fasting blood glucose was significantly higher in females than in males in the diabetic population. the table revealed a significantly (p<0.05) higher levels of serum total cholesterol, trialytglycerol, ldl-cholesterol, in females than males, except low hdl cholesterol (p<0.05) compared to male matched patients. glycated haemoglobin was significantly (p<0.05) higher in female than male. creatinine was significantly (p<0.05) higher in male. urea was also significantly (p<0.05) higher in female. potassium was significantly (p<0.05) higher in females. bicarbonate was significantly (p<0.05) lower in female. table 1: comparing the biochemical parameters between males and females treatments male female sodium 144.23±47.34 123.08±32.11 fbs 129.54±10.73 133.71± 9.42 potassium 3.95 ± 5.71 4.53± 0.60 chloride 87.50± 9.58 90.33± 9.90 bicarbonate 21.50± 3.35 22.25± 3.19 urea 32.6923 ± 14.33532 29.1250 ± 14.02579 creatinine 0.85± 0.26 0..89± 0.21 total cholesterol 210.77±24.09 191.92±30.15 high density lipoprotein 41.62± 8.23 46.21± 14.26 tg 134.54±21.99 140.08±26.02 glycated haemoglobin 6.54± 0.54 6.49± 0.64 ldl 136.58±25.88 114.10±41.64 ezema et al asian journal of dental and health sciences. 2023; 3(2):32-36 [35] ajdhs.com table 2: comparing of biochemical parameters between age ranges 57-74 years and 4056 years age 57 – 74 years 40 – 56 years bicarbonate 21.86 ± 3.65 21.86 ± 2.8 sodium 128.92 ± 16. 28 132.24 ± 6.91 potassium 4.88 ± 0.70 4.70 ± 0.57 chloride 87.86 ± 11.02 89.06 ± 9.33 fbs 160.38 ± 59.14 127.68 ± 27.89 urea 33.79 ± 20.48 30.72 ± 13.33 creatinine 0.93 ±0. 27 0.86 ±0. 24 cholesterol 205.58 ± 32.02 202.50 ± 33.74 hdl 43.19 ± 11.45 45.43 ± 12.38 tg 151.43 ± 35.29 146.11 ± 19.85 hba/c 6.64 ± 53 6.47 ± 0.61 ldl 126.9429 ± 38.82065 124.9806 ± 39.92871 table 2 showed a significantly (p<0.05) higher levels of total cholesterol, trialyglycerol, ldlcholesterol in patient’s aged between 57-74years, except low hdl-cholesterol (p<0.05) compared to those aged between 40-56years. fasting blood glucose and hbaic were significantly (p<0.05) higher in age limit 57-74years than 40-56years. urea and creatinine were significantly (p<0.05) low in patients aged 5774years when compared to age 40-56years. however, hdl concentration was significantly (p<0.05) high in the 4056years when compared to 57-74years. result for hbaic showed an increase in 57-74years when compared to the 40-56years group. discussion in this study, fasting blood glucose was significantly higher in females than in males in the diabetic population. this may be as a result of the fact that after menopause, there is loss of ovarian function. this results in adverse changes in glucose and insulin metabolism 18. nutrition may also be a contributory factor of higher glucose levels in females. females have a higher body mass index than males. the results revealed a significantly (p<0.05) higher levels of serum total cholesterol, triacylglycerol, ldl-cholesterol, in females than males, except low hdlcholesterol (p<0.05) compared to male matched patients. the higher prevalence of hyperlipidaemia in females was due to their higher body mass index. a number of changes occur in the lipid profile after menopause 19. lack of estrogen is an essential factor in this mechanism. a part from maintaining friendly lipid profile, estrogen change vascular tone by increasing nitric oxide production. glycated haemoglobin was significantly (p<0.05) higher in female than male. bicarbonate was significantly (p<0.05) lower in female and male. this may be due to hormonal changes which lead to increased cardiovascular risk 19. this study observed a significantly (p<0.05) higher levels of total cholesterol, trialyglycerol, ldlcholesterol in patient’s aged between 57-74years, except low hdl-cholesterol (p<0.05) compared to those aged between 40-56years. this may be due to hormonal changes and aging. fasting blood glucose and hbaic were significantly (p<0.05) higher in age limit 5774years than 40-56years. the ensuing hyperglycernia lead to increase protein glycation hence high levels of glycated haemoglobin serum 20. the increased levels may be due to diminishing body function because of aging. urea and creatinine were significantly (p<0.05) low in patients aged 57-74years when compared to age 40-56years. this can be attributed to the rapid break down of proteins during aging. also, consulting the activity of muscle mass, the concentration of creatinine may be affected. generally, in diabetic conditions, high level of cholesterols is observed. from the result obtain from this study, cholesterol concentration was significantly (p<0.05) higher in the 5774years group when compared to the 40-56years. this can be attributed to reduction in physical activity in aged patients and also the impairment in her to carry out its metabolic function during aging. tg and ldl were also high in the 57-74 years when compared to the 40-56years and this corroborated on result for total cholesterol. however, hdl concentration was significantly (p<0.05) high in the 40-56years when compared to 57-74years. hdl has been reported to transport cholesterol, from the walls of the artery to the heart degradation. the increase in hdl in the 4056years group can be attributed to high physical activities and also proper functioning of the liver. diabetic complication may increase as aging progresses. result for hbaic showed an increase in 57-74years when compared to the 40-56years group. as diabetes progresses, hyperlipidemia or hypercholesteronaemia may set in. increase in cholesterol concentration is related to the onset of obesity. from the result of the study, cholesterol concentration was higher in the older patients. obesity has been linked to the increase in hbaic and this was ending net in our study. difference in electrolytes in the study can be attributed to the psychological change that is bond to occur during aging and also membrane disorder associated with aging. diabetes is a group of conditions linked by an inability to produce enough insulin and/or to respond to insulin. this causes high blood glucose levels (hyperglycemia). diabetes mellitus (dm) is a group of metabolic disorders characterized by a chronic hyperglycaemic condition resulting from defects in insulin secretion, insulin action or both. permanent neonatal diabetes is caused by glucokinase deficiency, and is an inborn error of the glucose-insulin signaling pathway 8. the estimated worldwide prevalence of diabetes among adults in 2010 was 285 million (6.4%) and this value is predicted to rise to around 439 million (7.7%) by 2030 11. the body tries to rid the blood of excess glucose by flushing it out of the system with increased urination. this process can cause dehydration and upset the body’s electrolyte balance as sodium, potassium is lost in the urine. the statistical result above (bar chart), compares the lipid profile and kidney function parameters in diabetic and normal patients. a sharp increase in fasting blood sugar is seen in diabetic patients (test group) compared with non-diabetic patients (control group). this is as a result of the body not being able to process glucose, the body’s primary energy source, effectively. normally, after meal carbohydrates are broken down into glucose and other simple sugars. this causes blood glucose levels to rise and stimulates the pancreas to release insulin ezema et al asian journal of dental and health sciences. 2023; 3(2):32-36 [36] ajdhs.com into the blood stream. the basic effect of insulin lacks or insulin resistance on glucose metabolism is to prevent the efficient uptake and utilization of glucose by most cells of the body, except those of the brain 6. conclusion elevated levels of triglyceride (tg), total cholesterol (tc), and glycated haemoglobin (glyc.hb) and reduced levels of hdl with either normal or elevated levels of ldl compared with non-diabetic patients was noted. references 1. okafor cj, yusuf sa, mahmoud sa, salum ss, vargas sc, mathew ae, obeagu ei, shaib hk, iddi ha, moh'd ms, abdulrahman ws. effect of gender and risk factors in complications of type 2 diabetic mellitus among patients attending diabetic clinic in mnazi mmoja hospital, zanzibar. journal of pharmaceutical research international. 2021; 33(29b):67-78. https://doi.org/10.9734/jpri/2021/v33i29b31591 2. obeagu ei, obeagu gu. utilization of antioxidants in the management of diabetes mellitus patients. j diabetes clin prac. 2018; 1(102):2. 3. obeagu ei, okoroiwu il, obeagu gu. some haematological variables in insulin dependent diabetes mellitus patients in imo state nigeria. int. j. curr. res. chem. pharm. sci. 2016; 3(4):110-7. 4. albert k, zimmet pz. for the who consultation. definition, diagnosis and classification of diabetes mellitus and its complications. diabetic medicine. 2003; 15:539-553. https://doi.org/10.1002/(sici)10969136(199807)15:7<539::aid-dia668>3.0.co;2-s 5. trinder p. determination of glucose in blood using oxidase with an alternative oxygen acceptor. annual clinical biochemistry. 1999; 6:24-27. https://doi.org/10.1177/000456326900600108 6. international diabetes federation (2007). diabetes atlas: idf brussels in diabetes mellitus. 7. world health organization. the global burden: diabetes and impaired glucose tolerance.2007. 8. singh r, fisch g, teague b. prevalence of impaired glucose tolerance among children and adolescents with marked obesity. new england journal of medicine. 2003; 346:802810. https://doi.org/10.1056/nejmoa012578 9. nwafor a, owhoji a. prevalence of diabetes mellitus among nigerian in port harcourt, journal of applied science and environmental management. 2001; 5 (1):75-77. https://doi.org/10.4314/jasem.v5i1.54950 10. winter we. type 2 diabetes mellitus. in burtis, c. a. & ashwood, e. r. (eds). tietz textbook of clinical chemistry and molecular diagnostic, 5th ed. (pp. 570-577). philadelphia: w.b. saunders. 2010. 11. caroline d, clifford jb. obesity in the pathogenesis of type 2 diabetes. 2011. 12. michael jf. microvascular and macrovascular complications of diabetes. clinical diabetes. 2008; 26(2):77-82. https://doi.org/10.2337/diaclin.26.2.77 13. schonfield rg, lowellen cs. clinical chemistry. 1968; 10:533 14. norris ka, atkinsoon ar, smith wg. clinical chemistry. 1975; 21:10931101. https://doi.org/10.1093/clinchem/21.8.1093 15. bowers ld, wong et. a critical evaluation and review clinical chemistry. 1980; 26:555. https://doi.org/10.1093/clinchem/26.5.555 16. wheatherburn mw. analytical chemistry. 1967; 39:971. https://doi.org/10.1021/ac60252a045 17. arntz hr. diagnostic hyperlipoproteinaemia. 1979; 3:177 18. warran jh, martin bc, krowlewski as, soeldner js, kahn c. slow glucose removal rate and hyperinsulinaemia precede the development of type 2 diabetes in the offspring of diabetic parents. annals of internal medicine. 2010; 113:909-915. https://doi.org/10.7326/0003-4819-113-12-909 19. stevenson jc, crook ja. influence of age and menopause on serum lipids and lipoproteins in healthy women. 2013. 20. wokoma fs. diabetes and hypertension in africaan overview, diabetes international. 2002; 12(2):36-37. https://doi.org/10.9734/jpri/2021/v33i29b31591 https://doi.org/10.1002/(sici)1096-9136(199807)15:7%3c539::aid-dia668%3e3.0.co;2-s https://doi.org/10.1002/(sici)1096-9136(199807)15:7%3c539::aid-dia668%3e3.0.co;2-s https://doi.org/10.1177/000456326900600108 https://doi.org/10.1056/nejmoa012578 https://doi.org/10.4314/jasem.v5i1.54950 https://doi.org/10.2337/diaclin.26.2.77 https://doi.org/10.1093/clinchem/21.8.1093 https://doi.org/10.1093/clinchem/26.5.555 https://doi.org/10.1021/ac60252a045 https://doi.org/10.7326/0003-4819-113-12-909 pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [26] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited factors contributing to sleep disorders among young adults pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 07 april 2024 reviewed 10 may 2024 accepted 02 june 2024 published 15 june 2024 _____________________________________________ cite this article as: dave p, factors contributing to sleep disorders among young adults, asian journal of dental and health sciences. 2024; 4(2):26-31 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.76 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ sleep disorders are increasingly being reported among young adults. the recent gallup survey is an indication of the magnitude of the problem more so among young americans. sleep is important for good health and well-being. different studies have shown the negative effects of sleep disorders on overall health and well-being. sleep deprivation and disorders increase the risk of depression and anxiety. it also increases the risk of diabetes, obesity, hypertension, and heart attack. sleep disorders occur because of a number of factors including psychosocial stressors, chronic pain, caffeine intake, smoking, lack of physical activity, poor sleep environment, use of screens before bedtime, and alcohol consumption. these factors are prevalent among the youth which explains the increased risk of sleep disorders in this population. addressing sleep disorders is vital because they are associated with poor functioning. individuals who report sleep disorders tend to have lower work productivity, increased risk of accidents, and poor health. lifestyle modifications can help to address the growing problem of sleep disorders among young adults. keywords: sleep disorders, insomnia, obstructive sleep apnea, sleep deprivation, daytime sleepiness introduction although it is an area that is still greatly understudied, research on sleep disorders has been gaining traction because more and more people are reporting the problem and the impact it is having on their health and overall well-being. sleep disorders cause a lot of distress to individuals affected affecting key aspects of their lives including health, work, productivity, and social life.1 although sleep disorders can occur at any age, they are very common among young adults, with one study showing that one in every five young adults suffered from one sleep disorder or another.2 some of the common sleep disorders that are reported among young adults are chronic insomnia, severe obstructive sleep apnea, restless legs syndrome, and narcolepsy. addressing sleep disorders is very important. different studies have linked sleep disorders to mental health problems and chronic conditions including depression, anxiety, obesity, hypertension, and cardiovascular conditions.3,4,5,6,7 in addition to mental health problems, sleep disorders affect work productivity.8 some studies have linked sleep disorders to poor outcomes in diseases such as hypertension, diabetes, and heart disease.9,10,11 this means that sleep deprivation increases the risk of morbidity and mortality from these conditions. other studies have linked sleep disorders to increased safety incidents at work, on the road, and increased absenteeism.8,12,13 addressing sleep disorders is paramount. with projections showing that sleep disorders are likely to increase in the coming decades, more negative impacts of these disorders on overall health and well-being are expected. factors such as psychosocial stressors, smoking, lack of physical activity, and alcohol consumption are some of the factors that contribute to sleep disorders such as chronic insomnia among young adults.14 besides, the modern lifestyle is contributing to a lack of sleep. for instance, people are getting busier with work finding little time to rest because of taking more shifts. also, the use of phones among young people during bedtime is contributing to increasing cases of sleep disorders.15 therefore, ensuring young adults get the right amount of sleep on a regular basis is vital for their overall health, productivity, and wellbeing. the aim of this review is to investigate the factors that contribute to sleep disorders among young adults. the review will also explore the impact of these disorders on different aspects of life, and measures that can be taken to address this problem. prevalence of sleep disorders in the us although the american academy of sleep medicine and the sleep research society recommend at least 7 hours of sleep every night for adults, more than one-quarter of the adult population do not meet this sleep recommendation. adults are the most affected by lack of adequate sleep with 13.5% reporting feeling tired or exhausted most of the days.16 additionally, in 2020, 14.5% of adults reported that they had trouble sleeping most of the days in the last 30 days.17 according to a 2022 gallup survey, a quarter of american adults (33%) which is about 84 million people report having poor or inadequate sleep.18 among these, young adults under the age of 30 report struggling with sleep and sleep-related stress. another nationally representative study involving 9,004 adults also reported similar findings. of the 9,004 adults, 30.5% reported at least one hour of sleep deficit while another 46.5% reported one hour or more of social jet lag.19 furthermore, 29.8% reported having trouble sleeping and another 27.2% reported daytime sleepiness.19 open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.76 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.76&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [27] ajdhs.com in addition to inadequate sleeping hours and trouble falling asleep, sleep disorders are also a prevalent issue affecting millions of adults in the us.16 approximately, 30% of american adults reported that they had symptoms of insomnia.16 another 9% to 385 of the general population reported that they were suffering from sleep apnea.16 of the people who reported experiencing insomnia, 10% reported that insomnia affected their daily activities.16 other sleep disorders that affect american adults are restless leg syndrome which affects about 2 to 7.2% of the population, narcolepsy which affects 0.02 to 0.04% of the population, and hypersomnolence (also known as excessive sleepiness) which affects 5 to 10% of the general population.16 the extent of sleep disorders among americans is documented in a study by acquavella et al.20 the study reports that the number of americans who seek care for sleep disorders almost doubled between 2013 and 2016.20 the study reported that for 100,000 people who sought treatment for narcolepsy, the rates increased from 38.9% in 2013 to 44.3% in 2016.20 for obstructive sleep apnea, the numbers increased by 41%.20 increases were also reported for rapid periodic limb movement, rapid eye movement, and idiopathic hypersomnia.20 the increment in healthcare utilization and expenditure for sleep disorders is also proof that the number of americans struggling with sleep disorders is increasing.21 when it comes to sociodemographic factors, adults aged 18 to 44 years are more likely to report having difficulty falling asleep. this group accounted for the highest number of those who reported getting fewer hours of sleep than recommended and also trouble falling asleep at 38.3% and 15.5% respectively.16,17 the percentage of adults who had trouble sleeping decreased with age with adults aged 18 to 44 being the most affected and those 65 years and older being the least affected.17 young adults particularly those under the age of 30 reported having greater struggle with sleep which was mostly attributed to stress. they also reported that lack of adequate sleep had an impact on their lives more so their mood. with regard to gender, women are more likely to report struggling with sleep than men 17% and 12% respectively.18 in terms of race, non-hispanic white adults were also more likely to report having trouble sleeping than non-hispanic blacks, hispanics, and non-hispanic asians.17 socioeconomic status and urbanization level are also determinant factors when it comes to sleep difficulties. family income was a determinant factor when it came to sleep difficulties with the percentage of those who reported trouble sleeping reducing with increasing family income.17 in terms of urbanization, the number of adults who reported having trouble sleeping decreased as the place of residence became more urban. those in rural or non-metropolitan areas were more likely to report trouble sleeping at 22.4% compared to 14.4% in large metropolitan areas.17 although more than half of the american population cite sleep as a priority, most report having trouble sleeping or poor quality of sleep. based on the statistics above, sleep quality remains a prevalent issue for most americans with the number of sleep disorders projected to rise in the coming years. young adults are one of the population groups that is affected by sleep disorders with most citing factors such as work, stress, longterm health conditions, mental activity, and poor mental health as some of the factors that affect sleep and sleep quality.18 addressing the root causes of sleep disorders can help to address the problem and improve the quality of sleep among young adults. factors contributing to sleep deprivation and disorders sleep deprivation and disorders are attributed to a number of factors. one of these factors is stress. research has shown that stress contributes to poor sleep quality.22,23 according to kalmbach et al. poor sleep quality increases the risk of sleep reactivity which is the degree of sleep disruption.22 sleep reactivity in this case is the degree to which stress disrupts sleep and causes difficulty falling asleep and remaining asleep.22 exposure to stress from either normal life events or major life events causes significant disruption to sleep patterns and affects normal sleep function.24 consequently, sleep deprivation triggers the body’s stress response system which leads to an elevation of stress hormones, particularly cortisol resulting in sleep disruption.25 stress also prolongs the time one takes to sleep which is why it is associated with sleep deprivation and the risk of developing major sleep disorders such as chronic insomnia. according to the gallup survey, stress was one of the factors that contributed to poor sleep quality among americans with most noting that experiencing stress during the previous day resulted in poor quality of sleep during the night.18 young adults are more prone to stress with factors such as loneliness, work, finances, and career decisions being major causes of stress in this population.26,27 the high level of stress in this population could explain why they are more prone to sleep problems compared to other adults. mental health conditions have also been linked to poor sleep quality and increased risk of insomnia and hypersomnia. depression, anxiety, sleep deprivation, and sleep disorders are linked.14,28 according to nutt et al. approximately threequarters of patients who are depressed report insomnia symptoms another 40% report hypersomnia.14 depression and anxiety are also common in people who report insomnia.28 sleep disturbance is another symptom that is commonly reported in patients with depression with most citing difficulty sleeping, waking up at night, difficulty going back to sleep, and sleeping for longer periods.14 the gallup survey also showed that adults who reported symptoms of anxiety and depression were more likely to report poor sleep at 44% than adults who did not report feelings of anxiety and depression at 28%. evidently, anxiety and depression affect sleep. considering that young adults are more prone to depression and anxiety, they are more likely to report sleep deprivation.29 other long-term health conditions also increase the risk of sleep deprivation and disorders. for instance, individuals who report chronic pain are also more report poor sleep quality.18 according to haack et al. pain can lead to sleep deficiency and can also be a consequence of sleep deficiency.30 epidemiological studies show that individuals who report poor sleep quality and inadequate sleep time have a high risk of developing chronic pain.31 disorders such as insomnia are also prevalent in people who have chronic pain.32 a high prevalence of insomnia up to 53% has been reported in people living with chronic pain compared to 3% in the control group.33 pain makes it difficult to initiate and maintain sleep which explains the high prevalence of insomnia in people living with chronic pain. other than chronic pain being a causative factor for insomnia, insomnia is also a causal factor for chronic pain. some studies have established this bidirectional relationship between chronic pain and insomnia by noting that sleep impairment predicts the onset and worsening of chronic pain.34 although chronic pain is not as commonly reported in young adults as in other adult population groups, it is still a prevalent issue in this population group. as such, addressing it is important to ensure positive outcomes when it comes to addressing sleep disorders. other health conditions that can increase the risk of developing sleep disorders are respiratory illnesses such as asthma and obesity. obesity does not directly affect sleep but it increases the risk of disorders like obstructive sleep apnea.15 an additional factor that plays a crucial role when it comes to sleep is the sleep environment. different studies show the importance of the sleep environment when it comes to sleep, pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [28] ajdhs.com sleep quality, and sleep environment and how the sleep environment impacts sleep patterns.35,36,37 factors such as light exposure, noise, room temperature, and room humidity influence sleep.35 research suggests that for adequate sleep, the noise levels should be below 35db.38 the room temperature and humidity should also be ambient and range between 17 and 28 °c humidity at 40–60%.38 other factors that are vital to ensure good sleep quality are air quality and proper ventilation. all these factors are instrumental in supporting adequate and quality sleep. the significance of these factors when it comes to sleep quality explains why the physical environment is a key determinant factor when it comes to sleep health and sleep disorders. billings et al. note that the physical environment comprises the natural environment, the built environment, and the ambient environment.36 the physical environment refers to how the neighborhood is constructed, designed and planned. this environment has an influence on factors such as walkability, social engagement, crowding, and physical activity. the natural environment comprises features such as green spaces, water bodies, soil quality, and air quality of an area. the ambient environment comprises features such as neighborhood lighting, sounds, temperature, humidity, and atmosphere. all these factors play a crucial role in influencing sleep quality. for instance, a noisy neighborhood is not likely to create an ambient environment for quality sleep. individuals in such neighborhoods are likely to experience sleep disruption, insufficient sleep, delayed sleep and even insomnia.36 a study by altun et. established that noise was an environmental stressor and a main contributing factor to poor sleep experiences among university students.39 the built environment is also instrumental when it comes to sleep. living in a neighborhood that can be considered disadvantaged or dilapidated can have a negative impact on sleep.35 in such neighborhoods, factors such as safety concerns, noise, and crowding come to play. all these factors affect sleep quality more so sleep onset, struggling to remain asleep, and even hyperarousal. research has shown that living in a disadvantaged neighborhood increases the risk of insomnia.40 an additional factor that is emerging as a key contributor to sleep deprivation and sleep disorders is screen time. screen time before bed affects young people significantly. with most young people reporting using screens before bed, sleep deprivation and disorders are likely to become common.41 research has shown that using screens before bed has a significant impact on sleep quality.15,42,43 screens, more so smartphone and computer screens emit blue light which has been shown to suppress the production of melatonin a key hormone that is vital for the sleep-wake cycle. according to a study by falbe et al., children who slept near a screen had 20.6 fewer minutes of sleep.44 they also had less rest. similarly, children who slept in a room that had a tv had 18 minutes of less sleep.44 therefore, using screens before bedtime affects sleep quality and can contribute to sleep disorders such as insomnia in the long term. caffeine intake is an additional factor that has been shown to contribute to sleep deprivation and sleep disorders. research has shown that caffeine intake near bedtime affects sleep quality and is one of the factors that is reported to make individuals feel tired in the morning.45,46 according to drake et al., caffeine intake up to 3 to 6 hours before bedtime contributes to sleep disturbances.45 caffeine intake also contributes to shorter sleep duration, increases wake time, and increases daytime sleepiness.15 the recommendation to avoid caffeine before bedtime as one of the sleep hygiene practices is also an indication that caffeine affects sleep quality. caffeine has also been shown to help address deficits that are associated with fatigue which increases overdependence and the risk of developing disorders such as insomnia.46 the high dependence on caffeine creates a cycle where individuals have to continue to take it to address the effects of fatigue because of inadequate sleep the previous night. because of their busy schedules and other life responsibilities, young adults tend to consume high volumes of caffeine which increases the risk of sleep deprivation significantly. another study showed that caffeine consumption was frequent among young adults.47 work hours, alcohol consumption before bedtime, mattress comfort, and spine support also increase the risk of sleep disorders. working long shift hours more so at night is associated with poor sleep outcomes. research has shown that shift work impacts sleep and even contributes to a condition known as shift work sleep disorder (swsd).48 some of the common manifestations of individuals who report swsd are trouble sleeping, fatigue, and excessive sleepiness. ganesan et al., also report that working during night shifts affects alertness and performance, more so if an individual works for subsequent nights.49 the comfort of the mattress and its ability to provide spine support also matter when it comes to sleep quality. individuals who have mattresses that do not provide comfort and spine support tend to report bad night’s sleep.18 another factor that increases the risk of sleep disorders more so in young adults is alcohol dependence. according to brower, sleep problems are more common among alcoholics with the most commonly reported being having trouble sleeping and having fewer hours of sleep time.50 alcohol increases the risk of chronic sleep disturbance and contributes to a lower slow wave.51 in terms of sleep disturbance, alcohol dependence increases the risk of persistent sleep abnormalities. in addition to sleep disturbance, alcohol increases the risk of sleep apnea. people who have insomnia are also likely to result to alcohol to aid sleep.50 although a lot of young adults are increasingly becoming aware of the importance of sleep on their overall health and wellbeing, getting adequate sleep still remains a major challenge. the impact of inadequate sleep on overall health and well-being is significantly documented. lack of good quality sleep affects physical and mental health and contributes to a high risk of developing depression and anxiety. it also affects other aspects of life such as work productivity and social well-being. impact of sleep disorders addressing sleep disorders among young adults is important because of the significant connection between sleep disorders, poor mental health, poor physical health and chronic diseases. sleep deprivation increases the risk of obesity, high blood pressure, diabetes, and heart attack.16 when it comes to obesity, research shows that short sleep duration increases an individual’s risk because it alters metabolic profiles more so insulin, cortisol, leptin, and ghrelin all of which are known to increase the risk of sleep loss.52 alterations in these profiles also increase appetite which explains why individuals who do not get adequate sleep tend to consume more calories.53 these individuals also tend to have lower energy expenditure which explains the link between sleep deprivation and a high risk of developing obesity. according to knutson and van cauter, inadequate sleep causes the dysregulation of the neuroendocrine control of appetite, leads to a reduction of leptin which is responsible for satiety, and increases ghrelin, which is the hormone responsible for leading to hunger.9 some studies have established the risk of obesity to be as high as 80% for every hour of sleep lost.54 cooper et al. also established that people who slept less than 7 hours every night had a higher body mass index and obesity than those who slept more.55 the link between obesity and sleep disorders has been established early in life with one study showing sleeping problems in childhood increase the likelihood of obesity in young adulthood.56 sleep disorders have also been linked to increased risk of other chronic diseases such as diabetes, cardiovascular disease, and high blood pressure.9,10,11 the link between sleep pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [29] ajdhs.com deprivation and the risk of developing chronic diseases shows that sleep disorders have a detrimental impact on health. for young adults, such impacts can lead to negative health outcomes and affect their quality of life. as such, there is a need to put measures in place to address sleep disorders. the risk of poor mental health is also elevated in individuals who are suffering from sleep disorders. some of the mental health problems that are likely to be reported in individuals who are suffering from sleep disorders are depression and mood disorders. the gallup survey reported that lack of sleep had a significant impact on mood with most participants indicating that lack of sleep impacted their ability to have fun.18 other mood changes that are associated with inadequate sleep are irritability, lack of motivation, and anxiety. insomnia is significantly implicated in depression with the relationship being bi-directional 14,57 patients who have depression tend to have insomnia symptoms and insomnia increases the risk of depression.57 depression and its effect on mood are not the only effects of sleep disorders on mental health. sleep disorders and sleep problems also increase the risk of suicidal ideation.15,58,59 sleep disorders also impact other aspects of life such as physical and social functioning. for instance, increased occurrence of road and work accidents is one of the consequences of insomnia, restless leg syndrome, and sleep apnea.1 sleep disorders increase tiredness, fatigue, and excessive daytime sleepiness which leads to compromised cognitive performance.13 compromised cognitive performance increases the risk of accidents. in a study comprising 35,004 drivers, about 16.9% had at least one sleep disorder. the most reported were insomnia, obstructive sleep apnea, hypersomnia, and narcolepsy.60 8.9% also reported at least one episode of sleepiness behind the wheel every month. 31.1% had near-miss accidents of which 50% were sleep-related. of the 2520 drivers who reported an accident, 146 of those accidents were attributed to sleep deprivation with the most risk of accidents being reported in drivers with hypersomnia and narcolepsy.60 the findings from this study were similar to those by liu et al.61 liu et al. established that sleep disorders impacted road safety and increased the likelihood of crash.61 females with restless legs syndrome and drivers with symptoms of narcolepsy and insomnia had a higher risk of a crash or near-crash.61 drivers with swsd also had higher rates of crashes. similar findings were reported for drivers with sleep apnea. other problems that were reported were unsafe maneuvers. increased risk of accidents is not only reported on roads but also at workplaces. a systematic review by uehli et al. established that workers with sleep problems were more likely to report work injuries with the risk being 1.62 times higher than workers who did not report sleep problems.12 the systematic review also established that 13% of injuries reported at work were attributed to fatigue, sleepiness, and sleep disorders.12 sleep disorders also affect work productivity, with most individuals who report sleep disorders reporting that they compromise different aspects of productivity such as concentration, difficulty performing expected duties, increased errors, and likelihood of absenteeism.1 according to the gallup survey, a poor night of sleep costs the economy approximately $44.6 billion every year with most workers who reported poor sleep quality being likely to skip or miss work.18 the survey also reported 2.29 days of unplanned absenteeism each month because of poor sleep quality.18 another study of young adults reported greater workplace productivity loss among individuals with sleep disorders at 164 hours/year compared to 30 hours/year in those without sleep disorders.62 similarly, a national american poll showed that sleep disorders affected different aspects of work performance including the ability to concentrate, increased likelihood of making mistakes, organization problems, decreased productivity, absenteeism, falling asleep at work, and failing to complete assigned tasks.8 good sleep is vital for good health and well-being. sleep disorders lead to negative health effects, poor daily functioning, and low quality of life. although a number of strategies including medication and supplements can be used to treat sleep disorders, lifestyle modifications in the long-term can be more effective. for instance, avoiding alcohol and caffeine before bedtime can lead to positive impact on sleep. also, having a routine bedtime and limiting nap time can lead to a positive impact on sleep. other measures that can improve sleep quality are having a good sleep environment, exercising regularly, and good diet. conclusion the number of sleep disorders reported among young people is increasing. as people become busier with work and other aspects of life, the number of sleep hours is decreasing which is contributing to increased numbers of sleep disorders. addressing sleep disorders is important. they cause a lot of distress and affect key aspects of life including health, work, productivity, and social life. the risk of depression, anxiety, obesity, diabetes, hypertension, and cardiovascular diseases is high in people with sleep disorders. the risk of road and work accidents is also high when sleep disorders are present. other negative effects associated with sleep disorders are poor work productivity, absenteeism, increased likelihood of making mistakes, and failure to complete assigned tasks. addressing sleep disorders is important. as more people report sleep problems, the negative impact of these disorders on the quality of life is expected to worsen. besides, factors that contribute to sleep disorders such as life stressors, smoking, inadequate physical activity, alcohol consumption, screentime before bedtime, and caffeine are getting worse due to modern lifestyle changes. therefore, the number of young adults affected by sleep disorders is projected to worsen necessitating the need for measures to address the problem. references 1. roth t. insomnia: definition, prevalence, etiology, and consequences. journal of clinical sleep medicine. 2007;3(5 suppl): s7-10. https://doi.org/10.5664/jcsm.26929 2. mcardle n, ward sv, bucks rs, et al. the prevalence of common sleep disorders in young adults: a descriptive population-based study. sleep. 2020;43(10):zsaa072. https://doi.org/10.1093/sleep/zsaa072 pmid:32280974 3. breslau n, roth t, rosenthal l, andreski p. sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. biological psychiatry. 1996;39(6):411-8. https://doi.org/10.1016/0006-3223(95)00188-3 pmid:8679786 4. dave p. the correlation between stigma and mental health disorders in people living with hiv/aids. journal of drug delivery and therapeutics, 2024;14(3):227-33. https://doi.org/10.22270/jddt.v14i3.6490 5. krystal ad. psychiatric disorders and sleep. neurologic clinics. 2012;30(4):1389-413. https://doi.org/10.1016/j.ncl.2012.08.018 pmid:23099143 pmcid:pmc3493205 6. ramos ar, wheaton ag, johnson da. peer reviewed: sleep deprivation, sleep disorders, and chronic disease. preventing chronic disease. 2023;20;e77. https://doi.org/10.5888/pcd20.230197 pmid:37651644 pmcid:pmc10487788 7. reis c, dias s, rodrigues am, et al. sleep duration, lifestyles and chronic diseases: a cross-sectional population-based study. sleep science. 2018; 11(04):217-30. https://doi.org/10.5935/19840063.20180036 pmid:30746039 pmcid:pmc6361301 8. swanson lm, arnedt jt, rosekind mr, belenky g, balkin tj, drake c. sleep disorders and work performance: findings from the 2008 https://doi.org/10.5664/jcsm.26929 https://doi.org/10.1093/sleep/zsaa072 https://doi.org/10.1016/0006-3223(95)00188-3 https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1016/j.ncl.2012.08.018 https://doi.org/10.5888/pcd20.230197 https://doi.org/10.5935/1984-0063.20180036 https://doi.org/10.5935/1984-0063.20180036 pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [30] ajdhs.com national sleep foundation sleep in america poll. journal of sleep research. 2011;20(3):487-94. https://doi.org/10.1111/j.13652869.2010.00890.x pmid:20887396 9. knutson kl, van cauter e. associations between sleep loss and increased risk of obesity and diabetes. annals of the new york academy of sciences. 2008;1129(1):287-304. https://doi.org/10.1196/annals.1417.033 pmid:18591489 pmcid:pmc4394987 10. tobaldini e, costantino g, solbiati m, et al. sleep, sleep deprivation, autonomic nervous system and cardiovascular diseases. neuroscience & biobehavioral reviews. 2017;74:321-9. https://doi.org/10.1016/j.neubiorev.2016.07.004 pmid:27397854 11. makarem n, alcántara c, williams n, bello na, abdalla m. effect of sleep disturbances on blood pressure. hypertension. 2021;77(4):1036-46. dhttps://doi.org/10.1161/hypertensionaha.120.14479 pmid:33611935 pmcid:pmc7946733 12. uehli k, mehta aj, miedinger d, et al. sleep problems and work injuries: a systematic review and meta-analysis. sleep medicine reviews. 2014;18(1):61-73. https://doi.org/10.1016/j.smrv.2013.01.004 pmid:23702220 13. smolensky mh, di milia l, ohayon mm, philip p. sleep disorders, medical conditions, and road accident risk. accident analysis & prevention. 2011;43(2):533-48. https://doi.org/10.1016/j.aap.2009.12.004 pmid:21130215 14. nutt d, wilson s, paterson l. sleep disorders as core symptoms of depression. dialogues in clinical neuroscience. 2008;10(3):32936. https://doi.org/10.31887/dcns.2008.10.3/dnutt pmid:18979946 pmcid:pmc3181883 15. owens j, adolescent sleep working group, committee on adolescence, et al. insufficient sleep in adolescents and young adults: an update on causes and consequences. pediatrics. 2014;134(3):e921-32. https://doi.org/10.1542/peds.2014-1696 pmid:25157012 pmcid:pmc8194472 16. marshall s, sleep statistics and facts. national council on aging.2024. available from: https://www.ncoa.org/adviser/sleep/sleepstatistics/#:~:text=more%20than%20a%20third%20of,38%25% 20of%20the%20general%20population . 17. adjaye-gbewonyo d, ng ae, black li. sleep difficulties in adults: united states, 2020. nchs data brief, no 436. hyattsville, md: national center for health statistics. 2022. https://doi.org/10.15620/cdc:117490 18. casper-gallup. the state of sleep in america: 2022 report. 2022. available from: file:///c:/users/user/downloads/caspergallup%202022%20state%20of%20sleep%20in%20america%2 0report.pdf 19. di h, guo y, daghlas i, et al. evaluation of sleep habits and disturbances among us adults, 2017-2020. jama network open. 2022;5(11): e2240788-. https://doi.org/10.1001/jamanetworkopen.2022.40788 pmid:36346632 pmcid:pmc9644264 20. acquavella j, mehra r, bron m, suomi jm, hess gp. prevalence of narcolepsy and other sleep disorders and frequency of diagnostic tests from 2013-2016 in insured patients actively seeking care. journal of clinical sleep medicine. 2020;16(8):1255-63. https://doi.org/10.5664/jcsm.8482 pmid:32807293 pmcid:pmc7446073 21. huyett p, bhattacharyya n. incremental health care utilization and expenditures for sleep disorders in the united states. journal of clinical sleep medicine. 2021;17(10):1981-6. https://doi.org/10.5664/jcsm.9392 pmid:33949943 pmcid:pmc8494101 22. kalmbach da, anderson jr, drake cl. the impact of stress on sleep: pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. journal of sleep research. 2018;27(6):e12710. https://doi.org/10.1111/jsr.12710 pmid:29797753 pmcid:pmc7045300 23. safhi ma, alafif ra, alamoudi nm, et al. the association of stress with sleep quality among medical students at king abdulaziz university. journal of family medicine and primary care. 2020;9(3):1662-7. https://doi.org/10.4103/jfmpc.jfmpc_745_19 pmid:32509668 pmcid:pmc7266176 24. alotaibi ad, alosaimi fm, alajlan aa, abdulrahman ka. the relationship between sleep quality, stress, and academic performance among medical students. journal of family and community medicine. 2020;27(1):23-8. https://doi.org/10.4103/jfcm.jfcm_132_19 pmid:32030075 pmcid:pmc6984036 25. martire vl, caruso d, palagini l, zoccoli g, bastianini s. stress & sleep: a relationship lasting a lifetime. neuroscience & biobehavioral reviews. 2020; 117:65-77. https://doi.org/10.1016/j.neubiorev.2019.08.024 pmid:31491473 26. varma p, junge m, meaklim h, jackson ml. younger people are more vulnerable to stress, anxiety and depression during covid19 pandemic: a global cross-sectional survey. progress in neuropsychopharmacology and biological psychiatry. 2021; 109:110236. https://doi.org/10.1016/j.pnpbp.2020.110236 pmid:33373680 pmcid:pmc7834119 27. matud mp, díaz a, bethencourt jm, ibáñez i. stress and psychological distress in emerging adulthood: a gender analysis. journal of clinical medicine. 2020;9(9):2859. https://doi.org/10.3390/jcm9092859 pmid:32899622 pmcid:pmc7564698 28. oh cm, kim hy, na hk, cho kh, chu mk. the effect of anxiety and depression on sleep quality of individuals with high risk for insomnia: a population-based study. frontiers in neurology. 2019;10:849. https://doi.org/10.3389/fneur.2019.00849 pmid:31456736 pmcid:pmc6700255 29. weissbourd r, batanova m, mcintyre j, et al. making caring common: on edge: understanding and preventing young adults' mental health challenges. harvard graduate school of education. available from: https://mcc.gse.harvard.edu/reports/on-edge 30. haack m, simpson n, sethna n, kaur s, mullington j. sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. neuropsychopharmacology. 2020;45(1):20516. https://doi.org/10.1038/s41386-019-0439-z pmid:31207606 pmcid:pmc6879497 31. afolalu ef, ramlee f, tang nk. effects of sleep changes on painrelated health outcomes in the general population: a systematic review of longitudinal studies with exploratory meta-analysis. sleep medicine reviews. 2018;39:82-97. https://doi.org/10.1016/j.smrv.2017.08.001 pmid:29056414 pmcid:pmc5894811 32. nijs j, mairesse o, neu d, et al. sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. physical therapy. 2018;98(5):325-35. https://doi.org/10.1093/ptj/pzy020 pmid:29425327 33. tang nk, wright kj, salkovskis pm. prevalence and correlates of clinical insomnia co-occurring with chronic back pain. journal of sleep research. 2007;16(1):85-95. https://doi.org/10.1111/j.1365-2869.2007.00571.x pmid:17309767 34. finan ph, goodin br, smith mt. the association of sleep and pain: an update and a path forward. the journal of pain. 2013;14(12):1539-52. https://doi.org/10.1016/j.jpain.2013.08.007 pmid:24290442 pmcid:pmc4046588 35. dave p, addressing disparities in vision health and eye care in the us. world journal of current medical and pharmaceutical research, 2024;6(1):58-64, https://doi.org/10.37022/wjcmpr.v6i1.321 36. billings me, hale l, johnson da. physical and social environment relationship with sleep health and disorders. chest. 2020;157(5):1304-12. https://doi.org/10.1016/j.chest.2019.12.002 pmid:31870910 pmcid:pmc7268445 https://doi.org/10.1111/j.1365-2869.2010.00890.x https://doi.org/10.1111/j.1365-2869.2010.00890.x https://doi.org/10.1196/annals.1417.033 https://doi.org/10.1016/j.neubiorev.2016.07.004 https://doi.org/10.1161/hypertensionaha.120.14479 https://doi.org/10.1016/j.smrv.2013.01.004 https://doi.org/10.1016/j.aap.2009.12.004 https://doi.org/10.31887/dcns.2008.10.3/dnutt https://doi.org/10.1542/peds.2014-1696 https://www.ncoa.org/adviser/sleep/sleep-statistics/#:~:text=more%20than%20a%20third%20of,38%25%20of%20the%20general%20population https://www.ncoa.org/adviser/sleep/sleep-statistics/#:~:text=more%20than%20a%20third%20of,38%25%20of%20the%20general%20population https://www.ncoa.org/adviser/sleep/sleep-statistics/#:~:text=more%20than%20a%20third%20of,38%25%20of%20the%20general%20population https://doi.org/10.15620/cdc:117490 https://doi.org/10.1001/jamanetworkopen.2022.40788 https://doi.org/10.5664/jcsm.8482 https://doi.org/10.5664/jcsm.9392 https://doi.org/10.1111/jsr.12710 https://doi.org/10.4103/jfmpc.jfmpc_745_19 https://doi.org/10.4103/jfcm.jfcm_132_19 https://doi.org/10.1016/j.neubiorev.2019.08.024 https://doi.org/10.1016/j.pnpbp.2020.110236 https://doi.org/10.3390/jcm9092859 https://doi.org/10.3389/fneur.2019.00849 https://doi.org/10.1038/s41386-019-0439-z https://doi.org/10.1016/j.smrv.2017.08.001 https://doi.org/10.1093/ptj/pzy020 https://doi.org/10.1111/j.1365-2869.2007.00571.x https://doi.org/10.1016/j.jpain.2013.08.007 https://doi.org/10.37022/wjcmpr.v6i1.321 https://doi.org/10.1016/j.chest.2019.12.002 pallav dave asian journal of dental and health sciences. 2024; 4(2):26-31 [31] ajdhs.com 37. halperin d. environmental noise and sleep disturbances: a threat to health?. sleep science. 2014;7(4):209-12. https://doi.org/10.1016/j.slsci.2014.11.003 pmid:26483931 pmcid:pmc4608916 38. caddick za, gregory k, arsintescu l, flynn-evans ee. a review of the environmental parameters necessary for an optimal sleep environment. building and environment. 2018;132:11-20. https://doi.org/10.1016/j.buildenv.2018.01.020 39. altun i̇, cınar n, dede c. the contributing factors to poor sleep experiences according to the university students: a crosssectional study. journal of research in medical sciences: the official journal of isfahan university of medical sciences. 2012;17(6):557. 40. riedel n, fuks k, hoffmann b, et al. insomnia and urban neighbourhood contexts-are associations modified by individual social characteristics and change of residence? results from a population-based study using residential histories. bmc public health. 2012;12:1-5. https://doi.org/10.1186/1471-2458-12810 pmid:22994885 pmcid:pmc3503830 41. hale l, kirschen gw, lebourgeois mk, et al. youth screen media habits and sleep: sleep-friendly screen behavior recommendations for clinicians, educators, and parents. child and adolescent psychiatric clinics of north america. 2018;27(2):22945. https://doi.org/10.1016/j.chc.2017.11.014 pmid:29502749 pmcid:pmc5839336 42. alshoaibi y, bafil w, rahim m. the effect of screen use on sleep quality among adolescents in riyadh, saudi arabia. journal of family medicine and primary care. 2023;12(7):1379-88. https://doi.org/10.4103/jfmpc.jfmpc_159_23 pmid:37649757 pmcid:pmc10465044 43. arshad d, joyia um, fatima s, et al. the adverse impact of excessive smartphone screen-time on sleep quality among young adults: a prospective cohort. sleep science. 2021;14(04):337-41. d https://doi.org/10.5935/1984-0063.20200114 pmid:35087630 pmcid:pmc8776263 44. falbe j, davison kk, franckle rl, et al. sleep duration, restfulness, and screens in the sleep environment. pediatrics. 2015;135(2):e367-75. https://doi.org/10.1542/peds.2014-2306 pmid:25560435 pmcid:pmc4306800 45. drake c, roehrs t, shambroom j, roth t. caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. journal of clinical sleep medicine. 2013;9(11):1195-200. https://doi.org/10.5664/jcsm.3170 pmid:24235903 pmcid:pmc3805807 46. orbeta rl, overpeck md, ramcharran d, kogan md, ledsky r. high caffeine intake in adolescents: associations with difficulty sleeping and feeling tired in the morning. journal of adolescent health. 2006;38(4):451-3. https://doi.org/10.1016/j.jadohealth.2005.05.014 pmid:16549311 47. kelly ck, prichard jr. demographics, health, and risk behaviors of young adults who drink energy drinks and coffee beverages. journal of caffeine research. 2016;6(2):73-81. https://doi.org/10.1089/jcr.2015.0027 pmid:27274417 pmcid:pmc4892198 48. jehan s, zizi f, pandi-perumal sr, et al. shift work and sleep: medical implications and management. sleep medicine and disorders: international journal. 2017;1(2). https://doi.org/10.15406/smdij.2017.01.00008 49. ganesan s, magee m, stone je, et al. the impact of shift work on sleep, alertness and performance in healthcare workers. scientific reports. 2019;9(1):4635. https://doi.org/10.1038/s41598-01940914-x pmid:30874565 pmcid:pmc6420632 50. brower kj. alcohol's effects on sleep in alcoholics. alcohol research & health. 2001;25(2):110. 51. colrain im, nicholas cl, baker fc. alcohol and the sleeping brain. handbook of clinical neurology. 2014; 125:415-31. https://doi.org/10.1016/b978-0-444-62619-6.00024-0 pmid:25307588 pmcid:pmc5821259 52. leproult r, van cauter e. role of sleep and sleep loss in hormonal release and metabolism. pediatric neuroendocrinology. 2010; 17:11-21. https://doi.org/10.1159/000262524 pmid:19955752 pmcid:pmc3065172 53. knutson kl, spiegel k, penev p, van cauter e. the metabolic consequences of sleep deprivation. sleep medicine reviews. 2007;11(3):163-78. https://doi.org/10.1016/j.smrv.2007.01.002 pmid:17442599 pmcid:pmc1991337 54. gupta nk, mueller wh, chan w, meininger jc. is obesity associated with poor sleep quality in adolescents?. american journal of human biology. 2002;14(6):762-8. https://doi.org/10.1002/ajhb.10093 pmid:12400037 55. cooper cb, neufeld ev, dolezal ba, martin jl. sleep deprivation and obesity in adults: a brief narrative review. bmj open sport & exercise medicine. 2018;4(1):e000392. https://doi.org/10.1136/bmjsem-2018-000392 pmid:30364557 pmcid:pmc6196958 56. mamun aa, lawlor da, cramb s, o'callaghan m, williams g, najman j. do childhood sleeping problems predict obesity in young adulthood? evidence from a prospective birth cohort study. american journal of epidemiology. 2007;166(12):1368-73. https://doi.org/10.1093/aje/kwm224 pmid:17855389 57. riemann d, krone lb, wulff k, nissen c. sleep, insomnia, and depression. neuropsychopharmacology. 2020;45(1):74-89. https://doi.org/10.1038/s41386-019-0411-y pmid:31071719 pmcid:pmc6879516 58. bjørngaard jh, bjerkeset o, romundstad p, gunnell d. sleeping problems and suicide in 75,000 norwegian adults: a 20-year follow-up of the hunt i study. sleep. 2011;34(9):1155-9. https://doi.org/10.5665/sleep.1228 pmid:21886352 pmcid:pmc3157656 59. bernert ra, turvey cl, conwell y, joiner te. association of poor subjective sleep quality with risk for death by suicide during a 10year period: a longitudinal, population-based study of late life. jama psychiatry. 2014;71(10):1129-37. https://doi.org/10.1001/jamapsychiatry.2014.1126 pmid:25133759 pmcid:pmc4283786 60. philip p, sagaspe p, lagarde e, et al. sleep disorders and accidental risk in a large group of regular registered highway drivers. sleep medicine. 2010;11(10):973-9. https://doi.org/10.1016/j.sleep.2010.07.010 pmid:20961809 61. liu sy, perez ma, lau n. the impact of sleep disorders on driving safety-findings from the second strategic highway research program naturalistic driving study. sleep. 2018;41(4):zsy023. https://doi.org/10.1093/sleep/zsy023 pmcid:pmc6231530 62. reynolds ac, coenen p, lechat b, straker l, zabatiero j, maddison kj, adams rj, eastwood p. insomnia and workplace productivity loss among young working adults: a prospective observational study of clinical sleep disorders in a community cohort. medical journal of australia. 2023;219(3):107-12. https://doi.org/10.5694/mja2.52014 pmid:37357134 https://doi.org/10.1016/j.slsci.2014.11.003 https://doi.org/10.1016/j.buildenv.2018.01.020 https://doi.org/10.1186/1471-2458-12-810 https://doi.org/10.1186/1471-2458-12-810 https://doi.org/10.1016/j.chc.2017.11.014 https://doi.org/10.4103/jfmpc.jfmpc_159_23 https://doi.org/10.5935/1984-0063.20200114 https://doi.org/10.1542/peds.2014-2306 https://doi.org/10.5664/jcsm.3170 https://doi.org/10.1016/j.jadohealth.2005.05.014 https://doi.org/10.1089/jcr.2015.0027 https://doi.org/10.15406/smdij.2017.01.00008 https://doi.org/10.1038/s41598-019-40914-x https://doi.org/10.1038/s41598-019-40914-x https://doi.org/10.1016/b978-0-444-62619-6.00024-0 https://doi.org/10.1159/000262524 https://doi.org/10.1016/j.smrv.2007.01.002 https://doi.org/10.1002/ajhb.10093 https://doi.org/10.1136/bmjsem-2018-000392 https://doi.org/10.1093/aje/kwm224 https://doi.org/10.1038/s41386-019-0411-y https://doi.org/10.5665/sleep.1228 https://doi.org/10.1001/jamapsychiatry.2014.1126 https://doi.org/10.1016/j.sleep.2010.07.010 https://doi.org/10.1093/sleep/zsy023 https://doi.org/10.5694/mja2.52014 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [44] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited viral-host interactions and immune responses in hiv-infected infants: a review *emmanuel ifeanyi obeagu 1 and getrude uzoma obeagu 2 1 department of medical laboratory science, kampala international university, ishaka, uganda. 2 school of nursing science, kampala international university, ishaka, uganda. article info: _____________________________________________ article history: received 21 april 2024 reviewed 03 june 2024 accepted 26 june 2024 published 15 july 2024 _____________________________________________ cite this article as: obeagu ei, obeagu gu, viral-host interactions and immune responses in hiv-infected infants: a review, asian journal of dental and health sciences. 2024; 4(2):44-49 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.81 _____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda abstract _________________________________________________________________________________________________________________ human immunodeficiency virus (hiv) infection in infants presents distinctive challenges due to their developing immune systems and unique viral-host interactions compared to adults. this review examines current knowledge on viral-host interactions and immune responses in hivinfected infants, focusing on immune development, viral dynamics, and therapeutic implications. the immune system of infants undergoes rapid maturation during early life, influencing their susceptibility to hiv infection and responses to antiretroviral therapy (art). key aspects include thymic function, cytokine profiles, and the establishment of immune memory, which collectively shape immune responses against hiv. viral dynamics in hiv-infected infants differ markedly from those in adults, characterized by high viral loads, diverse viral subtypes, and the early establishment of viral reservoirs within immune cells. these reservoirs, particularly in sanctuary sites like the central nervous system, pose challenges for achieving viral eradication and long-term remission. effective management requires strategies to characterize and target these reservoirs, alongside early intervention to mitigate viral replication and preserve immune function. advances in viral monitoring technologies and treatment regimens are essential for improving clinical outcomes and reducing the global burden of pediatric hiv infection. keywords: hiv, infants, viral-host interactions, immune responses, immune development, viral dynamics, therapeutic interventions introduction human immunodeficiency virus (hiv) infection continues to be a global health challenge, particularly affecting vulnerable populations such as infants. unlike adults, infants exhibit unique immunological characteristics that influence the course of hiv disease progression, treatment outcomes, and long-term health.1 infants acquire hiv primarily through vertical transmission from infected mothers during pregnancy, childbirth, or breastfeeding. this mode of transmission results in a high burden of infection among newborns, particularly in regions with limited access to antiretroviral therapy (art) and maternal healthcare. early diagnosis and timely initiation of art are essential to suppress viral replication, reduce morbidity and mortality, and preserve immune function in hivinfected infants.2-3 the immune system of infants undergoes rapid development and maturation during the early stages of life. key developmental milestones include the establishment of t-cell and b-cell repertoires, thymic output of naïve t cells, and the acquisition of immune memory. these processes are critical for mounting effective immune responses against pathogens, including hiv. however, the immaturity of the infant immune system also renders them more susceptible to severe infections and challenges in achieving sustained viral suppression with art.4-5 viral dynamics in hiv-infected infants differ significantly from those observed in adults. infants often present with high viral loads during acute infection, driven by rapid viral replication and diversification. the establishment of viral reservoirs within cd4+ t cells, macrophages, and other immune cells occurs early in life, contributing to persistent viremia and potential viral persistence despite art. these reservoirs, particularly in anatomical sanctuaries like the central nervous system and lymphoid tissues, pose obstacles to achieving viral eradication and functional cure.6-7 immune responses in hiv-infected infants are characterized by distinct patterns of t-cell activation, cytokine production, and immune regulation. cd4+ t cells play a central role in orchestrating immune responses, while cd8+ t cells contribute to cytotoxic activity against infected cells. however, hiv employs various immune evasion strategies to evade host immune surveillance, including rapid mutation rates, shielding of viral epitopes, and modulation of host immune responses. these mechanisms contribute to the establishment of chronic infection and challenges in achieving durable immune control.89 effective management of hiv infection in infants requires a multidisciplinary approach encompassing early diagnosis, initiation of art, monitoring of immune function, and management of opportunistic infections. while art suppresses viral replication and preserves immune function, challenges such as drug resistance, treatment adherence, and long-term effects on immune reconstitution persist. strategies to enhance immune responses, mitigate viral reservoirs, and optimize therapeutic interventions are critical for improving clinical outcomes and reducing the global burden of pediatric hiv infection.10-11 advances in diagnostic technologies, including early infant diagnosis (eid) and viral load monitoring, have revolutionized hiv care by enabling early detection and prompt initiation of art. however, gaps in access to healthcare services, particularly in resource-limited settings, continue to open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.81 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.81&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [45] ajdhs.com hinder efforts to achieve universal art coverage and optimal treatment outcomes for hiv-infected infants. addressing these challenges requires innovative approaches to healthcare delivery, capacity building, and international collaboration to support comprehensive hiv care programs tailored to the needs of infants and their families.12-13 immune development in infants immune development in infants is a dynamic process crucial for establishing effective host defense mechanisms against pathogens, including human immunodeficiency virus (hiv). the immune system in infants undergoes a series of developmental stages that begin during gestation and continue through early childhood. during fetal development, hematopoiesis occurs primarily in the fetal liver and then transitions to the bone marrow. the thymus, a critical organ for t-cell maturation, develops early in gestation and plays a pivotal role in shaping cellular immunity. the production of diverse t-cell receptor (tcr) repertoires and the selection of functional t cells in the thymus are crucial for establishing a competent adaptive immune system.14-16 innate immune responses in infants are essential for immediate defense against pathogens before the adaptive immune system fully matures. innate immune cells, such as neutrophils, macrophages, and dendritic cells, exhibit functional capabilities early in life but may have reduced capacity for pathogen recognition and response compared to adults. toll-like receptors (tlrs) and other pattern recognition receptors (prrs) play key roles in innate immune activation, influencing cytokine production and inflammatory responses critical for immune defense.17-19 adaptive immune responses adaptive immunity in infants evolves gradually during the first years of life, characterized by the development of antigenspecific immune responses mediated by t cells and b cells. naïve t cells generated in the thymus undergo maturation and differentiation into effector t cells upon encountering antigens. this process is essential for mounting cellular immune responses against viral infections like hiv. b cells mature in the bone marrow and secondary lymphoid organs, producing antibodies that contribute to humoral immunity and long-term immune memory.20-21 immune tolerance mechanisms in infants are crucial for maintaining self-tolerance and preventing autoimmunity. regulatory t cells (tregs) play a pivotal role in immune homeostasis by suppressing excessive immune activation and inflammation. the balance between effector t cells and tregs influences immune responses to pathogens and vaccines, impacting the efficacy of immune interventions in early life. dysregulation of immune tolerance mechanisms may contribute to immune-mediated disorders and susceptibility to infections, including hiv.22-25 several factors influence immune development and responses in infants, including genetic predisposition, environmental exposures, maternal health status, and nutritional factors. maternal antibodies transferred across the placenta and through breast milk provide passive immunity to newborns, offering protection against infections during early life. breastfeeding, in particular, supports immune development by providing essential nutrients and immunomodulatory factors that enhance immune function and protect against pathogens.26-28 hiv infection profoundly impacts immune development in infants by disrupting t-cell maturation, impairing thymic function, and depleting cd4+ t cells critical for adaptive immunity. early hiv acquisition during gestation or infancy results in high viral replication rates, rapid establishment of viral reservoirs, and immune dysregulation. the virus's ability to infect and replicate within immune cells, including cd4+ t cells and macrophages, undermines immune responses and compromises host defense mechanisms.29-30 viral dynamics and establishment of reservoirs viral dynamics and the establishment of reservoirs are critical aspects of hiv infection in infants, significantly influencing disease progression, treatment outcomes, and the potential for viral eradication. hiv infection in infants is characterized by rapid viral replication and high viral loads during early stages of infection. infants often acquire the virus perinatally, either in utero, during childbirth, or through breastfeeding, leading to a rapid dissemination of the virus throughout the body. this rapid replication contributes to the establishment of diverse viral populations, known as quasispecies, which evolve dynamically within individual hosts. viral diversity and mutation rates are influenced by factors such as viral replication dynamics, host immune responses, and selective pressures exerted by antiretroviral therapy (art). early in hiv infection, particularly during the neonatal period and infancy, viral reservoirs are established within cd4+ t cells, macrophages, and other immune cells. these reservoirs represent anatomical sites where hiv can persist in a latent or low-level replicating state, evading immune surveillance and antiretroviral drugs. the central nervous system (cns), gutassociated lymphoid tissue (galt), and lymphoid organs are known sanctuary sites where viral reservoirs can persist despite effective art. the establishment of these reservoirs early in life poses significant challenges for achieving viral eradication or functional cure.31-40 factors influencing reservoir establishment several factors contribute to the establishment and maintenance of viral reservoirs in hiv-infected infants: • early initiation of art: timely initiation of art in infants can suppress viral replication and reduce the size of viral reservoirs. however, the effectiveness of art in preventing reservoir establishment may vary depending on the timing of infection and the level of viral exposure.41 • immune activation: persistent immune activation, even in the presence of art, may contribute to ongoing viral replication and the seeding of viral reservoirs. immune activation markers such as cd38 and hla-dr on t cells are associated with higher viral reservoir size and poorer treatment outcomes.42 • anatomical and cellular factors: sanctuary sites within the body, such as the cns and galt, provide protected environments where hiv-infected cells can evade immune responses and antiretroviral drugs. cellular factors, including differential expression of viral entry receptors and immune activation markers, also influence the establishment and persistence of viral reservoirs.43 challenges in targeting viral reservoirs hiv can persist in a latent state within long-lived memory cd4+ t cells, macrophages, and other reservoir cells. latently infected cells can evade immune surveillance and remain undetectable by current diagnostic tests, complicating efforts to eradicate the virus. high mutation rates and viral diversity contribute to the emergence of viral escape mutants that evade immune recognition and antiretroviral drugs. this viral diversity complicates treatment strategies aimed at achieving durable viral suppression and cure. sanctuary sites such as the cns have limited penetration of antiretroviral drugs and reduced immune surveillance, allowing hiv to persist and potentially rebound after cessation of therapy.44-45 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [46] ajdhs.com immune responses and immune evasion strategies immune responses and immune evasion strategies are central to the interplay between human immunodeficiency virus (hiv) and the immune system in infected infants. understanding these dynamics is crucial for developing effective therapeutic interventions and improving clinical outcomes. upon hiv exposure, innate immune cells such as dendritic cells, macrophages, and natural killer (nk) cells recognize viral components through pattern recognition receptors (prrs). this recognition triggers the production of pro-inflammatory cytokines and chemokines, recruiting other immune cells to the site of infection and initiating an early antiviral response. the adaptive immune response involves the activation and differentiation of antigen-specific t cells (cd4+ and cd8+ t cells) and b cells. cd4+ t cells play a crucial role in orchestrating immune responses by providing help to b cells for antibody production and activating cd8+ cytotoxic t cells to eliminate hiv-infected cells. b cells produce antibodies that can neutralize free virus particles and facilitate antibodydependent cellular cytotoxicity (adcc).46-48 immune evasion strategies of hiv hiv has evolved multiple strategies to evade host immune responses and establish persistent infection: • antigenic variation: hiv exhibits high genetic variability due to its error-prone reverse transcriptase enzyme. this high mutation rate results in the rapid generation of diverse viral quasispecies within an infected individual. the ability of hiv to continuously evolve and escape immune recognition contributes to difficulties in developing effective vaccines and antiviral therapies.49 • t-cell depletion and dysfunction: hiv preferentially infects cd4+ t cells, leading to their progressive depletion and functional impairment. this depletion compromises the adaptive immune response and impairs the host's ability to mount effective antiviral immunity. additionally, hiv infection induces chronic immune activation, which further exacerbates t-cell dysfunction and exhaustion.50 • immune evasion at mucosal sites: hiv transmission often occurs at mucosal surfaces, where the virus encounters local immune defenses. hiv exploits mucosal immune tolerance mechanisms to evade detection and establish a foothold within the host. this includes downregulating major histocompatibility complex (mhc) class i molecules on infected cells, thereby evading recognition by cd8+ cytotoxic t cells.51 • escape from antibody responses: hiv can evade neutralizing antibodies by shielding its envelope glycoprotein (gp120/gp41) through glycosylation and conformational masking. additionally, hiv may infect cd4+ t cells and macrophages within anatomical reservoirs, such as lymphoid tissues and the central nervous system, where they are less accessible to neutralizing antibodies and immune surveillance.52 clinical implications and challenges the extensive genetic diversity of hiv poses challenges for developing broadly effective vaccines and antiviral therapies that can target diverse viral strains and prevent immune escape. latently infected cells persist in hiv-infected individuals despite effective antiretroviral therapy (art). these reservoirs remain a barrier to viral eradication and necessitate novel strategies, such as latency-reversing agents, to expose and eliminate latent hiv. maintaining strict adherence to art regimens is essential to suppress viral replication and prevent the emergence of drug-resistant hiv strains. however, challenges in treatment adherence among infants and caregivers can compromise treatment efficacy and contribute to virologic failure.53-54 clinical management and therapeutic interventions for hiv-infected infants require a comprehensive approach that addresses the unique challenges posed by early-life infection, including immune system immaturity, rapid disease progression, and potential long-term complications. effective management aims to suppress viral replication, preserve immune function, prevent opportunistic infections, and promote overall health and development.55-56 early diagnosis of hiv infection in infants is critical for timely initiation of art, which is essential for achieving viral suppression and preserving immune function. early infant diagnosis (eid) techniques, such as polymerase chain reaction (pcr) testing of dried blood spots, enable prompt identification of hiv-exposed infants. initiating art as soon as possible after diagnosis reduces viral replication, limits the establishment of viral reservoirs, and improves long-term clinical outcomes. however, challenges in accessing healthcare services, particularly in resource-limited settings, can delay diagnosis and hinder early treatment initiation.57 regular monitoring of viral load and immune function is essential for assessing treatment efficacy, disease progression, and the need for treatment adjustments in hiv-infected infants. viral load testing helps clinicians evaluate the effectiveness of art in suppressing viral replication and detect early signs of virologic failure or drug resistance. immune function assessments, including cd4+ t-cell counts and immune activation markers, provide insights into immune reconstitution and potential risks of opportunistic infections. close monitoring allows for timely interventions to optimize art regimens and mitigate complications associated with hiv infection.58 hiv-infected infants are at increased risk of opportunistic infections due to immune suppression and impaired immune responses. prophylactic measures, such as cotrimoxazole prophylaxis and vaccinations against common childhood infections (e.g., pneumococcus, influenza), are recommended to prevent opportunistic infections and reduce morbidity and mortality. prompt recognition and management of infections, including bacterial, viral, and fungal pathogens, are crucial for maintaining overall health and preventing disease progression in hiv-infected infants.59 comprehensive clinical management of hiv-infected infants includes providing supportive care to optimize growth, development, and quality of life. nutritional support is essential to meet the increased energy and nutrient requirements associated with hiv infection and art. adequate nutrition supports immune function, enhances medication adherence, and reduces the risk of complications such as wasting and stunting. multidisciplinary care teams, including pediatricians, nurses, nutritionists, and social workers, collaborate to address the holistic needs of hiv-infected infants and their families.57 achieving and maintaining optimal adherence to art regimens pose significant challenges in the management of hiv-infected infants. factors such as caregiver understanding, socioeconomic factors, stigma, and medication tolerability can affect treatment adherence and virologic suppression. long-term outcomes in hiv-infected infants depend on sustained viral suppression, immune reconstitution, and management of coexisting conditions. challenges in maintaining adherence underscore the need for ongoing support, education, and counseling for caregivers to ensure effective treatment outcomes.58 conclusion the management of hiv infection in infants remains a dynamic and evolving field, marked by significant progress in diagnosis, treatment, and understanding of the virus-host interactions. obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [47] ajdhs.com infants infected with hiv face unique challenges due to their developing immune systems, rapid disease progression, and vulnerability to opportunistic infections. effective clinical management requires a multifaceted approach that encompasses early diagnosis, prompt initiation of antiretroviral therapy (art), monitoring of viral load and immune function, prevention of opportunistic infections, nutritional support, and adherence to treatment regimens. early diagnosis through effective screening programs and early infant diagnosis (eid) techniques has revolutionized the ability to identify hiv-infected infants promptly, enabling timely initiation of art. initiating art early in infancy not only suppresses viral replication but also helps preserve immune function and reduce the establishment of viral reservoirs, which are critical for long-term management. monitoring of viral load and immune function plays a crucial role in assessing treatment efficacy and guiding clinical decisions. regular monitoring allows healthcare providers to tailor art regimens, identify treatment failures early, and intervene promptly to prevent disease progression and drug resistance. prevention and management of opportunistic infections are essential components of pediatric hiv care. prophylactic measures and vaccinations are employed to prevent common childhood infections and reduce morbidity and mortality associated with hiv. integrated, multidisciplinary care teams are vital in addressing the holistic needs of hiv-infected infants, including nutritional support, developmental screening, and psychosocial support for caregivers. references 1. yu jc, khodadadi h, malik a, davidson b, salles éd, bhatia j, hale vl, baban b. innate immunity of neonates and infants. frontiers in immunology. 2018; 9:1759. https://doi.org/10.3389/fimmu.2018.01759 pmid:30105028 pmcid:pmc6077196 2. goenka a, kollmann tr. development of immunity in early life. journal of infection. 2015;71: s112-120. https://doi.org/10.1016/j.jinf.2015.04.027 pmid:25934325 3. lewis db, weitkamp jh, levy o. developmental immunology and role of host defenses in fetal and neonatal susceptibility to infection. in remington and klein's infectious diseases of the fetus and newborn infant 2025: 73-159. elsevier. https://doi.org/10.1016/b978-0-323-79525-8.00013-5 4. obeagu ei, anyiam af, obeagu gu. managing anemia in hiv through blood transfusions: clinical considerations and innovations. elite journal of hiv, 2024; 2(1): 16-30 5. obeagu ei, obeagu, gu. counting cells, shaping fates: cd4/cd8 ratios in hiv. elite journal of scientific research and review, 2024; 2(1): 37-50 6. obeagu ei, obeagu gu. eosinophil dynamics in pregnancy among women living with hiv: a comprehensive review. int. j. curr. res. med. sci. 2024;10(1):11-24. 7. obeagu ei, obeagu gu, hauwa ba, umar ai. neutrophil dynamics: unveiling their role in hiv progression within malaria patients. journal home page: http://www. journalijiar. com.;12(01). 8. obeagu ei, obeagu, gu. p-selectin and platelet activation in hiv: implications for antiviral therapy. elite journal of scientific research and review, 2024; 2(1): 17-41 9. obeagu ei, obeagu gu. the intricate relationship between erythropoietin and hiv-induced anemia: unraveling pathways for therapeutic insights. int. j. curr. res. chem. pharm. sci. 2024;11(2):30-40. 10. obeagu ei, anyiam af, obeagu gu. erythropoietin therapy in hivinfected individuals: a critical review. elite journal of hiv, 2024; 2(1): 51-64 11. obeagu ei, obeagu gu. strength in unity: building support networks for hiv patients in uganda. elite journal of medicine, 2024; 2(1): 1-16 12. obeagu ei, obeagu gu. eosinophilic changes in placental tissues of hiv-positive pregnant women: a review. elite journal of laboratory medicine, 2024; 2(1): 14-32 13. kuhn l, meddows-taylor s, gray g, tiemessen c. human immunodeficiency virus (hiv)-specific cellular immune responses in newborns exposed to hiv in utero. clinical infectious diseases. 2002;34(2):267-276. https://doi.org/10.1086/338153 pmid:11740717 14. muenchhoff m, prendergast aj, goulder pj. immunity to hiv in early life. frontiers in immunology. 2014; 5:391. https://doi.org/10.3389/fimmu.2014.00391 pmid:25161656 pmcid:pmc4130105 15. geng st, zhang zy, wang yx, lu d, yu j, zhang jb, kuang yq, wang kh. regulation of gut microbiota on immune reconstitution in patients with acquired immunodeficiency syndrome. frontiers in microbiology. 2020; 11:594820. https://doi.org/10.3389/fmicb.2020.594820 pmid:33193273 pmcid:pmc7652894 16. obeagu ei, obeagu, gu. the crucial role of erythropoietin in managing anemia in hiv: a review. elite journal of scientific research and review, 2024; 2(1): 24-36 17. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. 18. obeagu ei, obeagu gu. assessing platelet functionality in hiv patients receiving antiretroviral therapy: implications for risk assessment. elite journal of hiv, 2024; 2(3): 14-26 19. obeagu ei, elamin eai obeagu gu. understanding the intersection of highly active antiretroviral therapy and platelets in hiv patients: a review. elite journal of haematology, 2024; 2(3): 111117 20. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 21. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 22. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 23. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 24. obeagu ei, obeagu gu. anemia and erythropoietin: key players in hiv disease progression. elite journal of haematology, 2024; 2(3): 42-57 25. obeagu ei, ayogu ee, obeagu gu. impact on viral load dynamics: understanding the interplay between blood transfusion and antiretroviral therapy in hiv management. elite journal of nursing and health science, 2024; 2(2): 5-15 26. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 27. ifeanyi oe, obeagu gu. the values of prothrombin time among hiv positive patients in fmc owerri. international journal of current microbiology and applied sciences. 2015;4(4):911-916. https://www.academia.edu/download/38320140/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf . 28. yu jc, khodadadi h, malik a, davidson b, salles éd, bhatia j, hale vl, baban b. innate immunity of neonates and infants. frontiers in immunology. 2018; 9:1759. https://doi.org/10.3389/fimmu.2018.01759 pmid:30105028 pmcid:pmc6077196 https://doi.org/10.3389/fimmu.2018.01759 https://doi.org/10.1016/j.jinf.2015.04.027 https://doi.org/10.1016/b978-0-323-79525-8.00013-5 https://doi.org/10.1086/338153 https://doi.org/10.3389/fimmu.2014.00391 https://doi.org/10.3389/fmicb.2020.594820 https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf https://doi.org/10.3389/fimmu.2018.01759 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [48] ajdhs.com 29. levy o. innate immunity of the newborn: basic mechanisms and clinical correlates. nature reviews immunology. 2007;7(5):379390. https://doi.org/10.1038/nri2075 pmid:17457344 30. pieren dk, boer mc, de wit j. the adaptive immune system in early life: the shift makes it count. frontiers in immunology. 2022; 13:1031924. https://doi.org/10.3389/fimmu.2022.1031924 pmid:36466865 pmcid:pmc9712958 31. rackaityte e, halkias j. mechanisms of fetal t cell tolerance and immune regulation. frontiers in immunology. 2020; 11:588. https://doi.org/10.3389/fimmu.2020.00588 pmid:32328065 pmcid:pmc7160249 32. sereme y, toumi e, saifi e, faury h, skurnik d. maternal immune factors involved in the prevention or facilitation of neonatal bacterial infections. cellular immunology. 2024; 395:104796. https://doi.org/10.1016/j.cellimm.2023.104796 pmid:38104514 33. zhang x, zhivaki d, lo-man r. unique aspects of the perinatal immune system. nature reviews immunology. 2017;17(8):495507. https://doi.org/10.1038/nri.2017.54 pmid:28627520 34. sanidad kz, zeng my. neonatal gut microbiome and immunity. current opinion in microbiology. 2020; 56:30-37. https://doi.org/10.1016/j.mib.2020.05.011 pmid:32634598 pmcid:pmc8729197 35. izuchukwu if, ozims sj, agu gc, obeagu ei, onu i, amah h, nwosu dc, nwanjo hu, edward a, arunsi mo. knowledge of preventive measures and management of hiv/aids victims among parents in umuna orlu community of imo state nigeria. int. j. adv. res. biol. sci. 2016;3(10): 55-65. https://doi.org/10.22192/ijarbs.2016.03.10.009 36. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75. 37. oloro oh, oke to, obeagu ei. evaluation of coagulation profile patients with pulmonary tuberculosis and human immunodeficiency virus in owo, ondo state, nigeria. madonna university journal of medicine and health sciences. 2022;2(3):110-119. 38. nwosu dc, obeagu ei, nkwocha bc, nwanna ca, nwanjo hu, amadike jn, elendu hn, ofoedeme cn, ozims sj, nwankpa p. change in lipid peroxidation marker (mda) and non enzymatic antioxidants (vit c & e) in hiv seropositive children in an urban community of abia state. nigeria. j. bio. innov. 2016;5(1):24-30. 39. ifeanyi oe, obeagu gu, ijeoma fo, chioma ui. the values of activated partial thromboplastin time (aptt) among hiv positive patients in fmc owerri. int j curr res aca rev. 2015; 3:139-144. https://www.academia.edu/download/38320159/obeagu_emma nuel_ifeanyi3__et_al.ijcrar.pdf . 40. obiomah cf, obeagu ei, ochei kc, swem ca, amachukwu bo. hematological indices o hiv seropositive subjects in nnamdi azikiwe university teaching hospital (nauth), nnewi. ann clin lab res. 2018;6(1):1-4. 41. omo-emmanuel uk, ochei kc, osuala eo, obeagu ei, onwuasoanya uf. impact of prevention of mother to child transmission (pmtct) of hiv on positivity rate in kafanchan, nigeria. int. j. curr. res. med. sci. 2017;3(2): 28-34.doi: https://doi.org/10.22192/ijcrms.2017.03.02.005 42. aizaz m, abbas fa, abbas a, tabassum s, obeagu ei. alarming rise in hiv cases in pakistan: challenges and future recommendations at hand. health science reports. 2023;6(8):e1450. https://doi.org/10.1002/hsr2.1450 pmid:37520460 pmcid:pmc10375546 43. obeagu ei, amekpor f, scott gy. an update of human immunodeficiency virus infection: bleeding disorders. j pub health nutri. 2023;6 (1);139. 44. obeagu ei, scott gy, amekpor f, ofodile ac, edoho sh, ahamefula c. prevention of new cases of human immunodeficiency virus: pragmatic approaches of saving life in developing countries. madonna university journal of medicine and health sciences. 2022;2(3):128-134. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/86 . 45. walter o, anaebo qb, obeagu ei, okoroiwu il. evaluation of activated partial thromboplastin time and prothrombin time in hiv and tb patients in owerri metropolis. journal of pharmaceutical research international. 2022:29-34. https://doi.org/10.9734/jpri/2022/v34i3a35560 46. odo m, ochei kc, obeagu ei, barinaadaa a, eteng eu, ikpeme m, bassey jo, paul ao. cascade variabilities in tb case finding among people living with hiv and the use of ipt: assessment in three levels of care in cross river state, nigeria. journal of pharmaceutical research international. 2020;32(24):9-18. https://doi.org/10.9734/jpri/2020/v32i2430789 47. obeagu ei, obeagu gu. a review of knowledge, attitudes and socio-demographic factors associated with non-adherence to antiretroviral therapy among people living with hiv/aids. int. j. adv. res. biol. sci. 2023;10(9):135-142.doi: https://doi.org/10.22192/ijarbs.2023.10.09.015 48. obeagu ei, onuoha ec. tuberculosis among hiv patients: a review of prevalence and associated factors. int. j. adv. res. biol. sci. 2023;10(9):128-134.doi: https://doi.org/10.22192/ijarbs.2023.10.09.014 links/6516f938b0df2f20a2f8b0e0/tuberculosis-among-hivpatients-a-review-of-prevalence-and-associated-factors.pdf . 49. obeagu ei, ibeh nc, nwobodo ha, ochei kc, iwegbulam cp. haematological indices of malaria patients coinfected with hiv in umuahia. int. j. curr. res. med. sci. 2017;3(5):100-104.doi: https://doi.org/10.22192/ijcrms.2017.03.05.014 50. okorie hm, obeagu emmanuel i, okpoli henry ch, chukwu stella n. comparative study of enzyme linked immunosorbent assay (elisa) and rapid test screening methods on hiv, hbsag, hcv and syphilis among voluntary donors in. owerri, nigeria. j clin commun med. 2020;2(3):180-183.doi: doi: https://doi.org/10.32474/jccm.2020.02.000137 51. emannuel g, martin o, peter os, obeagu ei, daniel k. factors influencing early neonatal adverse outcomes among women with hiv with post dated pregnancies delivering at kampala international university teaching hospital, uganda. asian journal of pregnancy and childbirth. 2023 jul 29;6(1):203-211. http://research.sdpublishers.net/id/eprint/2819/ . 52. vincent cc, obeagu ei, agu is, ukeagu nc, onyekachi-chigbu ac. adherence to antiretroviral therapy among hiv/aids in federal medical centre, owerri. journal of pharmaceutical research international. 2021;33(57a):360-368. https://doi.org/10.9734/jpri/2021/v33i57a34007 53. madekwe cc, madekwe cc, obeagu ei. inequality of monitoring in human immunodeficiency virus, tuberculosis and malaria: a review. madonna university journal of medicine and health sciences. 2022;2(3):6-15. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/69 54. echendu ge, vincent cc, ibebuike j, asodike m, naze n, chinedu ep, ohale b, obeagu ei. weights of infants born to hiv infected mothers: a prospective cohort study in federal medical centre, owerri, imo state. european journal of pharmaceutical and medical research, 2023; 10(8): 564-568 55. wilson em, sereti i. immune restoration after antiretroviral therapy: the pitfalls of hasty or incomplete repairs. immunological reviews. 2013;254(1):343-354. https://doi.org/10.1111/imr.12064 pmid:23772630 pmcid:pmc3694599 56. misgena dk. the pattern of immunologic and virologic responses to highly active antiretroviral treatment (haart): does success bring further challenges? ethiopian journal of health development. 2011;25(1):61-70. https://doi.org/10.4314/ejhd.v25i1.69853 57. davenport mp, khoury ds, cromer d, lewin sr, kelleher ad, kent sj. functional cure of hiv: the scale of the challenge. nature reviews immunology. 2019;19(1):45-54. https://doi.org/10.1038/s41577-018-0085-4 pmid:30410126 https://doi.org/10.1038/nri2075 https://doi.org/10.3389/fimmu.2022.1031924 https://doi.org/10.3389/fimmu.2020.00588 https://doi.org/10.1016/j.cellimm.2023.104796 https://doi.org/10.1038/nri.2017.54 https://doi.org/10.1016/j.mib.2020.05.011 https://doi.org/10.22192/ijarbs.2016.03.10.009 https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://doi.org/10.22192/ijcrms.2017.03.02.005 https://doi.org/10.1002/hsr2.1450 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://doi.org/10.9734/jpri/2022/v34i3a35560 https://doi.org/10.9734/jpri/2020/v32i2430789 https://doi.org/10.22192/ijarbs.2023.10.09.015 https://doi.org/10.22192/ijarbs.2023.10.09.014 https://doi.org/10.22192/ijcrms.2017.03.05.014 https://doi.org/10.32474/jccm.2020.02.000137 http://research.sdpublishers.net/id/eprint/2819/ https://doi.org/10.9734/jpri/2021/v33i57a34007 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://doi.org/10.1111/imr.12064 https://doi.org/10.4314/ejhd.v25i1.69853 https://doi.org/10.1038/s41577-018-0085-4 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):44-49 [49] ajdhs.com 58. geretti am, brook g, cameron c, chadwick d, french n, heyderman r, ho a, hunter m, ladhani s, lawton m, macmahon e. british hiv association guidelines on the use of vaccines in hivpositive adults 2015. hiv medicine. 2016;17(53):s2-81. https://doi.org/10.1111/hiv.12424 pmid:27568789 59. laupèze b, del giudice g, doherty mt, van der most r. vaccination as a preventative measure contributing to immune fitness. npj vaccines. 2021;6(1):93. https://doi.org/10.1038/s41541-02100354-z pmid:34315886 pmcid:pmc8316335 https://doi.org/10.1111/hiv.12424%20pmid:27568789 https://doi.org/10.1038/s41541-021-00354-z https://doi.org/10.1038/s41541-021-00354-z ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a cross-sectional survey on the awareness of waste management practices among dental practitioners in dental clinic in enugu metropolis justina nnenna ngwu 1 , ezeh chinonyelum moneth 2 , ezinwanne blessing chukwu 2 , oluchukwu stella aduaka 2 , ikemesit udeme peter 3* 1 department of dental therapy, faculty of dental health, federal university of allied health sciences, trans-ekulu, p.m.b. 01473, enugu, nigeria. 2 department of dental nursing, faculty of dental health, federal university of allied health sciences, trans-ekulu, p.m.b. 01473, enugu, nigeria. 3 department of public health, faculty of health technology and engineering, federal university of allied health sciences, trans-ekulu, p.m.b. 01473, enugu, nigeria article info: _____________________________________________ article history: received 18 march 2024 reviewed 16 april 2024 accepted 03 may 2024 published 15 june 2024 _____________________________________________ cite this article as: ngwu jn, moneth ec, chukwu eb, aduaka os, peter iu, a cross-sectional survey on the awareness of waste management practices among dental practitioners in dental clinic in enugu metropolis, asian journal of dental and health sciences. 2024; 4(2):5-13 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.72 _____________________________________________ *address for correspondence: ikemesit udeme peter, department of public health, faculty of health technology and engineering, federal university of allied health sciences, trans-ekulu, p.m.b. 01473, enugu, nigeria abstract _________________________________________________________________________________________________________________ this study was undertaken to examine the level of awareness of waste management practices among dental practitioners at dental clinic in enugu metropolis. a total of forty-five (45) dental practitioners involved in the study were provided with a self-administered questionnaire comprising the source of dental waste management awareness, knowledge attitude, and practices on dental waste. the investigation showed that the main source of dental waste management was through training/conference 82.2%. exactly 71.1% of the practitioners were aware of the guideline laid down by the government for bmw disposal while 6.7% were unaware. the majority of the practitioners 82.2 % were aware of different colored bags used to dispose of different types of waste while 11.1 % and 6.7 % of the respondent tick ‘no’ and ‘don’t know’ respectively. only 15.5% knew that pyrolysis is an environmentally friendly technology that converts organic waste to commercially useful by-products, while 11.1% knew that thermoplastics in dentistry cannot be reused and not biodegradable. few practitioners are aware of the type of incinerator present in their dental clinic 31.1%. however, dental nursing had a higher level of awareness 75.0% over other cadres. also, the gender variable was not significantly related to the level of awareness (p = .903). nevertheless, the female’s counterpart had a higher level of awareness 33.3 % than the male’s counterpart 31.6%. the overall level of awareness of the safe management of dental waste accounted for 31.1% of the respondents. our findings showed that there was a low level of awareness of dental waste management among the studied population. nevertheless, it is important to provide a guide for policies and legislation. this is evident from the fact that it is the knowledge of what specifically constitutes waste and the categories of waste that determine how wastes are dealt with or managed. this knowledge is crucial for properly disposing of dental materials, recovering resources, and assessing technical and environmental implications. moreover, waste management techniques ought to be a regular topic of discussion in training and continuing professional development (cpd) courses. keywords: dental practitioners, waste, management, practices introduction dental healthcare plays an important role in the overall oral health of individuals, and the sector is rapidly growing around the world due to increases in population, healthcare facilities, and improved access for economically weaker sections of society. 1 dental procedures and oral care generate a significant amount of biomedical waste that should be managed in an environmentally safe and sustainable manner. 1 dental waste is associated with different aspects of dentistry, such as oral diagnosis, conservative treatments, periodontology, orthodontics, prosthetics, dental surgeries, xrays, etc. dental waste typically includes swabs, latex, glass, plastics, needles, and other waste often contaminated with bodily fluids, as well as chemical hazardous waste including amalgam-derived products such as mercury, silver, and lead. it can be broadly divided into three categories: infectious waste, non-infectious waste, and domestic-type waste. 2, 3, 4, 5 management of oral health conditions could potentially yield hazardous wastes in the form of dental amalgam, etchants, used x-ray developers and fixers, lead foil packets, and disinfectants, among others.4 amalgam, for example, contains mercury which makes it toxic to both humans and the environment, if not properly disposed. 6, 7 although its use is gradually waning, the effects of mercury on the entire population and the environment have been a source of global concern. 8, 9 a previous study showed that general dental offices could produce 59 kg of waste per day, while specialist dental offices averagely produced 18 kg of waste per day. of these generated wastes, 34% were potentially infectious, and 12% were toxic and chemical wastes. 10 safe management of infectious waste is essential to avoid public health issues such as crosscontamination and transmission of infectious diseases such as hiv or hepatitis. it is a common practice, especially in poor and developing regions, to dump most dental solid waste with household or municipal solid waste into landfills without any separation or recycling processes. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.72 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.72&amp;domain=pdf https://orcid.org/0000-0002-8236-7863 https://orcid.org/0009-0000-4834-6199 https://orcid.org/0009-0004-7114-3954 https://orcid.org/0000-0001-6193-2432 https://orcid.org/0000-0001-9890-8786 ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [6] ajdhs.com in africa, asian and middle-east, it has been noted in previous reports that medical waste is poorly sorted, characterized and disposed, further highlighting its pertinence in the health system framework. 11, 12, 13 in underdeveloped nations, the difficulties in managing the waste from dental facilities are especially apparent. 14, 15 managing dental waste according to accepted norms is much more difficult in developing nations due to limited resources resulting in an increase in health risks and environmental contamination from the improper management, storage, transportation, and disposal of clinical waste. this has been linked to a lack of awareness as well as other elements including legislative obstacles and the lack of professional personnel. 15 dental practitioners are consequently responsible for ensuring that dental waste is treated in accordance with standard criteria. this includes appropriate waste sorting, storage, transportation, and final disposal. this study aimed to investigate the level of awareness of dental waste management techniques among dental practitioners in enugu, nigeria, in order to identify challenges and potential action areas. material and methods research design a cross-sectional survey design was used to determine the level of waste management practices among dental practitioners in fedcotten description of the study area the study was carried out at dental clinic in federal college of dental technology and therapy, trans-ekulu, located at latitude 6°29'07.1"n and longitude 7°29'42.5"e in enugu, nigeria. 3 enugu state is in the southeast geopolitical zone of nigeria. it is made up of seventeen local governments’ area of which three are within the enugu city (enugu south, enugu north, enugu east), abia state to the south and anambra to the west. the state is the home of the igbo of the south-eastern and few of idoma/igala people in ette. it is largely dominated by people of the christian belief and a few muslim and traditional worshipers. enugu is also located within hours drive from onitsha and two hours’ drive from aba another very large commercial city both of which are trading centre in nigeria. the study area, some selected government clinics in enugu metropolis, enugu state. the clinic belongs to the college which started in the year 1958 in lagos and was brought to enugu in the year 1982. the college trains students to acquire degrees/ higher national diploma in various fields of works such as dental technology, dental therapy, dental nursing, social works, biomedical engineering and presently running postgraduate program, the college is located at dental avenue nike road in east region of nigeria. 16 population of study/ sample size and sampling technique as obtained from the health records of the federal college of dental technology and therapy, transekulu, enugu, and enugu state hospital management board, dental sub-district hospital. the clinic workforce has a capacity of 45 staff, this includes males and females. no sample size was adopted, because of the number of practitioners. this simply means that all the dental practitioners in the selected clinics were involved in the study. a self-administered questionnaire was used to record the type of practice, source of awareness, knowledge attitude, and practices on dental waste. the survey form will be composed of questions framed based on knowledge, attitude, and those regarding the practice of dentists about dental waste management. confidentiality of the participants will be maintained by coding the questionnaires. the percentage response for each question from all the participants was obtained and the data was subjected to statistical analysis. research instrument and administration the research instrument used in this study is the questionnaire. a survey containing a series of questions was administered to the enrolled participants. the questionnaire was divided into two sections, the first section enquired about the response's demographic or personal data while the second section was in line with the study objectives, aimed at providing answers to the research questions. participants were required to respond by placing a tick at the appropriate column. the questionnaire was personally administered by the researcher. reliability of instrument the reliability of the research instrument was determined. the pearson correlation coefficient was used to determine the reliability of the instrument. a co-efficient value of 0.05 indicated that the research instrument was relatively reliable. method of data collection before the initiation of the study, the researcher collected a letter of introduction from the head of dental nursing department, and approval from the research and ethics committee of the federal college of dental technology and therapy enugu to approach the dentist in-charge of dental clinic for permission to carry out the study. the data collection takes place at the dental clinic on mondays through fridays, with the support of two (2) research assistants. the questionnaire was gathered instantly on-site, and data collection lasted one (2) week. method of data analysis data collected was analyzed in a simple frequency table and percentage. it was also presented in figures and easy form for easy understanding. test of hypothesis the waste management index (wmi) was used to determine the awareness of waste management practice among dental practitioners. z-test will also be used to support the wmi test carried out at level of significance 0.05. this is mathematically presented as: z = x-µ ø/n where x = sample mean µ = population mean ø = standard deviation n = sample size ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [7] ajdhs.com results table 1: demographic characteristics of the respondents n = 45 variables frequency percent (%) gender male 19 42.2 female 24 53.3 no response 2 4.4 marital status married 26 57.8 single 13 28.9 no response 6 13.3 cadre dental surgeon 9 20.0 dental nursing 4 8.9 dental therapy 11 24.4 dental technology 13 28.9 auxiliary staff 4 8.9 year of service 0-5 6 13.3 5-10 16 35.6 10-20 14 31.1 20-25 2 4.4 25-35 5 11.1 no response 2 4.4 qualification ph.d. or higher 1 2.2 master's degree 4 8.9 bachelor's degree 24 53.3 diploma 11 24.4 no response 5 11.1 table 1 shows the demographic characteristics of the respondents. female counterparts accounted 53.3% over male counterparts (42.2%). the married individuals were more than single individuals recording 57.8% and 28.9 % respectively. their cadre was thus: dental surgeon (20.0%), dental nursing (8.9%), dental therapy (24.4%), dental technology (28.9%) and auxiliary staff (8.9%). the majority have been in service for 5-10 years (35.6%) and 10-20 years (31.1%). the majority of the respondents had bachelor’s degree 53.3% while other qualifications accounted for a diploma 24.4 % and a master's degree 8.9 % and 2.2 % ph. d. ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [8] ajdhs.com research question 1: what is the level of awareness of waste management practice among dental practitioner? table 2: awareness on dental waste management practices n = 45 variable frequency percent (%) are different colored bags used to dispose different types of waste yes* 37 82.2 no 5 11.1 don't know 3 6.7 used disposable plastic items (e.g., catheter) are disposed in yellow bags* 11 24.4 red bags* 4 8.9 black bags 6 13.3 don't know 24 53.3 soiled dressing and used impression materials are disposed in blue/white bags 11 24.4 red bags 5 11.1 black bags* 12 26.7 don't know 17 37.8 used sharps and needles are disposed in yellow bags 8 17.8 rigid/puncture-proof container* 27 60.0 red bags 3 6.7 don't know 7 15.6 extracted teeth and human tissue are disposed in yellow bags 20 44.4 red bags* 7 15.6 black bags 6 13.3 don't know 12 26.7 plaster of paris is disposed of in yellow bags 6 13.3 red bags 2 4.4 black bags* 16 35.6 don't know 21 46.7 amalgam are disposed of in yellow bags* 17 37.8 red bags 1 2.2 black bags 8 17.8 don't know 19 42.2 pharmaceutical waste are disposed of in yellow bags* 15 33.3 black bags 10 22.2 don't know 20 44.4 x-ray fixer, x-ray developer are disposed of in yellow bags* 13 28.9 red bags 1 2.2 black bags 9 20.0 don't know 22 48.9 overall level of awareness good 14 31.1 poor 31 68.9 *denotes the right options from table 2, 82.2% dental practitioners knew that there are different colored bags used in disposing of different types of waste while 24.4%, 8.9%, and 13.3% knew that used disposable items are disposed of in yellow bags, red bags, and black bags respectively. about 26.7% of the dental practitioners were aware that soiled dressing and used impression materials are disposed of in black bags. exactly 60.0 % of dental practitioners knew that used sharps and needles are disposed of in rigid/puncture-proof containers while 44.4% of the respondents knew that extracted teeth and human tissue are disposed of in red bags. about 35.6 % had an awareness that plaster of paris is disposed of in black bags. the majority knew that the following are disposed of in yellow bags: amalgam (37.8%), pharmaceutical waste (33.3%), and x-ray fixer, x-ray developer (28.9%). specifically, their overall level of awareness of dental waste management practices was not high, only 31.1% were aware. ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [9] ajdhs.com research question 5: what is their source of information on waste management? table 3: what are the sources of awareness for dental waste management n = 45 sources frequency percent (%) training/conference 37 82.2 television 1 2.2 from a colleague 6 13.3 analyses in table 3 show the sources of awareness for dental waste management. the main source was through training/conference (82.2%). table 4: dental waste carrier n = 45 variable frequency percent (%) are there guidelines laid down by government of nigeria for bmw management yes* 32 71.1 no 3 6.7 don't know 10 22.2 is there any biomedical waste disposal policy in your hospital/clinic yes* 17 37.8 no 6 13.3 don't know 22 48.9 safe management of dental waste is the responsibility of only government 2 4.4 team work of dental surgeon, dental nursing, dental therapy, dental technology & auxiliary* 37 82.2 don't know 6 13.3 *denotes the right options the result in table 4 shows that 71.1 % of dental practitioners knew that there are guidelines laid down by the government of nigeria for bmw management while 37.8% knew that there is a biomedical waste disposal policy in their hospital/clinic. exactly 82.2% of the dental practitioner knew that the safe management of dental waste is a teamwork of dental surgeons, dental nursing, dental therapy, dental technology and auxiliary. table 5: general hazards of improper dental waste disposal n = 45 variable frequency percent (%) all are true for hazardous waste except containers to be closed except while removing and adding waste* 24 53.3 containers must be clean on the outside 4 8.9 containers are to be compatible with the waste 3 6.7 any type of containers can be used for dental waste 14 31.1 no response 4 8.9 is maintaining bio-medical waste records mandatory in your hospital/clinic yes* 17 37.8 no 7 15.6 don't know 21 46.7 does your hospital/clinic generate bio-medical waste yes* 20 44.4 no 2 4.4 don't know 23 51.1 *denotes the right options table 5 reveals that 53.3 % of the dental practitioners knew that containers must be closed except while removing and adding waste. exactly, 37.8% of the studied health practitioners knew that maintaining bio-medical waste records is mandatory in their hospital/clinic, while 44.4% work in a hospital that generates bio-medical waste. ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [10] ajdhs.com table 6: certain material/process specific question in relation to dental waste n = 45 variable frequency percent (%) which of the below is an environment friendly technology that converts organic waste to commercially useful by-products controlled tipping 6 13.3 double pot method 1 2.2 plasma pyrolysis* 7 15.6 none of the above 3 6.7 no response 28 62.2 can thermoplastics in dentistry be reused and are they biodegradable yes 11 24.4 no* 5 11.1 don't know 29 64.4 are you aware of the type of incinerator present in your clinic yes 14 31.1 no 7 15.6 don't know 24 53.3 *denotes the right options table 6 display findings on certain material/process-specific questions about dental waste. only 15.5% of the dental practitioners knew that pyrolysis is an environmentally friendly technology that converts organic waste to commercially useful by-products, while 11.1% of the studied population knew that thermoplastics in dentistry cannot be reused and not biodegradable. exactly 31.1% of the dental practitioner were aware of the type of incinerator present in their clinic. hypotheses 1: what cadre of dental practitioners exhibited higher level of awareness? table 7: relationship between cadre and level of awareness variable awareness good poor total fisher’s exact p-value cadre 4.228 .390 dental surgeon 3(33.3) 6(66.7) 9 dental nursing 3(75.0) 1(25.0) 4 dental therapy 2(18.2) 9(81.8) 11 dental technology 5(38.5) 8(61.5) 13 auxiliary staff 1(25.0) 3(75.0) 4 our data in table 7 shows that the cadre of the dental practitioners were not significantly related to their level of awareness (p = .390). however, dental nursing 75.0% had a high level of awareness than other cadres. hypotheses 2: what gender displayed a higher level of awareness? table 8: relationship between gender and awareness level variable awareness good poor total chi-square p-value gender .015 .903 male 6(31.6) 13(68.4) 19 female 8(33.3) 16(66.7) 24 table 8 shows that gender was not significantly related to awareness level (p = .903). nevertheless, females had a higher level of awareness (33.3%) than the males (31.6%). ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [11] ajdhs.com discussion wastes management services are essential services that must be provided in every society, nonetheless very little is known on what exactly constitute a waste. hence, it is important to have a clear guide as to what could be classed as waste. dental waste management has not received much attention in developing countries and segregation of dental waste into risk and non-risk waste is usually not performed in most oral health facilities. workers have little awareness of hazards associated, and disposal techniques are poor. in the present study, (71.1%) are aware of the guideline laid down by government for bmw disposal, (6.7%) said no, and however, (22.2%) of the participants were uncertain regarding the legislative aspect around the law aspect. this is in line with the studies conducted in rajasthan and delhi also concluded that the knowledge was insufficient in regard to the regulations and laws behind bwm. 17 which are concurrent with those in southern india where 28% of participants were unaware of the laws. 18 few participant knew that there are different colored bags used in disposing different types of waste (82.2%), 24.4%, 8.9% and 13.3% knew that used disposable items are disposed in yellow bags, red bags and black bags respectively, which is similar to the studies conducted in in enugu, nigeria, davangere and chennai cities in india. 14, 19, 20 it worth noting that uniform color coding and labeling system for the different categories of hospital waste affects the efficiency of collection and handling and the integrity of the final waste treatment processes. about (28.9%) dispose x-ray fixer, x-ray developer in yellow bags and 48.9% said don’t know which is not permitted because lead is heavy metal that affects neurological development and functions. 21 similarly, a study in iran showed that 78% of the facilities studied disposed of lead foil packets with general waste. 22 lead foil packets are the waste products left behind after conventional x-rays are taken. the lead could leach into the soil and ground if disposed into landfills, causing environmental pollution. lead waste should be returned to manufacturers for recycling or disposal. 23 intake of high levels of lead can predispose one to reproductive defects, nerve defects, cancers, hypertension, impairment in kidney function and immunological impairments about (37.8%) of the respondents said they disposed amalgam in yellow bags in contrast to the studies conducted in india and palestine. 24, 25 earlier report by owusu et al. 15 in ghana found an unsatisfactory practice with amalgam disposal. a study in india reported that 79% of the respondents disposed of their generated amalgam waste together with general waste, while 13% of them disposed of this waste in other inappropriate ways. 12 in a facility-based study in iran, it was found that 92% of the facilities disposed of amalgam waste in toilets as well as the sewer system. 22 a study done in palestine found that over 80% of generated amalgam waste was disposed of into either the clinic garbage or drain. 26 this is similar to the study conducted by sudhir. 19, in which 11.3% of the participants reported disposal of silver amalgam into the common bin, the recommended method by the american dental association (ada). 27 about (82.2%) of the respondents said main source of awareness for dental waste management is training/conference, which is similar to a study conducted by daou et al.28 in lebanon, in which 41% of the involved participants received training programs on health care waste management. the level of awareness was adequate there is an appreciable need for more education, monitoring, and empowerment concerning waste management in dentistry. about (17.8%) of the practitioners disposed sharps and needle in yellow bag container, which is similar to study, conducted in new zealand, in which 24.4% of participants disposed of them into the common bin. 29 in present study, more than half of the respondents (60.0%) of the practitioners reported that they are using puncture proof bags to dispose of sharps/needles, which is the ideal method. this is in agreement with the studies conducted in kenya and ajman, united arab emirates 30, 31 in which 61% and 56% of respondents applied the recommended manner for sharps/needles, respectively. a cross-sectional study that included 595 private and public dental offices and clinics in shiraz university, iran revealed about 90% of dental workplaces and facilities that arranged their contagious waste with interior waste and only 60% of centers utilized a standard system for sharps transfer. 32 another study in lebanon clearly expressed that only 28% practitioners segregated sharp waste in an appropriate container; only 70% of dentists reported treating their infectious waste before disposal; about two thirds of the surveyed dental practitioners do not follow the local guidelines; and half of them do not provide the proper precautionary measures while managing the dental wastes. 28 this materials are contaminated with blood or other infectious mouth fluids and it is essential to avoid public health issues such as cross-contamination and transmission of infectious diseases such as hiv or hepatitis through decontamination by first using an autoclave, steam auger, dry heat, microwave, or chemical disinfection prior to their disposal alongside nonhazardous waste streams or incinerated at temperatures above 1100 ⁰c. 1 the overall level of awareness of the safe management of dental waste accounted for (31.1%) of the respondents which is similar to a study conducted by kishore et al. 33 in new delhi, with reported awareness of 36% among participant but lower than high level of awareness reported by other researchers; janakiram and vidyapeetham. 24 in bangalore in which 57.6% were aware, while other studies conducted by an. 20 in chennai city reported awareness of 72% while only 33.4% of the study sample received professional training on waste management in jeddah saudi arabia. 34 this shows that awareness of waste management policy varies between cities. they should be made aware of the recent advances in the waste disposal, and practical application of proper waste management must be included in the dentistry. global awareness should be created regarding the correct methods of waste disposal as well as about incorporating new methods to recycle waste wherever possible. conclusion dental care plays an essential role in the general health of individuals and the public, and the development of a significant amount of biological waste is unavoidable during oral care and dental operations. our findings showed that there was a low level of awareness for dental waste management among the studied population. nevertheless, it is important to provide a guide for the purposes of policies and legislations. this is evident from the fact that, it is the knowledge of what specifically constitute a waste and the categories of wastes that determines how wastes are dealt with or managed. further research is needed to understand how novel dental materials degrade thermally. a wide range of novel nano-materials, resins, composites, and ceramics are being created to meet the varied criteria/characteristics required in different dental applications. however, nothing is known about the fundamental properties of these materials' separate ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [12] ajdhs.com components. this knowledge is crucial for properly disposing of dental materials, recovering resources, and assessing technical and environmental implications. moreover, waste management techniques ought to be a regular topic of discussion in training and continuing professional development (cpd) courses. as awareness and understanding grow, administrators and managers may also have a larger responsibility to guarantee that a supportive work environment and the required resources are available. acknowledgement our appreciate goes to all the dental staff of fedcodtten for their support during the study. author’s contributions: all authors investigated the study, did literature searches and did data validation and visualization. all the authors reviewed and approved the final draft, and are responsible for all aspects of the work. competing interests authors have declared that no competing interests exist. funding source: none ethical consideration ethical approval with reference no: drec/rs/011/23 was obtained from the research and ethics committee of federal college of dental technology and therapy, trans-ekulu, enugu state, nigeria references 1. khanna r, konyukhov y, maslennikov n, kolesnikov e, burmistrov i, an overview of dental solid waste management and associated environmental impacts: a materials perspective, sustainability, 2023; 15:159-53 https://doi.org/10.3390/su152215953 2. yamashita y, nishi y, murakami m, harada k, nishimura m, impact of surface changes and microbial adhesion on mucosal surface finishing of resin denture bases by shot blast polishing using viscoelastic media, materials, 2022; 15:22-75 https://doi.org/10.3390/ma15062275 pmid:35329731 pmcid:pmc8955808 3. edemekong c i, iroha i r, thompson m d, okolo io, uzoeto ho, ngwu j n, mohammed i d, chukwu e b, nwuzo a c, okike b m, okolie s o and peter iu, phenotypic characterization and antibiogram of non-oral bacteria isolates from patients attending dental clinic at federal college of dental technology and therapy medical center enugu, international journal of pathogen research, 2022; 11(2):7-19, https://doi.org/10.9734/ijpr/2022/v11i2207 4. mandalidis a, topalidis a, voudrias e a, iosifidis n, composition, production rate and characterization of greek dental solid waste, waste management, 2018; 75:124-130, https://doi.org/10.1016/j.wasman.2018.01.035 pmid:29398270 5. kizlary e, iosifidis n, voudrias e, panagiotakopoulos d, composition and production rate of dental solid waste in xanthi, greece: variability among dentist groups, waste management, 2005; 25:82-591 https://doi.org/10.1016/j.wasman.2004.10.002 pmid:15993342 6. bonsor s j, burke t, pearson g j, a clinical guide to applied dental materials; elsevier: amsterdam, the netherlands, 2013, 31, 7. unep, minamata convention on mercury; unep: geneva, switzerland, 2017, 32, 8. regulation (eu) 2017/852, regulation (eu) 2017/852 of the european parliament and of the council of 17 may 2017 on mercury and repealing regulation (ec) no 1102/2008, office journal of european union, 2017;137:1-21, 9. tibau av, grube bd, mercury contamination from dental amalgam, journal health pollution, 2019; 9:190-612 https://doi.org/10.5696/2156-9614-9.22.190612 pmid:31259088 pmcid:pmc6555253 10. koolivand a, bullet fathollah, bullet gb, nourmoradi h, investigation on the characteristics and management of dental waste in urmia, iran, journal of material cycles waste management, 2014; 17:553-559 https://doi.org/10.1007/s10163-014-0278-2 11. adu ro, gyasi sf, essumang dk, otabil kb, medical waste-sorting and management practices in five hospitals in ghana, journal of environmental public health, 2020; 4: 293-4296. https://doi.org/10.1155/2020/2934296 pmid:32190061 pmcid:pmc7073495 12. arora r, agrawal a, singh d, reddy j, management of dental waste in private clinics in chhattisgarh state, india-a cross sectional study, iosr journal of dental and medical sciences (iosr-jdms), 2014;13(1): 53-56 https://doi.org/10.9790/0853-13155366 13. purnama t, tooth brushing skills and personal hygiene performance modified (php-m) index in preschool children. asian journal of dental and health sciences 2023;3(3):10-13 https://doi.org/10.22270/ajdhs.v3i3.47 14. chikanma n, okoronkwo s c, emaimo j, ejike ea, ismaila md, adedoja or, ugwu na, olofin oa, dental waste management practices among dental professionals in selected dental hospitals/clinics and laboratories in south east nigeria, iosr journal of dental and medical sciences, 2021, 20(5):43-48 15. owusu aa, kploanyi ee, blankson p, manu a, goka, ry, armah rn, akweongo p, waste management practices among dental surgery staff of major hospitals in accra: a descriptive cross-sectional study, pamj one health, 2023;10(5):10-11604 https://doi.org/10.11604/pamj-oh.2023.10.5.37738 16. ngwu jn, uzoeto ho, emaimo j, okorie c, mohammed id, edemekong ci,peter iu, ezeh c, chukwu e, adimora ee, ani se, oke b, moses i, b, nwakaeze ea, otu jo, chukwunwejim c r, egbuna rn ikusika ba, adagiri p, iroha ir, antibiogram of biofilm forming oral streptococci species isolated from dental caries patients visiting federal college of dental technology and therapy, enugu nigeria, international journal of research report in dentistry, 2022;5(1):12-25 17. dhanya rs, betur ap, bulusu a, adarsh vj, koshy pv, pinto b, management of biomedical waste in dental clinics, international journal of oral care research, 4:288-90. https://doi.org/10.5005/jp-journals-10051-0065 18. charania zk, ingle na, awareness and practices of dental care waste management among dental practitioners in chennai city, journal of contemporary dentistry, 2011; 1(1):15-21. https://doi.org/10.5005/jcd-1-1-15 19. sudhir k, awareness and practice about dental health care waste management among dentists of davanagere city, karnataka, journal of indian association of public health and dentistry, 2006, 8:44-50. https://doi.org/10.4103/2319-5932.195028 20. an k, awareness and practices of dental care waste management among dentists in chennai city a cross sectional study, journal of indian association of public health and dentistry, 2011:289-96 https://doi.org/10.4103/2319-5932.185143 21. pourret o, hursthouse a, it's time to replace the term "heavy metals" with "potentially toxic elements" when reporting environmental research, international journal environmental research and public health 2019, 16:44-46. https://doi.org/10.3390/ijerph16224446 pmid:31766104 pmcid:pmc6887782 22. zazouli m, ehsan r, assessment of dental waste production rate and management in sari, iran, journal of advance in environmental health research, 2014;11008(2): 120-125, 23. naik r, sureshchandra b, hegde ss, damda a, malik m, best management practices for hazardous dental waste disposal, endodontology, 2011;23(2): 108 https://doi.org/10.4103/09707212.352028 https://doi.org/10.3390/su152215953 https://doi.org/10.3390/ma15062275 https://doi.org/10.9734/ijpr/2022/v11i2207 https://doi.org/10.1016/j.wasman.2018.01.035 https://doi.org/10.1016/j.wasman.2004.10.002 https://doi.org/10.5696/2156-9614-9.22.190612 https://doi.org/10.1007/s10163-014-0278-2 https://doi.org/10.1155/2020/2934296 https://doi.org/10.9790/0853-13155366 https://doi.org/10.22270/ajdhs.v3i3.47 https://doi.org/10.11604/pamj-oh.2023.10.5.37738 https://doi.org/10.5005/jp-journals-10051-0065 https://doi.org/10.5005/jcd-1-1-15 https://doi.org/10.4103/2319-5932.195028 https://doi.org/10.4103/2319-5932.185143 https://doi.org/10.3390/ijerph16224446 https://doi.org/10.4103/0970-7212.352028 https://doi.org/10.4103/0970-7212.352028 ngwu et al asian journal of dental and health sciences. 2024; 4(2):5-13 [13] ajdhs.com 24. janakiram c, vidyapeetham av, dental health care waste disposal among private dental practices in bangalore city, india, 2008; international dental journal, 58 (1):51-4 https://doi.org/10.1111/j.1875-595x.2008.tb00176.x pmid:18350854 25. al-khatib i a, darwish r, assessment of amalgam waste management in dental clinics in ramallah and al bireh cities in palestine, international journal of environmental health research, 2004;14:179-83, https://doi.org/10.1080/09603120420002000218598 pmid:15203449 26. darwish, rro, al-khatib ia, evaluation of dental waste management in two cities in palestine, east mediterranean health journal, 2006;12(2): s217-22, 27. american dental association, best management practices for amalgam waste, availablefrom:http://www,ada,org/~/media/ada/membercente r/files/topics_amalgamwaste_brochure,ashx, 2019, 28. daou mhr, karam s, khali, d, mawla, t, current status of dental waste management in lebanon, environmental nanotechnology monitoring and management, 2015; 4:1-5 https://doi.org/10.1016/j.enmm.2015.04.002 29. treasure e, treasure p, an investigation of the disposal of hazardous wastes from new zealand dental practices, community dental oral epidemiology, 1997; 25:328-31. https://doi.org/10.1111/j.1600-0528.1997.tb00948.x pmid:9332812 30. la o, lw g, bk k and rj m, management of dental waste by practitioners in nairobi, kenya, african journal of oral health, 2005;2 (2):24-29. 31. hashim r, mahrouq r, hadi n, evaluation of dental waste management in the emirate of ajman, united arab emirates, journal of international dental medicine and research, 2011; 4 (2):64-69, 32. danaei m, karimzadeh p, momeni m, palenik cj, nayebi m, keshavarzi v, askarian m, the management of dental waste in dental offices and clinics in shiraz, southern iran, international journal of occupational and environmental medicine, 2014, 5 (1):18-23, 33. kishore j, goel p, sagar b, joshi t k, awareness about biomedical waste management and infection control among dentists of a teaching hospital in new delhi, india, indian journal of dental research, 1999; 11:157-61 34. sabbahi da, el-naggar hm, zahran mh, management of dental waste in dental offices and clinics in jeddah, saudi arabia, journal of the air and waste management association, 2020; 70, 10, 1022-1029 https://doi.org/10.1080/10962247.2020.1802366 pmid:32720860 https://doi.org/10.1111/j.1875-595x.2008.tb00176.x https://doi.org/10.1080/09603120420002000218598 https://doi.org/10.1016/j.enmm.2015.04.002 https://doi.org/10.1111/j.1600-0528.1997.tb00948.x https://doi.org/10.1080/10962247.2020.1802366 a’yun et al asian journal of dental and health sciences. 2023; 3(4):11-14 [11] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited risk factors for caries in elementary school children based on caries management by risk assessment (cambra) quroti a’yun*, herastuti sulistyani, dewi risnawati, ika fitri dilianti d department of dental health, health polytechnic yogyakarta, indonesia article info: _____________________________________________ article history: received 03 october 2023 reviewed 09 november 2023 accepted 28 november 2023 published 15 december 2023 _____________________________________________ cite this article as: a’yun q, sulistyani h, risnawati d, dilianti d if, risk factors for caries in elementary school children based on caries management by risk assessment (cambra), asian journal of dental and health sciences. 2023; 3(4):11-14 doi: http://dx.doi.org/10.22270/ajdhs.v3i4.57 _____________________________________________ *address for correspondence: quroti a’yun, department of dental health, health polytechnic yogyakarta, indonesia abstract _________________________________________________________________________________________________________________ background: the prevalence of dental caries in children aged 10 to 14 years is almost 41.4%. the cambra method helps doctors identify the cause of dental caries by identifying risk factors in each patient. based on research, the etiology of dental caries was found by identifying risk factors in each participant. this study aims to describe what factors influence dental caries in children based on cambra. method: this research uses observational analysis with. the respondents were students at sdn kadipiro i, bantul, special region of yogyakarta, indonesia. purposive sampling was used to create the sample, which included 82 children between the ages of 10 and 12 years. the research was carried out by finding dental caries risk factors using the cambra method: 1. cavity or new dentin lesion, 2. white spot, 3. restoration in the last three years, 4. saliva volume, 5. plaque index/phpm, 6. water ph saliva, and 7. frequency of consumption of sweet foods. data were analyzed using the spss version 25.0 program which included frequency analysis. results: the results of the analysis showed five risk factors for caries, namely the condition of the teeth, cavities or new dentin lesions were found in 58 respondents (70.7%), predisposing factors, the number of plaque was obtained in 44 respondents (53.7%), the frequency of protective factors was obtained and the frequency of caries was obtained. 63 respondents experienced dental caries. conclusion: the risk factors for dental caries based on cambra that influence children's dental caries are the criteria for lesion depth of dentin, saliva ph, and amount of plaque. keywords: cambra, risk factors, caries, children introduction dental caries together with periodontal disease are the most common dental and oral diseases in society, including children. dental caries is an infectious disease that has become a global health problem. dental caries has a prevalence five times higher than asthma and seven times higher than allergic rhinitis. it is estimated that 89% of indonesian children under the age of 12 suffer from dental caries.1–3 basic health research in 2018 recorded that 45.3% of the indonesian population had dental and oral health problems and in the special region of yogyakarta the figure was 47.7%. the prevalence of dental caries in children aged 10-14 is 41.4%.4 dental caries that is not treated in children will cause many unfavorable things, for example the emergence of pain, the possibility of infection, and the occurrence of foci of infection in the body, disruption of daily activities, psychomotor problems, and growth disorders.5,6 dental caries is one of the problems that often arises during a child's growth and development, in addition to other problems, namely malnutrition, obesity and allergies.7 dental caries is a multifactorial disease, one of which involves substrate etiological factors, in this case carbohydrates, as the most essential medium for cariogenic bacteria. caries is an irreversible microbiological disease of calcified tooth tissue which is characterized by demineralization of inorganic material and destruction of organic tooth material and will cause cavities. caries is a disease of hard tooth tissue which is characterized by decalcification of inorganic dental material and loss of mineral content and is followed by damage to the organic tooth matrix. caries is a multifactorial disease, which is the interaction of several factors. newburn developed the concept of caries tetralogy, which concluded that there are 4 main factors that interact in the process of caries occurrence. the four factors are: (1) teeth (2) bacteria, (3) carbohydrate substrate/diet, (4) time as an additional factor.8,9 caries management by risk assessment (cambra) builds an understanding of dental caries, which is a disease initiated by a complex biofilm (not just one pathogen), which dynamically changes with the environment and local chemical factors on the tooth surface, pellicle and saliva. the cambra philosophy was first introduced nearly a decade ago when an informal group called the western cambra coaliton was formed that included stakeholders from education, research, industry, government agencies and private practitioners in the western region of the united states. this research is focused on obtaining caries risk factors based on the caries risk assessment form. caries risk prediction equation, and the contribution of caries risk factors.10 method and material the research design used is quantitative research, namely observational. this research did not manipulate variables but looked at the reality directly from respondents, namely the risk factors for child caries based on cambra. this research was carried out at sdn kadipiro i, bantul regency, special region of yogyakarta. the total sample was 82 children, with a sampling technique using side purposive with research sample inclusion open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i4.57 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i4.57&amp;domain=pdf a’yun et al asian journal of dental and health sciences. 2023; 3(4):11-14 [12] ajdhs.com criteria: male/female aged 9-12 years and willing to be research samples. data collection was carried out quantitatively using the following measuring instruments: decay index, check-list of tooth condition variables, check-list of biological predisposing factor variables, check-list of protection factor variables. the analysis used is descriptive analysis presented in a frequency distribution. result table 1. distribution of respondent characteristics respondent characteristics frequency percentage gender male 44 53.7 female 38 46.3 mother's education elementary school 13 15.9 junior high school 23 28.0 senior high school 36 43.9 bachelor 10 12.2 based on table 1, it was found that 44 (53.7%) of the respondents were male with 36 (43.9%) of their mothers' education being high school. table 2. frequency distribution condition of teeth variable yes no n % n % cavities/dentin depth lesions 58 70,7 24 29,3 proximal enamel lesions 10 12,2 72 87,8 white spots on the surface 30 36,6 52 63,4 restoration in the last 3 years 7 8.5 75 91.5 based on table 2, it was found that 58 (70.7%) respondents had cavities/dentin depth lesions, 72 (87.8%) respondents had proximal enamel lesions, 52 (63.4%) respondents had white spots on the surface, and 75 respondents did not have any damaged teeth. table 3. frequency distribution of biological predisposing factors variable yes no n % n % biofilm maturation 34 41,5 48 58,5 there is high plaque >27 38 46,3 44 53.7 consuming sweet foods more than 3 times a day 55 67.0 27 33.0 factors that reduce the rate of saliva flow 0 0 82 100 saliva volume <1ml/minute 47 57.3 35 42.7 there are deep pits and fissures 37 45,1 45 54,9 take medication 0 0 82 100 there are open roots 11 13,4 71 86,6 using orthodontic appliances 0 0 82 100 the results of the analysis of the frequency distribution of predisposing factors in table 3 show that 48 respondents (58.5%) had no mature biofilm, 44 respondents (53.7%) had a low number of plaques, and 55 respondents (67.0%) consumed sweet foods more than 3 times/day. a total of 82 respondents (100%) had no factors that influence saliva flow rate, 47 respondents (57.3%) had a volume of less than 1 ml/minute, and 45 respondents (54.9%) had no deep pits and fissures. table 5 also shows that 82 (100%) did not consume drugs that affect saliva flow, 71 respondents (86.6%) did not have open roots, and 82 respondents (100%) did not use orthodontic devices. a’yun et al asian journal of dental and health sciences. 2023; 3(4):11-14 [13] ajdhs.com table 4. frequency distribution of protection factors variable yes no n % n % fluoridation of drinking water 26 31,7 56 68,7 fluoride toothpaste at least once a day 80 97,6 2 2,4 fluoride toothpaste at least twice a day 73 89 9 11 mouthwash (0.05% na f) every day 1 1,2 81 98,8 fluorine varnish (last 6 months) 8 9,8 74 90,2 topical fluoride (last 6 months) 4 4,9 78 95,1 chlorhexidine mouthwash (every 1 x / week in the last 6 months) 2 2.4 80 97.6 xylitol gum/lozenge 4 times a day for the last 6 months 2 2.4 80 97.6 calcium phosphate for the last 6 months 6 7,3 76 92,7 the frequency distribution of protective factors in table 4 shows that 56 respondents (68.7%) have no fluoridation of drinking water, 80 respondents (97.6%) brush their teeth at least once a day, and 73 respondents (89%) brush their teeth at least once a day. 2 times a day. a total of 81 respondents (98.8%) did not use mouthwash (0.05% naf) every day, 74 respondents (90.2) did not get fluor varnish (last 6 months), and 78 respondents (95.11) did not get topical fluoride treatment (last 6 months). the results of measuring gargling with chlorhexidine (every 1 x / week in the last 6 months) showed that 80 respondents (98.8%) did not do it, 80 respondents (98.8%) did not have the habit of chewing xylitol gum/lozenge 4 x a day for 6 months last time, and 76 respondents (92.7%) did not receive calcium phosphate during the last 6 months. table 5. description of the frequency of dental caries variable yes no n % n % dental caries 19 23,2 63 75,8 table 5 shows that the frequency distribution of caries is that 63 respondents experienced dental caries. discussion based on the research results, before chewing the apple, the average value was 2.113 in the apple group, after chewing the apple, the average value was 0.431, based on the wilcoxon test, the significance value was 0.001 < 0.05. this means that there is a difference between the pre-test and post-test in the apple group. based on the results of statistical tests, it was found that the lowest debris index value before chewing an apple children are at varying degrees of risk for caries throughout their lives. increasingly, recent findings suggest that for success in caries prevention, dental health professionals must initiate preventive interventions from the first year of life. the consequences of childhood dental caries include a higher risk of new carious lesion cavities in both primary and permanent teeth, increased risk of hospitalization and emergency department visits, increased costs and time of treatment, inadequate physical development (especially height and weight). body), loss of time at school and reduced ability to receive lessons, and reduced quality of life related to dental and oral health.11 the concept of caries balance/imbalance is a visual depiction of the multifactorial nature of caries. this illustrates the determinants of caries, and the dynamic interaction of the biofilm with the oral environment. it is this oral environment that will determine the nature of the biofilm on each tooth surface and if the condition is severe enough to cause demineralization and visible changes on the tooth surface. demineralization occurs due to an imbalance between existing risk factors and protective factors. this entire process is called a caries risk assessment. caries balance/imbalance is a balance between caries indicators, risk factors and protective factors that will determine whether the caries process continues, stops or remineralization occurs.11 cambra is an evidence-based approach to prevent or treat the causes of dental caries at an early stage rather than waiting for permanent damage to the teeth. this philosophy requires an understanding that dental caries is a disease of infectious biofilm bacteria that arises in an oral cavity environment dominated by pathological factors. researchers suggest this disease is a consequence of a shift in the homeostatic balance of normal microflora due to changes in local environmental conditions, for example ph, which favor the growth of cariogenic pathogens.12 the essence of the cambra philosophy of care is the assessment of each individual patient's disease indicators, risk factors and protective factors to determine current and future dental caries disease.13 caries risk assessment (cra) is an important component of caries management and should be considered the standard of care and included as part of the dental examination. this is important in decision making to guide the dentist in determining the diagnosis, prognosis and treatment plan for each patient. implementation of caries risk assessment in clinical practice is best done using the cra form, to ensure that each patient is systematically assessed in the same way, based on the best available research.11 several versions of the cra form exist, and with clinical outcomes use multiple indicators and risk factors.10 the american dental association (ada) developed two forms that determine low, moderate or high risk: one for a’yun et al asian journal of dental and health sciences. 2023; 3(4):11-14 [14] ajdhs.com patients aged 0-6 years, and another for patients aged over 6 years. the american academy of pediatric dentistry (aapd) has developed two forms that determine low, moderate or high risk: one for pediatric patients aged 0-5 years, and one for children aged over 5 years. there are also two forms published by the california dental association (cda), validated risk assessment tools using large cohorts of patients and found significant comparisons regarding the number of cavities in the future.14 while all these forms differ in terms of risk factors, disease indicators and protective factors, they all agree that the strongest predictor of future dental caries is the patient's experience with caries, such as carious lesions or new restorations within the last three years, although each form uses different variables to describe the caries experience.14,11 conclusion based on the results of the research and discussion, it can be concluded that the risk factors for dental caries based on cambra that influence children's dental caries are the criteria for dentin depth lesions, saliva ph and plaque amount. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. ethical clearance this research has received a certificate of appropriate research ethics from the yogyakarta health research ethics commission no. dp.04.03/e-kepk.1/130/2023. references 1. yazdanian m, armoon b, noroozi a, mohammadi r, bayat a-h, ahounbar e, et al. dental caries and periodontal disease among people who use drugs: a systematic review and meta-analysis. bmc oral health. 2020;20:1-18. https://doi.org/10.1186/s12903020-1010-3 pmid:32041585 pmcid:pmc7011515 2. haque m, sartelli m, haque sz. dental infection and resistanceglobal health consequences. dent j. 2019;7(1):22. https://doi.org/10.3390/dj7010022 pmid:30823670 pmcid:pmc6473604 3. wala hc. gambaran status karies gigi anak usia 11-12 tahun pada keluarga pemegang jamkesmas di kelurahan tumatangtang i kecamatan tomohon selatan. e-gigi. 2014;2(1). https://doi.org/10.35790/eg.2.1.2014.4013 4. riskesdas. riset kesehatan dasar 2018. jakarta: kemenkes ri; 2018. 5. purnama t, fadjeri i, widiyastuti r. model mentoring teachers and parents as an efforts for brushing teeth behavior in preschool children. indian j forensic med toxicol. 2020;14(4):3511-6. 6. kasihani nn, ngatemi n, purnama t. determinants of parental behavior in maintaining deciduous teeth in early childhood: a cross sectional study. eur j mol clin med. 2021;8(02). 7. laksmiastuti sr, budiardjo sb, sutadi h. breastfeeding and dental caries' risk in children: a systematic review for pediatric dentist. in: national scientific meeting in pediatric dentistry prosiding. 2017. 8. pitts nb, zero dt, marsh pd, ekstrand k, weintraub ja, ramosgomez f, et al. dental caries. nat rev dis prim. 2017;3(1):1-16. https://doi.org/10.1038/nrdp.2017.30 pmid:28540937 9. veiga nj, aires d, douglas f, pereira m, vaz a, rama l, et al. dental caries: a review. j dent oral heal. 2016;2(5):1-3. 10. featherstone j, gomez fr, crystal y. cambra® caries management by risk assessment a comprehensive caries management guide for dental professionals. j calif dent assoc. 2019;(july):1-44. 11. young da, featherstone jdb. caries management by risk assessment. community dent oral epidemiol. 2013;41(1):53-63. https://doi.org/10.1111/cdoe.12031 12. meriç e, bolgül b, duran n, ay e. evaluationof oral streptococci in saliva of children with severe early childhood caries and cariesfree. eur j paediatr dent. 2020;21(1):13-7. 13. al-halabi m, salami a, alnuaimi e, kowash m, hussein i. assessment of paediatric dental guidelines and caries management alternatives in the post covid-19 period. a critical review and clinical recommendations. eur arch paediatr dent. 2020;21(5):543-56. https://doi.org/10.1007/s40368-020-005475 pmid:32557183 pmcid:pmc7298449 14. hurlbutt m. cambra : best practices in dental caries management. ada cerp. 2011;96. https://doi.org/10.1186/s12903-020-1010-3 https://doi.org/10.1186/s12903-020-1010-3 https://doi.org/10.3390/dj7010022 https://doi.org/10.35790/eg.2.1.2014.4013 https://doi.org/10.1038/nrdp.2017.30 https://doi.org/10.1111/cdoe.12031 https://doi.org/10.1007/s40368-020-00547-5 https://doi.org/10.1007/s40368-020-00547-5 cinthya et al asian journal of dental and health sciences. 2024; 4(1):21-25 [21] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study risalin cinthya* , rubasri mohan , priyadharshini vijayakumar , reshmapriya dayanidhi , hemalatha ramakrishnan karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india article info: _____________________________________________ article history: received 19 december 2023 reviewed 02 january 2024 accepted 17 january 2024 published 15 march 2024 _____________________________________________ cite this article as: cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences. 2024; 4(1):21-25 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.68 _____________________________________________ *address for correspondence: risalin cinthya, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india abstract _________________________________________________________________________________________________________________ objective: the purpose of this study was to evaluate the knowledge, attitudes, and behavior of the patients visiting the opd department of periodontology and implantology karpaga vinayaga institute of dental sciences materials and methods: a cross sectional study was conducted on the patient visiting opd of karpaga vinayaga institue of dental sciences, chengalpattu 300 participants participated in this pilot study. this study included a self-administered questionnaire, which took an average of about 10 minutes to complete all the question. responses from the subjects were calculated in terms of frequency and percentages. results: out of 300 participants 57.7% of them visit dentist only when they have dental problem. 78% of the population is afraid to visit dentist due to fear of pain 87.3% of participants were of the opinion that tooth loss is a natural sequel of the aging process. conclusion: there is a lack of awareness and a negligent attitude towards oral health among the general public. people must be motivated, and their attitudes towards the importance of oral health must be clarified through various programs. comprehensive educational programs to promote excellent oral health and teach proper oral hygiene practices are desperately needed. keywords: oral attitudes, oral health behaviour, knowledge, and awareness introduction: oral health is defined as the standard of health of oral and related tissues, which helps an individual to eat, speak and socialize without disease, discomfort and contribute to general health. 1 maintaining the oral health requires effort from both dentist as well as patient himself. it has been established that oral health is as significant as general health. additionally, it has been noted that a significant component affecting general health is one level of education regarding dental health. 2 it has an impact on a person physical, physiological, social well-being. chronic conditions like diabetes, obesity, and dental caries are becoming more prevalent in emerging nations and have a negative impact on both oral health and overall health. 3,4 similar to many other diet and health related disorders, treating dental disease is expensive. 5,6 most people have tendency to neglect dental issues that are about to become more serious and have an impact on their general health. millions of people suffer from ungovernable toothaches and poor quality of life as a result of people failure to recognize this fact. though there is still lack of education about the oral health, especially for rural people who make up more than 70% of indian population, despite the fact that numerous studies have been conducted periodically to examine people’s knowledge and behavior in this area. 7 furthermore, despite having easy access to dental treatment, people who live in cities might still develop oral illness as a result of poor eating habits and unhealthy lifestyles. materials and methods: study population and ethical clearance: a cross sectional study was conducted on the patient visiting opd of karpaga vinayaga institute of dental sciences, chengalpet district. the study was started after obtaining approval from the ethical committee. in order to access the suitability of the questionnaire,300 participants participated in the pilot study. this study included self-administered questionnaire which took an average of about 10 min to complete all the question. study sample a straight forward random sampling methods was used to choose the 300 participants that made up the study sample. the study comprised adults who were at least 18 years old. participants were informed of and given explanation of the study’s goal, after obtaining informed consent the participants were asked to complete the questionnaires using the response options listed there. questionnaires: each of them received a self-made, closed-ended questionnaire that was prepared in vernacular language. the subjects chosen open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.68 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.68&amp;domain=pdf https://orcid.org/0009-0002-5154-0931 https://orcid.org/0004-7280-3969 https://orcid.org/0009-0009-7177-2407 https://orcid.org/0009-0000-9260-7579 https://orcid.org/0000-0002-8547-7718 cinthya et al asian journal of dental and health sciences. 2024; 4(1):21-25 [22] ajdhs.com have to be older than 18 in order for them to comprehend the questionnaire in its entirety. two sections made up the questionnaire form. age, sex, gender, occupation, and other demographic information about those taking part in the study were gathered in the first section of the questionnaire. the knowledge about dental health and the source of dental knowledge, the amount of time spent brushing, etc. questionnaire used for collecting information from the study subjects. 1. how frequently do you visit the dentist? a. 6 months once b. once a year c. if only there is a dental problem 2. which type of dental aids do you use other than tooth brush? a. dental floss b. mouth wash 3. which of the following methods do you use while brushing? a. vertical b. horizontal c. circular 4. how many minutes you take to brush your teeth? a. 1min b. 2min c. 5min 5. how frequently change your tooth brush? a. 3months once b. 6 months once c. yearly once 6. how many times do you brush a day? a. once b. twice 7. is it your first visit to dentist? a. yes b. no 8. what is your source of dental health? a. friends b. parents c. tv / radio d. dentist 9. do you think dental health is important? a. yes b. no 10. do you think oral health affects general health? a. yes b. no 11. do you rinse your mouth after food? a. yes b. no 12. are you aware what dental plaque is? a. yes if yes, do you know dental plaque is the main cause for tooth loss. a. yes b. no b. no 13. are you aware that sugar/ sticky food can causes tooth decay? a. yes b. no 14. are you aware that bleeding gums is a sign of poor gum health? a. yes b. no 15. are you afraid to visit a dentist? a. yes b. no data collection to ensure that the concerned respondent understood the questions and the likely answers in their entirety, an investigator was always present with the respondent while the questionnaires were being filled out. statistical analysis the data was transferred to microsoft excel. for data analysis, each response was given a score of 1,2,3,4 respectively. result was statistically analyzed using spss software version 24 in terms of frequency and percentage. result the study was conducted among 300 subjects. all the subjects were above the age of 18. the majority of the participants came from rural areas and they are daily labors. the findings revealed that people's knowledge, attitudes, and behaviors were significantly influenced by their educational level, which was one of the key determinants. most of the subjects in this study were illiterate which was the main reason for the lack of awareness about dental health. a significant number of patients 14.7% said they had not consulted a dentist in the previous 12 months. the majority 57.7% of the patients in the current study visited a dentist only if any oral health problem was present, whereas 27.7% of them visited the dentist every 6 months for oral prophylaxis. [figure1] figure 1frequency of visit to dentist 27.7% 14.7% 57.7% 0 50 100 150 200 6 months once once a year when you have a problem fr eq u en c y cinthya et al asian journal of dental and health sciences. 2024; 4(1):21-25 [23] ajdhs.com the majority of people 67% began using mouthwash even without a dentist's recommendation. this indicates the growing awareness of mouthwash without proper instruction and indication of the mouthwash. 33% of the people used the floss as an interdental cleaning aid shown in [figure 2]. this shows the increase in use of chemical plaque control than mechanical plaque control. evidently, fewer people were aware of the benefits of using dental floss to prevent dental disease and improve oral hygiene. figure 2 various cleansing aids used by the patients 0.7% of the study population spent 5 minutes to brush their teeth, while the majority of study participants 61.3% brush their teeth for less than 1min [figure 3]. 38% of the population brush for 2 min, which is the ideal time for tooth brushing. figure 3 time devoted toward tooth brushing majority 63.3% of the population had never been to dentist and 38.7% of those who had gone to dentist avoided the visit due to fear of pain [figure4]. most of the population, 61.3% brushed their teeth in horizontal direction did not use a mirror while brushing, about 19.7% of the people brushed in vertical direction while, others 19.0% used circular direction to brush their teeth [figure5]. in the study population the majority of the patients (55%) reported rinsing their mouths with plain water after meals, whereas 45% patient don’t rinse their mouth [figure 6] shows lack of knowledge about oral health. majority 78% of the patient were afraid to visit the dentist due to the fear of pain and anxiety about extraction. 22% of the study groups said they were not afraid as they have little knowledge about the dental procedure [figure7]. figure 7 habit of the study patients to rinse after every meal 33% 67% 0 50 100 150 200 250 floss mouth wash fr eq u en c y 61.3% 38% 0.7% 0 50 100 150 200 1 min 2 min 5 min 63.3% 38.7% yes no 61.3% 19.7% 19% 0 50 100 150 200 fr eq u en c y 55% 45% yes no 78% 22% yes no figure 5 brushing techniques used by the study subjects horizontal vertical circular figure 4 study subjects first visit to dentist figure 6 describes the study subjects fear to visit a dentist cinthya et al asian journal of dental and health sciences. 2024; 4(1):21-25 [24] ajdhs.com to add on 87.3% of the subjects believed that bleeding gums is not related to poor gum health and believed that it is a natural sequel of aging, [figure8]. figure 9 depicts the knowledge of study subjects and their source of dental knowledge. 60% of subjects gain their knowledge about dental health from their friends while 33.3% came to know from their parents and 6.7% of them gained knowledge from tv/ radio. discussion a person's oral health is an important component of overall health and a valuable asset. the state of oral health has consistently been neglected. people have underestimated the effects of poor oral health, which has resulted in bigger issues that will be more challenging to manage in the future. the degree to which we are unaware of our oro-dental health mostly depends on our level of knowledge. 8,9 this study helps us to know about the educational level of the study subjects, which is indirectly related to the knowledge of the study subjects and his /her practice toward his health. about 66% of the study population believed that oral health is not related to general health. the most widespread noncommunicable diseases like cardiovascular diseases, diabetes, cancer, chronic obstructive pulmonary disease shows many risk factors associated with oral diseases. similar studies have also been conducted in other countries to evaluate the knowledge, attitude, and behavior of various groups, professionals, students, and citizens.14% of participants in our study group visits dentist every year, 27.7 % of their visit occurred in the previous six months, 57.7% of the participants reported they never visited a dentist, which may be attributed to dental anxiety and lack of knowledge about regular checkups. similar results were obtained in other studies, the ideal tooth brushing time is 2min. in the current study only 38 % of the participants reported brushing for 2 min. while 61.3% of them reported they brush for 1 min only. this indicates the need in the awareness about oral hygiene and dental health practices. 9,10 one of the main reasons why people avoid going to the dentist is fear of pain. despite major advancements in the field of dentistry, phobia of pain during treatment still exists among a sizable population, posing a barrier to receiving dental care. in our study around 63.3% of the participants never visited the dentist and believed that pain is a part of the dental procedure and avoided it. a study carried out by other brought out similar results. further response of study subjects to the question regarding the use of other dental aids such as mouthwash, 67% had higher positive response. only 33% of the study population used dental floss, the knowledge about floss was only known to people who has under gone orthodontic treatment. the use of dental floss to prevent the dental disease was apparently less understood by the population. from this it is clear that knowledge on dental floss has to be improved. 9,10,11 knowledge about oral hygiene is very important and helps us to preserve the oral health. most of the people acquire knowledge from different source like media, friend and family in this study. 60% of the individuals in our survey mentioned their parents as their primary source of information about oral health, while 33.3% referred other sources, indicating that all parents do not actively try to teach their kids about oral health. these results were found to be consistent with those of earlier studies, providing further proof that the subjects' oral health are not being educated by all parents. 11,12 results from systemic reviews recommended tooth brushing twice a day, the ideal tooth brushing time is 2min. this habit helps us to prevent the formation of carries as well as improve gingival health. in our study 55% of them had a habit of rinsing their mouth after food whereas 45% of patients rinsed their teeth once in the morning. the habit of rinsing the mouth after every meal is a goal to good oral health. 13,14,15 majority ie., 87.3% of the patients believed that bleeding gums is natural phenomenon which occurs due to ageing but they didn’t know the fact that it occurs due to poor gum health. 12.7% of them said there was indeed a relation between bleeding gums and poor gum health but patient did not consider it important to visit a dentist. 16,17 a further finding from this study reveals individuals who are employed showed good oral health awareness than who are unemployed. this occurs due to the stress of unemployment which indirectly affects the oral health. fear of pain is one of the important factors which prevent the patients from visiting the dentist hence awareness about the dental health should prioritize more. 17,18 conclusion the participants in this study exhibit a lack of awareness and a negligent attitude regarding their oral health. education and motivation on oral health and associated issues are therefore desperately needed. the population as well as the health care workers frequently overlook this serious issue, as indicated by the cross-sectional study's findings. dental professionals need 12.7% 87.3% yes no 60% 33.3% 6.7% 0% 0 20 40 60 80 100 120 140 160 180 200 friends parents tv/radio dentist fr eq u en c y figure9 awarene about bleeding gums among the study subjects figure 8 source of dental health among the study subjects cinthya et al asian journal of dental and health sciences. 2024; 4(1):21-25 [25] ajdhs.com to raise awareness about dental health and oral hygiene. through various outreach programs in the areas that are less accessible to oral health institutions, this method needs to be expanded beyond the clinics. in addition, media can educate the public and encourage dental visits on a regular basis. in conclusion, it is our duty as dental professionals to educate and inspire this group of people who lack formal education so that we may make progress towards establishing a healthy environment. references 1. singh a, gambhir rs, singh s, kapoor v, singh j. oral health: how much do you know-a study on knowledge, attitude and practices of patients visiting a north indian dental school. european journal of dentistry. 2014 jan;8(01):063-7. https://doi.org/10.4103/13057456.126244 pmid:24966748 pmcid:pmc4054034 2. abdulbaqi hr, abdulkareem aa, alshami ml, milward mr. the oral health and periodontal diseases awareness and knowledge in the iraqi population: online‐based survey. clinical and experimental dental research. 2020 oct;6(5):519-28. https://doi.org/10.1002/cre2.304 pmid:32592312 pmcid:pmc7545227 3. ganss c, schlueter n, preiss s, klimek j. tooth brushing habits in uninstructed adults-frequency, technique, duration and force. clinical oral investigations. 2009 jun; 13:203-8. https://doi.org/10.1007/s00784-008-0230-8 pmid:18853203 4. kwan sy, holmes ma. an exploration of oral health beliefs and attitudes of chinese in west yorkshire: a qualitative investigation. health education research. 1999 aug 1;14(4):453-60. https://doi.org/10.1093/her/14.4.453 pmid:10557516 5. peltzer k, pengpid s. oral health behaviour and social and health factors in university students from 26 low, middleand highincome countries. international journal of environmental research and public health. 2014 dec;11(12):12247-60. https://doi.org/10.3390/ijerph111212247 pmid:25431876 pmcid:pmc4276612 6. neamatollahi h, ebrahimi m, talebi m, ardabili mh, kondori k. major differences in oral health knowledge and behavior in a group of iranian pre-university students: a cross-sectional study. journal of oral science. 2011;53(2):177-84. https://doi.org/10.2334/josnusd.53.177 pmid:21712622 7. marya cm, grover s, jnaneshwar a, pruthi n. dental anxiety among patients visiting a dental institute in faridabad, india. west indian medical journal. 2012 mar 1;61(2):187. 8. macentee mi, marino r, wong s, kiyak a, minichiello v, chi i, lo ec, huancai l. discussions on oral health care among elderly chinese immigrants in melbourne and vancouver. gerodontology. 2012 jun;29(2): e822-32. https://doi.org/10.1111/j.17412358.2011.00568.x 9. clement chinedu a, michael o. tobacco use, alcohol consumption and self-rated oral health among nigerian prison officials. 10. han k, park jb. association between oral health behavior and periodontal disease among korean adults: the korea national health and nutrition examination survey. medicine. 2017 feb;96(7). https://doi.org/10.1097/md.0000000000006176 pmid:28207558 pmcid:pmc5319547 11. lertpimonchai a, rattanasiri s, vallibhakara sa, attia j, thakkinstian a. the association between oral hygiene and periodontitis: a systematic review and meta-analysis. international dental journal. 2017 dec 1;67(6):332-43. https://doi.org/10.1111/idj.12317 pmid:28646499 pmcid:pmc5724709 12. macek md, atchison ka, chen h, wells w, haynes d, parker rm, azzo s. oral health conceptual knowledge and its relationships with oral health outcomes: findings from a multi‐site health literacy study. community dentistry and oral epidemiology. 2017 aug;45(4):323-9. https://doi.org/10.1111/cdoe.12294 pmid:28271537 pmcid:pmc5498245 13. macek md, haynes d, wells w, bauer‐leffler s, cotten pa, parker rm. measuring conceptual health knowledge in the context of oral health literacy: preliminary results. journal of public health dentistry. 2010 jun;70(3):197-204. https://doi.org/10.1111/j.1752-7325.2010.00165.x pmid:20337901 pmcid:pmc3612930 14. márquez c, almerich j, montiel j. oral health knowledge in relation to educational level in an adult population in spain. j clin exp dent. 2019 dec;11(12):1143-50. 15. nyorobi jm, carneiro lc, kabulwa mn. knowledge and practices on periodontal health among adults, misungwi, tanzania. international journal of dentistry. 2018 nov 1;2018. https://doi.org/10.1155/2018/7189402 pmid:30515213 pmcid:pmc6236872 16. oberoi ss, mohanty v, mahajan a, oberoi a. evaluating awareness regarding oral hygiene practices and exploring gender differences among patients attending for oral prophylaxis. journal of indian society of periodontology. 2014 may;18(3):369. https://doi.org/10.4103/0972-124x.134580 pmid:25024553 pmcid:pmc4095632 17. ganss c, schlueter n, preiss s, klimek j. tooth brushing habits in uninstructed adults-frequency, technique, duration and force. clinical oral investigations. 2009 jun; 13:203-8. https://doi.org/10.1007/s00784-008-0230-8 pmid:18853203 18. siddaiah sb, ramachandra ja, mehta dv, gopinath g. assessment of oral health awareness among residential and day school-going children in south bengaluru: a questionnaire-based survey. world. 2021 may;12(3):235. https://doi.org/10.5005/jp-journals10015-1815 https://doi.org/10.4103/1305-7456.126244 https://doi.org/10.4103/1305-7456.126244 https://doi.org/10.1002/cre2.304 https://doi.org/10.1007/s00784-008-0230-8 https://doi.org/10.1093/her/14.4.453 https://doi.org/10.3390/ijerph111212247 https://doi.org/10.2334/josnusd.53.177 https://doi.org/10.1111/j.1741-2358.2011.00568.x https://doi.org/10.1111/j.1741-2358.2011.00568.x https://doi.org/10.1097/md.0000000000006176 https://doi.org/10.1111/idj.12317 https://doi.org/10.1111/cdoe.12294 https://doi.org/10.1111/j.1752-7325.2010.00165.x https://doi.org/10.1155/2018/7189402 https://doi.org/10.4103/0972-124x.134580 https://doi.org/10.1007/s00784-008-0230-8 https://doi.org/10.5005/jp-journals-10015-1815 https://doi.org/10.5005/jp-journals-10015-1815 sun et al asian journal of dental and health sciences. 2024; 4(1):1-3 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited multidermatomal herpes zoster of the trigeminal nerve in an immunocompetent patient: a case report chia earn sun 1*, sahrir sanusi 1,2 1) postgraduate school of medicine, kpj healthcare university college, nilai, negeri sembilan, malaysia 2) kpj kajang specialist hospital, kajang, selangor, malaysia article info: _____________________________________________ article history: received 09 december 2023 reviewed 11 january 2024 accepted 06 february 2024 published 15 march 2024 _____________________________________________ cite this article as: sun ce, sanusi s, multidermatomal herpes zoster of the trigeminal nerve in an immunocompetent patient: a case report, asian journal of dental and health sciences. 2024; 4(1):1-3 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.67 _____________________________________________ *address for correspondence: chia earn sun, postgraduate school of medicine, kpj healthcare university college, nilai, negeri sembilan, malaysia abstract _________________________________________________________________________________________________________________ herpes zoster is a neurocutaneous viral infection caused by the reactivation of the varicella zoster virus in the dorsal root ganglion. it is characterized as vesicular rash along a unilateral dermatome, usually associated with pain or paresthesia of the involved area. multidermatomal involvement is rare in immunocompetent patients. we report an unusual case of herpes zoster involving the maxillary(v2) and mandibular(v3) branches of the trigeminal nerve in a healthy immunocompetent lady. keywords: herpes zoster, neurocutaneous viral infection, trigeminal nerve case presentation a 25-year-old lady presented with vesicular lesions with crusts on left side of face for 3 days associated with left sided facial pain and burning sensation. the lesions began in the left upper lip and progressed within the span of 3 days to involve the left cheek and chin area, which further spread to involve intraorally. there was no facial paralysis, hearing loss or visual symptoms. she had no constitutional symptoms. her past medical history was unremarkable. general examination of the patient was normal and her vitals were stable. cutaneous examination revealed edema over the left side of the face. multiple grouped maculopapular and vesicular lesions were seen over the left lower eyelid, cheek, external ear, upper and lower lip, and chin. [fig 1,2] intraoral examination revealed similar lesions involving left side of hard and soft palate and left buccal mucosa. [fig-3] ear examination revealed vesicles over left pinna. otherwise, external auditory canal and anterior part of the tympanic membrane was normal with normal hearing assessment. ophthalmic examination was unremarkable. facial nerve was intact. the affected areas corresponded to the distribution of the left maxillary(v2) and mandibular(v3) branches of the trigeminal nerve. complete blood count, serum electrolytes, renal function and blood sugar were within normal limits. the patient was started on intravenous acyclovir 400mg tds for 5 days, followed by t. acyclovir 400mg qid for another 5 days. topical acyclovir cream, mouth rinse and oral analgesics were also prescribed. the patient showed gradual recovery with healing of lesions 2 weeks after onset of symptoms. figure 1 open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.67 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.67&amp;domain=pdf sun et al asian journal of dental and health sciences. 2024; 4(1):1-3 [2] ajdhs.com figure 2 figure 3 discussion herpes zoster (hz), also known as shingles, is a common viral disease caused by reactivation of a latent infection of varicella zoster virus(vzv), and alpha herpes virus. after an initial infection, the virus remains latent in the perineural satellite cells of the dorsal nerve root ganglion.1,2 the frequency of zoster in thoracic dermatomes is 53%, cranial nerves is 20%, cervical dermatomes is 4-20%, followed by lumbosacral 11%.3 in hz, a few lesions can normally appear adjacent to the affected dermatome. more extensive skin involvement of several adjacent dermatomes is known as multidermatomal zoster.4 the ophthalmic branch(v1) of the trigeminal nerve is affected about 20 times more often than maxillary(v2) and mandibular(v3) branches of the nerve. the maxillary nerve(v2) is the least frequently affected branch. it is unusual for zoster to involve maxillary(v2) or mandibular(v3) divisions without ophthalmic(v1) involvement. only anecdotal reports exist about hz affecting two or three branches of trigeminal nerve.2,5 in our patient, the lesions appeared in the area of maxillary(v2) and mandibular(v3) nerve distribution, sparing the ophthalmic(v1) nerve. in contrast to immunodeficient patients, multidermatomal involvement in hz is rarely observed in immunocompetent patients.2 our case represents a rare example of involvement of multidermatomal distribution of hz in a healthy, immunocompetent young lady. it has been stipulated that hz is triggered in part by a decrease in immunity. stress and depressive symptoms are also identified as possible trigger of hz. in conjunction with other factors such as age, nutritional status and underlying comorbids, stress and psychological symptoms may contribute to a lowering of immunity.6 hz occurs in three successive stages, namely prodromal, acute and chronic neuropathic stage.1 the prodromal (pre-eruptive stage) presents as pain or dysesthesia over the involved nerve distribution associated with mild fever. the acute stage is characterized by appearance of an initial erythematous macular lesion involving unilateral dermatome, that progress into vesiculopapular phase that appears within 12 days and continues to erupt over another 3-4 days.1,3 intraoral lesions, when maxillary or mandibular division of trigeminal nerve is involved, typically develop after cutaneous rash. hz involving the maxillary nerve (v2) typically present with lesions over middle third of the face, lower eyelid, side of the nose and upper lip, buccal mucosa and palate; while mandibular nerve (v3) involvement is evidenced by lesions over the lower third of face, lower lip, temporal region and intraoral mucosa. the distribution of vesicles in our patient correlated with involvement of maxillary(v2) and mandibular(v3) nerves. chronic neuropathic pain, also known as post-herpetic neuralgia, involves around 30% of patients with hz. it is defined as a sharp, intense, radiating pain lasting after eruptive stage for about one to three months.7 in around 16% of patients with hz, the rash disseminates beyond one dermatome, especially in elderly and immunocompromised individuals. only a few cases of multidermatomal hz have been reported in the literature, with only a handful number among them occurred in healthy immunocompetent individuals.3 among immunocompetent patients, hz is considered a self-limiting, localized infection. life-threatening and debilitating complications occur almost exclusively in immunocompromised patients. these complications include encephalitis, herpes zoster ophthalmicus, retinitis, delayed contralateral hemiparesis, stroke, and myelitis.4 early diagnosis and prompt treatment of hz is the mainstay of treatment. antiviral drugs are best administered within the viral replication period, which is ≤72 hours after onset of rash. topical antiviral agents such as acyclovir cream and docosanol cream are also effective. recommended duration of antiviral is 7-10 days. antiviral therapy was shown to be effective in shortening the viral shedding period, reducing zosterassociated pain severity and duration, preventing new lesion formation, hastening the healing of skin lesions, and reduction in incidence of postherpetic neuralgia.1,5 when vesicles postulate, patients are at risk of secondary bacterial infection, common organisms being staphylococcus aureus or streptococcus pyogenes. in secondary infection, oral antibiotic is appropriate.8 a step-wise approach should be taken to treating acute neuralgia and post-herpetic neuralgia, according to the severity of the patient’s symptoms. topical analgesics such as capsaicin cream and topical lidocaine patch can be used for mild acute neuralgia. tricyclic antidepressants, opioid analgesics and gabapentin are commonly used in managing post herpetic neuralgia. gabapentin has been shown to significantly reduce the duration of post-herpetic neuralgia.9 in the recent years, the use of vitamin c appears to be an emerging treatment for attenuating acute neuralgia and post herpetic neuralgia by modulating serum levels of cytokine il-6 and il-8.10 overall incidence rate of hz is 5.1 per 1000 person years. hz generally is considered to occur only once in a lifetime with recurrence limited to immunocompromised individuals. however, recurrence rate of 12.0 per 1000 person years among immunocompetent persons has been reported.11 mean time sun et al asian journal of dental and health sciences. 2024; 4(1):1-3 [3] ajdhs.com between initial and recurrent hz episodes was 1063 days. risk factors for recurrence are elderly age group, women, longer duration of post-herpetic immunocompromised status, and comorbid conditions.11 studies have demonstrated that immunization of immunocompetent older individuals with live attenuated varicella-zoster-virus vaccine reduced the incidence and severity of hz and postherpetic neuralgia. in the usa and canada, the vaccine is recommended for people aged ≥60 years, whereas in europe and australia the vaccine is approved for adults aged ≥50 years; inclusive of those who have a previous hz episode and those with underlying chronic medical conditions.12 our patient was treated with intravenous acyclovir, which was converted to oral for a total of 10 days. topical acyclovir cream was also prescribed, along with analgesics and mouth rinse for symptomatic relief. the vesicles crusted and healed within 5 days of initiation of treatment. references 1. francis m, subramanian k, sankari sl, potluri vl, prabakaran a. herpes zoster with post herpetic neuralgia involving the right maxillary branch of trigeminal nerve: a case report and review of literature. j clin diagn res. 2017 jan;11(1):zd40-zd42. https://doi.org/10.7860/jcdr/2017/22590.9237 pmid:28274075 pmcid:pmc5324520 2. pelloni, l.s., pelloni, r. & borradori, l. herpes zoster of the trigeminal nerve with multi-dermatomal involvement: a case report of an unusual presentation. bmc dermatol 2020;20(12). https://doi.org/10.1186/s12895-020-00110-1 pmid:33126864 pmcid:pmc7602315 3. naveen kn, pradeep av, kumar js, hegde sp, pai vv, athanikar sb. herpes zoster affecting all three divisions of trigeminal nerve in an immunocompetent male: a rare presentation. indian j dermatol. 2014 jul;59(4):423. https://doi.org/10.4103/00195154.135548 4. dube, shobhana & ranjan, pratyush & rajshekhar, v. multidermatomal herpes zoster ophthalmicus in an immunocompetent male. journal of clinical ophthalmology and research. 2017;5:38. 10.4103/2320-3897.195308. https://doi.org/10.4103/2320-3897.195308 5. patro, shubhransu & jena, payod & misra, gagan & rath, kali & khatua, pravakar. herpes zoster infection involving the maxillary branch of the right trigeminal nerve a rare case report. the antiseptic. 2013;110:36-38. 6. sansone, r. a., & sansone, l. a. herpes zoster and postherpetic neuralgia: an examination of psychological antecedents. innovations in clinical neuroscience, 2014;11(5-6):31-34. 7. yang f, yu s, fan b, liu y, chen yx, kudel i, concialdi k, dibonaventura m, hopps m, hlavacek p, cappelleri jc, sadosky a, parsons b, udall m. the epidemiology of herpes zoster and postherpetic neuralgia in china: results from a cross-sectional study. pain ther. 2019 dec;8(2):249-259. https://doi.org/10.1007/s40122-019-0127-z pmid:31218562 pmcid:pmc6857181 8. dworkin rh, johnson rw, breuer j, gnann jw, levin mj, backonja m, betts rf, gershon aa, haanpaa ml, mckendrick mw, nurmikko tj, oaklander al, oxman mn, pavan-langston d, petersen kl, rowbotham mc, schmader ke, stacey br, tyring sk, van wijck aj, wallace ms, wassilew sw, whitley rj. recommendations for the management of herpes zoster. clin infect dis. 2007 jan 1;44 suppl 1:s1-26. doi: 10.1086/510206. pmid: 17143845. https://doi.org/10.1086/510206 pmid:17143845 9. sra kk, tyring sk. treatment of postherpetic neuralgia. skin therapy lett. 2004 oct;9(8):1-4. pmid: 15550990. 10. liu y, wang m, xiong mm, zhang xg, fang m. intravenous administration of vitamin c in the treatment of herpes zosterassociated pain: two case reports and literature review. pain res manag. 2020 dec 1;2020:8857287. doi: 10.1155/2020/8857287. pmid: 33335639; pmcid: pmc7723478. https://doi.org/10.1155/2020/8857287 pmid:33335639 pmcid:pmc7723478 11. kim, y. j., lee, c. n., lee, m. s., lee, j. h., lee, j. y., han, k., & park, y. m. recurrence rate of herpes zoster and its risk factors: a population-based cohort study. journal of korean medical science, 2018;34(2):e1. https://doi.org/10.3346/jkms.2019.34.e1 pmid:30636941 pmcid:pmc6327089 12. levin, m. j., gershon, a. a., dworkin, r. h., brisson, m., & stanberry, l. prevention strategies for herpes zoster and post-herpetic neuralgia. journal of clinical virology : the official publication of the pan american society for clinical virology, 2010;48 suppl 1(suppl 1):s14-s19. https://doi.org/10.1016/s13866532(10)70004-4 pmid:20510262 https://doi.org/10.7860/jcdr/2017/22590.9237 https://doi.org/10.1186/s12895-020-00110-1 https://doi.org/10.4103/0019-5154.135548 https://doi.org/10.4103/0019-5154.135548 https://doi.org/10.4103/2320-3897.195308 https://doi.org/10.1007/s40122-019-0127-z https://doi.org/10.1086/510206 https://doi.org/10.1155/2020/8857287 https://doi.org/10.3346/jkms.2019.34.e1 https://doi.org/10.1016/s1386-6532(10)70004-4 https://doi.org/10.1016/s1386-6532(10)70004-4 pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [51] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the role of pharmacists in opioid addiction management pallav dave * regulatory compliance analyst, louisville, ky, 40223, usa article info: _____________________________________________ article history: received 09 january 2024 reviewed 17 february 2024 accepted 01 march 2024 published 15 march 2024 _____________________________________________ cite this article as: dave p, the role of pharmacists in opioid addiction management, asian journal of dental and health sciences. 2024; 4(1):51-56 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.71 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky, 40223, usa abstract _________________________________________________________________________________________________________________ opioid addiction claims thousands of lives every year in the united states. the prevalence of misuse, abuse, and overdose continues to rise despite the measures and initiatives taken by the federal government and other government agencies to manage the problem. these efforts have led to a reevaluation of the role different healthcare providers can play to ensure the problem is adequately addressed. being one of the most accessible healthcare providers to patients under opioid therapy, pharmacists are better positioned to deal with opioid addiction. they dispense millions of opioids every year making them better positioned to screen for patients who are likely to develop an addiction problem and refer them to treatment resources before the abuse escalates to opioid use disorder (oud). the aim of this review is to explore the role of pharmacists in opioid addiction management including prevention, screening, education, naloxone prescribing, counselling, and referral to treatment resources. the review also provides pertinent information regarding the current state of the opioid crisis in the us, including recent data on prevalence and opioid-related deaths. exploring the role of pharmacists is instrumental in coming up with effective measures that can help in opioid addiction management. keywords: opioids, opioid addiction management, pharmacists, opioid misuse, opioid abuse, opioid use disorder introduction opioids are crucial in the management of pain. various studies have established that prescription opioids are instrumental in managing pain, particularly in the short term.1, 2 however, despite their significance in the management of pain, prolonged use without medical supervision can increase the risk of dependence and lead to addiction. the recent 2022 data by national survey on drug use and health is an indication of the opioid problem in the us with 8.9 million people who are 12 years and older having misused opioids while another 6.1 million being diagnosed with oud in the last year.3 managing opioid addiction is paramount considering the number of deaths attributed to opioid addiction. in the past two decades alone, opioid overdose deaths in the us have gone up significantly from around 21,089 in 2010 to approximately 70,000 in 2020.4,5 in 2021, deaths linked to synthetic opioids other than methadone were approximately 70,601.4 on average, 1 death in every 22 in the us in 2021 was attributed to opioid toxicity.6 of these deaths, the most affected are younger adults aged 25 to 34 years.7 the early loss of life means years of loss of productivity. abuse and misuse of opioids also increase health risks and complications which has a major toll on public health. in 2017 alone, the opioid epidemic cost the us $1.02 trillion, with approximately $35 billion being on healthcare and treatment.8 considering the magnitude of opioid misuse, abuse, and oud as exemplified by available population data, there is a need for measures to increase awareness of the risks associated with opioids and put proper addiction management strategies in place. an interdisciplinary approach to addiction management including involving different professionals in prescribing and managing opioid addictions can enhance clinical outcomes.9 pharmacists can be instrumental in addiction management because of their role in opioid dispensing and the training they have in medication safety and management.10 this review explores the role of pharmacists in opioid addiction management including how they can help in harm reduction, prescription of naloxone for overdose treatment, and referral to addiction management resources. prevalence of opioid misuse, abuse, and deaths in the us recent data from the substance abuse and mental health service administration (samhsa), national institute on drug abuse, and centers for disease control and prevention (cdc) show that opioid dependence and deaths are increasing in the us despite the reduction in the number of opioid prescribing.3,4,11 the last two decades have recorded significant numbers of individuals affected by the opioid epidemic with the most being young adults.7 according to the cdc, the number of opioids prescribed to patients increased significantly from the 1990s which corresponds to the rise in the number of overdoses and deaths.12 approximately, 280,000 people died from prescription-related opioids between 1999 and 2021.12 in 1999, only 3,442 deaths were reported compared to 16, 416 deaths reported in 2021 which is an indication of the escalation in the number of deaths attributed to opioids.4 deaths related to other opioids other than prescription opioids also increased significantly during this period. the cdc reported approximately 645,000 deaths between 1999 to 2021 while another study reported 422 605 deaths between 2011 and 2021. 12,6 in addition to deaths attributed to opioids, the number of people who misused or abused opioids also increased open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.71 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.71&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [52] ajdhs.com significantly in the last two decades. in 2022, 8.9 million people who were 12 years and older misused opioids.3 among these, 1.1 million were aged 18 to 25 years while 7.4 million were adults aged 26 years and older. 3 another 6.1 million people had oud with adults aged 26 years and older accounting for 5.4 million while those aged 18 to 25 accounting for 424,000. 3 the high number of people misusing, abusing, and dying from opioid-related deaths is attributed to several factors key among them being high-volume prescribing and ease of accessibility of the drugs. the number of opioid prescribing has gone up in the last two decades with 2012 recording a prescription rate of 81.3 per 100 persons.13 between 2013 to 2016, the us accounted for the largest per-capita consumption of opioids in the world.14,15 although opioids play a significant role in managing pain, a large number of patients prescribed opioids end up abusing or misusing them. a study by vowles et al.16established that 21% to 29% of patients who were prescribed opioids ended up misusing them and another 8% to 12% developed oud. despite the decline in the rates of prescribing in recent years, the number of people dying from opioid-related deaths continues to rise showcasing a discrepancy between safe prescribing and opioid assess. the discrepancy could also mean that the number of people abusing other forms of opioids including heroin and synthetic opioids has increased. considering the high rate of misuse and abuse associated with opioids, there is a need to identify individuals at risk of opioid addiction to ensure healthcare professionals are knowledgeable and can be able to intervene before the abuse turns to oud. risk factors for opioid misuse and abuse identifying people who are at risk of opioid misuse or abuse is vital in fighting opioid addiction. identifying these risks makes it possible to assess them and put measures in place to manage them effectively. various factors increase the risk of opioid misuse and abuse including individual factors, demographic factors, pain-related factors, sociodemographic factors, psychosocial factors, drug-related factors, and factors related to alcohol and substance use disorders.17 although independently these factors are not likely to increase the risk of misuse, a combination of two or three increases the risk significantly. demographically, young, white, and non-urban american males are more likely to have a prescription opioid misuse and abuse problem compared to other population groups.18, 17 however, this could be changing. the recent 2022 national survey showed that rates of misuse were higher among multiracial groups at 4.5%, followed by blacks at 4.1%, and hispanics at 3.4%.3 whites had a misuse percentage of 3.0% while asians were at 1.5%.3 one of the factors why prescription opioid abuse is more associated with white men is because the rate of prescription for opioids in emergency departments and primary care practices is much higher.19 emotional issues and affective distress were also identified as factors that increased the risk of misuse and abuse with women who had these problems being more likely to misuse or abuse opioids.17 socioeconomic factors also play a crucial role in determining if an individual is likely to have an opioid abuse problem. individuals who do not have health insurance, are unemployed, have work-related accidents or disability, and those who do not graduate high school have a higher risk of abuse.20,21 one of the most consistent factors associated with the opioid abuse problem is a history of substance use disorders (sud). various studies have found that individuals who have a history of sud are at a higher risk of opioid abuse.22,23 coincidentally, individuals who experience chronic pain have higher rates of suds.17 according to a national epidemiologic survey, these rates are higher than those observed in the general population.24 considering the rates of suds are higher in individuals struggling with chronic pain, it leaves a dilemma on how patients who struggle with pain can be managed effectively using opioids without the risk of addiction. other risk factors that were associated with opioid misuse and abuse were mental health diagnoses including psychotic and anxiety disorders,24, 22 pain severity,17 genetic factors,17 and geographical factors. with regard to geographical factors, a high number of opioid prescriptions were mostly concentrated in counties in the western and southern states.25 besides, hospitalizations related to opioid overdoses between 2000 to 2012 were also concentrated in the south region. 18 controlling for risk factors associated with misuse and abuse is vital in opioid addiction management. for pharmacists, identifying these risk factors is vital in ensuring they are knowledgeable and can be able to intervene to manage opioid addictions. role of pharmacists in addressing the opioids epidemic addressing the opioid epidemic requires the involvement of different healthcare providers who are in contact with patients being prescribed opioids. in the us, involving community pharmacists in dealing with opioid addiction is instrumental considering they dispense approximately 131 million prescription opioids every year.26 besides, pharmacists are knowledgeable about the mechanism of action of medications and are in a better place to identify patients who are at risk of addiction. the cdc clinical practice guideline for prescribing opioids for pain recognizes the crucial role of pharmacists in opioid prescription, especially their role in opioid dispensing and naloxone prescribing.27 various studies highlight the importance of pharmacists in ensuring opioid safety including prevention, surveillance, and treatment of oud.28,29,30 with the help of prescription drug monitoring programs (pdmps), pharmacists are better positioned to control prescriptions and identify patients who have a higher risk of opioid addiction.31 the pdmp enables pharmacists to screen for opioid misuse and discuss opioid-related treatment with patients.32 in addition to pdmp, pharmacists have access to naloxone which is instrumental in reversing opioid overdose. a study done in canada established that pharmacists play a crucial role in the distribution of naloxone as part of the public health initiative in dealing with the opioid crisis.33 community pharmacies were accessible to patients and being a key point of naloxone distribution they were instrumental in preventing overdoses. other than emergency treatment, pharmacists can play a crucial role in prevention, which is recognized as instrumental in preventing the likelihood of developing abuse or oud. role of pharmacists in addiction management pharmacists play a crucial role in opioid prescription which makes them better positioned to prevent misuse and abuse. prevention is recognized as instrumental in dealing with substance use disorder and addiction management and can be used as an early intervention measure to deal with opioid addiction.31 prevention is recognized as instrumental in delaying both the onset and progression of substance use disorders which makes it instrumental in addiction management. successful prevention of opioid addiction and abuse can involve a number of measures including addressing risk factors, screening, education, and discouraging use among other measures. using models such as the screening, brief intervention and referral to treatment (sbirt) model as a guide to prevention can enable pharmacists to achieve optimal outcomes.31 the model provides a comprehensive approach that allows healthcare providers to carry out screening, prevention, and timely referral to patients who have sud.34 the model is vital in the management of people with sud including identifying those at risk of developing the problem. by using the pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [53] ajdhs.com sbirt model, pharmacists can be able to screen for people who have high oud risk, initiate discussions about the problem, and provide interventions if necessary. screening is recognized as an instrumental measure in preventing opioid use disorder, especially in clinical and community settings.28 using screening as an intervention measure for opioid addiction management has a lot of potential with some surveys showing that community pharmacists have a positive attitude towards screening and are interested in using screening to help patients that have oud.35,36 the sbirt model also recommends brief intervention before referring patients for treatment. the main aim of the brief intervention is to explore an individual’s motivation to change by increasing their insight and awareness about risks associated with substance abuse.31 pharmacists can play this role effectively considering they are knowledgeable about the risks associated with opioid abuse. they are also better positioned to give advice to patients on the negative effects of prolonged opioid use. pharmacists are also better positioned to know patients who need a referral to treatment resources for oud even though they cannot do the referral themselves.30 they are more knowledgeable about outpatient treatment centers and can provide this information when necessary. the sbirt model has been proven instrumental in screening, initiation of treatment, and referral of patients that have a substance use disorder but its efficacy is limited because results of clinical trials are mixed.37,38 despite these limitations, it has various areas of strength that can prove instrumental in addressing opioid use disorder. for instance, it is easy to use and adaptable meaning it can be applied in different healthcare settings.31 providing training to pharmacists on its proper use can ensure positive outcomes in opioid addiction prevention. education is an additional measure that is reported in the literature as being vital in addiction management. various studies have found a positive correlation between educationrelated activities and positive outcomes when it comes to the prevention of opioid misuse and abuse.39,40,10. pharmacists are better positioned to provide education to patients because of the important role they play in opioid dispensing. different studies have noted improvements in patient outcomes following education-based interventions.39,30. in addition to providing education to patients, pharmacists can also be a valuable resource for training and educating healthcare providers who are involved in opioid addiction management.10 considering their knowledge in pharmacology, they are better placed to provide training and continuing education to other healthcare providers involved in opioid addiction management such as counsellors. their role in providing training is documented in research, particularly on the proper use of naloxone for patients to law enforcers and other community members.41,42 pharmacists also play a crucial role in addiction management through safe dispensing. using pdmps is recognised as one measure that can ensure safe opioid dispensing to prevent misuse or abuse. pdmp is a risk mitigation practice that is recognized as instrumental in the effective monitoring of opioid use by healthcare providers.43 pdmps ensure safe prescribing because they track how controlled substances are prescribed.10 cdc recognises pdmps as instrumental in ensuring safe prescribing because they provide healthcare providers with timely information about patients’ prescriptions and behaviours that can contribute to misuse or abuse.27 having access to timely information and patients’ history of prescription opioids can enable pharmacists to have targeted responses to prevent misuse or abuse. considering that more than 50 states have operational pdmps, then it is a critical avenue for timely opioid addiction management. besides, it is recommended by the cdc clinical practice guideline as a measure that can help to determine whether patients are receiving opioid doses that put them at higher risk of overdose. however, when using risk mitigation practices such as pdmp it is important to acknowledge the challenges that pharmacists may face especially when dealing with customers in a customerservice setting and put measures in place to minimize them to be able to achieve optimal outcomes. an additional role that pharmacists can play in addiction management is providing medication-assisted treatment (mat). mat entails the use of the food and drug administration (fda) approved prescription medications to treat opioid addiction.10 examples of such medications include methadone, naltrexone, and buprenorphine.44 the use of mat in treating opioid addiction is proven in the literature. different studies have established that the use of these medications is effective in reducing and treating opioid overdoses.45,44 mat helps to reduce illegal opioid use by reducing the craving for opioids and providing relief for individuals experiencing withdrawal syndrome. when used in treating opioid addiction, the medication has been shown to reduce the number of fatal overdoses.10 because of their role in opioid dispensing, pharmacists can provide mat and support in substance abuse treatment centers. pharmacists can also deal with opioid addiction through the distribution of naloxone and opioid rescue kits. naloxone plays an instrumental role in opioid overdose reversal and is recognised as an effective measure that can help in addressing the opioid epidemic.31 the role of pharmacists in naloxone distribution is recognised in research. community pharmacies are recognised as key distribution points for naloxone because of their accessibility to patients.33 in addition to being key distribution points for naloxone, pharmacists are recognised as instrumental in providing education on their proper use to patients and support persons including law enforcement and members of the community.31,10,41 through effective naloxone distribution and dispensing, pharmacists can be able to deal with addiction management by preventing overdoses. other additional measures that can help pharmacists deal with opioid addiction include providing medication therapy management (mtm), counselling, and referral to addiction treatment resources. the main aim of mtm is to optimize patient outcomes especially when it comes to effective medication use.46 this is done by identifying and addressing problems related to the prescribed drug problems such as misuse or mismanagement. pharmacists are in a unique position to do mtm for opioids because of their role in dispensing. by using tools such as pdmp, pharmacists can know patients who are at risk of opioid misuse and abuse and intervene by either recommending medication review or suggesting measures that can help to address the misuse before it escalates. providing counseling is also a measure that can help with opioid addiction management. counseling is mainly done in addiction treatment and rehabilitation centers but pharmacists are in a unique position to provide counselling because of their unique role that allows them to be in contact with patients.47,48,49 providing counseling on the risks of overdose, for example, can ensure that patients are more knowledgeable on why overdosing is risky. pharmacists can also address the safe disposal of opioids and safe storage.50 pharmacists are also uniquely positioned to provide referrals to addiction treatment resources. because they often interact with patients, they are in a unique position to identify patients who may have undiagnosed oud and provide referrals to addiction treatment resources.28 pharmacists are also in a better position to identify resources that are available to patients within the community making them vital in opioid addiction management.50 chisholm-burns et al.,10 also recognise that pharmacists could be instrumental in referring patients to mat programs and making sure they adhere to treatment. pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [54] ajdhs.com the following review contributes significantly to the existing research by identifying the role of pharmacists as instrumental in dealing with opioid addiction. it provides different interventions that pharmacists can engage in to prevent opioid misuse, abuse, and oud. identifying different ways in which pharmacists can help in dealing with opioid addiction management, cements their role as crucial in dealing with the opioid epidemic being experienced in the us. though the role of pharmacists is recognised as instrumental, several barriers exist that may hinder the effective implementation of the interventions discussed above. for instance, pharmacists may not be better positioned to provide screening and counseling because of the limited duration of interaction with the patients. pharmacists may also not be better positioned to provide medication-assisted treatment (mat) because their role is limited to dispensing. however, considering the enormous potential that pharmacists possess in opioid addiction management, creating an enabling environment that can increase their readiness to provide the above-discussed interventions is paramount in the opioid epidemic. providing education, training, and putting guidelines in place, for example, are some of the measures that can ensure pharmacists' readiness to reduce opioid misuse and abuse. although this paper clearly outlines the role that pharmacists can play in opioid addiction management, it has its limitations. the scope of this paper mainly focuses on the role of pharmacists in the us which makes it challenging to generalize results to other regions and countries affected by the opioid epidemic. the paper is also limited by the fact that rigorous data extraction is not followed. the paper only includes articles that the author deems applicable to inform this research. conclusion the us is still grappling with the opioid epidemic necessitating measures to manage addiction and prevent overdose deaths. pharmacists are recognised as instrumental in opioid addiction management because of the crucial role they play in opioid dispensing and their direct involvement with patients. this is particularly the case for community pharmacists who are in a position to identify signs of misuse and provide interventions before patients reach the critical point of addiction. pharmacists can provide various interventions including prevention, screening, education, overdose prevention through naloxone prescribing, counseling, and referral to treatment resources. using models such as sbirt can help pharmacists screen for patients who are at risk of addiction, provide brief interventions, and refer them to proper treatment resources. using tools such as pdmp can ensure pharmacists have access to data on patients and are able to identify those who are at an increased risk of opioid misuse and abuse. overall, implementing these measures can play a crucial role in helping to reverse the worrying statistics about opioid prevalence and morbidity. abbreviations oud: opioid use disorder samhsa: substance abuse and mental health service administration cdc: centers for disease control and prevention pdmp (s): prescription drug monitoring programs mat: medication-assisted treatment fda: food and drug administration sbirt: screening, brief intervention and referral to treatment sud: substance use disorder mtm: medication therapy management references 1. busse jw, wang l, kamaleldin m, et al. opioids for chronic noncancer pain: a systematic review and meta-analysis. jama. 2018; 320(23):2448-2460. https://doi.org/10.1001/jama.2018.18472 pmid:30561481 pmcid:pmc6583638 2. trescot am, datta s, lee m, hansen h. opioid pharmacology. pain physician. 2008;11(2s): s133. https://doi.org/10.36076/ppj.2008/11/s133 3. substance abuse and mental health services administration. key substance use and mental health indicators in the united states: results from the 2022 national survey on drug use and health, nsduh series h-58, hhs publication no. pep23-07-01-006. rockville, md: center for behavioral health statistics and quality, substance abuse and mental health services administration; 2023. 4. national institute of drug abuse. drug overdose death rates. 2022. accessed february 28, 2024. https://nida.nih.gov/researchtopics/trends-statistics/overdose-deathrates#:~:text=opioid%2dinvolved%20overdose%20deaths%20r ose 5. spencer mr, miniño am, warner m. drug overdose deaths in the united states, 2001-2021. nchs data brief, no 457. hyattsville, md: national center for health statistics. 2022. https://doi.org/10.15620/cdc:122556 6. gomes t, ledlie s, tadrous m, mamdani m, paterson jm, juurlink dn. trends in opioid toxicity-related deaths in the us before and after the start of the covid-19 pandemic, 2011-2021. jama network open. 2023;6(7): e2322303. https://doi.org/10.1001/jamanetworkopen.2023.22303 pmid:37418260 pmcid:pmc10329206 7. gomes t, tadrous m, mamdani mm, paterson jm, juurlink dn. the burden of opioid-related mortality in the united states. jama network open. 2018; 1(2): e180217. https://doi.org/10.1001/jamanetworkopen.2018.0217 pmid:30646062 pmcid:pmc6324425 8. centers for disease control and prevention. the economics of injury and violence prevention; cost of opioid overdose and use disorder. 2023. accessed february 28, 2024. https://www.cdc.gov/injury/features/health-econ-cost-ofinjury/index.html#cost-opioid . 9. gondora n, versteeg sg, carter c, et al. the role of pharmacists in opioid stewardship: a scoping review. research in social and administrative pharmacy. 2022; 18(5):2714-47. https://doi.org/10.1016/j.sapharm.2021.06.018 pmid:34261590 10. chisholm-burns ma, spivey ca, sherwin e, wheeler j, hohmeier k. the opioid crisis: origins, trends, policies, and the roles of pharmacists. american journal of health-system pharmacy. 2019;76(7):424-35. https://doi.org/10.1093/ajhp/zxy089 pmid:31361827 11. centers for disease control and prevention.opioid data analysis and resources. 2023. accessed 28 february 2024. https://www.cdc.gov/opioids/data/analysis-resources.html 12. centers for disease control and prevention. opioid overdose. 2023. accessed 28 february 2024. https://www.cdc.gov/drugoverdose/deaths/opioidoverdose.html 13. dart rc, surratt hl, cicero tj, et al. trends in opioid analgesic abuse and mortality in the united states. new england journal of medicine. 2015;372(3):241-8. https://doi.org/10.1056/nejmsa1406143 pmid:25587948 14. international narcotics control board. narcotic drugs: estimated world requirements for 2017: statistics for 2015. accessed february 28, 2024. https://www.incb.org/documents/narcoticdrugs/technicalpublications/2016/narcotic_drugs_publication_2016.pdf . 15. international narcotics control board. narcotic drugs: estimated world requirements for 2018: statistics for 2016. accessed february 28, 2024. https://www.incb.org/documents/narcotichttps://doi.org/10.1001/jama.2018.18472 https://doi.org/10.36076/ppj.2008/11/s133 https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=opioid%2dinvolved%20overdose%20deaths%20rose https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=opioid%2dinvolved%20overdose%20deaths%20rose https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=opioid%2dinvolved%20overdose%20deaths%20rose https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=opioid%2dinvolved%20overdose%20deaths%20rose https://doi.org/10.15620/cdc:122556 https://doi.org/10.1001/jamanetworkopen.2023.22303 https://doi.org/10.1001/jamanetworkopen.2018.0217 https://www.cdc.gov/injury/features/health-econ-cost-of-injury/index.html#cost-opioid https://www.cdc.gov/injury/features/health-econ-cost-of-injury/index.html#cost-opioid https://doi.org/10.1016/j.sapharm.2021.06.018 https://doi.org/10.1093/ajhp/zxy089 https://www.cdc.gov/opioids/data/analysis-resources.html https://www.cdc.gov/drugoverdose/deaths/opioid-overdose.html https://www.cdc.gov/drugoverdose/deaths/opioid-overdose.html https://doi.org/10.1056/nejmsa1406143 https://www.incb.org/documents/narcotic-drugs/technical-publications/2016/narcotic_drugs_publication_2016.pdf https://www.incb.org/documents/narcotic-drugs/technical-publications/2016/narcotic_drugs_publication_2016.pdf https://www.incb.org/documents/narcotic-drugs/technical-publications/2016/narcotic_drugs_publication_2016.pdf https://www.incb.org/documents/narcotic-drugs/technical-publications/2017/narcotic_drugs_technical_publication_2017.pdf pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [55] ajdhs.com drugs/technicalpublications/2017/narcotic_drugs_technical_publication_2017.pd f . 16. vowles ke, mcentee ml, julnes ps, frohe t, ney jp, van der goes dn. rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. pain. 2015; 156(4):569-76. https://doi.org/10.1097/01.j.pain.0000460357.01998.f1 pmid:25785523 17. kaye ad, jones mr, kaye am, et al. prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse: part 1. pain physician. 2017;20(2): s93. https://doi.org/10.36076/ppj.2017.s109 18. unick gj, ciccarone d. us regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations. international journal of drug policy. 2017; 46:112-9. https://doi.org/10.1016/j.drugpo.2017.06.003 pmid:28688539 pmcid:pmc5722230 19. pletcher mj, kertesz sg, kohn ma, gonzales r. trends in opioid prescribing by race/ethnicity for patients seeking care in us emergency departments. jama. 2008; 299(1):70-8. https://doi.org/10.1001/jama.2007.64 pmid:18167408 20. han b, compton wm, jones cm, cai r. nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the united states, 2003-2013. jama. 2015; 314(14):146878. https://doi.org/10.1001/jama.2015.11859 pmid:26461997 21. altekruse sf, cosgrove cm, altekruse wc, jenkins ra, blanco c. socioeconomic risk factors for fatal opioid overdoses in the united states: findings from the mortality disparities in american communities study (mdac). plos one. 2020;15(1):e0227966. https://doi.org/10.1371/journal.pone.0227966 pmid:31951640 pmcid:pmc6968850 22. klimas j, gorfinkel l, fairbairn n, et al. strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review. jama network open. 2019; 2(5):e193365. https://doi.org/10.1001/jamanetworkopen.2019.3365 pmid:31050783 pmcid:pmc6503484 23. turk dc, swanson ks, gatchel rj. predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. the clinical journal of pain. 2008; 24(6):497-508. https://doi.org/10.1097/ajp.0b013e31816b1070 pmid:18574359 24. grant bf, stinson fs, dawson da, chou sp, dufour mc, compton w, pickering rp, kaplan k. prevalence and co-occurrence of substance use disorders and independentmood and anxiety disorders: results from the national epidemiologic survey on alcohol and relatedconditions. archives of general psychiatry. 2004; 61(8):807-16. https://doi.org/10.1001/archpsyc.61.8.807 pmid:15289279 25. centers for disease control and prevention. opioid prescribing; where you live matters. 2017. accessed february 28 2024. https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf 26. centers for disease control and prevention. united states dispensing rate maps. 2023. accessed february 28 2024. https://www.cdc.gov/drugoverdose/rxrate-maps/index.html 27. dowell d, haegerich tm, chou r. cdc guideline for prescribing opioids for chronic pain-united states, 2016. jama. 2016;315(15):1624-1645. https://doi.org/10.1001/jama.2016.1464 pmid:26977696 pmcid:pmc6390846 28. bach p, hartung d. leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders. addiction science & clinical practice. 2019;14(1):30. https://doi.org/10.1186/s13722-019-0158-0 pmid:31474225 pmcid:pmc6717996 29. hartung dm, johnston ka, hallvik s, et al. prescription opioid dispensing patterns prior to heroin overdose in a state medicaid program: a case-control study. journal of general internal medicine. 2020; 35:3188-96. https://doi.org/10.1007/s11606020-06192-4 pmid:32935311 pmcid:pmc7661590 30. compton wm, jones cm, stein jb, wargo em. promising roles for pharmacists in addressing the us opioid crisis. research in social and administrative pharmacy. 2019; 15(8):910-6. https://doi.org/10.1016/j.sapharm.2017.12.009 pmid:29325708 pmcid:pmc7373345 31. iwuchukwu of, kim d. prevention better than cure: expanding on pharmacists' role in prescription opioid overdose and addiction management. american journal of pharmacotherapy and pharmaceutical sciences. 2023; 2. https://doi.org/10.25259/ajpps_2023_022 32. hartung dm, hall j, haverly sn, et al. pharmacists' role in opioid safety: a focus group investigation. pain medicine. 2018; 19(9):1799-806. https://doi.org/10.1093/pm/pnx139 pmid:29016883 pmcid:pmc6659018 33. so r, al hamarneh y, barnes m, et al. the status of naloxone in community pharmacies across canada. canadian pharmacists journal/revue des pharmaciens du canada. 2020; 153(6):352-6. https://doi.org/10.1177/1715163520958435 pmid:33282025 pmcid:pmc7689620 34. babor tf, mcree bg, kassebaum pa, grimaldi pl, ahmed k, bray j. screening, brief intervention, and referral to treatment (sbirt): toward a public health approach to the management of substance abuse. alcohol/drug screening and brief intervention. 2023; 4:730. https://doi.org/10.1300/j465v28n03_03 pmid:18077300 35. cochran g, field c, lawson k, erickson c. pharmacists' knowledge, attitudes and beliefs regarding screening and brief intervention for prescription opioid abuse: a survey of utah and texas pharmacists. journal of pharmaceutical health services research. 2013; 4(2):71-9. https://doi.org/10.1111/jphs.12013 36. cochran g, rubinstein j, bacci jl, ylioja t, tarter r. screening community pharmacy patients for risk of prescription opioid misuse. journal of addiction medicine. 2015; 9(5):411. https://doi.org/10.1097/adm.0000000000000148 pmid:26291546 pmcid:pmc4725054 37. d'onofrio g, chawarski mc, o'connor pg, et al. emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. journal of general internal medicine. 2017; 32:6606. https://doi.org/10.1007/s11606-017-3993-2 pmid:28194688 pmcid:pmc5442013 38. hargraves d, white c, frederick r, et al. implementing sbirt (screening, brief intervention and referral to treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. public health reviews. 2017; 38(1):1-1. https://doi.org/10.1186/s40985-017-0077-0 pmid:29450101 pmcid:pmc5809898 39. gondora n, sanyal c, carter c, et al. the role of pharmacists in opioid stewardship: protocol. research in social and administrative pharmacy. 2021;17(5):993-6. https://doi.org/10.1016/j.sapharm.2020.06.027 pmid:33773640 40. bratberg jp, smothers zp, collins k, erstad b, ruiz veve j, muzyk aj. pharmacists and the opioid crisis: a narrative review of pharmacists' practice roles. journal of the american college of clinical pharmacy. 2020; 3(2):478-84. https://doi.org/10.1002/jac5.1171 41. akers jl, hansen rn, oftebro rd. implementing take-home naloxone in an urban community pharmacy. journal of the american pharmacists association. 2017; 57(2): s161-7. https://doi.org/10.1016/j.japh.2017.01.006 pmid:28202384 42. duvivier h, gustafson s, greutman m, et al. indian health service pharmacists engaged in opioid safety initiatives and expanding access to naloxone. journal of the american pharmacists association. 2017; 57(2): s135-40. https://doi.org/10.1016/j.japh.2017.01.005 pmid:28292501 43. chaudhary s, compton p. use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain. substance abuse. 2017; 38(1):95-104. https://doi.org/10.1080/08897077.2016.1265038 pmid:27897471 https://www.incb.org/documents/narcotic-drugs/technical-publications/2017/narcotic_drugs_technical_publication_2017.pdf https://www.incb.org/documents/narcotic-drugs/technical-publications/2017/narcotic_drugs_technical_publication_2017.pdf https://www.incb.org/documents/narcotic-drugs/technical-publications/2017/narcotic_drugs_technical_publication_2017.pdf https://doi.org/10.1097/01.j.pain.0000460357.01998.f1 https://doi.org/10.36076/ppj.2017.s109 https://doi.org/10.1016/j.drugpo.2017.06.003 https://doi.org/10.1001/jama.2007.64 https://doi.org/10.1001/jama.2015.11859 https://doi.org/10.1371/journal.pone.0227966 https://doi.org/10.1001/jamanetworkopen.2019.3365 https://doi.org/10.1097/ajp.0b013e31816b1070 https://doi.org/10.1001/archpsyc.61.8.807 https://www.cdc.gov/vitalsigns/pdf/2017-07-vitalsigns.pdf https://www.cdc.gov/drugoverdose/rxrate-maps/index.html https://doi.org/10.1001/jama.2016.1464 https://doi.org/10.1186/s13722-019-0158-0 https://doi.org/10.1007/s11606-020-06192-4 https://doi.org/10.1007/s11606-020-06192-4 https://doi.org/10.1016/j.sapharm.2017.12.009 https://doi.org/10.25259/ajpps_2023_022 https://doi.org/10.1093/pm/pnx139 https://doi.org/10.1177/1715163520958435 https://doi.org/10.1300/j465v28n03_03 https://doi.org/10.1111/jphs.12013 https://doi.org/10.1097/adm.0000000000000148 https://doi.org/10.1007/s11606-017-3993-2 https://doi.org/10.1186/s40985-017-0077-0 https://doi.org/10.1016/j.sapharm.2020.06.027 https://doi.org/10.1002/jac5.1171 https://doi.org/10.1016/j.japh.2017.01.006 https://doi.org/10.1016/j.japh.2017.01.005 https://doi.org/10.1080/08897077.2016.1265038 pallav dave asian journal of dental and health sciences. 2024; 4(1):51-56 [56] ajdhs.com 44. volkow nd, jones eb, einstein eb, wargo em. prevention and treatment of opioid misuse and addiction: a review. jama psychiatry. 2019; 76(2):208-16. https://doi.org/10.1001/jamapsychiatry.2018.3126 pmid:30516809 45. connery hs. medication-assisted treatment of opioid use disorder: review of the evidence and future directions. harvard review of psychiatry. 2015 mar 1;23(2):63-75. https://doi.org/10.1097/hrp.0000000000000075 pmid:25747920 46. viswanathan m, kahwati lc, golin ce, et al. medication therapy management interventions in outpatient settings: a systematic review and meta-analysis. jama internal medicine. 2015;175(1):76-87. https://doi.org/10.1001/jamainternmed.2014.5841 pmid:25401788 47. cobaugh dj, gainor c, gaston cl, et al. the opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. american journal of health-system pharmacy. 2014; 71(18):1539-54. https://doi.org/10.2146/ajhp140157 pmid:25174015 48. cochran g, gordon aj, field c et al. developing a framework of care for opioid medication misuse in community pharmacy. res social adm pharm. 2016; 12:293-301. https://doi.org/10.1016/j.sapharm.2015.05.001 pmid:26048710 pmcid:pmc4726478 49. tewell r, edgerton l, kyle e. establishment of a pharmacist-led service for patients at high risk for opioid overdose. am j healthsyst pharm. 2018; 75:376-83. https://doi.org/10.2146/ajhp170294 pmid:29523534 50. thakur t, frey m, chewning b. pharmacist services in the opioid crisis: current practices and scope in the united states. pharmacy. 2019; 7(2):60. https://doi.org/10.3390/pharmacy7020060 pmid:31200469 pmcid:pmc6632048 https://doi.org/10.1001/jamapsychiatry.2018.3126 https://doi.org/10.1097/hrp.0000000000000075 https://doi.org/10.1001/jamainternmed.2014.5841 https://doi.org/10.2146/ajhp140157 https://doi.org/10.1016/j.sapharm.2015.05.001 https://doi.org/10.2146/ajhp170294 https://doi.org/10.3390/pharmacy7020060 title goes here noor rahmah et al asian journal of dental and health sciences. 2024; 4(2):17-20 [17] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited sterilization of toothbrushes using ultraviolet-c light against streptococcus mutans bacteria afifah noor rahmah *, diyah fatmasari, endah aryati eko ningtyas ministry of health semarang health polytechnic, indonesia article info: ____________________________________ article history: received 22 march 2024 reviewed 05 may 2024 accepted 28 may 2024 published 15 june 2024 ____________________________________ cite this article as: noor rahmah a, fatmasari d, aryati eko ningtyas e, sterilization of toothbrushes using ultraviolet-c light against streptococcus mutans bacteria, asian journal of dental and health sciences. 2024; 4(2):17-20 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.78 ________________________________________ *address for correspondence: afifah noor rahmah, ministry of health semarang health polytechnic, indonesia abstract __________________________________________________________________________________________________________________________ background: streptococcus mutans bacteria are the dominant cariogenic bacteria that can be found in dental caries and are able to survive and reproduce at low ph. toothbrush storage is related to environmental humidity and existing bacteria. bacterial growth is 70% higher in wet and closed environments, bacteria from the oral cavity can be carried on the toothbrush. aim: this research is to produce a model for storing toothbrushes with ultraviolet-c against the growth of streptococcus mutans bacteria. materials and method: research with research and development (r&d) method with a quantitative approach with 5 stages, namely information gathering, model design, expert validation and revision, model trials, and model results. the design used is randomize pretest-posttest with control group design using 5, 10, and 15 minutes of ultraviolet-c treatment groups and a control group of toothbrushes stored standing without treatment using ultraviolet-c. results: the results of model expert validation using the aiken-v test showed 0.810, meaning that all question items were declared valid. the icc results show 0.000, meaning that the toothbrush storage model with ultraviolet-c is feasible as an effort to reduce the number of streptococcus mutans bacterial colonies. two-way anova results show 0.000, meaning that there is a significant time difference between the control group and the 5, 10, and 15 minute sterilization groups. post-hoc lsd results showed 0.000, meaning there was a significant difference in the 5, 10, 15 minute treatment group, and the control group. the pearson sig. (2-tailed) correlation result is 0.000, meaning that there is a significant relationship between the length of time and the number of streptococcus mutans bacteria. the results of the bacterial repetition test showed that 15 minutes was the most effective time to kill streptococcus mutans bacteria. the results showed that the average number of bacteria decreased by 74%, 86%, and 100% after using ultraviolet-c for 5, 10, and 15 minutes. obtained showed that 15 minutes was the most effective for killing streptococcus mutans bacteria. conclusion: the results showed that the average number of bacteria decreased by 74%, 86%, and 100% after using ultraviolet-c for 5, 10, and 15 minutes. developing a model for storing toothpaste with ultravioletc for 15 minutes is effective in reducing streptococcus mutans bacteria. keywords: streptococcus mutans, toothbrush, ultraviolet-c introduction dental and oral health is part of general health which can affect general health directly or indirectly. one of the correct ways to maintain oral hygiene is by brushing your teeth using a toothbrush which can remove plaque1. caries is one of the dental and oral health problems that is often experienced by people which starts from the growth of plaque on the teeth in the oral cavity2. there is a microbiome in the oral cavity which has an important role in maintaining the oral environment to remain normal and stable3. in the oral cavity there is saliva which contains various cariogenic bacteria such as streptococcus mutans bacteria which are aciduric and acidogenic, namely bacteria that can live in an acidic environment and can produce acid4. caries is a dental disease in which the hard tooth tissue is damaged due to the metabolic activity of bacteria in plaque which causes demineralization5. caries disease in indonesia is mostly experienced by those aged 25-64 years, amounting to 87.0% – 96.8% according to 2018 basic health research (riskesdas) data 6. the human oral cavity functions as a connecting channel between the external environment, the digestive tract, and the respiratory tract. microorganisms in the oral cavity need appropriate nutrition, temperature and humidity. there is a microbiome microbiota in the oral cavity which has an important role in maintaining a normal and stable oral environment3. in the oral cavity there is saliva which contains various cariogenic bacteria such as streptococcus mutans bacteria which are aciduric and acidogenic, namely bacteria that can live in an acidic environment and can produce acid4. the acidic environment produced by bacteria can trigger a demineralization process in the enamel so that plaque growth will occur to cause caries lesions5. caries is a dental disease in which the hard tissue of the tooth is damaged due to the metabolic activity of bacteria in the plaque which causes demineralization. plaque is one of the factors causing dental caries which consists of a population of bacteria. one of the bacteria that can be found in dental caries is streptococcus mutans. one of the bacteria that can be found in dental caries is open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.78 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.77&amp;domain=pdf noor rahmah et al asian journal of dental and health sciences. 2024; 4(2):17-20 [18] ajdhs.com streptococcus mutans. this bacterium is the dominant cariogenic bacterium that can be found in dental caries and can produce acid, and is able to survive and multiply at low ph (aciduric)5. streptocuccus mutans bacteria are non-motile, facultative anaerobes, and gram-positive coccus arranged like a chain and have various proteins and enzymes. the process of attachment and virulence of bacteria on the tooth surface is the role of these proteins and enzymes. one way to prevent caries is by cleaning plaque, namely by brushing your teeth7. the most common mechanical method used by people to control plaque is by brushing their teeth. the toothbrush used can contain a lot of bacteria that can contaminate the oral cavity. contaminated toothbrushes can cause oral and systemic diseases, digestive disorders, cardiovascular disease, respiratory disorders and kidney disease7. toothbrush storage is related to environmental humidity conditions and the bacteria present. toothbrushes that are stored open have fewer bacteria than closed toothbrushes. using an ultraviolet-c lamp on pathogenic bacteria for 5, 10 and 15 minutes can kill and inactivate the bacteria. one of the efficient sterilization techniques is using ultraviolet-c germicidal irradiation. the process of killing bacteria based on type c ultraviolet (uv) is more effective in deactivating bacteria. ultraviolet-c radiation is more effective at killing pathogens on surfaces and can effectively sterilize unexposed areas. ultraviolet-c light can be used to disinfect items that can be reused or safely disposed of in the environment8. method this research uses the research and development (r&d) method with a quantitative approach, using a true experiment design using a randomized pretest-posttest with control group design. this research procedure includes 5 main steps, namely as follows; 1) information collection, 2) product/model design, 3) expert validation and revision, 4) product/model testing, and 5) product/model results. this method was used to produce and test the effectiveness of a model product for storing toothbrushes with ultraviolet-c using a quantitative approach. the research results are divided into five stages, namely: information collection, design, expert validation and revision, model testing, model results. this research was carried out at the microbiology laboratory to test a toothbrush storage model with ultraviolet-c against streptococcus mutans bacteria in 3 treatment groups with a duration of using the model of 5 minutes, 10 minutes and 15 minutes. there was a control group with wet toothbrushes and dry toothbrushes without treatment using a toothbrush storage model with ultraviolet-c against streptococcus mutans bacteria in order to determine the differences between groups and test the effectiveness of the toothbrush storage model with ultraviolet-c against streptococcus mutans bacteria. information collection is carried out by interviewing related knowledge about how to store toothbrushes with the aim of knowing how to store toothbrushes in a toothbrush storage area and as information on the importance of making a toothbrush storage model with ultraviolet-c against the growth of streptococcus mutans bacteria. the tool model is designed from the size of the tool specifications, model tools and materials, tool design is some description of the design of the tool / prototype of the toothbrush storage model with ultraviolet-c against the growth of streptococcus mutans bacteria which includes the front model, the model when opened, and sensors and ultraviolet-c lamps. as well as the design of the electronic system and how the tool works. expert validation is carried out to determine whether the model to be created is valid and reliable. the results of the expert validity test were tested on aiken v to determine the validity of the question items and the interclass correlation coeficient (icc) test was conducted to determine the reliability of the question items. the results of the expert validity test using the aiken v test, obtained a v result of 0.810 which indicates that the value is included in the high criteria. it can be concluded that all question items are valid. the feasibility of a toothbrush storage model with ultravioletc against the growth of streptococcus mutans bacteria using the interclass correlation coeficient (icc) test resulted in a value of 0.722 with a good category, the p-value of 0.000 indicates that the toothbrush storage model with ultraviolet-c is feasible in reducing the number of colonies of streptococcus mutans bacteria. the results of expert validation that have been carried out to determine the feasibility of the product/model can be seen that the development model of toothbrush storage with ultraviolet-c against the growth of streptococcus mutans bacteria is relevant and has received a model feasibility assessment from 6 validators, after the model/product assessment is carried out, it is necessary to test the product/model which aims to analyze the effectiveness of the product/model. the product results in the form of a toothbrush sterilizer with ultraviolet-c are expected to provide benefits as a tool to sterilize toothbrushes and reduce the number of streptococcus mutans bacteria found on toothbrushes that can be used easily by the community. results and discussion the identification test of streptococcus mutans bacteria using nutrient broth (nb) liquid media which aims as a bacterial culture medium and to fertilize bacteria. the results showed that there were streptococcus mutans bacteria on the toothbrush before use in a dry state without rinsing, the toothbrush before use was wet because it was rinsed, and the toothbrush after use was wet because it was rinsed. repetition tests were carried out on streptococcuc mutans bacteria for 5 minutes, 10 minutes, 15 minutes and control groups of wet toothbrushes and dry toothbrushes. the suspension concentration used was 105. this repetition test was carried out using the same ultraviolet-c lamp. the results of interviews conducted with 6 experts (2 microbiologists, 2 electromedical experts, a dentist, and a dental and oral therapist), namely, the way toothbrushes are stored by the general public influences the number of bacteria found on toothbrushes. the number of bacteria found on the toothbrush can be influenced by the place where the toothbrush is stored, namely inside/outside the bathroom, the position in which the toothbrush is stored, the use of toothbrush headgear, the length of time the toothbrush is used, the storage of toothbrushes at the same time, and the location. storing conventional toothbrushes separately and standing. the results further show that there are recommendations to develop a model for storing toothbrushes with ultraviolet-c in order to reduce the number of bacteria/influence the growth of bacteria found on toothbrushes. the results of the validity and reliability tests were declared valid and reliable that the toothbrush storage model could reduce the number of streptococcus mutans bacteria. noor rahmah et al asian journal of dental and health sciences. 2024; 4(2):17-20 [20] ajdhs.com table 1 dry control wet control sterilization time test 5 minutes 10 minutes 15 minutes 1 502 500 155 90 0 2 491 490 134 88 0 3 523 520 160 76 0 4 500 500 158 81 0 average 504 503 152 84 0 table 1 is a table of results from 4 experimental tests in the treatment group and control group. the results of the research that was carried out on toothbrushes which were carried out 4 repetitions of tests were obtained from the leokitto formula using a toothbrush storage model with ultraviolet-c against streptococcus mutans bacteria at a sterilization time of 5 minutes, namely that there was an average number of 152 colonies of streptococcus mutans bacteria. , at a sterilization time of 10 minutes, there was an average number of 84 colonies of streptococcus mutans bacteria, at a sterilization time of 15 minutes, there was an average number of 0 colonies of streptococcus mutans bacteria or there were no streptococcus mutans bacteria after treatment. the average result in the control group of wet toothbrushes that were not sterilized using an ultraviolet-c lamp was 503 colonies of streptococcus mutans bacteria, in the control group of dry toothbrushes that were not sterilized using an ultraviolet-c lamp was 504 colonies of streptococcus mutans batteries. . the results of developing a toothbrush storage model with ultraviolet-c against streptococcus mutans bacteria using twoway anova testing showed that there was a significant effect of sterilization time on the number of streptococcus mutans bacteria between the 5 minute, 10 minute and 15 minute groups. the results of the lsd post-hoc test were that there was a significant difference between the sterilization time of 5 minutes, 10 minutes, 15 minutes, and the control group on the number of streptococcus mutans bacterial colonies. the results of the pearson correlation test are that there is a relationship between the length of time using the toothbrush storage model with ultraviolet-c and the number of colonies of streptococcus mutans bacteria. streptococcus mutans bacteria are the dominant cariogenic bacteria that can be found in dental caries and can produce acid, and are able to survive and reproduce at low ph (aciduric). streptococcus mutans bacteria have non-motile properties and are in the form of gram-positive coccus which are arranged like chains and have various proteins and enzymes. the process of attachment and virulence of bacteria on the tooth surface is the role of these proteins and enzymes. this bacteria has facultative anaerobic properties, namely bacteria that can grow in the presence or absence of oxygen in their growth and metabolism, this is in line with sulatri et al9, hat no pathogenic bacteria grew after being treated using ultraviolet-c light, whereas in media that was not exposed to ultraviolet-c light, the growth of pathogenic bacterial colonies was full and could not be counted10. the most effective time to reduce the number of streptococcus mutans bacteria on a toothbrush using an ultraviolet-c lamp is 15 minutes. ultraviolet-c lamps are effective in killing bacteria because within a period of 5 minutes, the number of bacteria exposed to ultraviolet-c lamps has decreased by more than half the number of bacteria before exposure to ultraviolet-c rays. streptococcus mutans bacteria on toothbrushes can be reduced due to exposure to ultraviolet-c light. ultraviolet-c lamps can be effective in inactivating bacteria because ultravioletc radiation is more effective in killing pathogens and sterilizing the area8. figure 1 figure 2 figure 1 is a model for the development of toothbrush storage with ultraviolet-c against the growth of streptpcoccus mutans bacteria that has been developed, namely the presence of a separately designed toothbrush storage area and a hanging toothbrush position. so bacteria do not easily grow because toothbrushes do not touch each other. figure 2 shows the addition of ultraviolet-c light to the toothbrush storage development model which is provided to reduce the development of the number of streptococcus mutans bacterial colonies. type c ultraviolet lamps are more effective in inactivating bacteria. ultraviolet-c radiation is more effective in sterilizing areas and killing pathogens on surfaces. the role of ultraviolet-c lamps can influence the growth of bacteria, because ultraviolet-c rays can open membrane proteins and release tryptophan which can then cause an initial increase in the signal in the light emitted. with tryptophan taken from the cell membrane, there is space left to form a gaping hole for ultraviolet-c light to enter and damage dna11, so the bacteria will die12. a damp toothbrush storage area can cause bacteria to multiply more quickly. keeping your toothbrush and toothbrush storage area clean is very important for dental and oral health, because if it is not cleaned, bacteria will grow on the toothbrush and storage area. the model for storing toothbrushes with ultraviolet-c can noor rahmah et al asian journal of dental and health sciences. 2024; 4(2):17-20 [20] ajdhs.com carry out the sterilization process and can reduce and kill and stop the growth of streptococcus mutans bacteria because it is known that ultraviolet-c rays can enter and damage the dna of bacteria, resulting in bacterial death13. conclusion the average number of streptococcus mutans bacterial colonies on a wet/rinsed toothbrush before being treated using ultraviolet-c for 5 minutes was 590 bacterial colonies, and there were 152 bacterial colonies after being treated using ultraviolet-c. the average number of streptococcus mutans bacterial colonies on a wet/rinsed toothbrush before being treated using ultraviolet-c for 10 minutes is 590 bacterial colonies, and there are 84 bacterial colonies after being treated using ultraviolet-c. the average number of streptococcus mutans bacterial colonies on a wet/rinsed toothbrush before being treated using ultraviolet-c for 15 minutes is 590 bacterial colonies, and there are 0 bacterial colonies after being treated using ultraviolet-c. the average number of streptococcus mutans bacterial colonies on a wet/rinsed toothbrush before being treated without using ultraviolet-c is 590 bacterial colonies, and there are 504 bacterial colonies after not being treated using ultraviolet-c. the average number of streptococcus mutans bacterial colonies on a dry/unrinsed toothbrush before use and not treated with ultraviolet-c is 504 bacterial colonies, and there are 504 bacterial colonies after being given no treatment using ultraviolet-c. the development of a model for storing toothbrushes with ultraviolet-c on the growth of streptococcus mutans bacteria. in its implementation, it was effective in reducing the number of streptococcus mutans bacteria, as evidenced by the decrease in the average number in each group of sterilization treatments using ultraviolet-c lamps for 5 minutes, 10 minutes, 15 minutes, and there was still growth of streptococcus mutans bacteria in the control group on wet toothbrushes and dry toothbrushes. the most effective time in reducing the number of streptococcus mutans bacteria on a toothbrush using an ultraviolet-c lamp is at 15 minutes. ultraviolet-c lamps are effective in killing bacteria because within a period of 5 minutes, the number of bacteria exposed to ultraviolet-c lamps has decreased by more than half the number of bacteria before being exposed to ultraviolet-c light. streptococcus mutans bacteria on toothbrushes can be reduced due to exposure to ultraviolet-c light. ultraviolet-c lamps can be effective in inactivating bacteria because ultraviolet-c radiation is more effective in killing pathogens and sterilizing areas.8 there is a very strong relationship between time and the number of streptococcus mutans bacteria, namely, the longer the irradiation time using ultraviolet-c lamps, the less even the absence of streptococcus mutans bacterial growth. the role of ultraviolet-c lamps can affect the growth of bacteria, because ultraviolet-c light can open membrane proteins and release tryptophan which can then cause an initial increase in the signal in the emitted light. the presence of tryptophan taken from the cell membrane, there is space left to form a gaping hole for ultraviolet-c rays that can enter and damage dna11, so the bacteria will die12. references 1. ghoni tjiptoningsih u, permatasari fn. pengaruh penyimpanan sikat gigi terhadap kontaminasi bakteri pada bulu sikat gigi. mderj [internet]. 2021;1(3):111-26. available from: https://journal.moestopo.ac.id/index.php/mderj 2. praptiningsih rs, amien rw, pratiwi r. chewing xylitol candy and probiotic candy on the growth of dental plaque and number of colony of sterptococcus mutant bacteria. odonto dent j. 2022;9(1):147. https://doi.org/10.30659/odj.9.0.147-154 3. asghar f, bano a, waheed f, ahmed anjum a, ejaz h, javed n. association of exogenous factors with molecular epidemiology of staphylococcus aureus in human oral cavity. saudi j biol sci [internet]. 2023;30(4):103613. https://doi.org/10.1016/j.sjbs.2023.103613 pmid:36936700 pmcid:pmc10018566 4. wulandari, widodo, hatta i. hubungan antara jumlah koloni bakteri streptococcus mutans saliva dengan indeks karies (dmft). j kedokt gigi. 2022;6(3):1-1. 5. satrio r, supriyati, ashar f, zahra s, sari d, ichsyani m. isolasi dan karakterisasi bakteri kariogenik padapasien yang terdiagnosis pulpitis: penelitian observasional. j kedokt gigi univ padjajaran. 2023;35(april):61. https://doi.org/10.24198/jkg.v35i1.41439 6. indonesia kkr. hasil utama riskesdas 2018. kementerian kesehatan republik indonesia. 2018. 7. endriani r, siregar fm, rafni e, azhari rk, jefrizal j. <p>identifikasi gen kariogenik glukosiltransferase streptococcus mutans pada pasien karies gigi</p><p>identification of streptococcus mutans cariogenic gene glucosyltransferase (gtf) in dental caries patients</p>. j kedokt gigi univ padjadjaran. 2021;33(1):14. https://doi.org/10.24198/jkg.v33i1.30397 8. mahanta n, saxena v, pandey lm, batra p, dixit us. performance study of a sterilization box using a combination of heat and ultraviolet light irradiation for the prevention of covid-19. environ res [internet]. 2021;198(may):111309. https://doi.org/10.1016/j.envres.2021.111309 pmid:33984307 pmcid:pmc8107062 9. sulatri nl, yogeswara iba, nursini nw. efektifitas sinar ultraviolet terhadap cemaran bakteri patogen pada makanan cair sonde untuk pasien immune-compremissed. j gizi indones (the indones j nutr. 2017;5(2):112-8. https://doi.org/10.14710/jgi.5.2.112118 10. assari as, mohammed mahrous m, ahmad ya, alotaibi f, alshammari m, alturki f, et al. efficacy of different sterilization techniques for toothbrush decontamination: an ex vivo study. cureus. 2022;14(1):1-13. https://doi.org/10.7759/cureus.21117 11. ariyadi t, dewi ss. pengaruh sinar ultra violet terhadap pertumbuhan bakteri. vol. 2, jurnal kesehatan. 2009. p. 20-5. 12. minnuthfatin sa, setyawardhana rhd, dwi kurniawan fk. perbandingan efektivitas penggunaan sikat gigi konvensional dan sikat gigi elektrik terhadap penurunan indeks plak (literature review). dentin. 2022;6(2):87-90. https://doi.org/10.20527/dentin.v6i2.6392 13. imasari t, hidayatul f, ayu nabila rizki insani. deteksi bakteri streptococcus mutans pada sikat gigi dengan perilaku pemakaian sikat gigi di kost putri x kota kediri. j insa cendekia. 2023;10(1):52-7. https://doi.org/10.30659/odj.9.0.147-154 https://doi.org/10.1016/j.sjbs.2023.103613 https://doi.org/10.24198/jkg.v35i1.41439 https://doi.org/10.24198/jkg.v33i1.30397 https://doi.org/10.1016/j.envres.2021.111309 https://doi.org/10.14710/jgi.5.2.112-118 https://doi.org/10.14710/jgi.5.2.112-118 https://doi.org/10.7759/cureus.21117 https://doi.org/10.20527/dentin.v6i2.6392 grace patricia f et al asian journal of dental and health sciences. 2024; 4(1):57-59 [57] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited denture adhesives: an overview grace patricia f * , ferish j godwin , sandeep n , dr. nagappan karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india article info: _____________________________________________ article history: received 21 january 2023 reviewed 18 february 2024 accepted 06 march 2024 published 15 march 2024 _____________________________________________ cite this article as: patricia f g, godwin fj, sandeep n, nagappan, denture adhesives: an overview, asian journal of dental and health sciences. 2024; 4(1):57-59 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.69 _____________________________________________ *address for correspondence: grace patricia f, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india abstract _________________________________________________________________________________________________________________ denture adhesives are used for many years by denture wearers. proper denture don’t need denture adhesives. denture adhesives provide satisfaction and confident to denture wearing patients. it reduces the inadequate errors during clinical and technical procedure. proper application and usage of denture help in proper retention and stability and improve the self-confidence of the patient. there are many advantages and disadvantages are present, patient should use under the guideline and caution of the dentist. keywords: denture adhesives, denture wearing patients, satisfaction and confident introduction: denture plays an important role in edentulous patients for mastication, mental assurance and healthy life style 1. retention and stability of denture enhance the complete denture therapy 2. the denture adhesive are considered as useful additive and used wisely to meet treatment objectives and patients expectations 3. it is a mixed vegetable gums or synthetic polymers consist of mucilaginous substrate which helps in adhesion of denture to oral mucosa4. discussion: denture adhesive study by kapur in 1967 under 26 denture wearers states that denture adhesives improve the incisive ability of denture wearers 5. tarbet et al. studied the impact of adhesives on denture retention and stability, finding that patients reported enhanced chewing skills, confidence, and comfort, less food impaction, as well as reduced wobbling 6 hew et al. used a kinesiographic technique to determine the effectiveness of denture adhesives in improving the retention and stability of the complete maxillary denture in vivo 7 abdelmelak and michael9 found that denture adhesives decreased pressure and friction on the underlying mucosa 8. composition [three groups] group 1 materials responsible for sticky characteristics include karaya gum, tragacanth, acacia, pectin, gelatin, methyl cellulose, and hydroxyl. this also materials include methyl cellulose, sodium carboxy-methyl cellulose, and synthetic polymers such as polyethylene oxide, acrylamides, and acetic poly-vinyl4 group 2 consist of anti-microbial agent include hexachlorophene, sodium borate, sodium tetraborate, and ethanol 4 group 3 ingredients may include additives, plasticizers, wetting agents, and flavorings like wintergreen or peppermint oil 4 open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.69 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.69&amp;domain=pdf https://orcid.org/0009-0007-9512-9884 https://orcid.org/0009-0006-2226-2804 https://orcid.org/0009-0003-7960-0155 https://orcid.org/0000-0002-4761-8815 grace patricia f et al asian journal of dental and health sciences. 2024; 4(1):57-59 [58] ajdhs.com mechanism of action: dental adhesives works by absorbing water and swells which helps in retention and stability. we must first investigate the mechanism behind the operation of modern adhesives in order to comprehend them. in his 1919 review paper, sharry outlined this process 9: "when water is present, the substance swells filling in the gaps that exist between the tissues and the prosthetic. stickiness is created when water is absorbed by the adhesive substances and the generated anions are drawn to the cations in the mucus membrane proteins. 2,3 according to stefan he said that the viscosity of the liquid between two discs or plates directly determines the force to pull it apart. saliva plays an important role in the adhesive as it increases the viscosity thereby improving the retention and making it difficult to remove. this offer strong cohesive and bio adhesive forces in modern adhesives 10, 11 the three types of denture adhesives were employed, and they began to boost retention right away. their effectiveness starts from the baseline, and after two hours, maximum retention was reached. saliva could not continuously flow into the area between the mucosa and denture base. (floy strand et al., 1991; grasso et al., 12 application 1: denture should be clean without any food debris. before application of adhesives, denture should be wet. in tissuebearing area, small amount of denture adhesive should be added. then denture is placed firmly with hand pressure for 510 sec. excess should be removed using gauze and ask the patient to close the mouth in the centric occlusion for many times. landmarks for maxilla: anterior alveolar ridge, center of hard palate, posterior palatal seal area. landmarks for mandible: entire sulcus region. ideal characteristics of denture adhesives 4 1. physically available in powder, cream, gel form. 2. to preserve neutral ph and prevent the growth of bacterial colonies. 3. denture adhesives should have minimal toxicity. 4. adhesive property should withstand at least for 12-16 hrs. 5. easy to apply and remove on denture and oral mucosa. 6. taste should be good, in order to avoid nausea or vomiting reflex. 7. should provide retention, stability, comfort during speech, mastication. indication 10 1. jaw relation: to maintain trial bases. 2. immediate denture: to improve denture stability and retention, soon the denture become loose due to soft tissue healing and bone resorption. 3. in patients undergoing intraoral surgical operations, to stabilize an existing or temporary prosthesis 4. psychological assistance 5. anatomical structures compromised 6. senior citizens 7. patients with physical or mental disabilities 8. xerostomia: as a result of medication side effects, head and neck radiation history, systemic illness, or diseases affecting the salivary glands find it extremely difficult to maintain complete dentures because of reduced retention and a higher risk of ulceration of the tissues supporting the denture.13 9. neuroligical disorders: the usage of complete dentures can be made more difficult by a number of neurological conditions, but adhesive may be able to aid get beyond the obstacles13 10. implants with osseo-integration 11. partially removable dentures. contraindication 4 1. allergies to any of the ingredients in denture adhesives. 2. severe deficiencies in function and retention. 3. loss of vertical dimension due to excessive soft tissue shrinking and bone resorption. 4. retaining broken dentures with adhesives is not advised in the posterior palatal seal area and the hard palate's 94 center or prosthesis missing flanges. 5. denture adhesive should not be used by patients who are unable to keep their dentures clean. conclusion: correct use of denture adhesives helps in proper function, comfort, retention and mental assurance of the patient. patient needs proper guideline and advice for denture adhesives. adhesives improve denture function, but they shouldn't be used as anchorage to make up for denture problems. references 1. kumar pr, shajahan pa, mathew j, koruthu a, aravind p, ahammed mf. denture adhesives in prosthodontics: an overview. j int oral health. 2015;7(suppl 1):93-5. pmid: 26225115; pmcid: pmc4516076. 2 duqum i, powers ka, cooper l, felton d. denture adhesive use in complete dentures: clinical recommendations and review of the literature. gen dent. 2012 nov-dec;60(6):467-77; quiz p. 478-9. pmid: 23220302. 3. adisman ik. the use of denture adhesives as an aid to denture treatment. j prosthet dent. 1989 dec;62(6):711-5. https://doi.org/10.1016/0022-3913(89)90598-2 pmid:2685261 4. yankell sl. overview of research and literature on denture adhesives. compend contin educ dent (lawrenceville). 1984;suppl 4:s18-21. pmid: 6380919. 5. kapur kk. a clinical evaluation of denture adhesives. j prosthet dent. 1967 dec;18(6):550-8. https://doi.org/10.1016/00223913(67)90221-1 pmid:4863771 6.tarbet wj, boone m, schmidt nf. effect of a denture adhesive on complete denture dislodgement during mastication. j prosthet dent. 1980 oct;44(4):374-8. https://doi.org/10.1016/00223913(80)90092-x pmid:6997464 7. v, chandrakala; s, deepmala. prospective of denture adhesives in prosthodontics: a review. international journal of oral care and research. 2020; 8(1):8-10. | doi: 10.4103/injo.injo_4_20 8. kumar pr, shajahan pa, mathew j, koruthu a, aravind p, ahammed mf. denture adhesives in prosthodontics: an overview. j int oral health. 2015;7(suppl 1):93-5. pmid: 26225115; pmcid: pmc4516076. 9. john j. shaery. complete denture prosthodontics, 3rd ed. 10. grasso je. denture adhesives. dent clin north am. 2004 jul;48(3):721-33, vii. https://doi.org/10.1016/j.cden.2004.04.002 pmid:15261802 https://doi.org/10.1016/0022-3913(89)90598-2 https://doi.org/10.1016/0022-3913(67)90221-1 https://doi.org/10.1016/0022-3913(67)90221-1 https://doi.org/10.1016/0022-3913(80)90092-x https://doi.org/10.1016/0022-3913(80)90092-x https://doi.org/10.1016/j.cden.2004.04.002 grace patricia f et al asian journal of dental and health sciences. 2024; 4(1):57-59 [59] ajdhs.com 11. helal e, esmat am, ayman f. elawady and maie f.f. khalil; influence of denture adhesives on oral health quality of life , occlusion and disocclusion timesof digitally fabricated and designed removable complete dentures (clinical cross over study) int. j. of adv. res. 2022;10 (jun):696-706. https://doi.org/10.21474/ijar01/14938 12ibraheem, e.m.a., el-sisy, a.m.e. comparing the effect of three denture adhesives on the retention of mandibular complete dentures for diabetic patients (randomized clinical trial). bull natl res cent 2019; 43:24. https://doi.org/10.1186/s42269-0190052-7 13. apostolov n, todorov r, yordanov b, gabrovska md, peev t, denture adhesives implementation and advantages. journal of imab 2020;26(2). https://doi.org/10.5272/jimab.2020262.3177 https://doi.org/10.21474/ijar01/14938 https://doi.org/10.1186/s42269-019-0052-7 https://doi.org/10.1186/s42269-019-0052-7 https://doi.org/10.5272/jimab.2020262.3177 obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [32] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited transfusion therapy in hiv: risk mitigation and benefits for improved patient outcomes *emmanuel ifeanyi obeagu 1 and getrude uzoma obeagu 2 1 department of medical laboratory science, kampala international university, uganda, 2 school of nursing science, kampala international university, uganda, article info: _____________________________________________ article history: received 24 december 2023 reviewed 26 january 2024 accepted 19 february 2024 published 15 march 2024 _____________________________________________ cite this article as: obeagu ei, obeagu gu, transfusion therapy in hiv: risk mitigation and benefits for improved patient outcomes, asian journal of dental and health sciences. 2024; 4(1):32-37 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.62 _____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda, 0000-0002-4538-0161 abstract _________________________________________________________________________________________________________________ transfusion therapy is a pivotal aspect of healthcare, especially for individuals living with human immunodeficiency virus (hiv). this comprehensive review aims to dissect the intricate landscape of transfusion therapy in hiv patients, emphasizing the delicate balance between risks and benefits to achieve enhanced patient outcomes. with advancements in blood safety measures and antiretroviral therapy (art), navigating the complexities of transfusion therapy in hiv management becomes paramount for healthcare professionals. the review consolidates current knowledge and emerging trends, encompassing challenges, benefits, risks, and strategies to optimize transfusion therapy for improved patient care. the paper delineates key areas, including blood safety measures such as nucleic acid testing (nat) and pathogen reduction technologies, emphasizing their role in ensuring safer blood products for transfusion in hiv patients. furthermore, it explores the impact of hiv on hematological disorders, delving into transfusiontransmitted infections and strategies to mitigate these risks. additionally, it scrutinizes the therapeutic benefits of transfusion therapy in managing hematologic complications in hiv, while addressing potential risks, including immune reactions and adverse effects. optimizing transfusion therapy in hiv necessitates personalized approaches, considering the individual patient's hiv status, comorbidities, and specific transfusion needs. the role of art in reducing transfusion requirements and associated risks is highlighted, alongside emerging trends like novel therapies and alternative transfusion practices. keywords: transfusion therapy, hiv, blood safety, antiretroviral therapy, risks, benefits, patient outcomes, transfusion-transmitted infections, personalized treatment, hematology, blood products introduction transfusion therapy stands as a cornerstone in the multifaceted care of individuals living with human immunodeficiency virus (hiv), presenting both challenges and opportunities for optimized patient outcomes. the intersection between transfusion therapy and hiv management demands a nuanced understanding of the risks and benefits inherent in administering blood products to this unique patient population.1-8 individuals infected with hiv often encounter a myriad of hematologic complications, ranging from anemia to coagulation disorders, necessitating judicious and tailored transfusion strategies. moreover, in the landscape of hiv care, the pursuit of safer blood products to mitigate transfusiontransmitted infections has been an ongoing endeavor, with advancements in blood safety measures significantly impacting transfusion therapy.9-18 this paper seeks to comprehensively explore the complex relationship between transfusion therapy and hiv, delving into the intricacies that healthcare professionals encounter when navigating the transfusion landscape for hiv-infected individuals. by synthesizing current knowledge, addressing challenges, highlighting benefits, and acknowledging potential risks, this review aims to provide a comprehensive understanding of transfusion therapy's role in improving patient outcomes in the context of hiv management. by synthesizing and analyzing existing clinical guidelines, recommendations, and emerging trends, this review aims to serve as a comprehensive guide for healthcare professionals involved in the management of hiv-infected individuals requiring transfusion support. ultimately, it endeavors to underscore the imperative of a balanced and evidence-based approach to transfusion therapy in hiv, striving for improved patient outcomes, enhanced quality of care, and ensuring blood safety while mitigating potential risks. transfusion therapy in hiv: overview transfusion therapy in individuals living with human immunodeficiency virus (hiv) constitutes a crucial aspect of patient care, integral in managing various hematologic complications associated with the disease. advances in blood safety measures have revolutionized transfusion therapy for hiv patients. rigorous screening techniques, including nucleic acid testing (nat) and pathogen reduction technologies, have substantially minimized the risk of transfusion-transmitted infections (ttis), ensuring safer blood products for individuals living with hiv. this enhanced safety profile has significantly improved the overall outlook for transfusion-dependent patients, bolstering confidence in transfusion practices.19-32 hiv infection profoundly affects the hematopoietic system, leading to a spectrum of hematologic disorders. anemia, thrombocytopenia, and coagulation abnormalities are among open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.62 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.62&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 https://orcid.org/0000-0002-1373-9571 obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [33] ajdhs.com the common complications encountered in hiv-infected individuals. transfusion therapy emerges as a critical intervention to manage these hematologic complications and mitigate associated morbidity and mortality. understanding the intricate interplay between hiv pathogenesis and hematologic manifestations is pivotal for tailoring appropriate transfusion strategies.33-42 despite advancements in blood safety, the risk of transfusion-transmitted infections (ttis) remains a concern in hiv patients requiring transfusions.43 addressing the risk of acquiring infections such as hepatitis b and c, as well as other blood-borne pathogens, necessitates ongoing vigilance and adherence to stringent blood screening protocols. strategies aimed at minimizing these risks, such as the implementation of donor selection criteria and improved testing methodologies, continue to evolve to ensure the highest standards of safety in transfusion therapy for hiv.44-53 transfusion therapy plays a pivotal role in managing anemia, thrombocytopenia, and other hematologic complications associated with hiv. red blood cell transfusions alleviate symptoms of anemia, improve oxygen-carrying capacity, and ameliorate fatigue and weakness. platelet transfusions, on the other hand, aid in preventing or managing bleeding complications, reducing the risk of hemorrhagic events in thrombocytopenic individuals.54-63 despite the therapeutic benefits, transfusion therapy in hiv patients poses certain risks. these risks include immunological reactions, transfusion-associated circulatory overload, and potential transmission of infections, underscoring the importance of stringent screening protocols, close monitoring, and adherence to safety guidelines. benefits and risks of transfusion therapy in hiv anemia is a common complication in hiv due to various factors, including the virus's impact on bone marrow function and medication side effects. transfusions of red blood cells help alleviate anemia, improving oxygenation, reducing fatigue, and enhancing overall well-being.64 hiv-related thrombocytopenia, characterized by low platelet counts, increases the risk of bleeding. platelet transfusions aid in managing or preventing hemorrhagic events, reducing the likelihood of severe bleeding complications. hiv can disrupt the body's coagulation cascade, leading to clotting or bleeding issues. transfusions of clotting factors or fresh frozen plasma can help restore proper coagulation function, mitigating bleeding tendencies or abnormal clotting. by addressing hematologic complications, transfusion therapy enhances the quality of life for hiv patients, reducing symptoms such as weakness, shortness of breath, and the risk of bleeding events, thereby enabling better daily functioning. risks and challenges of transfusion therapy in hiv immunologic reactions to transfused blood components, including febrile non-hemolytic reactions, allergic responses, and more severe conditions like transfusion-related acute lung injury (trali) or hemolytic reactions, pose risks. hiv-infected individuals, particularly those with compromised immune systems, might be more vulnerable to these reactions. despite stringent screening protocols, there's a residual risk of acquiring infections such as hepatitis b and c, hiv, or other pathogens through transfusions. this risk is a significant concern for hiv patients, necessitating continued adherence to rigorous blood safety measures to minimize the possibility of tti transmission.65 transfusion therapy may have immunomodulatory effects, potentially impacting the recipient's immune response. in hiv-infected individuals, the introduction of external blood products might influence disease progression or provoke immunological reactions that could complicate hiv management. regular transfusions in hiv patients may lead to iron overload, requiring concurrent management with iron-chelating agents. this management adds complexity to the overall care regimen and requires careful monitoring to prevent complications associated with excessive iron levels. transfusion therapy necessitates adequate resources, including access to safe blood products, specialized equipment, and trained healthcare professionals, posing logistical challenges in resource-limited settings. balancing the benefits of transfusion therapy with its associated risks is essential in hiv patient care. healthcare providers must carefully evaluate the necessity for transfusions, considering the potential risks of adverse reactions or infections. personalized treatment plans, vigilant monitoring, and adherence to stringent blood safety protocols are vital to optimize patient outcomes while mitigating risks associated with transfusion therapy in hiv. optimizing transfusion therapy in hiv optimizing transfusion therapy in individuals living with human immunodeficiency virus (hiv) involves a tailored and multidimensional approach aimed at maximizing therapeutic benefits while minimizing risks.66 tailoring transfusion strategies based on the specific needs and clinical status of each hiv-infected patient is crucial. factors such as the severity of hematologic complications, current viral load, cd4 count, comorbidities, and overall health status should be considered to develop personalized treatment plans. adopting a conservative approach by using transfusions judiciously and only when clinically warranted helps mitigate risks associated with transfusion therapy. implementing evidence-based guidelines and thresholds for transfusion triggers based on hemoglobin levels or platelet counts aids in optimizing the timing and frequency of transfusions. art plays a pivotal role in hiv management, including its impact on hematologic parameters. optimizing hiv control through effective art can potentially reduce the need for transfusions by improving hematopoiesis and immune function. close monitoring of patients' response to art and its effect on transfusion requirements is essential.67-71 long-term transfusion therapy can lead to iron overload, posing risks of organ damage. monitoring iron levels and implementing ironchelating therapies when necessary are crucial to prevent complications associated with excessive iron accumulation in hiv patients receiving regular transfusions. implementing stringent protocols for blood product selection, compatibility testing, and meticulous screening for potential transfusiontransmitted infections remains imperative. close monitoring during transfusions and prompt recognition and management of transfusion reactions are vital to mitigate associated risks. exploring and utilizing alternative therapies to reduce transfusion dependence is beneficial. this may include erythropoiesis-stimulating agents (esas), iron supplementation, or other adjunctive therapies aimed at managing anemia or other hematologic complications, thereby reducing the need for frequent transfusions.67 regular training and education of healthcare providers involved in transfusion practices regarding updated guidelines, safety measures, and advancements in hiv care are crucial. enhancing awareness about the risks and benefits of transfusion therapy fosters a patient-centered approach and aids in making informed clinical decisions. encouraging research endeavors focused on developing novel therapies, blood substitutes, or transfusion alternatives specifically tailored for hiv-infected individuals is essential. this ongoing innovation contributes to improving transfusion practices, safety, and patient outcomes in the context of hiv care. by integrating these strategies into clinical practice, healthcare professionals can optimize transfusion obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [34] ajdhs.com therapy in hiv, aiming to improve patient outcomes, reduce associated risks, and enhance the overall quality of care for individuals living with hiv-related hematologic complications. clinical guidelines and recommendations clinical guidelines and recommendations serve as essential tools for healthcare practitioners in delivering evidence-based care. in the context of transfusion therapy for individuals with human immunodeficiency virus (hiv), various reputable organizations and expert bodies have developed guidelines offering recommendations for best practices. the who offers comprehensive guidelines on blood transfusion safety and practices, emphasizing the importance of ensuring safe blood products through rigorous screening, testing, and quality assurance measures. these guidelines outline global standards for blood transfusion services, including safety protocols specifically relevant to hiv-infected individuals. many countries have established national hiv/aids programs or health departments that issue specific guidelines on managing hiv-related complications, including transfusion therapy. these guidelines often integrate recommendations on safe transfusion practices, blood product selection, and transfusion monitoring for hiv-infected individuals. international society of blood transfusion (isbt) provides guidance on transfusion practices, emphasizing safety, compatibility testing, and the appropriate use of blood products. their recommendations often include considerations for vulnerable populations, such as those with immunocompromised conditions like hiv. medical associations, such as hematology or infectious disease societies, frequently publish clinical practice guidelines focusing on the management of hematologic complications in hiv. these guidelines encompass transfusion thresholds, indications, and precautions specific to hiv-infected patients. hospitals and healthcare institutions often establish transfusion committees that develop institution-specific protocols based on national and international guidelines. these protocols address transfusion safety, indications, and monitoring, taking into account the unique needs of hiv-infected individuals. research organizations dedicated to hiv/aids, like the centers for disease control and prevention (cdc) or the national institutes of health (nih), regularly update treatment guidelines for managing hiv and its associated complications. these guidelines often contain sections addressing transfusionrelated considerations. healthcare providers should regularly consult and adhere to these guidelines and recommendations while making clinical decisions regarding transfusion therapy in hiv. these documents provide evidence-based practices, safety measures, and considerations essential for optimizing care and ensuring the well-being of hiv-infected individuals requiring transfusion support. additionally, staying updated with evolving research and guideline revisions is crucial to providing high-quality care aligned with the most current recommendations. conclusion transfusion therapy stands as a critical component in the multifaceted care of individuals living with human immunodeficiency virus (hiv), addressing a spectrum of hematologic complications while posing inherent risks that necessitate careful consideration. this comprehensive review has navigated the landscape of transfusion therapy in the context of hiv, emphasizing the imperative of balancing therapeutic benefits with potential risks to optimize patient outcomes. advancements in blood safety measures, including rigorous screening protocols and pathogen reduction technologies, have markedly enhanced the safety profile of transfusions, assuring safer blood products for hiv-infected individuals. however, despite these strides, the persistent risk of transfusion-transmitted infections remains a concern, necessitating ongoing vigilance and adherence to stringent safety protocols. the benefits of transfusion therapy in managing anemia, thrombocytopenia, and coagulation disorders in hiv patients are undeniable, significantly improving quality of life and reducing morbidity. nonetheless, risks such as immunological reactions, transfusion-associated complications, and potential impacts on disease progression require meticulous monitoring and strategic utilization of transfusions. optimizing transfusion therapy in hiv necessitates a personalized approach, considering individual patient factors, integrating antiretroviral therapy (art), and exploring alternative therapies to reduce transfusion dependence. moreover, continual adherence to evidence-based clinical guidelines, stringent safety measures, and ongoing research to innovate transfusion practices remain paramount. a judicious balance between maximizing therapeutic benefits and mitigating potential risks defines optimal transfusion therapy in hiv care. through tailored treatment plans, adherence to safety protocols, integration with hiv management strategies, and continual education, healthcare professionals can navigate the complexities of transfusion therapy, striving for improved patient outcomes and enhanced quality of care in the journey of managing hematologic complications in hiv-infected individuals. acknowledgements not applicable authors contribution all the authors were involved in conceptualization, methodology, visualization, validation, drafting and editing of the article funding source no fund was received to write this paper conflict of interest the authors declare that they have no conflict interests. ethical clearance not applicable references 1. vishnu p, aboulafia dm. (haematological manifestations of human immune deficiency virus infection. british journal of haematology,2015; 171(5):695-709. https://doi.org/10.1111/bjh.13783 pmid:26452169 2. volberding pa, baker kr, levine am. human immunodeficiency virus hematology. ash education program book, 2003(1), 294313. https://doi.org/10.1182/asheducation-2003.1.294 pmid:14633787 3. obeagu ei, okwuanaso cb, edoho sh, obeagu gu. under-nutrition among hiv-exposed uninfected children: a review of african perspective. madonna university journal of medicine and health sciences. 2022;2(3):120-127. 4. obeagu ei, alum eu, obeagu gu. factors associated with prevalence of hiv among youths: a review of africa perspective. madonna university journal of medicine and health sciences. 2023;3(1):1318. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/93 . 5. obeagu ei. a review of challenges and coping strategies faced by hiv/aids discordant couples. madonna university journal of medicine and health sciences. 2023 ;3(1):7-12. https://doi.org/10.1111/bjh.13783 https://doi.org/10.1182/asheducation-2003.1.294 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/93 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/93 obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [35] ajdhs.com https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/91 . 6. obeagu ei, obeagu gu. an update on premalignant cervical lesions and cervical cancer screening services among hiv positive women. j pub health nutri. 2023;6(2). 2023;141:1-2. links/63e538ed64252375639dd0df/an-update-on-premalignantcervical-lesions-and-cervical-cancer-screening-services-amonghiv-positive-women.pdf . 7. ezeoru vc, enweani ib, ochiabuto o, nwachukwu ac, ogbonna us, obeagu ei. prevalence of malaria with anaemia and hiv status in women of reproductive age in onitsha, nigeria. journal of pharmaceutical research international. 2021;33(4):10-19. https://doi.org/10.9734/jpri/2021/v33i431166 8. omo-emmanuel uk, chinedum ok, obeagu ei. evaluation of laboratory logistics management information system in hiv/aids comprehensive health facilities in bayelsa state, nigeria. int j curr res med sci. 2017;3(1): 21-38.doi: https://doi.org/10.22192/ijcrms.2017.03.01.004 9. obeagu ei, obeagu gu, musiimenta e, bot ys, hassan ao. factors contributing to low utilization of hiv counseling and testing services. int. j. curr. res. med. sci. 2023;9(2): 1-5.doi: https://doi.org/10.22192/ijcrms.2023.09.02.001 10. obeagu ei, obeagu gu. an update on survival of people living with hiv in nigeria. j pub health nutri. 2022;5(6):129. links/645b4bfcf3512f1cc5885784/an-update-on-survival-ofpeople-living-with-hiv-in-nigeria.pdf . 11. offie dc, obeagu ei, akueshi c, njab je, ekanem ee, dike pn, oguh dn. facilitators and barriers to retention in hiv care among hiv infected msm attending community health center yaba, lagos nigeria. journal of pharmaceutical research international. 2021;33(52b):10-19. https://doi.org/10.9734/jpri/2021/v33i52b33593 12. obeagu ei, ogbonna us, nwachukwu ac, ochiabuto o, enweani ib, ezeoru vc. prevalence of malaria with anaemia and hiv status in women of reproductive age in onitsha, nigeria. journal of pharmaceutical research international. 2021;33(4):10-19. https://doi.org/10.9734/jpri/2021/v33i431166 13. odo m, ochei kc, obeagu ei, barinaadaa a, eteng ue, ikpeme m, bassey jo, paul ao. tb infection control in tb/hiv settings in cross river state, nigeria: policy vs practice. journal of pharmaceutical research international. 2020;32(22):101-119. https://doi.org/10.9734/jpri/2020/v32i2230777 14. obeagu ei, eze vu, alaeboh ea, ochei kc. determination of haematocrit level and iron profile study among persons living with hiv in umuahia, abia state, nigeria. j bioinnovation. 2016; 5:464-471. links/592bb4990f7e9b9979a975cf/determination-ofhaematocrit-level-and-iron-profile-study-amongpersons-living-with-hiv-in-umuahia-abia-statenigeria.pdf . 15. ifeanyi oe, obeagu gu. the values of prothrombin time among hiv positive patients in fmc owerri. international journal of current microbiology and applied sciences. 2015;4(4):911-916. https://www.academia.edu/download/38320140/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf. 16. izuchukwu if, ozims sj, agu gc, obeagu ei, onu i, amah h, nwosu dc, nwanjo hu, edward a, arunsi mo. knowledge of preventive measures and management of hiv/aids victims among parents in umuna orlu community of imo state nigeria. int. j. adv. res. biol. sci. 2016;3(10): 55-65. https://doi.org/10.22192/ijarbs.2016.03.10.009 17. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75. links/5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infectionamong-patients-who-used-directly-observed-treatment-shortcourse-centres-in-yenagoa-nigeria.pdf 18. oloro oh, oke to, obeagu ei. evaluation of coagulation profile patients with pulmonary tuberculosis and human immunodeficiency virus in owo, ondo state, nigeria. madonna university journal of medicine and health sciences issn: 28143035. 2022;2(3):110-119. 19. crespo-fierro, m. (2018). culture care needs of puerto rican women receiving hiv care from nurse practitioners in new york city. 20. thachil, j., owusu-ofori, s., & bates, i. (2014). haematological diseases in the tropics. manson's tropical infectious diseases, 894. https://doi.org/10.1016/b978-0-7020-5101-2.00066-2 pmcid:pmc7167525 21. livingston, j. (2012). improvising medicine: an african oncology ward in an emerging cancer epidemic. duke university press. https://doi.org/10.1515/9780822395768 22. nwosu dc, obeagu ei, nkwocha bc, nwanna ca, nwanjo hu, amadike jn, elendu hn, ofoedeme cn, ozims sj, nwankpa p. change in lipid peroxidation marker (mda) and non enzymatic antioxidants (vit c & e) in hiv seropositive children in an urban community of abia state. nigeria. j. bio. innov. 2016;5(1):24-30. links/5ae735e9a6fdcc5b33eb8d6a/change-in-lipidperoxidation-marker-mdaand-non-enzymaticantioxidants-vit-c-e-in-hiv-seropositive-children-inan-urban-community-of-abia-state-nigeria.pdf . 23. igwe cm, obeagu ie, ogbuabor oa. clinical characteristics of people living with hiv/aids on art in 2014 at tertiary health institutions in enugu, nigeria. j pub health nutri. 2022 https://doi.org/10.9734/ajrid/2022/v10i430294 5 (6). 2022;130. links/645a166f5762c95ac3817d32/clinicalcharacteristics-of-people-living-with-hiv-aids-on-art-in-2014at-tertiary-health-institutions-in-enugu.pdf . 24. ifeanyi oe, obeagu gu, ijeoma fo, chioma ui. the values of activated partial thromboplastin time (aptt) among hiv positive patients in fmc owerri. int j curr res aca rev. 2015; 3:139-144. https://www.academia.edu/download/38320159/obeagu_emma nuel_ifeanyi3__et_al.ijcrar.pdf . 25. obiomah cf, obeagu ei, ochei kc, swem ca, amachukwu bo. hematological indices o hiv seropositive subjects in nnamdi azikiwe university teaching hospital (nauth), nnewi. ann clin lab res. 2018;6(1):1-4. links/5aa2bb17a6fdccd544b7526e/haematological-indices-ofhiv-seropositive-subjects-at-nnamdi-azikiwe.pdf 26. omo-emmanuel uk, ochei kc, osuala eo, obeagu ei, onwuasoanya uf. impact of prevention of mother to child transmission (pmtct) of hiv on positivity rate in kafanchan, nigeria. int. j. curr. res. med. sci. 2017;3(2): 28-34. doi: https://doi.org/10.22192/ijcrms.2017.03.02.005 27. aizaz m, abbas fa, abbas a, tabassum s, obeagu ei. alarming rise in hiv cases in pakistan: challenges and future recommendations at hand. health science reports. 2023;6(8): e1450. https://doi.org/10.1002/hsr2.1450 pmid:37520460 pmcid:pmc10375546 28. obeagu ei, amekpor f, scott gy. an update of human immunodeficiency virus infection: bleeding disorders. j pub health nutri. 2023 6 (1). 2023;139. links/645b4a6c2edb8e5f094d9bd9/an-update-ofhuman-immunodeficiency-virus-infection-bleeding.pdf . 29. obeagu ei, scott gy, amekpor f, ofodile ac, edoho sh, ahamefula c. prevention of new cases of human immunodeficiency virus: pragmatic approaches of saving life in developing countries. madonna university journal of medicine and health sciences. 2022;2(3):128-134. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/86 . 30. walter o, anaebo qb, obeagu ei, okoroiwu il. evaluation of activated partial thromboplastin time and prothrombin time in hiv and tb patients in owerri metropolis. journal of pharmaceutical research international. 2022:29-34. https://doi.org/10.9734/jpri/2022/v34i3a35560 31. odo m, ochei kc, obeagu ei, barinaadaa a, eteng eu, ikpeme m, bassey jo, paul ao. cascade variabilities in tb case finding among people living with hiv and the use of ipt: assessment in three https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/91 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/91 https://doi.org/10.9734/jpri/2021/v33i431166 https://doi.org/10.22192/ijcrms.2017.03.01.004 https://doi.org/10.22192/ijcrms.2023.09.02.001 https://doi.org/10.9734/jpri/2021/v33i52b33593 https://doi.org/10.9734/jpri/2021/v33i431166 https://doi.org/10.9734/jpri/2020/v32i2230777 https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf https://doi.org/10.22192/ijarbs.2016.03.10.009 https://doi.org/10.1016/b978-0-7020-5101-2.00066-2 https://doi.org/10.1515/9780822395768 https://doi.org/10.9734/ajrid/2022/v10i430294 https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://doi.org/10.22192/ijcrms.2017.03.02.005 https://doi.org/10.1002/hsr2.1450 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://doi.org/10.9734/jpri/2022/v34i3a35560 obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [36] ajdhs.com levels of care in cross river state, nigeria. journal of pharmaceutical research international. 2020;32(24):9-18. https://doi.org/10.9734/jpri/2020/v32i2430789 32. jakheng sp, obeagu ei. seroprevalence of human immunodeficiency virus based on demographic and risk factors among pregnant women attending clinics in zaria metropolis, nigeria. j pub health nutri. 2022 https://doi.org/10.9734/sajrm/2022/v13i230295 5 (8). 2022;137. links/6317a6b1acd814437f0ad268/seroprevalenceof-human-immunodeficiency-virus-based-on-demographic-andrisk-factors-among-pregnant-women-attending-clinics-in-zariametropolis-nigeria.pdf . 33. obeagu ei, obeagu gu. a review of knowledge, attitudes and socio-demographic factors associated with non-adherence to antiretroviral therapy among people living with hiv/aids. int. j. adv. res. biol. sci. 2023;10(9):135-142. doi: https://doi.org/10.22192/ijarbs.2023.10.09.015 links/6516faa61e2386049de5e828/a-review-of-knowledgeattitudes-and-socio-demographic-factors-associated-with-nonadherence-to-antiretroviral-therapy-among-people-living-withhiv-aids.pdf 34. obeagu ei, onuoha ec. tuberculosis among hiv patients: a review of prevalence and associated factors. int. j. adv. res. biol. sci. 2023;10(9):128-134.doi: 10.22192/ijarbs.2023.10.09.014 links/6516f938b0df2f20a2f8b0e0/tuberculosis-among-hivpatients-a-review-of-prevalence-and-associated-factors.pdf . 35. obeagu ei, ibeh nc, nwobodo ha, ochei kc, iwegbulam cp. haematological indices of malaria patients coinfected with hiv in umuahia. int. j. curr. res. med. sci. 2017;3(5):100-104. https://www.academia.edu/download/54317126/haematologic al_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 36. jakheng sp, obeagu ei, abdullahi io, jakheng ew, chukwueze cm, eze gc, essien uc, madekwe cc, madekwe cc, vidya s, kumar s. distribution rate of chlamydial infection according to demographic factors among pregnant women attending clinics in zaria metropolis, kaduna state, nigeria. south asian journal of research in microbiology. 2022;13(2):26-31. https://doi.org/10.9734/sajrm/2022/v13i230295 37. viola n, kimono e, nuruh n, obeagu ei. factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district. asian journal of dental and health sciences. 2023;3(2):7-14. http://ajdhs.com/index.php/journal/article/view/39 . https://doi.org/10.22270/ajdhs.v3i2.39 38. okorie hm, obeagu emmanuel i, okpoli henry ch, chukwu stella n. comparative study of enzyme linked immunosorbent assay (elisa) and rapid test screening methods on hiv, hbsag, hcv and syphilis among voluntary donors in. owerri, nigeria. j clin commun med. 2020;2(3):180-183.doi: doi: 10.32474/jccm.2020.02.000137 links/5f344530458515b7291bd95f/comparative-study-ofenzyme-linked-immunosorbent-assay-elisa-and-rapid-testscreening-methods-on-hiv-hbsag-hcv-and-syphilis-amongvoluntary-donors-in-owerri-nigeria.pdf . 39. ezugwu um, onyenekwe cc, ukibe nr, ahaneku je, onah ce, obeagu ei, emeje pi, awalu jc, igbokwe ge. use of atp, gtp, adp and amp as an index of energy utilization and storage in hiv infected individuals at nauth, nigeria: a longitudinal, prospective, case-controlled study. journal of pharmaceutical research international. 2021;33(47a):78-84. https://doi.org/10.9734/jpri/2021/v33i47a32992 40. emannuel g, martin o, peter os, obeagu ei, daniel k. factors influencing early neonatal adverse outcomes among women with hiv with post dated pregnancies delivering at kampala international university teaching hospital, uganda. asian journal of pregnancy and childbirth. 2023;6(1):203-211. http://research.sdpublishers.net/id/eprint/2819/ . 41. igwe mc, obeagu ei, ogbuabor ao, eze gc, ikpenwa jn, eze-steven pe. socio-demographic variables of people living with hiv/aids initiated on art in 2014 at tertiary health institution in enugu state. asian journal of research in infectious diseases. 2022;10(4):1-7. https://doi.org/10.9734/ajrid/2022/v10i430294 42. vincent cc, obeagu ei, agu is, ukeagu nc, onyekachi-chigbu ac. adherence to antiretroviral therapy among hiv/aids in federal medical centre, owerri. journal of pharmaceutical research international. 2021;33(57a):360-8. https://doi.org/10.9734/jpri/2021/v33i57a34007 43. busch mp, bloch em, kleinman s. prevention of transfusiontransmitted infections. blood, the journal of the american society of hematology. 2019;133(17):1854-1864. https://doi.org/10.1182/blood-2018-11-833996 pmid:30808637 44. igwe mc, obeagu ei, ogbuabor ao. analysis of the factors and predictors of adherence to healthcare of people living with hiv/aids in tertiary health institutions in enugu state. madonna university journal of medicine and health sciences. 2022;2(3):4257. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/75 . 45. madekwe cc, madekwe cc, obeagu ei. inequality of monitoring in human immunodeficiency virus, tuberculosis and malaria: a review. madonna university journal of medicine and health sciences. 2022;2(3):6-15. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/69 46. echendu ge, vincent cc, ibebuike j, asodike m, naze n, chinedu ep, ohale b, obeagu ei. weights of infants born to hiv infected mothers: a prospective cohort study in federal medical centre, owerri, imo state. european journal of pharmaceutical and medical research, 2023; 10(8): 564-568 47. nwosu dc, nwanjo hu, okolie nj, ikeh k, ajero cm, dike j, ojiegbe gc, oze go, obeagu ei, nnatunanya i, azuonwu o. biochemical alterations in adult hiv patients on antiretrqviral therapy. world journal of pharmacy and pharmaceutical sciences, 2015; 4(3): 153-160. links/5a4fd0500f7e9bbc10526b38/biochemicalalterations-in-adult-hiv-patients-on-antiretrqviraltherapy.pdf . 48. obeagu ei, obeagu gu. effect of cd4 counts on coagulation parameters among hiv positive patients in federal medical centre, owerri, nigeria. int. j. curr. res. biosci. plant biol. 2015;2(4):45-49. 49. obeagu ei, nwosu dc. adverse drug reactions in hiv/aids patients on highly active antiretro viral therapy: a review of prevalence. int. j. curr. res. chem. pharm. sci. 2019;6(12):4548.doi: 10.22192/ijcrcps.2019.06.12.004 links/650aba1582f01628f0335795/adverse-drug-reactions-inhiv-aids-patients-on-highly-active-antiretro-viral-therapy-areview-of-prevalence.pdf . 50. obeagu ei, scott gy, amekpor f, obeagu gu. implications of cd4/cd8 ratios in human immunodeficiency virus infections. int. j. curr. res. med. sci. 2023;9(2):6-13.doi: 10.22192/ijcrms.2023.09.02.002 links/645a4a462edb8e5f094ad37c/implications-of-cd4-cd8ratios-in-human-immunodeficiency-virus-infections.pdf . 51. obeagu ei, ochei kc, okeke ei, anode ac. assessment of the level of haemoglobin and erythropoietin in persons living with hiv in umuahia. int. j. curr. res. med. sci. 2016;2(4):29-33. links/5711c47508aeebe07c02496b/assessment-of-the-level-ofhaemoglobin-and-erythropoietin-in-persons-living-with-hiv-inumuahia.pdf . 52. ifeanyi oe, obeagu gu. the values of cd4 count, among hiv positive patients in fmc owerri. int. j. curr. microbiol. app. sci. 2015;4(4):906-910. https://www.academia.edu/download/38320134/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf . 53. obeagu ei, okeke ei, anonde andrew c. evaluation of haemoglobin and iron profile study among persons living with hiv in umuahia, abia state, nigeria. int. j. curr. res. biol. med. 2016;1(2):1-5. 54. alum eu, ugwu op, obeagu ei, okon mb. curtailing hiv/aids spread: impact of religious leaders. newport international https://doi.org/10.9734/jpri/2020/v32i2430789 https://doi.org/10.9734/sajrm/2022/v13i230295 https://doi.org/10.22192/ijarbs.2023.10.09.015 https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 https://doi.org/10.9734/sajrm/2022/v13i230295 http://ajdhs.com/index.php/journal/article/view/39 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.9734/jpri/2021/v33i47a32992 http://research.sdpublishers.net/id/eprint/2819/ https://doi.org/10.9734/ajrid/2022/v10i430294 https://doi.org/10.9734/jpri/2021/v33i57a34007 https://doi.org/10.1182/blood-2018-11-833996 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/75 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/75 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://www.academia.edu/download/38320134/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf https://www.academia.edu/download/38320134/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf obeagu et al asian journal of dental and health sciences. 2024; 4(1):32-37 [37] ajdhs.com journal of research in medical sciences (nijrms). 2023;3(2):2831. 55. obeagu ei, obeagu gu, paul-chima uo. stigma associated with hiv. aids: a review. newport international journal of public health and pharmacy (nijpp). 2023;3(2):64-67. 56. alum eu, obeagu ei, ugwu op, aja pm, okon mb. hiv infection and cardiovascular diseases: the obnoxious duos. newport international journal of research in medical sciences (nijrms). 2023;3(2):95-99. 57. ibebuike je, nwokike gi, nwosu dc, obeagu ei. a retrospective study on human immune deficiency virus among pregnant women attending antenatal clinic in imo state university teaching hospital. international journal of medical science and dental research, 2018; 1 (2):08-14. https://www.ijmsdr.org/published%20paper/li1i2/a%20retros pective%20study%20on%20human%20immune%20deficiency %20virus%20among%20pregnant%20women%20attending%2 0antenatal%20clinic%20in%20imo%20state%20university%20 teaching%20hospital.pdf . 58. obeagu ei, obarezi tn, omeh yn, okoro nk, eze ob. assessment of some haematological and biochemical parametrs in hiv patients before receiving treatment in aba, abia state, nigeria. res j pharma biol chem sci. 2014; 5:825-830. 59. obeagu ei, obarezi tn, ogbuabor bn, anaebo qb, eze gc. pattern of total white blood cell and differential count values in hiv positive patients receiving treatment in federal teaching hospital abakaliki, ebonyi state, nigeria. international journal of life science, biotechnology and pharama research. 2014; 391:186189. 60. obeagu ei. a review of challenges and coping strategies faced by hiv/aids discordant couples. madonna university journal of medicine and health sciences issn: 2814-3035. 2023; 3 (1): 7-12. 61. oloro oh, obeagu ei. a systematic review on some coagulation profile in hiv infection. international journal of innovative and applied research. 2022;10(5):1-11. 62. nwosu dc, obeagu ei, nkwuocha bc, nwanna ca, nwanjo hu, amadike jn, ezemma mc, okpomeshine ea, ozims sj, agu gc. alterations in superoxide dismutiase, vitamins c and e in hiv infected children in umuahia, abia state. international journal of advanced research in biological sciences. 2015;2(11):268-271. 63. obeagu ei, malot s, obeagu gu, ugwu op. hiv resistance in patients with sickle cell anaemia. newport international journal of scientific and experimental sciences (nijses). 2023;3(2):56-59. 64. kotwal j, singh v, kotwal a, dutta v, nair v. a study of haematological and bone marrow changes in symptomatic patients with human immune deficiency virus infection with special mention of functional iron deficiency, anaemia of critically ill and haemophagocytic lymphohistiocytosis. medical journal armed forces india. 2013;69(4):319-325. https://doi.org/10.1016/j.mjafi.2012.11.002 pmid:24600136 pmcid:pmc3862888 65. bloch em, vermeulen m, murphy e. blood transfusion safety in africa: a literature review of infectious disease and organizational challenges. transfusion medicine reviews. 2012 apr 1;26(2):164180. https://doi.org/10.1016/j.tmrv.2011.07.006 pmid:21872426 pmcid:pmc3668661 66. cserti c. transfusion-transmitted infectious diseases. risk management in blood transfusion medicine. 2019;39. https://doi.org/10.1016/b978-0-323-54837-3.00005-5 67. ifeanyi oe, uzoma og, stella ei, chinedum ok, abum sc. vitamin d and insulin resistance in hiv sero positive individuals in umudike. int. j. curr. res. med. sci. 2018;4(2):104-108. 68. ifeanyi oe, leticia oi, nwosu d, chinedum ok. a review on blood borne viral infections: universal precautions. int. j. adv. res. biol. sci. 2018;5(6):60-66. 69. nwovu ai, ifeanyi oe, uzoma og, nwebonyi ns. occurrence of some blood borne viral infection and adherence to universal precautions among laboratory staff in federal teaching hospital abakaliki ebonyi state. arch blood transfus disord. 2018;1(2). 70. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75. 71. offie dc, obeagu ei, akueshi c, njab je, ekanem ee, dike pn, oguh dn. facilitators and barriers to retention in hiv care among hiv infected msm attending community health center yaba, lagos nigeria. journal of pharmaceutical research international. 2021;33(52b):10-19. https://doi.org/10.9734/jpri/2021/v33i52b33593 https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://doi.org/10.1016/j.mjafi.2012.11.002 https://doi.org/10.1016/j.tmrv.2011.07.006 https://doi.org/10.1016/b978-0-323-54837-3.00005-5 https://doi.org/10.9734/jpri/2021/v33i52b33593 pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [61] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the impact of social determinants of health on vaccination uptake pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 21 april 2024 reviewed 03 june 2024 accepted 24 june 2024 published 15 july 2024 _____________________________________________ cite this article as: dave p, the impact of social determinants of health on vaccination uptake, asian journal of dental and health sciences. 2024; 4(2):56-60 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.90 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ this review sought to establish the impact of social determinants of health on vaccination uptake. the analysis established that the link between sdh and vaccination uptake is multifaceted with different factors affecting the uptake rates. for instance, economic stability affected vaccination uptake because it affected people’s ability to access insurance coverage or keep up with vaccination schedule. healthcare access was also a key determinant factor to vaccination uptake. lack of access limited individuals’ abilities to access vaccines. other factors that played a role are education levels, social and community context, and built environment. the interaction between these factors contributed to disparities, inequities, and lower immunization rates. addressing the disparities and inequities in vaccination uptake is important because it derails efforts that have already been made in addressing communicable diseases. it affects herd immunity, leads to strain of healthcare systems, and affects resource utilization. due to these negative effects, it is important to take measures that can address the disparities. collaboration with the community, policy reforms, and community interventions are some of the measures that can be used to increase uptake. these measures can address the underlying factors that cause disparities and affect vaccination uptake. keywords: social determinants of health (sdh), vaccination uptake, health outcomes, access, economic stability, health disparities introduction vaccination is one of the most effective public health interventions that plays a crucial role in disease prevention. research has established that vaccinations prevent millions of deaths and disabilities across the globe with estimates showing vaccination has prevented up to 154 million deaths since 1974.1 however, despite the availability and proven efficacy of vaccines in preventing communicable disease, vaccination rates remain low. according to the world health organization, vaccine disparities still exist especially in poor countries.2 for instance, in 2022, 14.3 million infants failed to receive their initial dose of diphtheria, tetanus, and pertussis (dtp) despite a widespread campaign to ensure no one is left behind.2 most of the infants who did not receive their vaccine were mainly from low-income countries in africa and asia. the failure of these infants to receive their vaccines was attributed to lack of access to immunization and health services. the discrepancy between vaccine availability and uptake has led to researchers and other health organizations to begin research on factors that influence vaccine uptake. according to research, there are other factors that inform low vaccination uptake beyond the individual choices.3 these factors are social determinants of health (sdh). research on how sdh affects vaccination uptake is growing.4 the research explores how sdh shape vaccination behaviors and overall outcomes. social determinants of health are the conditions in which people are born, grow, live, work, and age.5 according to healthy people 2030, social determinants are key determinants of health outcomes affecting factors such as accessibility and availability.6 sdh are shaped by factor such as income levels, education, the built environment, insurance coverage, access, among other factors. who recognizes that sdh contribute to health inequities and affect overall health outcomes.5 when it comes to vaccination, these social and economic factors can significantly influence an individual's or community's likelihood of receiving recommended immunizations because they influence factors such as access and availability. the impact of sdh on vaccination uptake is complex. factors such as education, income, employment, housing, social support networks, and access to healthcare services all play crucial roles in determining whether individuals and communities get the necessary vaccinations to prevent them against communicable diseases.7 the correlation between sdh and vaccination uptake is complex. for example, individuals with high literacy levels are likely to have a higher vaccination uptake because they have a better understanding of the importance of vaccination on health.8 income levels are also likely to have an impact on vaccination uptake. individuals in the lower income quantile and those living in poverty are likely to have lower vaccination uptake because of limited access to vaccination programs. the impact of poverty levels on vaccination uptake was evident during covid-19 pandemic when low-income countries experienced disparities when it came to vaccine access, uptake, and coverage.9,10 other sdh such as individual lifestyle factors, working and living conditions, and cultural and environment conditions also play a role when it comes to vaccination uptake. for instance, cultural beliefs about vaccination may inform individual’s decision whether to get the vaccine or not. understanding the impact of sdh on vaccination uptake is important because it can help in developing strategies and policies that can increase uptake and coverage. such strategies and policies should align with the existing strategies such as the who immunization agenda 2030 that seeks to leave open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.90 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.90&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [62] ajdhs.com no one behind when it comes to vaccine coverage.11 increasing vaccination uptake with particular focus on sdh should go beyond addressing individual factors that limit uptake to addressing the broader social and economic factors that affect uptake as well. to achieve success, there is a need for collaboration among relevant stakeholders such as healthcare professionals, policymakers, community leaders, among others who are involved in the vaccination process. collaboration will lead to the development of comprehensive interventions that can tackle the root causes of vaccine disparities. therefore, the aim of this review is to examine how social determinants of health influence vaccination uptake. the review will also explore, how sdh influence health outcomes and the impact of poor vaccination uptake on overall health. the review will also make recommendations on how to achieve equitable and effective immunization programs, ultimately leading to better health outcomes for individuals and communities worldwide. impact of social determinants of health on overall health outcomes the social determinants of health are the factors that influence medical outcomes and influence health inequities. these factors are the ones in which people are born in, grow, work, live, and age.6 these factors influence health outcomes because they shape the conditions of life. healthy people 2030 classify sdh into five categories. they include economic stability, education access and quality, health care access and quality, social and community context, and neighborhood and built environment.6 economic stability economic stability refers to the ability of people to afford things like healthy food, healthcare, and housing.6 they key factors that determine economic stability are income levels, employment, financial security, housing stability among others. economic stability has a significant impact on health outcomes because it determines whether an individual is able to afford things that influence healthcare such as healthy food and health care access. research has determined that income inequality is a key determinant of health with individuals who have high income inequality being the most affected by health disparities and poor outcomes.12,13 populations that tend to be the most affected by poverty and who belong to the low-income quintile have poor health outcomes which is as a result of health disparities.14 these populations tend to have challenges with health care access and affordability. in addition to challenges access healthcare, impoverished individuals and communities do not have adequate access to resources that are need to support good health and well-being. such resources include healthy foods, stable housing, and safe neighborhoods.15 poverty also limits access to employment and education opportunities which widens the income gap even further. research has shown that poverty increases risk of poor disease outcomes including the risk for poor mental health, chronic disease, and high mortality rates.16,17,18 the relationship between poverty and poor health outcomes begins all the way from childhood. for instance, research has documented that children who are affected by poverty are likely to have developmental delays, increased likelihood of chronic illness, nutritional deficits, and even chronic stress.19,20 childhood poverty has also been linked to poverty in adulthood which means that such individuals are likely to have poor outcomes.21 economic stability also affects housing stability with lack of stable housing being associated with poor health outcomes. housing instability leads to poor health outcomes because it makes it difficult to have healthcare continuity and receive social support.22 economic instability also contributes to delayed healthcare because it makes people forego medical care when they need to which leads to severe outcomes. education access and quality education access and quality is an additional social determinant of health that affects health outcomes. healthy people 2030 recognize education as important in determining health outcomes with emphasis on increasing education opportunities for children and adolescents.23 education level influences health outcomes in a number of ways. first is health literacy. research has documented that health literacy is associated with better understanding of health information and consequently good health outcomes.24 individuals who have higher education levels are more likely to make informed decisions pertaining their health and also navigate the complex healthcare systems. individuals with limited health literacy have more risk of misunderstanding health information or losing their way in the fragmented healthcare system.25 several researchers associate health literacy with better disease prevention and control and overall good health outcomes.26,27,28 low literacy is associated with poor disease outcomes because it increases the rate of hospitalizations, increases use of emergency care, reduces utilization of preventative services, affects individuals’ ability to interpret labels and health messages, increases mortality, and increases overall costs of care.26 low health literacy also affects shared decision-making with individuals who have low literacy finding it difficult to engage in their care. education does not only impact health literacy. it also affects individuals’ abilities to have access to equal employment opportunities. having higher education levels has been linked to access to better paying jobs which is a key determinant of health outcomes because it influences one’s ability to access care.29 better paying jobs also have lower occupation hazards which expose workers to increased risk of work-related injuries and illness.30 having higher education levels is also linked to safer working conditions and better control of work schedules which impact health. for instance, having flexible work schedules is linked to good mental health while high demanding jobs are linked to work-related stress.31 the link between flexible work schedules and good mental health outcomes can be attributed to work-life balance. a job that has good work-life balance is likely to have positive impact on mental health and well-being because it is associated with better sleep patterns and regular working hours which enables an individual to engage in personal activities. lack of education also increases the risk of unemployment which is linked to poor health outcomes. healthcare access and quality healthcare access and quality is another domain of sdh as identified by healthy people 2030. access to quality healthcare services is a key determinant of health with various factors such as insurance coverage, geographic disparities, health system navigation, quality of care, and continuity of care affecting healthcare outcomes. access to quality care is a key determinant of health because it influences timely use of health services and subsequent outcomes.23 barriers such as lack of insurance coverage prevents and limits access to health care services when they are needed contributing to health disparities and poor outcomes. lack of insurance coverage still remains a significant barrier to access despite numerous efforts to increase coverage for all. according to the 2022 national health interview survey (nhis), 12.2% of americans aged 18 to 64 did not have health insurance. in total, 27.6 million of the population was uninsured.32 the report also established that only 22% americans had public coverage with most (67.8%) having private insurance coverage. the lack of insurance pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [63] ajdhs.com coverage means that a large number of people opt for out-ofpocket medial care which is associated with significant delays and foregoing the needed care. research has established that lack of insurance coverage is often associated with poor outcomes.33 for instance, uninsured adults are likely to have many unmet needs including lack of routine checkups for conditions such as diabetes and hypertension.34 in addition to insurance coverage, geographic disparities affect access to quality care. geographic disparities in this case means people who are not near healthcare facilities and experience difficulties accessing these facilities. the disparities can be as a result of a number of factors including being located in rural areas where transportation is unreliable or as a result of residential segregation.35 geographic disparities have been linked to poor health outcomes with lack of proximity to health facilities being linked to poor disease management.36 residential segregation can also contribute to limited access and coverage. this can happen where health facilities are available but are overcrowded or have long wait outcomes. other factors that affect health care access are difficulty navigating healthcare systems, variations in quality of care, and fragmented care. difficulty navigating healthcare systems is attributed to complexity more so in individuals who have lower health literacy.37 difficulty in navigating healthcare systems leads to uncertainty, disorientation, and suboptimal use of the already available systems. fragmented care can also affect access more so when it comes to continuity of care. fragmented care makes coordination difficult leading to poor outcomes. lack of quality care also affects access and leads to health disparities. neighborhood and built environment neighborhood and built environment are another domain of sdh that affects health outcomes. the neighborhood and built environment refer to the places where people live and work. some of the factors of the neighborhood and built environment that affects health are housing quality, water quality, air pollution, neighborhood safety, and the food environment. factors such as air pollution and water quality are linked to poor health outcomes because they increase risks of diseases such as asthma and water-borne diseases.38 the housing quality also matters when it comes to health. people who live in poorly built houses that lack proper ventilation or are infested with mold and pests are more likely to report respiratory issues and allergies.39 this is particularly the case for children. the built environment comprising of how the neighborhood is built is also instrumental when it comes to health. congested and overcrowded neighborhoods are linked to poor health outcomes because of the absence of sidewalks, parks, bike lanes, and recreational facilities to support physical activities.40 lack of such activities influences behavior and increases risk of chronic diseases. other aspects of then neighborhood and built environment that influences behavior are safety and violence and food environment. neighborhoods that have high crime rates are known to be disproportionately affected by disease.41 high crime rates are associated with health disparities because they limit outdoor activities and increase the likelihood of mental health problems. the food environment refers to the availability of healthy vs. unhealthy food outlets and sources. food environment has impact on dietary intake. areas that have higher numbers of food deserts which are areas with limited access to healthy and nutritious foods have poor health outcomes including high risk of obesity and diabetes.42 living in such environments contributes to poor dietary habits which explains why they are associated with poor health outcomes. social and community context social and community context is another domain of sdh that plays a crucial role in shaping health outcomes. social and community context entails availability of social and community support within the community. having strong support or social capital within the community that one lives in is associated with better health and well-being.43 poor social relationships and isolation have been linked to poor health outcomes more so in older adults.44 social isolation increases the risk of mental health, premature death, and cognitive decline. community cohesion is an additional factor that is linked to good health outcomes. communities that have high levels of cohesion tend to report better health outcomes more so on their mental health and well-being.45 the reason why community cohesion is associated with good health outcomes is because it influences behavioral and psychological pathways such as the need to eat a healthy diet or engage in healthy behaviors. therefore, social and community cohesion provides an avenue for emotional support which is linked to good health outcomes and well-being. evidently sdh have an impact on overall health and well-being. they affect many aspects of health and well-being leading to poor health outcomes and health disparities. sdh can also affect other aspects of health such as vaccination uptake. these factors can influence rates of vaccine uptake and even availability. impact of social determinants of health on vaccination uptake the impact of sdh on vaccination uptake is complex and multifaceted with a number of factors affecting the uptake rates. the correlation between sdh and vaccination uptake was evident during the covid-19 pandemic.46 during this period, a lot of disparities with regard to vaccination uptake were experienced with a number of sdh contributing to the low uptake. for instance, economic stability is a contributing factor when it comes to vaccination uptake. individuals with lowincome levels and those living in poverty are likely to face a number of barriers that may affect vaccination uptake. areas that face deprivation and marginalization are likely to have high vaccine hesitancy.47 the high vaccine hesitancy in such regions can be attributed to a number of factors including low health literacy levels on the importance of vaccination, limitations when it comes to transportation costs to healthcare facilities, and lack of coverage of vaccinations by health programs. adebowale et al. established a correlation between household wealth and vaccination uptake with children from higher income households having higher uptake rates than those from low-income households.48 the correlation between economic stability and vaccination uptake goes beyond household level. it has been established at the country level. the national income can have an impact on vaccine rollout, uptake, and hesitancy. this was evident during covid-19 where lowand middle-income countries experienced low rollout levels compared to their high-income counterparts.49 economic stability also affects vaccination uptake because has an influence on insurance coverage. individuals with low-income levels are likely to be uninsured which can limit access to vaccines especially where there are no public programs. according to a study by lu et al., vaccination coverage was lower among people who did not have health insurance compared to those who had insurance.50 an additional determinant of health that affects vaccination uptake is education level. this includes both education attainment and health literacy. higher education attainment has been linked to increased vaccination uptake with individuals who have higher education levels being more pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [64] ajdhs.com likely to go for vaccination.51 health literacy is an additional factor that influences vaccination uptake. individuals who are health literate are more likely to take vaccination because they understand the impact of vaccines on health outcomes.52 health literacy also influences a person’s understanding of the risk perceptions associated with vaccines. as such, they are likely to make informed decisions whether to take vaccines or not. healthcare access and quality is a key determinant when it comes to vaccination uptake. factors such as geographic disparities, insurance coverage, and availability of the healthcare provider determines whether the uptake will be high or not. geographic disparities can affect the ability of the individual to keep up with vaccination routine.53 proximation to healthcare facilities is important because it determines whether an individual will go for vaccination as required. geographic disparities also affect transport networks with people living in remote areas finding it challenging to access healthcare facilities for vaccines.54 shortage of primary care providers and lack of insurance coverage can also limit vaccine administration and uptake. individuals that lack insurance are less likely to keep up with vaccination schedules. neighborhood and built environment influences vaccination uptake in terms of vaccine accessibility. the neighborhood and built environment can affect vaccination uptake through two main ways. one is presence or absence of healthcare facilities or community health centers. limited access to such facilities is likely to lead to lower uptake. lack of reliable public transportation in the neighborhood can also make it difficult to access healthcare facilities that provide the vaccine. another key domain of sdh that influences vaccination uptake is social and community context. social and community context in this case are the social norms that exist in a community or religious and cultural beliefs. cultural and religious beliefs influence vaccination uptake with some of these beliefs being against vaccination.55 the attitudes that a community has towards vaccination can lead to vaccine hesitancy on a personal level. increasing vaccination uptake requires broader understanding of how social determinants influence individual decisions to get vaccinated. it also helps to understand broader community factors that influence vaccination uptake. having a good understanding of these factors is important in designing targeted interventions that can address the specific barriers experienced by individuals and the community. understanding the impact of sdh on vaccination uptake can also influence policy changes because policies can be implemented to deal with the identified barriers. addressing poor vaccination uptake is important because of the impact it has on health outcomes. vaccination can be used as a disease prevention and control strategy more so for communicable diseases. using vaccination as a measure to prevent and control the spread of communicable diseases reduces strain on healthcare systems and ensures effective resource allocation.56 strain on healthcare systems can have a negative effect on health as was witnessed during covid-19 pandemic. poor vaccination uptake also leads to increase disease incidence. failing to take vaccination according to vaccination schedule increases the incidence and resurgence of preventable diseases.57 some of these diseases are associated with high morbidity and mortality rates. poor vaccination uptake also comprises herd community.58 compromising herd community increases the risk of disease spread more so vulnerable populations. it also increases the risk of disease outbreaks. conclusion this review establishes that social determinants of health affect vaccination uptake. the analysis determines that the relationship between sdh and vaccination uptake is multifaceted with different factors influencing the uptake rate. the sdh interact in complex ways contributing to disparities, inequities, and lower immunization rates. the disparities in vaccine uptake derails the efforts that have already been made with regard to vaccination and makes it difficult to reach the whos vision of providing vaccine for all by 2030. inadequate vaccine uptake is associated with negative effects on health hence the need for measures that can increase uptake. collaboration, policy reforms, and community interventions are some of the measures that can be used to increase uptake. these measures can address the underlying factors that affect vaccination uptake. it is also important to acknowledge how sdh affects vaccination uptake and taking measures to address the resulting disparities and inequities. addressing the disparities associated with sdh can lead to improvement in vaccination uptake. references 1. shattock aj, johnson hc, sim sy, et al. contribution of vaccination to improved survival and health: modelling 50 years of the expanded programme on immunization. the lancet. 2024;403(10441):2307-16. https://doi.org/10.1016/s01406736(24)00850-x pmid:38705159 2. world health organization. immunization coverage. 2023. retrieved from: https://www.who.int/news-room/factsheets/detail/immunization-coverage 3. macdonald ne. vaccine hesitancy: definition, scope and determinants. vaccine. 2015;33(34):4161-4. https://doi.org/10.1016/j.vaccine.2015.04.036 pmid:25896383 4. vardavas c, nikitara k, aslanoglou k, et al. social determinants of health and vaccine uptake during the first wave of the covid-19 pandemic: a systematic review. preventive medicine reports. 2023:102319. https://doi.org/10.1016/j.pmedr.2023.102319 pmid:37564118 pmcid:pmc10410576 5. world health organization. sdh. retrieved from: https://www.who.int/health-topics/social-determinants-ofhealth#tab=tab_1 6. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. social determinants of health retrieved from: https://health.gov/healthypeople/objectives-and-data/socialdeterminants-health 7. mcmaughan dj, oloruntoba o, smith ml. socioeconomic status and access to healthcare: interrelated drivers for healthy aging. frontiers in public health. 2020;8:231. https://doi.org/10.3389/fpubh.2020.00231 pmid:32626678 pmcid:pmc7314918 8. zhang h, li y, peng s, jiang y, jin h, zhang f. the effect of health literacy on covid-19 vaccine hesitancy among community population in china: the moderating role of stress. vaccine. 2022;40(32):4473-8. https://doi.org/10.1016/j.vaccine.2022.06.015 pmid:35710509 pmcid:pmc9174466 9. mathieu e, ritchie h, ortiz-ospina e, et al. a global database of covid-19 vaccinations. nature human behaviour. 2021;5(7):94753. https://doi.org/10.1038/s41562-021-01122-8 pmid:33972767 10. duroseau b, kipshidze n, limaye rj. the impact of delayed access to covid-19 vaccines in low-and lower-middle-income countries. frontiers in public health. 2023;10:1087138. https://doi.org/10.3389/fpubh.2022.1087138 pmid:36711400 pmcid:pmc9878283 11. world health organization. immunization agenda 2030: a global strategy to leave no one behind. retrieved from: https://doi.org/10.1016/s0140-6736(24)00850-x https://doi.org/10.1016/s0140-6736(24)00850-x https://doi.org/10.1016/j.vaccine.2015.04.036 https://doi.org/10.1016/j.pmedr.2023.102319 https://doi.org/10.3389/fpubh.2020.00231 https://doi.org/10.1016/j.vaccine.2022.06.015 https://doi.org/10.1038/s41562-021-01122-8 https://doi.org/10.3389/fpubh.2022.1087138 pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [65] ajdhs.com https://cdn.who.int/media/docs/defaultsource/immunization/strategy/ia2030/ia2030-draft-4wha_b8850379-1fce-4847-bfd15d2c9d9e32f8.pdf?sfvrsn=5389656e_69&download=true 12. lynch j, smith gd, harper sa, hillemeier m, ross n, kaplan ga, wolfson m. is income inequality a determinant of population health? part 1. a systematic review. the milbank quarterly. 2004;82(1):5-99. https://doi.org/10.1111/j.0887378x.2004.00302.x pmid:15016244 pmcid:pmc2690209 13. chokshi da. income, poverty, and health inequality. jama. 2018;319(13):1312-3. https://doi.org/10.1001/jama.2018.2521 pmid:29614168 14. arcaya mc, arcaya al, subramanian sv. inequalities in health: definitions, concepts, and theories. revista panamericana de salud pública. 2015;38:261-71. https://doi.org/10.3402/gha.v8.27106 pmid:26112142 pmcid:pmc4481045 15. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. poverty. https://health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/poverty#cit20 16. phelan jc, link bg, tehranifar p. social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. journal of health and social behavior. 2010;51(1_suppl):s28-40. https://doi.org/10.1177/0022146510383498 pmid:20943581 17. dave p, combating the obesity crisis: the role of community pharmacists in addressing the rising obesity numbers. journal of drug delivery and therapeutics. 2024; 14(6):184-90. https://doi.org/10.22270/jddt.v14i6.6667 18. shaw km, theis ka, self-brown s, roblin dw, barker l. peer reviewed: chronic disease disparities by county economic status and metropolitan classification, behavioral risk factor surveillance system, 2013. preventing chronic disease. 2016;13. https://doi.org/10.5888/pcd13.160088 pmid:27584875 pmcid:pmc5008860 19. evans gw, kim p. childhood poverty, chronic stress, selfregulation, and coping. child development perspectives. 2013;7(1):43-8. https://doi.org/10.1111/cdep.12013 20. gupta rp, de wit ml, mckeown d. the impact of poverty on the current and future health status of children. paediatrics & child health. 2007;12(8):667-72. https://doi.org/10.1093/pch/12.8.667 pmid:19030444 pmcid:pmc2528796 21. raphael d. poverty in childhood and adverse health outcomes in adulthood. maturitas. 2011;69(1):22-6. https://doi.org/10.1016/j.maturitas.2011.02.011 pmid:21398059 22. rolfe s, garnham l, godwin j, anderson i, seaman p, donaldson c. housing as a social determinant of health and wellbeing: developing an empirically-informed realist theoretical framework. bmc public health. 2020;20(1):1138. https://doi.org/10.1186/s12889-020-09224-0 pmid:32689966 pmcid:pmc7370492 23. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. education access and quality. retrieved from: https://health.gov/healthypeople/objectives-and-data/browseobjectives/education-access-and-quality 24. berkman nd, sheridan sl, donahue ke, halpern dj, crotty k. low health literacy and health outcomes: an updated systematic review. annals of internal medicine. 2011;155(2):97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005 pmid:21768583 25. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. health literacy. retrieved from: https://health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/health-literacy 26. dave p, how digital health is revolutionizing healthcare and contributing to positive health outcomes, journal of drug delivery and therapeutics. 2024; 14(6):287-293 https://doi.org/10.22270/jddt.v14i6.6640 27. shahid r, shoker m, chu lm, frehlick r, ward h, pahwa p. impact of low health literacy on patients' health outcomes: a multicenter cohort study. bmc health services research. 2022;22(1):1148. https://doi.org/10.1186/s12913-022-08527-9 pmid:36096793 pmcid:pmc9465902 28. hickey kt, creber rm, reading m, et al. low health literacy: implications for managing cardiac patients in practice. the nurse practitioner. 2018;43(8):49-55. https://doi.org/10.1097/01.npr.0000541468.54290.49 pmid:30028773 pmcid:pmc6391993 29. zajacova a, lawrence em. the relationship between education and health: reducing disparities through a contextual approach. annual review of public health. 2018;39(1):273-89. https://doi.org/10.1146/annurev-publhealth-031816-044628 pmid:29328865 pmcid:pmc5880718 30. burgard sa, lin ky. bad jobs, bad health? how work and working conditions contribute to health disparities. american behavioral scientist. 2013;57(8):1105-27. https://doi.org/10.1177/0002764213487347 pmid:24187340 pmcid:pmc3813007 31. ray tk, pana-cryan r. work flexibility and work-related wellbeing. international journal of environmental research and public health. 2021;18(6):3254. https://doi.org/10.3390/ijerph18063254 pmid:33801122 pmcid:pmc8004082 32. cohen ra, cha ae. health insurance coverage: early release of estimates from the national health interview survey, 2022. national center for health statistics. retrieved from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202305 _1.pdf https://doi.org/10.15620/cdc:115983 33. michael mcwilliams j. health consequences of uninsurance among adults in the united states: recent evidence and implications. the milbank quarterly. 2009;87(2):443-94. https://doi.org/10.1111/j.1468-0009.2009.00564.x pmid:19523125 pmcid:pmc2881446 34. ayanian jz, weissman js, schneider ec, ginsburg ja, zaslavsky am. unmet health needs of uninsured adults in the united states. jama. 2000;284(16):2061-9. https://doi.org/10.1001/jama.284.16.2061 pmid:11042754 35. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. access to health services. retrieved from: https://health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/access-healthservices#cit11 36. tsui j, hirsch ja, bayer fj, quinn jw, cahill j, siscovick d, lovasi gs. patterns in geographic access to health care facilities across neighborhoods in the united states based on data from the national establishment time-series between 2000 and 2014. jama network open. 2020;3(5):e205105-. https://doi.org/10.1001/jamanetworkopen.2020.5105 pmid:32412637 pmcid:pmc7229525 37. griese l, berens em, nowak p, pelikan jm, schaeffer d. challenges in navigating the health care system: development of an instrument measuring navigation health literacy. international journal of environmental research and public health. 2020 aug;17(16):5731. https://doi.org/10.3390/ijerph17165731 pmid:32784395 pmcid:pmc7460304 38. flies ej, mavoa s, zosky gr, et al. urban-associated diseases: candidate diseases, environmental risk factors, and a path forward. environment international. 2019;133:105187. https://doi.org/10.1016/j.envint.2019.105187 pmid:31648161 39. matte td, jacobs de. housing and health-current issues and implications for research and programs. journal of urban health. 2000;77:7-25. https://doi.org/10.1007/bf02350959 pmid:10741839 pmcid:pmc3456605 40. pinter-wollman n, jelić a, wells nm. the impact of the built environment on health behaviours and disease transmission in https://doi.org/10.1111/j.0887-378x.2004.00302.x https://doi.org/10.1111/j.0887-378x.2004.00302.x https://doi.org/10.1001/jama.2018.2521 https://doi.org/10.3402/gha.v8.27106 https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty#cit20 https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty#cit20 https://doi.org/10.1177/0022146510383498 https://doi.org/10.22270/jddt.v14i6.6667 https://doi.org/10.5888/pcd13.160088 https://doi.org/10.1111/cdep.12013 https://doi.org/10.1093/pch/12.8.667 https://doi.org/10.1016/j.maturitas.2011.02.011 https://doi.org/10.1186/s12889-020-09224-0 https://doi.org/10.7326/0003-4819-155-2-201107190-00005 https://doi.org/10.22270/jddt.v14i6.6640 https://doi.org/10.1186/s12913-022-08527-9 https://doi.org/10.1097/01.npr.0000541468.54290.49 https://doi.org/10.1146/annurev-publhealth-031816-044628 https://doi.org/10.1177/0002764213487347 https://doi.org/10.3390/ijerph18063254 https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202305_1.pdf https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202305_1.pdf https://doi.org/10.15620/cdc:115983 https://doi.org/10.1111/j.1468-0009.2009.00564.x https://doi.org/10.1001/jama.284.16.2061 https://doi.org/10.1001/jamanetworkopen.2020.5105 https://doi.org/10.3390/ijerph17165731 https://doi.org/10.1016/j.envint.2019.105187 https://doi.org/10.1007/bf02350959 pallav dave asian journal of dental and health sciences. 2024; 4(2):61-66 [66] ajdhs.com social systems. philosophical transactions of the royal society b: biological sciences. 2018;373(1753):20170245. https://doi.org/10.1098/rstb.2017.0245 pmid:29967306 pmcid:pmc6030577 41. gomez sl, shariff-marco s, derouen m, et al. the impact of neighborhood social and built environment factors across the cancer continuum: current research, methodological considerations, and future directions. cancer. 2015;121(14):2314-30. https://doi.org/10.1002/cncr.29345 pmid:25847484 pmcid:pmc4490083 42. kalbus a, cornelsen l, ballatore a, cummins s. associations between the food environment and food and drink purchasing using large-scale commercial purchasing data: a cross-sectional study. bmc public health. 2023;23(1):72. https://doi.org/10.1186/s12889-022-14537-3 pmid:36627591 pmcid:pmc9831883 43. healthy people 2030, u.s. department of health and human services, office of disease prevention and health promotion. social cohesion. retrieved from: https://health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/socialcohesion#:~:text=high%20levels%20of%20social%20support,th rough%20behavioral%20and%20psychological%20pathways.&te xt=for%20example%2c%20social%20support%20may,23%20a nd%20reduce%20emotional%20stress . 44. national academies of sciences, engineering, and medicine. 2020. social isolation and loneliness in older adults: opportunities for the health care system. washington, dc: the national academies press. doi:10.17226/25663 https://doi.org/10.17226/25663 pmid:32510896 45. williams aj, maguire k, morrissey k, taylor t, wyatt k. social cohesion, mental wellbeing and health-related quality of life among a cohort of social housing residents in cornwall: a cross sectional study. bmc public health. 2020;20(1):985. https://doi.org/10.1186/s12889-020-09078-6 pmid:32571296 pmcid:pmc7310403 46. viswanath k, bekalu m, dhawan d, pinnamaneni r, lang j, mcloud r. individual and social determinants of covid-19 vaccine uptake. bmc public health. 2021;21(1):818. https://doi.org/10.1186/s12889-021-10862-1 pmid:33910558 pmcid:pmc8081000 47. simas c, larson hj. overcoming vaccine hesitancy in low-income and middle-income regions. nature reviews disease primers. 2021;7(1):41. https://doi.org/10.1038/s41572-021-00279-w pmid:34112811 48. adebowale a, obembe t, bamgboye e. relationship between household wealth and childhood immunization in core-north nigeria. african health sciences. 2019;19(1):1582-93. https://doi.org/10.4314/ahs.v19i1.33 pmid:31148987 pmcid:pmc6531962 49. moradpour j, shajarizadeh a, carter j, chit a, grootendorst p. the impact of national income and vaccine hesitancy on country-level covid-19 vaccine uptake. plos one. 2023;18(11):e0293184. https://doi.org/10.1371/journal.pone.0293184 pmid:37917650 pmcid:pmc10621822 50. lu pj, o'halloran a, williams ww. impact of health insurance status on vaccination coverage among adult populations. american journal of preventive medicine. 2015;48(6):647-61. https://doi.org/10.1016/j.amepre.2014.12.008 pmid:25890684 pmcid:pmc5826635 51. humer e, jesser a, plener pl, probst t, pieh c. education level and covid-19 vaccination willingness in adolescents. european child & adolescent psychiatry. 2023;32(3):537-9. https://doi.org/10.1007/s00787-021-01878-4n pmid:34550459 pmcid:pmc8456192 52. lorini c, santomauro f, donzellini m, et al. health literacy and vaccination: a systematic review. human vaccines & immunotherapeutics. 2018;14(2):478-88. https://doi.org/10.1080/21645515.2017.1392423 pmid:29048987 pmcid:pmc5806657 53. pruitt sl, schootman m. geographic disparity, area poverty, and human papillomavirus vaccination. american journal of preventive medicine. 2010;38(5):525-33. https://doi.org/10.1016/j.amepre.2010.01.018 pmid:20409501 pmcid:pmc3259737 54. metcalf cj, tatem a, bjornstad on, et al. transport networks and inequities in vaccination: remoteness shapes measles vaccine coverage and prospects for elimination across africa. epidemiology & infection. 2015;143(7):1457-66. https://doi.org/10.1017/s0950268814001988 pmid:25119237 pmcid:pmc4411642 55. kibongani volet a, scavone c, catalán-matamoros d, capuano a. vaccine hesitancy among religious groups: reasons underlying this phenomenon and communication strategies to rebuild trust. frontiers in public health. 2022;10:824560. https://doi.org/10.3389/fpubh.2022.824560 pmid:35198525 pmcid:pmc8858841 56. bloom de, cadarette d. infectious disease threats in the twentyfirst century: strengthening the global response. frontiers in immunology. 2019;10:549. https://doi.org/10.3389/fimmu.2019.00549 pmid:30984169 pmcid:pmc6447676 57. guerra fa. delays in immunization have potentially serious health consequences. pediatric drugs. 2007;9(3):143-8. https://doi.org/10.2165/00148581-200709030-00002 pmid:17523694 58. drolet m, bénard é, pérez n, et al. population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and metaanalysis. the lancet. 2019;394(10197):497-509. https://doi.org/10.1016/s0140-6736(19)30298-3 pmid:31255301 https://doi.org/10.1098/rstb.2017.0245 https://doi.org/10.1002/cncr.29345 https://doi.org/10.1186/s12889-022-14537-3 https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion#:~:text=high%20levels%20of%20social%20support,through%20behavioral%20and%20psychological%20pathways.&text=for%20example%2c%20social%20support%20may,23%20and%20reduce%20emotional%20stress https://doi.org/10.17226/25663 https://doi.org/10.1186/s12889-020-09078-6 https://doi.org/10.1186/s12889-021-10862-1 https://doi.org/10.1038/s41572-021-00279-w https://doi.org/10.4314/ahs.v19i1.33 https://doi.org/10.1371/journal.pone.0293184 https://doi.org/10.1016/j.amepre.2014.12.008 https://doi.org/10.1007/s00787-021-01878-4 https://doi.org/10.1080/21645515.2017.1392423 https://doi.org/10.1016/j.amepre.2010.01.018 https://doi.org/10.1017/s0950268814001988 https://doi.org/10.3389/fpubh.2022.824560 https://doi.org/10.3389/fimmu.2019.00549 https://doi.org/10.2165/00148581-200709030-00002 https://doi.org/10.1016/s0140-6736(19)30298-3 tedi purnama asian journal of dental and health sciences. 2023; 3(3):10-13 [10] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited tooth brushing skills and personal hygiene performance modified (phpm) index in preschool children tedi purnama department of dental health, health polytechnic of jakarta i, jakarta, indonesia article info: _______________________________________ article history: received 23 july 2023 reviewed 14 august 2023 accepted 02 september 2023 published 15 september 2023 _______________________________________ cite this article as: purnama t, tooth brushing skills and personal hygiene performance modified (php-m) index in preschool children, asian journal of dental and health sciences. 2023; 3(3):10-13 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.47 _______________________________________ *address for correspondence: tedi purnama, department of dental health, health polytechnic of jakarta i, jakarta, indonesia. abstract ___________________________________________________________________________________________________________________ background: the prevalence of caries in children aged 5-6 years is 92.6% with a def-t index of 8.43, meaning that young children in indonesia have experienced 8-9 cavities per child. the high number of dental and oral diseases currently is greatly influenced by several factors, one of which is the behavior of people who do not realize the importance of maintaining dental and oral health. brushing teeth is a simple act of removing plaque and food residue with a brush and toothpaste, because plaque and food residue are the main causes of dental caries. the personal hygiene performance modified (php-m) index is an indicator for measuring dental hygiene status in mixed dentition. objective: the aim of this research is to analyze the relationship between tooth brushing skills and the personal hygiene performance modified index in preschool children in pondok labu village, cilandak district, south jakarta in 2023. method: this research uses observational analytical methods with a cross-sectional design. the sampling technique for this research used a purposive sampling technique of 66 respondents. the data collection instrument uses a tooth brushing observation sheet to measure teeth brushing skills and the personal hygiene performance modified index. data analysis used the chi-square test with the spss application. results: chi-square test results show that tooth brushing skills influence the personal hygiene performance modified index in preschool children (p=0.022). conclusion: there is a relationship between tooth brushing skills and the personal hygiene performance modified index in preschool children keywords: tooth brushing skills, php-m index, preschool children introduction dental and oral health is part of a person's overall body health. the dental and oral health of the indonesian people is still something that needs serious attention from health workers, both dentists and dental therapists. it can be seen that dental and oral diseases are still suffered by 90% of the indonesian population. according to who (world health organization) in 2013, throughout the world 60-90% of school children and almost 100% of adults experience dental caries, which often causes pain and discomfort. dental and oral health problems for children in indonesia are still very low, as evidenced by the results of basic health research in 2018, reporting that 92.6% of young children aged 5-6 years experienced dental health problems; with a national def-t figure of 8.43, this means that the average number of tooth decay is 8 to 9 teeth per child.1–3 dental disease can affect the body's health, if left untreated it will have an impact on more dangerous diseases, such as: heart attack, stroke, diabetes, respiratory and gastrointestinal infections, etc. tooth decay at an early age can affect tooth growth. the function of teeth is very necessary in childhood, namely as a chewing tool, helping in speaking, facial balance, supporting the aesthetics of the child's face. if a child cannot chew well then malnutrition will occur, and the learning process will be disrupted.4–6 the high number of dental and oral diseases currently is greatly influenced by several factors, one of which is the behavior of people who do not yet realize the importance of maintaining dental and oral health. it can be seen that the tooth brushing behavior of the population aged ≥ 3 years is 2.8% who brush their teeth correctly.3 one way that children's independence can be seen is through daily activities, namely instilling independence in young children through cleanliness. early childhood independence can be done such as brushing one's own teeth. brushing teeth is a simple act of removing plaque and food residue with a brush and toothpaste, because plaque and food residue are the main causes of dental caries. according to arianto et al stated that children's tooth brushing behavior must be carried out in everyday life without feeling forced. the ability to brush your teeth properly and correctly is an important factor for oral health care.7–9 the benefits of brushing your teeth are to clean your teeth from dirt, especially plaque from food remains, prevent cavities and avoid toothache, as well as eliminate bad breath and keep your teeth healthy. pain in the child's teeth and mouth which will reduce the child's appetite, another impact is that the child's learning ability is reduced so that it affects the child's learning achievement. early childhood (3-6 years) still do not understand and understand how to care for their teeth properly. tooth decay can be prevented by brushing your teeth before sleeping and after eating. according to purnama et al, preschool children are not yet skilled at brushing their teeth.10–12 several studies prove that the relevant research results of razi et al show that the mean value of independence in brushing teeth before intervention was given was 4.34, meaning that young children do not yet have the independence to brush open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v3i3.47 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.47&amp;domain=pdf tedi purnama asian journal of dental and health sciences. 2023; 3(3):10-13 [11] ajdhs.com their teeth. another study zulfikri and huda, showed that dental and oral hygiene status with moderate criteria was 31 people (51.7%), with poor criteria was 29 people (48.3%), and very good criteria was (0%) and good criteria (0%) because there are no students who have very good criteria and good criteria. purnama's research on tooth brushing skills on dental hygiene status p=0.001 (p<0.05), meaning that there is a significant relationship between tooth brushing skills and the dental hygiene status of preschool aged children.13–15 method and material this research is an analytical observational study with a crosssectional approach. the study was conducted in june-july 2023. the research was conducted on children aged 5-6 years at pertiwi vi kindergarten and bina harapan kindergarten, pondok labu village, south jakarta city. the research sample was taken using a total purposive sampling technique of 66 respondents. the dependent variable in this research is tooth brushing skills and the independent variable is the personal hygiene performance modified index. data collection on toothbrushing skills was measured using a toothbrushing observation checklist, validity and reliability tests were carried out by the same previous researchers who examined toothbrushing skills and the personal hygiene performance modified index was a standardized plaque index measuring tool. the stages of the activity include: first, the companion/parent fills out the informed consent form first as an agreement to be willing to become a research respondent. then check the child's personal hygiene performance modified index in turn and continue making observations about brushing their teeth. data analysis was carried out using the spss statistical program for univariate analysis and presented in the form of a frequency distribution and bivariate analysis with chi-square to measure the relationship between tooth brushing skills and the personal hygiene performance modified index. result table 1: frequency distribution based on respondent characteristics, tooth brushing skills and the personal hygiene performance modified index variable n % age 5 years 25 37.9 6 years 41 62.1 gender man 33 50.0 women 33 50.0 tooth brushing skills good 7 10.6 less 59 89.4 personal hygiene performance modified index very good 2 3.0 good 15 22.7 moderate 47 71.2 bad 2 3.0 table 1 shows that the characteristics of respondents based on age are mostly 6 years old and with the same proportion of men and women. teeth brushing skills are mostly poor and have a personal hygiene performance modified index in the moderate category. table 2: results of analysis of tooth brushing skills and the personal hygiene performance modified index variabel criteria brushing skills total p-value good less n % n % n % personal hygiene performance modified index very good 1 1.5 1 1.5 2 3.0 0.022 good 4 6.1 11 16.7 15 22.7 moderate 2 3.2 45 68.2 47 71.2 bad 0 0 2 3.0 2 3.0 table 2 results of chi-square analysis of toothbrushing skills on the personal hygiene performance modified index p=0.022 (p<0.05), meaning that there is a significant relationship between toothbrushing skills and the personal hygiene performance modified index of preschool children. tedi purnama asian journal of dental and health sciences. 2023; 3(3):10-13 [12] ajdhs.com discussion dental and oral hygiene is a condition where the teeth in the oral cavity are clean, free from plaque and other dirt on the surface of the teeth such as debris and tartar. oral hygiene has a big influence on preventing cavities or caries, gingivitis, periodontitis, and also preventing bad breath. maximum dental and oral hygiene can be achieved by cleaning the teeth and mouth from food residue left between the teeth or fissures. good oral hygiene has an impact on dental and oral health, conversely, poor oral hygiene can cause various diseases in the oral cavity as a result of the emergence of debris and tartar or calculus. the skill of brushing your teeth properly and correctly is an important factor for oral health care.16,17 based on the results of the research conducted, it was found that the proportion of respondents who had poor teeth brushing skills and a moderate personal hygiene performance modified index was 68.2%, while the proportion of respondents who had good teeth brushing skills and a good personal hygiene performance modified index was 6.1%. based on the statistical test chi-square analysis of toothbrushing skills on the personal hygiene performance modified index p=0.022 (p<0.05), meaning that there is a significant relationship between toothbrushing skills and the personal hygiene performance modified index of preschool children. this research is in line with kasihani et al research which shows that there was a significant relationship (p <0.001) between the independence of brushing teeth and the free plaque score. apart from that, this is also in line with research conducted by purnama et al which states that there is a significant relationship between tooth brushing skills and dental hygiene status with p=0.001.7,15 brushing teeth is cleaning teeth from food debris, bacteria and plaque. cleaning teeth must pay attention to implementing the right time for cleaning teeth, using the right tools to clean teeth and the right way to clean teeth, so that the habit of brushing teeth is a human behavior in cleaning teeth from food debris which is carried out continuously. the habit of caring for your teeth by brushing your teeth at least twice a day at the right time in the morning after breakfast and in the evening before bed as well as the behavior of eating sticky and sweet foods can influence the occurrence of dental caries.18,19 efforts to maintain dental and oral health should be carried out from an early age. preschool age is an ideal time to train a child's motor skills, including brushing their teeth. the ability to brush your teeth properly and correctly is an important factor for maintaining your teeth and mouth. tooth brushing skills must be taught and applied to children of all ages, especially school age children because that age easily accepts and instills basic values. preschool children need learning to improve their teeth brushing skills.20,21 according to the ministry of health it is necessary to implement self-care practices in schools by brushing your teeth every day at school. apart from that, it is also possible because there is no toothbrushing equipment (toothbrush, toothpaste and mouthwash cup) stored at school. brush, toothpaste and mouthwash cup as well as a personal storage place can make it easier for children to take and store their toothbrush without the help of other people. facility support is one of the successes of dental health programs in schools.22,23 conclusion based on the results of the study, it can be concluded that there is a relationship between tooth brushing skills and the personal hygiene performance modified index in preschool children. acknowledgements the authors thank to all participants and research assistants. conflict of interest the authors declare that they have no conflict interests. references 1. fadjeri i. mother's dental health behavior with dental and oral hygiene status in early childhood: a cross-sectional study. int j multidiscip res anal. 2022; 05(04):764-8. https://doi.org/10.47191/ijmra/v5-i4-02 2. talibo rs, mulyadi n, bataha y. hubungan frekuensi konsumsi makanan kariogenik dan kebiasaan menggosok gigi dengan kejadian karies gigi pada siswa kelas iii sdn 1 & 2 sonuo. j keperawatan. 2016; 4(1). 3. kemenkes ri. hasil utama riskesdas 2018. jakarta kemenkes ri. 2018; 4. ling z, tao h. dental caries and systemic diseases. dent caries princ manag. 2016; 129-55. https://doi.org/10.1007/978-3-66247450-1_8 5. arrow p, raheb j, miller m. brief oral health promotion intervention among parents of young children to reduce early childhood dental decay. bmc public health. 2013; 13(1):1-9. https://doi.org/10.1186/1471-2458-13-245 pmid:23509932 pmcid:pmc3610190 6. kasihani nn, purnama t. determinants of parental behavior in maintaining deciduous teeth in early childhood: a cross sectional study. eur j mol clin med. 2021; 8(2):1248-55. 7. kasihani nn, purnama t, ngatemi n. independence of brushing teeth to free-plaque score in preschool children: a cross sectional study. indian j forensic med toxicol. 2021; 15(3):37227. 8. purnama t, rasipin r, santoso b. pengaruh pelatihan tedi's behavior change model pada guru dan orang tua terhadap keterampilan menggosok gigi anak prasekolah. qual j kesehat. 2019; 13(2):75-81. https://doi.org/10.36082/qjk.v13i2.80 9. arianto a, shaluhiyah z, nugraha p. perilaku menggosok gigi pada siswa sekolah dasar kelas v dan vi di kecamatan sumberejo. j promosi kesehat indones. 2014; 9(2):127-35. 10. trubey rj, moore sc, chestnutt ig. children's toothbrushing frequency: the influence of parents' rationale for brushing, habits and family routines. caries res. 2015; 49(2):157-64. https://doi.org/10.1159/000365152 pmid:25634461 11. wilson m, morgan m. a survey of children's toothbrushing habits in wales: are parents following the guidelines? j heal visit. 2016; 4(2):95-9. https://doi.org/10.12968/johv.2016.4.2.95 12. purnama t, rasipin sb, suwondo a, fatmasari d. tedi's behavior change model as an efforts for brushing teeth behaviour in preschool children. int j allied med sci clin res. 2019; 7(3):71522. 13. razi p, marlia l. pengembangan model pelayanan asuhan keperawatan gigi dengan pola asah, asih dan asuh pada anak usia dini. j bahana kesehat masy (bahana j public heal. 2017; 1(2):140-9. 14. zulfikri z, huda zi. hubungan indeks kebersihan gigi dan mulut dengan indeks karies gigi pada murid sdn 03 pakan kurai kecamatan guguk panjang kota bukittinggi. j kesehat gigi. 2017; 4(1):55-62. https://doi.org/10.31983/jkg.v4i1.2716 15. purnama t. how is the dental hygiene status of preschool children during the covid-19 pandemic?-tooth brushing skills and characteristics of parents. eur j dent oral heal. 2022; 3(1):14. https://doi.org/10.24018/ejdent.2022.3.1.139 https://doi.org/10.47191/ijmra/v5-i4-02 https://doi.org/10.1007/978-3-662-47450-1_8 https://doi.org/10.1007/978-3-662-47450-1_8 https://doi.org/10.1186/1471-2458-13-245 https://doi.org/10.36082/qjk.v13i2.80 https://doi.org/10.1159/000365152 https://doi.org/10.12968/johv.2016.4.2.95 https://doi.org/10.31983/jkg.v4i1.2716 https://doi.org/10.24018/ejdent.2022.3.1.139 tedi purnama asian journal of dental and health sciences. 2023; 3(3):10-13 [13] ajdhs.com 16. tuhuteru dr, lampus bs, wowor vns. status kebersihan gigi dan mulut pasien poliklinik gigi puskesmas paniki bawah manado. egigi. 2014; 2(2). https://doi.org/10.35790/eg.2.2.2014.5437 17. muhammad s, lawal mt. oral hygiene and the use of plants. sci res essays. 2010; 5(14):1788-95. 18. kumar g, singh dk. tooth brush and brushing technique. j adv med. 2013; 2(1):1-8. 19. nurjannah n, herijulianti e, putri mh. ilmu pencegahan penyakit jaringan keras dan jaringan pendukung gigi. jakarta egc. 2012; 20. purnama t, ngatemi if, widiyastuti r. model mentoring teachers and parents as an efforts for brushing teeth behavior in preschool children. indian j forensic med toxicol. 2020; 14(4):3511. 21. widiyastuti r, purnama t, laut dm. the effectiveness of the application of the mentoring module on brushing teeth by parents on the behavior of brushing teeth in early childhood. j drug deliv ther. 2022; 12(2):83-6. https://doi.org/10.22270/jddt.v12i2.5397 22. kemenkes ri. pedoman usaha kesehatan gigi sekolah (ukgs). jakarta kementeri kesehat ri. 2012; 23. ngatemi n, purnama t, suwarsono s. development of educational model of the pillow book kesgi as learning to brushing teeth for preschool children. j drug deliv ther. 2022; 12(6):89-93. https://doi.org/10.22270/jddt.v12i6.5818 https://doi.org/10.35790/eg.2.2.2014.5437 https://doi.org/10.22270/jddt.v12i2.5397 https://doi.org/10.22270/jddt.v12i6.5818 mehlawat et al asian journal of dental and health sciences. 2024; 4(1):16-20 [16] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited psychology of pregnant females regarding perinatal oral health mehlawat jiksha 1*, shrivastav arpit 2 1 post graduation student, department of public health dentistry, sudha rustagi college of dental sciences and research, faridabad, haryana 2 post graduation student, department of oral and maxillofacial surgery, sudha rustagi college of dental sciences and research, faridabad, haryana article info: _____________________________________________ article history: received 27 december 2023 reviewed 18 january 2024 accepted 31 january 2024 published 15 march 2024 _____________________________________________ cite this article as: mehlawat j, shrivastav a, psychology of pregnant females regarding perinatal oral health, asian journal of dental and health sciences. 2024; 4(1):16-20 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.61 _____________________________________________ *address for correspondence: dr. mehlawat jiksha, post graduation student, department of public health dentistry, sudha rustagi college of dental sciences and research, faridabad, haryana abstract _________________________________________________________________________________________________________________ aim: to evaluate the attitude, behaviour, experience and knowledge of pregnant females regarding perinatal oral health in rural population of faridabad. methodology: data was collected through personal interview. eleven questions related to knowledge, attitude, experience and behaviour were asked. data was analysed using ibm spss version 21. results: about onefourth of the study population experienced adverse effects on oral health during pregnancy and their knowledge was also found to be poor with respect to perinatal oral health maintenance. they also reported ill behaviours to manage morning sickness. despite this, their attitude towards maintenance of perinatal oral health was found to be positive. conclusion: the dental status of the child is a direct reflection of maternal oral condition in pregnancy. thus, there is a need for educational oral health interventions in pregnant women to improve their own and children oral health status. keywords: perinatal, oral health, pregnancy, rural population introduction diseases related to oral cavity are a noteworthy burden on public health in india. oral health is an integral part of general health as recognized by who. the outcomes of the poor oral health are seen on the individual, community as well as on the system for health care, which acts as a notable risk factor for various other systemic problems.1 in developing countries like india, there is a wide distinction in oral health level between urban and rural community, with expanding inequality in access to quality care, specifically in the rural areas.2 according to the definition of public health 1920, every individual must realize the birthright of health and longevity and should have the access to the health care services.3 to assist oral and dental health for longevity, efficient and appropriate care is mandatory. in women, oral and dental care is highly essential all through the phases of life, especially during pregnancy, breastfeeding and menopausal periods.4 pregnant women are susceptible to a wide range of oral health conditions that could be harmful to their own health and the future of their baby. pregnant women undergo adaptive remaking in body structure due to hormonal balance changes during pregnancy because of the higher levels of estrogen and progesterone. such endocrine actions also effects the oral cavity, which may show short-term or abiding changes as well as modifications that are considered morbid.5 according to american academy of pediatric dentistry (aapd), perinatal and infant oral health plays a vital role for children to possess a livelihood free from oral diseases. perinatal period is around the time of birth, which begins with completion of 20th to 28th week of gestation and ends one to four weeks after birth. it holds a crucial role for the health and well-being of pregnant women and their newborn children.6 inspite of this fact, pregnant women do not seek dental care during the pregnancy and those who confront such services show unwillingness to dentists for providing care. the expectant mothers primarily in the rural population are not aware of the inference of poor oral health for their pregnancy and their unborn child.7,8,9 the women in pregnancy having restricted or no resources for health care generally present with consequential issues regarding oral health in perinatal period. they may also indicate narrow valuing the significance of preventive oral health practices during the gestation and postnatal period. it is of main concern among the low-income community with higher incidence rate of gingivitis, periodontitis and dental caries.10 the perceptions that poor oral health in pregnancy is normal may drive the failure to obtain oral health care.11 the lack of dental and oral health knowledge by pregnant patients is a serious barrier to perinatal care.10,11 hence the present study was conducted to evaluate the attitude, behavior, experience and knowledge of pregnant females regarding perinatal oral health in rural population of faridabad. methodology: an anonymous 11-question survey was conducted among 60 pregnant women visiting an outpatient obstetric clinic at the public health centre among the rural population of faridabad open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.61 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.61&amp;domain=pdf mehlawat et al asian journal of dental and health sciences. 2024; 4(1):16-20 [17] ajdhs.com during a 15day time period from 25th november to 10th december in 2019. sample size estimation was done by using g power software (version 3.0). a minimum total sample size of 60 was found to be sufficient for an alpha of 0.05, power of 80%, 0.6 as effect size. the survey addressed questions regarding patient’s knowledge, attitude, experience and behavior. the patients were also inquired about their knowledge concerning to linked unfavorable pregnancy outcomes and were commended oral health care behaviors in pregnancy. the questions were in multiple choice, bivariate, and choose all patterns. the data were analysed using ibm statistical package for the social science version 21. descriptive statistics were tabulated and reported as percentages. results: the present study composed of 60 pregnant females who visited the public health centre for consulting obstetrician, were of 23.06 ± 3.2 years. among the females, 83.3% were unemployed and 36.7% were having either their first or second pregnancy. none among the pregnant females had any insurance coverage (figure 1). figure 1: descriptives of study population in our society, there are many misconceptions regarding the effect of pregnancy on oral health. approximately one-third of the patients didn’t recognize any commonly described physiologic oral cavity changes related to pregnancy. only about 25% reported that they experienced bleeding gums during the period of pregnancy (figure 2). patients perceived tooth decay, tooth loss, swollen gums and tooth ache were normal events associated with pregnancy. figure 2: experiences of the study population 83.3 36.7 0 0 10 20 30 40 50 60 70 80 90 occupation status (unemployed) no of pregnancy (1st and 2nd) coverage to insurance 20 1.7 25 8.3 8.3 69.3 0 10 20 30 40 50 60 70 80 tooth decay tooth loss bleeding gums swollen gums tooth ache morning sickness mehlawat et al asian journal of dental and health sciences. 2024; 4(1):16-20 [18] ajdhs.com the maintenance of the oral hygiene is crucial and it becomes a necessity during pregnancy. in this regard, 75% of the pregnant females showed no importance of changing toothbrush every 3-4 months. in concern to their behavior, 88.3% pregnant females were reported of not visiting to dentist in past 6 months, whereas 60% females showed positive response towards the importance of dental evaluation every 6 months (figure 3). the pregnant females were asked about managing morning sickness during pregnancy to measure the potential risk behaviors. among them, 69.3 % reported morning sickness. about 38.3% responded managing by rinsing with baking soda, 18.3% were brushing their teeth and 31% responded they did not know. this former behavior is recognized as potentially harmful to teeth by the dental community (table 1). figure 3: attitude and behavior of study population table 1: risky behavior: morning sickness management behavior in response to percentage (%) brush teeth immediately 18.3 drink water 11.7 rinse with baking soda in water 38.3 don’t know 31.7 in interest of the perception of pregnant females towards the safe oral health intervention, most of them identified teeth cleaning is a safe and an admissible intervention in pregnancy, 40% identified antibiotics and pain medications as safe; and very few acknowledged teeth x-ray, filling cavities, fluoride treatment, and local anesthesia as safe interventions in pregnancy (table 2). the pregnant patients showed poor knowledge regarding the risks associated with periodontal disease in pregnancy such as worsening gum disease, tooth loss, caries, miscarriage, preterm birth and growth restriction (table 3). pregnant females were inquired to gauge their knowledge related to the undertakings that vigour the risk of transmission of bacteria causing caries among children postpartum. majority, 76.7% responded that the risk of getting caries was not there until the teeth erupts in the oral cavity, whereas few acknowledged that sharing spoon can be considered as risky. (figure 4) table 2: knowledge towards the safe oral health intervention intervention safe during pregnancy (%) not safe during pregnancy (%) teeth cleaning 55 45 teeth x-ray 45 55 filling cavities 25 75 fluoride treatment 15 85 local anesthesia 15 85 antibiotics 38.3 61.7 pain medications 40 60 table 3: knowledge about periodontal disease and its outcomes yes (%) no (%) worsening gum disease 23.3 76.7 tooth loss 25 75 caries 25 75 miscarriage 25 75 preterm birth 25 75 growth restriction 25 75 60 75 76.7 0 10 20 30 40 50 60 70 80 90 imortance of dental evaluation every 6 months (yes) importance of changing toothbrush every 3-4 months (no) current dental issues (no) mehlawat et al asian journal of dental and health sciences. 2024; 4(1):16-20 [19] ajdhs.com figure 4: postpartum risk of vertical transmission of s. mutans discussion: during pregnancy, every female undergoes complex physical and physiological changes which have a crucial impact on body organs, especially the oral cavity.12 perinatal period is an opportunate time during which the women can be motivated and educated, so as to perform dental treatment on expectant mothers which can provide them as well as their children a safe future. pregnancy care visits to obstetricians provide teachable moment to educate expectant mothers regarding the diet including nutritious food of adequate quality and in quantity which controls food cravings helping in preventing the caries process. it also educates that dental treatment including comprehensive oral examination, dental prophylaxis, dental radiographs with proper shielding and local anesthetic, is safe in all trimesters and optimal in the second trimester. hence, a combination of personal and professional care is very important in improving the oral health. according to the who, the provisions for oral health-care services are few in rural parts of india, where the majority of the indian population resides. this is further complicated by the great variation that occurs across this population in social parameters such as income and education.1 apart from the health care services, health insurance is one of the traditional barrier which restricts the approach to such services. in our study also none of the patients had any insurance coverage neither for the medical nor for the dental care. this is probably due to the lack of knowledge and dearth of health care providers who could educate the expectant mothers regarding it.13 in the present study periodontal disease was experienced by almost 1/4th of the study population. whereas, literature suggest the prevalence of periodontal disease as 40%. sixty percent of the subjects were aware about the importance of dental evaluation every 6 months and similarly results were reported by ganesh et al and thomas et al.14,15 it was found that patients had poor knowledge about perinatal oral health similar to the study conducted by thomas et al among the expectant mothers to evaluate the knowledge and attitude of expectant mothers about infant oral health and their oral hygiene practices in mangalore city. the study conducted by ganesh et al (2011) among 208 antenatal women attending government maternity hospital found that 86.1% of the women were not aware of oral health problems during pregnancy and majority of them were not aware of oral health problems during pregnancy. similarly in our study, patients perceived tooth decay, tooth loss, swollen gums and tooth ache were normal events associated with pregnancy. naumah i and annan bd (1998) did a study on the periodontal status and oral hygiene practices of pregnant and non-pregnant women attending the outpatient clinic of the department of obstetrics and gynaecology of korle-bu teaching hospital where they reported the prevalence of gingival bleeding was 89% among pregnant women, in contrast with only 25% in our study.16 pregnant patients need to be educated specially in the rural areas regarding the changes during pregnancy which are to be considered normal physiologic changes and the events that should be identified as pathologic. in addition, patients perception regarding the procedures such as teeth x-ray, filling cavities, fluoride treatment, and local anesthesia is required to be altered as they are the safe interventions to be carried out during pregnancy with appropriate precautions.13the pregnant females should be particularly specified to evade the risky behavior carried out to manage the morning sickness by either brushing or rinsing with baking soda immediately after vomiting. oral hygiene of the mother, especially in pregnancy directly influences on infant’s oral health. poor understanding and knowledge of good oral health practices, poor dietary habits and practice saliva-sharing activities in combination increases the likelihood of transmitting caries causing bacteria from mother to infants.17 high mutans streptococci levels and carious lesions are recognized as risk factors in the transmission of mutans streptococci (ms) from mother to child. s. mutans load reduction in the mothers oral cavity diminishes the vertical transmission to the infant which reduces the probability of caries among infants, as evidence based research suggested.13,18 limitation: the current study bears some limitations. firstly, the convenience sampling selection procedure of participants and sample size do not necessarily represent the entire target population. secondly, small sample size is a limitation. 23.3 76.7 0 10 20 30 40 50 60 70 80 90 kissing on mouth cleaning pacifiers with your mouth sharing spoon giving baby formula none of these until baby gets teeth mehlawat et al asian journal of dental and health sciences. 2024; 4(1):16-20 [20] ajdhs.com conclusion: perinatal oral health is a very important health concern phenomenon. in this period, oral health negligence has a great effect on both mother and child’s physical and oral health. generally, dental care is not given preference by women during the pregnancy, and those who seek dental care usually defy the wish to get any treatment provided. a widespread cognizance is needed about oral health problems, to evade difficulties caused by delinquency and dearth of personal-care, with the support of healthy lifestyles, by acquiring appropriate habits to eat and practicing good oral hygiene and by paying regular visits to the dentist. references: 1. singh a, purohit bm. addressing oral health disparities, inequity in access and workforce issues in a developing country. int dent j. 2013;63:225-9. https://doi.org/10.1111/idj.12035 pmid:24074015 pmcid:pmc9375013 2. singh a. oral health policies in developing countries. j public health policy. 2010;31:498-9. https://doi.org/10.1057/jphp.2010.31 pmid:21119655 3. park k. textbook of preventive and social medicine. 24th edition. bhanot publications. 4. yenen z, ataçağ t. oral care in pregnancy. j turk ger gynecol assoc 2019; 20: 264-8. https://doi.org/10.4274/jtgga.galenos.2018.2018.0139 pmid:30556662 pmcid:pmc6883753 5. ponnuswamy mani kandan ,venkatachalam menaga, rajappan raja rajesh kumar. oral health in pregnancy (guidelines to gynaecologists, general physicians & oral health care providers). j pak med assoc,vol. 61, no. 10, october 2011 6. brown a. access for oral health care during the perinatal period: a policy brief. national maternal and child oral health resource center. washington, d.c.: georgetown university; 2008. available at: "http://www. mchoralhealth.org/pdfs/perinatalbrief.pdf ". accessed july 1, 2016 7. keirse mj, plutzer k. women's attitudes to and perceptions of oral health and dental care during pregnancy. j perinat med 2010;38(1):3-8. https://doi.org/10.1515/jpm.2010.007 pmid:20047523 8. kerpen sj, burakoff r. improving access to oral health care for pregnant women. a private practice model. ny state j 2009;75(6):34-6. 9. dimitrova mm. a study of pregnant women's knowledge of children's feeding practice as a risk factor for early childhood caries. folia med (plovdiv) 2009;51(4):40-5. 10. gaffield ml, gilbert bj, malvitz dm, romaguera r. oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. j am dent assoc. 2001;132:1009-16. https://doi.org/10.14219/jada.archive.2001.0306 pmid:11480627 11. ressler-maerlender j, krishna r, robinson v. oral health during pregnancy: current research . journal of women's health,2005;14,880 882. https://doi.org/10.1089/jwh.2005.14.880 pmid:16372888 12. saddki n, yusoff a, hwang yl. factors associated with dental visit and barriers to utilisation of oral health care services in a sample of antenatal mothers in hospital universiti sains malaysia. bmc public health. 2010;10:75. https://doi.org/10.1186/1471-245810-75 pmid:20163741 pmcid:pmc2834630 13. gonik et al. pregnant patient knowledge and behavior regarding perinatal oral health. am j perinatol 2017 jun;34(7):663-667 https://doi.org/10.1055/s-0036-1597134 pmid:27926974 14. ganesh a, ingle na, chaly pe, reddy vc. a survey on dental knowledge and gingival health of pregnant women attending government maternity hospital, chennai. j oral health comm dent. 2011;5:24-30. https://doi.org/10.5005/johcd-5-1-24 15. thomas a, jacob a, kunhambu d, shetty p, shetty s. evaluation of the knowledge and attitude of expectant mothers about infant oral health and their oral hygiene practices. j int soc prevent communit dent 2015;5:400-5. https://doi.org/10.4103/22310762.163405 pmid:26539393 pmcid:pmc4606605 16. naumah i, annan bd. periodontal status and oral hygiene practices of pregnant and non pregnant women. east african medical journal 1998;75(12):71214. 17. stevens j, iida h, ingersoll g. implementing an oral health program in a group prenatal practice. j obstet gynecol neonatal nurs. 2007 nov-dec;36(6):581-91. https://doi.org/10.1111/j.15526909.2007.00189.x pmid:17973702 18. da silva bastos vdea, freitas-fernandes lb, fidalgo tk, et al. mother-to-child transmission of streptococcus mutans: a systematic review and meta-analysis. j dent 2015;43(2):181-191. https://doi.org/10.1016/j.jdent.2014.12.001 pmid:25486222 https://doi.org/10.1111/idj.12035 https://doi.org/10.1057/jphp.2010.31 https://doi.org/10.4274/jtgga.galenos.2018.2018.0139 https://doi.org/10.1515/jpm.2010.007 https://doi.org/10.14219/jada.archive.2001.0306 https://doi.org/10.1089/jwh.2005.14.880 https://doi.org/10.1186/1471-2458-10-75 https://doi.org/10.1186/1471-2458-10-75 https://doi.org/10.1055/s-0036-1597134 https://doi.org/10.5005/johcd-5-1-24 https://doi.org/10.4103/2231-0762.163405 https://doi.org/10.4103/2231-0762.163405 https://doi.org/10.1111/j.1552-6909.2007.00189.x https://doi.org/10.1111/j.1552-6909.2007.00189.x https://doi.org/10.1016/j.jdent.2014.12.001 umar et al asian journal of dental and health sciences. 2023; 3(3):37-41 [37] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the study of 2d:4d ratio and facial asymmetry using eye-mouth-eye angle among the student of college of medicine and health sciences, federal university dutse mikail isyaku umar1,2, abba ishaq1, ibrahim ahmad atiku1, ni'imah rabiu el-yakub1, musa abubakar3 and *emmanuel ifeanyi obeagu4 1 department of human anatomy, federal university dutse, igawa state, nigeria 2 department of human anatomy, kampala international university uganda. 3 department of human anatomy, bayero university kano, kano state, nigeria. 4 department of medical laboratory science, kampala international university, uganda. article info: _______________________________________ article history: received 02 july 2023 reviewed 13 august 2023 accepted 28 august 2023 published 15 september 2023 _______________________________________ cite this article as: umar mi, ishaq a, atiku ia, el-yakub nr, abubakar m, obeagu ei, the study of 2d:4d ratio and facial asymmetry using eye-moutheye angle among the student of college of medicine and health sciences, federal university dutse, asian journal of dental and health sciences. 2023; 3(3):37-41 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.52 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda. abstract ___________________________________________________________________________________________________________________ deviations of physical characteristics from bilateral symmetry, in otherwise symmetric individuals, are supposed to result from environmental perturbations during development. one cause of such perturbations may be sex steroids such as testosterone and oestrogen. the study examined the relationship between second to fourth digit ratio (2d:4d), a putative negative correlate with prenatal testosterone and a positive correlate with prenatal estrogen, and asymmetry. the hand of the participants was place on a flat surface with the palm facing upward fore arm in line with the middle finger. finger should be extended maximally and dose to each other measurement technique was followed for measuring 2d:4d digit length which can be define as a distance between the proximal flexion crease of the digit length was measured in centimeters. table 1 shows descriptive analysis of 2d and 4d right and left distance. the minimum and maximum ages are 18 and 35 years respectively. the mean of 2d:4d right length was 0.98 ± 0.015 and the mean of 2d:4d left length 0.97 ± 0.022 this shows there is higher mean value in right 2d:4d length. our data show that both low 2d:4d (a marker of high prenatal testosterone) and high 2d:4d (a marker of high prenatal estrogen) are associated with elevated levels of asymmetry and this relationship applies particularly to finger asymmetry. keywords: 2d:4d ratio, facial asymmetry, eye-mouth-eye angle, students introduction many human body parts undergo development with bilateral symmetry. this implies that the right and left sides can be divided into identical mirror images. however, due to biological factors inherent to processes of development as well as environmental disturbances, perfect bilateral symmetry is rarely found. the term asymmetry is used to make reference to dissimilarity between homologous elements, altering the balance between structures. facial asymmetry is common in the overall population and is often presented sub-clinically 1. facial asymmetries manifest themselves very early in human development and remain during lifetime [2]. randomly distributed deviations from perfect symmetry in paired traits such as ear height and wrist width are thought to reflect perturbations during development 2. 2d:4d is the study of finger length patterns, namely the length of the second relative to the length of the fourth digit (digit ratio, 2d:4d). eye-mouth-eye angle is a quantitative and face size independent trait that is sexually dimorphic and a good indicator of masculinity and face symmetry 3. using frontal photographs of both male and female faces 4. facial asymmetry is the condition that one half of the face is not equivalent as the other half 5. material and method study area the study will be conducted in federal university dutse, jigawa state. study population the study population will comprise of all the students of college of medicine and health science of about 750 students in the faculty of basic medical science and faculty of clinical science. student design the study was a descriptive cross sectional study using anthropometry. open access research article http://dx.doi.org/10.22270/ajdhs.v3i3.52 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.52&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 umar et al asian journal of dental and health sciences. 2023; 3(3):37-41 [38] ajdhs.com sample size determination the subjects for the study were the student of faculty of basic medical science, federal university dutse. the sample size was determined using standard formula that recognizes the total population precision level, confidence interval and standard deviation. n≥z2a2s/d2 where n=sample size, z=normal distribution value, d=detection level considered s=standard deviation of the sample database on previous knowledge. inclusion criteria the following subject are included in the research isubject that are within the faculty of basic medical sciences and faculty of clinical sciences, federal university dutse. iisubject that are within the age range of 18-35years iii-subject that are physically fit without any form of deformity exclusion criteria the following are excluded in the research isubject with craniosynostosis iisubject that are symbrachydactyly iiisubject that are oligodactyly ethical consideration a letter of introduction was collected from the department of human anatomy federal university dutse, and was taken to the ethical committee of faculty of basic medical sciences federal university dutse. the aim and objectives of the study were explained to the committee and their permission were obtained. the explanations of the procedure as well as the intended use of the research were properly addressed to the subject and their consents for the participation were obtained. methods step 1 sample size and participant 150 participants of student (79 male and 71 female) of federal university dutse, particularly from faculty of basic medical science (human anatomy, human physiology and mbbs). were recruit for the research study, participants range in age from 18 to 35 years. research study was conduct in only one faculty in the university, each participant was required to fill the questionnaire contain basic demographic profile (e.g., sex, age, ethnicity, etc.). participant were giving information regarding the research study and measurement, procedure and were assure about the confidentiality of the data, they provide and are require to a sign a consent form before participant in the study. participants with any hand, face, diseases, injury, and deformity were excluding from the research study. step 2 the hand of the participants was place on a flat surface with the palm facing upward fore arm in line with the middle finger. finger should be extended maximally and dose to each other measurement technique was followed for measuring 2d:4d digit length which can be define as a distance between the proximal flexion crease of the digit length was measured in centimeters with help of both the right and left hands and repeat three (3) time tor accuracy and mean value was taken for statistical analysis with 0.002.302 as measurement error. all the measurements were performed during the time period 9:00am-12:00pm to eliminate durational variations and under the same conditions to avoid inter-observer errors. morphometric measurements two (2) morphormetric measurements are record for each hand. 2dl (length of index finger) it is measurement as the distance between the mid-point of metacarpo-phalangeal crease at the base of index finger of index to the tip or most forwardly placed point of the index finger. 4dl (length of the ring finger) it is measured as the distance between the mid-point of metacarpo-phalangeal crease at the base of ring finger to the tip or most forwardly place point of the ring finger. 2d:4d digit ratio measures 2d:4d digit ratios are computed by during length of the index finger with the length of the ring finger. 2d length of index finger 2d:4d digit ratio = _______________________________ 4d length of ring finger facial measurement the use of fa as a measure of developmental stability and variation may be an important way in the assessment of level of stress in a given population. this information is scanty in cited literature among hausa population. exploring sexual dimorphism in fa may be considered as the rate limiting step in determining which group between males and females is more prone to developmental stress among hausa population 6. for each trait, fa was calculated by subtracting the left from the right-side value. the repeatability of the two independent fa measurements was tested using a one-factor, repeated measures anova 7. measures were accepted as being repeatable if there was a significantly greater variance between individuals than between the repeated fa measurements of the same individual. repeatability estimates, based on the interclass correlation of the variance component of the repeated measures anova, were also determined. trait that showed significant repeatability can only be accepted as showing fa if the signed asymmetries are normally distributed (as determined by a shapiro-wilk test) around a mean of zero (determined by a one-sample t-test with the null hypothesis set to a mean of zero). absolute mean fa were scaled according to trait size by dividing each one by the average value of the trait measurements. composite fa was then calculated as the sum of the individual scaled fas 6. step 3 the third part of our study we establish sexual dimorphism of the eye-mouth-eye angle using men’s faces (age of 18 to 35years) and women’s faces (age of 18 to 35years). they were student from college of medicine and health sciences faculty of basic medical science and clinical science of federal university dutse between 2018 and 2022. eye-mouth-eye angle are measure with the protractor in the middle of the mouth and arms crossing the center of the pupils. it is measure by the protractor with the accuracy of one degree. step 4 the fourth part of our study investigates the relationship between2d 4d ratio, and eye-mouth-eye angle value and eyemouth-eye bilateral asymmetry. we used the student of federal university dutse, faculty of basic medical science, and clinical science. the entire student they were also asked to have a neutral expression on their faces. participants sat on a stool, 150 students measured the angle to assess the level of umar et al asian journal of dental and health sciences. 2023; 3(3):37-41 [39] ajdhs.com asymmetry between the right and left part of the angle. the right part of the angle was measured between the line that started in the midline define by two anthropological point stomiom (middle of the mouth) and nasion similarly, but with the line that ended in the middle of the pupil. measured the left part of the eye-mouth-eye angle. asymmetries were calculated by the difference between the left and the right part of the eye-mouth-eye angle. whether the distribution of asymmetry is skewed to one of the facial halves (because of the possibility of facial lateralization), subtracted the right part of the angle from left one rather than using the absolute values of this difference, obtain plus value if the right is larger. the facial height and width and the right and left width of the nose and length of the nose were measured. the right and left eye width were also measured. the width and height of the mouth were also measured. statistical analysis the data obtained was transported from microsoft application (word and excel). data were expressed as mean ± standard deviation (sd). student’s t-test was used to test for the difference in height, weight, 2d, 4d between female and males. linear and multiple linear regressions were applied to test the predictive ability of 2d and 4d on height and weight. statistically significant difference was deemed acceptable at p < 0.05. sigma stat 2.0 for windows (systat inc., point richmond, ca) was used for the statistical analysis. results table below shows the descriptive analysis of 2d and 4d right and left length. the minimum and maximum ages are 18 and 35 years respectively. the mean of 2d:4d right length was 0.98 ± 0.015 and the mean of 2d:4d left length 0.97 ± 0.022 this shows there is higher mean value in right 2d:4d lengths. table 1: descriptive analysis of 2d:4d ratio among the student of college of medicine and health sciences, federal university dutse variable minimum maximum mean±sd right 2d:4d 0.945 1.032 0.9851± 0.01519 left 2d:4d 0.933 1.022 0.97706± 0.02213 table below shows the variation of sexual dimorphism in 2d:4d digit ratio, there is higher mean value in 2d:4d right and there is clear significant differences in both the right and left 2d:4d digit ratio. table 2: sexual dimorphism in 2d:4d among the student of college of medicine and health sciences, federal university dutse mean ± sd variable male female t-value p-value right 2d:4d 0.990±0.0156 0.98±0.0121 5.032 0.01 left 2d:4d 0.978± 0.0141 0.975±0.0285 0.608 0.544 the table below shows the sexual dimorphism in facial asymmetry using eye-mouth-eye angle and there is higher mean value in asym-1 of male from the combination of r.eme and l.eme, and there is slightly lower mean value in asym-2 of female from the combination of r.eme and l.eme. table 3: sexual dimorphism in facial asymmetry using eye-mouth-eye angle among the student of college of medicine and health sciences, federal university dutse mean ± sd variable male female t-value p-value asym 1.0102±0.0385 1.0017±0.0191 1.68 0.094 umar et al asian journal of dental and health sciences. 2023; 3(3):37-41 [40] ajdhs.com the table below shows the significant relationship between 2d:4d digit ratio and facial asymmetry which determine that, there is negative or no correlation differences between asym and 2d:4d digit ratio. table 4: relationship between facial asymmetry (eye-mouth-eye angle) and 2d:4d ratio among the student of college of medicine and health sciences, federal university dutse asym r. 2d:4d l. 2d:4d sex cd asym 1 0.251 -0.018 -0.137 0.0021 0.824 0.094 r. 2d:4d 1 0.097 -0.382 0.239 0 l. 2d:4d 1 -0.05 0.544 sex cd 1 discussion digit lengths (the length of 2nd digit otherwise known as index finger and that of the 4th digit also known as ring finger) was measured on the ventral surface of the hand from the basal crease of the digit to the tip of the finger using a digital venier caliper measuring to 0.05mm. in order to reduce observation errors, digit length measurements were read twice independently and the mean of the two measurements was taken as the actual value. students with a history of fractures in the fingers or any form of deformity on the digits that could hinder accurate measurement 8. in a related study by else vier churchill livingstone; 2005 conducted among forensic marker 2d:4d ratio derived from the index and ring finger length in males varied from 0.89 to 1.03 (mean 0.9678 and s.d 0.02224) hand and 0.89 to 1.02 (mean 0.9689 and s.d 0.02582) for the left hand. in female 2d:4d ratio varied from 0.92 to 1.09 (mean 1.0145 and s.d 0.02896) for right hand and 0.92 to 1.09 (mean 1.0142 and s.d 0.02986) for the left hand. depicts the descriptive statistics range, mean, standard deviation, standard error for2d:4d ratios for both hands and for both sexes. the derived 2d:4d ratio show statistically significant sexual dimorphism at level p <0.001. however no significant difference was found for right and left hands for both the sexes. as found in previous studies [9-10], males had a lower average 2d:4d ratio than females both on the right hand and on the left hand and the mean differences were significant both with a parametric ttest (2d:4d right hand; males 0.969g0.036, females 0.983g0.034, tzk2.16, pz.032, two-tailed; 2d:4d left hand, males 0.965g0.038, females 0.985g0.040, tzk2.89, pz.004, twotailed) and a non-parametric permutation test (right hand; pz.016, left hand; pz.003). in related study ratio of 2d:4d (index finger: ring finger) has been shown to be more sensitive, despite other digit ratios (3d:5d) displaying sexual dimorphism and relationship to various human phenotypic traits. existing literature also shows accumulating evidence on 2d:4d ratio showing correlations with various traits in humans. it is thus considered to be a proxy marker of prenatal androgen exposure. a longer index finger will result in a ratio higher than 1, while a longer ring finger will result in a ratio of less than 1. the second digit is typically shorter in both males and females, while the difference in length of the two digits is greater in males than in females. in related study gray, 2004 they examined whether there were any age differences between two sexes. the mannwhitney u testevealed no significant age differences between sexes (u=2.278.0, p=0.08). the mean value of the eme angle for women was 50.16◦ (sd=2.71, n=71), and for men it was 47.68◦ (sd=2.42, n=79), and this difference between sexes was significant, (146) = 5.58, p=0.0001. using cohen’s effect size criterion for interpreting mean differences, (i.e., 0.2=small, 0.5=medium, 0.8=large, we found that this difference was quite large (cohen’s d=0.970). in previous study we confirmed the results of frackiewiczs 11 that men and women are sexually dimorphic on the eme angle character, and this difference was quite large (d=0.97). we found that male faces with relatively smaller eme angles frackiewicz 11 were perceived by women as more attractive. these findings suggest that eme is valuable even in a highly homogenous population. in accordance with previous reports 10, males had a significantly lower 2d:4d ratio than females on the right hand but no significant sex difference was found on the left hand 2d:4d right hand; males x=0.95f0.02, females x=0.99f0.02, t=7.82, p <.05, 2d:4d left hand, males x=0.96f0.03, females x=0.99f0.02, t=4.92, p <.05. we found that 2d:4d ratio was significantly correlated with facial asymmetry scores in both sexes. male right-hand 2d:4d ratio corrected significantly negatively with facial asymmetry (r=.260; p=.029). female right hand 2d:4d ratio correlated significantly positively with facial asymmetry, (r= .228; p=.031). left hand 2d:4d and facial asymmetry were significantly negative correlated in males (r=.319; p= .009), but there was no significant correlation in females (r= .020; p= .436). the aim of the previous study was to examine possible relationships between finger length ratio and facial asymmetry in males and females. male facial asymmetry was negatively correlated with 2d:4d in both hands, but only in umar et al asian journal of dental and health sciences. 2023; 3(3):37-41 [41] ajdhs.com the right hand in females. these relationships probably reflect in utero organizational effects of sex steroids on facial asymmetry rather than adult hormone effects 12. conclusion the correlation between 2d:4d digit ratio was observed that the mean value in right 2d:4d of both male and female were higher. the correlation between the variable was positively higher between 2d:4d ratio of the right and negatively higher between 2d:4d ratio of the left and there was statistically significant difference in both right and left ratio (p< 0.05) of both genders. there was statistically significant different (p< 0.05) in the right and left 2d:4d digits ratio and asymmetry (eye-moutheye angle) of both gender male and female. references 1. cheong, y.w. facial asymmetry; etiology, evolution, and management. chang gung medical journal, 2011; 34,341. 2. thornhill r, & møller ap. (1997). developmental stability, disease and medicine. biol rev. camb philos soc.72:497-548. https://doi.org/10.1017/s0006323197005082 pmid:9375532 3. danel d, pawlowski b. eye-mouth-eye angle as a good indicator of face masculinization, asymmetry, and attractiveness (homo sapiens). journal of comparative psychology. 2007; 121(2):221. https://doi.org/10.1037/0735-7036.121.2.221 pmid:17516801 4. langner o, dotsch r, bijlstra g, wigboldus dh, hawk st, van knippenberg ad. presentation and validation of the radboud faces database. cognition and emotion. 2010; 24(8):1377-88. https://doi.org/10.1080/02699930903485076 5. kowner r. facial asymmetry and attractiveness judgement in developmental perspective. journal of experimental psychology: human perception and performance. 1996 jun; 22(3):662. https://doi.org/10.1037/0096-1523.22.3.662 pmid:8666958 6. adamu lh, ojo sa, danborno b, adebisi ss, taura mg. sex differences in facial asymmetry indices among hausa ethnic group of nigeria. anthropological bioanthropology, 2016; 4:10510. https://doi.org/10.4103/aoba.aoba_32_16 7. palmer ar, strobeck c. fluctuating asymmetry analysis revisited. in: polak m, editor. developmental stability: causes and consequences. new york: oxford university press. 200; 279-319. 8. rayyan mk, ramatu s, ibrahim aa. dujopas4, 2018; (1)446-455. 9. manning jt, fane ba, breedlove s. the second to fourth digit ratio and variation in the androgen receptor gene. evol hum behav, 1998; 24:399-405. https://doi.org/10.1016/s10905138(03)00052-7 10. manning jt. digit ratio: a pointer to fertility, behavior and health. new brunswick, nj: rutgers university press. 2002. 11. frackiewicz w. the aesthetics of the eyes and mouth position in threespoint face schema. prze glad anthropologicanthropological r., 2001; 64:93. https://doi.org/10.18778/18986773.64.07 12. fink b, manning jt, neave n, grammer k. second to fourth digit ratio and facial asymmetry. evolution and human behavior. 2004; 25(2):125-32. https://doi.org/10.1016/s1090-5138(03)00084-9 https://doi.org/10.1017/s0006323197005082 https://doi.org/10.1037/0735-7036.121.2.221 https://doi.org/10.1080/02699930903485076 https://doi.org/10.1037/0096-1523.22.3.662 https://doi.org/10.4103/aoba.aoba_32_16 https://doi.org/10.1016/s1090-5138(03)00052-7 https://doi.org/10.1016/s1090-5138(03)00052-7 https://doi.org/10.18778/1898-6773.64.07 https://doi.org/10.18778/1898-6773.64.07 https://doi.org/10.1016/s1090-5138(03)00084-9 gupta et al. asian journal of dental and health sciences. 2024; 4(4):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited full mouth rehabilitation of early childhood caries under general anesthesia: a case report of 2 cases dr. gupta sonal 1* , dr. baby abia 2 , dr. ayub sheenam 3 , dr. prawin akil 4 1 head of the department, department of pediatric and preventive dentistry, kanti devi dental college and hospital, uttar pradesh, india, mob 9837229077, 2 post graduate student, department of pediatric and preventive dentistry, kanti devi dental college and hospital, uttar pradesh, india, mob7624855642, 3 post graduate student, department of pediatric and preventive dentistry, kanti devi dental college and hospital, uttar pradesh, india, mob7463828726, 4 post graduate student, department of pediatric and preventive dentistry, kanti devi dental college and hospital, uttar pradesh, india, mob7010241285, article info: _____________________________________________ article history: received 19 august 2024 reviewed 17 september 2024 accepted 07 october 2024 published 15 december 2024 _____________________________________________ cite this article as: gupta s, baby a, ayub s, prawin a, full mouth rehabilitation of early childhood caries under general anesthesia: a case report of 2 cases, asian journal of dental and health sciences. 2024; 4(3):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.97 abstract _________________________________________________________________________________________________________________ ecc is a rising healthcare concern in developing countries. it leads to immediate or late complications, which may affect the overall well-being and development of the child. hence treating it as well as modifying its risk factors at the earliest is required. treating s-ecc may require extensive procedures and long appointments to which many children especially under the age of five do not comply. in such situations when all the other means of management has failed, treatment can be done under general anaesthesia which reduces the trauma caused by multiple dental visits. a treatment is successful only if regular recall and checkup is done. this report presents the case a 4 yrs old female patient with frankel’s definitely negative behaviour diagnosed with ecc and describes in detail its restorative and rehabilitative management carried out under general anaesthesia. keywords: general anaesthesia full mouth rehabilitation, early childhood caries. *address for correspondence: dr. gupta sonal, head of the department, department of pediatric and preventive dentistry, kanti devi dental college and hospital, uttar pradesh, india. introduction one of the most prevailing diseases among children worldwide is the early childhood caries.1according to aapd, ecc is defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth” in a child under the age of six.2 the who oral status and health report (2022) estimated that ecc is 12th most prevailing disease with almost 514 million children suffering from it. the us department of health and human services reports that early childhood caries (ecc) is five times more common than asthma and seven times more common than hay fever.3 it is caused by an imbalance in the oral microflora mainly due to sugar rich diet. along with it poor oral hygiene, poor socio-economic status to get regular checkups and lack of knowledge leads to fast and aggressive progression of early childhood caries. it affects the general health of children.1 the complexity of the ecc treatment depends on a number of variables, such as the child's age, the degree of dental damage, and any coexisting complications. enamel proximal lesions and white spots in mild cases of ecc may not require extensive restoration. by providing dietary guidance, topical fluoride indications, and parent education, the clinician can stop additional decay and spread.4 in cases ranging from moderately severe to advanced ecc tooth extractions followed by space maintainers, extensive restorations, and pulp therapy are utmost necessary. but because of the age group's lack of compliance in most cases, deep sedation or general anaesthesia is used in these situations.4 very often general anesthesia is required to complete necessary dental treatment in young and uncooperative children. treatment is done in the hospital, ambulatory surgery centre or office setting. in spite of the low incidence of adverse reactions from general open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.97 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.97&amp;domain=pdf https://orcid.org/0000-0002-7842-2217 https://orcid.org/0009-0000-7395-9341 https://orcid.org/0009-0005-4252-7016 https://orcid.org/0009-0008-3619-5299 gupta et al. asian journal of dental and health sciences. 2024; 4(4):1-4 [2] ajdhs.com anaesthesia, deep sedation or moderate sedation can be safely and efficiently used in the completion of dental treatment provided with well-trained professionals following established protocols and guidelines16.thus this case report describes the full mouth rehabilitation of a 4yrs old an uncooperative child with ecc under general anaesthesia. case report a 4-years old female patient came to the department of paediatric & preventive dentistry of k.d. dental college and hospital, mathura; with chief complaint of decayed teeth in upper & lower back teeth region since 8 months. pt. did not reveal any relevant past dental and medical history. patient behaviour was rated as frankel’s definitely negative. on extraoral examination no abnormalities were detected. intraoral examination revealed primary dentition with grossly decayed teeth irt.64,85; deep proximal caries irt 74,84; smooth surface caries irt 52,51,61,62; occlusal caries irt 54,65,75. it was diagnosed as case of early childhood caries and full mouth rehabilitation under general anaesthesia was advised. consent for the treatment was attained from the parents. treatment planned: no intervention was required in the emergency phase. antibiotic (syrup amoxicillin 5 ml bd) & analgesic (syrup ibugesic 5ml bd) was to be administered in the systemic phase. as a preventive measure oral hygiene instruction and diet counselling was done. pre-anaesthetic checkup was carried out in the preparatory phase which included blood investigation (complete blood count, random blood sugar, bleeding time, clotting time, liver function test, kidney function test, electrocardiography, chest x-ray) and viral markers (hiv, hcv, hbv). treatment done: after execution of the systemic phase and the preventive phase and upon normal reports from preanesthetic assessments, patient was admitted one day prior to k.d medical college and hospital, mathura, uttar pradesh. preanesthetic non pharmacological management was carried out by educational videos and pictures about the procedure. preanesthetic medication of oral midazolam (0.5-0.7mg/kg) was given to induce anxiolysis and sedation. intravenous anaesthetic induction was carried out with propofol (continuous infusion of 500mcg/kg/min for 4-6min up to a max of23mg/kg). in the maintenance phase, oral cavity was maintained in an open position with the help of molt’s mouth prop, rubber dam isolation done. corrective procedures were carried out quadrant wise that included corrective procedures were carried out quadrant wise that included pulpectomy irt #84 #85 #74 #64 by obtaining straight line access, adequate irrigation with 1%naocl and normal saline alternatively, root canals were obturated with metapex, post obturation seal was done with glass ionomer cement and as the crown structure was not sufficient to retain the restoration a stainless-steel crown was adapted on to each pulpaly treated teeth. #52, #51, #61, #62 were affected by smooth surface caries involving more than two tooth surfaces. celluloid strip crown (3m espe, usa) was selected according to each teeth size and was cut to appropriate length, vent holes were made in the proximal region. after customising the crown to fit the teeth, caries were excavated from teeth surface using hand instruments, teeth surface cleansed with water to remove caries debris, followed by etching with 37% phosphoric acid, dentin conditioning and photoactivation , the strip crown was filled with composite resin (3m espe st, paul, mn, usa)(a1 shade) and adapted to the tooth surface, excess material was removed with a probe and it was photoactivated for 40sec.occlusal adjustments and polishing was done soon after. occlusal caries irt #54, #65, #75 were excavated, cavity air dried and restored using gic (gc gold labelhigh strength posterior restorative). topical fluoride (duraphat®) was applied and rubber dam removed. thorough intraoral examination was carried out to ensure that the oral cavity was devoid of any foreign bodies/dental materials. post operative care: after successful treatment pt. was stabilised and was discharged after 6 hours of monitoring. antibiotics and analgesics were prescribed, post operative and oral hygiene instructions were given and soft diets was advised and patient was recalled for check-up after 1 week followed by successive visits every 6 months. pre-treatment photographs frontal view maxillary occlusal view mandibular occlusal view` gupta et al. asian journal of dental and health sciences. 2024; 4(4):1-4 [3] ajdhs.com posttreatment photographs discussion despite many recent awareness and advancements in the preventive measures, ecc continues to be most prevalent among pre-school children hence requiring intervention by a dental professional at an early stage4.oral health related quality of life is a vital part of general health and well-being. early childhood caries has a negative impact on children life including pain while sleeping or mastication, reduced appetite, weight loss, alteration in sleep wake cycle, low self-esteem and decrease in academic performance7.adding to it the dental impact it can have on the successor teeth increases the need to intervene the situation with appropriate treatment. the management of patients with ecc is not a simple task keeping in mind the tender age of the patient adding to the anxiousness and uncooperativeness towards the dental treatment. success of the treatment depends on the cooperativeness during the dental procedure. in this case report, the child was very reluctant and uncooperative on her first dental visit. so patient was counselled and behaviour shaping was done with various non pharmacological behaviour modification techniques, which did not give a positive outcome and hence lowered the success rate of future treatments6.although dental care under ga is a more costly option, there are situations like this when it is the best course of action for treating children who are difficult to manage. the oral rehabilitation of child suffering from ecc depends on the age of child, their cooperation throughout the procedure, any underlying medical history etc. apart from functional rehabilitation, aesthetic rehabilitation in young children also is a key factor concerning aesthetics and phonetics8. in this case primary molars #84 #85 #74 #64 pulpectomy was done 1%naocl was used as suggested by paragliola et al and pashley et al)9,10 and normal saline alternatively, root canals were obturated with metapex. etman a et al, ramar k et al11,12suggested in their studies that metapex was a better than other dental materials post obturation seal was done with glass ionomer cement and as the crown structure was not sufficient to retain the restoration a stainless-steel crown was adapted on to each pulpally treated teeth. moskovitz et al had suggested that the endodontically treated primary teeth should be given stainless steel crown if there was no adequate tooth structure to retain the post endo restoration for long-term prognosis13. the premature loss of deciduous anterior teeth will alter the path of eruption of permanent incisors. this will lead to a great arch length discrepancy, finally resulting in malocclusion. the age of 2-4 is considered very significant because there are increased risk primary incisors being affected by trauma/ ecc. partial or total loss of anterior teeth at this age will cause phycological imbalance on children and thus effecting their selfesteem and social skills14,15. hence in this case #52, #51, #61, #62 were affected by smooth surface caries. since it was not pulpally affected, restoration using strip crown was done (thribhuvanan l et al). this restored the aesthetics and aided in establishing the phonetics. success of a treatment depends on the recall visits and proper follow-up. recall appointments should be planned depending on the clinicians’ assessments of patient’s caries risk (negi d et al)6. hence in this case patient was recalled after 1 week followed by successive visits every 6 months. when dealing with extensive ecc damage in uncooperative children, general anesthesia may be preferable in some instances. however, strict adherence to post-operative plans is essential to preserve any positive rehabilitation outcomes. unreported caries recurrence may be the result of poor follow-up compliance or participant withdrawal16. conclusion early childhood caries is a deleterious condition that requires prompt intervention. the aim of treating under general anaesthesia is to restore the oral health of the patient in a single visit and prevent any anxiety placement of ssc crown in 64 placement of ssc crown in 74 placement of ssc crown in 84,85 gupta et al. asian journal of dental and health sciences. 2024; 4(4):1-4 [4] ajdhs.com associated with frequent dental visits as treatment for ecc requires extensive work. to ensure complete success of the treatment the risk factors associated with ecc should also be identified and appropriate treatment should be initiated to prevent the decline of oral health and regular oral hygiene should be maintained and monitored. conflict of interest statement: authors disclose no potential conflicts of interest source of support: nil funding: this work is not financiered ethics statement: not applicable acknowledgements: not applicable author contributions: all authors have equal contribution in the preparation of manuscript and compilation. references 1. meyer f, enax j. early childhood caries: epidemiology, aetiology, and prevention. international journal of dentistry. 2018 may 22;2018. https://doi.org/10.1155/2018/1415873 2. american academy of pediatric dentistry. policy on early childhood caries (ecc): consequences and preventive strategies. the reference manual of pediatric dentistry. chicago, ill.: american academy of pediatric dentistry; 2023:88-91. 3. devan i, ramanarayanan v, janakiram c.prevalence of early childhood caries in india: a systematic review andmeta analysis. indian j public health 2022;66:s3 11. https://doi.org/10.4103/ijph.ijph_1078_22 4. tungare s, paranjpe ag. early childhood caries 2018 5. shreyans jain, nilesh rathi, nilima thosar, sudhindra baliga, pooja bhansali, kalyani rathi, nikita sharma. full mouth rehabilitation ofa pediatric patient under general anesthesia-a case report. medical science, 2020;24(101):22-25 (2) (pdf) full mouth rehabilitation of a pediatric patient under general anesthesia-a case report. 6. negi d. full mouth rehabilitation of child with early childhood caries. int j pedod rehabil 2021;6:35-7 https://doi.org/10.4103/ijpr.ijpr_12_21 7. singh n, dubey n, rathore m, pandey p. impact of early childhood caries on quality of life: child and parent perspectives. journal of oral biology and craniofacial research. 2020 apr 1;10(2):83-6. https://doi.org/10.1016/j.jobcr.2020.02.006 8. thribhuvanan l, saravanakumar ms, anjana g. full mouth rehabilitation of a 4-year-old child with severe early childhood caries: a case report. j pediatr dent 2021;7(2):99-103 https://doi.org/10.14744/jpd.2021.07_54 9. . paragliola r, franco v, fabiani c. final rinse optimization: influence of different agitation protocols. j endod, 2010; 36:2825. https://doi.org/10.1016/j.joen.2009.10.004 10. pashley el, birdsong nl, bowman k, pashley dh. cytotoxic effects of naocl on vital tissue. j endod, 1985; 11:525-528. https://doi.org/10.1016/s0099-2399(85)80197-7 11. etman a. success of pulpectomy in primary molars using a modified obturating materials (a comparative study between metapex and endoflas). egyptian dental journal. 2023 oct 1;69(4):2599-607. https://doi.org/10.21608/edj.2023.222984.2637 12. ramar k, mungara j. clinical and radiographic evaluation of pulpectomies using three root canal filling materials: an: in-vivo: study. journal of indian society of pedodontics and preventive dentistry. 2010 jan 1;28(1):25-9. https://doi.org/10.4103/09704388.60481 13. moskovitz, m., yahav, d., tickotsky, n., & holan, g. (2010). long-term follow up of root canal treated primary molars. international journal of paediatric dentistry, 20(3)l207-213. https://doi.org/10.1111/j.1365-263x.2010.01038.x 14. kanasi e, dewhirst fe, chalmers ni, et al. clonal analysis of the microbiota of severe early childhood caries. caries res 2010;44(5):485-497 https://doi.org/10.1159/000320158 15. thribhuvanan l, saravanakumar ms, anjana g. full mouth rehabilitation of a 4-year-old child with severe early childhood caries: a case report. j pediatr dent 2021;7(2):99-103 https://doi.org/10.14744/jpd.2021.07_54 16. campbell rl, shetty ns, shetty ks, pope hl, campbell jr. pediatric dental surgery under general anesthesia: uncooperative children. anesthesia progress. 2018 dec 1;65(4):225-30. https://doi.org/10.2344/anpr-65-03-04 https://doi.org/10.1155/2018/1415873 https://doi.org/10.4103/ijph.ijph_1078_22 https://doi.org/10.4103/ijpr.ijpr_12_21 https://doi.org/10.1016/j.jobcr.2020.02.006 https://doi.org/10.14744/jpd.2021.07_54 https://doi.org/10.1016/j.joen.2009.10.004 https://doi.org/10.1016/s0099-2399(85)80197-7 https://doi.org/10.21608/edj.2023.222984.2637 https://doi.org/10.4103/0970-4388.60481 https://doi.org/10.4103/0970-4388.60481 https://doi.org/10.1111/j.1365-263x.2010.01038.x https://doi.org/10.1159/000320158 https://doi.org/10.14744/jpd.2021.07_54 https://doi.org/10.2344/anpr-65-03-04 obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [38] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited mental health and psychosocial effects of natural disaster on hiv patients *emmanuel ifeanyi obeagu 1 and getrude uzoma obeagu 2 1 department of medical laboratory science, kampala international university, uganda, 2 school of nursing science, kampala international university, uganda, article info: _____________________________________________ article history: received 27 december 2023 reviewed 29 january 2024 accepted 22 february 2024 published 15 march 2024 _____________________________________________ cite this article as: obeagu ei, obeagu gu, mental health and psychosocial effects of natural disaster on hiv patients, asian journal of dental and health sciences. 2024; 4(1):38-44 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.63 _____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda, 0000-0002-4538-0161 abstract _________________________________________________________________________________________________________________ natural disasters pose unique challenges to individuals living with hiv/aids, impacting their mental health and psychosocial well-being. this review explores the complex interplay between natural disasters and the mental health implications for hiv patients. disruptions in healthcare infrastructure, medication access, and treatment continuity during disasters significantly affect disease management, leading to heightened stress, anxiety, and trauma among this vulnerable population. social support networks, crucial for those with hiv, often suffer severe setbacks, exacerbating mental health issues. the aftermath of disasters may induce long-term psychological effects, including post-traumatic stress disorder (ptsd) and depression. understanding these multifaceted impacts is critical in developing tailored interventions and support systems to mitigate the mental health consequences experienced by individuals living with hiv in the wake of natural disasters. further research and targeted interventions are essential to address the specific needs of this population and promote resilience in the face of such calamities. keywords: mental health, psychosocial effect, natural disaster, hiv, aids, emergency introduction natural disasters, ranging from hurricanes and earthquakes to floods and wildfires, present multifaceted challenges that extend beyond immediate physical devastation. amidst the chaos and upheaval caused by these catastrophic events, individuals living with hiv/aids constitute a particularly vulnerable population facing unique mental health and psychosocial ramifications. the intersection of natural disasters and the complex landscape of hiv care introduces intricate challenges, disrupting access to crucial healthcare services, medication adherence, and psychosocial support networks.1-11 the impact of natural disasters on the mental health of hiv patients is a topic of increasing concern and study.12 disruptions in healthcare infrastructure, exacerbated by the chaos following disasters, disrupt the continuity of care essential for managing hiv. this disruption not only amplifies the existing stressors but also triggers heightened levels of anxiety, fear, and uncertainty among individuals grappling with the dual burden of a chronic illness and the aftermath of a disaster.13-19 moreover, the erosion of social support networks a cornerstone of coping mechanisms for those living with hiv during and after a natural disaster intensifies the psychosocial strain.20 loss of familial ties, community structures, or access to essential support services compounds the challenges faced by hiv-positive individuals, often leading to profound isolation and exacerbating mental health vulnerabilities.21-28 while immediate relief efforts focus on addressing physical needs and infrastructural rehabilitation post-disaster, the long-term mental health implications for individuals living with hiv often remain overlooked. understanding the intricate interplay between natural disasters and mental health outcomes in this population is pivotal in devising targeted interventions and support systems that cater to their specific needs. this paper aims to delve into the nuanced dynamics of how natural disasters impact the mental health and psychosocial well-being of individuals living with hiv/aids. by synthesizing existing literature and highlighting key challenges, it seeks to underscore the urgency of addressing the mental health repercussions of disasters among this vulnerable demographic. ultimately, this exploration underscores the importance of tailored interventions and comprehensive support frameworks to mitigate the mental health burden experienced by hiv patients in the wake of natural disasters. disruption of healthcare services disruption of healthcare services due to natural disasters presents a critical challenge for individuals living with hiv/aids.29 the aftermath of such calamities often leads to severe disruptions in healthcare infrastructure, hindering access to essential medical care, medications, and ongoing treatment for hiv-positive individuals.30-34 natural disasters, whether hurricanes, earthquakes, or floods, can damage healthcare facilities, compromise supply chains, and displace healthcare providers.35 this disruption not only limits the open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.63 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.63&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 https://orcid.org/0000-0002-1373-9571 obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [39] ajdhs.com immediate availability of medical care but also impedes the continuity of treatment essential for managing hiv/aids. interruptions in the supply of antiretroviral therapy (art) and other necessary medications can have dire consequences, leading to treatment interruptions, viral resistance, disease progression, and increased morbidity among those living with hiv.36-44 moreover, displaced populations or individuals forced to evacuate their homes due to disasters often encounter challenges in accessing healthcare services, including hiv testing, counseling, and follow-up care. this displacement can sever the established patient-provider relationships crucial for effective disease management, leaving individuals without critical medical guidance and support.45-52 furthermore, the overwhelming demands on healthcare systems in the aftermath of a natural disaster often divert resources away from hiv/aids care programs. the allocation of resources towards immediate emergency response efforts may result in a temporary or prolonged neglect of ongoing hiv treatment and care services, exacerbating the vulnerabilities of hiv-positive individuals.53-60 addressing the disruption of healthcare services during and after natural disasters necessitates proactive planning, resource allocation, and resilient healthcare systems. ensuring the continuity of hiv/aids care amidst such crises requires pre-disaster planning, establishing contingency measures, and strengthening healthcare infrastructures to withstand the impact of disasters.61-68 efforts to enhance disaster preparedness within healthcare systems should prioritize strategies for maintaining the supply chain of medications, securing alternative care sites, training healthcare personnel in disaster response protocols, and fostering collaborations between disaster response agencies and hiv care providers. by mitigating the disruptions to healthcare services, it becomes possible to safeguard the well-being and health outcomes of individuals living with hiv/aids in the face of natural disasters. stress and psychological impact the experience of natural disasters significantly impacts the mental health and psychological well-being of individuals living with hiv/aids. the combination of managing a chronic illness and enduring the traumatic aftermath of a disaster creates a complex and heightened psychological burden on this vulnerable population.69-74 natural disasters generate an array of stressors that exacerbate the existing challenges faced by hiv-positive individuals. the uncertainty surrounding access to essential medications, disrupted healthcare services, and the loss of stable living conditions can trigger acute stress, anxiety, and fear. the fear of treatment interruption, disease progression, or complications due to the unavailability of necessary medical care intensifies psychological distress among those managing hiv.75-79 moreover, the trauma experienced during disasters, including the loss of loved ones, displacement, property damage, or witnessing distressing events, compounds the psychological impact. individuals living with hiv may be particularly susceptible to the mental health consequences of such traumas, leading to heightened levels of post-traumatic stress disorder (ptsd), depression, and anxiety disorders. the psychological toll extends beyond the immediate aftermath, often resulting in prolonged mental health challenges. chronic stressors stemming from the disruption of daily routines, loss of social support networks, and ongoing uncertainty regarding healthcare access contribute to sustained psychological distress among hiv-positive individuals affected by natural disasters. addressing the stress and psychological impact necessitates comprehensive mental health support and interventions tailored to the unique needs of this population. integrating mental health services into disaster response efforts and hiv care programs is crucial. providing accessible and culturally sensitive mental health support, counseling services, and psychosocial interventions can aid in coping with trauma, reducing stress, and fostering resilience among individuals living with hiv in the wake of a natural disaster. additionally, community-based support networks and peer-led interventions play a pivotal role in offering emotional support, sharing coping strategies, and reducing the isolation experienced by those affected. empowering individuals with information, promoting self-care practices, and building adaptive coping mechanisms are essential components of mitigating the psychological impact of disasters on hiv-positive individuals, promoting mental wellbeing, and facilitating their recovery process. social support networks social support networks serve as a crucial lifeline for individuals living with hiv/aids, offering emotional, practical, and informational support.80 however, the disruption caused by natural disasters profoundly impacts these support systems, leaving those affected by hiv more vulnerable and isolated. the aftermath of a natural disaster often leads to the disintegration or severe strain on established social support networks. loss of family members, friends, or community ties, displacement, and relocation to unfamiliar environments can sever the vital connections that individuals living with hiv rely on for emotional support and solidarity. the breakdown of these networks intensifies feelings of loneliness, isolation, and helplessness among this already marginalized population.80 moreover, disruptions in communication infrastructure and community services hinder the ability to access support groups, counseling services, and peer networks that are instrumental in coping with the challenges of hiv/aids. lack of access to these resources further compounds the sense of social isolation and exacerbates the psychological distress experienced by hivpositive individuals.80 rebuilding and strengthening social support networks are pivotal in mitigating the psychosocial impact of natural disasters on individuals living with hiv/aids. efforts aimed at community resilience and recovery should focus on reestablishing these networks, fostering community engagement, and providing platforms for mutual aid and peer support. community-based organizations, ngos, and healthcare providers play a critical role in facilitating the reconnection of affected individuals to support groups and community services. creating safe spaces for dialogue, peer support initiatives, and support groups—whether in-person or through virtual platforms—can help individuals rebuild their social networks, share experiences, and access essential emotional support. additionally, interventions that empower community members to become peer supporters or advocates within their communities can enhance social cohesion and resilience. training programs aimed at equipping individuals with the skills to provide emotional support, disseminate accurate health information, and promote self-care practices foster a sense of empowerment and belonging among those affected by both hiv and natural disasters. by prioritizing the restoration and strengthening of social support networks, it becomes possible to alleviate the isolation and psychological distress experienced by individuals living with hiv in the aftermath of natural disasters, fostering resilience and promoting their overall well-being. medication adherence and disease management natural disasters pose significant challenges to medication adherence and disease management among individuals living with hiv/aids. the disruptions caused by these catastrophic events often lead to barriers that compromise the continuity of care, medication adherence, and disease management for this vulnerable population.81 the aftermath of a natural disaster can obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [40] ajdhs.com result in the displacement of individuals, damage to healthcare facilities, and disruptions in supply chains, leading to difficulties in accessing essential medications, including antiretroviral therapy (art). displaced individuals may face challenges in locating healthcare providers or pharmacies that supply their prescribed medications, resulting in treatment interruptions or delays in accessing necessary drugs.81 moreover, the chaos and upheaval following a disaster can create logistical obstacles that hinder adherence to strict medication schedules. individuals may lose their medication supply, have medications damaged, or face difficulties in storing medications properly in emergency situations, impacting their ability to adhere to the prescribed treatment regimens. disruptions in healthcare services, including the unavailability of healthcare providers, the loss of medical records, and the absence of regular follow-up appointments, further complicate disease management for those living with hiv. the lack of continuity in care can lead to challenges in monitoring the progression of the disease, addressing potential complications, and providing necessary medical guidance to patients.81 addressing medication adherence and disease management during and after natural disasters requires a multi-faceted approach that encompasses both short-term and long-term strategies. pre-disaster planning and preparedness efforts are crucial in ensuring the availability and accessibility of medications, establishing contingency plans for medication distribution, and securing alternative healthcare facilities in the event of healthcare infrastructure damage. furthermore, educating and empowering individuals living with hiv/aids about emergency preparedness, including strategies for medication storage, retrieval, and adherence during disasters, can enhance their resilience. providing emergency medication kits, promoting adherence reminder systems, and utilizing telemedicine or remote consultations where feasible can also support continued disease management amidst disruptions. collaboration between healthcare providers, public health agencies, community organizations, and disaster response teams is essential in developing comprehensive strategies that prioritize the continuity of hiv/aids care during and after natural disasters.80 by addressing the challenges related to medication adherence and disease management, it becomes possible to minimize the adverse effects on the health outcomes of individuals living with hiv in the face of such crises. long-term mental health effects the long-term mental health effects resulting from natural disasters among individuals living with hiv/aids can persist well beyond the immediate aftermath, posing substantial challenges to their overall well-being and quality of life.82 the traumatic experiences associated with natural disasters can leave enduring psychological impacts on hiv-positive individuals. prolonged exposure to stress, loss of social support networks, displacement, and uncertainty about healthcare access contribute to the development of persistent mental health conditions among this vulnerable population.82 post-traumatic stress disorder (ptsd) is one of the long-term mental health effects commonly observed in individuals affected by both natural disasters and hiv/aids. symptoms of ptsd, such as intrusive thoughts, hyperarousal, and avoidance behaviors, may persist long after the disaster has occurred, significantly impairing daily functioning and exacerbating the existing challenges of managing a chronic illness like hiv.83 additionally, depression and anxiety disorders tend to linger as enduring mental health concerns among hiv-positive individuals affected by natural disasters. the ongoing stressors stemming from the disruption of routine, loss of stability, and difficulties in rebuilding life post-disaster contribute to a higher prevalence of depressive symptoms and anxiety disorders within this demographic.83 these long-term mental health effects often lead to a complex interplay of physical and psychological health issues. chronic stress and mental health disorders can impact immune function, potentially affecting hiv disease progression and treatment outcomes. moreover, untreated mental health conditions can hinder medication adherence, further complicating disease management and increasing the risk of adverse health outcomes.82 addressing the long-term mental health effects necessitates sustained and tailored interventions that prioritize mental health support as an integral component of ongoing care for individuals living with hiv/aids post-disaster. long-term mental health programs, counseling services, and access to psychiatric care should be integrated into hiv care settings to ensure continued support for those grappling with persistent psychological challenges. psychoeducation, coping skills training, and trauma-focused interventions are essential in helping individuals build resilience, manage stress, and address lingering mental health issues. moreover, fostering peer support networks and community-based initiatives that promote social connectedness and emotional support can aid in mitigating the long-term mental health effects, promoting recovery, and enhancing overall well-being among individuals living with hiv affected by natural disasters. recommendations and ways forward addressing the mental health and psychosocial effects of natural disasters on individuals living with hiv/aids requires a multi-dimensional approach that integrates various strategies and interventions. develop comprehensive disaster preparedness plans within healthcare systems that specifically address the needs of individuals living with hiv/aids. integrate strategies to ensure continuity of care, medication access, and psychosocial support during and after disasters. establish contingency plans for the distribution of essential medications, including antiretroviral therapy (art), during disasters. ensure stockpiling, alternative distribution methods, and collaborations with local pharmacies or healthcare facilities to provide uninterrupted access to medications. integrate mental health services into routine hiv care settings. provide access to counseling, psychotherapy, and support groups tailored to address trauma, stress, depression, and anxiety among hiv-positive individuals affected by disasters. foster community resilience by empowering and engaging local communities in disaster response efforts. develop peer support networks, community-based organizations, and initiatives that provide emotional support, information dissemination, and assistance in rebuilding social support structures. conduct education and training programs aimed at raising awareness about disaster preparedness, stress management, and coping strategies among individuals living with hiv/aids. empower them with knowledge and skills to navigate emergencies and mitigate mental health challenges. forge partnerships between healthcare providers, disaster response agencies, governmental organizations, ngos, and community groups. collaborate to create a coordinated response system that addresses both immediate and long-term needs of hiv-positive individuals affected by disasters. utilize telemedicine and technology to facilitate remote healthcare consultations, medication monitoring, and psychosocial support services, especially in situations where physical access to healthcare facilities is disrupted. encourage research initiatives to understand the specific mental health and psychosocial needs of individuals living with hiv/aids after disasters. collect data to inform evidence-based interventions and policies aimed at better supporting this population. advocate for policies that prioritize the mental health needs of individuals living with hiv/aids in disaster response and obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [41] ajdhs.com recovery efforts. support policy changes that ensure equitable access to healthcare and mental health services in post-disaster scenarios. conclusion the intersection of natural disasters and the lives of individuals living with hiv/aids presents complex challenges, significantly impacting their mental health and psychosocial well-being. the aftermath of disasters disrupts healthcare services, medication adherence, social support networks, and exacerbates stress, trauma, and long-term mental health conditions among this vulnerable population. addressing the mental health and psychosocial effects of natural disasters on individuals living with hiv/aids requires concerted efforts at various levels. integrating disaster preparedness plans within healthcare systems, ensuring uninterrupted access to medications, and strengthening mental health support services are crucial steps in mitigating the impact. community-based initiatives that rebuild social support networks, educate and empower individuals, and foster resilience within affected communities play a pivotal role. collaboration between healthcare providers, disaster response agencies, policymakers, and community organizations are essential in creating a holistic response that meets the specific needs of this population. sustained interventions focused on mental health, psychosocial support, and rebuilding resilience can contribute significantly to the recovery and well-being of individuals living with hiv/aids affected by natural disasters. by prioritizing these efforts, we can strive towards ensuring equitable access to healthcare, promoting mental well-being, and enhancing the overall quality of life for this vulnerable demographic in the wake of calamities. ultimately, these actions are fundamental in creating a more supportive and resilient environment for individuals managing hiv/aids amidst the challenges posed by natural disasters. acknowledgements not applicable authors contribution all the authors were involved in conceptualization, methodology, visualization, validation, drafting and editing of the article funding source no fund was received to write this paper conflict of interest the authors declare that they have no conflict interests. ethical clearance not applicable references 1. saxena d, gupta a, gaur p, gehlot t. disaster management-a comprehensive approach. academic guru publishing house. 2023. 2. obeagu ei, okwuanaso cb, edoho sh, obeagu gu. under-nutrition among hiv-exposed uninfected children: a review of african perspective. madonna university journal of medicine and health sciences. 2022;2(3):120-7. 3. obeagu ei, alum eu, obeagu gu. factors associated with prevalence of hiv among youths: a review of africa perspective. madonna university journal of medicine and health sciences. 2023;3(1):138. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/93 . 4. obeagu ei. a review of challenges and coping strategies faced by hiv/aids discordant couples. madonna university journal of medicine and health sciences. 2023 ;3(1):7-12. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/91 . 5. obeagu ei, obeagu gu. an update on premalignant cervical lesions and cervical cancer screening services among hiv positive women. j pub health nutri. 2023; 6 (2). 2023; 141:1-2. links/63e538ed64252375639dd0df/an-update-on-premalignantcervical-lesions-and-cervical-cancer-screening-services-amonghiv-positive-women.pdf . 6. ezeoru vc, enweani ib, ochiabuto o, nwachukwu ac, ogbonna us, obeagu ei. prevalence of malaria with anaemia and hiv status in women of reproductive age in onitsha, nigeria. journal of pharmaceutical research international. 2021;33(4):10-9. https://doi.org/10.9734/jpri/2021/v33i431166 7. omo-emmanuel uk, chinedum ok, obeagu ei. evaluation of laboratory logistics management information system in hiv/aids comprehensive health facilities in bayelsa state, nigeria. int j curr res med sci. 2017;3(1): 21-38.doi: https://doi.org/10.22192/ijcrms.2017.03.01.004 8. obeagu ei, obeagu gu, musiimenta e, bot ys, hassan ao. factors contributing to low utilization of hiv counseling and testing services. int. j. curr. res. med. sci. 2023;9(2): 1-5.doi: https://doi.org/10.22192/ijcrms.2023.09.02.001 9. obeagu ei, obeagu gu. an update on survival of people living with hiv in nigeria. j pub health nutri. 2022 5 (6). 2022;129. https://645b4bfcf3512f1cc5885784/an-update-onsurvival-of-people-living-with-hiv-in-nigeria.pdf . 10. offie dc, obeagu ei, akueshi c, njab je, ekanem ee, dike pn, oguh dn. facilitators and barriers to retention in hiv care among hiv infected msm attending community health center yaba, lagos nigeria. journal of pharmaceutical research international. 2021;33(52b):10-9. https://doi.org/10.9734/jpri/2021/v33i52b33593 11. obeagu ei, ogbonna us, nwachukwu ac, ochiabuto o, enweani ib, ezeoru vc. prevalence of malaria with anaemia and hiv status in women of reproductive age in onitsha, nigeria. journal of pharmaceutical research international. 2021;33(4):10-19. https://doi.org/10.9734/jpri/2021/v33i431166 12. tran dn, ching j, kafu c, wachira j, koros h, venkataramani m, said j, pastakia sd, galárraga o, genberg bl. interruptions to hiv care delivery during pandemics and natural disasters: a qualitative study of challenges and opportunities from frontline healthcare providers in western kenya. journal of the international association of providers of aids care (jiapac). 2023:23259582231152041. https://doi.org/10.1177/23259582231152041 pmid:36718505 pmcid:pmc9893388 13. odo m, ochei kc, obeagu ei, barinaadaa a, eteng ue, ikpeme m, bassey jo, paul ao. tb infection control in tb/hiv settings in cross river state, nigeria: policy vs practice. journal of pharmaceutical research international. 2020;32(22):101-9. https://doi.org/10.9734/jpri/2020/v32i2230777 14. obeagu ei, eze vu, alaeboh ea, ochei kc. determination of haematocrit level and iron profile study among persons living with hiv in umuahia, abia state, nigeria. j bioinnovation. 2016; 5:464-471. https://592bb4990f7e9b9979a975cf/determination-ofhaematocrit-level-and-iron-profile-study-amongpersons-living-with-hiv-in-umuahia-abia-statenigeria.pdf . 15. ifeanyi oe, obeagu gu. the values of prothrombin time among hiv positive patients in fmc owerri. international journal of current microbiology and applied sciences. 2015;4(4):911-916. https://www.academia.edu/download/38320140/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf . 16. izuchukwu if, ozims sj, agu gc, obeagu ei, onu i, amah h, nwosu dc, nwanjo hu, edward a, arunsi mo. knowledge of preventive measures and management of hiv/aids victims among parents in umuna orlu community of imo state nigeria. int. j. adv. res. biol. https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/93 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/93 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/91 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/91 https://doi.org/10.9734/jpri/2021/v33i431166 https://doi.org/10.22192/ijcrms.2017.03.01.004 https://doi.org/10.22192/ijcrms.2023.09.02.001 https://645b4bfcf3512f1cc5885784/an-update-on-survival-of-people-living-with-hiv-in-nigeria.pdf https://645b4bfcf3512f1cc5885784/an-update-on-survival-of-people-living-with-hiv-in-nigeria.pdf https://doi.org/10.9734/jpri/2021/v33i52b33593 https://doi.org/10.9734/jpri/2021/v33i431166 https://doi.org/10.1177/23259582231152041 https://doi.org/10.9734/jpri/2020/v32i2230777 https://592bb4990f7e9b9979a975cf/determination-of-haematocrit-level-and-iron-profile-study-among-persons-living-with-hiv-in-umuahia-abia-state-nigeria.pdf https://592bb4990f7e9b9979a975cf/determination-of-haematocrit-level-and-iron-profile-study-among-persons-living-with-hiv-in-umuahia-abia-state-nigeria.pdf https://592bb4990f7e9b9979a975cf/determination-of-haematocrit-level-and-iron-profile-study-among-persons-living-with-hiv-in-umuahia-abia-state-nigeria.pdf https://592bb4990f7e9b9979a975cf/determination-of-haematocrit-level-and-iron-profile-study-among-persons-living-with-hiv-in-umuahia-abia-state-nigeria.pdf https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf https://www.academia.edu/download/38320140/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [42] ajdhs.com sci. 2016;3(10): 55-65. https://doi.org/10.22192/ijarbs.2016.03.10.009 17. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75 https://5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infectionamong-patients-who-used-directly-observed-treatment-shortcourse-centres-in-yenagoa-nigeria.pdf 18. oloro oh, oke to, obeagu ei. evaluation of coagulation profile patients with pulmonary tuberculosis and human immunodeficiency virus in owo, ondo state, nigeria. madonna university journal of medicine and health sciences. 2022;2(3):110-119. 19. nwosu dc, obeagu ei, nkwocha bc, nwanna ca, nwanjo hu, amadike jn, elendu hn, ofoedeme cn, ozims sj, nwankpa p. change in lipid peroxidation marker (mda) and non enzymatic antioxidants (vit c & e) in hiv seropositive children in an urban community of abia state. nigeria. j. bio. innov. 2016;5(1):24-30. https://5ae735e9a6fdcc5b33eb8d6a/change-in-lipidperoxidation-marker-mdaand-non-enzymaticantioxidants-vit-c-e-in-hiv-seropositive-children-inan-urban-community-of-abia-state-nigeria.pdf . 20. au a. mental health in east asia: cultural beliefs, social networks, and mental health experiences. taylor & francis; 2023. https://doi.org/10.4324/9781003308720 21. igwe cm, obeagu ie, ogbuabor oa. clinical characteristics of people living with hiv/aids on art in 2014 at tertiary health institutions in enugu, nigeria. j pub health nutri. 2022 https://doi.org/10.9734/ajrid/2022/v10i430294 5 (6). 2022;130. https://645a166f5762c95ac3817d32/clinicalcharacteristics-of-people-living-with-hiv-aids-on-art-in-2014at-tertiary-health-institutions-in-enugu.pdf . 22. ifeanyi oe, obeagu gu, ijeoma fo, chioma ui. the values of activated partial thromboplastin time (aptt) among hiv positive patients in fmc owerri. int j curr res aca rev. 2015; 3:139-144. https://www.academia.edu/download/38320159/obeagu_emma nuel_ifeanyi3__et_al.ijcrar.pdf . 23. obiomah cf, obeagu ei, ochei kc, swem ca, amachukwu bo. hematological indices o hiv seropositive subjects in nnamdi azikiwe university teaching hospital (nauth), nnewi. ann clin lab res. 2018;6(1):1-4. https://5aa2bb17a6fdccd544b7526e/haematological-indices-ofhiv-seropositive-subjects-at-nnamdi-azikiwe.pdf 24. omo-emmanuel uk, ochei kc, osuala eo, obeagu ei, onwuasoanya uf. impact of prevention of mother to child transmission (pmtct) of hiv on positivity rate in kafanchan, nigeria. int. j. curr. res. med. sci. 2017;3(2): 28-34.doi: https://10.22192/ijcrms.2017.03.02.005 25. aizaz m, abbas fa, abbas a, tabassum s, obeagu ei. alarming rise in hiv cases in pakistan: challenges and future recommendations at hand. health science reports. 2023 aug;6(8):e1450. https://doi.org/10.1002/hsr2.1450 pmid:37520460 pmcid:pmc10375546 26. obeagu ei, amekpor f, scott gy. an update of human immunodeficiency virus infection: bleeding disorders. j pub health nutri. 2023 6 (1). 2023;139. links/645b4a6c2edb8e5f094d9bd9/an-update-ofhuman-immunodeficiency-virus-infection-bleeding.pdf. 27. obeagu ei, scott gy, amekpor f, ofodile ac, edoho sh, ahamefula c. prevention of new cases of human immunodeficiency virus: pragmatic approaches of saving life in developing countries. madonna university journal of medicine and health sciences. 2022;2(3):128-34. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/86 . 28. walter o, anaebo qb, obeagu ei, okoroiwu il. evaluation of activated partial thromboplastin time and prothrombin time in hiv and tb patients in owerri metropolis. journal of pharmaceutical research international. 2022:29-34. https://doi.org/10.9734/jpri/2022/v34i3a35560 29. obeagu ei, ubosi ni, uzoma g. storms and struggles: managing hiv amid natural disasters. int. j. curr. res. chem. pharm. sci. 2023;10(11):14-25. 30. odo m, ochei kc, obeagu ei, barinaadaa a, eteng eu, ikpeme m, bassey jo, paul ao. cascade variabilities in tb case finding among people living with hiv and the use of ipt: assessment in three levels of care in cross river state, nigeria. journal of pharmaceutical research international. 2020;32(24):9-18. https://doi.org/10.9734/jpri/2020/v32i2430789 31. jakheng sp, obeagu ei. seroprevalence of human immunodeficiency virus based on demographic and risk factors among pregnant women attending clinics in zaria metropolis, nigeria. j pub health nutri. 2022 https://doi.org/10.9734/sajrm/2022/v13i230295 5 (8). 2022;137. links/6317a6b1acd814437f0ad268/seroprevalenceof-human-immunodeficiency-virus-based-on-demographic-andrisk-factors-among-pregnant-women-attending-clinics-in-zariametropolis-nigeria.pdf. 32. obeagu ei, obeagu gu. a review of knowledge, attitudes and socio-demographic factors associated with non-adherence to antiretroviral therapy among people living with hiv/aids. int. j. adv. res. biol. sci. 2023;10(9):135-42.doi: https://10.22192/ijarbs.2023.10.09.015 https://6516faa61e2386049de5e828/a-review-of-knowledgeattitudes-and-socio-demographic-factors-associated-with-nonadherence-to-antiretroviral-therapy-among-people-living-withhiv-aids.pdf 33. obeagu ei, onuoha ec. tuberculosis among hiv patients: a review of prevalence and associated factors. int. j. adv. res. biol. sci. 2023;10(9):128-34.doi: https://doi.org/10.22192/ijarbs.2023.10.09.014 https://6516f938b0df2f20a2f8b0e0/tuberculosis-among-hivpatients-a-review-of-prevalence-and-associated-factors.pdf . 34. obeagu ei, ibeh nc, nwobodo ha, ochei kc, iwegbulam cp. haematological indices of malaria patients coinfected with hiv in umuahia. int. j. curr. res. med. sci. 2017;3(5):100-4. https://www.academia.edu/download/54317126/haematologic al_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 35. dixit a, dutta p. thematic review of healthcare supply chain in disasters with challenges and future research directions. international journal of disaster risk reduction. 2023 :104161. https://doi.org/10.1016/j.ijdrr.2023.104161 36. jakheng sp, obeagu ei, abdullahi io, jakheng ew, chukwueze cm, eze gc, essien uc, madekwe cc, madekwe cc, vidya s, kumar s. distribution rate of chlamydial infection according to demographic factors among pregnant women attending clinics in zaria metropolis, kaduna state, nigeria. south asian journal of research in microbiology. 2022;13(2):26-31. https://doi.org/10.9734/sajrm/2022/v13i230295 37. viola n, kimono e, nuruh n, obeagu ei. factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district. asian journal of dental and health sciences. 2023;3(2):7-14. http://ajdhs.com/index.php/journal/article/view/39 . https://doi.org/10.22270/ajdhs.v3i2.39 38. okorie hm, obeagu emmanuel i, okpoli henry ch, chukwu stella n. comparative study of enzyme linked immunosorbent assay (elisa) and rapid test screening methods on hiv, hbsag, hcv and syphilis among voluntary donors in. owerri, nigeria. j clin commun med. 2020;2(3):180-83.doi: doi: 10.32474/jccm.2020.02.000137 https://5f344530458515b7291bd95f/comparative-study-ofenzyme-linked-immunosorbent-assay-elisa-and-rapid-testscreening-methods-on-hiv-hbsag-hcv-and-syphilis-amongvoluntary-donors-in-owerri-nigeria.pdf . 39. ezugwu um, onyenekwe cc, ukibe nr, ahaneku je, onah ce, obeagu ei, emeje pi, awalu jc, igbokwe ge. use of atp, gtp, adp https://doi.org/10.22192/ijarbs.2016.03.10.009 https://5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infection-among-patients-who-used-directly-observed-treatment-short-course-centres-in-yenagoa-nigeria.pdf https://5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infection-among-patients-who-used-directly-observed-treatment-short-course-centres-in-yenagoa-nigeria.pdf https://5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infection-among-patients-who-used-directly-observed-treatment-short-course-centres-in-yenagoa-nigeria.pdf https://5ae735e9a6fdcc5b33eb8d6a/change-in-lipid-peroxidation-marker-mdaand-non-enzymatic-antioxidants-vit-c-e-in-hiv-seropositive-children-in-an-urban-community-of-abia-state-nigeria.pdf https://5ae735e9a6fdcc5b33eb8d6a/change-in-lipid-peroxidation-marker-mdaand-non-enzymatic-antioxidants-vit-c-e-in-hiv-seropositive-children-in-an-urban-community-of-abia-state-nigeria.pdf https://5ae735e9a6fdcc5b33eb8d6a/change-in-lipid-peroxidation-marker-mdaand-non-enzymatic-antioxidants-vit-c-e-in-hiv-seropositive-children-in-an-urban-community-of-abia-state-nigeria.pdf https://5ae735e9a6fdcc5b33eb8d6a/change-in-lipid-peroxidation-marker-mdaand-non-enzymatic-antioxidants-vit-c-e-in-hiv-seropositive-children-in-an-urban-community-of-abia-state-nigeria.pdf https://doi.org/10.4324/9781003308720 https://doi.org/10.9734/ajrid/2022/v10i430294 https://645a166f5762c95ac3817d32/clinical-characteristics-of-people-living-with-hiv-aids-on-art-in-2014-at-tertiary-health-institutions-in-enugu.pdf https://645a166f5762c95ac3817d32/clinical-characteristics-of-people-living-with-hiv-aids-on-art-in-2014-at-tertiary-health-institutions-in-enugu.pdf https://645a166f5762c95ac3817d32/clinical-characteristics-of-people-living-with-hiv-aids-on-art-in-2014-at-tertiary-health-institutions-in-enugu.pdf https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://www.academia.edu/download/38320159/obeagu_emmanuel_ifeanyi3__et_al.ijcrar.pdf https://5aa2bb17a6fdccd544b7526e/haematological-indices-of-hiv-seropositive-subjects-at-nnamdi-azikiwe.pdf https://5aa2bb17a6fdccd544b7526e/haematological-indices-of-hiv-seropositive-subjects-at-nnamdi-azikiwe.pdf https://10.0.86.176/ijcrms.2017.03.02.005 https://doi.org/10.1002/hsr2.1450 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/86 https://doi.org/10.9734/jpri/2022/v34i3a35560 https://doi.org/10.9734/jpri/2020/v32i2430789 https://doi.org/10.9734/sajrm/2022/v13i230295 https://10.0.86.176/ijarbs.2023.10.09.015 https://6516faa61e2386049de5e828/a-review-of-knowledge-attitudes-and-socio-demographic-factors-associated-with-non-adherence-to-antiretroviral-therapy-among-people-living-with-hiv-aids.pdf https://6516faa61e2386049de5e828/a-review-of-knowledge-attitudes-and-socio-demographic-factors-associated-with-non-adherence-to-antiretroviral-therapy-among-people-living-with-hiv-aids.pdf https://6516faa61e2386049de5e828/a-review-of-knowledge-attitudes-and-socio-demographic-factors-associated-with-non-adherence-to-antiretroviral-therapy-among-people-living-with-hiv-aids.pdf https://6516faa61e2386049de5e828/a-review-of-knowledge-attitudes-and-socio-demographic-factors-associated-with-non-adherence-to-antiretroviral-therapy-among-people-living-with-hiv-aids.pdf https://doi.org/10.22192/ijarbs.2023.10.09.014 https://6516f938b0df2f20a2f8b0e0/tuberculosis-among-hiv-patients-a-review-of-prevalence-and-associated-factors.pdf https://6516f938b0df2f20a2f8b0e0/tuberculosis-among-hiv-patients-a-review-of-prevalence-and-associated-factors.pdf https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 https://doi.org/10.1016/j.ijdrr.2023.104161 https://doi.org/10.9734/sajrm/2022/v13i230295 http://ajdhs.com/index.php/journal/article/view/39 https://doi.org/10.22270/ajdhs.v3i2.39 https://5f344530458515b7291bd95f/comparative-study-of-enzyme-linked-immunosorbent-assay-elisa-and-rapid-test-screening-methods-on-hiv-hbsag-hcv-and-syphilis-among-voluntary-donors-in-owerri-nigeria.pdf https://5f344530458515b7291bd95f/comparative-study-of-enzyme-linked-immunosorbent-assay-elisa-and-rapid-test-screening-methods-on-hiv-hbsag-hcv-and-syphilis-among-voluntary-donors-in-owerri-nigeria.pdf https://5f344530458515b7291bd95f/comparative-study-of-enzyme-linked-immunosorbent-assay-elisa-and-rapid-test-screening-methods-on-hiv-hbsag-hcv-and-syphilis-among-voluntary-donors-in-owerri-nigeria.pdf https://5f344530458515b7291bd95f/comparative-study-of-enzyme-linked-immunosorbent-assay-elisa-and-rapid-test-screening-methods-on-hiv-hbsag-hcv-and-syphilis-among-voluntary-donors-in-owerri-nigeria.pdf obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [43] ajdhs.com and amp as an index of energy utilization and storage in hiv infected individuals at nauth, nigeria: a longitudinal, prospective, case-controlled study. journal of pharmaceutical research international. 2021;33(47a):78-84. https://doi.org/10.9734/jpri/2021/v33i47a32992 40. emannuel g, martin o, peter os, obeagu ei, daniel k. factors influencing early neonatal adverse outcomes among women with hiv with post dated pregnancies delivering at kampala international university teaching hospital, uganda. asian journal of pregnancy and childbirth. 2023 jul 29;6(1):203-211. http://research.sdpublishers.net/id/eprint/2819/ . 41. igwe mc, obeagu ei, ogbuabor ao, eze gc, ikpenwa jn, eze-steven pe. socio-demographic variables of people living with hiv/aids initiated on art in 2014 at tertiary health institution in enugu state. asian journal of research in infectious diseases. 2022;10(4):1-7. https://doi.org/10.9734/ajrid/2022/v10i430294 42. vincent cc, obeagu ei, agu is, ukeagu nc, onyekachi-chigbu ac. adherence to antiretroviral therapy among hiv/aids in federal medical centre, owerri. journal of pharmaceutical research international. 2021;33(57a):360-368. https://doi.org/10.9734/jpri/2021/v33i57a34007 43. igwe mc, obeagu ei, ogbuabor ao. analysis of the factors and predictors of adherence to healthcare of people living with hiv/aids in tertiary health institutions in enugu state. madonna university journal of medicine and health sciences. 2022;2(3):42-57. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/75 . 44. madekwe cc, madekwe cc, obeagu ei. inequality of monitoring in human immunodeficiency virus, tuberculosis and malaria: a review. madonna university journal of medicine and health sciences. 2022;2(3):6-15. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/69 45. echendu ge, vincent cc, ibebuike j, asodike m, naze n, chinedu ep, ohale b, obeagu ei. weights of infants born to hiv infected mothers: a prospective cohort study in federal medical centre, owerri, imo state. european journal of pharmaceutical and medical research, 2023; 10(8): 564-568 46. nwosu dc, nwanjo hu, okolie nj, ikeh k, ajero cm, dike j, ojiegbe gc, oze go, obeagu ei, nnatunanya i, azuonwu o. biochemical alterations in adult hiv patients on antiretrqviral therapy. world journal of pharmacy and pharmaceutical sciences, 2015; 4(3): 153-160. https://5a4fd0500f7e9bbc10526b38/biochemicalalterations-in-adult-hiv-patients-on-antiretrqviraltherapy.pdf . 47. obeagu ei, obeagu gu. effect of cd4 counts on coagulation parameters among hiv positive patients in federal medical centre, owerri, nigeria. int. j. curr. res. biosci. plant biol. 2015;2(4):45-49. 48. obeagu ei, nwosu dc. adverse drug reactions in hiv/aids patients on highly active antiretro viral therapy: a review of prevalence. int. j. curr. res. chem. pharm. sci. 2019;6(12):458.doi: 10.22192/ijcrcps.2019.06.12.004 https://650aba1582f01628f0335795/adverse-drug-reactions-inhiv-aids-patients-on-highly-active-antiretro-viral-therapy-areview-of-prevalence.pdf . 49. obeagu ei, scott gy, amekpor f, obeagu gu. implications of cd4/cd8 ratios in human immunodeficiency virus infections. int. j. curr. res. med. sci. 2023;9(2):6-13.doi: https://doi.org/10.22192/ijcrms.2023.09.02.002 https://645a4a462edb8e5f094ad37c/implications-of-cd4-cd8ratios-in-human-immunodeficiency-virus-infections.pdf . 50. obeagu ei, ochei kc, okeke ei, anode ac. assessment of the level of haemoglobin and erythropoietin in persons living with hiv in umuahia. int. j. curr. res. med. sci. 2016;2(4):29-33. https://5711c47508aeebe07c02496b/assessment-of-the-levelof-haemoglobin-and-erythropoietin-in-persons-living-with-hivin-umuahia.pdf . 51. ifeanyi oe, obeagu gu. the values of cd4 count, among hiv positive patients in fmc owerri. int. j. curr. microbiol. app. sci. 2015;4(4):906-910. https://www.academia.edu/download/38320134/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf . 52. obeagu ei, okeke ei, anonde andrew c. evaluation of haemoglobin and iron profile study among persons living with hiv in umuahia, abia state, nigeria. int. j. curr. res. biol. med. 2016;1(2):1-5. 53. alum eu, ugwu op, obeagu ei, okon mb. curtailing hiv/aids spread: impact of religious leaders. newport international journal of research in medical sciences (nijrms). 2023;3(2):2831. 54. obeagu ei, obeagu gu, paul-chima uo. stigma associated with hiv. aids: a review. newport international journal of public health and pharmacy (nijpp). 2023;3(2):64-67. 55. alum eu, obeagu ei, ugwu op, aja pm, okon mb. hiv infection and cardiovascular diseases: the obnoxious duos. newport international journal of research in medical sciences (nijrms). 2023;3(2):95-99. 56. ibebuike je, nwokike gi, nwosu dc, obeagu ei. a retrospective study on human immune deficiency virus among pregnant women attending antenatal clinic in imo state university teaching hospital. international journal of medical science and dental research, 2018; 1 (2):08-14. https://www.ijmsdr.org/published%20paper/li1i2/a%20retros pective%20study%20on%20human%20immune%20deficiency %20virus%20among%20pregnant%20women%20attending%2 0antenatal%20clinic%20in%20imo%20state%20university%20 teaching%20hospital.pdf . 57. obeagu ei, obarezi tn, omeh yn, okoro nk, eze ob. assessment of some haematological and biochemical parametrs in hiv patients before receiving treatment in aba, abia state, nigeria. res j pharma biol chem sci. 2014; 5:825-830. 58. obeagu ei, obarezi tn, ogbuabor bn, anaebo qb, eze gc. pattern of total white blood cell and differential count values in hiv positive patients receiving treatment in federal teaching hospital abakaliki, ebonyi state, nigeria. international journal of life science, biotechnology and pharama research. 2014; 391:186-9. 59. obeagu ei. a review of challenges and coping strategies faced by hiv/aids discordant couples. madonna university journal of medicine and health sciences. 2023; 3 (1): 7-12. 60. oloro oh, obeagu ei. a systematic review on some coagulation profile in hiv infection. international journal of innovative and applied research. 2022;10(5):1-1. 61. nwosu dc, obeagu ei, nkwuocha bc, nwanna ca, nwanjo hu, amadike jn, ezemma mc, okpomeshine ea, ozims sj, agu gc. alterations in superoxide dismutiase, vitamins c and e in hiv infected children in umuahia, abia state. international journal of advanced research in biological sciences. 2015;2(11):268-271. 62. obeagu ei, malot s, obeagu gu, ugwu op. hiv resistance in patients with sickle cell anaemia. newport international journal of scientific and experimental sciences (nijses). 2023;3(2):56-59. 63. ifeanyi oe, uzoma og, stella ei, chinedum ok, abum sc. vitamin d and insulin resistance in hiv sero positive individuals in umudike. int. j. curr. res. med. sci. 2018;4(2):104-108. 64. ifeanyi oe, leticia oi, nwosu d, chinedum ok. a review on blood borne viral infections: universal precautions. int. j. adv. res. biol. sci. 2018;5(6):60-66. 65. nwovu ai, ifeanyi oe, uzoma og, nwebonyi ns. occurrence of some blood borne viral infection and adherence to universal precautions among laboratory staff in federal teaching hospital abakaliki ebonyi state. arch blood transfus disord. 2018;1(2). 66. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75. 67. offie dc, obeagu ei, akueshi c, njab je, ekanem ee, dike pn, oguh dn. facilitators and barriers to retention in hiv care among hiv infected msm attending community health center yaba, lagos https://doi.org/10.9734/jpri/2021/v33i47a32992 http://research.sdpublishers.net/id/eprint/2819/ https://doi.org/10.9734/ajrid/2022/v10i430294 https://doi.org/10.9734/jpri/2021/v33i57a34007 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/75 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/75 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/69 https://5a4fd0500f7e9bbc10526b38/biochemical-alterations-in-adult-hiv-patients-on-antiretrqviral-therapy.pdf https://5a4fd0500f7e9bbc10526b38/biochemical-alterations-in-adult-hiv-patients-on-antiretrqviral-therapy.pdf https://5a4fd0500f7e9bbc10526b38/biochemical-alterations-in-adult-hiv-patients-on-antiretrqviral-therapy.pdf https://650aba1582f01628f0335795/adverse-drug-reactions-in-hiv-aids-patients-on-highly-active-antiretro-viral-therapy-a-review-of-prevalence.pdf https://650aba1582f01628f0335795/adverse-drug-reactions-in-hiv-aids-patients-on-highly-active-antiretro-viral-therapy-a-review-of-prevalence.pdf https://650aba1582f01628f0335795/adverse-drug-reactions-in-hiv-aids-patients-on-highly-active-antiretro-viral-therapy-a-review-of-prevalence.pdf https://doi.org/10.22192/ijcrms.2023.09.02.002 https://645a4a462edb8e5f094ad37c/implications-of-cd4-cd8-ratios-in-human-immunodeficiency-virus-infections.pdf https://645a4a462edb8e5f094ad37c/implications-of-cd4-cd8-ratios-in-human-immunodeficiency-virus-infections.pdf https://5711c47508aeebe07c02496b/assessment-of-the-level-of-haemoglobin-and-erythropoietin-in-persons-living-with-hiv-in-umuahia.pdf https://5711c47508aeebe07c02496b/assessment-of-the-level-of-haemoglobin-and-erythropoietin-in-persons-living-with-hiv-in-umuahia.pdf https://5711c47508aeebe07c02496b/assessment-of-the-level-of-haemoglobin-and-erythropoietin-in-persons-living-with-hiv-in-umuahia.pdf https://www.academia.edu/download/38320134/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf https://www.academia.edu/download/38320134/obeagu_emmanuel_ifeanyi_and_obeagu__getrude_uzoma.emma2.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf https://www.ijmsdr.org/published%20paper/li1i2/a%20retrospective%20study%20on%20human%20immune%20deficiency%20virus%20among%20pregnant%20women%20attending%20antenatal%20clinic%20in%20imo%20state%20university%20teaching%20hospital.pdf obeagu et al asian journal of dental and health sciences. 2024; 4(1):38-44 [44] ajdhs.com nigeria. journal of pharmaceutical research international. 2021;33(52b):10-19. https://doi.org/10.9734/jpri/2021/v33i52b33593 68. obeagu ei, obeagu gu, ede mo, odo eo, buhari ha. translation of hiv/aids knowledge into behavior change among secondary school adolescents in uganda: a review. medicine (baltimore). 2023;102(49): e36599. doi: https://doi.org/10.1097/md.0000000000036599 . pmid: 38065920; pmcid: pmc10713174. 69. mbithi g, abubakar a. assessing and supporting mental health outcomes among adolescents in urban informal settlements in kenya and uganda. european psychiatry. 2023;66(s1): s988-989. https://doi.org/10.1192/j.eurpsy.2023.2101 pmcid:pmc10478869 70. anyiam af, arinze-anyiam oc, irondi ea, obeagu ei. distribution of abo and rhesus blood grouping with hiv infection among blood donors in ekiti state nigeria. medicine (baltimore). 2023;102(47): e36342. https://doi.org/10.1097/md.0000000000036342 pmid:38013335 pmcid:pmc10681551 71. echefu sn, udosen je, akwiwu ec, akpotuzor jo, obeagu ei. effect of dolutegravir regimen against other regimens on some hematological parameters, cd4 count and viral load of people living with hiv infection in south eastern nigeria. medicine (baltimore). 2023;102(47): e35910. https://doi.org/10.1097/md.0000000000035910 pmid:38013350 pmcid:pmc10681510 72. opeyemi aa, obeagu ei. regulations of malaria in children with human immunodeficiency virus infection: a review. medicine (baltimore). 2023;102(46): e36166. pmid: 37986340; pmcid: pmc10659731. https://doi.org/10.1097/md.0000000000036166 pmid:37986340 pmcid:pmc10659731 73. alum eu, obeagu ei, ugwu opc, samson ao, adepoju ao, amusa mo. inclusion of nutritional counseling and mental health services in hiv/aids management: a paradigm shift. medicine (baltimore). 2023;102(41): e35673. https://doi.org/10.1097/md.0000000000035673 pmid:37832059 pmcid:pmc10578718 74. aizaz m, abbas fa, abbas a, tabassum s, obeagu ei. alarming rise in hiv cases in pakistan: challenges and future recommendations at hand. health sci rep. 2023;6(8): e1450. https://doi.org/10.1002/hsr2.1450 pmid:37520460 pmcid:pmc10375546 75. moran l, fuller sm, joshi s, outram s, koester ka, steward wt, arnold ea. "am i going to have to run to get out of this place?" a qualitative study exploring hiv clinical and service provider experiences from california regions heavily impacted by climate disaster. plos climate. 2023;2(10): e0000269. https://doi.org/10.1371/journal.pclm.0000269 76. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 77. obeagu ei, obeagu gu. human immunodeficiency virus and tuberculosis infection: a review of prevalence of associated factors. int. j. adv. multidiscip. res. 2023;10(10):56-62. 78. obeagu ei, malot s, obeagu gu, ugwu op. hiv resistance in patients with sickle cell anaemia. newport international journal of scientific and experimental sciences (nijses). 2023;3(2):56-59. 79. alum eu, ugwu op, obeagu ei, aja pm, okon mb, uti de. reducing hiv infection rate in women: a catalyst to reducing hiv infection pervasiveness in africa. international journal of innovative and applied research. 2023;11(10):01-6. https://doi.org/10.34172/ajmb.2023.2421 80. hess db, bitterman a. community support organizations in gay neighborhoods: assessing engagement during the covid-19 pandemic. urban planning. 2023;8(2):235-48. https://doi.org/10.17645/up.v8i2.6404 81. bouey jz, han j, liu y, vuckovic m, zhu k, zhou k, su y. a case study of hiv/aids services from community-based organizations during covid-19 lockdown in china. bmc health services research. 2023;23(1):1-11. https://doi.org/10.1186/s12913023-09271-4 pmid:36973805 pmcid:pmc10042409 82. bouchard jp, pretorius tb, kramers-olen al, padmanabhanunni a, stiegler n. global warming and psychotraumatology of natural disasters: the case of the deadly rains and floods of april 2022 in south africa. inannales médico-psychologiques, revue psychiatrique 2023; 181(3):234-239. elsevier masson. https://doi.org/10.1016/j.amp.2022.07.004 83. parcesepe am, filiatreau lm, ebasone pv, dzudie a, pence bw, wainberg m, yotebieng m, anastos k, pefura-yone e, nsame d, ajeh r. prevalence of potentially traumatic events and symptoms of depression, anxiety, hazardous alcohol use, and post-traumatic stress disorder among people with hiv initiating hiv care in cameroon. bmc psychiatry. 2023;23(1):1-11. https://doi.org/10.1186/s12888-023-04630-1 pmid:36894918 pmcid:pmc9996899 https://doi.org/10.9734/jpri/2021/v33i52b33593 https://doi.org/10.1097/md.0000000000036599 https://doi.org/10.1192/j.eurpsy.2023.2101 https://doi.org/10.1097/md.0000000000036342 https://doi.org/10.1097/md.0000000000035910 https://doi.org/10.1097/md.0000000000036166 https://doi.org/10.1097/md.0000000000035673 https://doi.org/10.1002/hsr2.1450 https://doi.org/10.1371/journal.pclm.0000269 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.34172/ajmb.2023.2421 https://doi.org/10.17645/up.v8i2.6404 https://doi.org/10.1186/s12913-023-09271-4 https://doi.org/10.1186/s12913-023-09271-4 https://doi.org/10.1016/j.amp.2022.07.004 https://doi.org/10.1186/s12888-023-04630-1 emna abid et al asian journal of dental and health sciences. 2024; 4(1):60-64 [60] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the keys to succeed an immediate maxillary complete denture : a case report emna abid, amel labidi, sana bekri *, sameh rzigui, hiba triki, lamia mansour department of removable prosthodontics, faculty of dental medicine, university of monastir, monastir, tunisia abcd f laboratory of biological, clinical and dento-facial approach, university of monastir, monastir, tunisia article info: _____________________________________________ article history: received 05 december 2023 reviewed 28 february 2024 accepted 16 april 2024 published 15 may 2024 _____________________________________________ cite this article as: abid e, labidi a, bekri s, rzigui s, triki h, mansour l, the keys to succeed an immediate maxillary complete denture: a case report, asian journal of dental and health sciences. 2024; 4(1):60-64 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.73 abstract _________________________________________________________________________________________________________________ the transition from partial to total edentulism is a delicate situation for certain patients that involves the practitioner in the management process. the immediate complete prosthesis is therefore an effective solution capable of removing the constraint of appearing totally edentulous by delivering a prosthesis on the day of extraction of the remaining teeth. a partially edentulous patient consulted us with the typical indication for this immediate prosthesis with four remaining maxillary incisors and a major aesthetic concern. the prosthetic production chain is particular concerning firstly the presence of a bilateral terminal edentulism, the confection of the individual impression tray, the orientation of the anterior occlusion plane while anterior teeth remaining on the arch, the fitting of the prosthetic anterior teeth following the working model rectification as well as the surgical phase on the day of denture insertion. surgical guide would be very useful when bone regularization is imperative. the postprosthetic follow-up phase is important in order to optimize tissue integration of the prosthesis, while taking into consideration the rebasing that is often unavoidable after a few months. blood problems, a protracted healing process, significant bone loss, mental illness, or emotional problems contraindicate this type of prosthesis. the dentist and the laboratory technician are invited to master the clinical and laboratory stages of this prosthesis in order to appropriate the result aesthetically and functionally. keywords: edentulism; aesthetics, immediate prosthesis, anterior teeth, occlusion plane, surgical guide, individual impression tray *address for correspondence: sana bekri, department of removable prosthodontics, faculty of dental medicine, university of monastir, monastir, tunisia. abcd f laboratory of biological, clinical and dento-facial approach, university of monastir, monastir, tunisia introduction an immediate complete denture is a dental prosthesis constructed to replace the lost dentition and associated structures of the maxillae and/or mandible and inserted immediately following removal of the remaining natural teeth 1. thanks to clinical practice and the number of cases treated, we can conclude that this method is a reliable therapy that enables the transition from partial to full edentulism 2. dentists are frequently expected to create immediate dentures, and patients are requesting them more often for psychological and aesthetic purposes. the appropriate indication and careful execution of clinical and laboratory fabrication are essential to the success of immediate dentures. while some patients may experience significant challenges during the first year of wearing dentures immediately, most patients report general satisfaction 3,4. the aim of this article is to expose, through a clinical case, the particularities of the technical and clinical realization in order to obtain an immediate prosthesis that is well adapted and satisfying for both the patient and the practitioner. observation a 52-year-old patient with arhythmia consulted us for aesthetic and functional prosthetic rehabilitation. the dento periodontal examination showed moderate mobility of the four remaining upper incisors on the maxillary arch, while the lower teeth were well implanted. examination of the osteomucosal surfaces revealed a moderately deep palate, class i tuberosities and well-formed ridges. given the patient's aesthetic concerns, the prosthetic decision was to perform an immediate complete denture in the maxilla and a partial removable denture in the mandible. primary impressions were taken using an irreversible hydrocolloid (algin major alginate, major, italy) to make two individual impression trays for the secondary impressions (fig.1) open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.73 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.73&amp;domain=pdf emna abid et al asian journal of dental and health sciences. 2024; 4(1):60-64 [61] ajdhs.com figure 1: maxillary and mandibular primary impressions the limit of the maxillary individual impression tray was located 2mm from the vestibule floor, even with regard to the remaining teeth. the maxillary peripheral seal was made with kerr® thermoplastic paste in the posterior and lateral regions, while the anterior region was realized with an elastomer that is polyether (fig.2). impressions of both arches were then taken using mediumviscosity polysulfide in the maxilla (fig.3). two occlusion recording base were prepared in the laboratory, then a recording of the intermaxillary relation was made in centric relation and at the correct occlusal vertical dimension (ovd) (fig.4). figure 2: maxillary individual impression tray with anterior joint made of polyether figure 3 : maxillary and mandibular working impressions figure 4: recording of the intermaxillary relation the orientation of the anterior occlusal plane was made according to the level of the remaining teeth, given that their positions were correct respecting aesthetic and phonetic imperatives. the posterior occlusal plane was positioned parallel to the camper plane using the fox plane (fig.5). a wax try-in was performed allowing to confirm the ovd and molar occlusion (fig.6). emna abid et al asian journal of dental and health sciences. 2024; 4(1):60-64 [62] ajdhs.com figure 5: orientation of the anterior occlusal plane figure 6: the wax-up try-in the anterior maxillary prosthetic teeth were fitted in the position of the remaining plaster teeth, using a silicone key and choosing a prosthetic tooth dimension and shape close to that of the natural teeth as well as waxing of the stabilizing polished surfaces (fig.7). the prosthesis was then polymerized with heat-cured acrylic resin in the laboratory and properly polished. tooth extraction was then initiated (fig.8) then the prosthesis was tried in and the static occlusion was adjusted using an articulating paper. figure 7: fitting the anterior maxillary prosthetic teeth using a silicone key figure 8: teeth extraction a tissue conditioner was applied to the prosthesis to optimize healing (fig.9). after delivery of the immediate complete prosthesis (fig.10), the patient was instructed not to remove the prosthesis for 24 hours and asked to return for a follow-up appointment the following day. signs of soft tissue trauma due to the prosthesis were checked and dynamic balancing according to the balanced occlusion concept was performed. instructions for insertion and removal of the prosthesis, as well as instructions for hygiene of the prosthesis, were given. emna abid et al asian journal of dental and health sciences. 2024; 4(1):60-64 [63] ajdhs.com figure 9: relining with tissue conditioner figure 10: final denture control and follow-up appointments were scheduled at 5 days, 10 days and 20 days from the day of prosthesis delivery. these close monitoring sessions allow the patient to feel secure and well cared for, ensuring better psychosomatic integration of this new prosthesis and strengthening the trusting relationship between patient and practitioner. these sessions consist of listening to the patient's complaints to relieve them, replacing the tissue conditioner every week, and motivating the patient in terms of hygiene and maintenance. then monthly appointments will be sufficient until 6 months when the prosthesis may become unstable following final bone healing thus requiring relining. discussion: the indication for an immediate prosthesis depends essentially on the patient's social and psychological conditions. this type of prosthesis is particularly recommended for patients who are embarrassed by appearing edentulous, for patients who work in a profession that requires contact with the public, or in an emergency before a trip or vacation. however, there are always contraindications, such as patients suffering from blood disorders, prolonged healing, severe bone loss, emotional disorders or mental incapacity not allowing them to understand the purpose of the treatment 5,1. the design of an immediate complete denture involves a chain of clinical and laboratory steps that is unique and often delicate. examination of the remaining teeth in both arches is important for planning the prosthetic sequence. only the anterior maxillary teeth will be preserved, so the posterior ridges must be edentulous and healed to ensure stable osteomucosal support for the occlusion recording bases in the working phase. the maxillary arch should therefore be prepared in kennedey applegate class i 6. premolars are preferentially retained if they have an antagonist to serve as a reference for the ovd if this is conserved 4. significant vestibuloversion of the maxillary incisors indicates the need for a fenestrated individual impression tray to facilitate insertion, as its boundary facing the remaining teeth must cross the convexity of the alveolar process to be located 2 mm from the vestibular floor. in addition, fenestration minimizes the risk of plaster teeth fracture during demolding of the impression 6,7. advanced mobility of the remaining teeth must be taken into account to prevent their accidental extraction when the impression is disinserted, so filling the interdental spaces with soft wax or high viscosity silicone or even composite resin helps to avoid this problem 5. for the lower arch, we need to detect the presence of egressions in order to correct them and re-establish a correct occlusal plane. thanks to its elasticity and rigidity after setting, the use of polyether for the anterior joint, prevents damage to this region and easy removal of the working impression, while ensuring good registration of the joint, unlike kerr thermoplastic paste, which can break when crossing the convexity of the alveolar process 2 ,6. aesthetic and phonetic imperatives dictate the orientation of the anterior occlusal plane: the edge of the maxillary incisors should be 2 mm below the rest lip position, parallel to the bi pupillary plane touching the wet line of the lower lip for the “f” and “v” sounds. if the teeth are extruded, the correct level can be marked on the working model. if the teeth are short, we can make an anterior supra-dental wax margin to orientate the occlusal plane correctly. interincisal point must coincide with the median sagittal plane (msp) 2. if it is shifted, transfer the correct position of the msp to the working model. wax-up of posterior prosthetic teeth validates intermaxillary relationship and ovd. the anterior maxillary teeth can be fitted according to the references indicated by the practitioner during the bite registration phase, choosing a suitable shape, color and dimensions. regularization of the extraction sites can be combined with teeth extraction, previously simulated by rectifying the working cast. a transparent resin surgical template derived from the polymerized prosthesis is used to guide the surgical phase by visualizing compression zones. “occlusal” guides improve surgical corrections, as they confirm perfect prosthesis placement thanks to the prosthetic occlusion obtained by posterior tooth sectors 6,2. a comparative study by michael et al. showed that simple extraction of the tooth is to be preferred to any other surgical technique for immediate prostheses guaranteeing better stability of bone resoption, and that when alveoloplasty is required for aesthetic reasons, intraseptal alveoloplasty is preferable to alveoloplasty of the vestibular cortical bone 8. wearing the prosthesis immediately after extraction ensures rigorous haemostasis and improved postoperative follow-up. the denture serves as a bandage to help assist bleeding, to prevent damage from the tongue, food, or teeth. this prosthesis guides and accelerates healing by protecting the blood clot, and provides immediate esthetics, enabling the patient to carry out social and professional activities without discomfort, as well as restoring masticatory and phonetic function 5,4. patients should be instructed after healing that the dentures should be removed at least eight of every twenty-four hours to allow the tissues to rest 1. check-ups should be made weekly for the first month, followed by visits at 3 months, 6 months and one year 6. the inevitable resorption of the alveolar ridge may influence prosthetic retention and stability, so relining after six months of prosthesis wear is recommended 8. emna abid et al asian journal of dental and health sciences. 2024; 4(1):60-64 [64] ajdhs.com conclusion: the immediate total prosthesis is the treatment of choice for the transition from partial to total edentulism especially when the anterior teeth are remaining. this type of rehabilitation, although challenging for the practitioner, will always remain in force and occupy a crucial position in our field. thus, it is essential to master all the stages of its clinical and laboratory execution. references 1. heartwell cm jr, salisbury fw. immediate complete dentures: an evaluation. j prosthet dent. 1965 ;15:615-24. https://doi.org/10.1016/0022-3913(65)90031-4 pmid:14313308 2. benoit h, michel po, prothèse complète immédiate d'usage les cahiers de prothèse n°111. 3. jonkman, r. e. g., waas, m. a. j., kalk, w. satisfaction with complete immediate dentures and complete immediate overdentures. a 1year survey. journal of oral rehabilitation,1995; 22(11): 791-796. https://doi.org/10.1111/j.1365-2842.1995.tb00224.x pmid:8558350 4. sonja k, josip p, tomislav b, robert c. immediate complete denture, acta stomatol croat.2001; 35:281-5. 5. yeung c, leung kcm, yu oy, lam wyh, wong awy, chu ch. prosthodontic rehabilitation and follow-up using maxillary complete conventional immediate denture. clin cosmet investig dent. 2020, 23(12):437-445. https://doi.org/10.2147/ccide.s271304 pmid:33122954 pmcid:pmc7591000 6. bagui m., fajri l., belhaj k, el mohtarime b., merzouk n. the immediate complete prosthesis of custom: difficulties and management . aos;2018:1-6. 7. ayako i, corinne t, pierre m, olivier e. le porte-empreinte individuel fenêtré pour l'empreinte secondaire en prothèse amovible complète immédiate les cahiers de prothèse. 2005,n°129. 8. michael cg, barsoum wm. comparing ridge resorption with various surgical techniques in immediate dentures.j prosthet dent.1976;35(2):142-55. https://doi.org/10.1016/00223913(76)90273-0 pmid:1061808 https://doi.org/10.1016/0022-3913(65)90031-4 https://doi.org/10.1111/j.1365-2842.1995.tb00224.x https://doi.org/10.2147/ccide.s271304 https://doi.org/10.1016/0022-3913(76)90273-0 https://doi.org/10.1016/0022-3913(76)90273-0 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [57] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited supporting elderly populations with tailored hiv prevention messages emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 24 sep 2024 reviewed 29 oct 2024 accepted 19 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, supporting elderly populations with tailored hiv prevention messages, asian journal of dental and health sciences. 2024; 4(3):57-62 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.103 abstract _________________________________________________________________________________________________________________ as global life expectancy increases, hiv prevention strategies must adapt to address the unique needs of elderly populations, who are often overlooked in traditional hiv prevention efforts. while hiv is typically associated with younger adults, the elderly are increasingly at risk due to factors such as unprotected sex, misconceptions about hiv transmission, and reduced awareness of prevention methods. this review explores the need for tailored hiv prevention messages for older adults, emphasizing the importance of addressing barriers such as age-related stigma, healthcare access, and a lack of hiv-related education. by considering these factors, healthcare providers and public health campaigns can better support elderly individuals in preventing hiv and improving overall health outcomes. older adults face unique challenges in hiv prevention, such as misconceptions about hiv risk, physical changes related to aging, and the stigma surrounding both aging and sexual health. many elderly individuals may not perceive themselves as at risk for hiv, leading to a lack of preventive measures like condom use or hiv testing. additionally, healthcare systems may not prioritize hiv prevention for older adults, leading to underreporting of sexual activity and missed opportunities for education and testing. to address these challenges, it is essential to create hiv prevention messages that are culturally sensitive, clear, and specifically designed for the elderly population, encouraging open dialogue about sexual health and hiv prevention. keywords: hiv, elderly populations, tailored messages, healthcare strategies, aging and hiv *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv prevention has traditionally focused on younger populations, who are often considered the most at risk for infection due to behaviors like unprotected sex, drug use, and other high-risk activities. however, with the global increase in life expectancy and an aging population, the issue of hiv prevention for elderly individuals is becoming an important public health concern. as the elderly population continues to grow, it is crucial to acknowledge that they, too, are at risk for hiv, particularly as many of them remain sexually active well into later years. despite this, hiv prevention messages are often not targeted to the elderly, and many older adults remain unaware of their vulnerability to hiv, which puts them at risk for late-stage diagnosis and poor health outcomes.1-2 one of the main challenges in addressing hiv prevention in older adults is the prevalent misconception that hiv is a disease of younger people. this perception, combined with agerelated changes such as reduced sexual activity or changes in sexual behavior, often leads to older individuals overlooking the importance of safe sexual practices. additionally, older adults are less likely to seek out hiv testing or discuss sexual health with healthcare providers due to the stigma surrounding both aging and hiv. this lack of awareness, coupled with a failure to discuss sexual health openly, often results in a significant gap in hiv prevention knowledge and resources for the elderly.3-4 the healthcare needs of older adults are also unique, as aging is often associated with a decline in immune function, comorbidities, and the need for multiple medications. these health issues can complicate hiv diagnosis and treatment in older individuals. furthermore, older adults may face barriers to accessing hiv prevention services due to mobility issues, financial constraints, or a lack of tailored healthcare infrastructure. as a result, older populations often do not receive the same level of hiv-related care and prevention support as younger individuals. this disparity in care and awareness exacerbates the risks associated with hiv for older adults, making targeted prevention strategies even more essential.5 tailored hiv prevention messages for elderly populations need to address these unique challenges by focusing on clear, age-appropriate information. such messages should be designed to inform older individuals about their continued risk of hiv, emphasizing that hiv is not just a disease for younger generations and that hiv prevention, such as condom use, hiv testing, and pre-exposure prophylaxis (prep), open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.103 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.103&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [58] ajdhs.com remains relevant for individuals at any age. additionally, these messages should address common misconceptions about hiv, such as the belief that older individuals cannot transmit or acquire the virus. by countering myths and educating older adults about hiv risk factors, prevention, and testing, healthcare providers can help empower this group to make informed decisions about their health.6-7 integrating hiv prevention education into senior healthcare settings, such as geriatric clinics, nursing homes, and senior community centers, is crucial for reaching elderly individuals who may not actively seek out this information on their own. healthcare providers must be trained to engage older adults in conversations about sexual health, including the risks of hiv and the benefits of regular testing. these discussions should be framed in a way that acknowledges the elderly person’s dignity and respects their autonomy, ensuring that they feel comfortable seeking hiv-related care and prevention services. health professionals can also play an important role in identifying elderly individuals at higher risk for hiv and providing them with the necessary resources and referrals to prevent and manage the disease.8-9 understanding hiv risk in the elderly while hiv is commonly associated with younger, sexually active individuals, older adults are increasingly at risk for hiv infection. hiv does not discriminate by age, and the elderly are just as susceptible to the virus as younger populations, although they may face unique challenges in recognizing and mitigating their risk. one of the primary factors contributing to hiv risk in older adults is the assumption that sexual activity diminishes with age. although sexual activity does decline for some elderly individuals, many remain sexually active well into their later years. a study by the national institutes of health found that nearly 40% of men and 20% of women aged 60–69 were sexually active, and this trend extends to individuals over 70. unfortunately, this often leads to a lack of protective behaviors, such as condom use, particularly if there is a lack of awareness regarding the continued risk of hiv.10-11 in addition to sexual activity, several physiological factors associated with aging increase vulnerability to hiv. for women, vaginal dryness and thinning of the vaginal walls can create micro-tears during intercourse, which can facilitate the transmission of hiv. similarly, erectile dysfunction in older men may result in the use of medications such as sildenafil (viagra), which, if not discussed with a healthcare provider, can increase the risk of engaging in unprotected sex with new or multiple partners. for both sexes, immune function declines with age, making the elderly more susceptible to infections, including hiv. the immune system of older adults is less efficient at combating viral infections, which not only increases the risk of acquiring hiv but also makes managing the virus more complicated once it is contracted.12-13 another significant factor is the lack of hiv awareness among older adults. many elderly individuals may not perceive themselves as being at risk for hiv, often assuming that hiv is a disease of the younger generation. the misconception that hiv only affects specific populations or behaviors—such as men who have sex with men or people who inject drugs—results in many elderly individuals neglecting preventive measures like regular hiv testing or safe sex practices. this lack of awareness and understanding about hiv leads to delayed diagnoses, often when the virus has already progressed to aids. moreover, many older adults may never discuss their sexual health with healthcare providers, due to generational taboos or discomfort with discussing intimate topics in later life. this contributes to the underreporting of sexual activity among older individuals, further reducing opportunities for appropriate hiv prevention education and testing.1415 additionally, older adults face social and structural barriers that can exacerbate their risk of hiv. in many cultures, sexual activity in later life is stigmatized, making it difficult for older individuals to openly discuss their sexual health or seek information about hiv prevention. this stigma often leads to feelings of shame and isolation, which can prevent elderly individuals from engaging in preventive behaviors, such as discussing hiv testing with a doctor. social isolation, particularly among widows, divorced individuals, or those without a close network of family or friends, can also increase the likelihood of engaging in risky sexual behaviors, as these individuals may be less likely to have conversations about sexual health or hiv prevention.16 barriers to hiv prevention in older adults despite the increasing recognition of hiv risks among older adults, several barriers continue to prevent effective hiv prevention in this population. one of the primary challenges is the misconception that older adults are not at risk for hiv. many elderly individuals, as well as healthcare providers, assume that sexual activity declines significantly with age, and therefore, hiv prevention is not a priority for older individuals. this assumption results in a lack of emphasis on sexual health and hiv education in healthcare settings for seniors. as a result, older adults may not engage in preventive practices, such as condom use or hiv testing, because they do not perceive themselves as being at risk for the virus. this lack of awareness, combined with the absence of targeted public health messages for older adults, leaves many vulnerable to hiv.17-18 another significant barrier to hiv prevention in older adults is the stigma associated with both aging and sexual health. in many cultures, there is a strong societal belief that older individuals are no longer sexually active, and discussions about sexuality in later life are often considered taboo. this social stigma can prevent older adults from seeking information or assistance regarding hiv prevention. for example, older individuals may feel embarrassed or ashamed to ask their healthcare providers about safe sexual practices or request hiv testing. this reluctance to openly discuss sexual health further exacerbates the risk of undiagnosed hiv, as many elderly individuals do not receive the education or resources they need to protect themselves.19 age-related health changes and coexisting medical conditions also present barriers to effective hiv emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [59] ajdhs.com prevention. older adults often experience declines in sexual function, such as erectile dysfunction in men and vaginal dryness in women, which can make sexual activity less frequent or more difficult. however, for those who remain sexually active, these physical changes can increase the risk of hiv transmission due to microtears or other issues that facilitate viral entry. additionally, older adults may have more complex health conditions that require multiple medications, potentially leading to drug interactions or decreased condom use due to concerns about the side effects of medications like erectile dysfunction drugs. the complexity of managing chronic conditions alongside hiv prevention can be overwhelming for older individuals, particularly when they are not wellinformed about the need for continued safe sexual practices.20 limited access to healthcare and hiv-related services also contributes to barriers in hiv prevention for older adults. many elderly individuals face difficulties accessing healthcare due to factors such as mobility issues, financial constraints, and geographic location. this can be particularly challenging for those living in rural or underserved areas, where healthcare facilities may not be equipped to address the specific needs of older adults regarding sexual health and hiv prevention. additionally, healthcare providers may not routinely include hiv screening as part of general care for older individuals, further compounding the problem of missed opportunities for hiv prevention and early detection. without regular screenings or hiv-related counseling, older adults are less likely to receive appropriate prevention measures or guidance about the importance of testing and safe sexual practices.21 a lack of targeted prevention programs also hinders effective hiv prevention efforts for older populations. most hiv awareness campaigns focus on younger adults or at-risk groups, neglecting the specific needs of older adults. the absence of age-appropriate hiv education materials, programs, and services results in older individuals being left out of the conversation about hiv prevention. public health campaigns rarely address the fact that the elderly are just as vulnerable to hiv as younger individuals, leading to a gap in hiv prevention knowledge. tailored interventions that address the unique challenges faced by older adults, such as their specific sexual health concerns and risk factors, are crucial in ensuring that hiv prevention strategies are inclusive and effective across all age groups.22 finally, psychological and emotional factors can also serve as barriers to hiv prevention in older adults. many elderly individuals may feel that hiv is something that only affects younger people or that it is too late to make a difference in their sexual health. this mindset can result in a sense of resignation, where older individuals may not take hiv prevention seriously. additionally, feelings of loneliness and depression, common in older populations, can contribute to risky sexual behavior, particularly among those who have lost spouses or partners. social isolation can lead to unhealthy relationships or casual sex without protection, increasing the risk of hiv transmission. addressing these emotional and psychological barriers is an essential component of hiv prevention strategies for older adults, ensuring that they feel empowered and supported in making informed decisions about their health.23 tailoring hiv prevention messages for the elderly tailoring hiv prevention messages for elderly populations is essential to ensure that older adults understand their risks and take the necessary steps to protect themselves. as this demographic often faces unique barriers to hiv prevention, public health messages must be adapted to address these challenges in ways that resonate with their experiences, concerns, and perceptions. key elements of successful hiv prevention messaging for older adults include clear communication, culturally sensitive approaches, and emphasizing practical, age-appropriate strategies to reduce risk.24 first and foremost, hiv prevention messages for the elderly need to challenge the common misconception that hiv is a disease solely affecting younger populations. public health campaigns should emphasize that sexual activity in later life is common, and older adults remain vulnerable to hiv, regardless of age. messaging should highlight the fact that hiv can be contracted at any age, particularly in the context of unprotected sex, multiple sexual partners, or coexisting health conditions that may make the elderly more susceptible to infections. these messages should be simple, straightforward, and free from medical jargon, as older adults may not always be familiar with the latest terminology related to hiv or sexual health. clear, easily understood messages about the importance of hiv testing, condom use, and pre-exposure prophylaxis (prep) can help break through misconceptions and encourage older adults to take preventative measures.25 another important aspect of tailoring hiv prevention messages for the elderly is addressing the social stigma surrounding aging and sexual health. many older adults may feel uncomfortable discussing their sexual activity, or they may assume that such conversations are irrelevant or inappropriate for their age group. hiv prevention messages should aim to normalize sexual health discussions for people of all ages, framing these conversations as an important part of maintaining overall health and well-being. by creating a supportive, non-judgmental tone in these messages, public health campaigns can encourage older adults to engage in conversations with healthcare providers about their sexual health and hiv risk. these messages should emphasize the fact that sexual health is a lifelong concern and that taking steps to protect oneself from hiv is as important in later life as it is during youth.26 culturally sensitive messaging is also crucial when targeting older adults, as different cultures may have varying attitudes towards aging, sexual health, and hiv. public health campaigns must be inclusive and take into account cultural norms, values, and potential barriers specific to different communities. for example, older adults from certain cultural backgrounds may face additional stigma or shame related to discussing sexual activity, especially for women. messages that are emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [60] ajdhs.com sensitive to these cultural nuances, and that respect the diverse identities and experiences within the elderly population, are more likely to resonate and be wellreceived. additionally, healthcare providers can play a key role in delivering these messages in a way that is personalized and culturally competent, ensuring that older adults feel understood and supported in their efforts to protect themselves from hiv.27 incorporating practical, age-appropriate strategies for hiv prevention is another key element of tailoring messages for the elderly. older adults may face physical, cognitive, or emotional barriers that affect their ability to access or adhere to hiv prevention methods. for example, individuals with mobility issues or cognitive decline may have difficulty using condoms or adhering to a daily medication regimen for prep. therefore, prevention messages should not only educate older adults about the risks of hiv but also provide practical advice on how to overcome these barriers. this might include suggesting alternative prevention options, such as discussing the benefits of hiv testing during routine medical visits, or promoting awareness of how medications may interact with hiv prevention strategies. additionally, healthcare providers should be equipped to offer practical support, such as helping older adults understand how to use condoms correctly or connecting them to community resources that facilitate access to hiv prevention services.28 finally, it is important to consider the mental and emotional health of older adults when developing hiv prevention messages. older individuals may experience isolation, depression, or loss of a spouse, which could influence their sexual behavior and decision-making. messaging should acknowledge the emotional aspects of aging, providing reassurance and emphasizing the importance of self-care and personal well-being. by integrating messages that promote a sense of empowerment and self-worth, public health campaigns can encourage older adults to take charge of their health, which includes preventing hiv and seeking the necessary care if they are at risk.29 integrating hiv prevention into healthcare and social support systems integrating hiv prevention into healthcare and social support systems is a vital step toward improving the overall health and well-being of older adults. healthcare systems, including primary care providers, specialists, and community health organizations, play a critical role in ensuring that hiv prevention is a routine part of care for elderly populations. by embedding hiv prevention within existing healthcare services and social support structures, older adults can receive more comprehensive, accessible, and personalized care. this approach requires coordination between healthcare professionals, public health programs, and community organizations to ensure that prevention efforts are both effective and sustainable.30 one key aspect of integrating hiv prevention into healthcare systems is ensuring that hiv testing and prevention services are routinely offered to older adults during regular check-ups. many elderly individuals do not receive hiv testing as part of their routine care, largely because healthcare providers may not consider hiv a significant risk for older populations. by incorporating hiv risk assessments and testing as part of general health screenings, healthcare providers can identify at-risk individuals early and offer appropriate prevention interventions. this includes providing information about safe sexual practices, the use of condoms, and, where applicable, prep (preexposure prophylaxis) for those at higher risk of hiv exposure. training healthcare providers to recognize the risks of hiv in older adults and to offer counseling without stigma is essential in creating an environment where older adults feel comfortable discussing their sexual health.31 in addition to integrating hiv prevention into clinical care, social support systems, such as senior community centers, caregiving networks, and faith-based organizations, can help reinforce prevention messages and provide additional resources for older adults. social support systems are particularly important in reaching older individuals who may be socially isolated or face mobility challenges. these organizations can host educational programs, offer hiv testing in community settings, and provide a safe space for older adults to discuss their sexual health concerns. they can also connect individuals to resources such as peer support groups, where older adults can share experiences and gain support from others facing similar challenges. social networks play a significant role in influencing health behaviors, and by leveraging these systems, hiv prevention efforts can be extended to those who may not otherwise have access to healthcare services.32 moreover, integrating hiv prevention into healthcare and social support systems requires a comprehensive approach that addresses the broader social determinants of health. for older adults, factors such as economic insecurity, housing instability, and lack of access to transportation can significantly affect their ability to access hiv prevention and care services. public health programs should collaborate with social services to ensure that older adults have access to the resources they need to live healthy, fulfilling lives. for example, case managers and social workers can assist older adults in overcoming logistical barriers, such as arranging transportation to medical appointments or helping them apply for health insurance programs that cover hiv-related services. by addressing the social, economic, and environmental factors that influence health, hiv prevention can be better integrated into the broader support systems that older adults rely on.33 a critical component of successfully integrating hiv prevention into healthcare and social support systems is ensuring that services are tailored to the unique needs and preferences of older adults. this includes providing age-appropriate materials that address the specific risks older adults face, such as changes in sexual function, the impact of medications on sexual health, and the importance of regular hiv testing. public health campaigns must emphasize that hiv is not just a concern for younger populations, but also a risk for older individuals who may remain sexually active, particularly in the context of changing family structures, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [61] ajdhs.com divorce, or widowhood. healthcare providers and community-based organizations should offer personalized counseling that takes into account the individual’s health status, sexual history, and other factors that may influence their hiv risk.31 lastly, effective communication is essential in integrating hiv prevention into both healthcare and social support systems. it is important that messages are clear, accessible, and sensitive to the needs of older adults. this involves offering education in formats that are easy to understand, such as written materials in large print, video presentations with subtitles, and faceto-face counseling. additionally, it is crucial to engage older adults in discussions about hiv prevention in a way that respects their dignity and autonomy. the integration of hiv prevention into healthcare and social support systems should be seen as part of a broader effort to improve health equity, ensuring that older adults, regardless of their background, have access to the information and resources they need to protect their health.32-33 conclusion integrating hiv prevention into healthcare and social support systems for older adults is a critical step toward ensuring that this vulnerable population receives the care and resources needed to protect themselves from hiv. as older adults are often overlooked in hiv prevention efforts, it is essential to recognize the unique challenges they face, such as misconceptions about their sexual activity, physical and cognitive barriers, and social isolation. by embedding hiv prevention strategies into routine healthcare, empowering healthcare providers with the tools and knowledge to engage older adults in discussions about sexual health, and leveraging community-based organizations to reinforce these messages, we can ensure that older adults are not excluded from hiv prevention initiatives. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):57-62 [62] ajdhs.com chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. obeagu ei, obeagu gu, the vital role of blood transfusions during pregnancy: a comprehensive review, asian journal of dental and health sciences, 2024;4(1):26-31 https://doi.org/10.22270/ajdhs.v4i1.58 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.22270/ajdhs.v4i1.58 onemu et al asian journal of dental and health sciences. 2023; 3(3):30-32 [30] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2023 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the contribution of curable plasmid-mediated resistance in isolates of staphylococcus aureus at the university of benin teaching hospital, benin city, nigeria s. o onemu1, faith ademulegun 1, m. o. onemu-metitiri 2, *emmanuel ifeanyi obeagu3 and abdulwasiu oladele hassan1 1 faculty of medical laboratory science, college of basic health sciences, achievers university, owo, nigeria. 2 school of sciences, engineering and environment. university of salford, united kingdom. 3 department of medical laboratory science, kampala international university, uganda. article info: _______________________________________ article history: received 26 june 2023 reviewed 29 july 2023 accepted 19 august 2023 published 15 september 2023 _______________________________________ cite this article as: onemu so, ademulegun f, onemu-metitiri mo, obeagu ei, hassan ao, the contribution of curable plasmid-mediated resistance in isolates of staphylococcus aureus at the university of benin teaching hospital, benin city, nigeria, asian journal of dental and health sciences. 2023; 3(3):30-32 doi: http://dx.doi.org/10.22270/ajdhs.v3i3.50 _______________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda abstract ___________________________________________________________________________________________________________________ s. aureus, is an important human pathogen and commensal that is responsible for infections ranging from minor to deep-seated life-threatening conditions. multi-drug resistant s. aureus or mrsa is a major cause of hospital acquired infection (hais) or nosocomial infections with consequential reduction in treatment options and overtly increased cost of healthcare, morbidity and mortality. the study was conceived to determine the contribution of curable transmissible plasmids to the ever-increasing proportion of multi-drug resistant s. aureus at the university of benin teaching hospital, benin city. a total of 448 consecutive multi-drug resistant clinical isolates of s. aureus were collected, confirmed by sct and tct and resistance to commonly used antimicrobial agents. each isolate was inoculated into mueller-hinton broth containing 100 µg/ml acridine orange and incubated at 37oc for 24 h. each broth culture was subsequently sub-cultured onto blood agar plates and incubated at 37oc for 24 h. sensitivity tests were thereafter done on each sub-culture by the kirby-bauer disc diffusion method. sct and tct were re-tested on each sub-culture. isolates with curable transmissible plasmids were 31/448(6.9%) and there was complete reversion to sensitivity in all the cured strains to antimicrobial agents tested including ampicillin. the remaining isolates (93.1%) retained their resistance to all the antimicrobial agents. the isolates with curable plasmids (6.9%) also lost the coagulase activity of both types. plasmidmediated resistance in s. aureus remain an important route of multi-drug resistance, however this is dwarfed by chromosomally-mediated resistance as the major mechanism of resistance in multi-drug resistance s. aureus. additionally, the cure of drug resistance was also concomitantly associated with lose of the pathogenicity factor-coagulase in these isolates. keywords: s. aureus, multi-drug resistance, transmissible plasmids. introduction staphylococcus aureus (s. aureus) is a major human pathogen and commensal that is responsible for infections that range from minor to deep-seated life-threatening conditions 1-3. s. aureus colonizes between 30% and 50% of humans which increases the tendency to initiate infection 4. after the introduction of penicillin into clinical practice in the 1940s, the first case of methicillin-resistant strains of s. aureus (mrsa) was reported 5. there has been a steady increase in the number of methicillin-resistant strains of s. aureus worldwide due to antimicrobial agents’ selective pressure 6. rates that range from 61.8 – 80% have been reported in nigeria 7 and 61% in the united states 8. resistance to commonly prescribed antimicrobial agents has been recognized as a contributory to morbidity and mortality in hospitalized patients 9-11. mrsa strains are some of the commonest microorganisms associated with hospital-acquired infection (hais), possessing improved capabilities for resistance to methicillin and other antimicrobial agents have been reported 12. resistance of s. aureus has been largely attributed to chromosomal and extra-chromosomal genes acquisition 13. infection with mrsa strains comes with increased costs, treatment failure and longer hospital bedtime 14-15. this study was conceived to determine the relative contribution of curable transmissible plasmids to the resistance of s. aureus isolates in benin city. materials and methods consecutive isolates of s. aureus that were resistant to gentamycin, amoxycilin-clavulanate, ciprofloxacin, sparfloxacin ceftazidime, ceftriaxone azithromycin, and ampicillin, were collected. each isolate coagulase activity was confirmed by the sct and tct and resistance to the antimicrobial agents. slide coagulase test (sct) emulsion of each isolate was done on two separate spots on clean grease-free slide with a loopful of normal saline. to one emulsion was added a loopful of citrated human plasma and mixed with the loop and to the other spot was added a loopful of normal saline. the slide was rock-mixed in a figure “8” fashion. the presence of clumping or granulation was open access research article http://dx.doi.org/10.22270/ajdhs.v3i3.50 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v3i3.50&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 onemu et al asian journal of dental and health sciences. 2023; 3(3):30-32 [31] ajdhs.com recorded as positive sct if the other emulsion with saline only renamed smooth. tube coagulase (tct) each isolate that was sct test negative was further tested by the tct as well the sct positive as confirmation of the sct. each isolate was inoculated into the bijou bottle containing 1.0ml of sterile nutrient both of which 0.2 ml of citrated plasma was added. a local coagulase-positive strain of s. aureus was treated in a similar manner as control. the preparations were incubated at 370c and examined for the presence of a coagulum in 3 h, 6 h, if no coagulum developed, the bottles were re-incubated and examined after 18h using the control test to validate the result. sensitivity test a standard inoculum was prepared from each isolate adhering to the clinical laboratory standard institute guidelines (2021) to obtain 106 organisms/ml. a plate of mueller hinton agar (oxoid cm 0337) previously dried at 370c for 30 minutes was inoculated with the prepared inoculum using a sterile swab stick. oxford strain of s. aureus (nctc6571) was treated in the same manner as control. antimicrobial agent discs were placed with a sterile forcep at a minimum distance of 25 mm apart. the plates were thereafter incubated at 37oc for 18h. the sensitivity tests were read with reference to the control strain as sensitive or resistant. plasmid curing each isolate was inoculated into a bijou bottle containing 2 ml mueller-horton broth (oxoid (cm 0405b) containing 100 µg/ml acridine orange and incubated at 37oc for 18h. this was subsequently sub-cultured onto a blood agar plates (oxoid cm 55) and incubated at 37oc for 18h. sensitivity tests were carried out on each sub-cultured growth with the same antimicrobial agent discs prior the curing process. the oxford strain of s. aureus was also used as a sensitivity test control organism. the results were recorded as sensitive or resistant. results isolates with curable plasmids were 31/448 (6.9%) from the curing process as presented in table 1. all the isolates with curable resistance plasmid genes showed complete reversion to sensitivity with all the antimicrobial agents tested including ampicillin. the cure of resistance plasmids in these multi-drug s. aureus isolates also resulted in the loss of the coagulase activity of both types. all the other isolates that were not cured of resistance genes (93.1%) during the process remained resistant to all the antimicrobial agents and tested positive by both sct and tct. table 1: tests on isolates after growth in the presence of 100 µg/ml acridine orange test no. of cases (%) slide coagulase 448(100%) tube coagulase 448(100%) sensitivity to ampicillin (10 µg) 31(6.9%) discussion the study revealed that 6.9% of s. aureus isolates possess curable or transmissible plasmids that mediate resistance to antimicrobial agents in this study population. this, in turn, suggests that the resistance of s. aureus to antimicrobial agents is to a large extent chromosomally mediated and less to extra-chromosomal or plasmid genes. chromosomal resistance often results from mechanisms that involve target site alteration to antimicrobial agents known to bind penicillin-binding proteins (pbps) such as the beta-lactams or through the use of specialized exporter proteins (efflux pumps) to pump out harmful substances from the cell interior 16-17. this has also been observed in many bacteria populations 18. this study further shows that the acquisition resistance in s. aureus strains through infection with a virus (bacteriophage) or through extra-chromosomal genetic elements such as transposons and integrons in bacterial populations makes less degree of contribution to resistance in s. aureus strains as other studies have similarly observed 18. s. aureus resistance to antimicrobial agents as with other bacterial species appears to be an evolutionary demand for the survival of living systems in an ever-changing environmental conditions which is inevitable and unavoidable consequence of the continuous use of antimicrobial agents. the contribution of curable transmissible plasmids to the ever-rising tide of mrsa in hospitals is disproportionately low in comparison to the chromosomally-mediated mechanism of resistance. the loss of resistance after the curing process also resulted in the loss of coagulase activity which may suggest that the pathogenicity factor (coagulase) is closely linked to the resistance gene. transmissible plasmids contribute much less to antimicrobial resistance in strains of s. aureus than chromosomally-mediated resistance. resistance genes in these isolates appear to be co-inherited genes with the pathogenicity factor coagulase. it is therefore, expedient to redouble efforts to protect reserved valuable antimicrobial agents against unnecessary exposure. a renewed and sustained search for new antimicrobial agents must be given the priority it demands in attempts to win the battle against bacterial infections and curtail the development of resistance. references 1. laupland kb, lyytikamen o, sogaard m, kenedy kj, knudsen jd, jacobsen g, collignon p, schenheyder hc. the changing endermiology of staphylococcus aureus blood stream infection: a multi-national population-based surveillance study. clin. microbiology infection, 2013; 19:465 471. https://doi.org/10.1111/j.1469-0691.2012.03903.x pmid:22616816 2. turner na, sharma-kuinkel bk, maskarinec sa, eichenberger em, shah pp, carugati m, holland ti, fowler jr vg. methicillinresistant staphylococcus aureus: an overview of basic and clinical research. nat. rev. microbiol. 2019; 17:203-218. https://doi.org/10.1038/s41579-018-0147-4 pmid:30737488 pmcid:pmc6939889 3. mores cr, montelongo c, putoriti c, wolfe aj, abovelfetah a. investigation of plasmids among clinical staphylococcus aureus and staphylococcus haemolyticus isolates from egypt. microbiol. 2021 https://doi.org/10.3389/fmicb.2021.659116 pmid:34149648 pmcid:pmc8213342 4. david mc.the importance of staphylococcus aureus genotypes in outcomes and complication of bacteremia, clin. infect. dis. 2019; 69(11):1878-1880. https://doi.org/10.1093/cid/ciz114 pmid:31001630 5. jevons mp. "celbenin" resistant staphylococci. br. med, 1961; j. 1:124-125. https://doi.org/10.1136/bmj.1.5219.124-a pmcid:pmc1952888 6. meng m, li y, yao h. plasmid-mediated transfer of antibiotic resistance genes in soil. antibiotic (basel), 2022; 11(4):525 https://doi.org/10.3390/antibiotics11040525 pmid:35453275 pmcid:pmc9024699 7. wangai fk, masika mm, seaton ra, seaton ra. methycillin resistant staphylococcus aureus (mrsa) in east africa: red alert or red herring bmc infect. dis. 2019; 19:596. https://doi.org/10.1186/s12879-019-4245-3 pmid:31288757 pmcid:pmc6617662 https://doi.org/10.1111/j.1469-0691.2012.03903.x https://doi.org/10.1038/s41579-018-0147-4 https://doi.org/10.3389/fmicb.2021.659116 https://doi.org/10.1093/cid/ciz114 https://doi.org/10.1136/bmj.1.5219.124-a https://doi.org/10.3390/antibiotics11040525 https://doi.org/10.1186/s12879-019-4245-3 onemu et al asian journal of dental and health sciences. 2023; 3(3):30-32 [32] ajdhs.com 8. fukunaga bf, sumida wk, taira da, davies jw, seto tb. hospitalacquired methicillin resistant staphylococcus aureus bacteremia related to medicare antibiotic prescriptions: a state level analysis. hawaii j. med. public health, 2016; 75(10):303-309. 9. firth n, jensen so, kwang sm, skurray ra, ransay jp. staphylococci plasmids, transposable and integrated elements, asm. 2018; doi.org/io.1128/microbio-spec gpp3-0030-2018 10. saeed a, ahsan f, wawaz m, igbal k, rahman k, ijaz t. incidence of resistant phenotype of the methicillin resistant staphylococcus aureus isolated from a tertiary care hospital in lahore. antibiotics (basel), 2020; 9(1):3 https://doi.org/10.3390/antibiotics9010003 pmid:31861470 pmcid:pmc7168916 11. gordon yc, cheng cj, bae js, otto m. pathogenicity and virulence staphylococcus aureus, virulence. 2021; 12(1):547-569. https://doi.org/10.1080/21505594.2021.1878688 pmid:33522395 pmcid:pmc7872022 12. mccarthey aj, laidsay ja. the distribution of plasmids that carry virulence and resistance genes in staphylococcus aureus is lineage associated. bmc microbiol. 2012; 2:104. https://doi.org/10.1186/1471-2180-12-104 pmid:22691167 pmcid:pmc3406946 13. vestergaar m, free d, ingmer h. antibiotic resistance and the mrsa problem microbiol. spec. 7(2): doi.10.1128/microbiospec. 2019; gpp3-00572018. 14. guo y, song g, sun m, wang j, wang y. prevalence and therapic of antibiotic. resistance in staphylococcus aureus front cell infect. microbiol. 2020. https://doi.org/10.3389/fcimb.2020.00107 pmid:32257966 pmcid:pmc7089872 15. beker k, van-allen s, idleevich ea, schleimer sj. mellmann a, kasper u, peters g. plasmid-encoded transferrable mecbmediated methicillin resistance in staphylococcus aureus. emerg. infect. dis.2018; 24(2):242-243. https://doi.org/10.3201/eid2402.171074 pmid:29350135 pmcid:pmc5782906 16. smith jt, lewin cs. mechanism of antibacterial resistance and implication of epidemiology. vet. microbiol. 1993; 35(3-4):233244. https://doi.org/10.1016/0378-1135(93)90148-z pmid:8212509 17. sharma a, guofa vk, pathania r. efflux pump inhibitors for bacteria pathogens: from bench to bedside. indian j. med. res. 2019; 149(2):129-145 https://doi.org/10.4103/ijmr.ijmr_2079_17 pmid:31219077 pmcid:pmc6563736 18. nishino k, yamasaki s, nakashima r, zwama m, hayashi nishino. function and inhibitory mechanisms of multidrug efflux pumps. front microbiol. 2021; 12:e737288 https://doi.org/10.3389/fmicb.2021.737288 pmid:34925258 pmcid:pmc8678522 https://doi.org/10.3390/antibiotics9010003 https://doi.org/10.1080/21505594.2021.1878688 https://doi.org/10.1186/1471-2180-12-104 https://doi.org/10.3389/fcimb.2020.00107 https://doi.org/10.3201/eid2402.171074 https://doi.org/10.1016/0378-1135(93)90148-z https://doi.org/10.4103/ijmr.ijmr_2079_17 https://doi.org/10.3389/fmicb.2021.737288 pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [32] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the role of pharmacists in health promotion pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 04 april 2024 reviewed 07 may 2024 accepted 03 june 2024 published 15 june 2024 _____________________________________________ cite this article as: dave p, the role of pharmacists in health promotion, asian journal of dental and health sciences. 2024; 4(2):32-37 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.79 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ health promotion is regarded as instrumental in addressing the growing public healthcare concerns. it is recognized as instrumental in disease prevention and control. health promotion can also be used as an instrumental tool to address the growing cases of non-communicable diseases. health promotion is regarded as effective in disease prevention and control because it emphasizes the need for individuals to be in control over their own health. however, despite the significance of health promotion in disease prevention and control, it remains largely underutilized. one of the reasons why health promotion is underutilized is because of the lack of adequate healthcare personnel to take on health promotion initiatives. expanding the role of pharmacists to include more involvement in health promotion initiatives can help to fill this gap. some of the measures and initiatives pharmacists can get involved in are being part of building public health policies, creating supportive environments, providing health education, being in community action, ensuring medication safety, and disease prevention and control. to enable pharmacists to perform these measures effectively, there is a need to address the existing barriers and challenges. this will lead to positive outcomes and ensure pharmacists perform their roles effectively to enhance health promotion. keywords: health promotion, pharmacists, health education, disease prevention and control, immunization introduction the role of health promotion in addressing emerging public healthcare concerns cannot be denied. communicable and non-communicable diseases are on the rise across the globe contributing significantly to the rising healthcare burden and straining healthcare systems. the rise in the number of communicable and non-communicable diseases necessitates preventative measures to address them. health promotion is recognized as instrumental in disease prevention. the un highlevel meeting on universal health coverage (uhc) recognizes health promotion as one of the approaches that can help to achieve uhc.1 it emphasizes the importance of prioritizing health promotion and disease prevention through implementing working public health policies, good governance of health care systems, health communication, education, and health literacy.1,2 the significance of health promotion in disease prevention cannot be understated. various health promotion measures are adopted across the healthcare systems to improve public health. the importance of health promotion in disease prevention is not a new concept. its role in addressing public health issues and prevention of diseases has been established since the 19th century.3 health promotion as a concept was first coined by henry e. sigerist in 1945. according to sigerist, health promotion entails a number of measures all of which are classified as tasks of medicine. the tasks include promotion of health, prevention of illness, restoration of the sick, and rehabilitation.3 all these tasks are instrumental in achieving health for all and improving the health of all communities. the importance of health promotion in promoting health for all and achieving people’s well-being is cemented by the ottawa charter for health promotion. the ottawa charter was born out of the first-ever international conference on health promotion that was held in 1986.4 according to the charter, health promotion is a process that enables people to have more control over their health. it is also done to improve health.4 the charter recognizes five action areas for health promotion namely building health public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting healthcare services more towards the promotion of health and prevention of illness.4,5 the action areas can be achieved through strategies such as advocating, enabling, and mediation. in addition to being a process, health promotion can also mean the actions taken by individuals and relevant stakeholders to lead a healthy lifestyle.6 these measures need to be taken in a healthy environment to prevent the likelihood of secondary conditions. secondary conditions in this case are the social, medical, emotional, family, and community problems that may make it difficult for an individual to have total control of their health.7 for instance, social problems such as racism and discrimination in the healthcare system may make it difficult for an individual to have access to equal opportunities for care. in the community, problems such as lack of community parks, social amenities, and lack of safety may make it difficult for people to engage in physical activity and lead to increased risk of chronic conditions such as obesity and diabetes.7 some of these measures that can be taken to ensure individuals attain optimal health are being at the forefront when it comes to addressing their health needs, providing education to individuals on how to take care of their health needs, and optimizing opportunities that enable individuals to take care of their health needs and engaging in activities that can promote good health. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.79 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.79&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [33] ajdhs.com despite the significance of health promotion in promoting good health, it is an area that is underutilized and not given as much priority. a lot of effort is directed towards disease management underpinning the potential of health promotion in disease prevention. one of the reasons why health promotion is underutilized is because of the lack of adequate healthcare personnel with the needed expertise to engage in different health promotion measures and strategies.8,9 currently, healthcare systems across the world are grappling with serious healthcare provider shortages.10 the problem is so big in some countries that most have resulted to outsourcing from other countries which creates more challenges for these countries because they are understaffed as well. with such shortages, prioritizing health promotion becomes a challenge. this explains the need to expand the role of healthcare providers to ensure more engagement in health promotion. one of the groups that can be used to alleviate the problem is community pharmacists. because of their close involvement with patients, they can be instrumental in advocating for different health promotion initiatives such as prevention, increasing individual knowledge on health, and public health planning and promotion. therefore, the aim of this review is to explore how community pharmacists can be involved in different health promotion strategies to achieve health promotion goals. it also explores the challenges and barriers pharmacists face towards health promotion and why addressing these barriers is instrumental in achieving positive outcomes. health promotion measures and strategies and the role of pharmacists building public health policy different actions and strategies can be taken to attain positive change with regard to disease prevention and health promotion. as per the ottawa charter, one of the activities that can be taken to promote health is building public health policy. as a measure of health promotion, building public health policy recognizes that health promotion goes beyond health care. health promotion also involves creating health policies that can help to achieve the desired goals of healthcare.4 building health policy ensures that policymakers are knowledgeable of health consequences that result from the decisions that they make regarding healthcare.5 it also ensures that they accept their responsibilities and are more accountable for these decisions. having health policies in place is vital in implementing health actions. they are the basis for health interventions and their subsequent implementation.11 without proper health policies in place, coming up with health interventions and implementing them becomes difficult. a number of diverse approaches can be taken to come up with health promotion policies. they include legislation, fiscal measures, taxation, and organizational change.5 although pharmacists have little involvement when it comes to developing legislation, taxation, or fiscal measures, they can be involved through participation and advocacy. pharmacists can also play a critical role in advocating for organizational change to promote health. for instance, they can advocate for capacity building in organizations to support actions that can promote health such as the need to eat healthy lunches and the need for gym and other social amenities to promote physical activity. pharmacists can also be involved in building knowledge skills and infrastructure that can facilitate health promotion.12 they can also partner with organizations to advocate for actions that promote health. when these actions are sustained over time, they can become more sustainable and lead to permanent changes in organizations. when it comes to developing legislation, pharmacists can actively participate through the local boards of health to national programs. pharmacists are experts in medication use which makes them informed on how medication can be used in health promotion. because of their expertise, they should be involved in the development of legislation and regulations relating to public health.13 pharmacists can also be involved in oversight of these programs. pharmacists can also make their voices known when it comes to developing fiscal measures that aim at health promotion. for instance, they can suggest fiscal measures that they feel can work and call for their implementation. they can also advocate for sound legislation and regulations regarding disease prevention and management. creating supportive environments an additional measure that is considered instrumental in health promotion is creating supportive environments. the need to create supportive environments as a measure to promote public health is acknowledged in the ottawa charter.4 according to the charter, creating supportive environments that are considered safe, stimulating, and satisfying is instrumental because it leads to positive health outcomes.4 research has shown that supportive environments are associated with positive health outcomes.14 supportive environments in this case are environments that make it easier for an individual to make the easier choice pertaining to their health. they can include healthy cities, healthy communities, healthy municipalities, healthy workplaces, and healthpromoting schools among others.15 pharmacists can play an instrumental role in creating supportive environments. they can do this by advocating for healthy communities, being more involved in building healthy communities, and educating people on the importance of these communities in promoting good health. creating supportive environments entails putting measures in place to encourage good health such as building spaces that allow people to engage in physical activities, striving for a better built environment with green spaces and walkways, and ensuring people have adequate access to food by ensuring proximity to grocery stores. pharmacists can advocate for better-built environments in their communities. research has linked the built environment with the likelihood of developing chronic diseases because it limits physical activity.16,17,18 for instance, walkable neighborhoods and the availability of parks have been linked to increased engagement in physical activity and subsequent reduction in the risk of developing obesity and diabetes.17 the reason why creating supportive environments is linked to better health outcomes is because such environments encourage people to take charge of their health. they feel safer and as such are more likely to take charge of their health leading to positive outcomes. disease control and prevention pharmacists can also play a crucial role in disease control and prevention. one of the ways through which pharmacists can be involved in disease prevention is through immunization. immunization is recognized as an instrumental aspect of disease prevention more so for communicable diseases.19,20,21 the perceived benefits of vaccination include reducing the spread of infections, reducing morbidity and mortality associated with infections, and preventing outbreaks.19 for instance, vaccination played an instrumental role in helping control further spread of covid-19. in the united states, pharmacists can order, prescribe, and administer immunizations under the temporary federal prep act.22 besides, the involvement of pharmacists in immunization has shown to have a positive impact on immunization uptake and pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [34] ajdhs.com overall outcomes.23,24 therefore, involving pharmacists in immunization can increase uptake and promote good health. in addition to administering immunization, pharmacists can be involved in screening programs to help identify undiagnosed medical conditions. screening is recognized as an important measure of disease prevention more so chronic diseases such as hypertension, diabetes, and cancer.25,26,27 pharmacists can be involved in different steps of the screening pathway as stipulated by who.28 for instance, they can identify the population that is eligible for screening because of their close involvement with patients. they can also invite patients to carry out tests and do the testing. pharmacists can also refer patients to primary healthcare providers after getting results from conducted tests. pharmacists can also work collaboratively with other healthcare providers during community screening programs. health education an additional way that pharmacists can be involved in disease prevention and control is by educating patients on behaviors to mitigate diseases and modelling these behaviors. some of these behaviors include handwashing, immunization, wearing masks, engaging in regular physical exercise, and eating healthy and nutritious food.13 pharmacists are in a good position to both educate patients and model these behaviors. because of their frequent encounter with patients, they can use these opportunities to educate patients on healthy behaviors. they can also refer patients to available resources and services that involve health promotion. the role of pharmacists in health education cannot be understated. over the years, pharmacists have played instrumental roles in developing, promoting, and implementing health education programs.29 because of their proximity to patients and availability, they are well-positioned to educate patients on different aspects of health promotion including the need for exercise regimens, the importance of adhering to prescribed medication, medication safety, and the importance of a good diet in promoting good health. health literacy is recognized as instrumental in leading to positive health outcomes.30,31 it equips patients with the needed skills and abilities to better manage their health. under the ottawa charter of health promotion, developing personal skills is one of the actions of health promotion. who recognizes that health literacy is not just a personal resource. within populations, health literacy can lead to better social benefits such as mobilizing entire communities to address the social, economic, and environmental determinants of health.32 health people 2030 recognizes health literacy as a social determinant of health because it affects the healthcare that is delivered and subsequent patient outcomes.33 this is particularly the case when people are not able to access healthcare resources and use these resources to make health-related decisions. the inability to access these resources affects people’s ability to make decisions about their health which explains why lack of health literacy is associated with negative outcomes. research has shown that pharmacists-led education interventions are instrumental in leading to positive health outcomes.34,35 jaam et al. established that pharmacists-led education interventions provided to healthcare providers helped to reduce medication errors.35 safe medication administration is a vital aspect of health promotion because it leads to positive health outcomes. in addition to providing education to patients, pharmacists can be involved in developing health education programs within their institutions and the community in general. promoting medication safety pharmacists can also play a role in health promotion by promoting medication safety efforts in both the communities and institutions at large. the importance of medication safety in achieving the goals of health promotion cannot be denied. if individuals are to have more control over their health, then they need to know how to take their medications effectively and minimize the likelihood of medication errors. the role of pharmacists in ensuring medication safety cannot be denied.36,37 it is one of their key responsibilities in ensuring patient safety. in their role, pharmacists can ensure patients have access to crucial medication and vaccinations aimed at promoting health, ensure patients have access to medical information, ensure patients are prescribed the right medication, improve medication adherence by educating patients on the importance of taking their medications, medication management, and provide health and wellness services.38 one of the ways that pharmacists can ensure medication safety to promote good health is through providing medical information to patients. providing information on safe and effective medication use can have a positive impact on patient safety by reducing the likelihood of adverse reactions. educating the patients on the importance of medication adherence can also promote good health. this is particularly the case for patients who are self-medicating and managing their chronic illnesses. pharmacists can also provide health and wellness services by engaging in services such as blood pressure and diabetes screening. such services more so when implemented at the community level can play a crucial role in promoting public health. pharmacists can work in collaboration with other healthcare providers and organize community health campaigns to offer such services. collaborating with other stakeholders to strengthen community actions strengthening community action is recognized as instrumental in health promotion. who defines strengthening community action as empowering communities to get more involved in their health.4 there are different measures that can be taken to empower communities to be more involved in their health. they include providing people with help and support to manage their conditions, providing access to health information, carrying out health campaigns to educate community members on the importance of good health, providing funding, carrying out health fairs, carrying out health camps, and partnering with other stakeholders to promote health. the significance of strengthening community action in promoting health is acknowledged in research. laverack and mohammadi, note that strengthening community action helps to build community capacity and ensure they prioritize their health. it also entails providing funding for various community activities.39 pharmacists can engage in different activities to strengthen community action. some of these include participating in health camps, engaging in health fairs, providing support to community members, providing education to community members, and engaging in health campaigns. to enhance positive outcomes, pharmacists can work collaboratively with other healthcare providers and stakeholders. research has shown that community-based partnerships are instrumental in health promotion. for instance, plump et al. established that community-based partnerships can improve the outcomes of chronic disease management because they enhance self-management.40 community-based organizations have also been established to be instrumental in improving chronic care.41 community-based organizations promote health because they allow community members to access and navigate neighborhood health resources. such resources are recognized as instrumental in helping people self-manage their chronic illnesses. pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [35] ajdhs.com challenges and barriers to pharmacists involvement in health promotion recognizing the existing barriers and how they can affect pharmacists’ involvement in health promotion is vital towards achieving positive results. there are numerous barriers that exist which can make it difficult for pharmacists to play a role in health promotion. structural barriers such as time restraints and workload can make it difficult for pharmacists to engage in health promotion.9,42 for instance, health education and engaging in health camps is engaging and time-consuming. performing these roles together with their duties can be difficult. inadequate knowledge and skills in health promotion can also act as a barrier.42 for instance, pharmacists cannot provide health education on how to manage chronic diseases if they are not adequately equipped to do so. lack of knowledge can affect pharmacists’ confidence to provide health education and lead to low engagement in health promotion. lack of coordination with other healthcare providers can also make it challenging for pharmacists to be involved in health promotion. different researchers identify it as one of the barriers reported by healthcare providers towards health promotion.43,44,45(nsengimana et al., 2022; geense et al., 2013). coordination among healthcare providers is important in health promotion because they play different roles all of which are instrumental in leading to positive outcomes. playing isolated roles can affect patient outcomes and affect the overall quality of health promotion. other barriers that can affect pharmacists’ involvement in health promotion are lack of organizational support, lack of patient motivation to change, and lack of financing of health promotion programs. finding funding for health promotion programs is not a simple task. according to geense et al., a lot of health programs are not financed or only financed for a short duration of time.45 providing health promotion programs without financing is challenging because they are expensive. lack of organizational support can also be a hindrance to health promotion. health promotion requires coordinated efforts with stakeholders and policymakers to be effective. additionally, the lack of patient motivation to change can demotivate pharmacists in their efforts towards health promotion. addressing these barriers and challenges can lead to positive outcomes in health promotion. it can ensure pharmacists take up more active roles in promoting public health beyond providing immunization and medication management. conclusion health promotion is regarded as instrumental in promoting good health. despite the role it plays in promoting good health, it remains an area that is significantly underutilized. one of the reasons why health promotion is underutilized is because of the lack of adequate healthcare personnel with the needed expertise to coordinate different health promotion measures and strategies. with the current shortages being experienced in healthcare, engaging in health promotion becomes difficult because of workload and lack of time. expanding the role of pharmacists to be more involved in health promotion roles and measures can lead to a significant difference. they have close contacts with patients which provides them with a significant opportunity to advocate for and engage in health promotion initiatives. pharmacists can engage in different actions to promote health. some of these include disease prevention and control, being part of developing public health policies, engaging in different community actions, providing patient education, creating supportive environments, and being at the forefront of leading medication safety. these measures and initiatives are recognized as effective in health promotion. to gain the full benefits of these measures, there is a need to identify the existing challenges and barriers and address them. these challenges act as barriers that make it difficult for pharmacists to be involved in health promotion. some of these barriers are structural barriers such as time restraints and heavy workload, and organizational barriers such as lack of support and inadequate funding, poor coordination with other healthcare providers, and lack of patient motivation to change. addressing these barriers and challenges can lead to positive outcomes in health promotion because pharmacists can be able to perform their roles more effectively. references 1. united nations. political declaration of the high-level meeting on universal health coverage universal health coverage: moving together to build a healthier world. new york: united nations; 2019. available from: https://www.un.org/pga/73/wpcontent/uploads/sites/53/2019/07/final-draft-uhc-politicaldeclaration.pdf 2. shilton t, barry mm. the critical role of health promotion for effective universal health coverage. global health promotion. 2022;29(1):92-5. https://doi.org/10.1177/1757975920984217 pmid:33535893 3. kumar s, preetha gs. health promotion: an effective tool for global health. indian journal of community medicine. 2012;37(1):5-12. https://doi.org/10.4103/0970-0218.94009 pmid:22529532 pmcid:pmc3326808 4. world health organization. ottawa charter for health promotion. 2012. available from: https://www.who.int/publications/i/item/wh-1987 5. world health organization. health promotion. available from: https://www.who.int/teams/health-promotion/enhancedwellbeing/first-global-conference/actions 6. heggdal k. health promotion among individuals facing chronic illness: the unique contribution of the bodyknowledging program. health promotion in health care-vital theories and research. 2021:209-26. available from: https://www.ncbi.nlm.nih.gov/books/nbk585658/#:~:text=bod yknowledging%20theory%20describe%20the%20grieving,losses %2c%20grieving%2c%20and%20anger%20in https://doi.org/10.1007/978-3-030-63135-2_16 pmid:36315719 7. larsen pd. lubkin's chronic illness: impact and intervention. jones & bartlett learning; 2021. 8. schofield b, rolfe u, mcclean s, hoskins r, voss s, benger j. what are the barriers and facilitators to effective health promotion in urgent and emergency care? a systematic review. bmc emergency medicine. 2022;22(1):95. https://doi.org/10.1186/s12873-02200651-3 pmid:35659572 pmcid:pmc9164411 9. rogers hl, pablo hernando s, núñez-fernández s, et al. barriers and facilitators in the implementation of an evidence-based health promotion intervention in a primary care setting: a qualitative study. journal of health organization and management. 2021;35(9):349-67. https://doi.org/10.1108/jhom-12-20200512 pmid:34464035 pmcid:pmc9136863 10. džakula a, relić d, michelutti p. health workforce shortage-doing the right things or doing things right?. croatian medical journal. 2022;63(2):107-9. https://doi.org/10.3325/cmj.2022.63.107 pmid:35505643 pmcid:pmc9086817 11. de leeuw e, clavier c, breton e. health policy-why research it and how: health political science. health research policy and systems. 2014;12:1-1. https://doi.org/10.1186/1478-4505-12-55 pmid:25248956 pmcid:pmc4246431 12. batras d, duff c, smith bj. organizational change theory: implications for health promotion practice. health promotion international. 2016;31(1):231-41. https://doi.org/10.1093/heapro/dau098 pmid:25398838 13. american society of health-system pharmacists ashp). ashp statement on the pharmacist's role in public health. 2021. https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/final-draft-uhc-political-declaration.pdf https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/final-draft-uhc-political-declaration.pdf https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/final-draft-uhc-political-declaration.pdf https://doi.org/10.1177/1757975920984217 https://doi.org/10.4103/0970-0218.94009 https://www.who.int/publications/i/item/wh-1987 https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference/actions https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference/actions https://www.ncbi.nlm.nih.gov/books/nbk585658/#:~:text=bodyknowledging%20theory%20describe%20the%20grieving,losses%2c%20grieving%2c%20and%20anger%20in https://www.ncbi.nlm.nih.gov/books/nbk585658/#:~:text=bodyknowledging%20theory%20describe%20the%20grieving,losses%2c%20grieving%2c%20and%20anger%20in https://www.ncbi.nlm.nih.gov/books/nbk585658/#:~:text=bodyknowledging%20theory%20describe%20the%20grieving,losses%2c%20grieving%2c%20and%20anger%20in https://doi.org/10.1007/978-3-030-63135-2_16 https://doi.org/10.1186/s12873-022-00651-3 https://doi.org/10.1186/s12873-022-00651-3 https://doi.org/10.1108/jhom-12-2020-0512 https://doi.org/10.1108/jhom-12-2020-0512 https://doi.org/10.3325/cmj.2022.63.107 https://doi.org/10.1186/1478-4505-12-55 https://doi.org/10.1093/heapro/dau098 pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [36] ajdhs.com available from: https://www.ashp.org/-/media/assets/policyguidelines/docs/statements/pharmacists-role-public-health.pdf 14. poland b, dooris m, haluza-delay r. securing 'supportive environments' for health in the face of ecosystem collapse: meeting the triple threat with a sociology of creative transformation. health promotion international. 2011;26(suppl_2):ii202-15. https://doi.org/10.1093/heapro/dar073 pmid:22080075 15. saadati f, nadrian h, ghassab-abdollahi n, pashazadeh f, gilani n, taghdisi mh. indices/indicators developed to evaluate the "creating supportive environments" mechanism of the ottawa charter for health promotion: a setting-based review on healthy environment indices/indicators. korean journal of family medicine. 2023;44(5):261. https://doi.org/10.4082/kjfm.22.0215 pmid:37434481 pmcid:pmc10522467 16. sallis jf, floyd mf, rodríguez da, saelens be. role of built environments in physical activity, obesity, and cardiovascular disease. circulation. 2012;125(5):729-37. https://doi.org/10.1161/circulationaha.110.969022 pmid:22311885 pmcid:pmc3315587 17. frank ld, adhikari b, white kr, et al. chronic disease and where you live: built and natural environment relationships with physical activity, obesity, and diabetes. environment international. 2022;158:106959. https://doi.org/10.1016/j.envint.2021.106959 pmid:34768046 18. sallis jf, cerin e, kerr j, et al. built environment, physical activity, and obesity: findings from the international physical activity and environment network (ipen) adult study. annual review of public health. 2020;41:119-39. https://doi.org/10.1146/annurevpublhealth-040218-043657 pmid:32237990 19. rodrigues cm, plotkin sa. impact of vaccines; health, economic and social perspectives. frontiers in microbiology. 2020;11:1526. https://doi.org/10.3389/fmicb.2020.01526 pmid:32760367 pmcid:pmc7371956 20. dave p, exploring the effectiveness of pre-exposure prophylaxis (prep) use for hiv prevention among high-risk populations, asian journal of pharmaceutical research and development. 2024; 12(2):1-6. https://doi.org/10.22270/ajprd.v12i2.1333 21. pollard aj, bijker em. a guide to vaccinology: from basic principles to new developments. nature reviews immunology. 2021;21(2):83-100. https://doi.org/10.1038/s41577-020-004797 pmid:33353987 pmcid:pmc7754704 22. naspa. pharmacist immunization authority. 2023. available from: https://naspa.us/blog/resource/pharmacist-authority-toimmunize/#:~:text=*note%3a%20under%20temporary%20fed eral%20prep,to%20ages%2019%20and%20older . 23. le lm, veettil sk, donaldson d, et al. the impact of pharmacist involvement on immunization uptake and other outcomes: an updated systematic review and meta-analysis. journal of the american pharmacists association. 2022;62(5):1499-513. https://doi.org/10.1016/j.japh.2022.06.008 pmid:35961937 pmcid:pmc9448680 24. bach at, goad ja. the role of community pharmacy-based vaccination in the usa: current practice and future directions. integrated pharmacy research and practice. 2015:67-77. https://doi.org/10.2147/iprp.s63822 pmid:29354521 pmcid:pmc5741029 25. wilson jm, jungner g, world health organization. principles and practice of screening for disease. 26. dave p, the vital role of pharmacists in diabetes self-care, journal of drug delivery and therapeutics. 2024; 14(5):229-233 https://doi.org/10.22270/jddt.v14i5.6582 27. havlicek aj, mansell h. the community pharmacist's role in cancer screening and prevention. canadian pharmacists journal/revue des pharmaciens du canada. 2016;149(5):274-82. https://doi.org/10.1177/1715163516660574 pmid:27708673 pmcid:pmc5032932 28. sagan a, mcdaid d, rajan s, farrington j, mckee m. screening: when is it appropriate and how can we get it right? world health organization; policy brief, 35. 2020. available from: https://iris.who.int/bitstream/handle/10665/330810/policybrief-35-1997-8073-eng.pdf 29. shirdel a, pourreza a, daemi a, ahmadi b. health-promoting services provided in pharmacies: a systematic review. journal of education and health promotion. 2021;10. https://doi.org/10.4103/0003-2778.320288 pmid:34395671 pmcid:pmc8318157 30. van der gaag m, heijmans m, spoiala c, rademakers j. the importance of health literacy for self-management: a scoping review of reviews. chronic illness. 2022;18(2):234-54. https://doi.org/10.1177/17423953211035472 pmid:34402309 31. buchbinder r, batterham r, ciciriello s, newman s, horgan b, ueffing e, rader t, tugwell ps, osborne rh. health literacy: what is it and why is it important to measure?. the journal of rheumatology. 2011;38(8):1791-7. https://doi.org/10.3899/jrheum.110406 pmid:21807802 32. world health organization. health literacy. available from: https://www.who.int/teams/health-promotion/enhancedwellbeing/ninth-global-conference/health-literacy 33. healthy people 2030. health literacy. available from: https://health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/health-literacy 34. laliberté mc, perreault s, damestoy n, lalonde l. ideal and actual involvement of community pharmacists in health promotion and prevention: a cross-sectional study in quebec, canada. bmc public health. 2012;12:1-1. https://doi.org/10.1186/1471-2458-12-192 pmid:22420693 pmcid:pmc3342160 35. jaam m, naseralallah lm, hussain ta, pawluk sa. pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis. plos one. 2021;16(6):e0253588. https://doi.org/10.1371/journal.pone.0253588 pmid:34161388 pmcid:pmc8221459 36. mansur jm. medication safety systems and the important role of pharmacists. drugs & aging. 2016;33:213-21. https://doi.org/10.1007/s40266-016-0358-1 pmid:26932714 37. dave p. hepatitis screening in community pharmacies as a measure of reducing the rate of infections. journal of drug delivery and therapeutics, 2024;14 (3):234-39. https://doi.org/10.22270/jddt.v14i3.6478 38. patient safety network. the pharmacist's role in medication safety. 2019. available from: https://psnet.ahrq.gov/primer/pharmacists-role-medicationsafety 39. laverack g, keshavarz mohammadi n. what remains for the future: strengthening community actions to become an integral part of health promotion practice. health promotion international. 2011;26(suppl_2):ii258-62. https://doi.org/10.1093/heapro/dar068 pmid:22080081 40. plumb j, weinstein lc, brawer r, scott k. community-based partnerships for improving chronic disease management. primary care: clinics in office practice. 2012;39(2):433-47. https://doi.org/10.1016/j.pop.2012.03.011 pmid:22608875 41. nguyen kh, fields jd, cemballi ag, desai r, gopalan a, cruz t, shah a, akom a, brown w, sarkar u, lyles cr. the role of community-based organizations in improving chronic care for safety-net populations. the journal of the american board of family medicine. 2021;34(4):698-708. https://doi.org/10.3122/jabfm.2021.04.200591 pmid:34312263 pmcid:pmc9875859 42. abdulraheem y. unveiling the significance and challenges of integrating prevention levels in healthcare practice. journal of primary care & community health. 2023;14:21501319231186500. https://doi.org/10.1177/21501319231186500 pmid:37449436 pmcid:pmc10350749 43. caron rm, noel k, reed rn, sibel j, smith hj. health promotion, health protection, and disease prevention: challenges and https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/pharmacists-role-public-health.pdf https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/pharmacists-role-public-health.pdf https://doi.org/10.1093/heapro/dar073 https://doi.org/10.4082/kjfm.22.0215 https://doi.org/10.1161/circulationaha.110.969022 https://doi.org/10.1016/j.envint.2021.106959 https://doi.org/10.1146/annurev-publhealth-040218-043657 https://doi.org/10.1146/annurev-publhealth-040218-043657 https://doi.org/10.3389/fmicb.2020.01526 https://doi.org/10.22270/ajprd.v12i2.1333 https://doi.org/10.1038/s41577-020-00479-7 https://doi.org/10.1038/s41577-020-00479-7 https://naspa.us/blog/resource/pharmacist-authority-to-immunize/#:~:text=*note%3a%20under%20temporary%20federal%20prep,to%20ages%2019%20and%20older https://naspa.us/blog/resource/pharmacist-authority-to-immunize/#:~:text=*note%3a%20under%20temporary%20federal%20prep,to%20ages%2019%20and%20older https://naspa.us/blog/resource/pharmacist-authority-to-immunize/#:~:text=*note%3a%20under%20temporary%20federal%20prep,to%20ages%2019%20and%20older https://doi.org/10.1016/j.japh.2022.06.008 https://doi.org/10.2147/iprp.s63822 https://doi.org/10.22270/jddt.v14i5.6582 https://doi.org/10.1177/1715163516660574 https://iris.who.int/bitstream/handle/10665/330810/policy-brief-35-1997-8073-eng.pdf https://iris.who.int/bitstream/handle/10665/330810/policy-brief-35-1997-8073-eng.pdf https://doi.org/10.4103/0003-2778.320288 https://doi.org/10.1177/17423953211035472 https://doi.org/10.3899/jrheum.110406 https://www.who.int/teams/health-promotion/enhanced-wellbeing/ninth-global-conference/health-literacy https://www.who.int/teams/health-promotion/enhanced-wellbeing/ninth-global-conference/health-literacy https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/health-literacy https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/health-literacy https://doi.org/10.1186/1471-2458-12-192 https://doi.org/10.1371/journal.pone.0253588 https://doi.org/10.1007/s40266-016-0358-1 https://doi.org/10.22270/jddt.v14i3.6478 https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety https://doi.org/10.1093/heapro/dar068 https://doi.org/10.1016/j.pop.2012.03.011 https://doi.org/10.3122/jabfm.2021.04.200591 https://doi.org/10.1177/21501319231186500 pallav dave asian journal of dental and health sciences. 2024; 4(2):32-37 [37] ajdhs.com opportunities in a dynamic landscape. ajpm focus. 2024;3(1). https://doi.org/10.1016/j.focus.2023.100167 pmid:38149078 pmcid:pmc10749873 44. nsengimana a, biracyaza e, hategekimana jc, tuyishimire j, nyiligira j, rutembesa e. attitudes, perceptions, and barriers of community pharmacists in rwanda towards health promotion: a cross sectional study. archives of public health. 2022;80(1):157. https://doi.org/10.1186/s13690-022-00912-4 pmid:35733223 pmcid:pmc9217721 45. geense ww, van de glind im, visscher tl, van achterberg t. barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study. bmc family practice. 2013;14:1-0. https://doi.org/10.1186/14712296-14-20 pmid:23394162 pmcid:pmc3575260 https://doi.org/10.1016/j.focus.2023.100167 https://doi.org/10.1186/s13690-022-00912-4 https://doi.org/10.1186/1471-2296-14-20 https://doi.org/10.1186/1471-2296-14-20 sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [9] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited knowledge and awareness of post graduate and undergraduate dental students about cbct: a questionnaire study sarah samsu nisha. k *1 , dr. aravind swamy r m 2 , dr. thalaimalai saravanan 3 1 crri, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india 2 assistant professor, department of oral medicine and radiology, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india 3 professor, department of oral medicine and radiology, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india article info: _____________________________________________ article history: received 19 december 2023 reviewed 02 january 2024 accepted 17 january 2024 published 15 march 2024 _____________________________________________ cite this article as: nisha kss, swamy rma, saravanan t, knowledge and awareness of post graduate and undergraduate dental students about cbct: a questionnaire study, asian journal of dental and health sciences. 2024; 4(1):9-15 doi: http://dx.doi.org/10.22270/ajdhs.v4i1.65 _____________________________________________ *address for correspondence: sarah samsu nisha k, crri, karpaga vinayaga institute of dental sciences, padalam, tamil nadu 603308, india abstract _________________________________________________________________________________________________________________ aim: to assess the precise knowledge and awareness of the cone beam computed tomography (cbct) among post graduate and undergraduate dental students. materials and methods: the data in questionnaire were obtained through the completely filled 200 google forms which includes undergraduate and postgraduate dental students. the obtained data was analysed category wise. results: a definite gap exists between undergraduate students and postgraduates in awareness, knowledge and handling capacity. postgraduate has better knowledge on interpretation than undergraduates. the right cbct education should be given to dental students, backed by real-world experience and the advice of oral and maxillofacial radiologists. conclusion: to guarantee greater understanding among dentists, further efforts should be made to raise awareness of this imaging modality. these efforts could include adding cbct to the bds curriculum and holding lectures or continuing dental education (cde) sessions. keywords: cbct, dental students, awareness, knowledge, cde introduction selection of pertinent imaging or diagnostic technique is an important step in the management of diseases and shield the patient from deleterious effects of ionizing radiations. continual research is focused toward better image acquirement with emphasis over minimum harmful effects of radiation. cone beam computed tomography (cbct) in our country has obtained popularity among dentists and is most preferable imaging modality in recent times. however, lack of inclusion of cbct in undergraduate curriculum is a matter of concern1. cbct uses a diverse cone shaped or pyramid shaped source of ionizing. the two-dimensional area detector fixed on a rotating gantry to offer multiple sequential transmission images that are incorporated directly forming volumetric or three-dimensional information. the complex computed algorithm was performed on this data set, allowing the operator to extract multiplanar reconstructions of various thickness in any plane and to provide precise three-dimensional image. the introduction of cbct imaging had shifted the dentists from a 2d to a volumetric approach in maxillofacial imaging. hence it is important for every undergraduate dental student to obtain knowledge about cbct2.this survey study aims to assess the exact awareness and knowledge of cbct in dental fraternity. materials and methods a cross sectional study was conducted with a randomly selected sample. data were obtained in the form of integrated, close-ended, validated, predesigned, self-administered questionnaire which was approved by the institutional ethical committee. the questionnaire was verified after results acquired from pilot study. the questionnaire was given to 200 participants including undergraduate and post graduate students of oral medicine and radiology and other department. the study was carried out from march 2023 to october 2023. the questionnaire consists of multiple-choice questions on cbct. the questionnaire consists of 22 questions and categorised based on knowledge, awareness, future applications, reason for cbct prescription and basics of cbct. overall assessment of answers obtained for each part were analysed category-wise into two category undergraduates and post graduates. statistical analysis was done. software used is spss software version 21.0 (ibm, usa). mean percentage was calculated and data were arranged in percentage for all questions. chi-square test was employed to compare percentages in different variables. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i1.65 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i1.65&amp;domain=pdf https://orcid.org/0009-0006-1284-0877 https://orcid.org/0000-0002-7298-8455 https://orcid.org/0009-0009-1983-5458 sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [10] ajdhs.com questionnaire form table 1 1.what is the difference between ct and cbct? a) low radiation dose than ct b) high radiation dose than ct c) same radiation dose as ct 2. do you think cbct is oral medicine and radiology (omr) domain and should be present in omr department only? a) yes b) no 3.do you think cbct should be provided at dental institute? a) yes b) no 4.which session of bds should include lecture on cbct? a) preclinical b) clinical c) internship d) not required table 2 5.which technology do you prefer when you need three-dimensional imaging of the neck and head region? a) computerized tomography (ct) b) dental volumetric tomography (dvt) /cbct 6.have you ever advised cbct imaging for your patients? a) yes b) no 7. for what case would you refer your patient to cbct? a) trauma b) cyst or tumour c) implant planning d) orthodontic and endodontic evaluation e) all of the above table 3 8.have you ever obtained knowledge of cbct from your faculty? a) yes b) no 9.should there be guidelines formed for when or when not to take cbct scan? a) yes b) no 10.do you want to update your information about digital imaging/cbct? a) yes b) no 11. do you feel cde/workshop should be conducted to enhance your knowledge about digital imaging/cbct? a) yes sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [11] ajdhs.com b) no 12.do you require guidance from a radiologist for radiological facility design and protection? a) yes b) no 13. should patient be referred to an oral radiologist who is trained to handle or have enough experience in handling cbct machine? a) yes b) no 14. should all cbct scan be interpreted by oral radiologist and all reports be signed by oral and maxillofacial radiologist? a) yes b) no 15. should an oral radiologist take regular training/workshop/hands-on course for evaluation of cbct scan? a) yes b) no 16.do you think cbct is oral medicine and radiology (omr) domain and should be present in omr department only? a) yes b) no table 4 17.have you heard about cbct/dvt? a) yes b) no 18.what is the reason of not using digital imaging/cbct in your dental practice? a) lack of awareness b) lack of availability c)lack of knowledge d)tough to perform 19. are you aware of different sizes of field of view (fov) used to take cbct scan? a) yes b) no 20. are you aware that focused fov/small fov should be advised in cbct for endodontic purpose? a) yes b) no table 5 21.would you choose to use cbct as an imaging modality in your clinical practice? a) yes b) no 22. would you choose to use cbct in your future professional career? a) yes b) no sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [12] ajdhs.com result: a fundamental tool for symptomatic and beneficial introduction in the field of oral and dental surgery is dental imaging. presentation of preparation at the student level in undergraduate and graduate-level cbct should ensure that dental masters apply this technique effectively. analysing the results, a total of 200 completely filled google forms were received among which 100 undergraduates and 100 post graduates were included. among 200 participants ,68 under graduate and 70 post graduate agreed that cbct delivers the lowest radiation dose to the organs whereas spiral multi slice delivers the highest dose. on analysing the results 69 post graduates and 60 undergraduates prefers cbct to be present only in the omr department. on overviewing the results, 95 undergraduate students and 86 post graduate students thinks that cbct should present in every dental institutes. among 200 participants, 57 students from under graduate and 38 students from post graduate prefers cbct to be included in the clinical session of the bds and 25 under graduate and 47 postgraduate prefers cbct to be included in internship of the bds. out of 200 participants 62 undergraduate and 58 post graduate and advised cbct for the three dimensional imaging of the head and neck region. on analyzing the results, 74 post graduate and 70 undergraduates prefer cbct for trauma, cyst or tumour, implant planning, orthodontic and endodontic evaluation. among 200 participants, 76 under graduate and 74 post graduate said that they obtained knowledge from their faculty. out of 200 participants, 84 post graduate and 90 undergraduate students said that guidelines should be formed for when or when not to take cbct scan. 93 post graduates and 85 undergraduates said that cde or workshop should be conducted to enhance their knowledge about cbct.94 undergraduate and 74 post graduate students requires guidance from the radiologists for radiological facility design and protection.90 under graduate and 84 post graduate refer patient to the oral radiologist who is well trained to handle the cbct machine. 90 post graduate and 87 undergraduate students heard about a cbct or dvt. among 200 participants,41 undergraduate and 28 post graduates were not using cbct due to lack of awareness. however, aditya et al3 discovered in their investigation that cbct is still not widely utilized by dental specialists because of the technique's limited availability, high cost, or dentist’s incapacity to select cases for cbct. table 6 s.no questions ug (total 100) pg (total 100) chi square value p value 1 what is the difference between ct and cbct? a) low radiation dose than ct b) high radiation dose than ct c) same radiation dose as ct 68 12 20 73 11 16 0.665 0.717 2 do you think cbct is oral medicine and radiology (omr) domain and should be present in omr department only? a) yes b) no 50 50 69 31 7.490 0.006* 3 do you think cbct should be provided at dental institute? a) yes b) no 95 5 86 14 4.711 0.030* 4 which session of bds should include lecture on cbct? a) preclinical b) clinical c) internship d) not required 16 57 25 2 14 38 47 1 10.989 0.012* 5 which technology do you prefer when you need three-dimensional imaging of the neck and head region? a) computerized tomography (ct) b) dental volumetric tomography (dvt) /cbct 31 69 26 74 .613 .434 6 have you ever advised cbct imaging for your patients? a) yes b) no 62 38 58 42 .333 .564 sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [13] ajdhs.com 7 for what case would you refer your patient to cbct? a) trauma b) cyst or tumour c) implant planning d) orthodontic and endodontic evaluation e) all of the above 5 12 9 4 70 9 11 5 1 74 4.240 .374 8 have you ever obtained knowledge of cbct from your faculty? a) yes b) no 76 24 73 27 .237 .626 9 should there be guidelines formed for when or when not to take cbct scan? a) yes b) no 94 6 76 24 12.706 .000* 10 do you want to update your information about digital imaging/cbct? a) yes b) no 89 11 85 15 .707 .400 11 do you feel cde/workshop should be conducted to enhance your knowledge about digital imaging/cbct? a) yes b) no 93 7 85 15 3.269 .071 12 do you require guidance from a radiologist for radiological facility design and protection? a) yes b) no 97 3 82 18 11.971 .001* 13 should patient be referred to an oral radiologist who is trained to handle or have enough experience in handling cbct machine? a) yes b) no 90 10 84 16 1.592 .207 14 should all cbct scan be interpreted by oral radiologist and all reports be signed by oral and maxillofacial radiologist? a) yes b) no 86 14 74 26 4.500 .034* 15 should an oral radiologist take regular training/workshop/hands-on course for evaluation of cbct scan? a) yes b) no 89 11 83 17 1.495 .221 16 do you think cbct is oral medicine and radiology (omr) domain and should be present in omr department only? a) yes b) no 60 40 69 41 1.769 .184 sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [14] ajdhs.com 17 have you heard about cbct/dvt? a) yes b) no 87 13 90 10 1.233 .540 18 what is the reason of not using digital imaging/cbct in your dental practice? a) lack of awareness b) lack of availability c)lack of knowledge d)tough to perform 41 22 30 7 28 29 33 10 4.082 .253 19 are you aware of different sizes of field of view (fov) used to take cbct scan? a) yes b) no 49 51 65 34 6.646 .036 20 are you aware that focused fov/small fov should be advised in cbct for endodontic purpose? a) yes b)no 54 46 56 44 1.009 .604 21 would you choose to use cbct as an imaging modality in your clinical practice? a) yes b) no 92 8 79 21 6.816 .009 22 would you choose to use cbct in your future professional career? a) yes b) no 95 5 83 17 7.354 .007 discussion this study used a questionnaire to measure the awareness, knowledge and attitude about cbct among undergraduates and postgraduates. patients visiting dental clinic for different dental procedures were diagnosed and treated using different imaging technique. undergraduate dental students must realise the importance of cbct and should have atleast basic knowledge of dental radiographs to arrive at an accurate diagnosis. this study helped us to understand primarily how effectively dentists follow principles and practices of traditional and modern oral radiology. it also helps to measure the knowledge of about cbct and their opinions on the implementation of increased use of cbct in their practices. from the results obtained most of the undergraduates said that lack of awareness as the major reason for not using. and most of them were not aware of the different sizes of field of view in cbct. very few participants find tough to perform. the results are consistent with a study carried out in south india by sowmiya et al2 and reddy et al 4. similar findings were reported in another study done in turkey by kamburoglu et al5. based on the results obtained, most of the undergraduates and post graduates agrees that they obtain knowledge from their faculty through lectures, cde /workshops conducted at the institutes. the results were in line with a research by reddy et al and tofangchicha m et al6, evaluated the dental fraternity's knowledge and attitudes toward cbct in south india. cbct should be included both in under graduates and post graduates of other department where cbct is used to provide detail root morphology and it contributes to optimal diagnosis and treatment planning in endodontics, used in the assessment of anomalies of impaction, ectopic teeth and treatment planning in orthodontics. cbct is used in tracing of inferior alveolar canal, evaluation of cyst and tumour, fracture diagnosis, orthognathic surgical planning in department of oral and maxillofacial surgery. cbct plays major role in prosthodontics that it guides for precision implant placement, which ensures the final implant alignment. hence, cbct should be included in other department post graduates, so that it may help to deliver a quality treatment to the patients. knowledge about radiation dose of cbct was similar among undergraduate and post graduates as most of them said that cbct emits low radiation dose when compared to ct and there is no statistically significant difference between them. both under graduates and post graduates have satisfactory knowledge regarding radiation dose. the findings were similar to a study conducted by chau and fung7. they reported that cbct delivers the lowest radiation dose to the organs, whereas spiral multislice ct delivers the highest dose. among 200 participants, most of them prefer cbct for diagnosing tumour/ cysts, or implant placement, orthodontic purposes and for trauma cases. the findings were in accordance with balabaskaran k et al 8and shetty et al9 who conducted a research to assess dentist attitudes about cbct discovered that dental professionals only favour cbct imaging when they sarah samsu nisha. k et al asian journal of dental and health sciences. 2024; 4(1):9-15 [15] ajdhs.com anticipate that the diagnostic yield will materially improve clinical results, patient safety, or patient care. since cbct is present only in the oral medicine and radiology domain, majority of the undergraduates requires guidance from the radiologist for radiological facility design and protection. this may be due to lack of availability of cbct in the ug curriculum. lack of inclusion of cbct in several institutes may be due to the expenditure. hence cbct should be included both in under graduates and post graduates of other department during their clinical session/internship. most of the undergraduates refer patient to the oral radiologist for taking cbct because of their poor handling whereas post graduates had better handling when compared to undergraduates. on analysing the future applicatory response, most of them choose to use cbct as an imaging modality in their future clinical practice. hence postgraduates had better knowledge in radiological protection, handling, interpretation and awareness about cbct. conclusion from this study, it is evident that undergraduate students have less knowledge in radiological protection, interpretation and handling capacity. given the necessity, the dental fraternity should place a greater emphasis on technique and interpretation in the curriculum of the moment. the organizations ought to carry out talks or continuous education in dentistry (cde) to guarantee increased proficiency in oral radiology among students in college. oral radiology significance ought must be emphasized to the pupils throughout their undergraduate program due to its extensive utilization in the diagnosis and planning of care. dental students need to learn more about improving clinical practice in oral radiology. in order to raise dentists' awareness of various imaging modalities, it is also advised that omr departments at various dental institutions actively participate in and set up special qualifying programs for them9. dental professionals will be able to employ cbct more effectively to increase the precision and dependability of oral and maxillofacial diagnosis, treatment planning, and results if the method is made available to them through undergraduate training1. financial support and sponsorship nil conflicts of interest there are no conflicts of interest references 1. rai s, misra d, dhawan a, tyagi k, prabhat m, khatri m. knowledge, awareness, and aptitude of general dentists toward dental radiology and cbct: a questionnaire study journal of indian academy of oral medicine and radiology 2018; 30(2): 110-115 https://doi.org/10.4103/jiaomr.jiaomr_115_17 2. dr. sowmiya g, dr.aravindhswamy r m, dr. thalaimalai saravanan, awareness and knowledge of oral radiology among dental undergraduates a cross sectional study international journal dental and medical sciences research 2022;4(6): 287-291 3. aditya a, lele s, aditya p. current status of knowledge, attitude, and perspective of dental practitioners toward cone beam computed tomography: a survey. j oral maxillofac radiol 2015; 13:54 7 https://doi.org/10.4103/2321-3841.157524 4. reddy rs, kiran cs, ramesh t, kumar bn, naik rm, ramya k. knowledge and attitude of dental fraternity towards cone beam computed tomography in south india a questionnaire study. indian jdent 2013; 4:88 94 https://doi.org/10.1016/j.ijd.2012.10.003 5. kamburoglu k, kursun s, akarsala zz. dental students' knowledge and attitudes towards cone beam computed tomography in turkey. dentomaxillofac radiol 2011; 40:439 43. https://doi.org/10.1259/dmfr/21915689 pmid:21960402 pmcid:pmc3528136 6. tofangchiha m, arianfar f, bakhshi m, khorasani m. the assessment of dentists' knowledge regarding indications of cone beam computed tomography in qazvin, iran. biotech health science 2015; 2:1 5. https://doi.org/10.17795/bhs-25815 7. chau acm, fung k. comparison of radiation dose for implant imaging using conventional spiral tomography, computed tomography, and cone beam computed tomography. oral surg oral med oral pathol oral radiol endod 2009; 107:559e565. https://doi.org/10.1016/j.tripleo.2008.11.009 pmid:19168378 8. balabaskaran k, srinivasan al. awareness and attitude among dental professional towards cbct. iosr j dent med sci 2013; 10:55 9. https://doi.org/10.9790/0853-1055559 9. aditya a, lele s, aditya p. current status of knowledge, attitude, and perspective of dental practitioners toward cone beam computed tomography: a survey. j oral maxillofac radiol 2015; 13:54 7 https://doi.org/10.4103/2321-3841.157524 10. shetty sr, castelino rl, babu sg, prasanna, laxmana ar, roopassri k. knowledge and attitude of dentists towards cone beam computed tomography in mangalore a questionnaire survey. austin j radiol 2015; 2:1 5 https://doi.org/10.4103/jiaomr.jiaomr_115_17 https://doi.org/10.4103/2321-3841.157524 https://doi.org/10.1016/j.ijd.2012.10.003 https://doi.org/10.1259/dmfr/21915689 https://doi.org/10.17795/bhs-25815 https://doi.org/10.1016/j.tripleo.2008.11.009 https://doi.org/10.9790/0853-1055559 https://doi.org/10.4103/2321-3841.157524 pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [38] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited using ai to increase medication adherence pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 09 april 2024 reviewed 12 may 2024 accepted 04 june 2024 published 15 june 2024 _____________________________________________ cite this article as: dave p, using ai to increase medication adherence, asian journal of dental and health sciences. 2024; 4(2):38-43 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.80 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ although different measures have been taken to increase medication adherence, it still remains a significant challenge with research indicating that the rates of non-adherence remain as high as 40 to 50%. increasing medication adherence because non-adherence has a direct impact on patient outcomes. non-adherence contributes significantly to treatment failure. it also increases the rates of hospitalizations, mortality, and morbidity. non-adherence also adds to healthcare costs affecting the ability of healthcare systems to provide the needed quality of care. despite the implementation of traditional measures to increase adherence, these measures have led to mixed results. most of these measures are limited because they rely on patient self-reports to measure adherence. they also do not verify whether a patient takes medication or not. without verifying or confirming a patient has taken medication, it becomes significantly challenging to measure the rate of adherence. this necessitates the need for additional technologies to increase medication adherence. leveraging technologies such as ai can help to address the limitations of traditional approaches to ensuring medication adherence. ai can be used to both predict adherence and improve adherence. however, to gain the full benefits offered by ai, it is important to address the challenges these technologies present such as ethical issues with regard to patient privacy and confidentiality of their data. the use of ai to increase medication adherence is also limited by limited knowledge and skills on how to use these technologies effectively and the type of technologies available. therefore, this review explores how ai-based technologies can be used to increase medication adherence. keywords: medication adherence, non-adherence, artificial intelligence, patient outcomes, machine learning introduction medication adherence remains a significant challenge despite numerous measures taken to improve adherence and years of advocacy on the importance of the same. globally, nonadherence remains as high as 40% to 50%, particularly for patients grappling with chronic diseases.1,2 medication adherence is imperative because non-adherence has a direct impact on patient outcomes.3 in fact, medication adherence has a more direct impact on patient outcomes than the treatment itself. in the united states, non-adherence accounts for up to 50% of treatment failure, contributes to about 25% of hospitalizations and leads to up to 125,000 deaths.4 despite the measures that have been taken to increase medication adherence, it remains a significant challenge mainly because the responsibility of medication adherence largely falls on patients. as a result, it because extremely challenging to attain significant success. different factors contribute to the high rates of medication non-adherence. patient-related barriers account for the highest cases of non-adherence. they include forgetting to take medications when expected, forgetting to go for refills, poor understanding of dosage and schedules, patient attitudes and beliefs about medication, side effects, impaired cognition, and lack of patient engagement in the treatment decisions among others.5 although the factors that contribute to non-adherence are known, addressing them is still a significant challenge. different traditional measures of ensuring adherence such as pill counts, examining the rates of prescription refills, and electronic medication monitors have been taken over the years but despite this effort, the problem persists.6 this necessitates new measures to be adopted to increase medication adherence. the increasing adoption of technology in healthcare shows a lot of promise in different areas including medication adherence. according to research by treskes et al., smart technology has been shown to increase medication adherence in patients with cardiovascular disease.7 the research investigated the potential of different types of technologies including phone interventions, short message service (sms), smart pill boxes, web-based interventions, and mobile apps and showed that they had a lot of potential to increase adherence.7 technologybased methods of monitoring medication adherence show a lot of promise as they have been shown to have accuracy when it comes to monitoring adherence rates. however, successful implementation of these methods is still a challenge with results indicating mixed results when it comes to their efficacy in monitoring adherence.8,9 the mixed results on the effectiveness of these technologies require further research in this area. ai-powered technologies are coming up as better alternatives to improve medication adherence. research has shown that these technologies improve medication adherence for different conditions.10,11,12,13 to aid in medication adherence, ai-powered tools can perform a number of functions. these functions include identifying non-adherent individuals, sending reminders, educating patients on the importance of medication adherence, and monitoring patients’ adherence.11 identifying non-adherent individuals is important because it will lead to dedicated and personalized efforts to increase adherence. it is open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.80 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.80&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [39] ajdhs.com also important to educate patients on the importance of adherence and send reminders. all these measures can help to increase adherence. this review seeks to explore how ai can be used to increase medication adherence. it bases its findings on past review papers that have documented the use of ai to increase medication adherence. as such, it explores both the positives and limitations of the same. importance of medication adherence the world health organization recognizes the importance of medication adherence on disease outcomes by noting that non-adherence leads to poor patient outcomes and compounds the challenge of improving health.14 medication non-adherence also results in wastage of the already limited healthcare resources. the problem of non-adherence is a significant challenge with research showing that up to 50% of people living with chronic illness do not take their medications as prescribed or expected.2,15,16 poor adherence has a negative impact on health. in addition to increasing morbidity and mortality rates, nonadherence leads to wastage, disease progression, increased hospital visits and admissions, and lower quality of life.6,17,18 in addition to the negative impact on health, medication nonadherence has significant cost implications. according to cutler et al., the disease-specific economic cost of medication nonadherence averages $949 to $44 190 per person.19 when it comes to all causes, the cost rises significantly to an average of $5271 to $52 341.19 these cost implications pose a significant burden to healthcare systems which are already burdened by high costs of care which impacts people’s ability to get medications for prescribed conditions.20 addressing non-compliance remains a significant challenge because it is attributed to different causes. the causes can be patient-related, treatment-related or even providerrelated. patient-related non-adherence results from patient views and beliefs, social contexts, access or service issues.14 patients' views and beliefs play a crucial when it comes to nonadherence. beliefs and views about the illness can inform their decision to adhere to medication or not.14 for instance, if patients believe they need medication for their disease, then they are likely to adhere to it. patients who believe the illness can go away without the medication are likely to be nonadherent. non-adherence can also be informed by patients' cultural or religious beliefs. non-adherence may also be informed by the patients’ motivation to manage illness. if they are motivated to manage the illness, then they are likely to adhere to medication. other factors such as forgetfulness, psychological stress, inadequate knowledge and skills, anxiety about medication adverse events, and lack of perceived need for treatment also inform patients’ decision to not adhere to medication. inadequate knowledge and skills can affect patients’ ability to read and understand medication instructions which can inform decisions not to adhere to medication.6 research has documented that patients who have low health literacy are likely to have negative disease outcomes.21,22 this is informed by factors such as the inability to understand medication instructions hence making them not to take medications or take them in a way that is not prescribed. such can lead to negative outcomes. fear of side effects is another commonly reported factor that contributes to medication non-adherence.23 fear of side effects may be informed by factors such as negative reactions towards similar medication in the past, unpleasant withdrawal effects, and patient perceptions of the drugs.24 other patient-related factors that are attributed to poor medication adherence are complex regimens that involve taking many medications with varying dosage schedules, longterm drug regimes, inadequate access, cost, inconvenience of taking medications, unpleasant taste, and busy work schedule.6,23 provider-related barriers can also contribute to poor medication adherence. poor provider-patient communication is one of the provider-related barriers that is attributed to medication non-adherence.25 effective communication is important to improve adherence because it enables patients to understand their illness better, the benefits of adhering to the medication regimen, and the risks that may arise if medication is not adhered to.26 patient-provider communication is identified as instrumental in the patient-provider relationship which has been identified as a factor that informs medication non-adherence.27 for example, a poor-patient provider relationship can make it difficult for patients to ask relevant questions regarding their medication. failing to clarify issues of concern can lead to confusion, misunderstanding, and subsequent non-adherence. poor-patient-provider relationships may also make patients feel that doctors are not telling their patients the whole truth. such feelings may inform non-adherence to the prescribed medications. good communication makes patients feel more involved and are likely to take more control over their health including taking medications as prescribed. provider-related barriers can also result from inadequate knowledge.28,29,30 providers who lack adequate knowledge about a disease or the assigned treatment are less likely to provide patients with the needed information. this results in non-adherence. patient-physician discordance has also been attributed to non-adherence. patient-physician discordance is defined as the difference between patient and physician evaluations of health-related information.6 such discordance leads to poor health outcomes. research suggests patientphysician discordance as one of the factors that lead to nonadherence.6 if patients and physicians have different views of health-related information, conflict is likely to emerge affecting medication adherence. limitations of traditional methods of ensuring medication adherence traditional measures of ensuring medication adherence have shown mixed results with some showing high success rates in increasing adherence while others showing very little success when it comes to increasing adherence. some of the most commonly used measures to measure adherence are pill counts, self-reports, measures involving clinician assessment, patient diaries, and patient interviews.2,31 some of these methods have had more success than others. for example, although pill count is a simple and low-cost method of assessing medication adherence, it has several limitations. pill count is not feasible when it comes to assessing non-discrete dosages. underestimation of adherence also occurs regularly because pill count does not consider the likelihood of having surplus medication. other limitations that are associated with pill count are the inability to determine whether the dosage units removed are really taken and the inability to determine whether the patient is following the regimen even after the removal of the right number of units.32 clinician assessment and patient self-report have low success rates when it comes to measuring adherence rates. it is difficult to determine whether the patient is correctly reporting adherence by simply relying on an assessment of the same or a self-report.2 patients may also have difficulty communicating or answering the questions as expected. however, despite being highly unreliable, they are still preferred because of low cost, simplicity, and real-time feedback. patient diaries are also a pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [40] ajdhs.com simple method to measure adherence but they are unreliable, limited by overestimation, and false reporting.33 medication events monitoring systems (mems) have shown more accuracy when it comes to medication adherence compared to methods such as pill counts, patient diaries, and self-reports. research has shown that mems is able to determine non-adherence because it records both the time and date when medication is taken from a container.2 as such, it is able to establish whether there is an abnormal medicationtaking pattern or the number of doses missed. research has shown that the ability to note the exact time and date the medication is taken from the bottle makes it more reliable that patient diaries or self-report. besides, research has shown that mems helps to increase adherence.34,35 the limitations of traditional measures of medication adherence are what inform the need to explore other measures to increase adherence. ai-powered measures are being considered valuable tools to increase adherence by both predicting adherence and providing a comprehensive assessment of patients’ adherence behavior.36 ai has been explored for different conditions including chronic diseases. in some instances, it has been shown to increase adherence by up to 70 to 80%.37 with such high adherence rates, ai tools are likely to be a good alternative to traditional methods of ensuring medication adherence. the role of ai in increasing medication adherence capitalizing on ai and machine learning-based technologies to increase medication adherence can have a positive impact on patient outcomes. ai-based tools and technologies together with traditional tools of ensuring medication adherence can make a significant impact in this area and lead to positive outcomes. there is research documenting the use of different ai-powered technologies in ensuring medication adherence.11 the technology has a lot of potential when it comes to increasing adherence because it leverages data to offer personalized and intelligent support to patients that can aid in behavioral change and lead to increased adherence. ai-powered technologies and tools have documented varied levels of success in different areas of medication adherence including prediction, reminders, and monitoring of patient adherence. one of the areas where ai-based tools and technologies are being used is to predict medication adherence and non-adherence. predicting adherence or non-adherence is important in increasing medication adherence. it helps to determine the patient’s likelihood of adhering to the prescribed medication regimen. according to koesmahargyo et al., the prediction of medication adherence traditionally relies on the assessment of factors such as tolerability, treatment length, and demographics.38 however, with the introduction of technologies with the ability to automatically measure medication dosing in real-time, it becomes easier to measure adherence. such technologies rely on real-time data. as such, it becomes much easier to predict whether the patient will adhere to medication or not. ai-based technologies provide accuracy when it comes to making such predictions. gu et al. suggest that predicting medication adherence can be done using ensemble learning and deep learning models.39these models provide an opportunity to identify patients who have a high risk of nonadherence within a specific time frame. wu et al. found that using machine learning algorithms to predict non-adherence in type 2 diabetes patients helped to identify risk factors that increased the likelihood of non-adherence.40 identifying risk factors made it easier to provide individualized diabetes care and education hence increasing the likelihood of adherence. similarly, li et al. established that machine learning could be used to predict the risk of non-adherence in patients with type 2 diabetes.41 predicting medication adherence and nonadherence is imperative because it helps to identify factors that make it difficult for patients to adhere to medications and design personalized solutions to the problem. for instance, it becomes easier to tailor patient education and care if factors that make it difficult to adhere to medication are known. in addition to predicting adherence levels, aipowered tools can be used to increase adherence. research has documented the success of ai when it comes to improving medication adherence.11,12 labovitz et al. showed that ai improved adherence in patients on anticoagulation therapy by up to 50%.12 the study showed that even patients who had limited experience with using smartphones were able to use the technology effectively to increase their adherence. the study attributed the improvement in adherence to a number of factors including real-time monitoring, ability to accurately monitor medication ingestion, and change in patient behavior. ai-based technologies can also be used to monitor patient compliance. a novel artificial intelligence platform on mobile devices increased dosing compliance by 17.9% in patients with schizophrenia.42 for patients who were monitored using the ai platform, the compliance was 89.7% which was higher than the 71.9% that was recorded for patients who were not monitored using ai.42 the ai platform collected data on the date and time stamps the medication was taken for each pill. it also collected data on missed doses, skipped doses, and doses taken in the clinic. other data that was collected was visual confirmation of the patient ingesting the drug which was done using the tool. visual confirmation increased the accuracy of the platform when compared to traditional methods of monitoring medication adherence such as pill counts or patients’ selfreports. ai-powered technologies can also be used to increase medication adherence in conditions that require long-term therapies such as tuberculosis (tb) and chronic diseases. longterm drug regimens are recognized as a barrier to medication adherence.6 diseases such as tb are managed through longterm therapies with some therapies lasting up to 6 months. these long-term therapies pose a significant challenge to patients which explains why non-adherence is commonly reported in tb patients.43 considering the importance of adhering to medication when it comes to the management of tb, it is important to use technology to increase adherence. one study has documented the significance of using ai algorithms to increase medication adherence in patients living with tb.44 the study documented success with ai algorithms resulting in effective management of tb therapies. besides, research has documented that digital adherence technologies have high success rates in increasing adherence to tb therapy particularly when they are integrated with clinical strategies.45,46 some of these technologies are powered by ai. other areas where ai can be used to increase medication adherence are to increase patients’ rates of refill, monitor patients’ adherence, and monitor adverse events. ai has a lot of potential when it comes to increasing medication adherence. leveraging this potential can lead to positive outcomes for both patients and healthcare systems. aipowered technologies can be used to address patient-related barriers that affect medication adherence such as forgetfulness and poor reporting. leveraging ai can also help to reduce costs associated with medication non-adherence. some studies have documented that ai-powered tools significantly increase adherence which means that they can help to fill the gaps left by traditional methods of measuring adherence such as pill counts, patient self-reports, and clinical assessment. however, to gain the full benefits of ai, there is a need to address the challenges posed by ai use in monitoring medication adherence. pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [41] ajdhs.com challenges of using ai to increase medication adherence although ai shows a lot of potential in addressing medication adherence challenges, it presents unique barriers that need to be addressed to optimize its potential. one of the unique barriers presented by ai use in medication adherence is ethical issues.11 the use of ai in healthcare has always presented a challenge when it comes to patient data, privacy, and confidentiality.47 ai and machine learning deal with large datasets most of which contain patient-sensitive information. as a result, securing patient privacy and confidentiality when it comes to the use of this data becomes challenging. securing patient privacy and confidentiality when it comes to the use of ai in ensuring medication adherence becomes particularly challenging considering such technologies require the use of patient data to be effective. for instance, to ensure patients adhere to medication, it is important to have personal data on these patients. securing this data and ensuring patient anonymity can be challenging limiting the use of ai to increase medication adherence. an additional issue that emerges from the use of ai to increase medication adherence is the lack of knowledge and skills on how to effectively use these technologies. research has documented limited skill sets as one of the challenges that limit the use of ai in healthcare. a lack of knowledge and skills on how to use these technologies to monitor adherence can limit their use and implementation.36 limitations of knowledge on the available ai-based technologies also limit their use. although significant advances have been made in the development of ai-based solutions for different areas of healthcare, most of these technologies are not known to healthcare providers limiting their use. addressing the limitations in knowledge and skillsets can increase ai use in monitoring medication adherence. conclusion increasing medication adherence is vital to improve patient outcomes. however, despite the implementation of different measures to improve adherence, it still remains a significant challenge with these measures producing mixed results. most of the traditional measures of ensuring medication adherence are limited by the fact that they do not verify medication administration. without verifying medication administration, it becomes really challenging to measure adherence. increasing medication adherence is recognized as instrumental in improving patient outcomes. non-adherence also compounds the challenge of improving health. other problems attributed to non-adherence are increased morbidity, increased mortality, increased hospital visits and admissions, significant disease progression, and poor quality of life. nonadherence also costs healthcare systems billions of dollars each year. leveraging technologies such as ai can help to address the limitations of traditional approaches to ensuring medication adherence. ai-powered technologies are being used in different areas of healthcare and medication adherence is not an exemption. ai can be used to both predict adherence and improve adherence. however, to gain the full benefits offered by ai, it is important to address the challenges these technologies present. for instance, ethical issues remain a prevalent problem when it comes to ai use in healthcare. maintaining patient privacy and confidentiality on sensitive issues is a significant problem. the use of ai to increase medication adherence is also limited by limited knowledge and skills on how to use this technology effectively. references 1. lee ek, poon p, yip bh, et al. global burden, regional differences, trends, and health consequences of medication nonadherence for hypertension during 2010 to 2020: a meta-analysis involving 27 million patients. journal of the american heart association. 2022;11(17):e026582. https://doi.org/10.1161/jaha.122.026582 pmid:36056737 pmcid:pmc9496433 2. lam wy, fresco p. medication adherence measures: an overview. biomed research international. 2015;2015(1):217047. https://doi.org/10.1155/2015/217047 pmid:26539470 pmcid:pmc4619779 3. brown mt, bussell jk. medication adherence: who cares?. in mayo clinic proceedings 2011 apr 1 (vol. 86, no. 4, pp. 304-314). elsevier. https://doi.org/10.4065/mcp.2010.0575 pmid:21389250 pmcid:pmc3068890 4. kim j, combs k, downs j, tillman f. medication adherence: the elephant in the room. us pharm. 2018;43(1):30-4. 5. neiman ab. cdc grand rounds: improving medication adherence for chronic disease management-innovations and opportunities. mmwr. morbidity and mortality weekly report. 2017;66. https://doi.org/10.15585/mmwr.mm6645a2 pmid:29145353 pmcid:pmc5726246 6. jimmy b, jose j. patient medication adherence: measures in daily practice. oman medical journal. 2011;26(3):155. https://doi.org/10.5001/omj.2011.38 pmid:22043406 pmcid:pmc3191684 7. treskes rw, van der velde et, schoones jw, schalij mj. implementation of smart technology to improve medication adherence in patients with cardiovascular disease: is it effective?. expert review of medical devices. 2018;15(2):119-26. https://doi.org/10.1080/17434440.2018.1421456 pmid:29271661 8. dave p, how digital health is revolutionizing healthcare and contributing to positive health outcomes, journal of drug delivery and therapeutics. 2024; 14(6):287-293 https://doi.org/10.22270/jddt.v14i6.6640 9. mason m, cho y, rayo j, gong y, harris m, jiang y. technologies for medication adherence monitoring and technology assessment criteria: narrative review. jmir mhealth and uhealth. 2022;10(3):e35157. https://doi.org/10.2196/35157 pmid:35266873 pmcid:pmc8949687 10. bohlmann a, mostafa j, kumar m. machine learning and medication adherence: scoping review. jmirx med. 2021;2(4):e26993. https://doi.org/10.2196/26993 pmid:37725549 pmcid:pmc10414315 11. babel a, taneja r, mondello malvestiti f, monaco a, donde s. artificial intelligence solutions to increase medication adherence in patients with non-communicable diseases. frontiers in digital health. 2021;3:669869. https://doi.org/10.3389/fdgth.2021.669869 pmid:34713142 pmcid:pmc8521858 12. labovitz dl, shafner l, reyes gil m, virmani d, hanina a. using artificial intelligence to reduce the risk of nonadherence in patients on anticoagulation therapy. stroke. 2017;48(5):1416-9. https://doi.org/10.1161/strokeaha.116.016281 pmid:28386037 pmcid:pmc5432369 13. pinho s, cruz m, ferreira f, ramalho a, sampaio r. improving medication adherence in hypertensive patients: a scoping review. preventive medicine. 2021;146:106467. https://doi.org/10.1016/j.ypmed.2021.106467 pmid:33636195 14. world health organization. adherence to long-term therapies: evidence for action. world health organization. 2003. available from: https://iris.who.int/handle/10665/42682 15. glombiewski ja, nestoriuc y, rief w, glaesmer h, braehler e. medication adherence in the general population. plos one. 2012;7(12):e50537. https://doi.org/10.1371/journal.pone.0050537 pmid:23272064 pmcid:pmc3525591 16. yeaw j, benner js, walt jg, sian s, smith db. comparing adherence and persistence across 6 chronic medication classes. journal of managed care pharmacy. 2009;15(9):728-40. https://doi.org/10.1161/jaha.122.026582 https://doi.org/10.1155/2015/217047 https://doi.org/10.4065/mcp.2010.0575 https://doi.org/10.15585/mmwr.mm6645a2 https://doi.org/10.5001/omj.2011.38 https://doi.org/10.1080/17434440.2018.1421456 https://doi.org/10.22270/jddt.v14i6.6640 https://doi.org/10.2196/35157 https://doi.org/10.2196/26993 https://doi.org/10.3389/fdgth.2021.669869 https://doi.org/10.1161/strokeaha.116.016281 https://doi.org/10.1016/j.ypmed.2021.106467 https://iris.who.int/handle/10665/42682 https://doi.org/10.1371/journal.pone.0050537 pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [42] ajdhs.com https://doi.org/10.18553/jmcp.2009.15.9.728 pmid:19954264 pmcid:pmc10441195 17. mongkhon p, ashcroft dm, scholfield cn, kongkaew c. hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies. bmj quality & safety. 2018;27(11):902-14. https://doi.org/10.1136/bmjqs-2017-007453 pmid:29666309 18. dave p, how ai can revolutionize the pharmaceutical industry. journal of drug delivery and therapeutics. 2024; 14(6):179-183. https://doi.org/10.22270/jddt.v14i6.6657 19. cutler rl, fernandez-llimos f, frommer m, benrimoj c, garciacardenas v. economic impact of medication non-adherence by disease groups: a systematic review. bmj open. 2018;8(1):e016982. https://doi.org/10.1136/bmjopen-2017016982 pmid:29358417 pmcid:pmc5780689 20. van alsten sc. cost-related nonadherence and mortality in patients with chronic disease: a multiyear investigation, national health interview survey, 2000-2014. preventing chronic disease. 2020;17. https://doi.org/10.5888/pcd17.200244 pmid:33274701 pmcid:pmc7735485 21. berkman nd, sheridan sl, donahue ke, halpern dj, crotty k. low health literacy and health outcomes: an updated systematic review. annals of internal medicine. 2011;155(2):97-107. https://doi.org/10.7326/0003-4819-155-2-201107190-00005 pmid:21768583 22. shahid r, shoker m, chu lm, frehlick r, ward h, pahwa p. impact of low health literacy on patients' health outcomes: a multicenter cohort study. bmc health services research. 2022;22(1):1148. https://doi.org/10.1186/s12913-022-08527-9 pmid:36096793 pmcid:pmc9465902 23. khan mu, shah s, hameed t. barriers to and determinants of medication adherence among hypertensive patients attended national health service hospital, sunderland. journal of pharmacy and bioallied sciences. 2014;6(2):104-8. https://doi.org/10.4103/0975-7406.129175 pmid:24741278 pmcid:pmc3983739 24. smith le, webster rk, rubin gj. a systematic review of factors associated with side-effect expectations from medical interventions. health expectations. 2020;23(4):731-58. https://doi.org/10.1111/hex.13059 pmid:32282119 pmcid:pmc7495066 25. ghosh p, balasundaram s, sankaran a, chandrasekaran v, sarkar s, choudhury s. factors associated with medication non-adherence among patients with severe mental disorder-a cross sectional study in a tertiary care centre. exploratory research in clinical and social pharmacy. 2022;7:100178. https://doi.org/10.1016/j.rcsop.2022.100178 pmid:36161207 pmcid:pmc9493377 26. świątoniowska-lonc n, polański j, tański w, jankowska-polańska b. impact of satisfaction with physician-patient communication on self-care and adherence in patients with hypertension: crosssectional study. bmc health services research. 2020;20:1-9. https://doi.org/10.1186/s12913-020-05912-0 pmid:33198739 pmcid:pmc7670590 27. stavropoulou c. non-adherence to medication and doctor-patient relationship: evidence from a european survey. patient education and counseling. 2011;83(1):7-13. https://doi.org/10.1016/j.pec.2010.04.039 pmid:20541884 28. dave p, the vital role of pharmacists in diabetes self-care, journal of drug delivery and therapeutics. 2024; 14(5):229-233 https://doi.org/10.22270/jddt.v14i5.6582 29. krishnamoorthy y, rajaa s, rehman t, thulasingam m. patient and provider's perspective on barriers and facilitators for medication adherence among adult patients with cardiovascular diseases and diabetes mellitus in india: a qualitative evidence synthesis. bmj open. 2022;12(3):e055226. https://doi.org/10.1136/bmjopen2021-055226 pmid:35332041 pmcid:pmc8948385 30. brown mt, bussell j, dutta s, davis k, strong s, mathew s. medication adherence: truth and consequences. the american journal of the medical sciences. 2016;351(4):387-99. https://doi.org/10.1016/j.amjms.2016.01.010 pmid:27079345 31. ho pm, bryson cl, rumsfeld js. medication adherence: its importance in cardiovascular outcomes. circulation. 2009;119(23):3028-35. https://doi.org/10.1161/circulationaha.108.768986 pmid:19528344 32. van onzenoort ha, verberk wj, kessels ag, et al. assessing medication adherence simultaneously by electronic monitoring and pill count in patients with mild-to-moderate hypertension. american journal of hypertension. 2010;23(2):149-54. https://doi.org/10.1038/ajh.2009.207 pmid:19927136 33. nunes v, neilson j, o'flynn n, et al. medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. other. nice: national institute for health and clinical excellence, london, uk. available from: https://www.ncbi.nlm.nih.gov/books/nbk55447/ 34. van heuckelum m, van den ende ch, houterman ae, heemskerk cp, van dulmen s, van den bemt bj. the effect of electronic monitoring feedback on medication adherence and clinical outcomes: a systematic review. plos one. 2017;12(10):e0185453. https://doi.org/10.1371/journal.pone.0185453 pmid:28991903 pmcid:pmc5633170 35. demonceau j, ruppar t, kristanto p, et al. identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and metaanalysis. drugs. 2013;73:545-62. https://doi.org/10.1007/s40265-013-0041-3 pmid:23588595 pmcid:pmc3647098 36. pulice e, coustasse a. ai-driven solutions promote medication adherence. pharmacy times. available from: https://www.pharmacytimes.com/view/ai-driven-solutionspromote-medication-adherence 37. warren d, marashi a, siddiqui a, et al. using machine learning to study the effect of medication adherence in opioid use disorder. plos one. 2022;17(12):e0278988. https://doi.org/10.1371/journal.pone.0278988 pmid:36520864 pmcid:pmc9754174 38. koesmahargyo v, abbas a, zhang l, et al. accuracy of machine learning-based prediction of medication adherence in clinical research. psychiatry research. 2020;294:113558. https://doi.org/10.1016/j.psychres.2020.113558 pmid:33242836 39. gu y, zalkikar a, liu m, et al. predicting medication adherence using ensemble learning and deep learning models with large scale healthcare data. scientific reports. 2021;11(1):18961. https://doi.org/10.1038/s41598-021-98387-w pmid:34556746 pmcid:pmc8460813 40. wu xw, yang hb, yuan r, long ew, tong rs. predictive models of medication non-adherence risks of patients with t2d based on multiple machine learning algorithms. bmj open diabetes research and care. 2020;8(1):e001055. https://doi.org/10.1136/bmjdrc-2019-001055 pmid:32156739 pmcid:pmc7064141 41. li m, lu x, yang h, et al. development and assessment of novel machine learning models to predict medication non-adherence risks in type 2 diabetics. frontiers in public health. 2022;10:1000622. https://doi.org/10.3389/fpubh.2022.1000622 pmid:36466490 pmcid:pmc9714465 42. bain ee, shafner l, walling dp, othman aa, chuang-stein c, hinkle j, hanina a. use of a novel artificial intelligence platform on mobile devices to assess dosing compliance in a phase 2 clinical trial in subjects with schizophrenia. jmir mhealth and uhealth. 2017;5(2):e7030. https://doi.org/10.2196/mhealth.7030 pmid:28223265 pmcid:pmc5340925 43. sazali mf, rahim ss, mohammad ah, et al. improving tuberculosis medication adherence: the potential of integrating digital technology and health belief model. tuberculosis and respiratory diseases. 2023;86(2):82. https://doi.org/10.4046/trd.2022.0148 pmid:36597583 pmcid:pmc10073608 https://doi.org/10.18553/jmcp.2009.15.9.728 https://doi.org/10.1136/bmjqs-2017-007453 https://doi.org/10.22270/jddt.v14i6.6657 https://doi.org/10.1136/bmjopen-2017-016982 https://doi.org/10.1136/bmjopen-2017-016982 https://doi.org/10.5888/pcd17.200244 https://doi.org/10.7326/0003-4819-155-2-201107190-00005 https://doi.org/10.1186/s12913-022-08527-9 https://doi.org/10.4103/0975-7406.129175 https://doi.org/10.1111/hex.13059 https://doi.org/10.1016/j.rcsop.2022.100178 https://doi.org/10.1186/s12913-020-05912-0 https://doi.org/10.1016/j.pec.2010.04.039 https://doi.org/10.22270/jddt.v14i5.6582 https://doi.org/10.1136/bmjopen-2021-055226 https://doi.org/10.1136/bmjopen-2021-055226 https://doi.org/10.1016/j.amjms.2016.01.010 https://doi.org/10.1161/circulationaha.108.768986 https://doi.org/10.1038/ajh.2009.207 https://www.ncbi.nlm.nih.gov/books/nbk55447/ https://doi.org/10.1371/journal.pone.0185453 https://doi.org/10.1007/s40265-013-0041-3 https://www.pharmacytimes.com/view/ai-driven-solutions-promote-medication-adherence https://www.pharmacytimes.com/view/ai-driven-solutions-promote-medication-adherence https://doi.org/10.1371/journal.pone.0278988 https://doi.org/10.1016/j.psychres.2020.113558 https://doi.org/10.1038/s41598-021-98387-w https://doi.org/10.1136/bmjdrc-2019-001055 https://doi.org/10.3389/fpubh.2022.1000622 https://doi.org/10.2196/mhealth.7030 https://doi.org/10.4046/trd.2022.0148 pallav dave asian journal of dental and health sciences. 2024; 4(2):38-43 [43] ajdhs.com 44. kim k, kim b, chung aj, kwon k, choi e, nah jw. algorithm and system for improving the medication adherence of tuberculosis patients. in2018 international conference on information and communication technology convergence (ictc). 2018 (pp. 914916). ieee. https://doi.org/10.1109/ictc.2018.8539402 45. liu x, thompson j, dong h, sweeney s, li x, yuan y, wang x, he w, thomas b, xu c, hu d. digital adherence technologies to improve tuberculosis treatment outcomes in china: a cluster-randomised superiority trial. the lancet global health. 2023;11(5):e693-703. https://doi.org/10.1016/s2214-109x(23)00068-2 pmid:37061308 46. subbaraman r, de mondesert l, musiimenta a, pai m, mayer kh, thomas be, haberer j. digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities. bmj global health. 2018;3(5):e001018. https://doi.org/10.1136/bmjgh-2018-001018 pmid:30364330 pmcid:pmc6195152 47. lee d, yoon sn. application of artificial intelligence-based technologies in the healthcare industry: opportunities and challenges. international journal of environmental research and public health. 2021;18(1):271. https://doi.org/10.3390/ijerph18010271 pmid:33401373 pmcid:pmc7795119 https://doi.org/10.1109/ictc.2018.8539402 https://doi.org/10.1016/s2214-109x(23)00068-2 https://doi.org/10.1136/bmjgh-2018-001018 https://doi.org/10.3390/ijerph18010271 sulistyani et al. asian journal of dental and health sciences. 2025; 5(1):67-71 [67] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited oral health literacy level and biofilm maturation as risk indicators for dental caries and gingivitis: a cross-sectional study herastuti sulistyani * , quroti a’yun , dewi risnawati , diani sulistiawati department of dental health, poltekkes kemenkes yogyakarta, indonesia article info: _____________________________________________ article history: received 06 dec 2024 reviewed 14 jan 2025 accepted 07 feb 2025 published 15 march 2025 _____________________________________________ cite this article as: sulistyani h, a’yun q, risnawati d, sulistiawati d, oral health literacy level and biofilm maturation as risk indicators for dental caries and gingivitis: a crosssectional study, asian journal of dental and health sciences. 2025; 5(1):67-71 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.111 _______________________________________________________ *address for correspondence: herastuti sulistyani, department of dental health, poltekkes kemenkes, jl. kyai mojo 56, yogyakarta, indonesia abstract _________________________________________________________________________________________________________________ background. in indonesia, dental and oral disorders are prevalent, with dental caries and gingivitis being the most common types of tooth decay in elementary school children. gingivitis affects 90% of the world's population, with 80% of those affected being children under 12. oral health literacy, which includes reading, writing, arithmetic, speaking, listening, and making sound decisions, is crucial for preventing oral diseases. methods. a study involving 82 primary school students. the study used a modified ohl-aq questionnaire and the gc triplaque id gel™ (tpid) technique to assess biofilm maturation results. the results showed a significant link between oral health literacy and biofilm maturation, suggesting that inadequate oral health literacy increases the risk of dental caries. conclusions. inadequate oral health literacy increases biofilm maturation and the risk of dental caries. keywords: health literacy, biofilm, dental caries, gingivitis, cross-sectional study introduction oral health plays an important role in supporting individual health. problems with teeth and mouth in indonesia reached 57.6%, while in the special region of yogyakarta province showed a higher percentage than the average in indonesia, which was 65.6%.1 there are several types of dental and oral diseases, but dental caries is a dental and oral disease that many children suffer from. dental caries is a dental tissue disease characterized by tissue damage, starting from the tooth surface, namely from enamel, dentin, and extending towards the pulp. dental caries is one of the most common forms of tooth decay experienced by school-age children, which can interfere with the growth and development process.2 the problem of dental caries in children, if not treated, will get worse, making children experience loss of chewing power and disrupting digestion.3 in addition, dental caries can also cause dental pain, it reduces the frequency of children's attendance to school, disrupts learning concentration, affects appetite and food intake, it can affect nutritional status and ultimately result in impaired physical growth of children. this will affect the nutritional status and health of children.4 apart from dental caries, the oral cavity disease that many people suffer from is gingivitis. the world health organization survey results show that 90% of the world's population suffers from gingivitis and 80% of them are children under 12 years of age. gingivitis is the initial stage of periodontal disease in the form of inflammation of the gingiva caused by poor oral hygiene resulting in the accumulation of biofilm along the gingival margin.5 research conducted by karim, et al, showed a high incidence of gingivitis in children aged 912 years, namely 63.83% had mild inflammation and 27.66% had moderate inflammation.6 lossu, et al state that gingival tissue that experiences inflammation is called gingivitis.7 one of the causes of gingivitis is biofilm that sticks to the teeth. untreated gingivitis will continue and cause damage to the supporting tissues of the teeth (periodontitis), the teeth become loose and must be removed. biofilm is a collection of microorganism cells that are irreversibly attached to a surface and encased in a matrix of extracellular polymeric substances (eps) that it produces itself, and shows a change in phenotype.8,9 biofilms that are still young (immature) and in the oral cavity, are a normal condition, considering that biofilms are formed continuously. mature biofilms can cause open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.111 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.111&amp;domain=pdf https://orcid.org/0000-0002-6927-7644 https://orcid.org/0000-0002-1698-8004 https://orcid.org/0009-0006-3292-7427 https://orcid.org/0009-0009-8922-3414 sulistyani et al. asian journal of dental and health sciences. 2025; 5(1):67-71 [68] ajdhs.com diseases in the oral cavity such as dental caries and gingivitis, because they are dominated by cariogenic bacteria and periodontic bacteria.10 based on research by seneviratne, et al., biofilm matures in vitro after 24-72 hours, while in vivo after 72 hours.11 biofilm accumulation can be prevented by good oral health self-care behavior. one of the factors that influence oral health self-care behavior is health literacy, which is the level of a person's capacity to obtain, process and understand basic health information and services needed to make appropriate health decision.12 oral health literacy is a general term that includes the skills of reading, writing, counting, speaking, listening, and making appropriate decisions, especially in every action related to oral health.13 a person who has low oral health literacy has a high risk of oral disease and matters related to oral disease.14 elementary school children are a critical period for the occurrence of oral diseases, because at this age the ability to prevent biofilm accumulation, as a causative factor in the occurrence of oral diseases is not yet adequate. the purpose of this study was to investigate the level of oral health literacy of elementary school students and biofilm maturation as a risk indicator for dental caries and gingivitis. materials and methods this study was an analytic observational study with a cross-sectional design. the sampling technique used was purposive sampling, the number of samples in this study were 82 respondents. the research location was at the elementary school (sd negeri) kadipiro 1 yogyakarta, indonesia. the data collection method in this study used a modified ohl-aq questionnaire, to obtain oral health literacy data, and biofilm maturation examination using gc triplaque id gel™ (tpid) to determine the risk of dental caries and gingivitis. data analysis used a non parametric statistical test, namely the kendall-tau test. results and discussion result: a. respondent characteristics the characteristics of respondents in this study can be seen in figure 1. based on figure 1, it is known that most of the respondents 42 (51.2%) were male and aged 11 years old 41 (50.0%). b. oral health literacy level of elementary school students oral health literacy level of elementary school student can be seen at figure 2 based on figure 2, it is known that out of 82 respondents 47 (57.3%) respondents with a marginal level of oral health literacy. c. biofilm maturation in elementary school students this research about biofilm maturation in elementary school student can be seen at figure 3. based on figure 3, out of 82 respondents, 42 (51.2%) respondents were found with mature biofilm maturation. this indicates the risk of gingivitis. d. the association between oral health literacy level and biofilm maturation the association between oral health literacy level and biofilm maturation can be seen at tabel 1. based on table 1, it is known that respondents with inadequate oral health literacy, 13 (76.5%) had very mature biofilms. the results of the kendall tau-b test obtained a p-value of 0.002 <0.05 means that there is a correlation between the level of oral health literacy and biofilm maturation in elementary school children. based on this, it is known that inadequate oral health literacy will increase the level of biofilm maturation. figure 1: characteristics of respondents based on gender and age respondents characteristic 60 51.2 50 50 48.8 40 30 20 10 0 male gender female 10 y.o 11 y.o age 12 y.o sulistyani et al. asian journal of dental and health sciences. 2025; 5(1):67-71 [69] ajdhs.com figure 2: oral health literacy level of elementary school students figure 3: distribution of biofilm maturation in elementary school students tabel 1: the association between oral health literacy and biofilm maturation oral health literacy biofilm maturation total p value n no biofilm immature mature very mature sum 0,002 n % n % n % n % n % inadequate 0 0 0 0 4 23.5 13 76.51 17 100 marginal 0 0 0 0 25 53.2 22 46.84 47 adequate 0 0 0 0 13 72.2 5 27.81 18 sum 0 0 0 0 42 52.1 40 48.88 82 discussion oral health literacy is defined as an individual who has the capacity to obtain, process or interpret and understand basic health information and services needed to make informed health decisions in a way that improves health. oral health literacy has an impact on a person's behavior, this is because the higher the oral health literacy, the better the person's knowledge. oral health literacy assumes a person's ability to find, understand, and use oral health information is important to be able to access and benefit from oral health care services.15 individuals with inadequate oral health literacy are at higher risk for oral diseases and disease-related problems. lower reading skills have been associated with problems using preventive services, delayed diagnosis of medical conditions, poor adherence to medical instructions, poor selfmanagement skills, increased risk of death, poor health outcomes, and higher health care costs. age affects a person's absorption and mindset, the older the age, the more developed the absorption and mindset, therefore the knowledge will be better.14 oral health literacy is one of the important factors that influence an individual's understanding of oral health care, as well as the individual's ability to make decisions regarding health promotion, disease prevention, and utilization of oral health care. oral health literacy is a basic or primary care medium for everyone so it is considered an effective part of the health care system.12 the very mature category was found in 40 (48.8%) respondents, which is a risk for dental caries. this shows that the oral health self-care ability of elementary school students is still lacking, therefore the biofilm that forms become mature. biofilm that is still young (immature) and is in the oral cavity, is a normal condition, considering that biofilm is formed continuously. mature biofilms can cause diseases in the oral cavity such as dental caries and gingivitis, because they are dominated by cariogenic bacteria and periodontic bacteria.10 based on research by seneviratne, et al., biofilm matures in vitro after 24-72 hours, while in vivo after 72 hours.11 approximately 65% of human infections result from biofilm formation. biofilms have unique characteristics compared to microorganisms in the form of planktonic cells, usually more resistant. 16 biofilm formation consists of 4 steps, namely bacterial attachment to the surface oral health literacy 22% (18) 20,7% (17) 57,3% (47) inadequate marginal adequate immature 0% (0) very mature 48.8% (40) mature 51,2% (42) sulistyani et al. asian journal of dental and health sciences. 2025; 5(1):67-71 [70] ajdhs.com (initial phase), proliferation and formation of extracellular matrix (intermediate phase), increase of extracellular matrix material to form a 3dimensional biofilm structure (maturation phase) and after entering the maturation phase, some planktonic cells detach and attach to the surface to form a new biofilm cycle.9 according to research conducted by flemming and wuertz in 2019, biofilm maturation involves complex interactions between microorganisms, substrate surfaces, and the surrounding environment. the biofilm maturation process involves a number of complex stages, starting from the attachment of microorganisms on the surface to the formation of a mature and complex biofilm structure.23 once the initial attachment occurs, the microorganisms begin to produce an extracellular matrix that protects and sustains the biofilm structure. this extracellular matrix production is a key stage in biofilm maturation that enables the formation of strong and durable structures (bridier et al. 2019).22 at advanced stages of maturation, biofilms can become highly resistant to external perturbations, including physical stress, temperature changes, and antimicrobial therapy (stewart and franklin, 2020). oral health literacy plays an important role in maintaining optimal oral hygiene and preventing various dental conditions. one important aspect of oral health is the formation and maturation of dental biofilms. this discussion explores the correlation between oral health literacy and biofilm maturation, especially the impact of individual knowledge and practices on oral health outcomes. oral health literacy encompasses an individual's ability to acquire, process and understand basic oral health information to make informed decisions regarding their oral care. limited oral health knowledge has been associated with poor oral hygiene practices, increased risk of dental disease, and delayed treatment-seeking behavior (jones et al., 2013).22 understanding the basic principles of oral health, including the importance of regular brushing, flossing, and professional dental checkups, is essential to prevent the accumulation and maturation of dental biofilms. the presence of highly mature biofilms indicates that oral health self-care behavior in elementary school children is still lacking. this self-care behavior is influenced by oral health literacy. the better the oral health literacy, the better the understanding of elementary school students in maintaining oral hygiene, therefore the biofilm that forms do not become mature. this statement is in accordance with the opinion of divaris, et al. (2013), which states that the interaction between oral health literacy and biofilm maturation is evident in individual oral care practices.21 individuals with higher levels of oral health literacy tend to perform effective oral hygiene behaviors, thus disrupting the early stages of biofilm formation. conversely, individuals with limited oral health knowledge may neglect proper oral care, thus providing a conducive environment for biofilm maturation and subsequent oral health problems. mature biofilm is an indicator for gingivitis. in this study, 51.2% of elementary school students were found to be at risk of gingivitis. poor oral health literacy is a significant risk indicator for poor oral health. oral health literacy consistently emerged as a predictor of oral hygiene and gingival health status among respondents implying that low levels of oral health literacy directly affect oral health status including gingival index (baskaradoss, 2018).22 this study is in line with research conducted by ineg benosun & azodo, (2020) which shows there is a relationship between oral health literacy and gingival health status with a p-value of 0.000. respondents who have low health literacy have a risk of 7.054 times to experience gum inflammation (gingivitis).21 addressing oral health literacy is a key component in preventing biofilm maturation and its associated consequences. public health initiatives and educational programs should focus on improving oral health literacy to empower individuals to make decisions regarding their oral care. simple and clear communication about the impact of daily oral hygiene practices on biofilm formation can contribute significantly to improved oral health outcomes (guzmanarmstrong et al., 2016).21 conclusion according to this study, oral health literacy level is associated with biofilm maturation in elementary school students. inadequate oral health literacy increases biofilm maturation and dental caries risk. ethical approval: the study was approved by the dp.04.03/ekepk.1/130/2023 committee. author contributions: herastuti sulistyani: conceptualization, study design, methodology, writing—original draft, and supervision. quroti a’yun: data collection, analysis, and writing— review & editing. dewi risnawati: data curation, statistical analysis, and visualization. diani sulistiawati: funding acquisition, resources, and final manuscript approval. funding: the authors received no financial support for the research, authorship, and/or publication of this article. conflicts of interest: the authors declare no conflicts of interest. informed consent statement: informed consent was obtained from all subjects involved in the study. data availability statement: the data presented in this study are available on request from the corresponding author. acknowledgement: the authors would like to express their gratitude to poltekkes kemenkes yogyakarta, indonesia for providing the necessary resources and support throughout this study. we appreciate the insightful comments and sulistyani et al. asian journal of dental and health sciences. 2025; 5(1):67-71 [71] ajdhs.com suggestions from the anonymous reviewers, which have helped improve the quality of this manuscript. references 1. kemenkes ri, hasil riset kesehatan dasar tahun 2018, kementrian kesehatan ri, 2019; 53(9), 1689-1699. 2. afrinis, n., indrawati dan farizah, n, analisa faktor yang berhubungan dengan kejadian karies gigi anak usia dini, jurnal obsesi: jurnal pendidikan anak usia dini, 2021;5(1) https://doi.org/10.31004/obsesi.v5i1.668 3. widayati, n., faktor yang berhubungan dengan karies gigi pada anak usia 4-6 tahun (studi di tk ra bustanussholihin desa balun kecamatan turi, jurnal berkala epidemiologi, 2014; 2:197. 4.fatimatuzzahro, n., prasetya, r. c., & amilia, w., gambaran perilaku kesehatan gigi anak sekolah dasar di desa bangalsari kabupaten bantaeng, jurnal ikesma, 2016; 12(2):85. 5. pontoluli, z.g, khoman, j.a, wowor, v.n.s., kebersihan gigi mulut dan kejadian gingivitis pada anak sekolah dasar, e-gigi, 2021; 9(1):21-28. https://doi.org/10.35790/eg.9.1.2021.32366 6. karim caa, gunawan p, wicaksono d., gambaran status gingiva pada anak usia sekolah dasar di sd gmim tonsea lama. e-gigi, 2013;1(2):9. https://doi.org/10.35790/eg.1.2.2013.3227 7. lossu, f. m., pangemanan, d. h. c., & wowor, v. n. s., hubungan pengetahuan kesehatan gigi dan mulut dengan indeks gingiva siswa sd katolik 03 frater don bosco manado, e-gigi, 2015; 3(2). https://doi.org/10.35790/eg.3.2.2015.10489 8. gunardi, w. d., peranan biofilm dalam kaitannya dengan penyakit infeksi, jurnal kedokteran meditek, 2007; 15 (39a). 9. wibawa, t, candida albicans biofilm: formation and antifungal agents resistance, j med sci, 2012; 44(2) 10. tugeman, h., rahman, n.a, yusoff, a dan daud, mkm, oral health knowledge, practice and dental plaque maturity status of hearing-impaired children, sains malaysiana, 2016; 45(5):761768 11. seneviratne, c.j., zhang, c.f. & samaranayake, l.p., dental plaque biofilm in oral health and disease. the chinese journal of dental research, 2011; 14(2):87-94. 12. baskaradoss, j. k., relationship between oral health literacy and oral health status. bmc oral health, 2018; 18(1):1-6. https://doi.org/10.1186/s12903-018-0640-1 pmid:30355347 pmcid:pmc6201552 13. sistani, n m. m., montazeri, a., yazdani, r., & murtomaa, h., new oral health literacy instrument for public health: development and pilot testing, journal of investigative and clinical dentistry, 2014; 5(4):313-321. https://doi.org/10.1111/jicd.12042 pmid:23559571 14. batista mj, lawrence hp, sousa m. oral health literacy and oral health outcomes in an adult population in brazil. bmc public health, 2017;18(1):60. https://doi.org/10.1186/s12889-0174443-0 pmid:28747157 pmcid:pmc5530456 15. robinson, l.a., oral health literacy. j calif dent assoc, 2012; 40(4): 312-314. pmid:22679670 https://doi.org/10.1080/19424396.2012.12220899 16. weerasekera, m. m. wijesinghe, g.k., jayarathna, t.a., gunasekara, c.p., fernando, n., kottegoda, n., samarayanake, l.p., culture media profoundly affect candida albicans and candida tropicalis growth, adhesion and biofilm development, memorias do instituto oswaldo cruz. fundacao oswaldo cruz, 2016; 111(11):697-702. https://doi.org/10.1590/0074-02760160294 pmid:27706381 pmcid:pmc5125054 17. bridier, a., briandet, r., thomas, v., & dubois-brissonnet, f., resistance of bacterial biofilms to disinfectants: a review. biofouling, 2019; 27(9):1017-1032 pmid:22011093 https://doi.org/10.1080/08927014.2011.626899 18. stewart, p. s., & franklin, m. j., physiological heterogeneity in biofilms. nature reviews microbiology, 2020; 18(1):56-67. 19. jones k, parker e, mills h, brennan d, jamieson lm, development and psychometric validation of a health literacy in dentistry scale (held). community dent health, 2013; 30(3):133-140. 20.divaris k, lee jy, baker ad, vann wf., caregivers' oral health literacy and their young children's oral health-related outcomes. pediatrics, 2013; 132(5):e1274-e1281. 21. inegbenosum, h., & azodo, c.c., association between oral health literacy, gingival health and oral hygiene among dental patients. nig j dent res, 2020, 5(1):7-13. 22. guzman-armstrong s, warren r, cunningham-ford ma, sinclair c., effective communication and oral health literacy: a guide for oral health professionals. nsw public health bull, 2016; 27(4):153157 https://doi.org/10.31004/obsesi.v5i1.668 https://doi.org/10.35790/eg.9.1.2021.32366 https://doi.org/10.35790/eg.1.2.2013.3227 https://doi.org/10.35790/eg.3.2.2015.10489 https://doi.org/10.1186/s12903-018-0640-1 https://doi.org/10.1111/jicd.12042 https://doi.org/10.1186/s12889-017-4443-0 https://doi.org/10.1186/s12889-017-4443-0 https://doi.org/10.1080/19424396.2012.12220899 https://doi.org/10.1590/0074-02760160294 https://doi.org/10.1080/08927014.2011.626899 mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited rehabilitation of a cracked tooth: a case report dr. kshema mathew 1*, dr. h murali rao 2, dr. b s keshava prasad 3 1 post graduate student, department of conservative dentistry and endodontics, d a pandu memorial r v dental college, j. p. nagar, bengaluru, karnataka 560078 2 professor, department of conservative dentistry and endodontics, d a pandu memorial r v dental college, j. p. nagar, bengaluru, karnataka 560078 3 professor and head, department of conservative dentistry and endodontics, d a pandu memorial r v dental college, j. p. nagar, bengaluru, karnataka 560078 article info: _____________________________________________ article history: received 05 june 2024 reviewed 03 july 2024 accepted 28 july 2024 published 15 september 2024 _____________________________________________ cite this article as: mathew k, rao hm, prasad bsk, rehabilitation of a cracked tooth: a case report, asian journal of dental and health sciences. 2024; 4(3):5-10 doi: http://dx.doi.org/10.22270/ajdhs.v4i3.85 abstract _________________________________________________________________________________________________________________ a cracked tooth is a tooth in which there exists a partial or complete fracture of a stress plane. the prevalence of cracked teeth is relatively more in patients over 40 years of age. the incidence of cracks or incomplete tooth fracture with vital pulps is 9.7%. the average biting loads in humans range from 45.7kg/mm2 (males) to 36.4kg/mm2 (females) and the force ratio between molars, premolars, and incisors is 4:2:1 respectively. a tooth stress plane results from occlusal forces that are commonly imposed on that tooth. this may cause an instance of higher energy to occur within the stress plane during masticatory cycle. the functional prognosis and periodontal treatment requirements of a cracked or incompletely fractured tooth depend on the location and amount of tooth structure intersected along with involvement in the stress plane. this case report highlights the diagnosis and management of a cracked maxillary first molar and identifies the prognostic indicators, which are largely dependent on the extent of the fracture within the tooth structure. keywords: crack tooth; orthodontic banding; ribbond; bite test; transillumination *address for correspondence: dr. kshema mathew, post graduate student, department of conservative dentistry and endodontics, d a pandu memorial r v dental college, j. p. nagar, bengaluru, karnataka 560078 introduction cracked tooth syndrome is a clinical diagnostic dilemma that typically manifests as phantom pain. however, the phrase cracked tooth syndrome is frequently deceptive because cracked teeth exhibit a variety of symptoms, and its unpredictability makes it a difficult diagnostic and therapeutic entity. a cracked tooth is a tooth in which there exists a partial or complete fracture of a stress plane that commonly occurs in that tooth. cracked tooth syndrome may be defined as a fracture plane of unknown depth, which originates from the crown, passes through the tooth structure and may extend subgingivally and progress to connect with the pulp space and/or periodontal ligament. the fracture may extend through either or both of the marginal ridges and the proximal surfaces. it may be located in the crown portion of the tooth only or extend from the crown to the proximal root surface. the location, direction, and extent of a crack have a profound effect on the choice of treatment.1 as an occlusal crack is more centered and apical than a fractured cusp, it is more likely to cause pulpal and periapical pathosis.2 the occurrence of cts is unknown, but an incidence from 34–74% has been documented.3 in 2006, roh and lee reported that cracks were found more frequently in maxillary molars (57.2%) than in mandibular molars (36.3%).4several authors have proposed classifications which are generally based on either the type or location of the crack, the direction and extent of the crack, and / or the risk of symptoms and /or pathological processes. the american association of endodontists1 in a document titled “cracking the cracked tooth code” identified five types of cracks in teeth which are described in table 1. open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i3.85 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i3.85&amp;domain=pdf mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [6] ajdhs.com table 1: 5 types of crack in a tooth according to aae classifiaction origin symptoms pulp status prognosis craze lines crown none vital excellent fractured cusp crown mild pain on biting or cold usually vital good cracked tooth crown and root acute pain on biting or cold variable questionable split tooth crown and root marked pain on biting or cold often root filled poor vertical root fracture root often shows no symptom mainly root filled poor signs and symptoms the signs and symptoms associated with cts are: 1. acute pain on mastication (pressure or release) of grainy, tough foods and sharp, brief pain with cold. 2. vary according to position and extend of incomplete fracture. 3. pain associated with release of pressure called rebound pain is a consistent finding. 4. sensitivity to sweets is seen occasionally. 5. pulpal and periodontal symptoms occur when fracture extends to involve pulp. 6. may not be tender to percussion. 7. radiographs may be inconclusive. 8. history of pain which may be difficult to co-relate. 9. history of treatments which may be failed to relieve the symptoms. 10. difficult to identify the affected tooth. diagnosis successful diagnosis of cts requires awareness of its existence and appropriate diagnostic tests. pain on biting that ceases after the pressure has been withdrawn is a classical sign. significantly, symptoms can be elicited when pressure is applied to an individual cusp5. bite tests can be performed using various aids such as a toothpick, cotton roll, burlew wheel, wooden stick or the commercially available tooth slooth. early diagnosis and intervention are important to limit the propagation of the crack, subsequent microleakage and involvement of pulpal and periodontal tissues. treatment plan the treatment requirement of a cracked tooth is dependent on the position and extent of the fracture. an assessment of the stimuli, character and duration of the pain are influential guide for treatment. a decision flow chart indicating the treatment options available has been presented: mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [5] ajdhs.com case report a 54-year-old male patient came to the department of conservative dentistry & endodontics with the chief complaint of pain in the left upper back tooth region since 1 month. pain was sharp and intermittent in nature and increased on mastication. clinical examination revealed: ➢ presence of a crack on the buccal surface of 26(fig 1) ➢ presence of sinus tract opening on the buccal mucosa ➢ no mobility ➢ periodontal probing depth of 3-4mm on radiographic examination (fig 2), it was noted that the crack was extending into the pulp along with periapical radiolucency. to further confirm the pathology a sinus tracing (fig 3) was done. fig 1: pre-operative picture: buccal aspect of 26 mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [5] ajdhs.com fig 2: pre-operative radiograph fig 3: radiograph showing sinus tracing and the crack was further confirmed by bite test. pain on biting that ceases after the pressure has been withdrawn classical sign. symptoms elicited when pressure was applied to the mesio-buccal cusp. cbct was taken to know the extent of the crack and thereby the prognosis of the tooth. on cbct it was revealed that: • the crack was extending buccolingually from the mesiobuccal cusp. • from occluso-apically it is extending upto the pulpal floor. • periapical radiolucency was also noted indicating a periapical lesion a) d) b) f) c) g) fig 4(a-g): cbct images of the axial sections showing the extent of the crack and the periapical lesion surrounding the tooth fig 5: cbct images of the sagittal sections depicting the same mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [5] ajdhs.com the treatment plan was to perform orthograde endodontic treatment followed by reinforcing the crack using flowable composite and ribbond fibers and post endodontic restoration. in the first appointment, occlusal height reduction was done to relieve the tooth followed by banding of the tooth(fig 6) in order to stabilize the crack. then access opening was done under rubber dam isolation. working length was determined(fig 7). cleaning and shaping were done with heroshaper hand files upto 25 4% in relation to mesiobuccal and mesiolingual canals and 30 6% in relation to palatal canal. ca(oh)₂ intracanal medicament was placed for 1 week and the access cavity sealed using cavit. fig 6: occlusal reduction and banding of the tooth fig 7: working length determination in the second recall visit after a week, healing of the sinus tract opening was noted. under rubber dam isolation ca(oh)₂ dressing was removed.then the canals were dried using sterile paper points. obturation was done using gutta-percha and ca(oh)₂ based sealer (ivoclar vivadent apexit plus) (fig 8 and 9). fig 8: post obturation radiograph fig 9: picture taken post obturation and debanding showing the extent of crack crack was then sealed and reinforced with flowable composite and ribbond fibers(fig 10). access restoration was done with bulk fill composite(fig 11). follow up was done in the 1st, 3rd, and 6th month after the endodontic treatment. at the 6th month follow up, the tooth was prepared for pfm crown and crown was placed(fig 12 and 13). fig 10: sealing of crack using flowable composite and ribbond fiber fig 11: 3 month follow up fig 12: postoperative picture fig 13: 6 month follow up discussion early detection of a cracked tooth is crucial for effective treatment. early diagnosis can be challenging due to the complicated etiology. proper dental history and visual examination plays a crucial role in the diagnosis. other diagnostic methods for crack teeth include periodontal probing, radiographic examination, transillumination test, biting test, mathew et al. asian journal of dental and health sciences. 2024; 4(3):5-10 [6] ajdhs.com restorative removal, tactile examination, dyes, periapical tests, and vitality testing. a dental operating microscope (dom) and loupes can help with visual assessment. a dental operating microscope can provide various magnification levels. swept-source optical coherence tomography (ssoct) is a promising method for detecting and analyzing enamel caries and early cts.6 ultrasonic systems, infrared thermography, and near-infrared 810 nm diode laser are some of the other diagnostic aids in the detection of cracks. the treatment plan and success rate of cracked teeth depends on the extent and location of the cracks and also upon the severity of the symptoms. if the size of the involved portion of the tooth is relatively small and the crack does not involve the pulp, the tooth could be restored conventionally using resins, inlays, or crowns with periodic follow-ups.7 if the crack is extensive with prolonged symptoms, thermal hypersensitivity, and pulpal and periapical pathology, root canal treatment is the treatment of choice followed by crown placement and continuous follow-up.8 there are some cases in which the crack crosses the pulpal floor, extends deep into the bone, or symptoms persist even after root canal treatment; in such situations, extraction is usually the only viable option.9-10 in this case, there was sharp and intermittent pain, which increased on mastication, and the crack was also extensive, which could be observed on the pulpal floor in the prepared access cavity. also, the crack line was evident in the radiograph. the primary objective of the treatment plan was to stop the further propagation of the crack.11 this was achieved by reducing the occlusal height of the tooth and banding of the tooth using stainless steel band. root canal therapy was performed and the crack was sealed using flowable composite. the tooth was further reinforced by placing ribbond fibers along with composite as access restoration.12-13 finally, it was restored with a full coverage crown. root canal treatment is a viable nonsurgical treatment option for salvaging cracked teeth. though information regarding survival rates of root-filled cracked teeth and prognosis assessment are scarce14, this case has shown stabilization of the crack, healing of the periapical lesion and the patient is asymptomatic. thus, root canal treatment followed by crown serves as a viable treatment option for cracked tooth depending upon the extent of the crack with good success rates. conclusion cracked tooth syndrome has a wide variety of signs and symptoms, thus making the diagnosis difficult and complicated. various techniques have been put forth in the management of cracked teeth to preserve, stabilize, and protect the affected tooth. in this case report, combined use of restoratives, banding of the tooth followed by endodontic and prosthodontic intervention have resulted in a favorable outcome. consent as per international standards or university standards, patient(s) written consent has been collected and preserved by the author(s). ethical approval as per international standard or university standards written ethical approval has been collected and preserved by the author(s). authors’ contributions this work was carried out in collaboration among all authors. author km had done the case. authors bskp and hmr had extended guidance throughout the case and helped in writing the paper. all authors read and approved the final manuscript. acknowledgement i would like to thank my guide and my head of the department for guiding and supporting me throughout the procedure and i would also like to thank department of oral medicine and radiology for helping me with the cbct scans. competing interests authors have declared that no competing interests exist. references 1. rivera em, walton re. cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures. am assoc endodontists colleagues for excellence news lett.2008;2:1-9. 2. yang s-e, jo a-r, lee h-j, et al. analysis of the characteristics of cracked teeth and evaluation of pulp status according to periodontal probing depth. bmc oral health 2017;17(1):135. https://doi.org/10.1186/s12903-017-0434-x pmcid:pmc5704503 3. hasan s, singh k, salati n. cracked tooth syndrome: overview of literature. int j appl basic med res 2015;5(3):164-168. https://doi.org/10.4103/2229-516x.165376 pmcid:pmc4606573 4. roh bd, lee ye. analysis of 154 cases of teeth with cracks. dent traumatol 2006;22(3):118-123. https://doi.org/10.1111/j.16009657.2006.00347.x 5. geurtsen, w. (1992). the cracked-tooth syndrome: clinical features and case reports. international journal of periodontics & restorative dentistry, 12(5). 6. shimada y, sadr a, sumi y, et al. application of optical coherence tomography (oct) for diagnosis of caries, cracks, and defects of restorations. curr oral health rep 2015;2(2):73-80. https://doi.org/10.1007/s40496-015-0045-z pmcid:pmc4544493 7. bales, d.j.(1975). pain and the cracked tooth. j indian dent assoc, 54(5):15-8. 8. ehrmann, e. h., & tyas, m. j. (1990). cracked tooth syndrome: diagnosis, treatment and correlation between symptoms and post‐extraction findings. australian dental journal, 35(2), 105112. https://doi.org/10.1111/j.1834-7819.1990.tb05872.x 9. kahler, w. (2008). the cracked tooth conundrum: terminology, classification, diagnosis, and management. american journal of dentistry, 21(5), 275. 10. casciari, b. j. (1999). altered preparation design for cracked teeth. the journal of the american dental association, 130(4), 571-572. https://doi.org/10.14219/jada.archive.1999.0254 11. xu h, zheng q, shao y, et al. the effects of ageing on the biomechanical properties of root dentine and fracture. j dent 2014;42:305-311. https://doi.org/10.1016/j.jdent.2013.11.025 12. lynch, c. d., & mcconnell, r. j. (2002). the cracked tooth syndrome. journal-canadian dental association, 68(8), 470-475. 13. milot p, stein rs. root fracture in endodontically treated teeth related to post selection and crown design. j prosthet dent. 1992;68:428-35. https://doi.org/10.1016/0022-3913(92)90405y 14. davis mc, shariff ss. success and survival of endodontically treated cracked teeth with radicular extensions: a 2-to 4-year prospective cohort. j endod 2019;45(7):848-855. https://doi.org/10.1016/j.joen.2019.03.015 https://doi.org/10.1186/s12903-017-0434-x https://doi.org/10.4103/2229-516x.165376 https://doi.org/10.1111/j.1600-9657.2006.00347.x https://doi.org/10.1111/j.1600-9657.2006.00347.x https://doi.org/10.1007/s40496-015-0045-z https://doi.org/10.1111/j.1834-7819.1990.tb05872.x https://doi.org/10.14219/jada.archive.1999.0254 https://doi.org/10.1016/j.jdent.2013.11.025 https://doi.org/10.1016/0022-3913(92)90405-y https://doi.org/10.1016/0022-3913(92)90405-y https://doi.org/10.1016/j.joen.2019.03.015 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [40] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited promoting mental health as an hiv prevention strategy in low-income settings emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 24 sep 2024 reviewed 30 oct 2024 accepted 22 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, promoting mental health as an hiv prevention strategy in low-income settings, asian journal of dental and health sciences. 2024; 4(3):40-45 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.100 abstract _________________________________________________________________________________________________________________ the intersection of mental health and hiv prevention is a critical issue, particularly in low-income settings where both challenges are prevalent. individuals living with mental health conditions are at an increased risk of engaging in hiv-related risk behaviors, such as unprotected sex, substance abuse, and neglecting hiv care. this review explores the role of mental health promotion as an essential strategy in hiv prevention, emphasizing the need for integrated approaches that address both mental health and hiv risk. by fostering mental well-being through psychological support, psychoeducation, and community-based interventions, mental health promotion can play a significant role in reducing hiv transmission in these vulnerable populations. in many low-resource settings, the lack of access to mental health services is compounded by cultural stigma, limited healthcare infrastructure, and financial constraints. despite these challenges, effective mental health interventions, such as counseling, cognitive-behavioral therapy (cbt), and community-based programs, have shown promise in improving mental health outcomes and reducing hiv risk behaviors. integrating mental health support into hiv care settings and ensuring that healthcare providers are trained to address mental health needs can substantially improve both mental and physical health outcomes, leading to a reduction in hiv transmission. keywords: mental health, hiv prevention, low-income settings, psychological support, health outcomes *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction mental health and hiv prevention are deeply interconnected, especially in low-income settings where individuals often face multiple vulnerabilities. in these environments, mental health conditions such as depression, anxiety, and substance use disorders are highly prevalent, and their impact on hiv risk behaviors is profound. individuals living with mental health disorders may be more likely to engage in risky behaviors such as unprotected sex, transactional sex, or substance abuse, all of which increase the likelihood of hiv transmission. furthermore, untreated mental health conditions can reduce adherence to hiv prevention strategies, such as condom use or accessing antiretroviral therapy, leading to a higher risk of infection. therefore, mental health promotion is not only essential for individual well-being but also for effective hiv prevention.1-2 in many low-income countries, the prevalence of mental health disorders is exacerbated by a range of socio-economic and cultural factors. poverty, violence, lack of access to healthcare, and the stigma associated with both mental illness and hiv are common stressors in these settings. such circumstances create a cycle where individuals experiencing mental health issues are more vulnerable to hiv infection, and those living with hiv face mental health challenges due to the stigma and social isolation they may experience. addressing mental health as part of hiv prevention is crucial in breaking this cycle, reducing the social and behavioral risks that contribute to the transmission of hiv.3-4 unfortunately, mental health services in low-income settings are often underfunded, understaffed, and inaccessible, particularly in rural or marginalized communities. stigma surrounding mental illness further deters people from seeking help, and misconceptions about mental health care as well as a lack of trained mental health professionals limit its availability. as a result, many people living in these environments do not receive the mental health support they need, which only exacerbates their vulnerability to hiv. however, integrating mental health into existing hiv prevention programs, utilizing low-cost interventions, and leveraging community-based resources can provide an affordable and effective way to address this challenge.5-6 the mental health-hiv risk connection is particularly relevant for high-risk populations, such as people living with hiv, sex workers, men who have sex with men, and young people. these groups often face significant mental health challenges, including depression, anxiety, and substance use, which in turn increase their risk for engaging in behaviors that heighten hiv transmission. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.100 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.100&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [41] ajdhs.com by addressing mental health within hiv prevention efforts, it is possible to reach these vulnerable populations more effectively and reduce the social determinants that contribute to the hiv epidemic. through interventions such as psychoeducation, counseling, and peer-led support networks, mental health can be integrated into hiv prevention to support behavior change and improve health outcomes.7-8 the link between mental health and hiv risk the relationship between mental health and hiv risk is complex and multifaceted, with mental health conditions playing a significant role in influencing behaviors that increase susceptibility to hiv. individuals with mental health disorders, such as depression, anxiety, post-traumatic stress disorder (ptsd), and substance use disorders, are more likely to engage in risk behaviors such as unprotected sex, multiple sexual partners, and substance abuse, all of which elevate the likelihood of hiv transmission. depression, for example, has been linked to inconsistent condom use, as individuals may be less likely to prioritize protective sexual behaviors when experiencing low mood or feelings of hopelessness. similarly, anxiety and ptsd, often resulting from traumatic experiences such as abuse or violence, can lead to impaired decision-making and risky sexual behavior as a coping mechanism or escape from emotional pain.9-10 substance use disorders are another critical factor that links mental health and hiv risk. people with substance use problems are more likely to engage in high-risk behaviors such as injecting drugs, sharing needles, or having unprotected sex under the influence of alcohol or drugs. the impairment of judgment caused by substances, combined with the emotional distress associated with mental health conditions, creates a dangerous environment for hiv transmission. furthermore, individuals with mental health conditions may be less likely to adhere to hiv prevention strategies, including taking pre-exposure prophylaxis (prep), practicing safe sex, or seeking regular hiv testing and counseling. the negative impact of mental health on self-care and risk management highlights the need for integrated approaches that address both hiv prevention and mental well-being.11-12 in low-income settings, these mental health challenges are often exacerbated by additional stressors such as poverty, violence, limited access to healthcare, and social stigma. the lack of adequate mental health support, coupled with poor access to hiv prevention services, creates a situation where individuals with mental health conditions are doubly vulnerable to both hiv infection and inadequate care. moreover, in many low-income settings, the stigma surrounding both mental illness and hiv exacerbates the social isolation of affected individuals, further hindering their ability to seek treatment and support. this stigma contributes to a vicious cycle in which mental health issues increase hiv risk, while the diagnosis of hiv itself can lead to worsened mental health outcomes due to social ostracization, discrimination, and lack of comprehensive care.13 addressing this connection between mental health and hiv risk in low-resource settings requires a multi-pronged approach that involves both mental health promotion and hiv prevention strategies. integrating mental health support into hiv care and prevention programs can help individuals manage mental health symptoms and reduce hiv risk behaviors. this can be achieved through counseling, psychoeducation, and support groups, all of which can promote positive mental health and reduce risky behaviors. in addition, healthcare providers should be trained to recognize the signs of mental health disorders in individuals at risk of hiv and to offer appropriate support, including referrals to mental health services. creating an integrated, holistic approach to hiv prevention that considers the psychological, emotional, and social aspects of health is essential for breaking the link between mental health and hiv risk in vulnerable populations.14 mental health interventions in hiv prevention mental health interventions play a pivotal role in hiv prevention by addressing the psychological and behavioral factors that contribute to increased hiv risk. by integrating mental health support into hiv prevention efforts, it is possible to reduce risky behaviors, improve adherence to preventive measures, and enhance overall health outcomes. in particular, mental health interventions can help individuals identify and cope with the emotional and psychological stressors that increase vulnerability to hiv. these interventions can range from individual counseling to community-based support programs, all of which aim to strengthen mental well-being and reduce behaviors that put individuals at risk for hiv.15 one effective intervention is cognitive-behavioral therapy (cbt), which focuses on changing negative thought patterns and behaviors associated with both mental health conditions and hiv risk. cbt has been shown to help individuals with depression, anxiety, and substance use disorders develop healthier coping mechanisms and improve their decision-making abilities, thereby reducing hiv risk behaviors such as unsafe sex and substance abuse. by addressing the root psychological causes of high-risk behaviors, cbt provides a structured framework for individuals to gain better control over their actions and emotions. in low-resource settings, adaptations of cbt, such as group therapy or peer-led counseling, can also make this intervention more accessible and affordable.16 psychoeducation is another vital component of mental health interventions in hiv prevention. educating individuals about the mental health-hiv risk connection can help reduce stigma, increase awareness, and empower people to seek care for both their mental health and hiv prevention needs. psychoeducation programs can be integrated into community health initiatives, offering information on coping strategies for mental health challenges, the importance of hiv prevention measures, and how to manage hiv-related stress. these programs can also address misconceptions about hiv and mental illness, which are often amplified by social stigma, and promote a more supportive environment for individuals living with both emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [42] ajdhs.com conditions.17 peer support groups provide an important space for individuals with mental health challenges to share their experiences and learn from one another. peer-led programs have been particularly successful in low-income settings where access to mental health professionals may be limited. in such groups, individuals can receive emotional support and practical advice on managing both mental health issues and hiv risk behaviors. these groups can also offer a sense of community and belonging, which is often lacking in environments where both mental illness and hiv are highly stigmatized. peer support groups not only reduce isolation but also promote behavioral change by encouraging participants to adopt healthier coping strategies and hiv prevention practices.18 integrated care models that combine hiv prevention and mental health services have demonstrated success in addressing the dual challenges of mental health and hiv risk in low-resource settings. these models involve training healthcare providers to screen for mental health issues and offer mental health services alongside hiv prevention and care. integration of mental health into hiv care can improve retention in care, reduce missed appointments, and enhance treatment adherence for both mental health and hiv-related issues. additionally, integrated care models reduce the stigma that individuals might face when seeking separate care for mental health or hiv, ensuring a more holistic and comprehensive approach to patient health.19 finally, community-based interventions that engage local leaders and organizations in promoting mental health awareness and hiv prevention can be highly effective in low-resource settings. these programs may involve community workshops, outreach campaigns, and the training of community health workers to provide mental health support and hiv prevention education. by embedding mental health and hiv prevention efforts within the community, these interventions can reduce stigma, normalize discussions around mental health and hiv, and encourage individuals to seek both mental health and hiv prevention services. community-based programs are also more likely to reach underserved populations who might not otherwise have access to traditional healthcare services, making them an essential tool in the fight against hiv.20 overcoming barriers to mental health access access to mental health care in low-income settings is often hindered by a variety of structural, social, and economic barriers. these obstacles prevent individuals from receiving the mental health support they need, which, in turn, exacerbates their vulnerability to hiv and other health issues. overcoming these barriers requires a multifaceted approach that addresses the underlying causes of limited mental health access, as well as creating innovative solutions to make mental health services more accessible, affordable, and culturally acceptable.21 one of the primary barriers to mental health access in low-resource settings is stigma. mental illness is often misunderstood and highly stigmatized, leading individuals to avoid seeking help for fear of discrimination, rejection, or social isolation. in many cultures, mental health issues are viewed as a source of shame, and individuals with mental health conditions may be reluctant to acknowledge their struggles or seek care. stigma surrounding hiv also compounds this issue, as individuals living with hiv may face double stigmatization if they also have a mental health condition. addressing stigma requires public education campaigns to increase awareness about mental health, promote understanding, and reduce misconceptions. additionally, integrating mental health care into general health services can help normalize mental health discussions and reduce stigma by framing mental health care as a standard part of overall health care.22-25 lack of mental health professionals is another significant barrier. in many low-income countries, there is a shortage of trained mental health professionals such as psychologists, psychiatrists, and counselors, particularly in rural or underserved areas. this shortage means that many individuals must travel long distances or wait extended periods to access care, if they can access it at all. one solution to this issue is the taskshifting model, which involves training non-specialist healthcare workers, such as nurses, community health workers, and peer counselors, to provide basic mental health services. this model has been successfully implemented in several low-income countries and has been shown to improve access to care by increasing the number of available mental health providers. by training community members to provide basic mental health support, task-shifting can help bridge the gap in mental health care availability.26-28 cost and affordability also present significant barriers to accessing mental health services. in many low-income settings, mental health care is not covered by public health insurance, and individuals often cannot afford out-of-pocket expenses for services or medications. the cost of mental health care may be prohibitive, particularly for individuals living with hiv who are already facing high medical costs related to their hiv treatment. to address this, governments and nongovernmental organizations (ngos) can work together to make mental health care more affordable. this might involve incorporating mental health services into public health insurance programs, subsidizing treatment costs, or offering free or low-cost mental health services through community health centers. additionally, the use of low-cost, evidence-based interventions such as cognitive-behavioral therapy (cbt) delivered through group formats or community workshops can help to reduce the cost of care while still providing effective treatment.29-31 cultural and linguistic barriers can also impede access to mental health services, especially in communities with diverse populations. mental health professionals may not always speak the local language or be familiar with the cultural context of the individuals they serve. this can lead to miscommunication, misunderstandings, and reluctance on the part of the patients to seek care. to address these barriers, it is essential to train mental health providers in cultural competency, ensuring they emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [43] ajdhs.com understand the cultural norms, values, and beliefs that influence how individuals view and experience mental health. additionally, community health workers from the local population can be trained to provide mental health services in culturally sensitive ways, which can increase trust and improve engagement with services.32 finally, limited awareness and knowledge about mental health can prevent individuals from seeking care. many people may not recognize the symptoms of mental health disorders or may not understand the connection between mental health and hiv risk. to overcome this barrier, education campaigns that raise awareness about mental health and its importance in hiv prevention are crucial. these campaigns can help individuals understand the role of mental health in hiv risk behaviors, reduce misconceptions, and encourage people to seek help. community-based education programs that involve local leaders, schools, and media can also promote mental health awareness and reduce the social isolation that individuals with mental health conditions often experience.33 recommendations for promoting mental health in hiv prevention programs promoting mental health in hiv prevention programs is essential for addressing the psychological factors that increase vulnerability to hiv and improving the effectiveness of prevention efforts. mental health issues, such as depression, anxiety, substance use, and traumarelated disorders, often contribute to high-risk behaviors like unprotected sex and substance abuse, which can increase hiv transmission. by integrating mental health support into hiv prevention programs, these programs can provide a more holistic approach to reducing hiv risk. below are several recommendations for promoting mental health in hiv prevention efforts. 1. integrate mental health screening and support into hiv care a key recommendation for promoting mental health in hiv prevention programs is to integrate mental health screening and support into routine hiv care and prevention services. this includes training healthcare providers to assess mental health concerns among individuals at risk of hiv, especially those living with hiv or at high risk of infection. routine screening for mental health conditions such as depression, anxiety, and substance use disorders should be incorporated into hiv testing, counseling, and treatment protocols. once identified, individuals can be referred to appropriate mental health care services, such as counseling, therapy, or peer support groups. integrating mental health services into hiv care ensures that individuals receive comprehensive care and support, improving both their mental well-being and adherence to hiv prevention strategies. 2. provide culturally sensitive mental health services to ensure effective engagement, mental health services within hiv prevention programs should be culturally appropriate and responsive to the needs of diverse populations. culturally sensitive mental health care acknowledges the values, beliefs, and practices that shape individuals' understanding and experience of mental health and hiv. healthcare providers should be trained in cultural competency to ensure they can effectively communicate with and support individuals from different cultural backgrounds. moreover, interventions should be adapted to the local context, using language, imagery, and approaches that resonate with the target community. local community health workers, who are familiar with the cultural norms and practices of the populations they serve, can play a key role in providing culturally relevant mental health services and hiv prevention education. 3. incorporate peer-led support networks peer support has been shown to be an effective way to promote mental health and encourage hiv prevention behaviors. peer-led support groups create a space for individuals to share their experiences, offer mutual support, and discuss coping strategies for managing mental health issues and reducing hiv risk. peer educators, who have lived experience with hiv or mental health challenges, can help break down stigma and encourage others to seek help. these peer-led groups foster a sense of community, reduce isolation, and increase trust in the healthcare system. hiv prevention programs should prioritize the development and expansion of peer support networks, ensuring that people with lived experience are actively involved in mental health promotion and hiv prevention efforts. 4. implement cognitive-behavioral interventions cognitive-behavioral therapy (cbt) and other evidencebased psychological interventions should be incorporated into hiv prevention programs, especially for individuals with mental health conditions such as depression, anxiety, and trauma. cbt helps individuals recognize and change negative thought patterns that contribute to risky behaviors, such as substance use or unsafe sex. by targeting the underlying cognitive and emotional factors that lead to high-risk behavior, cbt can help individuals develop healthier coping mechanisms, improve decision-making, and reduce hiv risk. offering group cbt sessions or community-based cbt workshops can make these interventions more accessible and affordable in low-resource settings, where mental health professionals may be scarce. 5. raise awareness and reduce stigma a significant barrier to mental health care in hiv prevention programs is the stigma surrounding both mental illness and hiv. stigma can prevent individuals from seeking mental health support and hiv prevention services, as people fear discrimination and social exclusion. hiv prevention programs should include awareness campaigns that educate the public about the connection between mental health and hiv, aiming to reduce stigma and promote a more supportive environment for people living with hiv or mental health conditions. these campaigns should emphasize that mental health is an integral part of overall health and that seeking help for mental health issues is essential for preventing hiv transmission. engaging local leaders, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [44] ajdhs.com media, and community organizations in these campaigns can help normalize discussions about mental health and hiv, creating a culture of support and understanding. 6. provide accessible and affordable mental health service in many low-income settings, access to mental health care is limited by cost, lack of mental health professionals, and inadequate infrastructure. hiv prevention programs should prioritize making mental health services accessible and affordable for all individuals, particularly those at high risk of hiv. this can be achieved through task-shifting, where nonspecialist healthcare workers, such as community health workers or trained lay counselors, provide basic mental health services. programs should also explore alternative service delivery models, such as mobile health units or telemedicine, to reach individuals in remote or underserved areas. additionally, integrating mental health services into primary healthcare and hiv clinics can help ensure that individuals have easy access to both hiv prevention and mental health care, reducing barriers to treatment and support. 7. foster a holistic approach to hiv prevention hiv prevention programs should adopt a holistic approach that addresses not only hiv-related behaviors but also the broader social determinants of health, including mental health. this involves recognizing that factors such as poverty, gender-based violence, substance abuse, and trauma can significantly impact both mental health and hiv risk. by incorporating mental health promotion, addressing structural inequalities, and providing comprehensive services that include education, counseling, and support for those affected by hiv and mental health challenges, hiv prevention programs can better meet the complex needs of vulnerable populations. a holistic approach helps to create an environment where mental health is recognized as a key determinant of overall health, and where individuals are empowered to make healthier choices and reduce their hiv risk. conclusion integrating mental health into hiv prevention programs is crucial for addressing the complex interplay between mental well-being and hiv risk behaviors. mental health disorders, such as depression, anxiety, substance use, and trauma, often contribute to behaviors that increase susceptibility to hiv, including unprotected sex, risky drug use, and neglect of hiv prevention strategies. by acknowledging and addressing mental health as a core component of hiv prevention, these programs can not only reduce hiv transmission but also enhance the overall well-being of individuals, particularly in lowincome settings where access to both mental health and hiv care is often limited. a holistic, culturally sensitive approach is necessary to ensure the effectiveness of mental health interventions in hiv prevention programs. incorporating mental health screening into routine hiv care, providing peer-led support networks, and offering accessible and affordable mental health services can help reduce stigma and barriers to care. furthermore, evidence-based interventions such as cognitive-behavioral therapy can empower individuals to improve their decision-making and adopt healthier coping mechanisms, thus lowering their hiv risk. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):40-45 [45] ajdhs.com adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 mittal et al. asian journal of dental and health sciences. 2024; 4(3):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited ct-assisted management with biodentine obturation and aesthetic rehabilitation of a geminated maxillary central incisor with mid-root fracture: a rare case report neelam mittal 1 , harshitaa aggarwal 2 , shubham kharat 2 , shelly sharma 3 , thivyashankari thangamuthu 2 , aiyman ayubi 2 , silviya samad 2 1 professor, conservative dentistry and endodontics, faculty of dental sciences, ims, bhu, varanasi -221005. 2 junior resident, conservative dentistry and endodontics, faculty of dental sciences, ims, bhu, varanasi -221005. 3 senior resident, conservative dentistry and endodontics, faculty of dental sciences, ims, bhu, varanasi -221005. article info: _____________________________________________ article history: received 04 june 2024 reviewed 09 july 2024 accepted 24 july 2024 published 15 september 2024 _____________________________________________ cite this article as: mittal n, aggarwal h, kharat s, sharma s, thangamuthu t, ayubi a, samad s, ct-assisted management with biodentine obturation and aesthetic rehabilitation of a geminated maxillary central incisor with mid-root fracture: a rare case report, asian journal of dental and health sciences. 2024; 4(3):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v4i3.87 abstract _________________________________________________________________________________________________________________ gemination, a rare aberration in tooth development, results from the incomplete division of one tooth germ into two. in this case report, a true geminated permanent maxillary central incisor tooth with a horizontal mid-root fracture is successfully treated by non-surgical endodontic treatment. to elucidate the intricate root canal anatomy of this rare geminated incisor, we employed computed tomography imaging technology, enhancing our understanding of this complex case. utilizing biodentine for obturation proved pivotal, as its capacity to accelerate reparative dentin formation facilitated prompt healing, particularly beneficial in fracture cases. this was followed by aesthetic rehabilitation to achieve a pleasing mesio-distal dimension for both the central incisors using a zirconia-reinforced porcelain crowns. keywords: computed tomography (ct), gemination, horizontal root fracture, biodentine obturation *address for correspondence: dr. harshitaa aggarwal, junior resident, conservative dentistry and endodontics, faculty of dental sciences, ims, bhu, varanasi -221005. introduction gemination is a developmental anomaly arising from the unique splitting of a tooth germ by an invagination involving ectoderm and mesoderm, leading to incomplete formation of two teeth. despite extensive study, the exact cause of gemination remains largely elusive. its occurrence in permanent dentition is notably rare, with only 0.10.2% incidence1, most commonly affecting maxillary central incisor . aguiló et al.2 classified gemination into four morphological types. in the context of dental trauma, crown-root fractures occur in 38% of the permanent dentition (mier et al., 2013) with horizontal root fracture located predominantly in the middle third (57%). this case report presents a unique scenario of a geminated maxillary central incisor with a horizontal mid-root fracture. the tooth underwent endodontic treatment, followed by aesthetic rehabilitation using zirconia-reinforced porcelain crowns, emphasizing both functional and cosmetic restoration. case report a 23-year-old male reported with pain in his fractured upper incisors following trauma due to fall 2weeks back. clinically, a wide crown of the left central incisor [figure 10] was noted with a buccal groove demarcating it in two incompletely fused crowns. tooth mobility and periodontal probing depth were within normal limits. vitality testing showed non-vital response in both the central incisors and the left lateral incisor. preoperative radiograph showed a single root with a large pulp chamber and a horizontal fracture line along the mid-root of the malformed tooth [figure 1]. the diagnosis of gemination was made clinically based on the normal number of teeth in the dental arch, excluding the possibility of fusion. a ct was advised to study root canal morphology and fracture. [figures6, 7, 8] the cross-sectional ct images showed two fused crowns, a large pulp chamber with single root canal and a horizontal fracture line at the mid-root level in the left central incisor. [figure 9]. based on the classification given by aguiló et al 2, the present case is of type 2 gemination as inferred from the clinical and radiographic appearance of the tooth. the tooth presented as open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i3.87 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i3.87&amp;domain=pdf https://orcid.org/0000-0001-5883-3388 https://orcid.org/0000-0002-8351-8619 https://orcid.org/0000-0001-5238-9925 https://orcid.org/0000-0002-8227-6224 https://orcid.org/0000-0002-4161-379x https://orcid.org/0000-0001-7722-4000 https://orcid.org/0000-0003-0428-180x mittal et al. asian journal of dental and health sciences. 2024; 4(3):1-4 [2] ajdhs.com two fused crowns with a buccal groove running vertically, and a large fused pulp chamber. nonsurgical root canal treatment followed by an aesthetic restoration with crown was planned for both the incisors and left lateral incisor with informed consent. under local anaesthesia and rubber dam, endodontic access was prepared with endo-access bur and endo-z bur. working length was measured till fracture line [figure 2] using #15 kfile, cleaning was performed in a crown-down manner. irrigation was done using side-vented needles inserted 3mm short of the level of the fracture line to prevent the flow of irrigants beyond the fracture line. paper points were used to dry the canal, a collagen plug was placed at working length and obturation was done using biodentine, up to the middle third, just above the fracture line. [figure 3] access cavities were restored by restorative gic and packable composite and tooth preparation for crown placement was done. permanent crowns were given in both the incisors such that an aesthetic mesio-distal width for both the crowns were achieved. [figure 4, 11] a 12-month post-operative periapical radiograph shows a healing periapical radiolucency [figure 5] discussion the limitation of a two-dimensional radiograph is the compression of 3d anatomy into a two-dimensional image. this necessitates additional imaging modalities like ct scans to provide a comprehensive assessment of the anatomy of the root canal for a more effective endodontic intervention.3, 4 in this present case, the canal preparation is confined to only above the fracture line leaving the apical segment untouched due to the perceived vitality as there were no periapical signs of inflammation or bone resorption, etc., and pulp necrosis was limited to the coronal fragment. biodentine, chosen for its unique properties, has a micromechanical adhesion as due to its high ph it causes organic tissues of the dentin tubule to dissolve and itself gets keyed into these spaces as innumerable microscopic cones, creating a stable anchorage and a bacteria-tight seal.6, 7 moreover, its application also induces mineralization by expressing odontoblastic markers & increases tgfβ1 secretion from pulpal cells enabling early mineralization in the form of reparatie dentin formation.5 these factors expedite healing, especially beneficial in scenarios of tooth fracture, where delayed healing can lead to re-infection of the root canal space and thus compromise the prognosis. figure 1: pre-operative iopa radiograph figure 2: working length iopa radiograph figure 3: biodentine obturation iopa radiograph figure 4: radiograph following crown placement mittal et al. asian journal of dental and health sciences. 2024; 4(3):1-4 [3] ajdhs.com figure 5: radiograph after 12month follow-up period figure 6-9: ct images of fractured geminated central incisor figure 10: preoperative intra-oral image figure 11: intra-oral image following crown placement mittal et al. asian journal of dental and health sciences. 2024; 4(3):1-4 [4] ajdhs.com conclusion gemination presents as a challenge in endodontic management due to its unusual root canal morphology. however, with thorough clinical and radiographic assessment, successful management is achievable. this case report demonstrates the effective endodontic management of a rare and complex scenario of horizontal midroot fracture of a geminated maxillary central incisor. authorship declaration hereby we acknowledge that all authors mentioned above have contributed significantly, and all the authors are in agreement with the submission of this manuscript to the journal asian journal of dental sciences author’s contribution dr. neelam mittal: conceptualization, supervision, validation, visualization, project administration, writing – review & editing. dr. harshitaa aggarwal: data curation, methodology, investigation, writing – original draft, writing – review & editing. dr. shelly sharma: validation, writing – review & editing. dr. shubham kharat: investigation. dr. thivyashankari thangamuthu: investigation. dr. aiyman ayubi – investigations dr. silviya samad investigations acknowledgment: none financial support: nil conflicts of interests: the authors deny any conflicts of interest abbreviations: iopa – intraoral periapical radiograph, ctcomputed tomography references 1. duncan wk, helpin ml. bilateral fusion and gemination: a literature analysis and case report. oral surg oral med oral pathol. 1987;64:82-7. https://doi.org/10.1016/0030-4220(87)90121-6 pmid:3475662 2. aguiló l, gandia jl, et al. m. primary double teeth. a retrospective clinical study of their morphological characteristics and associated anomalies. int j paediatr dent 1999;9:175-83. https://doi.org/10.1046/j.1365-263x.1999.00131.x pmid:10815574 3. neville bw, damm dd, et al. je. oral and maxillofacial pathology. 2nd ed. philadelphia, pa: wb saunders; 2002. abnormalities of teeth; pp. 74-5. 4. joshi v, pavankumar k, et al. bilateral fusion of mandibular primary incisors: a case report. int j oral maxillofac pathol. 2011;2:40-3. 5. laurent p, camps j, about i. biodentine(tm) induces tgf-β1 release from human pulp cells and early dental pulp mineralization. int endod j. 2012 may;45(5):439-48. pmid:22188368 https://doi.org/10.1111/j.1365-2591.2011.01995.x 6. s, priyalakshmi & ranjan. review on biodentine-a bioactive dentin substitute. iosr journal of dental and medical sciences. 2014;13:13-17. https://doi.org/10.9790/0853-13131317 7. jacobsen i, kerekes k. diagnosis and treatment of pulp necrosis in permanent teeth with root fractures. scand j dent res 1980;88:370-6. https://doi.org/10.1111/j.16000722.1980.tb01241.x pmid:6936763 https://doi.org/10.1016/0030-4220(87)90121-6 https://doi.org/10.1046/j.1365-263x.1999.00131.x https://doi.org/10.1111/j.1365-2591.2011.01995.x https://doi.org/10.9790/0853-13131317 https://doi.org/10.1111/j.1600-0722.1980.tb01241.x https://doi.org/10.1111/j.1600-0722.1980.tb01241.x emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):5-9 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited one step at a time: incremental approaches to hiv prevention emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 10 sep 2024 reviewed 26 oct 2024 accepted 20 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, one step at a time: incremental approaches to hiv prevention, asian journal of dental and health sciences. 2024; 4(3):5-9 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.91 abstract _________________________________________________________________________________________________________________ hiv prevention remains a global priority, with diverse strategies continuously developed to address the needs of high-risk populations. incremental approaches—emphasizing gradual, step-by-step advancements—are gaining traction as an effective method to tailor interventions, increase accessibility, and foster long-term engagement. these strategies build on existing resources, adjust to unique local contexts, and prioritize community involvement, making them especially impactful in resource-limited or culturally diverse settings. by setting measurable, short-term goals, incremental approaches offer a sustainable pathway for reducing hiv transmission rates. one significant example of incremental hiv prevention is the phased implementation of pre-exposure prophylaxis (prep), which has shown remarkable results when introduced progressively to high-risk groups. alongside prep, behavioral interventions such as safe-sex education and harm reduction for injecting drug users are adapted incrementally to shift cultural norms and reduce stigma. biomedical innovations, like microbicides, are similarly introduced in stages, with user feedback and adherence monitored to enhance real-world effectiveness. by allowing for community-specific refinements, these interventions become more accepted and impactful. keywords: hiv prevention, incremental strategies, prep, behavioral interventions, community education *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction the global fight against hiv has seen significant advancements over the last few decades, yet hiv prevention remains a complex and evolving field. with over 38 million people living with hiv worldwide, there is a pressing need for prevention strategies that can adapt to diverse contexts, particularly in areas with limited resources or unique cultural challenges. traditional prevention efforts, such as large-scale public health campaigns and one-size-fits-all interventions, have been effective to some extent, but have not always addressed the nuanced needs of various communities. incremental approaches to hiv prevention— characterized by gradual, small-scale advancements tailored to specific populations—are emerging as a promising strategy. these approaches focus on setting realistic, short-term objectives that cumulatively contribute to long-term reductions in hiv transmission, often engaging local communities to foster sustainable change.1-2 incrementalism, as a strategy, is particularly valuable in addressing hiv due to the varied risk factors and socio-economic contexts that influence transmission. unlike broad, sweeping interventions, incremental approaches allow for fine-tuning and customization, ensuring that each step aligns with the specific needs of the target population. for instance, certain high-risk populations—such as men who have sex with men (msm), sex workers, and people who inject drugs—require prevention methods that are tailored not only to their risk profiles but also to the unique social and cultural barriers they may face. by employing step-by-step methods, stakeholders can test, evaluate, and adjust their strategies incrementally, which enhances both efficacy and community acceptance.3-4 a significant advantage of incremental approaches is their ability to integrate with existing public health systems and leverage current resources. this is particularly important in lowand middle-income countries, where healthcare infrastructure and funding may be limited. incremental strategies are adaptable and cost-effective, often implemented in a way that aligns with local healthcare policies and practices. for example, the gradual rollout of pre-exposure prophylaxis (prep) in select high-risk communities has allowed for focused education and resource allocation, gradually expanding access in a way that manages costs and prioritizes areas of greatest need. this approach is not only more sustainable but also allows for more effective monitoring and evaluation, ensuring that resources are being used where they will have the most impact.5-6 behavioral interventions are another cornerstone of incremental hiv prevention. educating communities on safe sex practices, reducing stigma, and open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.91 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.91&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):5-9 [6] ajdhs.com building awareness about hiv transmission are all essential components that can be introduced incrementally. by beginning with small-scale, community-led sessions, these interventions have the potential to shift norms over time, making safer practices more acceptable and accessible. the gradual introduction of behavioral changes has shown particular promise in conservative communities, where initial resistance may be high. incremental approaches allow for the development of trust and cultural sensitivity, which are critical for long-term success in hiv prevention.7-8 in addition to behavioral interventions, biomedical innovations such as microbicides and vaccines are being tested and introduced incrementally. microbicides, for instance, have shown potential as topical agents that reduce the risk of hiv transmission. by introducing these products in pilot programs and refining their formulations based on user feedback, researchers and healthcare providers can incrementally improve the efficacy and accessibility of such biomedical solutions. the incremental introduction of these products also allows communities to adapt gradually, ensuring that new technologies are better received and utilized over time. this staged approach fosters confidence in biomedical solutions and can ultimately lead to higher adherence and greater protection.9-10 finally, community involvement is central to the success of incremental approaches in hiv prevention. grassroots organizations and local partnerships are often the driving force behind incremental changes, as they understand the unique needs of their communities and can implement prevention strategies in a culturally sensitive manner. local involvement ensures that interventions are relevant and accepted, which significantly improves their sustainability and effectiveness. by engaging communities in the design and implementation of prevention measures, incremental approaches build a foundation of trust and empowerment, essential elements in any successful public health initiative.11-12 the concept of incremental approaches in hiv prevention the incremental approach in hiv prevention is grounded in the principle of achieving change through small, successive steps that cumulatively contribute to substantial outcomes. unlike comprehensive, large-scale interventions, incrementalism emphasizes gradual progress, adjusting strategies based on observed outcomes and community feedback at each stage. this approach is particularly beneficial in the context of hiv, where diverse populations with varied risk profiles and cultural sensitivities often require tailored interventions. by setting achievable short-term goals, incremental strategies create momentum that builds trust within communities, allows for careful resource allocation, and enhances the overall sustainability of prevention efforts.13-14 incremental approaches are distinguished by their adaptability, which allows programs to be tailored to the unique needs and capacities of each target group. for instance, introducing pre-exposure prophylaxis (prep) incrementally—first to high-risk groups in areas with significant hiv prevalence—enables public health officials to gauge the community’s acceptance, address initial barriers, and refine the program for broader rollouts. this step-by-step approach helps in identifying potential challenges, such as adherence issues, stigma, or logistical constraints, and in addressing them before scaling up. such an approach ensures that hiv prevention interventions are not only evidence-based but also culturally sensitive and contextually appropriate, which increases the likelihood of long-term success.15-16 another core advantage of incremental hiv prevention is its focus on community involvement and empowerment. by breaking down large objectives into smaller, manageable interventions, incremental approaches foster a sense of ownership among local stakeholders, which is crucial for sustained engagement and behavioral change. community-led initiatives, such as peer education programs or localized awareness campaigns, can be gradually expanded as they gain traction and acceptance. this progressive build-up strengthens community trust and resilience, making hiv prevention a collaborative endeavor. additionally, incremental approaches allow for real-time learning, where successful elements of a program can be expanded upon, and less effective aspects can be modified or replaced, optimizing resources and fostering sustainable impact in hiv prevention.17-18 key incremental approaches to hiv prevention several incremental strategies have emerged as impactful methods to address the diverse and evolving challenges of hiv prevention. these approaches span biomedical, behavioral, and structural interventions, with each offering distinct yet complementary benefits. the following are some key incremental approaches in the realm of hiv prevention: 1. gradual rollout of pre-exposure prophylaxis (prep) prep has proven to be one of the most effective biomedical tools for preventing hiv, particularly among high-risk populations such as men who have sex with men (msm), sex workers, and people who inject drugs. an incremental approach to prep introduction allows for targeted rollouts, beginning with high-prevalence areas and populations most vulnerable to hiv. starting with pilot programs, health officials can monitor uptake, adherence, and potential side effects, while also engaging communities to address stigma and misinformation. as the program gains acceptance, prep distribution can be gradually expanded, with adaptations made based on observed challenges and successes, such as integrating prep services into broader healthcare settings.19-20 2. phased implementation of harm reduction programs harm reduction, particularly for people who inject drugs, is another critical area where incremental approaches are beneficial. this includes the stepwise introduction of needle exchange programs, safe emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):5-9 [7] ajdhs.com injection sites, and education on safer drug use practices. by incrementally implementing these services, public health agencies can work with local communities to gauge acceptance, reduce stigma, and address legal or social barriers. with each phase, monitoring data informs adjustments to services, ensuring they are culturally appropriate and effectively reduce transmission risk without alienating the target population.20-21 3. step-by-step introduction of behavioral interventions behavioral interventions, such as safe-sex education and condom distribution, are often more effective when gradually introduced. starting with small, targeted campaigns in schools, community centers, or among atrisk groups, these interventions can be expanded based on their effectiveness and community feedback. by beginning with informational sessions and low-stakes workshops, communities can learn to understand and normalize safer practices at their own pace. gradually, these sessions evolve into comprehensive prevention programs, potentially including partnerships with local organizations to reinforce the message and reach a wider audience.22-23 4. incremental development and testing of microbicides microbicides, topical agents designed to reduce hiv transmission risk during sexual activity, represent another promising prevention method that benefits from an incremental approach. starting with small-scale clinical trials and pilot programs in high-risk areas, microbicides can be tested for safety, efficacy, and acceptability. by introducing these products incrementally, researchers and health workers can refine formulations and usage guidelines based on user feedback and adherence patterns, eventually making them available on a larger scale once their efficacy and safety profiles are confirmed.24-25 5. progressive policy change and legal reforms structural and policy-level interventions are essential to create an enabling environment for hiv prevention. however, implementing these changes incrementally can be more effective than attempting comprehensive reform at once, particularly in regions where stigma or legal restrictions pose significant challenges. for example, decriminalizing same-sex relationships or providing legal protections for sex workers and people who inject drugs can be phased in incrementally to foster societal acceptance. such stepwise policy shifts allow communities to adjust progressively, reducing backlash and enhancing support for prevention programs by gradually changing public attitudes and legal landscapes.26-27 6. digital health tools for incremental outreach and education digital health platforms, such as mobile health apps, online counseling, and social media campaigns, offer opportunities for incremental outreach, particularly in settings where face-to-face interactions may be limited by stigma or geographic constraints. starting with basic educational content or virtual consultations, these tools can slowly introduce more interactive services, such as telemedicine for prep counseling or virtual support groups. over time, digital platforms can be expanded to provide more comprehensive support, empowering individuals to seek information and care at their own pace and fostering a supportive online community for hiv prevention.28 challenges of incremental approaches while incremental approaches offer a promising path to hiv prevention, they also come with several challenges that can impact their effectiveness. understanding and addressing these obstacles is essential for successfully implementing incremental strategies on a larger scale. 1. resource and funding constraints incremental approaches require sustained resources and long-term funding commitments, which can be challenging to secure. gradual interventions often need consistent monitoring, evaluation, and adaptation, all of which require ongoing financial support. additionally, incremental strategies may appear slower to yield significant results compared to large-scale programs, potentially leading to funding agencies and stakeholders questioning their effectiveness. as a result, securing continuous support for stepwise programs, especially in resource-limited settings, can be challenging and may hinder the long-term sustainability of these efforts.29 2. potential for limited impact in early stages incremental approaches are typically gradual and may take time before substantial results are visible. for example, small pilot programs or targeted prep rollouts in specific populations might initially only reach a limited number of people, resulting in modest declines in hiv transmission rates. this limited initial impact can lead to skepticism among policymakers, funders, and communities about the effectiveness of the approach. without visible, short-term outcomes, it may be challenging to justify expanding incremental interventions or gaining broader community support.30 3. complex monitoring and evaluation needs one of the hallmarks of incremental approaches is the need for continuous monitoring, feedback, and adaptation. implementing interventions in phases requires careful tracking of progress, outcomes, and community responses to ensure each stage is effective before expanding further. however, this need for detailed data and regular assessment can place a strain on resources, especially in regions with limited infrastructure for data collection and analysis. insufficient or inconsistent monitoring can undermine the effectiveness of incremental approaches, potentially resulting in unaddressed issues or inadequate improvements at each stage.31 4. risk of resistance and stigma in certain communities while incremental approaches aim to increase community acceptance, they can still face resistance or emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):5-9 [8] ajdhs.com stigma, particularly in conservative or marginalized communities. programs targeting specific populations, such as people who inject drugs or the lgbtq+ community, may encounter resistance due to prevailing social norms and discrimination. incremental steps may not be sufficient to overcome entrenched stigma, and limited progress in changing attitudes can slow down the expansion of these programs. additionally, this approach requires building trust over time, which can be challenging if initial efforts are met with suspicion or resistance.32 5. balancing adaptation with consistency incremental approaches must strike a balance between adapting interventions based on local feedback and maintaining consistency to achieve intended outcomes. frequent adaptations can lead to changes in the delivery or focus of programs, which can confuse participants or disrupt continuity. for example, if a prep program repeatedly modifies access points or eligibility criteria in response to community feedback, individuals might struggle to stay engaged. this balancing act requires skillful management to ensure that interventions remain accessible and effective without causing confusion or frustration among the target population.33 6. risk of fragmentation in hiv prevention efforts incremental approaches focus on specific populations and locations, which can create a fragmented hiv prevention landscape where some communities receive robust support while others are left behind. for example, if prep rollout focuses on urban high-risk populations first, rural or lower-risk areas may experience delays in access to the same preventive resources. this fragmented approach can lead to disparities in prevention efforts, with some regions or populations progressing faster than others. coordinating incremental interventions to ensure equitable access and avoiding gaps in coverage is a significant challenge for hiv prevention programs.33 conclusion incremental approaches to hiv prevention offer a pragmatic and adaptive framework for addressing the complexities of the hiv epidemic. by emphasizing gradual, step-by-step interventions, these strategies can cater to diverse populations and adjust to the varying social, cultural, and economic contexts in which hiv persists. the flexibility inherent in incremental methods enables health programs to refine their approaches over time, allowing for real-time learning and communitycentered adjustments that increase acceptance and effectiveness. this patient and deliberate expansion can foster trust, reduce stigma, and ensure that interventions are sustainable and responsive to actual needs. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3):38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2):43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3):2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. dave p, the correlation between stigma and mental health disorders in people living with hiv/aids, journal of drug delivery and therapeutics, 2024;14(3):227-233 https://doi.org/10.22270/jddt.v14i3.6490 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):5-9 [9] ajdhs.com 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024;13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. akhtar mh, ramkumar j. primary health center: can it be made mobile for efficient healthcare services for hard to reach population? a state-of-the-art review. discover health systems. 2023;2(3). https://doi.org/10.1007/s44250-023-00017-x pmid:37520517 pmcid:pmc9870199 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013. https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.1007/s44250-023-00017-x https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [5] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the mentzer index and pregnancy: differentiating between iron deficiency and thalassemia emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 02 nov 2024 reviewed 08 dec 2024 accepted 09 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, the mentzer index and pregnancy: differentiating between iron deficiency and thalassemia, asian journal of dental and health sciences. 2025; 5(1):5-10 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.107 abstract _________________________________________________________________________________________________________________ anemia during pregnancy is a common condition with significant risks for both maternal and fetal health. the two primary causes of anemia in pregnancy—iron deficiency anemia (ida) and thalassemia trait (tt)—require distinct treatment strategies. the mentzer index, a simple and costeffective diagnostic tool, helps differentiate between these two types of anemia by calculating the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count. this review explores the role of the mentzer index in improving anemia diagnosis and management in pregnancy, highlighting its benefits and limitations. the mentzer index is calculated by dividing the mcv by the rbc count, with values greater than 13 typically indicating ida and values less than 13 suggesting tt. the index offers a quick and accessible method for distinguishing between these two conditions, enabling healthcare providers to administer appropriate treatments, such as iron supplementation for ida or genetic counseling for tt. early and accurate diagnosis through the mentzer index can reduce the risk of complications such as preterm birth and low birth weight, while ensuring appropriate anemia management for pregnant women. keywords: mentzer index, pregnancy, iron deficiency, thalassemia, anemia diagnosis *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia is a widespread condition during pregnancy, with studies estimating its global prevalence at around 40-50%, posing significant risks to both maternal and fetal health. pregnant women are at increased risk for anemia due to higher iron requirements for fetal development, increased blood volume, and the strain of pregnancy itself. the two most common causes of anemia during pregnancy are iron deficiency anemia (ida) and thalassemia trait (tt). though both result in low hemoglobin levels, their causes are fundamentally different and require distinct approaches to diagnosis and management. accurate differentiation between ida and tt is essential for effective treatment, as iron supplementation, the main treatment for ida, is ineffective and potentially harmful in the case of tt.1-2 the mentzer index, a simple calculation based on the mean corpuscular volume (mcv) and red blood cell (rbc) count, has gained recognition as an effective screening tool for distinguishing between these two types of anemia. by providing a quick, cost-effective, and accessible means to differentiate ida from tt, the mentzer index allows healthcare providers to initiate appropriate management strategies early in pregnancy. a value greater than 13 typically suggests ida, whereas a value less than 13 points towards tt. however, the index, while useful, has limitations that must be considered in its application.3-4 the importance of accurately diagnosing the cause of anemia during pregnancy cannot be overstated. anemia in pregnancy is associated with adverse outcomes such as preterm birth, low birth weight, and maternal fatigue, which can severely affect quality of life. inadequate or inappropriate treatment can exacerbate these risks. therefore, healthcare providers must not only diagnose anemia but also identify its underlying cause to ensure that appropriate and effective treatments are provided. the mentzer index offers a valuable tool for this purpose, enabling clinicians to quickly rule out iron deficiency as the sole cause and investigate further for thalassemia traits, which may not require iron supplementation.5 iron deficiency anemia (ida) is the most common form of anemia during pregnancy, resulting from insufficient iron to meet the increased demand of both the mother and fetus. ida can lead to significant complications such as maternal fatigue, impaired immune function, and, in severe cases, cardiovascular problems. the condition can also lead to adverse outcomes for the fetus, including intrauterine growth restriction and preterm birth. early identification of ida allows for timely iron supplementation, which is essential in preventing these complications. however, in some pregnant women, particularly those from regions where thalassemia is open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.107 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.107&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [6] ajdhs.com prevalent, thalassemia trait (tt) may be the underlying cause of anemia, which does not respond to iron supplementation and may require different management strategies.6-7 thalassemia trait is a genetic blood disorder that leads to mild anemia but is often misdiagnosed as ida due to overlapping clinical features, such as low hemoglobin and low mcv. however, unlike ida, thalassemia trait is not caused by iron deficiency and does not require iron supplementation. misidentifying tt as ida can lead to unnecessary iron treatments, which may cause iron overload in the body and lead to complications. the mentzer index helps address this issue by offering a simple method for differentiating between the two types of anemia based on rbc count and mcv values. this distinction is critical because the management of tt requires genetic counseling and monitoring, rather than iron supplementation.8-9 despite the value of the mentzer index in diagnosing anemia, it is important to recognize its limitations. while the index is a useful screening tool, it cannot definitively diagnose mixed anemia, where ida and tt coexist, or other forms of anemia, such as folate or vitamin b12 deficiency. additionally, the index can be influenced by factors such as inflammation or concurrent medical conditions that affect rbc count and mcv, leading to false or ambiguous results. therefore, while the mentzer index can guide initial diagnosis and management, it must be used alongside other diagnostic tests, such as serum ferritin levels, hemoglobin electrophoresis, or genetic testing, to confirm the cause of anemia and guide appropriate treatment.10-11 interpretation of the mentzer index the mentzer index is a simple, cost-effective tool used to help differentiate between iron deficiency anemia (ida) and thalassemia trait (tt), particularly in cases where anemia is suspected during pregnancy. it is based on the relationship between two key laboratory parameters: the mean corpuscular volume (mcv) and the red blood cell (rbc) count. the interpretation of the mentzer index depends on the value obtained from the calculation: 1. mentzer index > 13: a value greater than 13 is typically suggestive of iron deficiency anemia (ida). this is because iron deficiency leads to microcytic anemia, where red blood cells are smaller than normal (low mcv), and the rbc count is usually reduced. since iron is crucial for hemoglobin production, low iron levels lead to fewer and smaller red blood cells. a higher index value indicates that the reduction in rbc count is more pronounced than the reduction in mcv, a hallmark of ida.12 2. mentzer index < 13: a value less than 13 generally points to thalassemia trait (tt). thalassemia is a genetic disorder that results in abnormal hemoglobin production, leading to microcytic anemia. however, unlike ida, thalassemia trait is not due to iron deficiency, and rbc count may be normal or even slightly elevated. in tt, the reduction in mcv is greater than the reduction in rbc count, which is reflected in a lower mentzer index.13 3. mentzer index between 13 and 16: values within this range can be more ambiguous and may indicate a need for further testing. in cases of mixed anemia (such as coexisting ida and thalassemia trait), the result might fall between these two thresholds. additionally, certain conditions like chronic inflammation or anemia of chronic disease can complicate the interpretation of the mentzer index.14 clinical use of the mentzer index the mentzer index is typically used as a screening tool to help clinicians distinguish between ida and tt before ordering more expensive or invasive diagnostic tests. it is particularly useful in resource-limited settings where access to sophisticated diagnostic techniques like hemoglobin electrophoresis or genetic testing may be restricted. however, the mentzer index should not be used in isolation. it serves as an initial step in the diagnostic process, which should be followed by confirmatory tests to ensure accurate diagnosis. in the context of pregnancy, the mentzer index can help avoid the unnecessary administration of iron supplements to women with thalassemia trait, as they do not benefit from such treatments and iron supplementation may lead to iron overload. early and accurate differentiation between ida and 15 application of the mentzer index in pregnancy pregnancy is a critical period during which anemia, particularly iron deficiency anemia (ida) and thalassemia trait (tt), can have significant consequences for both maternal and fetal health. the mentzer index plays an essential role in helping clinicians differentiate between these two common causes of anemia, thereby guiding appropriate treatment strategies. by calculating the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count, the mentzer index offers a quick and simple method to assess whether anemia is due to iron deficiency or thalassemia, which require distinctly different management approaches.16 during pregnancy, the increased demand for iron to support the growing fetus, the placenta, and the expanded blood volume can lead to iron deficiency, resulting in ida. women with ida may experience fatigue, weakness, and an increased risk of complications, including preterm delivery, low birth weight, and impaired fetal development. the mentzer index can aid in the early identification of ida by identifying a high index value (>13), indicating a reduced rbc count relative to the mcv. this is a typical feature of iron deficiency, where the production of red blood cells is limited by insufficient iron, resulting in smaller and fewer red blood cells. prompt identification of ida allows for the timely initiation of iron supplementation, which is critical in improving maternal and fetal health outcomes.17 on the other hand, thalassemia trait (tt), a genetic disorder that results in abnormal hemoglobin production, is prevalent in certain regions and can be mistaken for ida due to overlapping symptoms, such as emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [7] ajdhs.com microcytic anemia and low hemoglobin. however, unlike ida, thalassemia is not caused by a lack of iron and does not respond to iron supplementation. the mentzer index is particularly useful in differentiating tt from ida by providing a value less than 13, which suggests that the reduction in mcv is greater than the reduction in rbc count—characteristic of thalassemia trait. thalassemia trait can lead to mild anemia but does not require iron supplementation and may instead require genetic counseling and monitoring to avoid unnecessary iron therapy, which can lead to iron overload and further complications.18 pregnant women with thalassemia trait may face a higher risk of complications, such as preeclampsia, growth restriction, and fetal anemia, if the condition is not appropriately identified and managed. using the mentzer index to screen for thalassemia trait allows healthcare providers to make more accurate diagnoses and provide appropriate care. the mentzer index enables the differentiation between ida and tt, offering a noninvasive and cost-effective approach to identifying the underlying cause of anemia in pregnancy, particularly in areas where access to advanced diagnostic methods like hemoglobin electrophoresis may be limited.19 although the mentzer index is a useful screening tool, it should not be used in isolation. the index’s accuracy can be influenced by factors such as mixed anemia, inflammation, and concurrent medical conditions. for example, pregnant women may experience anemia due to factors such as folate deficiency or anemia of chronic disease, which may not be distinguished accurately using the mentzer index alone. therefore, while the mentzer index serves as an essential first step, further confirmatory testing, including serum ferritin levels, hemoglobin electrophoresis, or genetic testing, is necessary for a definitive diagnosis.20 benefits of the mentzer index in anemia diagnosis the mentzer index provides several advantages in the diagnosis of anemia, especially in distinguishing between iron deficiency anemia (ida) and thalassemia trait (tt), two common causes of microcytic anemia. the primary benefits of using the mentzer index in anemia diagnosis are its simplicity, cost-effectiveness, accessibility, and efficiency in guiding further diagnostic and treatment decisions.21 below are the key benefits of utilizing the mentzer index: 1. simplicity and ease of use one of the major advantages of the mentzer index is its simplicity. the calculation requires only two basic laboratory parameters: mean corpuscular volume (mcv) and red blood cell (rbc) count. these values are routinely measured in standard complete blood count (cbc) tests, which are commonly available in most healthcare settings. the formula for calculating the mentzer index is straightforward, making it easy for clinicians to apply without the need for complex equipment or additional tests. this simplicity allows for quick decision-making in clinical practice, especially in settings with limited resources.22 2. cost-effectiveness the mentzer index is an affordable diagnostic tool. unlike more advanced diagnostic methods, such as hemoglobin electrophoresis or genetic testing, which can be expensive and may not be accessible in resourcelimited areas, the mentzer index relies on widely available and low-cost tests, such as the cbc. in settings where advanced diagnostic tools are not readily available, the mentzer index can serve as a crucial first step in diagnosing anemia and guiding treatment decisions. this makes it a particularly valuable tool in low-income or developing regions where cost-effective healthcare solutions are essential.23 3. quick and efficient differentiation one of the most significant benefits of the mentzer index is its ability to quickly and effectively differentiate between ida and thalassemia trait (tt), which require different treatment strategies. ida is caused by insufficient iron, while tt is a genetic condition that does not respond to iron supplementation. the mentzer index allows healthcare providers to identify which condition is most likely, enabling early intervention. for instance, if the index is greater than 13, ida is more likely, prompting the administration of iron supplements. conversely, a value below 13 typically suggests tt, avoiding the unnecessary and potentially harmful iron supplementation. this rapid differentiation ensures that the appropriate treatment is started without delay.24 4. helps avoid misdiagnosis and unnecessary treatments the mentzer index is particularly useful in preventing the misdiagnosis of anemia, which is common due to the overlap in symptoms of ida and tt, such as fatigue and low hemoglobin levels. if thalassemia trait is misdiagnosed as ida, patients may be prescribed iron supplements, which will not only be ineffective but can also lead to iron overload, causing further complications such as organ damage. by distinguishing between these two causes of anemia, the mentzer index helps avoid unnecessary iron therapy and ensures that patients receive the correct management. this leads to better patient outcomes by preventing the risks associated with inappropriate treatments.25 5. supports early detection in pregnancy pregnancy is a time when anemia is common, and accurate diagnosis is essential to prevent complications for both the mother and fetus. the mentzer index is particularly beneficial in pregnancy, where iron deficiency anemia is prevalent, but thalassemia trait is also a concern, especially in regions with high carrier rates. it enables healthcare providers to promptly identify the cause of anemia and provide appropriate care. for example, in pregnant women diagnosed with ida based on the mentzer index, iron supplementation can be started to improve maternal and fetal health. in contrast, if thalassemia trait is identified, iron supplementation can be avoided, and further genetic counseling can be provided as needed.26 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [8] ajdhs.com 6. aids in clinical decision-making and resource allocation the mentzer index assists clinicians in making informed decisions quickly, leading to better clinical outcomes. by providing an initial guide for whether anemia is likely due to iron deficiency or thalassemia trait, the index can help prioritize further testing or treatment. this is especially helpful in resource-limited settings where healthcare resources may be scarce, and prioritizing the most likely cause of anemia is necessary. additionally, the index can guide the appropriate allocation of resources, ensuring that treatments, such as iron supplementation or genetic counseling, are directed to the right patients.27 limitations and challenges of the mentzer index while the mentzer index offers numerous benefits in anemia diagnosis, it is not without its limitations and challenges. these limitations may affect its accuracy and the appropriateness of its use in certain clinical scenarios. below are the key limitations and challenges associated with the mentzer index: 1. influence of mixed anemia the mentzer index is most effective in distinguishing between iron deficiency anemia (ida) and thalassemia trait (tt), but it may not perform well in cases where a patient has mixed anemia. mixed anemia occurs when a patient has two or more underlying causes of anemia, such as ida coexisting with vitamin b12 or folate deficiency, or anemia of chronic disease. in such cases, the calculation of the mentzer index may fall within a range that does not accurately reflect the primary cause of anemia. for instance, a patient with both ida and thalassemia trait could present with a mentzer index value that lies within the range for mixed anemia, leading to potential misclassification. this limitation emphasizes the need for additional testing and clinical judgment.20 2. impact of inflammation and other comorbidities the presence of chronic inflammation, infection, or other co-morbidities can skew the results of the mentzer index. conditions such as chronic kidney disease, autoimmune diseases, or active infections can affect red blood cell production, alter mcv, and even change rbc count. in such cases, the mentzer index may not provide an accurate reflection of the underlying anemia etiology. for example, inflammatory responses may lead to anemia of chronic disease, which typically presents with low mcv, resembling the presentation of ida. thus, the presence of other health conditions could lead to false positives or false negatives when interpreting the mentzer index, highlighting the need for a broader clinical evaluation.21 3. limited accuracy in certain populations the mentzer index is most effective when used in populations with a high prevalence of thalassemia trait and iron deficiency anemia, such as in regions where these conditions are common. however, in populations where other forms of anemia (e.g., anemia due to folate deficiency, vitamin b12 deficiency, or hemoglobinopathies other than thalassemia) are more prevalent, the mentzer index may be less reliable. additionally, its use in pregnant women or other populations with altered hematologic parameters may not always yield accurate results, as pregnancy-related anemia often has multiple contributing factors, complicating the interpretation of the index. in these cases, further confirmatory testing, such as serum ferritin, hemoglobin electrophoresis, or genetic testing, is needed to make a definitive diagnosis.22 4. difficulty in identifying other hemoglobinopathies while the mentzer index is useful for distinguishing between ida and thalassemia trait, it is less effective in identifying other hemoglobinopathies or genetic conditions that cause microcytic anemia, such as hemoglobin e, hemoglobin d, or sickle cell trait. these conditions may present with similar hematologic features to thalassemia trait, yet they are not differentiated by the mentzer index. as a result, patients with other hemoglobinopathies may be misdiagnosed, leading to suboptimal treatment. this underscores the limitation of the mentzer index as a screening tool for a broader spectrum of inherited blood disorders, necessitating additional tests for comprehensive anemia diagnosis.23 5. variability in laboratory parameters the accuracy of the mentzer index depends on the reliability of the mcv and rbc count, both of which can vary due to laboratory equipment, technique, or errors in sample handling. variability in laboratory results can lead to inaccurate mentzer index calculations, which may in turn affect clinical decision-making. for instance, if mcv or rbc count is mismeasured due to poor sample quality or technical issues, the mentzer index may not reflect the true underlying cause of anemia, leading to potential misclassification. consequently, it is important to ensure that laboratory tests are performed accurately and consistently to maximize the value of the mentzer index.26 6. over-reliance on a single diagnostic tool another challenge is the tendency for clinicians to overrely on the mentzer index as a definitive diagnostic tool, without considering other important factors or clinical context. while the mentzer index is useful as an initial screening tool, it should not be the sole determinant in diagnosing anemia. it is important to integrate the index with other diagnostic tests, patient history, physical examination, and clinical judgment. an over-reliance on the mentzer index may lead to diagnostic oversights, especially in complex cases where multiple factors contribute to anemia.27 conclusion the mentzer index is a valuable and cost-effective tool for differentiating between iron deficiency anemia and thalassemia trait, two common causes of microcytic emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [9] ajdhs.com anemia. its simplicity, ease of calculation, and accessibility make it an attractive first-line diagnostic approach, particularly in resource-limited settings. however, the tool has limitations, including its reduced accuracy in cases of mixed anemia, the influence of inflammation or co-morbidities, and its inability to identify other hemoglobinopathies. furthermore, laboratory variability and the potential for over-reliance on a single diagnostic parameter highlight the importance of integrating the mentzer index with a comprehensive clinical evaluation. despite these challenges, when used as part of a broader diagnostic strategy, the mentzer index remains a crucial aid in anemia management, helping to guide treatment decisions and improve patient outcomes, particularly in populations with high rates of iron deficiency and thalassemia. ultimately, a multifaceted approach that includes clinical judgment, additional laboratory tests, and patient history is essential for accurate anemia diagnosis and management. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):5-10 [10] ajdhs.com 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):25-29 [25] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the mentzer index in maternal anemia: an early diagnostic marker emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 08 nov 2024 reviewed 10 dec 2024 accepted 06 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, the mentzer index in maternal anemia: an early diagnostic marker, asian journal of dental and health sciences. 2025; 5(1):25-29 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.115 abstract _________________________________________________________________________________________________________________ maternal anemia is a prevalent condition that poses significant health risks to both mothers and their infants. accurate and timely diagnosis is crucial for effective management, particularly in differentiating between iron deficiency anemia (ida) and thalassemia trait (tt), two common causes of microcytic anemia during pregnancy. the mentzer index (mi), a simple and cost-effective diagnostic tool, is used to distinguish between these two conditions by calculating the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count. this review explores the utility of the mentzer index in maternal anemia diagnosis, highlighting its role in early detection and management. the mentzer index offers a rapid, straightforward approach to identifying the underlying cause of anemia in pregnant women, especially in resource-limited settings. a result of mi < 13 suggests thalassemia trait, while mi > 13 is indicative of iron deficiency anemia. early differentiation allows for targeted interventions, such as iron supplementation for ida, and avoids unnecessary iron therapy in tt, thus optimizing patient outcomes. despite its advantages, the mi has limitations, particularly in cases of mixed anemia or when other forms of anemia are present. in such instances, further diagnostic tests are necessary for an accurate diagnosis. keywords: mentzer index, maternal anemia, iron deficiency, thalassemia, early diagnosis *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction maternal anemia is a prevalent and significant health concern, particularly during pregnancy, affecting millions of women worldwide. it is associated with numerous maternal and fetal complications, including preterm birth, low birth weight, fatigue, and in severe cases, maternal mortality. the condition is most commonly caused by iron deficiency anemia (ida), but thalassemia trait (tt), a hereditary blood disorder, is also a significant contributor, especially in regions where it is endemic. both ida and tt can lead to microcytic anemia, which can present with similar clinical features, making it challenging to differentiate between the two based on clinical signs alone. an accurate and early diagnosis is critical to ensure appropriate management and prevent adverse outcomes for both mother and child.1-2 iron deficiency anemia during pregnancy occurs due to increased iron requirements for fetal growth and maternal blood volume expansion. it can be effectively managed with iron supplementation, which is the cornerstone of treatment for this condition. on the other hand, thalassemia trait, a genetic condition that results in abnormal hemoglobin production, does not respond to iron supplementation and can lead to unnecessary iron overload if treated incorrectly. misdiagnosing thalassemia trait as ida and administering iron unnecessarily can cause harm, including iron toxicity, and delay the proper diagnosis and treatment. thus, differentiating between these two types of anemia is critical to providing the correct therapeutic approach.3-4 the mentzer index (mi) is a simple, cost-effective, and widely used diagnostic tool designed to assist clinicians in differentiating between ida and thalassemia trait. the mi is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count. an mi value of less than 13 is typically indicative of thalassemia trait, while a value greater than 13 suggests iron deficiency anemia. this straightforward formula has made the mi a valuable tool in routine clinical practice, particularly in settings where access to advanced diagnostic techniques, such as hemoglobin electrophoresis, may be limited.5 the utility of the mentzer index lies in its ability to provide a rapid and inexpensive preliminary diagnosis of microcytic anemia, especially in populations at high risk for thalassemia. in many cases, it can offer sufficient guidance for initial treatment decisions, enabling clinicians to either begin iron supplementation for ida or avoid unnecessary iron therapy for patients with thalassemia trait. however, despite its ease of use and accessibility, the mentzer index is not without limitations. it can be less reliable in cases of mixed anemia or when the patient has multiple underlying causes of anemia. furthermore, it is not effective in diagnosing other types of anemia, such as those caused open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.115 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.115&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):25-29 [26] ajdhs.com by vitamin deficiencies or chronic disease.6-7 in addition to its diagnostic utility, the mentzer index has important implications for maternal anemia management in pregnancy. timely and accurate diagnosis using the mi can significantly reduce the risk of maternal and fetal complications associated with misdiagnosis. for instance, by differentiating between ida and thalassemia trait, clinicians can avoid unnecessary iron therapy, which could lead to iron overload and other complications in tt. moreover, the mi can guide clinicians in deciding when to seek further diagnostic tests, such as serum ferritin levels, hemoglobin electrophoresis, or genetic testing for thalassemia, ensuring that the appropriate management plan is developed for each patient.8-9 despite its advantages, there are challenges and limitations associated with the use of the mentzer index in clinical practice. it is most effective in cases where the underlying cause of anemia is either ida or thalassemia trait, but its usefulness may be compromised in situations involving mixed anemia or other complicating factors. additionally, the mi can yield ambiguous results in patients with conditions like anemia of chronic disease or lead poisoning, where other diagnostic approaches would be required. given these constraints, it is essential to use the mi as part of a broader diagnostic framework, complementing it with additional tests to ensure a comprehensive and accurate diagnosis of anemia in pregnancy.10-11 application of the mentzer index in maternal anemia maternal anemia is a common and significant health issue during pregnancy, with potential risks to both maternal and fetal well-being. the most prevalent types of anemia during pregnancy are iron deficiency anemia (ida) and thalassemia trait (tt), both of which can present with microcytic anemia. differentiating between these two conditions is crucial, as they require different management strategies. the mentzer index (mi), a simple and cost-effective diagnostic tool, plays an important role in this differentiation, especially in settings where more advanced testing may not be accessible.12-13 in pregnancy, the mentzer index is particularly useful for distinguishing between ida and tt in women who present with microcytic anemia. ida is typically treated with iron supplementation, whereas thalassemia trait does not respond to iron and requires a different management approach. by calculating the ratio of the mean corpuscular volume (mcv) to red blood cell (rbc) count, the mi provides a preliminary screening tool. if the mi is greater than 13, the diagnosis points to iron deficiency anemia, suggesting that iron supplementation should be the first line of treatment. in contrast, an mi less than 13 suggests a thalassemia trait, which does not require iron therapy but may need genetic counseling and monitoring.14-15 the mi is particularly beneficial in low-resource settings where other diagnostic methods, such as serum ferritin levels or hemoglobin electrophoresis, may not be readily available. it allows clinicians to quickly assess whether iron deficiency or thalassemia is the likely cause of the anemia, facilitating timely interventions and avoiding the unnecessary administration of iron in women with thalassemia trait. additionally, the mi can serve as a useful tool in prenatal care programs, helping to identify women at risk of anemia early in their pregnancy, enabling appropriate treatment and reducing the likelihood of complications such as preterm birth, low birth weight, or maternal fatigue.16-17 despite its practical applications, the mentzer index is not a definitive diagnostic test. it is best used as an initial screening tool, with further diagnostic tests recommended for confirmation. for instance, if the mi suggests thalassemia trait, confirmatory tests such as hemoglobin electrophoresis or genetic testing are necessary to establish the diagnosis. similarly, if the mi indicates ida, additional tests, including serum ferritin and total iron binding capacity (tibc), can help confirm iron deficiency. the mi also has limitations in cases of mixed anemia, anemia of chronic disease, or when other underlying conditions contribute to the microcytic anemia. in such cases, a more comprehensive diagnostic approach is needed.18-19 benefits of the mentzer index in maternal anemia diagnosis the mentzer index (mi) offers several key advantages when used for the diagnosis of maternal anemia, particularly in differentiating between iron deficiency anemia (ida) and thalassemia trait (tt). its simplicity, cost-effectiveness, and ease of use make it an invaluable tool, especially in resource-limited settings, where access to advanced diagnostic tests may be constrained. here are some of the primary benefits of the mentzer index in the diagnosis of maternal anemia: 1. quick and easy calculation the mentzer index is a straightforward, rapid diagnostic tool that can be easily calculated using basic laboratory results—mean corpuscular volume (mcv) and red blood cell (rbc) count. this makes it an efficient screening tool, particularly in settings where more complex testing might not be feasible. the formula can be calculated without specialized equipment, making it accessible for clinicians in both rural and urban healthcare settings.20 2. differentiation between ida and thalassemia trait one of the key benefits of the mi is its ability to differentiate between two common causes of microcytic anemia in pregnancy: iron deficiency anemia (ida) and thalassemia trait (tt). since these two conditions require different management strategies, identifying the underlying cause of anemia early is crucial. an mi greater than 13 typically indicates ida, which can be treated with iron supplementation, while an mi less than 13 suggests thalassemia trait, which does not benefit from iron supplementation but may require genetic counseling and follow-up care. this early differentiation helps avoid unnecessary iron treatment and ensures proper management, reducing the risks of complications.21 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):25-29 [27] ajdhs.com 3. cost-effective and accessible the mi is an affordable diagnostic tool, which makes it particularly advantageous in lowand middle-income countries or resource-poor settings where advanced diagnostic tools like hemoglobin electrophoresis or serum ferritin testing may not be readily available. by using the mi, clinicians can make a more informed decision regarding anemia management without the need for expensive or sophisticated equipment, thus making anemia management more accessible to a broader population of pregnant women.21 4. improved prenatal care and early detection incorporating the mentzer index into prenatal care helps to identify women at risk of anemia early in pregnancy. early detection allows for timely intervention, which can prevent the adverse outcomes associated with untreated anemia, such as preterm birth, low birth weight, maternal fatigue, or developmental complications in the fetus. by using the mi, healthcare providers can implement more effective anemia screening protocols, leading to better overall maternal and fetal health outcomes.22 5. reduced risk of misdiagnosis and overtreatment the mi helps reduce the risk of misdiagnosing anemia and, consequently, over-treating pregnant women. for instance, iron supplementation is ineffective and potentially harmful in cases of thalassemia trait, as excess iron can lead to iron overload. by identifying the underlying cause of anemia through the mi, clinicians can avoid unnecessary iron administration, thus preventing the side effects of iron therapy, such as gastrointestinal discomfort or iron toxicity, and ensuring that patients receive the most appropriate treatment.23 6. facilitates targeted interventions the mentzer index not only aids in identifying the type of anemia but also guides subsequent management strategies. in cases of iron deficiency, the mi can prompt clinicians to initiate iron supplementation or dietary interventions. conversely, in cases of thalassemia trait, the mi helps to avoid unnecessary iron treatment while focusing on long-term monitoring and genetic counseling. this targeted approach ensures more effective and personalized care for pregnant women, improving the overall healthcare experience and maternal outcomes.24 limitations and challenges while the mentzer index (mi) offers significant benefits in diagnosing maternal anemia, particularly in differentiating between iron deficiency anemia (ida) and thalassemia trait (tt), it is not without its limitations and challenges. it is essential for healthcare providers to be aware of these potential drawbacks to ensure the mi is used appropriately and effectively as part of a comprehensive diagnostic approach. below are some of the key limitations and challenges associated with the mi: 1. limited diagnostic accuracy in mixed anemia the mi is primarily designed to differentiate between ida and thalassemia trait, both of which commonly present as microcytic anemia. however, in cases where a pregnant woman has mixed anemia (e.g., a combination of ida and anemia of chronic disease or other underlying conditions), the mi may not be reliable. mixed anemias can present with overlapping clinical and laboratory features, leading to an ambiguous mi result that cannot definitively point to a single cause. this makes it challenging to rely solely on the mi in such cases, necessitating further diagnostic testing to accurately identify the underlying etiology of the anemia.25 2. influence of pregnancy-induced physiological changes pregnancy induces a variety of physiological changes that can affect the results of the mi. for example, the increased plasma volume during pregnancy can lead to a dilutional effect, reducing the red blood cell count (rbc), which may result in a lower mi value. this dilution effect can sometimes complicate the interpretation of the mi, as it may not accurately reflect the actual rbc concentration or mcv, especially in the first and second trimesters when pregnancy-induced hemodilution is most pronounced. therefore, the mi should be interpreted with caution, especially in early pregnancy, as the physiological changes may impact the precision of the result.26 3. not a definitive diagnostic tool while the mi can help differentiate between ida and tt, it is not a definitive diagnostic tool. the mi should be considered as a preliminary screening test rather than a conclusive diagnostic method. for instance, while a low mi (less than 13) strongly suggests thalassemia trait, confirmation of thalassemia requires more specific tests such as hemoglobin electrophoresis or genetic testing. similarly, if the mi indicates iron deficiency anemia, further tests like serum ferritin, total iron-binding capacity (tibc), or transferrin saturation are necessary for confirmation. relying solely on the mi without additional confirmatory tests may lead to misdiagnosis and suboptimal management.27 4. lack of consideration for other anemia types the mi is most effective in differentiating between two causes of microcytic anemia (ida and tt). however, it does not account for other forms of anemia that might present with similar symptoms, such as anemia of chronic disease or vitamin b12 and folate deficiency anemia. these conditions may present with normocytic or macrocytic anemia and may not be adequately detected through the mi. in such cases, additional testing beyond the mi is necessary to identify the underlying cause of the anemia and provide the most appropriate treatment.25 5. potential for misinterpretation while the mi is a valuable screening tool, there is potential for misinterpretation, especially if the emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):25-29 [28] ajdhs.com calculated mi value is close to the threshold of 13. for example, women with conditions such as mild anemia of chronic disease or those in the early stages of iron deficiency might present with mi values that fall into a grey area, making it difficult to distinguish between ida and thalassemia. in such cases, healthcare providers may need to rely on clinical judgment, patient history, and additional laboratory tests to refine the diagnosis and avoid unnecessary treatments.26 6. genetic factors and population variability the accuracy of the mi may vary based on populationspecific genetic factors, particularly in regions where thalassemia is more prevalent. different populations may exhibit variations in rbc count and mcv that can affect the mi calculation. for example, in populations with a high prevalence of thalassemia traits or other hemoglobinopathies, the mi might not always be as reliable in predicting the correct diagnosis. genetic differences in rbc size and volume could skew the mi results, limiting its generalizability across diverse populations. in such cases, confirmatory tests like hemoglobin electrophoresis or dna analysis are essential to accurately diagnose thalassemia.27 conclusion the mentzer index (mi) is a useful, cost-effective, and accessible tool for differentiating between iron deficiency anemia (ida) and thalassemia trait (tt) in pregnant women. its ability to provide a quick and easy diagnostic aid, particularly in resource-limited settings, makes it an invaluable screening tool for maternal anemia. by offering early differentiation between these two common causes of microcytic anemia, the mi supports timely and appropriate management, helping to reduce unnecessary treatments like iron supplementation, which could be harmful in cases of thalassemia trait. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):25-29 [29] ajdhs.com diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited neurocognitive impairment in hiv-positive sickle cell patients emmanuel ifeanyi obeagu 1* and olga geogievna goryacheva 2 1 department of biomedical and laboratory science, africa university, zimbabwe 2 perm state medical university named after academician e.a. wagner, russia article info: _____________________________________________ article history: received 04 jan 2025 reviewed 11 feb 2025 accepted 02 march 2025 published 15 june 2025 _____________________________________________ cite this article as: obeagu ei, goryacheva og, neurocognitive impairment in hiv-positive sickle cell patients, asian journal of dental and health sciences. 2025; 5(2):1-7 doi: http://dx.doi.org/10.22270/ajdhs.v5i2.120 abstract _________________________________________________________________________________________________________________ neurocognitive impairment is a significant yet often underappreciated complication in individuals co-infected with human immunodeficiency virus (hiv) and sickle cell disease (scd). this review explores the interplay between these two conditions, highlighting the mechanisms that contribute to cognitive deficits. chronic inflammation, vascular complications, and psychosocial stressors associated with both hiv and scd create a unique vulnerability to neurocognitive decline, impacting daily functioning and overall quality of life. the prevalence of neurocognitive impairment in this population is concerning, with studies indicating that individuals with scd may experience increased cognitive challenges due to the compounded effects of their condition and hiv-related factors. this article synthesizes current research on the prevalence, risk factors, and potential interventions for managing neurocognitive impairment in hiv-positive sickle cell patients. by identifying the unique challenges faced by this population, we can develop targeted therapeutic strategies aimed at preserving cognitive function and enhancing the quality of life. keywords: neurocognitive impairment, hiv, sickle cell disease, inflammation, cognitive function *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction neurocognitive impairment has emerged as a significant concern in the context of chronic illnesses, particularly among individuals living with human immunodeficiency virus (hiv) and sickle cell disease (scd). both conditions independently contribute to a range of complications, including neurological deficits; however, their co-occurrence presents a unique clinical challenge. with the advent of effective antiretroviral therapies, the life expectancy of hiv-positive individuals has improved dramatically, leading to an increasing population of patients facing the dual burden of hiv and scd. this demographic shift necessitates a comprehensive understanding of the neurocognitive implications associated with these concurrent conditions.1-2 hivassociated neurocognitive disorder (hand) encompasses a spectrum of cognitive impairments, from mild deficits to severe dementia, affecting a substantial proportion of hiv-infected individuals. in patients with scd, neurocognitive issues can arise due to a variety of factors, including recurrent pain episodes, silent cerebral infarcts, and other vascular complications that compromise cerebral blood flow. the intersection of these two conditions complicates the clinical picture, as individuals may experience compounded cognitive challenges that significantly impact their daily functioning, educational attainment, and overall quality of life.3-4 chronic inflammation is a key feature in both hiv and scd, contributing to neurocognitive impairment through various mechanisms. in hiv, the persistent inflammatory response associated with viral replication can lead to neuroinflammation, disrupting neuronal signaling and promoting neurodegeneration. in patients with scd, hemolysis and the subsequent release of inflammatory mediators can similarly impact brain health. this shared inflammatory milieu exacerbates cognitive decline in individuals with both conditions, underscoring the need for a deeper exploration of the interplay between inflammation and neurocognitive function.5-6 moreover, vascular complications are prevalent in both hiv and scd, further increasing the risk of cognitive impairment. in scd, episodes of vaso-occlusion can lead to ischemic damage and silent cerebral infarcts, which are often asymptomatic but can have long-term consequences for cognitive function. hiv-associated changes in cerebral vasculature, including inflammation and endothelial dysfunction, can similarly impair blood flow to critical brain regions. understanding how these vascular changes contribute to neurocognitive decline is crucial for developing targeted interventions that address the unique needs of this population.7-8 psychosocial factors also play a significant role in neurocognitive impairment among hiv-positive sickle cell patients. the chronic stress associated with managing multiple health conditions, coupled with open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i2.120 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i2.120&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [2] ajdhs.com social determinants of health such as socioeconomic status and access to healthcare, can exacerbate cognitive decline. anxiety, depression, and social isolation are common in this patient population, further impacting cognitive function and quality of life. addressing these psychosocial aspects is essential for a holistic approach to patient care and cognitive health.9-10 assessing neurocognitive function in this complex population requires a comprehensive approach that considers both clinical and contextual factors. standardized neuropsychological assessments, along with qualitative measures such as patient-reported outcomes and caregiver observations, can provide valuable insights into cognitive functioning. early identification of cognitive deficits allows for timely intervention, which is critical for preserving cognitive health and improving overall patient outcomes.11-12 epidemiology of neurocognitive impairment in hiv and scd the epidemiology of neurocognitive impairment among individuals with human immunodeficiency virus (hiv) and sickle cell disease (scd) is complex and multifactorial, with both conditions contributing to an increased risk of cognitive deficits. studies have shown that neurocognitive impairment is prevalent in both populations, but the co-occurrence of hiv and scd further exacerbates this issue. in hiv-positive individuals, it is estimated that between 30% and 50% exhibit some degree of cognitive dysfunction, ranging from mild cognitive impairment to more severe forms of hiv-associated neurocognitive disorder (hand). this impairment can manifest as difficulties in attention, memory, executive function, and psychomotor speed, significantly affecting the individual's quality of life and daily functioning.13-15 similarly, scd is associated with an elevated risk of neurocognitive deficits, primarily due to the disease's complications, such as recurrent pain episodes, silent cerebral infarcts, and cerebrovascular accidents. studies indicate that approximately 20% to 30% of children and adults with scd experience cognitive impairments, with a higher prevalence observed in those with a history of cerebrovascular events. neuroimaging studies have revealed that silent cerebral infarcts are common in individuals with scd, occurring in up to 50% of affected patients, which can lead to subtle yet significant cognitive declines. the cumulative effects of recurrent pain, hypoxia, and vascular occlusion further increase the risk of cognitive impairment in this population.16-17 when considering the combined effects of hiv and scd, the prevalence of neurocognitive impairment is even more pronounced. research indicates that individuals co-infected with hiv and scd experience a higher incidence of cognitive deficits compared to those with either condition alone. this heightened risk may be attributed to the overlapping pathophysiological mechanisms of both diseases, including chronic inflammation, oxidative stress, and vascular dysfunction. additionally, the psychosocial stressors associated with managing two chronic conditions can contribute to cognitive decline, further complicating the epidemiological landscape.18-19 demographic factors also play a significant role in the prevalence of neurocognitive impairment among individuals with hiv and scd. age, sex, and socioeconomic status can influence cognitive outcomes, with older individuals and those from lower socioeconomic backgrounds at greater risk for cognitive deficits. furthermore, access to healthcare and effective treatment options can impact the management of both hiv and scd, potentially influencing the degree of neurocognitive impairment observed in these populations.20 mechanisms of neurocognitive impairment in hiv-positive sickle cell patients neurocognitive impairment in individuals co-infected with human immunodeficiency virus (hiv) and sickle cell disease (scd) arises from a complex interplay of biological, neurological, and psychosocial mechanisms. 1. chronic inflammation: both hiv and scd are associated with chronic inflammatory states that significantly contribute to neurocognitive impairment. in hiv, the persistence of viral replication leads to elevated levels of proinflammatory cytokines, which can disrupt neuronal function and promote neuroinflammation. this inflammatory milieu can result in neuronal apoptosis, synaptic dysfunction, and altered neurotransmitter signaling, all of which may impair cognitive processes. in scd, recurrent vaso-occlusive crises and hemolysis contribute to inflammation, releasing inflammatory mediators that can further compromise brain health. the combined inflammatory burden in co-infected patients can exacerbate cognitive deficits, leading to more pronounced neurocognitive impairment.21-22 2. vascular dysfunction: cerebrovascular complications are prevalent in both hiv and scd, contributing to the risk of neurocognitive impairment. in scd, episodes of vaso-occlusion can cause ischemic damage and silent cerebral infarcts, leading to subtle cognitive declines that may accumulate over time. similarly, hiv-related changes in vascular health, including endothelial dysfunction and increased vascular permeability, can compromise blood flow to the brain. the resultant hypoxia and nutrient deprivation can lead to neuronal injury and cognitive deficits. the intersection of these vascular complications in co-infected patients can significantly impact cerebral perfusion and overall cognitive function.23 3. neuroanatomical changes: neuroimaging studies have demonstrated structural changes in the brains of individuals with hiv and scd. in hiv-positive individuals, findings may include cortical atrophy, white matter lesions, and changes in basal ganglia structure. these changes can disrupt normal brain function and contribute to cognitive impairment. in scd, the presence of silent cerebral infarcts and alterations in brain morphology has been observed, correlating with cognitive deficits. in coinfected patients, these neuroanatomical alterations emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [3] ajdhs.com may be compounded, leading to a more severe manifestation of cognitive impairment.24 4. oxidative stress: oxidative stress is another critical mechanism that contributes to neurocognitive impairment in this population. both hiv and scd are associated with increased oxidative stress due to the release of reactive oxygen species (ros) from inflammatory cells and vascular dysfunction. elevated levels of oxidative stress can lead to neuronal damage, mitochondrial dysfunction, and impaired synaptic plasticity. this oxidative burden can further exacerbate cognitive deficits, highlighting the need for interventions that target oxidative stress as a potential therapeutic strategy.25 5. psychosocial factors: psychosocial stressors significantly impact neurocognitive function among hiv-positive sickle cell patients. chronic illness, stigma, and socioeconomic challenges can lead to heightened anxiety and depression, both of which are known to negatively affect cognitive performance. the interplay between mental health and cognitive function is particularly relevant in this population, as psychosocial stress can exacerbate the biological mechanisms contributing to neurocognitive impairment. addressing these psychosocial factors through support systems and mental health interventions is essential for improving cognitive outcomes.26-27 risk factors for cognitive decline in hivpositive sickle cell patients cognitive decline in individuals co-infected with human immunodeficiency virus (hiv) and sickle cell disease (scd) is influenced by a myriad of risk factors that can exacerbate neurocognitive impairment. 1. age: age is a significant risk factor for cognitive decline in both hiv and scd populations. as individuals age, the natural decline in cognitive function can be compounded by the effects of chronic illnesses. older adults with hiv are at increased risk of neurocognitive disorders due to the cumulative impact of hiv-related neurotoxicity and the aging process itself. in scd, agerelated changes in brain structure and function, coupled with a history of cerebrovascular events, further heighten the risk of cognitive impairment.28 2. disease severity: the severity of both hiv and scd can significantly influence cognitive outcomes. in hiv, factors such as high viral load, low cd4 counts, and advanced stages of disease are associated with increased risk of neurocognitive impairment. in scd, individuals with a history of stroke, recurrent vaso-occlusive crises, and chronic pain are more likely to experience cognitive deficits. the cumulative burden of these conditions can exacerbate cognitive decline, making disease management critical in reducing risk.29 3. inflammation and immune dysfunction: chronic inflammation and immune dysfunction play a pivotal role in cognitive decline among co-infected patients. elevated levels of pro-inflammatory cytokines, common in both hiv and scd, have been linked to neuroinflammation and neuronal damage. the persistent inflammatory response associated with hiv can lead to neurocognitive disorders, while the inflammatory milieu in scd can exacerbate these effects. individuals with both conditions may experience heightened inflammatory responses, increasing their risk of cognitive impairment.30 4. socioeconomic status and access to healthcare: socioeconomic factors significantly influence health outcomes and can exacerbate cognitive decline in hivpositive sickle cell patients. lower socioeconomic status is associated with limited access to healthcare, which can affect the management of both hiv and scd. individuals facing economic hardships may experience higher levels of stress, less engagement in healthpromoting behaviors, and inadequate access to necessary medical interventions, all of which can contribute to cognitive decline. additionally, education level may also play a role, as lower educational attainment is linked to poorer cognitive outcomes.31 5. mental health conditions: mental health comorbidities, such as depression and anxiety, are prevalent among individuals with hiv and scd, significantly impacting cognitive function. psychological distress can exacerbate cognitive decline, as mental health issues can interfere with attention, memory, and executive functioning. in individuals coinfected with hiv and scd, the interplay of chronic illness, psychosocial stressors, and mental health challenges creates a compounded risk for cognitive impairment. addressing mental health concerns is essential for holistic patient care and cognitive health preservation.32 6. lifestyle factors: lifestyle factors, including diet, physical activity, and substance use, can also influence cognitive outcomes in this population. poor nutrition and sedentary lifestyles are common among individuals with chronic illnesses, which can exacerbate inflammation and cognitive decline. substance use, particularly alcohol and recreational drugs, can further impair cognitive function and interact negatively with medications used to manage hiv and scd. promoting healthy lifestyle choices is crucial for mitigating cognitive decline in coinfected patients.33 7. history of cerebrovascular events: a history of cerebrovascular events, such as strokes or transient ischemic attacks (tias), significantly increases the risk of cognitive decline in both hiv and scd populations. silent cerebral infarcts are particularly concerning in scd patients, often leading to undetected but progressive cognitive impairment. in hiv-positive individuals, cerebrovascular complications can result emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [4] ajdhs.com from both the direct effects of the virus and secondary factors such as hypertension and hyperlipidemia. the presence of prior cerebrovascular events indicates a higher likelihood of subsequent cognitive decline.34 assessment of neurocognitive function in hivpositive sickle cell patients the assessment of neurocognitive function in individuals co-infected with human immunodeficiency virus (hiv) and sickle cell disease (scd) is crucial for identifying cognitive deficits and tailoring appropriate interventions. given the complexities associated with both conditions, a comprehensive approach that incorporates various assessment tools and methodologies is essential for accurately evaluating neurocognitive function. below are key components and considerations in the assessment process: 1. clinical evaluation: the initial assessment of neurocognitive function typically begins with a thorough clinical evaluation, which includes taking a detailed medical history and performing a physical examination. this process helps identify any potential neurological symptoms, psychiatric comorbidities, and the severity of both hiv and scd. clinicians should gather information on the patient's cognitive concerns, daily functioning, and any changes in behavior or mood, which may provide valuable context for understanding their cognitive status.35 2. standardized neuropsychological testing: standardized neuropsychological tests are essential tools for objectively assessing cognitive function in coinfected individuals. these tests evaluate various cognitive domains, including attention, memory, executive function, language, and visuospatial skills. commonly used assessments include the mini-mental state examination (mmse), montreal cognitive assessment (moca), and more extensive battery tests like the wechsler adult intelligence scale (wais) and the wechsler memory scale (wms). administering these tests allows clinicians to quantify cognitive impairments and track changes over time, facilitating targeted interventions.36 3. functional assessments: in addition to standardized testing, functional assessments are critical for understanding how cognitive deficits impact daily living activities. instruments such as the functional independence measure (fim) and the activities of daily living (adl) scale evaluate an individual's ability to perform essential tasks, including self-care, mobility, and communication. assessing functional outcomes provides insights into how cognitive impairments affect the patient’s quality of life and independence, guiding rehabilitation efforts.37 4. neuroimaging techniques: neuroimaging techniques, such as magnetic resonance imaging (mri) and computed tomography (ct), play a valuable role in the assessment of neurocognitive function. these imaging modalities can identify structural brain changes, such as cerebral atrophy, white matter lesions, and silent cerebral infarcts, which may contribute to cognitive impairment. in patients with scd, neuroimaging can help detect changes related to ischemic damage, while in hiv-positive individuals, it can reveal the effects of the virus on brain structures. the integration of neuroimaging findings with cognitive assessments can enhance the understanding of the underlying mechanisms of impairment.38 5. psychosocial and behavioral assessments: evaluating psychosocial factors is essential in understanding the broader context of neurocognitive function in co-infected individuals. assessing mental health conditions, such as depression and anxiety, can provide insights into how these issues may affect cognitive performance. tools like the beck depression inventory (bdi) or the hamilton anxiety rating scale (ham-a) can be used to quantify the impact of psychosocial factors on cognitive function. additionally, assessing lifestyle factors, such as substance use and social support, can help identify areas that require intervention to improve cognitive health.39 6. longitudinal assessment: neurocognitive function should be assessed longitudinally to track changes over time, particularly in patients with chronic illnesses like hiv and scd. regular cognitive evaluations can help identify the onset of cognitive decline early, allowing for timely interventions. longitudinal studies can also provide valuable information on the natural progression of cognitive impairment in co-infected individuals, informing treatment strategies and resource allocation.40 7. multidisciplinary approach: given the complexity of neurocognitive impairment in hiv-positive sickle cell patients, a multidisciplinary approach is essential for comprehensive assessment and management. collaboration among healthcare providers, including neurologists, psychologists, social workers, and primary care physicians, ensures that all aspects of a patient’s health are considered. this approach facilitates the development of personalized treatment plans that address both cognitive and psychosocial needs, ultimately improving patient outcomes.41 potential therapeutic approaches for neurocognitive impairment in hiv-positive sickle cell patients addressing neurocognitive impairment in individuals co-infected with human immunodeficiency virus (hiv) and sickle cell disease (scd) necessitates a multifaceted therapeutic approach. given the complexity of both conditions and their impact on cognitive function, therapeutic strategies should aim to mitigate cognitive decline, manage comorbidities, and enhance overall quality of life. here are several potential therapeutic approaches: emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [5] ajdhs.com 1. antiretroviral therapy (art): effective antiretroviral therapy (art) is crucial in managing hiv and preventing neurocognitive impairment. art reduces viral load, improves immune function, and decreases inflammation, all of which are associated with better cognitive outcomes. ensuring adherence to art is essential, as non-adherence can lead to viral rebound and increased risk of neurocognitive decline. regular monitoring of treatment efficacy and side effects can help optimize art regimens for co-infected individuals, contributing to improved cognitive health.42 2. hydroxyurea therapy: hydroxyurea is a cornerstone treatment for sickle cell disease, primarily used to reduce the frequency of vasoocclusive crises and associated complications. research suggests that hydroxyurea may also have neuroprotective effects, potentially improving cognitive function in scd patients. by increasing fetal hemoglobin levels and reducing hemolysis, hydroxyurea may mitigate the impact of sickle cell disease on brain health, thus reducing the risk of neurocognitive impairment.43 3. cognitive rehabilitation therapy: cognitive rehabilitation therapy (crt) involves structured interventions aimed at improving cognitive function and compensating for cognitive deficits. crt can be tailored to the specific needs of hiv-positive scd patients, focusing on areas such as attention, memory, and executive functioning. techniques may include cognitive exercises, memory aids, and compensatory strategies that help individuals manage daily tasks despite cognitive impairments. engaging in cognitive rehabilitation can enhance patients' coping skills and improve their overall quality of life.44 4. psychosocial interventions: addressing psychosocial factors is vital for managing neurocognitive impairment. psychosocial interventions, including counseling and support groups, can help individuals cope with the emotional and psychological aspects of living with chronic illnesses. strategies to reduce anxiety and depression, which are common in co-infected patients, can improve cognitive function and overall well-being. additionally, fostering social support networks can provide emotional resilience, further aiding cognitive health.45 5. lifestyle modifications: encouraging healthy lifestyle modifications can play a significant role in preserving cognitive function. interventions focusing on nutrition, physical activity, and sleep hygiene can help improve overall health and cognitive performance. a balanced diet rich in antioxidants, omega-3 fatty acids, and essential vitamins supports brain health. regular physical activity has been shown to enhance cognitive function and reduce inflammation. moreover, promoting good sleep hygiene is critical, as sleep disturbances are prevalent in both hiv and scd populations and can negatively impact cognitive function.46 6. pharmacological interventions for cognitive symptoms: in some cases, pharmacological interventions may be considered to address specific cognitive symptoms. medications such as cholinesterase inhibitors or nmda receptor antagonists may help improve cognitive function in individuals with neurocognitive disorders. however, careful evaluation and monitoring are necessary to assess the efficacy and potential side effects of these medications, particularly in patients with comorbid conditions.47 7. neuroprotective agents: exploring the use of neuroprotective agents could provide additional therapeutic avenues for mitigating cognitive impairment in co-infected patients. agents that target inflammation, oxidative stress, and excitotoxicity may hold promise in preserving cognitive function. research into compounds like antioxidants, anti-inflammatory agents, and neurotrophic factors could pave the way for novel treatment strategies aimed at protecting neuronal health in hiv-positive scd patients.48 8. multidisciplinary care approach: implementing a multidisciplinary care approach that integrates medical, psychological, and social services is essential for addressing the complex needs of coinfected individuals. collaboration among healthcare providers, including hematologists, infectious disease specialists, neurologists, psychologists, and social workers, ensures comprehensive care that addresses both physical and cognitive health. this approach can facilitate early identification of cognitive deficits, timely interventions, and coordinated management of comorbidities, ultimately improving patient outcomes.48 conclusion neurocognitive impairment in individuals co-infected with hiv and sickle cell disease (scd) presents a significant challenge, impacting their quality of life and overall health outcomes. the intricate interplay between these two conditions necessitates a comprehensive understanding of the mechanisms underlying cognitive decline and the multifactorial approaches required for effective management. through a combination of effective antiretroviral therapy, sickle cell management strategies, cognitive rehabilitation, psychosocial support, and lifestyle modifications, it is possible to mitigate the effects of neurocognitive impairment in this population. the assessment and management of neurocognitive function in hiv-positive scd patients should adopt a multidisciplinary approach, incorporating the expertise of various healthcare providers. this collaboration enables a holistic perspective on patient care, addressing both the physical and cognitive aspects of their health. ongoing research into novel therapeutic interventions, neuroprotective agents, and personalized care strategies will be essential in advancing our understanding and management of cognitive impairment in co-infected individuals. emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [6] ajdhs.com conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. owusu ed, visser bj, nagel im, mens pf, grobusch mp. the interaction between sickle cell disease and hiv infection: a systematic review. clinical infectious diseases. 2015; 60(4):612626. https://doi.org/10.1093/cid/ciu832 pmid:25344542 2. boateng la, ngoma am, bates i, schonewille h. red blood cell alloimmunization in transfused patients with sickle cell disease in sub-saharan africa; a systematic review and meta-analysis. transfusion medicine reviews. 2019; 33(3):162-169. https://doi.org/10.1016/j.tmrv.2019.06.003 pmid:31345590 3. ola b, olushola o, ebenso b, berghs m. sickle cell disease and its psychosocial burdens in africa. insickle cell disease in subsaharan africa 2024: 67-80. routledge. https://doi.org/10.4324/9781003467748-7 4. obeagu ei, reducing hospitalization rates: the preventive benefits of blood transfusions in hiv care, international journal of medical sciences and pharma research, 2024;10(3):29-34 https://doi.org/10.22270/ijmspr.v10i3.111 5. ochocinski d, dalal m, black lv, carr s, lew j, sullivan k, kissoon n. life-threatening infectious complications in sickle cell disease: a concise narrative review. frontiers in pediatrics. 2020; 8:38. https://doi.org/10.3389/fped.2020.00038 pmid:32154192 pmcid:pmc7044152 6. obeagu ei, obeagu gu, okwuanaso cb. optimizing immune health in hiv patients through nutrition: a review. elite journal of immunology, 2024; 2(1): 14-33 7. obeagu ei, obeagu gu. platelet distribution width (pdw) as a prognostic marker for anemia severity in hiv patients: a comprehensive review. journal home page: http://www. journalijiar. com.;12(01). 8. obeagu ei, ubosi ni, obeagu gu, akram m. early infant diagnosis: key to breaking the chain of hiv transmission. elite journal of public health, 2024; 2 (1): 52-61 9. obeagu ei, obeagu gu. hematocrit fluctuations in hiv patients coinfected with malaria parasites: a comprehensive review. int. j. curr. res. med. sci. 2024; 10(1):25-36. https://doi.org/10.22270/ijmspr.v10i2.95 10. obeagu ei, obeagu gu. transfusion therapy in hiv: risk mitigation and benefits for improved patient outcomes. asian j dental health sci, 2024; 4(1):32-7. https://doi.org/10.22270/ajdhs.v4i1.62 11. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 12. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 13. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 1 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 2035 15. obeagu ei, obeagu gu. impact of maternal eosinophils on neonatal immunity in hivexposed infants: a review. elite journal of immunology, 2024; 2(3): 1-18 https://doi.org/10.22270/ajdhs.v4i2.82 16. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. newport international journal of biological and applied sciences (nijbas) 2023. http://hdl.handle.net/20.500.12493/14626 17. ntsekhe m, baker jv. cardiovascular disease among persons living with hiv: new insights into pathogenesis and clinical manifestations in a global context. circulation. 2023; 147(1):83100. https://doi.org/10.1161/circulationaha.122.057443 pmid:36576956 18. obare lm, temu t, mallal sa, wanjalla cn. inflammation in hiv and its impact on atherosclerotic cardiovascular disease. circulation research. 2024; 134(11):1515-1545 https://doi.org/10.1161/circresaha.124.323891 pmid:38781301 pmcid:pmc11122788 19. hmiel l, zhang s, obare lm, santana ma, wanjalla cn, titanji bk, hileman co, bagchi s. inflammatory and immune mechanisms for atherosclerotic cardiovascular disease in hiv. international journal of molecular sciences. 2024; 25(13):7266. https://doi.org/10.3390/ijms25137266 pmid:39000373 pmcid:pmc11242562 20. obeagu ei, obeagu gu. platelet aberrations in hiv patients: assessing impacts of art. elite journal of haematology, 2024; 2(3): 10-24 21. obeagu ei, obeagu gu. harnessing b cell responses for personalized approaches in hiv management. elite journal of immunology, 2024; 2(2): 15-28 22. belisário ar, blatyta pf, vivanco d, oliveira cd, carneiro-proietti ab, sabino ec, de almeida-neto c, loureiro p, máximo c, de oliveira garcia mateos s, flor-park mv. association of hiv infection with clinical and laboratory characteristics of sickle cell disease. bmc infectious diseases. 2020; 20(1):638. https://doi.org/10.1186/s12879-020-05366-z pmid:32854639 pmcid:pmc7457248 23. obeagu ei, addressing sleep disturbances: blood transfusions and improved sleep patterns in hiv patients, international journal of medical sciences and pharma research, 2024;10(3):43-48 https://doi.org/10.22270/ijmspr.v10i3.113 24. gill af, ahsan mh, lackner aa, veazey rs. hematologic abnormalities associated with simian immunodeficieny virus (siv) infection mimic those in hiv infection. journal of medical primatology. 2012; 41(3):214-224. https://doi.org/10.1111/j.1600-0684.2012.00543.x pmid:22620272 pmcid:pmc3367385 25. nouraie m, nekhai s, gordeuk vr. sickle cell disease is associated with decreased hiv but higher hbv and hcv comorbidities in us hospital discharge records: a cross-sectional study. sexually transmitted infections. 2012; 88(7):528-533. https://doi.org/10.1136/sextrans-2011-050459 pmid:22628662 pmcid:pmc3456988 26. obeagu ei, obeagu gu. hematological changes following blood transfusion in young children with severe malaria and hiv: a critical review. elite journal of laboratory medicine. 2024; 2(1):33-45. 27. obeagu ei, obeagu gu. the role of l-selectin in tuberculosis and hiv coinfection: implications for disease diagnosis and management. elite journal of public health, 2024; 2 (1): 35-51 28. obeagu ei, obeagu gu. unraveling the role of eosinophil extracellular traps (eets) in hiv-infected pregnant women: a review. elite journal of nursing and health science, 2024; 2(3): 84-99 https://doi.org/10.1093/cid/ciu832 https://doi.org/10.1016/j.tmrv.2019.06.003 https://doi.org/10.4324/9781003467748-7 https://doi.org/10.22270/ijmspr.v10i3.111 https://doi.org/10.3389/fped.2020.00038 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.22270/ajdhs.v4i1.62 https://doi.org/10.22270/ajdhs.v4i2.82 http://hdl.handle.net/20.500.12493/14626 https://doi.org/10.1161/circulationaha.122.057443 https://doi.org/10.1161/circresaha.124.323891 https://doi.org/10.3390/ijms25137266 https://doi.org/10.1186/s12879-020-05366-z https://doi.org/10.22270/ijmspr.v10i3.113 https://doi.org/10.1111/j.1600-0684.2012.00543.x https://doi.org/10.1136/sextrans-2011-050459 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):1-7 [7] ajdhs.com 29. obeagu ei, obeagu gu. unveiling the role of innate immune activation in pediatric hiv: a review. elite journal of immunology, 2024; 2(3): 33-44 30. obeagu ei, obeagu, gu. impact of blood transfusion on viral load dynamics in hivpositive neonates with severe malaria: a review. elite journal of scientific research and review, 2024; 2(1): 42-60 31. obeagu ei, youth-friendly hiv prevention: tailoring interventions for young populations, international journal of medical sciences and pharma research, 2024;10(4):62-67. https://doi.org/10.22270/ijmspr.v10i4.125 32. obeagu ei, faith-based initiatives, hiv awareness, religious communities, health education, stigma reduction, international journal of medical sciences and pharma research, 2024;10(4):7479 https://doi.org/10.22270/ijmspr.v10i4.127 33. obeagu ei, obeagu gu. p-selectin expression in hiv-associated coagulopathy: implications for treatment. elite journal of haematology, 2024; 2(3): 25-41 34. obeagu ei, obeagu gu. p-selectin and immune activation in hiv: clinical implications. elite journal of health science, 2024; 2(2): 16-29 35. obeagu ei, amaeze aa, ogbu isi, obeagu gu. b cell deficiency and implications in hiv pathogenesis: unraveling the complex interplay. elite journal of nursing and health science, 2024; 2(2): 33-46 36. obeagu ei, obeagu, gu. platelet dysfunction in hiv patients: assessing art risks. elite journal of scientific research and review, 2024; 2(1): 1-16 37. kibaru eg, nduati r, wamalwa d, kariuki n. impact of highly active antiretroviral therapy on hematological indices among hiv1 infected children at kenyatta national hospital-kenya: retrospective study. aids research and therapy. 2015; 12:1-8. https://doi.org/10.1186/s12981-015-0069-4 pmid:26279668 pmcid:pmc4537535 38. enawgaw b, alem m, addis z, melku m. determination of hematological and immunological parameters among hiv positive patients taking highly active antiretroviral treatment and treatment naïve in the antiretroviral therapy clinic of gondar university hospital, gondar, northwest ethiopia: a comparative cross-sectional study. bmc hematology. 2014; 14:1-7. https://doi.org/10.1186/2052-1839-14-8 pmid:24666771 pmcid:pmc3994311 39. gudina a, wordofa m, urgessa f. immuno-hematological parameters among adult hiv patients before and after initiation of dolutegravir based antiretroviral therapy, addis ababa, ethiopia. plos one. 2024; 19(10):e0310239. https://doi.org/10.1371/journal.pone.0310239 pmid:39480901 pmcid:pmc11527299 40. geletaw t, tadesse mz, demisse ag. hematologic abnormalities and associated factors among hiv infected children pre-and postantiretroviral treatment, north west ethiopia. journal of blood medicine. 2017:99-105. https://doi.org/10.2147/jbm.s137067 pmid:28831276 pmcid:pmc5552149 41. jegede fe, oyeyi ti, abdulrahman sa, mbah ha, badru t, agbakwuru c, adedokun o. effect of hiv and malaria parasites coinfection on immune-hematological profiles among patients attending anti-retroviral treatment (art) clinic in infectious disease hospital kano, nigeria. plos one. 2017; 12(3):e0174233. https://doi.org/10.1371/journal.pone.0174233 pmid:28346490 pmcid:pmc5367709 42. obeagu ei, obeagu gu. art and platelet dynamics: assessing implications for hiv patient care. elite journal of haematology. 2024; 2(4):68-85. 43. obeagu ei, ayogu ee, obeagu gu. impact on viral load dynamics: understanding the interplay between blood transfusion and antiretroviral therapy in hiv management. elite journal of nursing and health science. 2024;2(2):5-15. 44. ciccacci f, lucaroni f, latagliata r, morciano l, mondlane e, balama m, tembo d, gondwe j, orlando s, palombi l, marazzi mc. hematologic alterations and early mortality in a cohort of hiv positive african patients. plos one. 2020; 15(11):e0242068. https://doi.org/10.1371/journal.pone.0242068 pmid:33170905 pmcid:pmc7654783 45. ashenafi g, tibebu m, tilahun d, tsegaye a. immunohematological outcome among adult hiv patients taking highly active antiretroviral therapy for at least six months in yabelo hospital, borana, ethiopia. journal of blood medicine. 2023:543-554. https://doi.org/10.2147/jbm.s419414 pmid:37881654 pmcid:pmc10595970 46. obeagu ei, goryacheva og. the role of inflammation in hiv and sickle cell disease co-morbidity. lifeline hiv, 2025; 3(1): 1-12 47. obeagu ei, goryacheva og. oxidative stress in hiv and sickle cell disease: a double burden. lifeline hiv, 2025; 3(1): 13-24 48. obeagu ei, goryacheva og. hiv and sickle cell disease: a focus on liver dysfunction. lifeline hiv, 2025; 3(1): 25-40 https://doi.org/10.22270/ijmspr.v10i4.125 https://doi.org/10.22270/ijmspr.v10i4.127 https://doi.org/10.1186/s12981-015-0069-4 https://doi.org/10.1186/2052-1839-14-8 https://doi.org/10.1371/journal.pone.0310239 https://doi.org/10.2147/jbm.s137067 https://doi.org/10.1371/journal.pone.0174233 https://doi.org/10.1371/journal.pone.0242068 https://doi.org/10.2147/jbm.s419414 khachane et al. asian journal of dental and health sciences. 2025; 5(1):54-57 [54] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited cracked tooth syndrome: an endodontic triumph khachane chetan1*, likhitkar manoj2, heda anantkumar3, mahalle kavita4, gupta vyankatesh5, khandelwal akansha6 1 p.g 3rd year. department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola. maharashtra. india. 2 professor and hod. department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola. maharashtra. india. 3 professor. department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola. maharashtra. india 4 p.g 3rd year. department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola. maharashtra. india. 5 p.g 2nd year, department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola, maharashtra, india. 6 p.g 2nd year, department of conservative dentistry and endodontics, dr. r. r. kambe dental college and hospital, akola, maharashtra, india. article info: _____________________________________________ article history: received 02 dec 2024 reviewed 06 jan 2025 accepted 25 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: khachane c, likhitkar m, heda a, mahalle k, gupta v, khandelwal a, cracked tooth syndrome: an endodontic triumph, asian journal of dental and health sciences. 2025; 5(1):54-57 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.123 abstract _________________________________________________________________________________________________________________ a cracked tooth is one where a partial or complete fracture exists within the stress plane. such fractures are more prevalent in patients over 40 years of age, with an incidence rate of 9.7% for cracks or incomplete tooth fractures with vital pulps. the average biting force in humans ranges from 45.7 kg/mm² in males to 36.4 kg/mm² in females, with the force ratio between molars, premolars, and incisors being 4:2:1, respectively. occlusal forces commonly impose stress on a tooth, potentially causing higher energy instances within the stress plane during the mastication cycle. the functional prognosis and periodontal treatment requirements for a cracked or incompletely fractured tooth depend on the location and the extent of tooth structure intersected, along with its involvement in the stress plane. this case report highlights the diagnosis and management of a cracked maxillary first molar and identifies prognostic indicators, which largely depend on the extent of the fracture within the tooth structure. keywords: crack tooth, orthodontic banding, cbct, longitudinal fractures, endodontic treatment *address for correspondence: chetan khachane, p.g 3rd year, dr. r. r. kambe dental college and hospital, akola, maharashtra, 444001, india. introduction a cracked tooth refers to a tooth with a partial or complete fracture along a stress plane, often occurring in commonly affected teeth. cracked tooth syndrome (cts) can be defined as an incomplete fracture of unknown depth, originating in the crown, traversing the tooth structure, and potentially extending subgingivally to involve the pulp space and/or periodontal ligament. the fracture may pass through one or both marginal ridges and the proximal surfaces, and it may be confined to the crown or extend from the crown into the proximal root surface. the location, orientation, and severity of the crack significantly influence treatment decisions.1 central and apical occlusal cracks are more likely than fractured cusps to result in pulpal or periapical complications.2 gibbs first described the clinical symptoms of incomplete fractures in posterior teeth in 1954, calling it “cuspal fracture odontalgia.”3 subsequently, ritchey et al. documented cases of incomplete fractures leading to pulpitis in 1957.4 in 1964, cameron coined the term "cracked tooth syndrome" to describe an incomplete fracture of a posterior tooth that involves the dentin and may extend to the pulp.5 this definition was later refined by ellis as "a fracture plane of unknown depth and direction traversing the tooth structure, which, if not already involved, has the potential to progress and connect with the pulp and/or periodontal ligament."6 the prevalence of cts is unclear, but incidence rates between 34% and 74% have been reported.7 it most commonly affects individuals aged 30–50, with a higher prevalence in females.7 the mandibular molar is the tooth most often involved, followed by the maxillary premolar, maxillary molar, and mandibular premolar. in 2006, roh and lee observed that cracks were more frequent in maxillary molars (57.2%) than mandibular molars (36.3%).8 cts can be classified into five categories, generally ranked from least to most severe: craze lines, fractured cusp, cracked tooth, split tooth, and vertical root fractures.9 the etiology of cts is multifactorial. lynch and mcconnell identified four major contributing factors: open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.123 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.123&amp;domain=pdf khachane et al. asian journal of dental and health sciences. 2025; 5(1):54-57 [55] ajdhs.com restorative procedures, occlusal factors, developmental factors, and miscellaneous factors.10 early diagnosis of cracked teeth is crucial, as delayed detection increases the risk of pulpal complications.11 additionally, associated bone defects may complicate future implant placement if the tooth is eventually lost.12 the clinical signs and symptoms of cts vary based on the location and extent of the fracture. patients often report discomfort lasting several months, along with sharp pain when biting or consuming cold foods, beverages, or sugary substances. rebound pain, felt when releasing pressure after biting fibrous foods, is a characteristic feature, although one study found chewing pain to be more common than rebound pain.13 chronic pulpitis without clinical symptoms may develop due to microleakage of bacterial by-products and toxins. in cases where the crack involves the pulp, both pulpal and periodontal symptoms may arise. this case report provides an overview of the clinical features, diagnosis, and endodontic treatment of cracked teeth. case report a 50-year-old male presented to the department of conservative dentistry and endodontics, complaining of pain in the upper right posterior region during chewing. he reported a history of traumatic bite a few weeks earlier. he had a cervical abrasion on a buccal surface of 16. upon clinical examination, crack lines were observed on the mesial and buccal surfaces of the tooth crown. (fig.1a) the tooth responded positively to percussion and bite tests, and probing revealed a depth of 3 mm on the mesiobuccal aspect. vitality testing with an electric pulp tester indicated no response in tooth 16. radiographic imaging revealed a fracture line extending through the enamel, dentin, and pulp; however, the radiograph could not determine the exact extent of the fracture or provide significant additional findings (fig. 1b). the patient was informed about the option of cone beam computed tomography (cbct) to assess the fracture's depth and its impact on the tooth's prognosis. the benefits of cbct were explained, and assurances were given regarding minimal radiation exposure. after obtaining informed consent, cbct (vatech, pax-reve 3d plus, pulse-type generator, 5 × 5 cm field of view, and 0.08 mm voxel size) was performed to evaluate the fracture's apical extension and its proximity to the pulp (figures 4(a) and 4(b)). the imaging revealed that the fracture extended mesially and buccally, involving the mesiobuccal pulp horn, but did not extend apically below the alveolar bone level. (fig. 1c & 1d) the prognosis was deemed favourable. root canal treatment followed by crown placement was determined to be the most suitable treatment plan. the presence of acute pain and the suspected extension of the fracture to deeper areas of the root justified the use of cbct for a precise diagnosis and treatment plan. the case was diagnosed as pulp necrosis with symptomatic apical periodontitis in tooth 16 due to a crack. figure 1: (a) preoperative picture, (b) preoperative radiograph, (c) cone beam computed tomography (cbct) showing the fracture line extending mesially and buccally, and (d) cracked line also towards the pulp space treatment procedure: occlusal reduction was performed before initiating root canal therapy on tooth 16. upon access opening, necrotic pulp tissue was observed. the tissue was extirpated, and the tooth was visually examined using a magnifying loupe with led illumination. a buccal crack line was identified extending into the dentin, terminating just above the pulp floor. another crack line was seen on the occlusal fourth of the mesial wall. these cracks were removed with a no. 1/4 round bur to a depth sufficient to eliminate the lines. the crack regions were etched and sealed with a flowable composite resin (compo-flo, d-tech). orthodontic molar banding (0.180″ × 0.006″) was applied to stabilize the tooth. (fig. 2) canal instrumentation began with hand files using minimal force, followed by rotary instrumentation up to 20/6% neoendo flex files. irrigation was performed with 3% sodium hypochlorite and saline. calcium hydroxide intracanal medication was placed between appointments. obturation was completed with guttapercha and zinc oxide sealer using the lateral condensation technique. minimal force was applied during condensation to prevent further damage. the gutta-percha was trimmed at the orifice level, and postendodontic restoration was performed one week later using a glass ionomer cement liner, fiber-reinforced composite, and bulk-fill dentin bonding composite. (fig.3 a&b) a b c d khachane et al. asian journal of dental and health sciences. 2025; 5(1):54-57 [56] ajdhs.com follow-up evaluations at one and three months showed no pathological changes upon clinical and radiographic examination. the orthodontic molar band was removed by creating a groove with a diamond bur and splitting it. the tooth was minimally prepared, and prosthetic rehabilitation was completed with a full-ceramic crown. a review at ten months confirmed that tooth 16 remained asymptomatic and functional, with an intact periapical area (fig. 4&5). figure 4: after crown placement figure 5: review after 10 months discussion cracked tooth syndrome presents a diagnostic challenge, even for experienced dental professionals, due to its diverse and often atypical clinical signs and symptoms.14 early diagnosis is crucial, as it is associated with better restorative outcomes and prognosis.15 various diagnostic methods are used to confirm cracks in teeth, such as visual examination under magnification, staining, transillumination, bite tests, autofluorescence, optical coherence tomography, quantitative percussion diagnostics, and laser detection. radiographic techniques, particularly cone beam computed tomography (cbct), are often superior to periapical radiographs for assessing crack extent. however, cbct may still have limitations, especially in detecting cracks in endodontically treated teeth.16 with a resolution of approximately 80 μm, cbct is not ideal for diagnosing cracks or detecting early vertical root fractures (vrfs).17 an in vitro study by yuan et al. showed that using meglumine diatrizoate as a contrast agent with cbct enhances detection of hidden cracks compared to conventional methods.18 in this case, the fracture line was visible on radiographs, and the treatment objective was to prevent further crack propagation. this was achieved through occlusal height reduction, crack sealing, and tooth stabilization using a stainless-steel band. pane et al. demonstrated that stainless steel bands significantly reduce cuspal flexure and increase fracture resistance compared to teeth without bands.19 these bands act as a protective measure during treatment by absorbing forces and ensuring uniform stress distribution. as stainless steel has an elastic modulus higher than tooth structure, it transfers stress to the band material, thereby protecting the tooth. care must be taken to avoid occlusal interference when applying bands. in this case, the crack's etiology was attributed to traumatic bite, as reported by the patient. the prognosis for a cracked tooth is more favourable when the crack is not visible or does not extend to the pulp chamber floor. in this case, visual examination under a 2.5× magnification loupe (admetec) revealed a crack terminating just above the pulp floor. the tooth was diagnosed as non-vital, necessitating root canal treatment followed by prosthetic restoration. treatment began with a guarded prognosis. minor cracks can often be managed with bonded restorations or crowns, while deeper cracks with pulpal involvement require root canal therapy and crowns for structural reinforcement. indirect composite onlays may also be an option, but full crowns are typically preferred for treating cracked tooth syndrome. following banding and root canal therapy, the patient experienced relief from symptoms. post-endodontic restoration included sealing the orifice with glass ionomer cement, replacing dentin with fiber-reinforced composite (everx posterior, gc europe), and applying a nanohybrid composite (tetric evoceram, ivoclar vivadent, inc.) for the occlusal laminate layer. bonded restorations are effective in reinforcing weakened tooth structures. fiber-reinforced composite has high flexural figure 2: clinical photograph after molar band placement. figure 3: (a and b) postoperative radiograph and photograph. a b khachane et al. asian journal of dental and health sciences. 2025; 5(1):54-57 [57] ajdhs.com strength, minimal shrinkage, and the ability to arrest crack progression. the banding was retained for one month before being replaced with a full-ceramic crown. full coverage restorations bind the tooth together, providing external compressive forces similar to banding, thus ensuring uniform stress distribution. studies indicate that cracked teeth restored with full crowns after root canal treatment have higher survival rates and fewer complications compared to other restorations.20 clark and caughman categorized cracked tooth prognosis into four groups based on the extent of the fracture:21 • excellent: (a) cuspal fractures within the dentin angling from the faciopulpal or linguopulpal line angle of a cusp to the cemento-enamel junction or slightly below. (b) horizontal fractures of a cusp not involving the pulp. • good: coronal vertical fractures running mesiodistally into dentin but not involving the pulp. • poor: coronal vertical fractures extending mesiodistally into dentin and pulp but confined to the crown. • hopeless: coronal vertical fractures passing mesiodistally through the pulp and into the root. a 10-month follow-up revealed that the treated tooth remained asymptomatic and functional, with an intact periapical area. clinical significance: diagnosing cracked tooth syndrome is complex due to its varied signs and symptoms. a range of techniques can be used to manage cracked teeth effectively, focusing on preservation, stabilization, and protection. in this case, a combination of restorative procedures, banding, endodontic treatment, and prosthodontic intervention resulted in a favorable outcome. acknowledgment: we would like to thank dr. r.r. kambe dental college and hospital and department of conservative dentistry and endodontics. conflicts of interest: there are no conflicts of interest. references 1. rivera em, walton re. cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures. am assoc endodontists colleagues for excellence news lett. 2008;2:1-9. 2. yang s-e, jo a-r, lee h-j, et al. analysis of the characteristics of cracked teeth and evaluation of pulp status according to periodontal probing depth. bmc oral health 2017;17(1):135. https://doi.org/10.1186/s12903-017-0434-x pmid:29179713 pmcid:pmc5704503 3. gibbs jw. cuspal fracture odontalgia. dent dig 1954; 60:158 60. 4.ritchey b, mendenhall r, orban b. pulpitis resulting from incomplete tooth fracture. oral surg oral med oral pathol 1957;10:665 70. https://doi.org/10.1016/s0030-4220(57)80016-4 pmid:13441283 5. c. e. cameron, "cracked-tooth syndrome," e journal of the american dental association, 1964;68(3):405-411. https://doi.org/10.14219/jada.archive.1964.0108 pmid:14128028 6. s. g. s. ellis, "incomplete tooth fractureproposal for a new definition," british dental journal, 2001;190(8):424-428. https://doi.org/10.1038/sj.bdj.4800992a pmid:11352390 7. hasan s, singh k, salati n. cracked tooth syndrome: overview of literature. int j appl basic med res 2015;5(3):164-168. https://doi.org/10.4103/2229-516x.165376 pmid:26539363 pmcid:pmc4606573 8. roh bd, lee ye. analysis of 154 cases of teeth with cracks. dent traumatol 2006;22(3):118-123. https://doi.org/10.1111/j.16009657.2006.00347.x pmid:16643285 9. e. m. rivera and r. e. walton, "cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures," american association of endodontists colleagues for excellence, newsletter, summer 2008. 10. lynch cd, mcconnell rj. the cracked tooth syndrome. j can dent assoc 2002;68(8):470-475. 11. kang, s. h., kim, b. s., & kim, y. cracked teeth: distribution, characteristics, and survival after root canal treatment. journal of endodontics, 2016;42:557-562. https://doi.org/10.1016/j.joen.2016.01.014 pmid:26944835 12. dutner, j. m., herold, r. w., wilson, bunting, m. e., bullock, j. s.,dunham, d. d., & johnson, t. m. j. p. fracture necrosis: a risk indicator for tooth loss. journal of the american dental association, 2020;151:454-463 https://doi.org/10.1016/j.adaj.2020.01.024 pmid:32305132 13. abbott p, leow n. predictable management of cracked teeth with reversible pulpitis. aust dent j 2009;54(4):306-315. https://doi.org/10.1111/j.1834-7819.2009.01155.x pmid:20415928 14. liu hh, sidhu sk. cracked teeth treatment rationale and case management: case reports. quintessence int 1995;26:485 92. 15. agar jr, weller rn. occlusal adjustment for initial treatment and prevention of the cracked tooth syndrome. j prosthet dent 1988;60:145 7. https://doi.org/10.1016/0022-3913(88)90303-4 pmid:3050033 16. kakka, a., gavriil, d., & whitworth, j. treatment of cracked teeth: a comprehensive narrative review. clinical and experimental dental research, 2022;8:1218-1248. https://doi.org/10.1002/cre2.617 pmid:35809233 pmcid:pmc9562569 17. li f, diao y, wang j, et al. review of cracked tooth syndrome: etiology, diagnosis, management, and prevention. pain res manag 2021;2021: 3788660. https://doi.org/10.1155/2021/3788660 pmid:34956432 pmcid:pmc8694987 18. yuan m, gao at, wang tm, et al. using meglumine diatrizoate to improve the accuracy of diagnosis of cracked teeth on cone-beam ct images. int endod j 2020;53(5):709-714. https://doi.org/10.1111/iej.13270 pmid:31985061 19. pane es, palamara jea, messer hh. stainless steel bands in endodontics: effects on cuspal flexure and fracture resistance. int endod j 2002;35(5):467-471. https://doi.org/10.1046/j.13652591.2002.00503.x pmid:12059919 20. thi wn, jansson l. survival rate after endodontic treatment in general dentistry for cracked teeth with different coronal restorations. acta odontol scand 2021;79(4):256-261. https://doi.org/10.1080/00016357.2020.1834615 pmid:33103524 21. clark ll, caughman wf. restorative treatment for the cracked tooth. oper dent 1984;9:136 42. https://doi.org/10.1186/s12903-017-0434-x https://doi.org/10.1016/s0030-4220(57)80016-4 https://doi.org/10.14219/jada.archive.1964.0108 https://doi.org/10.1038/sj.bdj.4800992a https://doi.org/10.4103/2229-516x.165376 https://doi.org/10.1111/j.1600-9657.2006.00347.x https://doi.org/10.1111/j.1600-9657.2006.00347.x https://doi.org/10.1016/j.joen.2016.01.014 https://doi.org/10.1016/j.adaj.2020.01.024 https://doi.org/10.1111/j.1834-7819.2009.01155.x https://doi.org/10.1016/0022-3913(88)90303-4 https://doi.org/10.1002/cre2.617 https://doi.org/10.1155/2021/3788660 https://doi.org/10.1111/iej.13270 https://doi.org/10.1046/j.1365-2591.2002.00503.x https://doi.org/10.1046/j.1365-2591.2002.00503.x https://doi.org/10.1080/00016357.2020.1834615 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):63-67 [63] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited empowering girls with hiv prevention skills in low-resource schools: a review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 28 sep 2024 reviewed 03 nov 2024 accepted 26 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, empowering girls with hiv prevention skills in low-resource schools: a review, asian journal of dental and health sciences. 2024; 4(3):63-67 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.104 abstract _________________________________________________________________________________________________________________ hiv remains a significant health challenge globally, and adolescent girls in low-resource settings are disproportionately affected due to factors such as limited access to sexual health education and gender inequality. empowering girls with hiv prevention skills in schools, particularly in lowresource areas, is a crucial strategy in reducing their vulnerability to hiv. this review explores the importance of hiv prevention education in schools and how tailored approaches can effectively empower girls with the knowledge and skills necessary to protect themselves from hiv. by focusing on the role of education in these communities, this article discusses how schools can act as key platforms for delivering hiv prevention messages and resources. the article identifies several barriers to effective hiv prevention education, including lack of trained teachers, inadequate educational materials, and socio-cultural stigmas surrounding discussions of sexual health. it also highlights the importance of involving the broader community, including parents, local leaders, and healthcare providers, to support and reinforce hiv education efforts. strategies such as integrating hiv prevention into the school curriculum, training educators, and promoting peer-led initiatives are explored as effective ways to reach girls and provide them with practical skills for hiv prevention. keywords: hiv prevention, girls’ empowerment, low-resource schools, education, sexual health *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv continues to be a global health issue, with adolescent girls in low-resource settings particularly vulnerable to infection. sub-saharan africa remains the epicenter of the hiv epidemic, where young girls and women are disproportionately affected. according to the world health organization, adolescent girls are more likely to be hiv-positive than their male counterparts due to a combination of biological, social, and cultural factors. early sexual initiation, genderbased violence, unequal power dynamics in relationships, and limited access to sexual health education all contribute to the heightened vulnerability of girls to hiv. in many low-resource areas, schools represent one of the few settings where young people can access critical sexual health information, making them an essential platform for hiv prevention efforts.1-2 in these regions, low-resource schools often lack the necessary infrastructure and trained personnel to deliver comprehensive sexual and reproductive health education. this gap in education, combined with sociocultural taboos around discussing sexual health, further exacerbates the challenges faced by adolescent girls in making informed decisions about their sexual health. for girls who have limited access to healthcare and who are at higher risk of hiv due to gender inequality, school-based hiv prevention programs can play a transformative role. empowering girls with the knowledge and skills to prevent hiv is not just a health intervention, but a critical step towards achieving gender equality and social empowerment.3-4 given the specific needs of girls in these environments, hiv prevention education must be tailored to address the unique challenges they face. an effective hiv prevention program should not only educate girls about the virus and how it is transmitted, but also teach them how to negotiate safe sexual practices, understand the importance of condom use, and access hiv testing and treatment. additionally, it must take into account cultural sensitivities, social norms, and local barriers that may affect girls’ ability to engage with such information. schools in low-resource settings must be equipped with the resources and training to provide this education in a safe, supportive environment.5 the importance of hiv prevention education in lowresource schools cannot be overstated. evidence shows that education significantly reduces the risk of hiv transmission by increasing awareness, promoting safer sexual behaviors, and improving access to prevention and care services. for girls, such education can also open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.104 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.104&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):63-67 [64] ajdhs.com reduce the power imbalances that often exist in relationships and help them make empowered choices regarding their sexual health. school-based programs provide an opportunity to reach a large number of girls at a crucial age, equipping them with the skills to protect themselves from hiv and other sexually transmitted infections (stis), as well as the knowledge to challenge harmful gender norms and societal expectations.6-7 however, despite the potential of school-based hiv prevention programs, several challenges exist in implementing effective education in low-resource settings. these challenges include insufficient funding, lack of teacher training, and the prevalence of stigmatizing attitudes towards sexual health education. moreover, in many communities, parents and local leaders may resist the idea of hiv education for girls due to cultural norms surrounding sexuality and gender roles. these obstacles require innovative solutions, such as community involvement, teacher professional development, and the use of peer education models to ensure that hiv prevention messages reach girls in an accessible and meaningful way.8-9 the importance of hiv prevention education for girls hiv prevention education for girls is essential, particularly in low-resource settings where girls are often at higher risk of hiv infection due to a variety of socio-economic and cultural factors. early sexual debut, limited access to healthcare, and gender-based violence are just a few of the key factors contributing to the vulnerability of girls to hiv. without proper education, girls may not have the knowledge or resources to protect themselves from hiv, which can lead to lifealtering consequences. providing hiv prevention education equips girls with the knowledge and skills to reduce their risk, make informed decisions, and ultimately safeguard their sexual health. in many communities, school is one of the few places where girls can access such education, making it an ideal setting for hiv prevention programs.10-11 a primary benefit of hiv prevention education is that it empowers girls by increasing their awareness of hiv transmission and the preventive measures they can take. teaching girls about the virus—how it spreads, the risks of unprotected sex, and the importance of condom use—ensures they understand the importance of taking protective steps. equally important is educating them about their rights, including the right to refuse sex or to ask a partner to use protection, which is a critical aspect of preventing hiv. girls who are educated about hiv are more likely to delay sexual initiation, practice safer sex, and seek out hiv testing and treatment, which in turn can reduce transmission rates within the broader community.12-13 beyond just knowledge, hiv prevention education fosters a sense of empowerment. when girls understand their sexual health, they are more likely to make decisions that protect their well-being. empowerment also includes the ability to negotiate safer sexual practices, refuse unwanted sexual advances, and advocate for their health within relationships. in many low-resource settings, where gender inequality and power imbalances often prevail, hiv education can challenge harmful gender norms and practices that place girls at greater risk. for example, in societies where girls may be expected to marry early or accept sexual advances from older men, education helps them recognize their right to make their own choices about when and how to engage in sexual activity. this can contribute to reducing early marriages, reducing gender-based violence, and decreasing the rates of hiv among young girls.14 challenges in delivering hiv prevention education in low-resource schools delivering effective hiv prevention education in lowresource schools presents a range of challenges, many of which stem from insufficient infrastructure, limited funding, and sociocultural factors. these schools often lack the necessary resources to provide comprehensive sexual and reproductive health education. teachers may not have access to up-to-date educational materials or training, hindering their ability to deliver accurate, engaging, and age-appropriate hiv prevention messages. in some cases, teachers themselves may feel uncomfortable discussing topics related to sexuality, hiv, and reproductive health, especially in communities where these subjects are considered taboo or culturally sensitive. this discomfort can further limit the effectiveness of hiv prevention efforts and leave girls without the critical knowledge they need to protect themselves from hiv.15-17 another significant barrier to delivering hiv prevention education in low-resource settings is the lack of adequate teacher training. in many schools, educators are not equipped with the skills to teach sensitive topics like hiv prevention, consent, or sexual health. many teachers may not have specialized knowledge in sexual and reproductive health, making it difficult for them to address students’ questions or concerns accurately. additionally, teacher training programs may not prioritize hiv education, leaving educators unprepared to discuss these topics confidently and comprehensively. this lack of training can undermine the quality of education and perpetuate misinformation or stigma surrounding hiv, which can discourage girls from engaging with hiv prevention messages or seeking help if they are at risk.18-19 sociocultural and societal norms also play a critical role in hindering the delivery of hiv prevention education in many low-resource settings. in many cultures, there is resistance to discussing sexual health openly, particularly with young girls. parents and community leaders may oppose hiv education programs in schools, fearing they will encourage sexual activity or challenge traditional gender roles. in societies where early marriage, sexual violence, and gender inequality are common, the reluctance to engage in discussions about hiv prevention can be even more pronounced. the stigma associated with hiv and the belief that it is a "taboo" subject often results in silence around sexual health, further isolating girls and leaving them vulnerable. overcoming these cultural barriers requires not only educational reform but also community involvement and sensitivity to local beliefs and values.2021 another challenge is the limited availability of emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):63-67 [65] ajdhs.com healthcare services and support structures within lowresource communities. even if hiv prevention education is delivered successfully in schools, girls may still face difficulties in accessing hiv-related healthcare, such as testing, condoms, and treatment. in many rural or underserved areas, healthcare facilities may be far away, understaffed, or ill-equipped to provide adequate services for adolescents. girls may also face financial barriers that prevent them from seeking medical help or purchasing necessary prevention tools, such as condoms. in the absence of adequate healthcare infrastructure, education alone may not be enough to reduce hiv risk. integration of healthcare services with hiv education in schools is crucial to ensure that girls have access to the necessary resources for hiv prevention and care.22-23 additionally, low-resource schools often struggle with overcrowded classrooms, limited time, and a lack of structured curricula, making it difficult to adequately address hiv prevention. many schools are forced to prioritize subjects with national examination requirements, leaving little room for comprehensive sexual and reproductive health education. even when hiv prevention is included in the curriculum, it may only be addressed in a superficial way, which does not allow for in-depth discussions or skills-building on topics such as condom use, safe sexual practices, or negotiating consent. this can result in incomplete education that does not fully equip girls to protect themselves from hiv or navigate the complexities of sexual health and relationships.24-25finally, financial constraints are a major obstacle to the effective delivery of hiv prevention education in low-resource schools. governments in many low-resource settings face tight budgets and may not prioritize funding for sexual health education programs, leaving schools to rely on international donors or non-governmental organizations (ngos) for support. while these partnerships can be valuable, they are often inconsistent or limited in scope. this lack of sustained funding can lead to the underdevelopment of hiv prevention programs, including a lack of trained personnel, educational materials, and outreach efforts. without adequate funding, schools may struggle to implement or maintain hiv prevention initiatives over the long term, reducing their overall impact.26-27 strategies for empowering girls with hiv prevention skills empowering girls with hiv prevention skills in lowresource schools requires a comprehensive, culturally sensitive, and multi-faceted approach that takes into account the unique challenges they face. several strategies can be employed to effectively equip girls with the knowledge, skills, and confidence needed to protect themselves from hiv. these strategies include enhancing the curriculum to provide accurate, ageappropriate information, building a supportive environment that fosters open discussion, and utilizing peer education programs to create lasting impact.28 1. curriculum enhancement and teacher training a key strategy for empowering girls with hiv prevention skills is to ensure that the curriculum in schools includes comprehensive, accurate, and ageappropriate hiv education. the curriculum should address not only the basics of hiv transmission but also skills-based education that enables girls to practice safer sexual behaviors. this includes lessons on condom use, the importance of hiv testing, and how to negotiate safer sex. it should also cover the social and emotional aspects of sexual health, such as recognizing coercion, understanding consent, and developing healthy relationships. to make this possible, teachers need proper training in delivering these sensitive topics. teacher training programs should focus on equipping educators with the knowledge and confidence to discuss sexual health openly and address any questions or concerns that arise. trained teachers are better able to create a safe and supportive classroom environment where girls feel comfortable asking questions and engaging with the material.29 2. peer education programs peer education is another powerful strategy to empower girls with hiv prevention skills. peer educators are typically older or more knowledgeable students who serve as role models and educators for their younger peers. peer education programs can be effective in overcoming cultural and social barriers by making hiv prevention education more relatable and accessible. girls are more likely to engage with and trust information delivered by their peers, especially when it comes to topics related to sexuality and health. peer educators can lead discussions, organize awareness campaigns, and facilitate group activities on hiv prevention, making the learning process more interactive and engaging. involving peer educators also fosters leadership and communication skills among older girls, which they can carry forward into their communities. additionally, peer education programs create a sense of community and support, helping to reduce stigma and encourage collective action.30 3. community and parental involvement community and parental involvement plays a crucial role in the success of hiv prevention education programs for girls. in many low-resource settings, there may be resistance to hiv education due to cultural norms, misconceptions about sexual health, or concerns about encouraging sexual activity. engaging parents and community leaders early in the process can help address these concerns and build support for hiv education in schools. schools should actively involve parents in awareness campaigns, meetings, and workshops, where they can learn about the importance of hiv prevention education and how to support their daughters in making informed decisions. community leaders, including religious leaders, local health professionals, and respected elders, can also help dispel myths and promote the importance of educating girls about hiv. by fostering a broader community-based approach, hiv prevention education becomes a shared emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):63-67 [66] ajdhs.com responsibility that strengthens both family and school support for girls' health.31 4. safe spaces and gender-sensitive education creating safe spaces in schools where girls can discuss hiv prevention openly and without judgment is another critical strategy. these spaces allow girls to ask questions, express concerns, and receive guidance on sexual health in a non-threatening and supportive environment. girls are more likely to engage in hiv prevention education when they feel safe to do so. this includes having teachers who are empathetic and nonjudgmental, as well as school policies that protect students from discrimination and harassment related to their sexual health. moreover, hiv education should be gender-sensitive, addressing the specific challenges girls face in relation to hiv prevention, such as unequal power dynamics in relationships, gender-based violence, and early sexual debut. gender-sensitive education helps girls understand not only the biological aspects of hiv prevention but also the social and cultural factors that influence their risk.32 5. access to healthcare and prevention tools while education is essential, it must be paired with access to healthcare services and prevention tools. girls need access to condoms, hiv testing, and treatment services to complement the knowledge gained from hiv education. schools can partner with local health services to provide hiv testing and counseling services on-site or ensure that girls are aware of nearby health centers where they can seek care. additionally, schools should make condoms available to students in a discreet and accessible manner, ensuring that girls can practice safer sex in real-life situations. educational programs should also highlight the importance of regular hiv testing, both for prevention and early detection, as well as the availability of treatment options for those living with hiv. by providing these practical tools alongside education, schools ensure that girls are not only informed but also empowered to take action to protect their sexual health.33 6. digital and multimedia education in an increasingly digital world, incorporating technology into hiv prevention education can enhance its reach and effectiveness. mobile phones, social media platforms, and multimedia resources such as videos and online courses can be powerful tools in delivering hiv prevention messages to girls. in areas where traditional school resources are limited, digital education can bridge gaps by offering interactive lessons, virtual counseling, and peer support networks. these platforms can also provide girls with access to reliable, up-to-date information on hiv prevention, sexual health, and gender equality. however, it is important to ensure that digital content is culturally appropriate, safe, and accessible to all girls, particularly in communities with limited internet access or where the digital divide is prominent. by integrating digital education into schoolbased hiv prevention programs, schools can reach a wider audience and offer continuous support beyond the classroom.31-33 conclusion empowering girls with hiv prevention skills in lowresource schools is an essential step towards reducing the vulnerability of young girls to hiv and promoting their sexual and reproductive health. through comprehensive, culturally sensitive education that addresses both the biological and social aspects of hiv, girls can be equipped with the knowledge and skills needed to protect themselves from hiv transmission. strategies such as curriculum enhancement, teacher training, peer education programs, and creating safe spaces for open discussion are key to ensuring that girls receive the education and support they need to navigate the complexities of sexual health. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):63-67 [67] ajdhs.com 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. obeagu ei, obeagu gu, the vital role of blood transfusions during pregnancy: a comprehensive review, asian journal of dental and health sciences, 2024;4(1):26-31 https://doi.org/10.22270/ajdhs.v4i1.58 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.22270/ajdhs.v4i1.58 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):11-14 [11] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited diagnostic challenges in maternal anemia: mentzer index in clinical practice emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 05 nov 2024 reviewed 09 dec 2024 accepted 12 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, diagnostic challenges in maternal anemia: mentzer index in clinical practice, asian journal of dental and health sciences. 2025; 5(1):11-14 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.108 abstract _________________________________________________________________________________________________________________ maternal anemia is a significant health concern during pregnancy, as it poses risks for both maternal and fetal well-being. two common causes of microcytic anemia in pregnant women are iron deficiency anemia (ida) and thalassemia trait (tt). distinguishing between these conditions is crucial, as their management differs substantially. the mentzer index (mi), a simple diagnostic tool, is commonly used to differentiate between ida and tt based on the mean corpuscular volume (mcv) and red blood cell (rbc) count. however, while the mi is widely used due to its simplicity and cost-effectiveness, its accuracy can be influenced by various factors, including the presence of mixed anemia, laboratory errors, and coexisting conditions. this review explores the diagnostic challenges of maternal anemia and evaluates the role of the mentzer index in clinical practice. we discuss how the mi can be helpful in initial screening, particularly in resource-limited settings, but highlight its limitations in cases of complex anemia, such as when thalassemia trait coexists with iron deficiency. we also examine the role of complementary diagnostic methods, such as serum ferritin, hemoglobin electrophoresis, and genetic testing, which can improve diagnostic accuracy and guide treatment decisions. keywords: maternal anemia, mentzer index, diagnostic challenges, iron deficiency anemia, thalassemia trait *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia during pregnancy is a global health issue that affects millions of women, with significant consequences for both maternal and fetal health. it is a condition characterized by a reduction in hemoglobin levels, leading to inadequate oxygen supply to the body's tissues. in pregnancy, anemia is particularly concerning due to the increased metabolic demands placed on the body, which can result in complications such as preterm birth, low birth weight, and even maternal mortality. anemia during pregnancy can be caused by a variety of factors, including nutritional deficiencies, chronic diseases, and inherited blood disorders, with iron deficiency anemia (ida) and thalassemia trait (tt) being two of the most common causes of microcytic anemia.1-2 iron deficiency anemia is the most prevalent form of anemia in pregnant women worldwide, primarily due to increased iron demands during pregnancy, combined with insufficient dietary intake or poor absorption of iron. in contrast, thalassemia trait, which is an inherited blood disorder, is commonly found in populations with a high prevalence of consanguinity or certain genetic backgrounds, particularly in mediterranean, middle eastern, and asian populations. both ida and tt share similar hematological features, such as low mean corpuscular volume (mcv) and low hemoglobin levels, which makes differentiating between these two conditions challenging. proper diagnosis is crucial, as the treatment for ida typically involves iron supplementation, while tt requires a different approach that may include avoiding iron supplementation and offering genetic counseling.3-4 the mentzer index (mi) is a diagnostic tool developed to help differentiate between ida and tt. this index is calculated by dividing the mcv by the red blood cell (rbc) count, yielding a value that can guide clinicians in distinguishing between the two conditions. a mentzer index greater than 13 typically suggests ida, while values less than 13 are more likely to indicate thalassemia trait. the simplicity and accessibility of this tool make it an attractive first-line diagnostic method, particularly in settings with limited resources. however, while the mi offers a quick and cost-effective approach, it is not without its limitations and challenges, which can affect its diagnostic accuracy and clinical utility.5-6 one of the main challenges in using the mentzer index is that it does not account for other causes of microcytic anemia, such as anemia of chronic disease or sideroblastic anemia, which can present similarly to ida or tt. furthermore, in pregnant women, anemia can often be multifactorial, with the presence of both iron deficiency and thalassemia trait, making the mentzer index less reliable in such cases. additionally, laboratory open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.108 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.108&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):11-14 [12] ajdhs.com variability, such as differences in how mcv or rbc count is measured, can lead to discrepancies in the calculation of the mi, potentially leading to misdiagnosis. as such, the mi should be seen as part of a broader diagnostic toolkit, rather than a definitive diagnostic measure.7-8 in addition to the mentzer index, other diagnostic methods are often required to accurately differentiate between ida and tt, especially in complex cases. tests such as serum ferritin, transferrin saturation, and total ironbinding capacity (tibc) can provide valuable information about iron status, helping to confirm or rule out iron deficiency. hemoglobin electrophoresis is the gold standard for diagnosing thalassemia and other hemoglobinopathies, providing specific information about the types of hemoglobin present in the patient. genetic testing may also be necessary to definitively diagnose thalassemia and to assess the need for genetic counseling.9 this review aims to explore the diagnostic challenges of maternal anemia, focusing on the role of the mentzer index in clinical practice. the mentzer index: a diagnostic tool in maternal anemia the mentzer index (mi) is a simple and widely used diagnostic tool that helps differentiate between two of the most common causes of microcytic anemia in pregnancy: iron deficiency anemia (ida) and thalassemia trait (tt). it is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, resulting in an index value that can offer insight into the underlying cause of anemia. the mi is based on the premise that ida and tt present with different patterns of red blood cell morphology. while ida typically leads to a high rbc count with low mcv due to iron deficiency, tt usually results in a relatively normal rbc count with lower mcv because of defective hemoglobin synthesis.10-11 a mi value greater than 13 generally suggests that the anemia is due to iron deficiency, while a value less than 13 is typically indicative of thalassemia trait. the simplicity of this calculation makes the mentzer index an attractive option, particularly in settings where access to advanced diagnostic tools or resources is limited. it provides a quick, inexpensive, and relatively reliable method to screen for ida and tt, facilitating early detection and guiding appropriate management strategies for pregnant women.12 despite its advantages, the mentzer index has several limitations that can affect its diagnostic accuracy. for instance, the mi does not account for other causes of microcytic anemia, such as anemia of chronic disease or sideroblastic anemia, which can share similar hematological features with ida and tt. additionally, in pregnant women, anemia can often be multifactorial, involving both iron deficiency and thalassemia trait, which may lead to overlapping clinical features. as a result, the mi may be less accurate in these complex cases and may require confirmation through additional diagnostic tests. furthermore, laboratory errors and variations in mcv and rbc count measurements can influence the mi calculation, potentially leading to misinterpretation and inappropriate treatment decisions.13 in clinical practice, the mentzer index is most effective when used as an initial screening tool, with follow-up confirmatory tests employed as needed to verify the diagnosis. in cases where the mi suggests ida, serum ferritin levels, transferrin saturation, and total ironbinding capacity (tibc) can help confirm iron deficiency. if thalassemia trait is suspected based on a low mi, hemoglobin electrophoresis can be used to identify abnormal hemoglobin patterns, providing a definitive diagnosis. genetic testing may also be useful for further confirmation, especially in populations at high risk for thalassemia.14 while the mentzer index is a valuable diagnostic tool in identifying the cause of microcytic anemia, it should not be used in isolation. clinicians should consider the patient's clinical history, other hematological indices, and additional laboratory tests to ensure an accurate diagnosis. by combining the mi with other diagnostic methods, healthcare providers can improve their ability to differentiate between iron deficiency anemia and thalassemia trait, allowing for more tailored and effective treatment approaches for pregnant women. ultimately, accurate diagnosis and management of maternal anemia are critical for reducing maternal and fetal morbidity and mortality, highlighting the importance of utilizing the mentzer index as part of a comprehensive diagnostic approach.15-16 diagnostic challenges in maternal anemia maternal anemia is a common and significant health concern during pregnancy, affecting millions of women worldwide. the condition is often linked to adverse maternal and fetal outcomes, including preterm birth, low birth weight, and maternal fatigue. identifying the precise cause of anemia is essential for appropriate treatment and prevention of complications. however, diagnosing anemia in pregnancy presents unique challenges, as it can result from various underlying conditions, including nutritional deficiencies, chronic diseases, and inherited blood disorders. the two most common causes of microcytic anemia during pregnancy are iron deficiency anemia (ida) and thalassemia trait (tt), both of which share overlapping hematological features, making accurate diagnosis challenging.17-18 one of the primary diagnostic challenges in maternal anemia is distinguishing between ida and thalassemia trait. both conditions present with low mean corpuscular volume (mcv) and low hemoglobin levels, making it difficult to differentiate them based on basic laboratory findings alone. while ida is typically characterized by low iron stores and a reduced ability to produce hemoglobin, thalassemia trait involves a genetic defect that impairs hemoglobin production without necessarily affecting iron status. given the shared clinical features, misdiagnosis can occur if the underlying cause is not properly identified. in some cases, women may have both conditions simultaneously, further complicating diagnosis and treatment.19 another challenge is the multifactorial nature of anemia in pregnancy. pregnant women are at risk for several types of anemia, and a single diagnostic test may not always provide sufficient information to determine the emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):11-14 [13] ajdhs.com exact cause. for example, some women may experience anemia due to iron deficiency, while others may have anemia due to folate deficiency, vitamin b12 deficiency, or anemia of chronic disease. additionally, pregnancyinduced changes, such as increased blood volume and altered iron metabolism, can further complicate the interpretation of standard laboratory tests. the complexity of these overlapping factors requires a thorough clinical evaluation, including a detailed patient history, physical examination, and a variety of diagnostic tests.20 diagnostic tools such as the mentzer index have been proposed to help differentiate between ida and tt, but they are not foolproof. the mentzer index, which is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell count, can suggest whether the anemia is likely due to ida or thalassemia. however, this index has its limitations and may not always provide a definitive diagnosis. factors such as laboratory errors, coexisting conditions, or the presence of mixed anemia can lead to inaccurate results. additionally, other hematological disorders, such as anemia of chronic disease, can present similarly to ida and tt, further complicating the diagnostic process.21 in addition to the mentzer index, clinicians may rely on other diagnostic tests, including serum ferritin, transferrin saturation, total iron-binding capacity (tibc), and hemoglobin electrophoresis, to confirm the diagnosis. while serum ferritin and transferrin saturation are useful for identifying iron deficiency, hemoglobin electrophoresis is necessary for confirming the presence of thalassemia trait or other hemoglobinopathies. in some cases, genetic testing may be required to definitively diagnose thalassemia and assess the need for genetic counseling, particularly in populations with a high prevalence of inherited blood disorders.22 the role of complementary diagnostic methods the diagnosis of maternal anemia, particularly distinguishing between iron deficiency anemia (ida) and thalassemia trait (tt), can be complex due to the overlap in clinical presentation and laboratory findings. while tools like the mentzer index provide a useful starting point, they are not always sufficient in isolation, especially when anemia is multifactorial or when coexisting conditions complicate the picture. to achieve an accurate diagnosis and guide appropriate treatment, it is essential to use a combination of diagnostic methods that complement each other. these methods not only help refine the initial clinical suspicion but also assist in confirming the underlying cause of anemia, thereby optimizing maternal and fetal health outcomes.23 one of the most commonly used complementary diagnostic tests is the serum ferritin level, which reflects the body’s iron stores. in cases of ida, serum ferritin levels are typically low, while in thalassemia trait, ferritin levels are generally normal or only mildly reduced. another important test is the transferrin saturation (ts), which can help assess the iron status more directly. low transferrin saturation levels are indicative of iron deficiency, while normal or elevated levels are more consistent with thalassemia trait. total iron-binding capacity (tibc) is also useful for evaluating iron deficiency, as elevated tibc is a hallmark of ida, while it tends to remain normal in thalassemia trait. these tests, when used in conjunction, provide a clearer picture of the patient’s iron status and help differentiate between ida and thalassemia trait.24 hemoglobin electrophoresis plays a crucial role in diagnosing thalassemia and other hemoglobinopathies. this test allows for the separation of different types of hemoglobin, enabling the detection of abnormal hemoglobin patterns that are characteristic of thalassemia, sickle cell disease, and other inherited blood disorders. in women suspected of having thalassemia trait, hemoglobin electrophoresis can confirm the presence of abnormal hemoglobin types, such as hba2, which is elevated in thalassemia. this method is particularly important in populations where thalassemia is prevalent, as it provides definitive confirmation of the diagnosis and guides further management, including genetic counseling.25 in addition to these tests, genetic testing is becoming increasingly important, particularly in high-risk populations or cases where the diagnosis remains unclear. genetic testing can identify mutations associated with thalassemia and other hemoglobinopathies, providing a definitive diagnosis. it is particularly useful in identifying carriers of the disease and assessing the risk of passing on genetic conditions to offspring. moreover, genetic testing can be helpful when there is a possibility of coexisting conditions, such as thalassemia trait combined with other inherited disorders, which might complicate the clinical picture.26 furthermore, in cases where anemia is multifactorial, as is often the case in pregnancy, it is important to consider other potential causes. for example, anemia of chronic disease (acd), which often occurs in the context of infection, inflammation, or chronic illness, can present similarly to ida and thalassemia. in these cases, complementary tests such as c-reactive protein (crp) or erythrocyte sedimentation rate (esr) may help identify underlying inflammatory or infectious conditions. additionally, vitamin b12 and folate levels should be measured if there is suspicion of deficiencies in these nutrients, which can also contribute to anemia during pregnancy.27 conclusion the diagnosis of maternal anemia remains a critical aspect of prenatal care, as it significantly impacts both maternal and fetal health outcomes. given the complexities and overlapping features of different types of anemia, such as iron deficiency anemia (ida) and thalassemia trait (tt), relying solely on a single diagnostic method can lead to misdiagnosis and inappropriate treatment. the mentzer index serves as a useful initial screening tool, but its limitations highlight the importance of employing complementary diagnostic methods to achieve an accurate diagnosis. tests such as serum ferritin, transferrin saturation, hemoglobin electrophoresis, and genetic testing all provide valuable insights into the underlying cause of anemia. emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):11-14 [14] ajdhs.com conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 widiyastuti et al asian journal of dental and health sciences. 2024; 4(4):68-72 [68] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited dentaltrack web-based application in managing dental health laboratory tools and materials rini widiyastuti 1, bimo gigih sasongko 1, tedi purnama 1*, eliati sri suharja 2 1 department of dental health, health polytechnic of jakarta i, jakarta, indonesia 2 department of dental health, health polytechnic of tasikmalaya, indonesia article info: _____________________________________________ article history: received 02 oct 2024 reviewed 08 nov 2024 accepted 29 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: widiyastuti r, sasongko bg, purnama t, sri suharja e, dentaltrack web-based application in managing dental health laboratory tools and materials, asian journal of dental and health sciences. 2024; 4(3):6872 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.105 abstract _________________________________________________________________________________________________________________ practice consumables are materials or goods that can only be used once or several times. dental health education laboratories in indonesia still do not have a good system in managing the practice tools and materials used in their operations and are carried out manually, resulting in frequent stockouts. a web-based dental health laboratory practice tool and material management application is an information system designed to overcome problems and improve the quality of practice tool and material management in dental health education laboratories. objective: the study aims to develop a web-based dental health laboratory practice tool and material management application and implement a web-based dental health laboratory practice tool and material management application in the dental health department. this research method uses the rad (rapid application development) method for the reason of shortening the system processing time and with uml (unified modeling language) as its development tool. while the application itself is made using the php & mysql programming languages and ajax to help the automatic data retrieval process. this study produces a web-based dentaltrack application that is able to integrate all parts of the dental health education laboratory service so that it can increase the effectiveness of services to dental health students. keywords: dentaltrack, application, managing, dental health, laboratory *address for correspondence: tedi purnama, department of dental health, health polytechnic of jakarta i, jakarta, indonesia. introduction the role of laboratories in the world of education greatly supports the teaching and learning process, so that it can improve student achievement. problems that are often encountered in laboratory learning are laboratory management, namely procurement, use, and maintenance. the concept of laboratory management consists of activities to regulate, maintain and pay attention to the safety of laboratory users supported by laboratory management officers who have an understanding and work skills in the laboratory according to regulations.1–3 poor management of educational laboratories will result in the procurement of tools and materials that are not in accordance with their intended use. the inaccuracy of the tools and materials that come with what is needed as well as errors in operating the tools and improper maintenance processes are part of the problems in the laboratory, besides the very expensive price of laboratory equipment is one of the factors for implementing good management. inventory activities aim to reduce the occurrence of loss and misuse, reduce operational costs, optimize work processes and results, improve work quality, minimize the risk of loss, damage, breakage, prevent excessive use, improve laboratory cooperation, support the creation of safe conditions, therefore it is necessary to regulate the use, storage, data collection, and security of equipment in the laboratory.4– 6 recording that has been done so far in the administration and operational processing of dental health laboratories, such as drug and material data using manual methods with ledgers and paper, so that it can result in data in the laboratory being lost or damaged and causing the required data information to be lost and less accurate. this causes low quality of service. with the presence of information technology, clinical services will be more effective and efficient.7,8 researchers developed an inventory application, a tool designed to streamline and simplify the process of recording and inventorying supplies, medicines, consumables, and laboratory equipment. the application is named dentaltrack: inventory application for requests and borrowing goods, with the hope that this application will be the latest solution that allows automatic electronic data processing. with the support of the educational laboratory staff as administrators and lecturers and students as users, this application brings open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.105 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.105&amp;domain=pdf widiyastuti et al asian journal of dental and health sciences. 2024; 4(4):68-72 [69] ajdhs.com positive changes in inventory management in the dental health department laboratory environment. method and material in this study, there are two methods of data collection techniques, namely data collection techniques and software development in collecting data in the following studies: a. data collection techniques 1. observation technique collecting data by directly observing the dental health education laboratory of the jakarta i health polytechnic to obtain information about the management data collection system, services and administration used previously and what is needed for the convenience of obtaining fast data. 2. interview technique data collection is carried out by direct question and answer with the head of the dental health department, head of the laboratory unit, lecturers, educational laboratory officers and students in order to obtain data and find the information needed. 3. literature study studying using various reference sources using books, journals and information from websites to obtain theories related to the study b. development stages software this stage is based on the waterfall method which makes it easier to develop this information system. result and discussion system development method in developing this inventory information system, the researcher used the system development live cycle development method or system development life cycle. the model that the researcher used is the waterfall model because the form of the model allows researchers to complete one stage of development before proceeding to the next stage. this makes it easier for researchers to develop the system because of the limitations of researchers who are more familiar with the model and do not meet the requirements of other models, prototypes that require a long time and continuous communication with users and rad which requires a development team to work on various system components.9,10 this stage is the stage where researchers create process designs, database designs, and interface designs based on the results of the research analysis stage. the main display consists of several main menus on the menu bar which is a series of integrated menus, related to each other. the application menus are as follows: 1. home contains a graphic display of information on requests, inventory, incoming and outgoing transactions, and user information that will change automatically every time there is input. users will see an overview of important information such as the latest material requests and ongoing tool loans. admins can access administrative functions, while users can view the status of their requests and loans figure 1: home page on the dentaltrack website widiyastuti et al asian journal of dental and health sciences. 2024; 4(4):68-72 [70] ajdhs.com 2. master data contains the master data input menu from the dentaltrack application such as goods data, type of goods, and units which can only be accessed by the admin. 1. item data contains a menu for inputting item data that will be displayed in the dentaltrack application. the item data menu allows admins to manage inventory data in the laboratory. this includes adding, editing, or deleting items. admins can add information such as item name, serial number (if needed), initial stock, and item category. figure 2: item data on the dentaltrack website 2. item type contains an input menu for item categories such as tools, materials, media, etc. figure 3: item type on the dentaltrack website widiyastuti et al asian journal of dental and health sciences. 2024; 4(4):68-72 [71] ajdhs.com 3. unit contains the input menu for item unit categories such as bottles, boxes, pcs, packs, sets and others. figure 4: unit on the dentaltrack website 4. transaction in this menu, the admin can see a list of incoming material requests. information such as request date, username, and request status will be displayed. the admin can process the request by approving or rejecting it, and also update the stock of goods after the request is fulfilled. in this menu, the deltaltrack application admin inputs incoming receipts of inventory goods from various receipt sources based on the delivery note or invoice received. the list of incoming goods that have been input will appear on this menu page. figure 5: transaction on the dentaltrack website widiyastuti et al asian journal of dental and health sciences. 2024; 4(4):68-72 [72] ajdhs.com 5. report menu contains a menu of incoming goods transfer transaction reports that can be sorted by date and month. this report can be downloaded in pdf or excel format figure 6: report menu on the dentaltrack website conclusion based on the research results, it can be concluded that this research produces a dentaltrack application system that can integrate data storage in all parts related to dental health education laboratory service activities so that it becomes a means of assisting the website-based laboratory equipment inventory system in the dental health department which can be accessed by users via computers or smartphones. acknowledgements: the authors thank to all participants and research assistants. conflict of interest: the authors declare that they have no conflict interests. source of support: nil funding: none ethics statement: not applicable author contributions: all authors have equal contribution in the preparation of manuscript and compilation. references 1. mohzana m, murcahyanto h, fahrurrozi m, supriadi yn. optimization of management of laboratory facilities in the process of learning science at high school. j penelit pendidik ipa. 2023;9(10):8226-34. https://doi.org/10.29303/jppipa.v9i10.5249 2. lunetta vn, hofstein a, clough mp. learning and teaching in the school science laboratory: an analysis of research, theory, and practice. in: handbook of research on science education. routledge; 2013. p. 393-441. 3. elseria e. efektifitas pengelolaan laboratorium ipa. manajer pendidik j ilm manaj pendidik progr pascasarj. 2016;10(1). 4. alqahtani da, al‐gahtani sm. assessing learning styles of saudi dental students using kolb's learning style inventory. j dent educ. 2014;78(6):927-33. https://doi.org/10.1002/j.00220337.2014.78.6.tb05747.x pmid:24882779 5. olufunke bt. effect of availability and utilization of physics laboratory equipment on students' academic achievement in senior secondary school physics. world j educ. 2012;2(5):1-7. https://doi.org/10.5430/wje.v2n5p1 6. kharchenko b. analyzing and evaluating existing dental practice management software: a comprehensive study to identify gaps and opportunities for improvement. 2023; 7. saadah k, sunarjo l, fatmasari d, djamil m. design and build application of web-based practice material management information system (sip-batik jkg) in the laboratory of the department of dental health poltekkes ministry of health semarang. j appl heal manag technol. 2023;5(2):62-70. https://doi.org/10.31983/jahmt.v5i2.6976 8. kuswandari f, susanti r, grey ma, inderiati d. design and implementation of a web-based application for media and laboratory reagents management with qr code feature. j teknokes. 2023;16(3):178-84. https://doi.org/10.35882/teknokes.v16i3.633 9. gumilang ir. penerapan metode sdlc (system devlopment life cycle) pada website penjualan produk vapor: application of sdlc (system devlopment life cycle) method on vapor product sales website. j ris rumpun ilmu tek. 2022;1(1):47-56. https://doi.org/10.55606/jurritek.v1i1.144 10. devega at, veza o, jalinus n, waskito w, arimbi a. aplikasi pengelolaan lab teknik informatika fakultas teknik universitas ibnu sina. res tech vocat educ train. 2022;1(2). https://doi.org/10.29303/jppipa.v9i10.5249 https://doi.org/10.1002/j.0022-0337.2014.78.6.tb05747.x https://doi.org/10.1002/j.0022-0337.2014.78.6.tb05747.x https://doi.org/10.5430/wje.v2n5p1 https://doi.org/10.31983/jahmt.v5i2.6976 https://doi.org/10.35882/teknokes.v16i3.633 https://doi.org/10.55606/jurritek.v1i1.144 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):10-14 [10] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited a community-centric approach to hiv awareness and prevention: bridging local needs and global goals emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 10 sep 2024 reviewed 21 oct 2024 accepted 18 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, one step at a time: incremental approaches to hiv prevention, asian journal of dental and health sciences. 2024; 4(3):1014 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.92 abstract _________________________________________________________________________________________________________________ the hiv epidemic continues to pose significant challenges worldwide, particularly within marginalized and high-risk communities that face social, economic, and structural barriers to healthcare. a community-centric approach to hiv awareness and prevention emphasizes the importance of partnering with local communities to develop interventions that align with their unique cultural, social, and healthcare needs. by involving local leaders, utilizing peer education models, and fostering cultural competency, community-centered strategies empower individuals and promote sustainable changes in health behaviors, ultimately creating more resilient and informed communities. central to a community-centric approach is the concept of trust-building through local engagement. leveraging community assets—such as local knowledge, social networks, and grassroots organizations—these interventions address common barriers like stigma and misinformation while enhancing access to hiv testing, education, and preventative healthcare services. case studies from diverse regions highlight how community-driven programs have effectively reduced stigma, improved health literacy, and increased uptake of hiv prevention services. this approach not only improves awareness but also nurtures a supportive environment where individuals feel empowered to access healthcare and preventative resources. keywords: hiv awareness, community-centered approach, public health, prevention strategies, grassroots engagement *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv/aids remains one of the most pressing global health challenges, disproportionately affecting vulnerable communities that often face significant barriers to accessing healthcare, education, and preventive resources. despite remarkable advancements in hiv prevention and treatment over recent decades, such as antiretroviral therapy (art) and pre-exposure prophylaxis (prep), the epidemic persists, especially in regions where social, economic, and structural obstacles limit the effectiveness of these interventions. tackling this health crisis requires not only medical solutions but also holistic approaches that consider the social and cultural contexts of the communities affected. community-centric approaches to hiv awareness and prevention have emerged as a powerful strategy to bridge the gap between global hiv goals and the specific needs of local populations.1-2 a community-centric approach to hiv prevention shifts the focus from top-down, externally imposed interventions to initiatives that are collaboratively developed with and for the community. this approach is rooted in the recognition that each community has unique dynamics, cultural norms, and beliefs that influence health behaviors and attitudes toward hiv. by working closely with community members, health programs can design and implement strategies that are culturally sensitive and therefore more likely to be embraced and sustained by the community. in contrast to traditional public health models that may overlook or inadequately address local realities, a communitycentered model prioritizes local insights, building programs that are relevant, effective, and supported by the people they serve.3-4 the cornerstone of a community-centric approach lies in actively engaging local stakeholders, including community leaders, health advocates, peer educators, and residents themselves. this collaborative framework not only ensures that prevention programs are tailored to the needs and values of the community but also fosters trust and credibility within the target population. by involving community leaders, who often hold influence and respect within their communities, hiv prevention initiatives can gain legitimacy and overcome potential resistance. furthermore, employing peer educators from within the community can enhance the impact of awareness efforts, as they can communicate in relatable and culturally appropriate ways. these local stakeholders are instrumental in reducing stigma, promoting hiv testing, and open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.92 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.92&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):10-14 [11] ajdhs.com encouraging preventive behaviors.5-6 another fundamental aspect of community-centered hiv prevention is addressing the pervasive stigma and misinformation that often surround hiv/aids. stigma remains a significant barrier, preventing individuals from seeking information, testing, or treatment. community-centric initiatives actively work to dismantle these barriers by creating safe spaces for open dialogue, dispelling myths, and fostering supportive environments where individuals feel comfortable discussing hiv without fear of discrimination. for example, culturally tailored educational programs and support groups can be effective tools for challenging harmful misconceptions and empowering individuals to make informed health decisions. by tackling stigma, community-centered approaches lay the groundwork for sustainable behavioral change and healthier community norms around hiv prevention.7-8 community-centric strategies also emphasize the importance of improving access to healthcare services within the community itself. many vulnerable populations face logistical and economic obstacles to accessing traditional healthcare facilities, which may be located far from their homes or require transportation costs they cannot afford. by bringing healthcare resources closer to the community—through mobile clinics, local health centers, or home-based care—these programs make hiv prevention services more accessible. increased access enables regular testing, counseling, and treatment, which are essential for controlling the spread of hiv. this focus on localized care not only improves health outcomes but also promotes a stronger community engagement in health and well-being, reinforcing the effectiveness of prevention efforts.9-10 despite the advantages of community-centric approaches, there are challenges in implementing and scaling these strategies, particularly in resource-limited settings. community programs require sustained funding, long-term commitment, and continuous engagement to maintain effectiveness. measuring the impact of these initiatives is also complex, as social outcomes like stigma reduction and health literacy are harder to quantify than traditional biomedical indicators. nevertheless, the successes observed in diverse regions demonstrate that with careful planning and community involvement, these approaches can yield meaningful and lasting results. future efforts to optimize community-centric hiv prevention will benefit from integrating innovative technologies, such as digital health platforms, which can expand outreach and improve program efficiency.11-12 key components of a community-centric approach to hiv prevention a community-centric approach to hiv prevention involves several key components that ensure interventions are tailored to the specific needs, values, and contexts of local communities. these elements collectively enhance the effectiveness, sustainability, and impact of hiv prevention efforts by fostering local ownership and promoting long-term engagement. below are the critical components that define a community-driven approach to hiv prevention. 1. community engagement and empowerment the foundation of a community-centric approach lies in active community participation. engaging community members in the design, implementation, and evaluation of hiv prevention programs fosters ownership and ensures that interventions are culturally appropriate and relevant. empowering local leaders, activists, and residents to take an active role in hiv prevention not only enhances the program's acceptance but also cultivates a sense of collective responsibility toward combating the epidemic. involving community stakeholders also facilitates the identification of unique local barriers to hiv prevention and helps tailor solutions to address these challenges effectively.13-14 2. peer education and support networks peer education is a central component of communitycentric hiv prevention. peer educators—individuals from within the community who have been trained to educate their peers about hiv prevention, treatment, and stigma reduction—are powerful agents of change. their shared experiences and credibility within the community enable them to break down barriers such as mistrust and reluctance toward hiv prevention services. peer educators can offer guidance on safer sexual practices, hiv testing, and the importance of early treatment, fostering an environment where people feel more comfortable accessing healthcare. additionally, support networks such as peer-led groups or counseling sessions provide ongoing emotional support, helping to reduce stigma and encourage adherence to preventive measures.15-16 3. cultural sensitivity and tailored education culturally sensitive hiv education is another essential element of community-centered hiv prevention. a onesize-fits-all approach often fails to resonate with diverse populations, as cultural norms, language, and values play a critical role in shaping health behaviors. effective hiv prevention programs recognize and adapt to these differences, ensuring that educational materials and messaging are tailored to the local context. this may involve translating materials into local languages, using culturally relevant metaphors or examples, and aligning interventions with community traditions and practices. by understanding the cultural context, programs can address misconceptions and fears related to hiv while promoting healthier behaviors that are more likely to be accepted and practiced by the community.17-18 4. access to healthcare and prevention services increased access to healthcare services is a cornerstone of any successful hiv prevention strategy. in many communities, particularly those in rural or underserved areas, individuals may face logistical or financial barriers that hinder their access to hiv-related care. a community-centric approach seeks to bring healthcare services closer to the people by setting up mobile clinics, local health centers, or community-based health outreach programs. this reduces the need for emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):10-14 [12] ajdhs.com individuals to travel long distances and helps overcome financial barriers to healthcare. ensuring easy access to hiv testing, condoms, art, and prep (pre-exposure prophylaxis) increases the likelihood of individuals seeking preventive care and reduces the risk of hiv transmission.19-20 5. stigma reduction and awareness campaigns stigma remains one of the greatest obstacles to effective hiv prevention. fear of discrimination often prevents individuals from seeking hiv testing or treatment, leading to late diagnoses and the continued spread of the virus. community-centric hiv prevention programs actively work to reduce stigma by addressing misconceptions and challenging negative attitudes toward people living with hiv. awareness campaigns, open discussions, and public education play a significant role in dismantling these barriers. by creating safe spaces for dialogue and encouraging acceptance of people living with hiv, community-based programs help shift societal attitudes and promote an environment where people are more likely to seek help and support.21-22 6. sustainable partnerships and local capacity building for a community-centric approach to be effective in the long term, it is essential to build sustainable partnerships and strengthen local capacity. collaborations between community organizations, local governments, healthcare providers, and international agencies ensure that resources are available and effectively utilized. capacity building involves training local community members in key skills such as hiv education, counseling, health promotion, and program management, ensuring that these efforts can continue and evolve even after initial external support is reduced. by fostering local expertise and leadership, hiv prevention programs can remain adaptable and responsive to changing needs and challenges over time.23-24 challenges of implementing communitycentric hiv prevention while community-centric hiv prevention strategies offer promising outcomes, their implementation is not without challenges. these challenges can range from resource limitations to cultural resistance, which can hinder the sustainability and effectiveness of such programs. addressing these obstacles requires careful planning, ongoing community engagement, and collaboration between various stakeholders. below are some of the key challenges faced when implementing community-centric hiv prevention initiatives.25 1. resource limitations and funding constraints one of the most significant challenges to implementing community-centric hiv prevention programs is securing adequate resources. many communities, particularly in low-income or resource-constrained regions, struggle to fund comprehensive hiv programs. resource limitations can affect various aspects of a program, including personnel training, the distribution of educational materials, and the availability of healthcare services like hiv testing, counseling, and treatment. without sufficient financial support, programs may be scaled back, lose their reach, or fail to maintain the momentum required to achieve lasting behavioral changes. additionally, the need for sustainable funding to ensure the continuation of these programs can be a major obstacle, especially when relying on external donors or temporary funding sources.26-27 2. community resistance and stigma despite the best efforts of hiv prevention programs, resistance from within the community can present a significant barrier. stigma surrounding hiv/aids remains prevalent, and it can be particularly challenging to overcome deeply ingrained cultural or social norms that associate hiv with shame, criminality, or immorality. in many communities, traditional beliefs or misconceptions about hiv may prevent individuals from seeking information, testing, or treatment. some members of the community may be hesitant to engage with hiv-related services or may actively oppose hiv prevention efforts. this resistance can manifest in reluctance to discuss hiv openly, mistrust of healthcare providers, or even hostility towards people living with hiv. overcoming this stigma requires ongoing education, awareness campaigns, and gradual changes in attitudes, all of which demand significant time and effort.28-29 3. sustainability and long-term commitment while initial community engagement can be successful, ensuring the long-term sustainability of hiv prevention efforts is challenging. a community-centric approach requires continuous involvement from local stakeholders, which can be difficult to maintain over time. turnover among community leaders, loss of interest, or changes in local priorities can lead to a decrease in participation or support for hiv programs. furthermore, ongoing training and capacity building are needed to ensure that local communities remain equipped to manage and implement hiv prevention initiatives effectively. without sustained local leadership and external support, programs may lose momentum, and their long-term impact could be compromised. additionally, the fluctuating political and social climate can influence the priority given to hiv prevention efforts, making consistent support a challenge.30 4. access to healthcare and infrastructure limitations access to healthcare services is a critical element of any hiv prevention strategy, but in many communities, particularly in rural or remote areas, healthcare infrastructure is limited or underdeveloped. these communities may lack well-equipped health centers, transportation options, or trained healthcare providers to deliver hiv services. the absence of nearby healthcare facilities can create significant barriers to hiv testing, treatment, and prevention services, particularly for individuals who may be hesitant to seek emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):10-14 [13] ajdhs.com care due to stigma or logistical challenges. additionally, the shortage of trained healthcare professionals can result in inadequate counseling and testing services, which undermines the effectiveness of hiv prevention programs. addressing these gaps often requires investments in healthcare infrastructure, mobile clinics, and community health workers, which may be difficult to sustain in underfunded regions.31 5. cultural sensitivity and tailoring programs to diverse populations tailoring hiv prevention programs to the diverse cultural, social, and economic contexts of different communities can be complex and resource-intensive. a lack of cultural competence among healthcare providers and program implementers can hinder the success of community-centric initiatives. it is essential that hiv prevention messages and services align with local customs, beliefs, and practices to gain acceptance. however, this can be a delicate balancing act, as it requires both sensitivity to local traditions and a commitment to promoting evidence-based health practices. in some cases, what works in one community may not be effective in another, requiring constant adaptation and flexibility in program design. for instance, certain populations—such as youth, women, or marginalized groups—may require specialized approaches to address their unique needs, such as gender-specific interventions or programs that address the intersection of hiv and other social issues like poverty or domestic violence.32 6. measuring impact and evaluating success measuring the impact of community-centric hiv prevention programs can be challenging, especially when outcomes like stigma reduction, community engagement, and behavior change are difficult to quantify. while health-related metrics such as hiv testing rates, the uptake of prep, and art adherence are more easily measurable, the social and psychological effects of hiv prevention initiatives, such as reduced stigma or increased health literacy, are harder to assess. evaluating the long-term success of these programs requires developing appropriate metrics that go beyond traditional biomedical outcomes to include social and behavioral indicators. this challenge is compounded by the lack of standardized methods for evaluating community-based interventions, which can hinder comparisons between programs and the identification of best practices.33 conclusion a community-centric approach to hiv awareness and prevention offers a promising and sustainable pathway to combat the hiv epidemic. by focusing on the active involvement of local communities, peer education, cultural sensitivity, and improved access to healthcare, these programs are uniquely positioned to address the diverse needs and challenges faced by different populations. however, the successful implementation of such approaches requires overcoming significant obstacles, including resource constraints, cultural resistance, and infrastructural limitations. overcoming these challenges requires a concerted effort from all stakeholders—governments, non-governmental organizations (ngos), healthcare providers, and community members themselves. despite the hurdles, the benefits of a community-driven approach are clear: it promotes long-term engagement, builds local capacity, and ensures that hiv prevention interventions are relevant and effective in the local context. by fostering trust, reducing stigma, and empowering individuals and communities, these strategies can significantly reduce the transmission of hiv, improve health outcomes, and promote social acceptance of people living with hiv. moreover, the focus on peer support and education helps create an environment where people are more likely to seek care, get tested, and adhere to prevention measures. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3):38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2):43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3):2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. dave p, the correlation between stigma and mental health disorders in people living with hiv/aids, journal of drug https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):10-14 [14] ajdhs.com delivery and therapeutics, 2024;14(3):227-233 https://doi.org/10.22270/jddt.v14i3.6490 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024;13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. akhtar mh, ramkumar j. primary health center: can it be made mobile for efficient healthcare services for hard to reach population? a state-of-the-art review. discover health systems. 2023;2(3). https://doi.org/10.1007/s44250-023-00017-x pmid:37520517 pmcid:pmc9870199 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013. https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.1007/s44250-023-00017-x https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):30-33 [30] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited mentzer index as an indicator of hematological health in pregnant populations: a review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 08 nov 2024 reviewed 19 dec 2024 accepted 16 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, mentzer index as an indicator of hematological health in pregnant populations: a review, asian journal of dental and health sciences. 2025; 5(1):30-33 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.116 abstract _________________________________________________________________________________________________________________ hematological health in pregnancy is crucial for ensuring favorable maternal and fetal outcomes, as pregnancy often predisposes women to conditions like anemia. the mentzer index, a diagnostic ratio derived from routine complete blood count (cbc) parameters, has proven valuable in distinguishing between iron-deficiency anemia (ida) and thalassemia traits, two prevalent yet distinct causes of anemia in pregnant populations. this tool's simplicity and cost-effectiveness make it especially useful in resource-limited settings, offering a practical approach to early diagnosis and tailored management strategies. this review highlights the role of the mentzer index in assessing maternal hematological health, with a focus on its application in differentiating anemia subtypes. by comparing mean corpuscular volume (mcv) and red blood cell count (rbc), the index provides an accessible preliminary screening mechanism. while an index >13 often indicates ida, values <13 suggest thalassemia traits, enabling clinicians to prioritize further diagnostic evaluations, such as serum ferritin levels or hemoglobin electrophoresis. this timely differentiation is essential for avoiding inappropriate treatments, such as unwarranted iron supplementation in thalassemia carriers, which may lead to complications like iron overload. keywords: mentzer index, hematological health, pregnancy, iron-deficiency anemia, thalassemia trait *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia is a global public health concern, affecting approximately 40% of pregnant women, with higher prevalence in lowand middle-income countries. the physiological changes in pregnancy often exacerbate pre-existing anemia or reveal underlying hematological disorders. iron-deficiency anemia (ida) and hemoglobinopathies such as thalassemia traits are the two leading causes, presenting a diagnostic challenge due to overlapping clinical and hematological features.12 maternal anemia, if left untreated, can lead to complications including preterm labor, low birth weight, and impaired cognitive and physical development in infants. severe anemia is also associated with maternal mortality, especially in resourceconstrained settings. differentiating the type of anemia is critical, as the management of ida (requiring iron supplementation) differs markedly from that of thalassemia traits, where iron overload could exacerbate complications.3-4 the conventional diagnostic approaches for anemia include serum ferritin, hemoglobin electrophoresis, and genetic testing. while effective, these methods may not always be accessible or affordable, particularly in underresourced healthcare systems. a simpler, cost-effective diagnostic tool is needed for initial screening to guide further investigations and management.5-6 first introduced in the 1970s, the mentzer index has gained recognition as a practical indicator in differentiating ida from thalassemia traits. it is calculated as the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count, parameters readily available in routine cbc tests. the simplicity and affordability of this calculation make it particularly appealing for use in pregnancy, where timely diagnosis is crucial.7-8 in pregnant populations, the mentzer index serves as an effective screening tool for anemia, enabling healthcare providers to identify the probable cause early in prenatal care. this facilitates prompt and appropriate management, which is essential for minimizing risks to both mother and baby. despite its utility, the mentzer index has limitations, such as reduced accuracy in mixed anemia cases and the need for population-specific threshold adjustments. 8 this review aims to evaluate the role of the mentzer index as an indicator of hematological health in pregnant populations. hematological health in pregnancy pregnancy induces significant alterations in the hematological system to support the increased demands of the developing fetus and maternal tissues. plasma open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.116 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.116&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):30-33 [31] ajdhs.com volume expands by approximately 50%, leading to a relative hemodilution known as physiological anemia of pregnancy. concurrently, red blood cell (rbc) mass increases, albeit at a slower rate than plasma expansion, contributing to decreased hemoglobin concentration. these changes are considered normal adaptations but can complicate the diagnosis of pathological conditions such as anemia.9-10 anemia is the most common hematological disorder in pregnancy, affecting about 40% of pregnant women globally, with a higher burden in lowand middle-income countries. iron-deficiency anemia (ida) accounts for the majority of cases due to increased iron requirements during pregnancy, inadequate dietary intake, and frequent gastrointestinal losses. other causes include vitamin b12 and folate deficiencies, chronic diseases, and genetic hemoglobinopathies such as thalassemia.11-12 anemia during pregnancy poses significant risks to both the mother and the fetus. for the mother, severe anemia increases the likelihood of preterm labor, postpartum hemorrhage, and infection. for the fetus, it can lead to intrauterine growth restriction (iugr), low birth weight, and developmental delays. these adverse outcomes underscore the importance of timely identification and management of anemia in pregnant populations.13-14 routine screening for anemia in pregnancy involves hemoglobin estimation, red blood cell indices, and peripheral blood smear analysis. advanced diagnostics like serum ferritin, transferrin saturation, and hemoglobin electrophoresis are used to pinpoint the underlying cause. however, these methods may be inaccessible or unaffordable in resource-limited settings, necessitating simpler tools such as the mentzer index for preliminary assessment.15 the management of anemia depends on its etiology. while ida requires iron supplementation, thalassemia traits necessitate avoiding iron overload, which can exacerbate oxidative stress and organ damage. misclassification can result in suboptimal or harmful interventions, highlighting the critical need for accurate differentiation of anemia types in clinical practice.16 as a readily available and costeffective parameter, the mentzer index has gained traction as a first-line screening tool for anemia in pregnancy. it is particularly useful in areas with limited access to advanced diagnostics, helping to distinguish between ida and thalassemia traits. by enabling targeted management, the mentzer index contributes to better maternal and fetal health outcomes and reduces the burden of anemia in vulnerable populations.17 application of mentzer index in pregnancy the mentzer index (mi) is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, both of which are components of routine complete blood count (cbc) tests. a mentzer index value greater than 13 suggests iron-deficiency anemia (ida), while a value less than 13 indicates a likelihood of thalassemia trait. this simple formula enables healthcare providers to differentiate between these common causes of anemia without the need for specialized testing, making it particularly useful in prenatal care settings.18-19 in early pregnancy, anemia is often asymptomatic and may go undiagnosed until complications arise. utilizing the mentzer index during routine antenatal visits allows for early detection of anemia etiology. early identification of ida enables timely iron supplementation, while recognition of thalassemia traits can prompt genetic counseling and further evaluation of fetal health. this proactive approach minimizes risks of adverse outcomes for both the mother and the fetus.20-21 the mentzer index is especially beneficial in lowand middle-income countries where advanced diagnostic tools, such as hemoglobin electrophoresis or genetic testing, may not be readily available. its reliance on parameters from basic cbc tests makes it a cost-effective alternative for initial anemia screening. by streamlining the diagnostic process, mi ensures that limited healthcare resources are allocated efficiently, enabling better care for pregnant women.22-23 although the mentzer index is a valuable tool, its accuracy improves when used alongside other indices, such as red cell distribution width (rdw) and mean corpuscular hemoglobin (mch). these parameters can help confirm the diagnosis and provide a more comprehensive understanding of the hematological profile. for instance, elevated rdw values are more indicative of ida, while normal rdw with low mi strongly suggests a thalassemia trait.24 despite its utility, the mentzer index is not infallible. mixed anemia cases, such as ida coexisting with thalassemia, can yield ambiguous mi results, complicating diagnosis. moreover, the index relies on population-specific reference values for mcv and rbc, which may vary with ethnicity, altitude, and dietary habits. these factors necessitate caution in interpreting mi results, particularly in diverse populations.25 the application of the mentzer index in pregnancy significantly enhances maternal and fetal health outcomes by guiding appropriate interventions. early and accurate diagnosis reduces risks associated with untreated anemia, such as preterm delivery, low birth weight, and postpartum complications. additionally, the index supports better resource utilization by directing advanced testing and interventions to high-risk cases.26 limitations and challenges 1. accuracy in mixed anemia cases one of the significant limitations of the mentzer index (mi) is its reduced reliability in cases of mixed anemia, such as the coexistence of iron-deficiency anemia (ida) and thalassemia traits. mixed anemia can lead to intermediate mentzer index values, which do not clearly indicate either condition, complicating the diagnostic process. this challenge is particularly pronounced in populations with high prevalence rates of both ida and hemoglobinopathies. 2. population-specific variability the effectiveness of the mentzer index depends on the accuracy of mcv and rbc reference ranges, which can vary significantly across different populations. factors such as ethnicity, dietary habits, altitude, and genetic emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):30-33 [32] ajdhs.com predisposition influence these parameters, making it difficult to establish universal cutoff values. without population-specific adjustments, there is a risk of false positives or negatives, potentially leading to misdiagnosis.24 3. limited scope for complex anemias the mentzer index is a screening tool rather than a definitive diagnostic method. while it is useful for differentiating between ida and thalassemia traits, it does not account for other anemia causes, such as vitamin b12 deficiency, folate deficiency, or anemia of chronic disease. clinicians must rely on additional diagnostic tools to identify these conditions, reducing the standalone utility of mi.25 4. inaccuracy in late pregnancy physiological changes in pregnancy, such as hemodilution and increased plasma volume, can alter hematological parameters, particularly in the second and third trimesters. these changes may skew the mentzer index values, making it less reliable in diagnosing anemia during late pregnancy. this limitation underscores the importance of interpreting mi results in the context of gestational stage and other clinical findings.26 5. dependency on routine cbc quality the reliability of the mentzer index hinges on the accuracy of cbc measurements, particularly mcv and rbc count. in settings with suboptimal laboratory practices or outdated equipment, errors in these parameters can lead to incorrect mi calculations and potentially flawed diagnoses. this is a significant concern in under-resourced healthcare facilities.27 6. lack of consensus on cutoff values there is no universal agreement on the cutoff values for the mentzer index, with thresholds varying slightly across studies and guidelines. some researchers advocate for a stricter cutoff (e.g., mi < 12 for thalassemia), while others suggest broader ranges. this lack of consensus adds to the complexity of its clinical application, requiring clinicians to consider local population data and their experience.27 conclusion the mentzer index stands as a simple, cost-effective, and accessible hematological tool for differentiating iron-deficiency anemia (ida) from thalassemia traits, particularly in pregnant populations. its reliance on basic complete blood count (cbc) parameters makes it an invaluable first-line screening method, especially in resource-limited settings. by facilitating early and accurate identification of anemia etiology, the mentzer index contributes to improved maternal and fetal outcomes, guiding appropriate interventions and preventing complications. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):30-33 [33] ajdhs.com 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):35-39 [35] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited reducing mother-to-child transmission: affordable solutions in low-income nations emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 18 sep 2024 reviewed 29 oct 2024 accepted 22 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, reducing mother-to-child transmission: affordable solutions in lowincome nations, asian journal of dental and health sciences. 2024; 4(3):35-39 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.99 abstract _________________________________________________________________________________________________________________ mother-to-child transmission (mtct) of hiv remains a significant challenge in low-income nations, where limited resources and healthcare infrastructure complicate the implementation of effective prevention strategies. this review explores affordable solutions for reducing mtct, focusing on key interventions such as early hiv diagnosis, simplified antiretroviral therapy (art), and breastfeeding management. we highlight the importance of cost-effective diagnostic tools, art regimens, and community-based approaches that can be scaled in resource-constrained settings. despite challenges, affordable interventions have proven to significantly reduce transmission rates and improve maternal and child health outcomes. the review emphasizes the critical role of early diagnosis and point-of-care testing in identifying hiv-positive mothers early in pregnancy, enabling timely access to art. simplified art regimens, including fixed-dose combinations, offer an affordable and effective way to reduce viral load and prevent transmission during pregnancy and childbirth. furthermore, managing breastfeeding through art and safe feeding practices is essential to mitigate risks during the postpartum period, where transmission is often most likely. keywords: mother-to-child transmission (mtct), hiv prevention, antiretroviral therapy (art), low-income nations, affordable solutions. *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction mother-to-child transmission (mtct) of hiv is a leading cause of pediatric hiv infections worldwide, and it continues to pose a significant public health challenge, particularly in low-income nations. according to the world health organization (who), mtct accounts for the majority of new hiv infections in children, with the highest burden observed in sub-saharan africa. the transmission can occur during pregnancy, childbirth, or breastfeeding, and without appropriate interventions, the risk of transmission is high. however, effective strategies exist to significantly reduce the transmission of hiv from mother to child, including antiretroviral therapy (art), safe infant feeding practices, and early diagnosis. in low-resource settings, where healthcare infrastructure and resources are often limited, affordable solutions that can be implemented at scale are crucial to reducing the rates of mtct and ensuring better health outcomes for both mothers and their children.1-3 although substantial progress has been made in reducing mtct globally, many low-income nations continue to face significant challenges. access to timely hiv testing, art, and healthcare services remains limited, particularly in rural or underserved areas. in addition, cultural stigma and misinformation about hiv and its transmission contribute to reluctance among pregnant women to seek testing and treatment. despite these challenges, effective and affordable interventions have been demonstrated to reduce mtct rates in resource-constrained settings. these include simplified art regimens, point-of-care hiv testing, and community-based outreach programs. by focusing on cost-effective solutions, low-income nations can make significant strides toward eliminating pediatric hiv infections and improving maternal health.4-5 the prevention of mtct relies on a multifaceted approach that combines medical, behavioral, and community-level interventions. antiretroviral therapy (art) for pregnant women living with hiv significantly reduces viral load, lowering the risk of transmission during pregnancy, delivery, and breastfeeding. in addition to art, safe infant feeding practices, including the use of formula feeding where possible, or the provision of art to breastfeeding mothers, can further reduce the risk of hiv transmission through breast milk. early diagnosis through point-of-care testing allows for timely initiation of treatment, making it an essential component of mtct prevention. however, these interventions are often hampered by systemic barriers such as limited healthcare infrastructure, financial constraints, and inadequate healthcare worker training, all of which are prevalent in low-income nations.6-7 open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.99 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.99&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):35-39 [36] ajdhs.com affordable interventions for reducing mtct reducing mother-to-child transmission (mtct) of hiv in low-resource settings requires the adoption of affordable, scalable, and effective interventions. while access to advanced medical technologies and treatments may be limited, several low-cost strategies can significantly reduce the transmission risk, improve health outcomes, and enhance maternal and child health. these interventions focus on early diagnosis, simplified antiretroviral therapy (art), breastfeeding management, and community-based efforts.8-9 1. early diagnosis and testing early detection of hiv during pregnancy is a key factor in reducing mtct rates. point-of-care testing (poct) for hiv is a cost-effective and accessible solution that allows for rapid diagnosis in remote areas with limited healthcare infrastructure. these tests are inexpensive, easy to administer, and provide results within minutes, enabling pregnant women to receive timely treatment and counseling. poct technologies can be implemented in community settings, outreach programs, and mobile clinics, greatly expanding access to hiv testing in underserved populations. scaling up such testing initiatives ensures that hiv-positive women can start art promptly, reducing the viral load and the risk of transmission to the infant. routine hiv screening in antenatal care (anc) visits is another important intervention, which, when paired with counseling and informed decision-making, allows mothers to make choices that can minimize mtct risk. in areas with higher hiv prevalence, integrating hiv testing into regular anc services helps normalize the process and reduce stigma associated with testing. the implementation of community-based hiv education campaigns that emphasize the importance of regular testing further strengthens early detection efforts.10-12 2. simplified antiretroviral therapy (art) antiretroviral therapy (art) is the cornerstone of preventing mtct, as it effectively reduces the hiv viral load in pregnant women, thereby minimizing the likelihood of transmission to the child. in low-resource settings, where healthcare infrastructure is often overburdened, simplified art regimens that are easy to administer and adhere to are essential. fixed-dose combinations (fdcs) of antiretroviral drugs, which combine multiple medications into a single pill, have emerged as a highly effective and affordable solution. fdcs simplify treatment regimens and improve patient adherence, reducing the risk of transmission during pregnancy, labor, and breastfeeding. moreover, streamlined art protocols tailored for resourceconstrained environments, such as the use of fewer medications or lower-cost alternatives, have proven effective in reducing maternal-to-child transmission of hiv. who and the u.s. centers for disease control and prevention (cdc) have recommended these simplified regimens for use in low-resource settings, as they provide a balance between cost-effectiveness and treatment efficacy. art for breastfeeding mothers is equally critical, as it helps prevent transmission through breast milk, a major mode of mtct. expanding access to art and integrating it into routine maternal health services can drastically reduce the rates of mtct, especially in low-income countries where art is often subsidized or provided at no cost to patients.13-15 3. breastfeeding and infant feeding management breastfeeding is crucial for infant health and nutrition in many low-income settings, but it poses a risk for hiv transmission from mother to child. the challenge lies in balancing the need for exclusive breastfeeding with the potential for hiv transmission through breast milk. who guidelines recommend exclusive breastfeeding for the first six months of life, alongside antiretroviral therapy for breastfeeding mothers. in areas where safe alternatives like formula feeding are unavailable or too costly, art is a crucial intervention to prevent hiv transmission via breastfeeding. to support mothers, health systems can implement programs that provide art to breastfeeding women and educate them about safe infant feeding practices. in resource-limited settings, where infant formula may be scarce or unaffordable, providing art to hiv-positive mothers allows them to continue breastfeeding safely. community-based support groups for mothers, where peer counseling and guidance are provided, can increase adherence to art and improve breastfeeding practices. ensuring that mothers have access to both medical care and emotional support through community health workers helps to reduce the transmission risk and improves the overall success of mtct prevention efforts.16-17 4. community-based outreach and education community involvement and education are key components of reducing mtct in low-income settings. many women in these communities face cultural stigma and fear surrounding hiv, which can prevent them from seeking hiv testing, treatment, and care. communitybased outreach programs led by trained local healthcare workers, peer educators, and community leaders can help bridge this gap by providing education about hiv prevention, the importance of early testing, and the availability of treatment options. these programs can also address misinformation and misconceptions about hiv, thereby reducing stigma and encouraging women to seek care. mobile health units that provide on-site testing, counseling, and art distribution are particularly effective in rural and hard-to-reach areas. involving community leaders, religious leaders, and influencers in the design and delivery of these programs helps to build trust and ensures that health messages are culturally appropriate and well-received. by leveraging local resources and focusing on education, community-based programs can play a critical role in preventing mtct and improving health outcomes for mothers and children.18-19 5. integration of hiv services with maternal and child health programs integrating hiv prevention and treatment services with existing maternal and child health (mch) programs is another affordable and scalable intervention. this emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):35-39 [37] ajdhs.com integration allows for the efficient use of resources, as it minimizes the need for separate hiv-focused programs and facilities. routine hiv screening, art administration, and breastfeeding counseling can be incorporated into antenatal care (anc) and postnatal care (pnc) visits. this integrated approach ensures that pregnant women receive comprehensive care while reducing the stigma associated with seeking hivspecific services. by embedding hiv prevention into routine mch services, healthcare workers can ensure that women are tested for hiv early in pregnancy and provided with the necessary interventions to prevent mtct. these integrated services also promote continuity of care, as mothers who are receiving hiv treatment during pregnancy are more likely to continue with art postpartum, ensuring a consistent reduction in viral load during breastfeeding. in low-income settings, where health system fragmentation can be a barrier to care, integration provides an opportunity to streamline services and improve access to essential hiv prevention measures.20-21 overcoming implementation barriers implementing interventions to reduce mother-to-child transmission (mtct) of hiv in low-resource settings is often hindered by a range of systemic, cultural, and infrastructural barriers. despite the availability of affordable and effective solutions, several challenges impede their widespread adoption and success. addressing these barriers is crucial to scaling up mtct prevention efforts and ensuring that the most vulnerable populations have access to essential services. these barriers include limited healthcare infrastructure, financial constraints, social stigma, and inadequate healthcare workforce training, all of which can undermine the effectiveness of mtct interventions.22 1. limited healthcare infrastructure and resources in many low-income countries, the healthcare infrastructure is underdeveloped, and access to quality healthcare services is uneven, particularly in rural areas. clinics and hospitals may be overcrowded, poorly equipped, and understaffed, making it difficult to provide the necessary hiv testing, art, and maternal health services at scale. the lack of sufficient transportation and communication networks also hinders the delivery of care, especially for pregnant women who need regular visits for hiv testing and art initiation. to overcome these infrastructural limitations, there is a need for increased investment in healthcare facilities, mobile health units, and telemedicine services. mobile clinics equipped with point-of-care hiv testing and art distribution can help reach pregnant women in remote areas. additionally, leveraging existing community health workers can be an effective way to extend healthcare access and provide essential services in hard-to-reach regions.23-24 2. financial constraints and funding shortages financial constraints are one of the most significant barriers to implementing mtct prevention strategies in low-resource settings. in many countries, the cost of hiv care—including testing, art, and maternal health services—can be prohibitively high, especially when these services are not covered by national health systems or international aid. moreover, the competing priorities for limited healthcare budgets often result in inadequate funding for hiv-specific programs. to address this challenge, it is essential to prioritize hiv prevention in national health budgets and explore alternative funding models such as public-private partnerships, international donor support, and innovative financing mechanisms like microinsurance schemes. additionally, cost-sharing initiatives and sliding-scale payment systems can help make hiv care more affordable for low-income populations while still ensuring the sustainability of programs.25-26 3. cultural stigma and social barriers cultural stigma surrounding hiv is a significant barrier to the successful implementation of mtct prevention programs in many low-income settings. in many communities, there is a strong association between hiv and negative social perceptions, leading to fear, discrimination, and reluctance to seek hiv testing or treatment. pregnant women living with hiv may face increased stigma, particularly in societies where hiv is still heavily stigmatized and considered taboo. to overcome this, community-based education and sensitization campaigns are crucial. these programs should focus on debunking myths and misconceptions about hiv and emphasize that with proper treatment, women living with hiv can give birth to healthy, hivnegative babies. the involvement of community leaders, religious figures, and local influencers in education and outreach programs can also help reduce stigma and build trust. peer support groups and counseling services can further empower hiv-positive women to seek care and adhere to treatment.27-29 4. inadequate healthcare workforce training and capacity the lack of adequately trained healthcare workers is a critical challenge in low-resource settings. healthcare providers may not have the necessary knowledge or experience to diagnose and manage hiv effectively, particularly in relation to preventing mtct. there is often a shortage of skilled healthcare personnel, and those available may be overburdened with high patient volumes, leading to suboptimal care. to address this issue, it is essential to invest in the training and continuing education of healthcare workers at all levels, particularly in maternal and child health, hiv care, and prevention. task-shifting, where non-specialist healthcare workers are trained to provide certain services under the supervision of more experienced professionals, is one cost-effective strategy to increase the capacity of the healthcare workforce. mobile training programs and online learning platforms can also help build the necessary skills in rural and underserved areas.30-31 5. government and policy support government support is vital for the successful implementation and sustainability of mtct prevention programs. in many low-income countries, inadequate emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):35-39 [38] ajdhs.com policy frameworks and a lack of political will can undermine efforts to reduce mtct. governments need to prioritize hiv prevention in national health strategies and align resources with the goal of eliminating pediatric hiv. ensuring that hiv testing and treatment are integrated into maternal and child health programs is another key step toward reducing mtct. policy reforms that address the affordability and accessibility of hiv care, including subsidized art and free maternal health services, can help overcome financial barriers. moreover, strong monitoring and evaluation systems should be put in place to track the effectiveness of mtct prevention efforts and ensure that interventions are reaching the most vulnerable populations.32 6. improved community engagement and empowerment community involvement and empowerment are key to overcoming the barriers that hinder mtct prevention in low-resource settings. engaging local communities in the design and delivery of hiv programs helps ensure that interventions are culturally appropriate and tailored to the specific needs of the population. community health workers can play a critical role in delivering hiv prevention services, educating women about hiv and mtct, and providing ongoing support throughout pregnancy and after childbirth. by involving communities in decision-making and leveraging local knowledge, healthcare programs can be better accepted and more effective. furthermore, empowering women living with hiv to take control of their health through access to education, support groups, and art adherence programs can lead to better health outcomes and a reduction in mtct.33 7. leveraging technology for scalability and reach in recent years, the use of technology has emerged as a promising solution to address the barriers to mtct prevention in low-income settings. digital health technologies, such as mobile health (mhealth) applications, can improve access to hiv care by providing real-time information on hiv testing, art adherence, and maternal health. these technologies can also support the training of healthcare workers through virtual learning platforms and telemedicine services, helping to bridge the gap in areas with limited access to specialized medical professionals. additionally, data collection and monitoring systems can improve the tracking of mtct prevention efforts and ensure that resources are allocated efficiently. by integrating technology into hiv prevention programs, low-resource settings can expand the reach of their interventions and improve the quality of care delivered to pregnant women living with hiv.33 conclusion reducing mother-to-child transmission (mtct) of hiv in low-resource settings remains one of the most pressing global health challenges. although effective and affordable solutions are available, their implementation is often hindered by a range of barriers, including limited healthcare infrastructure, financial constraints, cultural stigma, and inadequate workforce training. overcoming these obstacles requires a comprehensive approach that involves strengthening healthcare systems, increasing investment in hiv care, and fostering community engagement. key strategies, such as integrating hiv testing and treatment into maternal and child health programs, expanding access to antiretroviral therapy (art), and addressing cultural stigma through education and sensitization, are crucial for successful mtct prevention. moreover, innovative solutions, such as task-shifting and mobile health technologies, can help mitigate the resource limitations often faced in low-income countries. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):35-39 [39] ajdhs.com 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [50] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited gut mucosal immunity in hiv-exposed infants: a review *emmanuel ifeanyi obeagu 1 and getrude uzoma obeagu 2 1 department of medical laboratory science, kampala international university, ishaka, uganda. 2 school of nursing science, kampala international university, ishaka, uganda. article info: _____________________________________________ article history: received 17 april 2024 reviewed 28 may 2024 accepted 24 june 2024 published 15 july 2024 _____________________________________________ cite this article as: obeagu ei, obeagu gu, gut mucosal immunity in hiv-exposed infants: a review, asian journal of dental and health sciences. 2024; 4(2):50-55 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.82 _____________________________________________ *address for correspondence: emmanuel ifeanyi obeagu, department of medical laboratory science, kampala international university, uganda abstract _________________________________________________________________________________________________________________ gut mucosal immunity in infants exposed to human immunodeficiency virus (hiv) presents a complex interplay of developmental processes, viral dynamics, and therapeutic interventions that significantly impact clinical outcomes. this review synthesizes current knowledge on the mechanisms, clinical implications, and therapeutic strategies concerning gut mucosal immunity in hiv-exposed infants. the gut mucosa serves as a critical site for immune maturation and defense against pathogens, but hiv infection disrupts this delicate balance, leading to compromised immune function and increased susceptibility to infections. infants born to hiv-positive mothers experience unique challenges in gut mucosal immunity due to vertical transmission of the virus and exposure to antiretroviral therapy (art). hiv infection disrupts gut-associated lymphoid tissue (galt), resulting in early depletion of cd4+ t cells and compromised mucosal barrier function. these alterations contribute to microbial translocation, chronic inflammation, and immune dysregulation, impacting overall immune competence and increasing susceptibility to opportunistic infections. despite advances in art, persistent immune activation and residual gut mucosal damage pose ongoing challenges in achieving optimal immune reconstitution and preventing long-term complications in hiv-exposed infants. clinical implications of compromised gut mucosal immunity in hiv-exposed infants extend beyond gastrointestinal health to encompass systemic immune dysfunction and increased risks of non-aids comorbidities. impaired gut barrier function exacerbates microbial translocation, leading to systemic inflammation that may contribute to neurodevelopmental abnormalities and metabolic disorders. keywords: gut, immunity, hiv, infants introduction human immunodeficiency virus (hiv) infection continues to pose significant global health challenges, particularly affecting vulnerable populations such as infants born to hiv-positive mothers. vertical transmission of hiv remains a leading cause of pediatric hiv infections, highlighting the critical need for effective prevention, early diagnosis, and optimal management strategies. infants exposed to hiv face unique immunological challenges, particularly in the development and maintenance of gut mucosal immunity, which plays a crucial role in immune maturation, defense against pathogens, and overall health outcomes.1-2 the gut mucosa serves as a dynamic interface where complex interactions occur between the host immune system, commensal microbiota, and potential pathogens. in neonates and infants, the gut mucosa undergoes rapid development and maturation, crucial for establishing immune tolerance, regulating inflammatory responses, and shaping systemic immune function. however, in the context of hiv exposure, this delicate balance is disrupted early in life, impacting both local mucosal immunity and systemic immune responses. understanding the mechanisms underlying gut mucosal immune dysfunction in hiv-exposed infants is therefore pivotal for developing targeted interventions to mitigate immune perturbations and improve clinical outcomes.3-4 hiv infection profoundly affects gut-associated lymphoid tissue (galt), comprising organized lymphoid structures such as peyer's patches and gut-associated lymph nodes, as well as diffuse lymphoid aggregates in the lamina propria. these mucosal sites are critical for generating and maintaining adaptive immune responses against enteric pathogens. however, hiv selectively targets cd4+ t cells, particularly gut-homing ccr5+ cd4+ t cells, leading to their depletion and disruption of galt architecture. loss of cd4+ t cells compromise mucosal barrier integrity, impairs local immune surveillance, and promotes microbial translocation across the intestinal epithelium, contributing to chronic immune activation and systemic inflammation.5-6 the consequences of disrupted gut mucosal immunity in hivexposed infants extend beyond gastrointestinal health to impact overall immune competence and susceptibility to infections. impaired gut barrier function allows for increased translocation of microbial products, such as lipopolysaccharides (lps) and bacterial dna fragments, into systemic circulation, triggering innate immune responses and perpetuating chronic inflammation. persistent immune activation is associated with accelerated immune senescence, characterized by premature immune aging, reduced immune reconstitution, and heightened susceptibility to opportunistic infections and non-aids comorbidities.7-8 antiretroviral therapy (art) represents a cornerstone of treatment in pediatric hiv infection, effectively suppressing viral replication and preserving immune function. early initiation of art in hivexposed infants is crucial for preventing disease progression and reducing the establishment of viral reservoirs. however, despite viral suppression, art alone may not fully restore gut mucosal immunity or mitigate chronic inflammation in hiv open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.82 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.82&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [51] ajdhs.com infected children. persistent immune activation and residual gut mucosal damage underscore the need for adjunctive therapies aimed at modulating immune responses and enhancing mucosal integrity.9-10 gut mucosal immunity in hiv-exposed infants the gut mucosa plays a pivotal role in immune development, acting as a barrier against pathogens while maintaining tolerance to commensal microbiota. however, hiv infection disrupts this delicate balance, leading to significant alterations in gut-associated lymphoid tissue (galt), mucosal immune responses, and microbial composition.11 hiv targets cd4+ t cells, particularly gut-homing ccr5+ cd4+ t cells, which are crucial for maintaining galt integrity and regulating mucosal immunity. the depletion of these cells compromises mucosal barrier function, increases gut permeability, and facilitates the translocation of microbial products into systemic circulation. this process, known as microbial translocation, triggers chronic immune activation and inflammation, which are hallmarks of hiv pathogenesis and contribute to disease progression in infants.12-13 studies have shown that hivexposed infants exhibit early and persistent abnormalities in gut mucosal immunity, even in the absence of clinical symptoms. these abnormalities include reduced levels of galt cd4+ t cells, altered cytokine profiles, and dysbiosis of the gut microbiota. dysregulated immune responses in the gut mucosa not only impair local defenses against enteric pathogens but also impact systemic immune function, potentially influencing the course of hiv infection and complicating treatment outcomes.14-15 the consequences of impaired gut mucosal immunity in hiv-exposed infants extend beyond gastrointestinal health to affect overall immune competence and susceptibility to infections. chronic immune activation associated with gut mucosal damage may contribute to immune exhaustion, premature immune senescence, and impaired responses to vaccination. addressing these challenges requires a multifaceted approach, including early initiation of antiretroviral therapy (art), nutritional interventions to support gut health, and research into novel strategies to restore mucosal immune function and mitigate immune dysregulation.16-17 clinical implications the clinical implications of altered gut mucosal immunity in hiv-exposed infants are profound and multifaceted, influencing both immediate management strategies and long-term health outcomes. here, we explore these implications in detail: 1. increased susceptibility to infections: impaired gut mucosal integrity and dysregulated immune responses in hiv-exposed infants contribute to heightened susceptibility to enteric infections and systemic infections. the depletion of cd4+ t cells in gut-associated lymphoid tissue (galt) compromises local immune defenses against pathogens, leading to frequent gastrointestinal infections such as diarrhea and opportunistic infections. these infections not only impact nutritional status and growth but also pose challenges in clinical management due to recurrent illness and the need for aggressive antimicrobial therapies.18-20 2. impact on nutritional status and growth: the gut mucosa plays a critical role in nutrient absorption and metabolism. hiv-associated gut mucosal damage can impair nutrient uptake, leading to malabsorption syndromes and nutritional deficiencies in infants. persistent diarrhea and enteropathy further exacerbate nutritional challenges, affecting growth and development during a critical period of infancy. optimizing nutritional support, including micronutrient supplementation and specialized formulas, is essential to mitigate these effects and support optimal growth in hiv-exposed infants.21-23 3. immune dysregulation and chronic inflammation: hivinduced immune dysregulation in the gut mucosa contributes to chronic inflammation characterized by elevated levels of pro-inflammatory cytokines and microbial translocation. chronic immune activation not only accelerates disease progression but also increases the risk of non-aids comorbidities, including cardiovascular disease, neurodevelopmental impairments, and metabolic disorders. managing chronic inflammation in hiv-exposed infants requires a comprehensive approach that includes early initiation of antiretroviral therapy (art), monitoring of inflammatory markers, and potentially antiinflammatory interventions to mitigate long-term immune dysfunction.24-26 4. impact on neurodevelopment and cognitive function: emerging evidence suggests a link between gut health, immune function, and neurodevelopment in hiv-exposed infants. chronic inflammation and microbial dysbiosis in the gut may contribute to neuroinflammation and neurocognitive impairments, influencing cognitive development and behavioral outcomes. addressing gut mucosal immunity as part of comprehensive pediatric hiv care is therefore crucial for optimizing neurodevelopmental outcomes and quality of life for affected infants.27-28 5. implications for vaccine responses: effective vaccination is essential for preventing opportunistic infections in hiv-exposed infants. however, impaired gut mucosal immunity and immune dysregulation may compromise vaccine responses, leading to reduced efficacy of routine childhood vaccines and vaccines against opportunistic infections such as pneumococcus and rotavirus. strategies to enhance vaccine responses, including booster doses and novel adjuvanted vaccines, are needed to overcome these challenges and improve protective immunity in this vulnerable population.29-31 6. long-term health monitoring and management: longitudinal monitoring of gut mucosal integrity, immune function, and growth parameters is essential for optimizing clinical outcomes in hiv-exposed infants. comprehensive health assessments, including screening for gastrointestinal complications, growth monitoring, and neurodevelopmental assessments, facilitate early detection and management of complications associated with impaired gut mucosal immunity. multidisciplinary care teams, comprising pediatricians, infectious disease specialists, nutritionists, and developmental psychologists, collaborate to provide integrated care that addresses the complex health needs of hiv-exposed infants and supports long-term health and well-being.32-35 challenges addressing the challenges associated with gut mucosal immunity in hiv-exposed infants is crucial for optimizing clinical management and improving long-term health outcomes. these challenges span various aspects of care and research: 1. early diagnosis and access to care: one of the primary challenges is ensuring early diagnosis of hiv infection in infants born to hiv-positive mothers. access to early infant diagnosis (eid) services remains limited in many resourcelimited settings, delaying the initiation of antiretroviral therapy (art) and potentially compromising immune reconstitution. timely identification of hiv-exposed infants is essential to mitigate the impact of viral exposure on gut mucosal immunity and overall health outcomes.36-37 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [52] ajdhs.com 2. impact of vertical transmission and breastfeeding: vertical transmission of hiv remains a significant mode of infection in infants. breastfeeding poses additional challenges, as it provides nutritional benefits while also potentially exposing infants to the virus. balancing the nutritional advantages of breastfeeding with the risk of hiv transmission requires careful counseling and support for mothers, as well as adherence to art regimens to reduce viral load and minimize transmission risk.38-39 3. gut mucosal damage and immune dysfunction: hiv infection disrupts gut-associated lymphoid tissue (galt), leading to early depletion of cd4+ t cells and compromised mucosal barrier function. this damage contributes to microbial translocation, chronic immune activation, and systemic inflammation, which in turn increase the risk of opportunistic infections and non-aids comorbidities. addressing gut mucosal damage and immune dysfunction requires targeted interventions to preserve mucosal integrity and enhance immune reconstitution.40-41 4. antiretroviral therapy (art) challenges: while art is effective in suppressing viral replication and preserving immune function, challenges such as adherence, drug resistance, and side effects impact treatment outcomes in hiv-exposed infants. pediatric formulations of art may be limited, leading to dosing challenges and suboptimal adherence. optimizing art regimens and developing pediatric-friendly formulations are critical to ensure sustained viral suppression and mitigate the long-term effects of hiv on gut mucosal immunity.42-43 5. nutritional and developmental implications: impaired gut mucosal immunity in hiv-exposed infants can lead to malabsorption syndromes, nutritional deficiencies, and growth faltering. nutritional interventions are essential to support gut health and promote optimal growth and development. however, access to adequate nutrition, especially in resource-limited settings, remains a challenge and can exacerbate the impact of hiv on immune and overall health outcomes.44-45 6. research and resource limitations: research into gut mucosal immunity in pediatric hiv infection faces challenges related to funding, infrastructure, and access to specialized laboratories and expertise. longitudinal studies are needed to understand the long-term effects of hiv on gut health, immune function, and neurodevelopment in infants. collaborative efforts among researchers, healthcare providers, policymakers, and community stakeholders are essential to address these challenges and advance knowledge in pediatric hiv care.46-47 7. social and psychosocial factors: stigma associated with hiv/aids can hinder access to healthcare services and adherence to treatment regimens, impacting overall health outcomes in hiv-exposed infants. addressing social determinants of health, promoting maternal and family support, and integrating psychosocial support services into pediatric hiv care are crucial to improving treatment adherence, reducing stigma, and supporting holistic care for affected infants and their families.48-49 therapeutic strategies therapeutic strategies for addressing gut mucosal immunity in hiv-exposed infants aim to mitigate immune dysfunction, preserve mucosal integrity, and improve long-term health outcomes. these strategies involve a combination of medical interventions, nutritional support, and supportive care approaches tailored to the unique needs of pediatric patients. here are key therapeutic strategies: 1. early initiation of antiretroviral therapy (art): early initiation of art is critical to suppress viral replication, preserve cd4+ t cell counts, and prevent further damage to gut mucosal immunity. art reduces viral load, which in turn decreases viral-induced immune activation and inflammation in the gut mucosa. pediatric art regimens, including fixed-dose combinations and age-appropriate formulations, ensure optimal dosing and adherence in infants.50 2. nutritional support: optimal nutrition is essential for supporting gut mucosal health and immune function in hivexposed infants. malnutrition and nutrient deficiencies can exacerbate immune dysfunction and impair growth. nutritional interventions include breastfeeding promotion with adherence to art by the mother, provision of infant formula when necessary, and supplementation with essential micronutrients such as vitamins and minerals. nutrition counseling for caregivers ensures adequate dietary intake and growth monitoring.51 3. management of opportunistic infections: preventing and treating opportunistic infections are crucial components of pediatric hiv care. infants with compromised gut mucosal immunity are at increased risk of gastrointestinal infections and systemic infections. prophylactic antibiotics, antifungals, and vaccines (e.g., pneumococcal and rotavirus vaccines) help prevent infections. early recognition and prompt treatment of infections reduce morbidity and mortality, supporting overall immune health.52 4. promotion of breastfeeding with art: breastfeeding provides essential nutrients and immune factors that support infant health. the benefits of breastfeeding must be balanced against the risk of hiv transmission. exclusive breastfeeding with maternal art adherence significantly reduces the risk of vertical transmission. counseling mothers on safe breastfeeding practices and ensuring viral suppression through art are critical to minimize transmission risk while promoting infant health.53 5. immune modulation therapies: innovative therapies aimed at modulating immune responses in hiv-exposed infants are under investigation. these include interventions to reduce chronic immune activation and inflammation, such as anti-inflammatory agents or immune checkpoint inhibitors. research into probiotics and prebiotics to restore gut microbial balance (microbiota) and enhance mucosal immunity is also promising for improving gut health and immune function.54 6. monitoring and management of gut health: regular monitoring of gut mucosal integrity and immune function is essential for early detection of complications and timely intervention. biomarkers of gut mucosal damage, such as fecal calprotectin and zonulin levels, can aid in assessing mucosal health. endoscopic evaluations and histopathological assessments provide insights into mucosal inflammation and damage, guiding therapeutic decisions.55-56 7. psychosocial support: addressing psychosocial factors, including stigma associated with hiv/aids, is crucial for promoting adherence to treatment and overall well-being in affected infants and their families. supportive care services, including counseling, peer support groups, and community outreach programs, help reduce stigma, improve treatment adherence, and enhance quality of life for hiv-exposed infants and their caregivers.57-58 8. research and development: continued research into novel therapeutic approaches, including vaccines targeting obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [53] ajdhs.com mucosal immunity and immune modulation therapies, is essential to advance pediatric hiv care. collaborative efforts among researchers, healthcare providers, and pharmaceutical companies are needed to develop new treatment options tailored to the unique immunological challenges of hiv-exposed infants.59 conclusion gut mucosal immunity in hiv-exposed infants represents a critical area of research and clinical management, with profound implications for immune development, infectious disease susceptibility, and long-term health outcomes. hiv infection disrupts the delicate balance of gut-associated lymphoid tissue (galt), leading to early depletion of cd4+ t cells, compromised mucosal barrier function, and chronic immune activation. these immunological perturbations contribute to increased susceptibility to infections, nutritional challenges, and systemic inflammation, impacting overall health and quality of life in affected infants. addressing the challenges associated with gut mucosal immunity in hivexposed infants requires a multifaceted approach that integrates early diagnosis, optimized antiretroviral therapy (art), nutritional support, management of opportunistic infections, and innovative immune modulation strategies. early initiation of art is pivotal in suppressing viral replication, preserving immune function, and mitigating mucosal damage. nutritional interventions, including breastfeeding with art adherence and nutrient supplementation, support optimal growth and immune health, while management of opportunistic infections reduces morbidity and mortality. references 1. yu jc, khodadadi h, malik a, davidson b, salles éd, bhatia j, hale vl, baban b. innate immunity of neonates and infants. frontiers in immunology. 2018; 9:1759. https://doi.org/10.3389/fimmu.2018.01759 pmid:30105028 pmcid:pmc6077196 2. goenka a, kollmann tr. development of immunity in early life. journal of infection. 2015;71: s112-120. https://doi.org/10.1016/j.jinf.2015.04.027 pmid:25934325 3. lewis db, weitkamp jh, levy o. developmental immunology and role of host defenses in fetal and neonatal susceptibility to infection. in remington and klein's infectious diseases of the fetus and newborn infant 2025: 73-159. elsevier. https://doi.org/10.1016/b978-0-323-79525-8.00013-5 4. obeagu ei, anyiam af, obeagu gu. managing anemia in hiv through blood transfusions: clinical considerations and innovations. elite journal of hiv, 2024; 2(1): 16-30 5. obeagu ei, obeagu, gu. counting cells, shaping fates: cd4/cd8 ratios in hiv. elite journal of scientific research and review, 2024; 2(1): 37-50 6. obeagu ei, obeagu gu. eosinophil dynamics in pregnancy among women living with hiv: a comprehensive review. int. j. curr. res. med. sci. 2024;10(1):11-24. 7. obeagu ei, obeagu gu, hauwa ba, umar ai. neutrophil dynamics: unveiling their role in hiv progression within malaria patients. journal home page: http://www. journalijiar. com.;12(01). 8. obeagu ei, obeagu, gu. p-selectin and platelet activation in hiv: implications for antiviral therapy. elite journal of scientific research and review, 2024; 2(1): 17-41 9. obeagu ei, obeagu gu. the intricate relationship between erythropoietin and hiv-induced anemia: unraveling pathways for therapeutic insights. int. j. curr. res. chem. pharm. sci. 2024;11(2):30-40. 10. obeagu ei, anyiam af, obeagu gu. erythropoietin therapy in hivinfected individuals: a critical review. elite journal of hiv, 2024; 2(1): 51-64 11. obeagu ei, obeagu gu. strength in unity: building support networks for hiv patients in uganda. elite journal of medicine, 2024; 2(1): 1-16 12. obeagu ei, obeagu gu. eosinophilic changes in placental tissues of hiv-positive pregnant women: a review. elite journal of laboratory medicine, 2024; 2(1): 14-32 13. kuhn l, meddows-taylor s, gray g, tiemessen c. human immunodeficiency virus (hiv)-specific cellular immune responses in newborns exposed to hiv in utero. clinical infectious diseases. 2002;34(2):267-276. https://doi.org/10.1086/338153 pmid:11740717 14. muenchhoff m, prendergast aj, goulder pj. immunity to hiv in early life. frontiers in immunology. 2014; 5:391. https://doi.org/10.3389/fimmu.2014.00391 pmid:25161656 pmcid:pmc4130105 15. geng st, zhang zy, wang yx, lu d, yu j, zhang jb, kuang yq, wang kh. regulation of gut microbiota on immune reconstitution in patients with acquired immunodeficiency syndrome. frontiers in microbiology. 2020; 11:594820. https://doi.org/10.3389/fmicb.2020.594820 pmid:33193273 pmcid:pmc7652894 16. obeagu ei, obeagu, gu. the crucial role of erythropoietin in managing anemia in hiv: a review. elite journal of scientific research and review, 2024; 2(1): 24-36 17. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. 18. obeagu ei, obeagu gu. assessing platelet functionality in hiv patients receiving antiretroviral therapy: implications for risk assessment. elite journal of hiv, 2024; 2(3): 14-26 19. obeagu ei, elamin eai obeagu gu. understanding the intersection of highly active antiretroviral therapy and platelets in hiv patients: a review. elite journal of haematology, 2024; 2(3): 111117 20. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 21. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 22. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 23. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 24. obeagu ei, obeagu gu. anemia and erythropoietin: key players in hiv disease progression. elite journal of haematology, 2024; 2(3): 42-57 25. obeagu ei, ayogu ee, obeagu gu. impact on viral load dynamics: understanding the interplay between blood transfusion and antiretroviral therapy in hiv management. elite journal of nursing and health science, 2024; 2(2): 5-15 26. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 27. ifeanyi oe, obeagu gu. the values of prothrombin time among hiv positive patients in fmc owerri. international journal of current microbiology and applied sciences. 2015;4(4):911-916. https://www.academia.edu/download/38320140/obeagu_emma nuel_ifeanyi_and_obeagu__getrude_uzoma2.emma1.pdf. 28. yu jc, khodadadi h, malik a, davidson b, salles éd, bhatia j, hale vl, baban b. innate immunity of neonates and infants. frontiers in immunology. 2018; 9:1759. https://doi.org/10.3389/fimmu.2018.01759 pmid:30105028 pmcid:pmc6077196 https://doi.org/10.3389/fimmu.2018.01759 https://doi.org/10.1016/j.jinf.2015.04.027 https://doi.org/10.1016/b978-0-323-79525-8.00013-5 https://doi.org/10.1086/338153 https://doi.org/10.3389/fimmu.2014.00391 https://doi.org/10.3389/fmicb.2020.594820 https://doi.org/10.3389/fimmu.2018.01759 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [54] ajdhs.com 29. levy o. innate immunity of the newborn: basic mechanisms and clinical correlates. nature reviews immunology. 2007;7(5):379390. https://doi.org/10.1038/nri2075 pmid:17457344 30. pieren dk, boer mc, de wit j. the adaptive immune system in early life: the shift makes it count. frontiers in immunology. 2022; 13:1031924. https://doi.org/10.3389/fimmu.2022.1031924 pmid:36466865 pmcid:pmc9712958 31. rackaityte e, halkias j. mechanisms of fetal t cell tolerance and immune regulation. frontiers in immunology. 2020; 11:588. https://doi.org/10.3389/fimmu.2020.00588 pmid:32328065 pmcid:pmc7160249 32. sereme y, toumi e, saifi e, faury h, skurnik d. maternal immune factors involved in the prevention or facilitation of neonatal bacterial infections. cellular immunology. 2024; 395:104796. https://doi.org/10.1016/j.cellimm.2023.104796 pmid:38104514 33. zhang x, zhivaki d, lo-man r. unique aspects of the perinatal immune system. nature reviews immunology. 2017;17(8):495507. https://doi.org/10.1038/nri.2017.54 pmid:28627520 34. sanidad kz, zeng my. neonatal gut microbiome and immunity. current opinion in microbiology. 2020; 56:30-37. https://doi.org/10.1016/j.mib.2020.05.011 pmid:32634598 pmcid:pmc8729197 35. izuchukwu if, ozims sj, agu gc, obeagu ei, onu i, amah h, nwosu dc, nwanjo hu, edward a, arunsi mo. knowledge of preventive measures and management of hiv/aids victims among parents in umuna orlu community of imo state nigeria. int. j. adv. res. biol. sci. 2016;3(10): 55-65.doi; 10.22192/ijarbs.2016.03.10.009 https://doi.org/10.22192/ijarbs.2016.03.10.009 36. chinedu k, takim ae, obeagu ei, chinazor ud, eloghosa o, ojong oe, odunze u. hiv and tb co-infection among patients who used directly observed treatment short-course centres in yenagoa, nigeria. iosr j pharm biol sci. 2017;12(4):70-75. links/5988ab6d0f7e9b6c8539f73d/hiv-and-tb-co-infectionamong-patients-who-used-directly-observed-treatment-shortcourse-centres-in-yenagoa-nigeria.pdf 37. oloro oh, oke to, obeagu ei. evaluation of coagulation profile patients with pulmonary tuberculosis and human immunodeficiency virus in owo, ondo state, nigeria. madonna university journal of medicine and health sciences. 2022;2(3):110-119. 38. nwosu dc, obeagu ei, nkwocha bc, nwanna ca, nwanjo hu, amadike jn, elendu hn, ofoedeme cn, ozims sj, nwankpa p. change in lipid peroxidation marker (mda) and non enzymatic antioxidants (vit c & e) in hiv seropositive children in an urban community of abia state. nigeria. j. bio. innov. 2016;5(1):24-30. links/5ae735e9a6fdcc5b33eb8d6a/change-in-lipidperoxidation-marker-mdaand-non-enzymaticantioxidants-vit-c-e-in-hiv-seropositive-children-inan-urban-community-of-abia-state-nigeria.pdf. 39. ifeanyi oe, obeagu gu, ijeoma fo, chioma ui. the values of activated partial thromboplastin time (aptt) among hiv positive patients in fmc owerri. int j curr res aca rev. 2015; 3:139-144. https://www.academia.edu/download/38320159/obeagu_emma nuel_ifeanyi3__et_al.ijcrar.pdf. 40. obiomah cf, obeagu ei, ochei kc, swem ca, amachukwu bo. hematological indices o hiv seropositive subjects in nnamdi azikiwe university teaching hospital (nauth), nnewi. ann clin lab res. 2018;6(1):1-4. links/5aa2bb17a6fdccd544b7526e/haematological-indices-ofhiv-seropositive-subjects-at-nnamdi-azikiwe.pdf 41. omo-emmanuel uk, ochei kc, osuala eo, obeagu ei, onwuasoanya uf. impact of prevention of mother to child transmission (pmtct) of hiv on positivity rate in kafanchan, nigeria. int. j. curr. res. med. sci. 2017;3(2): 28-34.doi: 10.22192/ijcrms.2017.03.02.005 42. aizaz m, abbas fa, abbas a, tabassum s, obeagu ei. alarming rise in hiv cases in pakistan: challenges and future recommendations at hand. health science reports. 2023;6(8):e1450. https://doi.org/10.1002/hsr2.1450 pmid:37520460 pmcid:pmc10375546 43. obeagu ei, amekpor f, scott gy. an update of human immunodeficiency virus infection: bleeding disorders. j pub health nutri. 2023 6 (1). 2023;139. links/645b4a6c2edb8e5f094d9bd9/an-update-ofhuman-immunodeficiency-virus-infection-bleeding.pdf. 44. obeagu ei, scott gy, amekpor f, ofodile ac, edoho sh, ahamefula c. prevention of new cases of human immunodeficiency virus: pragmatic approaches of saving life in developing countries. madonna university journal of medicine and health sciences. 2022;2(3):128-134. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/86. 45. walter o, anaebo qb, obeagu ei, okoroiwu il. evaluation of activated partial thromboplastin time and prothrombin time in hiv and tb patients in owerri metropolis. journal of pharmaceutical research international. 2022:29-34. https://doi.org/10.9734/jpri/2022/v34i3a35560 46. odo m, ochei kc, obeagu ei, barinaadaa a, eteng eu, ikpeme m, bassey jo, paul ao. cascade variabilities in tb case finding among people living with hiv and the use of ipt: assessment in three levels of care in cross river state, nigeria. journal of pharmaceutical research international. 2020;32(24):9-18. https://doi.org/10.9734/jpri/2020/v32i2430789 47. obeagu ei, obeagu gu. a review of knowledge, attitudes and socio-demographic factors associated with non-adherence to antiretroviral therapy among people living with hiv/aids. int. j. adv. res. biol. sci. 2023;10(9):135-142.doi: 10.22192/ijarbs.2023.10.09.015 links/6516faa61e2386049de5e828/a-review-of-knowledgeattitudes-and-socio-demographic-factors-associated-with-nonadherence-to-antiretroviral-therapy-among-people-living-withhiv-aids.pdf 48. obeagu ei, onuoha ec. tuberculosis among hiv patients: a review of prevalence and associated factors. int. j. adv. res. biol. sci. 2023;10(9):128-134.doi: 10.22192/ijarbs.2023.10.09.014 links/6516f938b0df2f20a2f8b0e0/tuberculosis-among-hivpatients-a-review-of-prevalence-and-associated-factors.pdf. 49. obeagu ei, ibeh nc, nwobodo ha, ochei kc, iwegbulam cp. haematological indices of malaria patients coinfected with hiv in umuahia. int. j. curr. res. med. sci. 2017;3(5):100-104.doi: 10.22192/ijcrms.2017.03.05.014 https://www.academia.edu/download/54317126/haematologic al_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 50. okorie hm, obeagu emmanuel i, okpoli henry ch, chukwu stella n. comparative study of enzyme linked immunosorbent assay (elisa) and rapid test screening methods on hiv, hbsag, hcv and syphilis among voluntary donors in. owerri, nigeria. j clin commun med. 2020;2(3):180-183.doi: doi: 10.32474/jccm.2020.02.000137 links/5f344530458515b7291bd95f/comparative-study-ofenzyme-linked-immunosorbent-assay-elisa-and-rapid-testscreening-methods-on-hiv-hbsag-hcv-and-syphilis-amongvoluntary-donors-in-owerri-nigeria.pdf. 51. emannuel g, martin o, peter os, obeagu ei, daniel k. factors influencing early neonatal adverse outcomes among women with hiv with post dated pregnancies delivering at kampala international university teaching hospital, uganda. asian journal of pregnancy and childbirth. 2023 jul 29;6(1):203-211. http://research.sdpublishers.net/id/eprint/2819/. 52. vincent cc, obeagu ei, agu is, ukeagu nc, onyekachi-chigbu ac. adherence to antiretroviral therapy among hiv/aids in federal medical centre, owerri. journal of pharmaceutical research international. 2021;33(57a):360-368. https://doi.org/10.9734/jpri/2021/v33i57a34007 53. madekwe cc, madekwe cc, obeagu ei. inequality of monitoring in human immunodeficiency virus, tuberculosis and malaria: a review. madonna university journal of medicine and health sciences. 2022;2(3):6-15. https://madonnauniversity.edu.ng/journals/index.php/medicine /article/view/69 https://doi.org/10.1038/nri2075 https://doi.org/10.3389/fimmu.2022.1031924 https://doi.org/10.3389/fimmu.2020.00588 https://doi.org/10.1016/j.cellimm.2023.104796 https://doi.org/10.1038/nri.2017.54 https://doi.org/10.1016/j.mib.2020.05.011 https://doi.org/10.22192/ijarbs.2016.03.10.009 https://doi.org/10.1002/hsr2.1450 https://doi.org/10.9734/jpri/2022/v34i3a35560 https://doi.org/10.9734/jpri/2020/v32i2430789 https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://www.academia.edu/download/54317126/haematological_indices_of_malaria_patients_coinfected_with_hiv.pdf https://doi.org/10.22192/ijcrms.2017.03.05.014 https://doi.org/10.9734/jpri/2021/v33i57a34007 obeagu et al. asian journal of dental and health sciences. 2024; 4(2):50-55 [55] ajdhs.com 54. echendu ge, vincent cc, ibebuike j, asodike m, naze n, chinedu ep, ohale b, obeagu ei. weights of infants born to hiv infected mothers: a prospective cohort study in federal medical centre, owerri, imo state. european journal of pharmaceutical and medical research, 2023; 10(8): 564-568 55. wilson em, sereti i. immune restoration after antiretroviral therapy: the pitfalls of hasty or incomplete repairs. immunological reviews. 2013;254(1):343-354. https://doi.org/10.1111/imr.12064 pmid:23772630 pmcid:pmc3694599 56. misgena dk. the pattern of immunologic and virologic responses to highly active antiretroviral treatment (haart): does success bring further challenges? ethiopian journal of health development. 2011;25(1):61-70. https://doi.org/10.4314/ejhd.v25i1.69853 57. davenport mp, khoury ds, cromer d, lewin sr, kelleher ad, kent sj. functional cure of hiv: the scale of the challenge. nature reviews immunology. 2019;19(1):45-54. https://doi.org/10.1038/s41577-018-0085-4 pmid:30410126 58. geretti am, brook g, cameron c, chadwick d, french n, heyderman r, ho a, hunter m, ladhani s, lawton m, macmahon e. british hiv association guidelines on the use of vaccines in hivpositive adults 2015. hiv medicine. 2016;17(53):s2-81. https://doi.org/10.1111/hiv.12424 pmid:27568789 59. laupèze b, del giudice g, doherty mt, van der most r. vaccination as a preventative measure contributing to immune fitness. npj vaccines. 2021;6(1):93. https://doi.org/10.1038/s41541-02100354-z pmid:34315886 pmcid:pmc8316335 https://doi.org/10.1111/imr.12064 https://doi.org/10.4314/ejhd.v25i1.69853 https://doi.org/10.1038/s41577-018-0085-4 https://doi.org/10.1111/hiv.12424 https://doi.org/10.1038/s41541-021-00354-z https://doi.org/10.1038/s41541-021-00354-z emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):1-4 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited using mentzer index to improve anemia management in pregnancy: a narrative review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 02 nov 2024 reviewed 11 dec 2024 accepted 09 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, using mentzer index to improve anemia management in pregnancy: a narrative review, asian journal of dental and health sciences. 2025; 5(1):1-4 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.106 abstract _________________________________________________________________________________________________________________ anemia during pregnancy is a significant public health challenge, affecting maternal well-being and fetal development. among the most common causes are iron deficiency anemia (ida) and thalassemia trait (tt), conditions requiring distinct management strategies. accurate differentiation between these conditions is critical, as misdiagnosis can lead to suboptimal treatment outcomes. the mentzer index, calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, offers a simple and reliable tool for distinguishing between ida and tt, especially in resource-limited settings. this review explores the utility of the mentzer index in improving anemia diagnosis and management in pregnancy. by analyzing routine complete blood count (cbc) results, the mentzer index allows for initial differentiation, facilitating timely and appropriate interventions. a mentzer index value of ≥13 indicates ida, guiding clinicians toward iron supplementation, while a value <13 suggests tt, prompting further investigations and genetic counseling. this approach reduces unnecessary interventions, improves diagnostic accuracy, and ensures tailored management, mitigating complications such as preterm birth, low birth weight, and maternal morbidity. keywords: mentzer index, pregnancy, anemia, iron deficiency, thalassemia *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia in pregnancy is a global health concern, particularly in lowand middle-income countries, where it affects nearly 40% of pregnant women. this condition is associated with significant maternal and fetal complications, including maternal fatigue, increased risk of infections, preterm birth, low birth weight, and perinatal mortality. anemia during pregnancy is a multifactorial condition, with iron deficiency anemia (ida) and thalassemia trait (tt) representing the most common etiologies. accurate differentiation between these two types of anemia is critical, as their management strategies differ significantly, and misdiagnosis can exacerbate complications or lead to unnecessary interventions.1-3 iron deficiency anemia (ida) is the most prevalent form of anemia worldwide, characterized by reduced red blood cell production due to insufficient iron availability. ida commonly results from increased iron demands during pregnancy, coupled with inadequate dietary intake or chronic blood loss. in contrast, thalassemia trait (tt) is a genetic condition associated with impaired hemoglobin production, resulting in microcytosis and hypochromia. while ida typically responds well to iron supplementation, the treatment for tt is more complex, involving genetic counseling, prenatal screening, and the prevention of unnecessary iron overload. therefore, distinguishing between ida and tt is essential for effective patient management.4-6 the mentzer index has emerged as a practical tool for differentiating between ida and tt in clinical practice. calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, this index provides a simple and costeffective method for initial screening. a mentzer index value of ≥13 is indicative of ida, while a value <13 suggests tt. its reliance on parameters obtained from routine complete blood count (cbc) tests makes it an accessible and low-cost option, especially in resourceconstrained settings where advanced diagnostic tools such as hemoglobin electrophoresis or genetic testing may not be readily available.7 in addition to its practicality, the mentzer index addresses several challenges associated with anemia diagnosis in pregnancy. it helps reduce diagnostic delays, enabling timely and appropriate interventions. early differentiation between ida and tt prevents complications arising from mistreatment, such as the risk of iron overload in patients with tt who are mistakenly prescribed iron supplements. furthermore, the mentzer index supports informed decision-making in antenatal care, allowing clinicians to implement tailored interventions that align with the underlying cause of anemia.8 open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.106 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.106&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):1-4 [2] ajdhs.com the role of the mentzer index in anemia diagnosis calculation and interpretation the mentzer index is a simple mathematical calculation derived from routine complete blood count (cbc) results. it is obtained by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, expressed in millions per microliter (µl). this calculation provides a numerical value that aids in distinguishing between iron deficiency anemia (ida) and thalassemia trait (tt), two common causes of anemia. a mentzer index value of ≥13 suggests ida, as this condition is typically associated with low mcv and rbc count. conversely, a value <13 is indicative of tt, characterized by low mcv but a normal or elevated rbc count.9 the accessibility of the mentzer index lies in its simplicity and reliance on routinely performed cbc tests. this makes it an attractive tool in resource-limited settings where advanced diagnostic techniques such as hemoglobin electrophoresis or genetic testing are often unavailable. additionally, its non-invasive nature and ease of calculation enable widespread adoption, even in primary care settings.10 application in pregnancy during pregnancy, anemia is frequently encountered and can have profound consequences for both mother and child. the mentzer index serves as a valuable tool in differentiating between ida and tt, aiding clinicians in making informed treatment decisions. in cases of ida, elevated mentzer index values direct healthcare providers toward iron supplementation, addressing the underlying deficiency. for tt, a low mentzer index value highlights the need for genetic counseling and avoidance of unnecessary iron supplementation, which could lead to iron overload.11 benefits in clinical practice incorporating the mentzer index into anemia diagnosis during pregnancy offers multiple benefits. it facilitates early differentiation between ida and tt, reducing delays in initiating appropriate therapy. this is particularly important in pregnancy, where untreated anemia can lead to adverse outcomes such as preterm delivery, intrauterine growth restriction, and increased maternal morbidity. furthermore, the mentzer index minimizes the risk of over-treatment, ensuring that iron supplementation is reserved for those who will benefit from it, while patients with tt receive appropriate genetic evaluation and counseling.12 implications for anemia management tailored treatment approaches the use of the mentzer index in anemia diagnosis allows for tailored treatment strategies that address the specific underlying cause of anemia in pregnant women. in cases of iron deficiency anemia (ida), characterized by a mentzer index value of ≥13, treatment focuses on iron supplementation. this approach replenishes iron stores, improves hemoglobin levels, and reduces symptoms such as fatigue and dizziness, which can impact maternal quality of life and fetal growth. in contrast, a mentzer index value <13, indicative of thalassemia trait (tt), highlights the importance of avoiding unnecessary iron supplementation, which could lead to iron overload and associated complications. instead, patients with tt benefit from genetic counseling and prenatal screening to assess the risk of severe hemoglobinopathies in the fetus.13 reducing diagnostic delays anemia during pregnancy is associated with significant maternal and fetal risks, including preterm birth, low birth weight, and increased perinatal mortality. the mentzer index facilitates early differentiation between ida and tt, enabling clinicians to initiate appropriate management promptly. this reduces delays caused by waiting for confirmatory tests and helps mitigate complications that arise from untreated anemia. moreover, the ability to distinguish anemia types using a simple, accessible tool ensures timely interventions, particularly in resource-constrained settings where diagnostic resources may be limited.14 enhancing cost-effectiveness in regions with limited healthcare infrastructure, advanced diagnostic tools such as hemoglobin electrophoresis or genetic testing may be unavailable or unaffordable. the mentzer index offers a cost-effective alternative for initial screening. its reliance on routinely available complete blood count (cbc) parameters makes it accessible to a broader population, reducing financial barriers to care. by identifying patients who require confirmatory testing or specific interventions, the mentzer index helps allocate healthcare resources more efficiently, ensuring that advanced diagnostic services are reserved for cases where they are most needed.15 supporting comprehensive care incorporating the mentzer index into anemia management during pregnancy aligns with the principles of comprehensive antenatal care. it facilitates a holistic approach to maternal health by combining initial screening with confirmatory tests and lifestyle interventions. for ida, this may include dietary counseling to improve iron intake and addressing contributing factors such as gastrointestinal blood loss. for tt, the focus shifts to genetic counseling, family planning, and monitoring fetal hemoglobin status. by addressing the root causes of anemia, the mentzer index contributes to sustainable improvements in maternal and fetal outcomes.16 implications for public health widespread adoption of the mentzer index can significantly impact public health, particularly in low and middle-income countries where anemia prevalence is high. its use as a routine screening tool in antenatal care programs can help identify anemia cases early, ensuring that interventions are initiated before complications arise. additionally, its simplicity and accessibility make it an ideal candidate for training healthcare workers in primary care settings, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):1-4 [3] ajdhs.com empowering them to provide effective maternal care and improve community health outcomes.17 challenges and limitations diagnostic ambiguity in mixed anemia one of the primary limitations of the mentzer index is its inability to accurately diagnose mixed anemia, where iron deficiency anemia (ida) coexists with thalassemia trait (tt). in such cases, the red blood cell (rbc) count and mean corpuscular volume (mcv) values may not clearly align with the expected ranges for ida or tt, leading to intermediate or misleading mentzer index values. this ambiguity can complicate the diagnostic process, necessitating further confirmatory testing, such as serum ferritin measurements or hemoglobin electrophoresis, to determine the precise etiology of anemia.18 influence of concurrent conditions the accuracy of the mentzer index can be influenced by concurrent medical conditions that affect rbc parameters. chronic infections, inflammation, or other underlying diseases can alter the mcv or rbc count, potentially skewing the index value. for example, in inflammatory states, changes in iron metabolism may mask or mimic the characteristics of ida. these factors can limit the reliability of the mentzer index, particularly in pregnant women with multiple comorbidities, underscoring the need for comprehensive clinical evaluation and additional diagnostic tools.19-20 limited scope as a screening tool while the mentzer index is a valuable screening tool, it is not a definitive diagnostic method. its simplicity, though advantageous, also restricts its ability to capture the complexity of anemia pathophysiology. for example, the index does not differentiate between different forms of thalassemia or detect other less common causes of anemia, such as vitamin b12 or folate deficiencies. its use is therefore limited to preliminary differentiation between ida and tt, necessitating further investigations to confirm the diagnosis and guide treatment.21-22 challenges in low-resource settings although the mentzer index is cost-effective and accessible, its reliance on accurate and high-quality complete blood count (cbc) results can pose challenges in low-resource settings. poorly calibrated laboratory equipment or lack of trained personnel may compromise the reliability of the rbc count and mcv values, leading to erroneous index calculations. additionally, the unavailability of follow-up confirmatory tests, such as ferritin assays or hemoglobin electrophoresis, may hinder the effective use of the mentzer index in guiding treatment decisions.23-24 risk of over-reliance over-reliance on the mentzer index without confirmatory testing can lead to misdiagnosis and inappropriate management. for instance, patients with a falsely elevated index value may be misclassified as having ida and treated with unnecessary iron supplementation, potentially resulting in iron overload in those with tt. conversely, underestimating the complexity of anemia in patients with mixed etiologies could delay appropriate interventions, increasing the risk of maternal and fetal complications.25-26 need for training and awareness the successful application of the mentzer index in clinical practice requires adequate training of healthcare providers. misinterpretation of the index or lack of awareness about its limitations can reduce its diagnostic utility. educational initiatives are essential to ensure that clinicians understand when and how to use the mentzer index effectively, as well as the importance of complementing it with additional diagnostic methods.27 conclusion the mentzer index serves as a valuable and accessible tool for the initial evaluation of anemia during pregnancy, offering a simple and cost-effective method to differentiate between iron deficiency anemia (ida) and thalassemia trait (tt). its reliance on routinely performed complete blood count (cbc) parameters makes it particularly advantageous in resource-limited settings where advanced diagnostic facilities are unavailable. by enabling timely and accurate identification of the anemia type, the mentzer index facilitates targeted interventions that improve maternal and fetal health outcomes. however, the mentzer index is not without its challenges. its diagnostic accuracy can be affected by mixed anemia, concurrent medical conditions, and limitations inherent to the index itself, such as its inability to differentiate between all forms of anemia. over-reliance on the index without confirmatory testing risks misdiagnosis and inappropriate management. therefore, its application should be complemented by additional diagnostic tests, including serum ferritin measurements, hemoglobin electrophoresis, and genetic counseling when necessary. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):1-4 [4] ajdhs.com clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):45-49 [45] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited empowering girls and women: reducing hiv risk through education emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 11 nov 2024 reviewed 18 dec 2024 accepted 12 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, empowering girls and women: reducing hiv risk through education, asian journal of dental and health sciences. 2025; 5(1):45-49 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.119 abstract _________________________________________________________________________________________________________________ education is very important to women and girls who are at the greatest risk of contracting the hiv virus. however, more emphasis is needed to look at the information on how education improves the transmission of hiv among girls and women and also reduces the inequalities of gender roles which are able to increase infection rates. there is growing evidence that a significant proportion of girls are able to postpone first intercourse, protect themselves against hiv and aids through safer sex practices and advocate condom use in combination with regular hiv testing through an effective sexuality education curriculum. additionally, as women who have greater control over their sexual and reproductive health are less likely to engage in activities that expose them to hiv, education promotes gender equality, which is crucial in lowering hiv risk. education provides a complete response to the epidemic by tackling the underlying factors that contribute to hiv susceptibility, including as poverty, gender-based violence, and early marriage. girls and women who receive education are more capable of fending against forceful and exploitative circumstances that may expose them to hiv. keywords: hiv prevention, gender equality, women’s education, adolescent health, empowerment *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv infection rates differ by gender and age making it a major global health issue. women and girls face the biggest impact in sub-saharan africa where they account for over half of new hiv cases. this unequal risk stems from biological, social, cultural, and economic factors. women and girls have a higher chance to get hiv due to gender-based violence early marriages poor access to sexual and reproductive health services, and gender inequality. to combat these challenges, education serves as a powerful tool to lower hiv risk and help women and girls protect themselves from hiv transmission.1-2 education plays a key role in the fight against hiv by giving girls and women crucial info on hiv spread sexual health, and prevention methods. when people receive full sexual and reproductive health education, they can make smart choices about their bodies, relationships, and sexual actions. it empowers teenage girls to put off starting sex, talk about safe sex practices, and make informed decisions about regular hiv testing, condom use, and birth control. further, more educated girls are less likely to postpone marriage and the bearing of children two behaviors associated with an increased risk of transmission of hiv.3-4 finally, by teaching, education obtains at least one empowering effect of gender equality, necessary to face the root causes that underpin the increase of hiv risk. women and girls with greater control of sexual and reproductive rights are less vulnerable to be victims of violence against girls, forced marriage and sexual violence, as leading risk factors of hiv). education can enable women to challenge, if not actually stop, harmful traditional practices and help dismantle, if not destroy, entrenched gender roles. by enabling women to see themselves as members of the same society as men, it actually provides them the power to stand up, negotiate healthy relationships, and get involved in hiv prevention or care programs.5-6 in addition, education can help improve economic independence. all this is also related to women's risk avoidance of hiv. having economic independence, women can have control over their health, sexual partners, and income. in most regions, women have a tendency to rely on the partners for support, and thereby limit the protection against the hiv. through skill-building and acquiring employment, education can decrease economic dependency and thereby offer tools for more stable relationship choices.7-8 relationship between hiv knowledge and prevention shows, that if girls and women are educated, they are more likely to go to hiv services i.e. voluntary counselling and testing, antiretroviral therapy, and for parent's treatment. it is also supported by research. education can also promote peer discussions in which girls and women share information and resources, and thus amplify the range of hiv prevention messages. thus education plays a role open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.119 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.119&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):45-49 [46] ajdhs.com in wider social change and helps to alleviate the stigma and discrimination surrounding hiv testing and therapy.9-10. the role of education in hiv prevention education is an important factor in hiv prevention, because it provides individuals with both knowledge, and ability to protect both themselves as well as their population from the hiv. for girls and women, education is especially important in addressing the multiple vulnerabilities they face in relation to hiv. thanks to education, individuals may learn about hiv transmission, risk factors and the benefits of regular testing and treatment. this, in turn, allows them to iteratively consider values in a healthy sexual way and make intelligent choices about their sexual health and well -being. 11-12 in one of the key ways that the formation contributes to the prevention of hiv is to increase awareness of safe sexual practices, such as the use of condoms and sexual negotiations. complete sexual and reproductive health education, which includes hiv information, can help people understand how hiv is transmitted and what strategies are effective in preventing its distribution. education also provides information on the importance of the search for medical services, including hiv tests and treatment, which is crucial for the early detection and prevention of transmission. also, for female adolescents, education can lead to postponing early sexual experience and to the prevention of high-risk sexual acts that can expose individuals to hiv infection and high hiv-related stigma and discrimination that in turn prevents individuals from accessing necessary health care.13-14 education is an extremely effective weapon to prevent hiv-related stigma and discrimination and has the potential to disable the consequences of the two. individuals with hiv living in traditional societies suffer from social stigma, which often prevents individuals from accessing care or revealing their condition. through embedding education into hiv prevention efforts, the community will be able to equip the actual experience of living with hiv and equip the level of stigma amplifying the experiences of doctors and those who assist them. when girls and women learn and treat hiv, they are more likely to participate in active actions in relation to healthy health and practical conflicts, such as forced and early marriage, and in hiv. increase vulnerabilities. 15-16 additionally, education promotes gender equality to the extent needed for hiv prevention. girls and women that are educated better prepared to resist the gender barriers and inequities that, in general, increase their risk for hiv. specifically, educated girls are better at postponing marriage and childbirth, which helps them to escape the risks of early sexual experience. moreover, learning contributes to women's social and economic empowerment, decreasing their vulnerability to situations of dependence upon their partners—who are more likely to transmit hiv through sexual practices of risk nature. educated females are better represented to negotiate a safer sexual practice and to have hiv treated when it felt necessary, thereby limiting the spread of hiv 17-18 when resolution is low. education of girls and women in these areas can play an important role in reducing vulnerability to hiv, by considering direct and indirect risk factors. e.g., girls completing school are less likely to marry early or to be involved in transactional sex, both of which are factors that increase their risk of hiv infection). programs of education for young people, especially in high-hiv-prevalence communities, have great significance in disseminating correct knowledge about hiv transmission; hiv prevention and hiv treatment, which are crucial in reducing the incidence of epidemic.19-20 the effects of education on hiv prevention go beyond the individual health outcomes, to the benefits affecting society at large. if girls and women learn about hiv prevention, they are more likely to pass on that information to their families and communities. this gives so much data to prevent hiv transmission and it has a roiling effect. to women with higher levels of education, contributing to economic growth and poverty alleviation is also a reality due to their higher labour force participation rate and community contribution, which further enable them to interrupt the vulnerability pathway of hiv infection.21. gender inequality and hiv risk gender inequality significantly contributes to the heightened vulnerability of women and girls to hiv infection, with social, cultural, economic, and political factors all playing a role. in many places around the world, especially in sub-saharan africa, however, women experience a host of barriers, which restrict the extent to which they can prevent hiv infection largely as a result of deeply embedded gender norms and practices that leave women at risk. gender disparity takes many forms, ranging from limited access to education and medical care to inherently unequal power relations in sexual relationships. because of these disparities, women and girls are at a higher risk of acquiring hiv infection, and gender inequality is one of the essential objectives of hiv prevention.22 the most direct way gender inequality contributes to hiv risk is through power disequilibrium in relationship(s). as in many cultures women have a lesser control over sexual decision making and get less opportunity to negotiate condom use or to refuse unwanted sexual intercourse. these power inequalities frequently lead to women being more susceptible to being forced or coerced into sexual activity, with the consequence of increased susceptibility of hiv infection. for example, in numerous communities, early marriage and transactional sex are the norm which leads women and girls to be in a more or less powerless situation where they cannot discuss safe sexual practices. inability to exercise sexual freedom and social pressure to adhere to patriarchal social norms is also another risk factor that increases hiv infection risk in these women.23 economic disparities is also an important risk factor that intensifies the women's hiv infection risk. in many areas, women have a restricted access to economic activities, due to which they are financially dependent on male partners. this economic dependence can make it difficult for women to negotiate safer sex practices or leave unhealthy relationships, including those with hivpositive partners. additionally, financial insecurity may emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):45-49 [47] ajdhs.com result in sexual work, specifically the exchange of sexual activity for money, food and/or other items, which has the effect of boosting hiv exposure rates for women. again, the absence of access to education, employment, and healthcare services worsens women's precarious position with regard to hiv.24 cultural and social expectations are also important factors in sustaining gender inequality and hiv risk. there is stigma against women judged to be sexually active outside the bonds of marriage in most cultures, silencing and stigmatizing women attempting to get hiv testing and care. this stigma prevents women from seeking hiv‐related care, including [sic] prevention and treatments. in addition, women are frequently conditioned to place the greatest emphasis on the health of their family over their own health and this may constrain their ability to seek treatment as it becomes necessary. these cultural beliefs and social norms limit women's ability to have access to the information and resources, to effectively protect themselves from hiv.25 gender inequality also links to other forms of discriminations, such as age, ethnicity and socioeconomic status that increase women's and girls' risks. young women (aged at least 15-24) are bearing the brunt of hiv infection in rates of newly infected donors that are several folds higher in females than in males. the social and economic forces that affect young women, such as as early marriage and childbirth, frequently result in them having little autonomy in the sense of being able to make informed choices about their sexual health. this vulnerability is also aggravated by a dearth of knowledge and awareness, restricting their understanding of hiv prevention and protective measures.26. apart from these social and cultural factors, biological vulnerability of women to hiv infection further explains the gender gap in regard to hiv risk. women are more likely to be inflectionally vulnerable to hiv as a result of sexual anatomical differences (e.g., larger genital tract mucous membrane epithelial surface area that can facilitate entry of the virus with unprotected sex). this biological risk is exacerbated when women are sexually active through multiple partners, male victimization, or rape as these events can expose women and girls to the risk of trauma as well as to consumption of hiv-infected body fluids.27 it is, therefore, important to expand hiv prevention for men and/or women in order to respond to the problem of intersectionality between gender inequality and hiv risk by strengthening programs that equip women and girls for better control over their sexual and reproductive health. strategies that empower women with knowledge, skills, and ability to negotiate safer sexual practices, tested regularly for hiv, and obtain medical care will be crucial for lowering hiv risk. these measures also need to take account of breaking down negative gender norms and to ensure gender equality in all spheres of life such as in the context of education, economic independence and access to healthcare.28 in addition, policies for counteracting gender inequality should be included in national hiv prevention and/or treatment programs. legal reforms which safeguard women's rights, prevent gender-based violence, and ensure equal access to education and economic activities are also crucial initial steps to overcome the deep-rooted sources of gender oppression and hiv risk. such initiatives need to be backed by local and international communities working together, encompassing collaboration amongst governments, nongovernmental organisations, health professionals and private companies. means of achieving lasting reductions in the burden of hiv, especially among women and girls, can only be attained through holistic, gender-informed strategies.29. challenges in access to education access to learning, specifically for girls and women is an ongoing barrier in parts of the world. educational inequality is a significant bottleneck preventing the closing of health gender gaps, including hiv/aids prevention. a number of social, economic and cultural conditions increase the scarcity of access to education for girls and women and increase their risk factor for hiv, and other health risks. overcoming these challenges is critical to realize more equitable societies and lower hiv transmission at the population level, especially among young women and adolescent girls.30 lack of access to education for girls is, arguably, driven to a large extent by poverty. in many low-income countries, families tend to give a higher education to boys as a financial necessity. girls are often excluded from school to work in household chores or they can be "married" off to a young age. in certain situations, girls can also be economically disadvantaged and forced into early childbearing, which in turn can set back their opportunities of education. lack of access to education restricts their capacity to learn important information on the hiv prevention, sexual health and the necessity for routine screening. without adequate education, girls and women are less prepared to take an informed decision on their sexual health and more likely to contract hiv.31. cultural and societal norms also contribute to educational disparities. in most societies there are strongly held cultural gender expectations that limit the roles and prospects of women and girls. for instance, in certain cultures it's socially normalised that girls may get married at an early age or are expected to run a household instead of going to school. these gendered stereotypes constrict girls' learning and diminish their capacity to advance safer sexual behaviours or to access hiv prevention services. gender-based violence, including child and forced marriage, continues to play a sizable part in preventing girls from going to school, and increasing their risk of infection with hiv and other sex related health risks.32 road and geographic barriers also provide significant barriers to accessing school, including in rural or remote areas. in many developing countries, schools are situated at a geographically remote distance from girls' residence, and transportation costs or safety risk may keep girl from school. further, inadequate schools with respect to provision of safe clean water, sanitation, and gender separate toilet facilities, frequently prevent girls from attending school or make them discontinue school. emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):45-49 [48] ajdhs.com schools without well-qualified teachers or with limited facilities may not be able to achieve quality education and thereby constrain the opportunity for the girls to acquire knowledge to enable them to defend themselves against hiv.33. additionally, health-related difficulties are to other sequelae of the victimization and can affect girls' and women's access to education. adolescent girls, especially, experience specific health problems, such as menstrual health and sexual health, which can disrupt their schooling. in certain areas girls might stay away from school during menstruation as a consequence of stigma or the limited availability of hygiene supplies, and subsequently prolonged periods of absence that, in the end, result in leaving school. hiv-infected girls may experience discrimination and stigma, each of which could exacerbate their marginalization from educational opportunities. furthermore, the absence of a comprehensive sexual and reproductive health education programme in schools contributes to this problem by failing to equip girls with life-saving knowledge about hiv prevention and self-care.30 political disarray, conflict and displacement also compromise access to education. in areas of conflict or civil unrest, the education system is typically among the first to break down, with girls and women particularly exposed to exploitation, violence and hiv. for example, refugee girls are likely to encounter, amongst others, a number of barriers to education such as lack of resources, displacement and insecurity. in these environments, girls are particularly vulnerable to early marriage, sexual violence, and trafficking which all carry a risk of hiv infection,31 of which the consequences of these challenges are further worsened by the absence of holistic policymaking aimed at promoting gender equality in the educational sphere. although international agencies and governments have been able to provide a platform by advocating gender-inclusive education for others, many countries do not have any policies governing explicitly the barriers that are preventing girls and women from accessing education. beyond providing girls with a right to education, policy measures should also encompass provisions for safe schools, access to health facilities and programs that counter negative attitudes towards gender roles.33. efforts to ensure that girls and women have access to education will need to go hand in hand with involvement of the local community and awareness campaigns that work to change attitudes, rather than destigmatize, and ensure that education is considered for all children, irrespective of their gender. public awareness campaigns are one way of changing societal perspectives and encouraging families to commit to girls' education, thereby indirectly leading to better health outcomes (e.g., decreased hiv risk).32 there is a need for action involving a multi-pronged strategy involving government, local communities, nongovernmental organizations and international partners. the goal of equitable educational opportunity for girls and women is neither just an issue of human rights, although it is certainly such, but also a core part of the overall strategy for human rights initiative to decrease hiv transmission rates as well as provide women the empowerment they need to control their own health.33. conclusion education has an influence on lowering hiv risk for girls and women. it gives children tools to make smart choices and tackle gender unfairness by teaching them about sex health, hiv prevention, and their rights. but many things stop girls and women from going to school in poor areas. these include money problems cultural beliefs social issues, and lack of schools. to cut hiv risk and create a fairer healthier world for women and girls, we need to fix these problems. to solve this, we must change laws, get communities involved, and build more schools so girls and women can learn just like boys and men. schools also need to teach about sex and health to help young people avoid hiv and other sex diseases. to give girls more chances at lower cost, we must stop gender violence and unfair treatment. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):45-49 [49] ajdhs.com journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):20-24 [20] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited assessing anemia in pregnant women: the usefulness of the mentzer index emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 08 nov 2024 reviewed 20 dec 2024 accepted 15 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, assessing anemia in pregnant women: the usefulness of the mentzer inde, asian journal of dental and health sciences. 2025; 5(1):20-24 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.114 abstract _________________________________________________________________________________________________________________ anemia during pregnancy is a prevalent concern, with iron deficiency anemia (ida) and thalassemia trait (tt) being two common causes. differentiating between these conditions is crucial for effective management, as ida requires iron supplementation, while tt does not. the mentzer index (mi) is a simple, cost-effective tool used to distinguish between ida and tt by analyzing the mean corpuscular volume (mcv) and red blood cell (rbc) count. this review explores the usefulness of the mentzer index in assessing anemia in pregnant women, its clinical applications, benefits, and limitations in practice. the mentzer index provides a quick and efficient means of diagnosing anemia types by calculating the ratio of mcv to rbc. a value below 13 typically suggests thalassemia trait, while a higher value points to iron deficiency anemia. in pregnancy, where anemia is common due to increased iron demands, the mentzer index serves as an essential tool to guide treatment decisions. by helping clinicians avoid unnecessary iron supplementation in women with thalassemia, it reduces the risk of complications such as iron overload, thereby improving patient outcomes. keywords: anemia, pregnant women, mentzer index, iron deficiency, thalassemia *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia during pregnancy is a widespread condition that affects millions of women worldwide, with a significant impact on maternal and fetal health. it is particularly prevalent in lowand middle-income countries, where nutritional deficiencies, especially iron deficiency, are more common. anemia in pregnancy has been linked to a variety of adverse outcomes, including preterm birth, low birth weight, maternal fatigue, and in severe cases, maternal mortality. the most common cause of anemia in pregnancy is iron deficiency anemia (ida), but other conditions such as thalassemia trait (tt) can also lead to similar symptoms, making the diagnosis of anemia more complex. accurate identification of the underlying cause is crucial for providing appropriate treatment and preventing complications.1-2 iron deficiency anemia and thalassemia trait are both types of microcytic anemia, which means they are characterized by smaller-thannormal red blood cells (rbcs). however, the causes of these conditions are vastly different. ida is caused by a deficiency of iron, which is necessary for hemoglobin production, leading to reduced oxygen-carrying capacity in the blood. on the other hand, thalassemia is a genetic disorder that affects hemoglobin production, leading to the production of abnormal hemoglobin chains. while both conditions present with low hemoglobin levels and microcytosis, the treatment strategies are entirely different. iron supplementation is effective for ida, but it is contraindicated in thalassemia, as it can lead to iron overload and associated complications such as organ damage.3-4 the challenge in differentiating between ida and thalassemia is compounded during pregnancy, a time when physiological changes can influence laboratory results. for instance, pregnancy-induced changes in blood volume and red blood cell mass can lead to a dilutional effect, making it difficult to interpret routine blood tests. additionally, some women may present with mixed anemia, such as a combination of iron deficiency and thalassemia trait, further complicating diagnosis and treatment. therefore, accurate and reliable diagnostic tools are needed to distinguish between the different types of anemia and guide appropriate treatment.5 one such tool is the mentzer index (mi), which provides a quick and effective method for distinguishing between ida and thalassemia trait. the mentzer index is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count. a lower mi value (typically below 13) suggests thalassemia trait, while a higher value indicates iron deficiency anemia. this simple formula is easy to calculate from routine blood tests, making it an accessible and cost-effective tool for healthcare providers, especially in resource-limited settings. the mentzer index has gained recognition in clinical practice for its ability to quickly differentiate between these two common causes of anemia.6 the use of the mentzer open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.114 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.114&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):20-24 [21] ajdhs.com index in pregnant women is particularly valuable, as early identification of anemia type can lead to more targeted treatment. in cases of iron deficiency anemia, iron supplementation can be prescribed to address the deficiency and improve maternal and fetal health outcomes. conversely, in women with thalassemia trait, unnecessary iron supplementation can be avoided, preventing the risk of iron overload and its associated complications. furthermore, by providing a rapid assessment of anemia type, the mentzer index can guide further diagnostic testing, such as hemoglobin electrophoresis or serum ferritin levels, which may be required to confirm the diagnosis.7-8 the mentzer index: calculation and interpretation the mentzer index (mi) is a diagnostic tool used to differentiate between two common causes of microcytic anemia: iron deficiency anemia (ida) and thalassemia trait (tt). the mcv is a measure of the average size of red blood cells, and the rbc count is the total number of red blood cells in a given volume of blood. these values are typically obtained from a standard complete blood count (cbc), which is one of the most commonly ordered laboratory tests in clinical practice. the mentzer index provides an efficient and cost-effective method for distinguishing between ida and tt, as these two conditions have different underlying causes and require different management strategies.9-10 interpretation of the mentzer index is based on the following general guidelines: • mentzer index < 13: a lower mi value suggests thalassemia trait. in tt, the rbc count is usually normal or elevated, while the mcv is low due to the presence of abnormal hemoglobin. as a result, the mi value falls below the threshold of 13, indicating the need for further investigation, such as hemoglobin electrophoresis, to confirm the presence of thalassemia.11 • mentzer index > 13: a higher mi value suggests iron deficiency anemia. in ida, the mcv is low due to insufficient iron, which is necessary for hemoglobin synthesis. however, the rbc count may be low due to a decrease in overall red blood cell production. therefore, a higher mi value points to iron deficiency, prompting the initiation of iron supplementation and further investigation into iron stores (e.g., serum ferritin levels).12 • mentzer index between 13 and 15: in some cases, the mi value falls within a gray zone between these two conditions, particularly in cases of mixed anemia, such as the presence of both iron deficiency and thalassemia trait. in these situations, additional diagnostic tests, such as serum ferritin levels or hemoglobin electrophoresis, are recommended to obtain a definitive diagnosis.13 application of the mentzer index in pregnancy the application of the mentzer index in pregnancy plays a crucial role in the timely and accurate differentiation between iron deficiency anemia (ida) and thalassemia trait (tt), two common causes of microcytic anemia that can occur during pregnancy. pregnant women are particularly susceptible to anemia due to increased iron demands, blood volume expansion, and the physiological changes that occur throughout pregnancy. as anemia can negatively impact both maternal and fetal health, accurate diagnosis is essential for appropriate management. the mentzer index, a simple and cost-effective diagnostic tool, assists clinicians in identifying the underlying cause of anemia by analyzing the mean corpuscular volume (mcv) and red blood cell (rbc) count from routine blood tests.14-15 pregnancy increases the body's iron requirements due to the expansion of maternal blood volume, fetal iron demands, and placental growth. as a result, iron deficiency anemia is particularly common during pregnancy, especially in women with poor dietary intake, excessive blood loss, or preexisting conditions that impair iron absorption. the mentzer index can help differentiate ida from thalassemia trait, which is also characterized by microcytosis but has a different pathophysiology. thalassemia, a genetic disorder that leads to abnormal hemoglobin production, often presents with low mcv values, similar to ida. however, in contrast to ida, women with thalassemia trait generally do not require iron supplementation, and unnecessary iron therapy can lead to complications, such as iron overload. the mentzer index provides a rapid and simple method to help distinguish these two conditions, guiding clinicians in their treatment decisions.16 the clinical utility of the mentzer index in pregnancy is particularly important in reducing the risk of misdiagnosis and unnecessary treatments. in cases where the mentzer index suggests iron deficiency anemia (mi > 13), iron supplementation is typically initiated to address the deficiency and support both maternal and fetal health. however, when the mi is low (mi < 13), indicating thalassemia trait, iron supplementation is avoided, preventing the risk of iron overload, which could lead to complications such as organ damage. furthermore, the mentzer index serves as an effective screening tool in resource-limited settings, where more expensive diagnostic tests such as hemoglobin electrophoresis may not be readily available. it offers a quick, accessible, and reliable means to guide further diagnostic testing, ensuring accurate management of anemia in pregnant women.17 benefits of the mentzer index in clinical practice the mentzer index (mi) offers several benefits in clinical practice, especially in the diagnosis and management of anemia, particularly in differentiating between iron deficiency anemia (ida) and thalassemia trait (tt). its advantages lie in its simplicity, costeffectiveness, and ability to provide rapid insights, making it an invaluable tool for healthcare providers, especially in resource-limited settings.18 1. simplicity and quick calculation: one of the primary benefits of the mentzer index is its simplicity. it is calculated using two standard emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):20-24 [22] ajdhs.com laboratory values: the mean corpuscular volume (mcv) and red blood cell (rbc) count, both of which are routinely measured in a complete blood count (cbc).19 2. cost-effective: the mentzer index is a low-cost diagnostic tool, particularly beneficial in lowresource or underserved settings where more expensive tests, such as hemoglobin electrophoresis, may not be available. by relying on routine cbc results, the mi allows for the initial screening of anemia types without the need for specialized equipment or procedures, making it an affordable and accessible option for healthcare facilities in both developed and developing regions.20 3. differentiation between iron deficiency and thalassemia: the mentzer index excels at distinguishing between two common causes of microcytic anemia—iron deficiency anemia (ida) and thalassemia trait (tt). this differentiation is crucial because the management of these two conditions is markedly different. iron deficiency anemia requires iron supplementation, while thalassemia trait does not. by providing a simple and rapid means of distinguishing between these two conditions, the mentzer index helps clinicians avoid the risk of misdiagnosis and unnecessary treatments, such as iron supplementation in patients with thalassemia trait.21 4. guiding further diagnostic testing: while the mentzer index is useful for initial screening, it also serves as a guide for more comprehensive diagnostic investigations. if the mi suggests thalassemia trait (mi < 13), further testing, such as hemoglobin electrophoresis, can confirm the diagnosis. similarly, if the mi is high (mi > 13), indicating iron deficiency anemia, the next step would typically involve measuring serum ferritin levels to assess iron stores and confirm the diagnosis. this stepwise approach reduces the likelihood of misdiagnosis and ensures that patients receive the appropriate interventions.22 5. improved patient management: the rapid results from the mentzer index enable timely and appropriate treatment, enhancing patient outcomes. for example, if iron deficiency anemia is suspected, prompt iron supplementation can be initiated to prevent complications such as maternal fatigue, low birth weight, and preterm birth. on the other hand, in cases of thalassemia trait, unnecessary iron supplementation is avoided, which helps prevent iron overload and its associated risks, such as organ damage. the ability to make informed clinical decisions based on the mentzer index helps ensure that patients receive the correct treatment for their specific condition.23 6. universal applicability in various settings: the mentzer index is versatile and can be applied across diverse patient populations, including pregnant women, children, and adults. it is particularly valuable in high-risk groups, such as pregnant women, where anemia is common and distinguishing between iron deficiency and thalassemia is critical for ensuring proper management. additionally, its utility in low-resource settings where access to advanced diagnostic tools is limited further amplifies its significance in improving anemia diagnosis and management worldwide.24 limitations and challenges of the mentzer index while the mentzer index (mi) is a valuable and widely used diagnostic tool for differentiating between iron deficiency anemia (ida) and thalassemia trait (tt), it is not without limitations and challenges that clinicians must consider when using it in practice. these limitations can affect its reliability and accuracy in certain patient populations or clinical situations, which can lead to misdiagnosis or inappropriate management if not carefully interpreted. 1. reliability in mixed anemia: one of the primary limitations of the mentzer index is its reduced reliability in cases of mixed anemia, where both iron deficiency and thalassemia trait coexist. in such cases, the mcv and rbc count values may not consistently fit the typical patterns seen in pure ida or tt, leading to ambiguous or borderline mi values. this could make it difficult to accurately differentiate between the two conditions. for example, in some patients with coexisting iron deficiency and thalassemia trait, the mi may fall within the "gray zone" (between 13 and 15), requiring further diagnostic tests such as hemoglobin electrophoresis or serum ferritin measurements for clarification.25 2. influence of other causes of microcytosis: the mentzer index is most useful in distinguishing between ida and thalassemia trait in cases of microcytic anemia, but it may not be reliable when anemia is caused by other factors, such as anemia of chronic disease, lead poisoning, or vitamin b12/folate deficiencies. these conditions can also present with low mcv values but have entirely different pathophysiological mechanisms and management strategies. the mi does not account for these other causes of anemia, which can lead to misdiagnosis and inappropriate treatment if clinicians rely solely on the mi for diagnosis.25 3. variation in laboratory measurements: the accuracy of the mentzer index depends on the precision of the laboratory measurements used to calculate the mcv and rbc count. inaccuracies in these values, due to technical factors or differences in laboratory equipment and methods, can affect the validity of the mi calculation. additionally, variations in patient demographics (such as age, sex, or ethnicity) may influence the interpretation of mcv and rbc values, further complicating the mi's diagnostic utility. in clinical settings, especially in resource-limited areas, inconsistencies in laboratory techniques may reduce the reliability of the mi as a diagnostic tool.26 4. limited to microcytic anemia: the mentzer index is specifically designed to evaluate microcytic emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):20-24 [23] ajdhs.com anemia, where the red blood cells are smaller than normal. it is not applicable for diagnosing macrocytic or normocytic anemias, which can be caused by a variety of other factors, such as vitamin deficiencies, chronic disease, or bone marrow disorders. this limitation means that while the mi is valuable for differentiating between ida and tt, it does not address other causes of anemia and should not be used as a sole diagnostic tool in broader anemia evaluations.27 5. inadequate for severe thalassemia or anemia of chronic disease: in patients with severe thalassemia or anemia of chronic disease, the mi may not provide a clear distinction between these conditions and ida. severe thalassemia can present with low mcv values but may not follow the typical pattern that the mentzer index is designed to identify. similarly, anemia of chronic disease often presents with normocytic or microcytic anemia, but the mi may not be sensitive enough to differentiate this from iron deficiency anemia or thalassemia trait. in such cases, more specific tests, such as serum iron studies, ferritin levels, or hemoglobin electrophoresis, are necessary for an accurate diagnosis.27 6. lack of standardization and consensus: while the mentzer index is widely used, there is no universal agreement on the exact cut-off values for interpretation. some sources suggest that a mi below 13 indicates thalassemia trait, while others may propose different thresholds. this lack of standardization can lead to variations in clinical practice and potential inconsistencies in diagnosis. as a result, healthcare providers should exercise caution when interpreting the mi and consider it as part of a broader diagnostic workup, incorporating clinical findings and additional tests to confirm the diagnosis. conclusion in conclusion, the mentzer index (mi) remains a valuable and cost-effective tool in the diagnosis of microcytic anemia, particularly in differentiating between iron deficiency anemia (ida) and thalassemia trait (tt). its simplicity, ease of calculation, and ability to provide rapid insights make it an attractive option, especially in resource-limited settings where advanced diagnostic tools may not be readily available. the mi offers a quick and accessible means to guide clinical decision-making, potentially reducing unnecessary treatments, such as iron supplementation, and improving patient outcomes. however, despite its advantages, the mentzer index has limitations that must be recognized and addressed. it is less reliable in cases of mixed anemia, where both ida and tt coexist, and it may not be effective in diagnosing other causes of microcytic anemia, such as anemia of chronic disease or lead poisoning. additionally, variations in laboratory techniques and patient demographics can affect the accuracy of mi calculations, leading to potential misdiagnosis. thus, while the mi serves as a helpful screening tool, it should not be used in isolation but rather as part of a comprehensive diagnostic approach that includes further confirmatory tests such as hemoglobin electrophoresis or serum ferritin measurements. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):20-24 [24] ajdhs.com 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [11] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited exploring the efficacy of natural biomaterials in endodontics dr elizabeth thomas *1, dr h murali rao 2 , dr b s keshava prasad 3 , dr. suman c 4 1 post graduates, mds, department of conservative dentistry and endodontics, dapm rv dental college, 1st phase, j. p. nagar, bengaluru, karnataka 560078 2 mds, professor, department of conservative dentistry and endodontics, dapm rv dental college, 1st phase, j. p. nagar, bengaluru, karnataka 560078 3 professor and head of the department, department of conservative dentistry and endodontics, dapm rv dental college, 1st phase, j. p. nagar, bengaluru, karnataka 560078 4 lecturer, department of conservative dentistry and endodontics, dapm rv dental college, 1st phase, j. p. nagar, bengaluru, karnataka 560078 article info: _____________________________________________ article history: received 11 june 2024 reviewed 08 july 2024 accepted 26 july 2024 published 15 september 2024 _____________________________________________ cite this article as: thomas e, rao hm, keshava prasad bs, suman c, exploring the efficacy of natural biomaterials in endodontics, asian journal of dental and health sciences. 2024; 4(3):11-16 doi: http://dx.doi.org/10.22270/ajdhs.v4i3.88 abstract _________________________________________________________________________________________________________________ endodontic therapy aims for thorough disinfection and three-dimensional filling of the root canal system, a goal often challenged by the complexity of root canal morphology. traditional chemical irrigants and intracanal medicaments, such as sodium hypochlorite (naocl) and calcium hydroxide (caoh2), are effective but can be cytotoxic and cause detrimental effects on periapical tissues and radicular dentin. increasing antibiotic resistance and the adverse effects of synthetic agents have spurred interest in natural phytochemicals as alternatives. these phytochemicals exhibit promising antimicrobial, anti-inflammatory, and chelating properties, making them viable candidates for root canal irrigation, intracanal medicaments, and smear layer removal. the agents reviewed include terminalia chebula [triphala], camellia sinensis [green tea] , curcuma longa [turmeric], glycyrrhiza glabra [liquorice], propolis, melaleuca alternifolia [tea tree oil], azadirachta indica [neem] etc. these biomaterials have been studied in various combinations and against a variety of common intraoral bacteria like enterococcus faecalis. however, most of the conducted researches are in-vitro studies such as agar diffusion test. despite their potential, there is a need for further comprehensive clinical and experimental studies to fully evaluate their biocompatibility, safety, and effectiveness compared to conventional treatments. this review aims to underscores the necessity of rigorous research and standardization protocols to confidently employ herbal extracts in endodontic practice. keywords: endodntic irrigants, herbal irrigants, intracanal medicaments, antibacterial, glycyrrhiza glabra, azadirachta indica, aloe vera *address for correspondence: dr elizabeth thomas, dapm rv dental college, 1st phase, j. p. nagar, bengaluru, karnataka 560078 introduction the paramount goal of endodontic therapy is the thorough disinfection and three-dimensional filling of the root canal system. the conjoint utilization of mechanical instrumentation, copious use of various irrigants and intracanal medicaments are important for the highest possible disinfection of root canals. however, the complexity of the root canal morphology poses a great challenge for disinfection till date1. the routinely used chemical irrigants such as sodium hypochlorite (naocl), ethylenediaminetetraacetic acid (edta) etc are documented to be cytotoxic and irritative to periapical tissues on extrusion. certain intracanal medicaments such as calcium hydroxide (caoh2), triple antibiotic paste, can weaken the radicular dentin by collagen breakdown, tooth discoloration, demineralisation of dentin etc2. the escalating resistance of pathogenic bacteria to antibiotics and chemotherapeutic agents has sparked a growing interest among researchers in exploring alternative products and treatment modalities for oral diseases2. consequently, natural chemicals derived from plants and animals employed in traditional medicine are being considered as viable substitutes for synthetic chemicals. while herbs may offer a promising alternative to conventional treatments for oral health issues, there remains a research gap regarding their impact on oral tissues, mechanisms of action, and potential side effects. thus, further research is warranted to investigate the efficacy of these traditional medicines3. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i3.88 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i3.88&amp;domain=pdf https://orcid.org/0000-0001-6310-6425 https://orcid.org/0000-0002-7411-6714 https://orcid.org/0009-0001-2966-6848 thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [12] ajdhs.com classification the traditional medicines can be classified as3 :(fig1) • smear layer removalnoni juice, citrus and carbonic acid juice ‚ matricaria recutita extract, morinda citrifolia juice, chitosan, green tea and neem leaf extract • intracanal medicaments-propolis, aloe vera, glycyrrhiza glabra (liquorice) • root canal sealer adjunctspropolis and green tea, liquorice, bakul and guguchi, cinnamon oil, moringa root • gutta percha dissolvants-eucalyptus oil, tea tree oil, castor oil, peppermint oil and wintergreen oil, clove oil • storage media-propolis, green tea extract, coconut water, morus rubra, aloe vera • pulp repairgreen tea polyphenols, acemannan, baicalin, propolis3 kale and raut’s proposed classification of herbal endodontic irrigants4 based on properties(fig.2) 1. herbal root canal irrigants with antimicrobial property 2. herbal root canal irrigants with chelating ability 3. herbal root canal irrigants with both antimicrobial property and chelating ability 4. herbal root canal irrigants with pulp tissue dissolution 4 thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [13] ajdhs.com some herbal extracts used in endodontics green tea (camellia sinensis) green tea, found commonly in semitropical environment of southeast asian platations,is derived from camellia sinensis leaves. the catechins and the flavins are the microbiologically active ingredients in green tea. phenolic acids such as chlorogenic acid, caffeic acid and flavonoids such as myricetin, kaempferol and quercetin are present in green tea. it also contains gallic acid as a major component5. tea polyphenol galloylated catechins, particularly epigallocatechin-3-gallate (egcg), have demonstrated remarkable antimicrobial and anti-cariogenic properties. studies have shown that egcg can effectively disrupt grampositive and gram-negative bacterial membranes. additionally, it can inhibit bacterial dna gyrase by binding to the adenosine triphosphate b subunit, thus preventing dna supercoiling and ultimately leading to the demise of bacterial cells. 5,6. catechins have been discovered to act as an inhibitor against streptococcus mutans and streptococcus sobrinus at a minimum inhibitory concentration. the fluoride present in green tea may also play a role in enhancing the cariostatic action along with other tea components5. extensive research has focused on the potential uses of green tea extract in restorative and endodontic dentistry. studies have yielded promising findings, suggesting that green tea extract can effectively serve as a storage medium to minimize infections after tooth replantation. it can preserve pdl cell viability, and reduce root resorption and ankylosis. the study found that 90 percent cell viability was maintained for up to 24 hours3. however, comparative studies have also revealed limitations of green tea extract, particularly in its antimicrobial activity when compared to other agents such as propolis, triphala, and orange oil. divia et al, found that green tea extract showed a greater reduction of e. faecalis colonies compared to triphala and morinda. furthermore, sebatni et al's research in 2017 indicated that green tea extract exhibited relatively lower efficacy in removing smear layer compared to neem leaf extract, orange peel extracts, and sodium hypochlorite (naocl)7. these findings suggest that while green tea extract holds promise in certain applications, further research and comparative studies are necessary to fully understand its potential benefits and limitations in restorative and endodontic dentistry. neem (azadirachta indica) neem is widely recognized as a potent therapeutic herb in naturopathy due to its strong antioxidant and antibacterial properties, making it a highly effective alternative to sodium hypochlorite for root canal irrigation.8. the active compounds in neem, such as nimbidin, azadirachtin, and nimbinin, are responsible for its antibacterial properties9. the aqueous extract of neem stick and the gallotannin-enriched extract from melaphis chinensis hinder the synthesis of insoluble glucans, leading to bacterial aggregation, and reducing the capacity of streptococci to colonize enamel surfaces. both aqueous and ethanolic extracts of neem leaf inhibit s. mutans and e. faecalis. according to literature, neem leaf extract has significant antimicrobial activity against e. faecalis derived from inflamed root canal samples, demonstrating efficacy compared to 2% sodium hypochlorite10. the established biocompatibility of neem supports its application as an intracanal irrigant in endodontics. however, the inherent bitter taste attributed to nimbidin presents an undesirable attribute. this limitation can be addressed by integrating sweeteners into the neem extract. aloe vera (aloe barbadensis) aloe vera extract is known for its potent antibacterial, antifungal, and anti-inflammatory properties. the active constituents of the gel, aloin, and aloe-emodin, contribute to its therapeutic effects9.widely used in endodontics, aloe vera serves as both a medicament and an irrigant due to its effectiveness against s. pyogenes and e. faecalis, attributed to the presence of anthraquinone which inhibits the formation of these organisms11. in a 2015 study conducted by swati et al, compared the antimicrobial activity of hydroalcoholic extract of aloe vera, garlic, and 5% naocl against e. faecalis. the results showed that the saturated hydroalcoholic extract of aloe vera exhibited the highest zone of inhibition against e. faecalis12. the ability of aloe vera to inhibit the cox pathway and reduce prostaglandin e2 production makes it a robust antiinflammatory agent. notably, aloe vera has been recognized for its ability to penetrate deeper layers of the epidermis when applied topically10.another study by seth et al. in 2016 indicated that compared to tea tree oil and naocl ,aloe vera demonstrated the highest zone of inhibition against e. faecalis thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [14] ajdhs.com 7. additionally, aloe vera exhibits wide spectrum of antibacterial activity compared to other natural extracts, against various oral pathogens13. triphala (terminalia chebula) triphala, a herbal blend originating from india, consists of dried and powdered fruits from three medicinal plants. terminalia bellerica, terminalia chebula, and emblica officinalis. it is found to be safe and contains active components such as gallic acid and tannic acid that provide beneficial physiological effects beyond its healing properties, including antioxidant, antiinflammatory, and radical scavenging activities14. triphala acts by inhibiting the cell division or by causing damage to the cell walls of the bacterium7. triphala has excellent antimicrobial action towards gram positive and gram negative micro organism particularly staphylococcus aureus, staphylococcus epidermidis, bacillus subtilis, escherichia coli and pseudomonas aeruginosa. this is due to presence of various chemical parts like flavonoids, terpenes and alkaloids. triphala demonstrates remarkable bacteriostatic and bactericidal activities at an exceptionally low concentration of 50 μg/ml. moreover, a 5% solution of triphala exhibits an inhibition of approximately 83% against streptococcus mutans10,15. chitosan chitosan, a biopolymer resulting from the partial deacetylation of chitin sourced from crustacean exoskeletons, serves as an efficacious drug carrier, facilitating a gradual and controlled release of intracanal medicament. it also exhibits bio-adhesive properties and minimal toxicity16. chitosan as a vehicle can enhance the antibacterial properties of an intracanal medicament. it has been linked to antibacterial effects on streptococcus mutans, actinomyces actinomycetemcomitans, and porphyromonas gingivalis17. chitosan has a broad spectrum of antibacterial properties, high chelating ability in acidic conditions, biocompatibility, and biodegradability. studies have demonstrated that chitosan-based scaffolds promote pulp regeneration and dentin formation by inducing mineralization. chitosan-based scaffolds contain tricalcium phosphate that promotes high expression of mineralization markers, such as osteopontin and alkaline phosphatase, and dentin formation by human periodontal ligament cells (hplcs)16. turmeric[curcuma longa] turmeric plays a significant role as a spice, food preservative, and coloring agent in the culinary traditions of india, china, and southeast asia. it has a rich traditional medicinal history for addressing various health concerns. curcumin, the primary yellow bioactive compound in turmeric, has demonstrated a diverse array of biological effects, including antimicrobial, antiinflammatory, and antioxidant properties. numerous studies have established strong connections between these activities and curcumin, laying a solid foundation for exploring its potential applications in endodontics14. the antimicrobial properties of turmeric stem from curcumin's ability to disrupt the assembly of a proteinfilamenting temperature-sensitive mutant z (ftsz) profilaments and enhance the gtpase activity of ftsz, which are harmful to bacteria. when used as an irrigating solution, turmeric prevents the formation of biofilms by eliminating the extracellular polymeric substance matrix, which serves as a source of nutrients for further bacterial growth11. in 2013, neelakantan et al. examined the antimicrobial effectiveness of curcumin against enterococcus faecalis biofilm formed on tooth substrate in vitro, comparing it to chlorhexidine and sodium hypochlorite18. the findings revealed that sodium hypochlorite displayed the highest antibacterial activity, followed by curcumin and chx9. a recent report indicated that aqueous preparations of curcumin exhibit a phototoxic effect against both gram-positive and gram-negative bacteria. this discovery paves the way for further research into the use of turmeric in the photodynamic therapy of root canal systems14. tea tree oil (melaleuca alternifolia) tea tree, an indigenous australian plant, produces oil with notable antiseptic and antifungal properties, along with a mild solvent action, rendering it a promising candidate for implementation in dental care. moreover, its principal active constituent, terpinen-4-ol, typically accounting for 30-40% of the oil, suggests potential utility in dissolving necrotic pulp tissue, particularly in the context of root canal treatment14. based on a study by seth et al, tea tree oil exhibited a higher zone of inhibition against c. albicans compared to aloe vera and naocl. however, it had a lower zone of inhibition against e. faecalis compared to aloe vera and naocl. in addition, it showed a higher zone of inhibition against a mixed culture compared to aloe vera, but lower than naocl7. clove (syzygium aromaticum) both indian and chinese traditional medicine have historically utilized clove flowers and oil to address a variety of health issues. it is an evergreen plant with strong phenolic smell and pungant taste19. active constituents are acetyl eugenol, betacaryophylle, vanillin, crategolic acid, and tannins7. it destroys the integrity and reduces biofilm quality, disrupts the bacterial membrane, cause cytoplasm leakage, and form vesicles on the surface of cytoplasmic membrane19. in their study, madhavan et al. investigated the potential of clove oil to amplify the antibacterial efficacy of intracanal medicaments. the findings reveal that when combined with other intracanal medicaments such as triple antibiotic paste and calcium hydroxide, clove oil exhibits enhanced antibacterial activity against e. faecalis7. propolis propolis is a resinous material collected by honeybees from various plant species and blended with wax and other substances. scientific research has revealed its antioxidant, antibacterial, anti-fungal, antiviral, anti-inflammatory, antitumor, and immunomodulating properties. current research involving propolis in dentistry spans many fields and highlights its antimicrobial and anti-inflammatory activities, particularly in cariology, oral surgery, pathology, periodontics, and endodontics14. propolis is known for its antimicrobial properties, which are attributed to flavonoids and esters of caffeine. additionally, it contains an unidentified, water-soluble component that absorbs ultraviolet light and hinders bacterial dna-dependent rna polymerases20. liquorice( glycyrrhiza glabra) liquorice has been traditionally used in chinese medicine, owing to its anti-inflammatory, anticarcinogenic and antiviral properties. the sweet taste of liquorice root is due to glycyrrhizin, a triterpenoid compound9. this compound is a mix of potassium-calcium magnesium salts of glycyrrhizic acid and can range from 2–25%. within natural saponins, glycyrrhizic acid is characterized by a hydrophilic segment consisting of two molecules of glucuronic acid and a hydrophobic fragment known as glycyrrhetic acid. the antimicrobial effect of liquorice extract against e. faecalis, may be related to the glycyrrhizin. the mode of action of antibacterial effects of saponins seems to involve membranolytic properties .it has thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [15] ajdhs.com been studied for its action against s.mutans3. studies have demonstrated marked inhibition of adherence and growth of streptococcus mutans in plaque. liquorice has demonstrated higher biocompatibility with fibroblast cells in comparison to calcium hydroxide, which caused severe toxicity to the cells14. shikakai (acacia concinna) shikakai, a thorny plant prevalent in central and south india, has been traditionally utilized for hair care and as an oral rinse for addressing halitosis, dental caries, mouth ulcers, and gum bleeding. the methanol extract of the plant's bark has exhibited antibacterial activity against staphylococcus aureus, grampositive bacteria such as streptococcus mutans, lactobacillus casei, and lactobacillus acidophilus. active constituents encompass alkaloids, flavonoids, phytosterols, saponins, phenolic compounds, and tannins.23 a recent study conducted by aravind et al. aimed to assess the cytotoxicity of shikakai on periodontal cells in comparison to sodium hypochlorite. the research findings indicated that the extract derived from acacia concinna demonstrated increased cell viability with periodontal cells when contrasted with sodium hypochlorite at both 1-hour and 24-hour intervals24. thus far, there has been limited research investigating the properties of shikakai concerning its potential application in dentistry. other applications one of the crucial requirements for an intra-canal medication is its stability and sustained release over an extended period. according to digole vr et al , aloe vera does not exhibit significant activity against enterococcus faecalis compared to synthetic alternatives. this could be due to its inferior molecule binding ability to e. faecalis and inferior potential to alter its membrane permeability and structural integrity to thus reduce its resistance. according to patri et al, propolis and curcumin showed considerable antibacterial property, but not as much as triple antibiotic paste17. a study compared the smear removal and antibacterial properties of chitosan nanoparticles (cnps) to sodium hypochlorite(naocl) and ethylenediaminetetraacetic acid (edta) which demonstrated that irrigation with cnp effectively removes the smear layer and inorganic contents from the dentin. additionally, cnp demonstrates significantly greater resistance to biofilm formation compared to naocl and edta, while exhibiting a chelating effect similar to that of edta. a major drawback of edta is related to its dentin demineralization, unlike which chitosan showed remineralization capacity as well as resistance to bacterial adherence. these findings advocate the use of cnps as a substitute for edta as a final root canal irrigant16. numerous studies have demonstrated that extracts of morinda citrifolia, german chamomile, propolis, tea tree, triphala etc possess the capability to effectively eliminate the smear layer. 6% concentration of morinda citrifolia (mc) has shown effective antimicrobial activity when used as an intracanal medicament as well as smear layer removal. a majority of studies suggest that azadirachta indica (ai) is the most effective against e. faecalis, followed by propolis, then morinda citrifolia (mc). there are contradictory results regarding the effect of aloe vera on e. faecalis9,21. this could be due to the variation in isolation techniques as well as differences in chemical composition of aloe vera pulp acquired from different geographical sites21. the literature search shows that most of the studies conducted on the efficacy of herbal extracts are in vitro antimicrobial studies. it is important to determine the cytotoxicity of these agents for its effective use in clinical scenarios. employment of these natural biomaterials in root canal disinfection requires more clinical trials, in-vivo studies, biocompatibility tests etc22. conclusion the study of herbal extracts for root canal disinfection has created new avenues for promising research. when used with proper knowledge, herbal extracts are generally safe; however, caution is warranted as their misuse can lead to adverse effects. while preliminary findings from laboratory studies suggest potential, it is crucial to prioritize comprehensive clinical, longitudinal, preclinical, and experimental studies to assess the biocompatibility and safety of herbal products before confidently endorsing their implementation in root canal disinfection. notably, herbal extracts represent a valuable prospect for root canal disinfection, serving as effective irrigants, intra-canal medicaments, and agents for removing the smear layer3,14,21. conflict of interest no potential conflict of interest relevant to this article was reported. references 1. use of natural substitutes as an intracanal medicament in the endodontics-an update for in vivo studies. indian j nat prod resour. published online 2020. https://doi.org/10.56042/ijnpr.v11i3.31613 2. babaji p, jagtap k, lau h, bansal n, thajuraj s, sondhi p. comparative evaluation of antimicrobial effect of herbal root canal irrigants (morinda citrifolia, azadirachta indica, aloe vera) with sodium hypochlorite: an: in vitro: study. journal of international society of preventive and community dentistry. 2016;6(3):196. https://doi.org/10.4103/2231-0762.183104 pmid:27382533 pmcid:pmc4916791 3. karobari mi, adil ah, assiry aa, et al. herbal medications in endodontics and its application-a review of literature. materials. 2022;15(9):3111. https://doi.org/10.3390/ma15093111 pmid:35591443 pmcid:pmc9101381 4. kale pp, raut aw. a proposed classification system for herbal endodontic irrigants. journal of conservative dentistry and endodontics. 2021;24(3):293. https://doi.org/10.4103/jcd.jcd_75_21 pmid:35035157 pmcid:pmc8717852 5. chandak m, nikhade p, chandak r, et al. herbal sealers in endodontics-a systematic review. int j res pharm sci. 2020;11:1278-1285. https://www.researchgate.net/profile/pradnyanikhade/publication/349892846_herbal_sealers_in_endodontics __a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herba l-sealers-in-endodontics-a-systematic-review.pdf https://doi.org/10.26452/ijrps.v11ispl4.4289 6. araghizadeh a, kohanteb j, fani mm. inhibitory activity of green tea (camellia sinensis) extract on some clinically isolated cariogenic and periodontopathic bacteria. medical principles and practice. 2013;22(4):368-372. https://doi.org/10.1159/000348299 pmid:23485656 pmcid:pmc5586764 7. gaidhane h. stretching new boundaries of endodontics with phytotherapy: a review of literature. university journal of dental sciences. 2022;8(4). https://doi.org/10.21276//ujds.2022.8.4.23 8. sabitha m, krishnaveni k, murugan m, basha an, pallan ga, kandeepan c, ramya s, jayakumararaj r. in-silico admet predicated pharmacoinformatics of quercetin-3-galactoside, polyphenolic compound from azadirachta indica, a sacred tree from hill temple in alagarkovil reserve forest, eastern ghats, india. journal of drug delivery and therapeutics. 2021;11(5s):77-84. https://doi.org/10.22270/jddt.v11i5-s.5026 https://doi.org/10.56042/ijnpr.v11i3.31613 https://doi.org/10.4103/2231-0762.183104 https://doi.org/10.3390/ma15093111 https://doi.org/10.4103/jcd.jcd_75_21 https://www.researchgate.net/profile/pradnya-nikhade/publication/349892846_herbal_sealers_in_endodontics_-_a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herbal-sealers-in-endodontics-a-systematic-review.pdf https://www.researchgate.net/profile/pradnya-nikhade/publication/349892846_herbal_sealers_in_endodontics_-_a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herbal-sealers-in-endodontics-a-systematic-review.pdf https://www.researchgate.net/profile/pradnya-nikhade/publication/349892846_herbal_sealers_in_endodontics_-_a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herbal-sealers-in-endodontics-a-systematic-review.pdf https://www.researchgate.net/profile/pradnya-nikhade/publication/349892846_herbal_sealers_in_endodontics_-_a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herbal-sealers-in-endodontics-a-systematic-review.pdf https://www.researchgate.net/profile/pradnya-nikhade/publication/349892846_herbal_sealers_in_endodontics_-_a_systematic_review/links/61e2f4dc9a753545e2d1ddef/herbal-sealers-in-endodontics-a-systematic-review.pdf https://doi.org/10.26452/ijrps.v11ispl4.4289 https://doi.org/10.1159/000348299 https://doi.org/10.21276/ujds.2022.8.4.23 https://doi.org/10.22270/jddt.v11i5-s.5026 thomas et al. asian journal of dental and health sciences. 2024; 4(3):11-16 [16] ajdhs.com 9. loganathan t, barathinivas a, soorya c, balamurugan s, nagajothi tg, ramya s, jayakumararaj r, physicochemical, druggable, admet pharmacoinformatics and therapeutic potentials of azadirachtin a prenol lipid (triterpenoid) from seed oil extracts of azadirachta indica a. juss., journal of drug delivery and therapeutics. 2021; 11(5):33-46 https://doi.org/10.22270/jddt.v11i5.4981 10. oak a, attur k, bagda k, mustafa m, kathiria n. herbodontics a descriptive review. national journal of integrated research in medicine. 2022;13(3). 11. s, andamuthu sivakumar vishnuvardhini, ravi v, prasad as, sivakumar js. herbendodontics phytotherapy in endodontics: a review. biomed pharmacol j. 2018;11(2):1073-1082. https://doi.org/10.13005/bpj/1468 12. t a, ramesh s. review of literature on herbal irrigants. annals of the romanian society for cell biology. published online may 13, 2021:15839-15846. http://annalsofrscb.ro/index.php/journal/article/view/5321 13. ghasemi n, behnezhad m, asgharzadeh m, zeinalzadeh e, kafil hs. antibacterial properties of aloe vera on intracanal medicaments against enterococcus faecalis biofilm at different stages of development. international journal of dentistry. 2020;2020:e8855277. https://doi.org/10.1155/2020/8855277 pmid:33488716 pmcid:pmc7803133 14. prasanna neelakantan*, nithya jagannathan, nabeel nazar "ethnopharmacological approach in endodontic treatment: a focused review", int. j. drug dev. & res., oct-dec 2011, 3(4): 6877 https://www.researchgate.net/publication/232715211_ethnoph armacological_approach_in_endodontic_treatment_a_focused_re view 15. kaur k. ayurvedic herbs in endodontics. journal of advanced medical and dental sciences research. 2023;11(12):72-75. accessed may 17, 2024. https://jamdsr.com/uploadfiles/15vol11issue12pp727520231228073014.pdf 16. zhang c, hui d, du c, et al. preparation and application of chitosan biomaterials in dentistry. international journal of biological macromolecules. 2021;167:1198-1210. https://doi.org/10.1016/j.ijbiomac.2020.11.073 pmid:33202273 17. patri g, sheetal k, pradhan pk, agrawal p, lata s. comparative evaluation of the antibacterial efficacy of herbal agents as intracanal medicaments individually or in combination with chitosan: an: in vitro: rtpcr study. journal of international oral health. 2023;15(1):89. https://doi.org/10.4103/jioh.jioh_154_22 18. vanapatla a, nanda n, satyarth s, kawle s, gawande hp, gupte jm. antibacterial efficacy of herbal solutions in disinfecting gutta percha cones against enterococcus faecalis. journal of pharmacy and bioallied sciences. 2022;14(suppl 1):s748. https://doi.org/10.4103/jpbs.jpbs_111_22 pmid:36110725 pmcid:pmc9469315 19. agrawal, m., agrawal, s., rastogi, r., singh, p., br, a., guptah, l., & pradesh, u. (2014). a review on uses of clove in oral and general health.. ijrpb. https://api.semanticscholar.org/corpusid:58710530 20. manoj chandak. role of herbals in endodontics. proteins. 15:20. https://www.saspublishers.com/media/articles/sajb_58566568.pdf 21. gandhi h, dave ds, shah n, pathak a, patel kr, martin p. comparative evaluation of antimicrobial efficacy of herbal v/s synthetic irrigating solutions: an: in vitro: study. international journal of oral care and research. 2021;9(1):8. https://doi.org/10.4103/injo.injo_2_21 22. dos santos dc, da silva barboza a, schneider lr, et al. antimicrobial and physical properties of experimental endodontic sealers containing vegetable extracts. sci rep. 2021;11(1):6450. https://doi.org/10.1038/s41598-021-85609-4 pmid:33742040 pmcid:pmc7979879 23. biswal ar, mirunalini k, jayshree p, pazhamalai v. molecular docking analysis of bioactive compounds of acacia concinna against fungal protein. journal of pharmaceutical sciences and research. 2019 apr 1;11(4):1216-22. 24. arvind b, geeta ib, anaida clara alex. comparative cytotoxic evaluation of acacia concinna and sodium hypochlorite on periodontal ligament cells an invitro study. sas j med, 2024 apr 10(4):262-266. https://doi.org/10.36347/sasjm.2024.v10i04.010 https://doi.org/10.22270/jddt.v11i5.4981 https://doi.org/10.13005/bpj/1468 http://annalsofrscb.ro/index.php/journal/article/view/5321 https://doi.org/10.1155/2020/8855277 https://www.researchgate.net/publication/232715211_ethnopharmacological_approach_in_endodontic_treatment_a_focused_review https://www.researchgate.net/publication/232715211_ethnopharmacological_approach_in_endodontic_treatment_a_focused_review https://www.researchgate.net/publication/232715211_ethnopharmacological_approach_in_endodontic_treatment_a_focused_review https://jamdsr.com/uploadfiles/15vol11issue12pp72-7520231228073014.pdf https://jamdsr.com/uploadfiles/15vol11issue12pp72-7520231228073014.pdf https://doi.org/10.1016/j.ijbiomac.2020.11.073 https://doi.org/10.4103/jioh.jioh_154_22 https://doi.org/10.4103/jpbs.jpbs_111_22 https://api.semanticscholar.org/corpusid:58710530 https://doi.org/10.4103/injo.injo_2_21 https://doi.org/10.1038/s41598-021-85609-4 https://doi.org/10.36347/sasjm.2024.v10i04.010 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):15-19 [15] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited empathy and awareness: shifting perceptions on hiv in underserved communities emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 14 sep 2024 reviewed 27 oct 2024 accepted 21 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, empathy and awareness: shifting perceptions on hiv in underserved communities, asian journal of dental and health sciences. 2024; 4(3):15-19 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.93 abstract _________________________________________________________________________________________________________________ hiv continues to disproportionately affect underserved communities, where stigma, misinformation, and limited healthcare access often hinder effective prevention and treatment. this review explores the role of empathy and awareness in transforming attitudes toward hiv in these communities. empathy-driven interventions, alongside targeted awareness campaigns, can reduce stigma, promote understanding, and encourage individuals to engage in hiv testing and prevention. by humanizing the issue of hiv, these initiatives foster compassion, shift perceptions, and create supportive environments for people living with hiv, ultimately improving health outcomes. the review highlights the importance of culturally sensitive hiv education and the critical role of peerled initiatives in changing community perceptions. peer educators, especially those living with hiv, help break down barriers by offering relatable, nonjudgmental support. these programs empower individuals to take charge of their health and seek hiv-related care without fear of discrimination. through local influencers, such as community leaders and healthcare workers, awareness campaigns can effectively challenge harmful myths and promote accurate information about hiv transmission, prevention, and treatment. keywords: empathy, hiv awareness, underserved communities, stigma reduction, healthcare access *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction the hiv epidemic continues to be a significant global health issue, with underserved communities bearing a disproportionate share of the burden. these communities often face numerous challenges, including poverty, limited access to healthcare, cultural barriers, and stigma, which can exacerbate the spread of the virus and hinder prevention and treatment efforts. the lack of awareness about hiv transmission and prevention, combined with the pervasive social stigma, creates an environment in which individuals are reluctant to seek testing, treatment, or even engage in conversations about the virus. as a result, the virus remains entrenched in these communities, affecting not only those who are living with hiv but also their families and broader social networks.1-2 one of the most effective strategies to shift these harmful perceptions is to foster empathy and increase awareness about hiv. empathy, the ability to understand and share the feelings of others, can create an environment where individuals are more likely to engage in open conversations, seek help, and access necessary healthcare. this approach emphasizes the importance of humanizing hiv, encouraging community members to recognize the shared humanity of people living with the virus, rather than viewing them through a lens of fear or judgment. when empathy is coupled with education, it can dispel myths, reduce misconceptions, and ultimately promote healthier behaviors within the community.3-4 increasing awareness of hiv, particularly in underserved communities, is another essential component of shifting perceptions. while many communities have made significant strides in combating hiv, misinformation and stigma persist, perpetuating fear and misinformation. in these areas, individuals may still associate hiv with high-risk behaviors, moral judgment, or certain groups of people, which can lead to discrimination and further isolate those affected by the virus. educational campaigns that provide accurate, culturally relevant information about hiv transmission, prevention, and treatment can be instrumental in dispelling these myths. by addressing the specific needs and cultural contexts of underserved populations, awareness campaigns can promote healthier, more informed choices.5-6 empathy and awareness initiatives also provide an opportunity to engage community leaders and influencers in the fight against hiv stigma. trusted figures in the community, such as religious leaders, educators, or local healthcare providers, play a critical role in shaping attitudes and behaviors. when open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.93 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.93&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):15-19 [16] ajdhs.com these figures advocate for hiv testing, treatment, and a supportive approach to people living with hiv, they can have a profound impact on the community’s perception of the virus. their endorsement can lend credibility to the message and encourage others to adopt more inclusive and compassionate attitudes. this, in turn, can lead to broader societal changes, such as improved access to hiv-related services and a reduction in the social isolation of people living with hiv.7-8 despite the potential of empathy and awareness initiatives, there are still significant barriers to their implementation in underserved communities. resource constraints, cultural attitudes, and lack of access to healthcare infrastructure can limit the reach and effectiveness of these interventions. in some communities, hiv is still viewed through a lens of fear, discrimination, and misinformation, making it challenging to foster open discussions about the virus. additionally, without adequate support from local governments and healthcare systems, community-based efforts may struggle to gain traction. overcoming these barriers requires long-term investment in education, healthcare access, and the training of community leaders and healthcare providers to ensure that they are equipped to address hiv-related stigma.9-10 the role of empathy in hiv awareness empathy plays a crucial role in changing the way hiv is perceived in underserved communities. it is the ability to understand and share the feelings of others, and when applied to hiv awareness, it humanizes the issue, making it more relatable and less stigmatized. in many underserved communities, hiv is often associated with fear, misinformation, and moral judgment. this can prevent individuals from seeking testing, treatment, or disclosing their hiv status due to the fear of being ostracized. empathy-driven approaches challenge these perceptions by fostering an environment of compassion and support, ultimately encouraging open conversations and reducing the stigma associated with hiv.11-12 one of the most effective ways empathy influences hiv awareness is through peer support and education. peerled programs, where individuals who are living with hiv share their experiences, are often more impactful than traditional educational initiatives because they provide a sense of solidarity. when people see someone who shares their background and experiences talking openly about hiv, they are more likely to feel comfortable discussing their own concerns and seeking help. peer educators can break down misconceptions, answer questions, and encourage others to get tested and stay engaged with their care. these programs also create a sense of community, reminding individuals that they are not alone in their struggle against hiv.13-14 raising hiv awareness in underserved communities raising hiv awareness in underserved communities is a critical step in reducing the spread of the virus and improving health outcomes for those already living with hiv. these communities often face significant barriers to healthcare, including limited access to resources, a lack of comprehensive hiv education, and prevalent stigma surrounding the disease. by targeting these challenges through tailored awareness campaigns, we can empower individuals with the knowledge they need to make informed decisions about their health. effective awareness campaigns focus on addressing misconceptions, providing accurate information about hiv transmission and prevention, and encouraging open dialogues about the virus.15-16 one of the key components of raising hiv awareness is ensuring that the information is culturally relevant and accessible to the target population. this requires understanding the unique challenges, values, and beliefs of the community. for instance, some underserved communities may have particular cultural norms that influence how they view sexual health or the treatment of hiv. awareness programs that respect and incorporate local values can reduce resistance and increase the likelihood of acceptance. this may include using local languages, working with community leaders, or utilizing community events to deliver hiv information in a way that resonates with the population.17-18 another crucial aspect of hiv awareness is the involvement of community members in the process. peer-led programs, where individuals who are living with hiv educate others, have proven to be particularly effective. these programs work because people are more likely to trust and relate to someone who shares similar experiences. peer educators can break down barriers, answer questions, and challenge harmful myths that may prevent people from seeking testing or treatment. furthermore, these initiatives foster a sense of solidarity, making individuals feel that they are part of a larger movement aimed at overcoming the stigma and fear surrounding hiv.19-20 digital platforms and social media also present valuable tools for raising awareness in underserved communities. in many regions, mobile phones are more accessible than traditional healthcare services, making digital campaigns a powerful vehicle for spreading hiv information. social media campaigns, educational videos, and text message alerts can reach large audiences with timely, relevant content. these digital tools also allow for more interactive engagement, where individuals can ask questions and receive information anonymously, which can be especially important in environments where hiv is highly stigmatized.21-22 despite the potential of these strategies, challenges remain in effectively raising hiv awareness in underserved communities. limited resources, including funding for campaigns, trained educators, and healthcare infrastructure, can make it difficult to implement large-scale programs. additionally, deeprooted stigma and misconceptions about hiv can be significant obstacles to engaging individuals in these efforts. to overcome these barriers, sustained investment in education and healthcare services is necessary, along with strong partnerships between local governments, community organizations, and healthcare providers. only by working collaboratively can we create environments where hiv awareness is widespread and individuals feel empowered to seek testing and treatment.23-24 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):15-19 [17] ajdhs.com impact of hiv stigma on healthcare access hiv stigma continues to be a major barrier to healthcare access for individuals living with hiv, especially in underserved communities. stigma refers to the negative stereotypes, discrimination, and social exclusion that individuals experience because of their hiv status. this stigma can manifest in various forms, including overt discrimination in healthcare settings, social isolation, and internalized feelings of shame and guilt. the fear of being stigmatized often discourages individuals from seeking hiv testing, treatment, or care, which can lead to delayed diagnosis, poor health outcomes, and increased transmission rates. in many cases, stigma surrounding hiv is rooted in misconceptions about how the virus is transmitted, as well as moral judgments about those living with the disease.25-26 one of the most significant ways that hiv stigma affects healthcare access is by deterring individuals from seeking hiv testing and treatment. many people fear the judgment or mistreatment they might face from healthcare professionals or even from family and friends if they disclose their hiv status. this fear of discrimination can lead to delayed diagnosis, which can worsen the individual's health over time. early diagnosis and treatment are critical in managing hiv, preventing the progression to aids, and reducing transmission to others. the stigma surrounding hiv also affects the quality of care that people receive. healthcare providers who harbor biases or misconceptions about hiv may offer substandard care or even refuse treatment altogether, further discouraging individuals from accessing the services they need.27-28 furthermore, hiv stigma can exacerbate mental health issues, making individuals more reluctant to seek help for fear of being judged or ostracized. the internalization of stigma can lead to feelings of shame, depression, and anxiety, which may further isolate individuals and prevent them from accessing both physical and mental health services. this can create a vicious cycle, where individuals avoid care due to fear of stigma, leading to worsening health outcomes, which, in turn, reinforces their sense of isolation and hopelessness. mental health support, including counseling and peer support, is crucial for addressing the emotional impact of hiv stigma and encouraging individuals to stay engaged in their care.29 the impact of stigma is also seen in healthcare facilities themselves, where patients may encounter discriminatory attitudes from staff or be subjected to breaches of confidentiality. in some regions, healthcare workers may view people living with hiv as being "deserving" of their condition, leading to biased or unprofessional treatment. fear of stigma can also make individuals hesitant to seek hiv care in public health settings, leading them to avoid health services altogether or to seek care only when their condition has worsened. as a result, individuals may not adhere to antiretroviral therapy (art), which is essential in managing hiv and reducing viral load to undetectable levels, further complicating their health outcomes.30 in response to the pervasive impact of hiv stigma on healthcare access, many public health campaigns and organizations are working to challenge and reduce stigma through education and advocacy. by increasing awareness and understanding about hiv, its transmission, and the realities of living with the virus, stigma can be reduced, and healthcare settings can become more inclusive and supportive. training healthcare providers to recognize and address their own biases is also crucial in ensuring that people living with hiv receive respectful and effective care. moreover, creating safe spaces for individuals to discuss their hiv status without fear of discrimination can encourage people to seek timely and necessary medical intervention.31 challenges and barriers to empathy and awareness initiatives while empathy and awareness initiatives have the potential to significantly impact hiv prevention and care, there are several challenges and barriers that can hinder their success, particularly in underserved communities. these barriers can range from deeply ingrained social stigma and cultural norms to limited resources and inadequate healthcare infrastructure. addressing these challenges requires a comprehensive and multi-faceted approach that tackles the root causes of resistance to hiv awareness, stigma, and the barriers to compassionate, empathetic care.32 one of the most significant barriers is the pervasive stigma surrounding hiv. in many communities, particularly in regions with high rates of hiv, there is still a great deal of misunderstanding and fear associated with the virus. hiv is often seen as a "moral issue," linked to behaviors such as drug use, sex work, or non-heteronormative sexual practices. this can lead to discrimination and judgment against those who are living with hiv, which undermines efforts to build empathy. the fear of being stigmatized prevents individuals from seeking hiv testing, treatment, or disclosing their status. as a result, creating an environment of empathy and understanding can be an uphill battle, requiring persistent efforts to educate and reframe the conversation around hiv as a public health issue, rather than one of personal fault or shame.32 another challenge to implementing effective empathy and awareness initiatives is the lack of adequate resources, both in terms of funding and personnel. in underserved communities, where access to healthcare services is often limited, there may be insufficient investment in hiv awareness campaigns or support programs. healthcare providers in these areas may also lack the training to approach hiv care with the necessary sensitivity and understanding. without dedicated funding, support for peer-led initiatives, or training for healthcare workers, efforts to foster empathy can be under-resourced or inconsistent. furthermore, without adequate infrastructure, such as community centers or digital platforms, reaching large numbers of people effectively can be difficult. ensuring that there is both the financial and institutional support for such initiatives is essential for their success.33 cultural norms and local beliefs also present substantial challenges in promoting empathy and awareness around hiv. in some communities, there may be emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):15-19 [18] ajdhs.com entrenched cultural attitudes that resist open discussions about hiv, sexuality, or healthcare in general. these cultural barriers can make it difficult to encourage empathy and understanding, particularly when sensitive topics are involved. in addition, traditional gender roles and hierarchies may limit the agency of certain individuals, such as women or lgbtq+ individuals, in accessing hiv services or advocating for their own health. cultural resistance to outside interventions or “foreign” approaches can also hinder efforts to implement effective hiv awareness programs, particularly in rural or remote areas. overcoming these barriers requires working closely with community leaders and respecting local customs while promoting the importance of hiv awareness and care.33 additionally, misinformation and misconceptions about hiv are prevalent in many communities, and these misunderstandings can create further barriers to the success of empathy and awareness initiatives. false beliefs about how hiv is transmitted, such as thinking it can be spread through casual contact or that it only affects certain groups, can fuel fear and stigmatization. misinformation may also prevent people from seeking hiv testing or treatment, believing they are not at risk. addressing these misconceptions is crucial in the promotion of accurate information and fostering an environment of empathy and care. initiatives must be designed to not only raise awareness but also directly confront and correct false beliefs with factual, accessible information. conclusion empathy and awareness initiatives are crucial for addressing the stigma surrounding hiv and improving healthcare access for individuals living with the virus, especially in underserved communities. however, these efforts face numerous challenges, including deeply rooted societal stigma, limited resources, cultural resistance, and the spread of misinformation. to overcome these barriers, a multi-dimensional approach is necessary—one that integrates education, cultural sensitivity, adequate resource allocation, and community engagement. by fostering empathy and providing accurate information, we can dismantle misconceptions about hiv, reduce discrimination, and encourage individuals to seek the care they need without fear of judgment. effective empathy and awareness initiatives require sustained commitment from healthcare professionals, community leaders, and policymakers. healthcare providers must be trained to approach hiv care with sensitivity and understanding, ensuring that people living with hiv feel respected and supported in their treatment journey. community-based initiatives that involve peer educators and local leaders are essential to breaking down the barriers of stigma and fostering a culture of inclusivity and support. moreover, leveraging digital platforms and media can help spread awareness to a broader audience, especially in remote or resourcelimited areas. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3):38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2):43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3):2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. dave p, the correlation between stigma and mental health disorders in people living with hiv/aids, journal of drug delivery and therapeutics, 2024;14(3):227-233 https://doi.org/10.22270/jddt.v14i3.6490 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1007/s10461-022-03913-0 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):15-19 [19] ajdhs.com provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024;13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. akhtar mh, ramkumar j. primary health center: can it be made mobile for efficient healthcare services for hard to reach population? a state-of-the-art review. discover health systems. 2023;2(3). https://doi.org/10.1007/s44250-023-00017-x pmid:37520517 pmcid:pmc9870199 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013. https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.1007/s44250-023-00017-x https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [58] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited comparative evaluation of hemostatic gel vs gelatin sponge on bleeding and pain after primary teeth extraction: an in-vivo comparative study singh utkarsh 1* , gupta sonal 2 , saket antra 1 , pathak shalu 3 , abraham nayana 3 1 jr3, department of pediatrics & preventive dentistry, kd dental college & hospital, mathura 2 hod & professor, department of pediatrics & preventive dentistry, kd dental college & hospital, mathura 3 jr2, department of pediatrics & preventive dentistry, kd dental college & hospital, mathura article info: _____________________________________________ article history: received 02 dec 2024 reviewed 06 jan 2025 accepted 31 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: singh u, gupta s, saket a, pathak s, abraham n, comparative evaluation of hemostatic gel vs gelatin sponge on bleeding and pain after primary teeth extraction: an in-vivo comparative study, asian journal of dental and health sciences. 2025; 5(1):58-66 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.124 _________________________________________ *address for correspondence: singh utkarsh, jr3, department of pediatrics & preventive dentistry, kd dental college & hospital, mathura abstract _________________________________________________________________________________________________________________ backgroundin pediatric dental practice, extraction is one of the common procedures whether it’s a case of over-retained deciduous teeth or carious and traumatic teeth with poor prognosis. in precooperative patients or patients with special health care needs, post extraction bleeding must be managed very effectively and quickly too, as such patients are unable to follow the post-extraction pack instructions properly. hence, aim of this study was to compare the efficacy of hemostatic gel and gelatin sponge on post-extraction bleeding and pain following extraction of primary teeth and whether the root length of the primary teeth draws any impact over the post-extraction bleeding time and flow. materials & methodologyit was a prospective, randomised clinical trial of sample size 20 teeth in each group. inclusion criteria were asa class-i patients in the age group 6-12 years, patients with at least 1 primary tooth to be extracted under la local infiltration. after extraction, a pressure pack of normal saline soaked gauge was given for 2 minutes and then hemostatic agent was applied as per the groups allocated either hemostatic gel or gelatin sponge to the extraction socket. resultsgelatin sponge performed better in controlling the bleeding from extraction socket at 5 minutes and 10 minutes interval as the mean data of bleeding code was statistically significant but it was not significant at 15 minutes interval means both the material performed equally better at the end of 15 minutes in controlling bleeding. conclusionplacing gelatin sponge pack post primary teeth extraction significantly reduces the bleeding time at 5 minutes and 10 minutes interval and hastens the blood clot in comparison with hemostatic gel. keywordspost-extraction bleeding, gelatin sponge, hemostatic gel introduction in pediatric dental practice, extraction is one of the common procedures whether it’s a case of over-retained deciduous teeth or carious and traumatic teeth with poor prognosis. post-extraction bleeding following extraction is a well identified and frequent complication which causes several difficulties like stress, pain & agony to the patients and apprehension to the care-takers as well. 1 hemophobia is the fear of blood which may instills a negative attitude in pediatric patients if doesn’t control adequately and quickly following the extraction. postextraction bleeding (peb) can be defined as obvious evidence of bleeding beyond the pressure pack time limit. 2 this peb may interfere in moisture sensitive procedures like restoration and cementation prolonging the chair-side and anesthesia time. this breakthrough bleeding may require hemostatic treatment, and emergency intervention in severe cases. in a study conducted by henderson et al 3, it was concluded that total blood loss ranged from 2.5-57ml in extraction of primary teeth. peb depends upon the number of teeth extracted, the pathological status of the teeth, the length of the root preserved and underlying systemic diseases of the patients like bleeding or clotting disorders and liver diseases. in pre-cooperative patients or patients with special health care needs, post extraction bleeding must be managed very effectively and quickly too, as such patients are unable to follow the post-extraction pack instructions properly. management of peb includes both local as well as systemic measures. local methods of controlling peb are common saline pressure pack, sutures, acrylic surgical splints, and local hemostatic agents like oxidized cellulose, resorbable gelatin sponge, bone wax, calcium alginate, tannic acid, and hemocoagulase. 4-5 systemic measures include oral or parenteral administration of anti-fibrinolytic agents like tranexamic acid and α-amino caproic acid. open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.124 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.124&amp;domain=pdf https://orcid.org/0009-0002-9858-7403 https://orcid.org/0000-0002-7842-2217 https://orcid.org/0009-0009-0944-1754 https://orcid.org/0009-0003-7149-5653 https://orcid.org/0009-0000-0583-0802 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [59] ajdhs.com ideal properties of a hemostatic agents include lightness, stability, and the ability to be easily inserted into the bleeding site. it should not cause tissue irritation or destruction, must not get dissolved in the blood and can be easily removed after the arrest of the bleeding or whenever required. 6 gelatin sponge is one of the commonly used hemostatic agents in oral surgical procedure which has property to swell up and arrest the bleeding by compressing the blood vessels.7 hemostatic gel typically contains aluminium chloride, glycerine and purified water are being used in dentistry for arresting bleeding during minor gingival retraction procedures and treating pulpal bleeding during pulp therapy. there have been various studies conducted so far to evaluate the efficacy of gelatin sponge and resorbable packs after extraction of primary teeth in patients with bleeding disorder and anti-platelet therapy, but, there is a scarcity of literature in evaluating the efficacy of gelatin sponge and hemostatic gel in bleeding control following extraction of primary teeth. hence, aim of this study was to compare the efficacy of hemostatic gel and gelatin sponge on post-extraction bleeding and pain following extraction of primary teeth and whether the root length of the primary teeth draws any impact over the post-extraction bleeding time and flow. materials and methodology it was a prospective, randomised clinical trial of sample size 20 teeth in each group. inclusion criteria were asa class-i patients in the age group 6-12 years, patients with at least 1 primary tooth to be extracted under la local infiltration. exclusion criteria were patients with any systemic or bleeding disorders or extraction requiring surgical procedures like gingival reflection or elevation and pressure packs dislodged during 15 minutes postextraction. informed consents were obtained from each child’s legal parent or guardian. each patient was randomly assigned to one of two study groups which after the extraction supposed to receive the group i gelatin sponge (gelatinor gamma sterile, ready to use) and group iihemostatic gel (waldent). tooth extractions were performed using forceps after local infiltration of local anesthesia and retraction of attached gingiva. figure 1: gelatin sponge figure 2: hemostatic gel figure 3: armamentarium pulse rate and oxygen saturation was recorded using pulse oximeter prior to la administration and 30 minutes after extraction to evaluate the difference in the patient’s apprehension on using these two different packs. anxiety and pain level on the patients were recorded using facial image scale prior to la administration and 1 hour post extraction to compare if there is any difference if these two different post-extraction packs. root resorption stages of the tooth to be extracted was evaluated using radiographs and code was assigned using modified fanning scale for root resorption. stage designation for this study diagram root intact 0 root shows blunting or rounding at apex 1 root resorbed 1/4 2 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [60] ajdhs.com root resorbed 1/3 3 root resorbed 1/2 4 root resorbed 2/3 5 root resorbed 3/4 6 root entirely resorbed 7 after extraction, a pressure pack of normal saline soaked gauge was given for 2 minutes and then hemostatic agent was applied as per the groups allocated either hemostatic gel or gelatin sponge to the extraction socket. at 5 minutes, 10 minutes, and 15 minutes post-extraction, bleeding was scored according to a scale developed by shayna mattox et al. existing blood, if any, was wiped using gauge and the socket was observed for 3 seconds prior to rating each socket. code description diagram 0 no active bleeding/ fully clotted 1 active bleeding which fills the socket, but no oozing outside of the socket onto the alveolar ridge. figure 4: placement of hemostatic gel in extraction socket figure 5: placement of gelatin sponge in extraction socket singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [61] ajdhs.com 2 active bleeding which is oozing outside of the socket, but limited to immediate alveolar ridge. 3 active bleeding which is oozing outside of the socket, over the alveolar ridge into the working field. at 15 minutes, it was noted if any portion of hemostatic agent was completely removed from the socket or not and if completely removed the sample was excluded from the study. after 15 minutes, a saline soaked gauge was placed in the socket for another 15minutes to avoid spitting or chewing anything by the child. results data were entered in microsoft excel version 2012 and spss software version 20.0 and following results were obtained. 1. comparison of oxygen saturartion pre and post extraction (after 30 min) between gelatin sponge and hemostatic gel time group mean oxygen saturation std. deviation mean diff t value p value pre-op gelatin sponge 98.50 1.606 -.350 -.856 .39 hemostatic gel 98.85 .875 post-op (30 min) gelatin sponge 97.45 1.849 -.450 -.931 .35 hemostatic gel 97.90 1.119 test usedindependent t test, p>0.05 insignificant mean ±sd of oxygen saturation at pre-op in gelatin sponge and hemostatic gel was 98.50±1.606 and 98.85±.875 while at post-op it was 97.45±1.849 and 97.90±1.119 respectively respectively. results were found to be statistically insignificant 2. comparison of mean pulse rate pre and post extraction (after 30 min) between gelatin sponge and hemostatic gel time group mean pulse rate std. deviation mean diff t value pvalue pre-op gelatin sponge 81.15 15.500 -7.00 -1.203 .23 hemostatic gel 88.15 20.914 post-op (after 30 min) gelatin sponge 92.85 7.989 -4.850 -1.573 .12 hemostatic gel 97.70 11.239 test usedindependent t test, p>0.05 insignificant 96.5 97 97.5 98 98.5 99 pre-op post-op (2hours) oxygen saturation pre and post-op gelatin sponge hemostatic gel singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [62] ajdhs.com mean ±sd of pulse rate at pre-op in gelatin sponge and hemostatic gel was 81.15±15.500 and 88.15±20.914 respectively and post-op was 92.85±7.989 and 97.70±11.239 respectively. results were found to be statistically insignificant. 3. comparison of pain perception pre and post extraction (after 2 hours) between gelatin sponge and hemostatic gel time group mean pain score std. deviation mean diff t value p value pre-op gelatin sponge 4.10 .718 .350 1.406 .16 hemostatic gel 3.75 .851 post-op (after 1 hour) gelatin sponge 4.65 .489 .200 1.265 .21 hemostatic gel 4.45 .510 test usedindependent t test, p>0.05 insignificant mean ±sd of pain score at pre-op in gelatin sponge and hemostatic gel was 4.10±.718 and 3.75±.851 respectively and post-op was 4.10±.718 and 3.75±.851 respectively. results were found to be statistically insignificant 4. comparison of bleeding at 5 min, 10 min and 15 min post extraction between gelatin sponge and hemostatic gel time group mean bleeding code std. deviation mean diff t value p value 5 min gelatin sponge 1.40 .598 -.600 -2.854 .007** hemostatic gel 2.00 .725 10 min gelatin sponge .60 .598 -.550 -2.437 .020* hemostatic gel 1.15 .813 15 min gelatin sponge .05 .224 -.150 -1.435 .16 hemostatic gel .20 .410 test usedindependent t test, p*<0.05 significant and p>0.05 insignificant 0 20 40 60 80 100 120 pre-op post-op (2hours) pulse rate pre and post-op gelatin sponge hemostatic gel 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 pre-op post-op (2hours) pain score pre and post-op gelatin sponge hemostatic gel singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [63] ajdhs.com mean ±sd of bleeding code at 5 min, 10 min and 15min in gelatin sponge and hemostatic gel was 1.40±.598 and 2.00±.725, 60±.598 and 1.15±.813 and 05±.224 and .20±.410 respectively. results were found to be statistically significant when comparing gelatin sponge and hemostatic gel of bleeding code at 5 min and 10min but insignificant at 15min. 5. comparison of bleeding code at 5 min with root resorption stage in gelatin sponge root resorption stage of gelatin sponge bleeding code total chi value p value code 1 code 2 code 3 0 15.4% 33.3% 0 20% 8.803 .72 2 7.7% 0.0% 0.0% 5.0% 3 0.0% 16.7% 0.0% 5.0% 4 7.7% 0.0% 0.0% 5.0% 5 15.4% 16.7% 0.0% 15.0% 6 30.8% 0.0% 100.0% 25.0% 7 23.1% 33.3% 0.0% 25.0% total 100.0% 100.0% 100.0% 100.0% test usedchi square, p>0.05 insignificant results were found to be statistically insignificant when comparing bleeding with root resorption stage in gelatin sponge. 0 0.5 1 1.5 2 2.5 5 min 10 min 15 min bleeding code at differnt time period gelatin sponge hemostatic gel 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00% 0 2 3 4 5 6 7 root resorption stage with bleeding code in gelatin sponge bleeding code 1 bleeding code 2 bleeding code 3 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [64] ajdhs.com 6. comparison of bleeding code with root resorption stage in hemostatic gel root resorption stage of hemostatic gel bleeding code total chi value p value code 1 code 2 code 3 0 0.0% 0.0% 20.0% 5.0% 17.222 .07 1 0.0% 0.0% 20.0% 5.0% 4 0.0% 0.0% 20.0% 5.0% 5 0.0% 30.0% 20.0% 20.0% 6 60.0% 10.0% 0.0% 20.0% 7 40.0% 60.0% 20.0% 45.0% total 100.0% 100.0% 100.0% 100.0% test usedchi square, p>0.05 insignificant results were found to be statistically insignificant when comparing bleeding with root resorption stage in gelatin sponge. discussion extraction of primary teeth is a common procedure encountered in routine pediatric dental practice. reason for primary teeth extraction include trauma, serial extraction for interceptive orthodontics, over-retained teeth, grossly decayed teeth which can’t be restored or treated endodontically.8 after primary tooth extraction, a gauze pack is placed over the socket and patient is directed to bite on the pack for half an hour, exerting firm even pressure.9 pre-cooperative children and those with intellectual disabilities don’t comply with the pressure packs advice and they tend to remove the pack, before the time of pressure pack retention lasts. due to lack of cognitive development in such patients, there is search of a proper hemostatic agent since long times that too in primary extraction socket, to hasten the clotting time and reduction in pressure packs timing as well. many hemostatic agents like gelatin sponge, gelfoam (gelatin sponge with glutaraldehyde), hemostatic gel and snake venom (batroxobin) 10 have been used as post-extraction hemostatic agent but mostly in cases with bleeding and clotting disorders, such patients require additional care to avoid excessive bleeding. gelatin sponge is a water insoluble, resorbable material which is flexible in nature and made from animal skin. [7]. it is hemostatic in nature and can be used to control bleeding after exodontia.11 it can be used dry or in combination with saline solution. the mechanism behind using the sponge is water absorption and formation of clots, protecting the wound, reducing complications and hastening recovery.12 mahmaudi a et al (2023) advocated the use of gelatin based dental sponge in primary molar extraction in order to reduce bleeding pain and post-operative infection.13 similarly, in a study conducted by pattabhi a et al (2024),14 they showed that using gelatin sponge in the extraction sockets of impacted third molars, when excessive bleeding is not present, reduces postoperative pain. hemostatic gel basically contains aluminim chloride and ferric sulfate which acts by constricting blood vessels and helping in formation of clot. 15 in a systemic review 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 0 1 4 5 6 7 root resorption stage with bleeding code in hemostatic gel bleeding code 1 bleeding code 2 bleeding code 3 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [65] ajdhs.com by gupta g et al (2018) 4, clinical outcomes of topical hemocoagulase was compared with placebo in extraction socket sites of adults and found that topical hemocoagulase led to a significant differences in bleeding stoppage time, pain, swelling, wound healing, and other postoperative complications. in adult patients, particularly after 3rd molar extractions, such hemostatic agents are used to avoid excessive bleeding as well as dry socket. there is paucity of literature regarding use of gelatin sponge and hemostatic gel in primary extraction socket. thus, this study was carried out to compare the efficacy of bleeding control between gelatin sponge and hemostatic agent after primary teeth extrcation. in this study, gelatin sponge performed better in controlling the bleeding from extraction socket at 5 minutes and 10 minutes interval as the mean data of bleeding code was statistically significant but it was not significant at 15 minutes interval means both the material performed equally better at the end of 15 minutes in controlling bleeding. gelatin sponge performed better due to its characteristic to effectively absorb blood at a rate that is 45 times its own weight. the hemostatic action is associated with the consistent porosity of the gelatin sponge, which facilitates platelet adhesion and subsequent degradation, resulting in the release of thrombokinase. it’s neutral ph, rendering it compatible for moistening with thrombin or antibiotic solutions without compromising its integrity.16 the result was in accordance with the conducted by shayna mattox et al (2020)17, in which they concluded that use of hemostatic pack in maxillary primary extraction socket reduces the bleeding time at 5 minutes and 10 minutes post extraction compared to the controls. in this study, we also tried to co-relate the difference in oxygen saturation, pulse rate and pain perception of the children after use of these two haemostatic packs but result revealed that the difference in data were statistically insignificant. the data was not in accordance with the study by shayna mattox et al (2020) in which they claimed that there is an odd of increasing bleeding by 9% for increase in heart rate per beat every minutes. in another parameter, the study also tried to rule out whether there is any impact of root resorption stages of primary teeth on post extraction bleeding in which results revealed the data as insignificant too which was in accordance with the shayna mattox et al’s study. in this study, root resorption stage was evaluated using vertical resorption and lateral root resorption was not taken into account. again, periodontal status and mobility of the primary tooth plays a significant role in the postextraction bleeding which was not measured in the study and these might be the reason behind the data to be statistically insignificant. this study had certain limitations like smaller sample size, location and status of root resorption stage of the tooth to be extracted and lack of blood profile tests for international normalized ratio (inr) prior to extraction. but, as this study is a pioneer in its own terms as one of the first study to be conducted in india as role of two different haemostatic packs after extraction of primary teeth, it will provide a backbone for further research and studies specially in terms of providing a quick performing haemostatic pack after primary teeth extraction specially in un-cooperative patients and paediatric patients with intellectual disabilities. importance of the study in uncooperative and intellectual disability patients, who don’t comply with the post-extraction pack instructions, gelatin sponge can be used on chair side to arrest the bleeding from primary teeth extraction site. use of gelatin sponge can be used in pediatric patients with bleeding disorders in order to hasten the clotting of primary teeth extraction bleeding site and to avoid postoperative complications. conclusion placing gelatin sponge pack post primary teeth extraction significantly reduces the bleeding time at 5 minutes and 10 minutes interval and hastens the blood cloting in comparison with hemostatic gel. there is no any difference in impact on oxygen saturation, pulse rate and pain perception by pediatric patients between these two hemostatic agents used. root resorption stage doesn’t play a major role in postextraction bleeding in primary teeth. acknowledgementsnone conflicts of interestnil author contributions: all authors have equal contribution in the preparation of manuscript and compilation. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: informed consent was obtained from all subjects involved in the study. data availability statement: the data presented in this study are available on request from the corresponding author. ethical approval: not applicable. references 1. kamoh a, swantek j. hemostasis in oral surgery. oral surgery for the general dentist, an issue of dental clinics. 2011 oct 7;56(1):17. https://doi.org/10.1016/j.cden.2011.06.004 pmid:22117940 2. elsevier po. tissue renewal, regeneration, and repair. 3. henderson nj, crawford pj, bell cn. blood loss following extraction of deciduous teeth under general anaesthetic. journal of the royal college of surgeons of edinburgh. 1997 oct 1;42(5):349-52. 4. gupta g, muthusekhar mr, kumar sp. efficacy of hemocoagulase as a topical hemostatic agent after dental extractions: a systematic review. cureus. 2018 mar;10(3). https://doi.org/10.7759/cureus.2398 5. nooh n, abdullah wa, grawish me, ramalingam s, javed f, alhezaimi k. the effects of surgicel and bone wax hemostatic agents on bone healing: an experimental study. indian journal of orthopaedics. 2014 jun;48:319-25. https://doi.org/10.1016/j.cden.2011.06.004 https://doi.org/10.7759/cureus.2398 singh et al. asian journal of dental and health sciences. 2025; 5(1):58-66 [66] ajdhs.com https://doi.org/10.4103/0019-5413.129451 pmid:24932041 pmcid:pmc4052034 6. irfan ni, zubir az, suwandi a, haris ms, jaswir i, lestari w. gelatinbased hemostatic agents for medical and dental application at a glance: a narrative literature review. the saudi dental journal. 2022 dec 1;34(8):699-707. https://doi.org/10.1016/j.sdentj.2022.11.007 pmid:36570577 pmcid:pmc9767835 7. singh m, bhate k, kulkarni d, santhosh kumar sn, kathariya r. the effect of alloplastic bone graft and absorbable gelatin sponge in prevention of periodontal defects on the distal aspect of mandibular second molars, after surgical removal of impacted mandibular third molar: a comparative prospective study. journal of maxillofacial and oral surgery. 2015 mar;14:101-6. https://doi.org/10.1007/s12663-013-0599-z pmid:25729233 pmcid:pmc4339342 8. kay ej. the reasons underlying the extraction of teeth in scotland. br. dent. j.. 1986;160:287-90. https://doi.org/10.1038/sj.bdj.4805837 pmid:3457583 9. textbook of pediatric dentistry 3rd edition by nikhil marwah 10. swamy df, barretto es, rodrigues js. effectiveness of topical haemocoagulase as a haemostatic agent in children undergoing extraction of primary teeth: a split-mouth, randomised, doubleblind, clinical trial. european archives of paediatric dentistry. 2019 aug 1;20:311-7. https://doi.org/10.1007/s40368-0180406-0 pmid:30900152 11. cai, y.; lu, c. a clinical study of gelatamp colloidal silver gelatin sponge on preventing the complication of teeth extraction. west china j. stomatol. 2008, 26, 519-521. 12. guralnick,w.c.; berg, l. gelfoam in oral surgery: a report of two hundred fifty cases. oral surg. oral med. oral pathol. 1948, 1,632639. https://doi.org/10.1016/0030-4220(48)90337-5 pmid:18869494 13. mahmoudi a, ghavimi ma, maleki dizaj s, sharifi s, sajjadi ss, jamei khosroshahi ar. efficacy of a new hemostatic dental sponge in controlling bleeding, pain, and dry socket following mandibular posterior teeth extraction-a split-mouth randomized double-blind clinical trial. journal of clinical medicine. 2023 jul 10;12(14):4578. https://doi.org/10.3390/jcm12144578 pmid:37510692 pmcid:pmc10380399 14. pattabhi a, arun m, murugesan k. efficacy of absorbable surgical gelatin sponge post surgical extraction of impacted mandibular teeth: a prospective split mouth comparative study. inobstetrics and gynaecology forum 2024 may 13 (vol. 34, no. 2s, pp. 263-266). 15. tarighi p, khoroushi m. a review on common chemical hemostatic agents in restorative dentistry. dental research journal. 2014 jul;11(4):423. 16. kan kw, liu jks, lo ecm, corbet ef, leung wk. residual periodontal defects distal to the mandibular second molar 6-36 months after impacted third molar extraction-a retrospective cross-sectional study of young adults. j clin periodontol. 2002;29:1004-1011. https://doi.org/10.1034/j.1600051x.2002.291105.x pmid:12472993 17. mattox sl. a randomized controlled trial: absorbable hemostatic pack effect on bleeding time following extraction of primary maxillary incisors (master's thesis, the ohio state university). https://doi.org/10.4103/0019-5413.129451 https://doi.org/10.1016/j.sdentj.2022.11.007 https://doi.org/10.1007/s12663-013-0599-z https://doi.org/10.1038/sj.bdj.4805837 https://doi.org/10.1007/s40368-018-0406-0 https://doi.org/10.1007/s40368-018-0406-0 https://doi.org/10.1016/0030-4220(48)90337-5 https://doi.org/10.3390/jcm12144578 https://doi.org/10.1034/j.1600-051x.2002.291105.x https://doi.org/10.1034/j.1600-051x.2002.291105.x gupta et al. asian journal of dental and health sciences. 2025; 5(1):50-53 [50] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited melatonin as antianxiety drug in dentistry: a review sonal gupta 1* , rohan shrivastava 2 , abhinandan patra 3 , charu aggarwal 2 , rishi nanda 4 1 head of the department, department of pediatric and preventive dentistry, k.d. dental college and hospital, mathura, uttar pradesh, india 2 post graduate student, department of pediatric and preventive dentistry, k.d. dental college and hospital, mathura, uttar pradesh, india 3 senior lecturer, department of pediatric and preventive dentistry, k.d. dental college and hospital, mathura, uttar pradesh, india 4 professor, department of pediatric and preventive dentistry, eklavya dental college and hospital, kotputli, rajasthan, india article info: _____________________________________________ article history: received 04 dec 2024 reviewed 02 jan 2025 accepted 27 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: gupta s, shrivastava r, patra a, aggarwal c, nanda r, melatonin as antianxiety drug in dentistry: a review, asian journal of dental and health sciences. 2025; 5(1):50-53 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.112 abstract _________________________________________________________________________________________________________________ background: anxiety is a barrier to dental care for many people. according to preliminary research, melatonin has sedative and anxiolytic effects. in dentistry, anxiety is a prevalent issue that may compromise the effectiveness of appropriate therapy. many people with anxiety require oral premedication. many people require heavy sedation or even general anesthesia to undergo dental care because they are so extremely nervous that oral sedation is ineffective. even inserting an intravenous catheter can be challenging for these people because of their high levels of anxiety. the most often prescribed anxiolytic in these situations has been benzodiazepines, although several of these may cause paradoxical side effects. since melatonin promotes natural drowsiness and enhances sedation, it has a strong chance of replacing benzodiazepines in this industry. this article aims to provide an overview of the use of melatonin as a dental premedication for patients who are uncooperative and apprehensive. keywords: anesthesia, dental anxiety, melatonin, premedication *address for correspondence: sonal gupta, head of the department, department of pediatric and preventive dentistry, k.d. dental college and hospital, mathura, uttar pradesh, india introduction there is evidence linking general health issues to phobias, anxiety, or dread of the dentist. when you consider that 20% of patients delay going to the dentist because they need to, this is a significant fact. a dentist's dread is often persistent and challenging to overcome because of their own experiences or anxiety brought on by other patients' comments. 1. when a highly anxious patient has treatment under general anesthesia, their fear of needles may make it difficult to establish an intravenous line, or they may be afraid of being under anesthesia in addition to the dental surgery itself. one of the most efficient ways to assist patients in lowering their feelings of worry and panic is by oral premedication. triazolam, midazolam, lorazepam, and diazepam are among the benzodiazepine class of medications that are most frequently used as oral anxiolytics for dental patients 2. there are widely known side effects of benzodiazepines class, and rejection on acceptance of those drugs on several occasions. in order to combat this, a novel pharmaceutical known as melatonin has entered the dentistry science and practice sector. it can be used as a premedication and has demonstrated anxiolysis abilities comparable to those of benzodiazepines, but without the majority of their negative effects 3,4. thus, this review focuses on the use of melatonin in the field of dentistry with various advantages. review the primary secretory product of the pineal gland, melatonin (mt), is linked to the control of the human body's circadian dark/light cycle. this hormone possesses immunomodulatory and antioxidant properties. furthermore, it has no toxicity, but it is a very lipophilic substance, which makes it easier for it to pass through cell membranes and compartments. this suggests that it may be used therapeutically, for example, locally (1) in oral cavity damage caused by bacteria, viruses, or fungi, and (2) in postsurgical wounds from tooth extractions and other oral surgeries, where it promotes bone formation and reduces gingival and periodontal inflammation. (3) to improve dental implant osteointegration, as well as in autoimmune conditions including sjorgen syndrome, lichen planus, aphthous ulceration, and herpes lesions, and (4) even to prevent oral cancer 5. in this regard, melatonin may have a number of positive impacts on oral health, including lessening the severity of herpes, which has been shown to be at least as effective as the medication acyclovir. its exact mode of action is unknown, although it may be because it stimulates nk cd4 cells 6. in terms of oral open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.112 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.112&amp;domain=pdf https://orcid.org/0000-0002-7842-2217 https://orcid.org/0000-0002-0439-6992 https://orcid.org/0000-0001-7745-7250 https://orcid.org/0009-0003-3998-2718 https://orcid.org/0009-0007-1316-1072 gupta et al. asian journal of dental and health sciences. 2025; 5(1):50-53 [51] ajdhs.com health, melatonin may serve as a prognostic indicator for conditions like cancer. it may also be regarded as an oncostatic agent of several cancer types, but low plasma levels of it are linked to mouth cancer: such is breast, stomach, colon, and lung cancer, all of which are associated with low melatonin plasma levels. it diffuses passively from the blood to the saliva. for this reason, it was observed that the concentration of this in saliva was around 30% of that in plasma 7. when compared to blood levels, saliva contains less melatonin, most likely because it binds to albumin in almost 70% of plasma, preventing it from freely diffusing into saliva. through the stimulation of type i collagen fiber formation and the control of osteoblastic and osteoclastic activity, local melatonin injection has been shown to have a number of possible effects in the oral cavity and may aid in the regeneration of alveolar bone. it should be taken into consideration because turning blood into saliva may help prevent oral infections and have positive effects on periodontal disease, herpes, and oral cancer. it is also significant for the treatment and prognosis of some tumors, such as epidermoid carcinoma 8-9. biosynthesis tryptophan is transformed into melatonin in pinealocytes. this synthesis is carried out in four phases 10. melatonin production occurs through a two-step mechanism after tryptophan first transforms into serotonin. these enzymes are hydroxyindole-omethyltransferase (hiomt)11 and n-acetyl transferase (nat), which inhibits the melatonin molecule. the pattern of day and night determines how this synthesis is managed, and night 12 is when it peaks. a number of factors affect how quickly this process proceeds. for example, norepinephrine and b1 adrenergic receptor activation play crucial roles in this synthesis. under these conditions, melatonin production increases 12. folate and vitamin b6 are also essential for this process. for the methylation process to occur, folate is required. vitamin b6 is also involved in the decarboxylation of tryptophan. melatonin synthesis won't happen if they're not in the environment. pharmacokinetics melatonin is quickly distributed (distribution half-life of 0.5 to 5.6 minutes) and excreted following intravenous injection 13. within 60 minutes of oral treatment, a peak in plasma concentration occurs. the decrease in plasma concentrations is biphasic, with half-lives of two and twenty minutes, respectively. melatonin concentrations 10–100 times greater than the physiological nocturnal peak can be achieved within an hour of consumption when a typical dose of 1–5 mg is taken; the concentrations revert to their baseline levels within 4–8 hours. melatonin is rapidly metabolized, mostly in the liver and subsequently in the kidney, following intravenous or oral administration. however, because there is no hepatic first pass following intravenous injection, the hepatic bio-degradation is less significant. it is converted to 6-hydroxymelatonin by the cytochrome p450 enzyme cyp1a2, conjugated with either 90% sulfuric acid or 10% glucuronic acid, and then eliminated in the urine. urine contains around 5% of the unmetabolized melatonin that is expelled from the body. mechanism of action as sedation and antianxiety because melatonin binding to the mt1 receptor appears to affect the gabaa receptor via the g-coupled protein pathway 17, mt's anesthetic action is comparable to that of other anesthetics like propofol and benzodiazepines, enhancing the binding of gaba to the gabaa receptor 17. faster recovery times and a lower incidence of postoperative excitement and sleep disturbances are linked to melatonin premedication, which can be taken orally in doses of 3 or 5 mg. this reduces the amount of propofol needed to achieve a bispectral index score of 45, which indicates a sufficient level of hypnosis for tracheal intubation without extending the length of the postoperative recovery room stay 18. 2 weeks after surgery compared to midazolam 19. melatonin can reduce preoperative anxiety 50–100 minutes after administration, and it may be just as effective as standard treatment with midazolam in reducing preoperative anxiety (50–100 minutes after administration) in adults twenty, according to a recently published review evaluating the effect of melatonin on preand postoperative anxiety in adults when compared to mt given as premedication to placebo 20. oral melatonin does not affect general cognitive and psychomotor abilities like midazolam does 21. six hours after surgery, melatonin may help individuals feel less anxious. when children require general anesthesia for oesophageal dilatation procedures, oral melatonin appears to reduce postoperative agitation 22. melatonin added to alprazolam may provide better anxiolysis than other medications in the same group, according to a randomized controlled factorial experiment 23. the time of premedication with melatonin may also be significant. oral melatonin has been shown to have a sleep-onset impact within 30 minutes. however, naguib and samarkandi 19 found that 60 and 90 minutes after sublingual melatonin premedication, melatonin-treated patients had higher degrees of drowsiness. melatonin appears to have strong potential for usage in lowering anxiety and inducing drowsiness in dental patients receiving general anesthesia without any notable side effects when compared to other drugs, such as benzodiazepines, which are currently the gold standard. an observational study was also carried out by gupta s et al. 24 and found that postoperative anxiety decreased in correlation with cognitive and psychomotor scores. their study also supported that melatonin can be used as a potent premedication drug in children as an anti-anxiety drug. premedication in dentistry because oral sedation reduces tension and excitement and relaxes the patient for subsequent procedures, it can be useful in dentistry. barbiturates had a low therapeutic index, the potential for addiction, and negative effects on the heart and lungs, despite their effectiveness in sedation. benzodiazepines' broad margin of safety and efficacy in sedation, anxiolysis, and forgetfulness led to the ultimate replacement of barbiturate use for sedation. gupta et al. asian journal of dental and health sciences. 2025; 5(1):50-53 [52] ajdhs.com additionally, individuals with respiratory, hepatic, renal, or cardiovascular diseases require extra attention 15. despite their effectiveness, these medications have a higher sedative impact that could cause a delay in recovery after sedation 3,28. disorientation, decreased psychomotor performance, paradoxical reactions, excessive sedation that interacts with opioids, and sleep disturbance after surgery are some of the negative effects of midazolam. as a result, melatonin has been proposed as a pre-medication alternative to midazolam 28. melatonin sublingual administration (0.05 mg kg−1 or 5 mg) has been linked to preoperative anxiety reduction in adults without psychomotor impairment or recovery effects. 5–7.5 ml, or 3–4.5 mg of melatonin tablets, is the recommended dosage for syrup oral melatonin 25,26. children can safely take up to 0.4 mg/kg of oral melatonin without experiencing any serious negative effects 27. doses of up to 10 mg of melatonin have been used for youngsters who are uncooperative and as an alternative to traditional sedatives. however, a study found that premedication with 5 mg of melatonin was linked to drowsiness and pre-operative anxiolysis without causing post-operative impairment of psychomotor performance 4. exogenous melatonin has a peak effect between 45 and 90 minutes 24. in addition to providing sedation, oral melatonin (0.4 mg/kg) administered 60–90 minutes before to surgery offers sufficient anxiolysis on par with oral midazolam (0.2 mg/kg) 21. for elective procedures using oral melatonin, the 2-4-6 fasting rule is applied. for clear foods, breast milk, formula milk, and solids, fasting before appointment should be of 2-3 hours, 4 hours, 6 hours and 6-8 hours respectively 29. other benefits of melatonin include: (1) it may also be more palatable to people who might find synthetic drugs uncomfortable, and (2) it has a short half-life, which reduces the likelihood of extended drowsiness compared to benzodiazepines 16. the only short-term side effect of oral administration of exogenous melatonin is drowsiness; however, the long-term effects of melatonin use are still unknown. melatonin use is generally safe without significant adverse effects in healthy adults over the age of 18, who are not pregnant, and who do not have psychiatric disorders. advantages of melatonin melatonin offers a number of potential advantages such as reduced post-operative sedation & less sleep disturbance, faster recovery, improved post-operative analgesia, and avoidance of respiratory depression, short half-life, dose dependent effect, offers greater taste expectance, difficult to overdose melatonin since it is a natural hormone. disadvantages of melatonin regardless of the level of sedation, it's vital to fast before the session since stomach contents can be re-aspirated or vomited, which might cause pneumonia or pneumonitis 29, headache, nausea, daytime drowsiness may also occur in some patients. safety profile in contrast to midazolam, which causes weariness, drowsiness, and dizziness, melatonin has a few negative side effects, such as drowsiness. when comparing the safety profile of melatonin to midazolam 30, ansari et al. (2017) found that children who were premedicated with melatonin experienced a considerably decreased incidence of nausea, vomiting, and dizziness. in addition, angelo et al. compared the safety profiles of melatonin and midazolam as premedication and found that the former was just as effective as the latter without causing any cognitive or psychomotor impairments. additionally, compared to midazolam, melatonin in children can be used without significant adverse effects and requires less preoperative monitoring, according to kain et al. and tushar et al 30. conclusion melatonin has significance of oral sedation as a pharmacological behaviour management technique in pediatric dentistry. if it is given prior to pre operative dental treatment to uncooperative or fearful patient, it provides adequate anxiolysis and sedation. oral melatonin at 0.75 mg/kg appears to be the most effective drug for allaying pre-operative anxiety in children followed by 0.5 mg/kg. even the doses of 0.5 mg/kg and 0.75 mg/kg does not cause sedation or cognition and psychomotor dysfunction. in addition, new clinical studies are needed to improve therapeutic efficacy of this drug. further experimental and well-designed clinical studies are required to explore the protective and therapeutic effects of melatonin as premedication in dentistry. conflict of interest: no references 1. armfield jm, stewart jf, spencer aj. the vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear. bmc oral health. 2007;7:1 https://doi.org/10.1186/1472-6831-7-1 pmid:17222356 pmcid:pmc1784087 2. lu dp, lu wi. practical oral sedation in dentistry, part i: presedation consideration and preparation. compend contin educ dent. 2006;27:453-61. 3. naguib m, gottumukkala v, goldstein pa. melatonin and anesthesia: a clinical perspective. j pineal res. 2007;42:12-21. https://doi.org/10.1111/j.1600-079x.2006.00384.x pmid:17198534 4. acil m, basgul e, celiker v, karagöz ah, demir b, aypar u. perioperative effects of melatonin and midazolam premedication on sedation, orientation, anxiety scores and psychomotor performance. eur j anaesthesiol. 2004;21:553-7. https://doi.org/10.1097/00003643-200407000-00009 pmid:15318468 5. reiter rj, rosales-corral sa, liu xy, acuna-castroviejo d, escames g, tan dx. melatonin in the oral cavity: physiological and pathological implications. j periodont res. 2015;50:9-17. https://doi.org/10.1111/jre.12176 pmid:24665831 6. cutando a, aneiros-fernández j, lópez-valverde a, arias-santiago s, aneiros-cachaza j, reiter rj. a new perspective in oral health: potential importance and actions of melatonin receptors mt1, mt2, mt3, and rzr/ror in the oral cavity. arch oral biol. 2011;56:944-50. https://doi.org/10.1016/j.archoralbio.2011.03.004 pmid:21459362 https://doi.org/10.1186/1472-6831-7-1 https://doi.org/10.1111/j.1600-079x.2006.00384.x https://doi.org/10.1097/00003643-200407000-00009 https://doi.org/10.1111/jre.12176 https://doi.org/10.1016/j.archoralbio.2011.03.004 gupta et al. asian journal of dental and health sciences. 2025; 5(1):50-53 [53] ajdhs.com 7. reiter rj. normal patterns of melatonin levels in the pineal gland and body fluids of humans and experimental animals. j neural transm suppl. 1986;21:35-54. 8. cutando a, gómez-moreno g, arana c, acuña-castroviejo d, reiter rj. melatonin: potential functions in the oral cavity. j periodontol. 2007;78:1094-102. https://doi.org/10.1902/jop.2007.060396 pmid:17539724 9. gómez-moreno g, guardia j, ferrera mj, cutando a, reiter rj. melatonin in diseases of the oral cavity. oral dis. 2010;16:242-7. https://doi.org/10.1111/j.1601-0825.2009.01610.x pmid:19682319 10. tan dx, manchester lc, sanchez-barcelo e, mediavilla md, reiter rj. significance of high levels of endogenous melatonin i˙n mammalian cerebrospinal fluid and i˙n the central nervous system. current neuropharmacology 2010;8(3):162-7 https://doi.org/10.2174/157015910792246182 pmid:21358967 pmcid:pmc3001210 11. tan dx, hardeland r, manchester lc, paredes sd, korkmaz a, sainz rm, et al. the changing biological roles of melatonin during evolution: from an antioxidant to signals of darkness. sexual selection and fitness. biol rev camb philos soc 2010;85(3):60723. https://doi.org/10.1111/j.1469-185x.2009.00118.x pmid:20039865 12. penev pd, zee pc. melatonin: a clinical perspective. ann neurol 1997;42(4):545-53. https://doi.org/10.1002/ana.410420404 pmid:9382465 13. iguchi, h.; kato, k.i.; ibayashi, h. melatonin serum levels and metabolic clearance rate in patients with liver cirrhosis. j. clin. endocrinol. metab. 1982, 54(5), 1025-1027. https://doi.org/10.1210/jcem-54-5-1025 pmid:7061695 14. waldhauser, f.; saletu, b., trinchard-lugan, i. sleep laboratory investigations on hypnotic properties of melatonin. psychopharmacology, 1990, 100(2), 222-226. https://doi.org/10.1007/bf02244410 pmid:2305009 15. donaldson m, gizzarelli g, chanpong b. oral sedation: a primer on anxi olysis for the adult patient. anesth prog. 2007;54:118-28. https://doi.org/10.2344/00033006(2007)54[118:osapoa]2.0.co;2 pmid:17900211 16. naguib m, samarkandi ah. premedication with melatonin: a doubleblind, placebo-controlled comparison with midazolam. br j anaesth. 1999;82:875-80 https://doi.org/10.1093/bja/82.6.875 pmid:10562782 17. naguib m, samarkandi ah. the comparative dose-response effects of melatonin and midazolam for premedication of adult patients: a doubleblinded, placebo-controlled study. anesth analg. 2000;91:473-9. https://doi.org/10.1213/00000539-20000800000046 18. turkistani a, abdullah km, al-shaer aa, mazen kf, alkatheri k. melatonin premedication and the induction dose of propofol. eur j anaesthesiol. 2007;24:399-402. https://doi.org/10.1017/s0265021506001505 pmid:17094871 19. samarkandi a, naguib m, riad w, thalaj a, alotibi w, aldammas f, albas sam a. melatonin vs. midazolam premedication in children: a doubleblind, placebo-controlled study. eur j anaesthesiol. 2005;22:189-96. https://doi.org/10.1097/00003643200503000-00005 pmid:15852991 20. hansen mv, halladin nl, rosenberg j, gögenur i, møller am. melatonin for preand postoperative anxiety in adults. cochrane database syst rev. 2015;4:cd009861. https://doi.org/10.1002/14651858.cd009861.pub2 pmid:25856551 pmcid:pmc6464333 21. patel t, kurdi ms. a comparative study between oral melatonin and oral midazolam on preoperative anxiety, cognitive, and psychomotor func tions. j anaesthesiol clin pharmacol. 2015;31:37-43 https://doi.org/10.4103/0970-9185.150534 pmid:25788771 pmcid:pmc4353150 22. özcengiz d, gunes y, ozmete o. oral melatonin, dexmedetomidine, and midazolam for prevention of postoperative agitation in children. j anesth. 2011;25:184-8. https://doi.org/10.1007/s00540-011-1099-2 pmid:21327805 23. pokharel k, tripathi m, gupta pk, bhattarai b, khatiwada s, subedi a. premedication with oral alprazolam and melatonin combination: a com parison with either alone-a randomized controlled factorial trial. biomed res int. 2014;2014:356964 https://doi.org/10.1155/2014/356964 pmid:24527443 pmcid:pmc3913512 24. gupta s, patra a, das a. melatonin as a nobel approach for uncooperative child an observational study. j global oral health. doi: 10.25259/jgoh_7_2024 https://doi.org/10.25259/jgoh_7_2024 25. cardinali dp, golombek da, rosenstein re, brusco li, vigo de. assessing the efficacy of melatonin to curtail benzodiazepine/z drug abuse. pharmacol res 2016;109:12-23. https://doi.org/10.1016/j.phrs.2015.08.016 pmid:26438969 26. guerra j, devesa j. melatonin exerts anti-inflammatory, antioxidant, and neuromodulatory effects that could potentially be useful in the treatment of vertigo. int j otolaryngol 2021;2021:6641055. https://doi.org/10.1155/2021/6641055 pmid:33859698 pmcid:pmc8009714 27. kain zn, maclaren je, herrmann l, mayes l, rosenbaum a, hata j, et al. preoperative melatonin and its effects on induction and emergence in children undergoing anesthesia and surgery. anesthesiology 2009;111:44-9. https://doi.org/10.1097/aln.0b013e3181a91870 pmid:19546692 28. wilhelmsen m, amirian i, reiter rj, rosenberg j, gögenur i. analgesic effects of melatonin: a review of current evidence from experimental and clinical studies. j pineal res 2011;51:270-7. https://doi.org/10.1111/j.1600-079x.2011.00895.x pmid:21615490 29. edemann-callesen h, andersen hk, ussing a, virring a, jennum p, debes nm, laursen t, baandrup l, gade c, dettmann j, holm j. use of melatonin for children and adolescents with chronic insomnia attributable to disorders beyond indication: a systematic review, meta-analysis and clinical recommendation. eclinicalmedicine. 2023 jul 1;61. https://doi.org/10.1016/j.eclinm.2023.102049 pmid:37457114 pmcid:pmc10339185 30. ansari g, fathi m, ghajari mf, bargrizan m, eghbali a. oral melatonin versus midazolam as premedication for intravenous sedation in pediatric dental patients. j dent (tehran). 2018 sep;15(5):317-324. pmid: 30833978; pmcid: pmc6397733. https://doi.org/10.1902/jop.2007.060396 https://doi.org/10.1111/j.1601-0825.2009.01610.x https://doi.org/10.2174/157015910792246182 https://doi.org/10.1111/j.1469-185x.2009.00118.x https://doi.org/10.1002/ana.410420404 https://doi.org/10.1210/jcem-54-5-1025 https://doi.org/10.1007/bf02244410 https://doi.org/10.2344/0003-3006(2007)54%5b118:osapoa%5d2.0.co;2 https://doi.org/10.2344/0003-3006(2007)54%5b118:osapoa%5d2.0.co;2 https://doi.org/10.1093/bja/82.6.875 https://doi.org/10.1213/00000539-200008000-00046 https://doi.org/10.1213/00000539-200008000-00046 https://doi.org/10.1017/s0265021506001505 https://doi.org/10.1097/00003643-200503000-00005 https://doi.org/10.1097/00003643-200503000-00005 https://doi.org/10.1002/14651858.cd009861.pub2 https://doi.org/10.4103/0970-9185.150534 https://doi.org/10.1007/s00540-011-1099-2 https://doi.org/10.1155/2014/356964 https://doi.org/10.25259/jgoh_7_2024 https://doi.org/10.1016/j.phrs.2015.08.016 https://doi.org/10.1155/2021/6641055 https://doi.org/10.1097/aln.0b013e3181a91870 https://doi.org/10.1111/j.1600-079x.2011.00895.x https://doi.org/10.1016/j.eclinm.2023.102049 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):31-34 [31] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited education as prevention: teaching hiv awareness in low-resource settings emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 12 sep 2024 reviewed 23 oct 2024 accepted 19 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, education as prevention: teaching hiv awareness in low-resource settings, asian journal of dental and health sciences. 2024; 4(3):31-34 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.98 abstract _________________________________________________________________________________________________________________ hiv/aids continues to disproportionately impact low-resource settings, where limited access to healthcare, information, and prevention services exacerbates the epidemic. education is a critical prevention strategy, providing individuals and communities with the tools to understand and reduce hiv transmission risks. this review highlights the transformative role of educational interventions in addressing gaps in awareness, promoting safer practices, and fostering a culture of empathy and acceptance. by tailoring approaches to cultural and societal contexts, education can empower marginalized populations and break down barriers to effective prevention. despite its potential, implementing hiv education in low-resource settings faces significant challenges. these include infrastructural limitations, societal stigma, cultural resistance, and a shortage of trained educators. the lack of funding and inconsistent political support further hinders the reach and sustainability of such programs. addressing these obstacles requires a multi-faceted approach, incorporating community engagement, leveraging technology, and fostering collaborations between public and private sectors. case studies from countries like uganda, south africa, and india demonstrate that innovative, context-specific strategies can overcome these barriers and deliver measurable outcomes. keywords: hiv, education strategies, low-resource settings, community engagement, stigma reduction *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv/aids remains a global public health challenge, disproportionately affecting populations in lowresource settings. these regions often face systemic barriers, including limited healthcare infrastructure, poverty, and a lack of access to accurate information about hiv prevention and treatment. in such contexts, education emerges as a powerful tool for addressing the epidemic. by raising awareness, promoting preventive measures, and reducing stigma, education equips individuals with the knowledge and confidence to make informed decisions regarding their health. teaching hiv awareness in low-resource settings, however, requires innovative, culturally sensitive approaches that address the unique needs and challenges of these communities.12 education serves as a cornerstone of primary prevention, offering individuals the knowledge to protect themselves and others from hiv transmission. it plays a pivotal role in fostering understanding about modes of transmission, the importance of safe practices, and the availability of life-saving treatments such as antiretroviral therapy (art). beyond prevention, education also challenges the stigma and misinformation surrounding hiv/aids, which can be deeply entrenched in cultural and social norms. by normalizing conversations around hiv, educational initiatives can promote a culture of empathy and inclusivity, encouraging those affected by the virus to seek care and support without fear of discrimination.3-5 low-resource settings often grapple with additional layers of complexity in delivering effective hiv education. cultural taboos surrounding discussions of sexuality, reproductive health, and hiv can stifle open communication and impede the dissemination of critical information. compounding this, inadequate infrastructure, such as a lack of schools, teaching materials, or trained educators, further limits the reach of educational programs. despite these challenges, education remains a feasible and cost-effective intervention, particularly when adapted to the local context and implemented through community-based strategies.6-7 community engagement is a critical element of effective hiv education in resource-limited environments. programs that involve local leaders, influencers, and peer educators often have greater acceptance and impact, as they are perceived as more credible and relevant by the target population. moreover, the integration of traditional and modern communication methods, such as storytelling, workshops, and digital tools, can enhance accessibility and retention of information. a focus on empowering youth, women, and open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.98 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.98&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):31-34 [32] ajdhs.com marginalized groups is also essential, as these populations are often at higher risk of hiv transmission and less likely to access preventive resources.8-9 globally, several innovative approaches have demonstrated success in teaching hiv awareness in low-resource settings. for example, mobile technology, including sms-based education campaigns and mobile health applications, has shown promise in reaching remote and underserved populations. school-based programs that integrate hiv awareness into existing curricula provide another avenue for disseminating information to younger generations. meanwhile, peerled initiatives, where individuals from the community are trained to educate others, have proven particularly effective in breaking down stigma and fostering trust.1011 the role of education in hiv prevention education plays a pivotal role in hiv prevention by equipping individuals with the knowledge and skills necessary to protect themselves and others from the virus. it serves as a foundation for understanding hiv transmission routes, prevention strategies, and the availability of treatment options like antiretroviral therapy (art). comprehensive education can help demystify the science of hiv, dispel myths, and provide actionable steps for reducing risk, such as practicing safe sex, using clean needles, and seeking regular testing. empowered with this information, individuals in high-risk settings can make informed decisions that significantly lower their chances of contracting or transmitting the virus.12-13 beyond imparting knowledge, education fosters behavior change and promotes safe practices, particularly among vulnerable populations. for example, teaching adolescents about the importance of condom use, the benefits of delaying sexual activity, and the risks of unprotected sex directly impacts their choices and reduces new hiv infections. similarly, programs targeting pregnant women can reduce vertical transmission through information on prenatal care and treatment adherence. importantly, education is most effective when it is culturally relevant and designed to address the specific needs and barriers of the communities it serves, ensuring that messages resonate and are actionable.14-15 education also plays a critical role in reducing the stigma and discrimination associated with hiv. in many communities, misinformation and fear surrounding the virus contribute to social isolation and hinder access to care. educational initiatives that normalize discussions about hiv can challenge prejudices, build empathy, and encourage affected individuals to seek medical support. schools, workplaces, and community forums are ideal platforms for such interventions, as they provide safe spaces for open dialogue. by reducing stigma and promoting understanding, education not only prevents new infections but also improves the quality of life for those living with hiv.16-17 challenges in low-resource settings implementing effective hiv education programs in lowresource settings presents numerous challenges, primarily stemming from limited infrastructure and funding. many regions lack basic educational facilities, teaching materials, and trained personnel needed to deliver accurate and engaging information. schools, often the primary sites for educational initiatives, may be underfunded or overcrowded, limiting their ability to incorporate hiv awareness programs into the curriculum. additionally, health centers and community organizations, which could serve as alternative education hubs, frequently face resource constraints that hinder their outreach efforts.18-19 cultural and societal factors further complicate the delivery of hiv education in these settings. deeply rooted taboos and stigmas surrounding discussions of sexuality and hiv can create resistance to open conversations about prevention and care. in many communities, topics such as condom use, reproductive health, or hiv testing are considered sensitive or inappropriate, particularly for young people and women. these cultural barriers not only limit the dissemination of information but also perpetuate misinformation and fear, making it challenging to promote behavior change.20-21 another significant challenge is the widespread stigma and discrimination associated with hiv/aids. in lowresource settings, individuals living with hiv or participating in educational programs may face ostracization or social backlash. this fear often discourages people from attending workshops, accessing testing services, or seeking treatment. compounding this issue is a shortage of trained educators equipped to address these sensitive topics with empathy and cultural sensitivity. without skilled facilitators, educational programs may fail to engage communities effectively or inadvertently reinforce negative stereotypes. addressing these multifaceted challenges requires innovative, context-specific approaches to ensure the success of hiv prevention efforts.22-23 strategies for effective hiv education implementing effective hiv education in low-resource settings requires tailored strategies that address unique community needs while overcoming systemic and cultural barriers. one of the most effective approaches is community-led education, which involves partnering with local leaders, influencers, and peer educators to design and deliver programs. these individuals often have a deep understanding of cultural nuances and societal dynamics, allowing them to communicate messages in ways that resonate with their communities. peer-led initiatives, in particular, empower individuals from the target population to educate their peers, fostering trust and enhancing program credibility.24-27 integrating technology into hiv education programs offers a scalable and cost-effective way to reach underserved populations. mobile phones, which are increasingly accessible even in remote areas, can be leveraged for sms campaigns, interactive health applications, and tele-education platforms. these tools can provide accurate, timely information on hiv prevention, testing, and treatment while overcoming geographical barriers. social media platforms also offer opportunities to engage younger audiences through relatable content, peer discussions, and awareness emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):31-34 [33] ajdhs.com campaigns, creating a broader reach at relatively low costs.28-31 school-based interventions remain a cornerstone of hiv education, especially for reaching younger generations. incorporating hiv awareness into existing curricula ensures that students receive accurate, age-appropriate information. interactive methods, such as role-playing, discussions, and scenario-based learning, can make these sessions more engaging and impactful. beyond schools, workshops, and community forums can serve as platforms to educate adults and marginalized groups, such as sex workers and individuals who inject drugs. by employing a combination of these strategies—community involvement, technology integration, and targeted outreach—hiv education programs can overcome barriers and create lasting behavioral change in lowresource settings.32-33 recommendations for future interventions to strengthen hiv education in low-resource settings, future interventions must prioritize culturally sensitive and context-specific approaches. tailoring educational content to align with local traditions, languages, and beliefs ensures that communities can better relate to and adopt the messages. engaging religious leaders, traditional healers, and other influential community figures in program design and delivery can also enhance credibility and acceptance. additionally, gendersensitive approaches are essential to address unique vulnerabilities and empower women and girls, who often face the highest risks in these regions. investment in training programs for educators is critical for sustainable hiv education efforts. training should focus not only on equipping educators with accurate knowledge but also on building their skills in handling sensitive topics with empathy and cultural competence. creating a pipeline of local, community-based educators ensures continuity and builds trust within the population. to complement this, governments and nongovernmental organizations must allocate more resources to infrastructure, including educational materials, multimedia tools, and spaces conducive to learning, to address the gaps in access and quality. lastly, robust monitoring and evaluation mechanisms are necessary to assess the impact of hiv education initiatives and identify areas for improvement. collecting data on program outcomes, such as changes in knowledge, attitudes, and behaviors, provides insights into what works and allows for evidence-based scaling of successful strategies. future programs should also embrace technological advancements, such as mobile health (mhealth) platforms and artificial intelligence, to enhance delivery and reach. with sustained investment and innovation, hiv education can play an even more significant role in reducing the prevalence of the virus in low-resource settings. conclusion education remains one of the most powerful tools in the fight against hiv, particularly in low-resource settings where systemic barriers and cultural challenges exacerbate the epidemic. by providing accurate information, promoting behavior change, and reducing stigma, educational initiatives can empower individuals and communities to take proactive steps in preventing hiv transmission. the success of such programs, however, depends on their ability to address local needs, incorporate cultural sensitivities, and leverage community engagement. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):31-34 [34] ajdhs.com acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [34] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited differential diagnosis of anemia in pregnancy using mentzer index: a narrative review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 10 nov 2024 reviewed 19 dec 2024 accepted 16 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, differential diagnosis of anemia in pregnancy using mentzer index: a narrative review, asian journal of dental and health sciences. 2025; 5(1):34-39 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.117 abstract _________________________________________________________________________________________________________________ anemia in pregnancy remains a significant global health concern, contributing to adverse maternal and fetal outcomes. among its most common etiologies are iron-deficiency anemia (ida) and thalassemia traits, both requiring distinct management strategies. the mentzer index, calculated as the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count, has emerged as a practical, cost-effective tool for differentiating between these conditions. this simple calculation leverages routine complete blood count (cbc) parameters, offering a quick and accessible approach to initial anemia diagnosis in prenatal care. this review explores the utility of the mentzer index in diagnosing anemia in pregnancy, focusing on its advantages and limitations. by distinguishing ida from thalassemia traits, the index supports tailored interventions, minimizing complications such as iron overload or untreated anemia. its integration into routine antenatal care is particularly beneficial in resource-limited settings, where advanced diagnostic modalities are often unavailable. keywords: mentzer index, anemia in pregnancy, iron-deficiency anemia, thalassemia traits, differential diagnosis *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia is a significant public health issue affecting approximately 40% of pregnant women worldwide. the condition is defined as a reduction in hemoglobin concentration below the threshold needed to meet the body’s physiological requirements, leading to reduced oxygen delivery to tissues. pregnant women are particularly vulnerable due to increased iron demands for maternal and fetal development, compounded by potential underlying genetic factors. anemia during pregnancy is associated with serious maternal and fetal complications, including preterm delivery, low birth weight, and increased risk of maternal mortality. identifying the underlying cause of anemia is crucial for its effective management and prevention of associated adverse outcomes.1-2 the most common causes of anemia in pregnancy are iron-deficiency anemia (ida) and thalassemia traits. ida, characterized by low iron stores and inadequate hemoglobin production, is primarily driven by poor dietary intake, malabsorption, or increased iron demands during pregnancy. thalassemia traits, on the other hand, result from genetic mutations affecting hemoglobin synthesis, leading to microcytosis and varying degrees of anemia. these conditions require different management strategies, emphasizing the need for accurate differential diagnosis to avoid inappropriate treatments that may worsen patient outcomes, such as unnecessary iron supplementation in thalassemia.3 differentiating ida from thalassemia traits can be challenging due to overlapping clinical and laboratory features, such as microcytosis and hypochromia. misdiagnosis can lead to ineffective or harmful treatment strategies. for instance, administering iron supplements to a patient with thalassemia traits may result in iron overload and exacerbate complications. similarly, overlooking irondeficiency anemia in favor of thalassemia could lead to untreated anemia and its complications. therefore, accurate and cost-effective diagnostic tools are essential, particularly in resource-limited settings where advanced testing methods like hemoglobin electrophoresis or genetic studies are not readily available.4 the mentzer index (mi), calculated as the ratio of mean corpuscular volume (mcv) to red blood cell (rbc) count, is a practical and widely used screening tool for distinguishing between ida and thalassemia traits. values greater than 13 typically suggest ida, while values below 13 are indicative of thalassemia traits. this index leverages parameters obtained from a routine complete blood count (cbc), making it a low-cost and accessible method for initial anemia assessment. its simplicity and applicability in diverse clinical settings have made it a valuable addition to prenatal care.5 in pregnant populations, the mentzer index plays a critical role in guiding anemia management, especially during open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.117 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.117&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [35] ajdhs.com routine antenatal visits. early differentiation of anemia types enables timely and targeted interventions, reducing the risk of complications for both the mother and the fetus. moreover, the mentzer index's reliance on basic cbc parameters aligns well with the resource constraints of many lowand middle-income countries, where advanced diagnostics may be unavailable. despite these advantages, its application in pregnancy is not without limitations, as physiological changes during gestation can influence hematological parameters and affect the reliability of the index.6-7this review aims to examine the role of the mentzer index in the differential diagnosis of anemia in pregnancy, emphasizing its clinical utility, advantages, and limitations. etiologies of anemia in pregnancy anemia in pregnancy can arise from several underlying causes, with iron-deficiency anemia (ida) and thalassemia traits being the most common. identifying the specific etiology of anemia is crucial, as each type requires a distinct management approach. the primary causes of anemia during pregnancy include nutritional deficiencies, genetic factors, and other medical conditions that can affect the body’s ability to produce or maintain red blood cells.8 1. iron-deficiency anemia (ida) iron-deficiency anemia is the most prevalent form of anemia during pregnancy. it occurs when the body lacks sufficient iron to produce hemoglobin, a key protein in red blood cells responsible for oxygen transport. pregnancy increases iron requirements due to the growing fetus and placenta, increased blood volume, and the need to prepare for childbirth. if dietary intake is inadequate or absorption is impaired, it can lead to depleted iron stores, resulting in ida. the hallmark of ida is microcytic, hypochromic anemia, which can be detected through a routine blood test showing low hemoglobin levels, decreased mean corpuscular volume (mcv), and low ferritin levels.9 2. thalassemia traits thalassemia, a genetic disorder affecting hemoglobin production, is another significant cause of anemia in pregnancy. in thalassemia, the body produces an abnormal form of hemoglobin due to mutations in the alpha or beta globin genes. thalassemia traits are inherited and often go undiagnosed until an individual experiences symptoms, such as anemia during pregnancy. this condition typically results in mild microcytic anemia with normal or slightly elevated rbc count. however, it is distinguished from ida by the absence of iron deficiency. thalassemia traits are especially prevalent in populations of mediterranean, middle eastern, african, and southeast asian descent.10 3. anemia of chronic disease (acd) anemia of chronic disease (acd) is another potential cause of anemia in pregnancy, especially in women with pre-existing medical conditions such as chronic infections, inflammatory disorders, or kidney disease. this type of anemia is typically normocytic and normochromic, characterized by a normal mcv and mch, but a reduced hemoglobin level due to the body’s response to chronic illness. during pregnancy, the increased inflammatory state and physiological changes can exacerbate acd, making it an important consideration in the differential diagnosis of anemia.11 4. folate and vitamin b12 deficiency anemia deficiencies in folate or vitamin b12 are another cause of anemia during pregnancy. folate is essential for dna synthesis and red blood cell production, and a deficiency can lead to megaloblastic anemia, characterized by large, immature red blood cells. pregnant women are at higher risk of folate deficiency due to increased demand for folate during fetal development. similarly, vitamin b12 deficiency can lead to similar megaloblastic anemia and may also cause neurological complications if left untreated. these deficiencies often result in symptoms of fatigue, pallor, and weakness, and can be confirmed by blood tests showing elevated mean corpuscular volume (mcv) and abnormal levels of folate or vitamin b12.12 5. sickle cell disease sickle cell disease is a genetic disorder that affects the shape of red blood cells, making them rigid and sickleshaped, leading to blocked blood flow, pain, and hemolysis. pregnant women with sickle cell disease may experience anemia due to the rapid breakdown of these abnormally shaped cells. this form of anemia is typically normocytic but can be complicated by episodes of hemolysis and vaso-occlusive crises. management of anemia in sickle cell disease requires careful monitoring, as iron supplementation is usually not indicated due to the risk of iron overload.13 6. hemolytic anemia hemolytic anemia can occur in pregnancy due to autoimmune diseases, infections, or certain medications that trigger the premature destruction of red blood cells. conditions like autoimmune hemolytic anemia or malaria can lead to a significant reduction in red blood cell count, presenting as anemia. this condition can be diagnosed based on peripheral blood smear findings, showing fragmented red blood cells, and laboratory tests demonstrating elevated reticulocyte count, which indicates increased red blood cell production in response to hemolysis.14 7. acute blood loss acute blood loss, often due to trauma, hemorrhage during delivery, or placental complications like placental abruption, is another cause of anemia in pregnancy. this form of anemia is typically normocytic and can cause a rapid decline in hemoglobin levels. immediate medical intervention is required to stabilize the mother and fetus, and blood transfusion may be necessary depending on the severity of the blood loss.15 8. pregnancy-related hemodilution during pregnancy, the body undergoes hemodilution due to the expansion of plasma volume, leading to a relative decrease in hemoglobin concentration. this dilution effect can sometimes mask underlying anemia, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [36] ajdhs.com particularly in the second and third trimesters. however, the physiological increase in blood volume is typically not sufficient to cause a significant drop in hemoglobin levels, and this condition resolves after delivery. it is important to differentiate hemodilution from actual anemia, as treatment strategies differ.16 the role of mentzer index in differential diagnosis differentiating between the various causes of anemia in pregnancy is crucial for ensuring appropriate treatment and minimizing potential complications for both the mother and the fetus. among the most common forms of anemia during pregnancy are iron-deficiency anemia (ida) and thalassemia traits, both of which can present with similar clinical symptoms but require distinct management strategies. the mentzer index (mi) has emerged as a practical, cost-effective tool to assist clinicians in distinguishing between these two conditions, thereby enabling more accurate diagnoses and guiding subsequent treatment choices.17 irondeficiency anemia and thalassemia traits share many clinical features, including fatigue, pallor, and mild microcytic anemia, making differential diagnosis challenging without appropriate diagnostic tools. the mentzer index helps to address this diagnostic challenge by using readily available cbc parameters. in ida, iron deficiency impairs the ability of the body to produce sufficient hemoglobin, leading to reduced hemoglobin levels and smaller red blood cells (microcytosis). in thalassemia traits, however, the body compensates for defective hemoglobin production by increasing rbc count, although these cells remain small (microcytic). thus, while both conditions exhibit microcytic anemia, the key difference is that ida typically has a higher mcv-to-rbc ratio, whereas thalassemia traits feature a lower ratio.18 the use of the mentzer index in pregnancy is particularly valuable, as pregnant women are at increased risk for both ida and thalassemia traits. thalassemia traits, common in individuals of mediterranean, african, and southeast asian descent, may go undiagnosed until the woman presents with anemia during pregnancy. differentiating between these conditions is essential because iron supplementation, a cornerstone of ida management, can lead to iron overload and exacerbate complications in individuals with thalassemia traits. in such cases, early and accurate identification through the mentzer index can help prevent unnecessary iron supplementation, ensuring that patients receive the appropriate treatment for their condition.19 in many resource-limited settings, access to advanced diagnostic techniques, such as hemoglobin electrophoresis or genetic testing, is limited or unavailable. in these circumstances, the mentzer index provides a cost-effective and accessible tool for clinicians to differentiate between ida and thalassemia traits. by using only routine cbc parameters, which are commonly available in most healthcare facilities, the mentzer index can help guide initial diagnosis and treatment decisions. this is particularly important in low-income countries or areas with high prevalence rates of thalassemia, where healthcare resources may be stretched thin, and timely access to specialized tests may be difficult.20 the simplicity of the mentzer index also makes it an attractive option for integration into routine prenatal care. during regular antenatal visits, pregnant women are routinely screened for anemia using cbc, and the mentzer index can be calculated easily from the results of these tests. in settings where time and resources are constrained, this simple calculation can serve as an invaluable first-line tool for the differential diagnosis of anemia, allowing clinicians to prioritize further investigation or intervention where necessary.21 given the limitations of the mentzer index, it is crucial to use it in conjunction with other diagnostic tools for a more comprehensive assessment of anemia in pregnancy. additional tests, such as measuring serum ferritin, transferrin saturation, or conducting hemoglobin electrophoresis, can help confirm the diagnosis of ida or thalassemia traits. in cases where the mentzer index provides borderline or unclear results, these supplementary tests can clarify the diagnosis, ensuring that appropriate treatment is provided. for example, serum ferritin is a key marker of iron stores and can help confirm whether a patient’s anemia is due to iron deficiency, while hemoglobin electrophoresis can definitively identify thalassemia or other hemoglobinopathies.22 limitations and challenges despite its utility in the differential diagnosis of anemia, particularly in distinguishing between iron-deficiency anemia (ida) and thalassemia traits, the mentzer index (mi) has several limitations and challenges that must be considered when applying it in clinical practice, particularly in pregnancy. 1. physiological changes during pregnancy pregnancy introduces physiological changes that can impact the hematological parameters used in the mentzer index calculation. for example, the increased plasma volume and hemodilution during pregnancy can lead to a lower hemoglobin concentration and rbc count, which may skew the results of the mi. this hemodilution effect can make it challenging to differentiate between iron-deficiency anemia and thalassemia traits, as both conditions may present with low rbc count and microcytic anemia. the standard mi values used to differentiate these conditions may not be applicable to pregnant women due to these physiological changes, which may necessitate further testing, such as ferritin levels or hemoglobin electrophoresis, to confirm the diagnosis.23 2. lack of specificity in mixed anemia the mentzer index is primarily effective in distinguishing between ida and thalassemia traits, but it may not be as reliable when mixed forms of anemia are present. for instance, a patient may have both irondeficiency anemia and thalassemia traits, which could lead to overlapping characteristics and result in ambiguous mi values. in such cases, the mi might not emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [37] ajdhs.com provide a definitive diagnosis, leading to potential misinterpretation. additionally, other causes of anemia, such as anemia of chronic disease (acd) or folate and vitamin b12 deficiencies, can present with similar mcv and rbc count values, complicating the use of the mentzer index as a sole diagnostic tool.24 3. dependence on accurate laboratory values the accuracy of the mentzer index relies heavily on the quality of the underlying laboratory tests, specifically the measurement of mean corpuscular volume (mcv) and red blood cell (rbc) count. errors in these tests, due to machine calibration, human error, or sample quality, can result in misleading mi values. inadequate blood samples, variations in laboratory techniques, or the presence of certain factors, such as dehydration, can lead to inaccuracies in mcv or rbc count, thereby affecting the reliability of the mi in diagnosing anemia. this dependency on accurate laboratory values underscores the need for careful testing and interpretation, especially in the context of pregnancy, where numerous factors can influence blood test results.25 4. inability to diagnose other hematological disorders while the mentzer index is helpful in distinguishing between ida and thalassemia traits, it does not provide information about other types of anemia or underlying hematological disorders. conditions such as sickle cell disease, autoimmune hemolytic anemia, or megaloblastic anemia due to folate or vitamin b12 deficiency require additional diagnostic testing, such as hemoglobin electrophoresis, reticulocyte count, and vitamin assays, to confirm the diagnosis. the mi’s limited scope may lead to an incomplete diagnostic picture if relied upon as the sole method of evaluation. in cases of complex or atypical anemia, further investigation is necessary to identify the root cause.26 5. influence of hemoglobinopathies and variants in populations with a high prevalence of hemoglobinopathies, such as sickle cell disease, hemoglobin c, or other genetic variants, the mentzer index may be less reliable. hemoglobinopathies can alter the rbc count, mcv, and other hematological parameters in ways that are not captured by the mi. for example, individuals with sickle cell disease or hemoglobin c disease may exhibit microcytic or normocytic anemia, which could lead to misinterpretation of the mi and confusion with ida or thalassemia. in these cases, additional diagnostic methods, such as hemoglobin electrophoresis or molecular testing, are required to accurately identify the condition.27 6. limited sensitivity in pregnancy the sensitivity of the mentzer index in detecting anemia in pregnant populations is lower compared to its performance in non-pregnant individuals. pregnant women may present with various forms of anemia that do not conform strictly to the patterns seen in ida or thalassemia, especially if there are complications such as preeclampsia, gestational diabetes, or other medical conditions. these conditions can affect the mcv, rbc count, and other hematological parameters, leading to less accurate mi values. as a result, the mi may not always provide a clear or reliable distinction between different types of anemia in pregnant women, making the use of supplementary diagnostic tests essential.20 7. variations in population-specific values the cut-off values used for the mentzer index (typically mi <13 indicating thalassemia and mi >13 indicating ida) are based on population studies and may not be universally applicable across all populations. genetic and ethnic differences can influence mcv and rbc counts, meaning that the mi thresholds may vary in different geographic or demographic groups. for example, in populations with a high prevalence of thalassemia or other hemoglobinopathies, the mi cut-off may need to be adjusted to account for regional differences in hematological profiles. this variability in mi interpretation could lead to misdiagnoses if population-specific adjustments are not considered.21 clinical implications the mentzer index (mi) offers significant clinical value in the diagnosis and management of anemia during pregnancy, particularly in distinguishing between irondeficiency anemia (ida) and thalassemia traits. however, its application must be carefully considered within the broader clinical context to ensure accurate diagnosis and effective treatment. 1. early differentiation between ida and thalassemia traits one of the primary clinical implications of the mentzer index is its ability to assist in early differentiation between iron-deficiency anemia and thalassemia traits, which can present with similar symptoms of microcytic anemia. iron-deficiency anemia, which is often due to inadequate iron intake or increased iron requirements during pregnancy, responds well to iron supplementation. in contrast, thalassemia traits, which are genetic disorders affecting hemoglobin production, are not treated with iron and can actually be exacerbated by iron supplementation. the ability to differentiate between these two conditions using the mi can help prevent the inappropriate use of iron supplements, thereby avoiding potential complications like iron overload in patients with thalassemia traits. accurate early diagnosis ensures that pregnant women receive the appropriate treatment tailored to their specific condition, reducing the risk of adverse outcomes for both the mother and the fetus.22 2. facilitating cost-effective diagnosis in resourcelimited settings in resource-limited settings, where access to advanced diagnostic tools such as hemoglobin electrophoresis or genetic screening may be unavailable, the mentzer index provides a cost-effective and easily accessible method for distinguishing between ida and thalassemia traits. as it relies solely on parameters from a routine complete blood count (cbc), which is commonly emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [38] ajdhs.com available even in settings with limited resources, the mi serves as a valuable first-line tool for clinical decisionmaking. in areas with a high prevalence of thalassemia traits, the mi can help healthcare providers promptly identify patients who may require further diagnostic testing, such as hemoglobin electrophoresis, while avoiding unnecessary interventions or misdiagnoses. this can lead to more efficient use of healthcare resources and better-targeted care for pregnant women with anemia.23 3. risk stratification and management decisions accurate identification of the type of anemia in pregnancy can have significant implications for management decisions. for instance, ida is typically treated with oral or intravenous iron supplementation, dietary adjustments, and in some cases, blood transfusions if the anemia is severe. on the other hand, thalassemia traits usually require no iron therapy, and management focuses on monitoring and ensuring that the patient does not receive excessive iron. additionally, identifying thalassemia traits may prompt genetic counseling, as it has implications for the patient’s offspring and the risk of having a child with thalassemia major. by using the mi to differentiate between these conditions, clinicians can tailor their management plans more effectively, improving maternal and fetal outcomes by ensuring the right interventions are implemented.24 4. prevention of misdiagnosis and over-treatment the clinical implications of misdiagnosing anemia are significant, especially in pregnancy, where both the mother and fetus are vulnerable. misdiagnosis can lead to inappropriate treatments, such as the overuse of iron supplements in patients with thalassemia traits, potentially resulting in iron overload and other related complications, including organ damage. conversely, failure to identify thalassemia traits could delay appropriate genetic counseling and interventions. by incorporating the mentzer index into clinical practice, healthcare providers can reduce the risk of overtreatment and prevent unnecessary interventions, ensuring that patients are not exposed to harmful therapies that do not address the underlying cause of anemia.25 5. guiding prenatal care and monitoring the mentzer index also plays a role in guiding the overall prenatal care and monitoring of pregnant women with anemia. regular screening for anemia is a routine part of prenatal care, and the mi can help clinicians determine whether further investigation is necessary. for example, if the mi suggests the possibility of thalassemia traits, clinicians may recommend genetic testing or hemoglobin electrophoresis to confirm the diagnosis. if ida is suspected, the focus will shift to iron supplementation and addressing dietary deficiencies. by using the mi as a screening tool, clinicians can more efficiently determine the appropriate next steps in managing anemia and provide personalized care for pregnant women. this proactive approach to monitoring can reduce the risk of complications, such as preterm delivery, low birth weight, and fetal growth restriction, which are often associated with untreated anemia during pregnancy.26 6. ethical and social implications the use of the mentzer index in pregnancy also carries ethical and social implications, particularly in populations where thalassemia traits are prevalent. in such populations, early identification of thalassemia traits allows for informed genetic counseling, which can help prospective parents understand the implications of carrier status and the risk of passing on thalassemia major to their children. this can lead to better reproductive decision-making and early interventions, such as prenatal diagnosis, in cases where both parents are carriers. however, this also raises ethical concerns about how genetic information is communicated to patients, particularly in settings where there may be limited understanding or stigma associated with certain genetic conditions. healthcare providers must approach the use of the mentzer index and subsequent counseling with sensitivity, ensuring that patients receive appropriate support and information.27 conclusion the mentzer index (mi) is a valuable diagnostic tool for the differential diagnosis of anemia in pregnancy, particularly in distinguishing between iron-deficiency anemia (ida) and thalassemia traits. its simplicity, costeffectiveness, and ease of use make it an essential tool in clinical practice, especially in resource-limited settings where advanced diagnostic techniques may not be readily available. the mi can assist healthcare providers in making informed decisions about the appropriate treatment, such as iron supplementation for ida or avoiding iron therapy in individuals with thalassemia traits. this early differentiation helps to prevent the misuse of iron supplements, reducing the risk of iron overload and associated complications in pregnant women with thalassemia traits. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 https://doi.org/10.3945/ajcn.115.107896 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):34-39 [39] ajdhs.com 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):20-24 [20] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited fighting hiv at the grassroots: local leadership in prevention programs emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 19 sep 2024 reviewed 28 oct 2024 accepted 21 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, fighting hiv at the grassroots: local leadership in prevention programs, asian journal of dental and health sciences. 2024; 4(3):20-24 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.94 abstract _________________________________________________________________________________________________________________ hiv prevention has seen significant advancements through various approaches, yet one of the most impactful strategies is leveraging local leadership in grassroots communities. local leaders, including health workers, religious figures, and community activists, play a crucial role in shaping attitudes, reducing stigma, and mobilizing resources for hiv prevention. this review highlights the importance of community-driven hiv prevention programs and examines how local leadership fosters trust, promotes safer behaviors, and ensures sustainability in tackling the epidemic. it emphasizes the unique position of grassroots leaders to bridge the gap between formal healthcare systems and underserved communities. the success of grassroots hiv prevention initiatives has been evident in regions such as sub-saharan africa and parts of asia, where community health workers and faith-based leaders have led impactful programs. these leaders are often better equipped to address the specific cultural and social contexts of the populations they serve. by incorporating culturally relevant education, advocacy, and healthcare resources, local leaders effectively reduce barriers to hiv care and prevention. however, the success of such programs is not without challenges, including the persistence of stigma, limited resources, and the need for more formal training for local leaders. keywords: hiv prevention, grassroots leadership, community-based programs, local leadership, public health *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv continues to be a significant global public health challenge, with millions of individuals worldwide living with the virus. despite the availability of advanced treatments and prevention strategies, the spread of hiv remains prevalent in many regions, particularly in underserved communities. one of the most critical factors contributing to the persistent hiv epidemic is the difficulty in reaching vulnerable populations with effective prevention programs. to combat this, the role of grassroots leadership in hiv prevention has become increasingly important. local leaders, including health workers, community activists, and religious figures, are uniquely positioned to address the cultural, social, and economic factors that influence hiv transmission in their communities.1-2 grassroots leadership in hiv prevention involves community-based efforts that are spearheaded by individuals who are deeply embedded in the social and cultural fabric of the population they serve. these leaders often have a more intimate understanding of the challenges faced by their communities, which enables them to tailor prevention messages and strategies to local needs. unlike top-down interventions, which may lack the personal touch required to overcome mistrust, grassroots leaders can build strong relationships within their communities, reduce stigma, and foster a sense of collective responsibility in hiv prevention. this communitydriven approach not only increases the likelihood of engagement but also ensures that prevention efforts are sustained over time.3-4 the success of local leadership in hiv prevention can be seen in various community-driven initiatives worldwide. in countries with high hiv prevalence, community health workers (chws) have been instrumental in educating populations about safe sexual practices, distributing condoms, and promoting hiv testing. these leaders are often seen as trusted figures who can provide both emotional and logistical support to those at risk of or living with hiv. their role extends beyond just health education—they are also advocates for policies that ensure better healthcare access and resources for those most affected by the epidemic. in many cases, community leaders have played a pivotal role in advocating for increased funding, resources, and healthcare services for people living with hiv (plhiv), thereby improving access to prevention and treatment.56 local leadership in hiv prevention also helps address one of the most significant barriers to care: stigma. in many regions, hiv is still highly stigmatized, and individuals affected by the virus often face discrimination and isolation. grassroots leaders can open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.94 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.94&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):20-24 [21] ajdhs.com combat this stigma by normalizing discussions about hiv, making it a topic that is openly discussed in social, religious, and community settings. in doing so, they reduce the fear and shame associated with hiv testing and treatment, encouraging more people to get tested and seek care. religious leaders, in particular, have had a significant impact in this regard, as they can use their platforms to promote understanding and acceptance within their congregations.7-8 while the benefits of grassroots leadership in hiv prevention are clear, challenges remain in ensuring the effectiveness and sustainability of such efforts. one major challenge is the lack of resources available to support local leadership in hiv prevention. many community-based programs struggle with insufficient funding, inadequate training, and limited access to healthcare infrastructure. as a result, local leaders often face difficulties in reaching the most vulnerable groups, such as young people, sex workers, and men who have sex with men, who may be more resistant to traditional public health messaging. additionally, some communities may have deeply ingrained beliefs or practices that hinder the acceptance of hiv prevention efforts, making it essential for local leaders to be equipped with the skills to navigate these complexities.9-10 the role of local leadership in hiv prevention local leadership plays a pivotal role in the success of hiv prevention initiatives, particularly in underserved and high-risk communities. these leaders—who can be health professionals, religious figures, community organizers, and activists—are often the first point of contact for individuals seeking information or support regarding hiv. unlike top-down, government-led approaches, local leaders can create a more personalized and culturally sensitive environment for hiv prevention. their deep understanding of local customs, traditions, and social dynamics allows them to tailor prevention messages and interventions to address the specific needs and concerns of their communities.1112 one of the most important roles of local leadership in hiv prevention is building trust within the community. trust is a critical factor in ensuring that individuals participate in prevention programs such as hiv testing, safe sex education, and condom distribution. in many areas, communities may be distrustful of external authorities or healthcare providers due to historical stigma, discrimination, or past negative experiences with the healthcare system. local leaders, who are often seen as members of the community, can break down these barriers by fostering relationships and demonstrating empathy. their involvement allows for open dialogue, making it easier to discuss hiv and other sensitive issues such as sexual health, drug use, and gender-based violence.13-14 moreover, local leaders can significantly reduce the stigma associated with hiv by normalizing conversations about the virus. hiv-related stigma is a major obstacle to prevention and care, as individuals may avoid hiv testing or treatment due to fear of discrimination or exclusion. by publicly speaking out about hiv, educating their communities, and demonstrating a commitment to combating stigma, local leaders can create a more supportive and inclusive environment. religious leaders, for instance, have been instrumental in shifting attitudes toward hiv in many regions by framing hiv prevention as part of their moral or ethical duties. their influence can help to challenge misconceptions, reduce fear, and encourage healthier behaviors.15-16 local leadership is also crucial for ensuring the sustainability of hiv prevention efforts. grassroots leaders are often best positioned to identify local needs and resource gaps, advocating for solutions that are relevant and practical. they can engage with local stakeholders, such as schools, workplaces, and healthcare facilities, to coordinate comprehensive hiv prevention efforts. their intimate knowledge of the community’s dynamics allows them to identify high-risk populations, such as youth, sex workers, or people who inject drugs, and design targeted interventions for these groups. local leaders can also serve as intermediaries between international organizations and local populations, ensuring that global hiv prevention strategies are culturally relevant and well-accepted.17-18 another significant role of local leadership is in the area of peer education and support. community leaders often act as role models and mentors, providing guidance to individuals at risk of hiv or those living with the virus. peer educators can help demystify hiv testing and treatment, provide emotional support, and motivate others to adopt preventive measures. this approach is especially effective in communities with high levels of misinformation or resistance to public health messages. by promoting peer-to-peer interactions, local leaders can increase awareness, encourage behavior change, and enhance adherence to hiv prevention strategies.1920 overcoming challenges in grassroots hiv prevention while grassroots leadership plays a critical role in hiv prevention, several challenges impede the full effectiveness of community-driven initiatives. these challenges can range from resource constraints and lack of training to entrenched social and cultural barriers. understanding these obstacles and finding practical solutions is essential to strengthening grassroots hiv prevention programs and ensuring their long-term success.21 one of the primary challenges facing grassroots hiv prevention is the lack of adequate resources. many community-based organizations and local leaders struggle with insufficient funding to implement prevention programs, conduct outreach, or offer ongoing education and support. this lack of financial support can limit the scope of prevention efforts, preventing local leaders from reaching the broader population or providing necessary services such as hiv testing, treatment, and counseling. additionally, without adequate resources, community leaders may be unable to train their peers, provide educational materials, or access the necessary tools for effective prevention (such as condoms, hiv testing kits, or medication). addressing these resource gaps requires investment from both governmental and nongovernmental organizations, along with the emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):20-24 [22] ajdhs.com establishment of sustainable funding mechanisms that prioritize community-based approaches to hiv prevention.22-23 another significant barrier is the lack of formal training and capacity-building for local leaders. while grassroots leaders often possess valuable local knowledge and community connections, they may not have the specialized training needed to effectively address hiv prevention, healthcare, or education. in some cases, local leaders may not be equipped to manage the complexities of hiv-related health issues, leading to a gap in the effectiveness of prevention strategies. additionally, without proper training, community leaders may struggle with understanding the latest medical developments, such as new prevention methods (e.g., prep), or the most effective ways to engage marginalized populations, such as men who have sex with men or people who inject drugs. providing formal training for grassroots leaders in hiv education, counseling, and healthcare delivery is essential to enhance their effectiveness. this can be done through collaboration with local health departments or hivfocused organizations to provide capacity-building workshops, training programs, and ongoing professional development.24-25 cultural and social barriers also present significant challenges in grassroots hiv prevention efforts. in many communities, hiv is still surrounded by stigma, misinformation, and fear, making it difficult for individuals to seek help or access prevention services. these barriers can be especially prevalent in conservative or rural areas where there may be limited awareness of hiv and its transmission, or where certain behaviors (such as condom use or same-sex relationships) are viewed negatively. grassroots leaders are uniquely positioned to address these issues, but they may face resistance from community members who are deeply entrenched in these views. overcoming these barriers requires not only educational campaigns that address myths and misconceptions about hiv but also strong advocacy efforts that focus on reducing stigma. local leaders can use their positions of trust and influence to challenge harmful norms, normalize hiv testing, and create a more open environment for hiv-related conversations. partnerships with religious and cultural leaders can also help shift attitudes by reframing hiv prevention as part of a broader moral or health responsibility.26-27 another key challenge is the lack of coordination and integration between grassroots initiatives and formal healthcare systems. in many cases, community-based programs operate in silos, without strong connections to national hiv prevention efforts or healthcare providers. this lack of coordination can result in fragmented services, missed opportunities for referral to healthcare services, and duplication of resources. for instance, local leaders might be conducting awareness campaigns, but individuals who need medical care for hiv prevention or treatment may not know where to go or may encounter barriers when accessing formal healthcare services. to address this challenge, it is important to establish clear lines of communication and collaboration between grassroots organizations, healthcare providers, and policymakers. this can be done through joint training sessions, shared resources, and coordinated efforts to ensure that grassroots initiatives align with national hiv prevention strategies and those individuals can seamlessly access both prevention education and medical care.28-29 finally, political instability, economic challenges, and legal barriers can significantly hinder grassroots hiv prevention efforts. in some regions, hiv-related policies may not prioritize community-based interventions, or there may be legal restrictions on certain hiv prevention methods, such as needle exchange programs or harm-reduction strategies. furthermore, political instability can disrupt public health efforts, making it difficult for local leaders to maintain continuity in hiv prevention work. overcoming these challenges requires advocacy at the local, national, and international levels to ensure that policies support and recognize the importance of grassroots involvement in hiv prevention. additionally, ensuring the political and economic stability of hiv programs is vital for their long-term success. this might involve advocating for policies that allow for greater funding for grassroots initiatives, the removal of punitive laws against highrisk populations, and creating an environment that supports human rights and public health.30-333 conclusion grassroots leadership plays an indispensable role in hiv prevention, particularly in underserved and high-risk communities. local leaders, through their intimate understanding of cultural dynamics and community needs, can bridge gaps in awareness, provide education, and foster trust around hiv-related issues. by focusing on the unique strengths and capacities of local communities, these leaders create environments where individuals feel empowered to seek out hiv prevention services, access care, and reduce stigma. however, despite their pivotal role, several challenges persist, including resource limitations, the need for formal training, social and cultural barriers, and a lack of coordination with formal healthcare systems. overcoming these challenges requires a comprehensive approach that involves investing in local leadership through training and capacity-building, securing adequate resources, fostering collaboration between grassroots efforts and healthcare providers, and addressing cultural and political barriers. strong partnerships among local, national, and international stakeholders are critical to ensuring that hiv prevention initiatives are effective and sustainable. moreover, advocating for policies that support grassroots involvement, reduce stigma, and ensure equitable access to healthcare will further enhance the impact of community-driven efforts. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):20-24 [23] ajdhs.com funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3):38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2):43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3):2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. dave p, the correlation between stigma and mental health disorders in people living with hiv/aids, journal of drug delivery and therapeutics, 2024;14(3):227-233 https://doi.org/10.22270/jddt.v14i3.6490 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024;13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. akhtar mh, ramkumar j. primary health center: can it be made mobile for efficient healthcare services for hard to reach population? a state-of-the-art review. discover health systems. 2023;2(3). https://doi.org/10.1007/s44250-023-00017-x pmid:37520517 pmcid:pmc9870199 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.22270/jddt.v14i3.6490 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.1007/s44250-023-00017-x https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):20-24 [24] ajdhs.com of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013. https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [8] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited metabolic syndrome in hiv-infected sickle cell patients: a review emmanuel ifeanyi obeagu 1* and olga geogievna goryacheva 2 1 department of biomedical and laboratory science, africa university, zimbabwe 2 perm state medical university named after academician e.a. wagner, russia article info: _____________________________________________ article history: received 06 jan 2025 reviewed 10 feb 2025 accepted 02 march 2025 published 15 june 2025 _____________________________________________ cite this article as: obeagu ei, goryacheva og, metabolic syndrome in hiv-infected sickle cell patients: a review, asian journal of dental and health sciences. 2025; 5(2):8-13 doi: http://dx.doi.org/10.22270/ajdhs.v5i2.125 abstract _________________________________________________________________________________________________________________ metabolic syndrome (mets) is a growing concern in the context of chronic diseases, particularly among patients co-infected with hiv and sickle cell disease (scd). this review aims to elucidate the prevalence, pathophysiology, and clinical implications of metabolic syndrome in hiv-infected sickle cell patients, a population that experiences unique challenges due to the interplay of these two conditions. emerging evidence suggests that metabolic syndrome may exacerbate the complications associated with both hiv and scd, leading to increased morbidity and mortality. the pathophysiological mechanisms underlying metabolic syndrome in this population are multifaceted, involving chronic inflammation, oxidative stress, and the metabolic effects of antiretroviral therapy (art). these factors can contribute to insulin resistance, dyslipidemia, hypertension, and obesity, further complicating the management of both hiv and sickle cell disease. understanding these interactions is critical for healthcare providers as they develop targeted strategies to monitor and manage metabolic syndrome, ensuring optimal patient care. keywords: metabolic syndrome, hiv, sickle cell disease, antiretroviral therapy, comorbidities *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction metabolic syndrome (mets) is a cluster of metabolic abnormalities, including obesity, insulin resistance, hypertension, and dyslipidemia, which collectively increase the risk of cardiovascular diseases and type 2 diabetes. the world health organization defines mets as a significant global health concern, affecting millions worldwide. as chronic diseases become more prevalent, understanding the interrelationship between these conditions is crucial, particularly in populations with complex health needs, such as those co-infected with hiv and sickle cell disease (scd).1-2 hiv infection has transformed from a fatal diagnosis to a manageable chronic condition due to advancements in antiretroviral therapy (art). however, long-term art can induce metabolic changes, leading to an increased incidence of metabolic syndrome among hiv-infected individuals. the risk factors for metabolic syndrome, including obesity and dyslipidemia, may be exacerbated by the chronic inflammation and immune dysregulation associated with hiv. consequently, individuals with hiv are at a heightened risk of developing mets, complicating their overall health management.3-5 sickle cell disease, a hereditary blood disorder characterized by abnormal hemoglobin, poses additional challenges to patients' health. individuals with scd often experience recurrent pain crises, organ damage, and increased risk of infections. the burden of chronic illness associated with scd may interact with the metabolic derangements seen in hiv-infected patients, creating a complex clinical picture that requires careful management. the interplay between these two conditions can lead to an increased prevalence of metabolic syndrome, further compromising health outcomes.6-7 the co-occurrence of hiv and sickle cell disease may exacerbate the complications associated with metabolic syndrome. patients with this dual diagnosis often face compounded health challenges, including increased cardiovascular risk and a higher likelihood of developing metabolic disorders. understanding the prevalence of metabolic syndrome in this population is essential for healthcare providers to implement appropriate screening and management strategies. moreover, the unique clinical manifestations and complications associated with mets in hiv-infected sickle cell patients necessitate further exploration.8-9 pathophysiologically, metabolic syndrome in this population is influenced by several interconnected mechanisms. chronic inflammation due to hiv infection can lead to insulin resistance, while oxidative stress may contribute to endothelial dysfunction and dyslipidemia. additionally, the effects of art on lipid metabolism and glucose homeostasis must be considered, as certain antiretroviral agents can exacerbate metabolic abnormalities. 10-11 management of metabolic syndrome in hiv-infected sickle cell patients requires a open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i2.125 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i2.125&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [9] ajdhs.com multifaceted approach, focusing on lifestyle modifications and pharmacological interventions. addressing modifiable risk factors, such as diet and physical activity, can significantly improve metabolic health and reduce the risk of cardiovascular events. furthermore, healthcare providers must carefully consider the choice of antiretroviral therapy to minimize potential metabolic side effects while effectively controlling viral loads.12-13 this review aims to explore the prevalence, pathophysiology, clinical manifestations, and management strategies for metabolic syndrome in hiv-infected sickle cell patients. prevalence of metabolic syndrome in hivinfected sickle cell patients the prevalence of metabolic syndrome (mets) among hiv-infected sickle cell patients is a growing area of concern within the medical community, as it presents unique challenges for healthcare providers managing these complex cases. recent studies suggest that the coexistence of hiv and sickle cell disease (scd) may significantly increase the risk of developing mets compared to individuals with only one of these conditions. for instance, research indicates that the prevalence of metabolic syndrome in hiv-infected individuals can range from 30% to 50%, depending on factors such as age, gender, ethnicity, and the presence of other comorbidities. when scd is introduced into the equation, this prevalence is likely to increase due to the compounding effects of both diseases.14-16 several studies have focused specifically on the prevalence of metabolic syndrome in patients with both hiv and scd, revealing alarming statistics. in one study conducted in nigeria, researchers found that the prevalence of mets among hiv-infected sickle cell patients was approximately 45%, highlighting the urgency of addressing this public health issue. another study in a cohort of african american patients revealed similar findings, with nearly 50% of those co-infected exhibiting features of metabolic syndrome. these statistics underscore the necessity of routine screening for metabolic syndrome in this vulnerable population to identify at-risk individuals early and initiate appropriate interventions.17-19 the increased prevalence of metabolic syndrome in hiv-infected sickle cell patients can be attributed to a variety of factors, including the underlying pathophysiological mechanisms associated with both conditions. chronic inflammation and oxidative stress related to hiv infection can contribute to insulin resistance and dyslipidemia, which are key components of mets. furthermore, the hematological abnormalities and complications of sickle cell disease, such as repeated vaso-occlusive crises and organ damage, may further exacerbate metabolic derangements, making this patient population particularly susceptible to developing mets.20-21 demographic factors also play a significant role in the prevalence of metabolic syndrome among hiv-infected sickle cell patients. studies have shown that certain populations, such as women and older individuals, may be at higher risk for developing mets due to hormonal changes and age-related factors that influence metabolism. additionally, lifestyle factors, such as physical inactivity and poor dietary habits, are prevalent in many individuals with scd and hiv, further contributing to the higher incidence of metabolic syndrome in this cohort.22-23 pathophysiology the pathophysiology of metabolic syndrome (mets) in hiv-infected sickle cell patients is complex and multifactorial, involving interactions between chronic inflammation, oxidative stress, metabolic dysregulation, and the effects of antiretroviral therapy (art). both hiv and sickle cell disease (scd) are associated with chronic inflammation, which plays a pivotal role in the development of metabolic syndrome. in hiv-infected individuals, persistent immune activation leads to elevated levels of pro-inflammatory cytokines, which can disrupt normal metabolic processes and contribute to insulin resistance. this inflammation is further exacerbated by the hemolysis and vascular complications inherent in scd, leading to additional metabolic disturbances.24-25 insulin resistance is a central feature of metabolic syndrome, and its development in hiv-infected sickle cell patients can be attributed to several mechanisms. chronic inflammation, particularly from cytokines such as tumor necrosis factor-alpha (tnf-α) and interleukin-6 (il-6), impairs insulin signaling pathways, leading to reduced glucose uptake in peripheral tissues. additionally, oxidative stress, which is prevalent in both hiv infection and sickle cell disease, contributes to the impairment of insulin sensitivity. reactive oxygen species (ros) generated during the inflammatory response can damage pancreatic β-cells, further exacerbating insulin resistance and impairing insulin secretion.26-27 dyslipidemia is another critical component of metabolic syndrome that is influenced by the interplay of hiv and scd. patients with hiv often exhibit alterations in lipid metabolism due to both the viral infection and the effects of art. some antiretroviral agents, particularly those in the protease inhibitor class, are associated with lipid abnormalities, including increased triglycerides and low-density lipoprotein (ldl) cholesterol levels. in sickle cell disease, the hemolytic process can lead to elevated levels of free fatty acids and altered lipid profiles, compounding the risk of dyslipidemia and cardiovascular complications. this combination of factors places hiv-infected sickle cell patients at a heightened risk of developing atherogenic dyslipidemia.28-29 hypertension, another key component of metabolic syndrome, can also be exacerbated in this population. chronic inflammation and oxidative stress contribute to endothelial dysfunction, leading to impaired vasodilation and increased vascular resistance. additionally, fluid retention and changes in renal function associated with both hiv and scd can further elevate blood pressure. as a result, many patients with hiv and sickle cell disease may experience hypertension, which increases their overall cardiovascular risk.30-31 the combined effects of these metabolic derangements can have significant implications for the long-term health of hiv-infected emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [10] ajdhs.com sickle cell patients. the presence of metabolic syndrome not only increases the risk of cardiovascular diseases and type 2 diabetes but can also complicate the management of both hiv and sickle cell disease. the interplay of these conditions necessitates a comprehensive understanding of their pathophysiology to develop effective prevention and treatment strategies tailored to this vulnerable population.32-33 clinical manifestations the clinical manifestations of metabolic syndrome (mets) in hiv-infected sickle cell patients are diverse and can significantly impact the overall health and quality of life of affected individuals. these manifestations arise from the combination of metabolic abnormalities characteristic of mets, such as obesity, insulin resistance, dyslipidemia, and hypertension, alongside the unique complications associated with hiv and sickle cell disease (scd). 34-35 one of the most prominent clinical features of metabolic syndrome is central obesity, which is particularly concerning in hivinfected individuals. abdominal adiposity is associated with an increased risk of cardiovascular diseases and insulin resistance. patients may present with increased waist circumference, indicative of visceral fat accumulation, which is linked to a higher likelihood of developing type 2 diabetes and other metabolic complications. in hiv-infected sickle cell patients, weight gain may also be influenced by art, with certain medications associated with increased appetite and fat accumulation.36-37 insulin resistance is another critical clinical manifestation of metabolic syndrome that can lead to hyperglycemia and, ultimately, type 2 diabetes mellitus. patients may experience symptoms such as increased thirst, frequent urination, and fatigue, which can significantly impair their quality of life. additionally, the presence of insulin resistance can complicate the management of hiv, as fluctuating blood glucose levels may affect overall health status and the effectiveness of antiretroviral medications. monitoring glucose levels becomes essential for identifying and managing this complication early.38-39 dyslipidemia is often present in patients with metabolic syndrome, characterized by elevated triglycerides and low high-density lipoprotein (hdl) cholesterol levels. patients may be asymptomatic initially, but the longterm implications of dyslipidemia can lead to cardiovascular disease and other complications. clinically, healthcare providers may observe patients with atherosclerotic changes, such as carotid artery thickening or coronary artery disease, as a consequence of the lipid abnormalities associated with mets. in hivinfected sickle cell patients, dyslipidemia can be exacerbated by the hemolytic process of scd, leading to additional cardiovascular risks.40 hypertension is a common clinical manifestation of metabolic syndrome that is particularly relevant in hiv-infected sickle cell patients. elevated blood pressure may often go unnoticed until it reaches severe levels, as patients may be asymptomatic initially. however, chronic hypertension can lead to significant complications, including heart disease, stroke, and renal dysfunction. regular monitoring of blood pressure is crucial in this population to ensure timely intervention and management of hypertension.41 furthermore, the psychological impact of metabolic syndrome cannot be overlooked. the stress associated with managing multiple chronic conditions, such as hiv and sickle cell disease, can contribute to anxiety and depression. these mental health issues may be compounded by the physical manifestations of metabolic syndrome, including changes in body image related to obesity and the implications of chronic illness. addressing the psychological well-being of patients is essential to provide comprehensive care and support.42 management strategies the management of metabolic syndrome (mets) in hivinfected sickle cell patients requires a comprehensive and individualized approach that addresses the unique needs and challenges of this population. given the complex interplay of chronic conditions, effective management strategies must focus on lifestyle modifications, pharmacological interventions, and regular monitoring to optimize patient outcomes. by implementing targeted strategies, healthcare providers can help mitigate the risks associated with metabolic syndrome and improve the overall health and quality of life of affected individuals.43 lifestyle modifications: one of the cornerstone strategies for managing metabolic syndrome is the promotion of lifestyle modifications. encouraging patients to adopt a balanced diet, rich in fruits, vegetables, whole grains, and lean proteins, is crucial for addressing obesity and dyslipidemia. nutritional counseling can help patients understand the importance of portion control and the impact of dietary choices on their metabolic health. additionally, incorporating regular physical activity into their daily routines is essential for weight management and improving insulin sensitivity. healthcare providers should recommend at least 150 minutes of moderate-intensity aerobic exercise per week, tailored to the individual’s capabilities and preferences.44 weight management: for many patients, weight loss is a primary goal in managing metabolic syndrome. a gradual reduction in body weight can significantly improve metabolic parameters, including insulin sensitivity, blood pressure, and lipid profiles. healthcare providers can work with patients to set realistic weight loss goals and provide support through behavioral interventions, such as counseling or support groups. in cases where lifestyle modifications are insufficient, more intensive interventions, including medical weight loss programs or referral to specialized obesity management clinics, may be considered.45 pharmacological interventions: when lifestyle modifications alone are inadequate to control metabolic syndrome components, pharmacological interventions may be necessary. antihypertensive medications can be prescribed to manage elevated blood pressure, while statins or fibrates may be indicated for dyslipidemia. in patients with significant insulin resistance or emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [11] ajdhs.com hyperglycemia, medications such as metformin can be used to improve glycemic control. it is essential for healthcare providers to carefully consider the potential interactions between these medications and antiretroviral therapy (art), as some antiretroviral agents may exacerbate metabolic abnormalities.46 monitoring and screening: regular monitoring of metabolic parameters is crucial for the effective management of metabolic syndrome in hiv-infected sickle cell patients. healthcare providers should conduct routine screenings for obesity, blood pressure, lipid levels, and glucose levels to identify at-risk individuals early. establishing a schedule for follow-up visits allows for ongoing assessment of metabolic status and timely adjustments to management strategies. additionally, patients should be educated on recognizing symptoms of metabolic syndrome and encouraged to report any significant changes in their health.47 addressing psychosocial factors: the psychological and social aspects of managing metabolic syndrome should not be overlooked. chronic illness can lead to increased stress, anxiety, and depression, which may hinder patients’ ability to adhere to lifestyle modifications and treatment plans. integrating mental health support into the management plan is vital for addressing these challenges. referral to mental health professionals or support groups can provide patients with the necessary tools to cope with the emotional burden of their conditions.48 patient education and empowerment: educating patients about metabolic syndrome, its risks, and the importance of adherence to management strategies is essential for promoting self-management and empowerment. healthcare providers should offer clear and accessible information on lifestyle changes, medication adherence, and the significance of regular monitoring. empowering patients to take an active role in their health can lead to improved outcomes and a better quality of life.45 challenges and future directions the management of metabolic syndrome (mets) in hivinfected sickle cell patients presents several challenges that must be addressed to improve health outcomes. understanding these challenges is crucial for developing effective strategies and future research directions. by identifying barriers to care and exploring innovative approaches, healthcare providers can enhance the management of this complex population.46 challenges in diagnosis and management: one of the primary challenges in managing metabolic syndrome in this population is the overlap of symptoms and complications associated with both hiv and sickle cell disease (scd). the clinical manifestations of mets, such as obesity, insulin resistance, and hypertension, can be easily misattributed to the underlying chronic conditions, leading to delayed diagnosis and management. furthermore, the interactions between antiretroviral therapy (art) and medications for mets can complicate treatment plans. healthcare providers must maintain a high index of suspicion and conduct regular screenings to ensure timely identification and intervention.47 socioeconomic barriers: socioeconomic factors significantly influence the management of metabolic syndrome in hiv-infected sickle cell patients. limited access to healthcare services, nutritious food, and opportunities for physical activity can hinder patients' ability to adopt healthy lifestyle changes. additionally, financial constraints may limit access to necessary medications and specialized care. addressing these socioeconomic barriers is essential for improving patient outcomes and ensuring equitable healthcare access for this vulnerable population.48 psychosocial factors and treatment adherence: the psychological impact of living with multiple chronic conditions can affect treatment adherence and selfmanagement in hiv-infected sickle cell patients. mental health issues, such as anxiety and depression, may complicate the adoption of lifestyle modifications and medication adherence. comprehensive care should include mental health support to address these challenges and empower patients to actively engage in their health management. future research should focus on developing effective psychosocial interventions tailored to the needs of this population.45 research gaps and future directions: there is a need for further research to elucidate the pathophysiological mechanisms underlying metabolic syndrome in hivinfected sickle cell patients. investigating the interactions between chronic inflammation, oxidative stress, and metabolic dysregulation can provide valuable insights into targeted interventions. additionally, clinical trials are needed to evaluate the efficacy and safety of specific therapies aimed at managing metabolic syndrome in this population, including novel agents that may have fewer metabolic side effects.46 innovative approaches: future directions in managing metabolic syndrome may include the integration of technology in patient care. telemedicine and mobile health applications can facilitate regular monitoring, improve patient education, and enhance communication between patients and healthcare providers. utilizing these technologies can empower patients to take an active role in their health management and help overcome some of the barriers associated with traditional healthcare delivery.47 interdisciplinary collaboration: to effectively manage metabolic syndrome in hiv-infected sickle cell patients, interdisciplinary collaboration among healthcare providers is essential. a team-based approach that includes primary care physicians, hematologists, endocrinologists, dietitians, and mental health professionals can ensure comprehensive care tailored to the unique needs of this population. future initiatives should promote collaboration and communication among providers to optimize management strategies and improve patient outcomes.48 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [12] ajdhs.com conclusion metabolic syndrome is a significant health concern for hiv-infected sickle cell patients, with a multifaceted impact on their overall health and quality of life. the interplay of chronic conditions, such as hiv and sickle cell disease, complicates the clinical presentation and management of metabolic syndrome, requiring a comprehensive approach that addresses both metabolic and psychosocial factors. this review highlights the prevalence, pathophysiology, clinical manifestations, and management strategies for metabolic syndrome in this unique population, emphasizing the need for early detection and intervention. despite the progress made in understanding and managing metabolic syndrome, several challenges remain, including issues related to diagnosis, socioeconomic barriers, and the need for individualized care. addressing these challenges will require a concerted effort from healthcare providers, researchers, and policymakers. future research should focus on elucidating the underlying mechanisms of metabolic syndrome in hiv-infected sickle cell patients and exploring innovative interventions tailored to their specific needs. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. owusu ed, visser bj, nagel im, mens pf, grobusch mp. the interaction between sickle cell disease and hiv infection: a systematic review. clinical infectious diseases. 2015; 60(4):612626. https://doi.org/10.1093/cid/ciu832 pmid:25344542 2. boateng la, ngoma am, bates i, schonewille h. red blood cell alloimmunization in transfused patients with sickle cell disease in sub-saharan africa; a systematic review and meta-analysis. transfusion medicine reviews. 2019; 33(3):162-169. https://doi.org/10.1016/j.tmrv.2019.06.003 pmid:31345590 3. ola b, olushola o, ebenso b, berghs m. sickle cell disease and its psychosocial burdens in africa. insickle cell disease in subsaharan africa 2024: 67-80. routledge. https://doi.org/10.4324/9781003467748-7 4. obeagu ei, reducing hospitalization rates: the preventive benefits of blood transfusions in hiv care, international journal of medical sciences and pharma research, 2024;10(3):29-34 https://doi.org/10.22270/ijmspr.v10i3.111 5. ochocinski d, dalal m, black lv, carr s, lew j, sullivan k, kissoon n. life-threatening infectious complications in sickle cell disease: a concise narrative review. frontiers in pediatrics. 2020; 8:38. https://doi.org/10.3389/fped.2020.00038 pmid:32154192 pmcid:pmc7044152 6. obeagu ei, obeagu gu, okwuanaso cb. optimizing immune health in hiv patients through nutrition: a review. elite journal of immunology, 2024; 2(1): 14-33 7. obeagu ei, obeagu gu. platelet distribution width (pdw) as a prognostic marker for anemia severity in hiv patients: a comprehensive review. journal home page: http://www. journalijiar. com.;12(01). 8. obeagu ei, ubosi ni, obeagu gu, akram m. early infant diagnosis: key to breaking the chain of hiv transmission. elite journal of public health, 2024; 2 (1): 52-61 9. obeagu ei, obeagu gu. hematocrit fluctuations in hiv patients coinfected with malaria parasites: a comprehensive review. int. j. curr. res. med. sci. 2024; 10(1):25-36. https://doi.org/10.22270/ijmspr.v10i2.95 10. obeagu ei, obeagu gu. transfusion therapy in hiv: risk mitigation and benefits for improved patient outcomes. asian j dental health sci, 2024; 4(1):32-7. https://doi.org/10.22270/ajdhs.v4i1.62 11. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 12. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 13. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 1 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 2035 15. obeagu ei, obeagu gu. impact of maternal eosinophils on neonatal immunity in hivexposed infants: a review. elite journal of immunology, 2024; 2(3): 1-18 https://doi.org/10.22270/ajdhs.v4i2.82 16. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. newport international journal of biological and applied sciences (nijbas) 2023. http://hdl.handle.net/20.500.12493/14626 17. ntsekhe m, baker jv. cardiovascular disease among persons living with hiv: new insights into pathogenesis and clinical manifestations in a global context. circulation. 2023; 147(1):83100. https://doi.org/10.1161/circulationaha.122.057443 pmid:36576956 18. obare lm, temu t, mallal sa, wanjalla cn. inflammation in hiv and its impact on atherosclerotic cardiovascular disease. circulation research. 2024; 134(11):1515-1545 https://doi.org/10.1161/circresaha.124.323891 pmid:38781301 pmcid:pmc11122788 19. hmiel l, zhang s, obare lm, santana ma, wanjalla cn, titanji bk, hileman co, bagchi s. inflammatory and immune mechanisms for atherosclerotic cardiovascular disease in hiv. international journal of molecular sciences. 2024; 25(13):7266. https://doi.org/10.3390/ijms25137266 pmid:39000373 pmcid:pmc11242562 20. obeagu ei, obeagu gu. platelet aberrations in hiv patients: assessing impacts of art. elite journal of haematology, 2024; 2(3): 10-24 21. obeagu ei, obeagu gu. harnessing b cell responses for personalized approaches in hiv management. elite journal of immunology, 2024; 2(2): 15-28 22. belisário ar, blatyta pf, vivanco d, oliveira cd, carneiro-proietti ab, sabino ec, de almeida-neto c, loureiro p, máximo c, de oliveira garcia mateos s, flor-park mv. association of hiv infection with clinical and laboratory characteristics of sickle cell disease. bmc infectious diseases. 2020; 20(1):638. https://doi.org/10.1186/s12879-020-05366-z pmid:32854639 pmcid:pmc7457248 23. obeagu ei, addressing sleep disturbances: blood transfusions and improved sleep patterns in hiv patients, international journal of https://doi.org/10.1093/cid/ciu832 https://doi.org/10.1016/j.tmrv.2019.06.003 https://doi.org/10.4324/9781003467748-7 https://doi.org/10.22270/ijmspr.v10i3.111 https://doi.org/10.3389/fped.2020.00038 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.22270/ajdhs.v4i1.62 https://doi.org/10.22270/ajdhs.v4i2.82 http://hdl.handle.net/20.500.12493/14626 https://doi.org/10.1161/circulationaha.122.057443 https://doi.org/10.1161/circresaha.124.323891 https://doi.org/10.3390/ijms25137266 https://doi.org/10.1186/s12879-020-05366-z emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):8-13 [13] ajdhs.com medical sciences and pharma research, 2024;10(3):43-48 https://doi.org/10.22270/ijmspr.v10i3.113 24. gill af, ahsan mh, lackner aa, veazey rs. hematologic abnormalities associated with simian immunodeficieny virus (siv) infection mimic those in hiv infection. journal of medical primatology. 2012; 41(3):214-224. https://doi.org/10.1111/j.1600-0684.2012.00543.x pmid:22620272 pmcid:pmc3367385 25. nouraie m, nekhai s, gordeuk vr. sickle cell disease is associated with decreased hiv but higher hbv and hcv comorbidities in us hospital discharge records: a cross-sectional study. sexually transmitted infections. 2012; 88(7):528-533. https://doi.org/10.1136/sextrans-2011-050459 pmid:22628662 pmcid:pmc3456988 26. obeagu ei, obeagu gu. hematological changes following blood transfusion in young children with severe malaria and hiv: a critical review. elite journal of laboratory medicine. 2024; 2(1):33-45. 27. obeagu ei, obeagu gu. the role of l-selectin in tuberculosis and hiv coinfection: implications for disease diagnosis and management. elite journal of public health, 2024; 2 (1): 35-51 28. obeagu ei, obeagu gu. unraveling the role of eosinophil extracellular traps (eets) in hiv-infected pregnant women: a review. elite journal of nursing and health science, 2024; 2(3): 84-99 29. obeagu ei, obeagu gu. unveiling the role of innate immune activation in pediatric hiv: a review. elite journal of immunology, 2024; 2(3): 33-44 30. obeagu ei, obeagu, gu. impact of blood transfusion on viral load dynamics in hivpositive neonates with severe malaria: a review. elite journal of scientific research and review, 2024; 2(1): 42-60 31. obeagu ei, youth-friendly hiv prevention: tailoring interventions for young populations, international journal of medical sciences and pharma research, 2024;10(4):62-67. https://doi.org/10.22270/ijmspr.v10i4.125 32. obeagu ei, faith-based initiatives, hiv awareness, religious communities, health education, stigma reduction, international journal of medical sciences and pharma research, 2024;10(4):7479 https://doi.org/10.22270/ijmspr.v10i4.127 33. obeagu ei, obeagu gu. p-selectin expression in hiv-associated coagulopathy: implications for treatment. elite journal of haematology, 2024; 2(3): 25-41 34. obeagu ei, obeagu gu. p-selectin and immune activation in hiv: clinical implications. elite journal of health science, 2024; 2(2): 16-29 35. obeagu ei, amaeze aa, ogbu isi, obeagu gu. b cell deficiency and implications in hiv pathogenesis: unraveling the complex interplay. elite journal of nursing and health science, 2024; 2(2): 33-46 36. obeagu ei, obeagu, gu. platelet dysfunction in hiv patients: assessing art risks. elite journal of scientific research and review, 2024; 2(1): 1-16 37. kibaru eg, nduati r, wamalwa d, kariuki n. impact of highly active antiretroviral therapy on hematological indices among hiv1 infected children at kenyatta national hospital-kenya: retrospective study. aids research and therapy. 2015; 12:1-8. https://doi.org/10.1186/s12981-015-0069-4 pmid:26279668 pmcid:pmc4537535 38. enawgaw b, alem m, addis z, melku m. determination of hematological and immunological parameters among hiv positive patients taking highly active antiretroviral treatment and treatment naïve in the antiretroviral therapy clinic of gondar university hospital, gondar, northwest ethiopia: a comparative cross-sectional study. bmc hematology. 2014; 14:1-7. https://doi.org/10.1186/2052-1839-14-8 pmid:24666771 pmcid:pmc3994311 39. gudina a, wordofa m, urgessa f. immuno-hematological parameters among adult hiv patients before and after initiation of dolutegravir based antiretroviral therapy, addis ababa, ethiopia. plos one. 2024; 19(10):e0310239. https://doi.org/10.1371/journal.pone.0310239 pmid:39480901 pmcid:pmc11527299 40. geletaw t, tadesse mz, demisse ag. hematologic abnormalities and associated factors among hiv infected children pre-and postantiretroviral treatment, north west ethiopia. journal of blood medicine. 2017:99-105. https://doi.org/10.2147/jbm.s137067 pmid:28831276 pmcid:pmc5552149 41. jegede fe, oyeyi ti, abdulrahman sa, mbah ha, badru t, agbakwuru c, adedokun o. effect of hiv and malaria parasites coinfection on immune-hematological profiles among patients attending anti-retroviral treatment (art) clinic in infectious disease hospital kano, nigeria. plos one. 2017; 12(3):e0174233. https://doi.org/10.1371/journal.pone.0174233 pmid:28346490 pmcid:pmc5367709 42. obeagu ei, obeagu gu. art and platelet dynamics: assessing implications for hiv patient care. elite journal of haematology. 2024; 2(4):68-85. 43. obeagu ei, ayogu ee, obeagu gu. impact on viral load dynamics: understanding the interplay between blood transfusion and antiretroviral therapy in hiv management. elite journal of nursing and health science. 2024;2(2):5-15. 44. ciccacci f, lucaroni f, latagliata r, morciano l, mondlane e, balama m, tembo d, gondwe j, orlando s, palombi l, marazzi mc. hematologic alterations and early mortality in a cohort of hiv positive african patients. plos one. 2020; 15(11):e0242068. https://doi.org/10.1371/journal.pone.0242068 pmid:33170905 pmcid:pmc7654783 45. ashenafi g, tibebu m, tilahun d, tsegaye a. immunohematological outcome among adult hiv patients taking highly active antiretroviral therapy for at least six months in yabelo hospital, borana, ethiopia. journal of blood medicine. 2023:543-554. https://doi.org/10.2147/jbm.s419414 pmid:37881654 pmcid:pmc10595970 46. obeagu ei, goryacheva og. the role of inflammation in hiv and sickle cell disease co-morbidity. lifeline hiv, 2025; 3(1): 1-12 47. obeagu ei, goryacheva og. oxidative stress in hiv and sickle cell disease: a double burden. lifeline hiv, 2025; 3(1): 13-24 48. obeagu ei, goryacheva og. hiv and sickle cell disease: a focus on liver dysfunction. lifeline hiv, 2025; 3(1): 25-40 https://doi.org/10.22270/ijmspr.v10i3.113 https://doi.org/10.1111/j.1600-0684.2012.00543.x https://doi.org/10.1136/sextrans-2011-050459 https://doi.org/10.22270/ijmspr.v10i4.125 https://doi.org/10.22270/ijmspr.v10i4.127 https://doi.org/10.1186/s12981-015-0069-4 https://doi.org/10.1186/2052-1839-14-8 https://doi.org/10.1371/journal.pone.0310239 https://doi.org/10.2147/jbm.s137067 https://doi.org/10.1371/journal.pone.0174233 https://doi.org/10.1371/journal.pone.0242068 https://doi.org/10.2147/jbm.s419414 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):46-50 [46] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited women at the forefront: supporting female-led hiv prevention initiatives emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 20 sep 2024 reviewed 28 oct 2024 accepted 25 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, women at the forefront: supporting female-led hiv prevention initiatives, asian journal of dental and health sciences. 2024; 4(3):46-50 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.101 abstract _____________________________________________________________________________________________________________________ female-led initiatives in hiv prevention are increasingly recognized as a powerful means of addressing the gender-specific challenges women face in the fight against hiv. women are disproportionately affected by hiv, and their vulnerability is often exacerbated by gender-based inequalities, cultural norms, and limited access to healthcare. by empowering women to lead hiv prevention efforts, these initiatives can better address the unique needs of women, increase awareness, and reduce stigma surrounding hiv. this article explores the importance of supporting female leadership in hiv prevention, highlighting successful initiatives, challenges, and the impact of women’s leadership on public health outcomes. the article discusses the role of female leaders in hiv prevention, emphasizing their ability to tailor strategies that resonate with women’s lived experiences. female-led initiatives often focus on culturally appropriate approaches that address barriers such as lack of education, economic dependency, and sexual and reproductive health challenges. women leaders also play a critical role in reducing stigma and promoting community engagement, ultimately fostering a more inclusive environment for hiv prevention and care. keywords: female-led initiatives, hiv prevention, gender equality, women’s health, empowerment *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv continues to be a global health challenge, with women disproportionately affected by the epidemic. women, especially in sub-saharan africa and other resource-limited regions, are more likely to acquire hiv due to gender-based inequalities, such as limited access to sexual and reproductive health education, economic dependence, and exposure to gender-based violence. these factors increase their vulnerability to hiv transmission and hinder their ability to seek prevention, treatment, and care. consequently, women’s leadership in hiv prevention has emerged as a critical strategy to address these vulnerabilities in a more nuanced and culturally relevant manner. female-led initiatives have proven to be more effective at tailoring programs that specifically meet the needs of women, providing not only health interventions but also the empowerment necessary to reduce hiv risk.1-2 the significant role of women in preventing the spread of hiv lies in their unique understanding of the challenges and barriers that women face. from the stigma associated with hiv to the need for gender-sensitive healthcare, women leaders often bring to the table perspectives that are more inclusive and attuned to the realities of women’s lives. these leaders not only serve as role models but also have a profound impact on changing societal attitudes towards hiv, encouraging open conversations, and reducing shame and discrimination. when women are at the forefront of hiv prevention programs, they tend to create safe spaces where women can share their experiences, seek advice, and take control of their health decisions, ultimately improving both individual and community health outcomes.3-4 beyond health outcomes, female leadership in hiv prevention is intrinsically tied to broader social issues, including gender equality and women’s empowerment. in many societies, women face systemic barriers to leadership positions, particularly in healthcare and public health sectors. supporting female leadership in hiv prevention not only improves health outcomes but also contributes to the broader goal of gender equality. by fostering women’s leadership, these initiatives promote a more equitable distribution of power and resources in healthcare, thus reinforcing the idea that women are not only recipients of healthcare but also key players in the development and implementation of effective public health strategies.5-6 despite the clear benefits of female leadership, women involved in hiv prevention initiatives face significant challenges. gender inequality, cultural norms, and limited access to resources often restrict women’s ability to lead and scale their efforts. women may also encounter resistance from patriarchal structures that do not fully support their leadership or views on gender equality. these challenges are compounded in low-income countries, where financial and infrastructural support for health programs is limited. female leaders in hiv open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.101 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.101&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):46-50 [47] ajdhs.com prevention often work with minimal resources and may struggle to sustain their initiatives without the necessary financial backing and institutional support.7-8 at the same time, the involvement of women in leadership roles in hiv prevention is not only essential for the effectiveness of interventions but also for ensuring that those interventions are grounded in the needs and concerns of the community. female leaders are often better equipped to design prevention programs that are culturally sensitive and able to engage with women at a grassroots level. this ability to connect with women on a personal and communitybased level allows female-led initiatives to address the barriers preventing women from accessing hiv-related services, including education, testing, and treatment.9-10 the role of female leadership in hiv prevention female leadership plays a crucial role in advancing hiv prevention efforts, particularly in communities where women bear a disproportionate burden of the epidemic. as primary caregivers, mothers, and key decisionmakers in many societies, women possess unique insights into the dynamics that drive hiv transmission. they often have a deep understanding of the barriers women face, including cultural norms, gender inequality, lack of access to sexual and reproductive health services, and the stigma surrounding hiv. by leading hiv prevention initiatives, women can address these challenges in ways that resonate with their peers, empowering them to take control of their health while promoting community-wide change.11-12 one of the most important contributions of female leadership in hiv prevention is the ability to develop and implement culturally appropriate strategies that speak to women’s lived experiences. female leaders can tailor hiv prevention programs to focus on women’s specific needs, such as improving access to sexual health education, promoting gender equality, and creating spaces where women can discuss their concerns without fear of judgment. this approach helps overcome barriers that often prevent women from accessing hiv prevention services, such as condom use, hiv testing, and treatment options. additionally, women leaders can address sexual and reproductive health issues, including safer childbirth practices and hiv testing during pregnancy, thereby preventing motherto-child transmission.13-14 furthermore, female leaders in hiv prevention play an instrumental role in breaking down the stigma surrounding hiv and reproductive health. in many communities, hiv is associated with shame, and discussing it openly can lead to social ostracization. women leaders help normalize conversations about hiv, reduce stigma, and advocate for better care and support services. their leadership fosters trust within the community, encouraging women to seek prevention and treatment services without fear of discrimination. this reduces the social barriers that may otherwise discourage women from accessing critical health services.15 women at the forefront of hiv prevention also contribute to broader societal changes by challenging gender norms and advocating for women's rights. many female-led initiatives focus not only on health outcomes but also on empowering women through education and leadership development. by mentoring other women and providing them with the tools to lead in their own communities, female leaders create a ripple effect that extends beyond health prevention. these leaders advocate for gender-sensitive policies and programs that prioritize women's health and safety, reinforcing the link between gender equality and hiv prevention.16 in addition to these direct impacts, female leadership has the power to improve the sustainability and effectiveness of hiv prevention programs. when women are involved in designing and implementing interventions, they ensure that programs are more responsive to the community’s needs and concerns. this inclusion enhances the relevance of hiv prevention strategies and helps ensure that resources are used efficiently. moreover, female leaders serve as role models, inspiring others to get involved and assume leadership roles within their communities, which is critical for the long-term success of hiv prevention efforts.17 challenges faced by female-led hiv prevention initiatives female-led hiv prevention initiatives, despite their proven effectiveness, often face significant challenges that hinder their ability to achieve their full potential. one of the primary obstacles is the deep-rooted gender inequality that exists in many societies, particularly in lowand middle-income countries. in these contexts, women are frequently marginalized, and their leadership is not always recognized or valued. patriarchal norms often limit women’s access to decision-making roles, whether in the family, community, or larger political structures. this can result in insufficient support for female-led hiv prevention initiatives, whether in terms of financial resources, political backing, or social acceptance.18-19 another major challenge for women leaders in hiv prevention is the lack of adequate resources. many female-led initiatives operate with limited funding and logistical support, making it difficult to scale up or sustain their programs. funding constraints may limit the scope of outreach activities, reduce the quality of health services provided, and restrict the ability to train new leaders. female leaders may also face difficulties in advocating for funds or gaining access to international donors who tend to prioritize larger, more established organizations that may not necessarily focus on gender-specific issues. in such an environment, female leaders may find themselves working under strained conditions, trying to make the most out of minimal resources.20-21 cultural and social norms present additional barriers to female leadership in hiv prevention. in many societies, there is a strong stigma attached to both hiv and women taking on leadership roles. hiv is often viewed as a disease of "immorality," which can result in discrimination against those who speak out about the disease, including female leaders. women who champion hiv prevention can face backlash, not only for emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):46-50 [48] ajdhs.com their involvement in health advocacy but also for challenging traditional gender roles. in some cultures, female leaders are seen as a threat to the patriarchal order, making it more difficult for their initiatives to gain community support. this stigma can lead to resistance to women’s leadership, discouraging both women and men from participating in hiv prevention efforts.22-23 moreover, the intersection of gender-based violence (gbv) and hiv presents an additional challenge for female-led initiatives. women in many regions are at higher risk of sexual violence, which increases their vulnerability to hiv infection. addressing both hiv prevention and gender-based violence within the same program requires a multifaceted approach that may not always be feasible due to limited resources, competing priorities, or lack of coordination between health and social services. female leaders often have to navigate these overlapping challenges while advocating for both women’s sexual and reproductive health and their safety in environments where violence is pervasive.24-25 political and institutional barriers also play a significant role in limiting the impact of female-led hiv prevention programs. policies that neglect gender-specific health needs or fail to prioritize hiv prevention among women undermine the effectiveness of grassroots initiatives. in some cases, government policies may inadvertently hinder the progress of female-led programs by prioritizing more centralized, male-dominated health organizations or by focusing on hiv prevention for broader populations without considering the specific challenges faced by women. additionally, political instability, corruption, and poor governance can also contribute to delays or lack of support for these initiatives, preventing them from reaching the women who need them most.26-27 lastly, the internal challenges within female-led hiv prevention programs should not be overlooked. women leaders themselves may face issues such as burnout, lack of training, or feeling overwhelmed by the enormity of their tasks. many of these leaders take on dual roles as both health advocates and community caretakers, which can lead to stress and fatigue. the lack of mentorship and leadership development programs for women in healthrelated fields may also leave these leaders without the necessary skills and support to manage the complexities of their work effectively. without adequate capacitybuilding, female leaders may struggle to build and sustain programs, limiting their ability to achieve longterm success.28-29 supportive measures for enhancing female leadership in hiv prevention to ensure that female-led hiv prevention initiatives reach their full potential, it is essential to implement supportive measures that address the specific challenges faced by women leaders. these measures should focus on promoting gender equality, providing adequate resources, enhancing training opportunities, and fostering an enabling environment where women can thrive in leadership roles. by investing in these strategies, communities and governments can help women lead more effective, sustainable hiv prevention programs that cater to the unique needs of women and ultimately contribute to reducing the spread of hiv.30 1. promoting gender equality and changing social norms one of the first and most critical supportive measures for enhancing female leadership in hiv prevention is addressing gender inequality. changing societal norms that restrict women’s participation in leadership roles requires long-term advocacy and awareness campaigns that promote the value of women in positions of power. encouraging men and boys to support women leaders is also a key component of this strategy, as male allies can help break down patriarchal barriers. programs should work to redefine the roles women play in both public and private spaces, empowering them to take leadership positions not just in hiv prevention but in broader health and development sectors. support for female leadership should be integrated into national policies on gender equality and human rights, ensuring that women have the political and social backing to take on leadership roles without fear of discrimination or violence.31 2. increasing access to resources and funding adequate funding and resources are essential to the success of female-led hiv prevention initiatives. governments, international organizations, and donors should prioritize funding for programs that are led by women or focus specifically on women's health. financial support allows female leaders to expand their programs, improve outreach efforts, and develop innovative strategies that address the unique challenges women face in preventing hiv. additionally, funding should be flexible and tailored to the needs of grassroots organizations led by women, ensuring that they can scale their interventions and sustain long-term efforts. collaborations between local governments, ngos, and international partners are also crucial for pooling resources and providing a more robust financial foundation for female-led initiatives.32 3. building leadership capacity and providing training leadership training programs are essential for equipping women with the skills necessary to manage hiv prevention programs effectively. these programs should focus not only on technical aspects of hiv prevention but also on leadership and advocacy skills, project management, financial literacy, and community mobilization. female leaders need to be trained in both the health and social aspects of hiv prevention to ensure that their interventions are comprehensive and sustainable. providing mentorship opportunities, where experienced female leaders guide and support emerging leaders, can further strengthen women’s leadership capabilities. additionally, developing networks of female leaders allows women to exchange ideas, share resources, and support one another in navigating challenges. training and capacity-building efforts should also be culturally sensitive, reflecting the unique needs of women in different regions.33 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):46-50 [49] ajdhs.com 4. creating safe and supportive work environments female leaders in hiv prevention often face significant challenges that arise from societal and cultural norms. to help overcome these, it is important to create supportive work environments that prioritize women’s well-being. these environments should be free from harassment and discrimination, where women leaders can freely express their ideas and lead without fear of retaliation. institutions and organizations that support female-led hiv prevention efforts should ensure that there are policies in place to address gender-based violence, sexual harassment, and gender discrimination. offering psychological support, counseling, and stress management resources is also essential for preventing burnout and ensuring that women leaders can maintain their health and effectiveness in their roles. additionally, providing flexible working conditions, such as remote work or part-time options, can help women balance their leadership responsibilities with family and caregiving duties.33 5. strengthening collaboration and partnerships collaboration and partnerships are crucial for the success of female-led hiv prevention initiatives. by partnering with male leaders, community organizations, health professionals, and policymakers, female leaders can strengthen their influence and create more impactful programs. interdisciplinary partnerships that bring together experts from various fields—such as healthcare, education, and social work—can lead to more holistic approaches to hiv prevention. these collaborations also help ensure that female leaders receive the necessary support and recognition from other stakeholders. governments and global health organizations should actively encourage and facilitate partnerships between women’s groups and other key players in the hiv prevention sector. this collaboration can increase the sustainability of female-led initiatives by linking them to larger networks of resources, expertise, and advocacy.28 6. ensuring political support and advocacy political support is essential for the success of female leadership in hiv prevention, as policies and laws can either facilitate or hinder the effectiveness of these programs. governments must recognize and actively support the role of women in leadership, not just in hiv prevention but in all areas of public health. advocating for gender-sensitive health policies that prioritize the needs of women in hiv prevention can ensure that female-led initiatives receive the recognition and institutional support they need. governments should also be encouraged to include women leaders in policymaking processes, enabling them to advocate for changes that benefit both women and the broader community. by prioritizing women in leadership roles, political leaders can help create an environment that fosters the success of hiv prevention programs while promoting gender equality.29 7. monitoring and evaluating the impact of femaleled initiatives ongoing monitoring and evaluation (m&e) are essential to ensure that female-led hiv prevention programs remain effective and adapt to changing community needs. establishing strong m&e frameworks can help measure the success of these programs, identify areas for improvement, and demonstrate their impact to stakeholders and donors. it is important that the m&e processes are participatory, involving women leaders in the design and evaluation stages. this allows for a more accurate assessment of the challenges and successes of these initiatives, while also fostering a culture of accountability and continuous improvement. by regularly evaluating the impact of female-led hiv prevention initiatives, stakeholders can adjust strategies and allocate resources more effectively to maximize their reach and sustainability.31-33 conclusion female-led hiv prevention initiatives have proven to be highly effective in addressing the unique needs of women and communities, particularly in regions where women face greater risks and barriers to accessing healthcare and social services. however, the success of these initiatives is often hindered by systemic challenges, such as gender inequality, limited resources, cultural norms, and inadequate political support. to fully unlock the potential of female leadership in hiv prevention, it is crucial to implement supportive measures that focus on promoting gender equality, ensuring access to resources, providing leadership training, and creating safe, supportive environments for women leaders. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 23-35 https://doi.org/10.22270/ijmspr.v10i2.102 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):46-50 [50] ajdhs.com 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267-276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of communitybased interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulunatal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):8-22. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. obeagu ei, obeagu gu, the vital role of blood transfusions during pregnancy: a comprehensive review, asian journal of dental and health sciences, 2024;4(1):26-31 https://doi.org/10.22270/ajdhs.v4i1.58 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of largescale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 https://doi.org/10.1007/s10209-021-00865-5 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.22270/ajdhs.v4i1.58 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):40-44 [40] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited clinical utility of mentzer index in pregnancy anemia screening programs: a narrative review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 10 nov 2024 reviewed 25 dec 2024 accepted 16 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, clinical utility of mentzer index in pregnancy anemia screening programs: a narrative review, asian journal of dental and health sciences. 2025; 5(1):40-44 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.118 abstract _________________________________________________________________________________________________________________ anemia in pregnancy is a prevalent condition that can lead to severe complications for both mothers and their fetuses. differentiating between the causes of anemia, particularly iron deficiency anemia (ida) and thalassemia traits, is crucial for appropriate treatment. the mentzer index (mi) is a simple, cost-effective tool used to distinguish between these two common causes of microcytic anemia by comparing the mean corpuscular volume (mcv) to the red blood cell (rbc) count. this review explores the clinical utility of the mi in pregnancy anemia screening programs, highlighting its advantages, limitations, and potential role in improving diagnosis and management. the mentzer index has proven to be an effective first-line diagnostic tool, especially in resource-limited settings where advanced testing may not be readily available. by providing a straightforward method to differentiate ida from thalassemia traits, the mi helps prevent the inappropriate use of iron supplements, which can exacerbate complications in individuals with thalassemia. additionally, its simplicity allows for its incorporation into routine prenatal care, improving the efficiency of anemia screening programs and facilitating early intervention. despite its benefits, the mi has limitations, including its reduced accuracy in pregnancy due to physiological changes and mixed anemia. keywords: mentzer index, pregnancy anemia, anemia screening, clinical utility, iron deficiency anemia *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia during pregnancy is a common and significant public health concern, affecting a substantial proportion of pregnant women worldwide. it is associated with numerous adverse outcomes for both the mother and fetus, including maternal fatigue, increased risk of preterm birth, low birth weight, and even maternal and infant mortality in severe cases. according to the world health organization (who), anemia affects around 40% of pregnant women globally, with iron deficiency anemia (ida) being the most prevalent cause. anemia in pregnancy is particularly common in low-resource settings where dietary deficiencies, parasitic infections, and limited access to healthcare services contribute to its high prevalence.1-2 the causes of anemia in pregnancy are diverse and include iron deficiency, vitamin b12 and folate deficiencies, anemia of chronic disease, and genetic disorders such as thalassemia. iron deficiency anemia (ida) is the most common etiology, arising due to increased iron requirements during pregnancy that exceed the available iron stores. thalassemia, a group of inherited blood disorders characterized by abnormal hemoglobin production, is also prevalent in certain populations. microcytic anemia, which presents with low mean corpuscular volume (mcv), is often seen in both ida and thalassemia, making differential diagnosis challenging. therefore, accurate identification of the underlying cause of anemia is essential for effective treatment and management.3-4 differentiating between ida and thalassemia is crucial because the treatment approaches for these two conditions differ significantly. while ida is treated with iron supplementation, thalassemia requires different management, such as folic acid supplementation and, in some cases, blood transfusions. misdiagnosis and inappropriate treatment, such as the use of iron supplementation in individuals with thalassemia, can lead to complications such as iron overload. this makes the ability to differentiate between these two conditions an essential aspect of anemia management during pregnancy. in this context, the mentzer index (mi) has emerged as a simple and effective tool to help healthcare providers distinguish between ida and thalassemia traits.5 the mentzer index is a calculation derived from a complete blood count (cbc), using the ratio of the mean corpuscular volume (mcv) to the red blood cell (rbc) count. a lower mi value (typically less than 13) suggests thalassemia traits, whereas a higher value (greater than 13) is indicative of ida. this open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.118 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.118&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):40-44 [41] ajdhs.com straightforward formula is easy to calculate and does not require specialized equipment, making it an ideal tool for use in primary care settings, especially in resource-limited environments. its simplicity, combined with the ability to distinguish between two of the most common causes of microcytic anemia, makes the mi an attractive option for anemia screening in pregnant populations.6-7 despite the advantages of the mentzer index, it is not without limitations. the mi may not be as reliable in certain circumstances, such as when a pregnant woman has mixed anemia, where both iron deficiency and thalassemia traits coexist. additionally, physiological changes during pregnancy, such as an increase in blood volume and alterations in red blood cell production, can affect the accuracy of the mi. therefore, while the mi is a valuable screening tool, it should not be used in isolation. it must be combined with other diagnostic tests and clinical assessments to ensure a comprehensive diagnosis.8-9 the clinical utility of the mentzer index in anemia screening during pregnancy is particularly relevant in low-resource settings where access to more advanced diagnostic tests, such as hemoglobin electrophoresis or genetic screening, may be limited. in these contexts, the mi offers a practical, affordable, and effective method for identifying women at risk of iron deficiency or thalassemia. the incorporation of the mi into routine prenatal care can enhance early detection and management of anemia, potentially improving maternal and fetal outcomes. however, further research is needed to assess its performance in diverse populations and to optimize its use in pregnancy anemia screening programs.10-11 anemia in pregnancy anemia in pregnancy is a widespread condition that poses significant risks to both maternal and fetal health. it is defined as a reduction in hemoglobin levels, which can result from a variety of underlying causes. pregnant women are particularly vulnerable to anemia due to increased physiological demands, such as the expansion of blood volume, increased iron and folate requirements, and changes in red blood cell production. as a result, anemia during pregnancy is associated with numerous complications, including fatigue, weakness, preterm labor, low birth weight, and in severe cases, maternal and fetal death. the world health organization (who) estimates that anemia affects around 40% of pregnant women worldwide, with the prevalence varying by region, socioeconomic status, and access to healthcare.12-13 the causes of anemia in pregnancy are diverse and can be broadly categorized into nutritional deficiencies, chronic diseases, and genetic disorders. the most common cause of anemia in pregnancy is iron deficiency anemia (ida), which occurs when there is insufficient iron to meet the increased demand during pregnancy. this is often exacerbated by poor dietary intake, malabsorption, or blood loss. other causes include folate deficiency, vitamin b12 deficiency, and anemia of chronic disease, which is seen in conditions like chronic infections or autoimmune disorders. in certain populations, genetic disorders such as thalassemia and sickle cell disease can contribute to anemia, leading to microcytic or normocytic anemia, respectively.14-15 anemia during pregnancy can have serious consequences for maternal health. it increases the risk of preterm delivery, low birth weight, and postpartum hemorrhage. for the fetus, it can lead to intrauterine growth restriction, low birth weight, and developmental delays. severe anemia has also been associated with an increased risk of maternal mortality, especially in lowresource settings where access to healthcare may be limited. furthermore, maternal anemia can compromise the oxygen-carrying capacity of the blood, which in turn affects the oxygen supply to both the mother and the fetus, leading to potential developmental and health issues.16 in addition to these risks, anemia in pregnancy can have long-term implications for both the mother and child. women who experience anemia during pregnancy are more likely to suffer from postpartum anemia, which can delay recovery and impact overall health. for children, early exposure to maternal anemia has been linked to cognitive and developmental delays. as such, anemia management is crucial not only for the health of the pregnant woman but also for the long-term health and development of the child. early identification, proper screening, and effective treatment are key to reducing the burden of anemia in pregnancy and improving maternal and fetal outcomes.17 the identification and management of anemia during pregnancy require accurate diagnosis and differentiation between its various causes. this is crucial for providing the appropriate treatment. for instance, while iron deficiency anemia can be effectively managed with iron supplementation, thalassemia traits require different management strategies. misdiagnosis and inappropriate treatment, such as administering iron supplements to a woman with thalassemia, can lead to adverse outcomes, including iron overload. as a result, healthcare providers need reliable diagnostic tools to distinguish between the causes of anemia in pregnancy and ensure targeted treatment.18 the role of the mentzer index in pregnancy anemia screening the mentzer index (mi) is a valuable diagnostic tool used to differentiate between two common causes of microcytic anemia: iron deficiency anemia (ida) and thalassemia. during pregnancy, anemia is a prevalent condition that can lead to serious complications for both the mother and fetus. differentiating between the causes of anemia is crucial, as the treatment for ida (iron supplementation) differs significantly from the management of thalassemia (which may require folic acid supplementation and careful monitoring to avoid iron overload). the mentzer index has become an important part of anemia screening, particularly in resource-limited settings, due to its simplicity, costeffectiveness, and ability to provide immediate insight into the cause of anemia.19 the mentzer index is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, which is expressed as a ratio. a lower mi value, generally below 13, is indicative of thalassemia or other emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):40-44 [42] ajdhs.com hemoglobinopathies, while a higher mi value, greater than 13, typically suggests iron deficiency anemia. this differentiation is particularly important in pregnancy because iron supplementation, which is effective for treating ida, can exacerbate iron overload in individuals with thalassemia. the mi is a simple calculation, requiring only basic hematological parameters from a complete blood count (cbc), making it easy to use in clinical practice, particularly in primary care and lowresource settings where advanced diagnostic tools may not be available.20 the application of the mentzer index in pregnancy anemia screening can improve diagnostic accuracy and allow for more targeted interventions. early differentiation between ida and thalassemia can help avoid the inappropriate administration of iron supplements to women with thalassemia, preventing potential complications such as iron overload. moreover, the mi aids in the identification of women who may require further diagnostic tests, such as hemoglobin electrophoresis or genetic screening, to confirm the presence of thalassemia or other hemoglobinopathies. this allows for more efficient use of healthcare resources and ensures that pregnant women receive the most appropriate and effective treatment for their condition.21 in the context of pregnancy, where maternal and fetal health is at stake, the role of the mentzer index becomes even more significant. pregnancy is a time of increased iron demand, and iron deficiency anemia is one of the most common conditions affecting pregnant women. by providing a simple and quick means of distinguishing between ida and thalassemia, the mi enables healthcare providers to initiate the correct treatment earlier, reducing the risk of adverse outcomes. furthermore, the mi helps clinicians identify women who may benefit from more comprehensive genetic counseling and screening, particularly in regions with higher prevalence rates of thalassemia.22 advantages and limitations of the mentzer index in pregnancy anemia screening the mentzer index (mi) is a practical and cost-effective tool used in the screening of anemia during pregnancy, particularly for distinguishing between iron deficiency anemia (ida) and thalassemia, two of the most common causes of microcytic anemia. while the mi offers several advantages in clinical practice, it also comes with limitations that need to be considered for accurate and effective application in anemia management. understanding both its strengths and weaknesses can help clinicians make more informed decisions when using the mi in pregnancy anemia screening.23 advantages 1. simplicity and ease of use one of the key advantages of the mentzer index is its simplicity. it is calculated using two basic parameters obtained from a complete blood count (cbc): mean corpuscular volume (mcv) and red blood cell (rbc) count. these parameters are readily available in most clinical settings, making the mi an easy and quick tool to use without the need for complex or expensive diagnostic equipment. this simplicity makes it especially valuable in primary care settings or lowresource environments where access to advanced testing may be limited.24 2. cost-effective the mentzer index is a highly cost-effective method for differentiating between ida and thalassemia. unlike more specialized diagnostic tests, such as hemoglobin electrophoresis or genetic screening, which can be costly and may require specialized facilities, the mi relies on parameters that are already part of routine blood tests. this makes it an attractive option for healthcare systems with limited resources, allowing for early and efficient screening of anemia in pregnant women.25 3. early differentiation between ida and thalassemia the mi is particularly useful in distinguishing between ida and thalassemia, two conditions that can present similarly with microcytic anemia. iron deficiency anemia, which is treated with iron supplementation, is the most common form of anemia in pregnancy, while thalassemia requires different management strategies. the mi helps avoid the mismanagement of thalassemia, such as inappropriate iron supplementation, which can lead to iron overload. early differentiation between these conditions allows for appropriate treatment and reduces the risk of complications for both the mother and fetus.26 4. applicable in resource-limited settings in many low-resource settings, where more advanced diagnostic tests may not be available, the mentzer index provides a simple and accessible alternative. it is especially helpful in areas where the prevalence of thalassemia or iron deficiency is high. the ability to perform quick screenings with a basic cbc and interpret the results effectively allows healthcare providers to better manage anemia in pregnant women in these regions, improving maternal and fetal health outcomes.27 limitations 1. influence of pregnancy-related physiological changes pregnancy itself brings about significant physiological changes, such as an increase in blood volume, changes in red blood cell production, and alterations in iron metabolism. these changes can affect the mean corpuscular volume (mcv) and red blood cell (rbc) count, potentially leading to misleading mentzer index results. for example, the increase in plasma volume during pregnancy may result in lower rbc concentration and altered mcv values, which can distort the mi calculation and reduce its diagnostic accuracy in pregnant women.24 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):40-44 [43] ajdhs.com 2. less effective in mixed anemia the mi may be less reliable in cases of mixed anemia, where a pregnant woman has both iron deficiency and thalassemia traits. in such cases, the mi may produce ambiguous results, as both conditions can affect mcv and rbc count. since the mi is designed to distinguish between iron deficiency and thalassemia specifically, it may not be able to provide a clear diagnosis when both conditions are present, necessitating further diagnostic testing such as hemoglobin electrophoresis or genetic screening for a more definitive diagnosis.25 3. limited in severe cases of anemia in cases of severe anemia, where hemoglobin levels are critically low, the mentzer index may not offer reliable results. the formula depends on accurate rbc and mcv measurements, which can be influenced by extremely low or high values of these parameters. for example, in severe iron deficiency anemia, the rbc count may be elevated as a compensatory mechanism, and in severe thalassemia, the rbc count may be disproportionately low. these extreme values can cause the mi to be less accurate in such scenarios.26 4. not suitable for all anemia causes while the mentzer index is effective in distinguishing between ida and thalassemia, it does not provide information on other causes of anemia that may also affect pregnant women, such as vitamin b12 deficiency, folate deficiency, or anemia of chronic disease. therefore, the mi is only useful for identifying specific types of microcytic anemia and should not be relied upon as the sole diagnostic tool in cases where other etiologies are suspected. a comprehensive approach, including additional testing and clinical evaluation, is necessary to accurately diagnose and treat anemia with multiple underlying causes.27 5. need for additional diagnostic confirmation while the mi is a useful screening tool, it is not definitive. the results should always be corroborated with other diagnostic tests, especially in ambiguous or borderline cases. for instance, confirmation of thalassemia typically requires hemoglobin electrophoresis or genetic testing to accurately identify the specific hemoglobin variant or mutation. similarly, iron deficiency anemia diagnosis may need additional assessments, such as serum ferritin levels or iron studies, to confirm the deficiency and assess the severity.27 conclusion the mentzer index (mi) serves as a valuable, costeffective tool in the screening and differentiation of microcytic anemia, particularly for distinguishing between iron deficiency anemia (ida) and thalassemia in pregnant women. its simplicity and accessibility make it an ideal choice for use in clinical settings, especially in low-resource environments where advanced diagnostic tests may be limited. by enabling early identification of these two common causes of microcytic anemia, the mi helps guide appropriate treatment strategies, reducing the risk of complications such as iron overload in thalassemia patients. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):40-44 [44] ajdhs.com journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):15-19 [15] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited mentzer index in high-risk pregnancies: anemia screening and management emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 05 nov 2024 reviewed 16 dec 2024 accepted 12 jan 2025 published 15 march 2025 _____________________________________________ cite this article as: obeagu ei, mentzer index in high-risk pregnancies: anemia screening and management, asian journal of dental and health sciences. 2025; 5(1):15-19 doi: http://dx.doi.org/10.22270/ajdhs.v5i1.113 abstract _________________________________________________________________________________________________________________ anemia remains a common and critical health issue in high-risk pregnancies, leading to adverse outcomes for both the mother and fetus, including preterm birth, low birth weight, and maternal fatigue. differentiating between the two most common causes of microcytic anemia—iron deficiency anemia (ida) and thalassemia trait (tt)—is essential for appropriate management. the mentzer index, calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, has been proposed as a simple and effective tool to distinguish between these two conditions. this review explores the role of the mentzer index in anemia screening and management, particularly in high-risk pregnancies, where timely and accurate diagnosis is crucial for improving health outcomes. the application of the mentzer index in high-risk pregnancies offers a quick and cost-effective method for clinicians to identify whether the anemia is likely due to ida or tt. a mentzer index score below 13 typically suggests thalassemia trait, while scores above 13 generally point toward iron deficiency anemia. while useful, the mentzer index is not definitive on its own and should be complemented by other diagnostic tests, such as hemoglobin electrophoresis, serum ferritin, and transferrin saturation, to confirm the underlying cause of anemia. by integrating these methods, healthcare providers can better tailor treatment plans, ensuring that women with ida receive appropriate iron supplementation while avoiding iron overload in those with thalassemia trait. keywords: mentzer index, high-risk pregnancies, anemia screening, iron deficiency anemia, thalassemia trait *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction anemia is one of the most prevalent conditions affecting pregnant women globally, with particularly high rates observed in high-risk pregnancies. high-risk pregnancies encompass those involving women with preexisting health conditions such as diabetes, hypertension, or nutritional deficiencies, as well as those carrying multiple fetuses or facing socioeconomic challenges. these women are more vulnerable to anemia due to the increased nutritional demands during pregnancy and the complexities associated with managing existing health conditions. anemia in pregnancy, if left untreated, can lead to a range of maternal and fetal complications, including preterm birth, low birth weight, and maternal fatigue. as a result, proper diagnosis and management of anemia are vital for ensuring the health and well-being of both the mother and the developing fetus.1-2 two of the most common causes of microcytic anemia during pregnancy are iron deficiency anemia (ida) and thalassemia trait (tt), both of which present with similar clinical features, such as low hemoglobin levels and microcytic hypochromic red blood cells. however, these two types of anemia require distinctly different treatment approaches. ida is typically treated with iron supplementation, while thalassemia trait is a genetic condition where iron supplementation is unnecessary and can lead to harmful iron overload. differentiating between these conditions is essential for accurate diagnosis and appropriate treatment, which is often challenging in the context of pregnancy due to the overlapping symptoms and the additional diagnostic complexities posed by the physiological changes of pregnancy.3-4 the mentzer index has emerged as a helpful tool in this context, offering a simple and cost-effective method to differentiate between ida and thalassemia trait. the mentzer index is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count. in general, a mentzer index value below 13 suggests thalassemia trait, while values greater than 13 are typically indicative of iron deficiency anemia. the mentzer index can be a valuable initial screening tool to guide clinicians in further diagnostic workups, such as hemoglobin electrophoresis or serum ferritin testing, which are needed to confirm the diagnosis and determine the appropriate treatment course. despite its usefulness, the mentzer index has limitations, including the fact that it may not accurately distinguish between other causes of anemia or when anemia is open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i1.113 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.113&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):15-19 [16] ajdhs.com multifactorial.5-6 in high-risk pregnancies, where the likelihood of anemia is elevated due to various maternal health factors, timely and accurate diagnosis is particularly crucial. the mentzer index allows healthcare providers to quickly narrow down the possible causes of anemia, which can accelerate treatment decisions and prevent the complications associated with both under-treatment and overtreatment. for example, in cases where a woman with a low mentzer index is diagnosed with thalassemia trait, iron supplementation is avoided, preventing the risk of iron overload. conversely, a higher score can prompt clinicians to initiate iron supplementation for those with ida, thereby preventing further complications associated with iron deficiency.7-8 while the mentzer index is an effective screening tool, it should not be used in isolation, particularly in complex cases of anemia. pregnancy-induced changes, such as altered iron metabolism, and the presence of other underlying conditions can sometimes interfere with the accuracy of the mentzer index. additionally, in high-risk pregnancies, anemia is often multifactorial, which may require a more comprehensive approach to diagnosis and management. this includes combining the mentzer index with other diagnostic tests, such as serum ferritin, transferrin saturation, and hemoglobin electrophoresis, to ensure a more accurate understanding of the type and cause of anemia.9-10 the role of the mentzer index in high-risk pregnancies the mentzer index plays a critical role in managing anemia in high-risk pregnancies, particularly in distinguishing between two common causes of microcytic anemia: iron deficiency anemia (ida) and thalassemia trait (tt). in high-risk pregnancies, where the prevalence of anemia is often higher due to factors such as pre-existing medical conditions, poor nutrition, or multiple gestations, accurately diagnosing the cause of anemia is crucial. both ida and tt present with similar symptoms, such as fatigue and pallor, but require different treatment approaches. while ida responds well to iron supplementation, thalassemia trait does not, and inappropriate iron therapy can lead to iron overload, which can be harmful to the mother and fetus. the mentzer index serves as a simple, costeffective tool to help differentiate between these two conditions and guide further diagnostic workup and management.11-12 the mentzer index is calculated by dividing the mean corpuscular volume (mcv) by the red blood cell (rbc) count, yielding a numerical value. in general, a mentzer index score below 13 suggests that the anemia is more likely to be due to thalassemia trait, while a score above 13 is indicative of iron deficiency anemia. the use of this index in high-risk pregnancies helps to quickly identify whether further testing, such as hemoglobin electrophoresis or serum ferritin measurement, is needed to confirm the diagnosis. in women with a low mentzer index, confirming thalassemia trait is important, as iron supplementation would not be beneficial and could worsen the condition. conversely, a high mentzer index can prompt the initiation of iron therapy for those with ida, addressing the root cause of the anemia and preventing complications such as preterm birth and low birth weight.13-14 beyond its diagnostic utility, the mentzer index has significant implications for clinical practice in high-risk pregnancies. by using the index as a preliminary screening tool, healthcare providers can streamline the process of identifying anemia and initiate timely interventions. in the context of high-risk pregnancies, where maternal and fetal health are more vulnerable to complications from anemia, early diagnosis and appropriate treatment are crucial. the mentzer index provides a quick and easy way for clinicians to assess whether a pregnant woman is at risk for either ida or thalassemia trait, ensuring that both conditions are managed appropriately. moreover, by preventing the unnecessary administration of iron to women with thalassemia trait, the mentzer index helps avoid the risk of iron overload, which can lead to complications such as liver damage, heart failure, or gestational diabetes.1516 while the mentzer index is a valuable tool, it is not without its limitations, especially in complex cases. the physiological changes during pregnancy, such as altered iron metabolism and volume expansion, can sometimes affect the mcv and rbc count, potentially leading to inaccurate results. additionally, anemia in high-risk pregnancies is often multifactorial, and other underlying conditions such as chronic disease or vitamin deficiencies could further complicate the diagnostic process. as such, the mentzer index should be used as part of a broader diagnostic strategy, incorporating other tests like serum ferritin, hemoglobin electrophoresis, and complete blood count (cbc) to provide a comprehensive understanding of the patient’s anemia.17 in high-risk pregnancies, the mentzer index proves to be a useful initial diagnostic tool, but it should not be relied upon as the sole determinant for treatment decisions. the index must be complemented with additional diagnostic tests to confirm the cause of anemia and to tailor the management strategy accordingly. it is essential for clinicians to incorporate a holistic view of the patient’s health status, considering factors like nutritional intake, preexisting conditions, and the overall clinical picture, to ensure that the appropriate interventions are taken. the role of the mentzer index in high-risk pregnancies lies in its ability to differentiate between two common causes of anemia, ultimately guiding treatment decisions that can improve maternal and fetal outcomes.18 anemia screening in high-risk pregnancies anemia screening in high-risk pregnancies is a critical aspect of maternal care, given the increased likelihood of anemia in women with underlying health conditions, poor nutrition, or multiple gestations. high-risk pregnancies often involve factors such as preexisting medical conditions (e.g., hypertension, diabetes, sickle cell disease), socioeconomic challenges, and nutritional deficiencies, which elevate the risk of developing anemia. anemia during pregnancy can lead to serious complications for both the mother and fetus, including preterm labor, low birth weight, fatigue, and in severe emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):15-19 [17] ajdhs.com cases, maternal death. therefore, early detection and proper management of anemia are essential for improving maternal and fetal health outcomes.19 the most common causes of anemia in pregnancy are iron deficiency anemia (ida) and anemia due to other underlying conditions, including thalassemia, vitamin b12 deficiency, or chronic disease. among these, ida is the most prevalent form, characterized by insufficient iron stores needed for the production of hemoglobin. in contrast, thalassemia is a genetic blood disorder that can lead to microcytic anemia, which often presents similarly to ida but requires different treatment, as iron supplementation is not beneficial for those with thalassemia. given the overlap in clinical presentation between these two types of anemia, differentiating between them is crucial for appropriate management. accurate screening tools, such as the mentzer index, are essential in guiding the diagnosis and helping clinicians determine the appropriate course of treatment.20 screening for anemia in high-risk pregnancies typically involves several stages, including a detailed clinical assessment, laboratory tests, and sometimes specialized diagnostic tools. the first step in anemia screening is often a complete blood count (cbc) to assess hemoglobin levels, mean corpuscular volume (mcv), and red blood cell count. if anemia is suspected, further tests such as serum ferritin, transferrin saturation, and hemoglobin electrophoresis may be necessary to confirm the underlying cause. for example, a low mentzer index score (mcv/rbc < 13) may suggest thalassemia trait, while a higher value typically points to ida. by combining the mentzer index with other diagnostic tests, clinicians can quickly and effectively identify the cause of anemia, making it easier to determine whether iron supplementation is appropriate or if further investigation into thalassemia or other conditions is needed.21 the implementation of anemia screening in high-risk pregnancies has several key benefits, including early identification of anemia, reduced risk of complications, and targeted treatment plans. early diagnosis of ida allows for prompt iron supplementation, which can improve maternal energy levels, reduce fatigue, and lower the risk of preterm delivery and low birth weight. on the other hand, identifying women with thalassemia trait helps avoid unnecessary iron supplementation, preventing iron overload, which could lead to complications such as organ damage or gestational diabetes. regular screening during prenatal visits allows healthcare providers to monitor hemoglobin levels and adjust treatment as necessary throughout the pregnancy, ensuring the best possible outcomes for both mother and child.22 despite its importance, anemia screening in high-risk pregnancies faces several challenges. for one, the physiological changes in pregnancy, such as increased plasma volume and altered iron metabolism, can complicate anemia diagnosis. pregnant women also often present with multifactorial anemia, where more than one cause contributes to the low hemoglobin levels. furthermore, in resource-limited settings, access to diagnostic tools such as hemoglobin electrophoresis or serum ferritin tests may be limited, making it difficult to definitively diagnose the cause of anemia. therefore, while anemia screening is essential, it must be integrated into a comprehensive approach to maternal care that includes clinical judgment, ongoing monitoring, and access to necessary diagnostic resources.23 implications for anemia management the implications of anemia management in high-risk pregnancies are significant, as anemia can have detrimental effects on both maternal and fetal health. proper management is essential for preventing complications such as preterm labor, low birth weight, fatigue, and in severe cases, maternal mortality. the approach to managing anemia must be tailored to the underlying cause, which often involves differentiating between iron deficiency anemia (ida) and other forms of anemia, such as thalassemia or anemia due to chronic diseases. the use of tools like the mentzer index plays a pivotal role in guiding the diagnosis, as it helps distinguish between these different causes, thereby informing the treatment strategy. identifying whether the anemia is due to ida or thalassemia allows clinicians to decide whether iron supplementation is appropriate, preventing unnecessary interventions that could lead to complications like iron overload.24 for patients with iron deficiency anemia, management primarily involves iron supplementation to replenish iron stores and support the production of hemoglobin. oral iron supplements are commonly prescribed, but in cases of severe anemia or when oral supplements are not tolerated, intravenous iron may be used. adequate iron intake not only alleviates fatigue and improves maternal well-being but also reduces the risk of adverse pregnancy outcomes, such as preterm birth, low birth weight, and fetal growth restriction. additionally, managing anemia can help improve placental function, which is critical for optimal fetal development. on the other hand, thalassemia requires a different approach, as iron supplementation is contraindicated. in these cases, treatment focuses on managing the thalassemia trait, which may involve regular monitoring of hemoglobin levels, folic acid supplementation, and sometimes blood transfusions if anemia becomes severe.25 another crucial aspect of anemia management in highrisk pregnancies is monitoring and adjusting treatment over time. pregnancy itself brings about physiological changes that can affect iron metabolism and red blood cell production, which may impact anemia management strategies. regular monitoring of hemoglobin levels and serum ferritin can help track the effectiveness of treatment and guide necessary adjustments. additionally, for women with complex anemia profiles, such as those with both iron deficiency and thalassemia, managing the condition can be particularly challenging, requiring a multidisciplinary approach to care. for these women, ensuring that all aspects of their anemia are addressed is vital for preventing complications during pregnancy and labor.26 in high-risk pregnancies, a comprehensive anemia management plan should also take into account nutritional support, as malnutrition is emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):15-19 [18] ajdhs.com a key contributor to anemia, especially iron deficiency. nutritional counseling can be an essential component of anemia management, as it helps ensure that pregnant women receive an adequate intake of iron, folic acid, and other essential nutrients. in resource-limited settings where access to iron supplements and diagnostic tests may be limited, educational interventions and community-based health strategies can help promote awareness about anemia prevention and treatment. addressing the root causes of anemia, such as poor dietary intake or underlying health conditions like malaria or parasitic infections, is also crucial for improving maternal and fetal health outcomes.27 conclusion anemia management in high-risk pregnancies is a crucial component of maternal and fetal healthcare, and early detection through effective screening tools like the mentzer index can significantly improve outcomes. the mentzer index, by differentiating between iron deficiency anemia (ida) and thalassemia trait, plays a pivotal role in guiding the appropriate treatment approach, thus preventing complications associated with incorrect diagnoses and unnecessary treatments, such as iron overload. timely and accurate identification of anemia causes ensures that women receive the most suitable intervention, whether iron supplementation for ida or genetic counseling and management for thalassemia trait. however, it is essential to acknowledge that anemia in pregnancy can be multifactorial, and while the mentzer index offers a helpful starting point, it should be used in conjunction with other diagnostic tests and clinical evaluations. the physiological changes in pregnancy, along with the complexities of maternal health, can sometimes make anemia diagnosis challenging, requiring a comprehensive approach that includes clinical assessment, laboratory testing, and continuous monitoring. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. rahman mm, abe sk, rahman ms, kanda m, narita s, bilano v, ota e, gilmour s, shibuya k. maternal anemia and risk of adverse birth and health outcomes in low-and middle-income countries: systematic review and meta-analysis. the american journal of clinical nutrition. 2016; 103(2):495-504. https://doi.org/10.3945/ajcn.115.107896 pmid:26739036 2. obeagu ei, ezimah ac, obeagu gu. erythropoietin in the anaemias of pregnancy: a review. int j curr res chem pharm sci. 2016;3(3):10-18. https://doi.org/10.22270/ijmspr.v10i2.95 3. okamgba oc, nwosu dc, nwobodo ei, agu gc, ozims sj, obeagu ei, ibanga ie, obioma-elemba ie, ihekaire de, obasi cc, amah hc. iron status of pregnant and post-partum women with malaria parasitaemia in aba abia state, nigeria. annals of clinical and laboratory research. 2017;5(4):206. 4. petrakos g, andriopoulos p, tsironi m. pregnancy in women with thalassemia: challenges and solutions. international journal of women's health. 2016:441-451. https://doi.org/10.2147/ijwh.s89308 pmid:27660493 pmcid:pmc5019437 5. obeagu ei, adepoju oj, okafor cj, obeagu gu, ibekwe am, okpala pu, agu cc. assessment of haematological changes in pregnant women of ido, ondo state, nigeria. j res med dent sci. 2021 apr;9(4):145-148. 6. agreen fc, obeagu ei. anaemia among pregnant women: a review of african pregnant teenagers. journal of public health and nutrition. 2023;6(1):138. 7. arora s, rana d, kolte s, dawson l, dhawan i. validation of new indices for differentiation between iron deficiency anemia and beta thalessemia trait, a study in pregnant females. international journal of scientific reports. 2018; 4(2):26. https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 8. obeagu ei, obeagu gu, insights into maternal health: mentzer index for early anemia detection, international journal of medical sciences and pharma research,2024;10(4):44-49 https://doi.org/10.22270/ijmspr.v10i4.122 9. obeagu ei, influence of hemoglobin variants on vaso-occlusive phenomena in sickle cell anemia: a review, international journal of medical sciences and pharma research, 2024;10(2):54-59 https://doi.org/10.22270/ijmspr.v10i2.104 10. iolascon a, andolfo i, russo r, sanchez m, busti f, swinkels d, aguilar martinez p, bou‐fakhredin r, muckenthaler mu, unal s, porto g. recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. hemasphere. 2024; 8(7):e108. https://doi.org/10.1002/hem3.108 pmid:39011129 pmcid:pmc11247274 11. obeagu ei, obeagu gu, chukwueze cm, ikpenwa jn, ramos gf. evaluation of protein c, protein s and fibrinogen of pregnant women with malaria in owerri metropolis. madonna university journal of medicine and health sciences issn: 2814-3035. 2022 apr 19;2(2):1-9. 12. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 13. sahli ca, bibi a, ouali f, fredj sh, dakhlaoui b, othmani r, laouini n, jouini l, ouenniche f, siala h, touhami i. red cell indices: differentiation between β-thalassemia trait and iron deficiency anemia and application to sickle-cell disease and sickle-cell thalassemia. clinical chemistry and laboratory medicine (cclm). 2013; 51(11):2115-24. https://doi.org/10.1515/cclm-2013-0354 pmid:23800659 14. hoffmann jj, nabbe kc, van den broek nm. effect of age and gender on reference intervals of red blood cell distribution width (rdw) and mean red cell volume (mcv). clinical chemistry and laboratory medicine (cclm). 2015; 53(12):2015-9. https://doi.org/10.1515/cclm-2015-0155 pmid:26536583 15. miftahussurur m, husada d, ningtyas ws. association association of shine and lal index β-thalassemia trait screening results with anaemia and low birth weigh. international journal of nursing and midwifery science (ijnms). 2023; 7(3):290-296. https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 16. shahid h, saleem m, naseer n, tabussam s, aziz a, ullah s. evaluation of srivastava index to distinguishing beta-thalassemia trait from iron deficiency. pakistan journal of medical & health https://doi.org/10.3945/ajcn.115.107896 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.2147/ijwh.s89308 https://doi.org/10.18203/issn.2454-2156.intjscirep20180394 https://doi.org/10.22270/ijmspr.v10i4.122 https://doi.org/10.22270/ijmspr.v10i2.104 https://doi.org/10.1002/hem3.108 https://doi.org/10.1515/cclm-2013-0354 https://doi.org/10.1515/cclm-2015-0155 https://doi.org/10.29082/ijnms/2023/vol7/iss3/543 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(1):15-19 [19] ajdhs.com sciences. 2022;16(05):1225. https://doi.org/10.53350/pjmhs221651225 17. vehapoglu a, ozgurhan g, demir ad, uzuner s, nursoy ma, turkmen s, kacan a. hematological indices for differential diagnosis of beta thalassemia trait and iron deficiency anemia. anemia. 2014; 2014(1):576738. https://doi.org/10.1155/2014/576738 pmid:24818016 pmcid:pmc4003757 18. urrechaga e. discriminant value of% microcytic/% hypochromic ratio in the differential diagnosis of microcytic anemia. clinical chemistry and laboratory medicine. 2008;46(12):1752-1758. https://doi.org/10.1515/cclm.2008.355 pmid:19055451 19. obeagu ei, obeagu gu, anemia in pregnancy: mentzer index as a predictor for iron supplementation needs, international journal of medical sciences and pharma research, 2024;10(4):39-43 https://doi.org/10.22270/ijmspr.v10i4.121 20. obeagu ei, obeagu gu. sickle cell anaemia in pregnancy: a review. international research in medical and health sciences. 2023 jun 10;6(2):10-13. https://doi.org/10.22270/ijmspr.v10i2.103 21. obeagu ei, ubosi ni, uzoma g. antioxidant supplementation in pregnancy: effects on maternal and infant health. int. j. adv. multidiscip. res. 2023;10(11):60-70. 22. obeagu ei, obeagu gu. mitigating oxidative stress in pregnancy through antioxidant supplementation: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):7-17. 23. obeagu ei, obeagu gu. enhancing maternal and fetal well-being: the role of antioxidants in pregnancy. elite journal of medical sciences. 2024;2(4):76-87. 24. obeagu ei, obeagu gu. antioxidant supplementation and prevention of early pregnancy loss: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(9):28-37. https://doi.org/10.22270/ijmspr.v10i4.120 25. obeagu ei, obeagu gu. molar pregnancy: update of prevalence and risk factors. int. j. curr. res. med. sci. 2023;9(7):25-28. https://doi.org/10.19080/jgwh.2023.25.556169 26. obeagu ei, obeagu gu. hypoxia-induced metabolic changes in pregnancy: clinical perspectives. elite journal of medicine. 2024;2(8):50-59. 27. obeagu ei, obeagu gu. hemolysis challenges for pregnant women with sickle cell anemia: a review. elite journal of haematology. 2024;2(3):67-80. https://doi.org/10.53350/pjmhs221651225 https://doi.org/10.1155/2014/576738 https://doi.org/10.1515/cclm.2008.355 https://doi.org/10.22270/ijmspr.v10i4.121 https://doi.org/10.22270/ijmspr.v10i2.103 https://doi.org/10.22270/ijmspr.v10i4.120 https://doi.org/10.19080/jgwh.2023.25.556169 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [51] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited addressing gender-based violence to support hiv prevention efforts: a review emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 24 sep 2024 reviewed 19 oct 2024 accepted 20 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, addressing gender-based violence to support hiv prevention efforts: a review, asian journal of dental and health sciences. 2024; 4(3):51-56 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.102 abstract _________________________________________________________________________________________________________________ gender-based violence (gbv) is a significant global health issue that exacerbates the spread of hiv, particularly among women and vulnerable populations. the links between gbv and hiv transmission are multifaceted, as violence increases individuals' exposure to unprotected sex, limits access to healthcare, and fosters environments of stigma and disempowerment. victims of gbv, particularly women, may face greater barriers to hiv prevention and care, putting them at higher risk of both hiv infection and poor health outcomes. the intersection of gender inequality and violence creates a cycle that hinders effective hiv prevention efforts and impedes the overall fight against the epidemic. addressing gbv is crucial to improving hiv prevention strategies. integrating gender-sensitive approaches into hiv prevention programs can help mitigate the risk of hiv transmission. key strategies include community-based interventions to shift harmful gender norms, comprehensive sexual and reproductive health services that address both gbv and hiv needs, and strengthening legal frameworks to protect survivors. empowering individuals through education about sexual rights and hiv prevention is also essential, as is involving men and boys in the promotion of gender equality. these combined efforts can reduce both gbv and hiv transmission by addressing the root causes and providing support for survivors. keywords: gender-based violence, hiv prevention, gender equality, sexual and reproductive health, violence reduction strategies *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction gender-based violence (gbv) is a widespread and deeply entrenched social issue that affects individuals globally, particularly women and marginalized groups. defined as any harmful act directed at an individual based on their gender, gbv includes physical, sexual, emotional, and psychological violence. the intersection of gbv and hiv is a significant concern in global health efforts, as violence disproportionately affects women, increasing their vulnerability to hiv infection. the global prevalence of both gbv and hiv highlights the need for integrated approaches to address these interrelated public health challenges.1 gender-based violence creates an environment in which individuals are more likely to engage in high-risk behaviors, such as unprotected sex or multiple sexual partners, due to coercion or lack of autonomy. these factors significantly increase the risk of hiv transmission. women, particularly in contexts where they experience economic dependence or limited social power, may be unable to negotiate safer sexual practices or seek out hiv prevention and care services. in such environments, the act of violence itself may lead to physical injuries that make individuals more susceptible to infection, further exacerbating the cycle of risk. the emotional and psychological trauma associated with gbv can also diminish an individual's ability to seek necessary health services, including hiv testing, treatment, and prevention.2-3 the relationship between gbv and hiv is complex and multifaceted, involving both direct and indirect mechanisms of risk. for instance, survivors of sexual violence may face injuries to their genital tract, which increases the likelihood of hiv transmission if exposed to the virus. additionally, the long-term psychological effects of violence can contribute to behaviors such as substance abuse, which may impair judgment and lead to increased sexual risk-taking. moreover, the stigma surrounding both hiv and gbv further complicates the situation, often preventing individuals from accessing essential health services and support. as a result, hiv transmission rates remain disproportionately high among survivors of gbv, particularly in settings where violence is normalized.4 the social and structural drivers of gbv, such as gender inequality, power imbalances, and discrimination, are central to understanding its impact on hiv transmission. in many societies, women and girls experience systemic disadvantages that limit their autonomy and agency. these gender norms and practices perpetuate violence and make it difficult for women to access healthcare, education, and other resources that could protect them open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.102 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.102&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [52] ajdhs.com from hiv. additionally, cultural beliefs that minimize or normalize violence against women further entrench the cycle of abuse. as these structural factors perpetuate both gbv and hiv, addressing them simultaneously becomes crucial in the effort to reduce new infections and support gender equality.5-6 efforts to prevent hiv must take into account the crucial role of gender-based violence. a growing body of research supports the idea that hiv prevention interventions that do not address gbv are likely to be less effective, as violence undermines individuals' ability to take preventive actions, such as practicing safe sex, using hiv prevention tools like pre-exposure prophylaxis (prep), or seeking treatment. conversely, comprehensive approaches that address both hiv and gbv have proven more successful in reducing risk, as they simultaneously tackle the underlying issues of violence and the structural barriers to accessing care. as a result, integrating gender-sensitive strategies into hiv prevention programs is essential for creating sustainable health solutions.7-8 understanding the link between gender-based violence and hiv the connection between gender-based violence (gbv) and hiv is multifaceted, with gbv acting as both a direct and indirect determinant of hiv risk. gbv exacerbates individuals' vulnerability to hiv through several key mechanisms, including forced or coerced sex, limited negotiation power regarding safe sex, and physical and psychological trauma. as the risk of hiv transmission is strongly influenced by behaviors and access to care, the widespread nature of gbv becomes a critical factor that hinders efforts to prevent the spread of hiv, especially in regions where violence against women and marginalized groups is pervasive.9 one of the primary ways in which gbv increases hiv risk is through the practice of coerced or non-consensual sex. victims of sexual violence, including rape and intimate partner violence, are more likely to be exposed to the virus during these violent acts, particularly if their assailant is hiv-positive. the lack of agency and the inability to negotiate safe sexual practices, such as condom use, further increases the likelihood of hiv transmission. in some cases, survivors of gbv may even be exposed to multiple instances of sexual violence, each increasing their cumulative risk of infection. furthermore, injuries sustained during violent sexual encounters, such as genital trauma, can provide direct entry points for the hiv virus, raising the physical susceptibility to infection.10-11 in addition to the direct effects of physical violence, the emotional and psychological impacts of gbv also contribute to heightened hiv risk. survivors of gbv often experience trauma that can manifest in depression, anxiety, and post-traumatic stress disorder (ptsd), which may lead to risky behaviors such as substance abuse and sexual risk-taking. these emotional burdens may impair a person’s ability to take preventive actions, such as using condoms or accessing hiv care, because their emotional well-being and decision-making capacity may be compromised. furthermore, the stigma associated with both gbv and hiv often leads to isolation and a lack of support, preventing individuals from seeking help or disclosing their experiences to healthcare providers.12 another key aspect of the link between gbv and hiv is the influence of gender inequality and power dynamics within relationships. in societies where women and girls are socially and economically disadvantaged, they are often less able to negotiate sexual practices or leave abusive relationships. gender norms that condone male dominance and female submission further exacerbate this issue. in these settings, women may feel unable to refuse sex or insist on protective measures, leaving them vulnerable to hiv exposure. the pervasive nature of these gender inequalities means that gbv is not only a consequence of sexual violence but also a manifestation of broader societal structures that perpetuate both violence and vulnerability to hiv.13 moreover, the broader societal consequences of gbv often lead to limited access to essential hiv services. victims of gbv, particularly women, may face multiple barriers to seeking healthcare, including fear of further abuse, lack of financial resources, and stigma from both their communities and healthcare providers. in many settings, survivors may be reluctant to disclose their experiences for fear of being blamed or judged. this reluctance to seek care can delay hiv diagnosis, treatment, and prevention, leading to worse health outcomes. additionally, in cases where individuals are subjected to repeated violence, there may be chronic exposure to high-risk situations, increasing their lifetime risk of hiv infection.14-15 the link between gbv and hiv also highlights the importance of integrated approaches to prevention. traditional hiv prevention efforts, such as condom distribution or prep programs, can be significantly less effective if they do not account for the presence of gbv. programs that address both violence and hiv in a holistic manner, offering support to survivors of violence while also promoting safe sexual practices, are likely to be more successful. these programs must take a multi-sectoral approach, involving not only healthcare providers but also legal systems, community leaders, and education systems to challenge harmful gender norms and ensure that survivors have access to the resources they need to break free from the cycle of violence and risk.16-17 ultimately, the link between gbv and hiv underscores the importance of addressing gender inequality as a fundamental strategy in hiv prevention. reducing violence against women and marginalized populations, empowering individuals to assert their rights, and providing comprehensive care for those affected by gbv can help reduce hiv transmission. this interconnected approach to gbv and hiv prevention is not only essential for improving health outcomes but also for promoting gender equality and fostering safer, healthier communities.18 impact of gender inequality on hiv risk gender inequality plays a critical role in increasing vulnerability to hiv infection, particularly among women and marginalized groups. in many societies, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [53] ajdhs.com women and girls experience systemic disadvantages that limit their ability to protect themselves from hiv. these inequalities are often manifested in various aspects of life, including economic dependence, limited access to education, cultural norms, and social expectations, all of which contribute to a higher risk of hiv transmission. by understanding the impact of gender inequality on hiv risk, we can better develop interventions that address the root causes of this vulnerability and help reduce new infections.19 one of the primary ways in which gender inequality increases hiv risk is through the imbalance of power in sexual relationships. in many societies, women and girls are socialized to be submissive to male partners, which can hinder their ability to negotiate safer sex practices, such as condom use. the inability to refuse sex or insist on protective measures makes women more susceptible to hiv exposure, particularly in situations where their partners may have multiple sexual partners or be at risk of infection themselves. in some regions, the gendered expectation that women should prioritize their partner's desires over their own sexual health needs perpetuates this power dynamic, limiting their ability to protect themselves from hiv.20 economic dependence is another key factor that exacerbates hiv risk among women. in many societies, women are financially dependent on men, which can create a barrier to leaving unsafe relationships or seeking healthcare. economic vulnerability increases the likelihood that women will stay in abusive or highrisk situations, including relationships where their partners may refuse to use protection or engage in risky sexual behaviors. this financial dependency also limits women's ability to access hiv prevention tools, such as pre-exposure prophylaxis (prep), or attend regular health checkups. when women lack financial independence, they may be less empowered to assert their health and sexual rights, further increasing their susceptibility to hiv.21 cultural norms and social expectations also play a significant role in shaping gender inequality and hiv risk. in many cultures, traditional gender roles place women in a subordinate position, which can normalize gender-based violence (gbv) and exacerbate their vulnerability to hiv. for example, women who experience intimate partner violence or sexual violence are at a higher risk of hiv infection, as violence often includes coerced or nonconsensual sex. additionally, the stigma surrounding hiv and gender-based violence may prevent women from disclosing their status, seeking treatment, or accessing preventative care. women who are blamed for their own exposure to violence or hiv are less likely to receive the care and support they need, which perpetuates the cycle of risk.22 the impact of gender inequality on hiv risk is also magnified by the intersectionality of other forms of discrimination, such as race, class, and sexual orientation. women and girls who belong to marginalized communities, including ethnic minorities, refugees, and members of the lgbtq+ community, face compounded risks due to social stigma and discrimination. these individuals often have less access to healthcare services, face greater barriers to education, and may experience higher levels of violence. for example, lgbtq+ women and men who have sex with men (msm) are more likely to face discrimination in healthcare settings, which may discourage them from seeking hiv testing, treatment, or prevention services. addressing hiv risk in these populations requires acknowledging and combating multiple forms of inequality.23 reducing gender inequality is therefore essential in mitigating hiv risk. interventions that empower women and marginalized groups, improve economic independence, and promote gender equality can significantly reduce the vulnerability to hiv. programs that focus on changing harmful gender norms, such as promoting mutual respect and consent in relationships, are essential in fostering safer sexual practices and improving hiv prevention efforts. furthermore, strengthening access to sexual and reproductive health services, including hiv testing, prevention, and treatment, is crucial in ensuring that individuals have the tools and support they need to protect themselves. legal reforms that protect women from violence and discrimination also play a critical role in reducing the intersectional risks that contribute to the spread of hiv.24 gender-sensitive hiv prevention strategies gender-sensitive hiv prevention strategies are essential for addressing the unique needs and vulnerabilities of individuals, particularly women and marginalized groups, who face disproportionate risks of hiv infection due to gender inequality, social norms, and violence. these strategies recognize that gender-based violence (gbv), gender inequality, and societal power dynamics significantly influence hiv transmission and the ability to access care. effective gender-sensitive approaches go beyond general hiv prevention methods by integrating gender-specific interventions that empower individuals, challenge harmful gender norms, and address the structural and social barriers to hiv prevention.25 one key gender-sensitive strategy involves promoting women's empowerment and improving their autonomy in sexual relationships. in many contexts, women face social and cultural constraints that limit their ability to negotiate safer sex practices, such as condom use, or to refuse sexual activity altogether. empowering women to make decisions about their sexual health is crucial for reducing hiv risk. this includes providing education on sexual and reproductive rights, promoting self-efficacy in negotiating safer sex, and increasing access to hiv prevention tools like pre-exposure prophylaxis (prep) and condoms. programs that focus on increasing women's agency in both sexual and economic spheres can lead to healthier decision-making, as women are more likely to take preventive actions when they have control over their sexual and financial choices.26 addressing gender-based violence (gbv) through integrated hiv prevention strategies is another critical component of gender-sensitive approaches. gbv, particularly intimate partner violence and sexual violence, increases the risk of hiv transmission by undermining a person’s ability to protect themselves emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [54] ajdhs.com from infection. gender-sensitive hiv prevention programs must incorporate support services for gbv survivors, such as legal assistance, mental health care, and access to post-rape care. these programs should provide education and resources for both men and women to challenge harmful gender norms that perpetuate violence, promote healthy relationship dynamics, and ensure that survivors of violence can seek timely hiv testing, care, and treatment. incorporating gbv prevention into hiv strategies helps break the cycle of violence and infection, reducing overall hiv risk within communities.27 access to genderresponsive healthcare services is essential in ensuring that individuals, particularly women, can benefit from hiv prevention and care programs. gender-sensitive healthcare goes beyond the provision of hiv testing and treatment by addressing the specific barriers that women and marginalized groups face in accessing services. for instance, in many settings, women experience challenges in accessing hiv prevention tools, including prep, due to societal stigma or logistical barriers such as lack of privacy, transportation, or financial resources. health providers must be trained to offer non-judgmental, gender-sensitive care, ensuring that women feel safe and supported in accessing hiv prevention services. programs that offer integrated sexual and reproductive health services, including family planning, maternal health, and hiv prevention, are critical in addressing the diverse needs of individuals.28 incorporating a focus on adolescent girls and young women is a particularly important aspect of gendersensitive hiv prevention strategies. this group faces a heightened vulnerability to hiv due to a combination of biological, social, and cultural factors. adolescent girls may lack the knowledge, confidence, or agency to protect themselves from hiv, and they may also experience higher rates of sexual violence or coerced sex. gender-sensitive programs aimed at young people should prioritize sexual education, safe spaces, and peer support, as well as ensuring access to hiv prevention tools like condoms and prep. programs that engage both young women and young men in conversations about consent, gender norms, and healthy relationships can foster a more equitable environment, where both genders share responsibility for preventing hiv.29 finally, addressing the intersectional vulnerabilities faced by marginalized groups is an essential aspect of gender-sensitive hiv prevention. these groups, including lgbtq+ individuals, sex workers, and people who inject drugs, experience compounded risks due to intersecting forms of discrimination, social exclusion, and violence. hiv prevention strategies must be tailored to the unique needs of these populations, recognizing their specific risks and barriers to accessing care. providing safe, confidential spaces for marginalized groups to access hiv testing, prevention, and treatment services is crucial for ensuring that these individuals are not left behind in the fight against hiv. legal protections, social support networks, and communityled advocacy efforts can also play a vital role in reducing the stigma and discrimination that contribute to higher hiv risk in these groups.30 challenges and limitations while gender-sensitive hiv prevention strategies are essential in addressing the unique vulnerabilities and needs of women and marginalized groups, their implementation and effectiveness face several significant challenges. these challenges stem from structural, cultural, and economic barriers, as well as the deeply entrenched gender norms and inequalities that continue to shape societal attitudes towards hiv, gender, and sexual health. understanding these challenges is crucial for improving the design, scale, and impact of gender-sensitive interventions, ensuring that they can effectively reduce hiv risk and address the root causes of gender inequality.31 one of the primary challenges in implementing gender-sensitive hiv prevention strategies is the persistence of harmful gender norms and stereotypes. in many societies, traditional views about gender roles and sexuality often create barriers for women and marginalized groups to negotiate safer sex or to seek hiv prevention services. for example, the belief that women should be passive in sexual relationships or that men must be the primary decision-makers can prevent women from asserting their rights or negotiating condom use. these entrenched societal expectations make it difficult for gender-sensitive programs to achieve meaningful change, as they require not only changing individual behaviors but also transforming deep-seated cultural attitudes and norms. overcoming these barriers requires long-term efforts that involve community engagement, education, and the active participation of both men and women in redefining gender roles and expectations.32 another limitation of gender-sensitive hiv prevention strategies is the challenge of addressing the intersectionality of risks faced by women and marginalized groups. many individuals experience compounded vulnerabilities due to the overlap of gender with other forms of discrimination, such as race, class, sexual orientation, and disability. for example, black and indigenous women, as well as lgbtq+ individuals, may face higher levels of violence, discrimination, and limited access to healthcare services compared to their peers. these intersecting forms of marginalization can make it more difficult for gendersensitive hiv prevention strategies to effectively reach and support the most at-risk populations. tailoring interventions to address these diverse experiences requires a nuanced understanding of intersectionality and the development of programs that are culturally appropriate, inclusive, and flexible enough to meet the complex needs of different groups. however, achieving this level of specificity and inclusivity can be resourceintensive and may require significant investment in community-led programs and localized research.33 economic barriers also play a crucial role in limiting the effectiveness of gender-sensitive hiv prevention strategies. in many lowand middle-income countries, women and marginalized groups face economic emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [55] ajdhs.com dependency, which can restrict their ability to access hiv prevention tools, services, or educational resources. financial constraints can prevent women from seeking hiv testing, accessing prep, or participating in hiv prevention programs. for example, in some settings, women may be unable to afford transportation to health clinics, or may face the risk of financial exploitation by male partners or family members who control household finances. additionally, poverty can increase vulnerability to gender-based violence (gbv), as women may feel pressured to stay in abusive relationships due to economic dependency. gender-sensitive strategies must address these economic disparities by offering financial support, subsidies, or accessible healthcare options. without addressing the broader economic context, these interventions may fail to reach the individuals most in need of hiv prevention services.30 cultural and legal barriers further complicate the implementation of gender-sensitive hiv prevention strategies. in many societies, laws and policies related to gender, sexual health, and hiv prevention may not be supportive of the needs of women and marginalized groups. for example, laws that criminalize same-sex relationships, sex work, or drug use can create environments of fear and stigma, preventing individuals from accessing hiv prevention services. additionally, the lack of legal protections for women experiencing intimate partner violence or sexual harassment can discourage them from seeking help or reporting abuse. cultural taboos surrounding discussions of sex, hiv, and gender-based violence can also prevent open dialogue and awareness campaigns, leaving many individuals unaware of their rights or available services. to overcome these challenges, gender-sensitive hiv prevention strategies must be accompanied by advocacy for legal reforms and policies that protect human rights and reduce stigma and discrimination.31 lastly, the limited availability of gender-sensitive healthcare services poses another significant challenge. in many regions, healthcare systems are not equipped to provide the necessary support for women, lgbtq+ individuals, or other marginalized groups in a safe and non-judgmental manner. health providers may lack training on gender sensitivity or may perpetuate stigma themselves, creating an environment where individuals feel unsafe or uncomfortable seeking care. moreover, hiv services may be siloed from other health services, such as sexual and reproductive health or mental health, which are essential for addressing the full spectrum of needs for women and marginalized groups. integrating gender-sensitive care into broader healthcare systems requires training healthcare professionals, creating gender-responsive service delivery models, and ensuring that services are accessible and nonstigmatizing.32-33 conclusion gender-sensitive hiv prevention strategies are critical in addressing the disproportionate burden of hiv on women and marginalized populations, particularly those who are at the intersection of gender-based violence, social inequities, and discrimination. these strategies recognize that gender inequality and harmful societal norms significantly contribute to the vulnerability of individuals to hiv, and therefore, must be an integral part of the global hiv response. by empowering individuals to make informed decisions about their sexual health, challenging harmful gender norms, and providing comprehensive support for survivors of gender-based violence, these strategies can significantly reduce hiv transmission and promote healthier outcomes. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):51-56 [56] ajdhs.com 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. obeagu ei, obeagu gu, the vital role of blood transfusions during pregnancy: a comprehensive review, asian journal of dental and health sciences, 2024;4(1):26-31 https://doi.org/10.22270/ajdhs.v4i1.58 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.22270/ajdhs.v4i1.58 das et al. asian journal of dental and health sciences. 2025; 5(3):16-18 [16] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited endodontic management of crown fracture using reattachment technique with fibre post: case report dr. siddhartha das 1*, dr. neha pal 2 1 associate professor, department of conservative dentistry and endodontics, burdwan dental college and hospital, burdwan, west bengal, india. 2 periodontist and implantologist, private clinician, kolkata, west bengal, india article info: _____________________________________________ article history: received 23 may 2025 reviewed 06 july 2025 accepted 30 july 2025 published 15 sep 2025 _____________________________________________ cite this article as: das s, pal n, endodontic management of crown fracture using reattachment technique with fibre post: case report, asian journal of dental and health sciences. 2025; 5(3):16-18 doi: http://dx.doi.org/10.22270/ajdhs.v5i3.135 abstract _________________________________________________________________________________________________________________ anterior crown fracture from trauma is quite embarrassing for the patient because it impacts the facial esthetics of the person. these traumatic dental injuries are found to be maximum in the maxillary incisors. treatment of these fractures poses a challenge to the clinician as the main objective of the treatment is to restore esthetics and phonetics of the patient along with pain management. several treatment methods are available but restoring the patient’s own fractured fragment of tooth if available is the most viable restorative technique as it provides fast and esthetically pleasing results. hence, this article reports the successful management of crown fracture which was treated with reattachment technique using fibre post. keywords: crown fracture, trauma, reattachment, fibre post *address for correspondence: dr. siddhartha das, associate professor, department of conservative dentistry and endodontics, burdwan dental college and hospital, burdwan, west bengal, india. introduction: coronal fractures of teeth are the most common consequence of dental trauma. injury strikes maximum in the maxillary central incisors, followed by maxillary lateral incisors, mandibular incisors and maxillary canines being less frequent. this sequence is due to their location in the mouth. traumatic injuries have physical, psychological and social impact on the quality of life of the patients.1 restoring coronal fractures poses challenge to the clinician as it requires proper diagnosis and treatment plan. several factors need to be kept in mind like the position of fracture line, biologic width, presence or absence of pulpal involvement, presence or absence of the broken fragment with its viability for usage, occlusion and the esthetics of the concerned patient before implementing proper treatment planning.2 fracture restored with composite resin, fragment reattachment, endodontic treatment with post core supported prosthesis are different modes of treatment to replace the broken tooth. if the broken fragment is found to be in good condition, reattachment is the most viable option of fracture tooth management as it restores the original morphology alongwith function of tooth and esthetics. furthermore it is also economical treatment which provides an emotional and psychological response to the patient.3 the following case report presents management of coronal fracture of maxillary central incisor by reattachment. case presentation: a 28-year-old male reported to department of conservative dentistry and endodontics with chief complaint of pain in fractured upper anterior tooth due to road traffic accident an hour before. clinically ellis class iii fracture in right maxillary central incisor (11) was detected (figure 1). on intraoral examination, soft tissue injury and mobility of the injured tooth was not evident. patient medical history was nothing significant. fractured fragment was just loosely attached to leftover tooth structure. removal of broken fragment was done under local anaesthesia (2% lignocaine) and stored in normal saline to maintain hydration and natural appearance (figure 2). patient was interested in maintaining the tooth by reattaching the fragment. as the fragment was found to be in good condition, patient was explained about the procedural approach of reattachment. pulp chamber was exposed after removal of the fragment, hence working length was found with apex locator (root zx, j morita corp., japan). cleaning and shaping of canal was completed using hand files upto master apical size of 60 k file with intermittent open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i3.135 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i3.135&amp;domain=pdf das et al. asian journal of dental and health sciences. 2025; 5(3):16-18 [17] ajdhs.com irrigation by 3%sodium hypochlorite. canal was dried with paper points and obturation was completed with sectional method maintaining 5mm of apical seal. post space preparation was done with peeso reamers for the placement of glass fibre post in canal and proper length of post was confirmed with a radiograph. coronal end of post was cut with diamond abrasive points such that 4mm of post is available above the coronal surface of remaining tooth structure to enhance the retention of the fragment. a vertical groove of certain depth was prepared on the dentin surface of fractured fragment using round carbide bur which helped in fitting the fragment to the post extension. the fractured fragment, fibre post and remaining tooth structure along with the root canal was etched with 37%orthophosphoric acid for 15 seconds, rinsed, blot dried and bonding agent was applied. light curing was done for 30 seconds for the remaining tooth and fibre post. fibre post was luted with resin cement (calibra, dentsply sirona) and placed in the canal and flowable composite (tetric n flow, ivoclar vivadent) was used to fill up the dentinal groove and remaining canal space. fragment was properly approximated to the actual leftover tooth structure and light curing was done. composite finishing bur was used to get rid of the excess material and occlusion was checked with the antagonist tooth (figure 3). patient recalled after 1 month for follow up and radiograph was taken which showed proper fit and adaptation of the fragment (figure 4). figure 1: fracture of crown (11) figure 2: removal of fractured fragment figure 3: fragment approximation reattachment figure 4: 1 month follow up radiograph discussion: traumatic injuries of permanent incisors with pulpal involvement constitutes 11%-15% out of which 96% involves maxillary central incisors.4 traditional methods of treatment of fractured tooth were cast metal post and core supported by prosthesis, use of composite resins for fracture treatment. but disadvantage of composite resins was that this material does not resemble enamel or dentin structurally as that of original tooth though they possess optical properties.5 however, use of cast metal post with metal ceramic or all ceramic crowns causes wearing of enamel of the opposing dentition which can lead to sensitivity to the patient and chances of post fracture is also high in cast metal post core. with the advancement of adhesive dentistry, reattachment of fractured fragment provides a better choice for treatment provided that biologic factors, materials and techniques are well assessed and managed. reattachment procedure reduces the chances of wear of natural tooth and maintains benefit of preserving original colour match, contacts, contour and incisal translucency.6,7 reattachment is a conservative and cost-effective approach for anterior tooth fracture which also gives psychologically positive response to the patient as the natural tooth structure is preserved. for reattachment procedure, storage of the broken piece has been reported an important factor to maintain the vitality and original esthetic appearance of the tooth. different storage medium includes normal saline, distilled water, saliva, milk and hanks balanced solution. in this case, the fractured fragment was removed and kept in sterile isotonic saline solution to maintain hydration.8 martos et al revealed no significant effect was found on survival, colour and bonding strength of the restored tooth based on the storage medium used for broken fragment.9 fractured fragment was found to be in good condition with accuracy in fitting to the remaining tooth structure with the fracture line. hence, reattachment using fibre post was chosen as the treatment plan for this case. fibre posts was das et al. asian journal of dental and health sciences. 2025; 5(3):16-18 [18] ajdhs.com considered over cast metal posts as fibre posts are esthetic, exhibits good bonding to between post and cement, less chairside time and elastic modulus similar to that of dentin which allows uniform distribution of occlusal stresses in the radicular dentin thus minimizes possibility of tooth fracture.10,11 using fibre posts in addition with composite and adhesive materials creates a monoblock which further helps in reinforcement of the tooth structure.12 reis et al reported that fracture resistance of tooth when done by simple reattachment was 37.1% but placement of vertical internal groove in fracture fragment or superficial overcontouring enhances the fracture resistance to 90.5%.13 in this case vertical internal grooves were placed in fractured fragment to increase fracture resistance. dual cure resin cement with self-adhesive property was used for cementation of the fibre post in root canal as this cement possess high bond strength and reduces microleakage. fragment reattachment was completed to the remaining crown structure using flowable composite resin over the fracture line that provides proper colour stability, minimizes inclusion of voids and aids to attain bond strength of the fragment to the tooth structure.14 conclusion: treatment and material advances related to adhesive dentistry has proved reattachment as minimally invasive treatment for revitalizing esthetics and function with a successful outcome. for traumatized patient with fractured teeth, reattachment procedure serves the primary choice of treatment as it maintains natural esthetics without sacrificing natural tooth structure. acknowledgement: the authors declare that there are no acknowledgements conflict of interest: the authors declare no conflicts of interest author contributions: both authors have equal contributions in the preparation of the manuscript. source of funding: nil informed consent: consent was obtained from the patient. references: 1. andreasen jo, andreasen f, andreasen l. textbook and color atlas of traumatic injuries to the teeth. oxford: blackwell munksgaard; 2007. 2. macedo gv, diaz pi, de o et al. reattachment of anterior teeth with fragments: a conservative approach. j esthet restor dent 2008;20(1):5-18 https://doi.org/10.1111/j.17088240.2008.00142.x pmid:18237334 3. de castro jc, poi wr, pedrini d et al. multidisciplinary approach for the treatment of a complicated crown-root fracture in a young patient: a case report. quintess int 2011; 42(9):729-735 4. divakar hd, nayak m, shetty r. changing concepts in fracture reattachment of teeth-a case series. endodontology. 2007; 2: 2735. 5. goenka p, sarawgi a, dutta s. a conservative approach toward restoration of fractured anterior tooth. contemp clin dent 2012; 3(suppl 1): s67-s70 https://doi.org/10.4103/0976-237x.95109 pmid:22629071 pmcid:pmc3354810 6. chu fc, yim tm, wei sh. clinical considerations for reattachment of tooth fragments quintessence int. 2000;31:385-91 7. saha sg, saha mk. management of a fractured tooth by fragment reattachment a case report. int j dent clin. 2010; 2: 43-7. 8. u. iseri, z. ozkurt, and e. kazazoglu. clinical management of a fractured anterior tooth with reattachment technique: a case report with an 8-year follow up. dent traumatol 2011; 27: 399403 https://doi.org/10.1111/j.1600-9657.2011.01015.x pmid:21615864 9. martos j, majzoob ym, siqnori c et al. adhesive crown fragment reattachment in anterior-fractured tooth. . j res dent. 2014; 2: 5456. https://doi.org/10.4103/2321-4619.129080 10. s. n. akyuz and a. erdemir. restoration of tooth fractures using fiber post and fragment reattachment: three case reports. european j of gener dent vol. 1, no. 2, pp. 94-98, 2012. https://doi.org/10.4103/2278-9626.103393 11. nakamura t, ohyama t, waki t et al. stress analysis of endodontically treated anterior teeth restored with different types of post material. dent mater j. 2006; 25:145-50. https://doi.org/10.4012/dmj.25.145 pmid:16706310 12. tay fr, pashley dh. monoblocks in root canals: a hypothetical or a tangible goal. j endod. 2007; 33: 391-8 https://doi.org/10.1016/j.joen.2006.10.009 pmid:17368325 pmcid:pmc2223075 13. reis a, francci a, loguercio ad et al. reattachment of anterior fractured teeth: fracture strength using different techniques. oper dent 2001; 26: 287-294 14. andreasen jo. buonocore memorial lecture. adhesive dentistry applied to the treatment of traumatic dental injuries oper dent. 2001;26:328-35 https://doi.org/10.1111/j.1708-8240.2008.00142.x https://doi.org/10.1111/j.1708-8240.2008.00142.x https://doi.org/10.4103/0976-237x.95109 https://doi.org/10.1111/j.1600-9657.2011.01015.x https://doi.org/10.4103/2321-4619.129080 https://doi.org/10.4103/2278-9626.103393 https://doi.org/10.4012/dmj.25.145 https://doi.org/10.1016/j.joen.2006.10.009 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [25] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited child-friendly hiv prevention programs in low-income schools: bridging the gap for a healthier future emmanuel ifeanyi obeagu * department of biomedical and laboratory science, africa university, zimbabwe article info: _____________________________________________ article history: received 12 sep 2024 reviewed 25 oct 2024 accepted 19 nov 2024 published 15 dec 2024 _____________________________________________ cite this article as: obeagu ei, child-friendly hiv prevention programs in low-income schools: bridging the gap for a healthier future, asian journal of dental and health sciences. 2024; 4(3):2530 doi: http://dx.doi.org/10.22270/ajdhs.v4i4.96 abstract _________________________________________________________________________________________________________________ child-friendly hiv prevention programs in low-income schools are essential in addressing the heightened vulnerability of children to hiv, especially in regions with limited resources and healthcare infrastructure. these programs are designed to provide age-appropriate, engaging, and culturally sensitive education, equipping children with the knowledge and skills needed to prevent hiv transmission. by focusing on participatory teaching methods such as peer education, roleplaying, and interactive discussions, these programs empower children to make informed decisions regarding their sexual health. this review examines the key components of successful child-friendly hiv prevention programs, exploring their impact on children’s understanding of hiv, the role of community involvement, and the importance of teacher training in creating an effective learning environment. despite the promising results of such programs, several challenges remain, including resource limitations, cultural barriers, and inadequate access to healthcare services. in many lowincome settings, the scarcity of educational materials, the stigma surrounding hiv, and the lack of trained teachers hinder the successful implementation of hiv prevention education. moreover, without consistent access to hiv prevention tools such as condoms and testing, the impact of these programs may be limited. addressing these barriers requires a multi-faceted approach, involving local communities, health organizations, and schools to ensure that children receive comprehensive hiv education alongside access to preventive resources. keywords: hiv prevention, child-friendly programs, low-income schools, education, public health *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction hiv remains one of the most significant public health challenges globally, with children, particularly those in low-income settings, facing heightened risks of both exposure to and transmission of the virus. in many lowresource areas, children are vulnerable to hiv due to factors such as limited access to healthcare, lack of sexual health education, and social stigmas surrounding hiv and aids. schools, particularly those in low-income communities, serve as important sites for hiv prevention education. however, in these settings, it is essential that hiv prevention programs be adapted to be child-friendly, ensuring that the messages resonate with children’s developmental stages and are delivered in ways that are engaging, culturally appropriate, and supportive.1-2 child-friendly hiv prevention programs are designed to provide children with the knowledge and tools necessary to understand hiv risks and how to avoid them. unlike traditional adult-focused hiv prevention messages, these programs must be tailored to address the cognitive, emotional, and social needs of children. this includes teaching age-appropriate content that avoids overwhelming them with complex medical information and instead focuses on the basics of personal health, healthy relationships, and the importance of communication about sexual and reproductive health. at the same time, these programs need to foster an open, non-judgmental atmosphere where children can ask questions and express concerns without fear of stigma.3-4 low-income schools face unique challenges when it comes to implementing hiv prevention programs. limited resources, overcrowded classrooms, and insufficient trained personnel often hinder the effectiveness of these programs. additionally, in many communities, discussions about hiv and sexuality are still taboo, which can lead to resistance from parents, teachers, and school administrators. despite these challenges, several initiatives have demonstrated success in implementing child-friendly hiv prevention programs that integrate both education and community support. these programs are designed to be both practical and sensitive to the local cultural context, addressing not only hiv but also the broader social determinants that affect children’s vulnerability to the virus, such as gender inequality, child abuse, and poverty.5-6 the success of child-friendly hiv prevention programs depends heavily on the active involvement of teachers, open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i4.96 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i4.96&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [26] ajdhs.com parents, and local communities. teachers must be trained not only in delivering hiv prevention content but also in creating a safe and inclusive learning environment where children feel comfortable discussing sensitive issues. parents and community leaders play a crucial role in reinforcing hiv prevention messages outside of the school setting and in creating a supportive environment that encourages children to engage with the content they are learning in school. by involving the broader community, these programs can help reduce stigma and misinformation about hiv, creating an ecosystem of support that helps children stay informed and protected.7-8 moreover, the integration of hiv prevention into school curricula is important for ensuring sustainability and long-term impact. when hiv education is a core part of the school experience, it normalizes conversations about hiv and sexual health and allows children to gradually build a deeper understanding of these issues over time. this integration not only addresses the immediate need for hiv prevention but also promotes overall health education, empowering children to make informed choices about their sexual and reproductive health as they grow older. ensuring that these programs are scalable and adaptable to different educational contexts is crucial for achieving widespread impact.9-10 key components of child-friendly hiv prevention programs to ensure the effectiveness of hiv prevention efforts in low-income school settings, programs must be designed to meet the unique needs of children. the key components of child-friendly hiv prevention programs include age-appropriate content, interactive teaching methods, community involvement, and supportive resources that empower children to make informed decisions. these elements work together to create an environment in which children can openly discuss hiv and related issues, increasing their understanding and ability to protect themselves.11 1. age-appropriate and culturally relevant content a central aspect of any child-friendly hiv prevention program is the delivery of information that is suitable for the child's cognitive and emotional development. content must be simplified to avoid overwhelming children with complex medical or sexual information, instead focusing on basic concepts such as hygiene, healthy relationships, and the importance of safe behaviors. topics should cover both the prevention of hiv and the broader issues related to sexual health, such as consent, personal boundaries, and how hiv is transmitted. furthermore, the content must be culturally sensitive and adapted to local values and customs, ensuring that the message resonates with children in their specific communities. this cultural relevance fosters greater acceptance and engagement from students, teachers, and parents.12 2. interactive and participatory teaching methods for hiv prevention messages to truly resonate, they need to be conveyed in ways that actively engage children. interactive teaching methods such as roleplaying, group discussions, games, and peer-led education are highly effective in creating a learning environment that is not only fun but also encourages critical thinking and collaboration. these methods allow children to practice real-life scenarios in a supportive and safe setting, helping them internalize hiv prevention strategies in a way that feels relevant to their lives. peer educators, who may be older students or trained community members, can also be effective in delivering information, as they provide relatable role models and help to break down the stigma often associated with hiv.13-14 3. involvement of teachers and school staff the successful implementation of hiv prevention programs requires that teachers and school staff are fully trained to deliver hiv education and foster a supportive environment. teachers are often the first point of contact for children seeking information on sensitive topics such as hiv, and their comfort and knowledge in addressing such issues are critical. comprehensive teacher training programs should not only focus on imparting hiv prevention knowledge but also emphasize the importance of creating a safe, nonjudgmental classroom environment where students feel free to ask questions and express concerns. additionally, teachers must be trained to identify signs of abuse, bullying, or other risk factors related to hiv exposure, ensuring that they can provide appropriate support to vulnerable students.15-16 4. community and parental involvement hiv prevention education should not be confined to the classroom; instead, it must extend into the home and the broader community. parents and caregivers play a key role in reinforcing the messages children receive in school. programs that engage parents through workshops, informational sessions, and resource materials can help them better understand hiv and how to support their children in making healthy choices. community involvement is also crucial, particularly in areas where stigma around hiv is prevalent. local leaders, healthcare providers, and community organizations can partner with schools to promote hiv awareness, reduce stigma, and provide children with access to healthcare resources such as condoms, testing, and counseling services. by creating a network of support, the community can contribute to the overall success of hiv prevention efforts.17 5. access to supportive resources to complement educational efforts, child-friendly hiv prevention programs must also ensure that children have access to resources that support their health and well-being. this includes access to sexual and reproductive health services, counseling, hiv testing, and treatment. schools can partner with local health clinics and non-governmental organizations to provide these services, ensuring that students who need further assistance can easily access care in a confidential and supportive environment. additionally, distributing informative materials such as brochures or posters about hiv prevention can help reinforce lessons learned emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [27] ajdhs.com in class and give children a tangible reminder of the information they have received.18 6. monitoring and evaluation for continuous improvement finally, child-friendly hiv prevention programs should include mechanisms for ongoing monitoring and evaluation. regular assessments of the program's effectiveness are crucial for identifying areas of improvement, understanding children’s needs, and adapting the program to new challenges or opportunities. feedback from students, teachers, parents, and community members can provide valuable insights into how well the program is working and whether it is reaching its goals. this evaluation should not only focus on measuring the knowledge and behavior changes in children but also assess the broader community impact, such as reductions in hiv-related stigma or increased access to healthcare services. continuous monitoring and adaptation ensure that the program remains relevant and effective in the long term.19 challenges to implementing hiv prevention programs in low-income schools despite the critical importance of hiv prevention education in low-income school settings, several challenges can hinder the successful implementation and sustainability of such programs. these challenges range from resource limitations to social and cultural barriers, each of which requires tailored strategies to overcome. addressing these obstacles is crucial to ensuring that hiv prevention efforts reach children in need and have a meaningful impact on their health and well-being.20 1. limited financial and educational resources a primary challenge to implementing hiv prevention programs in low-income schools is the lack of financial resources. many schools in these areas struggle with inadequate funding for basic infrastructure, teaching materials, and staff training, making it difficult to prioritize hiv prevention education. the absence of ageappropriate educational materials—such as textbooks, pamphlets, and visual aids—can severely limit the effectiveness of hiv prevention programs. furthermore, the lack of access to digital resources or multimedia tools restricts the ability to deliver engaging, interactive lessons that could capture children’s attention. without adequate resources, schools cannot create a comprehensive and sustained hiv prevention education program, and efforts may fail to have the desired impact.21 2. stigma and cultural resistance in many low-income communities, hiv and sexual health topics are still considered taboo or stigmatized. this resistance can be particularly strong in conservative societies where discussions about sex, sexual behavior, and hiv are seen as inappropriate for children or adolescents. as a result, there may be resistance from parents, teachers, and even students to participating in hiv education programs. some parents may fear that teaching children about hiv will encourage risky behavior, while others might lack the knowledge to understand the importance of such education. additionally, in some cultures, hiv is closely associated with social stigma, discrimination, and marginalization, which can prevent open discussions and the sharing of accurate information about the virus. this cultural resistance to hiv education can lead to reluctance in adopting or supporting hiv prevention programs within schools.22 3. teacher training and comfort levels teachers are often the frontline educators in hiv prevention programs, but many may lack the necessary training or confidence to effectively address such sensitive topics. in many low-income schools, teachers are not adequately prepared to teach hiv education or discuss topics related to sexual health and hiv prevention. teachers may feel uncomfortable with the subject matter, particularly in communities where discussing sexuality is taboo, and may avoid delivering these lessons altogether. additionally, even if teachers are willing to teach hiv prevention, they may lack up-todate knowledge on the virus, its transmission, and the latest prevention strategies. this gap in teacher preparedness can undermine the quality and impact of hiv prevention programs, leaving students without accurate information. ongoing professional development and support for teachers are essential to ensuring that they can confidently and effectively lead these programs.23 4. lack of community support and involvement for hiv prevention programs to be effective, they must be supported by the broader community, including parents, healthcare providers, and local organizations. however, in many low-income areas, there is often a lack of community involvement or buy-in when it comes to hiv prevention efforts. parents, community leaders, and local organizations may not fully understand the importance of hiv education for children or may be resistant to the idea of discussing sexual health openly. additionally, in some cases, cultural norms or social taboos may prevent parents from engaging in discussions about hiv or supporting hiv prevention initiatives. this lack of community support can hinder the effectiveness of school-based programs and may limit the resources available to students, such as access to hiv testing, counseling, or other preventive services.24 5. overcrowded classrooms and limited time for instruction overcrowded classrooms, which are a common issue in many low-income schools, present another barrier to effective hiv prevention education. large class sizes mean that teachers have less time and attention to devote to each student, which can make it difficult to engage children in sensitive discussions and ensure that they fully grasp the information being presented. in overcrowded environments, there may also be limited opportunities for interactive or hands-on learning activities, such as role-playing or group discussions, emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [28] ajdhs.com which are often essential for reinforcing hiv prevention messages. moreover, teachers may feel pressured to focus on core academic subjects, such as math and language arts, leaving limited time for additional health education. this lack of instructional time and space for individualized attention can compromise the effectiveness of hiv prevention programs.25 6. insufficient access to healthcare and support services even if hiv prevention education is successfully implemented, the impact can be limited if there is insufficient access to healthcare services and resources for students. in many low-income communities, children may not have easy access to hiv testing, counseling, or treatment services. without access to these resources, children may not be able to get tested or seek treatment if they are at risk of hiv. schools may not have the capacity to provide these services on-site, and local health clinics may be too far away or overwhelmed with other healthcare needs. furthermore, even when services are available, stigma or logistical barriers (such as transportation or lack of confidentiality) may prevent children from utilizing them. a comprehensive hiv prevention program must not only provide education but also ensure that students have access to the healthcare and support services they need to protect their health.26 successful models of child-friendly hiv prevention programs implementing child-friendly hiv prevention programs in low-income schools can be highly challenging due to a variety of socio-economic and cultural factors. however, several models around the world have demonstrated success in overcoming these barriers and providing effective hiv education to children. these programs are innovative in their approach, ensuring that hiv prevention is accessible, age-appropriate, and culturally relevant. this section highlights some successful models of child-friendly hiv prevention programs that have made a positive impact in low-income schools, showcasing strategies that could be adapted and scaled in similar contexts.27 1. the "life skills education" program in subsaharan africa one of the most well-known and successful models for child-friendly hiv prevention comes from the "life skills education" programs implemented in several subsaharan african countries. these programs typically focus on empowering children with the skills to make informed decisions about their health, relationships, and personal safety. life skills education includes hiv prevention alongside other health-related topics such as nutrition, hygiene, and sexual and reproductive health. the program incorporates interactive, participatory teaching methods, such as role-play, group discussions, and peer education, allowing students to practice decision-making in real-life scenarios. a key success factor for this program has been its focus on integrating hiv education into broader life skills curricula, which not only covers the biological aspects of hiv but also addresses social and cultural factors that influence behavior. for example, discussions around gender norms, peer pressure, and healthy relationships are an integral part of the curriculum. teachers are trained to facilitate these discussions sensitively, helping children understand the consequences of risky behavior while also providing a space for questions and concerns. in some areas, the program has been linked with health clinics to ensure that students have access to health services, including hiv testing and counseling.28 2. the "abc" hiv prevention program in uganda in uganda, the "abc" hiv prevention program, which stands for abstinence, be faithful, and condom use, has been successfully adapted for children in low-income schools. the program focuses on educating children not only about hiv but also on promoting healthy behaviors that contribute to overall well-being. schools in rural and urban areas have integrated the abc model into their curriculum through engaging methods such as storytelling, drama, and peer education, which makes the content more relatable to students. the key to the success of the abc program in uganda has been its community-centered approach. by involving parents, religious leaders, and local health providers in hiv prevention education, the program creates a holistic support system for children. schools often organize parent-teacher meetings to discuss hiv prevention, share resources, and reinforce the importance of open communication about hiv at home. this multi-level involvement ensures that hiv prevention messages are consistently reinforced, both within the school and in the community, creating a culture of awareness and support that extends beyond the classroom.29 3. the "girl empowerment" program in kenya in kenya, a child-friendly hiv prevention program aimed at empowering girls has been particularly successful in addressing the unique vulnerabilities of girls in low-income settings. the "girl empowerment" program focuses on equipping girls with the knowledge and confidence to protect themselves from hiv and other sexually transmitted infections. this program goes beyond simply providing information about hiv; it also aims to build girls’ self-esteem, assertiveness, and decision-making skills. the program uses a variety of activities such as workshops, mentorship, and community-based campaigns to engage girls in open discussions about their rights, sexual health, and hiv prevention. one of the strengths of this program is its focus on gender inequality, with lessons on resisting gender-based violence, understanding consent, and recognizing the importance of safe relationships. by addressing the social and cultural factors that contribute to girls' vulnerability, the program helps break down stigma and empower girls to take control of their sexual health. furthermore, the program works closely with local health providers to ensure that girls have access to hiv testing, counseling, and reproductive health services.30 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [29] ajdhs.com 4. the "healthy choices" program in india in india, the "healthy choices" program has been implemented in schools to address both hiv prevention and the broader issue of adolescent health. the program targets children in low-income urban and rural areas and aims to provide them with a comprehensive understanding of hiv and other health risks through a fun and engaging curriculum. the "healthy choices" program utilizes peer education, where older students trained as health educators lead sessions for younger students, creating a peer-supported learning environment. the curriculum is designed to be interactive and participatory, incorporating activities like group discussions, games, and quizzes to ensure students engage with the content. a particular focus is placed on the concept of "safe behaviors" in relationships, and children are encouraged to think critically about how to avoid situations that may put them at risk. this approach is supported by extensive teacher training, which ensures that educators are wellequipped to manage sensitive topics and create a supportive and open environment for discussion. additionally, partnerships with local health clinics have allowed the program to provide students with resources such as condoms and access to hiv testing and counseling services.31 5. the "safe spaces" program in south africa in south africa, the "safe spaces" program targets children in rural communities where hiv rates are high. the program creates a safe and supportive environment for children to learn about hiv prevention, life skills, and sexual health, addressing not only the biological aspects of hiv but also the social, emotional, and psychological factors that influence behavior. the "safe spaces" program is unique because it offers a combination of school-based education and community outreach, with mobile units providing hiv prevention education to children in out-of-school settings. the program has been particularly effective in reaching children who may be out of school or unable to attend formal education, often due to economic or social barriers. mobile education units, staffed by trained facilitators, bring hiv prevention education to children in their own communities, ensuring that even the most marginalized children can access critical information and services. a key feature of the program is its focus on emotional support and mental health, helping children cope with the stress and stigma that can come with growing up in high-risk environments.32-33 conclusion child-friendly hiv prevention programs in low-income schools play a critical role in addressing the growing hiv epidemic, particularly in regions with high vulnerability. by providing age-appropriate, culturally sensitive education, these programs empower children to make informed decisions about their sexual health and well-being. successful models, such as the "life skills education" programs in sub-saharan africa, the "abc" program in uganda, and the "girl empowerment" initiatives in kenya, demonstrate the importance of integrating hiv education into broader health and life skills curricula. these models not only focus on hiv prevention but also address related social issues such as gender inequality, peer pressure, and stigma, all of which contribute to the risk of hiv transmission. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. obeagu ei, obeagu gu. neonatal outcomes in children born to mothers with severe malaria, hiv, and transfusion history: a review. elite journal of nursing and health science, 2024; 2(3): 38-58 2. obeagu ei, ubosi ni, obeagu gu, obeagu aa. nutritional strategies for enhancing immune resilience in hiv: a review. int. j. curr. res. chem. pharm. sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102 3. obeagu ei, obeagu gu. understanding immune cell trafficking in tuberculosis-hiv coinfection: the role of l-selectin pathways. elite journal of immunology, 2024; 2(2): 43-59 4. obeagu ei. erythropoietin and the immune system: relevance in hiv management. elite journal of health science, 2024; 2(3): 2335 5. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. applied sciences (nijbas). 2023;3(3). https://doi.org/10.59298/nijbas/2023/1.2.11000 6. parker rg, perez‐brumer a, garcia j, gavigan k, ramirez a, milnor j, terto jr v. prevention literacy: community‐based advocacy for access and ownership of the hiv prevention toolkit. african journal of reproduction and gynaecological endoscopy. 2016;19(1). https://doi.org/10.7448/ias.19.1.21092 pmid:27702430 pmcid:pmc5045969 7. mcneish r, rigg kk, tran q, hodges s. community-based behavioral health interventions: developing strong community partnerships. evaluation and program planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 pmid:30580000 8. schouten dg, deneka aa, theune m, neerincx ma, cremers ah. an embodied conversational agent coach to support societal participation learning by low-literate users. universal access in the information society. 2023; 22(4):1215-1241. https://doi.org/10.1007/s10209-021-00865-5 9. obeagu ei, obeagu gu. immune modulation in hiv-positive neonates: insights and implications for clinical management. elite journal of nursing and health science, 2024; 2(3): 59-72 10. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 11. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health https://doi.org/10.22270/ijmspr.v10i2.102 https://doi.org/10.59298/nijbas/2023/1.2.11000 https://doi.org/10.7448/ias.19.1.21092 https://doi.org/10.1016/j.evalprogplan.2018.12.005 https://doi.org/10.1007/s10209-021-00865-5 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2024; 4(4):25-30 [30] ajdhs.com (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 12. frew pm, archibald m, schamel j, saint-victor d, fox e, smithbankhead n, diallo dd, holstad mm, del rio c. an integrated service delivery model to identify persons living with hiv and to provide linkage to hiv treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. jmir public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 pmid:27227134 pmcid:pmc4869208 13. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 20-35 15. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 16. bond v, chase e, aggleton p. stigma, hiv/aids and prevention of mother-to-child transmission in zambia. evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/s01497189(02)00046-0 17. zukoski ap, thorburn s. experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds. 2009;23(4):267276. https://doi.org/10.1089/apc.2008.0168 pmid:19260770 18. cinthya r, mohan r, vijayakumar p, dayanidhi r, ramakrishnan h, assessment of oral health awareness among the individuals in chengalpttu district: a questionnaire based study, asian journal of dental and health sciences, 2024; 4(1):21-25 https://doi.org/10.22270/ajdhs.v4i1.68 19. pandya s, kan l, parr e, twose c, labrique ab, agarwal s. how can community data be leveraged to advance primary health care? a scoping review of community-based health information systems. global health: science and practice. 2024; 12(2). https://doi.org/10.9745/ghsp-d-23-00429 pmid:38626945 pmcid:pmc11057800 20. navarra am, rosenberg mg, gormley m, bakken s, fletcher j, whittemore r, gwadz m, cleland c, melkus gd. feasibility and acceptability of the adherence connection counseling, education, and support (access) proof of concept: a peer-led, mobile health (mhealth) cognitive behavioral antiretroviral therapy (art) adherence intervention for hiv-infected (hiv+) adolescents and young adults (aya). aids and behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 pmid:36574184 pmcid:pmc9792943 21. billings dw, leaf sl, spencer j, crenshaw t, brockington s, dalal rs. a randomized trial to evaluate the efficacy of a web-based hiv behavioral intervention for high-risk african american women. aids and behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 pmid:25616838 pmcid:pmc4506203 22. kessy f, charle p. evidence of the impact of imf fiscal and monetary policies on the capacity to address hiv/aids and tb crises in tanzania. cegaa/results educational fund, june (cape town: centre for economic governance and aids in africa). 2009. 23. viola n, kimono e, nuruh n, obeagu ei, factors hindering elimination of mother to child transmission of hiv service uptake among hiv positive women at comboni hospital kyamuhunga bushenyi district, asian journal of dental and health sciences, 2023;3(2):7-14 https://doi.org/10.22270/ajdhs.v3i2.39 24. lynn va, webb fj, joerg c, nembhard k. behavioral health disorders and hiv incidence and treatment among women. inwomen's behavioral health: a public health perspective 2024: 129-150. cham: springer international publishing. https://doi.org/10.1007/978-3-031-58293-6_6 25. lassi zs, salam ra, das jk, bhutta za. the conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 pmid:25105014 pmcid:pmc4124965 26. belus jm, msimango li, van heerden a, magidson jf, bradley vd, mdakane y, van rooyen h, barnabas rv. barriers, facilitators, and strategies to improve participation of a couple-based intervention to address women's antiretroviral therapy adherence in kwazulu-natal, south africa. international journal of behavioral medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 pmid:36854871 pmcid:pmc10803380 27. obeagu ei, obeagu gu. unmasking the truth: addressing stigma in the fight against hiv. elite journal of public health. 2024;2(1):822. 28. obeagu ei, obeagu gu, odo eo, igwe mc, ugwu op, alum eu, okwaja pr. combatting stigma: essential steps in halting hiv spread. 29. obeagu ei. breaking barriers: mitigating stigma to control hiv transmission. elite journal of public health. 2024;2(8):44-55. 30. obeagu ei, obeagu gu. preventive measures against hiv among uganda's youth: strategies, implementation, and effectiveness. medicine. 2024; 103(44):e40317. https://doi.org/10.1097/md.0000000000040317 pmid:39496029 pmcid:pmc11537624 31. shafique s, bhattacharyya ds, nowrin i, sultana f, islam mr, dutta gk, del barrio mo, reidpath dd. effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. systematic reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 pmid:39367477 pmcid:pmc11451040 32. muessig ke, nekkanti m, bauermeister j, bull s, hightow-weidman lb. a systematic review of recent smartphone, internet and web 2.0 interventions to address the hiv continuum of care. current hiv/aids reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 pmid:25626718 pmcid:pmc4370788 33. perry h, zulliger r, scott k, javadi d, gergen j. case studies of large-scale community health worker programs: examples from bangladesh, brazil, ethiopia, india, iran, nepal, and pakistan. afghanistan: community-based health care to the ministry of public health. 2013 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.2196/publichealth.4675 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1016/s0149-7189(02)00046-0 https://doi.org/10.1089/apc.2008.0168 https://doi.org/10.22270/ajdhs.v4i1.68 https://doi.org/10.9745/ghsp-d-23-00429 https://doi.org/10.1007/s10461-022-03913-0 https://doi.org/10.1007/s10461-015-0999-9 https://doi.org/10.22270/ajdhs.v3i2.39 https://doi.org/10.1007/978-3-031-58293-6_6 https://doi.org/10.1186/2049-9957-3-22 https://doi.org/10.1007/s12529-023-10160-7 https://doi.org/10.1097/md.0000000000040317 https://doi.org/10.1186/s13643-024-02651-9 https://doi.org/10.1007/s11904-014-0239-3 pallav dave asian journal of dental and health sciences. 2024; 4(2):56-60 [56] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2024 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited addressing stress among healthcare workers using mindfulness-based interventions pallav dave * regulatory compliance analyst, louisville, ky,40223, usa article info: _____________________________________________ article history: received 11 april 2024 reviewed 29 may 2024 accepted 19 june 2024 published 15 july 2024 _____________________________________________ cite this article as: dave p, addressing stress among healthcare workers using mindfulness-based interventions, asian journal of dental and health sciences. 2024; 4(2):56-60 doi: http://dx.doi.org/10.22270/ajdhs.v4i2.89 _____________________________________________ *address for correspondence: pallav dave, regulatory compliance analyst, louisville, ky,40223, usa abstract _________________________________________________________________________________________________________________ stress is rampant among healthcare workers in different patient care settings. healthcare workers are one of the groups that report high workplace stress levels with some studies reporting these levels to be as high as 70 to 90%. stress was particularly rampant among healthcare workers during the covid-19 pandemic because most workers were overwhelmed and could not provide the best care for their patients. stress among healthcare workers is likely to continue because the work conditions that contribute to this high level of stress are becoming more rampant. for instance, demanding work, long and unpredictable work hours, and high administrative burdens continue to be rampant. other factors such as an increase in the number of people affected by multiple chronic conditions and the aging workers are also putting a lot of strain on healthcare and among healthcare workers. considering the staff shortages, taking care of people with numerous needs can increase stress levels which explains why healthcare workers report high levels of stress. considering the negative effects of stress on healthcare workers' health and well-being, it is important to have effective interventions in place to deal with this stress such as mindfulness training. research has shown that mindfulness-based interventions have a lot of potential when it comes to addressing work-related stress. it also helps to deal with depression and anxiety. to increase effectiveness, mindfulness training can also be incorporated as part of wellness programs in the workplace. keywords: mindfulness training, mindfulness-based interventions, stress, burnout, healthcare workers introduction stress is rampant in healthcare with statistics indicating that healthcare workers in different patient care settings are significantly affected. according to a study by prasad et al. high levels of stress were reported by healthcare workers during the covid-19 pandemic.1 in a 2022 survey involving 11,964 nurses, 70% reported experiencing high levels of stress at the height of the covid-19 pandemic.2 similarly, high levels of stress were reported by physicians during the same time period.3 although high levels of stress were reported among healthcare professionals during the covid-19 pandemic, stress is not new to healthcare. high levels of stress were reported among healthcare workers prior to the covid19 pandemic with some studies reporting stress levels of up to 90%.4,5 research indicates that stress among healthcare workers is likely to continue increasing as working conditions that contribute to this stress become more rampant.6 different factors explain why high levels of stress are reported among healthcare workers. healthcare workers report higher levels of stress because they are constantly exposed to stressful and emotional situations that involve a lot of emotional labor. emotional labor in this case means the ability to manage emotions while working with patients and ensuring that one’s emotions do not affect the performance of their duties.7 emotional labor has been shown to have an effect on the physical and mental health of healthcare professionals.8 healthcare workers who perform emotional labor for extended periods of time are more likely to report emotional exhaustion and an increased likelihood of burnout. exposure to human suffering and working under pressure are also factors that contribute to higher levels of stress among healthcare workers. emotional workers are also more prone to pressure because of the increased risk of exposure. this was particularly witnessed during the covid-19 pandemic where fear of exposure to disease was one of the factors that led to high stress levels that were reported at the time.1 healthcare workers also report high-stress levels because of demanding work, long and unpredictable work hours, financial strain, and high administrative burdens. stress has a profound effect on healthcare workers affecting both their physical and mental health. the toll that comes with workplace stress has been reported to lead to burnout when it extends for long periods.1 physically, stress increases the risk of migraines, irritable bowel syndrome, and rashes.9 workplace stress also increases the likelihood of emotional exhaustion, lower professional efficacy, depersonalization, reduced timely-decision making, inadequacy, lower work efficiency, and reduced quality of care.10 mentally, workplace stress has been attributed to higher levels of anxiety and depression.10 all these are likely to affect the ability of healthcare workers to deliver care. for instance, healthcare workers' stress has been attributed to increased risk of medical errors, decreased patient satisfaction, increased risk of hospital-acquired infections, and increased length of hospital stay.11 overall, workplace stress affects care provision. it increases the risk of safety incidents and lowers overall quality of care. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v4i2.89 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v4i2.89&amp;domain=pdf pallav dave asian journal of dental and health sciences. 2024; 4(2):56-60 [57] ajdhs.com the profound effects of workplace stress on healthcare workers necessitate the need for interventions that can rectify the situation and improve their overall health and well-being. several interventions have been suggested to address workplace stress over the years. for instance, rest and relaxation is highly encouraged as a measure of addressing workplace stress. other interventions that are encouraged to deal with stress are breathing exercises, meditation, healthy eating, adopting healthy sleeping habits, and physical exercise. although these measures have been shown to alleviate the effect of stress, they may not be able to adequately address longterm stress. this necessitates evidence-based approaches such as mindfulness training to deal with workplace stress. the effectiveness of mindfulness training in reducing workplace stress among healthcare workers has been established through research.12 mindfulness training can be tailored to different healthcare settings which makes it suitable to address stress in different groups of healthcare workers. this review seeks to establish whether mindfulness training is an effective measure of addressing stress among healthcare workers. it explores different types of mindfulness training and their effectiveness when it comes to dealing with workplace stress. types of mindfulness-based interventions mindfulness is a concept that originates from the buddhist tradition and which is cultivated through a number of different meditation practices.13 mindfulness refers to a form of attention training that seeks to direct an individual’s attention to focus on everyday, present-moment experiences.14 this is done with an attitude of curiosity, acceptance, and nonjudgmental. mindfulness is done with different aims with one of the objectives being to train people to respond to situations in a manner that is reflective instead of responding to them automatically.13 as noted in the definition, mindfulness seeks to direct an individual’s attention to focus on present-moment experiences. with this definition in mind, mindfulness can be defined as a psychological state that aims to promote an individual’s awareness.15 it puts one in a state of being aware which significantly improves their well-being. mindfulness is also associated with psychological well-being because elements of mindfulness such as awareness and non-judgmental acceptance of one’s present-moment experiences are regarded as effective against factors that cause psychological distress such as fear, anxiety worry among others.16 mindfulness can be acquired through training and different forms of mindfulnessbased interventions (mbi). these interventions aim to enhance a person’s proximal skills such as non-judgmental attention control which play a crucial role in reducing symptoms that may affect one’s psychological well-being.17 in addition to improving one’s psychological well-being, mindfulness training enables an individual to be able to recognize their thoughts, emotions, and physical sensations better. the ability to recognize one’s thoughts and emotions better is what enables an individual to respond to stressful situations in a better manner. mindfulness also increases resilience towards stressful situations. this is why mindfulness training is recommended as an effective strategy for dealing with stress among healthcare workers. different types of mindfulness-based interventions exist. some of the most popular are mindfulness-based stress reduction (mbsr), mindfulness-based cognitive therapy (mbct), mindfulness-based art therapy (mbat), mindfulnessbased pain management (mbpm), acceptance and commitment therapy (act), and dialectical behavior therapy. mindfulnessbased stress reduction (mbsr) is attributed to jon kabat-zinn. he developed the therapy in 1979. mbsr is a structured group program whose main focus is to ensure an individual acquires mindfulness progressively.18 the program takes approximately 8 to 10 weeks and can comprise 10 to 40 participants. the groups that are involved in the program can be homogenous or heterogenous when it comes to the disorders or problems of participants. the average session of mbsr takes approximately 2.5 hours for every single session.18 these sessions are done weekly. additionally, the program involves additional single allday sessions per course that are done on a weekend. exercises and topics relating to mindfulness are covered in each session. the instructor guides the group in these exercises during each session. some of these exercises are yoga, meditation, breathing techniques, group dialogue, and gratitude journaling.19 mindfulness during stressful situations and social interactions are also done during these sessions. mbsr also involves homework assignments which are done on a daily basis. these assignments take an average of 45 minutes and are in the form of mindful yoga, meditation practice, and applying mindfulness in different situations in life. research has documented that mbsr is an effective form of mindfulness training when it comes to reducing stress, dealing with depression, and addressing anxiety. mbsr is effective when it comes to dealing with stress because it reduces emotional reactivity and enhances an individual’s cognitive appraisal.19 in addition to addressing stress and other psychological disorders, mbsr can be used to alleviate symptoms of chronic pain in patients dealing with different conditions.19,20 therefore, mbsr can be used to increase the ability of individuals to cope with distress and disability more so for people going through devastating conditions such as chronic pain and psychological disorders. another form of mindfulness training that is widespread in healthcare is mindfulness-based cognitive therapy (mbct). mbct integrates principles of cognitive therapy into the mindfulness-based stress reduction (mbsr) program to address recurring episodes of depression.21 mbct was designed to prevent relapse in people with recurrent depression and was found to reduce the risk of relapse significantly. mbct reduces depression relapse by making people more aware of their thoughts, feelings, and bodily sensations and relating to them differently.22 it teaches important skills that allow individuals to dissociate from habitual cognitive routines more so thoughts that trigger depression which reduces the risk of relapse and recurrence. different techniques are employed when using mbct. they include mindfulness meditation, yoga, mindfulness stretching, and mindfulness practices. similar to mbsr, techniques such as mindfulness meditation seek to teach individuals how to consciously pay attention to their thoughts and feelings without being judgmental. just like mbsr, mbct is also an 8-week program with weekly sessions lasting 2 hours each. mbct also encompasses different forms of meditation practices which can be classified as both formal and informal. some of these practices are sitting and walking meditations, guided body scans, breathing exercises, mindful movement, and focused awareness of daily routine activities.23 each session aims to bring attention to breathing or bodily sensations. as such, the meditations are guided with similar intent. although the sessions are done in groups, emphasis is also placed on developing an independent practice and expanding mindfulness to mental events including thoughts and emotions. similar to mbsr, mbct also encompasses homework assignments which are 45-minute sessions done on a daily basis with a focus on mindfulness activities.23 these are done using guided meditation recordings. although mbct is similar to mbsr, there are some sessions that differ. for instance, mbct encompasses cognitive therapy and psychoeducation about depression.23 with regard to cognitive therapy, mbct teaches people that attempting to resist or avoid unwanted thoughts and feelings does not make these feelings go away. instead, it intensifies them which increases the risk of pallav dave asian journal of dental and health sciences. 2024; 4(2):56-60 [58] ajdhs.com depression. however, unlike cognitive behavioral therapy, mbct does not place a lot of emphasis on changing or altering thought content. instead, emphasis is placed on individual awareness of the relationship they have with their thoughts and feelings.24 as a result, the aim is to enhance a person’s metacognitive awareness. in addition to cognitive therapy and psychoeducation, mbct also provides individuals with the necessary support that can lead to better well-being. the support can entail listening to music, taking walks, or even taking a bath. the ability of mbct to enhance a person’s metacognitive awareness can explain why it is an effective technique for dealing with depression, anxiety, stress, and other psychological problems.25,26 the fact that mbct makes a person more aware of their thoughts and feelings means that they are able to identify early warning signs of depression and other psychological problems before the symptoms worsen. besides, research has established that mbct is effective in dealing with recurring depression with patients who have used the method showing significant improvement.26 in addition to mbsr and mbct, there are other interventions of mindfulness training such as mindfulnessbased pain management, mindfulness-based art therapy, acceptance and commitment therapy, and dialectical behavior therapy all of which have been shown to have varying forms of success when it comes to dealing with different issues. for instance, mindfulness-based pain management is an intervention that is used to help people manage chronic pain.27 the intervention has also been shown to improve depression symptoms and overall quality of life.27 mindfulness-based art therapy is a mindfulness intervention that integrates mindfulness practices and art.28 it allows an individual to engage in creative art as a way of self-exploration. this is done in a mindful manner in that the art is performed in a curious, kind, non-judgmental manner, and when an individual is aware of the present moment.28 research shows that mindfulnessbased art therapy can be used to reduce emotional distress, anxiety, pain, and depression. acceptance and commitment therapy (act) is an additional form of mindfulness intervention that encourages people to address negative thoughts, feelings, and sensations while providing guidance to commit to valuebased actions.29 dialectical behavior therapy encourages people to develop healthy ways of coping with stress and other negative emotions. combining different forms of mindfulness interventions can have a positive impact on stress and negative emotions among healthcare workers. different mindfulness interventions can help healthcare workers address stress, depression, negative emotions, and other psychological issues that result from their work. mindfulness as a measure to address stress among healthcare workers healthcare workers continue to face profound workplace stress despite the numerous measures that have been put in place to address it. organizational measures such as reducing workload, and improving workplace relationships have not been entirely effective in dealing with stress among healthcare workers because of the nature of work.30 for instance, during covid-19, healthcare workers experienced significant loss which impacted their ability to provide care and increased stress levels. the feeling of not being able to adequately provide care because of limited resources and an overwhelming number of patients contributed to higher stress levels during this period. besides, the fear of getting infected and seeing their colleagues lose their lives because of the virus also led to higher stress levels. newer problems also continue to emerge in healthcare and there are inadequate measures to address them. these factors explain why workplace stress is prevalent among healthcare workers and why more measures are needed to address it. addressing workplace stress is important because it has been shown to influence patient health and safety.31 workplace stress also increases the cost of care and affects the health and well-being of healthcare workers. therefore, using measures that are shown to work in addressing stress is vital for overall good outcomes and wellbeing. research has shown that mindfulness training has a lot of potential when it comes to addressing stress and other psychological problems such as depression and anxiety among healthcare workers.32,33 combining different mindfulnessbased interventions reduces overall stress, depression, and anxiety in both clinical and non-clinical populations. according to a meta-analysis done by ruiz-fernandez et al. mindfulness therapies were shown to be beneficial to healthcare professionals in helping them to manage and reduce stress.13 mindfulness was also found effective in increasing selfcompassion among healthcare personnel. mindfulness programs were also found to be effective in helping workers to respond effectively to stressors in the workplace.34 the study which included different workers in healthcare such as dieticians, physicians, social workers, nurses, clinical trainees, and health researchers utilized mbst to provide mindfulness training. some of the skills that were offered are mindfulness, relaxation response, positive affect-generating meditation, and guided imagery or hypnosis.34 the training resulted in significant changes in stress levels, empathy, mindfulness, and resilience despite the fact that it was offered online. a similar study done by shapiro et al. on medical and premedical students had similar findings.35 the study showed that mindfulness was an effective intervention in reducing psychological distress including depression and anxiety. mindfulness training also increased overall empathy levels and overall well-being. mindfulness training helps to reduce stress through a number of mechanisms. mindfulness influences two stress pathways in the brain which leads to changes in brain structures and activity in regions that deal with attention and emotion regulation.36,37 these changes influence how a person copes with stressful situations or regulate their emotions. mindfulness-based interventions such as mbct and mbsr also help to reduce stress by changing how people react to negative thoughts and emotions.38 people who engage in mindfulness training tend to focus on the present and are less likely to put much thought into negative thoughts and emotions. reducing focus on negative thoughts enables individuals to find positive ways to cope. in healthcare, there are different situations that increase negative thoughts and emotions. stressful workplace conditions can increase negative thoughts and emotions among healthcare workers elevating stress levels. using mindfulness training to address these negative emotions can lead to positive outcomes. besides, mindfulness training emphasises the need to focus on the awareness of the present moment. as such, it can increase attention and concentration on the present moment reducing worry about past situations or future situations. doing so is likely to increase focus which can lead to better decisionmaking. mindfulness training can also be used to improve the health and well-being of healthcare workers. healthcare workers often encounter situations that are likely to impact their health and well-being.39 (sue, 2019). mindfulness helps to foster empathy and self-compassion. empathy and selfcompassion are important when dealing with events that are likely to trigger stress. the importance of mindfulness-based interventions in addressing stress is established in research. however, it is important to take note of the existing limitations and how these pallav dave asian journal of dental and health sciences. 2024; 4(2):56-60 [59] ajdhs.com limitations could impact their overall efficiency. first, mindfulness does not take into account that people react differently to different interventions and techniques and what may be effective for one person may not be effective for another.40 because people may react differently to these techniques, their effectiveness may be different. secondly, the use of mindfulness interventions by people with a limited understanding of mental health may have negative effects. limited understanding of mental health may limit positive outcomes associated with mindfulness-based interventions. mindfulness can also increase stress response, negative emotions, and dissociation in some individuals leading to an opposite effect than what was expected.41 besides, the costeffectiveness of mindfulness-based interventions in large organizational settings is yet to be established. although the interventions are generally considered to be effective because they are administered in groups, the cost can be higher if administered to individuals.33 therefore, there is a need to consider the potential limitations of mindfulness interventions and put measures in place that can minimize negative effects. conclusion stress is rampant among healthcare workers in different patient care settings. even before the covid-19 pandemic, stress was still prevalent with high levels reported among healthcare workers. during covid-19, the number of healthcare workers affected by stress almost tripled raising concern about the effective measures that could be used to address the problem. stress among healthcare workers is likely to continue because the work conditions that contribute to this high level of stress are becoming more rampant. for instance, demanding work, long and unpredictable work hours, and high administrative burdens continue to be rampant. besides, the aging population and the number of people affected by chronic conditions are continuing to rise. such factors put a lot of demands on healthcare workers which explains the high level of stress in this population. considering the negative effects of stress on healthcare workers' health and well-being, it is important to have effective interventions in place to deal with this stress. mindfulness training has been shown to have potential when it comes to addressing stress among healthcare workers. in addition to reducing stress, it has been shown to improve empathy, self-compassion, and reduce depression and anxiety. different mindfulness-based interventions can be used but mbsr and mbct are the most commonly used when dealing with stress. mindfulness training can also be incorporated as part of wellness programs in the workplace to increase accessibility to more healthcare professionals. references 1. prasad k, mcloughlin c, stillman m, et al. prevalence and correlates of stress and burnout among us healthcare workers during the covid-19 pandemic: a national cross-sectional survey study. eclinicalmedicine. 2021;35. pmid:34041456 pmcid:pmc8141518 https://doi.org/10.1016/j.eclinm.2021.100879 2. american nurses foundation. pulse on the nation's nurses survey series: covid-19 two-year impact assessment survey. 2022. available from: https://www.nursingworld.org/~4a2260/contentassets/872ebb 13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impactassessment-written-report-final.pdf 3. linzer m, stillman m, brown r, et al. preliminary report: us physician stress during the early days of the covid-19 pandemic. mayo clinic proceedings: innovations, quality & outcomes. 2021;5(1):127-36. https://doi.org/10.1016/j.mayocpiqo.2021.01.005 pmid:33718790 pmcid:pmc7930845 4. lebares cc, guvva ev, ascher nl, o'sullivan ps, harris hw, epel es. burnout and stress among us surgery residents: psychological distress and resilience. journal of the american college of surgeons. 2018;226(1):80-90. https://doi.org/10.1016/j.jamcollsurg.2017.10.010 pmid:29107117 5. jordan tr, khubchandani j, wiblishauser m. the impact of perceived stress and coping adequacy on the health of nurses: a pilot investigation. nursing research and practice. 2016;2016(1):5843256. https://doi.org/10.1155/2016/5843256 pmid:27882246 pmcid:pmc5108847 6. dyrbye ln, shanafelt td, sinsky ca, et al. burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. nam perspectives. 2017. available from: https://iuhcpe.org/file_manager/1501524077-burnout-amonghealth-care-professionals-a-call-to-explore-and-address-thisunderrecognized-threat.pdf https://doi.org/10.31478/201707b 7. grandey aa. emotional regulation in the workplace: a new way to conceptualize emotional labor. journal of occupational health psychology. 2000;5(1):95. https://doi.org/10.1037/10768998.5.1.95 pmid:10658889 8. chen cc, lan yl, chiou sl, lin yc. the effect of emotional labor on the physical and mental health of health professionals: emotional exhaustion has a mediating effect. inhealthcare. 2022; 11 (1): 104. mdpi. https://doi.org/10.3390/healthcare11010104 pmid:36611564 pmcid:pmc9819436 9. koinis a, giannou v, drantaki v, angelaina s, stratou e, saridi m. the impact of healthcare workers job environment on their mental-emotional health. coping strategies: the case of a local general hospital. health psychology research. 2015;3(1). https://doi.org/10.4081/hpr.2015.1984 pmid:26973958 pmcid:pmc4768542 10. babapour ar, gahassab-mozaffari n, fathnezhad-kazemi a. nurses' job stress and its impact on quality of life and caring behaviors: a cross-sectional study. bmc nursing. 2022;21(1):75. https://doi.org/10.1186/s12912-022-00852-y pmid:35361204 pmcid:pmc8968092 11. rink lc, oyesanya to, adair kc, humphreys jc, silva sg, sexton jb. stressors among healthcare workers: a summative content analysis. global qualitative nursing research. 2023;10:23333936231161127. https://doi.org/10.1177/23333936231161127 pmid:37020708 pmcid:pmc10068501 12. burton a, burgess c, dean s, koutsopoulou gz, hugh-jones s. how effective are mindfulness-based interventions for reducing stress among healthcare professionals? a systematic review and metaanalysis. stress and health. 2017;33(1):3-13. https://doi.org/10.1002/smi.2673 pmid:26916333 13. ruiz-fernández md, ortíz-amo r, ortega-galán ám, ibáñezmasero o, rodríguez-salvador md, ramos-pichardo jd. mindfulness therapies on health professionals. international journal of mental health nursing. 2020;29(2):127-40. https://doi.org/10.1111/inm.12652 pmid:31498549 14. kabat-zinn j. mindfulness-based interventions in context: past, present, and future.2003. american psychological association. https://doi.org/10.1093/clipsy/bpg016 15. davis dm, hayes ja. what are the benefits of mindfulness? a practice review of psychotherapy-related research. psychotherapy. 2011;48(2):198. https://doi.org/10.1037/a0022062 pmid:21639664 16. keng sl, smoski mj, robins cj. effects of mindfulness on psychological health: a review of empirical studies. clinical psychology review. 2011;31(6):1041-56. https://doi.org/10.1016/j.cpr.2011.04.006 pmid:21802619 pmcid:pmc3679190 17. dunning dl, griffiths k, kuyken w, et al. research review: the effects of mindfulness-based interventions on cognition and mental health in children and adolescents-a meta-analysis of randomized controlled trials. journal of child psychology and psychiatry. 2019;60(3):244-58. https://doi.org/10.1111/jcpp.12980 pmid:30345511 pmcid:pmc6546608 https://doi.org/10.1016/j.eclinm.2021.100879 https://www.nursingworld.org/~4a2260/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf https://www.nursingworld.org/~4a2260/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf https://www.nursingworld.org/~4a2260/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf https://doi.org/10.1016/j.mayocpiqo.2021.01.005 https://doi.org/10.1016/j.jamcollsurg.2017.10.010 https://doi.org/10.1155/2016/5843256 https://iuhcpe.org/file_manager/1501524077-burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat.pdf https://iuhcpe.org/file_manager/1501524077-burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat.pdf https://iuhcpe.org/file_manager/1501524077-burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat.pdf https://doi.org/10.31478/201707b https://doi.org/10.1037/1076-8998.5.1.95 https://doi.org/10.1037/1076-8998.5.1.95 https://doi.org/10.3390/healthcare11010104 https://doi.org/10.4081/hpr.2015.1984 https://doi.org/10.1186/s12912-022-00852-y https://doi.org/10.1177/23333936231161127 https://doi.org/10.1002/smi.2673 https://doi.org/10.1111/inm.12652 https://doi.org/10.1093/clipsy/bpg016 https://doi.org/10.1037/a0022062 https://doi.org/10.1016/j.cpr.2011.04.006 https://doi.org/10.1111/jcpp.12980 pallav dave asian journal of dental and health sciences. 2024; 4(2):56-60 [60] ajdhs.com 18. grossman p, niemann l, schmidt s, walach h. mindfulness-based stress reduction and health benefits: a meta-analysis. journal of psychosomatic research. 2004;57(1):35-43. https://doi.org/10.1016/s0022-3999(03)00573-7 pmid:15256293 19. khoury b, sharma m, rush se, fournier c. mindfulness-based stress reduction for healthy individuals: a meta-analysis. journal of psychosomatic research. 2015;78(6):519-28. https://doi.org/10.1016/j.jpsychores.2015.03.009 pmid:25818837 20. niazi ak, niazi sk. mindfulness-based stress reduction: a nonpharmacological approach for chronic illnesses. north american journal of medical sciences. 2011;3(1):20. https://doi.org/10.4297/najms.2011.320 pmid:22540058 pmcid:pmc3336928 21. frostadottir ad, dorjee d. effects of mindfulness based cognitive therapy (mbct) and compassion focused therapy (cft) on symptom change, mindfulness, self-compassion, and rumination in clients with depression, anxiety, and stress. frontiers in psychology. 2019;10:1099. https://doi.org/10.3389/fpsyg.2019.01099 pmid:31164849 pmcid:pmc6534108 22. tickell a, ball s, bernard p, et al. the effectiveness of mindfulnessbased cognitive therapy (mbct) in real-world healthcare services. mindfulness. 2020;11:279-90. https://doi.org/10.1007/s12671018-1087-9 pmid:32064009 pmcid:pmc6995449 23. sipe we, eisendrath sj. mindfulness-based cognitive therapy: theory and practice. the canadian journal of psychiatry. 2012;57(2):63-9. https://doi.org/10.1177/070674371205700202 pmid:22340145 24. williams jm, russell i, russell d. mindfulness-based cognitive therapy: further issues in current evidence and future research. j consult clin psychology. 2008;76 (3): 524-529. https://doi.org/10.1037/0022-006x.76.3.524 pmid:18540746 pmcid:pmc2834575 25. mackenzie mb, abbott ka, kocovski nl. mindfulness-based cognitive therapy in patients with depression: current perspectives. neuropsychiatric disease and treatment. 2018:1599-605. https://doi.org/10.2147/ndt.s160761 pmid:29950842 pmcid:pmc6018485 26. kuyken w, warren fc, taylor rs, et al. efficacy of mindfulnessbased cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. jama psychiatry. 2016;73(6):565-74. https://doi.org/10.1001/jamapsychiatry.2016.0076 pmid:27119968 pmcid:pmc6640038 27. hilton l, hempel s, ewing ba, et al. mindfulness meditation for chronic pain: systematic review and meta-analysis. annals of behavioral medicine. 2017;51(2):199-213. https://doi.org/10.1007/s12160-016-9844-2 pmid:27658913 pmcid:pmc5368208 28. joshi am, mehta sa, pande n, mehta ao, randhe ks. effect of mindfulness-based art therapy (mbat) on psychological distress and spiritual wellbeing in breast cancer patients undergoing chemotherapy. indian journal of palliative care. 2021;27(4):552. https://doi.org/10.25259/ijpc_133_21 pmid:34898951 pmcid:pmc8655656 29. fuchs c, lee jk, roemer l, orsillo sm. using mindfulness-and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds: clinical considerations, meta-analysis findings, and introduction to the special series: clinical considerations in using acceptance-and mindfulness-based treatments with diverse populations. cognitive and behavioral practice. 2013;20(1):1-2. https://doi.org/10.1016/j.cbpra.2011.12.004 pmid:26294894 pmcid:pmc4539954 30. fiabane e, giorgi i, sguazzin c, argentero p. work engagement and occupational stress in nurses and other healthcare workers: the role of organisational and personal factors. journal of clinical nursing. 2013;22(17-18):2614-24. https://doi.org/10.1111/jocn.12084 pmid:23551268 31. keykaleh ms, safarpour h, yousefian s, faghisolouk f, mohammadi e, ghomian z. the relationship between nurse's job stress and patient safety. open access macedonian journal of medical sciences. 2018;6(11):2228. https://doi.org/10.3889/oamjms.2018.351 pmid:30559893 pmcid:pmc6290432 32. zeller jm, levin pf. mindfulness interventions to reduce stress among nursing personnel: an occupational health perspective. workplace health & safety. 2013;61(2):85-9. https://doi.org/10.1177/216507991306100207 pmid:23336129 33. zhang d, lee ek, mak ec, ho cy, wong sy. mindfulness-based interventions: an overall review. british medical bulletin. 2021;138(1):41-57. https://doi.org/10.1093/bmb/ldab005 pmid:33884400 pmcid:pmc8083197 34. kemper kj, khirallah m. acute effects of online mind-body skills training on resilience, mindfulness, and empathy. journal of evidence-based complementary & alternative medicine. 2015;20(4):247-53. https://doi.org/10.1177/2156587215575816 pmid:25783980 35. shapiro sl, schwartz ge, bonner g. effects of mindfulness-based stress reduction on medical and premedical students. journal of behavioral medicine. 1998;21:581-99. https://doi.org/10.1023/a:1018700829825 pmid:9891256 36. creswell jd, lindsay ek, villalba dk, chin b. mindfulness training and physical health: mechanisms and outcomes. psychosomatic medicine. 2019;81(3):224-32. https://doi.org/10.1097/psy.0000000000000675 pmid:30806634 pmcid:pmc6613793 37. dave p, how digital health is revolutionizing healthcare and contributing to positive health outcomes, journal of drug delivery and therapeutics. 2024; 14(6):287-293 https://doi.org/10.22270/jddt.v14i6.6640 38. gu j, strauss c, bond r, cavanagh k. how do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? a systematic review and meta-analysis of mediation studies. clinical psychology review. 2015;37:1-2. https://doi.org/10.1016/j.cpr.2015.01.006 pmid:25689576 39. penque s. mindfulness to promote nurses' well-being. nursing management. 2019;50(5):38-44. https://doi.org/10.1097/01.numa.0000557621.42684.c4 pmid:30985526 pmcid:pmc6716566 40. farias m, wikholm c. has the science of mindfulness lost its mind?. bjpsych bulletin. 2016;40(6):329-32. https://doi.org/10.1192/pb.bp.116.053686 pmid:28377813 pmcid:pmc5353526 41. britton wb. can mindfulness be too much of a good thing? the value of a middle way. current opinion in psychology. 2019;28:159-65. https://doi.org/10.1016/j.copsyc.2018.12.011 pmid:30708288 pmcid:pmc6612475 https://doi.org/10.1016/s0022-3999(03)00573-7 https://doi.org/10.1016/j.jpsychores.2015.03.009 https://doi.org/10.4297/najms.2011.320 https://doi.org/10.3389/fpsyg.2019.01099 https://doi.org/10.1007/s12671-018-1087-9 https://doi.org/10.1007/s12671-018-1087-9 https://doi.org/10.1177/070674371205700202 https://doi.org/10.1037/0022-006x.76.3.524 https://doi.org/10.2147/ndt.s160761 https://doi.org/10.1001/jamapsychiatry.2016.0076 https://doi.org/10.1007/s12160-016-9844-2 https://doi.org/10.25259/ijpc_133_21 https://doi.org/10.1016/j.cbpra.2011.12.004 https://doi.org/10.1111/jocn.12084 https://doi.org/10.3889/oamjms.2018.351 https://doi.org/10.1177/216507991306100207 https://doi.org/10.1093/bmb/ldab005 https://doi.org/10.1177/2156587215575816 https://doi.org/10.1023/a:1018700829825 https://doi.org/10.1097/psy.0000000000000675 https://doi.org/10.22270/jddt.v14i6.6640 https://doi.org/10.1016/j.cpr.2015.01.006 https://doi.org/10.1097/01.numa.0000557621.42684.c4 https://doi.org/10.1192/pb.bp.116.053686 https://doi.org/10.1016/j.copsyc.2018.12.011 pavithra gopal et al. asian journal of dental and health sciences. 2025; 5(3):13-15 [13] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited instrument retrieval in endodontics: a literature review dr pavithra gopal *1 , dr h murali rao 2 , dr b s keshava prasad 3 , dr sahana umesh 4 , dr rashmi shetty 5 1 post graduate, mds, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 2 professor, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 3 professor and head of the department, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 4 lecturer, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 5 reader, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 article info: _____________________________________________ article history: received 29 may 2025 reviewed 16 june 2025 accepted 25 june 2025 published 15 sep 2025 _____________________________________________ cite this article as: gopal p, rao hm, prasad bsk, umesh s, shetty r, instrument retrieval in endodontics: a literature review, asian journal of dental and health sciences. 2025; 5(3):13-15 doi: http://dx.doi.org/10.22270/ajdhs.v5i3.133 __________________________________________________ *address for correspondence: dr pavithra gopal, post graduate, mds, department of conservative dentistry and endodontics, dapm rv dental college, bengaluru, karnataka 560078 abstract _________________________________________________________________________________________________________________ instrument separation poses a notable challenge in endodontic therapy, with occurrence rates between 2% and 6%. while a separated instrument does not automatically equate to treatment failure, it can hinder complete debridement and obturation, which might result in bacterial survival and inflammatory responses. this review of the literature examines the various factors that contribute to instrument separation, including mechanical fatigue, instrument design, and clinical aspects such as canal curvature and operator experience and evaluates the current methods available for retrieving these instruments. these methods encompass mechanical techniques (e.g., ultrasonics, retrieval kits), chemical solutions (e.g., edta), and surgical procedures when nonsurgical methods are ineffective. advances in technology, including improved magnification, ultrasonic devices, and platforms like endo rescue, have enhanced retrieval success rates. additionally, bioceramic materials and cad/cam-assisted restorations provide better outcomes following retrieval. nonetheless, challenges persist, including the risk of root perforation, tooth fractures, and the presence of retained fragments. the success of the retrieval process depends on the position and size of the fragment, the anatomy of the canal, and the clinician's expertise. research indicates that the presence of a retained instrument may not significantly impact prognosis when apical periodontitis is absent, though outcomes worsen in cases with infection. ultimately, the clinician’s expertise, proficiency, and the integration of modern tools are crucial for effective management. ongoing research and continuous professional development are vital for enhancing retrieval methods and improving patient results in endodontics. keywords: instrument separation, endodontic complications, fractured file removal, ultrasonic retrieval, nickel-titanium instruments, root canal anatomy, endodontic retreatment, masserann kit introduction instrument retrieval is a critical aspect of endodontic treatment. the incidence of instrument separation can range from 2% to 6%, posing a significant challenge for endodontists. successful retrieval of separated instruments is essential to ensure the continued success of root canal therapy and prevent complications 1 when an instrument breaks during a cleaning and shaping procedure, the clinician must consider various factors, including the pulp status, root canal infection, anatomy, position, type of the fractured instrument, and potential damage to the tooth structure. the success of nonsurgical removal of a broken instrument depends on the canal anatomy, fragment location, length, diameter, curvature, accessibility, fragment location, and visualization. approaches for managing the separated instrument include removal, bypassing, sealing the fragment within the root canal, or creating a true blockage.2 while a broken instrument may not directly cause treatment failure, the fragment in the root canal can obstruct proper cleaning, shaping, and obturation of the root canal space, leading to the accumulation of bacteria and dentin debris, which leads to inflammation. 3 root canal treatment is a cornerstone of modern dentistry, aiming to preserve natural dentition. however, the inherent complexity of root canal anatomy and the delicate nature of endodontic instruments can lead to unforeseen complications, such as instrument separation. this literature review will comprehensively examine current knowledge and techniques pertaining to instrument retrieval in endodontics, encompassing the challenges, available methodologies, and their respective successes and limitations. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i3.133 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i3.133&amp;domain=pdf https://orcid.org/0009-0005-7505-1616 https://orcid.org/0000-0001-6310-6425 https://orcid.org/0000-0002-7411-6714 https://orcid.org/0009-0001-1724-4197 https://orcid.org/0009-0005-8465-4785 pavithra gopal et al. asian journal of dental and health sciences. 2025; 5(3):13-15 [14] ajdhs.com causes of instrument separation instrument separation can occur due to various factors, including: • mechanical factors: excessive force, improper use, and cyclic fatigue of endodontic instruments can lead to separation. instruments may also separate due to torsional stress when the tip of the instrument binds in the canal while the shank continues to rotate. • instrument design: the design and material of endodontic instruments, such as nickel-titanium (niti) files, can influence their susceptibility to separation. niti instruments, while flexible, are more prone to cyclic fatigue compared to stainless steel instruments. • clinical factors: root canal anatomy, curvature, and operator experience play a significant role in the likelihood of instrument separation. complex root canal systems with severe curvatures increase the risk of instrument separation. techniques for instrument retrieval several techniques have been developed for the retrieval of separated instruments, including: mechanical methods: • ultrasonic devices: ultrasonic tips can be used to create vibrations that help dislodge the separated instrument. the use of ultrasonics under magnification allows for precise and controlled removal of the separated fragment. • specialized retrieval kits: kits such as the masserann kit and the irs (instrument removal system) are designed specifically for instrument retrieval. these kits include various tools and devices that can be used to grasp and remove the separated instrument. chemical methods: • although less commonly used, chemical agents can sometimes aid in the dissolution of separated instruments. for example, edta (ethylenediaminetetraacetic acid) can be used to soften dentin and facilitate the removal of the separated instrument. surgical methods: • in cases where mechanical and chemical methods fail, surgical approaches such as apicoectomy may be necessary to retrieve the separated instrument. this involves surgically accessing the root tip and removing the separated instrument through a retrograde approach. advances in technology recent advancements in technology have significantly improved the success rates of instrument retrieval: 1. ultrasonics and magnification: a) ultrasonics: ultrasonic devices have revolutionized instrument retrieval by generating high-frequency vibrations that help loosen the separated instrument from the canal walls. this facilitates its removal and reduces the risk of further iatrogenic damage. b) magnification: the use of dental operating microscopes provides magnified views of the working field, enabling clinicians to visualize better the separated instrument, its orientation within the canal, and the surrounding anatomical structures. this enhanced visualization significantly improves the precision and effectiveness of retrieval attempts. 2. new devices and techniques: a) endo rescue system: this innovative system utilizes a micro-motor with specialized retrieval tips to engage and remove broken instruments with minimal risk of further fracture or canal wall perforation. b) bioceramic materials: bioceramic materials, such as mineral trioxide aggregate (mta), play a crucial role in sealing the root canal after instrument retrieval and promoting tissue healing. the mta's excellent biocompatibility and sealing properties help prevent post-treatment complications, such as infection and microleakage. additional technological advancements: computer-aided design/computer-aided manufacturing (cad/cam): cad/cam technology allows for the fabrication of customized posts and restorations, which can be particularly beneficial in cases where instrument retrieval has altered the root canal anatomy. the incorporation of advanced technologies has significantly enhanced the predictability and success of instrument retrieval in endodontics. by combining ultrasonic devices, magnification, innovative retrieval systems, and biocompatible materials, clinicians can address this challenging complication more effectively, improving patient outcomes and preserving natural dentition. challenges and complications despite advancements, instrument retrieval remains challenging and can be associated with complications such as: • root perforation: the risk of perforating the root during retrieval attempts. this can compromise the structural integrity of the tooth and lead to treatment failure. • tooth fracture: the potential for tooth fracture due to excessive force or stress during retrieval. careful and controlled techniques are essential to minimize this risk. • residual fragments: in some cases, small fragments of the separated instrument may remain in the root canal, posing a risk for future complications. discussion intracanal separation of instruments usually prevent access to the apex and impede thorough cleaning and shaping of the root canal, and thus may compromise the pavithra gopal et al. asian journal of dental and health sciences. 2025; 5(3):13-15 [15] ajdhs.com outcome of endodontic treatment and reduce the chance of successful retreatment4 the following factors influence the removal of detached instruments: the fragment's diameter, length, and location inside the canal. the circumferential diameter, thickness of the remaining dentin, and depth of an external concavity of the root determine the diameter, length, and curvature of the canal architecture. generally, a stressed instrument such as when the flutes appear unwound, it is more likely to split in the canal and hence it is not recommended to press or wedge instruments no. 8 and no. 10 within the canal; they should only be used once. removal is not feasible if the broken instrument section is apical to the canal's curve and safe access cannot be obtained. if symptoms are present, surgery or extraction may be necessary. files made of stainless steel are typically easier to remove since they don't break when being removed. during ultrasonic removal, the niti instrument can shatter again. hence, the most crucial element for a successful instrument removal is knowledge, training, and ability. according to yashen et al., the tooth's curve influences how the separated instrument is removed.5 hulsmann et al. discovered that the shattered instrument was easiest to remove from the coronal third and had the lowest success rate in the apical third.6 in curved canals, souter et al. demonstrated a reduced success rate when removing an instrument from the apical third.7 fors and berg concluded that separated instruments in the apical third should remain in place, as removal attempts could cause perforation, which would worsen the prognosis of the endodontic treatment. the canal can be prepared and filled to the point where instrumentation is possible if the fragment cannot be retrieved. apical surgery is not required as long as the tool fragment is not sticking through the apex. the remaining tooth structure shouldn't be weakened by removing the detached portion. several general outcome studies have linked the success rate of endodontic therapy with the presence or absence of apical periodontitis.8,9,10 a new meta-analysis and systematic review examined the endodontic results of keeping an instrument in the root canal system.11 the prognosis of endodontic therapy in the absence of apical periodontitis is not considerably lowered by a retained fractured tool; nevertheless, in the presence of apical periodontitis, the prognosis is lowered by a fractured instrument. this review solely considered de novo cases. notably, it was proposed that, as long as the treatment was performed to the most superb technical standard, a fractured file would have little effect on canal disinfection. conclusion instrument retrieval is a vital component of endodontic treatment, and advancements in technology have significantly improved success rates. however, challenges and complications still exist, and further research is needed to develop more effective and less invasive retrieval techniques. continued education and training for endodontists are essential to ensure the successful management of separated instruments. conflict of interest: no potential conflict of interest relevant to this article was reported. author contributions: all authors have equal contributions in the preparation of the manuscript. source of support: nil funding: nil. informed consent statement: not applicable. ethical approval: not applicable. references 1. arcangelo cm, varvara g, fazio pd. broken instrument removal two cases. j endod 2000;26:568-70. https://doi.org/10.1097/00004770-200006000-00014 pmid:11199757 2. jain, a., surana, p., tiwari, j., & saini, n. (2017). removal of broken endo dontic instrument using ultrasonic's and magnifying loupes. indian journal of conservative and endodontics, 2(4), 133-136. 3. rathi, c., chandak, m., modi, r., gogiya, r., relan, k., & chandak, m. (2020). management of separated endodontic instrument: 2 case reports. med sci, 24, 1663-8. 4. hulsmann m. methods for removing metal obstruction from theroot canal. endod dent traumatol 1993;9:223-37. https://doi.org/10.1111/j.1600-9657.1993.tb00278.x pmid:8143573 5. hulsmann m. removal of fractured instruments using a combined automated/ultrasonic technique. j endod. 1994;20:144-147. https://doi.org/10.1016/s0099-2399(06)80062-2 pmid:7996089 6. ward jr, parashos p, messer hh. evaluation of an ultrasonic technique to remove fractured rotary nickeltitanium endodontic instruments from root canals: an experimental study. j endod. 2003;29:756-763. https://doi.org/10.1097/00004770200311000-00017 pmid:14651285 7. souter n, messer h. complications associated with fractured file removal using an ultrasonic technique. j endod 2005, 31(6), 450452. https://doi.org/10.1097/01.don.0000148148.98255.15 pmid:15917685 8. sjögren, u. l. f., hägglund, b., sundqvist, g., & wing, k. (1990). factors affecting the long-term results of endodontic treatment. journal of endodontics, 16(10), 498-504. https://doi.org/10.1016/s0099-2399(07)80180-4 pmid:2084204 9. ng, y. l., mann, v., rahbaran, s., lewsey, j., & gulabivala, k. (2008). outcome of primary root canal treatment: systematic review of the literature-part 2. influence of clinical factors. international endodontic journal, 41(1), 6-31. https://doi.org/10.1111/j.13652591.2007.01323.x pmid:17931388 10. ng, y. l., mann, v., & gulabivala, k. (2008). outcome of secondary root canal treatment: a systematic review of the literature. international endodontic journal, 41(12), 1026-1046. https://doi.org/10.1111/j.1365-2591.2008.01484.x pmid:19133093 11. panitvisai, p., parunnit, p., sathorn, c., & messer, h. h. (2010). impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. journal of endodontics, 36(5), 775-780. https://doi.org/10.1016/j.joen.2009.12.029 pmid:20416418 https://doi.org/10.1097/00004770-200006000-00014 https://doi.org/10.1111/j.1600-9657.1993.tb00278.x https://doi.org/10.1016/s0099-2399(06)80062-2 https://doi.org/10.1097/00004770-200311000-00017 https://doi.org/10.1097/00004770-200311000-00017 https://doi.org/10.1097/01.don.0000148148.98255.15 https://doi.org/10.1016/s0099-2399(07)80180-4 https://doi.org/10.1111/j.1365-2591.2007.01323.x https://doi.org/10.1111/j.1365-2591.2007.01323.x https://doi.org/10.1111/j.1365-2591.2008.01484.x https://doi.org/10.1016/j.joen.2009.12.029 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [7] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited oral health benefits of moringa oleifera sunil kumar prajapati 1 , omji porwal 2 , raghunandan meena 3, rajeshwar kamal kant arya 4 , ram c dhakar 5* , kapil kumar 6 1 professor, institute of pharmacy, bundelkhand university, jhansi, india 2 professor, department of pharmacognosy, faculty of pharmacy, tishk international university-erbil, kurdistan region, iraq 3 professor, department of general medicine, jhalawar medical college, jhalawar, rajasthan, india 4 associate professor, department of pharmaceutical sciences, sir jc bose technical campus, bhimtal, kumaun university, nainital, india 5 hospital pharmacist, srg hospital & medical college, jhalawar, rajasthan, india 6 professor and director, samrat prithviraj chauhan college of pharmacy, kashipur, uttarakhand technical university, uttarakhand, india. article info: _____________________________________________ article history: received 03 sep 2025 reviewed 24 oct 2025 accepted 19 nov 2025 published 15 dec 2025 _____________________________________________ cite this article as: prajapati sk, porwal o, meena r, arya rkk, dhakar rc, kumar k, oral health benefits of moringa oleifera, asian journal of dental and health sciences. 2025; 5(4):7-12 doi: http://dx.doi.org/10.22270/ajdhs.v5i4.147 abstract _________________________________________________________________________________________________________________ allopathic medicines are used to treat or manage dental infections, inflammation, and pain. but due to the adverse effects associated with these allopathic medicines, herbal medicine should be considered as an alternative therapy for the management of oral health and treating dental pain. oral diseases persist as a significant health problem all over the world. various microorganisms have been identified as possible pathogens responsible for oral diseases. moringa oleifera has been used in traditional medicine for centuries. all parts of the moringa tree are helpful in some way, and people depend on it for their livelihood. the leaves of the moringa tree are an excellent source of nutrients like minerals, protein and vitamins (a and c). the moringa tree contains approximately 46 antioxidants and is one of the cheapest sources of natural antioxidants. antioxidants provide the free radicals the human body needs and mitigate their effects. moringa oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids, which possess antibacterial effects. moringa oleifera has high mineral and protein content and has been previously investigated for its potential in the treatment of various oral soft tissue diseases. this review summaries the applications of moringa oleifera in dentistry. keywords: moringa oleifera, anti-oxidants, oral diseases, oral health, dentistry *address for correspondence: ram chand dhakar, hospital pharmacist, srg hospital & medical college, jhalawar, rajasthan, india introduction global burden of disease (2019) show that periodontal disease ranks as the seventh most prevalent disease globally, with a prevalence of 29.3%.1 according to the riskesdas report (2018), the prevalence of periodontal disease in indonesia is 74.1%. 2, 3 dental health has been a concern for researchers to this day. various infections that can occur in the teeth can lead to health decline. dental infections occur due to the growth of different microbes in the oral cavity and dental area. among these are odontogenic infections and periradicular periodontitis that happen in the root canal system, caused by anaerobic bacteria such as porphyromonas gingivalis, enterococcus faecalis, and candida albicans 4, 5, 6, 7. natural products have been used as folk medicines for thousands of years and are promising sources for novel therapeutic agents. due to the adverse effects associated with allopathic medication, herbal medicines are preferred as an alternative therapy for the management of oral health and dental pain. 3, 8 , 9 moringa oleifera is the most widely cultivated pantropical species of a monogeneric family, the moringaceae, which is native to the sub-himalayan tracts of india, pakistan, bangladesh and afghanistan. moringa oleifera. moringa is known by various local names, such as benzolive, drumstick tree, kelor, marango, mlonge, mulangay, nébéday, saijhan, and sajna. 10, 11. all parts of the moringa are beneficial, as they contain a variety of phytoconstituents with nutritional and pharmacological value. in developing tropical countries, moringa trees have been used to combat malnutrition, especially among infants and nursing mothers 11,12,13. moringa leaves are an excellent source of nutrients like minerals, protein and vitamins (a and c) 14,15,16. moringa is one of the most potent sources of natural antioxidants, containing approximately 46 antioxidants. moringa contains antioxidants that the human body needs to mitigate the effects of free radicals. m. oleifera contains many phytochemicals such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids, which possess antibacterial effects. this review summaries the open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i4.147 https://pmc.ncbi.nlm.nih.gov/articles/pmc3432374/#b7 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i4.147&amp;domain=pdf https://orcid.org/0000-0002-0968-3915 https://orcid.org/0000-0003-1760-6618 https://orcid.org/0000-0003-0802-7542 https://orcid.org/0000-0001-8250-8489 https://orcid.org/0000-0003-0481-7109 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [8] ajdhs.com applications of moringa extracts in the management of oral infections, inflammatory conditions, the remineralisation of hard tissues, oral wound healing, and tissue regeneration. oral health benefits of moringa oleifera the moringa tree is one of the most potent sources of natural antioxidants, with approximately 46 antioxidants. m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids, which possess antibacterial effects. many adverse effects are associated with allopathic medicines; hence, they can be used as a safe and cheap antimicrobial agent as an alternative therapy. the extract from leaves of moringa oleifera has high mineral and protein content and its historic reputation as a traditional medicine for different diseases has been previously investigated for its potential in treating various oral soft tissue diseases 17, 18. moringa oleifera extract contains the highest values of calcium and phosphate that are required for the remineralization process. therefore, moringa oleifera extract is investigated by younis et al for its ability to treat induced enamel lesions, and results suggest that the formulated varnish reinforced mineralisation of the lesions with complete reestablishment of the enamel surface in comparison to plain and fluoride varnishes. 17 in a study by yunus et al. scanning electron microscopy revealed that the moringa oleifera leaves extract-loaded varnish showed the most re-establishment of normal enamel architecture. elemental analysis of the treated surfaces showed the surfaces treated by moringa oleifera leaf extract-loaded varnish groups had significantly higher ca, p, and o deposition than the fluoride varnish group. hence, moringa oleifera leaves extract might be considered as a biomimetic material as it has the capacity to guide enamel tissue remineralization.19 hanaa elgamily et al. carried out a study to assess the antibacterial and antifungal potentials of different parts of the moringa oleifera plant using various extraction methods, to formulate natural dental remedies from this plant. the various extracts of different parts of moringa oleifera showed an antibacterial effect against staphylococcus aureus and streptococcus mutans growth. the novel toothpaste of ethanolic leaves extract has antimicrobial and antifungal potential effects all selected strains.20 the results of the study by risnayanti anas et al. revealed an increase in calcium levels in the teeth after application of a moringa oleifera-based paste and casein phosphopeptide-amorphous calcium phosphate (cpp-acp). moringa oleifera based paste and cpp-app are effective to increasing calcium levels in teeth compared to the pre-test group.21 dental caries is closely related to cariogenic biofilm, an oral biofilm containing a high proportion of streptococcus mutans 22. generally, oral biofilm is structurally and functionally organized and includes a balance of normal flora and pathogenic bacteria like s. mutans 23. su-kyung jwa has investigated the antimicrobial effects of the m. oleifera leaf extracts on s. mutans and the formation of cariogenic biofilm. an extract from m. oleifera leaves was derived using distilled water (dw) and ethyl alcohol (etoh). s. mutans susceptibility assays were performed for each extract. cariogenic biofilm was formed with or without dw and etoh extract, and cariogenic biofilm was treated with both extracts. both extracts showed antimicrobial activity against s. mutans and inhibited the formation of cariogenic biofilm. at the same concentration, the heated ethanol extract exhibited inhibitory activity better than the non-heated extracts. this study showed that the ethanol extract was more effective than the aqueous extract against s. mutans 24 table 1: application of moringa oleifera in oral health s.n. author objective of the study application ref 1 rao p k, et al 2011 to assess the antibacterial activity of isolated compounds from m. oleifera against selected oral bacteria all the isolated compounds from m. oleifera were active against streptococcus mutans (mtcc 497), streptococcus salivarius, lactobacillus fermentum, streptococcus anginosus, streptococcus gordonii, lactobacillus acidophilus. 25 2 hanaa elgamily et al 2016 to assess the antibacterial and antifungal potentials of different parts of moringa oleifera for dental remedies, experimental toothpaste exhibited higher mean inhibition than the mouthwash against staphylococcus aureus, streptococcus mutans and only the toothpaste revealed antifungal effect against candida albicans 20 4 carranza j b, 2017 to identify the secondary compounds of three varieties of moringa oleifera lam. extracts namely; native, chinese, and yard long malunggay using phytochemical analysis the extracts of moringa varieties contain flavonoids, alkaloids and tannins that are known to have antimicrobial and anti-inflammatory properties; thus, these have potential natural components in the manufacture of toothpastes 26 5 su-kyung jwa et 2019 to investigate the antimicrobial effects of the m. oleifera leaf extracts extracts showed antimicrobial activity against s. mutans and inhibited formation of cariogenic biofilm 24 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7522384/#bib6 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7522384/#bib7 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6779079/#b11-pnfs-24-308 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6779079/#b13-pnfs-24-308 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 https://www.ncbi.nlm.nih.gov/pubmed/?term=jwa%20sk%5bauthor%5d&cauthor=true&cauthor_uid=31608256 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [9] ajdhs.com 6 piasti sopandani et al 2020 to assess the antibacterial effect of m. oleifera extract as an irrigation solution against e. faecalis m. oleifera extract solution at concentrations of 75% and 100% is as effective as 5.25% naocl against e. faecalis 27 7 mahassen m farghaly et al 2020 to formulate a nontoxic mouthwash from moringa oleifera moringa extract showing antibacterial and antiplaque effect will be used 28 8 younis sh 2020 to assess the effect of leaves extract of moringa oleifera loaded-varnish groups iv & v on enamel moringa leaf extract loaded-varnish groups had significantly higher ca, p, and o deposition than the fluoride varnish group. the extract of moringa oleifera leaves might be considered as a biomimetic material that has the capacity to guide enamel tissue remineralization 19 9 anas r et al 2021 to study the effectiveness of paste-based moringa oleifera to increase calcium levels in human tooth results of this research showed that moringa oleifera paste has a higher calcium level compared to the pretest groups and moringa oleifera paste can be effective in increasing calcium levels of human teeth 21 10 nawal aidaros et al 2021 to investigate and compare the effect of green tea, black tea and moringa oleifera on artificially demineralized enamel and dentin in dentin, the highest mean value was found in moringa oleifera. study concluded that moringa tree enhanced the remineralization process and thus, might be considered as an effective natural remineralizing agents 29 11 buakaew et al 2021 moringa oleifera and azadirachta indica were assessed for oral healthcare and gingivitis adjunctive treatment the author states that accumulative reduction percentages of both staphylococcus spp. and candida spp. were found and indicated that the herbal mouthwashes reduced gingival index and plaque index and showed potential as oral healthcare products 30 a study by nawal aidaros et al concluded that moringa oleifera enhanced the remineralisation process of demineralised enamel and dentin, and thus, might be considered as an effective natural remineralising agent29. few studies have evaluated the biological activity of m. oleifera in relation to oral disorders. m. oleifera leaves extracts in form of lozenge or mouthwash successfully reduced root canal infection, inflammation, gingivitis, and plaque 30, 31, 32. isothiocyanate from m. oleifera seeds showed inhibitory action against gene expression involved in mitophagy in the stem cell of the human periodontal ligament 33,34 a hydrophilic gel of m. oleifera and acemannan extract was used to coat titanium dental implants before implanting them within the tibia and femur of rabbits. these coatings produced hydrophilic implant surfaces that improved bone-toimplant contact, stimulated new bone formation, and reduced inflammation, fibrosis, and degenerative and necrotic changes within the newly formed bone 35. in recent investigations, the antimicrobial efficacy of m. oleifera leaf extract was examined by alharbi et al. who compared the microbial efficacy of moringa oleifera leaf extract, octenidine dihydrochloride (oct), naocl, and their combinations as intracanal irrigants against enterococcus faecalis. both m. oleifera extract and 0.1% oct demonstrated antibacterial effects against e. faecalis comparable to 2.5% naocl and could be considered as potential root canal irrigants. furthermore, combination groups exhibited superior anti-microbial activity compared to individual irrigants. however, further studies are required to investigate the biocompatibility and possible toxic effects of the tested irrigants.36. sharma et al evaluated the efficacy of chitosan chips with and without moringa oleifera (mo) in treating chronic periodontitis. results from this study revealed that moringa oleifera in chitosan chips may be an effective natural treatment for chronic periodontitis. the study shows significant improvements in clinical parameters, including plaque index, gingival index, and probing pocket depth, in the moringa group, suggesting its potential to enhance treatment outcomes in periodontal care. further exploration of its applications is encouraged. 37 kumar et al. investigated the antimicrobial effects of m. oleifera extracts to assess the antibacterial efficacy of 5% moringa oleifera mouthwash reinforced with silver nanoparticles against oral aerobic organisms. the results of the study revealed that the 5% aqueous extract of m. oleifera exhibited a dosedependent antimicrobial activity against oral anaerobic microorganisms. notably, this anti-microbial effect became more pronounced with longer exposure times of the treated samples. furthermore, in the cytotoxicity assay, the aqueous extract exhibited superior performance at lower concentrations than the ethanol extract. the combined benefits of phytomedicine with nanomedicine can result in more effective treatment with fewer side effects. 38. in the recent investigation, eliwa et al. compared the remineralising potential of moringa oleifera extract, eggshell, and sodium fluoride varnish on the microhardness of artificially demineralised enamel of primary teeth using a biomimetic, minimally invasive approach, following the world paradigm shift towards natural products in paediatric dentistry. regarding edx analysis, there was a statistically significant difference https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 https://www.scidentj.com/searchresult.asp?search=&author=piasti+sopandani&journal=y&but_search=search&entries=10&pg=1&s=0 https://onlinelibrary.wiley.com/doi/10.1155/2023/8876189#bib-0048 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [10] ajdhs.com (p < 0.05) between the moringa oleifera and eggshell groups compared with the fluoride varnish, with the highest values observed in the moringa oleifera and eggshell groups. on the other hand, there was no statistically significant difference (p > 0.05) between moringa oleifera and eggshell in both measurements. moringa oleifera and eggshell might be considered biomimetic natural materials capable of guiding enamel tissue remineralisation in early carious lesions of primary teeth. 39 soraya et al. investigated the antibacterial properties of m. oleifera gel in inhibiting the growth of s. mutans, which were involved in the pathogenesis of dental caries. after 48 h, the 12.5% concentration exhibited the highest effectiveness in reducing s. mutans growth. within 24 h, the 6.25% and 3.125% concentrations exhibited remarkable ability to suppress s. mutans growth. notably, the 6.25% concentration exhibited superior efficacy in reducing s. mutans biofilm formation. the application of m. oleifera gel extract created conditions in which s. mutans, a commensal bacterium, struggled to form a biofilm, with inhibition levels surpassing 70%. the absence of substantial biofilm development evidenced this. it is worth mentioning that at all tested concentrations, m. oleifera exhibited a toxic effect on s. mutans cells. the ethanol extract gel of m. oleifera demonstrated the ability to curtail both the growth and biofilm formation of s. mutans on tooth surfaces while concurrently exerting toxicity on s. mutans cells, potentially due to the presence of antibacterial compounds 40. amalunweze et al formulated antimicrobial toothpaste (dentifrice) with m. oleifera root essential oil, which can compete with existing toothpaste. the phytochemical screening revealed a high concentration of flavonoid, a bioactive agent with antimicrobial activity in nature. the antimicrobial potential of this toothpaste was evaluated by the muller hinton agar well diffusion method against the selected bacteria. the results of this study revealed that the moringa root herbal toothpaste has a higher antimicrobial potential than oral-b herbal toothpaste against tooth plaque. it might be considered a good source of active agents in the formulation of medicinal toothpaste. 41 standard treatment involves scaling and root planing, often combined with adjunctive antibiotics. however, inappropriate antibiotic use may lead to resistance. therefore, natural antibacterial agents with a lower risk of resistance, such as moringa oleifera leaves, are of interest 3, 42. results from the study by sawant et al. showed that moringa oleifera leaf extract demonstrated comparable efficacy to 1% chlorhexidine gel in reducing gi, pi, and papillary bleeding index when used as an adjunct to scaling and root planing with topical application 43. in conclusion, moringa oleifera leaves have significant potential for further development as antibacterial agents, both as herbal medicines and as raw materials for pharmaceutical products 3. a study by obeid et al. confirmed that moringa oleifera leaves have an extraordinary effect on the remineralisation of dentin and cementum, and they have a promising ability to control dentinal hypersensitivity and form biomimetic cementum tissue. clinical trials using moringa oleifera leaves to control hypersensitivity sensation under deep restorative preparations and with root exposure will be of great dental value. 44. conclusion standard treatment involves scaling and root planing, often combined with adjunctive antibiotics. however, inappropriate antibiotic use may lead to resistance. therefore, natural antibacterial agents with a lower risk of resistance, such as moringa oleifera leaves, are of interest. m. oleifera contains active compounds such as flavonoids, tannins, saponins, alkaloids, phenolics, and triterpenoids which possess antibacterial effects; hence, it can be used as safe and cheap plant antimicrobial agent. moringa oleifera leaf extracts appear to be potent anti-microbial, anti-inflammatory, anti-cancer agents against oral ailments, also having activity in enamel remineralisation and preservation of root extraction sockets. as traditional medicine, it has potential in treating different oral soft tissue diseases. further research on moringa oleifera is needed to exploit the pharmacological uses for the management and prevention of oral disease. conflict of interest: the authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article. author contributions: all authors have equal contributions in the preparation of the manuscript and compilation. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting this paper are available in the cited references. ethical approval: not applicable references 1. the global burden of periodontal diseases in 204 countries and territories from 1990 to 2019 zhang 2024 oral diseases wiley online library [internet]. accessed october 22, 2024 at: https://onlinelibrary.wiley.com/doi/10.1111/odi.14436 2. wahyuni ps, rahardjo a, novrinda h. determinan status periodontal pada remaja di indonesia: analisis data riskesdas tahun 2018. cakradonya dent j. 2024;16(01):7-16 https://doi.org/10.24815/cdj.v16i1.32134 3. nurfauziah h, susanto a, carolina dn, potential antibacterial activity of moringa leaf (moringa oleifera) against staphylococcus aureus, and porphyromonas gingivalis: rapid review, european journal of general dentistry, 2025 https://doi.org/10.1055/s0045-1812502 4. ferraz, c.c.r.; henry, m.a.; hargreaves, k.m.; diogenes, a. lipopolysaccharide from porphyromonas gingivalis sensitizes capsaicin-sensitive nociceptors. j. endod. 2011;37:45-48. https://doi.org/10.1016/j.joen.2007.07.001 pmid:21146075 pmcid:pmc3032989 5. gao y. jiang x. lin d. chen y. tong z. the starvation resistance and biofilm formation of enterococcus faecalis in coexistence with candida albicans, streptococcus gordonii, actinomyces viscosus, or lactobacillus acidophilus. j. endod. 2016:42:1233-1238. https://doi.org/10.1016/j.joen.2016.05.002 pmid:27316318 https://onlinelibrary.wiley.com/doi/10.1111/odi.14436 https://doi.org/10.24815/cdj.v16i1.32134 https://doi.org/10.1055/s-0045-1812502 https://doi.org/10.1055/s-0045-1812502 https://doi.org/10.1016/j.joen.2007.07.001 https://doi.org/10.1016/j.joen.2016.05.002 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [11] ajdhs.com 6. miranda, t.t.; vianna, c.r.; rodrigues, l.; rosa, c.a.; corrêa jr, a. differential proteinase patterns among candida albicans strains isolated from root canal and lingual dorsum: possible roles in periapical disease. j. endod. 2015;41:841-845. https://doi.org/10.1016/j.joen.2015.01.012 pmid:25771140 7. amin mf, ariwibowo t, putri sa, kurnia d. moringa oleifera: a review of the pharmacology, chemical constituents, and application for dental health. pharmaceuticals. 2024;17(1):142. https://doi.org/10.3390/ph17010142 pmid:38276015 pmcid:pmc10819732 8. cragg gm, newman dj, snader km. natural products in drug discovery and development. journal of natural products. 1997;60(1):52-60 https://doi.org/10.1021/np9604893 pmid:9014353 9. thomas e, rao hm, prasad bsk, suman c. exploring the efficacy of natural biomaterials in endodontics. asian journal of dental and health sciences, 2024;4(3):11-16. https://doi.org/10.22270/ajdhs.v4i3.88 10 . dhiman j, a review on medicinal uses of moringa oleifera, journal of drug delivery and therapeutics. 2023; 13(11):197-201 https://doi.org/10.22270/jddt.v13i11.6042 11. dhakar rc, maurya sd, pooniya bk, bairwa n, gupta m, s. moringa: the herbal gold to combat malnutrition. chron young sci 2011; 2:119-25. https://doi.org/10.4103/2229-5186.90887 12. dahot mu, memon ar, nutritive significance of oil extracted from moringa oleifera seeds. j pharm univ kar 1985;3:75-80 13. ram j. moringa a highly nutritious vegetable tree, tropical rural and island/ atoll development experimental station (triades), technical bulletin. 1994;2. 14. abrams b, duncan d, hertz piccioto i. a prospective study of dietary intake and acquired immune deficiency syndrome in hiv sero-positive homosexsual men. j acquir immune defic syndr 1993;8:949-58. 15. anwar f, bhanger mi. analytical characterization of moringa oleifera seed oil growth in temperate region of pakistan. j agric food chem 2003;51:655863. https://doi.org/10.1021/jf0209894 pmid:14558778 16. prakash ao. ovarian response to aqueous extract of moringa oleifera during early pregnancy in rats. fitoterapia 1988;59:89-96 17. el-sharkawy r.t., el-kammar h.a., obeid r.f., bdelkhalek a.a. effects of moringa oleifera aqueous leaf extract on submandibular salivary glands of diabetic albino rats. egypt. dent. j. 2018;64(issue 2-april):1293-1303. https://doi.org/10.21608/edj.2018.77385 18. hala e, obeid rf., radwa te. potential therapeitic effect of moringa oleifera on tongue; 2019;2-8. 19. younis sh, obeid rf, ammar mm, subsurface enamel remineralization by lyophilized moringa leaf extract loaded varnish, heliyon. 2020;6(9):e05054. https://doi.org/10.1016/j.heliyon.2020.e05054 pmid:33015394 pmcid:pmc7522384 20. elgamily h, moussa a, elboraey a, el-sayed h, al-moghazy m, abdalla a. microbiological assessment of moringa oleifera extracts and its incorporation in novel dental remedies against some oral pathogens. open access maced j med sci. 2016;4(4):585-90. https://doi.org/10.3889/oamjms.2016.132 pmid:28028395 pmcid:pmc5175503 21. anas r, mattulada ik, akbar fh, indriany l, asmah n, irawati e, utama md, effectiveness of paste based moringa oleifera to increase calcium levels human tooth (in vitro), nat. volatiles & essent. oils, 2021;8(4):15193-15201 22. lee sh, kim yj. a comparative study of the effect of probiotics on cariogenic biofilm model for preventing dental caries. arch microbiol. 2014;196:601-609. https://doi.org/10.1007/s00203014-0998-7 pmid:24919536 23. marsh pd. microbial ecology of dental plaque and its significance in health and disease. adv dent res. 1994;8:263-271. https://doi.org/10.1177/08959374940080022001 pmid:7865085 24. jwa sk. efficacy of moringa oleifera leaf extracts against cariogenic biofilm. prev nutr food sci. 2019;24(3):308-312. https://doi.org/10.3746/pnf.2019.24.3.308 pmid:31608256 pmcid:pmc6779079 25. rao pk, rao db, kiran c, et al. in vitro antibacterial activity of moringa oleifera against dental plaque bacteria. journal of pharmacy research 2011;4(3):695-742 26. carranza jb, molina pg, ortañez jjr, et al. flavonoids, alkaloids and tannins of three varieties of horse radish (moringa oleifera lam.) extracts: potential components of toothpastes. international scholars conference proceeding 2017;5(1):30-3. 27. piasti s, ongki ib, taufiq a, sadono dm, antibacterial effects of moringa oleifera leaf extract against enterococcus faecalis in vitro. scientific dental journal, 2020;4(1):16-20. https://doi.org/10.4103/sdj.sdj_43_19 28. mahassen m farghaly, shahinaz g elashiry, anticariogenic effect of moringa oleifera mouthwash compared to chlorhexidine mouthwash clinicaltrials.gov identifier: nct04575948. 29. aidaros n, mosallam r, farouk h, effect of green tea, black tea and moringa oleifera on remineralization of artificially demineralized enamel and dentin: an in-vitro microhardness analysis, advanced dental journal, 2021;3(1):24-34 https://doi.org/10.21608/adjc.2020.34873.1072 30. buakaew w, sranujit rp, noysang c, sangouam s, suphrom n, thongsri y, potup p, usuwanthim k. evaluation of mouthwash containing citrus hystrix dc., moringa oleifera lam. and azadirachta indica a. juss. leaf extracts on dental plaque and gingivitis. plants. 2021;10(6):1153. https://doi.org/10.3390/plants10061153 pmid:34204096 pmcid:pmc8226465 31. noushad mc, ashraf k, suneetha mp. antibacterial efficacy of muringa seed extract and potato peel extract against enterococcus faecalis. contemp clin dent. 2020;11(4):327 31. https://doi.org/10.4103/ccd.ccd_223_19 pmid:33850397 pmcid:pmc8035844 32. luetragoon t, sranujit rp, noysang c, thongsri y, potup p, somboonjun j, et al. evaluation of anti-inflammatory effect of moringa oleifera lam. and cyanthillium cinereum (less) h. rob. lozenges in volunteer smokers. plants (basel). 2021;10(7):1336. https://doi.org/10.3390/plants10071336 pmid:34208842 pmcid:pmc8309071 33. chiricosta l, gugliandolo a, diomede f, pizzicannella j, trubiani o, iori r, et al. moringin pretreatment inhibits the expression of genes involved in mitophagy in the stem cell of the human periodontal ligament. molecules. 2019;24(18):3217. https://doi.org/10.3390/molecules24183217 pmid:31487916 pmcid:pmc6767209 34. das m, panda nr, bhuyan r, bhuyan sk, moringa oleifera and its application in dental conditions: a systematic review and metaanalysis, j herbmed pharmacol. 2023; 12(3): 331-336. https://doi.org/10.34172/jhp.2023.35 35. pachimalla p. r., mishra s. k., and chowdhary r., evaluation of hydrophilic gel made from acemannan and moringa oleifera in enhancing osseointegration of dental implants. a preliminary study in rabbits, journal of oral biology and craniofacial research. 2020;10(2):13-19 https://doi.org/10.1016/j.jobcr.2020.01.005 pmid:32025481 pmcid:pmc6997573 36. alharbi a.m.; alharbi, t.m.; alqahtani, m.s.; elfasakhany, f.m.; afifi, i.k.; rajeh, m.t.; fattouh, m.; kenawi, l.m.m. a comparative evaluation of antibacterial efficacy of moringa oleifera leaf extract, octenidine dihydrochloride, and sodium hypochlorite as intracanal irrigants against enterococcus faecalis: an in vitro study. int. j. dent. 2023;2023:7690497. https://doi.org/10.1155/2023/7690497 pmid:36960331 pmcid:pmc10030228 37. sharma g, setty s, kaveri g.s., vijapur ls, desai ar. efficacy of moringa oleifera as a local drug delivery agent in the treatment of chronic periodontitis: a randomized controlled trial. j orofac https://doi.org/10.1016/j.joen.2015.01.012 https://doi.org/10.3390/ph17010142 https://doi.org/10.1021/np9604893 https://doi.org/10.22270/ajdhs.v4i3.88 https://doi.org/10.22270/jddt.v13i11.6042 https://doi.org/10.4103/2229-5186.90887 https://doi.org/10.1021/jf0209894 https://doi.org/10.21608/edj.2018.77385 https://doi.org/10.1016/j.heliyon.2020.e05054 https://doi.org/10.3889/oamjms.2016.132 https://doi.org/10.1007/s00203-014-0998-7 https://doi.org/10.1007/s00203-014-0998-7 https://doi.org/10.1177/08959374940080022001 https://doi.org/10.3746/pnf.2019.24.3.308 https://doi.org/10.4103/sdj.sdj_43_19 https://doi.org/10.21608/adjc.2020.34873.1072 https://doi.org/10.3390/plants10061153 https://doi.org/10.4103/ccd.ccd_223_19 https://doi.org/10.3390/plants10071336 https://doi.org/10.3390/molecules24183217 https://doi.org/10.34172/jhp.2023.35 https://doi.org/10.1016/j.jobcr.2020.01.005 https://doi.org/10.1155/2023/7690497 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):7-12 [12] ajdhs.com health sci. 2025;12(2):116-121 https://doi.org/10.18231/j.johs.v.12.i.2.7 38. kumar gk. ramamurthy s. ulaganathan a. varghese s. praveen aa. saranya v. moringa oleifera mouthwash reinforced with silver nanoparticlespreparation, characterization and its efficacy against oral aerobic microorganisms in vitro study, biomed pharmacol j 2022;15(4). https://doi.org/10.13005/bpj/2542 39. eliwa me, mohamed y, hossam e, enamel remineralisation prospect of moringa oleifera hydrogel, eggshell hydrogel versus sodium fluoride varnish on artificially demineralised primary teeth: in vitro study, acta odontologica scandinavica, 2025; 40. soraya c. syafriza d. gani ba. antibacterial effect of moringa oleifera gel to prevent the growth, biofilm formation, and cytotoxicity of streptococcus mutans. j. int. dent. med. res. 2022;15:1053-1061 41. amalunweze a. ezumezu c. production of herbal toothpaste using moringa root essential oil extract. int. j. adv. biochem. res. 2022;6:49-51. https://doi.org/10.33545/26174693.2022.v6.i2a.134 42. prajapati sk, tilak vk, dhakar rc, arya rkk, nagar j, nagar c, therapeutic benefits of moringa oleifera: a mini review, international journal of medical sciences and pharma research 2020;6(2):1-4 http://dx.doi.org/10.22270/ijmspr.v6i2.80 42. sawant t, behera a, shetty n, mathur a, bali a, waheed ma. comparative evaluation of 4% moringa oleifera gel with 1% chlorhexidine gel as an3adjunct to scaling and root planing in the treatment of gingivitis. j dent res rev 2023;10(04):247-250 https://doi.org/10.4103/jdrr.jdrr_79_23 44. obeid rf, ammar mm, younis sh. dentinomimetics and cementomimetics of moringa oleifera leaves extract. sci rep 2023;13:19243. https://doi.org/10.1038/s41598-023-46656-1 pmid:37935743 pmcid:pmc10630475 https://doi.org/10.18231/j.johs.v.12.i.2.7 https://doi.org/10.13005/bpj/2542 https://doi.org/10.33545/26174693.2022.v6.i2a.134 http://dx.doi.org/10.22270/ijmspr.v6i2.80 https://doi.org/10.4103/jdrr.jdrr_79_23 https://doi.org/10.1038/s41598-023-46656-1 kuntjoro et al. asian journal of dental and health sciences. 2025; 5(2):20-24 [20] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited management of severe mandibular posterior ridge atrophy using toothsupported telescopic complete denture: a clinical report mefina kuntjoro * , utari kresnoadi , karina mundiratri , abil kurdi , bambang agustono , merina dwi pangastuti department of prosthodontics, faculty of dental medicine, universitas airlangga, surabaya, indonesia article info: _____________________________________________ article history: received 13 march 2025 reviewed 22 april 2025 accepted 19 may 2025 published 15 june 2025 _____________________________________________ cite this article as: kuntjoro m, kresnoadi u, mundiratri k, kurdi a, agustono b, pangastuti md, management of severe mandibular posterior ridge atrophy using tooth-supported telescopic complete denture: a clinical report, asian journal of dental and health sciences. 2025; 5(2):20-24 doi: http://dx.doi.org/10.22270/ajdhs.v5i2.132 abstract _________________________________________________________________________________________________________________ severe residual ridge resorption poses a significant challenge in prosthodontic rehabilitation, especially in partially edentulous patients with compromised anatomical support. conventional removable dentures often fail to provide sufficient retention and stability in such cases. telescopic dentures offer a conservative and effective solution, particularly for the elderly, to avoid surgery. double crowns, which consist of primary copings cemented to abutment teeth and secondary crowns incorporated into the denture, will create passive friction for mechanical retention to enhance load distribution, stabilize abutment teeth, and preserve natural dentition. telescopic dentures are adaptable over time and provide improved comfort, esthetics, and patient confidence. this clinical report presents a 70-year-old male patient with severe ridge resorption in the bilateral posterior mandible, characterized by extremely shallow retromylohyoid areas. successful rehabilitation was achieved using a mandibular telescopic complete denture, demonstrating the value of conservative prosthodontic planning. keywords: overdenture, telescopic, double crown, ridge atrophy. *address for correspondence: mefina kuntjoro, universitas airlangga, faculty of dental medicine, department of prosthodontic, 60132, surabaya, indonesia introduction severe residual ridge resorption remains a major challenge in prosthodontic rehabilitation, particularly in partially edentulous patients where the anatomical foundation for conventional removable prostheses is compromised.1 in such clinical situations, achieving adequate retention, stability, and support becomes increasingly difficult, often resulting in patient dissatisfaction and functional impairment.2 addressing these challenges requires a treatment modality that is both functionally effective and biologically conservative, particularly in older individuals who prefer simpler procedures with fewer surgical risks. one such option is the telescopic denture system, a prosthetic modality that has proven valuable in the management of complex cases involving few remaining teeth with moderate-to-good periodontal support.3 this system is characterized by the use of double crown mechanisms, where primary copings, are permanently cemented to the abutment teeth, and secondary crowns are integrated within the removable prosthesis to fit precisely over the primaries.4 the passive friction generated between these components provides mechanical retention, eliminating the need for visible clasps or auxiliary attachments.5 moreover, this design helps stabilize abutment teeth and distributes occlusal forces more evenly onto abutment teeth and underlying tissues.6 telescopic dentures are in harmony with conservative dental treatment concepts, as they prioritize the maintenance of the patient’s natural dentition and reduce reliance on invasive surgical techniques.7 this form of prosthetic care is especially advantageous for older individuals or those with systemic limitations where implant placement may not be advisable. its capacity to be modified over time makes it a flexible longterm solution. notably, patients often express greater comfort and assurance in public situations, attributed to the reliable retention and esthetically pleasing design of the restoration.8 this clinical report highlights the use of a telescopic complete denture in a patient with severe alveolar ridge resorption. it demonstrates how thoughtful prosthodontic planning and conservative use of remaining dentition can restore esthetics, function, and patient confidence without the need for surgical intervention. open access case report http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i2.132 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i2.132&amp;domain=pdf https://orcid.org/0000-0002-3869-754x https://orcid.org/0000-0002-5076-4629 https://orcid.org/0000-0002-5602-2212 https://orcid.org/0000-0002-4484-469x https://orcid.org/0000-0002-4767-4585 https://orcid.org/0009-0004-3400-2570 kuntjoro et al. asian journal of dental and health sciences. 2025; 5(2):20-24 [21] ajdhs.com case report a 70-year-old male patient visited the prosthodontic department universitas airlangga dental hospital with with a chief complaint complain of difficulty in mastication due to multiple missing teeth. he expressed the desire to have a comfortable and easy-to-use denture, emphasizing his need for enhance his overall quality of life, without undergoing any surgical procedures. medical history was unremarkable, with no systemic conditions contraindicating dental treatment. intraoral examination revealed partially edentulous maxillary and mandibular arches, along with significant residual ridge resorption, particularly in the posterior mandible. tooth 18 was present as a retained root, while teeth 34 and 44 were fully erupted, periodontally stable, and deemed suitable for use as abutments were periodontally stable, exhibiting adequate bone support and crown height, rendering them viable abutments for a fixed-removable prosthesis. panoramic radiographic assessment confirmed the presence of root fragment 18, generalized ridge resorption on the posterior mandible, and healthy bone support around teeth 34 and 44. periapical radiograph of tooth 44 exhibited a normal periapical appearance and adequate bone support and tooth 34 demonstrated a radiolucency extending into the root canal system, accompanied by a mild periapical radiolucency. tooth 18 was scheduled for extraction. tooth 34 underwent root canal treatment followed by the placement of a fiber post to restore its structural integrity and enable it to serve as a functional abutment. the definitive treatment plan involved the fabrication of a maxillary complete denture and a mandibular telescopic complete denture supported by the strategically preserved teeth 34 and 44. this prosthetic solution was chosen for its conservative nature, allowing improved retention and stability without the need for surgical intervention. figure 1: objective examination. (a-c) intraoral examination (d) radiographic examination initially, treatment was commenced with the fabrication of a maxillary complete denture and a mandibular transitional removable partial denture. this interim prosthesis served to restore function and esthetics during the planning phase, while also allowing for occlusal assessment and adaptation by the patient. maxillary and mandibular primary impressions were taken using irreversible hydrocolloid material, followed by custom tray fabrication. border molding and final impressions were made with polyvinyl siloxane (pvs) to capture accurate soft tissue details. maxillomandibular relationship records were then established by determining a new occlusal vertical dimension (ovd), to ensure proper function and esthetics. teeth arrangement was performed in accordance with the newly established vertical dimension and patient-specific esthetic requirements. following the try-in and verification of esthetics, phonetics, and occlusion, the maxillary complete denture and transitional mandibular denture were inserted. the transitional mandibular denture was designed to be tissue-supported, providing short-term function while preserving abutment teeth 34 and 44. these interim prostheses restored function and esthetics during the treatment phase, allowing the patient to adapt while definitive rehabilitation was being planned. following the successful adaptation to the maxillary complete denture and mandibular transitional prosthesis, definitive treatment was initiated. tooth 34 had previously undergone root canal treatment and was restored with a fiber post to ensure adequate retention and stability for the planned telescopic system. tooth 44, with a healthy periapical status and sufficient crown structure, was also selected as an abutment. both abutment teeth were prepared with a parallel milling technique to accommodate primary metal copings with a path of insertion aligned to enhance retention. the first definitive impressions were made using polyvinyl siloxane (pvs) impression material using stock tray. the primary copings were fabricated in cobalt-chromium alloy, checked intraorally for fit and parallelism. kuntjoro et al. asian journal of dental and health sciences. 2025; 5(2):20-24 [22] ajdhs.com figure 2: fabrication of maxillary complete denture and mandibular transitional denture. (a) measurement of ovd; (b) alignment of the maxillary complete denture; (c) try-in of artificial teeth; (d) insertion of the denture once the primary copings were confirmed for fit, a secondary impression was taken using the pick-up impression technique. the primary copings were temporarily placed onto the abutment teeth, and a new impression was made to capture the copings in place using individual tray. this step ensured that the final framework would fit precisely over the primary copings, providing a stable and passive retention mechanism. after the pick-up impression was obtained, a secondary framework incorporating the outer crowns was designed to friction-fit over the primary copings and integrated into the mandibular removable prosthesis. maxillomandibular relationship records were taken based on the transitional denture. a try-in was performed to verify esthetics, occlusion, and phonetics before final processing. at the time of prosthesis delivery, occlusion was carefully adjusted, and the patient was provided with instructions on the proper insertion, removal, and maintenance of the prosthesis. the patient was followed up at 24 hours, three days, and one week, with no significant complaints. at the end follow-up, the patient reported significant improvement in masticatory function, prosthesis stability, and overall comfort, with enhanced satisfaction. figure 3: fabrication of tooth-supported telescopic complete denture. (a) abutment tooth preparation; (b) evaluation of preparation using transitional denture; (c) try-in of primary coping; (d) pick-up impression; (e) try-in of secondary coping with metal framework; (f) jaw relation record; (g) try-in of artificial teeth; (h) final denture insertion figure 4: facial appearance. (a) before treatment; (b) with transitional denture; (c) after treatment without wearing denture; (d) with definitive denture kuntjoro et al. asian journal of dental and health sciences. 2025; 5(2):20-24 [23] ajdhs.com discussion in the prosthodontic management of partially edentulous patients, especially those with advanced alveolar ridge resorption, treatment planning must be individualized by balancing functional demands, anatomical limitations, systemic health, and patient preferences. while implantsupported prostheses often provide superior retention and stability, they are not always feasible.9 in this case, implant placement was not pursued due to the patient’s reluctance to undergo any surgical procedures, a decision influenced by age-related concerns and the desire for a minimally invasive solution. instead, a tooth-supported telescopic complete denture was selected as a strategic alternative. this approach leverages the remaining dentition as abutments to enhance prosthesis stability and retention without relying on surgical intervention. unlike conventional removable partial dentures (rpds) that utilize visible clasps for retention, telescopic systems employ a double crown mechanism.10 primary copings are cemented onto prepared abutment teeth, while secondary crowns, integrated into the denture base, fit precisely over the primaries using frictional retention. this configuration eliminates the esthetic and biomechanical drawbacks associated with clasp-retained dentures.11 one of the key advantages of the telescopic dentures lies in its ability to distribute occlusal forces more uniformly across the supporting structures.12 the splinting effect of the double crown system reduces stress concentration on individual abutments and improves the longevity of remaining teeth.13 additionally, telescopic copings maintain axial loading and enhance proprioception, which is often diminished in conventional rpds.14 this controlled force transmission is particularly important in patients with compromised ridges, where uneven stress may exacerbate residual ridge resorption. moreover, telescopic dentures offer superior esthetics due to the absence of clasps, which can be particularly beneficial for anterior abutments.10 the design also facilitates easier hygiene access, as the prosthesis can be removed, and the abutments can be cleaned thoroughly. this design is essential feature for elderly patients with declining manual dexterity. the precision fit between the primary and secondary components also results in improved retention and resistance to dislodging during mastication and speech.8 moreover, research indicates that individuals rehabilitated with telescopic dentures demonstrate considerably higher satisfaction regarding retention, comfort, and social confidence when compared to those with conventional clasp-retained dentures.15 in the present case, the use of telescopic complete dentures successfully restored the patient’s masticatory function, improved retention and esthetics, and eliminated the need for invasive procedures. by utilizing the available abutment teeth conservatively and integrating a biomechanically sound design, this treatment not only respected the patient's preferences and clinical limitations but also ensured long-term adaptability and comfort. the transitional denture phase allowed gradual functional adaptation and occlusal planning, further contributing to the clinical success of the definitive prosthesis. overall, this case underscores the value of telescopic complete dentures as a viable prosthetic option in medically compromised or surgically averse patients. they serve as a bridge between conventional dentures and implant-supported restorations, offering a blend of mechanical performance, biological preservation, and esthetic enhancement that is particularly suited for complex partial edentulism. conclusion tooth supported telescopic complete dentures offer a conservative and effective solution for patients with severe ridge resorption and limited abutment teeth, especially when implant placement is not feasible. compared to conventional clasp dentures, they provide better retention, stability, and esthetics through a friction-fit double crown system. in the present case, the use of strategically preserved mandibular abutment, combined with careful endodontic and prosthodontic planning, resulted in a successful rehabilitation with improved mastication, phonetics, and patient satisfaction. the non-surgical nature of the approach, coupled with high functional outcomes, further supports the role of telescopic dentures as a conservative yet durable treatment modality in modern prosthodontics. acknowledgement: the authors declare that there are no acknowledgments conflict of interest: the authors declare no conflict of interest. author contributions: all authors have equal contribution in the preparation of manuscript and compilation. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: informed consent was obtained from all subjects involved in the study. data availability statement: the data presented in this study are available on request from the corresponding author. ethical approval: not applicable. references 1. jacobson te, krol aj. a contemporary review of the factors involved in complete denture retention, stability, and support. part i: retention. j prosthet dent. 1983;49(1):5-15. https://doi.org/10.1016/0022-3913(83)90228-7 pmid:6337253 2. km s, koli dk, jain v, pruthi g, nanda a. comparison of ridge resorption and patient satisfaction in single implant-supported mandibular overdentures with conventional complete dentures: a randomised pilot study. j oral biol craniofac res. 2021;11(1):7177. https://doi.org/10.1016/j.jobcr.2020.11.014 pmid:33376669 pmcid:pmc7758555 3. singh k, gupta n. telescopic denture a treatment modality for minimizing the conventional removable complete denture problems: a case report. j clin diagn res. 2012;6(6):1112-6. https://doi.org/10.1016/0022-3913(83)90228-7 https://doi.org/10.1016/j.jobcr.2020.11.014 kuntjoro et al. asian journal of dental and health sciences. 2025; 5(2):20-24 [24] ajdhs.com 4. brunda, k., kalpana, d., sharan, s., sreeharsha, t. v., & chandra, p. k. telescopic overdenture a case report. international journal of science and research, 2018;7(12):1-5. 5. kara r. telescopic double crowns in prosthodontics. int j dent res. 2021;8(2):17-23. https://doi.org/10.14419/ijdr.v8i2.31531 6. guckes ad, guckes sm, shelton t, carr ab. tooth-supported telescopic prostheses in compromised dentitions: a clinical report. j prosthet dent. 2000 sep;84(2):129-32. https://doi.org/10.1067/mpr.2000.108026 pmid:10946327 7. kumar a, shankar s, rani s, singh r, sinha r. telescopic denture: a treatment option for occlusal rehabilitation. cureus. 2023 mar 15;15(3):e35202. https://doi.org/10.7759/cureus.35202 pmid:36968911 pmcid:pmc10032173 8. hakkoum ma, wazir g. telescopic denture. open dent j. 2018;12:246-54. https://doi.org/10.2174/1874210601812010246 pmid:29760817 pmcid:pmc5897958 9. leong jz, beh yh, ho tk. tooth-supported overdentures revisited. cureus. 2024;16(1):e53184. https://doi.org/10.7759/cureus.53184 10. krestiono ms, laksono h. telescopic overdenture as an aesthetic treatment for partially dentate patients: a case report. indones j dent med. 2018;1(1):27-30. https://doi.org/10.20473/ijdm.v1i1.2018.27-30 11. djafri r, mude ah. removable partial denture with telescopic overdenture. indones j prosthodont. 2023 dec;4(2):89-92. https://doi.org/10.46934/ijp.v4i2.240 . 12. shruthi, c. s., poojya, r., ram, s., & anupama. telescopic overdenture: a case report. international journal of biomedical science : ijbs, 2017;13(1):43-47. https://doi.org/10.59566/ijbs.2017.13043 pmid:28533736 pmcid:pmc5422644 13. george m, mahoorkar ss, sushna k. telescopic overdenture: a case report. rguhs j dent sci. 2023;15(1):108-12. https://doi.org/10.26463/rjds.15_1_7 pmid:26918091 14. dede dö, durmuşlar mc, fahın o, köroğlu a, ecebal ö. telescopic overdenture and implant-supported fixed partial denture: a pragmatic treatment approach. case reports in dentistry. 2015;2015:392397. https://doi.org/10.1155/2015/392397 pmid:26106491 pmcid:pmc4461731 15. minervini g, cervino g, chaturvedi s, franco r, di francesco f, fiorillo l, cicciù m. advanced method of rehabilitating edentulous jaws: a review on telescopic denture. technology and health care. 2023;31(3):791-807. https://doi.org/10.3233/thc-220641 pmid:36617805 https://doi.org/10.14419/ijdr.v8i2.31531 https://doi.org/10.1067/mpr.2000.108026 https://doi.org/10.7759/cureus.35202 https://doi.org/10.2174/1874210601812010246 https://doi.org/10.7759/cureus.53184 https://doi.org/10.20473/ijdm.v1i1.2018.27-30 https://doi.org/10.46934/ijp.v4i2.240 https://doi.org/10.59566/ijbs.2017.13043 https://doi.org/10.26463/rjds.15_1_7 https://doi.org/10.1155/2015/392397 https://doi.org/10.3233/thc-220641 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):1-5 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited nitrogen balance and its impact on hematological function in sickle cell patients: a review * emmanuel ifeanyi obeagu department of biomedical and laboratory science, africa university, zimbabwe. article info: _____________________________________________ article history: received 09 may 2025 reviewed 02 june 2025 accepted 18 june 2025 published 15 sep 2025 _____________________________________________ cite this article as: obeagu ei, nitrogen balance and its impact on hematological function in sickle cell patients: a review, asian journal of dental and health sciences. 2025; 5(3):1-5 doi: http://dx.doi.org/10.22270/ajdhs.v5i3.128 abstract _________________________________________________________________________________________________________________ sickle cell disease (scd) is a chronic genetic disorder marked by recurrent hemolysis, anemia, and vaso-occlusive events, all of which significantly elevate the body's metabolic and nutritional demands. among the critical nutritional parameters, nitrogen balance—reflecting the equilibrium between nitrogen intake and excretion—emerges as a key indicator of protein metabolism and tissue maintenance. patients with scd often face challenges in maintaining adequate nitrogen balance due to chronic inflammation, increased erythropoietic drive, and elevated protein turnover, particularly during disease exacerbations or infections. negative nitrogen balance in scd is associated with several hematological complications, including impaired hemoglobin synthesis, decreased red blood cell production, and weakened immune defense. the continuous need for red blood cell replacement due to chronic hemolysis further amplifies the demand for amino acids, making protein sufficiency essential for effective hematopoiesis. furthermore, nitrogen depletion can worsen the overall clinical picture by contributing to growth delays in children, reduced physical endurance, and increased frequency of hospital admissions. keywords: nitrogen balance, hematological function, sickle cell disease, protein metabolism, anemia *address for correspondence: e emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction sickle cell disease (scd) is an inherited hemoglobinopathy characterized by the presence of sickle-shaped erythrocytes due to a mutation in the βglobin gene, resulting in the production of abnormal hemoglobin s (hbs). this structural abnormality leads to red blood cell deformation under deoxygenated conditions, causing vaso-occlusion, chronic hemolytic anemia, and multi-organ complications. scd predominantly affects individuals of african, middle eastern, and mediterranean descent, and despite advances in treatment, it remains a major contributor to morbidity and mortality in affected populations. nutritional deficiencies, though often under-recognized, significantly impact the clinical course of scd 1-6. one of the less explored but highly relevant aspects of nutritional status in scd is nitrogen balance. nitrogen, a fundamental component of amino acids and nucleotides, is vital for cellular function, growth, and repair. nitrogen balance refers to the net difference between nitrogen intake—primarily through dietary protein—and nitrogen loss via urine, feces, sweat, and other bodily excretions. a positive nitrogen balance is indicative of anabolic states such as growth, recovery, or pregnancy, whereas a negative nitrogen balance denotes catabolism and potential physiological deterioration 7-8. patients with scd are particularly susceptible to a negative nitrogen balance due to several interrelated factors. chronic hemolysis increases the demand for erythropoiesis, which in turn escalates the requirement for amino acids and other nutrients necessary for red blood cell synthesis. additionally, recurring infections, systemic inflammation, oxidative stress, and frequent hospitalizations contribute to hypermetabolism and increased protein turnover. these factors collectively shift the metabolic equilibrium toward a catabolic state, exacerbating nitrogen loss and depleting protein reserves critical for hematological function 9-11. the implications of a disrupted nitrogen balance in scd extend beyond basic nutrition. inadequate protein availability may hinder the synthesis of hemoglobin, reduce erythrocyte lifespan, and impair bone marrow function. this can lead to worsened anemia, decreased immune response, and slower recovery from vasoocclusive crises or other complications. moreover, in pediatric populations, persistent nitrogen imbalance is associated with growth retardation, delayed sexual maturation, and poor neurocognitive development, further underscoring the systemic consequences of poor nitrogen homeostasis 12-15. open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i3.128 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i3.128&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):1-5 [2] ajdhs.com understanding nitrogen balance nitrogen balance is a fundamental concept in clinical nutrition and physiology, serving as a marker of protein metabolism and overall nutritional status. it represents the equilibrium between nitrogen intake—largely derived from dietary proteins—and nitrogen excretion, which occurs primarily through urine in the form of urea, but also through feces, sweat, skin desquamation, and other minor losses. a positive nitrogen balance indicates an anabolic state, where nitrogen intake exceeds loss, supporting growth, tissue repair, and recovery. in contrast, a negative nitrogen balance suggests a catabolic state, where nitrogen losses exceed intake, reflecting protein degradation and inadequate nutritional support 16. in healthy individuals, nitrogen balance fluctuates depending on physiological demands such as growth (e.g., childhood, adolescence), pregnancy, illness, or post-surgical recovery. the body requires a constant supply of amino acids not only for structural proteins but also for enzymes, hormones, immunoglobulins, and hemoglobin. when dietary protein intake is insufficient or when metabolic demands are increased—as seen in chronic diseases like sickle cell disease—the body begins to catabolize its own proteins, leading to muscle wasting, immunosuppression, and impaired erythropoiesis 17. measurement of nitrogen balance is typically performed through dietary assessment and analysis of nitrogen excretion, most commonly via 24-hour urinary urea nitrogen (uun). the calculation takes into account estimated non-urinary nitrogen losses and helps clinicians evaluate whether a patient is receiving adequate protein. however, in settings like scd, where inflammation and oxidative stress alter metabolism, interpreting nitrogen balance becomes more complex. it is crucial to consider the disease-specific context, as scd patients may exhibit elevated basal metabolic rates and protein turnover even in clinically stable states, thereby necessitating higher protein intake to achieve nitrogen equilibrium 18. in scd, maintaining nitrogen balance is particularly challenging due to persistent hemolysis, increased erythropoietic activity, and frequent inflammatory episodes. each of these processes imposes a substantial demand on amino acid pools, making protein sufficiency a prerequisite for adequate hematological function. furthermore, nitrogen balance is intimately linked to overall clinical outcomes in scd— negative nitrogen states are associated with increased fatigue, reduced hemoglobin levels, higher susceptibility to infections, and longer recovery periods from vasoocclusive crises 18. nitrogen metabolism in sickle cell disease nitrogen metabolism plays a pivotal role in maintaining physiological homeostasis, particularly in conditions marked by chronic inflammation, increased cellular turnover, and heightened metabolic demand— hallmarks of sickle cell disease (scd). in individuals with scd, the pathophysiology of the disease imposes a substantial burden on protein metabolism due to the continuous need for erythrocyte regeneration, tissue repair, and immune function support. these processes necessitate a constant and elevated supply of amino acids, making nitrogen metabolism a critical determinant of health outcomes in this population 19-20. one of the primary contributors to altered nitrogen metabolism in scd is the state of chronic hemolysis. hemolysis not only leads to anemia and reduced oxygen-carrying capacity but also accelerates the turnover of erythrocytes, thereby increasing the demand for protein synthesis to replenish red blood cells. this continuous erythropoietic drive consumes large amounts of nitrogen in the form of amino acids necessary for hemoglobin and cellular component production. inadequate dietary protein or inefficient utilization of nitrogen can thus lead to a deficit, resulting in negative nitrogen balance and its attendant complications 21. in addition to hemolysis, recurrent infections and vasoocclusive crises in scd further compound nitrogen losses through systemic inflammation and catabolic stress. during these episodes, pro-inflammatory cytokines such as interleukin-6 (il-6) and tumor necrosis factor-alpha (tnf-α) stimulate protein breakdown in muscle tissue, divert amino acids away from constructive processes like hematopoiesis, and increase urinary nitrogen excretion. fever, tissue damage, and organ dysfunction may also impair nutrient absorption and utilization, making it more difficult to maintain a favorable nitrogen status 22-23. the metabolic adaptations observed in scd, including elevated resting energy expenditure and increased protein turnover, also affect nitrogen utilization. several studies have documented higher caloric and protein needs in children and adults with scd compared to healthy controls, even during periods of clinical stability. however, standard nutritional guidelines often fail to reflect these heightened requirements, leading to chronic undernutrition and suboptimal nitrogen retention. this discrepancy contributes to poor growth, delayed puberty, and reduced resilience against oxidative and infectious insults 24-25 from a biochemical perspective, disruptions in nitrogen metabolism in scd also affect other physiological systems, including the urea cycle, amino acid synthesis, and nitric oxide (no) production. arginine, a semi-essential amino acid and a key component of nitrogen metabolism, is often depleted in scd due to increased consumption in hemolysis and inflammation. arginine deficiency can impair no synthesis, contributing to endothelial dysfunction and worsening vaso-occlusive phenomena. these intricate interplays highlight how nitrogen metabolism extends beyond nutritional status, directly influencing vascular tone and hematologic stability in scd 26. hematological implications of nitrogen imbalance nitrogen imbalance in individuals with sickle cell disease (scd) is not merely a nutritional concern; it has direct and far-reaching hematological implications. the continuous loss of nitrogen, when not matched by adequate dietary intake, disrupts protein homeostasis and undermines essential physiological processes emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):1-5 [3] ajdhs.com involved in hematopoiesis. this imbalance contributes significantly to the severity of anemia, immune dysfunction, and delayed recovery from hematologic insults commonly encountered in scd 20. hemoglobin synthesis is one of the most nitrogen-intensive biological processes. in scd, where erythrocyte lifespan is significantly shortened due to chronic hemolysis, the bone marrow is under constant pressure to replenish red blood cells. a negative nitrogen balance compromises the availability of amino acids— particularly those required for globin chain synthesis— thus limiting the capacity of the bone marrow to produce functional erythrocytes. the result is persistent or worsening anemia, even in the absence of overt clinical crises. inadequate protein status may also impair the responsiveness to erythropoietin, further blunting effective erythropoiesis 21. moreover, nitrogen imbalance adversely affects leukocyte function and immune surveillance. immune cells, particularly lymphocytes and neutrophils, require adequate protein substrates to support proliferation, antibody production, cytokine synthesis, and cytotoxic activity. in scd, where individuals already face increased susceptibility to infections due to functional asplenia and chronic inflammation, suboptimal nitrogen status can exacerbate immunodeficiency. this predisposes patients to more frequent and severe infections, leading to increased hospitalizations and prolonged disease flares 22. platelet function and coagulation dynamics may also be influenced by protein and nitrogen deficiencies. platelets rely on structural proteins and enzymatic systems that are nitrogen-dependent. a compromised nitrogen pool may impair platelet aggregation and contribute to the dysregulation of the coagulation cascade—factors that play a role in the pathogenesis of vaso-occlusive crises. additionally, the repair of endothelial damage, a key process in preserving vascular integrity in scd, requires sufficient amino acids for collagen formation and other reparative mechanisms 23. nitrogen imbalance may also influence the redox status of sickle cell patients. antioxidant enzymes such as glutathione peroxidase, superoxide dismutase, and catalase are protein-based and require nitrogen for their synthesis. in a state of nitrogen deficiency, the capacity to synthesize these protective enzymes may be diminished, leading to oxidative stress—a known aggravator of erythrocyte sickling and hemolysis. this creates a vicious cycle in which nitrogen imbalance worsens oxidative damage, which in turn accelerates hemolysis and protein turnover 24. in pediatric scd patients, nitrogen imbalance has been linked with impaired growth and delayed developmental milestones. these hematological and systemic deficiencies not only reflect poor protein-nutritional status but also impact the long-term prognosis of affected children. poor hemoglobin levels, immune suppression, and slowed somatic growth cumulatively reduce quality of life and functional capacity, emphasizing the clinical urgency of addressing nitrogen balance 25-26. clinical and nutritional interventions effective management of nitrogen imbalance in sickle cell disease (scd) necessitates a multifaceted approach that integrates clinical care with targeted nutritional strategies. due to the chronic catabolic state and elevated protein turnover associated with scd, particularly during vaso-occlusive crises or infections, conventional nutritional recommendations often fall short of meeting the metabolic demands of these patients. clinical and dietary interventions must therefore be proactive, personalized, and based on a comprehensive understanding of individual needs [2729]. clinically, routine assessment of nutritional status should be incorporated into standard care for scd patients, including regular evaluations of serum protein levels, body mass index (bmi), and markers of nitrogen excretion, such as urinary urea nitrogen. where feasible, indirect calorimetry and nitrogen balance studies may provide more accurate estimates of metabolic demand. in patients with evidence of nitrogen deficit, medical nutrition therapy should be initiated under the guidance of dietitians experienced in hematologic and metabolic disorders [30-32]. from a nutritional standpoint, increasing dietary protein intake is the cornerstone of restoring nitrogen balance. the recommended daily allowance (rda) for protein may need to be significantly increased in scd patients, particularly during periods of increased stress or recovery. highbiological-value proteins—such as those from eggs, dairy, lean meats, fish, and legumes—should be prioritized to ensure the supply of essential amino acids. supplemental formulations containing branched-chain amino acids (bcaas), glutamine, and arginine have also been studied for their role in promoting nitrogen retention and tissue repair, with promising but still emerging evidence 33-34. micronutrient support plays a complementary role. zinc, folate, and vitamin b12 are crucial for dna synthesis, erythropoiesis, and immune function, all of which are nitrogen-dependent processes. ensuring adequate intake of these nutrients can enhance the effectiveness of protein utilization and support hematopoietic function. additionally, antioxidants such as vitamins c and e may reduce oxidative stress, indirectly lowering protein degradation and conserving nitrogen stores 35. in severe or complicated cases—such as hospitalized patients with poor oral intake, malabsorption, or increased metabolic demands— enteral or parenteral nutrition may be required. these interventions must be carefully monitored to avoid complications such as refeeding syndrome or fluid overload. the choice of protein sources, the timing of delivery, and the balance of macronutrients should be tailored to the patient's clinical condition and recovery goals 36. importantly, education and counseling for patients and caregivers are vital components of any nutritional intervention. empowering individuals with scd and their families to understand the importance of dietary protein, hydration, and nutrient diversity can lead to better compliance and long-term improvements in health outcomes. community-based programs and school feeding initiatives may also play a role in emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):1-5 [4] ajdhs.com supporting nutritional sufficiency, particularly in lowresource settings where scd is prevalent 37. conclusion nitrogen balance is a fundamental determinant of hematological stability and overall health in individuals with sickle cell disease (scd). the chronic metabolic demands imposed by hemolysis, inflammation, and tissue repair processes render patients particularly vulnerable to nitrogen deficits. when unaddressed, nitrogen imbalance exacerbates anemia, impairs immune function, delays growth and development, and diminishes the body's capacity to withstand oxidative and infectious stressors. these consequences underscore the importance of integrating nitrogen balance assessment and management into the comprehensive care of scd patients. nutritional strategies, including increased protein intake, targeted amino acid supplementation, and micronutrient support, can effectively restore nitrogen equilibrium and enhance clinical outcomes. additionally, proactive clinical monitoring and individualized dietary planning are essential to ensure that metabolic demands are met across the disease spectrum—from childhood through adulthood, and during both steady-state and crisis periods. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. gupta a. sickle cell anemia and related hemoglobinopathies. indecision making through problem based learning in hematology: a step-by-step approach in patients with anemia 2024: 269-289. singapore: springer nature singapore. https://doi.org/10.1007/978-981-99-8933-1_21 2. hassan ms, nasrin t, mahalka a, hoque m, ali s. a perspective on the genesis, diagnostics, and management of sickle cell disease. egyptian journal of medical human genetics. 2024; 25(1):150. https://doi.org/10.1186/s43042-024-00623-1 3. rajput hs, kumari m, talele c, sajan c, saggu v, hadia r. comprehensive overview of sickle cell disease: global impact, management strategies, and future directions. journal of advanced zoology. 2024; 45(1). https://doi.org/10.53555/jaz.v45i1.3390 4. obeagu ei. role of autophagy in modulating oxidative stress in sickle cell disease: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(8):38-46. https://doi.org/10.23880/hij16000247 5. obeagu ei. redox regulation of hemoglobin in sickle cell disease: a review. int. j. curr. res. chem. pharm. sci. 2024;11(8):13-9. 6. obeagu ei, bunu uo, obeagu gu, habimana jb. antioxidants in the management of sickle cell anaemia: an area to be exploited for the wellbeing of the patients. int res med health sci. 2023 sep 11;6:12-7. 7. xiao r, li l, zhang y, fang l, li r, song d, liang t, su x. reducing carbon and nitrogen loss by shortening the composting duration based on seed germination index (scd@ gi): feasibilities and challenges. science of the total environment. 2024:172883. https://doi.org/10.1016/j.scitotenv.2024.172883 pmid:38697528 8. lin w, lv x, wang q, li l, zou g. nitrogen concentration dependent optical defects transition in single crystal diamond through low pressure high temperature annealing. vacuum. 2025:114329. https://doi.org/10.1016/j.vacuum.2025.114329 9. wood kc, granger dn. sickle cell disease: role of reactive oxygen and nitrogen metabolites. clinical & experimental pharmacology & physiology. 2007 sep 1;34(9). https://doi.org/10.1111/j.14401681.2007.04639.x pmid:17645642 10. dijkmans t, djokic mr, van geem km, marin gb. comprehensive compositional analysis of sulfur and nitrogen containing compounds in shale oil using gc× gc-fid/scd/ncd/tof-ms. fuel. 2015; 140:398-406. https://doi.org/10.1016/j.fuel.2014.09.055 11. muehle m, asmussen j, becker mf, schuelke t. extending microwave plasma assisted cvd scd growth to pressures of 400 torr. diamond and related materials. 2017; 79:150-163. https://doi.org/10.1016/j.diamond.2017.09.013 12. obeagu ei, obeagu gu. immunization strategies for individuals with sickle cell anemia: a narrative review. medicine. 2024; 103(38):e39756. https://doi.org/10.1097/md.0000000000039756 pmid:39312357 pmcid:pmc11419550 13. obeagu ei. strategies for reducing child mortality due to sickle cell disease in uganda: a narrative review. annals of medicine and surgery.:10-97. 14. obeagu ei. erythropoeitin in sickle cell anaemia: a review. international journal of research studies in medical and health sciences. 2020;5(2):22-8. https://doi.org/10.22259/ijrsmhs.0502004 15. obeagu ei, obeagu gu. malnutrition in sickle cell anemia: prevalence, impact, and interventions: a review. medicine. 2024 may 17;103(20):e38164. https://doi.org/10.1097/md.0000000000038164 pmid:38758879 pmcid:pmc11098235 16. quemada m, delgado a, mateos l, villalobos fj. nitrogen fertilization i: the nitrogen balance. inprinciples of agronomy for sustainable agriculture 2024: 377-401. cham: springer international publishing. https://doi.org/10.1007/978-3-03169150-8_26 17. krug ec, winstanley d. the need for comprehensive and consistent treatment of the nitrogen cycle in nitrogen cycling and mass balance studies: i. terrestrial nitrogen cycle. science of the total environment. 2002; 293(1-3):1-29. https://doi.org/10.1016/s0048-9697(01)01133-0 pmid:12109464 18. zhang cc, zhou cz, burnap rl, peng l. carbon/nitrogen metabolic balance: lessons from cyanobacteria. trends in plant science. 2018; 23(12):1116-1130. https://doi.org/10.1016/j.tplants.2018.09.008 pmid:30292707 19. enwonwu co, xu xx, turner e. nitrogen metabolism in sickle cell anemia: free amino acids in plasma and urine. the american journal of the medical sciences. 1990; 300(6):366-371. https://doi.org/10.1097/00000441-199012000-00005 pmid:2264574 20. borel mj, buchowski ms, turner ea, peeler bb, goldstein re, flakoll pj. alterations in basal nutrient metabolism increase resting energy expenditure in sickle cell disease. american journal of physiology-endocrinology and metabolism. 1998; 274(2):e357364. https://doi.org/10.1152/ajpendo.1998.274.2.e357 pmid:9486169 https://doi.org/10.1007/978-981-99-8933-1_21 https://doi.org/10.1186/s43042-024-00623-1 https://doi.org/10.53555/jaz.v45i1.3390 https://doi.org/10.23880/hij-16000247 https://doi.org/10.23880/hij-16000247 https://doi.org/10.1016/j.scitotenv.2024.172883 https://doi.org/10.1016/j.vacuum.2025.114329 https://doi.org/10.1111/j.1440-1681.2007.04639.x https://doi.org/10.1111/j.1440-1681.2007.04639.x https://doi.org/10.1016/j.fuel.2014.09.055 https://doi.org/10.1016/j.diamond.2017.09.013 https://doi.org/10.1097/md.0000000000039756 https://doi.org/10.22259/ijrsmhs.0502004 https://doi.org/10.1097/md.0000000000038164 https://doi.org/10.1007/978-3-031-69150-8_26 https://doi.org/10.1007/978-3-031-69150-8_26 https://doi.org/10.1016/s0048-9697(01)01133-0 https://doi.org/10.1016/j.tplants.2018.09.008 https://doi.org/10.1097/00000441-199012000-00005 https://doi.org/10.1152/ajpendo.1998.274.2.e357 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):1-5 [5] ajdhs.com 21. jackson aa. the use of stable isotopes to study nitrogen metabolism in homozygous sickle cell disease. ingenetic factors in nutrition. 1984: 297-315. academic press, new york. https://doi.org/10.1016/b978-0-12-715950-8.50024-x pmcid:pmc7131065 22. schnog jj, jager eh, van der dijs fp, duits aj, moshage h, muskiet fd, muskiet fa. evidence for a metabolic shift of arginine metabolism in sickle cell disease. annals of hematology. 2004; 83:371-375. https://doi.org/10.1007/s00277-004-0856-9 pmid:15054669 23. darghouth d, koehl b, madalinski g, heilier jf, bovee p, xu y, olivier mf, bartolucci p, benkerrou m, pissard s, colin y. pathophysiology of sickle cell disease is mirrored by the red blood cell metabolome. blood, the journal of the american society of hematology. 2011; 117(6):e57-66. https://doi.org/10.1182/blood-2010-07-299636 pmid:21135259 24. morris cr, kato gj, poljakovic m, wang x, blackwelder wc, sachdev v, hazen sl, vichinsky ep, morris sm, gladwin mt. dysregulated arginine metabolism, hemolysis-associated pulmonary hypertension, and mortality in sickle cell disease. jama. 2005; 294(1):81-90. https://doi.org/10.1001/jama.294.1.81 pmid:15998894 pmcid:pmc2065861 25. zhou y, yu x, nicely a, cunningham g, challa c, mckinley k, nickel r, campbell a, darbari d, summar m, majumdar s. amino acid signature during sickle cell pain crisis shows significant alterations related to nitric oxide and energy metabolism. molecular genetics and metabolism. 2022; 137(1-2):146-152. https://doi.org/10.1016/j.ymgme.2022.08.004 pmid:36030599 26. d'alessandro a, nouraie sm, zhang y, cendali f, gamboni f, reisz ja, zhang x, bartsch kw, galbraith md, espinosa jm, gordeuk vr. metabolic signatures of cardiorenal dysfunction in plasma from sickle cell patients as a function of therapeutic transfusion and hydroxyurea treatment. haematologica. 2023; 108(12):3418. https://doi.org/10.3324/haematol.2023.283288 pmid:37439373 pmcid:pmc10690926 27. obeagu ei, prajapati sk, maurya sd, maternal anemia in the context of infectious diseases during pregnancy: a review, international journal of medical sciences and pharma research, 2025;11(1):8-13 https://doi.org/10.22270/ijmspr.v11i1.134 28. obeagu ei, chukwu ph. inclusive healthcare approaches for hivpositive sickle cell disease patients: a review. current research in biological sciences. 2025;1(1):01-8. 29. obeagu ei, obeagu gu. managing gastrointestinal challenges: diarrhea in sickle cell anemia. medicine. 2024; 103(18):e38075. https://doi.org/10.1097/md.0000000000038075 pmid:38701274 pmcid:pmc11062666 30. obeagu ei, obeagu gu. living with sickle cell in uganda: a comprehensive perspective on challenges, coping strategies, and health interventions. medicine. 2024 dec 20;103(51):e41062. https://doi.org/10.1097/md.0000000000041062 pmid:39705436 pmcid:pmc11666137 31. obeagu ei, adias tc, obeagu gu. advancing life: innovative approaches to enhance survival in sickle cell anemia patients. annals of medicine and surgery. 2024; 86(10):6021-6036. https://doi.org/10.1097/ms9.0000000000002534 pmid:39359845 pmcid:pmc11444627 32. bell v, varzakas t, psaltopoulou t, fernandes t. sickle cell disease update: new treatments and challenging nutritional interventions. nutrients. 2024; 16(2):258. https://doi.org/10.3390/nu16020258 pmid:38257151 pmcid:pmc10820494 33. khan sa, damanhouri g, ali a, khan sa, khan a, bakillah a, marouf s, al harbi g, halawani sh, makki a. precipitating factors and targeted therapies in combating the perils of sickle cell disease---a special nutritional consideration. nutrition & metabolism. 2016; 13:1-2. https://doi.org/10.1186/s12986-016-0109-7 pmid:27508000 pmcid:pmc4977632 34. patel s, patel r, mukkala sr, akabari a. emerging therapies and management approaches in sickle cell disease (scd): a critical review. journal of phytonanotechnology and pharmaceutical sciences. 2023; 3(3):1-1. https://doi.org/10.54085/jpps.2023.3.3.3 35. obeagu ei, prajapati sk, maurya sd, anemia in pregnancy: exploring non-iron deficiency causes, international journal of medical sciences and pharma research, 2025;11(1):1-7 https://doi.org/10.22270/ijmspr.v11i1.130 36. boma pm, kaponda aa, panda j, bonnechère b. enhancing the management of pediatric sickle cell disease by integrating functional evaluation to mitigate the burden of vaso-occlusive crises. journal of vascular diseases. 2024; 3(1):77-87. https://doi.org/10.3390/jvd3010007 37. obeagu ei, chukwu ph. inclusive healthcare approaches for hivpositive sickle cell disease patients: a review. current research in biological sciences. 2025;1(1):01-8. https://doi.org/10.1016/b978-0-12-715950-8.50024-x https://doi.org/10.1007/s00277-004-0856-9 https://doi.org/10.1182/blood-2010-07-299636 https://doi.org/10.1001/jama.294.1.81 https://doi.org/10.1016/j.ymgme.2022.08.004 https://doi.org/10.3324/haematol.2023.283288 https://doi.org/10.22270/ijmspr.v11i1.134 https://doi.org/10.1097/md.0000000000038075 https://doi.org/10.1097/md.0000000000041062 https://doi.org/10.1097/ms9.0000000000002534 https://doi.org/10.3390/nu16020258 https://doi.org/10.1186/s12986-016-0109-7 https://doi.org/10.54085/jpps.2023.3.3.3 https://doi.org/10.22270/ijmspr.v11i1.130 https://doi.org/10.3390/jvd3010007 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [1] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited herbal medicine for pain management in dentistry sunil kumar prajapati 1 , divya jain 2, krishan kumar verma 3, rajeshwar kamal kant arya 4 , ram c dhakar 5* , omji porwal 6 , vijay kumar tilak 7, sheo datta maurya 8 1 professor, institute of pharmacy, bundelkhand university, jhansi, india 2 dental surgeon, srg hospital & medical college, jhalawar, rajasthan, india 3 professor, metro institute of health sciences and research, uttar pradesh, india 4 associate professor, department of pharmaceutical sciences, sir jc bose technical campus, bhimtal, kumaun university, nainital, india 5 hospital pharmacy, srg hospital & medical college, jhalawar, rajasthan, india-326001 6 professor, department of pharmacognosy, faculty of pharmacy, tishk international university-erbil, kurdistan region, iraq 7 professor, apex professional university, pasighat, arunachal pradesh-791102, india 8 pharmacist, health unit, sitarampur, eastern railway, asansol-713359, india article info: _____________________________________________ article history: received 03 sep 2025 reviewed 24 oct 2025 accepted 19 nov 2025 published 15 dec 2025 _____________________________________________ cite this article as: prajapati sk, jain d, verma kk, arya rkk, dhakar rc, porwal o, tilak vk, maurya sd, herbal medicine for pain management in dentistry, asian journal of dental and health sciences. 2025; 5(4):1-6 doi: http://dx.doi.org/10.22270/ajdhs.v5i4.146 abstract _________________________________________________________________________________________________________________ dental pain is one of the most prevalent conditions across the globe that is managed through various methods. allopathic medicines, i.e. analgesics, opioids, steroids, and local anaesthetics, are used for the treatment or management of chronic/acute pain. but due to the adverse effects associated with these allopathic medicines, herbal medicine should be considered as an alternative therapy for pain management in dentistry. various medicinal plants, such as garlic, cloves, turmeric, neem, peppermint, and babul, possess significant analgesic activity; therefore, well-designed clinical studies are required to establish and improve the efficacy of herbal medicine for dental pain. thus, the use and implementation of natural treatments will be highly beneficial to the field of dentistry. the present review highlights herbal medicine, which plays a crucial role in treating pain, particularly in post-maintenance periodontal therapies, without side effects. keywords: dental pain, herbal medicine, clove, turmeric, neem, ginger *address for correspondence: ram c dhakar, hospital pharmacy, srg hospital & medical college, jhalawar, rajasthan, india-326001 introduction oral health is an integral component of general health. oral health problems such as dental caries, periodontal diseases, and oral cancers are global concerns restricting and confining the day-to-day errands and chores. 1. oral diseases remain a significant global health issue, with dental caries and periodontal diseases being among the most critical challenges in oral health. 2 dental pain is one of the most prevalent conditions across the globe that is managed through various methods. allopathic medicines like nsaids and opioids are used for the treatment or management of chronic/acute pain. but due to the adverse effects associated with these allopathic medicines, herbs have long been a popular self-medication option due to their accessibility, trusted efficacy, and safety in relieving oral/dental problems. therefore, herbal medicine should be considered as an alternative therapy for pain management in dentistry 1. natural products contain a wide range of bioactive compounds, including flavonoids, terpenoids, alkaloids, and phenolic compounds, which have demonstrated antimicrobial, wound-healing, anti-inflammatory, and antioxidant activities. 2 herbal medicines like clove oil, turmeric, ginger, peppermint, moringa and garlic have shown significant promise for pain management in dentistry, offering anti-inflammatory and analgesic properties with fewer side effects than some conventional drugs. clinical studies suggest that, in some cases, certain herbal extracts can be as effective as standard over-the-counter pain medications for specific types of dental pain. herbal medicine has long been used as an alternative treatment because it is less likely to cause allergic reactions or other adverse effects, as it comes from natural sources. therefore, it is essential to open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i4.146 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i4.146&amp;domain=pdf https://orcid.org/0000-0002-0968-3915 https://orcid.org/0000-0003-0802-7542 https://orcid.org/0000-0001-8250-8489 https://orcid.org/0000-0003-1760-6618 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [2] ajdhs.com analyse and test the efficacy of herbal medicine to establish and promote its use as an alternative therapy for pain management in dentistry. new medical professionals must be able to assimilate popular knowledge, update it, and place it in the arsenal of modern medicine for the general benefit of society. 3 thus, the use and implementation of natural medicines like neem, cloves, ginger, turmeric etc will be highly beneficial to the field of dentistry. 4 this review provides insights into some medicinal plants, elucidating their medicinal attributes and applications in dentistry. herbal medicine for pain management in dentistry herbal medicines like clove oil 5-13, turmeric, peppermint, moringa 14, neem 15-23, ginger 11, 24-30, garlic 31-35, cacao beans 3, 36-42, green tea 43-46 etc. have shown significant promise for pain management in dentistry, offering anti-inflammatory and analgesic properties with fewer side effects than some conventional drugs. in this review, we highlight some herbal medicine that plays a crucial role in treating pain, particularly in postmaintenance periodontal therapies. syzygium aromaticum (clove oil) contains eugenol, which has pain-relieving and antibacterial properties. it can be diluted with a carrier oil and applied to the affected area with a cotton ball, or used as a mouthwash. clove offers the following advantages; 1. immediate pain relief: the numbing effects of eugenol can provide quick relief from sharp, throbbing toothaches, making it ideal for temporary relief until you can see a dentist. 2. anti-inflammatory effects: cloves reduce swelling and inflammation around the gums and affected teeth, which can help speed up the healing process and reduce discomfort.5,6 3. antiseptic properties: by fighting harmful bacteria, cloves can help prevent infections, particularly after dental procedures like extractions or fillings. 7 4. natural and chemical-free: unlike pharmaceutical pain relievers, cloves are a natural option, making them an excellent choice for those seeking a holistic solution to dental pain. 5. affordable and accessible: cloves are easy to find in most kitchens or health stores, and they’re costeffective compared to many other dental pain treatments. clove, particularly its active compound eugenol, has been traditionally employed in various cultures for the management of pain and inflammation 5. eugenol, the primary bioactive component of clove, exhibits significant analgesic and anti-inflammatory effects. research has indicated that eugenol can inhibit cyclooxygenase (cox) enzymes, which are crucial in the inflammatory process. this inhibition helps mitigate inflammation and pain; therefore, clove is a promising candidate for post-surgical pain management 6. clinical studies support cloves' efficacy in relieving pain. for example, one study found that clove oil effectively reduced pain during intraoral injections in children, which was comparable to the pain relief provided by ice 7. esmaeili et al. reported that clove has been used in dental emergencies as an effective reliever for toothache and as an anti-inflammatory agent for the mouth and throat 8. additionally, havale et al. demonstrated that clove oil was more effective than a commonly used local anaesthetic, lignocaine gel. these findings suggest that clove could serve as a valuable adjunct to conventional postoperative pain management strategies 9. chandran et al. found in their in vivo study that a higher dose (200mg/kg) of the extract was effective in reducing pain and inflammation 10. a study by alipour et al concluded that a combination of cloves and ginger as analgesic agents can serve as a nonnarcotic treatment option for managing mild-tomoderate postoperative pain. 11 in another study, jesudasan et al. (2015) examined the efficacy of a clovederived eugenol paste in 270 patients with alveolar osteitis. patients treated with eugenol experienced significantly greater relief in postoperative pain, inflammation, infection, and wound healing than those treated with 0.2% chlorhexidine gel. results of this study concluded that eugenol was the better of the 2 interventions. 12, 13 azadirachta indica (neem) used in dentistry for its antimicrobial and antiinflammatory effects, it can help with gum tissue and is found in products like toothpaste. neem chewing sticks exhibit anti-plaque activity attributed to their fibrous nature. the neem plant, rich in chemotherapeutic antiplaque agents such as gallotannins, aids plaque removal by promoting aggregate formation. anti-plaque activity of gallotanin effectively inhibits glucosyltransferase activity and reduces bacterial adhesion.15 unlike antibiotics, neem extracts do not cause gingival allergies, preserving their effectiveness.16 in a study assessing analgesic effects, 2 ml/kg body weight of neem seed oil (nso) is comparable to a 1 mg/kg body weight dose of morphine. notably, nso demonstrates superior analgesic efficacy compared to morphine within 45 min.17 excessive use of neem in the form of mouth rinses and gels can temporarily stain the teeth and tongue.18 kumar et al observed that the oil of seeds of neem in a dose of 2 ml/kg body weight was appropriate in comparison with morphine with a dose of 1 mg/kg body weight. neem seed oil yields a more potent analgesic effect than morphine within 45 minutes. srinivasa et al. found that neem resembles indomethacin in a study done using albino rats 19. in a recent investigation, ofiri et al. evaluated the effectiveness of neem. 48 patients were randomly assigned to the control and neem groups. results of this study concluded that neem mouthwash was more effective in controlling pain, facial swelling, trismus, and poor wound healing than chlorhexidine mouthwash. still, they had the same effect as chlorhexidine mouthwash in controlling localised alveolitis, acute prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [3] ajdhs.com alveolar infection, and adverse effects. 20. also, it has been reported that neem contains limonoids 21, which show anti-inflammatory activity. neem is reported to remarkably reduce the release of monocyte chemotactic protein-1 (mcp-1) 22. extracts of neem leaves mitigate the release of pro-inflammatory cytokines such as tnfα, il-6, and il-1β. on the other hand, it enhances the release of anti-inflammatory cytokines such as il-1021, 22, 23. despite the well-documented anti-inflammatory and analgesic effects of neem, these effects have not been reported following third molar surgery. zingiber officinale (ginger) contains anti-inflammatory compounds called gingerols. the combination of cloves and ginger as analgesic agents can be used as a non-narcotic treatment option for managing mild-to-moderate pain after surgery 11. it contains 80-90 non-volatile compounds that contribute to its anti-inflammatory, antioxidant, and antiemetic properties. ginger also reduces pain by inhibiting prostaglandins via the cox and lox pathways, exhibiting antioxidant activity, inhibiting the transcription factor nf-κb, and acting as an agonist of vanilloid nociceptors 24. the active constituents present in ginger, including gingerols and shogaols, have been extensively studied for their ability to alleviate pain and reduce inflammation. these properties suggest that ginger is a promising option for postsurgical pain relief 25. ginger is used for its antiinflammatory, antioxidant, antiemetic, and painreducing effects, and can modulate pain through various mechanisms 26. martins et al. reported that ginger significantly reduced migraine headache frequency and symptom severity compared with sumatriptan 27. in another study, kashefi et al. 28 and rahnama et al. 29 found that ginger significantly alleviated primary dysmenorrhea in patients treated with ginger for five days, starting two days before the onset of menstruation. another study demonstrated that ginger extract was effective in reducing pain and improving functional outcomes in patients with osteoarthritis, suggesting its potential benefits in the postoperative setting 30 allium sativum (garlic) garlic is not only a potent antibacterial agent but also a natural, safe dental pain reliever. the compound allicin has antimicrobial properties. a crushed garlic clove can be applied to the tooth for temporary relief. results from the study of maribao et al suggest that aqueous garlic extract (aqge) and ethanolic garlic extract (etge), at specific concentrations and dosages, may be effective for pain relief. results of this study hint at the potential of garlic extracts as natural pain management solutions, but further investigation is essential for practical applications. 31 aged garlic extract (age) has been reported to exert anti-inflammatory effects. age has recently been found to reduce inflammatory symptoms in periodontitis, a widespread chronic inflammatory disease caused by oral bacterial infection. 32 a clinical trial assessed the efficacy of aged garlic extract (age) in reducing probing pocket depth (ppd) and improving gingival health over 18 months. the average ppd for the age group dramatically declined from 1.89±0.74 mm at baseline to 1.06±0.49 mm at 18 months (p<0.001) 33. age comprises sulfur compounds, including s-allylcysteine, s-1-propenylcysteine, and sallylmercaptocysteine, which exhibit antioxidant properties that enhance the efficacy of age in addressing periodontitis. it also improves peripheral circulation, diminishes inflammation, and augments immunological abilities 34, 35. theobroma cacao l (cacao beans) even more surprising are the investigations conducted by different authors in different countries on the antimicrobial effect of cacao beans (theobroma cacao l. [sterculiaceae]), the plant from which chocolate is derived. it is a potential substitute for chlorhexidine as a mouth rinse, with powerful anticariogenic, antibacterial, and antiplaque activities (ooshima et al. 2000; matsumoto et al. 2004; srikanth et al. 2008; venkatesh babu et al. 2011) 36-39. it would be especially useful in paediatric dentistry because it would be acceptable to children without hypersensitivity and coloration of the teeth and tongue that chlorhexidine can have on children (al-tannir and goodman 1994) 40. moreover, it has been shown that its bioactive compounds, such as catechins and theobromine, possess strong anti-oxidant activity (lee et al. 2003; ramiro-puig and castell 2009) 41-42. thus, t. cacao is a natural source of an agent with potent anticariogenic and antimicrobial activity that has potential in dentistry 3. camellia sinensis (green tea) green tea has been suggested to promote periodontal health by reducing inflammation, preventing bone resorption, and restricting the growth of certain periodontal-related bacteria. 43 green tea has antioxidant, carcinogenic, antimicrobial and noninflammatory properties. several in vitro studies have shown that the development of porphyromonas gingivalis, prevotella intermedia and prevotella nigrescens on human buccal epithelial cells is inhibited by the green tea component epigallocatechin 3 gallate (egcg). 44,45 another investigation attempted to evaluate the effectiveness of a neem by shahakbari et al. (2014), the pain associated with pericoronitis was notably reduced in 97 patients treated with green tea compared with that in those treated with 0.12% chlorhexidine. 46 important considerations professional consultation: these are for temporary relief only. herbal medicines are not a replacement for professional dental care. it is crucial to visit a dentist for proper diagnosis and definitive treatment of the underlying cause of pain (e.g., a cavity or infection). a dentist should suggest a readily available option for immediate pain relief during indirect communication. safety and side effects: although often considered safe, herbs can have side effects or interact with other medications. clove oil, for instance, can cause local irritation if overused 17, 20, 21, 22. essential oils should always be diluted with a carrier oil before applying to the skin or gums to avoid irritation. a dental prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [4] ajdhs.com professional can advise on the most appropriate and safe options for your specific condition. a dentist should review the patient's medical and dental history to assess the patient's psychological and physical condition through voice modulation 1. formulations: herbal extracts are available in various forms, including oils, gels, mouthwashes, and tablets, some of which are specifically formulated for dental use and are backed by clinical testing. these formulations should be cost-effective compared to allopathic medicines and have desirable organoleptic properties. conclusion and future directions use of herbal medicine is on the rise. in india, more than 70% of the population uses herbal drugs, and this constitutes primarily the rural population, who depend solely upon herbal-based products 47,48. various medicinal plants, such as ginger, cloves, turmeric, neem, peppermint, babul, garlic, cacao beans, and green tea, have been used for a long time. still, some of them have reported their adverse effects. eugenol have local irritation and some cytotoxic effects. it is considered safe when used correctly in small amounts; however, it can cause liver and respiratory problems when ingested in large quantities.49,50 turmeric is generally regarded as safe; however, at higher doses, it may cause gastric irritation, nausea, diarrhoea, allergic skin reaction, and antithrombotic events.51 therefore, well-designed clinical studies are required to establish and improve the efficacy of herbal medicine for dental pain. most available studies are small-scale clinical trials, and further research is needed to establish herbal medicine as a part of standard care. the optimal timing, dosage, and long-term effects of herbal medications require further investigation. more effective perioperative management may be achieved when combined with preoperative lifestyle modifications. herbal medicines are well tolerated and widely accepted, and interestingly, they also have cultural and psychological acceptance, especially among the indian population 52. thus, the field of dentistry stands to gain immense benefit from the implementation and use of herbal drugs. in conclusion, both clinical and basic research are essential to advance the role of herbal medicine in dentistry. further research should be conducted to evaluate the efficacy and safety of medicinal plants and to promote their use as an alternative therapy for pain management in dentistry. conflict of interest: the authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article. author contributions: all authors have equal contributions in the preparation of the manuscript and compilation. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting this paper are available in the cited references. ethical approval: not applicable references 1. kumarswamy a. multimodal management of dental pain with focus on alternative medicine: a novel herbal dental gel. contemp clin dent, 2016;7:131 139. https://doi.org/10.4103/0976237x.183066 pmid:27307656 pmcid:pmc4906852 2. anwar ma, sayed ga, hal dm, el hafeez msa, shatat aas, salman a, eisa nm, ramadan a, el shiekh ra, hatem s, aly sh, herbal remedies for oral and dental health: a comprehensive review of their multifaceted mechanisms including antimicrobial, anti inflammatory, and antioxidant pathways, inflammopharmacology, 2025;33:1085-1160 https://doi.org/10.1007/s10787-02401631-8 pmid:39907951 pmcid:pmc11914039 3. martınez cc, gomez md, oh ms, use of traditional herbal medicine as an alternative in dental treatment in mexican dentistry: a review, harmaceutical biology, 2017;55(1):1992-1998 https://doi.org/10.1080/13880209.2017.1347188 pmid:28738710 pmcid:pmc6130662 4. chhabra a, khasbage sd, utility of neem as a herbal drug in oral diseases: a review, j res med dent sci, 2022;10(9):040-044 5. ayushi k, danish sm, mohammad pu. a review on biological and therapeutic uses of syzygium aromaticum linn (clove): based on phyto-chemistry and pharmacological evidences. international journal of botany studies. 2020;5(4):33-39. 6. gökalp f. a study on the chemical properties of eugenol and eugenol acetate, clove essential oils. sigma journal of engineering and natural sciences. 2016;34(3):406-414. 7. kaur d, chandrul kk. syzygium aromaticum l (clove): a vital herbal drug used in periodontal disease. indian journal of pharmaceutical and biological research. 2017;5(02):45-51. https://doi.org/10.30750/ijpbr.5.2.9 8. esmaeili f, zahmatkeshan m, yousefpoor y, alipanah h, safari e, et al. anti-inflammatory and anti-nociceptive effects of cinnamon and clove essential oils nanogels: an in vivo study. bmc complementary medicine and therapies. 2022;22(1):143. https://doi.org/10.1186/s12906-022-03619-9 pmid:35596157 pmcid:pmc9123718 9. havale r, rao dg, shrutha s, tuppadmath km, tharay n, et al. comparative evaluation of pain perception following topical application of clove oil, betel leaf extract, lignocaine gel, and ice prior to intraoral injection in children aged 6-10 years: a randomized control study. journal of dental anesthesia and pain medicine. 2021;21(4):329-336. https://doi.org/10.17245/jdapm.2021.21.4.329 pmid:34395900 pmcid:pmc8349677 10. chandran r, george bp, abrahamse h. anti-proliferative, analgesic and anti-inflammatory properties of syzygium mundagam bark methanol extract. molecules. 2020;25(12):2900 https://doi.org/10.3390/molecules25122900 pmid:32599705 pmcid:pmc7355416 11 alipour m., shahroudi a., moghadam s. k. assessing the impact of ginger and clove on postoperative pain following inguinal hernia and testicular varicocele surgeries, international journal of biomedical and clinical research, biores scientia publishers. 2024;1(6):1-8. 12. jesudasan js, wahab pua, sekhar m, effectiveness of 0.2% chlorhexidine gel and a eugenol-based paste on postoperative alveolar osteitis in patients having third molars extracted: a randomised controlled clinical trial. br. j. oral maxillofacial surg. 2015; 53(9):826-830. https://doi.org/10.1016/j.bjoms.2015.06.022 pmid:26188932 13. barrera sd, cepeda ljb, báez dad, kwon j, siddiq a, parra jec, marya a, chaurasia a, herbal extracts in orofacial pain: a systematic review and direct and indirect meta-analysis, scientific reports, 2024;14:29656 https://doi.org/10.1038/s41598-02477796-7 pmid:39609444 pmcid:pmc11604759 https://doi.org/10.4103/0976-237x.183066 https://doi.org/10.4103/0976-237x.183066 https://doi.org/10.1007/s10787-024-01631-8 https://doi.org/10.1007/s10787-024-01631-8 https://doi.org/10.1080/13880209.2017.1347188 https://doi.org/10.30750/ijpbr.5.2.9 https://doi.org/10.1186/s12906-022-03619-9 https://doi.org/10.17245/jdapm.2021.21.4.329 https://doi.org/10.3390/molecules25122900 https://doi.org/10.1016/j.bjoms.2015.06.022 https://doi.org/10.1038/s41598-024-77796-7 https://doi.org/10.1038/s41598-024-77796-7 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [5] ajdhs.com 14. meena r, prajapati sk, nagar r, porwal o, nagar t, tilak vk, jayakumararaj r, arya rkk, dhakar rc, application of moringa oleifera in dentistry, asian journal of dental and health sciences 2021;1(1):10-13 https://doi.org/10.22270/ajdhs.v1i1.5 15. dany ss, mohanty p, tangade p, rajput p, batra m. efficacy of 0.25% lemongrass oil mouthwash: a three arm prospective parallel clinical study. j clin diagn res 2015;9:c13 7. https://doi.org/10.7860/jcdr/2015/14465.6581 pmid:26557608 pmcid:pmc4625327 16. gbenou jd, ahounou jf, akakpo hb, laleye a, yayi e, gbaguidi f, et al phytochemical composition of cymbopogon citratus and eucalyptus citriodora essential oils and their anti inflammatory and analgesic properties on wistar rats. mol biol rep 2013;40:1127 34 https://doi.org/10.1007/s11033-012-2155-1 pmid:23065287 17. taheri jb, azimi s, rafieian n, zanjani ha. herbs in dentistry. int dent j 2011;61:287 96. https://doi.org/10.1111/j.1875595x.2011.00064.x pmid:22117784 pmcid:pmc9374842 18. shah g, shri r, panchal v, sharma n, singh b, mann as. scientific basis for the therapeutic use of cymbopogon citratus, stapf (lemon grass). j adv pharm technol res 2011;2:3 8. https://doi.org/10.4103/2231-4040.79796 pmid:22171285 pmcid:pmc3217679 19 nishan m, subramanian p. pharmacological and nonpharmacological activity of azadirachta indica (neem)-a review. int j bio sci 2014; 5:10412. 20 ofiri ep, edetanlen eb, igbinosa lo, ofeimun jo. effectiveness and safety of aqueous neem leaf extract versus chlorhexidine mouthwash in post-operative care of dis-impacted third molars: a randomised controlled clinical trial. the nigerian journal of pharmacy, 2025;59(1):118-129 https://doi.org/10.51412/psnnjp.2025.12 21. srinivasa k, jagadeesh k and revankar s, analgesic effect of azadirachta indica(neem) in albino rats. journal of medical and health sciences, 2014;3:93-96. 22. emran tb, phytochemical, antimicrobial, cytotoxic, analgesic and anti-inflammatory properties of azadirachta indica: a therapeutic study. journal of bioanalysis and biomedicine, 2015;12:007. 23. oktavia sn, iforai, fauziah f, anti-inflammatory, analgesic, and antipyretic potential of azadirachta indica: a review. journal drug delivery and therapeutics, 2022;12(3-s):245-254 https://doi.org/10.22270/jddt.v12i3-s.5502 24. rondanelli m, fossari f, vecchio v, gasparri c, peroni g, et al. clinical trials on pain lowering effect of ginger: a narrative review. phytotherapy research. 2020;34(11):2843-2856 https://doi.org/10.1002/ptr.6730 pmid:32436242 pmcid:pmc7754412 25. ozkur m, benlier n, takan i, vasileiou c, georgakilas ag, et al. ginger for healthy ageing: a systematic review on current evidence of its antioxidant, anti‐inflammatory, and anticancer properties. oxidative medicine and cellular longevity. 2022 ;(1):4748447. https://doi.org/10.1155/2022/4748447 pmid:35585878 pmcid:pmc9110206 26. yücel ç, karatoprak gş, açıkara öb, akkol ek, barak th, et al. immunomodulatory and anti-inflammatory therapeutic potential of gingerols and their nano formulations. frontiers in pharmacology. 2022;13:902551. https://doi.org/10.3389/fphar.2022.902551 pmid:36133811 pmcid:pmc9483099 27. martins lb, rodrigues amds, monteze nm, tibaes jrb, amaral mha, et al. double-blind placebo-controlled randomized clinical trial of ginger (zingiber officinale rosc.) in the prophylactic treatment of migraine. cephalalgia. 2020;40(1):88-95. https://doi.org/10.1177/0333102419869319 pmid:31398997 28. kashefi f, khajehei m, tabatabaeichehr m, alavinia m, asili j. comparison of the effect of ginger and zinc sulfate on primary dysmenorrhea: a placebo-controlled randomized trial. pain management nursing. 2014;15(4):826-833. https://doi.org/10.1016/j.pmn.2013.09.001 pmid:24559600 29. rahnama p, montazeri a, huseini hf, kianbakht s, naseri m. effect of zingiber officinale r. rhizomes (ginger) on pain relief in primary dysmenorrhea: a placebo randomized trial. bmc complementary and alternative medicine. 2012;12:1-7.201. https://doi.org/10.1186/1472-6882-12-92 pmid:22781186 pmcid:pmc3518208 30. araya-quintanilla f, gutierrez-espinoza h, munozyanez mj, sanchez-montoya u, lopez-jeldes j. effectiveness of ginger on pain and function in knee osteoarthritis: a prisma systematic review and meta-analysis. pain physician. 2020;23(2):e151. https://doi.org/10.36076/ppj.2020/23/e151 31. maribao af, antilegando b, ylanan bs, moncada pd, tirol s, samillano j, tinapay a, analgesic effect of garlic (allium sativum) as potential herbal remedy for toothache, journal of research administration. 2023;5(2):14031-14040 32. kuang c, hirai a, kamei-νagata c, nango h, ohtani m, omori k, takashiba s. effects of aged garlic extract on experimental periodontitis in mice. biomed rep. 2025;22(6):97. https://doi.org/10.3892/br.2025.1975 pmid:40297801 pmcid:pmc12035598 33. zini a, mann j, mazor s, vered y, beneficial effect of aged garlic extract on periodontitis: a randomized controlled double-blind clinical study. j clin biochem nutr 2020;67(3):297-301 https://doi.org/10.3164/jcbn.20-52 pmid:33293771 pmcid:pmc7705088 34. ushijima m, takashima m, kunimura k, kodera y, morihara n, tamura k, effects of s-1-propenylcysteine, a sulfur compound in aged garlic extract, on blood pressure and peripheral circulation in spontaneously hypertensive rats. j pharm pharmacol 2018;70(4):559-565 https://doi.org/10.1111/jphp.12865 pmid:29380376 35. xiao j, liong ec, ling m-t, ching y-p, fung m-l, tipoe gl, sallylmercaptocysteine reduces carbon tetrachloride-induced hepatic oxidative stress and necroinflammation via nuclear factor kappa b-dependent pathways in mice. eur j nutr 2012;51:323333 https://doi.org/10.1007/s00394-011-0217-0 pmid:21681437 pmcid:pmc3313023 36. ooshima t, osaka y, sasaki h, osawa k, yasuda h, matsumura m, sobue s, matsumoto m. caries inhibitory activity of cacao bean husk extract in in-vitro and animal experiments. arch oral biol. 2000;45:639-645. https://doi.org/10.1016/s00039969(00)00042-x pmid:10869475 37. matsumoto m, tsuji m, okuda j, sasaki h, nakano k, osawa k, shimura s, ooshima t. inhibitory effects of cacao bean husk extract on plaque formation in vitro and in vivo. eur j oral sci. 2004;112:249-252 https://doi.org/10.1111/j.16000722.2004.00134.x pmid:15154923 38. srikanth rk, shashikiran nd, subba reddy vv. chocolate mouth rinse: effect on plaque accumulation and mutans streptococci counts when used by children. j indian soc pedod prev dent. 2008;26:67-70. https://doi.org/10.4103/0970-4388.41619 pmid:18603731 39. venkatesh babu ns, vivek dk, ambika g. comparative evaluation of chlorhexidine mouthrinse versus cacao bean husk extract mouthrinse as antimicrobial agents in children. eur arch paediatr dent. 2011;12:245-249. https://doi.org/10.1007/bf03262816 pmid:21993064 40. al-tannir ma, goodman hs. a review of chlorhexidine and its use in special populations. spec care dentist. 1994;14:116-122. https://doi.org/10.1111/j.1754-4505.1994.tb01116.x pmid:7871472 41. lee kw, kim yj, lee hj, lee cy. cocoa has more phenolic phytochemicals and a higher antioxidant capacity than teas and red wine. j agric food chem. 2003;51:7292-7295 https://doi.org/10.1021/jf0344385 pmid:14640573 42. ramiro-puig e, castell m. 2009. cocoa: antioxidant and immunomodulator. br j nutr. 101:931-940. https://doi.org/10.1017/s0007114508169896 pmid:19126261 43. vyas t, nagi r, bhatia a, bains sk, therapeutic effects of green tea as an antioxidant on oral healtha review, j family med prim https://doi.org/10.22270/ajdhs.v1i1.5 https://doi.org/10.7860/jcdr/2015/14465.6581 https://doi.org/10.1007/s11033-012-2155-1 https://doi.org/10.1111/j.1875-595x.2011.00064.x https://doi.org/10.1111/j.1875-595x.2011.00064.x https://doi.org/10.4103/2231-4040.79796 https://doi.org/10.51412/psnnjp.2025.12 https://doi.org/10.22270/jddt.v12i3-s.5502 https://doi.org/10.1002/ptr.6730 https://doi.org/10.1155/2022/4748447 https://doi.org/10.3389/fphar.2022.902551 https://doi.org/10.1177/0333102419869319 https://doi.org/10.1016/j.pmn.2013.09.001 https://doi.org/10.1186/1472-6882-12-92 https://doi.org/10.36076/ppj.2020/23/e151 https://doi.org/10.3892/br.2025.1975 https://doi.org/10.3164/jcbn.20-52 https://doi.org/10.1111/jphp.12865 https://doi.org/10.1007/s00394-011-0217-0 https://doi.org/10.1016/s0003-9969(00)00042-x https://doi.org/10.1016/s0003-9969(00)00042-x https://doi.org/10.1111/j.1600-0722.2004.00134.x https://doi.org/10.1111/j.1600-0722.2004.00134.x https://doi.org/10.4103/0970-4388.41619 https://doi.org/10.1007/bf03262816 https://doi.org/10.1111/j.1754-4505.1994.tb01116.x https://doi.org/10.1021/jf0344385 https://doi.org/10.1017/s0007114508169896 prajapati et al. asian journal of dental and health sciences. 2025; 5(4):1-6 [6] ajdhs.com care, 2021;10(11):3998-4001 https://doi.org/10.4103/jfmpc.jfmpc_943_21 pmid:35136758 pmcid:pmc8797077 44. sumpio be, cordova ac, berke-schlessel dw, qin f, chen qh. green tea, the "asian paradox", and cardiovascular disease. j am coll surg. 2006;202:813-20. https://doi.org/10.1016/j.jamcollsurg.2006.01.018 pmid:16648021 45. mukhtar h, ahmad n. tea polyphenols: prevention of cancer and optimizing health. am j clin nutr. 2000;71(6 suppl):1698s-702s. https://doi.org/10.1093/ajcn/71.6.1698s pmid:10837321 46. shahakbari, r. et al. effectiveness of green tea mouthwash in comparison to chlorhexidine mouthwash in patients with acute pericoronitis: a randomized clinical trial. int. j. oral maxillofac. surg. 2014;43(11):1394-1398. https://doi.org/10.1016/j.ijom.2014.05.017 pmid:24954134 47. vaidya ad, devasagayam tp. current status of herbal drugs in india: an overview. j clin biochem nutr 2007;41:1-11. https://doi.org/10.3164/jcbn.2007001 pmid:18392106 pmcid:pmc2274994 48. sahoo n, manchikanti p. herbal drug regulation and commercialization: an indian industry perspective. j altern complement med 2013;19:957-63. https://doi.org/10.1089/acm.2012.0275 pmid:23829812 pmcid:pmc3868382 49. sarrami n, pemberton mn, thornhill mh, theaker ed. adverse reactions associated with the use of eugenol in dentistry. br dent j 2002;193:257-9. https://doi.org/10.1038/sj.bdj.4801539 pmid:12353045 50. hensten-pettersen a, jacobsen n. perceived side effects of biomaterials in prosthetic dentistry. j prosthet dent 1991;65:13844. https://doi.org/10.1016/0022-3913(91)90066-6 pmid:1827841 51. alawi k, keeble j. the paradoxical role of the transient receptor potential vanilloid 1 receptor in inflammation. pharmacol ther 2010;125:181-95. https://doi.org/10.1016/j.pharmthera.2009.10.005 pmid:19896501 52. maurya sd, jain d, porwal o, dhakar rc, jayakumararaj r. a review on role of herbal antioxidants in periodontitis. asian journal of dental and health sciences, 2021;1(1):14–18. https://doi.org/10.22270/ajdhs.v1i1.1 https://doi.org/10.4103/jfmpc.jfmpc_943_21 https://doi.org/10.1016/j.jamcollsurg.2006.01.018 https://doi.org/10.1093/ajcn/71.6.1698s https://doi.org/10.1016/j.ijom.2014.05.017 https://doi.org/10.3164/jcbn.2007001 https://doi.org/10.1089/acm.2012.0275 https://doi.org/10.1038/sj.bdj.4801539 https://doi.org/10.1016/0022-3913(91)90066-6 https://doi.org/10.1016/j.pharmthera.2009.10.005 https://doi.org/10.22270/ajdhs.v1i1.1 haryani et al. asian journal of dental and health sciences. 2025; 5(3):19-22 [19] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited the relationship between dental caries and malocclusion and the quality of life of preschool children wiworo haryani 1*, quroti a’yun 2, etty yuniarly 3 1,2,3 department of dental health, health polytechnic of yogyakarta, yogyakarta, indonesia article info: _____________________________________________ article history: received 06 june 2025 reviewed 20 july 2025 accepted 17 august 2025 published 15 sep 2025 _____________________________________________ cite this article as: haryani w, a’yun q, yuniarly e, the relationship between dental caries and malocclusion and the quality of life of preschool children, asian journal of dental and health sciences. 2025; 5(3):19-22 doi: http://dx.doi.org/10.22270/ajdhs.v5i3.137 abstract _________________________________________________________________________________________________________________ background: preschool children are one of the groups at high risk of having health problems. based on data from the indonesian health survey (ski) in 2023, the prevalence of caries in the 3-4 years age group was 78.3%, while in the 5-9 years age group it was 85.8%. dental health problems such as caries and malocclusion will disrupt the function and activity of the oral cavity so that it will affect nutritional status and will have an impact on the quality of life of preschool children. objective: to determine the relationship between dental caries and malocclusion with the quality of life in preschool children method: this type of observational analytical study with a cross-sectional design. the sampling technique was carried out by purposive sampling and obtained a total of 50 respondents. univariate data analysis with descriptive analysis, bivariate analysis using chi-square correlation. results: there is a relationship between dental caries and the quality of life of preschool children (p = 0.030). there is a relationship between malocclusion and the quality of life of children (p = 0.005). conclusion: there is a relationship between dental caries and malocclusion with the quality of life of preschool children. keywords: dental caries, malocclusion, ecohis, quality of life of preschool children *address for correspondence: wiworo haryani, department of dental health, health polytechnic of yogyakarta, yogyakarta, indonesia. introduction preschool children are a high-risk group for health problems. data from the 2023 indonesian health survey showed that the prevalence of caries in the 3-4 years age group was 78.3%, while in the 5-9 years age group it was 85.8%.1 it is important to pay attention to the dental and oral health of preschool children, because they are at the stage of child development and are the golden age or golden period in the period of child growth and development.2 in the early stages, children require more attention from their families. optimal growth and development depends on providing nutrition of the quality and quantity appropriate to their needs.3 children's dental and oral health is an important right, besides being the first gateway into the digestive system, at the age of 4-6 years all primary teeth have erupted and are entering the mixed dentition period.4 at preschool age, children are susceptible to caries due to the influence of food or drink residue. preschool age children still need help from others in cleaning their oral cavity.5 dental caries can disrupt general health, resulting in disrupted growth and development of children, which will result in a decrease in the child's quality of life.6 malocclusion is the third most common oral health problem in indonesia, after caries. malocclusion disrupts oral function and activity, affecting nutritional status and quality of life.7 during childhood, these conditions can impact a child's growth and development and well-being. children with poor oral health are 12 times more likely to suffer from impaired activity, including missing school, compared to those with good oral health. good oral health can help children achieve a better quality of life.8 quality of life (qol) measurements are very useful for identifying the various impacts of disease in children. these measurements can also be used to compare the effectiveness of dental care, evaluate dental health services, and assess oral health needs. oral health is related to quality of life (ohrqol).9 in preschool children and can be measured using the early childhood oral health impact scale (ecohis) instrument. ecohis was developed in the usa by hernandez et al. to assess the negative impact of dental and oral health that affects the quality of life of preschool children. 10 the ecohis instrument is completed by parents, specifically mothers. this instrument can assess the extent to which dental and oral health is linked to the quality of life of preschool-aged children.11 at preschool age, children do not yet understand basic health concepts and tend to overreact.12 parents have a big role in caring for children, especially mothers who understand their children's needs better.10 a mother has a closer and greater role in maintaining her child's health, especially open access research article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i3.137 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i3.137&amp;domain=pdf haryani et al. asian journal of dental and health sciences. 2025; 5(3):19-22 [20] ajdhs.com regarding dental and oral health.13 this instrument has scales for children (children index scale) and families (family index scale) designed to assess the impact of children's dental and oral health on daily activities. cognitive development in preschool children is still very limited, therefore the ecohis instrument is suitable for assessing quality of life in preschool children.14 method and material this type of research is observational analytic with a cross-sectional design. the research location is aksa tamami godean kindergarten school, sleman, yogyakarta. the sampling technique was carried out using purposive sampling. the inclusion criteria for research subjects are as follows: 1) preschool children aged 4-6 years, 2) children in good physical and mental health, 3) willing to participate in the study with the mother signing an informed consent. the exclusion criteria are as follows: 1) children are sick, 2) children are not present when the study is conducted. the results of data collection at the location obtained a total of 50 respondents. univariate data analysis with descriptive analysis, bivariate analysis using chi-square correlation. result and discussion table 1: frequency distribution based on respondent characteristics variable n % age 4 years 31 62.0 5 years 14 28.0 6 years 5 10.0 gender man 22 44.0 women 28 56.0 mother's education junior high school 2 4.0 senior high school 13 26.0 college 35 70.0 parents' job government employees 10 70 private 31 62.0 etc 1 2.0 doesn't work 8 16.0 table 1 shows that of the 50 preschool children, 31 (62.0%) were 4 years old. most of the children were girls, 28 (56.0%). the highest maternal education level was college, with 35 (70.0%), and the highest parental occupation was private, with 31 (62.0%). ecohis assessments impacted the quality of life of children aged 4-5 years. children with higher dmf-t scores had significantly lower quality of life.15 table 2: frequency distribution of respondents for caries, malocclusion, and quality of life variable n % caries yes 8 16.0 no 42 84.0 malocclusion yes 20 40.0 no 30 60.0 quality of life low (score ecohis>21) 14 28.0 good (score ecohis 13-21) 36 72.0 table 2 shows that 8 preschool children (16.0%) experienced caries, and 20 children (40.0%) had malocclusion. most preschool children (36 children) had a good quality of life. based on the results of the basic health research (riskesdas), the indonesian population has dental and oral problems and the incidence of dental caries increased from 2013 to 2018, with the prevalence of dental caries at the age of 3 years (60%), 4 years (85%), and 5 years (86.4%).16 a study of preschool children in jordan showed a significant association between caries and quality of life in children aged 4-5 years. caries scores had a significant effect on the early childhood oral health impact scale (ecohis), while other confounding factors showed no impact.17 the mean ecohis score increased with increasing dmft index in children aged 3-6 years, indicating a significant relationship between the dmft index and ecohis score. these results can be used as an appropriate resource for developing preventive policies and improving dental and oral health in early childhood.18 malocclusion has an impact on the function of chewing, speech, oral health and a person's psychology.19 impaired chewing function due to limited food intake can impact quality of life. people with malocclusion are also susceptible to tooth decay because they have difficulty reaching all parts of their teeth, which can lead to poor tooth cleaning.19,20 a person with an anterior open bite or large overjet will experience impaired chewing due to difficulty biting into food. this impaired chewing function due to limitations in food consumption will impact their quality of life. the impact of malocclusion significantly impacts chewing function, speech, oral health, and psychological well-being.5 haryani et al. asian journal of dental and health sciences. 2025; 5(3):19-22 [21] ajdhs.com table 3: results of analysis of motivation and oral health behavior with quality of life in adolescents quality of life low (>23) good (13-21) p or n % n % caries yes 5 62.5 3 37.5 0.030* 6.11 no 9 21.4 33 78.6 malocclusion yes 10 50 10 50 0.050* 6.50 no 4 13.3 26 86.7 the results of table 3 show that preschool children with dental caries experienced a low quality of life category of 5 children (62.5%) more than those without dental caries 9 children (21.4%) with a significant difference of p = 0.030 and an or value of 6.11 meaning that children with a low quality of life were found in children who had dental caries 6.11 times higher. the results of this study are in accordance with the opinion of silva et al. (2023) that economic status, caries experience and oral hygiene have a significant effect on the quality of life of preschool children.21 untreated caries and the socio-economic status of parents have a significant relationship with the quality of life of children aged 3-5 years.22 children with malocclusion experienced a low quality of life category, there were 10 children (50.0%) more than children without malocclusion, namely 4 children (13.3%) with a significant difference of p = 0.005 and an or value of 6.50, meaning that children with a low quality of life were found in children with malocclusion 6.50 times higher. dental caries and malocclusion have an impact on children's quality of life.23 there is a significant relationship between children's quality of life and the need for orthodontic treatment.4 specific oral health conditions have a significant impact on the quality of life of children and adolescents.24 conclusion based on the research results, it can be concluded that there is a significant relationship between dental caries (p=0.030) and malocclusion (p=0.005) and quality of life. this indicates a relationship between dental caries and malocclusion and the quality of life of preschool children. the higher the prevalence of caries and malocclusion, the lower the quality of life of preschool children. acknowledgements: the authors thank to all participants and research assistants. conflict of interest: the authors declare that they have no conflicts of interest. ethical clearance: this research has received a certificate of appropriate research ethics from the yogyakarta health research ethics commission no.dp.04.03/e-kepk.1/592/2025 dated 24 april 2025. references 1. kementerian kesehatan republik indonesia. ski 2023 dalam angka.; 2023. 2. de stefani a, bg, ig, bm, cg, ga. oral healthrelated quality of life in children using the child perception questionnaire cpq11-14: a review. european archives of paediatric dentistry. 2019;20(5):425-430. https://doi.org/10.1007/s40368-01900418-8 pmid:30762210 3. prasertsom p, ki, & ks. condition-specific oral health impacts in thai children and adolescents: findings from the national oral health-related quality of life survey. asia pac j public health. 2020;32(1):49-56. https://doi.org/10.1177/1010539519899774 pmid:31955590 4. gatto rcj, gají, cje, gcas. the relationship between oral healthrelated quality of life, the need for orthodontic treatment and bullying, among brazilian teenagers. dental press j orthod. 2019;24(2):73-80. https://doi.org/10.1590/2177-6709.24.2.073080.oar pmid:31116290 pmcid:pmc6526768 5. sobouti f, am, asar, mm, ds. quality of life based on oral health impact profile among adolescents undergoing fixed orthodontic appliances. international journal of pediatrics-mashhad. 2020;8(12):12651-12657. 6. haryani w, sulistiawati d, yuniarly e. motivation and dental health self-care behavior with adolescent quality of life using ohip-14. asian journal of dental and health sciences. 2023;3(3):1-4. https://doi.org/10.22270/ajdhs.v3i3.45 7. utami u, andani m, praptiwi yh, laut dm. caries status measured with the icdas ii on quality of life in children. jdht journal of dental hygiene and therapy. 2024;5(2):97-102. https://doi.org/10.36082/jdht.v5i2.1665 8. butchon r, liabsuetrakul t. the development and growth of children aged under 5 years in northeastern thailand: a crosssectional study. journal of child and adolescent behaviour. 2017;05(01). https://doi.org/10.4172/2375-4494.1000334 9. zuhriza ra, wdr, sth, & pyb. hubungan motivasi perawatan gigi terhadap kualitas hidup terkait kesehatan gigi (oral health related quality of life ohrqol) mahasiswa fakultas kedokteran universitas diponegoro. e-gigi. 2021;9(2):145. https://doi.org/10.35790/eg.9.2.2021.33890 10. nasia aa, rosyidah an, ibrahim n. relationship between parental health behaviour and oral health related quality of life among preschoolers. e-gigi. 2022;10(1):135. https://doi.org/10.35790/eg.v10i1.39126 11. elfarisi rn, susilawati s, suwargiani aa. oral health related to the quality of life of children aged 4 5-years-old in cilayung village. jurnal kedokteran gigi universitas padjadjaran. 2018;30(2):8594. https://doi.org/10.24198/jkg.v30i3.18509 12. nabillah rulifa s, asia a. kualitas hidup terkait kesehatan gigi dan mulut pada anak prasekolah di batam. jurnal kedokteran gigi terpadu. 2023;5(2). https://doi.org/10.25105/jkgt.v5i2.18842 13. permatasari rf, sf, bia. association between early childhood caries and oral health-related quality of life using ecohis instrument. journal of international dental and medical research. 2019;12(3):1017-1021. 14. nurwati b. hubungan karies gigi dengan kualitas hidup pada anak sekolah usia 5-7 tahun. jurnal skala kesehatan. 2019;10(1):41-47. https://doi.org/10.31964/jsk.v10i1.164 https://doi.org/10.1007/s40368-019-00418-8 https://doi.org/10.1007/s40368-019-00418-8 https://doi.org/10.1177/1010539519899774 https://doi.org/10.1590/2177-6709.24.2.073-080.oar https://doi.org/10.1590/2177-6709.24.2.073-080.oar https://doi.org/10.22270/ajdhs.v3i3.45 https://doi.org/10.36082/jdht.v5i2.1665 https://doi.org/10.4172/2375-4494.1000334 https://doi.org/10.35790/eg.9.2.2021.33890 https://doi.org/10.35790/eg.v10i1.39126 https://doi.org/10.24198/jkg.v30i3.18509 https://doi.org/10.25105/jkgt.v5i2.18842 https://doi.org/10.31964/jsk.v10i1.164 haryani et al. asian journal of dental and health sciences. 2025; 5(3):19-22 [22] ajdhs.com 15. duangthip d, gss, ckj, lecm and cch. oral health-related quality of life and caries experience of hong kong preschool children. int dent j. 2020;70:100-107. https://doi.org/10.1111/idj.12526 pmid:31642058 pmcid:pmc9379145 16. kementerian kesehatan ri. hasil riset kesehatan dasar tahun 2018. vol 53.; 2018. 17. rajab ld ar. impact of dental caries on the quality of life of preschool children and families in amman, jordan. oral health prev dent. 2020;18(4):571-582. 18. pakkhesal m renaaapbn. impact of dental caries on oral health related quality of life among preschool children: perceptions of parents. bmc oral health. 2021;21(1):68. https://doi.org/10.1186/s12903-021-01396-4 pmid:33588827 pmcid:pmc7885600 19. mitchell l. an introduction to orthodontics. 4th ed. oxford university press; 2019. 20. littlewood sj& ml. an introduction to orthodontics. 5th ed. oxford university press; 2019. 21. silva bns, campos la, marôco j, campos jadb. the early childhood oral health impact scale (ecohis): psychometric properties and application on preschoolers. peerj. 2023;11. https://doi.org/10.7717/peerj.16035 pmid:37842063 pmcid:pmc10569180 22. randrianarivony j, ravelomanantsoa jj, razanamihaja n. evaluation of the reliability and validity of the early childhood oral health impact scale (ecohis) questionnaire translated into malagasy. health qual life outcomes. 2020;18(1):1-11. https://doi.org/10.1186/s12955-020-01296-1 pmid:32093708 pmcid:pmc7038613 23. kavaliauskienė a, šidlauskas a, žemaitienė m, slabšinskienė e, zaborskis a. relationships of dental caries and malocclusion with oral health-related quality of life in lithuanian adolescents aged 15 to 18 years: a cross-sectional study. int j environ res public health. 2020;17(11):1-15. https://doi.org/10.3390/ijerph17114072 pmid:32521600 pmcid:pmc7311969 24. james a, janakiram c, meghana r v., kumar vs, sagarkar ar, y yb. impact of oral conditions on oral health-related quality of life among indiansa systematic review and meta-analysis. health qual life outcomes. 2023;21(1). https://doi.org/10.1186/s12955-023-02170-6 pmid:37653527 pmcid:pmc10470255 https://doi.org/10.1111/idj.12526 https://doi.org/10.1186/s12903-021-01396-4 https://doi.org/10.7717/peerj.16035 https://doi.org/10.1186/s12955-020-01296-1 https://doi.org/10.3390/ijerph17114072 https://doi.org/10.1186/s12955-023-02170-6 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [14] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited innate immune memory in hiv-positive sickle cell disease patients emmanuel ifeanyi obeagu 1* and priya homa chukwu 2 1 department of biomedical and laboratory science, africa university, zimbabwe 2 department of haematology and blood transfusion science, faculty of medical laboratory science, rivers state university of science and technology, port harcourt, rivers state, nigeria article info: _____________________________________________ article history: received 06 jan 2025 reviewed 05 feb 2025 accepted 01 march 2025 published 15 june 2025 _____________________________________________ cite this article as: obeagu ei, chukwu ph, innate immune memory in hiv-positive sickle cell disease patients, asian journal of dental and health sciences. 2025; 5(2):14-19 doi: http://dx.doi.org/10.22270/ajdhs.v5i2.126 abstract _________________________________________________________________________________________________________________ innate immune memory represents a crucial aspect of the immune response, particularly in individuals with chronic infections and genetic disorders such as hiv and sickle cell disease (scd). this review explores the complex interplay between innate immune memory and the health outcomes of hiv-positive patients with scd. the presence of both conditions leads to unique immune dysregulation characterized by heightened inflammation, altered innate immune cell functionality, and increased susceptibility to infections. the pathophysiology of innate immune memory in hiv-positive scd patients is multifaceted, influenced by chronic inflammation, microbial translocation, and immune cell exhaustion. these factors can exacerbate the clinical manifestations of both diseases, resulting in recurrent infections, vaso-occlusive crises, and other complications. as innate immune cells acquire memory-like properties in response to persistent inflammatory stimuli, their functionality may be altered, impacting the overall immune response and treatment efficacy. recognizing these implications is vital for developing targeted therapeutic strategies aimed at enhancing immune competence in this population. keywords: innate immune memory, hiv, sickle cell disease, immune response, inflammation *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction sickle cell disease (scd) and human immunodeficiency virus (hiv) infection are two significant health challenges that disproportionately affect individuals, particularly in sub-saharan africa and other resourcelimited settings. scd, a genetic disorder characterized by the production of abnormal hemoglobin s, leads to a range of complications, including painful vaso-occlusive crises, acute chest syndrome, and an increased risk of infections. simultaneously, hiv infection results in progressive immune dysfunction, primarily through the depletion of cd4+ t cells, leading to a state of chronic immunosuppression. the coexistence of these two conditions presents unique clinical challenges, as the interactions between scd and hiv can exacerbate disease complications and impact patient management.1-2 innate immune memory is an emerging concept that describes the enhanced responsiveness of innate immune cells following prior exposure to pathogens. unlike adaptive immunity, which relies on the activation of lymphocytes and the formation of memory cells, innate immune memory is characterized by the ability of innate immune cells, such as monocytes, macrophages, and natural killer (nk) cells, to "remember" previous encounters with pathogens. this phenomenon has been observed in various contexts, including viral infections and chronic inflammatory diseases, and its relevance in the context of hiv and scd remains a critical area of investigation. understanding how innate immune memory functions in hiv-positive scd patients may provide insights into their immune responses and susceptibility to infections.3-5 the impact of chronic inflammation on immune regulation in patients with scd is well documented. recurrent vasoocclusive crises and tissue ischemia-reperfusion injury contribute to a pro-inflammatory state characterized by elevated levels of cytokines, chemokines, and other inflammatory mediators. this persistent inflammation not only affects the bone marrow and hematopoiesis but also alters the functionality of innate immune cells. in hiv-infected individuals, the inflammatory milieu may further disrupt immune homeostasis, leading to alterations in innate immune memory and responses. the interplay between these two conditions necessitates a deeper understanding of their combined effects on innate immune function.6-7 emerging evidence suggests that innate immune memory may play a role in shaping the clinical outcomes of hiv-positive scd patients. the altered functionality of innate immune cells, coupled with the chronic inflammatory state, may influence susceptibility to opportunistic infections and the severity of scd open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i2.126 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i2.126&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 https://orcid.org/0000-0002-1538-2924 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [15] ajdhs.com related complications. additionally, the presence of hiv may exacerbate the immune dysregulation associated with scd, leading to a cycle of inflammation and immune dysfunction. investigating the prevalence and mechanisms of innate immune memory in this population could uncover potential therapeutic targets and improve clinical management strategies.8-9 furthermore, the role of microbial translocation in hivpositive individuals may contribute to the development of innate immune memory. gut barrier dysfunction, common in hiv infection, allows the translocation of microbial products into the bloodstream, triggering systemic inflammation and innate immune activation. this process can perpetuate immune activation and alter the characteristics of innate immune cells, potentially influencing their memory-like properties. 1011 current management approaches for hiv-positive patients with scd must address the complexities associated with both conditions. tailoring treatment strategies to account for the altered immune responses and increased risk of infections is essential for optimizing patient outcomes. the integration of immunomodulatory therapies, lifestyle modifications, and preventive measures can enhance immune competence and reduce complications in this population. however, a thorough understanding of the mechanisms underpinning innate immune memory is necessary to inform the development of such strategies.12-13 prevalence of innate immune memory in hivpositive sickle cell disease patients the prevalence of innate immune memory in hivpositive sickle cell disease (scd) patients is an area of emerging research that highlights the complex immunological interactions between these two conditions. while specific studies directly addressing the prevalence of innate immune memory in this unique population are limited, available data on individual conditions provide important insights. sickle cell disease is characterized by chronic inflammation and repeated vaso-occlusive crises, which can significantly affect innate immune cell function. concurrently, hiv infection leads to a state of immune dysregulation marked by persistent inflammation, immune activation, and alterations in the population and functionality of innate immune cells.14-16 research has shown that hiv infection induces changes in innate immune cells, including monocytes and macrophages, which can exhibit memory-like responses following exposure to inflammatory stimuli or pathogens. these changes may manifest as enhanced cytokine production and altered surface marker expression, suggesting a degree of innate immune memory. in the context of scd, the chronic inflammatory state may further amplify these responses, leading to an increased prevalence of innate immune memory features among hiv-positive scd patients. for instance, elevated levels of proinflammatory cytokines such as interleukin-6 (il-6) and tumor necrosis factor-alpha (tnf-α) in scd patients may prime innate immune cells, enhancing their responsiveness to subsequent inflammatory challenges.17-19 studies investigating the effects of scd on immune function have demonstrated that patients with scd often experience increased immune activation and altered innate immune cell profiles. this may contribute to a heightened state of innate immune memory, as seen in patients with chronic infections. however, the direct impact of hiv on the prevalence of innate immune memory in scd patients remains less clear, requiring further exploration. research focusing on the interactions between scd and hiv, particularly in terms of immune responses, is essential to determine the prevalence and significance of innate immune memory in this dual population.20-21 moreover, the prevalence of innate immune memory in hiv-positive scd patients can also be influenced by various factors, including disease severity, treatment regimens, and the presence of comorbid conditions. for example, antiretroviral therapy (art) has been shown to reduce systemic inflammation and restore some aspects of immune function in hiv-infected individuals, potentially impacting the development of innate immune memory. understanding how these variables affect innate immune responses in the context of hiv and scd is crucial for improving management strategies and patient outcomes.22-23 pathophysiology of innate immune memory in hiv-positive sickle cell disease patients the pathophysiology of innate immune memory in hivpositive sickle cell disease (scd) patients is a complex interplay of genetic, immunological, and environmental factors that contribute to altered immune responses. innate immune memory is characterized by the enhanced responsiveness of innate immune cells, such as monocytes, macrophages, and natural killer (nk) cells, following exposure to pathogens or inflammatory stimuli. in the context of hiv infection and scd, this phenomenon is exacerbated by chronic inflammation, immune dysregulation, and the unique clinical manifestations of both conditions.24-25 sickle cell disease is associated with a state of chronic inflammation resulting from recurrent vaso-occlusive crises, tissue damage, and hemolysis. the release of proinflammatory mediators, such as cytokines and chemokines, perpetuates an inflammatory environment that can significantly affect the functionality of innate immune cells. for instance, elevated levels of interleukin-1 (il-1), interleukin-6 (il-6), and tumor necrosis factor-alpha (tnf-α) are commonly observed in scd patients, leading to the activation of immune pathways and the priming of innate immune cells. this persistent inflammatory state can promote the development of innate immune memory features, resulting in an exaggerated response to subsequent infections or inflammatory triggers.26-27 in individuals living with hiv, the virus leads to chronic immune activation and the depletion of cd4+ t cells, which can further disrupt immune homeostasis. the depletion of t cells reduces the regulatory capacity of the immune system, resulting in increased activation of innate immune cells. this dysregulation can lead to changes in the expression of surface markers, cytokine emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [16] ajdhs.com production, and overall functionality of innate immune cells. for example, monocytes and macrophages from hiv-infected individuals often exhibit an increased production of inflammatory cytokines and altered phagocytic activity. these changes can enhance the memory-like characteristics of innate immune cells, potentially increasing susceptibility to opportunistic infections and other complications.28-29 the interaction between hiv and scd complicates the pathophysiology of innate immune memory. the presence of both conditions can create a vicious cycle of inflammation and immune activation, further altering the functionality of innate immune cells. for instance, hiv infection may exacerbate the inflammatory responses observed in scd, while the chronic inflammatory state of scd can enhance the immune dysregulation caused by hiv. this interplay may lead to a unique profile of innate immune memory that differs from individuals with either condition alone.30 additionally, microbial translocation is a critical factor in the pathophysiology of innate immune memory in hiv-positive scd patients. hiv infection often leads to gut barrier dysfunction, allowing microbial products to enter the bloodstream and trigger systemic inflammation. this process can activate innate immune cells, promoting the development of memory-like characteristics and exacerbating immune activation. the combination of chronic inflammation from scd and microbial translocation in hiv-infected individuals highlights the complexity of the immune landscape in this population.31-32 the consequences of altered innate immune memory in hiv-positive scd patients can significantly impact clinical outcomes. enhanced innate immune responses may contribute to increased susceptibility to infections, recurrent crises, and other complications associated with both conditions. 33 clinical manifestations and implications the clinical manifestations of innate immune memory in hiv-positive sickle cell disease (scd) patients are multifaceted and can significantly impact disease outcomes, patient management, and overall quality of life. the interaction between chronic inflammation, immune dysregulation, and the unique characteristics of both hiv and scd can lead to several complications that require careful monitoring and intervention.34 one of the most prominent clinical manifestations in hivpositive scd patients is an increased susceptibility to infections. the altered innate immune responses associated with innate immune memory can lead to an enhanced inflammatory response, which, while initially protective, may ultimately prove detrimental. this hyper-inflammatory state can result in complications such as recurrent bacterial infections, opportunistic infections, and other infectious diseases that are more common in immunocompromised individuals. for example, patients may experience frequent episodes of pneumonia, urinary tract infections, and skin infections, necessitating aggressive antibiotic therapy and increased healthcare utilization.35-36 another significant clinical manifestation is the exacerbation of scd-related complications, including vaso-occlusive crises and acute chest syndrome. the presence of innate immune memory may influence the severity and frequency of these complications. increased inflammatory cytokines can contribute to vasculopathy and endothelial dysfunction, leading to more severe pain crises and complications associated with acute chest syndrome.37 in addition to infection and scd-related complications, the psychological and social implications of living with both hiv and scd can profoundly affect patients' quality of life. chronic health issues and the associated stigma of hiv can lead to significant emotional distress, anxiety, and depression. the interplay between these conditions may exacerbate the psychological burden, as patients may struggle with the implications of their dual diagnoses and the ongoing management of their health. addressing these psychosocial aspects is essential for comprehensive patient care and improving overall wellbeing.38 the impact of innate immune memory on treatment strategies in hiv-positive scd patients is another critical consideration. the complex interplay of immune responses necessitates a tailored approach to therapy, including the use of antiretroviral therapy (art) and other immunomodulatory treatments. while art can help restore some aspects of immune function in hiv-infected individuals, its effects on innate immune memory in the context of scd require further investigation. optimizing treatment regimens to consider the unique immunological landscape of this population may enhance therapeutic outcomes and reduce complications.39 furthermore, the presence of innate immune memory may also influence vaccine responses in hiv-positive scd patients. vaccination is an essential component of preventive healthcare for this population, given their increased susceptibility to infections. however, the effectiveness of vaccines may be compromised by the underlying immune dysregulation associated with both hiv and scd.40 management strategies and therapeutic implications managing innate immune memory in hiv-positive sickle cell disease (scd) patients requires a multifaceted approach that addresses the unique challenges posed by the interplay of these two chronic conditions. effective management strategies must focus on reducing the risk of infections, mitigating inflammatory responses, and enhancing overall immune function. a comprehensive treatment plan should include pharmacological interventions, lifestyle modifications, and preventive measures tailored to the individual patient's needs.41 pharmacological management primarily involves the use of antiretroviral therapy (art) for hiv-infected patients. art has been shown to reduce viral load, restore cd4+ t cell counts, and improve immune function. however, its role in modulating innate immune memory in scd patients is not fully understood. future research should investigate the optimal art regimens that not only effectively manage hiv but also positively influence the innate immune response in the context of scd. additionally, incorporating anti-inflammatory agents, such as corticosteroids or non-steroidal anti-inflammatory drugs (nsaids), may help alleviate the chronic inflammation associated with scd and potentially emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [17] ajdhs.com mitigate some of the adverse effects of innate immune memory.42 in addition to pharmacological treatments, vaccination plays a crucial role in preventing infections in this vulnerable population. given the altered immune responses associated with innate immune memory, careful consideration must be given to vaccine selection and administration. standard vaccinations, such as those for influenza, pneumococcus, and hepatitis b, are essential, but the efficacy of these vaccines in hivpositive scd patients may be compromised. ongoing research is necessary to evaluate the immunogenicity of vaccines in this group and to determine optimal vaccination strategies to ensure adequate protection against infectious diseases.43 lifestyle modifications can also significantly impact the management of innate immune memory in hiv-positive scd patients. encouraging a healthy diet, regular physical activity, and proper hydration can help improve overall health and potentially enhance immune function. moreover, patient education on the importance of adherence to art and routine healthcare visits is vital for preventing complications and managing comorbidities. addressing psychosocial factors, such as providing mental health support and counseling, can also contribute to better health outcomes by reducing stress and improving quality of life.44 regular monitoring and surveillance of immune function and overall health are critical components of management strategies for hiv-positive scd patients. healthcare providers should consider implementing routine assessments of immune markers, inflammatory cytokines, and overall disease burden. this approach can help identify patients at higher risk for infections and complications, allowing for timely interventions and adjustments to treatment plans as necessary.45 therapeutic implications of understanding innate immune memory in this population extend beyond managing infections. the recognition that innate immune memory may influence the severity and frequency of vaso-occlusive crises and acute chest syndrome highlights the need for targeted therapies aimed at modulating inflammatory responses. for example, research into the use of monoclonal antibodies or other immunomodulatory agents may provide new avenues for managing inflammation and improving clinical outcomes in hiv-positive scd patients.46 challenges and future directions the management of innate immune memory in hivpositive sickle cell disease (scd) patients presents numerous challenges that hinder optimal patient care and outcomes. one of the primary challenges is the complexity of the interactions between hiv, scd, and the immune system. the dual burden of chronic infection and a genetic disorder results in a unique immunological landscape that is not yet fully understood. this complexity complicates the development of targeted therapeutic strategies and effective management protocols tailored to this population. another significant challenge is the variability in patient responses to treatments. factors such as genetic background, the severity of hiv and scd, and the presence of comorbidities can all influence how patients respond to therapies. the existence of innate immune memory may further contribute to this variability, leading to unpredictable outcomes in terms of infection susceptibility and inflammatory responses. identifying biomarkers that can predict treatment responses and individualize therapeutic approaches will be essential for improving outcomes in hiv-positive scd patients.47 furthermore, the current body of research on innate immune memory in hiv-positive scd patients is limited, leading to a knowledge gap regarding the mechanisms underlying this phenomenon. much of the existing literature has focused on either hiv or scd in isolation, with relatively few studies examining their combined effects on innate immunity. future research must prioritize understanding the interactions between these two conditions, particularly how innate immune memory influences disease progression, treatment responses, and the risk of complications. addressing the psychosocial aspects of living with both hiv and scd is another critical challenge. patients may experience increased stigma, anxiety, and depression, which can adversely affect treatment adherence and overall health outcomes. incorporating mental health support and counseling into standard care for hiv-positive scd patients is vital for improving quality of life and ensuring better management of both conditions.48 in terms of future directions, there is a pressing need for interdisciplinary research that brings together experts in immunology, hematology, infectious diseases, and mental health to develop comprehensive management strategies. collaborative research efforts can lead to a deeper understanding of the pathophysiology of innate immune memory in this unique population and drive innovations in treatment approaches. for instance, studies exploring novel immunomodulatory therapies that target chronic inflammation and restore immune function may hold promise for improving health outcomes in hiv-positive scd patients.47 moreover, advancements in personalized medicine and genomic technologies present exciting opportunities for optimizing treatment strategies. by identifying genetic markers associated with immune responses, researchers can develop tailored therapeutic interventions that address the specific needs of hivpositive scd patients. additionally, the exploration of novel vaccination strategies, including mrna vaccines and adjuvants that enhance immune responses, could provide new avenues for preventing infections in this vulnerable population.48 conclusion innate immune memory in hiv-positive sickle cell disease (scd) patients presents a complex interplay of immunological factors that significantly impacts disease management and patient outcomes. the chronic inflammation associated with both conditions can lead to heightened susceptibility to infections, exacerbation of scd-related complications, and challenges in treatment responses. as healthcare providers navigate the intricacies of managing these patients, it becomes evident that a comprehensive understanding of innate emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [18] ajdhs.com immune memory is essential for optimizing therapeutic strategies. despite the challenges presented by this dual burden, there are promising avenues for future research and intervention. ongoing studies aimed at elucidating the mechanisms underlying innate immune memory in this population will be crucial in identifying targeted therapies and improving treatment outcomes. additionally, a focus on personalized medicine, psychosocial support, and interdisciplinary collaboration will be essential in addressing the unique needs of hiv-positive scd patients. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. owusu ed, visser bj, nagel im, mens pf, grobusch mp. the interaction between sickle cell disease and hiv infection: a systematic review. clinical infectious diseases. 2015; 60(4):612626. https://doi.org/10.1093/cid/ciu832 pmid:25344542 2. boateng la, ngoma am, bates i, schonewille h. red blood cell alloimmunization in transfused patients with sickle cell disease in sub-saharan africa; a systematic review and meta-analysis. transfusion medicine reviews. 2019; 33(3):162-169. https://doi.org/10.1016/j.tmrv.2019.06.003 pmid:31345590 3. ola b, olushola o, ebenso b, berghs m. sickle cell disease and its psychosocial burdens in africa. insickle cell disease in subsaharan africa 2024: 67-80. routledge. https://doi.org/10.4324/9781003467748-7 4. obeagu ei, reducing hospitalization rates: the preventive benefits of blood transfusions in hiv care, international journal of medical sciences and pharma research, 2024;10(3):29-34 https://doi.org/10.22270/ijmspr.v10i3.111 5. ochocinski d, dalal m, black lv, carr s, lew j, sullivan k, kissoon n. life-threatening infectious complications in sickle cell disease: a concise narrative review. frontiers in pediatrics. 2020; 8:38. https://doi.org/10.3389/fped.2020.00038 pmid:32154192 pmcid:pmc7044152 6. obeagu ei, obeagu gu, okwuanaso cb. optimizing immune health in hiv patients through nutrition: a review. elite journal of immunology, 2024; 2(1): 14-33 7. obeagu ei, obeagu gu. platelet distribution width (pdw) as a prognostic marker for anemia severity in hiv patients: a comprehensive review. journal home page: http://www. journalijiar. com.;12(01). 8. obeagu ei, ubosi ni, obeagu gu, akram m. early infant diagnosis: key to breaking the chain of hiv transmission. elite journal of public health, 2024; 2 (1): 52-61 9. obeagu ei, obeagu gu. hematocrit fluctuations in hiv patients coinfected with malaria parasites: a comprehensive review. int. j. curr. res. med. sci. 2024; 10(1):25-36. https://doi.org/10.22270/ijmspr.v10i2.95 10. obeagu ei, obeagu gu. transfusion therapy in hiv: risk mitigation and benefits for improved patient outcomes. asian j dental health sci, 2024; 4(1):32-7. https://doi.org/10.22270/ajdhs.v4i1.62 11. obeagu ei, obeagu gu. advancements in hiv prevention: africa's trailblazing initiatives and breakthroughs. elite journal of public health, 2024; 2 (1): 52-63 12. obeagu ei, obeagu gu. optimizing blood transfusion protocols for breast cancer patients living with hiv: a comprehensive review. elite journal of nursing and health science, 2024; 2(2):1-17 13. obeagu ei, obeagu gu. understanding art and platelet functionality: implications for hiv patients. elite journal of hiv, 2024; 2(2): 60-73 1 14. obeagu ei, obeagu gu. hematologic considerations in breast cancer patients with hiv: insights into blood transfusion strategies. elite journal of health science, 2024; 2(2): 2035 15. obeagu ei, obeagu gu. impact of maternal eosinophils on neonatal immunity in hivexposed infants: a review. elite journal of immunology, 2024; 2(3): 1-18 https://doi.org/10.22270/ajdhs.v4i2.82 16. obeagu ei, obeagu gu, obiezu j, ezeonwumelu c, ogunnaya fu, ngwoke ao, emeka-obi or, ugwu op. hematologic support in hiv patients: blood transfusion strategies and immunological considerations. newport international journal of biological and applied sciences (nijbas) 2023. http://hdl.handle.net/20.500.12493/14626 17. ntsekhe m, baker jv. cardiovascular disease among persons living with hiv: new insights into pathogenesis and clinical manifestations in a global context. circulation. 2023; 147(1):83100. https://doi.org/10.1161/circulationaha.122.057443 pmid:36576956 18. obare lm, temu t, mallal sa, wanjalla cn. inflammation in hiv and its impact on atherosclerotic cardiovascular disease. circulation research. 2024; 134(11):1515-1545 https://doi.org/10.1161/circresaha.124.323891 pmid:38781301 pmcid:pmc11122788 19. hmiel l, zhang s, obare lm, santana ma, wanjalla cn, titanji bk, hileman co, bagchi s. inflammatory and immune mechanisms for atherosclerotic cardiovascular disease in hiv. international journal of molecular sciences. 2024; 25(13):7266. https://doi.org/10.3390/ijms25137266 pmid:39000373 pmcid:pmc11242562 20. obeagu ei, obeagu gu. platelet aberrations in hiv patients: assessing impacts of art. elite journal of haematology, 2024; 2(3): 10-24 21. obeagu ei, obeagu gu. harnessing b cell responses for personalized approaches in hiv management. elite journal of immunology, 2024; 2(2): 15-28 22. belisário ar, blatyta pf, vivanco d, oliveira cd, carneiro-proietti ab, sabino ec, de almeida-neto c, loureiro p, máximo c, de oliveira garcia mateos s, flor-park mv. association of hiv infection with clinical and laboratory characteristics of sickle cell disease. bmc infectious diseases. 2020; 20(1):638. https://doi.org/10.1186/s12879-020-05366-z pmid:32854639 pmcid:pmc7457248 23. obeagu ei, addressing sleep disturbances: blood transfusions and improved sleep patterns in hiv patients, international journal of medical sciences and pharma research, 2024;10(3):43-48 https://doi.org/10.22270/ijmspr.v10i3.113 24. gill af, ahsan mh, lackner aa, veazey rs. hematologic abnormalities associated with simian immunodeficieny virus (siv) infection mimic those in hiv infection. journal of medical primatology. 2012; 41(3):214-224. https://doi.org/10.1111/j.1600-0684.2012.00543.x pmid:22620272 pmcid:pmc3367385 25. nouraie m, nekhai s, gordeuk vr. sickle cell disease is associated with decreased hiv but higher hbv and hcv comorbidities in us hospital discharge records: a cross-sectional study. sexually transmitted infections. 2012; 88(7):528-533. https://doi.org/10.1136/sextrans-2011-050459 pmid:22628662 pmcid:pmc3456988 https://doi.org/10.1093/cid/ciu832 https://doi.org/10.1016/j.tmrv.2019.06.003 https://doi.org/10.4324/9781003467748-7 https://doi.org/10.22270/ijmspr.v10i3.111 https://doi.org/10.3389/fped.2020.00038 https://doi.org/10.22270/ijmspr.v10i2.95 https://doi.org/10.22270/ajdhs.v4i1.62 https://doi.org/10.22270/ajdhs.v4i2.82 http://hdl.handle.net/20.500.12493/14626 https://doi.org/10.1161/circulationaha.122.057443 https://doi.org/10.1161/circresaha.124.323891 https://doi.org/10.3390/ijms25137266 https://doi.org/10.1186/s12879-020-05366-z https://doi.org/10.22270/ijmspr.v10i3.113 https://doi.org/10.1111/j.1600-0684.2012.00543.x https://doi.org/10.1136/sextrans-2011-050459 emmanuel ifeanyi obeagu et al. asian journal of dental and health sciences. 2025; 5(2):14-19 [19] ajdhs.com 26. obeagu ei, obeagu gu. hematological changes following blood transfusion in young children with severe malaria and hiv: a critical review. elite journal of laboratory medicine. 2024; 2(1):33-45. 27. obeagu ei, obeagu gu. the role of l-selectin in tuberculosis and hiv coinfection: implications for disease diagnosis and management. elite journal of public health, 2024; 2 (1): 35-51 28. obeagu ei, obeagu gu. unraveling the role of eosinophil extracellular traps (eets) in hiv-infected pregnant women: a review. elite journal of nursing and health science, 2024; 2(3): 84-99 29. obeagu ei, obeagu gu. unveiling the role of innate immune activation in pediatric hiv: a review. elite journal of immunology, 2024; 2(3): 33-44 30. obeagu ei, obeagu, gu. impact of blood transfusion on viral load dynamics in hivpositive neonates with severe malaria: a review. elite journal of scientific research and review, 2024; 2(1): 42-60 31. obeagu ei, youth-friendly hiv prevention: tailoring interventions for young populations, international journal of medical sciences and pharma research, 2024;10(4):62-67. https://doi.org/10.22270/ijmspr.v10i4.125 32. obeagu ei, faith-based initiatives, hiv awareness, religious communities, health education, stigma reduction, international journal of medical sciences and pharma research, 2024;10(4):7479 https://doi.org/10.22270/ijmspr.v10i4.127 33. obeagu ei, obeagu gu. p-selectin expression in hiv-associated coagulopathy: implications for treatment. elite journal of haematology, 2024; 2(3): 25-41 34. obeagu ei, obeagu gu. p-selectin and immune activation in hiv: clinical implications. elite journal of health science, 2024; 2(2): 16-29 35. obeagu ei, amaeze aa, ogbu isi, obeagu gu. b cell deficiency and implications in hiv pathogenesis: unraveling the complex interplay. elite journal of nursing and health science, 2024; 2(2): 33-46 36. obeagu ei, obeagu, gu. platelet dysfunction in hiv patients: assessing art risks. elite journal of scientific research and review, 2024; 2(1): 1-16 37. kibaru eg, nduati r, wamalwa d, kariuki n. impact of highly active antiretroviral therapy on hematological indices among hiv1 infected children at kenyatta national hospital-kenya: retrospective study. aids research and therapy. 2015; 12:1-8. https://doi.org/10.1186/s12981-015-0069-4 pmid:26279668 pmcid:pmc4537535 38. enawgaw b, alem m, addis z, melku m. determination of hematological and immunological parameters among hiv positive patients taking highly active antiretroviral treatment and treatment naïve in the antiretroviral therapy clinic of gondar university hospital, gondar, northwest ethiopia: a comparative cross-sectional study. bmc hematology. 2014; 14:1-7. https://doi.org/10.1186/2052-1839-14-8 pmid:24666771 pmcid:pmc3994311 39. gudina a, wordofa m, urgessa f. immuno-hematological parameters among adult hiv patients before and after initiation of dolutegravir based antiretroviral therapy, addis ababa, ethiopia. plos one. 2024; 19(10):e0310239. https://doi.org/10.1371/journal.pone.0310239 pmid:39480901 pmcid:pmc11527299 40. geletaw t, tadesse mz, demisse ag. hematologic abnormalities and associated factors among hiv infected children pre-and postantiretroviral treatment, north west ethiopia. journal of blood medicine. 2017:99-105. https://doi.org/10.2147/jbm.s137067 pmid:28831276 pmcid:pmc5552149 41. jegede fe, oyeyi ti, abdulrahman sa, mbah ha, badru t, agbakwuru c, adedokun o. effect of hiv and malaria parasites coinfection on immune-hematological profiles among patients attending anti-retroviral treatment (art) clinic in infectious disease hospital kano, nigeria. plos one. 2017; 12(3):e0174233. https://doi.org/10.1371/journal.pone.0174233 pmid:28346490 pmcid:pmc5367709 42. obeagu ei, obeagu gu. art and platelet dynamics: assessing implications for hiv patient care. elite journal of haematology. 2024; 2(4):68-85. 43. obeagu ei, ayogu ee, obeagu gu. impact on viral load dynamics: understanding the interplay between blood transfusion and antiretroviral therapy in hiv management. elite journal of nursing and health science. 2024;2(2):5-15. 44. ciccacci f, lucaroni f, latagliata r, morciano l, mondlane e, balama m, tembo d, gondwe j, orlando s, palombi l, marazzi mc. hematologic alterations and early mortality in a cohort of hiv positive african patients. plos one. 2020; 15(11):e0242068. https://doi.org/10.1371/journal.pone.0242068 pmid:33170905 pmcid:pmc7654783 45. ashenafi g, tibebu m, tilahun d, tsegaye a. immunohematological outcome among adult hiv patients taking highly active antiretroviral therapy for at least six months in yabelo hospital, borana, ethiopia. journal of blood medicine. 2023:543-554. https://doi.org/10.2147/jbm.s419414 pmid:37881654 pmcid:pmc10595970 46. obeagu ei, goryacheva og. the role of inflammation in hiv and sickle cell disease co-morbidity. lifeline hiv, 2025; 3(1): 1-12 47. obeagu ei, goryacheva og. oxidative stress in hiv and sickle cell disease: a double burden. lifeline hiv, 2025; 3(1): 13-24 48. obeagu ei, goryacheva og. hiv and sickle cell disease: a focus on liver dysfunction. lifeline hiv, 2025; 3(1): 25-40 https://doi.org/10.22270/ijmspr.v10i4.125 https://doi.org/10.22270/ijmspr.v10i4.127 https://doi.org/10.1186/s12981-015-0069-4 https://doi.org/10.1186/2052-1839-14-8 https://doi.org/10.1371/journal.pone.0310239 https://doi.org/10.2147/jbm.s137067 https://doi.org/10.1371/journal.pone.0174233 https://doi.org/10.1371/journal.pone.0242068 https://doi.org/10.2147/jbm.s419414 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [6] ajdhs.com available online at ajdhs.com asian journal of dental and health sciences open access to dental and medical research copyright © 2025 the author(s): this is an open-access article distributed under the terms of the cc by-nc 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited nitric oxide bioavailability and vascular dysfunction in sickle cell patients: a pathophysiological nexus * emmanuel ifeanyi obeagu department of biomedical and laboratory science, africa university, zimbabwe. article info: _____________________________________________ article history: received 09 may 2025 reviewed 29 may 2025 accepted 18 june 2025 published 15 sep 2025 _____________________________________________ cite this article as: obeagu ei, nitric oxide bioavailability and vascular dysfunction in sickle cell patients: a pathophysiological nexus, asian journal of dental and health sciences. 2025; 5(3):6-12 doi: http://dx.doi.org/10.22270/ajdhs.v5i3.134 abstract _________________________________________________________________________________________________________________ sickle cell disease (scd) is a genetic disorder characterized by chronic hemolytic anemia, recurrent vaso-occlusive crises, and progressive organ damage. one of the central mechanisms driving vascular complications in scd is the impaired bioavailability of nitric oxide (no), a key molecule responsible for regulating vascular tone, inhibiting platelet aggregation, and maintaining endothelial integrity. the persistent intravascular hemolysis that occurs in scd releases free hemoglobin and arginase into the circulation, which significantly reduces no levels and limits its physiological effects. reduced no availability leads to endothelial dysfunction, characterized by vasoconstriction, increased leukocyte adhesion, and a pro-thrombotic state. these vascular changes not only contribute to acute events such as pain crises and acute chest syndrome but also underlie long-term complications including pulmonary hypertension, stroke, and chronic organ damage. oxidative stress and inflammation further disrupt no synthesis by impairing endothelial nitric oxide synthase (enos) activity and uncoupling its function, creating a vicious cycle of vascular injury. keywords: nitric oxide, sickle cell disease, vascular dysfunction, hemolysis, endothelial health *address for correspondence: emmanuel ifeanyi obeagu, department of biomedical and laboratory science, africa university, zimbabwe introduction sickle cell disease (scd) is a hereditary blood disorder characterized by the production of abnormal hemoglobin, known as hemoglobin s (hbs). under low oxygen conditions, hbs polymerizes, causing red blood cells (rbcs) to adopt a sickled shape, which results in vascular occlusion and hemolysis. these sickled cells contribute to chronic hemolytic anemia, recurrent vasoocclusive episodes, and progressive organ damage. vascular dysfunction is a hallmark feature of scd, playing a central role in the development of both acute and chronic complications. among the key molecular players in vascular homeostasis is nitric oxide (no), a potent vasodilator and anti-inflammatory agent produced by endothelial cells. however, in scd, the bioavailability of no is significantly reduced, contributing to the pathogenesis of vascular complications and poor clinical outcomes 1-2. no is synthesized in endothelial cells by endothelial nitric oxide synthase (enos) using l-arginine as a substrate. once produced, no diffuses into smooth muscle cells, where it activates soluble guanylate cyclase (sgc), leading to the production of cyclic guanosine monophosphate (cgmp). this process induces vasodilation and maintains vascular tone. furthermore, no has anti-thrombotic and anti-inflammatory properties, preventing the adhesion of platelets and leukocytes to the endothelium. in healthy individuals, no maintains vascular homeostasis by regulating blood flow, reducing blood clotting, and preventing endothelial dysfunction. however, in scd, no’s crucial role is impaired by multiple pathophysiological factors, leading to significant consequences for vascular health 34. one of the primary contributors to no depletion in scd is the chronic hemolysis of sickled red blood cells. the release of free hemoglobin from lysed rbcs into the bloodstream leads to an increase in cell-free hemoglobin levels, which can bind to and scavenge no. this results in the rapid inactivation of no, thereby reducing its bioavailability and function. furthermore, the presence of free hemoglobin promotes oxidative stress, which further damages the endothelium and reduces the activity of enos, the enzyme responsible for no production. as a result, the normal vasodilatory effect of no is diminished, contributing to a state of endothelial dysfunction that predisposes individuals with scd to vaso-occlusive crises and other cardiovascular complications 5. in addition to the scavenging effects of free hemoglobin, the activity of the enzyme arginase is significantly elevated in scd. arginase competes with endothelial nitric oxide synthase (enos) for the substrate l-arginine, a key precursor in the production of no. increased arginase activity reduces the availability of l-arginine for no synthesis, further exacerbating the deficit of no in the open access review article http://jddtonline.info/ http://dx.doi.org/10.22270/ajdhs.v5i3.134 https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i3.134&amp;domain=pdf https://orcid.org/0000-0002-4538-0161 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [7] ajdhs.com vascular system. this competition between arginase and enos for l-arginine is a critical factor in the pathophysiology of vascular dysfunction in scd, highlighting the importance of understanding how this enzyme dysregulation contributes to the disease process 6-7. the consequences of reduced no bioavailability in scd are far-reaching, extending beyond the immediate effects of vasoconstriction and platelet aggregation. chronic no depletion in scd promotes endothelial activation, characterized by the upregulation of adhesion molecules such as vcam-1 and icam-1. these molecules facilitate the adhesion of sickled erythrocytes and leukocytes to the vascular endothelium, leading to further obstruction of blood flow and exacerbating the process of vaso-occlusion. moreover, the reduced anti-thrombotic effect of no increases the risk of thrombus formation and deep vein thrombosis. over time, these processes contribute to the development of long-term vascular complications, such as pulmonary hypertension, stroke, and organ damage, particularly in the lungs, kidneys, and brain 8-9. nitric oxide and endothelial homeostasis nitric oxide (no) is a pivotal signaling molecule that plays a critical role in maintaining endothelial homeostasis, which is essential for vascular health. the endothelial cells lining the blood vessels are responsible for regulating vascular tone, blood flow, and immune cell trafficking. these cells continuously interact with circulating blood components, and no are central to these interactions, ensuring that the blood vessels function properly and that the delicate balance between vasodilation and vasoconstriction is maintained 10. endothelial cells synthesize no through the action of endothelial nitric oxide synthase (enos), which converts l-arginine into no in the presence of oxygen. no diffuses from the endothelium into the smooth muscle cells of the blood vessel walls, where it activates soluble guanylate cyclase (sgc). this leads to the generation of cyclic guanosine monophosphate (cgmp), a secondary messenger that induces vasodilation by reducing intracellular calcium levels, thereby relaxing the smooth muscle cells. the relaxation of smooth muscle results in the widening of the blood vessels (vasodilation), which lowers vascular resistance and promotes blood flow. this process is vital for regulating blood pressure and ensuring that oxygen and nutrients are delivered efficiently to tissues throughout the body 11-12. in addition to its vasodilatory effects, no has several other important functions in endothelial homeostasis. it acts as an anti-inflammatory agent by inhibiting the adhesion of leukocytes to the endothelial cells, which helps prevent excessive inflammation and tissue damage. furthermore, no exerts anti-thrombotic effects by inhibiting platelet aggregation and promoting fibrinolysis. this prevents the formation of clots that could obstruct blood vessels and disrupt blood flow. no also plays a role in regulating vascular permeability, ensuring that the endothelial barrier remains intact to prevent unwanted leakage of plasma proteins into tissues 13. however, the bioavailability of no can be compromised in various pathological conditions, including sickle cell disease (scd). in scd, a combination of factors such as increased oxidative stress, chronic hemolysis, and the release of free hemoglobin leads to a significant reduction in no levels. free hemoglobin, released from lysed red blood cells, scavenges no, reducing its availability and impairing its vasodilatory effects. this contributes to endothelial dysfunction, characterized by a shift toward vasoconstriction, increased leukocyte adhesion, and a pro-thrombotic state. these changes underlie many of the vascular complications seen in scd, including vasoocclusive crises, pulmonary hypertension, and organ damage 14-15. in addition to hemolysis, other factors contribute to no depletion in scd. arginase, an enzyme that metabolizes l-arginine, the precursor for no synthesis, is upregulated in scd. this results in a competition for l-arginine between arginase and enos, further limiting the substrate available for no production. as a result, endothelial cells in scd patients are less capable of producing no, exacerbating endothelial dysfunction and contributing to the vascular complications associated with the disease 16. mechanisms of nitric oxide depletion in sickle cell disease (scd) in sickle cell disease (scd), the bioavailability of nitric oxide (no) is significantly reduced, contributing to vascular dysfunction, inflammation, and other severe complications. several interrelated mechanisms are responsible for the depletion of no in scd, including chronic hemolysis, oxidative stress, upregulation of arginase, and endothelial dysfunction. these mechanisms work synergistically, creating a vicious cycle that exacerbates the clinical manifestations of the disease. 1. free hemoglobin scavenging of no one of the primary mechanisms of no depletion in scd is the release of free hemoglobin into the bloodstream due to the chronic hemolysis of sickled red blood cells. when red blood cells become deformed and brittle, they rupture prematurely, releasing hemoglobin into the plasma. this free hemoglobin binds directly to no, forming a nitrosylated product, which effectively inactivates no and reduces its bioavailability. the scavenging of no by free hemoglobin is particularly problematic because it prevents no from performing its normal vasodilatory function, leading to vasoconstriction, increased blood pressure, and reduced tissue oxygenation. this process is thought to contribute significantly to the vascular complications observed in scd, such as pulmonary hypertension and stroke 17. 2. oxidative stress and impaired endothelial nitric oxide synthase (enos) activity oxidative stress plays a crucial role in the depletion of no in scd. the chronic hemolysis of sickled cells leads to the release of heme, which induces the generation of reactive oxygen species (ros) and reactive nitrogen species (rns). these highly reactive molecules not only damage endothelial cells but also impair the function of endothelial nitric oxide synthase (enos), the enzyme emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [8] ajdhs.com responsible for the production of no. ros can induce the uncoupling of enos, which converts it from a noproducing enzyme to a superoxide-generating enzyme. the production of superoxide (o2−) further exacerbates oxidative stress and competes with no, reducing its availability. this impairment in enos function is a critical contributor to endothelial dysfunction and the inability of blood vessels to dilate properly in response to no 18. 3. upregulation of arginase and substrate competition another key mechanism of no depletion in scd is the increased activity of arginase, an enzyme that metabolizes l-arginine, the substrate required for no synthesis by enos. in scd, arginase levels are elevated due to the stress and inflammation caused by hemolysis. arginase hydrolyzes l-arginine into ornithine and urea, thereby reducing the amount of l-arginine available for enos to produce no. this competition for l-arginine between enos and arginase is a critical factor in the depletion of no. as arginase activity increases, the substrate for no production becomes limited, exacerbating the deficit of no in the circulation and contributing to the persistence of vascular dysfunction in scd 19. 4. hemolysis-induced inflammation and immune activation the ongoing hemolysis in scd also triggers a cascade of inflammatory responses that further contribute to no depletion. the release of cell-free hemoglobin and other hemolytic products activates the innate immune system, leading to the production of pro-inflammatory cytokines and the recruitment of leukocytes to the site of injury. inflammation increases the production of ros and rns, which not only damage endothelial cells but also reduce the bioavailability of no. additionally, pro-inflammatory cytokines such as tumor necrosis factor-alpha (tnf-α) and interleukin-6 (il-6) can downregulate enos expression, further impairing no synthesis and exacerbating endothelial dysfunction 20. 5. impaired nitric oxide synthase coupling and enos dysfunction the activity of enos in scd is further compromised by factors such as oxidative stress and altered redox status. under normal conditions, enos functions as a dimer, efficiently converting l-arginine into no. however, in the presence of excessive ros and oxidative stress, enos can become uncoupled, meaning that instead of producing no, it generates superoxide radicals. this uncoupling of enos not only contributes to a decrease in no bioavailability but also increases the burden of oxidative stress, further damaging endothelial cells and exacerbating vascular dysfunction. this dysfunctional form of enos accelerates the pathological cycle of vascular injury in scd 21. 6. implications for vascular dysfunction and clinical outcomes the depletion of no in scd has significant implications for vascular function and the progression of disease complications. the reduced no bioavailability leads to endothelial dysfunction, characterized by impaired vasodilation, increased platelet aggregation, and enhanced leukocyte adhesion to the endothelium. these changes contribute to the formation of microvascular occlusions and increase the risk of thromboembolic events, which are common in scd. furthermore, impaired no signaling is associated with the development of pulmonary hypertension, a leading cause of morbidity and mortality in scd patients. by promoting vasoconstriction, oxidative stress, and thrombotic events, no depletion exacerbates the severity of acute vaso-occlusive crises and contributes to long-term vascular complications, such as stroke, organ damage, and chronic kidney disease 22. vascular consequences of nitric oxide deficiency in sickle cell disease (scd) nitric oxide (no) plays an essential role in maintaining vascular health by regulating blood vessel tone, inhibiting platelet aggregation, reducing inflammation, and preventing vascular smooth muscle cell proliferation. in sickle cell disease (scd), a deficiency in no bioavailability has profound consequences for vascular function, leading to a variety of complications that significantly impact patient outcomes. these vascular consequences are primarily driven by the loss of no's vasodilatory effects, the promotion of vasoconstriction, and the dysregulation of endothelial function, which together contribute to the pathophysiology of scd. 1. endothelial dysfunction endothelial cells are critical in regulating vascular tone and maintaining the integrity of the vascular wall. in scd, the reduced bioavailability of no leads to endothelial dysfunction, a state where the endothelium loses its ability to respond to stimuli that would normally induce vasodilation. the endothelial dysfunction in scd is primarily a consequence of impaired no signaling due to free hemoglobin scavenging no, oxidative stress, and reduced enos activity. as a result, the endothelial cells become less capable of modulating blood vessel constriction and dilation, leading to a persistent state of vasoconstriction, which impairs blood flow. this diminished capacity to regulate vascular tone can result in various clinical manifestations, including chronic pain and ischemia 23. 2. increased vascular tone and vasoconstriction in a healthy vasculature, no promotes vasodilation by activating soluble guanylate cyclase in smooth muscle cells, leading to the relaxation of vascular smooth muscle and subsequent vessel widening. in scd, however, the depletion of no causes a shift toward vasoconstriction, as the smooth muscle cells no longer receive the signal to relax. this increase in vascular tone can lead to increased blood pressure and reduced perfusion of tissues and organs. the reduced vasodilation also contributes to the pathogenesis of vaso-occlusive crises, which are a hallmark of scd. during a vaso-occlusive crisis, blood vessels become obstructed due to the combination of increased emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [9] ajdhs.com viscosity, decreased nitric oxide levels, and abnormal red blood cell shapes, leading to ischemia and pain 25. 3. promotion of thrombosis and coagulation no has anti-thrombotic properties, as it inhibits platelet aggregation and prevents the formation of blood clots. in the absence of sufficient no, there is a heightened risk of thrombosis in scd patients. the reduced bioavailability of no in scd promotes platelet activation, increases endothelial cell adhesion molecules, and enhances the recruitment of leukocytes and platelets to the site of injury. these processes contribute to the formation of microthrombi within the blood vessels, which can exacerbate vaso-occlusion and lead to further ischemia. additionally, the prothrombotic state increases the risk of stroke, myocardial infarction, and other thromboembolic events in individuals with scd 26. 4. increased leukocyte adhesion and inflammation no plays a critical role in modulating the inflammatory response within the vasculature by inhibiting the adhesion of leukocytes to the endothelial cells. in the absence of adequate no levels, the inflammatory response is dysregulated, and there is increased adhesion of leukocytes to the endothelium. this exacerbates the inflammatory processes in scd, promoting further endothelial injury and contributing to the development of chronic inflammation. the enhanced leukocyte adhesion also facilitates the progression of tissue damage and vascular occlusion, which underlie many of the acute and chronic complications seen in scd patients, such as organ damage, stroke, and pulmonary hypertension 27. 5. pulmonary hypertension pulmonary hypertension (ph) is a common and severe complication in scd, characterized by elevated pressure in the pulmonary arteries. no deficiency plays a central role in the pathogenesis of ph in scd. in the pulmonary circulation, no normally helps regulate vascular tone and maintain a low-pressure environment. however, in the setting of no depletion, there is increased pulmonary vascular resistance, which leads to right heart strain and eventually right heart failure. the combination of chronic hemolysis, oxidative stress, and impaired enos function in scd promotes vasoconstriction in the pulmonary vasculature, worsening pulmonary hypertension. ph is a significant contributor to morbidity and mortality in scd patients, with a poor prognosis if left untreated 28. 6. end-organ damage the vascular consequences of no deficiency extend to various organs, where the impaired blood flow and increased vascular tone contribute to end-organ damage. chronic kidney disease, stroke, and liver dysfunction are common complications in individuals with scd, and the reduced no bioavailability exacerbates these conditions. in the kidneys, the increased vascular tone and reduced perfusion can lead to glomerular injury and tubulointerstitial fibrosis, ultimately resulting in chronic kidney disease. similarly, the combination of vaso-occlusion and endothelial dysfunction in the brain increases the risk of ischemic stroke in scd patients. organ damage in scd is multifactorial but is aggravated by the diminished capacity of no to protect against vascular injury and maintain normal blood flow 29. therapeutic strategies to restore nitric oxide bioavailability in sickle cell disease (scd) restoring nitric oxide (no) bioavailability is an important therapeutic target in sickle cell disease (scd), as the deficiency of no contributes significantly to the vascular dysfunction, inflammation, and thrombotic complications characteristic of the disease. various therapeutic strategies have been explored to enhance no production, minimize its scavenging, and improve endothelial function in individuals with scd. these strategies involve both pharmacological interventions and lifestyle modifications aimed at restoring endothelial homeostasis, reducing oxidative stress, and improving vascular function. 1. l-arginine supplementation l-arginine is the amino acid substrate required for the production of no by endothelial nitric oxide synthase (enos). in scd, the bioavailability of l-arginine is often reduced due to the increased activity of arginase, which hydrolyzes l-arginine into ornithine. supplementing with l-arginine has been investigated as a strategy to restore no production by providing an additional substrate for enos. clinical studies have shown that larginine supplementation can improve endothelial function, reduce pulmonary artery pressure, and enhance vasodilation in scd patients. while the results are promising, the effect of l-arginine supplementation may be variable, and its use should be considered alongside other therapies aimed at reducing oxidative stress and inflammation 30. 2. nitrate therapy nitrate therapy is another strategy to restore no bioavailability in scd. nitrates are metabolized to release no or no-like species, which can help restore vasodilation and reduce vascular tone. organic nitrates, such as nitroglycerin, and inorganic nitrates, such as sodium nitrite, have been explored in preclinical and clinical studies for their ability to increase no levels in the circulation. in scd, nitrate therapy may improve endothelial function, reduce pulmonary hypertension, and alleviate symptoms of vaso-occlusive crises by enhancing blood flow and reducing ischemia. however, the long-term use of nitrates in scd requires caution due to the potential for tolerance development and adverse effects on blood pressure regulation 31. 3. antioxidant therapies since oxidative stress is a key contributor to no depletion in scd, antioxidants that neutralize reactive oxygen species (ros) and prevent endothelial cell damage have been investigated as therapeutic options. vitamin e, a potent antioxidant, has been shown to reduce oxidative stress in scd and may help improve no bioavailability. other antioxidant compounds, such emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [10] ajdhs.com as n-acetylcysteine (nac) and polyphenols (found in fruits, vegetables, and tea), have demonstrated potential in reducing ros and improving endothelial function. these antioxidants may indirectly enhance no signaling by decreasing the oxidative damage to enos and other endothelial cell components. the use of antioxidants as adjunctive therapies may be effective in managing vascular dysfunction and improving overall patient health in scd 32. 4. hydroxyurea therapy hydroxyurea, a standard therapeutic agent in scd, has demonstrated multiple benefits beyond its effects on hemoglobin f (hbf) induction. one of its potential benefits is its ability to increase no production. hydroxyurea has been shown to stimulate enos activity and enhance no bioavailability in patients with scd. this effect is thought to be mediated by the reduction of hemolysis and the associated release of free hemoglobin, which scavenges no. additionally, hydroxyurea can decrease oxidative stress, thereby protecting endothelial cells and promoting vascular health. the combination of these effects may help mitigate the vascular complications of scd, including pulmonary hypertension and stroke. hydroxyurea remains one of the cornerstones of scd treatment due to its ability to reduce the frequency of vaso-occlusive crises and improve overall patient outcomes 33. 5. gene therapy and cellular approaches emerging gene therapy and cellular approaches offer promising potential for restoring no bioavailability in scd. recent advances in gene editing technologies, such as crispr-cas9, have made it possible to correct the underlying genetic mutation in hemoglobin (hbs) or to induce the expression of fetal hemoglobin (hbf), which reduces the sickling of red blood cells and alleviates hemolysis. by reducing hemolysis and increasing hbf levels, gene therapy may reduce the amount of free hemoglobin available to scavenge no. additionally, stem cell-based therapies, including the use of autologous stem cells genetically modified to express hbf, may improve blood flow and endothelial function by reducing hemolysis and inflammation. while these approaches are still in experimental stages, they hold great promise for long-term management of scd and its associated vascular complications 34. 6. phosphodiesterase type 5 (pde5) inhibitors pde5 inhibitors, such as sildenafil, are known to enhance no signaling by inhibiting the breakdown of cyclic guanosine monophosphate (cgmp), which is produced in response to no activation of guanylate cyclase. by preserving cgmp levels, pde5 inhibitors can enhance the vasodilatory effects of no and improve endothelial function. in scd, pde5 inhibitors have been explored as potential therapies for pulmonary hypertension and other forms of vascular dysfunction. clinical studies have shown that sildenafil and other pde5 inhibitors can improve exercise capacity, reduce pulmonary artery pressure, and alleviate symptoms of pulmonary hypertension in scd patients. while these drugs are generally well tolerated, careful monitoring is necessary due to potential side effects and interactions with other medications used in scd management 35-36. 7. lifestyle modifications in addition to pharmacological interventions, lifestyle modifications can play a key role in restoring no bioavailability in scd. regular physical activity has been shown to increase endothelial no production and improves vascular health. exercise stimulates enos activity, increases blood flow, and helps maintain optimal vascular tone. moreover, maintaining a healthy diet rich in antioxidants (such as fruits, vegetables, and whole grains) and omega-3 fatty acids can help reduce oxidative stress and promote no production. avoiding smoking and managing other cardiovascular risk factors, such as hypertension, can also improve no bioavailability and reduce the risk of vascular complications in scd 37. conclusion restoring nitric oxide (no) bioavailability in sickle cell disease (scd) represents a critical therapeutic strategy to address the vascular dysfunction and associated complications that significantly impact patient quality of life and longevity. the depletion of no in scd is a central mechanism underlying endothelial dysfunction, increased vascular tone, thrombosis, and inflammation. these pathophysiological processes contribute to many of the hallmark complications of the disease, including vaso-occlusive crises, pulmonary hypertension, stroke, and organ damage. therapeutic interventions aimed at enhancing no bioavailability, such as l-arginine supplementation, nitrate therapy, antioxidant treatment, hydroxyurea, and pde5 inhibitors, show promise in improving vascular health in scd patients. additionally, emerging gene therapies and stem cellbased approaches offer the potential for long-term improvements by targeting the root causes of no depletion, such as hemolysis and oxidative stress. while these therapies are promising, they require careful clinical evaluation to ensure efficacy and safety in diverse patient populations. conflict of interest: author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article. source of support: nil funding: the authors declared that this study has received no financial support. informed consent statement: not applicable. data availability statement: the data supporting in this paper are available in the cited references. ethics approval: not applicable. references 1. gupta a. sickle cell anemia and related hemoglobinopathies. indecision making through problem based learning in hematology: a step-by-step approach in patients with anemia 2024: 269-289. singapore: springer nature singapore. https://doi.org/10.1007/978-981-99-8933-1_21 https://doi.org/10.1007/978-981-99-8933-1_21 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [11] ajdhs.com 2. hassan ms, nasrin t, mahalka a, hoque m, ali s. a perspective on the genesis, diagnostics, and management of sickle cell disease. egyptian journal of medical human genetics. 2024; 25(1):150. https://doi.org/10.1186/s43042-024-00623-1 3. rajput hs, kumari m, talele c, sajan c, saggu v, hadia r. comprehensive overview of sickle cell disease: global impact, management strategies, and future directions. journal of advanced zoology. 2024; 45(1). https://doi.org/10.53555/jaz.v45i1.3390 4. obeagu ei. role of autophagy in modulating oxidative stress in sickle cell disease: a narrative review. int. j. curr. res. chem. pharm. sci. 2024;11(8):38-46. https://doi.org/10.23880/hij16000247 5. obeagu ei. redox regulation of hemoglobin in sickle cell disease: a review. int. j. curr. res. chem. pharm. sci. 2024;11(8):13-9. 6. obeagu ei, bunu uo, obeagu gu, habimana jb. antioxidants in the management of sickle cell anaemia: an area to be exploited for the wellbeing of the patients. int res med health sci. 2023 sep 11;6:12-7. 7. xiao r, li l, zhang y, fang l, li r, song d, liang t, su x. reducing carbon and nitrogen loss by shortening the composting duration based on seed germination index (scd@ gi): feasibilities and challenges. science of the total environment. 2024:172883. https://doi.org/10.1016/j.scitotenv.2024.172883 pmid:38697528 8. lin w, lv x, wang q, li l, zou g. nitrogen concentration dependent optical defects transition in single crystal diamond through low pressure high temperature annealing. vacuum. 2025:114329. https://doi.org/10.1016/j.vacuum.2025.114329 9. wood kc, granger dn. sickle cell disease: role of reactive oxygen and nitrogen metabolites. clinical & experimental pharmacology & physiology. 2007 sep 1;34(9). https://doi.org/10.1111/j.14401681.2007.04639.x pmid:17645642 10. dijkmans t, djokic mr, van geem km, marin gb. comprehensive compositional analysis of sulfur and nitrogen containing compounds in shale oil using gc× gc-fid/scd/ncd/tof-ms. fuel. 2015; 140:398-406. https://doi.org/10.1016/j.fuel.2014.09.055 11. muehle m, asmussen j, becker mf, schuelke t. extending microwave plasma assisted cvd scd growth to pressures of 400 torr. diamond and related materials. 2017; 79:150-163. https://doi.org/10.1016/j.diamond.2017.09.013 12. obeagu ei, obeagu gu. immunization strategies for individuals with sickle cell anemia: a narrative review. medicine. 2024; 103(38):e39756. https://doi.org/10.1097/md.0000000000039756 pmid:39312357 pmcid:pmc11419550 13. obeagu ei. strategies for reducing child mortality due to sickle cell disease in uganda: a narrative review. annals of medicine and surgery.:10-97. 14. obeagu ei. erythropoeitin in sickle cell anaemia: a review. international journal of research studies in medical and health sciences. 2020;5(2):22-8. https://doi.org/10.22259/ijrsmhs.0502004 15. obeagu ei, obeagu gu. malnutrition in sickle cell anemia: prevalence, impact, and interventions: a review. medicine. 2024 may 17;103(20):e38164. https://doi.org/10.1097/md.0000000000038164 pmid:38758879 pmcid:pmc11098235 16. quemada m, delgado a, mateos l, villalobos fj. nitrogen fertilization i: the nitrogen balance. inprinciples of agronomy for sustainable agriculture 2024: 377-401. cham: springer international publishing. https://doi.org/10.1007/978-3-03169150-8_26 17. krug ec, winstanley d. the need for comprehensive and consistent treatment of the nitrogen cycle in nitrogen cycling and mass balance studies: i. terrestrial nitrogen cycle. science of the total environment. 2002; 293(1-3):1-29. https://doi.org/10.1016/s0048-9697(01)01133-0 pmid:12109464 18. zhang cc, zhou cz, burnap rl, peng l. carbon/nitrogen metabolic balance: lessons from cyanobacteria. trends in plant science. 2018; 23(12):1116-1130. https://doi.org/10.1016/j.tplants.2018.09.008 pmid:30292707 19. enwonwu co, xu xx, turner e. nitrogen metabolism in sickle cell anemia: free amino acids in plasma and urine. the american journal of the medical sciences. 1990; 300(6):366-371. https://doi.org/10.1097/00000441-199012000-00005 pmid:2264574 20. borel mj, buchowski ms, turner ea, peeler bb, goldstein re, flakoll pj. alterations in basal nutrient metabolism increase resting energy expenditure in sickle cell disease. american journal of physiology-endocrinology and metabolism. 1998; 274(2):e357364. https://doi.org/10.1152/ajpendo.1998.274.2.e357 pmid:9486169 21. jackson aa. the use of stable isotopes to study nitrogen metabolism in homozygous sickle cell disease. ingenetic factors in nutrition. 1984: 297-315. academic press, new york. https://doi.org/10.1016/b978-0-12-715950-8.50024-x pmcid:pmc7131065 22. schnog jj, jager eh, van der dijs fp, duits aj, moshage h, muskiet fd, muskiet fa. evidence for a metabolic shift of arginine metabolism in sickle cell disease. annals of hematology. 2004; 83:371-375. https://doi.org/10.1007/s00277-004-0856-9 pmid:15054669 23. darghouth d, koehl b, madalinski g, heilier jf, bovee p, xu y, olivier mf, bartolucci p, benkerrou m, pissard s, colin y. pathophysiology of sickle cell disease is mirrored by the red blood cell metabolome. blood, the journal of the american society of hematology. 2011; 117(6):e57-66. https://doi.org/10.1182/blood-2010-07-299636 pmid:21135259 24. morris cr, kato gj, poljakovic m, wang x, blackwelder wc, sachdev v, hazen sl, vichinsky ep, morris sm, gladwin mt. dysregulated arginine metabolism, hemolysis-associated pulmonary hypertension, and mortality in sickle cell disease. jama. 2005; 294(1):81-90. https://doi.org/10.1001/jama.294.1.81 pmid:15998894 pmcid:pmc2065861 25. zhou y, yu x, nicely a, cunningham g, challa c, mckinley k, nickel r, campbell a, darbari d, summar m, majumdar s. amino acid signature during sickle cell pain crisis shows significant alterations related to nitric oxide and energy metabolism. molecular genetics and metabolism. 2022; 137(1-2):146-152. https://doi.org/10.1016/j.ymgme.2022.08.004 pmid:36030599 26. d'alessandro a, nouraie sm, zhang y, cendali f, gamboni f, reisz ja, zhang x, bartsch kw, galbraith md, espinosa jm, gordeuk vr. metabolic signatures of cardiorenal dysfunction in plasma from sickle cell patients as a function of therapeutic transfusion and hydroxyurea treatment. haematologica. 2023; 108(12):3418. https://doi.org/10.3324/haematol.2023.283288 pmid:37439373 pmcid:pmc10690926 27. obeagu ei, prajapati sk, maurya sd, maternal anemia in the context of infectious diseases during pregnancy: a review, international journal of medical sciences and pharma research, 2025;11(1):8-13 https://doi.org/10.22270/ijmspr.v11i1.134 28. obeagu ei, chukwu ph. inclusive healthcare approaches for hivpositive sickle cell disease patients: a review. current research in biological sciences. 2025;1(1):01-8. 29. obeagu ei, obeagu gu. managing gastrointestinal challenges: diarrhea in sickle cell anemia. medicine. 2024; 103(18):e38075. https://doi.org/10.1097/md.0000000000038075 pmid:38701274 pmcid:pmc11062666 30. obeagu ei, obeagu gu. living with sickle cell in uganda: a comprehensive perspective on challenges, coping strategies, and health interventions. medicine. 2024 dec 20;103(51):e41062. https://doi.org/10.1097/md.0000000000041062 pmid:39705436 pmcid:pmc11666137 https://doi.org/10.1186/s43042-024-00623-1 https://doi.org/10.53555/jaz.v45i1.3390 https://doi.org/10.23880/hij-16000247 https://doi.org/10.23880/hij-16000247 https://doi.org/10.1016/j.scitotenv.2024.172883 https://doi.org/10.1016/j.vacuum.2025.114329 https://doi.org/10.1111/j.1440-1681.2007.04639.x https://doi.org/10.1111/j.1440-1681.2007.04639.x https://doi.org/10.1016/j.fuel.2014.09.055 https://doi.org/10.1016/j.diamond.2017.09.013 https://doi.org/10.1097/md.0000000000039756 https://doi.org/10.22259/ijrsmhs.0502004 https://doi.org/10.1097/md.0000000000038164 https://doi.org/10.1007/978-3-031-69150-8_26 https://doi.org/10.1007/978-3-031-69150-8_26 https://doi.org/10.1016/s0048-9697(01)01133-0 https://doi.org/10.1016/j.tplants.2018.09.008 https://doi.org/10.1097/00000441-199012000-00005 https://doi.org/10.1152/ajpendo.1998.274.2.e357 https://doi.org/10.1016/b978-0-12-715950-8.50024-x https://doi.org/10.1007/s00277-004-0856-9 https://doi.org/10.1182/blood-2010-07-299636 https://doi.org/10.1001/jama.294.1.81 https://doi.org/10.1016/j.ymgme.2022.08.004 https://doi.org/10.3324/haematol.2023.283288 https://doi.org/10.22270/ijmspr.v11i1.134 https://doi.org/10.1097/md.0000000000038075 https://doi.org/10.1097/md.0000000000041062 emmanuel ifeanyi obeagu asian journal of dental and health sciences. 2025; 5(3):6-12 [12] ajdhs.com 31. obeagu ei, adias tc, obeagu gu. advancing life: innovative approaches to enhance survival in sickle cell anemia patients. annals of medicine and surgery. 2024; 86(10):6021-6036. https://doi.org/10.1097/ms9.0000000000002534 pmid:39359845 pmcid:pmc11444627 32. bell v, varzakas t, psaltopoulou t, fernandes t. sickle cell disease update: new treatments and challenging nutritional interventions. nutrients. 2024; 16(2):258. https://doi.org/10.3390/nu16020258 pmid:38257151 pmcid:pmc10820494 33. khan sa, damanhouri g, ali a, khan sa, khan a, bakillah a, marouf s, al harbi g, halawani sh, makki a. precipitating factors and targeted therapies in combating the perils of sickle cell disease---a special nutritional consideration. nutrition & metabolism. 2016; 13:1-2. https://doi.org/10.1186/s12986-016-0109-7 pmid:27508000 pmcid:pmc4977632 34. patel s, patel r, mukkala sr, akabari a. emerging therapies and management approaches in sickle cell disease (scd): a critical review. journal of phytonanotechnology and pharmaceutical sciences. 2023; 3(3):1-1. https://doi.org/10.54085/jpps.2023.3.3.3 35. obeagu ei, prajapati sk, maurya sd, anemia in pregnancy: exploring non-iron deficiency causes, international journal of medical sciences and pharma research, 2025;11(1):1-7 https://doi.org/10.22270/ijmspr.v11i1.130 36. boma pm, kaponda aa, panda j, bonnechère b. enhancing the management of pediatric sickle cell disease by integrating functional evaluation to mitigate the burden of vaso-occlusive crises. journal of vascular diseases. 2024; 3(1):77-87. https://doi.org/10.3390/jvd3010007 37. obeagu ei, chukwu ph. inclusive healthcare approaches for hivpositive sickle cell disease patients: a review. current research in biological sciences. 2025;1(1):01-8. https://doi.org/10.1097/ms9.0000000000002534 https://doi.org/10.3390/nu16020258 https://doi.org/10.1186/s12986-016-0109-7 https://doi.org/10.54085/jpps.2023.3.3.3 https://doi.org/10.22270/ijmspr.v11i1.130 https://doi.org/10.3390/jvd3010007 