Perception And Attitude Of Health Professionals Of Pakistan Towards Stemcells From Human Exfoliated Deciduous Teeth (SHED) Practice

Keywords

Perception; Dental Stem Cells; SHED (Stem Cells from Exfoliated Deciduous Teeth); Tooth Bank.

Introduction

The discovery of stem cells is a significant advancement in regenerative medicine [1]. There are primarily two types of stem cells, namely embryonic stem cells (ESCs) and adult stem cells (ASCs) or somatic cells, depending on the developmental stage from which they are obtained [2]. Dental stem cell (DSC) is a type of ASC, which based on its originisfurther classified into: dental pulp stem cells(DPSCs), stem cells from human exfoliated deciduous teeth(SHED), periodontal ligament derived stem cells (PDLSCs), dental follicle stem cells (DFSCs), tooth germ progenitor cells obtained from third molars (TGPCs), immature dental pulp stem cells from deciduous teeth (IDPSCs) and stem cells from the apical papilla (SCAP)[3-7].

So far, the best multipotent and proliferative results from anyDSCsthat have beenobservedare from SHED,evolving,tissue engineering and regenerative medicine [8, 9]. SHED has demonstrated MSC (mesenchymal stem cells) like capacity for selfrenewal and multilineage differentiation potential [10]. They have shown abilities to repair damaged tooth structures, promote bone regeneration and treat neural tissue injury or degenerative diseases [11]. SHEDs are also easier to obtain, carrying no major ethical constraints [3]. Therefore, they are more favourable to use in medicine than any other stem cells.

The application of SHED in Pakistan could bea promisingnovel advancement in the field of medicine. However, complete awareness and specialized skills in this areaare required.Thus, to estimate its future successful execution in Pakistan, it is important to estimate Pakistani health professionals’ perception and their attitudes towards SHED practice.

Therefore, this study was conducted to estimate the interestin- SHED, among medical and dental professionals from Karachi and perception ofits use inmedical sciences including research and tissue regenerative/reconstructive therapies. Moreover, the study also aimed to estimate choices towards donation of exfoliated primary teeth in stem cell banks when given a chance. The objectives of this study are as follows:

• To assess perceptions of use of SHED in medical sciences, amongmedical and dental professionals.

• To assess attitude towards storage of primary teeth in stem cell bank,among medical and dental professionals.

• To assess perceptions related to future application of SHED in Pakistan among medical and dental professionals.

• To assess the level of interest among medical and dental professionals towards subject of SHED

Materials And Methods

Study design and Sampling: This cross-sectional study was conducted among medical and dental professionals working in random private and public health-care setups, including educational institutions, clinical offices and tertiary care in urban areas of Karachi. A convenient sampling procedure was used. Medical and dental professionals, currently practising in their respective fields were included as study participants. Minimum sample size of 150 was required, using 95% confidence level, 5% bound on the error of estimation and using 89% prevalence of interest in stem cells, [12, 13]. Finally, 135 professionals in each medical and dental group were recruited, making actual sample size of 270.

Data collection and Questionnaire: The data collection was done using self-constructed questionnaires. The questionnaire comprises 17 questions, which were primarily derived from previous dental surveys using careful consideration for question type, wording and layout. The questionnaire was designed to collect data including; demographic background andfield of speciality of participants. Besides that, ithasquestions regarding:awareness of term SHED, use of SHED in medicinefor research purpose and for regenerative therapy, interest level on a Likert scale of 5, attitude towards stem cell donation/storage in stem cell bank and future of SHED practice in Pakistan.

Statistical Analysis: Data obtained was analysed using SPSS software 21. For descriptive statistics, variables were categorized; and frequencies and percentages were calculated. Proportions in response between dental and medical groups were compared using chi-square test. Pvalue of <0.05 was considered statistically significant.

Ethical consideration: Verbal consent was taken prior to data collection from every participant. Ethical clearance was obtained from the Ethical Review Committee of Jinnah medical and dental college, Karachi, Pakistan. The ethical protocol number is (000025/20). This study was conducted between December 2019 to June 2020.

Results

A total of 247 completely filled, out of 270 distributed questionnaires were received back by the researcher. The completely filled forms were received from 114 medical and 133 dental professionals, making response rate of 91.48%. Age and gender distributions are given in Table 1.

More than half of participants, [56.68% (n=140)] had never heardabout term SHED before, and majority of them are medical professionals [30.7% (n=76)] as shown in Table 2. Only 43.3%, (n=107) of all professionals were familiar with theterm SHED and the most frequent source of information was the internet [51.40%(n=55)], followed by the Journal/Article [29.90 %(n=32)] (Figure 1).

Both professional groups have shown moderate level of interest towards SHED (38.6% medical and 36.1% dental), which is level 3 on Likert scale (Figure 2). Significant difference (p=0.015) in the interest towards SHED was observed between the two groups, where dental professionals have exhibited more interest (moderate to high) in SHED [81.2% (n=108)] than medical professionals [64.9% (n=74)] as presented in Table 3.

Both groups ofprofessionals, (dental 77.4%,n=103 and medical 76.3%, n=87)believed that SHED should be used in regenerative or reconstructive therapy (Table 4). About half of the medical professionals(49.1%, n=56) believe that the stem cells from exfoliated primary teeth can be useful in recovery from the neural and degenerative diseases, whereas, most dental professionals (47.4%, n=63) were not sure about it (Table 4). Both dental 60.2% (n=80) and medical 58.8%(n= 67) professionals, believe in possibility of using stem cells from primary teeth for the research purposes (Table 4).

Both dental (63.2%, n=84) and medical (59.6%,n=68) professionals agreed on recommending their patients, to donate their child’s exfoliated teeth, along their own child’s primary teeth (dental 60.2n=80 and medical 58.8% n=67) instem cell bank (Table 5). However, majority 50.6%, (n=125) of respondentshad no idea aboutmedico-legal implications of SHED’s donation in stem cell banks (Table 5).

Both groups, (dental 48.1%, n=64 and medical 47.4%, n=54) were not sure about an acceptance of SHED by the society of Pakistan, as a legal or ethical practice (Table 6). Moreover, more than half of them 54.7% (n=135) believed that there is a chance of misuse of stem cells, donated for research and therapeutic purposes (Table 6). High positive response was received from both groups, [dental; 83.5% (n=111) andmedical; 70.2%(n=80)], when asked about creating awareness among the populace of Pakistan regarding the benefits ofSHED practice, however, significant difference (p=0.015) appeared in responses. Overall, most of the respondents have considered internet (38.5%) as the medium of choice for raising SHED awareness, followed by social media( 30.8%) (Table 6).

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Figure 1:

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Figure 1. Source of information about SHED received from all participants who were aware of term SHED.

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Figure 2:

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Figure 2. Comparison of rate of interest among medical and dental professionals towards SHED.

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Table 1:

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Table 1. Age and gender distribution of the participants.

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Table 2:

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Table 2. Awareness of term SHED among medical and dental professionals.

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Table 3:

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Table 3. Rate of interest among medical and dental professionals regarding SHED on a numerical scale from 1 (no interest) to 5 (high interest).

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Table 4:

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Table 4. Comparison of dental and medical professionals’responses in each question about use of SHED in medical sciences. (Chi square).

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Table 5:

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Table 5: Comparison of dental and medical professionals’ responses in each question about storing exfoliated primary teeth in stem cells bank. (Chi square test).

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Table 6:

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Table 6: Comparison of dental and medical professionals’responses in each question regarding SHED’s future application in Pakistan (Chi square test).

Discussion

The domain of stem cell research has emerged with various medical and dental applications, due tostem cell’s abilities to regenerate and repair damaged tissues [14]. Likewise, SHED’s various prospective medical and dental uses have necessitated, building an interest in applications of SHED, among medical and dental professionals. Therefore, this study was intended to evaluate interest level and practice of stem cell from human exfoliated deciduous teeth (SHED), among medical and dental professionals of Pakistan. Due to availability of limited previous original studies, specifically related to SHED, results of current study have been compared with results of similarly designed previous studies, however, done on stem cells in general or on DSCs.

According to the results of the current study, more than half of the participants hadnever heard about SHED before. Interestingly, moremedical professionals were unaware compared to the dental professionals. Among all participants, the most frequent source of information was the internet, followed by the journal/ article. Likewise, in an Indian study, a large proportion (74%) of dentists was well-aware of dental stem cells (DSCs) and the most frequent source of information was journals, followed by internet [15].

Interest among professionals:

In this study, both medical and dental professionals demonstrated a moderate level of interest in stem cells from exfoliated deciduous teeth (SHED).Comparatively, dental professionals have exhibited more interest (moderate to high) in SHED than medical professionals. This is parallel toanother Indian study,wherealmost all of the responding dentists have shown interest in learning about application of stem cells, when given a chance [16]. A study conducted involving medical doctors of Italy, found that the majority of physicians (70%) were interested in stem cells and believed in the potential benefits of developing stem cells strategies in their country [17]. Similarly,in our study, although, proportion of medical respondents, showing moderate to high interest in the subject of SHED was not high (64%), it was more than half of the respondents.

Use in medicine for therapy and research purpose

SHED has been proven to be beneficial in repairing and treatingneural tissue injuries and degenerative diseases [11, 18]. In the current study, majority of medical professionals agreed to the fact that SHED can be useful in recovery from the neural and degenerative diseases. This responseis similar to the findings froma study conducted on health care providers in Saudi Arabia, in which prominent number of the health professionals confirmed that stem cells can be used to treat neurological problems such as Alzheimer’s and Parkinson’s diseases(19). The concept of regeneration instead of repair will be the reason why medical professionals would recommend stem cell-based regenerative treatments to their patients (13). Unlike medical professionals, dental professionals were not sure about the use of SHED to treat neurological and degenerative diseases, in the current study.

Both the professionals in our study, showed willingness to use primary teeth as a source of stem cells for the purpose of research. Results showed similarity with a survey, conducted on the health professionals in China, in which majority of the participants, expressed high level of interest in stem cellsuse, for research [20].

Stem cell Bank donation:

Dental stem cells are considered a viable source of ASCs, as they can be easily obtained by tooth extraction [21]. This has led to an increase in the popularity of tooth banking and harvesting of dental stem cells for allogenic and autologous cell therapy [22]. Majority of dental and medical professionals in our study, agreed on recommending to their patients, to donate their child’s exfoliated teeth. Similarly, according to Indian studies, majority of health professionals were willing to recommend their patients to donate their teeth for preservation of the dental stem cells [11, 23]. When asked about their own child’s teeth, two-third of both the dental and medical respondents agreed on donating their child’s exfoliated teeth in stem cell bank, in our study. This is in contrast with the Iranian study, where only 45.2% of the dentists were interested in collecting and storing dental tissues for stem cell banking [24]. Although, health professionals have agreed on donating exfoliated teeth in stem cell bank in our study,majority of them had no idea about medico-legal implications of SHED’s donation in stem cell banks.

Ethical practice and future application in Pakistan:

In current study, both professional groups were not sure about an acceptance of SHED by the general public of Pakistan, as a legal or ethical practice. More than half of them believed that there is a chance of misuse of stem cells, donated for research and therapeutic purposes. This is different from Saudidentists’ perception on stem cells, who believed that use of stem cells did not contradict ethical and religious principles [25].

Nevertheless, majority of participants in both groups, (83.5%, dental and 70.2%, medical), agreed on creating awareness among the populace of Pakistan about the benefits of SHED practice, this time resemblingthe same Saudi study, in which almost all the participants recommended more public awareness programs, about stem cells and their therapeutic applications [25]. In the current study, medium of choice chosen by health professionals to promote SHED awareness was internet, followed by social media. Whereas, according to Indian study, dentists preferred seminars and conferences, to increase dental stem cells awareness followed by journals and advertisements [15].

One of the limitations of this study is narrow availability of original studies related to beliefs and attitude of health care professionals towards SHED. Most of the studies discovered, were focused on dental stem cells, which has led to limitedspecific comparison in the current study, aiming SHED.

Understanding of SHED practice will open a new era of research and prospective advancement inthe treatment of various diseases. However, at present many Pakistani health professionals are still new to the term SHED, according to the study. Moreover, despite showing moderate interest, many health professionals seem unsure about recognition of SHED, as an ethical practice in Pakistan. Thus, it is recommended that health professionals of Pakistan should be educated regarding benefits of SHED and its limited ethical concern, tohelp them develop confidence in its use.