Attitudes of Health Professionals in Pakistan Towards SHED (Stem Cells from Human Exfoliated Deciduous Teeth) Practice

INTRODUCTION:

The use of stem cells in regenerative medicine is a proven beneficial innovation in treating incurable diseases or injuries. Depending on the developmental stage from which they are derived, there are two kinds of stem cells: adult stem cells (ASCs), also known as somatic cells, and embryonic stem cells (ESCs).1,2 Dental stem cell (DSC) is a type of ASC is further subdivided into different types, based on their origin. Tooth germ progenitor cells derived from third molars (TGPCs), dental pulp stem cells (DPSCs), stem cells from human exfoliated deciduous teeth (SHED), periodontal ligament derived stem cells (PDLSCs), dental follicle stem cells (DFSCs), immature dental pulp stem cells from deciduous teeth (IDPSCs), and stem cells from the apical papilla (SCAP) are some of these stem cells.3-7 Among all DSCs, SHEDs had demonstrated the finest multipotent results, high proliferative capacity, minimal risk of oncogenesis and immunosuppressive ability.^7-10 Tissue treatments including, regeneration of damaged tooth structures, bone regeneration and treatment of neural tissue injuries or other degenerative diseases by means of SHED had already been reported previously.11 In addition to that, procedure of collecting and preserving SHED was costeffective, noninvasive, painless and ethically sound.^3-7 Consequently, considering all of SHED's benefits, it might be a better option for regenerative medicine than any other kind of stem cell.

The findings of earlier research revealed varying degrees of clinical applicability and stem cell expertise among medical and dental practitioners. For instance, recent dental graduates' attitudes about stem cells and their therapeutic applications in dentistry were generally relatively positive, according to a recent study conducted in several Saudi Arabian dental schools; nonetheless, their understanding was insufficient.¹²

The results of a study conducted by Kerman indicated that Iranian dentists' attitudes on dental stem cells are acceptable. Positivity toward the use of stem cells can result in increased utilization and improved clinical applications.¹³

There is insufficient data regarding Pakistanis health care professionals understanding and awareness of DPSCs and their banking, despite the fact that they have the capacity to regenerate. While SHED is a potential medical breakthrough, understanding Pakistan's health professionals' attitudes and preferences toward SHED practice is essential to predicting the program's effective adoption in this developing nation. In addition to clarifying the acceptance of this therapy by health care professionals, the results of this study would be helpful in establishing ethical guidelines in this area. 

The objectives of our study were to assess the attitude of health professionals, regarding the use of SHED in regenerative medicine and to explore its prospects in a developing country like Pakistan.

METHODOLOGY:

A cross-sectional study was conducted in Karachi, which is the biggest and most diverse city in Pakistan. A convenient sampling procedure was used for the study where dental and medical health professionals were reached. Bachelor's degree in medicine or dentistry was assigned as the primary inclusion criteria for health professionals in the study. In Pakistan, MBBS is a verified degree for the medical field and BDS for the field of dentistry. The exclusion criteria was auxiliaries, including nursing staff and any health professionals who were unemployed at the period of data collection. The Jinnah Medical and Dental College's ethical committee at Sohail University (Protocol # 000025/20) provided approval to conduct the study.

Openepi, on the basis of 89%14 prevalence, 5% margin of error, 80 % power and 95% confidence interval level. A minimum sample size of 150 was estimated, using prevalencebased formula. To improve the generalization of the study, the final sample size was increased to 250.

The data was collected from December 2019 to June 2020, using a self-constructed questionnaire. Data was collected from practitioners in medicine and dentistry working in clinical offices and tertiary care hospitals located in the city including Medicare Cardiac and General Hospital, Karachi Medical Complex and Medicenter Karachi. A convenient sampling procedure was used to approach these premises and health professionals. Prior to data collection, written informed consent was obtained from each participant. The participants were given consent of leaving the study at any time

A questionnaire was designed to collect data including age, sex, a field of study, graduation/specialty and question related to interest and attitude towards SHED. The questionnaire commenced with demographic and professional background questions and followed by 11 descriptive questions. Those 11 questions include, awareness of the term SHED, interest rating on a 5-point Likert scale, choice to use SHED for research purposes and regenerative therapy, opinion of storing and donating stem cells in a stem cell storage facility, medico-legal support for SHED in Pakistan and lastly medium of choice to raise awareness regarding SHED. Questionnaires were circulated by hand to the health professionals, irrespective of the specialty within their respective fields and years of experience. All participants were instructed to complete the questionnaire and returned it to the researcher.

Version 21 of the SPSS software was used for evaluating the data. Variables were initially classified for descriptive statistics, after which frequencies and percentages were generated. Groups were divided into medical and dental fields based on their category of qualification. The chi-square test was used to compare the results and determine if there were any significant differences in the responses between the dentistry and medical groups. P-values less than 0.05 were deemed statistically significant.

RESULTS:

All 250 distributed questionnaires were returned to the researchers. Forms were returned fully completed by 114 medical and 133 dental practitioners, making a total data of 247 with a response rate of 98.8 %. The 3 questionnaires out of 250 received were incomplete so they were not considered for data analysis. The study sample's demographic distributions are provided in Table 1. 56.7% of the participants (n = 140) were unfamiliar with the term SHED and majority [30.7 % (n = 76)] of them were medical professionals, as shown in Table 2. There was a slight difference in frequency between dentists who were aware of term SHED (n = 69) and those who were not (n = 64).

43.3 % (n = 107) of all health professionals were aware of the term SHED and the internet was the primary information source [51% (n = 55)], with the Journal/Article [30 % (n = 32)] coming in second as shown in Figure 1.

Figure 2 shows comparison of dentistry and medical professionals’ interest rates. All participants (38.6% medical and 36.1% dental) showed an overall moderate degree of

interest in SHED, which equates to level 3 on the Likert scale. Table 3 indicates that there existed a significant difference (p = 0.015) in the two groups' interest in SHED

with dental professionals showing a greater interest (moderate to high) in SHED [81.2% (n = 108)] than medical professionals [64.9% (n = 74)].

A comparison of all responses from participated health professionals, on questions related to attitude towards SHED practice, is presented in Table 4. 77.4 % (n = 103) of dental and 76.3 % (n = 87) of medical professionals agreed to use SHED in reconstructive or recuperative medicine. Approximately 50% of medical professions 49.1 % (n = 56) concurred to employ exfoliated primary teeth stem cells to treat neurological and degenerative illnesses, however only 47.4% (n = 63) of dental practitioners were unsure about it. Medical professionals (58.8%; n = 67) and dental professionals (60.2%; n = 80) agreed to using primary teeth for stem cell research purposes as shown in Table 4. When asked about tooth banking, 63.2 % (n = 84) of dental and 60 % (n = 68) of medical professionals agreed on recommending their own child's primary teeth as well as their patients to donate their child's exfoliated teeth (dental 60.2 %, n = 80 and medical 59 %, n = 67) in stem cell respository. 50.6 % (n = 125) of respondents accepted to support the medico-legal status of SHED practice in Pakistan followed by 30.8 % (n = 76) of health professionals, who were not sure of supporting the medico-legal status of SHED, as given in Table 4.

77.3% (n=191) health professionals [dental; 83.5% (n = 111) and medical; 70.2% (n=80)] responded yes when questioned about raising knowledge of the advantages of SHED practice among Pakistanis, where dental professionals demonstrated significantly (p= 0.015) more interest in creating awareness regarding the benefits of SHED practice, as presented in Table 4.

Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second Table 5 demonstrates that the majority of respondents said that the internet (38.5%) as their preferred source for increasing awareness of SHED in Pakistan, with social media (30.8%) coming in second.

DISCUSSION:

SHED offers various regenerative and repairing functions^15,16 in medical and dental fields without immense cost or hassle. For this reason, it can emerge as a successful practice in a low-income country like Pakistan. Therefore, authors attempted to estimate the prospect of SHED in Pakistan by evaluating the attitude and level of interest among health professionals toward SHED practice in the country. According to the study's results, a moderate interest in SHED practice was reported by health professionals. Dental professionals have more awareness of the term SHED than medical professionals and likewise exhibited more interest in creating a relevant awareness in Pakistan.

Due to the scarcity of literature related to SHED, authors have compared the results of the current study with the results of previous studies done on DSCs. The current study's findings demonstrated that over half of the participated health professionals in Karachi have never heard about SHED before. Although, more dental professionals were aware of the term SHED as compared to the medical professionals, still a minor difference in frequency was reported between dentists who were aware of the term SHED (n = 69) and those who were not (n = 64). Differing Indian studies where a large proportion of dentists were aware of SHED15,17,18 and DSCs in general.19 The internet source has appeared as the most common source of information about SHED among Pakistani health professionals in our study, followed by the journals/articles, in contrast to previous Indian studies where reading journals appeared more than the internet as a source of information on SHED for health professionals in India.17,19 Dental curriculum and undergraduate training have also been reported as the main source of information on SHED in other previous Indian studies with health professionals.17,18.

Although a majority of health professionals in our study have demonstrated a moderate level of interest in SHED, dentists comparatively have shown greater interest in SHED compared to medical practitioners. This is similar to previous studies including an Indian study in which 78% of the responding dentists expressed an interest in regenerative practice.13 Interest in learning through CMEs, articles, or advanced training about DSCs applications appeared common among dentists in previous studies.15,18,20,21 Moreover, according to a previous study, most Italian doctors had an interest in stem cells in general and were aware of the benefits of creating stem cell programs in their nation22 matching the interest level of medical professionals in our study. \

Despite growing anticipations, stem cell research (SCR) still carries ethical and religious worries in different societies23 , which may restrain many health professionals to perform SCR. Among all the Muslim countries, the total number of SCR publications from Pakistan is the lowest24 thus, signifies that the SCR field is still in its infancy in Pakistan. Since dental stem cells carry no major religious or ethical obstacle as they can easily be obtained from primary extracted or exfoliated teeth25, DSCs or SHEDs research should be promoted in Pakistan. In our survey, most medical experts expressed a strong desire to use deciduous teeth for SCR. Results show similarity with the findings of a a chinese study on health professionals revealed that participants were very enthusiastic about SCR in any forms.26 The mainstream health professionals in our study favored using stem cells from exfoliated primary teeth in regenerative or reconstructive therapy, matching South African dentists' willingness to use teeth for regenerative treatments.27

SHED is a proven beneficial source of tissue repair including treatment for neural tissue injuries and degenerative diseases11,28 According to studies conducted on Saudi healthcare providers, multitude of medical experts concurred that stem cells can be utilized for medical and dental treatments21 including neurological conditions like Parkinson's and Alzheimer's.23 These verdicts are consistent with the findings of the current study, in which most medical specialists acknowledged that SHED should be used in curing, neural and degenerative diseases. Patients are advised by medical specialists to undergo stem cell-based restorative therapy due to its regenerative potential rather than repair.15 The current study found that dental experts were unaware of the application of SHED to treat neurological and degenerative illnesses, in contrast to medical specialists. This response is contradictory to a previous study, where, about three-quarters of Indian dentists acknowledged that DSCs are useful for non-dental tissue development.15.

Ease of exfoliated or extracted tooth collection with limited ethical concern has gained popularity in tooth preservation and dental stem cell extraction for allogenic and autologous cell therapies.25,29 Globally health professionals, irrespective of their social and religious backgrounds, appeared to favor tooth donation and banking including exfoliated deciduous teeth. According to Indian, South African and Iranian studies, the majority of health professionals agreed to suggest to their patients regarding donation of their teeth for dental stem cell preservation.17,18,30,31 Similarly, the majority of health professionals in our study agreed on suggesting their own child's exfoliated teeth as well as their patients child teeth for contribution to stem cell repositories.

Discussion about stem cell therapy is intense due to the involvement of religious, political, ethical and societal opinions. Since, SHED collection is simple, non-invasive and painless carrying wide-ranging medical benefits, they have been identified as the most ethical cell source for regenerative treatments. National bioethics committee Pakistan (http://nbcpakistan.org.pk/) has provided guidelines on stem cell use for transplantation from blood and bone marrow sources only. Regulation authorities should support the recognition of SHED practice as legal practice since it has no religious, ethical, or safety concerns. In the current study, except for a few health professionals, many were ready to support the medico-legal status of SHED practice in Pakistan. Similarly, the majority of health professionals across the globe have supported the use of DSC as legal practice, including regenerative dentistry.18,20,27 Moreover, Health professionals including Muslim health professionals, claim that DSC practice does not contradict religious ethical principles.21,27,31 The majority of health professionals in the current study agreed on raising public awareness about the benefits of SHED practice in Pakistan using the internet and social media, mirroring the Saudi health professionals, who supported the idea of spreading knowledge by arranging programs about stem cells and their therapeutic implementation.21 Overall, dentists in the study showed more interest and were more aware of the term SHED than medical doctors.

One of the study's limitations is the scarcity of original studies availability on health professionals' attitudes toward SHED. The majority of the studies that have been discovered were focused on dental stem cells or stem cells in general, which has resulted in a limited specific comparison aiming at SHED. The study was conducted only in one city therefore, a similar study should be conducted on a larger scale to get generalized results from Pakistani health professionals.

CONCLUSIONS:

SHED practice will open new door in the field of research and in the management of various incurable conditions in Pakistan. Currently, a large number of Pakistani healthcare workers are unfamiliar with the phrase SHED. Despite showing a moderate level of interest in SHED, few health professionals still seemed hesitant to support the medico-legal status of SHED practice in Pakistan. Thus, the implementation of SHED practice in medicine remains uncertain. It is recommended that educational interventions, regarding the economical and medical benefits of SHED including its limited ethical concern, should be organized for health professionals, to develop confidence in its use.

CONFLICT OF INTEREST:

None declared.

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