All posts by Turacoz Group

Evidence-Based Practice

Medical Writing

Evidence-based practice (EBP) is defined asthe conscientious, explicit and judicious use of current best evidence in making correct, prompt and individualistic patient care decisions. (Sackett D, 1996)
EBP integrates the clinician’sown expertise, the best available scientific evidence, and the patient values and preferences (Figure 1).

Figure 1: Elements of Evidence-Based Practice (EBP)
Inability of current medical practice to cape pace with the available evidences generated interest in the use of evidence-based practice while a varied number of steps have been defined to be applied for the use of EBP (Figure 2).

Figure 2:Steps Involved in Evidence-Based Practice (EBP)
1. Problem definition: Clinician formulates an answerable clinical question based on the most updated and relevant data to solve individual patient problem. Defining the problem may provide answers to certain areas ofdisease prevention, diagnosis, prognosis, therapy, causation, cost-effectiveness, etc.
A defined PICO (Population, Intervention, Comparison, Outcome) approach which directly focuses on the clinical question may ensures that it will be helpful in finding the relevant evidences to bridge the prevailing clinical gap.
2. Search for information sources:
After formulating the clinical question, search for appropriate scientific evidences in various databases including PubMed, EMBASE etc. must be done. Firstly, a search for the relevant evidence-based guidelines is done and if it is not available, scientific evidences including systematic reviews or individual studies are referred too.
3. Appraise the information for validity and applicability:
After literature search,each review/study needs to be critically appraisedfor relevance, reliability, validity, and applicability to the persisting clinical question. A clinician can rapidly appraise the study by assessing three important aspects which are:
Validity of study results: It should include assessment of research methods (randomization or non-randomization), characteristics of patients prior to intervention, and instruments used to measure outcomes.
Results and their importance: It should include effectiveness of the intervention, its impact on outcomes, and probability of getting similar results in the clinicians’ own practice settings.
Applicability of the results in patent care: Clinical considerations of the study results such as similarity between study subjects and one’s own patients, benefits/risks ratio, and patient values and preferences, and feasibility and cost-effectiveness needs to be incorporated.
4.Integration of the evidence with one’s clinical expertise and patient preferences and values:
As discussed above, EBM is not solely based on appraising scientific evidences. In the integration step, the relevant scientific evidences are combined with clinical expertise andalso the patient’s perspective. This step requires answering to several questions on: similarity between study patients and one’s own patient; availability of the treatment; alternative treatments available; side effects of the treatment, outweighing risks and appropriateness of the patient outcomes.
5. Evaluating the effectiveness of EBP for individual patients
The last and the final step in EBP is to assess the effectiveness of evidence-based approach when applied to a specific patient. It assesses the clinical improvement of the patient achieved with the evidence and whether it is comparable and as found in the research study.
Level of Evidence
The Level-of-Evidence pyramid represents the types of studies which represents their research quality and risk of biasness. As we move up in the pyramid, the research quality increases while risk of biasness decreases.Studies are assigned to specific hierarchy in the pyramid based on their methodological design quality, results validity, and applicability to patient care. Levels of evidence for different subjects including therapy, diagnosis, prognosis etc. can be viewed at the Oxford Centre for Evidence-based Medicine website (http://www.cebm.net/blog/2009/06/11/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) Researchers practicing EBP should have an understanding of level of evidences to prioritize all the information collected. EBP holds a strong ground in the top-order of the pyramid as shown in Figure 3.
Current Status of EBP Application
Presently, the implementation of EBP is not sufficient in making healthcare decision. A recent survey assessed the factors which facilitates or hinders the application of EBP in the clinical context. Respondents stated that in clinical healthcare currently EBP is underused and explained this shortcoming with several practical and structural barriers, which they felt can be better monitored by individual organization and directors. In the survey, only 11% of the respondents used EBP and 20% stated that they worked ‘in the way they always had’.
It was also highlighted that increased awareness about EBP and implementation systems for the same in future will be useful in providing evidence-based, best quality and cost-effective healthcare to individual patients.

Figure 3: Level-of-Evidence Pyramid
Evidence based practice is central to providing high-quality care and decreasing unwarranted variation in practice. Turacoz Healthcare Solutions aims to spread awareness about the latest offerings of evidence based practice so that we are able to do our bit and contribute more towards patient healthcare.

Pharma Mergers and Acquisitions

Medical Writing

Mergers and acquisitions (M&As) refer to consolidation of companies or assets. Merger means combining two companies into one, while acquisition refers to taking over of one company by the other one. In pharmaceutical world, mergers and acquisitions are quite common. According to the insights, M&As help the pharmaceutical companies in achieving their goals easily by acquiring it, instead of making it. Moreover, the companies with products which are soon to be off-patent also seek for companies with high revenue potential to acquire. Moreover, the expenditure involved in research and development has also attracted the investors to merge with or acquire other companies.

Indian pharmaceutical industry, which is known for its highly skilled core players and low-cost manufacturing, has also been highly influenced by M&As. Many domestic and cross-border M&As have been witnessed by the Indian Pharma companies. The major reasons which have drawn the attention of Indian pharma companies towards M&As are presented in Figure 1.

Figure 1: Major reasons of Pharma Mergers and Acquisition in India

Some of the major M&A Deals that took place in India recently (2015-2017) are:

  1. Mergers of Ranbaxy and SunPharmaceuticals
  2. Acquisition of Primal Healthcare by Abbott
  3. Acquisition of Ranbaxy by DaiichiSankyo
  4. Acquisition of US-based Gavin by Lupin Ltd.
  5. Acquisition of Russian Biocom by Lupin Ltd.
  6. Acquisition of Taro by Sun Pharmaceuticals
  7. Acquisition of UCB by Dr Reddy’s Laboratories
  8. Acquisition of Beta Pharma by DrReddy’s Laboratories
  9. Acquisition of Elder Pharma by Torrent Pharma

It is apparent that such M&As have become essential for the pharmaceutical industry to grow. Moreover, the trend does not seem to slow down due to their necessity to meet the expenditures. However, the loss of expected R&D and thoroughness associated with M&As warrants development of comprehensive guidelines for successful M&As.

Turacoz Healthcare Solutions keeps a tab of the latest healthcare update and studies Pharma mergers and acquisitions in detail. We extend our services in assisting pharmaceutical companies by providing them end-to-end writing support in both the publication and regulatory arena.

World Diabetes Day

Medical Writing

The term diabetes mellitus is defined as a metabolic disorder which is characterized by hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion or insulin action or both.The long-term effects of Diabetes Mellitus include retinopathy with potential blindness, nephropathy that may lead to renal failure or neuropathy with the risk of foot ulcers and autonomic dysfunction which may lead to sexual dysfunction.

There are various treatment strategies for diabetes mellitus which are successful in recovering clinical status but cause a variety of complications such as cardiomyopathy, retinopathy, neuropathy, etc.The most promising approach for diabetes mellitus is restoration of insulin-secreting pancreatic beta cells. This approach controls the blood sugar level and helps in the regeneration of insulin-secreting pancreatic beta cells from adult cells.

Diabetes poses a major heath issue for women who tend to face the same joys and problems, but with an added element where theyhave to battle a chronic disease with various social and personal challenges every now and then. In 1983, the American Assistant Secretary for Health established the Public Health Service Task Force on Women’s Health Issues. In 1985, this task force reported the health issues intervening in women’s life stages. Diabetes in pregnancy is a serious condition that is unique to women as it affects the health of both the mother and her unborn child.The most common complication attributable to diabetes is the risk of cardiovascular disease which is more serious among women than men. Also, it has been reported that women with diabetes lose their premenopausal protection from ischemic heart disease and have risk for this condition as great as or greater than that of diabetic or nondiabetic men. Women are also at greater risk for blindness due to diabetes than men.

In India, gestational diabetes mellitus (GDM), which affects pregnant women, is of major concern for women and gynaecologists. Fig.1 mentions the management of gestational diabetes. The incidence of GDM has grown fourfold in the past 10 years, according to Dr B Rajkumar, a doctor of Indian systems of medicine at the Keezhariyoor government ayurveda dispensary in the state’s northern coastal district of Kozhikode. According to few medical researchers, the disease that was earlier considered an ailment of the rich, is on the rise in India. Nearly 70 million people, half of them women, in a population of 1.21 billion have diabetes, and the number is predicted to rise to 101 million by 2030.According to a 2012 report published by the Brussels-based International Diabetes Federation,about 60% of diabetics in India have never been screened or diagnosed due to lack of awareness.

 

Figure 1: Management of Gestational Diabetes

As we know, diabetes mellitus is one disorder that has no cure till date. IPSC (Induced Pluripotent Stem Cell) is one such prodigious breakthrough to generate functional insulin -secreting- pancreatic -beta cells. However, there are a lot of lacunas and challenges that have to be addressed in case of IPSC based diabetic therapy. One of the major limitations of this therapy is the lack of supply of pancreatic islets.Moreover, awareness and management of the diabetic condition is becoming more crucial after reports stating the rise in the incidence of gestational diabetes.

Turacoz Healthcare Solutions wishes to spread the awareness on World Diabetes Day, i.e., 14th November. World Diabetes Day is the primary global awareness campaign focusing on diabetes. There are few ways by which this disease can be prevented such as having a balanced diet, exercising regularly, maintaining ideal body weight, avoiding alcohol and tobacco. Also, having regular health checks should be a priority for every individual over the age of 40.

Diabesity

Medical Writing

When the balance of body’s metabolic processes is disrupted, certain conditions arise which are known as ‘metabolic conditions’, of which diabetes and obesity are at top of the list. These two metabolic conditions go hand in hand and are putting a major burden on global healtheconomy. The co-existence of these diseases is collectively known as ‘Diabesity’.According to WHO, the global burden of obesity has raised three times between the year 1975 and 2016, with more than 650 million obeseadults reported in 2016.The number of diabetics has grown from 108 million to 422 million from the year 1980 to 2014. WHO reports that around 50% of deaths in diabetic patients occur before the age of 70 years and it is predicted to be the seventh leading cause of mortalityby 2030. Hence, both diabetes and obesity are counted as the biggest concerns to human health and well-being.

Major reasons behind the raising epidemic status of diabesity include adoption of modern or sedentary lifestyle, fast food habits and relying on technology.Both diabetes and obesity come in a package with other health complications, reduced quality of life, and reduced life expectancy. The major associated challenges include myocardial infarction, cerebrovascular stroke, and renal diseases.

The pathophysiological mechanisms of diabetes and obesity are strongly inter-connected.Insulin resistance and beta cell dysfunction lead to diabetes. Body mass index, the direct measure of obesity, has been found to have positive association with insulin resistance, and consequently with diabetes. In obese people, non-esterified fatty acids, glycerol, hormones,cytokines, and proinflammatory markers are increased, which further lead to development of insulin resistance.Each kilogram rise in bodyweight has been reported to increase the risk of diabetes by 4.5%.

Various medical treatments that improve insulin sensitivity and beta cell functionare available to manage diabetes. Apart from pharmacological approaches, it is also important to practice lifestyle modifications, which not only impart benefits to the treatment, but also improvepatient’s quality of life. Consuminglow-calorie diet,doing regular exercise, maintaining weight, avoiding smoking and regular self-monitoring are highly beneficial in successfully improvement in health status of diabetics and obese patients.

We, at Turacoz Healthcare Solutions, believe that health is real wealth. In an attempt to reduce the global burden of diabetes and obesity, we wish to remind everyone to adopt healthy lifestyle.

Pharmacovigilance Chicago Conference

News

Turacoz represented in 13th Pharmacovigilance Conference in Chicago (27-28 Sep) as Speaker and participated as Panel member for discussion on very interesting topics. It was a platform wherein people from various domains of the industry shared their experience and future perspective related to Pharmacovigilance and it was extremely an honor meeting such brilliant experienced people.

 

Alzheimer’s Disease

Medical Writing

Alzheimer’s Disease (AD) is emerging as one of the critical public health concerns among elderly in various countries around the world including United States (US)and India.It is the fifth leading cause of death among older individuals in US. Over 35 million people worldwide suffer from AD or other forms of dementia. This number is expected to increase over 65 million people by 2030 and 115 million by 2050. In India,14.2% of elderly population is expected to be afflicted with AD by 2020. With the intend to spread awareness about the disease globally,September was launched as World Alzheimer’s month in 2012 and since then 21st September has been marked as World Alzheimer’s Day.

AD poses a significant burden on individual’s physical, social, mental and financial well being. It is characterized by degeneration of nerves which manifests itself as episodes of memory loss in initial stages. As the disease progress, individual have trouble in planning or solving problems, becomes confused with time or place, have mood swings and changes in personality. Person may face problems in speaking or writing and has decreased judgement4. These symptoms worsen with the progression of disease. During the final stages of disease, individual’s ability to communicate is lost and often become bed-ridden, and need around-the-clock care.

The cause of disease is multifactorial, with risk factors like age, gender and genetics being non-modifiable. AD is commonly seen in older age group, prevalent among females and associated with apolipoprotein E gene. The modifiable risk factors associated with disease includes education, lifestyle factors like smoking and conditionssuch as diabetes, hypercholesterolemia,and hypertension. It has been suggested by studies that people with low educational attainment are at increased risk of developing AD. Education develops the cognitive features of individuals, thereby decreasing the risk of AD. Modification in lifestyle can further, reduce the risk of development of AD. Regular aerobic exercise and physical activity serves to improve cognitive function and decrease the risk of disease. It is further suggested that proper prevention or management of above mentioned lifestyle conditions may decrease the likelihood of AD development. Further, eating healthy diet, and specific adherence to Mediterranean diet, with adequate dietary and vitamin supplements can help prevent occurrence of AD.

Alzheimer’s Disease (AD) is an emerging threat to health amongst elderly. Turacoz Healthcare Solutions (THS) aims to spread awareness about Alzheimer’s Disease amongst masses. Let’s unite and spread awareness to prevent Alzheimer’s disease.

Clinical practice guidelines (CPGs)

Medical Writing

Healthcare professionals are expected to provide the best evidence based care to the patients. However, due to continuous medical advancements, it becomes challenging for the clinicians to keep abreast with the new developments and implement them in everyday practice.

Clinical practice guidelines (CPGs) have become increasingly important in the healthcare practice. They are evidence-based recommendations, intended to standardize treatment and provide high quality care to patients. These guidelines are a tool for translating research findings into clinical practice, thus, bridging the gap between what clinicians do and what scientific evidence supports. There is growing evidence that developing and adhering to CPG, can reduce practice variation, and improve outcomes and cost effectiveness of healthcare.

World over, physicians, healthcare organizations, professional societies, disease advocacy groups, government appointed workgroups etc. have been involved in developing CPG to standardize clinical practices.

Greater adherence to CPG is critical to improving healthcare processes and achieving the best patient outcomes. Now, the question arises, why these guidelines need to be followed? They are designed to:

  • Improveclinical outcomes
  • Provide easy access to quality information, so that clinicians have a wide range of options for patient care, improving efficiency and consistency of care
  • Helping clinicians stayapprised of the new developments, by use of up-to-date guidelines
  • Improve patient safety and quality of life by facilitating the treatment of patients based on the summary of benefits and limitations of interventions and procedures
  • By finding gaps in current knowledge, research activities can be prioritized

Some of the practitioners believe that guidelines are cookbook medicines, not allowing them to make their own independent decisions. The other reasons for non-adherence to these guidelines could be lack of awareness, lack of transparency in guideline development, lack of relevance to clinical practice, complex and conflicting guidelines, and lack of insufficient access to guidelines at point of care.

The development of a good guideline, includes, healthy participation of key stakeholders, access to accurate, credible, up-to-date,relevant scientific information, correct interpretation of the available evidence, clinical flexibility, and use of proper tools for implementation and monitoring in day to day practice. The guidelines must be clearly expressed in a user-friendly, logically organized format,written in anunambiguous, easy to follow language, and with clear links of recommendations to the available evidence.

To ensure improved care outcomes, emphasis should be placed on effective guideline implementation and evaluating their effectiveness in real world clinical settings. The guidelines should be evaluated for practicality and significance, projected benefits and harm,quality and strength of the scientific evidence and should be periodically updated to keep pace with latest advancements in the field of medicine.

Given the large number of guidelines, following are the key questions, one should keep in mind while reviewing any guideline:

  • Who developed the guideline?
  • Was systematic review of the literature carried out?
  • Were the recommendations valid?
  • Were all relevant outcomes (overall survival, impact on quality of life, absence of complications etc.) considered?
  • Does it report conflict of interest and how was it managed?
  • When was the guideline last updated and assessed for validity?

Turacoz Healthcare Solutions, understands the importance of clinical practice guidelines in improving healthcare standards and patient outcomes and recommends strict adherence to them.

Summing up Results of Research with Meta-Analysis: How it is Done and Why is it Important?

Awareness Day/Month, ,

We all are aware of the different types of publication documents, and meta-analysis is one of those documents with the highest level of evidence (Figure). Meta-analysis is a statistical analysis that combines or integrates the results of several independent clinical trials considered by the analyst to be combinable. It usually aims to resolve controversy over true effect, when results of individual studies are variable; and validate a statistically non-significant but clinically important result of small studies.

A meta-analysis usually considers the main outcome of the overall magnitude of the effect. The process of conducting a meta-analysis is often rigorous and well defined which leaves very less opportunities for bias to distort the results. While systematic reviews summarize the medical literature textually, meta-analyses statistically summarize results to obtain overall estimate of treatment effect.

Conducting a Meta-analysis

Over the years, the methodologies involved in conducting meta-analyses have changed. The Cochrane Collaboration has been the most important contributor to streamline and validate the procedures involved in conducting a meta-analysis. Major contributions of the Cochrane Handbook include development of protocols which describe literature search, and analytic and diagnostic methods for evaluating the output of meta-analyses. Additionally, the PreferredReporting Items for Systematic reviews and Meta-analyses(PRISMA) statement provides a more robust procedure in which meta-analyses can be conducted. Steps involved in a meta-analysis include:

A sound literature search is the key to achieving robust results. A clear definition of the hypotheses to be investigated can provide the framework for the overall process to be followed in a meta-analysis. The PRISMA statement recommends inclusion of PICOS (Participants, Interventions, Comparators, Outcomes, and Study Designs) explicitly in the research question. Inclusion of PICOS incorporates all aspects being considered for the selection of studies which further helps in searching for studies with specific information/results. Searching most electronic databases with relevant search terms is important to identify articles. However; identifying appropriate search terms is the first step to achieving this. According to the PRISMA statement, complete search strategy used for at least one electronic database must be reported.

The quality assessment of studies to be included is done by evaluating each study for the eligibility for inclusion, study bias, study quality, and reported findings. Often, two independent reviewers are involved in assessing the study quality of the included studies. This assessment basically provides insights to the degree to which the trial design, conduct, analysis, and presentation have minimized or avoided systematic biases.Several tools are available to assess the study quality of which JADAD, and QUADAS are a few to name.

Data extraction decides the result of the meta-analysis. Important data which requires to be collected includes study design, description of study groups, diagnostic information, treatments, length of follow-up evaluations, and outcome measures. Sometimes, data extraction may pose a challenge when studies use different outcome metrics. In these cases, the data must be converted to a uniform metric for easy pooling.

Measuring inter-study heterogeneity is very important to understand whether the data of the meta‑analysis has addressed the two most important questions:

  1. What is the overall relationship between the treatment/intervention/ exposure and the health outcomes?
  2. Is this association consistent across the studies that constitute the systematic review and meta-analysis?

Heterogeneity can be addressed by checking if the data is correct, analyzing variation in results of the study, further exploring heterogeneity by conducting sub-group analysis/ meta‑regression, using analysis procedures which ignore heterogeneity, change the effect measure, and finally exclude the studies which may create conflict.

The data analysis is very complex and involves several analysis techniques. This is usually done using the random effects model or the fixed effect model. The random effects model is used when there is considerable heterogeneity in the studies included while fixed effects model is used when the overall outcome is similar in all studies included. Meta-analyses may also include sensitivity analysis which is a repeat meta-analysis substituting alternative decisions and a meta-regression in which the outcome variable is predicted according to the values of one or more explanatory variables.

Interpretation of the analyzed results must provide answers which are relevant to the context of the current healthcare, state the methodological limitations of studies, consider size of effect in studies and review, their consistency and presence of dose-response relationship, consider interpreting results in context of temporal cumulative meta-analysis, make recommendations that are clear and practical, and finally propose future research age.

In conclusion, conducting a meta-analysis can prove beneficial as it summarizes the overall results in an area of research. However; it must be noted that a single study cannot provide definitive conclusions. In addition, larger randomized controlled trials may sometimes contradict to the results of a meta-analysis. Meta-analysis can summarize the results of studies with varying sample size, diverse populations across different ages which provide an opportunity to explore newer hypotheses. Having said that, meta-analysisstill remains the most important and efficient tool in adding value to the already available evidence. Turacoz Healthcare Solutions (THS) provides guidance in understanding the different attributes of a meta-analysis and its finer details.

Current Scenario of Medical Device Industry in India

Medical Writing

The Indian healthcare industry is on a high growth trajectory and undergoing transformation across the continuum since the last decade. Technology is redefining the possibilities in healthcare delivery and expanding global industry leadership of the healthcare sector while seeking elusive solutions for addressing India’s needs. With the recent approval of National Health Policy 2017 by the Government of India, healthcare expenditure intends to increase to 2.5% of gross domestic product (GDP)and India embarks on a planned approach to bridge the healthcare divide while maintaining industry competitiveness.

Medical device industry is rapidly moving into an era of growth driven by unmet clinical needs and greater focus on domestic manufacturing. Indian medical devices market is the 4th largest in Asia and in the list of top 20 in the world.1 The medical device sector represents 9% of the overall Indian healthcare industry. It was estimated at the value of USD 4 billion in 2014 and is growing at a compounded annual growth rate (CAGR) of 16% over the period of five years.2

Key Driving Factors of the Medical Device Industry

Key Driving Factors of the Medical Device Industry

In current scenario, there is an immense need to use medical devices effectively to address the huge gap between demand and supply of healthcare services in India. The medical devices sector in India is at a nascent stage with most of the indigenous manufacturing restricted to medical consumables. In true sense, imports still constitute over 75% of the current medical devices market. India is looking forward to improving self-sufficiency in medical devices as a part of the “Make in India” initiative.

The rapidly expanding sector presents immense opportunities to local manufacturers and startups as well global players. There is a big shift in health burden from communicable to non-communicable diseases, which in turn is driving key medical devices segment. There is a huge demand for both cutting‑edge precision technologies as well as affordable low technology. The Indian medical device innovation ecosystem is fast evolving with academic research, venture capital firms, government funding, and promising startups which are developing products specifically for the Indian market. Innovation is a transforming force across the industry to propel growth, improving value, creating sustainable business opportunities, and expanding “Make in India” drive.

Although there is robust growth across segments, new challenges abound which need attention from both policymakers and industry to sustain the momentum across segments.Major hurdles that slow the growth pace of the medical device industry arethat of price control and uncertainty about the effect of new Medical Device Rules, 2017 which will be applicable from 1st Jan 2018.Despite the above challenges, medical device represents the segment where greater change and growth is expected in coming future.

Turacoz Healthcare Solutions, as a knowledge partner of the medical device companies are well equipped to raise up to the occasion and support the industry with a wide range of service spectrum. Our regulatory experts can give consultancy services for global regulatory strategies development and medical device approval and registration, and provide support for Indian market with registration and approval in India (Form 41), manufacturing license (Form 28), import license (Form 10), CE Marking / European MDD Compliance, and FDA 510(k) Notifications / PMA Submissions.

Feel free to reach out at [email protected] for any query or RFI/RFP related to medical devices.

 

1IBEF Healthcare Report 2017

2FICCI and Quintiles IMS reports

Importance of Good Oral Health

Health & Fitness

Oral health is an integral part of our general health, yet is the most neglected one. The Indian Dental Association (IDA), in a National Oral Health Survey, 2005, highlighted that 95% of the Indian population suffers from gum diseases and only 50% of the population use a toothbrush. The survey also noted that, only 2% of the population visit the dentist.

A good oral health plays an important role in overall health improvement, improving quality of life, boosting of self-confidence and performance enhancement at workplace. However, the irony lies in the factthatmost people remain unaware of the benefits of maintaining a good oral health. Further, individual’s lack of knowledge, a neglecting attitude, and inadequate oral hygiene practices adds to the oral health problems.

Pyorrhea (periodontitis), tooth decay/ cavities, misaligned teeth, and oral cancer are amongst the most common oral health problems affecting people worldwide as well as in the India. It has also been proved by researchers and has been widely accepted by doctors/ dental professionals worldwide that oral and general/systemic healthshare a two-way relationship between them. This means that oral diseases especially,pyorrhea may predispose an individual to different systemic diseases such as uncontrolled blood sugar levels/ diabetes, hypertension, heart diseases and many more. The implications of poor oral health have been shown in Figure 1. Similarly, systemic diseases especially diabetes may also lead to/ worsen oral diseases especially, pyorrhea/ periodontitis. Thus, to keep ourselves healthy, it is very important to maintain an adequate oral health.

Figure 1 : The implications of poor oral health