Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 22nd publication JOOO Innovative -2nd name

JournalofOralMedicine,OralSurgery,
Voulme3 Issue4 October-December2017
OralPathologyandOralRadiology
ISSN:2395-6186
e-ISSN:2395-6194

Journal of Oral Medicine, Oral Surgery, Oral, Pathology and Oral Radiology
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King George Medical University,
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ORAL PATHOLOGY & MICROBIOLOGY ORAL MEDICINE & RADIOLOGY
Dr. Harkanwal Preet Singh Dr G Komali
Dasmesh Institute of Research and Dental
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Jaipur Dental College - Rajasthan
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ORAL & MAXILLOFACIAL SURGERY
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Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology
Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology, 2017; 3(4)
Volume 3 Issue 4 October-December 2017
CONTENTS
Original Research Articles:
Evaluation of Efficacy of Antibiotic Therapy Post Extraction 187-189
Meka Sridhar, Rahul VC Tiwari, Raviteja painam, Anand Vijay Somuri, Vijay K Thumpala
Evaluation of Association between Periodontitis and Early Carotid Atherosclerosis– 190-196
A Clinico-Biochemical Study
Harini.K, Lalith Vivekanand, Aparna Rahul, Shruthi Hegde, Vidya Ajila
A prospective double blind clinical comparative study of extraction socket healing 197-201
in patients with Type 2 diabetes on oral hypoglycemic drugs
Hemanth Kumar HR, Vinuta Hegde
Effects of Lignocaine with Adrenaline on Blood Pressure and Pulse Rate in Normotensive 202-204
and Hypertensive Patients Undergoing Extraction: A clinical Study
Anil Kumar Karanam, Bujunuru Sridhar Reddy
Histopathological correlation with computed tomography in respect to evaluation of 205-208
Paranasal sinus diseases
Krishnakant Vaghela, Bhaven Shah
Patterns of pediatric facial fractures: A five year retrospective study 209-213
Ali Mohammad Ali Al-Dheer, Hassan M Abouelkheir, Mahmoud Talaa
Antibacterial Effect of Juglans Regia L. Bark extract at different Concentrations 214-217
Against Human Salivary Microflora
Tuqa Aldawood, Alaa Alyousef, Shima Alyousef, Nora Aldosari, Sara Hussam,
AlaaAlhadad, Fikrat Bhaian, Dalia Sharaf Eldeen, Nishanth Sayed Abdul
Review Articles:
Ultrasound as Diagnostic and Therapeutic Aid-A boon in the field of Dentistry: 218-221
A Brief Review
Madhukar Nayaka Chandrabanda, Sujata Byahatti, Renuka Ammanagi
Duloxetine- a novel therapeutic regimen for Trigeminal Neuralgia 222-224
Akhilanand Chaurasia
Case Reports:
Keratocystic Odontogenic Tumour: -An Unusual Presentation 225-227
Arush Thakur, Jagdish Vishnu Tupkari, Tabita Joy, Shraddha C. Jugade,
Natarajan Chellappa
Tubercular osteomyelitis of the mandible– A Case Report 228-230
Arush Thakur, Jagdish Vishnu Tupkari, Kavita R Wadde, Monali Patil, Nazmul Alam

Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology
Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology, 2017; 3(4)
Bilateral inferiorly based nasolabial flaps for the management of
“Oral submucous fibrosis”: A case report 231-233
Amit Sangle, Aruna Tambuwala, Ashvini Kishor Vadane, Shailly Dwivedi
Mammary Analogue Secretory Carcinoma - A Case Report 234-237
Nandhini.V

Original Research Article
Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology, 2017; 3(4):187-189 187
Evaluation of Efficacy of Antibiotic Therapy Post Extraction
Meka Sridhar1
, Rahul VC Tiwari2,*
, Raviteja painam3
, Anand Vijay Somuri4
, Vijay K Thumpala5
1
Professoer, 2,3
PG Student, 4
Reader, 5
PG Student, Dept. of Oral & Maxillofacial Surgery, Guntur, Andhra Pradesh
*Corresponding Author:
Email: drrahulvctiwari@gmail.com
Abstract
Background
It is always a question whether to prescribe antibiotics post extraction in clinicians mind whereas an antibiotic in the market acts
on various methods.
Aim
The main aim of this clinical study was to evaluate the efficacy of antibiotic therapy on post extraction healing of socket and
infection after routine dental extraction.
Material and Methods
100 patients presenting to department of oral and maxillofacial surgery, Sibar institute of dental sciences, Guntur with no
systemic illness were divided into two groups in which antibiotics were prescribed and not prescribed respectively. All the
extraction cases were performed by a single oral and maxillofacial surgeon to remove the bias in the study. In group I all the
patient were prescribed Cap. Amoxicillin 500mg TID for three days. Post extraction healing of the socket and infection was
evaluated with an intermediate follow up till one month.
Results
50 patients in group I were prescribed antibiotics and 50 patients in group II were not prescribed antibiotics post extraction. All
the patients of group II had uneventful healing of extraction socket and none of the patient encountered infection. There was
delay in healing in 2 male patients in group II due to history of smoking.
Conclusion
Our study concluded that no post-operative antibiotics are required after routine dental extractions in normal healthy patients. So,
we advise clinicians for appropriate use of antibiotics whenever necessary after routine dental extractions.
Keywords: Antibiotics, Dental Extractions, Post Extraction, Complications.
Introduction
It is at utmost important thing to understand the
requirement of antibiotics whether to prescribe or not
and if yes then which one to prescribe. In normal
routine extractions when patient is systemically well,
non-usage of antibiotics after dental extraction have
been described in published literature. Antibiotics are
chemical substances available from a mould or
bacterium that can kill microorganisms and cure
bacterial infection.(1)
Antibiotics are used since years
and are a historical evidence of medicine regularly used
by clinicians. Antibiotics are also used prophylactically
which refers to their administration via various routes
pre operatively to prevent an infection which can occur
post-operatively. In routine dental procedures
performed under local anesthesia on normal healthy
patients, prophylactic antibiotics are usually not
required. In some dental procedures where chances of
encountering blood are present clinicians prefer to
provide prophylactic antibiotics. Antibiotics after
routine dental extraction are prescribed to patients to
prevent post-operative infections and to promote post-
operative healing of the socket. Although extraction
sockets are considered contaminated wounds still the
organisms present in our oral cavity are a part of normal
oral flora and therefore they are an unusual source of
post extraction infection.(2)
It is advisable to prescribe
antibiotics in case of dental infection. Even
prophylactic antibiotics are used in infected cases prior
to dental extraction. If antibiotics are not prescribed
prophylactically in infected cases, routine dental
extraction may aggravate the infectious stage.
Aims and Objectives
The aim of this randomized clinical trial was to
evaluate the efficacy of antibiotic post extraction with
objectives of assessing the post-operative healing and
presence or absence of post-operative infection.
Material and Method
100 patients presenting to the outpatient
department of oral and maxillofacial surgery, Sibar
institute of dental sciences, Guntur from March 2017 to
April 2017 were enrolled in the study with an inclusion
criteria of patients requiring routine dental extractions.
Patients with any systemic illness and patients who are
allergic to antibiotics were excluded from the study. A
proper complete clinical case history were obtained
from the subjects. All the necessary investigatory
hematological investigations like complete blood
picture including vitals and radiological procedures like
intra oral periapical radiographs were taken. Patients
were in between age group of 25-55 years of age.
Patient with extraction of one multi rooted tooth were
included. All the cases were extraction of posterior
molar teeth. Patients were informed about clinical trial

Rahul VC Tiwari et al. Evaluation of Efficacy of Antibiotic Therapy Post Extraction
and informed consent was taken prior performing the
procedures. All the patients were operated under local
anesthesia for extraction of tooth. All the 100 patients
were randomly divided into two equal groups. Group I
i.e. case group consists of 50 subjects in which
antibiotics were prescribed post extraction. All the
extraction cases were performed by a single oral and
maxillofacial surgeon to remove the bias in the study.
All the 50 patients of group I were prescribed with Cap.
Amoxicillin 500mg TID for three days. Group II i.e.
control group consists of 50 subjects who were not
advised antibiotics post extraction. All the 100 patients
were properly explained all the post-operative
instructions to be followed after routine dental
extractions. A proper follow up of both the groups was
performed after 3 days, 7 days/1 week and 30 days/1
month post extraction. The two parameters were post-
operative healing of the socket and post-operative
infection. An eventful healing was graded 1 and
uneventful healing was graded 2. Post-operative
infection if present was graded 1 and if absent was
graded 2 in follow up. Descriptive statistical analysis
was used for comparision and statistical analysis was
done after data collection using statistical package for
the social sciences version 21.
Results
A total of 100 patients were enrolled in the study.
50 patients in group I and 50 patient in group II were
followed up. There was 100% response rate from the
subjects. Subject age ranges from 28 yrs. to 66 yrs.
Majority of the subjects were in the age of 40-50 yrs.
There were 54 females and 46 males. All the patients
had single tooth extraction with 63 cases of mandibular
teeth and 37 cases of maxillary teeth. In 63 mandibular
teeth, 44 were mandibular posteriors and 19 were
mandibular anteriors. In 37 maxillary teeth, 26 were
maxillary posteriors and 11 were maxillary anteriors.
Most common etiological factors were dental caries and
periodontally compromised tooth. In total, 4 cases were
having habit of smoking and 7 cases of alcohol
consumption, 2 cases of smoking and 3 cases of alcohol
consumption in group II. The data analysis showed no
post-operative infection and uneventful healing of
extraction sockets in both the groups. Only 2 cases in
group II were smokers and showed delayed healing.
There was no statistically significant difference in
groups of any of the variables compared (p>0.05).
Discussion
As the definition of extraction elicits that tooth
extraction should be a painless procedure without
harming the adjacent tissues so that healing will be
uneventful and the further prosthesis will be better.(3)
Different studies and ample of literature is available
regarding extractions, its etiology, techniques,
pharmacology, healing and complications. There were
two parameters which were examined in the study in
two different groups. In group I where post extraction
antibiotics were given, none of the case in 50 cases had
any post-operative complications and all the cases had
uneventful healing. In group II, same data was obtained
as group I form the patients in follow ups. None of the
patient had post-operative pain or infection or any other
complications. Healing of the socket was uneventful
except two cases who had delayed healing due to
smoking comparative over 48 cases of group II who
had normal healing. A similar study in other parts of the
world has also been performed to evaluate the efficacy
of antibiotics post operatively. A double blind
randomized controlled trial was performed in 150 cases
and patients were divided into two equal groups. Group
1 was given metronidazole which is an anaerobic
antibiotic for 5 days post-operatively and group 2 was a
placebo group where they gave identical looking
placebo drugs rather than antibiotics. Their study
resulted in 86% healing and 14% complications. In
placebo group they found 5 subjects of actually
inflamed socket as a most common complication. They
concluded that prescription of antibiotics after routine
intra alveolar dental extraction in healthy patients may
not play any significant role in wound healing
complications.(4)
A review in Nigerian population was
done regarding indication for extraction of 3rd
molar in
1763 cases. They found 89% uneventful healing socket
and 11% complications which was almost equally
distributed among dental caries and periodontitis.(5)
Some studies have found dry socket as most common
complication post extraction.(6)
A study on clinical
evaluation of post extraction site wound healing also
concluded the same with 11% of alveoli healing
complications in 282 subjects with 318 extraction
sites.(7)
Similar studies like Nigerian population is also
done in Chinese population but to evaluate the healing
of post extraction sockets and found 87.5% uneventful
healed sockets and 12.5% complicated sockets in the
groups. They used the clean and sterile gloves as their
differentiation criteria for extraction.(8)
In study on
Iraqian population concluded with 89.3% healing and
10.7% complicated sockets.(9)
A controlled trial done by
Murli et al to understand the need of antibiotics during
routine dental extractions concluded a contrast results
in which he reported pain and possible healing
complications of about 24% in the antibiotic group and
only 6% in the placebo group. The author has not
mentioned the reasons of complication.(10)
A
randomized controlled clinical study was done in 262
patients unequally divided into two groups as group 1
with case and group 2 with control group. They find
only 3% minor complications and delayed healing in
the group where antibiotics were not given.(11)
A study
on 520 patients after consecutive dental extraction
surgeries reported pain as the most common
complication.(12)
Our study was almost similar to the
studies published in the literature but small sample size,
duration of performed procedure and trauma caused due
to the extraction are not considered which are the
limitations of the study.

Rahul VC Tiwari et al. Evaluation of Efficacy of Antibiotic Therapy Post Extraction
Conclusion
As per the planned study we found an uneventful
healing no post-operative complication in the group II.
According to published literature and results of our
study we suggest that there is no need of antibiotics
post routine dental extraction in normal healthy
patients.
References
1. The Oxford English Dictionary. 2nd ed. 1989. OED
Online. Oxford University Press. 30 April 2007.
http://dictionary.oed.com.
2. Laskin DM. Should prophylactic antibiotics be used for
patients having removal of erupted teeth? Oral Maxillofac
Surg Clin North Am 2011;23:537–9.
3. Howe GL. The extraction of teeth. 2nd ed. Bristol, UK:
John Wright and Sons;1970:1–4.
4. Gbotolorun OM, et al. Are systemic antibiotics necessary
in the prevention of wound healing complications after
intra-alveolar dental extraction? Int J Oral Maxillofac
Surg.2016;45:1658-1664.
5. Adeyemo WL, James O, Ogunlewe MO,Ladeinde AL,
Taiwo AO, Olojede ACO. Indications for extraction of
third molars: a review of 1763 cases. Niger Postgrad Med J
2008;15:42–6.
6. Peterson LJ. Contemporary oral and maxillofacial surgery.
4th ed. Philadelphia: Mosby Inc.;2003:113–83.
7. Adeyemo WL, Ladeinde AL, Ogunlewe MO. Clinical
evaluation of post extraction site wound healing. J
Contemp Dent Pract 2006;7:40–9.
8. Cheung LK, Chowe LK, Tsang MH, Tung LK. An
evaluation of complications following dental extractions
using either sterile or clean gloves. Int J Oral Maxillofac
Surg 2001;30:550–4.
9. Jabbar JK. Post-operative complications associated with
non-surgical tooth extraction. Mustansiria Dent J 2008;
5:104–12.
10. Murali R, Satish K, Vinay KN. Controlled trial to
understand the need for antibiotics during routine dental
extractions. e- J Dent 2011;1:87–90.
11. Akinbami BO, Osagbemiro BB. Is routine antibiotic
prescription following exodontias necessary? A
randomized controlled clinical study. J Dent Oral Hyg
2015;7:1–8.
12. Bortoluzzi MC, Manfro AR, Nodari RJ, Presta AA.
Predictive variables for postoperative pain after 520
consecutive dental extraction surgeries. Gen Dent 2012;
60:58–63.

Evaluation of Association between Periodontitis and Early Carotid
Atherosclerosis – A Clinico-Biochemical Study
Harini.K1,*
, Lalith Vivekanand2
, Aparna Rahul3
, Shruthi Hegde4
, Vidya Ajila5
1
Assitanat Professor, 2
Associate Professor, 3
Professor, 4,5
Associate Professor, Dept. of Periodontics, Mr. Ambedkar
Dental College, Bangalore, Karnataka
Email: harinikeshav@gmail.com
Abstract
Background & Objectives
A mechanism has been proposed whereby periodontitis contributes to the process of thermogenesis and
thromboembolic events. The purpose of the present study is to evaluate the association between periodontitis and early
carotid atherosclerosis in systemically healthy individuals.
Material and Method
Sixty patients aged between 18–50 years, with BMI ranging between 25-30 kg/m2
and systemically healthy were
included in the study. Based on the clinical parameters subjects were grouped into test group and control group. All the
patients were subjected for blood investigations to assess lipid profile and ultrasonography of common carotid artery to
assess the Intima Media Thickness. Descriptive statistical analysis has been carried out in the present study.
Results
Data analysis showed that subjects with periodontitis from test group had statistically significant increase in
Carotid Intima Media Thickness when compared to the subjects without periodontitis from control group. It was found
that in test group the values of Total Cholesterol, Triglycerides, LDL, and VLDL were higher than values found in
control group. However significant differences were observed only with triglycerides and VLDL levels.
Conclusion
Periodontitis is associated with increased carotid IMT showing early carotid atherosclerosis.
Keywords: Carotid Intima Media Thickness, Lipid profile, Chronic Periodontitis, Sub Clinical Atherosclerosis.
Introduction
In the last ten years, several epidemiological
studies have assessed the association between oral
infection and systemic disease. Studies have
provided support that oral infections, specifically
periodontitis, may present independent risks for
different systemic conditions like, diabetes
mellitus, cardiovascular diseases, pulmonary
infections, pre-term low-weight births and
osteoporosis. Since cardiovascular diseases are the
leading cause of death worldwide, greater attention
has been focused on evidence that infections of the
oral cavity might be associated with
atherothrombosis: heart infarction, stroke, and
peripheral vascular disease.(1)
The conservative risk factors for atherosclerosis are
well understood, but they can account for only
about 50% to 70% of atherosclerotic events in the
general population.(2)
Among the panel of novel
risk factors, dental and periodontal disease are
potential candidates.(3)
Accumulating evidence
suggests that dental and periodontal diseases are
potentially associated with atherosclerosis.
There are several possible explanations for the
association between periodontal disease and
complications of atherosclerosis. First, it may
merely reflect confounding by common risk factors
such as smoking, obesity, and diabetes. Second, the
association may reflect an individual propensity to
develop an exuberant inflammatory response to
intrinsic (age, sex, genes) or extrinsic stimuli (diet,
smoking, etc).Third, an inflammatory focus in the
oral cavity may stimulate humoral and cell-
mediated inflammatory pathways. Fourth, the
presence of periodontal infection may lead to brief
episodes of bacteremia with inoculation of
atherosclerotic plaques by periodontal pathogens.(3)
Atherosclerosis, unless in a severe form, is often
asymptomatic, so that a direct examination of the
vessel wall is necessary to detect affected
individuals in the early stages. Measurement of the
intima-media thickness (IMT) of the common
carotid artery (CCA) by B-mode ultrasound was
found to be a suitable non-invasive method to
visualize the arterial walls and to monitor the early
stages of the atherosclerotic process. Carotid intima
media thickness is considered as a surrogate
marker of atherosclerosis. Increase in carotid
intima media thickness is associated with an
increased risk of Ischemic heart disease (IHD) and
Cerebrovascular disease (CVD) in periodontitis
patients.
Several studies have indicated that severe
periodontitis is associated with a modest decrease
in high density lipoprotein (HDL) cholesterol,
increase in low density lipoprotein (LDL)

Harini .K et al. Evaluation of association between periodontitis and early carotid…
cholesterol, and a more robust increase in plasma
triglycerides. However, it is unclear whether
periodontitis causes an increase in levels of serum
lipids or hyperlipidemia is a risk factor for both
periodontitis and cardiovascular disease.(4)
Thus to investigate the role of hyperlidemia in
periodontitis and early atherosclerosis there is a
need to correlate between serum lipid levels and
carotid intima media thickness values. In this study
the association between periodontitis and early
atherosclerosis in systemically healthy individuals
was evaluated. Aim of this study was to evaluate
the association of periodontitis with Carotid
Intima- Media Thickness (IMT) and to compare the
values in Lipid Profile and Body Mass Index
(BMI) between test group and control group.
Methodology
This study included Sixty patients visiting to the
Department of Periodontics.
Inclusion Criteria
1. Both male and female patients aged 18-50 years
participated in the study.
2. Patients having BMI ranging between 25-30
Kg/m2.
3. Systemically healthy subjects.
Exclusion Criteria
1. Pregnant or Lactating women and smokers.
2. Patients with history of any antibiotics therapy 3
months prior to study enrolled or any other
regular medication.
3. Patients who underwent periodontal therapy for
last six months.
Method of Collection of Data
Patients visiting the outpatient of
Department of Periodontics were screened for their
Body Mass Index (BMI). BMI was calculated by
measuring height of the patient in meter and weight
of the patient in Kilogram. BMI was calculated
using WHO formula (Kg/m2
). Sixty patients whose
BMI was ranging between 25-30 Kg/m(2)
according
to the WHO chart were included in the study. The
nature and purpose of the study was explained to
the patients and written consent was obtained. Oral
health status examination was carried out for all the
patients.
Periodontal status was assessed by following
parameters
1. Plaque Index by Sillness and Loe (1964).(5)
(PI)
2. Gingival Sulcus Bleeding Index by Muhlemann
.H.R. and Son.S (1971).(6)
(BI)
3. Mean probing pocket depth. (PPD)
4. Mean clinical attachment level. (CAL)
After screening, sixty patients were segregated into
test group and control group consisting 30 patients
in each.
Criteria for test group and control group were as
follows.
Test group
Generalized chronic Periodontitis.
1. With probing depth ≥ 5mm in > 30% of the sites
2. With clinical attachment loss > 30% of the sites .
Control group
Periodontally healthy individuals.
1. With probing depth < 3mm.
2. With no clinical attachment loss.
Both the groups were subjected for
ultrasonography for the assessment of Carotid
Intima-Media Thickness (IMT) and Lipid Profile.
Measurement of PPD
Probing Pocket depth measured was the distance
from the free gingival margin to the base of the
sulcus or pocket. 0-3 mm is normal gingival sulcus
and >3mm probing depth was considered as
periodontal pocket. The pocket depth was measured
by using Williams’s graduated periodontal probe at
six sites i.e. Distobuccal, midbuccal, mesiobuccal,
distolingual, midlingual and mesiolingual of each
tooth. All six measurements were added and divided
by the number of sites examined i.e. 6 to obtain the
mean probing depth for an individual tooth.
Measurement of Carotid IMT
Carotid IMT was assessed by a single
experienced MD Radiologist at Clumax
Diagnostics in Bangalore. In each group, Carotid
IMT was bilaterally assessed by using B mode
ultrasonograghy at the common carotid artery in
both the groups, using high frequency linear probe
(4- 5.5 MHz), with the patient in supine position
and the examiner seated near the patient’s head.
Tilting the patient’s head away from the side being
examined facilitates neck exposure. With this
technique, two parallel echogenic lines separated
by an anechoic space can be visualized at levels of
the artery wall. These lines are generated by the
blood-intima and media-adventitial interfaces.
Carotid IMT was measured with an orthogonal
incidence of the ultrasonic beam to the axial course
of the artery, on a 10mm segment of the far wall of
the common carotid artery using software. The
average of both right and left IMT was considered
for statistical analysis.

Fig. 1 Mean CIMT in different groups. Mean
CIMT value is greater in the test group
compared to th control group.
Fig.2 Ultrasonogram image of LEFT CIMT
Fig.2 Ultrasonogram image of LEFT CIMT
Collection of blood sample for lipid profile
Under aseptic measures, venous blood
samples were drawn by venipuncture in antecubital
fossa using 5ml syringe and collected in a plain
vacuum tubes and transported to clinical laboratory
for lipid profile analysis.
Ethical clearance
Ethical clearance was obtained from the
institutional ethical committee.
Statistical analysis
Descriptive statistical analysis has been carried
out in the present study. Results on continuous
measurements are presented on Mean  SD (Min-
Max) and results on categorical measurements are
presented in Number (%). Significance is assessed
at 5 % level of significance. Analysis of covariance
was carried out to adjust for the effect of
significant age and gender difference among the
groups. Chi-square/ Fisher Exact test has been used
to find the significance of study parameters on
categorical scale between two or more groups.
Partial correlation of study variables with CIMT
was performed after controlling for age.
Results
Total 60 patients aged between 18-50 years
with BMI ranging between 25-30kg/m(2)
were
examined. Clinical parameters like PI, BI, PPD and
CAL, Lipid profile and CIMT were compared
between control and test group to find any
association present between periodontitis and
carotid atherosclerosis. Age was distributed into
four groups for observation where in the control
group 20(66.7%) patients were in the age group of
21-30 yrs and in the test group 18(60.0% ) patients
were in the age group of 41-50 yrs. It was found
that in control group out of 30 subjects 22(73.3% )
were females and 8(26.7% ) were males. In the test
group 19(63.3%) were males and 11(36.7%) were
females. Even though Periodontal disease is age
related, since the criteria for inclusion of subjects
to this study was based on only BMI (overweight
subjects), age and gender were not statistically
matching. However, since the groups were
different in age and gender distribution, Analysis
of Covariance was employed for the comparison of
groups, as it adjusts for the effects of age and
gender.
Table.1 Age distribution
Age in years Control group Test group
18-20 6(20.0%) 0
21-30 20(66.7%) 2(6.7%)
31-40 4(13.3%) 10(33.3%)
41-50 0 18(60.0%)
Total 30(100.0%) 30(100.0%)
Mean ± SD 24.27±5.36 42.67±6.12

Table.2 Gender distribution
Gender Control group Test group
Male 8(26.7%) 19(63.3%)
Female 22(73.3%) 11(36.7%)
Total 30(100.0%) 30(100.0
Table.3 Clinical parameters of the subjects (Mean  SD)
Control group Test group p value F value
BMI (kg/m2
) 27.02±1.35 27.46 ±1.87 0.202 1.59
PI 0.88±0.42 1.03±0.28 0.020* 3.54
GI
0.30±0.22 0.67±0.34
<
0.001**
8.3
PPD(mm)
1.25±0.37 2.69±0.87
<
0.001**
25
CAL(mm)
0.000 1.67±1.3
<
0.001**
16.8
Table no 3 shows the mean BMI, Plaque
Index, Gingival Sulcus Bleeding Index (BI),
Probing Pocket Depth (PPD), Clinical Attachment
Level (CAL) of control group and test group. Mean
BMI of control and study group was
27.02±1.35kgm2
and27.46 ±1.87kg/m2
respectively
showing p value 0.202 and F value 1.59.Clinical
parameters like PI, BI, PPD and CAL were
assessed in both the groups. Results showed that
mean Plaque index (PI) in the test group was
1.03±0.28 which was moderately significant with
the p value 0.020 and F value 3.54 when compared
with control group in which mean PI was
0.88±0.42. Mean Gingival Sulcus Bleeding Index
(BI) in the test group was 0.67±0.34 which was
highly significant with the p value < 0.001 and F
value 8.3 when compared with control group in
which mean GI was 0.30 ±0.22.The mean PPD in
the test group is 2.67±0.87mm which was highly
significant with the p value < 0.001 and F value 25
when compared to the control group in which the
mean PPD score is 1.27±0.37mm. The mean CAL
in the test group is 1.67±1.3mm which is
statistically highly significant with the p value <
0.001 and F value 16.8 when compared to the
control group showing mean CAL score 0. All 60
subjects were investigated for the lipid profile.
Table.4 Comparison of mean value of Lipid parameters in control and test groups
Control group Test group p value F value
Total Cholesterol (mg/dl) 182.83±23.40 201.43±34.79 0.085 2.32
Triglycerides (mg/dl) 130.33±43.56 216.67±111.25 < 0.001** 7.6
HDL(mg/dl) 39.70±4.53 40.67±3.57 0.397 1.005
LDL (mg/dl) 117.46±21.06 120.77±31.58 0.310 1.22
VLDL(mg/dl) 25.20±9.22 42.97±22.35 <0.001** 8.4
Table.5 Comparison of CIMT (normal thickness 0.5 to 0.8 mm) between test and control group
CIMT Control group Test group p value F value
Mean CIMT(mm) 0.76±0.22 0.84±0.21 0.035* 3.1
Following observations were made from the Table
no 4.
Total Cholesterol (TC)
Mean Total Cholesterol (TC) level in controls
and test group was 182.83±23.40 and
201.43±34.79 respectively. No significant
difference was observed between both the groups.
Triglycerides (TG)
We found that mean Triglycerides level in the
test group was 216.67±111.25 which was highly
significant with the p value <0.001when compared
with control group in which mean TG value was
130.3±43.56.
High Density Lipoprotein (HDL)
Results showed that mean HDL level in
controls and test was 39.70 ±4.53 and 40.67±3.57

respectively. No significant difference was
observed between both the groups.
Low Density Lipoprotein (LDL)
Results showed that mean LDL level in
controls and test was 117.46±21.06 and
120.77±31.58 respectively. No significant
difference was observed between both the groups.
Very Low Density Lipoprotein (VLDL)
Results showed that mean VLDL level in the
test group was 25.20±9.22 which was highly
significant with the p value < 0.001 when
compared with control group having mean VLDL
value 42.97±22.35.
Table 5 shows the comparison of Carotid
Intima Media Thickness (CIMT) between both the
groups .The mean CIMT in the test group was
0.84±0.21 which was moderately significant with
the p value of 0.035 when compared with control
group showing mean CIMT value 0.76±0.22.
Correlation of CIMT with BMI, clinical
parameters and lipid parameters was of no
significance.
Discussion
Atherosclerosis is a process that significantly
involves the coronary, cerebral, and peripheral
arteries which are of clinical importance.(7)
Clinical
manifestations tend to coexist, and the presence of
one manifestation increases the likelihood of
developing others because, major risk factors tend
to affect all arterial territories. Also, clinical
atherosclerosis in one area may directly predispose
the patient to occurrence of atherosclerosis in
another vascular territory. In spite of significant
medical advances, atherosclerotic coronary artery
disease such as myocardial infarction and
atherosclerotic cerebrovascular disease such as
stroke are responsible for more deaths than all
other causes combined.(8,9)
The risk factors for
CVD that are unique to Asian Indians are low HDL
cholesterol, high LDL cholesterol ,high
triglycerides, central obesity-Insulin resistance
syndrome.(10,11)
Recent reports point towards a possible
increased risk for cardiovascular disease.
Periodontitis and cardiovascular disease share
common risk factors, and association between
periodontitis and coronary heart disease may be
due to the elevated levels of plasma lipids.
Epidemiological and clinical studies have also
suggested that there is a relationship between
periodontal disease and impaired lipid metabolism.
Although there are several studies regarding the
systemic lipid levels, the results are extremely
controversial. Some reports(12,13)
suggested that
there is a relationship between cholesterol levels
and periodontitis, while other studies showed(14,15)
a
relationship between triglyceride levels and
periodontitis; however, it also was reported that
there is a relationship between periodontal disease
and cholesterol and triglyceride levels.(16)
This
discrepancy may arise from the methodological
difficulties associated with the complexity of lipid
metabolism and variety in the metabolic lipid
parameters.
So, the challenge for all health care
professionals is to implement comprehensive
method for identification of initial atherosclerotic
events in high risk patients and also in general
public so that more vigorous preventive measures
can be taken. For this, various non-invasive
markers of early arterial wall alteration are
currently available such as arterial wall thickening
and stiffening, endothelial dysfunction and
coronary artery calcification.(17)
Intima media
thickness (IMT) of large artery walls, especially
carotid, can be assessed by B-Mode ultrasound in a
relatively simple way and represents a safe,
inexpensive, precise and reproducible measure.(1)
This study was designed to evaluate the IMT of
common carotid arteries in subjects with healthy
periodontium and in periodontitis subjects.
Physical parameters like BMI, and biochemical
parameters like lipid profile were determined and
their effects on IMT was studied.
Results of assessment of Plaque Index,
Gingival Sulcus Bleeding Index (BI), Probing
pocket depth and Clinical attachment level(Ref
.Table no 3) in the present study indicated that
mean PI, BI, PPD and CAL were significantly high
in the test group subjects when compared to the
control subjects. The association between altered
lipid profile and periodontitis has been investigated
in several studies.(4, 12, 13,14,16,18,19,20,21)
The results of
these studies, however, are somewhat inconsistent.
Machado et al. (2005)(18)
reported no significant
differences between the serum lipid levels of
periodontitis cases and controls. Hyperlipidemia
has been suggested to be one possible mechanism
explaining the association between obesity and
periodontitis, which has been found in several
cross-sectional studies in recent years.(22,23)
In the present study we found that there was
strongly significant increase in the Triglycerides
values and VLDL values with P value <0.001 in
the test group (Ref. Table no 2). There was an
increased level of LDL and TC in the test group as
compared to the levels found in control group, but
the difference was not statistically significant.
Similar results were found with previous studies
conducted by Morita et al (2004)(15)
and Taleghani
F, Shamaei M (2010).(24)
Although we found higher total cholesterol
and LDL levels in the test group, and also more

frequent pathological values of serum lipids, the
results were not statistically significant. On the
contrary significant association was found between
periodontitis and hyperlipidemia, specifically in
relation to the triglycerides and total cholesterol
levels (Cutler et al.1999,Losche et al.2000).(13,16)
Similarly significant association was seen between
hyperlipidemia and periodontal disease in
systemically healthy subjects,(20)
showing LDL and
HDL serum levels not significantly higher in test
group than in control group, which was similar to
our study. But in contrast, test and control groups
were matched by sex and age in this study.(19)
Although the difference in HDL levels from test
and control group were not significant, increased
triglyceride levels in test group was highly
significant as compared to the levels in control
group in the study conducted by Morita et al
(2004).(15)
These results were matching with the
results we got from our study.
Acute infections are known to interfere with
lipid metabolism, and elevation of plasma
triglycerides has been observed especially in
infection with gram-negative bacteria (Alvarez et
al. 1986).(25)
These changes are thought to be
mediated by cytokines, which may be produced at
the inflamed periodontal tissue in high quantities.
Many studies showed the association between
periodontal disease and increased carotid IMT.(26,
27, 28,29,30,31)
CIMT >8mm is considered abnormal and
associated with a greater cardiovascular risk for
myocardial infarction and stroke. (32)
In our study
mean CIMT in the test group was moderately
significant with p value (0.035) when compared
with mean CIMT in control group. Similar results
were found in many other studies.(26, 27, 28,29,30,31)
Infections with Chlamydia pneumonia and with
Helicobacter pylori which are believed to be
associated with an increased risk of cardiovascular
disease has been recently shown to be associated
with increased plasma cholesterol and triglyceride
levels.33
These findings support the hypothesis that
chronic infections including periodontitis may
modify the serum lipid profile and increases the
risk of atherosclerosis.
When compared with healthy individuals without
periodontitis, the periodontal patients showed
carotid IMT 0.84±0.21 in our study which is
assumed as critical index of increased
cardiovascular risk as per the study conducted by
Cairo et al.(26)
The results of this study showed an association
between periodontal disease and early carotid
atherosclerosis exists in systemically healthy
patients which was moderately significant (P=
0.035). Many studies showed that periodontal
disease is a predictor variable causing increased
carotid IMT. (26, 27,28,29,30,31)
When CIMT was correlated with all lipid
parameters in test and control groups, no
significant association was found in both the
groups. Similar results were seen in studies
conducted by Cairo et al(26)
and Beck et al.(27)
Obesity is a common risk factor for both
periodontitis and atherosclerosis. Various reports
found a stronger association between obesity,
cardiovascular and chronic adult diseases in
younger age groups.(34,35)
Thus exclusion of
subjects with BMI > 30kgm may have tend to
dilute the association.
The limitations of the present study were:
1. Smaller sample size.
2. Differences in age between test and the control
group: test group patients were older than
control group subjects. However, in the present
study the association was seen after adjusting
the age using ANCOVA test.
Conclusion
The results obtained in this study, provides
evidence that periodontal disease has association
with early carotid atherosclerosis which is a risk
factor for cardiovascular diseases .Thus oral health
and systemic health are closely related and overall
systemic health of an individual can be improved
by maintaining a proper oral health regimen.
References
1. Jukka H. Meurman, Mariano Sanz and Sok-Ja Janket.
Oral Health, Atherosclerosis, and Cardiovascular
Disease. Crit Rev Oral Biol Med. 2004;15:403-13.
2. Greenland P, Knoll MD, Stamler J, Neaton JD, Dyer
AR, Garside DB et al. Major risk factors as
antecedents of fatal and nonfatal coronary heart disease
events. JAMA 2003;290:891– 897.
3. Haynes WG, Stanford C. Periodontal disease and
atherosclerosis-from dental to arterial plaque.
Arterioscler Thromb Vasc Biol 2003;23:1309–1311.
4. Noack B, Jachmann I, Roscher S, Sieber L, Kopprasch
S, Luck C et al. Metabolic diseases and their possible
link to risk indicators of periodontitis. J Periodontol
2000;71:898-903.
5. Loe H .The gingival index, the plaque index and the
retention index systems. J Periodontol 1967;38:610.
6. Muhlemann, H. R., and Son, S. Gingival sulcus
bleeding—A leasing symptom in initial gingivitis. Heh
OdontolActa 1971;15:107.
7. Chobanian A. Path physiology of atherosclerosis. Am J
Cardiol 1992;70: 3-7.
8. Polak, J.F, O’Leary D.H, Kronmar, R.A. et al.
Sonographic evaluation of carotid artery
atherosclerosis in the elderly: Relationship of disease
severity to stroke and transient ischemic attack.
Radiology 1993;188:363- 370.
9. Jadhav UM, Kadam NN. Carotid intima-media
thickness as an independent predictor of coronary
artery disease. Indian Heart J 2001;53:458–462.
10. Mohan V. Intimal medial thickness of the carotid
artery in south Indian diabetic and non-diabetic

subjects: the Chennai Urban Population Study (CUPS).
Diabetologia 2000;43:494-499.
11. Reddy KS, Yusuf S. Emerging epidemic of
cardiovascular disease in the developing countries.
Circulation 1998;97:596–601.
12. Katz J, Chaushu G, Sharabi V. On the association
between hypercholesterolemia, cardiovascular disease
and severe periodontal disease. J Clin Periodontol
2001;28:865-868.
13. Cutler CW, Shinedling EA, Nunn M, et al. Association
between periodontitis and hyperlipidemia: Cause or
effect? J Periodontol 1999;70:1429-1434.
14. Katz J, Flugelman MY, Goldberg A, Heft M.
Association between periodontal pockets and elevated
cholesterol and low density lipoprotein cholesterol
levels. J Periodontol 2002;73:494-500.
15. Morita M, Horiuchi M, Kinoshita Y, Yamamato T,
Watanabe T. Relationship between blood triglyceride
levels and periodontal status. Community Dent Health
2004;21:32-36.
16. Losche W, Karapetow F, Pohl A, Pohl C, Kocher T.
Plasma lipid and blood glucose levels in patients with
destructive periodontal disease. J Clin Periodontol
2000;27:537-541.
17. Hoeks AP, Brands PJ, Smeets FA, Reneman RS.
Assessment of the distensibility of superficial arteries.
Ultrasound Med Biol 1990;16:121–128.
18. Machado ACP, Quirino MRDS, Nascimento LFC.
Relation between chronic periodontal disease and
plasmatic levels of triglycerides, total cholesterol and
fractions. Braz Oral Res 2005;19:284-289.
19. Moeintaghavi A, Haerian Ardakani A, Talebi Ardakani
M, Tabatabaie I. Hyperlipidemia in patients with
periodontitis. J Contemp Dent Pract 2005;6:78-85.
20. Nibali LD, Aiuto F, Griffiths G, Patel K, Suvan J,
Tonetti MS. Severe periodontitis is associated with
systemic inflammation and a dysmetabolic status: a
case-control-study. J Clin Periodontol 2007;34:931–
937.
21. Su TC, Jeng JS, Chien KL, Torng PL, Sung FC, Lee
YT. Measurement reliability of common carotid artery
Intima-media thickness by ultrasonographic
assessment. J Med Ultrasound 1999;7:73–79.
22. Vecchia CFD, Susin C, Rosing CK, Oppermann RV,
Albandar JM. Overweight and obesity as risk
indicators for periodontitis in adults. J Periodontol
2005;76:1721-1728.
23. Genco RJ, Grossi SG, Ho A, Nishimura F, Murayama
Y. A Proposed Model Linking Inflammation to
Obesity, Diabetes, and Periodontal Infections. J
Periodontol 2005;76:2075-2084.
24. Taleghani F and Shamaei M. Association between
Chronic Periodontitis and Serum Lipid Levels. Acta
Medica Iranica 2010;48:47-50.
25. Alvarez C, Ramos A. Lipids, lipoproteins, and
apoproteins in serum during infection. Clin Chem
1986;32:142-5.
26. Cario F,Castellani S. Gori AM, Nieri M, Baidelli G ,
Abbate R, Pini- Prato GP. Severe Periodontitis in
Young Adults is Associated with Sub Clinical
Atherosclerosis. J Clin Periodontol 2008;35:465-472.
27. Beck JD, Elter JR, Heiss G, Couper D, Mauriello SM
and Offenbacher S) .Relationship of periodontal
disease to Carotid Artery Intima- Media Wall
Thickness: The Atherosclerosis risk in Communities
(AIRC) study . Arterioscler Thromb Vasc Biol
2001;2:1816-1822.
28. Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP,
Kesaniemi YA, Syrjala SL, Jungell PS, Isoluoma M,
Hietaniemi K, Jokinen MJ. Association between dental
health and acute myocardial infarction. BMJ 1989;
298:779-81.
29. Soder PO, Soder B, Nowak J, Jogestrand T. Early
carotid atherosclerosis in subjects with periodontal
diseases. Stroke 2005;36:1195-200.
30. Desvarieux M, Demmer RT, Rundeck T , Boden–
Albala B, Jacobs DR ,Jr Ralph L. Sacco RL and
Papapanou PN . Periodontal Microbiota and Carotid
Intima – Media Thickness; The Oral Infections and
Vascular disease Epidemiology Study (INVEST).
Circulation 2005;111:576-582.
31. Leivadaros E, Van der Velden U, Bizzarro S, Ten
Heggeler JM, Gerdes VE, Hoek FJ, Nagy TO, Scholma
J, Bakker SJ, Gans RO, Ten Cate H, Loos BG. A pilot
study into measurements of markers of atherosclerosis
in periodontitis. J Periodontol 2005;76:121-8.
32. Aminbakhsh A and Mancini GB. Carotid Intima Media
thickness measurements: What defines an
abnormality? A systematic review. Clinical
Investigation in Medicine 1999;22:149-157.
33. Ellis RW. Infection and coronary heart disease. J Med
Microbiol 1997;46:535-539.
34. Fitzgerald AP, Jarrett RJ. Body weight and coronary
heart disease mortality: an analysis in relation to age
and smoking habit. 15 years follow-up data from the
Whitehall Study. Int J Obes Relat Metab Disord 1992;
16:119-123.
35. Vanhala M, Vanhala P, Kumpusalo E, Halonen P,
Takala J. Relation between obesity from childhood to
adulthood and the metabolic syndrome: population
based study. Br Med J1998;8:317-319.

A prospective double blind clinical comparative study of extraction socket healing in
patients with Type 2 diabetes on oral hypoglycemic drugs
Hemanth Kumar HR1
, Vinuta Hegde2,*
1
Assistant Professor, 2
Junior Resident, Dept. of Dentistry, Karwar Institute of Medical Sciences, Karwar
Email: drvinu07@yahoo.co.in
Abstract
Aim
The present study aims to assess the factors involved in delayed tooth extraction socket healing in healthy and Type 2 diabetes on
oral hypoglycemic agents.
Materials &Methods
Patients requiring dental extraction upon referral were included in the study prospectively, grouped accordingly into Type 2
diabetes (Group 1) and Healthy (Group 2) based on medical history. Random Blood Glucose Levels (BGL) was noted for all the
patients, dental extractions were performed under local anesthesia. Factors causing delay in wound healing were tabulated,
evaluated statistically and risk factors were noted.
Results
There were 30 participants with Type 2 diabetes on oral hypoglycemic medication (random blood glucose between136-178
mg/dl) and 30 non-diabetics (random blood glucose between66-138 mg/dl), diabetics group were older in age as compared to
non-diabetics. Statistical significance was not seen in diabetics and smokers for delayed wound healing
Conclusion
This study highlighted that there was similar healing between Type 2 diabetics on hypoglycemics and healthy group.
Keywords: Diabetes, Delayed healing, tooth extraction.
Introduction
Diabetes is one of the most common metabolic
disorders affecting around 422 million people
worldwide. Globally a rise is seen from4.7% to 8.5%
people being affected.(1)
Estimates as per International
diabetes Federation (IDF) states that there are around
40.9 million diabetic subjects in India which further
may raise to 69.9 million by 2025.(2)
Advanced
laboratory tests are required to distinguish between
Type 1 diabetes which requires insulin injection for
survival and Type 2 diabetes where the body cannot use
the insulin produced. It was noted that majority of
population being affected by Type 2 diabetes.(1)
In
dentistry tooth extraction socket healing is a complex
process which involves repair and regeneration of tissue
and traditionally person with diabetes is considered to
have a increased healing problem, thus is recommended
to determine the stability of known diabetics by means
Blood Glucose Level (BGL), by taking patient history,
referral from physician or by directly conducting the
tests prior to commencement of surgery.(1,3,4)
Factors
such as age,obesity,malnutrition with associated
macrovascular and microvascular changes due to
diabetes are known to contribute towards delayed
wound healing.(5)
The initial hindrance towards healing
in diabetes is increased glucose levels, which causes
cell wall to be rigid and thickened impairing blood flow
to the wound surface and impeding red blood cell
permeability which leads to tissue stress and hypoxia.(6-
8)
In dento-alveolar surgery, diabetics could be expected
to suffer similar complication to those observed in other
surgical procedures.(9)
Study aimed to compare and determine a difference in
healing between subjects with Type 2 diabetics and
healthy individuals undergoing extraction based on the
difference in random BGL.
Materials and Methods
This prospective study was performed in the
Department of Dentistry, Karwar Institute of Medical
Sciences, Karwar. The protocol for the study was
approved by the ethics committee of the institution and
informed consent was obtained from the participating
patients .Study period was for 6 months from February
2017 to July 2017.
Patient selection
Sixty patients of the both gender with age group
ranging from 18 – 75 years who visited the Dentistry
Department, for simple dental extraction either due to
extensive caries, periodontal problems or any other
purpose and who were in good health except for Type2
diabetes condition in the test group and able to follow
the post-operative instruction were enrolled in the study
Inclusion criteria
1. Patients referred for simple extraction with
detailed medical history with age 18 years and above.
2. Patients with no history of severe infection,
pain or other problems 1 week before the extraction.
3. Patient with Type 2 diabetes on oral
hypoglycemic medication willing to give consent to
participate in the study.
Exclusion criteria

Vinuta Hegde et al. A prospective double blind clinical comparative study of extraction…
1. Patients with history of hypersensitivity,
irradiation of oro-facial area and other
condition like chemotherapy anticoagulant and
antiplatelet therapy, physical and mental
disability ,malignant and benign pathology .
2. Pregnant patients.
3. Patients with peptic ulcers.
4. Patients not willing for follow up and patients
not reporting after 1 week.
Patients were divided into Group1 (Known Type 2
non-insulin dependent diabetics mellitus) and Group 2
(Control group of healthy individuals without known
conditions to impair wound healing) consisting of 30
patients in each group .Closed simple intra alveolar
extractions were performed with forceps and elevators,
same surgeon performed the surgery in both group and
was blinded. Patients were asked to follow up review at
one week post extraction. Recording forms were given
to patients and were explained how to enter the details
for any pain and other discomfort .Those patients who
reported with marginally high BGL were referred for
Medical reference .Filled patients questionnaire forms
were collected at the time of suture removal or at one
week follow up review.
Preoperative recording of data
Type of Tooth, duration of the treatment (Time
from the injection of local anesthesia till the placement
of the suture), amount of the local anesthesia used.Post-
operative pain was assessed subjectively and
accordingly marked by the patient on 10point visual
analogue scale which was collected at the time of one
week review or at the time of removal of suture (0= No
pain, 10=severe pain). All extractions were performed
using a standardized forceps and elevator technique
under 2% Xylocaine which was used as an anesthetic
agent comprising lignocaine hydrochloride with
1:200,000 epinephrine.
Medications
Identical medications were used in the study in
both groups Tablet Diclofenac sodium 50mg and
Capsule Amoxicillin 500 mg three times daily
respectively for five days as a standard protocol.
Post–operative follow up (Signs of delayed healing
were observed)
Primary Outcome Measure were noted
1. Edema
2. Erythema
3. Alveolar bone exposure
4. Halitosis
5. Trismus
6. Fever
7. Infection
8. Other conditions like unpleasant taste,malaise
and itching were noted.
Secondary Outcome measures noted
1. Dental alveolus filled with blood clot and fibrin at
day 3 after dental extraction.
2. On the post-operative day 7 the alveolus is filled with
granulation tissue or not.
3. On post-operative day 21 wound epithelialization has
taken place or not.
4. Delayed wound healing factors like dry socket, bony
sequester or excess granulation tissue were also noted.
Along with observation as closed and open wound each
sign of inflammation were given each point.
Based on the both primary and secondary outcome
measures, each factor was marked as 1 point and the
corresponding healing scores were noted.
Statistical Methods
Data collected was coded and entered into
Microsoft Excel 2010. The validated data was imported
into statistical software, SPSS 16
(Chicago) and analyzed. Results were expressed using
descriptive analysis like mean, standard error of mean,
range and standard deviation. The difference between
mean healing score between diabetics and non-diabetics
was analyzed by using independent sample Student's t
test with 95% confidence intervals. The association
between delayed healing and variables like smoking
and blood glucose was analyzed using Fisher's exact
test. Results were said to be statistically significant if
the P value was <0.05.
Results
The mean age of diabetic’s individuals (Group 1)
was 60.67± 7.827 (mean ± SD) and of the non-diabetic
(Group 2) was 53.20 ± 11.171 (mean ± SD)Table 1.
The mean RBS score for Diabetic group was 157.2
mg/dland in non-diabetic group was 103.3 mg/dlTable
2.The Mean healing scores with diabetic group was
1.73±1.2 (Mean ± SD) and for non-diabetics it was
1.57±1.0 (Mean ± SD)Table 3. Among the 5 patients
with delayed wound healing with diabetics 3(60.00%)
were smokers as seen in Table 4 and 5.
Table 1.Distribution of study participants according
to Age
Diabetes
Status
Mean
Age
(in
years)
Std.
Deviation
Minimu
m
Maxim
um
Diabetic
(n=30)
60.67 7.827 47 76
Non Diabetic
(n=30)
53.20 11.171 33 76

Table 2. Distribution of study participants according to RBS
Diabetes Status
Mean (in mg/dl)
Range(in mg/dl) Std.
Error
Std.
Deviation
Minimum Maximum
Diabetic (n=30) 157.2 136.0 178.0 2.0 10.8
Non Diabetic (n=30) 103.3 66.9 138.0 4.2 22.9
Table 3. Comparison of mean healing score between Diabetics and
Non-diabetics among the study participants
Diabetics
(n=30)
Non
Diabetics(n=30)
T P-value 95 % CI
Mean Healing
Score
1.73 1.57 0.559 0.578 -.430 to .763
Inference
The difference between mean healing score of Diabetics and Non-diabetics among the study participants is not
statistically significant (P=0.578)
Table 4. Relationship between Delayed Healing and Blood Glucose Level
BLOOD GLUCOSE LEVEL (in
mg/dl)
DIABETIC with
Delayed Healing
(n=5)*
NON DIABETICS with
Delayed Healing
(n=3)**
P – Value***
BELOW 120 - 2 (66.67%) 0.2143
ABOVE 120 5 (100.0%) 1 (33.33%)
* 5 among diabetics had delayed healing
**3 among non-diabetics had delayed healing
*** Fishers exact test, P value < 0.05 is significant
Table 5. Relationship between Delayed Healing and Smoking
Smoking DIABETIC with Delayed Healing (n=5)*
NON DIABETICS with
Delayed Healing (n=3)**
P - Value
YES 3 (60.0%) 2 (66.67%) 0.999
NO 2 (40.0%) 1 (33.33%)
* Among 5 diabetics with delayed wound healing 3
were smokers
** Among 3 non diabetics with delayed wound healing
2 were smokers
*** Fishers exact test, P value < 0.05 is
significant
Discussion
Dental extraction are procedures carried out in the
Dental departments on routine basis and diabetes is one
of the major factors traditionally known to delay tooth
socket extraction healing. Diabetes is defined as a
metabolic disease which is characterized by
hyperglycemia either due to defects in insulin secretion
, insulin action or combination of both.(10)
It has become
important to know oral health problems in elderly with
geriatric dental needs. In our study it was seen that the
mean age of the patients in both diabetic and non-
diabetic was 60.67±7.83 and 53.20±11.17 respectively.
It has been observed that elderly with a mean age above
45 years are more prone to dental problems requiring
tooth extraction and diabetes is one of the most
important co-morbidities seen in them and have also
noted previously patients with poorly controlled
diabetes are prone to increased rate of surgical wound
infection and poor wound healing.(4,11,12,13)
Traditionally
hyperglycemia is noted leading to a range of
complication categorized as macro vascular,micro
vascular and neuropathic(14)
For wound healing the
initial barrier in diabetics is increased blood glucose
level which causes thickening of basement membrane
of the capillaries leading to cell wall becoming rigid ,
altered permeability is seen.(15,16)
It is also stated by
authors in diabetics due to increased glucose level,
accumulation of toxic sorbitol in the tissues,
pericapillary albumin deposition which hampers
nutrient and oxygen diffusion with disturbed collagen
synthesis and collagen maturation.(11)
Macrophage
dysfunction too is observed in diabetics which causes
the inflammatory phase to last longer.(17)
All these
change could adversely effect and thus delaying wound
healing. In our study it was seen that number of

diabetics with impaired wound healing were less,
showing a P value of 0.2143 which is statistically
insignificant these could be due the diabetics
individuals are already on hypoglycemic agents and
antimicrobials before the procedure thus decreasing
chances of delayed wound healing .Our study was also
in concordance with other studies where delayed wound
healing was seen comparatively less in diabetic
individuals.(14)
There were 2 patients in whom BGL was
between 120-150 mg/dl and out of whom 1(33.33%)
showed delayed wound healing as seen in earlier works
by other noted that every year 3-10 % of the people
with prediabetes may go on to develop diabetes and
these patients could belong to this group.(18)
Among the 5 diabetics (Group 1) who showed
delayed wound healing 3(60%) were smokers and in
healthy group, out of 3 showing delayed wound healing
2(66.67%) were smokers. Nicotine influences and
delays wound healing. It causes microvascular
occlusions leading to tissue ischemia due to increased
platelets adhesiveness causing micro clots.(19)
Nicotine
is also known to decrease proliferation of RBC’s,
fibroblasts, macrophages and causes
vasoconstriction.(20,21)
Wound healing requires enzymes
but hydrogen cyanide inhibits enzyme systems which is
required for oxidative metabolism and oxygen transport
at cellular level.(22)
It was seen that harmful substances
of smoking have a potential to create unfavorable
conditions and cause delay in healing but in this
statistical significant difference was not observed
between smokers and non-smokers among both the
groups with regards to delayed wound healing. It was
seen that there was no significant difference in the
mean healing score between healthy and group of Type
2 diabetics. Both general health care combined with
oral health care systems should work together towards
improving overall diabetic status of the affected
patients.
Conclusion
This study highlighted that elderly were the most
affected group but it also concluded that there was
similar healing between Type 2 diabetics on
hypoglycemics and healthy group and among smokers.
Acknowledgements
The authors would like to acknowledge Dr
Malatesh Undi, Assistant Professor (Epidemiologist)
Department of Community Medicine ,Karwar Institute
of Medical Sciences Karwar for all the help in the
statistical analysis.
References
1. World Health Organisation. Global report on diabetes.
WHO Library Cataloguing in Publication Data .2016.
2. International Diabetes Federation 2006.Diabetes Atlas
.3rd
edition, International Diabetes Federation,
Belgium, pp.387.
3. Al-Rawi N, Yaseen N. Molecular events on tooth
socket healing in diabetic rabbits. British Journal of
oral and Maxillofacial Surgery 2013;51:932-936.
4. Australian Research centre for Population Oral Health.
Special Topic No 3 – Diabetes and Oral Health. March
2012.
5. Rosenberg CS. Wound healing in the patients with
diabetes mellitus. NursClin North AM 1990;25(1):
247-61.
6. Flynn MD, Tooke JE. Aetiology of diabetics foot
ulceration: a role for the microcirculation. Diabet Med
1992;9:320-329.
7. Probes JS, Cortan RS. The role of endothelial cells in
inflammation. Transplantation 1990;50:537-544.
8. Christopherson K. The impact of diabetes on wound
healing: implications of microcirculatory change. Br J
Community Nurs 2003;8:S6-13.
9. Barasch A, Safford MM, Litaker MS, Gilbert GH. Risk
factors for oral postoperative infection in patients with
diabetes. Spec Care Dentist 2008;28:159–166.
10. Peleg AY, Weerarathna T, McCarthy J S, Davis TME
.Common infections in diabetes: Pathogenesis,
management and relationship to glycaemic control.
Diabetes Metab Res Rev 2007;23:3-13.
11. Politis C, Schoenaer J, Jacobs R, Agbaje JO. Wound
healing problems in the mouth. Frontiers in Physiology
2016;7:1-13.
12. Lu P, Gong Y, Chen Y, Cai W, Sheng J. Safety
analysis of tooth extraction in elderly patients with
cardiovascular disease .Med SciMonit 2014;20:782-
788.
13. Galili D, FindlerM , Garfunkel AA. Oral and dental
complications associated with diabetes and their
treatment. Compendium 1994;15:496-509.
14. Huang S, Dang H, Huynh W, Sambrook PJ, Goss AN .
The healing of dental extraction sockets in patients
with Type 2 diabetes on oral hypoglycaemics: a
prospective cohort. Australian Dental Journal 2013;
58:89-93.
15. Ekmektzoglou KA, Zografos GC. A concomitant
review of the effect of diabetes mellitus and
hypothyroidism in wound healing.World J
Gastroenterol 2006;12:2721–2729.
16. Lioupis C. Effects of diabetes mellitus on wound
healing: an update. J Wound Care 2005;14:84–86.
17. Roy S, Das A, Sen C K . Disorder of localised
inflammation in wound healing: a systems perspective.
Complex systems and computational Biology
Approaches to acute inflammation. New York:
Springer; 2013,173-183.
18. Twigg SM, Kamp MC, Davis TM, Neylon EK, Flack
JR. Prediabetes: a position statement from the
Australian Diabetes Society and Australian Diabetes
Educators Association. Med J Aust 2007;186:461–465.
19. Mayfield L, Soderholm G, Hallstorm H, Kullendorff
B, Edwardsson S, Bratthall G, et al. Guided tissue
regeneration for the treatment of intraosseous defects
using a bioabsorbable membrane: a controlled clinical
study. J Clin. Periodontol 1998;25:585-95.
20. The health consequences of smoking: cardiovascular
disease. A report of the surgeon general. Rockville,
Maryland: U.S. Department of Health and Human
Services, 1983.

21. Sherwin MA, Gastwirth CM. Detrimental effects of
cigarette smoking on lower extremity wound healing. J
Foot Surg.1990:29:84-7.
22. Rees TD. The acute effects of cigarette smoke
exposure on experimental skin flaps: a discussion.
PlastReconstrSurg 1985;75:550-1.

Effects of Lignocaine with Adrenaline on Blood Pressure and Pulse Rate in
Normotensive and Hypertensive Patients Undergoing Extraction: A clinical Study
Anil Kumar Karanam1*
, Bujunuru Sridhar Reddy2
1
Assistant Professor, 2Associate Professor, 1
Dept. of Oral & Maxillofacial Surgery, Govt Dental College and Hospital, Kadapa,
2
Associate Professor, Dept. of Oral & Maxillofacial Surgery, Govt Dental College and Hospital, Hyderabad
Email: anil_karanam@yahoo.com
Abstract
Objective
This study is intended to study the effects of Local Anaesthesia containing adrenaline (vasoconstrictor) on Blood pressure and
pulse rate in hypertensive patients and to ascertain the safety of using Local Anaesthesia with adrenaline in such patients.
Materials & Methods
The present study has been carried out in Rajiv Gandhi Institute of Medical Sciences, Adilabad from January 2011 to December
2012. The study included 100 male patients, 24 to 60 years of age who underwent extraction of firm mandibular molar tooth. Out
of 100 male patients, 50 patients were normotensive patients with systolic blood pressure of <120 mm of Hg and diastolic blood
pressure of < 80 mm of Hg and remaining 50 patients were Hypertensive patients out of which 25 patients had Stage I
Hypertension (SBP 140 – 159 mm of Hg & DBP 90 – 99 mm of Hg) and 25 patients had Stage II Hypertension (SBP >160 mm
Hg & DBP >100 mm Hg). All patients were given Inferior Alveolar Nerve Block followed by Lingual & Long Buccal Nerve
Blocks with 2% Lignocaine with 1:2, 00,000 Adrenaline. The Blood pressure and pulse rate were recorded 6 times.
Results
All patients showed a considerable increase in Systolic and Diastolic BP recorded at 2 min but gradually showed a reduction until
60 min post-operatively. The pulse rate also shown a sudden increase followed by gradual reduction to preoperative level.
Conclusion
All patients showed a considerable increase in blood pressure and pulse rate but not significantly which may be attributed to
stress induced by dental extraction.
Keywords: Blood pressure, hypertensive, local anaesthesia, normotensive.
Introduction
It is known that pain during dental treatments can
trigger endogenous catecholamine release, which in
turn can give rise to hemodynamic changes, such as
increase in blood pressure and heart rate, and may even
produce arrhythmias.(1)
The main drug used to reduce and eliminate the
pain to control the patient for therapeutic procedures is
Local anaesthesia. The use of local anesthetics in
combination with vasoconstrictor agents is justified in
dentistry (2,3)
Doing so counteracts the local vasodilation
effect of local anesthetic agents and delays its
absorption into the cardiovascular system. These effects
are beneficial in increasing the duration of local
anesthesia and diminishing the risk of toxicity and also
provide hemostasis during surgery.(4,5)
Hypertension represents one of the most common
histories presented by patients in dental clinics.
Additionally, increase in blood pressure is common
during dental surgery.(6)
The objective of this study was
to evaluate and compare the changes in blood pressure
and pulse rate in normotensive and hypertensive
patients undergoing dental extraction using 2%
Lignocaine Hydrochloride with 1:2,00,000 Adrenaline.
Materials and Methods
The study was conducted on 100 male patients (24-
60 years; mean age of 40.3 ± 3.9 years) who underwent
dental extraction at Rajiv Gandhi Institute of Medical
Sciences, Adilabad.
After obtaining institutional ethical committee
clearance. The patients were divided into three groups
based upon their medical history and Blood pressure
recordings in the outpatient department: Group I - 50
Normotensive patients (BP < 120/80 mm of Hg); Group
II - 25 patients with Stage I Hypertension (BP 140-
159/90-99 mm of Hg); Group III - 25 patients with
Stage II Hypertension (BP >160/100 mm of Hg).
The following inclusion criteria were established:
all male patients to eliminate gender bias; patients
presented with medical history of prediagnosed
hypertension and on anti-hypertensive drugs and
reportedly certified as well controlled hypertension
without any associated CVS problems by their
respective physicians; uncomplicated extractions were
planned only of mandibular molars without any
sequelae of pulpitis; with an history of extraction and
lastly willing to participate in the study.
All the patients were explained and written
informed consent were obtained. Preoperative
antibiotics and analgesics were prescribed and patients
were advised to start the night before dental extraction.
The procedures were performed in morning sessions
without any preoperative anxiolytics. On the day of
extraction, the patients were made to sit in a calm

Anil Kumar Karanam et al. Effects of Lignocaine with Adrenaline on Blood Pressure…
waiting room. BP and pulse rate were recorded using a
Multi-para Monitor twice: immediately after reporting
and after 15 min of reporting; the lowest of both the
readings was considered as baseline BP and pulse rate.
All the patients were given Inferior Alveolar Nerve
Block with Lingual Nerve Block and Long buccal nerve
block using 4 ml of 2% Lignociane Hydrochloride with
1:200000 Adrenaline. The patients were made to sit in
dental chair and Blood pressure and pulse rate were
recorded immediately before Injection of LA, 2 minutes
after Injection, 5 minutes after injection, 30 minutes
after injection, 60 minutes after injection using the
same Multi-para monitor.
Results
Out of 100 male patients, the mean ages for
normotensive patients, Stage I Hypertensive and Stage
II hypertensive patients was 29 ± 3.16; 39.56 ± 4.29
and 50.32 ± 3.90 years respectively.
All the patients showed an elevation of Blood
pressure by 2-3 mm of Hg and mean pulse rate of 1-2
beats from baseline to immediately before injection,
followed by elevation 4-5 mm of Hg 2 min after
injection and 5 min after injection and gradually shown
a fall after 30 min and 60 min after injection. (Table 1)
Table 1. Mean Blood Pressure (± SD) and Pulse Rate Before and After Extraction Using 2% Lidocaine with
1:2,00,000 Adrenaline
Baseline BP &
Pulse Rate
Before Injection
of LA with
Adrenaline
2 Minutes
after Injection
5 Minutes
after Injection
30 Minutes
after Injection
60 Minutes
after
Injection
NORMOTENSIVE PATIENTS (n=50)
Systolic BP 108.04 ± 3.24 110.64 ± 4.14 115.88 ± 3.82 115.88 ± 3.82 111.44 ± 3.42 108.04± 3.24
Diastolic BP 70.80 ± 3.86 73.76 ± 3.75 75.28 ± 2.47 74.40 ± 3.18 74.04 ± 3.69 70.80 ± 3.86
Pulse Rate 69.36 ± 5.32 71.76 ± 5.34 73.36 ± 5.32 74.44 ± 4.21 74.20 ± 4.08 69.36 ± 5.32
STAGE – I HYPERTENSIVE PATIENTS (n=25)
Systolic BP 148.20 ± 5.09 149.16 ± 5.74 152.92 ± 6.29 152.92 ± 6.29 151.28 ± 5.82 148.20± 5.09
Diastolic BP 91.74 ± 1.87 92.24 ± 1.60 93.32 ± 2.31 93.32 ± 2.31 93.04 ± 2.61 91.74 ± 1.87
Pulse Rate 87.40 ± 3.19 88 ± 3.39 91.20 ± 2.93 91.52 ± 2.61 91.52 ± 2.61 87.40 ± 3.19
STAGE – II HYPERTENSIVE PATIENTS (n=25)
Systolic BP 164.48 ± 4.02 165.80 ± 3.94 167.68 ± 3.86 166.76 ± 4.24 166.08 ± 3.55 164.48± 4.02
Diastolic BP 93.32 ± 2.31 100.20 ± 0.96 93.32 ± 2.31 93.32 ± 2.31 93.32 ± 2.31 93.32 ± 2.31
Pulse Rate 85.96 ± 4.62 87.40 ± 3.19 91.20 ± 2.93 90.36 ± 3.95 89.84 ± 3.49 85.96 ± 4.62
Discussion
This study primarily evaluated the effect of 2%
Lignocaine with 1:2,00,000 Adrenaline on blood
pressure and pulse rate on normotensive and
hypertensive patients. The measurement of these
parameters was performed at 6 different intervals.
Patients with Hypertension are considered high risk
group when administering dental local anaesthesia
containing a vasoconstrictor because of the potential to
undergo adrenaline induced sudden dramatic increase in
blood pressure leading to life-threatening hypertensive
crisis.(7,8)
Some studies have shown that while
adrenaline injected as a vasoconstrictor is associated
with transient effects in normotensive patients,
hemodynamic complications could develop in
uncontrolled hypertensive subjects, with possible
cardiovascular accidents though such problems would
be related to the dose of vasoconstrictor administered
and to the local anesthesic used.(1,5)
However, in the
present study all the subjects, irrespective of
normotensive or hypertensive, showed a significant
increase in Systolic Blood pressure and a mild increase
in Diastolic Blood pressure. This could be either
because of vasoconstrictor effect or anxiety or
discomfort due to the dental extraction.
Similarly, Silvestre et al(5)
reported no
significant changes were observed in any of the study
parameters. The patients subjected to local anesthesia
with a vasoconstrictor showed behaviour similar to that
observed in an earlier study by our group in patients
without hypertension. In another study, Mostafa et al(9)
the differences of diastolic blood pressure, heart rate
and oxygen saturation after anesthetia and after
extraction showed no significant difference among
three groups.
In a similar study, Matsumura et al(10)
concluded that dental surgery using local anaesthesia
caused significant increases in systolic blood pressure
and pulse rate, and the increase in systolic blood
pressure was greater in the middle-aged and the older
patients. Factors other than the sympathetic input to the
heart contribute to the increase in blood pressure during
dental surgery.
In a similar study, Chaudry et al(11)
concluded
that within the limitations of the study, a decrease in

Anil Kumar Karanam et al. Effects of Lignocaine with Adrenaline on Blood Pressure…
SBP was observed with use of two 1.8ml cartridges of
lignocaine with 1:100000 epinephrine in patients
suffering from stage 2 hypertension. This decrease was
not associated with adverse effects when observed
changes in BP and PR noted among the patients of this
study.
Cardiovascular disadvantages attributed to the use
of epinephrine in hypertensive patients are negligible
compared to their benefits. Painful extraction in a
hypertensive patient can result in increased stress which
in turn can lead to over production of endogenous
epinephrine by the body.(12,13)
This could prove far more
dangerous to the patients
Conclusion
To conclude, the results obtained in this study
hereby affirm that the rise in the blood pressure and
pulse rate in normotensive as well as hypertensive
patients is attributed to stress from dental extraction
induced by anxiety or discomfort and not because of
vasoconstrictor used in the local anaesthesia. This
affirms the fact that local anaesthesia containing
vasoconstrictor can be safely used in both healthy and
hypertensive patients.
References
1. Akinmoladun VI, Okoje VN, Akinosun OM, Adisa AO,
Uchendu OC. Evaluation of the haemodynamic and
metabolic effects of local anaesthetic agent in routine
dental extractions. J Maxillofac Oral Surg.
2013;12(4):424-428.
2. Bader JD, Bonito AJ, Shugars DA. A systematic review
of cardiovascular effects of epinephrine on hypertensive
dental patients. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2002;93(6):647-53.
3. Brown RS and Rhodus NL. Epinephrine and local
anesthesia revisited. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod.2005;100(4):401-408.
4. Ezmek B, Arslan A, Delilbasi C, Sencift K. Comparison
of hemodynamic effects of lidocaine, prilocaine and
mepivacaine solutions without vasoconstrictor in
hypertensive patients. J Appl Oral Sci. 2010;18(4):354-
359.
5. Silvestre FJ, Isabel SM, Bautista D, Javier SR. Clinical
study of hemodynamic changes during extraction in
controlled hypertensive patients. Med Oral Patol Oral
Cir Bucal. 2011;16(3):e354-8.
6. Godzieba A, Smektala T, Jedrzejewski M, Sporniak-
Tutak K. Clinical assessment of the safe use local
anesthesia with vasoconstrictor agents in cardiovascular
compromised patients: A systematic review. Med Sci
Monit 2014;20:393-8.
7. Gungormus M and Buyukkurt MC. The evaluation of
the changes in blood pressure and pulse rate of
hypertensive patients during tooth extraction. Acta Med
Austriaca. 2003;30(5):127-9.
8. Hersh EV, Giannakopoulos H, Levin LM, Secreto S,
Moore PA, Peterson C, et al. The pharmacokinetics and
cardiovascular effects of high-dose articaine with
1:100,000 and 1:200,000 epinephrine. J Am Dent Assoc
2006;137:1562-71.
9. Abu-Mostafa N, Al-Showaikhat F, Al-Shubbar F, Al-
Zawad K, Al- Banawi F. Hemodynamic changes
following injection of local anesthetics with different
concentrations of epinephrine during simple tooth
extraction: A prospective randomized clinical trial. Clin
Exp Dent. 2015;7(4):e471-6
10. Matsumura K, Miura K, Takata Y, Kurokawa H,
Kajiyama M, Abe I, et al. Changes in Blood Pressure
and Heart Rate Variability During Dental Surgery.
American Journal of Hypertension 1998;11:1376–80.
11. Chaudhry S, Iqbal HA, Izhar F, Mirza KM, Khan NF,
Yasmeen R, Khan AA. Effect on blood pressure and
pulse rate after administration of an epinephrine
containing dental local anaesthetic in hypertensive
patients. J Pak Med Assoc.2011;61:1088.
12. Meyer FU. Hemodynamic changes of local dental
anesthesia in normotensive and hypertensive subjects.
Int J Clin Pharmacol Ther Toxicol. 1986;24(9):477-81.
13. Meral G, Tasar F, Sayin F, Saysel M, Kir S, Karabulut
E. Effects of lidocaine with and without epinephrine on
plasma epinephrine and lidocaine concentrations and
hemodynamic values during third molar surgery. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2005;100(2):e25-30.

Histopathological correlation with computed tomography in respect to evaluation of
paranasal sinus diseases
Krishnakant Vaghela1
, Bhaven Shah2,*
1
Assistant Professor, 2
Associate Professor, Dept. of Radiology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
Email: researchguide86@gmail.com
Abstract
Introduction
Contrast enhanced CT scans are obtained only in patients who are acutely ill and suspected of having a complication of
acute sinusitis. The present study was aimed to evaluate the spectrum of PNS diseases on CT and correlate their clinical and
histopathological findings.
Materials & Methods
After fulfilling the necessary criteria for enrollment, first 100 patients with PNS diseases were included in the study. Patients
who have failed medical management i.e., prolonged course of broad spectrum antibiotics for 3 weeks and trial of corticosteroid
nasal spray, were included in the study. Patients with revision surgery were excluded from the study.
Results
The most common CT diagnosis was found to be chronic sinusitius (57/100), followed by fungal sinusitis (28/100) and
lastly 10 cases of nasal polyp. The entire specimens were sent for histopathological examination.
Discussion & Conclusion
CT helps to delineate the anatomy of nose and sinuses, and drainage pathways of sinuses preoperatively. It is helpful in
evaluating the site and extent of sinus pathology. Preoperative CT enabled the surgeon to visualize the drainage pathways,
anatomical and critical variants in PNSs thus allowing effective management of the patient. However, a potential pitfall was its
inability to accurately differentiate in cases of fungal sinusitis and high‑density secretions.
Keywords: CT, Paranasal Sinus, Pathologies, Biopsy, Histopathology.
Introduction
The nose is the most prominent part of the face
with functional and considerable aesthetic importance.
Anatomical position of the nose and it passage have
been considered as the direct route to the brain,
individual's source of intelligence and spirituality.
Presence of any mass in the nose and paranasal sinuses
seems to be a simple problem; however it raises many
questions about the differential diagnosis.(1)
Pathological lesions of the paranasal sinuses
include a wide spectrum of conditions ranging from
inflammation to neoplasms both benign and malignant.
These sinuses are in close anatomical relationship with
orbit, cranial fossa and pterygopalatine fossa.(2)
Hence,
early involvement of these areas is an important feature.
Since clinical assessment is hampered by the
surrounding bony structures, diagnostic radiology is of
paramount importance.(3)
Plain radiography is the commonly used imaging
modality for diagnosis of PNS diseases as it is
economical, simple, and widely available. It can
provide limited views of the anterior ethmoid cells
along with the upper two‑thirds of the nasal cavity.(4)
Computerized tomography (CT) is considered the gold
standard for preoperative evaluation of PNS diseases
for appropriate patient selection for functional
endoscopic sinus surgery (FESS).(4,5)
It is mandatory to
evaluate the PNS and nose by CT before planning for
FESS. It can provide a “ROAD MAP” to direct the
surgical approach to otolaryngologist. CT has some
medico‑legal importance as well. Computed
tomography scan has become modality of choice for
evaluation of peripheral nervous system (PNS)
pathologies as it optimally displays bony details, air and
outlines soft tissue as well.(6)
Computed tomography proves to be the most
reliable method of preoperative assessment of patients
undergoing functional endoscopic sinus surgery (FESS)
as it delineates the extent of the disease, define any
anatomical variants and relationship of the sinuses with
the surrounding important structures — thus providing
a road map for sinus surgery.(7)
Coronal imaging plane offers the best visualization
of the drainage pathways of the sinuses, whereas some
drainage pathways (such as sphenoid sinus ostia) and
sinus walls, oriented close to the coronal plane, are
better seen on axial images.(8)
Contrast enhanced CT
scans are obtained only in patients who are acutely ill
and suspected of having a complication of acute
sinusitis. The present study was aimed to evaluate the
spectrum of PNS diseases on CT and correlate their
clinical and histopathological findings.
Materials & Methods
The present study was conducted at Gujarat Adani
Institute of Medical Sciences, Gujarat, India, for a
period of 6 months. After fulfilling the necessary

Bhaven Shah et al. Histopathological correlation with computed tomography…
criteria for enrollment, first 100 patients with PNS
diseases were included in the study. Patients who have
failed medical management i.e., prolonged course of
broad spectrum antibiotics for 3 weeks and trial of
corticosteroid nasal spray, were included in the study.
Patients with revision surgery were excluded from the
study.
Methodology
All postoperative cases and patients with any
traumatic conditions involving PNS were excluded
from the study. A detailed clinical history including
age, sex, occupation, duration of symptoms and specific
complaints such as headache, nasal obstruction, nasal
discharge, and facial pain were taken. Family history
and personal history were also recorded. A thorough
clinical examination was done, and obtained data were
recorded, and a provisional diagnosis was prepared.
The detailed clinical assessment was performed,
and their informed consent was obtained before
subjecting them for the imaging modality. After
fulfilling the desired criteria, all the selected patients,
PNS was done. Computed tomography was done on
128 slice scanner (AS Siemens, Germany). Axial
images were acquired using thin collimation, followed
by reformats in all three planes, i.e., axial, coronal, and
sagittal, with soft tissue and bony algorithms.
Results
Of the 100 patients included in the present study,
52 were females and 48 were males in the age group 10
to 50 years. Among the clinical symptoms, chronic
nasal discharge was the most common symptom seen in
49 patients, postnasal drip in 63, followed by nasal
obstruction in 58, anosmia in 28, headache in 40, and
facial pain in 25 patients.
FESS was done in all patients in and biopsy
specimen was taken for histopathological evaluation.
The clinical, CT and histopathological diagnosis were
recorded for their correlation and data analysis.
The most common CT diagnosis was found to be
chronic sinusitius (57/100), followed by fungal sinusitis
(28/100) and lastly 10 cases of nasal polyp. The entire
specimens were sent for histopathological examination.
The diagnosis received was as follows: maximum cases
were diagnosed as non specific inflammation (62%),
this was followed by inflammatory polyp (18%), fungal
sinusitis (12%) and carcinomatous changes in (8%).
Table 1. Distribution of patients with sinus lesions in
respect to CT diagnosis
Diagnosis CT (%)
Chronic Sinusitis 57
Fungal sinusitis 28
Nasal Polyp 10
Neoplastic 5
CT: Computed tomography
Table 2. Distribution of patients of sinus lesion
histopathology
Histopathology Diagnosis Frequency (%)
Chronic Sinusitis 62
Fungal sinusitis 12
Nasal Polyp 18
Neoplastic 8
In the study, maxillary sinus was the most
commonly involved sinus followed by ethmoid sinus,
sphenoid sinus, and frontal sinus. Table 3
Table 3. Sinus distribution
Sinus Involved Number of Cases
Maxillary 85
Ethmoid 72
Sphenoid 43
Frontal 57
High sensitivity, specificity, positive and negative
predictive values were noted in all diagnosis except
fungal sinusitis. Table 4
Table 4. Diagnostic performance of computed tomography in comparison to histopathological diagnosis.
Diagnosis Sensitivity Specificity PPV NPV P
Chronic Sinusitis 98.2 96.2 98.6 97.5 <0.001
Polyp 94 98.3 97.5 98.3 <0.001
Fungal Infections 60 90.2 44.2 97.8 <0.001
Neoplastic 100 96.3 68.7 100 <0.001

Axial noncontrast computed tomography image in bone window showing polypoidal mass arising from
lateral wall of the left maxillary sinus
Discussion
The majority of the cases were in the age group of
31–40 years and least number of patients were in age
group of 61–70 years. There was a male predominance
of 56.2% as compared to females 43.8%. Followed by
nasal discharge, nasal obstruction, facial pain, and
others. Kushwah et al. and Dewan et al. also noted
similar findings their studies. They all concluded that a
headache was the predominant presenting complaint. In
the present study, maxillary sinus was the most
commonly involved sinus followed by ethmoid,
sphenoid and frontal. Kushwah et al., Maru and Gupta
noted similar results in their studies.
Traditionally, plain films were the modality of
choice in the evaluation of sinus pathology. In recent
years, it has become evident that sinusitis is primarily a
clinical diagnosis. The role of imaging is to document
the extent of disease, to answer questions regarding
ambiguous cases, and to provide an accurate display of
the anatomy of sinonasal system. Today, CT has
become the modality of choice for imaging evaluation
of the morphology in this area.(9)
It is now generally accepted that CT is the optimum
imaging method of demonstrating simple inflammatory
disease to neoplasms in the paranasal sinuses. Clinical
assessment can be used to evaluate acute sinus infection
and CT is used for the investigation of persistent and
chronic sinus disease refractory to medical therapy.(10)
Computed tomography evaluates the osteomeatal
complex anatomy which is not possible with plain
radiographs. Removal of disease in osteomeatal
complex region is the basic principle of FESS which is
best appreciated on CT scan.
In the present study it was found that most
common CT inflammatory pattern was sinonasal
polyposis, followed by infudibular pattern, osteomeatal
pattern, spenoethmoidal recess pattern and lastly
sporadic pattern. According to the study conducted by
Chaitanya et al, it was reported that sinonasal polyposis
pattern was the most common followed by infundibular
and sporadic pattern in last.
In the present study good correlation was noted in
cases of chronic sinusitis, polyp and neoplastic lesions,
as evident by high sensitivity and specificity vales.
However poor correlation was obtained in cases of
fungal sinusitis which was supported by low sensitivity.
Similar results were noted when positive and negative
predictive values were calculated for all diagnosis.
Conclusion
CT helps to delineate the anatomy of nose and
sinuses, and drainage pathways of sinuses
preoperatively. It is helpful in evaluating the site and
extent of sinus pathology. Preoperative CT enabled the
surgeon to visualize the drainage pathways, anatomical
and critical variants in PNSs thus allowing effective
management of the patient. However, a potential pitfall
was its inability to accurately differentiate in cases of
fungal sinusitis and high‑density secretions.
References
1. Dhillon V, Dhingra R, Davessar J, Chaudhary A,
Monga S, Kaur M, Arora H: Correlation of clinical,
radiological and histopathological diagnosis among
patients with sinonasal masses. International Journal of
Contemporary Medical Research 2016,3:1612-15.
2. Weber AL, Stanton AC: Malignant tumors of the
paranasal sinuses: radiologic, clinical, and
histopathologic evaluation of 200 cases. Head & Neck
1984,6:761-76.
3. Parsons C, Hodson N: Computed tomography of
paranasal sinus tumors. Radiology 1979,132:641-5.
4. Kanwar SS, Mital M, Gupta PK, Saran S, Parashar N,
Singh A: Evaluation of paranasal sinus diseases by
computed tomography and its histopathological
correlation. Journal of Oral and Maxillofacial
Radiology 2017,5:46.
5. Branch I: Endoscopic Findings and Radiological
Appearance in Chronic Rhinosinusitis-A Comparative
Study.2012.
6. Chaita CS: Computed Tomographic Evaluati. 2015.
7. Vining EM, Yanagisawa K, Yanagisawa E: The
importance of preoperative nasal endoscopy in patients
with sinonasal disease. The Laryngoscope
1993,103:512-9.
8. Zinreich SJ, Kennedy DW, Rosenbaum AE, Gayler B,
Kumar A, Stammberger H: Paranasal sinuses: CT
imaging requirements for endoscopic surgery.
Radiology 1987,163:769-75.

9. Josephson JS: Update on diagnosis and treatment of
sinus disease: the functional endoscopic sinus surgery
approach. Medical Clinics of North America
1991,75:1293-309.
10. Slavin RG, Spector SL, Bernstein IL, Kaliner MA,
Kennedy DW, Virant FS, Wald ER, Khan DA,
Blessing-Moore J, Lang DM: The diagnosis and
management of sinusitis: a practice parameter update.
Journal of Allergy and Clinical Immunology
2005,116:S13-S47.

Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 22nd publication JOOO Innovative -2nd name

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