Neuromonitoring of the recurrent laryngeal nerve in thyroid gland surgery – results and experiences

2021 ◽  
Vol 70 (2) ◽  
pp. 89-96
Author(s):  
Jiří Hložek ◽  
Jan Rotnágl ◽  
Jaromír Astl
Keyword(s):  
Thyroid Gland ◽  
Recurrent Laryngeal Nerve ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Laryngeal Nerve ◽  
Operative Strategy ◽  
Predictive Values ◽  
Group A ◽  
Group B ◽  
Neural Monitoring

Paresis of the recurrent laryngeal nerve (RLN) is one of the serious complications of thyroid and parathyroid gland surgery. The intraoperative neural monitoring (IONM) enables to verify the functionality of RLN. The aim of this study is to compare the incidence of postoperative RLN palsy in patients who underwent surgery with and without the use of IONM RLN and to evaluate the positive and negative predictive values, sensitivity, specifi city and accuracy of the method. Methods: Retrospective analysis of thyroid gland surgeries performed within the period from 1. 7. 2016 to 1. 7. 2018. A total of 467 operations were performed (780 nerves exposed). One hundred and thirty procedures (215 nerves) were carried out without IONM (group A). In total, 337 procedures (565 nerves) were performed with IONM (group B). Results: In group A, unilateral postoperative RLN paresis occurred in 7 cases (3.26%); 6 of them were temporary (2.79%) and 1 was permanent (0.47%). In group B, unilateral postoperative RLN paresis occurred in 33 cases (5.84%); 32 of them were temporary (5.66%) and 1 was permanent (0.18%). The incidence of postoperative RLN paresis related to the use of IONM was not considered statistically signifi cant. (Chi-square test: P = 0.146; Fisher‘s exact test: P = 0.2015, P = 0.4715). The sensitivity, specifi city, positive predictive value, negative predictive value and accuracy were 78.79%, 99.25%, 86.67%, 98.69%, and 98.05%, respectively. There was no case of bilateral postoperative RLN paresis. Conclusion: There was no statistically significant diff erence in the incidence of postoperative RLN palsy in patients who underwent surgery with IONM compared to the group without IONM. The high negative predictive value, specifi city and accuracy indicate high reliability of the method. The IONM provides the surgeon with valuable information regarding the functional status of the nerve. This knowledge allows for changing the operative strategy during the procedure. Keywords: intraoperative neural monitoring – IONM – recurrent laryngeal nerve injury – recurrent laryngeal nerve – thyroid surgery

scholarly journals Identification of recurrent laryngeal nerve: a dilemma in thyroid surgery

2021 ◽  
Vol 7 (9) ◽  
pp. 1450
Author(s):  
Atishkumar B. Gujrathi ◽  
Harshada S. Kurande ◽  
Nishikant Gadpayale ◽  
Yogesh Paikrao
Keyword(s):  
Thyroid Gland ◽  
Recurrent Laryngeal Nerve ◽  
Nerve Injury ◽  
Thyroid Surgery ◽  
Recurrent Laryngeal Nerve Injury ◽  
Laryngeal Nerve ◽  
Recurrent Nerve ◽  
Group A ◽  
Laryngeal Nerve Injury ◽  
Group B

<p class="abstract"><strong>Background: </strong>Surgery of the thyroid gland is one of the most common surgical procedures performed. Recurrent laryngeal nerve injury is the most dreaded complication of thyroid surgery. Hence reducing intraoperative injury is of utmost importance. Routine dissection and identification of the recurrent nerve remain controversial.</p><p class="abstract"><strong>Methods:</strong> This study consists of 70 patients who underwent thyroid surgery. This study was conducted at our institute during the period of 2 years (2018-2020). Patients were evaluated and operated. Patients with thyroid diseases and normal vocal cords were allocated to two groups randomly; in group A the nerve was identified and in group B the nerve was not identified.</p><p class="abstract">Results: Most of the patients participating in the study were in the age group of 33-42 years. Male to female disease ratio was 0.13:1. In our study out of 70 patients who underwent thyroid surgery, 18 (25.71%) patients suffered from recurrent laryngeal nerve palsy. Amongst those 18 patients, 2 palsies (5.71%) were in Group A and 16 palsies (45.71%) were in Group B. Recurrent laryngeal nerve most commonly lied posterior to the inferior thyroid artery on both right (65.38%) as well as left side (45.45%). Most commonly injured recurrent laryngeal nerve was the right sided recurrent laryngeal nerve (77.77%).</p><p class="abstract"><strong>Conclusions:</strong> Careful dissection of nerve during thyroid surgery eliminates the risk of recurrent laryngeal nerve injury. A thorough knowledge of thyroid gland, recurrent laryngeal nerve and its anatomical relations and variations is of utmost importance in preserving the recurrent laryngeal nerve in thyroid surgery.</p>

The Role of HE4, a Novel Biomarker, in Predicting Optimal Cytoreduction After Neoadjuvant Chemotherapy in Advanced Ovarian Cancer

2017 ◽  
Vol 27 (4) ◽  
pp. 696-702 ◽  
Author(s):  
Francesco Plotti ◽  
Giuseppe Scaletta ◽  
Stella Capriglione ◽  
Roberto Montera ◽  
Daniela Luvero ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Neoadjuvant Chemotherapy ◽  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Advanced Ovarian Cancer ◽  
Debulking Surgery ◽  
Gynecology And Obstetrics ◽  
Group A ◽  
Group B

ObjectivesThis study aimed to evaluate serum human epididymis protein 4 (HE4) changes during neoadjuvant chemotherapy (NACT) to establish HE4 predebulking surgery cutoff values and to demonstrate that CA125, HE4, and computed tomography (CT) taken together are better able to predict complete cytoreduction after NACT in advanced ovarian cancer patients.MethodsFrom January 2006 to November 2015, patients affected by epithelial advanced ovarian cancer (International Federation of Gynecology and Obstetrics stage III–IV), considered not optimally resectable, were included in this prospective study. After 3 cycles of NACT, all patients underwent debulking surgery and were allocated, according to residual tumor (RT), into group A (RT = 0) and group B (RT > 0). Serum CA125, HE4, and CT images were recorded during NACT and compared singularly and with each other in term of accuracy, sensitivity, specificity, and positive and negative predictive value.ResultsA total of 94 and 20 patients were included in group A and group B, respectively. The HE4 values recorded before debulking surgery correlated with RT. The identified HE4 cutoff value of 226 pmol/L after NACT was able to classify patients at high or low risk of suboptimal surgery, with a sensitivity of 75% and a specificity of 85% (positive predictive value, 0.87; negative predictive value, 0.70). The combination of CA125, HE4, and CT imaging resulted in the best combination with a sensitivity of 96% and a specificity of 92% (positive predictive value, 0.96; negative predictive value, 0.94).ConclusionsThe novel biomarker HE4, in addition to CA125 and CT, is better able to predict the RT at debulking surgery and the prognosis of patients.

scholarly journals A Comparison of Two Operation Methods Revealed the Risk Factors and the Necessity of LN-prRLN Dissection in Papillary Thyroid Carcinoma: A Retrospective Cohort Study in FUSCC

2020 ◽  
Vol 2020 ◽  
pp. 1-8
Author(s):  
Yunjun Wang ◽  
Dezhi Wang ◽  
Lili Chen ◽  
Kai Guo ◽  
Tuanqi Sun
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Recurrent Laryngeal Nerve ◽  
Laryngeal Nerve ◽  
Papillary Thyroid ◽  
Multivariate Logistic Regression ◽  
Group A ◽  
Central Lymph ◽  
Group B ◽  
The Right

Background. Although the American Thyroid Association (ATA) guidelines indicate that central lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) should be routinely dissected, pr-RLN dissection is often neglected due to the high risk of injury to the recurrent laryngeal nerve (RLN). The purpose of this study was to investigate the risk factors associated with LN-prRLN metastasis in patients with papillary thyroid carcinoma (PTC) by preoperative examination and the indications for LN-prRLN dissection. Methods. A total of 1487 consecutive patients with PTC who underwent total thyroidectomy or right lobectomy plus isthmic resection with central LN dissection (CLND) were divided into two groups: patients with LN-prRLN dissection (group A) and patients without LN-prRLN dissection (group B). Clinicopathologic data were reviewed of the patients who were operated on by the same thyroid surgery team in the Department of Head Neck Surgery, Fudan University Shanghai Cancer Center (FUSCC) between August 2011 and May 2019. The relationships of LN-prRLN metastasis with clinicopathologic characteristics were analyzed by univariate and multivariate logistic regression. Results. The incidence of LN-prRLN metastasis was 34.1% (129/378). Univariate analysis showed that sex (P≤0.001), tumor size (P≤0.001), extrathyroidal extension (P=0.002), concurrent Hashimoto’s thyroiditis (P=0.009), cLNMa (central lymph nodes anterior to the right recurrent laryngeal nerve) (P≤0.001), cLNMa number (P≤0.001), and lateral LN metastasis (LLNM) (P≤0.001) were significantly associated with LN-prRLN metastasis in PTC. Multivariate logistic regression analysis revealed that tumor size (P=0.039), cLNMa (P=0.001), and LLNM (P=0.025) were independent risk factors for LN-prRLN metastasis in patients with PTC. Although there was no significant difference between the two groups in recurrence, we found that 4 cases relapsed in the LN-prRLN compartment in group B, while none relapsed in group A. Conclusion. LN-prRLN metastasis is often identified in patients with PTC. Patients with large tumor sizes, cLNMa and LLNM are at a high risk of LN-prRLN metastasis and should be recommended for careful LN-prRLN dissection.

Use of the nine-step inflation/deflation test and resting middle-ear pressure range as predictors of middle-ear barotrauma in aircrew members

2014 ◽  
Vol 128 (7) ◽  
pp. 612-617 ◽  
Author(s):  
A Hussein ◽  
A Abousetta
Keyword(s):  
Negative Predictive Value ◽  
Middle Ear ◽  
Predictive Value ◽  
Pressure Range ◽  
Test Results ◽  
Randomised Study ◽  
Middle Ear Pressure ◽  
Group A ◽  
Group B

AbstractObjective:To explore the role of the nine-step inflation/deflation tympanometric test and resting middle-ear pressure range as predictors of barotrauma in aircrew members.Methods:A prospective, non-randomised study was conducted on 100 aircrew members. Resting middle-ear pressure was measured and the nine-step inflation/deflation test performed on all subjects before flights. Subjects were allocated to two groups according to resting middle-ear pressure range (group A, within the range of +26 to +100 and −26 to −100 mmH2O; group B, −25 to +25 mmH2O). All aircrew members were assessed after flights regarding the presence and the grade of barotrauma.Results:In both groups, the sensitivity and specificity values of the entire post-inflation/deflation test were close to those of the post-deflation part of the test. The post-deflation test had a higher negative predictive value than the post-inflation test. Ears with resting middle-ear pressure lower than −55 mmH2O experienced barotrauma, regardless of good or poor post-inflation or post-deflation test results.Conclusion:In an aircrew member, a resting middle-ear pressure within the range of −55 and +50 mmH2O, together with good post-deflation test results, are considered reliable predictors for fitness to fly.

Comparison of a Handheld Device vs Endotracheal Tube–Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation

2021 ◽  
pp. 019459982110137
Author(s):  
Derek Kai Kong ◽  
Amanda M. Kong ◽  
Raymond L. Chai
Keyword(s):  
Positive Predictive Value ◽  
Recurrent Laryngeal Nerve ◽  
Endotracheal Tube ◽  
Predictive Value ◽  
Tertiary Care ◽  
Laryngeal Nerve ◽  
Care Hospital ◽  
Predictive Values ◽  
Handheld Device ◽  
Difficulty Score

Objective To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube–based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. Study Design Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. Setting Single-surgeon series at a tertiary care hospital. Methods Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. Results Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty ( R2 = 0.97). Conclusion ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. Evidence level 2.

Ascitic procalcitonin as a diagnostic and prognostic marker of spontaneous bacterial peritonitis

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Amira Ahmed Salem ◽  
Sarah Abd ElKader ElNakeep ◽  
Ahmed Mohamed ElGhandourl ◽  
Mohamed Ahmed Ahmed Mohamed
Keyword(s):  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Prognostic Marker ◽  
Ascitic Fluid ◽  
Neutrophil Count ◽  
Predictive Value ◽  
Spontaneous Bacterial Peritonitis ◽  
Bacterial Peritonitis ◽  
Group A ◽  
Group B

Abstract Background SBP is a condition that requires a high index of suspicion, rapid and accurate diagnosis in addition to prompt and effective therapy. It is also characterized by a high recurrence rate within one year of the 1st episode. Objective Evaluation of ascitic fluid procalcitonin as a possible diagnostic and prognostic marker for spontaneous bacterial peritonitis and to study its role in diagnosis of SBP with no increase in the neutrophil count (where neutrophils in the ascitic fluid are less than 250 per ccm while the culture is positive). Patients and Methods Study was conducted at Hepatology and Gastroenterology Department in Ahmed Maher Teaching Hospital and Internal Medicine Department in Ain Shams University from January 2019 till July 2019. Total number of 50 patients with cirrhotic ascites entered this study were divided into three groups: Group A (patient group): 20 patients with SBP as diagnosed by 250 neutrophils or greater per cmm of the ascitic fluid as present in the guidelines. Group B (patient group): 20 patients with criteria suggestive of SBP (abdominal pain, fever, liver function deterioration, leukocytosis in the CBC with no other localization for the infection), but shows neutrophil count in the ascitic fluid less than 250 i.e not diagnostic by itself. Only Patients with positive culture will be included in this group. Group C (control group): 10 patients with ascites,but no evidence of SBP (symptomatic or laboratory) as the control. Results Ascitic fluid procalcitonin level was statistically significant higher in both groups A&B (SBP group) than group C (non-SBP group). As regards Group A VS Group B+ Group C: The cutoff point is 520 (pg). Its sensitivity is 95%. Its specificity is 53.3%. The AUC is 0.633. The positive predictive value is 57.6%. The negative predictive value is 94.1%. Regarding Group B VS Group C: The cut-off point is 300 (pg). Its sensitivity is 85%. Its specificity is 70%. The AUC is 0.823. The positive predictive value is 85%. The negative predictive value is 70%. Conclusion Ascitic fluid procalcitonin had high sensitivity and specificity in diagnosis of SBP. Procalcitonin is valuable in diagnosis and prognosis of SBP. Procalcitonin is more useful as inflammatory marker than in infections

scholarly journals Dynamic Monitoring of sTREM-1 and Other Biomarkers in Acute Cholangitis

2020 ◽  
Vol 2020 ◽  
pp. 1-14
Author(s):  
Jiahui Jiang ◽  
Xiaolei Wang ◽  
Tongtong Cheng ◽  
Mingyue Han ◽  
Xinxin Wu ◽  
...  
Keyword(s):  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Acute Cholangitis ◽  
Dynamic Monitoring ◽  
Sepsis Group ◽  
Reactive Protein ◽  
Significant Difference ◽  
Group A ◽  
Group B

Background. Sepsis is a common complication of acute cholangitis (AC), which is associated with a high mortality rate. Our study is aimed at exploring the significance of white blood cell (WBC), C-reactive protein (CRP), procalcitonin (PCT), soluble triggering receptor expressed on myeloid cells 1 (sTREM-1), and temperature (T) alone or combined together in early identification and curative effect monitoring of AC with or without sepsis. Methods. 65 consecutive cases with AC and 76 control cases were enrolled. They were divided into three groups: Group A (AC with sepsis), Group B (AC without sepsis), and Group C (inpatients without AC or other infections). The levels of WBC, CRP, PCT, sTREM-1, and temperature were measured dynamically. The study was carried out and reported according to STARD 2015 reporting guidelines. Results. CRP had the highest AUC to identify AC from individuals without AC or other infections (AUC 1.000, sensitivity 100.0%, specificity 100.0%, positive predictive value 100.0%, and negative predictive value 100.0%). Among various single indexes, PCT performed best (AUC 0.785, sensitivity 75.8%, specificity 72.2%, positive predictive value 68.7%, and negative predictive value 78.8%) to distinguish sepsis with AC, while different combinations of indexes did not perform better. From day 1 to day 5 of hospitalization, the levels of sTREM-1 in Group A were the highest, followed by Groups B and C (P<0.05); on day 8, sTREM-1 levels in Groups A and B declined back to normal. However, other index levels among three groups still had a significant difference on day 10. Both in Groups A and B, sTREM-1 levels declined fast between day 1 and day 2 (P<0.05). Conclusions. CRP is the best biomarker to suggest infection here. PCT alone is sufficient enough to diagnose sepsis with AC. sTREM-1 is the best biomarker to monitor patients’ response to antimicrobial therapy and biliary drainage.

scholarly journals ROLE OF USG FINDINGS AS A PREDICTIVE MARKER IN THREATENED ABORTION

2021 ◽  
Vol 5 (4) ◽  
Author(s):  
Kamlesh Yadav ◽  
Pragya Ojha
Keyword(s):  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Predictive Marker ◽  
World Health ◽  
Pregnant Females ◽  
Obstetrics And Gynaecology ◽  
Group A ◽  
Threatened Abortion ◽  
Group B

Background: The Centers for disease control and prevention, and the World Health Organization all define abortion as pregnancy termination before 20 week gestation or with fetus born weighing <500g [1].  Early pregnancy USG parameters: - fetal crown-rump length (CRL), the presence/absence of sub-chorionic hematoma and Fetal Heart Rate (FHR) are good predictors of outcome. Material and Methods: The study was conducted in the Department of Obstetrics and Gynaecology, S.P. Medical College Bikaner& associated Group of Hospital, Bikaner, Rajasthan. This is a hospital based prospective comparative study. The study group comprise of pregnant females attending Obstetrics and Gynaecology OPD. A total of 200 pregnant women are examined in this study. We divided these patients into 2 groups i.e group A and group B. Group A consists of 100 pregnant females with threatened abortion and group B with 100 normal pregnant female. Results: FHR at 115bpm is 76.32% sensitive, 90.32% specific in predicting abortion with 82.86%  positive predictive value and  86.15% negative predictive value.  While CRL at 11 mm is 50% sensitive, 69.35% specific in predicting abortion with 55% positive predictive value and 69.35% negative predictive value.   Conclusion: FHR is best predictive marker followed by presence or absence of sub-chorionic hematoma and CRL  in threatened abortion which results in loss of pregnancy. Keywords: Pregnancy, Abortion, Threatened, USG

Abstract T P170: Carotid Artery Intima-Media Thickness and Ankle-Brachial Index are Strong Predictors of Complicated Aortic Arch Plaque in Acute Cerebral Embolism Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kazuyoshi Kaneko ◽  
Hiroki Saito ◽  
Yuichi Tsunoda ◽  
Shigeo Sugawara ◽  
Masahiro Akasaka ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Aortic Arch ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Ankle Brachial Index ◽  
Intima Media Thickness ◽  
Cerebral Embolism ◽  
Media Thickness ◽  
Group A ◽  
Group B

Background: Complicated aortic arch plaque (CAP) detected by transesophageal echocardiography (TEE) provides prognostic information regarding cerebrovascular disease risk. Coexistence of peripheral atherosclerotic disease worsens the prognosis in ischemic stroke patients. Methods: We examined TEE, carotid artery intima-media thickness (CIMT, calculated from carotid echograms), and ankle-brachial index (ABI, calculated from ankle/brachial blood pressure ratios) in 100 consecutive cerebral embolism patients within 2 weeks of onset of symptoms. CAP was defined as atherosclerotic plaque (≥4mm) or presence of ulcerated plaque assessed by TEE. Patients were classified into those with CAP (n=36, Group A) or without CAP (n=64, Group B). Results: Comparing patients in the two groups, significantly higher values were seen in Group A for age (69±8 vs. 63±11 years, p<0.01), prevalence of hypertension (75% vs. 50%, p<0.05) and ischemic heart disease (19% vs. 3%, p<0.01), and CIMT (1.9±0.8 vs. 1.2±0.5 mm, p<0.0001). Significantly lower values were seen in Group B for ABI (0.93±0.22 vs. 1.11±0.11, p<0.0001). Defining arteriosclerosis obliterans (ASO) as ABI <0.9 and CIMT thickening as CIMT ≥1.1mm, CAP was predicted by ASO with 39% sensitivity and 97% specificity, and by CIMT thickening with 78% sensitivity and 48% specificity. Combined ASO and CIMT thickening predicted CAP with 83% sensitivity and 81% positive predictive value, and with 97% specificity and 83% negative predictive value in all of the subjects. Furthermore, aortic arch intima-media thickness was significantly correlated with CIMT and ABI (r=0.441, p<0.0001 and r=-0.384, p<0.0001, respectively). Conclusions: For non-invasive evaluation of patients with acute cerebral embolism, the combination of both ABI and CIMT predicts CAP more strongly than either ABI or CIMT considered alone, with higher figures for sensitivity, specificity, and positive and negative predictive value.

Histological Study of Human Thyroid Gland Relative Proportion of Parenchyma and Stroma in Thyroid Glands of Bangladeshi People

2013 ◽  
Vol 1 (2) ◽  
pp. 17-20
Author(s):  
Md Enayet Ullah ◽  
Hasna Hena ◽  
Rubina Qasim
Keyword(s):  
Thyroid Gland ◽  
Histological Study ◽  
Relative Proportion ◽  
Age Groups ◽  
Human Thyroid ◽  
Structural Units ◽  
Thyroid Glands ◽  
Group A ◽  
Group B ◽  
Connective Tissue Sheath

Deep cervical fascia forms a connective tissue sheath around the thyroid gland. Delicate trabeculae and septa penetrate the gland indistinctly dividing the gland into lobes and lobules which in turn composed of follicles.1,2,3 These follicles are structural units of thyroid gland which varies greatly in size and shape.4 The number of follicles varies in different age groups. The study was carried out to see the percentage of area occupied by follicles in the stained section of thyroid glands in different age groups. The collected samples were grouped as A (3.5 – 20yrs), B (21- 40yrs) & C (41 – 78yrs). Percentage of area occupied by follicles was (58.55±10.72) in group A, (63.79±12.35) in group B + (63.39±8.29) in group C.DOI: http://dx.doi.org/10.3329/updcj.v1i2.13981 Update Dent. Coll. j. 2011: 1(2): 17-20

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