Prevalence of Odontogenic Cysts - A Retrospective Clinico-Pathological Study

M. Gayathri¹, K. R. Don²

¹Third Year BDS Undergraduate Student, Saveetha Dental College, Chennai-600077, Tamil Nadu, India

²Senior Lecturer, Department of Oral and maxillofacial Pathology, Saveetha Dental College, Chennai-600077, Tamil Nadu, India

*Corresponding Author E-mail: arthimohan2010@gmail.com

Abstract:

Background: Odontogenic cysts are unique in a way that they only affect the oral and maxillofacial region. The Odontogenic cysts arise from the epithelial components of the odontogenic apparatus or its remnants that lie entrapped within bone or in the gingival tissue. Even though the prognosis of the lesion is excellent, there are possibilities that the cyst may undergo a neoplastic change or may affect occlusion and eruption. It is important to determine the prevalence pattern of odontogenic cysts for proper management.

Aim: To determine the prevalence pattern of odontogenic cysts and its clinico-pathological correlation and to compare the results with the findings in the literature.

Methodology: This retrospective study included reports of 163 histopathologically diagnosed cases of odontogenic cysts from the year 2004. Clinical history and relevant data were recorded. The cases were analyzed for type of cyst, age, sex and anatomical site.

Results: The most frequent type of odontogenic cyst was periapical cyst (38.03%), followed by odontogenic keratocyst (35.6%), dentigerous cyst (10.4%), residual cyst (8.5%), orthokeratinised odontogenic cyst (4.2%), glandular odontogenic cyst (2.45%) and lateral periodontal cyst (0.6%). The most prevalent age group was 21-30 years except for residual cyst which was 31-40 years and lateral periodontal cyst which was 61-70 years. The most prevalent gender was male for all the odontogenic cysts. The most common anatomic site of the cysts was posterior mandible except for dentigerous cyst, periapical cyst and lateral periodontal cyst.

KEY WORDS: Odontogenic cyst, prevalence

INTRODUCTION:

A cyst is defined as a pathologic cavity containing fluid, semifluid or gaseous contents frequently lined by epithelium.[1] The oral and maxillofacial region presents with a bewildering variety of cystic lesions that may either be odontogenic or non-odontogenic.[2]

Odontogenic cysts are unique in a way that they only affect the oral and maxillofacial region.[3] Odontogenic cysts are structures derived from odontogenic epithelium or its remnants that lie entrapped within bone or in the gingival tissue associated with tooth development.[4] They exhibit slow growth and a tendency towards expansion.[5] Odontogenic cysts are of two types. They include the “developmental type” and the "inflammatory type”. Developmental odontogenic cysts include odontogenic keratocyst, dentigerous cyst, glandular cyst, orthokeratinised odontogenic cyst, lateral periodontal cyst, sialo odontogenic cyst, and eruption and gingival cysts. The inflammatory type includes radicular, residual and paradental cysts. Radicular and dentigerous cysts are very common and can be diagnosed easily.[6,7] Odontogenic cysts are usually asymptomatic. They can sometimes cause bone inflation, teeth mobility, fistula formation, pain, parasthesia, and mucofacial fold swelling.[4] Even though the prognosis of the lesion is excellent, there are possibilities that the cyst may undergo a neoplastic change or may affect occlusion and eruption. It is important to determine the prevalence of odontogenic cyst for proper diagnosis and management.  Several studies on prevalence of odontogenic cysts have been carried out in various countries. However, there is little information regarding the relative frequency of these lesions among the Indian population. The aim of the present study is to determine the prevalence pattern of odontogenic cysts and its clinico-pathological correlation and to compare the results with the findings in the literature.

MATERIALS AND METHODS:

This retrospective study included reports of 163 histopathologically diagnosed cases of odontogenic cysts from the year 2004 - 2016 obtained from the Department of Oral and Maxillofacial Pathology, Saveetha Dental College and Hospital, Chennai, India. Clinical history and relevant data were recorded. The cases were analyzed for type of cyst, age, sex and anatomical site. Inclusion criteria involved only the histopathologically confirmed cases of odontogenic cysts. The odontogenic cysts diagnosed histopathologically as infected cysts were not included. Site distribution for maxilla and mandible was divided in two regions – anterior and posterior. Anterior region was defined from distal aspect of right canine to distal aspect of left canine. Posterior region was defined from mesial aspect of first premolar to distal aspect of third molar including ramus for mandibular posterior region. Microsoft Excel™ software was used for data analysis and construction of the graphs.

RESULTS:

Table 1 and graph 1 shows the frequency distribution of odontogenic cysts. A total of 163 cases were recorded from the year 2004-2016 of which 62 cases (38.03%) were periapical cysts, 58 cases (35.6%) were odontogenic keratocyst, 17 cases (10.4%) were dentigerous cyst, 14 cases (8.5%) were residual cysts, 7 cases (4.2%) were orthokeratinised odontogenic cyst, 4 cases (2.45%) were glandular odontogenic cysts and 1 case (0.6%) was lateral periodontal cyst.

Table 1: Frequency distribution of odontogenic cyst

S. No.	Type of cyst	No.  of cases	Percentage  (%)
1	Periapical cyst	62	38.03
2	Residual cyst	14	8.5
3	Dentigerous cyst	17	10.4
4	Odontogenic keratocyst	58	35.6
5	Orthokeratinised odontogenic cyst	7	4.2
6	Lateral periodontal cyst	1	0.6
7	Glandular odontogenic cyst	4	2.45
	Total	163	100

Figure 1: Frequency distribution of odontogenic cysts

Table 2: Age distribution of odontogenic cyst

S. N.	Type of cyst	Age in decades								Total
		1 - 10	11-20	21-30	31-40	41-50	51-60	61-70	71-80
1	Periapical cyst	4 (6.4%)	9 (14.5%)	18 (29%)	9 (14.5%)	15 (24.2%)	4 (6.45%)	2 (3.22%)	1 (1.6%)	62
2	Residual cyst	-	2 (14.3%)	4 (28.5%)	5(35.7%)	-	-	2 (14.3%)	1 (7.1%)	14
3	Dentigerous cyst	1 (5.9%)	5 (29.4%)	7 (41.2%)	4 (23.5%)	-	-	-	-	17
4	Odontogenic keratocyst	2 (3.4%)	9 (15.5%)	21(36.2%)	14 (24.1%)	5 (8.6%)	6 (10.3%)	1(1.72%)	-	58
5	Ortho-keratinised odontogenic cyst	-	2(28.6%)	3 (42.9%)	2(28.6%)	-	-	-		7
6	Lateral periodontal cyst							1 (100%)		1
7	Glandular odontogenic cyst	-	-	3 (75%)		1 (25%)		-	-	4

Figure 2: Age distribution of odontogenic cysts

Table 2 and graph 2 shows the age distribution of odontogenic cysts. Age distribution of odontogenic cysts showed periapical cysts with a peak incidence in third decade 18 (29%) cases, odontogenic keratocyst in third decade 21 (36.2%) cases, dentigerous cyst in third decade 7 (41.2%) cases, residual cyst in fourth decade 5 (35.71%) cases, orthokeratinised odontogenic cyst in third decade 3 (42.85%) cases, glandular odontogenic cyst in third decade  3 (75%) cases and lateral periodontal cyst in seventh decade 1 (100%) case. Table 3 and graph 3 shows the gender distribution of odontogenic cysts.

Assessing the gender distribution of the odontogenic cysts, 40 (64.5%) cases of male patients and 22 (35.5%) cases of female patients were recorded in case of periapical cysts, 36 (62%) cases of male patients and 22 (38%) cases of female patients were recorded in case of odontogenic keratocysts, 15 (88.2%) cases of male patients and 2 (11.2%) cases of female patients were recorded in case of dentigerous cysts, 8 (57.2%) cases of male patients and 6 (42.8%) cases of female patients were recorded in case of residual cysts, 4 (57.1%) cases of male patients and 3 (42.9%) cases of female patients were recorded in case of orthokeratinised odontogenic cysts, 3 (75%) cases of male patients and 1 (25%) case of female patient were recorded in case of glandular odontogenic cyst and 1 (100%) case of male patient was recorded in case of lateral periodontal cyst. All the odontogenic cysts showed male predominance.

Table 4 and graph 4 shows the distribution of Anatomical site of odontogenic cysts. Radicular and dentigerous and lateral periodontal cysts were common in the anterior region of maxilla with 29 (47%) cases, 9 (53%) cases and 1 (100%) case respectively.

Table 3: Gender distribution of odontogenic cyst

S. No.	TYPE OF CYST	GENDER				Total
		No. of Male	% of Male	No. of Female	% of Female
1	Periapical cyst	40	64.5%	22	35.5%	62
2	Residual cyst	8	57.2%	6	42.8%	14
3	Dentigerous cyst	15	88.2%	2	11.8%	17
4	Odontogenic keratocyst	36	62.0%	22	38.0%	58
5	Orthokeratinised odontogenic cyst	4	57.1%	3	42.9%	7
6	Lateral periodontal cyst	1	100.0%	0	0.0%	1
7	Glandular odontogenic cyst	3	75.0%	1	25.0%	4

Figure 3: Gender distribution of odontogenic cysts

Table 4:Anatomical site distribution of odontogenic cyst

S. No.	TYPE OF CYST	ANATOMICAL SITE
		Anterior Maxilla	Posterior Maxilla	Anterior Mandible	Posterior Mandible	Total
1	Periapical cyst	29 (47%)	6 (9.6%)	7 (11.2%)	20 (32.2%)	62
2	Residual cyst	4 (28.5%)	1 (7.2%)	2 (14.3%)	7 (50%)	14
3	Dentigerous cyst	9 (53%)	1 (5.9%)	1 (5.9%)	6 (35.2%)	17
4	Odontogenic keratocyst	3 (5.2%)	7 (12.05%)	7 (12.05%)	41 (70.7%)	58
5	Orthokeratinised odontogenic cyst	0	0	2 (28.8%)	5 (71.2%)	7
6	Lateral periodontal cyst	1 (100%)	0	0	0	1
7	Glandular odontogenic cyst	1 (25%)	0	0	3 (75%)	4

Figure 4: Site distribution of odontogenic cysts

Other cysts like odontogenic keratocyst, residual cyst, orthokeratinized odontogenic cyst, glandular odontogenic cyst and lateral periodontal cyst were predominant in posterior region of mandible with 41 (70.7%) cases, 7 (50%) cases, 5 (71.2%) cases and 3 (75%) cases. Table 5 shows the overall most predominant distribution pattern of age, sex and anatomical site of odontogenic cysts. The most frequent type of odontogenic cyst was periapical cyst (38.03%), followed by odontogenic keratocyst (35.6%), dentigerous cyst (10.4%), residual cyst (8.5%), orthokeratinised odontogenic cyst (4.2%), glandular odontogenic cyst (2.45%) and lateral periodontal cyst (0.6%). The most prevalent age group was 21-30 years except for residual cyst which was 31-40 years and lateral periodontal cyst which was 61-70 years. The most prevalent gender was male for all the odontogenic cysts. The most common anatomic site of the cysts was posterior mandible except for dentigerous cyst, periapical cyst and lateral periodontal cyst.

Table 5:Overall most predominant distribution pattern of odontogenic cysts

S. No.	TYPE OF CYST	PREVALENCE	AGE	SEX	ANATOMICAL SITE
1	Periapical cyst	38.03%	21-30 (29%)	Male  (64.5%)	Anterior maxilla (47%)
2	Residual cyst	8.50%	31-40 (35.71%)	Male  (57.2%)	Posterior mandible (50%)
3	Dentigerous cyst	10.40%	21-30 (41.2%)	Male  (88.2%)	Anterior maxilla (53%)
4	Odontogenic keratocyst	35.60%	21-30 (36.2%)	Male  (62%)	Posterior mandible (70.7%)
5	Orthokeratinised odontogenic cyst	4.20%	21-30 (42.85%)	Male  (57.1%)	Posterior mandible (71.2%)
6	Lateral periodontal cyst	0.60%	61-70 (100%)	Male (100%)	Anterior maxilla (100%)
7	Glandular odontogenic cyst	2.45%	21-30 (75%)	Male  (75%)	Posterior mandible (75%)

Table 6:Comparison of prevalence of the odontogenic cysts

S. No.	AUTHOR	Radicular cyst	Odonto-genic keratocyst	Dentigerous cyst	Residual cyst	Ortho-keratinised odontogenic cyst	Glandular odontogenic cyst	Lateral periodontal cyst
1	Gayathri (2016)	38.30%	35.60%	10.40%	8.50%	4.20%	2.45%	0.60%
2	El Gehani (2007)	68.10%	14.00%	15.00%				1.50%
3	Deepashri (2014)	48.67%	8.00%	17.33%	6.00%		2.00%	6.00%
4	Selvamani (2012)	69.30%	5.20%	20.30%	3.30%	-	-	1.90%
5	Khosravi (2013)	34.98%	23.04%	26.27%	12.98%
6	Ackigoz (2011)	54.70%	3.30%	26.60%	13.70%			0.20%
7	AV Jones (2006)	52.30%	11.60%	18.10%	8.00%		0.20%	0.40%
8	Niranjan (2014)	50.80%		10.30%	1.10%	5.90%	0.20%	0.30%
9	Fahimeh (2014)	18.60%	18.60%	27.20%	1.40%
10	Sagharavanian (2015)	30.45%	25.00%	26.80%	6.50%	0.35%	0.85%	0.75%

Table 7:Comparison of most prevalent age group of odontogenic cysts

S. No	AUTHOR	Radicular cyst	Odonto-genic keratocyst	Dentigerous cyst	Residu-al cyst	Ortho-keratinised odontogenic cyst	Glandular odontogenic cyst	Lateral periodontal cyst
1	Gayathri (2016)	21-30	21-30	21-30	31-40	21-30	21-30	61-70
2	El Gehani (2007)	21-50	21-50	1-20				51-80
3	Deepashri (2014)	21-30	11-30	11-20	31-40	-	11-61	41-50
4	Selvamani (2012)	21-30	21-30	11-20	21-70	-	-	21-30
5	Khosravi (2013)	31-40	31-40	21-30	21-30	41-50	31-40	31-40
6	Ramachandra (2014)	21-50	21-50	21-50			21-50
7	AV Jones (2006)	31-40	41-50	31-40	41-50		11-20	41-50
8	Rafael (2009)	21-30		21-30	11-20		31-40	21-30
9	Silvia (2008)	31-40	31-40	31-40

Table 8:Comparison of most prevalent gender distribution of odontogenic cysts

S.No	AUTHOR	Radicular cyst	Odonto-genic keratocyst	Dentigerous cyst	Residu-al cyst	Ortho-keratinised odontogenic cyst	Glandular odontogenic cyst	Lateral periodontal cyst
1	Gayathri (2016)	Male	Male	Male	Male	Male	Male	Male
2	El Gehani (2007)	Male	Male	Male				Female
3	Deepashri (2014)	Male	Male	Male	Male		Male
4	Selvamani (2012)	Female	Male	Male	Male			Male
5	Khosravi (2013)	Male	Male	Male	Male	Both	Female	Female
6	Ackigoz (2011)	Male	Female	Male	Male			Female
7	Al-Rawi (2013)	Female	Female
8	Ramachandra  (2014)	Male	Male	Male			Male
9	Rafael (2009)	Male		Male	Female		Male	Male
10	Silvia (2008)	Male	Male	Male
11	Sagharavanian (2015)	Female	Male	Male	Female	Male	Male	Female

Table 9:Comparison of most prevalent site of distribution of odontogenic cysts

S.No	AUTHOR	Radicular cyst	Odontogenic keratocyst	Dentigerous cyst	Residual cyst	Ortho-keratinised odontogenic cyst	Glandular odontogenic cyst	Lateral periodontal cyst
1	Gayathri (2016)	Anterior maxilla	Posterior mandible	Anterior maxilla	Posterior mandible	Posterior mandible	Posterior mandible	Anterior maxilla
2	El Gehani (2007)	Anterior maxilla	Posterior mandible	Posterior mandible				Posterior mandible
3	Deepashri (2014)	Anterior maxilla	Posterior mandible	Posterior mandible	Anterior mandible		Posterior mandible	Posterior mandible
4	Selvamani (2012)	Anterior maxilla	Posterior mandible	Anterior maxilla	Posterior mandible			Posterior mandible
5	Khosravi(2013)	Posterior mandible	Posterior mandible	Posterior mandible	Posterior mandible	Posterior mandible	Anterior mandible	Posterior mandible
6	Ackigoz (2011)	Anterior maxilla	Posterior mandible	Posterior mandible	Posterior mandible
7	Ramachandra (2014)	Anterior maxilla	Posterior mandible	Posterior mandible			Posterior mandible
8	Silvia (2008)	Anterior maxilla	Posterior mandible	Posterior mandible				Anterior mandible

DISCUSSION:

One of the most common lesions affecting the jaws is odontogenic cysts and many of them share similar clinical and radiographic features. Hence, the diagnosis of odontogenic cysts should be based on careful clinical examination, radiographic and histopathologic features. The incidence and prevalence pattern of odontogenic cysts exhibits geographical variations in different regions of the world. In the present study, the most frequent type of odontogenic cyst was periapical cyst (38.03%). (Table 6) On comparison of this study with other studies based on the prevalence of the cysts, this study was found to be in accordance with several other studies done in different countries like (El Gehani et al. 2007 (68.1%), Deepashri et al. 2014 (48.67%), Selvamani et al. 2012 (69.3%), khosravi et al. 2013 (34.98%), ackigoz et al.  2011 (54.7%), Jones et al. 2006 (52.3%), niranjan et al. 2014 (50.8%) and sagharavanian et al.  2015 (30.45%). But in contrast to the report by Fahimeh et al (2014) who reported dentigerous cyst as the most frequent type. increased incidence of odontogenic cysts in the female gender. [1,3,4,6,8,9,10]

Periapical Cyst:

In the present study, the periapical cyst was predominantly seen between the age group of 21-30. This was found to be in accordance with several other studies like Selvamani et al. 2012, Deepashri et al. 2014 and Rafael et al. 2009. [1,8,11] But few other studies done by Khosravi et al. 2013, Silvia et al. 2008 and AV Jones et al. (2006) suggest that the prevalent age group is between 31-40 years. (Table 7) In the present study, the radicular cyst showed male predominance which was found to be in accordance with several other studies like El Gehani et al. 2007, Deepashriet al. 2014, Khosravi et al. 2013, Ackigoz et al. 2011, Ramachandra et al. 2014, Rafael et al. 2009 and Silvia et al. 2008. But the studies done by Al-Rawi et al. 2013, Selvamani et al. 2012 and Sagharavanian et al. 2015 showed female predominance. [1,3,8,12,13,14,15,16] (Table 8) In the present study, the most common site of periapical cyst was found to be anterior maxilla. This was in accordance to the studies done by El Gehani et al. 2007, Deepashri et sl. 2014, Selvamani et al. 2012, Ackigoz et al. 2011, Ramachandra et al. 2014, and Silvia et al. 2008.  But according to Khosravi et al. 2013, the most common site was posterior mandible. (Table 9)

Odontogenic Keratocyst:

The second most prevalent cyst in this study was the odontogenic keratocyst (35.6%). (Table 6) In our study, the most prevalent age group was between 21-30 years and this was found to be in accordance to the study done by Selvamani et al. (2012). But this was in contradiction to the study done by Khosravi et al. 2013 and Silvia et al. 2008 who found that the most prevalent age group was 31-40 and Jones et al. 2006 found that the most prevalent age group was 41-50. [3,4,12] (Table 7) In the present study, in case of odontogenic keratocyst, there was a male predominance which was found to be in accordance with several other studies like El Gehani et al. 2007, Deepashri et al. 2014, Khosravi et al. 2013, Selvamani et al. 2012, Sagharavanian et al. 2015, Ramachandra et al. 2014, Rafael et al. 2009 and Silvia et al. 2008. But the studies done by Al-Rawi et al 2013 and Ackigoz et al. 2011 showed female predominance. [1,3,6,8,12,13] (Table 8)

On comparison of this study with all other studies based on the anatomical site of the cyst, the most common location of odontogenic keratocyst was posterior mandible. (Table 9)

Dentigerous Cyst:

The third most commonly seen cases of odontogenic cyst in our present study was the dentigerous cyst (10.4%) (Table 6). In our study, the most prevalent age group was between 21-30 years and this was found to be in accordance with the studies done by Rafael et al. 2009 and khosravi et al. 2013. But the studies done by Jones et al. 2006 and Silvia et al.2008 showed that the most prevalent age group was 31-40 years and Deepashri et al. 2014 and Selvamani et al. 2012 inferred that it was between 11–20. (Table 7) In the present study, in case of dentigerous cyst, there was a male predominance which was found to be in accordance with all other studies. (Table 8) The most prevalent site of dentigerous cyst in this study and the study done by Selvamani et al. 2012 was anterior maxilla. But the rest of the studies showed that it was posterior mandible. [1,3,6,8,12,13,16] (Table 9)

Residual Cyst:

The next most prevalent cyst in our study was the residual cyst (8.5%). (Table 6) On assessing the age group it was found that the residual cyst was more common among people of 31-40 years which was found to be in accordance with Deepashri et al. 2014. Other studies showed a wide age range. (Table 7) In the present study, in case of residual cyst, there was a male predominance which was found to be in accordance with several other studies like Deepashriet al. 2014, Khosravi et al. 2013, Ackigoz et al. 2011 and Selvamani et al. 2012. But the studies done by Rafael et al. 2009 and Sagharavanian et al. 2015 showed female predominance. (Table 8) In our study, for residual cyst the predominant site was posterior mandible which was found to be in accordance with studies like Selvamani et al. 2012, Ackigoz et al. 2011 and Khosravi et al. 2013. But the study done by Deepashri et al. 2014 recorded that the most common site was anterior mandible. [1,3,6,8,12,13] (Table 9)

Orthokeratinised Odontogenic Cyst:

The next most prevalent cyst in our study was the orthokeratinised odontogenic cyst (4.2%) (Table 6) On assessing the age group it was found that the orthokeratinised odontogenic cyst was more common among people of 31-40 years. But the study done by Khosravi et al. 2013 showed 41-50 years. (Table 7) Orthokeratinised odontogenic cyst was seen more commonly in male patients in our study which was found to be in accordance with the study done by Sagharavanian et al. 2015. Khosravi2013 reported equal predominance in both males and females. (Table 8) In our study, for orthokeratinised odontogenic cyst, the predominant site was posterior mandible which was found to be in accordance with the study conducted by Khosravi et al. 2013. (Table 9)

Glandular Odontogenic Cyst:

The glandular odontogenic cyst (2.45%) was the next common cyst seen in this study. (Table 6) In our study, the common age group was between 21-30 years. But Khosravi et al. 2013 and Rafeal et al. 2009 reported that the cyst was more predominant between the ages of 31-40. Jones2006 reported that the prevalent age group was between 11-20. (Table 7) In our study, glandular odontogenic cyst showed male predominance which was found to be in accordance with the studies done by Deepashri et al. 2014, Ramachandra et al. 2014, Rafeal et al. 2009 and Sagharavanian et al. 2015. But the study done by Khosravi et al. 2013 showed female predominance. (Table 8) In our study, the most prevalent site was posterior mandible which was found to be in accordance with the studies done by Deepashri et al. 2014 and Ramachandra et al. 2014. But the study done by Khosravi et al. 2013 found that the common site was anterior mandible. [3,17] (Table 9)

Lateral Periodontal Cyst:

The lateral periodontal cyst was the least common cyst in our study. (Table 6) On comparison of this study with other studies based on the age revealed a contradictory finding, our study showed that the most prevalent age group was 61-70 years while studies done by Deepashri et al. 2014 and Jones et al. 2006 showed that the age group was 41-50 years and the studies done by Selvamani et al. 2012 and Rafael et al. 2009 showed that the prevalent age group was 21-30 years. (Table 7)  In our study, lateral periodontal cyst showed male predominance which was in accordance to the studies done by Selvamani et al. 2012 and Rafael et al. 2009. But studies done by Khosravi et al. 2013, Ackigoz et al. 2011, Sagharavanian et al. 2015 and El Gehani et al. 2007 showed a female predominance. (Table 8) In our study, the most common site was anterior maxilla. But the studies done by El Gehani et al. 2007, Deepashri et al. 2014, Selvamani et al. 2012 and Khosravi et al. 2013 showed that the common site of lateral periodontal cyst was posterior mandible and according to Silvia et al. 2008 the most common site was anterior mandible.[1,3,6,8,12] (Table 9)

CONCLUSION:

It can be concluded that the prevalence pattern of odontogenic cysts in Indian population is relatively similar to the studies from other parts of the world with some geographic differences. Variations in results when compared to other studies may be due to differences in sample size and different ethnicity. It is important to realize that some of these cysts have a marked propensity to recur as well as behave in a locally aggressive manner. It is essential that these lesions are detected as early as possible. Patients need to be reviewed regularly to monitor possible recurrence.

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Received on 13.04.2017       Modified on 20.04.2017

Accepted on 10.05.2017      ©A&V Publications All right reserved

Research J. Science and Tech. 2017; 9(2): 259-266.

DOI: 10.5958/2349-2988.2017.00047.X