International Journal of Critical Illness and Injury Science (Int J Crit Illn Inj Sci) 2018 | October-December | Volume 8 | Issue 4

Turnaround time for red blood cell transfusion in the hospitalized patient: A single-center "Blood Ordering, Requisitioning, Blood Bank, Issue (of Blood), and Transfusion Delay" study Naveen Agnihotri, Ajju Agnihotri Indian Journal of Critical Care Medicine 2018 22(12):825-830 Background and Aim: The turnaround time (TAT) for blood transfusion (BT) is an important quality indicator for the health-care institutions undertaking this procedure. There is no established national or international benchmark for this TAT due to the dearth of a published literature. We thus studied the TAT and the contributory procedures leading to delay in commencing a red blood cell transfusion in the hospitalized patient. Materials and Methods: Delay was captured for the blood order transcription, requisitioning and sampling by the nurse, blood bank (BB) processing, blood issue, and the transfusion commencement in the hospitalized patients. The study was done prospectively over a 1-year period and involved all the patient locations spread over six floors in a tertiary care accredited hospital. Results: A total of 2022 blood requests were analyzed during the study period. Most (73%) of the blood requests were marked as urgent by the treating unit. The average time from ordering to initiation of BT was 135 min in our study. BB processes (compatibility testing and issue) comprised approximately 47% of this delay (63 min), while rest of the delay happened in the processes (ordering 13 min, sample transport 34 min, and BT commencement 25 min) outside the BB (72 min). Conclusion: Majority of the delay for blood transfusion happens due to the processes outside blood bank premises. Understanding the steps where delay happens has the potential to reduce the turnaround time for lifesaving procedures such as blood transfusion in the hospitalized patients.

Acute kidney injury in Malaysian intensive care setting: Incidences, risk factors, and outcome Azrina Md Ralib, Suhaila Nanyan, Nur Fariza Ramly, Lim Chew Har, Tan Cheng Cheng, Mohd Basri Mat Nor Indian Journal of Critical Care Medicine 2018 22(12):831-835 Introduction: Acute kidney injury (AKI) is common in the intensive care unit (ICU) with a high risk of morbidity and mortality. The high incidence of AKI in our population may be attributed to sepsis. We investigated the incidence, risk factors, and outcome of AKI in four tertiary Malaysian ICUs. We also evaluated its association with sepsis. Materials and Methods: This retrospective cohort study extracted de-identified data from the Malaysian Registry of Intensive Care in four Malaysian tertiary ICUs between January 2010 and December 2014. The study was registered under the NMRR and approved by the ethics committee. AKI was defined as twice the baseline creatinine or urine output <0.5 ml/kg/h for 12 h. Results: Of 26,663 patients, 24.2% had AKI within 24 h of admission. Patients with AKI were older and had higher severity of illness compared to those without AKI. AKI patients had a longer duration of mechanical ventilation, length of ICU, and hospital stay. Age, Simplified Acute Physiological II Score, and the presence of sepsis and preexisting hypertension, chronic cardiovascular disease independently associated with AKI. About 32.3% had sepsis. Patients with both AKI and sepsis had the highest risk of mortality (relative risk 3.43 [3.34–3.53]). Conclusions: AKI is common in our ICU, with higher morbidity and mortality. Independent risk factors of AKI include age, the severity of illness, sepsis and preexisting hypertension, and chronic cardiovascular disease. AKI independently contributes to mortality. The presence of AKI and sepsis increased the risk of mortality by three times.

Comparison of hemodynamic monitoring between transesophageal Doppler and ultrasonography-guided inferior vena cava distensibility in supine versus prone position: A pilot study Pralay Shankar Ghosh, Afzal Azim, Sai Saran, Arvind Kumar Baronia, Banani Poddar, Ratender Kumar Singh, Mohan Gurjar, Prabhaker Mishra Indian Journal of Critical Care Medicine 2018 22(12):836-841 Introduction: Lung-protective ventilation strategy and prone positioning are the strategies practiced to manage patients suffering from acute respiratory distress syndrome (ARDS). Inferior Vena Cava Distensibility (dIVC) Index has been used for predicting fluid responsiveness (FR) in supine position. We conducted this study to observe the utility of dIVC in prone position in ARDS patients and compare it with esophageal Doppler (ED) parameters. Materials and Methods: After ethical clearance, a prospective observational pilot study was conducted in a 12-bedded tertiary care hospital. Adult ARDS patients who were treated with prone ventilation were included. Informed consent was taken from the relatives. IVC was visualized through right lateral approach both in supine and prone positions. We compared IVC distensibility and ED parameters, first in 45° head up and then in prone. FR was defined as an increase in the stroke volume of ≥15% as measured by ED. The patients with dIVC >18% were assumed to be fluid responsive. Statistical analysis was done using SPSS software version 20. Results: Twenty-five patients met the inclusion criteria. ARDS was (mean P/F ratio 116.64 ± 44.76) mostly due to pulmonary etiology. Out of 25 patients, 10 patients were fluid responsive based on dIVC (cutoff >18%) in supine position. When compared to ED values after passive leg raising, dIVC had a sensitivity and specificity of 77.78% and 81.25%, respectively, in predicting FR with a moderate-to-absolute agreement between the two methods. IVC distensibility showed statistically significant negative correlation with corrected flow time (FTc) values both in supine and in prone positions. Conclusion: IVC variability can be observed in acute respiratory distress syndrome patients in prone position. Inferior Vena Cava Distensibility correlates with flow time in both the positions.

Comparison of various severity assessment scoring systems in patients with sepsis in a tertiary care teaching hospital Keertana Badrinath, Monica Shekhar, Moturu Sreelakshmi, Meenakshi Srinivasan, Girish Thunga, Sreedharan Nair, Karthik Rao Nileshwar, Athira Balakrishnan, Vijayanarayana Kunhikatta Indian Journal of Critical Care Medicine 2018 22(12):842-845 Background: Sepsis is a complex condition defined by the systemic response to infection. Severity assessment scoring systems are used to aid the physician in deciding whether aggressive treatment is needed or not. In this study, various severity assessment scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), Predisposition, Infection, Response, and Organ Dysfunction (PIRO), and Mortality in Emergency Department Sepsis (MEDS), were compared to assess their sensitivity and specificity. Materials and Methods: A prospective cohort study was conducted over 6 months. The study was conducted in the intensive care unit (ICU) of a tertiary care teaching hospital. All patients above 18 years of age with confirmed sepsis diagnosis and a well-defined outcome were included in the study. Results: A total of 193 patients were included in the study. The mean age was 57.2 ± 15.3 (mean ± standard deviation) years. Majority of the patients were male, 125 (64.76%). Overall mortality was 108 (55.9%). The calculated area under the receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.80–0.90) for APACHE II, 0.81 (95% CI: 0.75–0.87) for REMS, 0.80 (95% CI: 0.74–0.86) for SOFA, 0.74 (95% CI: 0.67–0.80) for MODS, 0.78 (95% CI: 0.71–0.84) for PIRO, and 0.77 (95% CI: 0.71–0.83) for MEDS. Sensitivity and specificity for APACHE II were 81.5 and 75.3, respectively. Conclusions: In our study, APACHE II score was found to be the most sensitive and specific in predicting the severity of sepsis compared to other scores.

The utilization of the surviving sepsis campaign care bundles in the treatment of pediatric patients with severe sepsis or septic shock in a resource-limited environment: A prospective multicenter trial Rujipat Samransamruajkit, Kawiwan Limprayoon, Rojanee Lertbunrian, Rattapon Uppala, Chutima Samathakanee, Pravit Jetanachai, Nopparat Thamsiri Indian Journal of Critical Care Medicine 2018 22(12):846-851 Background: Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned. Methods: The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles. Results: A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001). Conclusion: Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management.

Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study Pooja Anthwal, Nirmal Kumar, Ayush Manchanda, Bhawna Garg Indian Journal of Critical Care Medicine 2018 22(12):852-857 Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.

An intervention study for the prevention and control of health care-associated infection in the critical cares area of a tertiary care hospital in Saudi Arabia Sanjay Kumar Gupta, Fahd Khaleefah Al Khaleefah, Ibrahim Saifi Al Harbi, Fiaz Ahmed, Sinimol Jabar, Marilou Andal Torre, Sunitha Lorin Mathias Indian Journal of Critical Care Medicine 2018 22(12):858-861 Introduction: Healthcare-associated infections (HAIs) are an infection that patients acquire during receiving treatment and care for the medical or surgical problem. Objective: The objective of this study is to find the patterns of HAIs cases in the hospital and to know the impact of the intervention on prevention and control of health care associated infection. Methodology: This was prospective interventional study. Results: The majority of cases of HAIs was reported from intensive care unit 47%. The most common site involved due to HAIs was catheter-associated urinary tract infection followed by central line-associated bloodstream infection. During the study period, around 28% reduction of cases were reported. During 6 months period (March to August 2016), around 540 cases were admitted in the critical care areas out of that 32 cases were reported as HAIs (5.9%) for the same period from (March to August 2017) was (3.4%), that difference came to be a statistically significant (χ2 = 4.12, P = 0.042, df = 1). Conclusion: This small study showed that strict implementation of care bundles with good compliance of hand hygiene, Personal protective equipment and antibiotic stewardship are helpful for prevention and control of hospital acquired infections. This study also demonstrated significant (28%) reduction of hospital acquired infections during the study period.

Extracorporeal treatment in the management of acute poisoning: What an intensivist should know? Vijoy Kumar Jha, KV Padmaprakash Indian Journal of Critical Care Medicine 2018 22(12):862-869 Extracorporeal treatment (ECTR) represents a treatment modality promoting removal of endogenous or exogenous poisons and supporting or temporarily replacing a vital organ. This article aims to provide a brief overview of the technical aspects and the potential indications and limitations of the different ECTRs, highlighting the important characteristics of poison amenable to ECTR and the most appropriate prescriptions used in the setting of acute poisoning. The various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance have also being discussed.

Management of symmetrical peripheral gangrene Agus Iwan Foead, Amuthaganesh Mathialagan, Raghu Varadarajan, Michael Larvin Indian Journal of Critical Care Medicine 2018 22(12):870-874 Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.

Dilemmas and challenges in treating seronegative autoimmune encephalitis in Indian children Bandya Sahoo, Mukesh Kumar Jain, Reshmi Mishra, Sibabratta Patnaik Indian Journal of Critical Care Medicine 2018 22(12):875-878 Objective: The main objective is to assess the challenges in diagnosis and treatment while managing seronegative cases of autoimmune encephalitis (AIE) in Indian children. Methods: A cohort study of patients with AIE was done where clinical presentations, investigations, management were analyzed and these patients were followed up to assess the evolution of the disease. Results: Nine patients were included in the study. Four patients presented with super-refractory status epilepticus (SRSE). Other presentations were behavioral change, hemiplegia, and autonomic dysfunction. Initial magnetic resonance imaging brain was suggestive of AIE in two patients. Only two were seropositive for cerebrospinal fluid (CSF) autoimmune panel. Five patients responded to the first-line immunotherapy and four required the second-line immunotherapy. Conclusion: The possibility of autoimmune encephalitis should be considered in patients with super-refractory status epilepticus. A large proportion of children with suspected AE may be “seronegative.” A trial of immunotherapy should be given to these children when there is a strong clinical suspicion of autoimmune encephalitis even in the absence of cerebrospinal fluid autoantibodies.

International Journal of Oral Health Sciences

PRESIDENTS MESSAGE
	President's message	p. 55
	K Sadashiva Shetty DOI:10.4103/ijohs.ijohs_50_18
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SECRETARYS MESSAGE
	Secretarys message	p. 56
	Dhanyakumar Budihal DOI:10.4103/ijohs.ijohs_51_18
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GUEST EDITORIAL
	Children and their gadgets: A pedodontist perspective	p. 57
	Saraswathi Vishnu Naik DOI:10.4103/ijohs.ijohs_45_18
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EDITORIAL
	Editorial	p. 59
	GP Sujatha DOI:10.4103/ijohs.ijohs_52_18
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REVIEW ARTICLES
	Hollow complete denture for resorbed ridges	p. 60
	U Krishna Kumar, Sanjay Murgod DOI:10.4103/ijohs.ijohs_55_18   The severely resorbed maxillary and mandibular edentulous arches that are narrow and constricted with increased inter-arch space provide decreased support, retention, and stability and pose a clinical challenge to the success of complete denture prostheses. The consequent weight of the processed complete denture only compromises them further. This article highlights a technique for the fabrication of a hollow maxillary complete denture in situation where there is excessive resorption of the maxillary residual alveolar ridge and thereby greatly reducing the weight of an exceptionally heavy maxillary denture. Weight of a denture may be a contributing factor to the successful resolution of a patient's problem; the hollow denture can be considered as one of the treatment modalities.
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	Grossing of tissue specimens in oral pathology - Elemental guidelines	p. 63
	Ruthushree Theresa, M Harsha, Vikram S Amberkar DOI:10.4103/ijohs.ijohs_32_18   Grossing is a gross examination of surgical specimens in which pathologists inspect the excised specimen with the bare eye to obtain diagnostic information. It refers to the examination and dissection of surgical specimens, along with preparation of sections from those tissues requiring processing, and is the initial step in surgical pathology dissection. Careful handling of the tissue with proper fixation and tissue processing will enable a confident histopathological diagnosis.
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	Probiotics and periodontal disease	p. 68
	Anjhana Asok, Rahul Bhandary, Mamatha Shetty, Nina Shenoy DOI:10.4103/ijohs.ijohs_10_18   Probiotics are live microorganisms that when administered in adequate amounts confer health benefits to the host. Lactobacillus acidophilus was the first probiotic species. Elie Metchnikoff reported fermented dairy products to have beneficial properties. Probiotics have been used in combination with prebiotics to produce synbiotics. Probiotics have been widely used in the medical field to combat various diseases. Probiotics have been found to be helpful in periodontal tissue destruction by altering the host defense mechanism and inhibiting the secretion of proinflammatory cytokines that can mediate tissue destruction. Probiotics have been demonstrated to produce high ecological pH and have inhibitory effect on volatile sulfur compounds that help to control halitosis. The concept of guided tissue recolonization has emphasized the increased use of probiotics in periodontal management. Although probiotics also include side effects, further longitudinal studies are required to provide substantial data on the use of probiotics.
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ORIGINAL ARTICLES
	Age estimation using tooth cementum annulations method by different types of microscope: A comparative study	p. 73
	HL Geetha, Venkat P Baghisath, Hari B Vinay, B Sudheer, Vijay J Kumar, CH Gayathri DOI:10.4103/ijohs.ijohs_56_18   Introduction: Age is an essential factor in establishing the identity of a person. Age estimation through dental parameters can be of valuable assistance in human identification as teeth can survive in most conditions encountered at death and during decomposition. Tooth cementum annulations are one of the many methods for determination of an individual's age. Incremental lines in cementum are counted in this method. Objective: The aim of this study was to examine the correlation between chronologic age and estimated age and to find the most accurate method of calculating cemental annulations using different types of microscopes (light microscope, phase contrast microscope, polarized, and stereomicroscope).Methodology: The extracted teeth were cleaned and polished. Block was prepared by embedding two third of each tooth root horizontally in self-cure acrylic. Using a hard tissue microtome (SP 1600) longitudinal sections of 100 μm thickness were made. The sections were cleaned in alcohol and were mounted on a glass slide. These sections were observed under different types of microscopes (light microscope, phase contrast microscope, polarized, and stereomicroscope) to count cemental annulations. Results: The relationship between chronological age and estimated age using light microscope, phase contrast and polarized microscope showed stronger correlation while stereo microscope showed a weaker correlation. Conclusion: The use of polarized microscope increases the accuracy and thus, can predict the near estimate of the age for all the age groups.
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	A comparative study of cone-beam computed tomography and intrasurgical measurements of intrabony periodontal defects	p. 81
	Santosh R Patil, Ibrahim A Al-Zoubi, Ravi Gudipaneni, Kuraym Khalid Kuraym Alenazi, Nidhi Yadav DOI:10.4103/ijohs.ijohs_16_17   Objective: The objective of this study was to analyze the correlation between cone-beam computed tomography (CBCT) measurements and intrasurgical measurements of intrabony periodontal defects.Materials and Methods: Thirty-two patients with intrabony defects, who underwent periodontal therapy and were advised for surgical therapy, were included in this study. Diagnostic images were obtained by periapical radiographs and CBCT before the surgical procedure. The distance from the cementoenamel junction to the base of the periodontal defect (CEJ–BD), the distance from the crest of bone to the deepest point of the defect, and mesiodistal (M-D) width of the periodontal defect were measured on CBCT and periapical radiographs during the surgical procedure. The faciolingual width of the defect was only measured on CBCT images during the surgical procedure. The linear measurements obtained during the surgical therapy were compared with that obtained by intraoral radiographs and CBCT imaging. Results: The M-D width of the defect measured during the surgical procedure was similar to that measured on the periapical radiograph. The distance of CEJ to BD and the distance from the crest of bone to the deepest point of the defect measured on the periapical radiographs were less than that of intrasurgical measurements. No significant difference was noted regarding the CBCT measurements of the faciolingual width and M-D width of the defect when compared with the measurements obtained during the surgical procedures. A significant difference was noted in the CBCT measurements from the CEJ to BD and the distance from the crest of bone to the deepest point of the defect when compared with the intrasurgical measurements. Conclusion: CBCT may lend comparatively discriminative dimensions of the periodontal defect similar to that of intrasurgical measurements.
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	A review of oral and maxillofacial biopsies from a new academic health facility in remote Northwestern Nigeria	p. 86
	Adebayo Aremu Ibikunle, Abdurrazaq Olanrewaju Taiwo, Ramat Oyebunmi Braimah, Mohammed Sambas Umar DOI:10.4103/ijohs.ijohs_25_18   Background: Histological diagnosis is invaluable in charting the overall management of human pathologies. Knowledge of the general trend of histological diagnosis in a population may impact the clinician's practice as well as public health policy formulation. There is a paucity of literature on biopsy-driven epidemiology of oral and maxillofacial lesions, especially in sub-Saharan Africa. Objective: This study aims to determine the pattern of biopsied oral and maxillofacial lesions at a Nigerian tertiary hospital. Materials and Methods: A 5-year retrospective review of the histological diagnoses of patients who had biopsies of oral and/or maxillofacial lesions done at our teaching hospital was done. Biopsy reports obtained within the study period were retrieved and analyzed. Analysis was performed using the IBM SPSS statistics for windows version 20 (IBM Corp, Armonk, NY) software. Results: Three hundred and sixteen biopsy reports were included in this review. A slight male preponderance was observed, with a male-to-female ratio of 1:0.96. The age ranged from 6 months to 90 years (mean ± standard deviation, 33.3 ± 19.9). The posterior mandible was the most commonly affected site 13.9% (44). Most of the lesions were neoplastic 70.9% (224) with a slight majority being malignant. Squamous cell carcinoma (SCC) was the most frequently diagnosed malignancy 11.7% (37). Most nonneoplastic lesions were inflammatory/infectious 52.8% (47). Conclusion: Nearly equal gender prevalence for oral and maxillofacial biopsies was observed. In contrast to several studies, malignancies were more frequently diagnosed than benign neoplasms. The high incidence of SCC suggests the need for population interventions targeted at screening and early diagnosis.
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	Assessment of knowledge, attitude, and practice toward oral hygiene among governmental secondary school students in Debre Tabor Town, Amhara Region, North Central Ethiopia 2018: Institutional-based cross-sectional survey	p. 92
	Yilkal Tafere Gualie, Asnakew Tigabu Tayachew DOI:10.4103/ijohs.ijohs_37_18   Introduction: Oral health is significantly related to oral hygiene behaviors and their knowledge. Poor oral hygiene can have a profound effect on the quality of life. Oral hygiene practices are those measures taken to ensure that the mouth is clean. Oral hygiene practices are essential for the prevention of dental and other associated systemic diseases. The aim of this study is to determine the level of knowledge, attitude, and oral hygiene practices among secondary school students in Debre Tabor town, Amhara region, North Central Ethiopia 2018. Materials and Methods: An institution-based cross-sectional study was conducted among 422 systematically selected students using stratified random sampling technique from January 20 to 30, 2018. Data were collected using a pretested questionnaire on 422 selected students in three secondary schools found in Debre Tabor town. Variables collected included the frequency of brushing teeth and the use of toothpaste, knowledge of plaque, and students' perception of the importance of oral hygiene practices. The data were entered into Epi-Info version 3.5 and cleaned and analyzed using SPSS version 20. Results: A total of 422 patients participated in the study; among whom 216 (51.2%) were female students. The study revealed that 253 (60%) of the respondents had good knowledge with regard to oral hygiene, more than half 281 (66.6%) of the students had positive attitude toward oral hygiene, but their oral hygiene practices were still low that 260 (61.6%) of the students had poor oral hygiene practice. Conclusions: The study showed that more than half of the respondents had good knowledge and positive attitude toward oral hygiene to maintain proper oral health, but their practices toward oral hygiene were remain poor. The majority of students were aware that teachers and parents had not an important role to play in their oral hygiene. Establishment of oral health education programs in the school curriculum that will help a life-long oral hygiene practice in the school environment and at large in the community with the support of teachers and parents are crucial.
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	Assessment of mandibular retrognathism and maxillary prognathism as contributory factors for skeletal Class II malocclusion: A cephalometric study	p. 99
	Suraj Prasad Sinha, Krishna U S Nayak, Crystal Runa Soans, PS Murali, Akhil Shetty, MS Ravi DOI:10.4103/ijohs.ijohs_3_18   Aim: The aim of this study is to evaluate the skeletal factor (maxillary excess and/or mandibular deficiency) contributing for the skeletal Class II malocclusion. Materials and Methods: Lateral cephalograms of 100 individuals (50 males and 50 females) in the age group of 18–30 years, having skeletal Class II malocclusion with ANB of more than 4, were evaluated. The parameters to be used for prediction of maxillary prognathism include linear measurement of Nasion perpendicular to point A, and for the mandibular retrognathism, it is linear measurement of Nasion perpendicular to Pogonion, as suggested by Burstone analysis. Results: The 34% of the studied sample size had the Class II skeletal pattern (ANB >4), but their observed values for the maxilla and the mandible (with respect to the cranium) were in the normal range according to Burstone's cephalometric norms. Mandibular retrognathism with 68% prevalence in the final studied sample size is the major contributory factor for the skeletal Class II malocclusion which is followed by maxillary prognathism with 27% prevalence in the studied sample size, and the last contributory factor is the combination of the above two which accounts for the 5% of the studied sample size. Conclusion: The cephalometric study of skeletal Class II participants suggests mandibular retrognathism to be the major component in the given sample size. The other important conclusion from this study is that the ANB angle is not a reliable indicator to assess the skeletal malocclusion.
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CASE REPORTS
	Management of flabby ridge case: An arduous task in undergraduate practice	p. 104
	Jnanashree Chiplunkar, Masrie Tumbil, MD Chethan, DB Nandeeshwar, Disha Patel DOI:10.4103/ijohs.ijohs_41_18   A fibrous or flabby ridge is a superficial area of mobile soft tissue affecting the maxillary or mandibular alveolar ridges. It can develop when hyperplastic soft tissue replaces the alveolar bone and is a common finding particularly in the upper anterior region of long-term denture wearers. Masticatory forces can displace this mobile denture-bearing tissue, leading to altered denture positioning and loss of peripheral seal. Unless managed appropriately, such "flabby ridges" adversely affect the support, retention, and stability of complete dentures. Many impression techniques have been proposed to help overcome this difficulty. This paper presents case report for prosthodontic rehabilitation of a patient with flabby ridge with McCord and Ahmad impression technique.
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	Multivariant lichen planus of lips and gingiva: Report of a case and a review	p. 109
	SM Rekha, Apeksha Basawant Annigeri, Sushama R Galgali, P Jagadish DOI:10.4103/ijohs.ijohs_18_18   Oral lichen planus (OLP) is a relatively common inflammatory mucocutaneous disorder that frequently involves the oral mucosa. There are many etiological factors, and some among them are stress, diabetes mellitus, and hypothyroidism. An important complication of OLP is the development of oral squamous cell carcinoma, which led the World Health Organization to classify OLP as a potentially malignant disorder. This article reports a multivariant (reticular, erosive, and papular) case of lichen planus that has affected a 40-year-old medically compromised female who was managed successfully and still under follow-up.
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	Colonic phenotype of adenocarcinoma base of the tongue: An entity rarely reported and treated with definitive chemoradiation	p. 116
	Neelam Sharma, Abhishek Purkayastha, Chhavi Arora, Kavita Sahai DOI:10.4103/ijohs.ijohs_55_17   The predominant histological type of oropharyngeal cancer is squamous cell carcinoma and approximately 9 times more frequent when compared with other types. Adenocarcinoma common histopathology for digestive system is very rarely reported in this region. In literature, there are limited data about the clinical presentation, histopathology, and treatment modalities for the primary adenocarcinoma of the base of the tongue (BOT). To the best of our knowledge, five cases of adenocarcinoma of the BOT with colonic differentiation have been reported in the world literature till date, and this is the first case report from India. The challenge in these type of cases is to differentiate between the primary adenocarcinoma of BOT which is extremely rare, metastatic lesion to this site from any other site, or its origin from minor salivary glands which is a more common possibility because all these situations have different treatment implications.
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	A case report of unusual presentation of mucoepidermoid carcinoma with review of literature	p. 120
	Gadadasu Swathi, Tatapudi Ramesh, Moturi Kishore, Govind Raj N Kumar DOI:10.4103/ijohs.ijohs_24_18   Head-and-neck cancers constitute about 30% of cancers in India, of which salivary gland tumor such as mucoepidermoid carcinoma (MEC) was the most common malignant salivary gland tumor. The parotid gland was the most common site of origin in both benign and malignant tumors, followed by submandibular and sublingual glands. Salivary gland tumors comprise a morphologically diverse group of rare tumors. Their multifaceted clinical presentation, varied morphologic configuration, and relatively unpredictable prognosis attract significant medical interest. Here is a rare case report of an asymptomatic swelling in the cheek region which was thought to be pleomorphic adenoma at the outset which on further investigations proved as MEC of early detection.
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	Hemorrhagic bulla on the lip: A diagnostic dilemma	p. 124
	Aravinda Konidena, Hena Shaw, Mansimran Kaur Uppal DOI:10.4103/ijohs.ijohs_17_18   Angina bullosa hemorrhagica (ABH) is a rare benign disorder characterized by the sudden onset of painless blood-filled blister in the oral cavity that rupture in 24–48 h. We recently encountered an interesting case of ABHon the lower lip of 68-year-old female patient referred back from the prosthodontic department following the procedure of impression making. This case will be presented along with a review of previous case summaries reporting four or more cases.
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	Actinomycotic infection of the tonsils: A case report and review of the literature	p. 129
	Stavanger Singh Bakshi, Ramiya Ramachandran Kaipuzha, Suriyanarayanan Gopalakrishnan, A Govindarajan DOI:10.4103/ijohs.ijohs_43_17   Actinomycotic infections of the head and neck, although fairly uncommon, represent an important entity because of its varied presentation, difficult diagnosis, and long course of treatment. A 20-year-old female presented with throat pain and difficulty in swallowing for 1 year. Examination revealed a Grade IV enlargement of the left tonsil. The patient underwent tonsillectomy, and the postoperative histopathology revealed actinomycosis. Actinomyces is anaerobic filamentous bacteria which are known to colonize as commensals in tonsillar crypts which on histology show an outer zone of granulation tissue and a central zone of necrosis containing many sulfur granules that represent microcolonies of Actinomyces. Actinomycosis of the head-and-neck region is a significant entity because it can mimic other common lesions, especially in the oropharynx. In cases of recurrent tonsillitis and tonsillar hypertrophy, tonsillectomy is the treatment of choice, and histopathological examination of resected tissue is strongly advocated. This report supports the view that Actinomyces may have a causal association with recurrent acute tonsillitis and tonsillar hypertrophy.
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	The course of double mandibular canal - confront to dentist	p. 133
	Jayasheela Mallappa, Neeharika Sree, B H Dhanya Kumar, Dhoom Singh Mehta DOI:10.4103/ijohs.ijohs_40_18   The mandibular canal is usually a single canal that begins with mandibular foramen on the medial surface of the ascending mandibular ramus. It transmits the inferior alveolar artery, vein, and the inferior alveolar nerve. The identification of the mandibular canal and its anatomic variations is of great importance in many branches of dentistry, especially in implant dentistry. Sometimes, there may be variations in the normal anatomic structures; one of the rarest among them is double mandibular canal. The clinician should be aware of such variations to avoid complications during the treatment. In the present case report, we have discussed about a case with double mandibular canal and the complications that can arise during the treatment.
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	Clear-cell squamous cell carcinoma: An uncommon variant of very common malignancy in the head and neck	p. 136
	Lopa Mudra Kakoti, Debanwita Mahanta, Jagannath Dev Sharma, Zachariah Chowdhury DOI:10.4103/ijohs.ijohs_23_18   Clear-cell squamous cell carcinoma (SCC) is an extremely rare and incompletely understood entity. Clear-cell change occurs due to cytoplasmic accumulation of glycogen, water, intermediate filaments, immature zymogen granules, or a paucity of cellular organelles. Clear-cell change can be seen in any of the neoplasms, but as pure form variant, it is difficult to find in head-and-neck SCC. The World Health Organization has recognized clear-cell SCC as separate entity at other few sites such as penis but not in the head-and-neck SCC, and these are known to aggressive variant. We, hereby, present a case of clear-cell variant of squamous carcinoma in lower gingivobuccal mucosa in a 59-year-old male patient. Histopathology showed sheets of clear cell separated by fibrous septa and foci showing squamous cells with malignant features. Periodic acid–Schiff and immunohistochemistry (IHC) were done to rule out differentials of clear-cell variants of different sites such as salivary gland, odontogenic origin, and cutaneous adnexal origin. To establish the prevalence, biological nature, significance, and clinical course of clear-cell SCC in the head-and-neck region, more number of case reports are expected to be published in future. We concluded by emphasizing on the need of further analysis of all clear-cell tumors in the head and neck with histochemistry and IHC investigations to arrive at the proper diagnosis.
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