Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contact Us Login 
An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists


 
  Table of Contents    
ORIGINAL ARTICLE  
Year : 2021  |  Volume : 25  |  Issue : 1  |  Page : 124-130
 

Expression of β-catenin in oral leukoplakia and oral submucous fibrosis: An immunohistochemical study


1 Department of Oral Pathology and Microbiology, Private Practitioner, Kharagpur, West Bengal, India
2 Department of Oral Pathology and Microbiology, A.E.C.S. Maaruti College of Dental Sciences and Research Centre, Bangalore, India
3 Senior Resident, Department of Oral Pathology and Microbiology, King George's Medical University, Lucknow, India

Date of Submission01-Feb-2020
Date of Decision30-Nov-2020
Date of Acceptance19-Jan-2021
Date of Web Publication14-May-2021

Correspondence Address:
Jaya Singh
Senior Resident, Department of Oral Pathology and Microbiology, King Georgefs Medical University
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomfp.JOMFP_41_20

Rights and Permissions

 

   Abstract 


Background: Oral potentially malignant disorders have increased propensity to turn malignant than its apparently normal counterparts. Histopathological examination, although gold standard, needs adjunct technique to give accurate diagnosis. Immunohistochemistry has proved to be a promising adjunct to aid in the diagnosis so far. The quest for a definitive marker is still on. Beta-catenin (β-catenin), a structural protein has been evaluated to identify its likely role in malignant transformation of potentially malignant lesions and possibly designate it as one of the identifiable signature molecules in the transformation.
Aim and Objective: To evaluate and estimate the expression of β-catenin in different grades of dysplasia, oral submucous fibrosis (OSMF) and normal mucosa and compare the same.
Methodology: A total number of 40 cases including different grades of dysplasia, OSMF and normal mucosa were immunohistochemically stained, location and intensity of its expression were evaluated for β-catenin. The results were statistically analyzed using the one-way analysis of variance and Chi-square test.
Results: The expression of β-Catenin in the cytoplasm as well as in the nucleus increased from mild-to-moderate dysplasia to OSMF and to severe epithelial dysplasia in an increasing order. The expression is seen to translocate from membranous to cytoplasm to nucleus indicating a proliferative potential in these group of lesions.
Conclusion: β-catenin is a promising marker which indicates the malignant transformation potential in the higher grades of dysplasia and OSMF.


Keywords: Beta-catenin, immunohistochemistry, oral potentially malignant disorders, oral submucous fibrosis, transformation


How to cite this article:
Chowdhury P, Nagamalini B R, Singh J, Ashwini B K, Sharada. Expression of β-catenin in oral leukoplakia and oral submucous fibrosis: An immunohistochemical study. J Oral Maxillofac Pathol 2021;25:124-30

How to cite this URL:
Chowdhury P, Nagamalini B R, Singh J, Ashwini B K, Sharada. Expression of β-catenin in oral leukoplakia and oral submucous fibrosis: An immunohistochemical study. J Oral Maxillofac Pathol [serial online] 2021 [cited 2021 Jun 12];25:124-30. Available from: https://www.jomfp.in/text.asp?2021/25/1/124/316046





   Introduction Top


Oral squamous cell carcinoma (OSCC) is the sixth leading cancer by the incidence worldwide. Most OSCCs arise in the epithelial lining of the oral cavity, oropharynx, larynx and hypopharynx, with a percentage of 5-year survival for patients with OSCC varying from 40% to 50% morbidity rate causing functional disability and associated esthetic implications.[1]

OSCC is commonly preceded by a range of tissue and cellular alterations consistent with carcinoma, yet restricted to the surface epithelial layer, termed oral epithelial dysplasia. These changes often manifest in a clinical mucosal lesion.[2] A creditable number of these lesions are thought to be associated with or preceded by precancerous lesions and conditions, now designated as potentially malignant lesions by the WHO recommendation.

The term implies that this is a family of morphological altered lesions some of which may have an increased potential for malignant transformation. These lesions not only predict the likely site of malignancy but also indicate an increased risk of future malignancies elsewhere in clinically normal appearing oral mucosa.

Recognised lesions in the group include leukoplakia, erythroplakia, palatal lesion of reverse cigar smoking, oral lichen planus, oral submucous fibrosis (OSMF) and discoid lupus erythematosus. A higher risk is observed in dysplasia and OSMF. Identifying these lesions has gained more importance nowadays. A disturbing new trend has been observed over the past few years with a greater percentage of younger age groups becoming susceptible to oral potentially malignant disorders (OPMDs) mainly attributed to increase in substance abuse among the youth.[3]

Although not always clinically obvious, many of these lesions most likely show tell-tale histopathological signs of dysplasia which helps in their recognition and evaluation.

Histopathological assessment alone, however, is not sufficient to provide an accurate assessment of malignant transformation risk thus necessitating use of varied molecular parameters.

Studying the altered expression of various signalling factors and other structural and functional protein through immunohistochemistry is one such well-recognized technique.

In this study, the expression of beta-catenin (β-catenin), a structural protein has been evaluated to identify its likely role in malignant transformation of potentially malignant lesions and possibly designate it as one of the identifiable signature molecules in the transformation.

β-catenin, is a multitasking and evolutionarily conserved molecule, belonging to the armadillo family of proteins and is found at multiple subcellular localizations, including junctions where it contributes to the stabilization of cell-cell contacts and cytoplasm and plays a crucial role in a multitude of homeostatic and developmental process. It is an integral part of Wnt pathway which plays a role in directing cell proliferation, cell polarity and cell fate determination during embryonic development and tissue homeostasis. A mutation in the Wnt pathway is often linked to human birth defects, cancer and other diseases.[4]

Thus, evaluating the expression of beta catenin in OPMDs might provide insight in the working of the transformation pathway as well as establish beta catenin as a more likely and easily identifiable bio marker.

Objectives of the study

  1. To immunohistochemically stain selected cases of different grades of oral dysplasia's, OSMF and normal mucosa with β-catenin antibody
  2. To evaluate the β-catenin expressions at different locations (membrane, cytoplasm and nuclear) in various strata of the epithelium in oral dysplasia's, OSMF and normal mucosa and statistically analyzed the result.



   Methodology Top


A retrospective, case–control study was conducted including a total of 40 cases, 10 of mild dysplasia, 5 each of moderate and severe dysplasia, 10 cases of OSMF and 10 clinically normal tissues. These cases were retrieved from the archives of Department of Oral Pathology and Microbiology, AECS Maaruti College of Dental Sciences and Research Center, Bangalore.

The cases were categorized as following: G1 = mild dysplasia, G2 = moderate dysplasia, G3 = severe dysplasia, G4 = OSMF, and G5 = normal mucosa. All the 40 specimens were subjected to immunohistochemical staining for β-catenin antibody, evaluated microscopically for its expression.

Hematoxylin and eosin staining

The formalin-fixed paraffin-embedded tissue sections were heated on slide warmer at 60°C for 5 min. The slides were then dewaxed in two changes of xylene, each for 5 min duration. The tissues were then hydrated through decreasing grades of ethyl alcohol (100%, 90% and 70%) and were washed under running water for 5 min. Stained in Harris hematoxylin for 3 min. The slides were then dipped in acid alcohol and placed in alkali water for 1 min. The sections were washed well in running tap water for 10–15 min or until “blueing.” Thereafter, they were stained in 1% Eosin-Y for 10 min. The slides were washed in running water, dried and then dehydrated through increasing grades ethyl alcohol (70%, 90% and 100%) and cleared using Xylene and mounted with DPX.[5],[6] The stained slides were then viewed under the research microscope.

Immunohistochemical staining

About 3 μm, thick sections were obtained and mounted on the Aminopropyltriethoxysilane coated slides. The slides were de-paraffinized, tissues hydrated, and then subjected to antigen retrieval. The antigen retrieval was carried out in the pressure cooker. The tissues were then incubated with peroxide block for 20 min at the room temperature to block endogenous peroxide activity. The sections were subsequently incubated for 15 min with protein block to eliminate background staining. The sections so treated were then incubated with primary antibody i.e., mouse β-Catenin (PathnSitu Biotechnologies PVT. LTD. India). Washed in phosphate buffer, the slides were incubated with target binder for 30 min. Subsequently, the slides were incubated with PathnSitu polymer for 30 min. Subsequently, the slides were incubated with fresh DAB chromogen for 3 min. After which, the slides were washed in water to stop the chromogen reaction and remove the excess DAB and counter stained with Mayer's hematoxylin provided with the kit for 30 s. The slides were then dehydrated, cleared and mounted with DPX. With each set of slides stained with mouse anti β-Catenin, one positive control slide of breast carcinoma was also stained. The immunostained slides were observed for positivity under ×4X/10X/40X under light microscope.

Interpretation of staining

All the 10 cases of mild dysplasia, 5 cases of moderate dysplasia, 5 severe dysplasia and 10 OSMF showed overall positivity (i.e., 100% of the total cases) for the expression for the antibody, varying in intensity and location [Table 1]. β-catenin expression was assessed in terms of location-membranous, cytoplasmic, nuclear, and also the extension up to which layer was estimated. The results were tabulated as given below and statistically analyzed using the one-way analysis of variance and Chi-square test. Photomicrographs were recorded from 3 representative areas under high-power objective (×40) in an orderly manner.
Table 1: No. of positive cells according to location

Click here to view



   Results Top


It was seen that OSMF showed highest mean cytoplasmic positivity ranging from 10% to 80% [Figure 1]e, followed by severe dysplasia ranging from 18% to 55% [Figure 1]d, then moderate dysplasia with 11%–45% [Figure 1]c and finally mild dysplasia ranging from 10% to 30% [Figure 1]b, [Table 2] and [Graph 1]. In OSMF as well as in severe dysplasia, the cytoplasmic positivity extended up to stratum superficiale and up to stratum granulosum in case of moderate and mild dysplasia [Figure 1]. There was a statistically significant increase in the expression in severe dysplasia and OSMF from mild dysplasia. OSMF also showed higher expression than moderate dysplasia. Normal mucosa did not show cytoplasmic staining [Table 2], [Graph 1] and [Figure 1].
Figure 1: (a) Normal oral mucosa showing membranous β-Catenin positivity (b) Mild epithelial dysplasia showing membranous and cytoplasmic β-Catenin positivity (c) Moderate epithelial dysplasia showing membranous, nuclear and cytoplasmic β-Catenin positivity (d) Severe epithelial dysplasia showing membranous, nuclear and cytoplasmic β-Catenin positivity (e) oral submucous fibrosis showing membranous, nuclear and cytoplasmic β-Catenin positivity (f) Control: Breast cancer tissue as positive control

Click here to view
Table 2: Comparison of mean between different groups based on cytoplasmic area marked by β-Catenin in different layers using one-way ANOVA test

Click here to view



Nuclear positivity was observed to be the highest in severe dysplasia ranging from 5% to 13% extending up to the superficial layer; followed by moderate dysplasia ranging from 2% to 9% extending up to stratum granulosum, then OSMF ranging from 1% to 7% extending up to stratum granulosum and least in mild dysplasia with 1%–3% extending up to stratum granulosum [Table 3], [Graph 2] and [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e. This difference was statistically significant between mild dysplasia and severe dysplasia as well as OSMF. Statistically significant difference was also observed between moderate dysplasia and severe dysplasia as well as between severe dysplasia and OSMF.
Table 3: Comparison of mean nuclear area marked by β-Catenin in different study groups using one-way ANOVA test

Click here to view



Membranous positivity was present in all the cases. It extended up to stratum granulosum in mild dysplasia and moderate dysplasia but till stratum superficiale in severe dysplasia as well as in OSMF [Table 3], [Graph 2] and Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e.

Hence, to sum up multiple comparison analysis conducted to assess the difference in β-catenin expression between the groups showed statistically significant increase with increasing grades of dysplasia and in OSMF, especially in terms of cytoplasmic and nuclear positivity.

Therefore, it can be concluded from the above-observed result that with the increasing in grades of dysplasia the β-catenin expression is seen to translocate from membranous to cytoplasm to nucleus indicating a proliferative potential in these group of lesions.


   Discussion Top


Oral cancer is the sixth-most common cancer worldwide, the higher incidence attributed to cultural, ethnic, geographic factors, and the popularity of addictive habits and can arise from mucosal lining of the floor of the mouth, cheek, gingiva, lips, or palate.

Though known to arise de novo, a large portion of these lesions are thought to be preceded by precancerous or potential cancerous lesions or conditions. The lesions referred to as OPMD precursors include leukoplakia, erythroplakia, oral sub-mucous fibrosis, lichen planus, actinic keratosis, discoid lupus erythematosus and palatal lesions among reverse smokers, constitute OPMDs.[7] The prevalence of OPMDs worldwide varies between 1% and 5%.[8]

However, the transformation potential of each of these lesions varies, is dependent on multiple co factors, with few of them showing unpredictable behavior. Under favorable conditions, many are considered reversible. The potential for malignant transformation among these conditions varies considerably, ranging from <1% to as high as 36%. It is presumed that mild dysplasia will progress to severe dysplasia and then to carcinoma.[9] Further, it is often influenced by the postdiagnosis cessation or continuity of the high-risk behaviors such as tobacco and alcohol use, as well as clinical intervention.[10]

Since prevention is anytime better than cure, an early treatment reduces the morbidity and mortality, so it is always a favorable choice.

Hence, early recognition of such a condition becomes important. Over the period, various modes and techniques of identification of these lesions, especially those with higher transformation potential have been investigated with differing results. Since the basis of such a tissue alteration is abnormal genetic modulation and signalling, identification of altered protein expression through immunohistochemistry is easy and highly followed. Accordingly, study of immunohistochemical expression of proliferative, adhesive, metastatic, oncogenic and other group of markers in potentially malignant lesion is a popular means of identifying high risk lesions.

In our study, an attempt is made to study the expression of the β-catenin in leukoplakia with various grades of dysplasia and OSMF of the oral cavity as compared to the normal oral mucosa to evaluate the role of altered beta catenin activation in carcinogenesis.

β-catenin is a proliferative marker belonging to the armadillo proteins, a central molecule in Wnt signaling pathway. β-catenin originally identified in the cell adherens junctions, functions to bridge the cytoplasmic domain of cadherins to α-catenin and the actin cytoskeleton. It is a primary component of the cell membrane and plays crucial roles in the regulation of processes such as cell survival, migration and polarity, cell proliferation, cell fate specification, body axis patterning and self-renewal in stem cells. Under resting condition, the cytoplasmic β-catenin is bound to its destruction complex. Phosphorylated beta catenin is recognized by ubiquitin ligase beta-TrCP and undergoes ubiquitylation and degradation. Therefore, the cytoplasmic level of β-catenin is kept low in the absence of Wnt/FZD signaling. Therefore, the cytoplasmic level of β-catenin is kept low in the absence of Wnt/FZD signalling.[11] If β-catenin is not present in the nucleus, the Lymphoid enhancer-binding factor/T-cell factor (1LEF/TCFs) cannot activate the target genes and acts when stabilized and translocated into the nucleus where it is able to associate with TCF/LEF-1 to form a functional transcription factor that mediates the transactivation of target genes involved in cancer progression.[12] As a result, mutations in the Wnt pathway are often linked to human birth defects, cancer and other diseases.[12]

When compared to normal oral mucosa, membranous β catenin expression was significantly reduced in moderate and severe dysplasia cases, accompanied by a change in the localization of βcatenin expression in the cytoplasm and/or nuclei with increased staining intensity.[13]

An association is already established between β-catenin and other tumors like actinic chelitis, OSCC, and lichen planus.[14] Studies have also been done to establish its role in oral lesions previously with varied results.

The study by Ishida et al. in 2007 showed that the normal oral epithelium and oral leukoplakia without dysplasia showed β-catenin expression only in the cell membrane and with its translocation to the nucleus in cases with dysplasia eliciting its role in the progression of dysplasia in oral leukoplakia [Table 4].[15]
Table 4: A systematic review of various studies done in Oral potentially malignant disorders and Oral squamous cell carcinoma

Click here to view


Chaw et al. in June 2012 found out that as there is an increase in the histopathological grading there is a shift in the epithelial-catenin localization from membranous to the cytoplasm or nucleus. Thus, concluding that β-catenin via Wnt pathway dysregulation is a potential marker for the malignant transformation [Table 4].[16]

Zaid in 2014 showed that the expression of β-catenin and E-cadherin were independent prognostic factors for histological grades of OSCC. E-cadherin was closely linked to β-catenin expression in OSCC and to tumor differentiation, which reflects a structural association and the role of both in tumor progression [Table 4].[17]

The study in 2015 by Reyes et al. showed increased presence of beta catenin in severe and moderate dysplasia compared to mild dysplasia; however, the expression of nuclear β-catenin decreased after starting the invasive neoplastic process [Table 4]. This suggests a role for this protein in the progression of dysplasia and early malignant transformation to OSCC, confirming immunodetection of β-catenin could be a possible immune marker in the detection of oral dysplasia.[18]

Our study results fall on the same lines with an increase in overall expression of beta catenin with increasing grades of dysplasia as well as in OSMF.

The β-catenin positivity was seen in normal mucosa cases confining only to the cell membrane. However, cytoplasmic positivity was noticed in mild and moderate dysplasia in an increasing order but restricting till the stratum granulosum. The OSMF and moderate and severe dysplasia showed the β-catenin positivity in cytoplasm as well as in the nucleus. Severe dysplasia showed the highest mean nuclear positivity, followed by OSMF and moderate dysplasia being the least amongst these three. Statistically significant difference in cytoplasmic positivity was seen between mild and severe dysplasia; mild and OSMF and between moderate and OSMF. Whereas pertaining to the nuclear positivity, statistical significance was seen in mild and severe dysplasia as well as between mild dysplasia and OSMF; also, was seen between moderate and severe dysplasia as well as between severe dysplasia and OSMF cases. Wherever statistically significant was not seen, it was due restriction of our study to only limited number of cases.


   Conclusion Top


The expression of β-Catenin in the cytoplasm as well as in the nucleus increased from mild to moderate dysplasia to OSMF and to severe epithelial dysplasia in an increasing order. It can be concluded that as the severity of the dysplastic features increases, there is an increase in the translocation of β-catenin from its primary site, i.e., from the cell membrane toward the cytoplasm to finally reach the nucleus triggering its proliferation. Such a shift observed at higher stratum level in severe dysplasia and OSMF in our study may also indicate increasing dedifferentiation occurring in these cases, thus indicating the cancerous potential in the higher grades of dysplasia and OSMF.

However, since our study group had a limited number of test samples a study on a broader number range would add substantial credit to the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[23]



 
   References Top

1.
Vigneswaran N, Williams MD. Epidemiologic trends in head and neck cancer and aids in diagnosis. Oral Maxillofac Surg Clin North Am. 2014 May;26(2):123-41. doi: 10.1016/j.coms.2014.01.001.  Back to cited text no. 1
    
2.
Singh J, Swaminathan U, Sharada P, Alur JB, Chowdhury P, Mrinal U, et al. Estimation of expression of beta-human chorionic gonadotropin levels through progression of disease from normal to epithelial dysplasia to malignancy. J Oral Maxillofac Pathol 2019;23:108-13.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Hosagadde S, Dabholkar J, Virmani N. A clinicopathological study of oral potentially malignant disorders. J Head Neck Physicians Surg 2016; 4:29-34  Back to cited text no. 3
    
4.
Bryan T. MacDonald, Keiko Tamai, and Xi He. Wnt /β-catenin signaling components, mechanisms, and diseases. Dev Cell 2009; 17(1): 9–26.  Back to cited text no. 4
    
5.
Feldman AT, Wolfe D. Tissue processing and hematoxylin and eosin staining. Methods Mol Biol 2014;1180:31-43.  Back to cited text no. 5
    
6.
Bancroft JD, Layton C. The hematoxylin and eosin. In: Suvarna SK, Layton C, Bancroft JD, editors. Theory Practice of Histological Techniques. 7th ed., Ch. 10 and 11. Philadelphia: Churchill Livingstone of El Sevier; 2013. p. 179-220.  Back to cited text no. 6
    
7.
Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007;36:575-80.  Back to cited text no. 7
    
8.
Mortazavi H, Baharvand M, Mehdipour M. Oral potentially malignant disorders: An overview of more than 20 entities. J Dent Res Dent Clin Dent Prospects 2014;8:6-14.  Back to cited text no. 8
    
9.
Speight PM. Update on oral epithelial dysplasia and progression to cancer. Head Neck Pathol 2007;1:61-6.  Back to cited text no. 9
    
10.
Arduino PG, Bagan J, El-Naggar AK, Carrozzo M. Urban legends series: Oral leukoplakia. Oral Dis 2013;19:642-59.  Back to cited text no. 10
    
11.
Silva FB, de Castro CD, Von Zeidler SL, de Sousa SC, Batista AC, Yamamoto-Silva FP, et al. Altered β-catenin expression in oral mucosal dysplasia: A comparative study. J Appl Oral Sci 2015;23(5).  Back to cited text no. 11
    
12.
Clevers H. Wnt/β-Catenin Signaling in Development and Disease. Cell 2006;127:469-80.  Back to cited text no. 12
    
13.
Komiya Y, Habas R. Wnt signal transduction pathways. Organogenesis. 2008;4:68-75. doi: 10.4161/org.4.2.5851.  Back to cited text no. 13
    
14.
Bryan T. MacDonald, Keiko Tamai, and Xi He. Wnt /β-catenin signaling components, mechanisms, and diseases. Dev Cell 2009;17:9–26.  Back to cited text no. 14
    
15.
Ishida K, Ito S, Wada N, Deguchi H, Hata T, Hosoda M, et al. Nuclear localization of beta-catenin involved in precancerous change in oral leukoplakia. Mol Cancer 2007;6:62.  Back to cited text no. 15
    
16.
Chaw SY, Abdul Majeed A, Dalley AJ, Chan A, Stein S, Farah CS. Epithelial to mesenchymal transition (EMT) biomarkers—E-cadherin, beta-catenin, APC and Vimentin—in oral squamous cell carcinogenesis and transformation. Oral Oncol 2012;48:997-1006.  Back to cited text no. 16
    
17.
Zaid KW. Immunohistochemical assessment of E-cadherin and β-catenin in the histological differentiations of oral squamous cell carcinoma. Asian Pac J Cancer Prev 2014;15:8847-53.  Back to cited text no. 17
    
18.
Reyes M, Alcayaga GR, Maturana A, Aitken JP, Rojas C, Ortega AV, et al. Increased nuclear β-catenin expression in oral potentially malignant lesions: A marker of epithelial dysplasia. Med Oral Patol Oral Cir Bucal 2015;20:E540-6.  Back to cited text no. 18
    
19.
Williams HK, Sanders DS, Jankowski JA, Landini G, Brown AM. Expression of cadherins and catenins in oral epithelial dysplasia and squamous cell carcinoma. J Oral Pathol Med 1998;27:308-17.  Back to cited text no. 19
    
20.
Bankfalvi A, Krassort M, Buchwalow IB, Vegh A, Felszeghy E, Piffko J. Gains and losses of adhesion molecules (CD44, E-cadherin, and β-catenin) during oral carcinogenesis and tumor progression. J Pathol 2002;198:343-51.  Back to cited text no. 20
    
21.
Lee SS, Tsai CH, Tsai LL, Chou MC, Chou MY, Chang YC, et al. B-catenin expression in areca quid chewing- associated oral squamous cell carcinomas and upregulated by arecoline in human oral epithelial cells. J Formosan Med Assoc 2012;111:194-200.  Back to cited text no. 21
    
22.
Kaur J, Sawhney M, Datta Gupta S, Shukla NK, Srivastava A, Walfish PG, et al. Clinical significance of altered expression of β-catenin and E-cadherin in oral dysplasia and cancer: Potential link with ALCAM expression. PLoS One 2013;8:E67361, 1-12.  Back to cited text no. 22
    
23.
Zhou S, Chen L, Mashrah M, Zhu Y, Liu J, Yang X, et al. Deregulation of secreted frizzled-related proteins is associated with aberrant β-catenin activation in the carcinogenesis of oral submucous fibrosis. Onco Targets Ther 2015;8:2923-31.  Back to cited text no. 23
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
Print this article  Email this article
            

    

 
   Search
 
  
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Article in PDF (1,365 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Methodology
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed80    
    Printed16    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal

Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow
Online since 15th Aug, 2007