Continental J.

Medical Research 3: 1 - 6, 2009

© Wilolud Online Journals, 2009.

THE EFFECT OF MOUTHWASH ON ORAL MICROFLORA.

Egharevba F1, Ohenhen R.E2, Imarenezor E.P.K2, Ebure C2.
1
Department of Chemistry, 2Department of Microbiology Ambrose Alli University, P. M. B. 14, Ekpoma,
Nigeria.

ABSTRACT.
Three different concentrations of mouthwashes 001, 002 and 003 formulated from
H₂O₂/Na₂B₄O₇ were assayed for their inhibitory effect on Streptococcus mutans,
Streptococcus salivarius and Candida albicans at different concentration of 12%, 9%, 6%,
3% and 1%. The results showed that the mouthwashes significantly reduced to different
levels the microbial count of all organisms used. The reduction in microbial count ranged
from initial count of 2.4 x 10⁶cfu/ml to 0.62 x 10⁶cfu/ml for Streptococcus mutans, 2.1 x
10⁶cfu/ml to 0.48 x 10⁶cfu/ml for Streptococcus salivarius and 1.0 x 10⁶cfu/ml to 0.23 x
10⁶cfu/ml for Candida albicans, depending on the mouthwash concentration. At P< 0.05,
there was no significant difference (P< 0.05) amongst the three different mouthwashes in
terms of inhibitory properties, though showing a significant decrease (P< 0.05) in
microbial count. The mouthwashes contained the same compositional compounds but at
different concentrations which most probably account for the observed differences in their
inhibitory activities. The above results show that the mouthwashes 001, 002 and 003 have
good antimicrobial properties.

KEYWORDS: Mouthwash, Streptococcal organisms, dental caries, periodontal

diseases, Hygiene

INTRODUCTION
The mouth is extensively colonized by a broad range of microbes. The mouth is also richly vascularised, making
it susceptible to oral infection. The two most common types of oral infections, dental caries (decay) and the
periodontal diseases (periodontitis and gingivitis) affect the tissues immediately adjacent to the teeth (Shay and
Ship, 1995). The oral flora on the circulatory and respiratory system consists of a diverse and populous
collection of bacteria, fungi, and transient viruses. Bacteria make up the largest number of varieties, more than
350 cultivable bacteria species have been identified in the mouth and molecular analyses suggest that an equal
number of non- cultivable flora are also present (Samaranayake et al, 2002).

Dental caries is largely due to the colonization of the teeth by a group of Streptococcal organisms, although both
Actinobacillus and Lactobacillus have been implicated as well. Dental caries is readily prevented through oral
hygiene after the morning meal and prior to going to bed. Ideally, it is handled by dental assessment and
professional cleaning on an annual or more frequent basis. Hygiene is accomplished through the use of one or
more of variety of manual and/ or electrical toothbrushes and commercial toothpaste (Walinsky, 1994).

Gingivitis is a local oedematous reaction of the gum to exotoxins excreted by plaque organisms residing on the
teeth. The affected tissues are usually asymptomatic and limited to the teeth on which plaque accumulated
(Holm Pederson et al., 1975). Prevention of gingivitis is accomplished in the same manner and at the same time
as prevention of dental caries. Periodontitis on the other hand is a lytic, inflammatory reaction of the plaque
within the relatively anaerobic gingival sulcus. Microorganisms which are responsible for periodontitis are
dominantly gram negative anaerobes (Nisengard et al., 1994). If the more aggressive cases of periodontitis are
untreated, mobility and avulsion of teeth may eventually result (Nisengard et al., 1994). A periodontal abscess is
an acute, focal, pyogenic inflammation that initiate within the gingival crevice or more commonly, the
periodontal pocket, usually in response to the presence of some foreign body. The inflammatory reaction is
exquisitely painful to palpation and chewing (Carbet, 2000).

In historical terms, oral hygiene as a means and an end is relatively novel concept which has only attracted the
attention of researcher in recent times (Shay and Ship, 1995). Toothbrushes, tooth powder and paste were
gradually embraced by the population at large, basically driven by purposeful advertising and the promise of

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 Egharevba F et al: Continental J. Medical Research 3: 1 - 6, 2009

white teeth. Today, tooth brushing and other mechanical cleaning procedures are considered to be the most
reliable means of controlling plaque, provided cleaning is sufficiently thorough and performed at regular

TABLE 1: TOTAL VIABLE COUNTS OF THE ISOLATES (CONTROL).

ISOLATES MICROBIAL COUNT (CFU/ml)
Streptococcus mutans 2.4 x 10⁶
Streptococcus salivarius 2.1 x 10⁶
Candida albicans 1.0 x 10⁶

TABLE 2: VIABLE COUNT OF STREPTOCOCCUS MUTANS TREATED WITH FIVE

CONCENTRATIONS OF DIFFERENT TYPES OF MOUTHWASHES.
ISOLATE MOUTH CONCENTRATION PLATE COUNT PLATE
WASH OF MOUTHWASH PRE- COUNT
(mw) (%) TREATMENT POST-
(cfu/ml) TREATMEN
T
(cfu/ ml)
Streptococcus MW 001 12 2.4 X 10⁶ 1.23 X 10⁶
mutans 9 2.4 X 10⁶ 1.47 X 10⁶
6 2.4 X 10⁶ 1.95 X 10⁶
3 2.4 X 10⁶ 2.00 X 10⁶
1 2.4 X 10⁶ 2.20 X 10⁶
MW 002 12 2.4 X 10⁶ 1.46 X 10⁶
9 2.4 X 10⁶ 1.73 X 10⁶
6 2.4 X 10⁶ 1.84 X 10⁶
3 2.4 X 10⁶ 1.81 X 10⁶
1 2.4 X 10⁶ 1.90 X 10⁶
MW 003 12 2.4 X 10⁶ 0.62 X 10⁶
9 2.4 X 10⁶ 1.50 X 10⁶
6 2.4 X 10⁶ 1.70 X 10⁶
3 2.4 X 10⁶ 2.00 X 10⁶
1 2.4 X 10⁶ 2.10 X 10⁶

intervals (Cumming and Loe, 1973). Tooth brushing is paramount in maintaining good oral hygiene under the
best of circumstances, however, toothbrushing is able to clean only the buccal lingual and occlusal surfaces
(excluding pits and fissures); proximal and interdental area are essentially left untouched. Therefore, the target
for modern hygiene programs or for any regimen attempting to prevent and reduce the incidence of caries and
periodontal disease must put a major focus on the interdental and proximal areas of the dentition (Kinane, 1998).
Mouthwashes (mouth rinses) are solutions or liquids used to rinse the mouth for a number of purposes. This
include to remove or destroy bacteria, to act as an astringent, to deodorized and to have a therapeutic effect by
relieving infection or preventing dental caries (Addy, 1986). A number of chemical agents are currently
available in the market and are designed to assist individuals in their efforts to achieve and maintain oral health.
While many agents are commercially available, the relative therapeutic benefits of most are not clearly defined
(Kornman, 1986). Mouthwashes are manufactured in two forms: the wash and the spray. For most individuals
the wash is simple and acceptable method for the delivery of topical medicaments into the oral cavity. Rinsing
with a chlorhexidine mouthwash is arguably the most effective chemical method to date of controlling plaque
accumulation (Kalaga et al, 1989). The most common regimen of use has been twice daily rinsing with 10ml of
a 0.2% chlorhexidine solution (Kalaga et al, 1986; and Jenkins et al., 1988). However, with availability of more
commercial mouthwashes similar antiplaque effects have been reported with twice daily rinsing with 15ml or
10ml of the solution according to manufacturer’s direction of use (Leenstra et al., 1996). Whereas previous
studies have shown the ability of mouthwashes on plaque accumulation, plaque composition, either biochemical
or microbiological, the possible effect of a mouthwash on bacterial load count in the mouth has received little or
no attention in human studies in this environment, hence this work is aimed at determining the effect of
mouthwash on oral microflora.

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TABLE 3: VIABLE COUNT OF STREPTOCOCCUS SALIVARIUS TREATED WITH FIVE

CONCENTRATIONS OF DIFFERENT TYPES OF MOUTHWASHES.
ISOLATE MOUTHWASH CONCENTRATION PLATE COUNT PLATE COUNT POST-
(MW) OF MOUTHWASH PRE- TREATMENT
(%) TREATMENT (cfu/ml)
(cfu/ml)
Streptococcus MW 001 12 2.10 X 10⁶ 1.10 X 10⁶
salivarius 9 2.10 X 10⁶ 1.30 X 10⁶
6 2.10 X 10⁶ 1.76 X 10⁶
3 2.10 X 10⁶ 1.87 X 10⁶
1 2.10 X 10⁶ 1.93 X 10⁶
MW 002 12 2.10 X 10⁶ 1.20 X 10⁶
9 2.10 X 10⁶ 1.40 X 10⁶
6 2.10 X 10⁶ 1.71 X 10⁶
3 2.10 X 10⁶ 1.89 X 10⁶
1 2.10 X 10⁶ 2.10 X 10⁶
MW 003 12 2.10 X 10⁶ 0.48 X 10⁶
9 2.10 X 10⁶ 0.96 X 10⁶
6 2.10 X 10⁶ 1.10 X 10⁶
3 2.10 X 10⁶ 1.48 X 10⁶
1 2.10 X 10⁶ 2.10 X 10⁶

MATERIALS AND METHODS.

EQUIPMENT/MATERIALS USED AND STERILIZATION METHODS: The equipment used include
electronic balance, incubator, autoclave, reagents for biochemical analyses, conical flasks, slides and cover
slides petridishes, test tubes, pipette, measuring cylinder, swab sticks, disinfectants (ethanol, formalin), bijoux
bottle, hot air oven, mouthwash used labelled 001,002 and 003 formulated from H₂O₂⁄Na₂B₄O₇ (Nig. Pat.
[2007]) (texture-liquid and colour- very clear), media (nutrient agar, blood agar, McConkey agar, nutrient broth
and potato dextrose agar , peptone water). All glass wares were washed and sterilization was done at standard
methods (160⁰C for 1 hr). The incubation and hot oven used were also thoroughly cleaned and disinfected.

COLLECTION OF SAMPLES: Samples were collected from 36 students from Ambrose Alli University
Ekpoma, taking into consideration the parameters (individual consent, full complement and good health of teeth,
high standard of oral hygiene, having no medical history and not currently receiving pharmacotherapy) and with
participant having had normal oral hygiene procedure(like tooth brushing with regular toothpaste) before
collection of samples by rubbing gently around the gums, teeth, tongue and cervices of the mouth and
transported immediately to the laboratory for microbiological investigation (Canfield and Griffen, 2000).

PREPARATION OF MOUTHWASH CONCENTRATION: Five concentrations of mouthwashes was prepared

as follows: 12%, 9%, 6%, 3% and 1% of mouthwashes were prepared by mixing 12ml, 9ml, 6ml and 1ml
respectively in 100ml of distilled water.

SERIAL DILUTION AND PLATE COUNT: 1ml of stock microbial solution was put in 9ml of sterile distilled
water and shaken vigorously. 1ml of the supernatant was pipette into 9ml of sterile distilled water. This was
serially diluted from 10⁻¹ to 10⁻¹⁰. 1ml of the diluents was pipette into 10 sterile petri dishes and sterile nutrient
agar was poured, rocked and allowed to gel before incubating at 37⁰C for 24hrs.

IDENTIFICATION OF ISOLATES: The isolates were identified on the basis of their cultural characteristics
(colonial morphological), gram staining and other biochemical reactions.

DETERMINATION OF EFFECT OF MOUTHWASHES ON THE ORAL MICROFLORA AND

STATISTICAL ANALYSIS: This was determined in terms of the effect they had in the reduction or elimination
of the oral micro flora identified by a comparison of control and experimental isolate count. Results obtained
were statistically analyzed using the t-test method.

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 Egharevba F et al: Continental J. Medical Research 3: 1 - 6, 2009

TABLE 4: VIABLE COUNT OF CANDIDA ALBICANS TREATED WITH FIVE CONCENTRATIONS OF

DIFFERENT TYPES OF MOUTHWASHES.
ISOLATE MOUTHWASH CONCENTRATION OF PLATE COUNT PLATE COUNT
(MW) MOUTHWASH PRE- TREATMENT POST-
(%) (cfu/ml) TREATMENT
(cfu/ml)
Candida albicans MW 001 12 1.0 X 10⁶ 0.23 X 10⁶
9 1.0 X 10⁶ 0.62 X 10⁶
6 1.0 X 10⁶ 0.70 X 10⁶
3 1.0 X 10⁶ 0.85 X 10⁶
1 1.0 X 10⁶ 0.97 X 10⁶
MW 002 12 1.0 X 10⁶ 0.36 X 10⁶
9 1.0 X 10⁶ 0.48 X 10⁶
6 1.0 X 10⁶ 0.64 X 10⁶
3 1.0 X 10⁶ 0.87 X 10⁶
1 1.0 X 10⁶ 0.93 X 10⁶
MW 003 12 1.0 X 10⁶ 0.96 X 10⁶
9 1.0 X 10⁶ 0.78 X 10⁶
6 1.0 X 10⁶ 0.63 X 10⁶
3 1.0 X 10⁶ 0.57 X 10⁶
1 1.0 X 10⁶ 0,50 X 10⁶

RESULTS.
All the mouthwashes used showed varying degree of inhibition on the isolated microorganisms. Treatment with
each mouthwash reduced the number of colony forming units (cfu) of the viable organisms. The total viable
counts of the isolates prior to treatment with mouthwashes (control) is shown on table 1 while tables 2, 3 and 4
show the microbial counts of the isolates after treatment with different concentration of the mouthwashes. The
isolated organisms include Streptococcus salivarius, Streptocuccos mutans and Candida albicans.

DISCUSSION
The oral microorganisms yielded specifically by all 36 swabs include Streptococcus mutans, Streptococcus
salivarius and Candida albicans. The three different mouth washes had inhibitory effect on microorganisms
with varying degrees depending on their concentration. It was observed that at higher concentrations, the
different mouthwashes had more effect on the microorganisms. Mouthwash 003 had more inhibitory effect on
the bacterial organisms (Streptococcus mutans and Streptococcus salivarius) when compared with mouthwashes
001 and 002. The effect of the mouthwashes were observed to produce inhibition on the microbial load as there
were decrease from initial microbial load count after the use of the mouthwashes. However, at lower
concentration, mouthwash 003 had inhibitory effect on the fungi organism (Candida albicans) but at higher
concentration it effect on this organism was observed to decrease. This suggests that low concentration is
required to effect inhibitory action against fungal and higher concentration is required for antibacterial activities.
This finding agreed with Combe (1980) and Ashley et al., (1998).

Inside Streptococcus mutans, the range of decrease of micro flora was 1.23 x 10⁶ - 2.20 x 10⁶ cfu/ml, 1.46 x 10⁶
- 1.9 x 10⁶ cfu/ml and 0.62 x 10⁶ - 2.1 x 10⁶ cfu/ml for mouthwash 001, 002 and 003 respectively when
compared to the original counts before treatments which was 2.4 x 10⁶ cfu/ml (Table 2). In the case of
Streptococcus salivarius, the decrease range was from 1.10 x 10⁶ - 1.93 x 10⁶cfu/ml, 1.20 x 10⁶ - 2.01 x
10⁶cfu/ml and 0.48 x 10⁶ - 2.1 x 10⁶ cfu/ml for mouthwash 001, 002 and 003 when compared to the pre-
mouthwash count which was 2.10 x 10⁶ cfu/ml (Table 3). However, in the case of Candida albicans the initial
count of 1.0 x 10⁶cfu/ml but when treated with different concentrations of mouthwashes 001, 002 and 003, the
microbial counts ranges from 0.20 x 10⁶ - 0.96 x 10⁶ cfu/ml, 0.36 x 10⁶ - 0.93 x 10⁶ cfu/ml and 0.50 x 10⁶ - 0.96
x 10⁶ cfu/ml respectively (Table 4).

This finding shows that mouthwashes are useful for purposes of removing or destroying bacteria from the mouth
and having a therapeutic effect. Also the differences observed in the inhibitory effect of mouthwash shows that a

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different component which have different mode of action against microbes and that the type of mouthwash used
determines the extent of microbial growth inhibition.

As result of the statistical analysis of data at P < 0.05, there was a significant reduction in microbial count after
treatment with mouthwash compared to the initial microbial count before treatment. However, there was no
significant difference (P < 0.05) among the three different mouthwashes in the way they separately reduced
microbial count.

In conclusion, we recommended that mouthwashes should be developed to have broad spectrum antibiotics in
order to enhance their effectiveness, also that further investigation should be carried out on the various
mouthwashes used in this study in order to determine and improve on the antimicrobial active constituents
present that give the mouthwashes it inhibitory property observed in them and also invivo studies using
laboratory animals should be carried out to determine the safety of the mouthwashes before use in human.

REFERENCES.
Addy, M. (1986). Chlorhexdine compared with other locally delivered antimicrobials. A short review. Journal
of Clinical Periodontal. 3:956

Ashley, F. P, Sinner A. Jackson, P., Wood A. and Wilson, R. F (1984). The effect of a 0.1% celyhpyridinum
chloride mouth rinses on plaque and gingivitis in adults subjects. Br. Dent Journal: 157-198.

Canfield, P. W. and Griffen, A. L. (2000). Dental caries: An infection and transmissible disease. Pediatr.
Clinical North Am. 47: 1001 – 1019.

Combe, E. C. (1980). Notes on Dental Materials. Churchill Livingstone. Edinburgh, London and New York:
268 – 269.

Corbet, E. F. (2000). Diagnosis of acute periodontal lesions. Periodontal. 34: 24 – 216.

Cumming, B. R and Loe, H. (1973). Consistency of plaque distribution in individuals without special home care
instruction. Journal Periodontal Res. 8: 94 – 100.

Halm- Pedersen, P., Agerback N. and Tholade, E. (1975). Experimental gingivitis in young and elderly
individuals. Journal Clinical Periodontal. 2: 14 – 24.

Jenkins, S., Addy, M. and Wade, W. (1988). The mechanism of action of chlorhexidine. A study of plaque
growth on enamel inserts in vivo. Journal Clinical Periodontal. 60 (3): 127- 129.

Kalaga, A., Addy M. And Hunter, B. (1989). Comparison of chlorhexidine delivery by mouth wash and spray
on plaque accumulation. Journal Periodontal. 60 (3): 127 – 129.

Kinane, D. F. (1998). The role of inter-dental cleaning in effective plaque control. Pp. 156 – 168.

Kornman, K. S. (1986). The role of supragingival plaque in the prevention and treatment of periodontal
diseases; a review of current concepts. Journal Periodontal Res. 21 (Supp 16): 5 – 22.

Leenstra, T. S., Van Seene, J. J., Van Seenett and Martin, M. V. (1996). Oral endotoxin in health adults; Oral
endotoxin in health adults; Oral surgery, Oral medicine. Oral pathology, Oral Radiology and Endodontics. 82
(6): 637 – 643.

Loe, H. and Schiott, C. R. (1970). The effect of mouth washes and typical application of chlorhexidine on the
development of dental plaque and gingivitis in man. Journal Periodontal Res. 5: 79 – 83.
Nig. Pat. (2007). RP: NG/C/2007/591.

Nisengard, R. J., Goodman, A. D., Schein, B. (1994). Periapical infections. In: Nisengard R. J., and
immunology (2nd ed ). Philadelphia WB. Saunden. Pp. 391 – 397.

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Samaran ayake, L. P., Jones, B .M., and Scully, C. (2002). Essential Microbiology for Dentistry, 2nd ed.: New
York: Churchill Livingstone.

Shay, K., and Ship, J. A. (1995). The important of oral health in the older patient. Journal Am. Geriatr. Soc.
43:1414 – 1422.

Walinsky, L. E. (1994). Caries and lariong. In: Nisengard, R. J. and Newman M. G., (eds). Oral Microbiology
and Immunobiology (2nd ed). Philadelphia WB. Saunders. Pp 341 – 359.

Received for Publication: 07/11/2008

Accepted for Publication: 24/03/2009

Corresponding Author:
Ohenhen R.E
Department of Microbiology Ambrose Alli University, P. M. B. 14, Ekpoma, Nigeria.
Email Addresses: drginaohen@yahoo.co.uk, kimarenezor@yahoo.com.

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© Wilolud Online Journals, 2009.

A COMPARATIVE STUDY OF PLASMA TOTAL CHOLESTEROL LEVELS AMONG UNTREATED

ESSENTIAL HYPERTENSIVE AND HEALTHY NON-HYPERTENSIVE NIGERIANS

Awusi Vincent Oghenekobaro1 and Onyeneke E.C2

1
Department of Family Medicine, Faculty of Medical Sciences, Delta State University, Abraka, Delta State,
Nigeria. 2Department of Biochemistry, University Of Benin

ABSTRACT
The reported co-existence of hypertension and hypercholesterolaemia increases the
probability of hypertensive patients developing premature ischaemic heart disease which is
the commonest cause of sudden death.

The aim of the study was to determine significant difference between the plasma total
cholesterol (Tc) levels of hypertensive and normotensive subjects and, the coronary risk
status of all the subjects.

Blood samples, to estimate plasma total cholesterol levels, were obtained from 150
untreated patients with uncomplicated essential hypertension and 150 healthy
normotensive controls of comparative ages, sexes and body mass index.

The hypertensive patients had significantly higher plasma total cholesterol levels (male =
189±22mg%, female = 198±342mg%) than the normotensive controls (male =
153±18mg%, female = 155±15mg%) (P < 0.05). Eleven (7.3%) of the hypertensives fell
within the high coronary risk group (World Health Organization – WHO – classification).

It is suggested that hypertension management should include preventative counseling for a

healthy lifestyle/diet, and control of plasma lipids and the raised blood pressure.

KEYWORDS: Hypertension, Hypercholesterolaemia, Ischaemic Heart Disease, Sudden

Death, Preventative Counseling

INTRODUCTION
Hypertension and hypercholesterolaemia - two independent risk factors in the causation of ischaemic heart
disease (IHD) – have been reported to co-exist, independent of confounding variables such as age, sex and body
mass index ( Adedeji et al., 1990), (Bamgboye et al., 1990),(Bonna et al., 1991),(Amens, 1991); thus increasing
the chances of hypertensive patients developing premature ischaemic heart disease(America Health Foundation,
1989) which is the commonest cause of sudden death(British Cardiac Society Working Group, 1987).

Ischaemic heart disease, therefore, should be of primary health concern as it can present first time in a patient as
sudden death, which have been reported in the lay press.

Since epidemiology of hypertension in Africa has successfully debunked the earlier claim that the blacks in
Africa were not sophisticated enough in life-style to be hypertensive, there is reason to research into all facets of
hypertension, knowing its effects on microarteries(Edington et al., 1976), consequent atherosclerosis, and
eventual morbidity and mortality in middle age and beyond(Edington et al.,1976), (Gordon, 1987); caused by
the plaqueing of the intima by poorly metabolized lipids.

Ischaemic heart disease is partly a disease of affluence(British Cardiac Society Working Group, 1987). It is
becoming more common in societies previously impoverished by history or recent circumstances, as living
standard “improve”( British Cardiac Society Working Group, 1987), ( Anderson et al., 1991). Thus the highest
socio-economic groups, the urban elite, carry special risks, and with increasing affluence generally, the
prevalence of the risk factor becomes higher(Gordon, 1987). The fact that developing countries, such as Nigeria,
are experiencing rapid growth in their urban population suggests that there will be a concurrent appearance of
large numbers of individuals with moderate risk. This makes the largest contribution to population morbidity

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 Awusi Vincent Oghenekobaro and Onyeneke E.C: Continental J. Medical Research 3: 7 - 11, 2009

and mortality. Like hypertension in the time past, IHD has been reported to be relatively rare in black
Africans(Osuntokun, 1987),(Ononogbu, 1994), which has been attributed to their dietary habit of consuming
diets low in fat content and rich in fibres, and their less sedentary life style( Akinkugbe, 1992), (Bamgboye et
al., 1990). However, the dietary habits and life-style of the Nigerian population is changing and approaching
those of the western industrialized societies(Ononogbu,1994), with the resultant probability of both societies
having almost equal blood cholesterol levels and therefore almost equal risk of developing IHD.

Plasma total cholesterol (Tc) levels is currently being recommended, by the World Health Organization (WHO),
for use in determining the coronary risk status of patients(WHO. Expert Committee on Prevention of Coronary
Heart Disease, 1990); it shows that a Tc level of less than 220mg% is free from risk, 220-260mg% is
borderline (suspicious) and, above 260mg% is considered high risk (hypercholesterolaemia requiring treatment).

The measurement of these lipid concentrations in plasma has been the subject of several studies for chronic
and/or degenerative diseases, such as IHD, but mostly on the white Caucasians. It is therefore necessary to have
a comparative plasma total cholesterol levels of African-Nigerian hypertensive and non-hypertensive subjects
and determine whether there is any significant difference in their Tc levels and, identify those subject that have
high risk of developing IHD. This in the author’s opinion will help to highlight to the medical profession the
increasing presence of IHD risk factors, such as hypertension and hypecholesterolaemia, in the African-Nigerian
population, as it is imperative for the medical profession to possess a clear knowledge of what constitute risk
factors for IHD, be in a position to recognize the groups likely to benefit from control measures and have the
ability to apply them.

MATERIALS AND METHODS

The study group was made up of 150 untreated essential hypertensive patients (76 males and 74 females), age
between 36 and 65 years old. They were recruited from the General Practice Clinic of the Delta State University
Teaching Hospital, Warri, Delta State of Nigeria. They were without complications, not being treated for any
chronic or longstanding disease at the time of study and had systolic blood pressure of ≥ 150mmHg or diastolic
blood pressure of ≥ 100mmHg or a combination of both. The control group was made up of 150 apparently
healthy individuals (76 males and 74 females), aged between 37 and 65 years old, and had arterial blood
pressure of < 140mmHg (systolic) and < 90mmHg (diastolic). They were recruited from among the hospital
staff and others living in the same environment as the hypertensive patients.

The subjects were selected consecutively from June 1st 2007 to May 31st 2008. Informed consent was obtained
and a data acquisition sheet was completed for each subject( Oyejide, 1992).

 Wt (kg ) 
Parameters measured included weight, height, body mass index  BMI −  and blood
2 
 Ht (m ) 
pressure (korotkoff method). Subjects with proteinuria or/and glycosuria from urinalysis, generally done for all
patients attending the General Practice Clinic, were excluded from the study. So were obese individuals (BMI ≥
30) and those on any drug such as hormonal contraceptive pills. All the subjects fasted over night for at least 12
hours( Akinyanju et al.,1997), before venous blood was collected the following morning. Plasma total
cholesterol levels were determined by enzymatic colorimetric method(Trinder,1969).

The data obtained were analyzed manually using sharp EL-531LH scientific calculator. The statistical methods
applied included means, standard deviation and the student’s t-test of independence between variables. The level
of significance was set at 5% (P<0.05)

RESULTS
Tables I and 2 show that at each level the hypertensive patients (male and female) had significantly higher mean
plasma total cholesterol levels (male = 189±22mg% and female = 198±34mg%) than their respective
normotensive controls (male = 153±18mg% and female = 155±15mg%) (P < 0.05). The mean plasma total
cholesterol level of the normotensive population (normal healthy Nigerian Africans) for male = 153±18mg%
and female = 155±15mg%. Although the plasma total cholesterol levels of the females were generally higher
than the males, it was not significant; and was not related to age or body mass index.

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 Awusi Vincent Oghenekobaro and Onyeneke E.C: Continental J. Medical Research 3: 7 - 11, 2009

Table3 show the distribution of the subjects (hypertensive and non-hypertensive) in the various atherogenic
coronary complication groups, using the World Health Organization (WHO) cholesterol classification criteria.
Eleven (7.3%) and 21 (14%) of the hypertensive patients were in the high and the borderline coronary risk
groups respectively. The other subjects including all the normotentive controls were in the coronary risk-free
zone. .

Table I: Mean plasma total cholesterol levels of males of study and control groups
Age Study group Control group
(years)
Mean plasma total Mean plasma total Statistical
cholesterol levels cholesterol levels differences
(mg/100ml) (mg/100ml between
cholesterol
N N levels ‘P’-Value
< 36 nil Nil - - -
36 – 40 6 190 ± 23 6 157 ± 21 2.357 < 0.05
41 – 45 24 198 ± 31 24 151 ± 19 6.184 < 0.05
46 – 50 20 191 ± 30 20 153 ± 17 4.810 < 0.05
51 – 55 11 188 ± 13 11 159 ± 16 4.462 < 0.05
56 – 60 9 193 ± 19 9 148 ± 19 4.737 < 0.05
> 60 6 172 ± 18 6 151 ± 15 2.000 < 0.05
Total 76 189 ± 22 76 153 ± 18 7.879 < 0.05
¶
Table 2 : Mean plasma total cholesterol levels of females of study and control groups
Age Study group Control group
(years)
Mean plasma total Mean plasma total Statistical
cholesterol levels cholesterol levels differences
(mg/100ml) (mg/100ml between
cholesterol
N N levels ‘P’-Value
< 36 nil - Nil - - -
36 – 40 5 177 ± 34 6 156 ± 13 2.079 < 0.05
41 – 45 27 204 ± 53 26 158 ± 16 4.182 < 0.05
46 – 50 20 227 ± 40 21 162 ± 15 6.771 < 0.05
51 – 55 11 203 ± 37 10 158 ± 13 3.462 < 0.05
56 – 60 6 198 ± 23 6 144 ± 20 3.971 < 0.05
> 60 5 179 ± 18 5 149 ± 13 2.703 < 0.05
Total 74 198 ± 34 74 155 ± 15 10.000 < 0.05
¶
Table 3: The distribution of the subjects in the various atherogenic coronary complication groups
Coronary risk groups/ plasma total cholesterol No. of hypertensive
levels (mg/100ml) No. of normotensive Subjects/%
subjects/%
Risk-free/> 220 150/100 118/79
Borderline (suspicious)/ Nil/0 21/14
220-260
High risk (requiring treatment)/> 260 Nil/0 11/7
Total 150/100 150/100

DISCUSSION
This study has confirmed the reported(Adedeji et al.,1990),(Bamgboye et al.,1990),(Bonna et
al.,1991),(Ames,1991)significantly higher Tc levels found in hypertensive patients compared to the normal
population. This could increase the chances of hypertensive patients developing premature ischaemic heart
disease and, presenting first time to the out patient department as sudden death. Tc is currently accepted as an

9
 Awusi Vincent Oghenekobaro and Onyeneke E.C: Continental J. Medical Research 3: 7 - 11, 2009

important risk factor in the pathogenesis of atherosclerosis and other forms of cardiovascular
diseases(Gordon,1987). Although Tc determination alone does not indicate whether there is an increase in the
atherogenic low-density lipoprotein (LDL) – cholesterol concentration, it is the index that determines whether
lipoprotein phenotyping is necessary or not. It is also well established that over 66% of the Tc are carried in the
LDL(Gotto,1996). The association of hypercholesterolaemia (found in 7.3% of the hypertensive patients in this
study) with premature ischaemic heart disease makes investigation of cholesterol a necessity.
Hypercholesterolaemia is associated with vascular endothelial dysfunction which precedes the development of
atheroma and may underlie coronary vasospasm(Edington et al.,1976 ). The mean Tc of the healthy
normotensive in this study population is within the range reported among African communities by other
studies(Adedeji et al.,1990),(Bamgboye et al.,1990), (Gordon, 1987) , but lower than those reported for the
developed societies(American Health Foundation, 1989),(Ononogbu,1994),(Ludewigs et al.,1992).

There are few studies in African countries, such as Nigeria, that have actually correlated plasma cholesterol to
the risk of developing morbidity and/or mortality from coronary heart disease. This may not be unconnected to
the held belief that IHD is rare amongst Africans, hence lack of research interest towards it. In a study by (Das
et al., 1997) in which the coronary risk status of 182 normal healthy Nigerian-Africans, aged one year and
above, was determined using the internationally accepted “desirable” level of plasma total cholesterol
concentrations, all the subjects fell within the coronary risk free zone; same as in this study where all the healthy
normotensive subjects were free from the risk of developing coronary heart disease. This is however, at variance
with studies on the Caucasians in whom about 10% of the general population was reported to fall within the
high risk group( Ludewigs et al.,1992).

However, the clinician in Nigeria, nay Africa, should recognize this group of hypertensive patients with
hypercholesterolaemia that are at special risk of developing premature ischaemic heart disease, for it is among
these group that IHD preventative counseling can be offered. Life style alteration(Adedeji et al.,1990), including
healthy diet and medical intervention( Lipid Research Clinics Programm,1994) , leading to a fall in Tc level as
well as control of high blood pressure have been reported to reduce mortality significantly.

In conclusion, this study confirms that individuals with hypertension have significantly higher Tc levels than the
normal population, and this could increase their probability of developing premature IHD. That the presence of
hypercholesterolaemia found in some of the studied hypertensive patients may suggest that cardiac
abnormalities may be far more frequent than presumed in the Nigeria-African population and therefore warrants
much closer attention. And knowing the relationship between high lipid levels and atherosclerosis, efforts
should be made to screen all hypertensive patients lipidwise, a practice which should be considered for routine
management of the disease. Prudent approach for prevention of IHD is to recommend preventive counseling on
diet, especially cutting down on saturated fats, cessation of smoking/excess intake of alcohol and weight loss
(where applicable) as well as aggressive blood pressure reduction for every patient diagnosed as hypertensive.
The preventive efforts should be made to have impact on the streets, not only on the patients, to halt any drift to
an epidemic position. The family physician, being the first-line doctor, has an important role to play in this
regard.

REFERENCES
Adedeji O.O, Onitiri A.C( 1990): Plasma lipids in Nigerian Hypertensives. Afr. J Med. Sc. 19(4):281-84.

Akinkugbe O.O.(1992). In: Expert Committee on Non-communicable Diseases in Nigeria. Series 1. Spectrum
Book Publications Ltd. ,Lagos, Nigeria; pp. 3-49.

Akinyanju P. A. , Banjoko J.D.(1997): Postprandial lipid levels in normal and hyperlipidaemic Nigerians. Nig.
Med. J. 7(3): 264-67.

American Health Foundation(1989): Conference on the effects of blood lipids: Optimal distributions for
population.Prev. Med. 8: 715-32.

Ames R.P.(1991): Hyperlipidaemia in hypertension: Causes and preventions. Am. Heart J. 122(42): 1219-24.

Anderson K.M., Wilson P.W.F., Odell P.M.(1991): An updated coronary risk profile. Circulation 83: 357-63.

10
 Awusi Vincent Oghenekobaro and Onyeneke E.C: Continental J. Medical Research 3: 7 - 11, 2009

Bamgboye A.E. and Taylor G.O.(1990): Serum Cholesterol and Disease in Nigerians. Am. J. Clin. Nutr. 32:
2540 – 45.

Bonaa K.H. and Thelle D.S.(1991): Association Between Blood Pressure and Serum Lipids in a population: The
Tromso Study. Circulation 83: 1305- 14.
.
British Cardiac Society Working Group(1987): On Coronary Heart Disease Prevention. Br. Med. J. 299: 1475 –
76.

Das S.C. and Isichei U.P.(1997): Beta lipoprotein and Triglycerides in a healthy Nigerian Population. Nig.
Postgrad. Med. J. 4(3): 88-92.

Edington G.M. and Gilles H.M.(1976). The circulatory system, In:Edington G.M. and Gilles H.M. (eds).
Pathology in the tropics. Amold Publishers, London; pp. 348 – 89.

Gordon T.(1987): Blood Lipids in Coronary heart disease risk: The Framingham Study. Ann. Int. Med. 87: P.
393.

Gotto A.M.(1996): The cholesterol Facts - A summary of the evidence relating dietary fats, serum cholesterol
and coronary heart disease. Circulation 81: 1721 – 33.

Lipid Research Clinics Programm(1994): The lipid Research Clinics Coronary primary prevention trial results:
the relationship of reduction in incidence of coronary heart disease to cholesterol lowering.J.A.M.A.251:365-74.

Ludewigs M. , Ceranna R. , and Timpin C.(1992): Diagnostic Report - Lipid Disorders. No.E4221. Boehringer
Mannheim, West Germany; pp. 1-20.

Ononogbu I.C.(1994): Comparison of high density lipoprotein and serum cholesterol levels in a European and
an African community. Atherosclerosis.90: 34-52.

Osuntokun B.O.(1987): Stroke in Africans. Afr. J. Med. Sc.6: 39- 53.

Oyejide C.O.(1992):Health Research Methods for Developing Country Scientists. Codat Publications, Ibadan,
Nigeria; pp.59-63.

Trinder P.(1969): Determination of serum cholesterol by enzymatic colometric method. Ann.Clin. Biochem. 6:
24-27.

W.H.O. Expert Committee(1990). Prevention of Coronary Heart Disease. In: World Health Organisation
Technical Report. Series 678. Geneva.

Received for Publication: 07/03/2009

Accepted for Publication: 24/05/2009

Corresponding Author:
Awusi Vincent O.
P.M. Box 8957, Benin, Benin City, Edo State, Nigeria.
E-MAIL: alpha.medicalcentre@yahoo.com

11
PREVALENCE OF SECRETORY OTITIS MEDIA AMONGST PRIMARY SCHOOL CHILDREN IN
BENIN CITY NIGERIA.

N.E. Okolugbo
Department Of Surgery Delta State University, Abraka
Email; Nekouokolugbo@Yahoo.Com

ABSTRACT
BACKGROUND: To determine the prevalence of secretory otitis media amongst primary
school children in Benin City, Nigeria,

METHODS: A six month prospective study of pupils aged between five and seven years
in primary one in the selected schools.
Techniques for data collection were;
Personal Identification,
Otoscopy,
Tympanometry,
Screening Audiometry,
Examination of the nose for presence of anterior rhinorrhea,
Examination of the throat for gross tonsillar enlargement.

RESULTS: The results showed the prevalence rate of otitis media to be 15.9% with no
significant difference in prevalence between males and females.

CONCLUSION: That OME is quite a common condition amongst primary school

children in Benin City with resultant hearing impairment and need for a school screening
and health programme to detect and prevent this common condition is emphasized.

KEYWORDS: secretory otitis, media, children, pupils, Nigeria,

INTRODUCTION
Secretory otitis media also known as Otitis Media with Effusion (OME) has been identified as the commonest
middle ear condition causing deafness in children in developed countries, De 1980. It affects children’s learning
ability through temporary and recurring hearing loss, permanent hearing impairment and language disorders.

A child with an episode of OME often experiences a mild to moderate fluctuating hearing loss, thus receiving
partial or inconsistent auditory cues, which may make speech more difficult to detect and/or filter from
background noise. It has been hypothesized that the resulting misperception or missing of words may affect the
input to the knowledge base or to the neural substrate on which language learning is built. It also has been
proposed that any difficulties attributable to OME associated hearing loss may become evident when a child
reaches school age and faces the challenges of school environment.
Academic skills particularly in reading and other language based subjects may be affected when there is a high
demand for attention to verbally presented information. Roberts et al 2002. Several studies have shown that
secretory otitis media also occurs in children in the developing countries even though they are not brought for
treatment. Most parents pay attention to suppurative problems of the ear. The conductive hearing loss associated
with OME must have been missed by parents and teachers. Okeowo 1985.

This study attempts to address this problem by evaluating the prevalence of Secretory otitis media amongst
primary school children in Benin City so that health care policy makers can be sensitized to taking positive steps
in combating this morbidity, while taking note of the fact that the prevalence of secretory otitis media varies in
different population groups and reports from studies from different parts of the world vary depending on the age
group of the children examined. Figures of 10- 60% have been variously reported. Renvall et al 1985, Roese et
al 1977, Tos et al 1982

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OBJECTIVES

To determine the prevalence of secretory otitis media amongst primary school children in Benin City.

MATERIALS AND METHODS

13
The subjects included in my study were primary 1 pupils in the selected primary schools with age range of 5-7
years. Each ear was considered as a separate entity suitable for analysis.
For tympanometric recordings, a Welch-Allyn Microtymp 2 was used with the following specifications
Probe Tone frequency – 226HZ
Sound Pressure level of 85 dB
Pressure range of + 200 to–400 dapa. Fiellau Nikolajsen (1983) modified Jerger’s (1970)
nomenclature; subdividing tympanograms into 4 types was used.
Type A - Middle ear pressure + 200 to – 99mm of
Water.
Type B - Flat traces without a well defined compliance.
Type C1 - Middle ear pressure – 100 to –199mm of
Water.
Type C2 - Middle ear pressure – 200 to 400 mm of
Water

Types C1 and C2 associated with a negative middle ear pressure as in Eustachian tube dysfunction and
which is also associated with middle ear effusion as well as the type B flat curve which is highly associated with
middle ear effusion were used as indicators of OME.

RESULTS
The total number of children enrolled in the study was 270.
Each pupil had the 2 ears examined and tested resulting in a total of 540 ears in the study.
The results showed a prevalence rate of 15.9% of OME with no significant difference in the prevalence of OME
between males and females.

FIRURE 1.

DIAGRAM OF TYMPANOMETRIC FINDINGS (540 EARS)

14
DISCUSSION.
In this study, the types C1 and C2 as well as the type B tympanograms were used as indicators of OME.
These combined gave a prevalence rate of 15.9%; this value was quite close to that of Ijaduola et al 2000,18.6%
and 18.2% which was obtained by Nwawolo et al 1998, which used the same diagnostic criteria as used in this
study. This shows that this condition is quite common, in Nigeria, which is at variance with what Murphy
reported in 1981 where he said the condition is relatively uncommon in West Africa.
Due to the difference in diagnostic criteria, comparisons of various studies are a bit difficult. However
comparing the results from this study with one earlier done in Benin City by Ogisi 1988, Ogisi used the type B
and C tympanograms as an indicator of OME and had a prevalence rate of 8%. The prevalence rate using only
the type B in this study was 6.7% which is quite close to that obtained by Ogisi, 5.2% and so much closer to
6.6% which was obtained by Okeowo in 1981.
These results are however still much lower than those reported from developed countries where
prevalence rates of up to 64% have been reported, depending on several factors, including the diagnostic
criteria, instruments used to detect the condition, age group of the children etc. Renvall 1985, this lower
prevalence rate in African children was suggested by Okeowo 1985 to be due to the fact that the Eustachian tube

15
functions better in Africans. While there is little scientific evidence to support this, further investigation in this
area is necessary.

CONCLUSION
That otitis media with effusion is quite a common condition amongst primary school children in Benin
City and as such parents and teachers should be educated on the prevalence of this condition and advised to
watch out for any signs of hearing impairment in a child such as not answering to calls promptly.

REFERENCES
1. De PB. Secretory otitis media and allergic Rhinitis. J. Laryng Otol 1980; 2: 185-189
2. Roberts JE, Burchinal MR, Zersel SA. Otitis Media in Early childhood in relation to children’s
school age language and academic skills. Pediatrics 2002:110:696-706
3. Okeowo P.A. observations on the incidence of secretory otitis media in Nigerian Children. Journal
of tropical pediatrics: 1985; 31:295-298.
4. Renvall U, liden G, Jungert S. and Nilsso E. impedance audiometry in the detection of secretory
otitis media. Scandinavian Audiometry: 1985; 4:119-124
5. Roese R.J., Dunckell D.C. Adams R.M. impedance screening for middle ear disease in children.
Grune and Stratton New York 1977:135-144
6. Tos M, Holm-jensen S, Sorensen C.H. and Mogensen C. Spontaneous course and frequency of
secretory otitis media in four year old children. Archives of Otolaryngology, 1982; 108:4-10
7. Olusanya B.O, Okolo A.A, Ijaduola G.T. The hearing profile of Nigerian school children. Int. J.
Paediatric otorhinolaryngology 2000: 55(3): 173-178
8. Akinlade O, Nwawolo C.C. Okeowo P.A. Tympanometric screening for secretory otitis
media(OME) in Nigeria Children aged 2-7 years Nig Qt. J. Hosp. Med. 1998:8;44-46.
9. Murphy J.P. Two years of Otolaryngology in Ghana, West Africa Archives of Otolaryn 1981:103:
228-231.
10. Ogisi F.O. Impedance screening of otitis media with effusion in Nigerian Children. The journal of
laryngology and otology 1988: 103; 986-988.
11. Okeowo P.A. Observations on the incidence and aethiology of secretory otitis media in Nigerian
Children. Journal of Tropical pediatrics, 1981; 4 – 24.

Received for Publication: 07/03/2009

Accepted for Publication: 24/05/2009

Corresponding Author:

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