Primary oral tuberculosis - A case report.

Tuberculosis is a chronic granulomatous disease which affects the lungs in majority of the cases. Oral manifestations of tuberculosis (TB) are seen both in primary and secondary stages of the disease but are most commonly associated with secondary TB. Primary oral TB is a rare entity and thus may pose a diagnostic challenge. This case reports isolated primary TB of the lower lip associated with an intraoral long-standing nonhealing ulcer present in a 12-year-old child. The diagnosis was confirmed by histopathological, hematological, and radiographic investigations. The lesion resolved with anti-tubercular treatment regimen. The case highlights the importance of clinician awareness toward oral lesions, which may present themselves without any symptoms and/or signs of systemic disease.

Comparative evaluation of shear bond strength and nanoleakage of conventional and self-adhering flowable composites to primary teeth dentin.

BACKGROUND: The latest advancement in adhesive dentistry is the development of self adhering flowable composite resin which incorporates the self-etch adhesion technology to eliminate the steps of etching, rinsing, priming and bonding. Few studies have addressed resin bonding to primary teeth. AIM: The aim of this study was to compare the shear bond strength and nanoleakage of conventional and self adhering flowable composites to primary teeth dentin. SETTINGS AND DESIGN: This study was conducted in the Department of Pedodontics and Preventive Dentistry, I.T.S Dental College, Hospital and Research Centre, Greater Noida; in association with the Department of Mechanical Engineering, I.T.S Engineering College, Greater Noida; and the Advanced Instrumentation Research Facility (AIRF), Jawaharlal Nehru University, New Delhi. MATERIALS AND METHODS: Sixty of the ninety primary teeth were evaluated for shear bond strength and thirty for nanoleakage. The samples were divided into three groups; Group I - Dyad Flow (Kerr), Group II - Fusio Liquid Dentin (Pentron Clinical Technologies) and Group III - G-aenial Universal Flo (GC). Shear bond strength was determined using a universal testing machine. Nanoleakage pattern was observed under scanning electron microscope. RESULTS: The shear bond strength of conventional flowable composite was significantly greater than self adhering flowable composite (p<0.05). Nanoleakage scores of both conventional and self adhering flowable composites were comparable. CONCLUSIONS: Self adhering flowable composites combine properties of composites and self etch adhesives, eliminating the need for separate bond application that simplifies direct restorative procedure. The evolution of self adhering materials could open new horizons for pediatric dentistry.

Use of a high caloric liquid meal as an alternative to a solid meal for gastric emptying scintigraphy.

BACKGROUND: Gastric emptying scintigraphy (GES) using a solid meal is often recommended for the evaluation of gastroparesis. However, some patients cannot tolerate the standardized egg-white sandwich (EWS) solid meal and an alternative meal is needed. AIM: The aim of this study was to compare GES, regional gastric emptying, and gastric contractility using a liquid nutrient meal (LNM; Ensure Plus(®)) to those using EWS. METHODS: Twenty healthy volunteers underwent GES using EWS and LNM on separate days. Gastric emptying was measured using scintigraphy and with a wireless motility capsule (WMC; SmartPill(®)). RESULTS: The gastric emptying half-time with LNM was similar to that with EWS (1.41 ± 0.11 vs 1.52 ± 0.08 h; P = 0.28) and the two were significantly correlated (r = 0.53; P = 0.017). There were time-related differences in gastric emptying of the LNM compared to EWS: in the first hour, gastric retention of EWS was slightly greater than that of LNM, whereas at 3 and 4 h, gastric retention of EWS was slightly less than that of LNM. Regionally, the percentage retention of the meal in the proximal stomach was greater for EWS than for LNM at 0.5 h. WMC gastric emptying times and gastric contractility for the two meals were not significantly different. CONCLUSIONS: Overall gastric emptying of the LNM was similar to that of the EWS meal. The LNM empties without a lag phase and takes slightly longer to empty from the distal stomach, likely due to its higher fat content. These differences are likely due to early accommodation with retention of solids in the proximal stomach and the need for trituration of solids. We conclude that this LNM can serve as an alternative to the conventional solid EWS for GES.

Clinical response and side effects of metoclopramide: associations with clinical, demographic, and pharmacogenetic parameters.

OBJECTIVES: Metoclopramide is associated with variable efficacy and side effects when used in the treatment of gastroparesis. AIM: To determine associations of clinical and pharmacogenetic parameters with response and side effects to metoclopramide in patients with upper gastrointestinal symptoms suggestive of gastroparesis. METHODS: Gastroparetic patients treated with metoclopramide were enrolled. Clinical parameters recorded were age, sex, weight, diabetic status, gastric emptying result, daily dose, effectiveness, and side effects. DNA was isolated from salivary samples; 20 single nucleotide polymorphisms were genotyped in 8 candidate genes (ABCB1, ADRA1D, CYP1A2, CYP2D6, DRD2, DRD3, HTR4, KCNH2). RESULTS: One hundred gastroparetic patients treated with metoclopramide participated. Dose averaged 33±16 mg/d for 1.1±1.7 years. Responders (53 of 100 patients) were older (48±15 vs. 38±11 y; P=0.0004) and heavier (body mass index of 28±7 vs. 25±7; P=0.0125). Efficacy was associated with polymorphisms in KCNH2 (rs1805123, P=0.020) and ADRA1D (rs2236554, P=0.035) genes. Side effects, occurred in 64 patients, were more common in females (83% vs. 64%; P=0.037), nondiabetics (77% vs. 47%; P=0.004), and patients with normal gastric emptying (41% vs. 17%; P=0.015). Side effects were associated with polymorphisms in CYP2D6 (rs1080985, P=0.045; rs16947, P=0.008; rs3892097, P=0.049), KCNH2 (rs3815459, P=0.015), and serotonin 5-HT4 receptor HTR4 gene (rs9325104, P=0.026). CONCLUSIONS: Side effects to metoclopramide were more common in nondiabetic patients with normal gastric emptying. Polymorphisms in CYP2D6, KCNH2, and 5-HT4 receptor HTR4 genes were associated with side effects, whereas polymorphisms in KCNH2 and ADRA1D genes were associated with clinical response. Clinical parameters and pharmacogenetic testing may be useful in identifying patients before treatment with metoclopramide to enhance efficacy and minimize side effects.

Gastric emptying scintigraphy: is four hours necessary?

INTRODUCTION: Recommendations for gastric emptying scintigraphy (GES) suggest imaging over 4 hours to better define gastroparesis. AIMS: To determine the value of defining delayed gastric emptying at time points earlier than 4 hours. METHODS: GES was performed with ingestion of a liquid egg white meal with imaging at 0, 0.5, 1, 2, 3, and 4 hours. Patients completed the Patient Assessment of Gastrointestinal Symptoms questionnaire immediately before GES. RESULTS: Of 1499 patients undergoing GES from September 2007 to January 2010 (76.2% were female, mean age of 45.5±0.5 y, 21.3% had diabetes, 9.5% had earlier gastric surgery), 160 (10.7%) had increased gastric retention at 1 hour (>90%), 404 (27%) had increased retention at 2 hours (>60%), 576 (38.4%) had increased retention at 3 hours (>30%), and 629 (42%) had increased retention at 4 hours (>10%). Gastric retention at 4 hours correlated with retention at 3 hours (r=0.890; P<0.001), 2 hours (r=0.738; P<0.001), and 1 hour (r=0.510; P<0.001). Symptoms correlated better with the gastric retention at later time points. The symptoms correlating with gastric retention at 4 hours included early satiety (r=0.170; P<0.01), vomiting (r=0.143; P<0.01), feeling excessively full after meals (r=0.123; P<0.01), and loss of appetite (r=0.122; P<0.01). CONCLUSIONS: Gastric retention at 4 hours correlates well with gastric retention at 3 hours, good at 2 hours, but only fair with gastric retention at 1 hour. Gastric retention at 1 hour may miss 36% of patients found to have delayed gastric emptying at 4 hours. Symptoms (early satiety, vomiting, feeling excessively full after meals, and loss of appetite) correlated better with the gastric retention at later time points.

Gastric emptying of solids and liquids for evaluation for gastroparesis.

BACKGROUND: Gastric emptying scintigraphy (GES) of solids is typically used to evaluate for gastroparesis. AIMS: The purpose of this study was to determine the value of simultaneously measuring gastric emptying of liquids and solids for assessing patients for delayed gastric emptying. METHODS: A total of 596 patients at our institution from September 2007 to January 2010 underwent GES with assessment of both solid and liquid gastric emptying. An EggBeaters® with jam sandwich meal radiolabeled with Tc-99 m was used for solid GES and water radiolabeled with In-111 for liquid GES. RESULTS: Inclusion criteria (no medications affecting gastric motility in 48 h prior to test; no prior gastric surgery) was met by 449 patients. Liquid gastric emptying was significantly correlated to solid gastric emptying: 30 min (r=0.652, P<0.001), 60 min (r=0.624, P<0.001) and 120 min (r=0.766, P<0.001). Interestingly, 60 patients, of which 57 were nondiabetic, had normal solid GES but delayed liquid emptying and represented 26% of the 228 patients with normal solid GES. Gastric retention of solids was mildly correlated with nausea, vomiting, loss of appetite, early satiety and feeling excessively full after meals. Gastric emptying of liquids was associated with early satiety and loss of appetite. CONCLUSIONS: Gastric emptying of liquids correlates well with gastric emptying of solids. When evaluating patients for gastroparesis, assessment of gastric emptying of liquids in addition to solids may help identify additional patients with delayed gastric emptying, particularly non-diabetic patients where 26% with normal solid emptying may have delayed emptying of liquids. Symptoms of gastroparesis, however, are primarily associated with delayed gastric emptying of solids.

Domperidone treatment for gastroparesis: demographic and pharmacogenetic characterization of clinical efficacy and side-effects.

BACKGROUND: Domperidone is a useful alternative to metoclopramide for treatment of gastroparesis due to better tolerability. Effectiveness and side-effects from domperidone may be influenced by patient-related factors including polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters, and domperidone targets. AIMS: The aim of this study was to determine if demographic and pharmacogenetic parameters of patients receiving domperidone are associated with response to treatment or side-effects. METHODS: Patients treated with domperidone for gastroparesis provided saliva samples from which DNA was extracted. Fourteen single-nucleotide polymorphisms (SNPs) in seven candidate genes (ABCB1, CYP2D6, DRD2, KCNE1, KCNE2, KCNH2, KCNQ1) were used for genotyping. SNP microarrays were used to assess single-nucleotide polymorphisms in the ADRA1A, ADRA1B, and ADRA1D loci. RESULTS: Forty-eight patients treated with domperidone participated in the study. DNA was successfully obtained from each patient. Age was associated with effectiveness of domperidone (p=0.0088). Genetic polymorphism in KCNH2 was associated with effectiveness of domperidone (p=0.041). The efficacious dose was associated with polymorphism in ABCB1 gene (p=0.0277). The side-effects of domperidone were significantly associated with the SNPs in the promoter region of ADRA1D gene. CONCLUSIONS: Genetic characteristics associated with response to domperidone therapy included polymorphisms in the drug transporter gene ABCB1, the potassium channel KCNH2 gene, and α1D--adrenoceptor ADRA1D gene. Age was associated with a beneficial response to domperidone. If verified in a larger population, this information might be used to help determine which patients with gastroparesis might respond to domperidone and avoid treatment in those who might develop side-effects.

Abdominal pain is a frequent symptom of gastroparesis.

BACKGROUND & AIMS: Although the most commonly recognized symptoms of gastroparesis (GP) are nausea and vomiting, patients also report abdominal pain. We aimed to define the prevalence, severity, and quality of abdominal pain in GP and to correlate abdominal pain with gastric emptying (GE) and quality of life. METHODS: Patients presumed to have GP underwent 4-hour GE scintigraphy and upper endoscopy examinations and completed the following: patient assessments of gastrointestinal symptoms (Patient Assessment of Upper Gastrointestinal Symptom Severity Index), abdominal pain questionnaires (Short-Form of the McGill Pain Questionnaire), and quality-of-life questionnaires. RESULTS: The study group consisted of 68 patients (58 female; 10 male) with delayed GE (18 diabetic gastroparesis [DG] and 50 idiopathic gastroparesis [IG]). Abdominal pain was present in 90% of patients (89% DG, 90% IG) and nausea was present in 96% (100% DG, 94% IG). Abdominal pain was epigastric in 43% and umbilical in 13%. Pain occurred daily in 43% and was constant in 38%. Pain often was induced by eating (72%), was nocturnal (74%), and interfered with sleep (66%). Severity ranking of symptoms based on the Patient Assessment of Upper Gastrointestinal Symptom Severity Index was as follows: abdominal fullness (3.8 +/- 0.2), bloating (3.6 +/- 0.2), nausea (3.6 +/- 0.2), upper abdominal discomfort (3.3 +/- 0.2), upper abdominal pain (3.0 +/- 0.2), and vomiting (2.2 +/- 0.2). Abdominal pain severity did not correlate with GE, but had moderate correlation with quality of life. CONCLUSIONS: Abdominal pain is a frequent symptom in patients with GP, comparable with nausea and vomiting. Abdominal pain correlates with impaired quality of life but not with GE.