Nonsurgical Management of Drug-induced Gingival Overgrowth in a Young Patient

Background

Gingival enlargement or gingival overgrowth (GO) is a very common complication of the various classes of drugs and the most common being, the anticonvulsant drug phenytoin (PHT). PHT and its metabolites have a direct effect on the periodontal tissues; with poor oral hygiene also contributing to the severity of inflammation in patients with drug-induced gingival overgrowth (DIGO).

Case description

Here we present a case of PHT-induced gingival overgrowth (PGO) in a 12-year-old male patient and discuss the management of the condition.

Conclusion

Management of drug-induced overgrowth of gingiva includes strict oral hygiene maintenance practice, meticulous professional care with several adjunctive periodontal therapies like photodynamic therapy and Local drug delivery. Surgical treatment is indicated if the overgrown tissue has become fibrotic.

Clinical significance

The pediatric dentist plays an important role in early identification and proper management of the condition by timely intervention and collaboration with other specialists.

How to cite this article

Dalal R, Garg S, Gupta A. Nonsurgical Management of Drug-induced Gingival Overgrowth in a Young Patient. Int J Clin Pediatr Dent 2023;16(S-3):S331-S334.

Positive deviance in child malnutrition of urban poor of Mumbai, India: A longitudinal analysis

Background

Maharashtra has the largest share of urban population in India (13.5%) and is home to the largest slums. Malnutrition rates in these settlements are very high due to insufficient feeding, poverty, poor water quality and sanitation. The Foundation for Mother and Child Health (FMCH) has been working on reducing malnutrition in the urban slums of Mumbai for about 14 years now. Longitudinal data (2014-2019) collected by them was used in this analysis.

Objectives

To analyze the nutritional status of children before and after the intervention of FMCH and identify underlying factors associated with positive deviance in them.

Methods

NFHS-4 urban data of the lowest wealth quintile was used to analyze nutritional status of urban poor in India. Primary data of 4634 children (age 0-5) from the slums of Mumbai was analyzed for nutritional status during baseline and end line using ENA software. Descriptive statistical methods and binary logistic regression model were applied on selected 1583 cases using SPSS.

Results

Malnutrition rates in these children were lesser than national averages until 2 years of age. From baseline to end line, 48% reduction was observed in wasting within the first 6 months of age. Binary logistic regression reveals that age at registration (Odds ratio, OR = 0.94, p-value=0.04) and area of residence (p-value=0.00) are two most significant factors contributing to positive deviance in the child's nutritional status. Another univariate logistic regression on categorized breastfeeding score reveals that a higher score results in higher odds (OR = 1.561, p-value=0.01) of positive deviance in nutritional status of the child.

Conclusions

Since the strategy in each area is different, the most successful strategy is thus identified. The importance of early identification and intervention for effective tackling of malnutrition is highlighted through this analysis. Also, the role of effective breastfeeding techniques has emerged to be extremely significant.

Key messages

Impacting over 4000 children, the right nutrition in the first 1000 days and regular monitoring resulted in almost 50% reduction in wasting. Effective breastfeeding techniques were found to be extremely significant in the improvement of child's nutritional status.

Long-term Rescue of Photoreceptors in a Rodent Model of Retinitis Pigmentosa Associated with MERTK Mutation

MERTK mutation reduces the ability of retinal pigment epithelial (RPE) cells to phagocytize the photoreceptor outer segments, which leads to accumulation of debris separating photoreceptors from RPE cells, resulting in their degeneration and loss of vision. In a rat model of Retinitis Pigmentosa due to MERTK mutation, we demonstrate that surgical removal of debris performed when about half of photoreceptors are lost (P38), allows the remaining photoreceptor cells to renew their outer segments and survive for at least 6 months - 3 times longer than in untreated eyes. In another set of experiments, patterned laser photocoagulation was performed before the debris formation (P19-25) to destroy a fraction of photoreceptors and thereby reduce the phagocytic load of shed outer segment fragments. This treatment also delayed the degeneration of the remaining photoreceptors. Both approaches were assessed functionally and morphologically, using electroretinography, optical coherence tomography, and histology. The long-term preservation of photoreceptors we observed indicates that MERTK-related form of inherited retinal degeneration, which has currently no cure, could be amenable to laser therapy or subretinal surgery, to extend the visual function, potentially for life.

Retinal safety of near infrared radiation in photovoltaic restoration of sight

Photovoltaic restoration of sight requires intense near-infrared light to effectively stimulate retinal neurons. We assess the retinal safety of such radiation with and without the retinal implant. Retinal damage threshold was determined in pigmented rabbits exposed to 880nm laser radiation. The 50% probability (ED50) of retinal damage during 100s exposures with 1.2mm diameter beam occurred at 175mW, corresponding to a modeled temperature rise of 12.5°C. With the implant, the same temperature was reached at 78mW, close to the experimental ED50 of 71mW. In typical use conditions, the retinal temperature rise is not expected to exceed 0.43°C, well within the safety limits for chronic use.

Delayed open reduction and internal fixation of a neglected fracture dislocation of the ankle

Neglected fracture dislocations of ankle are rare in western countries. Failure to achieve anatomic reduction is associated with a poor prognosis. We present a case of a patient with a neglected Weber B fracture of the fibula with postero-lateral subluxation of the ankle. In theatre, the subluxation could not be reduced, and a posterior and lateral soft tissue release was performed. Granulation tissue was removed from the medial gutter. The fibular fracture was reduced and fixed with a six-hole dynamic compression plate. Post-operative radiographs was satisfactory and the patient was followed up for 12 months with full range of movement and function of the joint. In our case, correction was not obtained by osteotomy of the lateral malleolus alone, and medial and posterior soft tissue release was required. This was due to disruption of the deltoid ligament and posterior tibiofibular ligament and the associated scar tissue. Previous studies have shown that, if anatomic reduction is achieved, results with delayed surgery can be as good as those obtained with immediate surgery. Surgically correcting an old fracture dislocation is a difficult undertaking due to soft-tissue contractures and malunited fractures. It is important to preserve as much soft tissue attachments and periosteum to prevent avascular necrosis.

Lateral plantar nerve injury following steroid injection for plantar fasciitis

A 41 year old man presented with pain and numbness affecting the lateral aspect of his foot after a steroid injection for plantar fasciitis. Examination confirmed numbness and motor impairment of the lateral plantar nerve. The findings were confirmed by electromyographic studies. The anatomy of the lateral plantar nerve and correct technique for injection to treat plantar fasciitis are discussed.

Novel structurally altered P(2X1) receptor is preferentially activated by adenosine diphosphate in platelets and megakaryocytic cells

Experimental and clinical data suggest the presence of multiple types of adenosine diphosphate (ADP) receptors, one coupled to ligand-gated cation channels (P(2X)) and others coupled to G-protein-coupled (P(2Y)) receptors. This report identifies cDNA for a structurally altered P(2X1)-like receptor in megakaryocytic cell lines (Dami and CMK 11-5) and platelets that, when transfected into nonresponsive 1321 cells, confers a specific sensitivity to ADP with the pharmacologic rank order of ADP > > ATP > > > alpha,beta-methylene-ATP as measured by Ca(++) influx. This receptor (P(2X1del)) contains a deletion of 17 amino acids (PALLREAENFTLFIKNS) that includes an NFT consensus sequence for N-linked glycosylation. Glycosylated forms of the P(2X1del) and P(2X1wt) receptors were indistinguishable electrophoretically by Western blot or by immunoprecipitation using available antihuman and antirat antibodies. These results indicate that the expression of the P(2X1del) receptor results in an influx of Ca(++) induced by ADP. Expression of P(2X1del) receptor homomeric subunits is sufficient to express a receptor preferentially activated by ADP and suggests that this altered form, alone or in combination with P(2X1wt) receptors, is a component of an ADP-activated ion channel.

Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective randomized controlled study

A prospective randomized controlled trial comparing open and percutaneous repair of closed ruptured Achilles tendons was performed over a period of 30 months. Sixty-six patients from seven district general hospitals were entered into the study with 33 patients randomized into each group. A modification of the technique described by Ma and Griffith was used in the percutaneous group and a Kessler suture supplemented with interrupted sutures was used in the open group. Patients were followed up for a minimum of six months. The mean age was 38.5 years (26 to 53 years). Forty patients were male and 26 female. After the rupturing event but prior to surgery, it was noted that seven patients had paresthesia in the territory of the sural nerve. The mean duration of immobilization was 12.4 weeks (10 to 14). The complications in the open group included seven wound infections (21%), two adhesions (6%) and two cases of re-rupture (6%). In the percutaneous group there were three cases of wound puckering (9%), one re-rupture (3%) and one case with persistent paresthesia in the sural nerve territory (3%). The difference in infective wound complications between the two groups was statistically significant (Fisher's exact test P = 0.01). Percutaneous repair is advocated on the basis of the low rate of complications and improved cosmetic appearance.

Eicosapentaenoic acid suppresses PDGF-induced DNA synthesis in rat mesangial cells: involvement of thromboxane A2

BACKGROUND

The administration of eicosapentaenoic acid (EPA) derived from marine oils has been shown to suppress vascular myocyte, lymphocyte, keratinocyte, and mesangial cell proliferation in vitro, although the effects are variable and most reports provide fragmented insight into the mechanism(s) responsible for altering cell growth, particularly the relationship of membrane lipid remodeling to changes in cell proliferation. Thus, these studies were designed to elucidate the effects of mesangial cell membrane fatty acid remodeling (induced by EPA) on cell growth, and to define the relevance of changes in the synthesis of growth-modulating eicosanoids.

METHODS

Mesangial cells were grown in RPMI and 17% fetal calf serum, and were subcultured and grown for 48 hours in 17% delipidated serum or delipidated serum supplemented with 0 to 50 micrograms/mL of EPA. Quiescent EPA-loaded and control mesangial cells were subjected to stimulation with 20 ng/mL of platelet-derived growth factor (PDGF) followed by measurement of 3H-thymidine incorporation and cell number.

RESULTS

Mesangial cells remodeled with EPA exhibited a significant decrease in PDGF-stimulated 3H-thymidine incorporation and cell number associated with a reduction in thromboxane A2 (TXA2) in the media. Importantly, the phospholipid fatty acid composition of mesangial cells grown in media enriched with EPA revealed an increase in EPA (0.5 +/- 0.02% to 17.02 +/- 0.52%) coupled with a reciprocal decrease in the precursor for TXA2, arachidonic acid (18.9 +/- 3.17% to 3.55 +/- 0.30%). Blockade of TXA2 synthesis in mesangial cells treated with indomethacin (0.1 to 100 mumol/L) or the specific TXA2 synthase inhibitor, U-63557A (0.1 to 100 mumol/L), evoked a similar reduction in PDGF-stimulated proliferation and TXA2 synthesis. Coincubation of PDGF with the TXA2 mimetic, U-46619 (1 mumol/L), reversed the growth suppression induced by cell membrane remodeling.

CONCLUSIONS

These studies suggest that changes in membrane fatty acid composition induced by EPA modulates PDGF-stimulated proliferation by engendering a change in PDGF-stimulated TXA2 synthesis. Furthermore, we conclude that TXA2 functions as a comitogen for PDGF-stimulated mesangial cell growth.

Gelatin/chondroitin 6-sulfate microspheres for the delivery of therapeutic proteins to the joint

OBJECTIVE

To develop a biodegradable, inflammation-responsive microsphere system for the intraarticular delivery of therapeutic proteins.

METHODS

Microspheres were synthesized by complex coacervation. Radiolabeled protein release and microsphere degradation were assessed by exposing the microspheres to human synovial fluids (SF) and recombinant gelatinase. Microsphere degradation was confirmed by scanning electron microscopy (SEM). Microsphere biocompatibility was evaluated in vitro by incubating the microspheres with human synoviocytes, and in vivo by injection into mouse joints.

RESULTS

Optimal microsphere formulation was developed. Significant (up to 100%) release of encapsulated protein occurred in SF samples with measurable metalloprotease activity, while release was minimal in SF with negligible activity. Dissolution of microspheres exposed to gelatinase was confirmed by SEM. Microspheres were found to be noncytotoxic in vitro, and noninflammatory in vivo.

CONCLUSION

Microsphere encapsulation is an inflammation-responsive and biocompatible system of protein delivery that holds promise for use in the delivery of therapeutic proteins to the joint.

Anemia in newborn

Various blood indices vary in a newborn as compared to older child or adult. It depends on the gestational age, day of life, maternal factors, mode of delivery and site of blood collection. Hemoglobin, HCT & MCV tend to be higher in newborns. They further increase in first 2 days of life. Reticulocytosis and presence of nucleated red cells are normally seen in first week of life. Neonatal anemia is a common problem in NICU. It is usually caused by either hemorrhage or hemolysis and rarely due to decreased production. Hemorrhage can be ante or intra or post natal and it could be external or internal. It could be acute or chronic. Management of acute severe hemorrhage includes packed cell transfusion. Hemolysis is usually due to isoimmune hemolysis, G6PD deficiency or rarely due to the hemoglobinopathy like alpha-thalassemia or due to spherocytosis. Usually patients will have indirect hyperbilirubinemia which needs phototherapy or exchange transfusion. Rarely congenital pure red cell aplasia can present at birth with physical anomalies and anemia. Treatment of neonatal anemia depends on the arteriology.

Molecular characterization of neurotrophin expression and the corresponding tropomyosin receptor kinases (trks) in epithelial and stromal cells of the human prostate

The prostate is one of the most abundant sources of nerve growth factor (NGF) outside of the nervous system. NGF is a member of the neurotrophin family of growth factors which in mammals also includes brain derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3) and neurotrophin-4/5 (NT-4/5). These neurotrophins can bind with high affinity to a family of tropomyosin receptor kinases (trks). These receptors are trkA, which binds NGF; trkB, which binds both BDNF and NT-4/5; and trkC, which binds NT-3. In order to characterize the molecular expression of the neurotrophins and their corresponding trk receptors in the prostate we performed Northern blot analysis for the neurotrophins and reverse transcription-polymerase chain reaction (RT-PCR) coupled with Southern blot analysis for the trk family of receptors on smooth muscle stromal cells from the prostate, the androgen responsive LNCaP prostate tumor cell line and the androgen refractory TSU-pr1 prostate tumor cell line. The results show that smooth muscle stromal cells expressed NGF, BDNF and trkC, whereas both epithelial cell lines expressed trkA, trkB and trkC to various degrees. NT-3 was not detected in either the smooth muscle stromal cells or in both epithelial cell lines. This suggests that the stromal cell derived NGF and BDNF may interact via paracrine mechanisms with trkA and trkB receptors, respectively, on the adjacent epithelial cells. Interestingly, the androgen responsive LNCaP cell line did not express any of the neurotrophins, whereas the androgen refractory TSU-pr1 cell line expressed NGF, BDNF and NT-4/5. This suggests that the autocrine expression of NGF, BDNF and NT-4/5 is up-regulated in prostate epithelial cells following their transformation to an androgen refractory pathology. Hence, the malignant transformation of prostate epithelial tumor cells may facilitate their escape from a paracrine dependence on stromal cell derived neurotrophins by the acquisition of the autocrine expression of neurotrophins. Since the pathology of malignant cell migration within the prostate is predominantly by direct extension around prostatic nerves the upregulation of autocrine neurotrophin expression within prostate epithelial tumor cells may be concomitant with transformation to a malignant phenotype capable of invasion along the perineural space and extracapsular metastasis to distant sites of tumor formation.

Loss of telomerase activity during male germ cell differentiation

Although the activity of telomerase, an enzyme which synthesizes telomeres de novo and stabilizes telomere length has been demonstrated in the testis, the precise expression of activity in different germ cell types is not known. We examined telomerase activity using a PCR-based telomeric repeat amplification protocol during development of the rat testis from birth to adulthood. Telomerase activity was relatively high from birth to the 4th week of age, and then low between the 5th to 10th week, suggesting that the type A spermatogonial stem cells may be the population which is expressing the highest levels of telomerase activity. To ascertain which germ cells expresses the telomerase activity, purified populations of type A spermatogonia from 9-day old rats, and pachytene spermatocytes, round spermatids and epididymal spermatozoa from adult rats were isolated. While type A spermatogonia expressed very strong telomerase activity, the fractions containing pachytene spermatocytes and round spermatids also expressed telomerase activity, but at comparatively lower levels. Telomerase activity was totally absent in epididymal spermatozoa. Thus, it appears that the telomerase activity is expressed at high levels in the type A spermatogonial stem cells, is down-regulated during spermatogenesis, and is absent in the differentiated spermatozoa.

An experimental model of retinal pigment epithelial and neurosensory serous detachment

PURPOSE

The authors document an animal model of retinal pigment epithelial (RPE) detachments.

METHODS

N-ethylmaleimide (NEM) and sodium iodate (sulfhydryl-alkylating agents) were injected into the vitreous of Dutch pigmented rabbits. Subretinal fluid samples were withdrawn 0.5 and 3 hours after NEM injections and analyzed for albumin content by gel electrophoresis. Selected eyes were examined histologically.

RESULTS

Injections of 9.2 micrograms NEM caused wrinkling of the retina within 15 minutes, at which time fluorescein angiography revealed multifocal RPE detachments. At this stage, histologic sections showed moderate choroidal edema and RPE detachment. Elevated retinal detachments developed over the next 15 to 25 minutes. Histologic sections showed massive choroidal edema and RPE fragmentation. The albumin concentration of subretinal fluid rose from 60% of serum level at 30 minutes after NEM to 80% after 3 hours. Sodium iodate did not cause choroidal edema or RPE detachment.

CONCLUSION

In rabbits, intravitreal NEM causes the rapid appearance of choroidal edema and RPE detachment, followed by serous retinal detachment. The initial effect probably is caused by an alteration of choroidal vascular permeability. The relationship of these effects to sulfhydryl alkylation is unclear because sodium iodate failed to produce RPE detachments. N-ethylmaleimide effects may model aspects of clinical RPE and serous retinal detachments.

Omega-3 fatty acids attenuate glomerular capillary hydraulic pressure in rats with renal ablation

To clarify the emerging role of omega-3 fatty acids (FAs) in the regulation of the renal microcirculation, we recently performed micropuncture studies in normal rats maintained on diets enriched with omega-3 FAs. Although those studies suggested that omega-3 FAs alter the renal microcirculation in normal rats, it was not apparent whether this dietary maneuver could modulate intrarenal hemodynamics in the setting of renal disease. Therefore, the present renal micropuncture studies were performed in nephrectomized rats maintained on control diets or diets enriched with omega-3 FAs. Omega-3 FAs abrogated glomerular capillary (56.2 +/- 0.8 vs. 63.9 +/- 2.0 mm Hg) and transcapillary hydraulic pressure (40.9 +/- 1.4 vs. 50.6 +/- 1.3 mm Hg) compared to untreated rats. This effect was attributable to (1) a reduction in mean arterial pressure (138 +/- 3 vs. 163 +/- 2 mm Hg) and (2) a decrease in efferent arteriolar resistance (0.43 +/- 0.06 vs 0.98 +/- 0.19 dyn x seconds x cm-5 x 10(10)). Sclerosis index and albuminuria were also lessened by this dietary maneuver. To further characterize the mechanism of altered renal arteriolar resistance, we then explored the effects of omega-3 FAs on renal prostaglandin synthesis and angiotensin II-stimulated phospholipid turnover. A significant decrease in the urinary excretion of the renal vasoconstrictor, TXA2 (12.8 +/- 2.3 vs. 35.1 +/- 14.0 ng/24 hr), was induced by treatment with omega-3 FAs. Moreover, angiotensin II-stimulated phospholipid turnover was attenuated in intact glomeruli pretreated with omega-3 FAs. We conclude that omega-3 FAs exert favorable effects on experimental renal injury by eliciting a salutary effect on the renal microcirculation of rats subjected to subtotal renal ablation. Moreover, the similarities between these findings and those obtained with sustained inhibition of angiotensin II converting-enzyme suggest that these compounds act through parallel pathways of inhibition.

Cytochalasin D reversibly weakens retinal adhesiveness

This study asks whether retinal adhesiveness is affected by cytochalasin D, a drug that is known to alter the apical morphology of the retinal pigment epithelium (RPE). Cytochalasin D was injected intravitreally in Dutch rabbits and retinal adhesiveness measured 0.5 to 72 h later by two methods: in vitro peeling of the retina from retinal pigment epithelium to observe the amount of adherent pigment, and in vivo measurement of the pressure needed to achieve retinal separation. Electroretinograms were recorded, and RPE apical morphology was examined by scanning electron microscopy. The injection of 60 microM cytochalasin D caused in vitro retinal adhesiveness to fall within 3 h to 10% of normal although the electroretinogram (a, b, and c-waves) remained normal. Smaller doses of cytochalasin D had a lesser effect. The RPE apical surface at 3 h showed large bullet-like microvilli, swollen cone sheaths, and an absence of filamentous microvilli. The severity of these changes was dose-related. At 72 h after cytochalasin D, retinal adhesiveness had largely recovered, and RPE apical morphology appeared normal again. Thus, cytochalasin D weakens retinal adhesiveness acutely but reversibly, and both the initial effect and recovery correlate with changes in RPE microvillar morphology. This suggests that actin microfilaments may be involved in mechanisms of retinal adhesion.

Ketorolac-induced acute renal failure and hyperkalemia: report of three cases

Ketorolac tromethamine (Toradol, Syntex Laboratories Inc, Palo Alto, CA) is a new nonsteroidal anti-inflammatory drug widely used in emergency departments and during the postoperative period because of its potent analgesic effects and lack of central nervous system activities. We present three new cases of acute renal failure and hyperkalemia secondary to ketorolac. All patients had at least one risk factor making them prone to the development of acute renal failure secondary to the nonsteroidal anti-inflammatory drugs. In all patients, acute renal failure developed after a moderate dose of ketorolac was administered for the management of postsurgical pain. Acute renal failure and hyperkalemia were transient, and improved after discontinuation of ketorolac treatment.

Irregular retinal and RPE damage after pressure-induced ischemia in the rabbit

PURPOSE

Pressure-induced ocular ischemia is a frequent model for the investigation of the mechanisms and therapy of retinal ischemic damage. It is important to know whether the tissue damage in such experiments is uniform or irregular.

METHODS

We reviewed histologic features of Dutch rabbit eyes after 60-80 min of pressure-induced ischemia. The eyes were enucleated 4 hr, 1 day, or 1 wk after circulation was restored, at which times the electroretinogram b-wave was moderately reduced.

RESULTS

Light microscopy showed an irregular distribution of damage involving all retinal layers and retinal pigment epithelium. Some regions of damage (or preservation) were several millimeters wide; others were as small as a few cell widths. Correlation with electroretinogram reduction in individual eyes was difficult.

CONCLUSIONS

These results show that pressure-induced ischemic damage in the rabbit, sufficient to reduce the electroretinogram, has a patchy and irregular effect on retina and retinal pigment epithelium. Erroneous judgments may be made about ischemic damage, or therapeutic intervention, if only small or selected regions of retina are examined histologically.

Effect of chronic non-lethal doses of non-metals and metals on hepatic metallothionein in Channa punctatus (Bloch)

Compared to non-metal toxicants (ammonia, 1.56 ppm; and phenol, 10 ppm), the metals (CdCl2, 30 ppm; HgCl2, 16.7 ppb; and ZnCl2, 6 ppm) significantly induced hepatic metallothionein (MT) concentrations in C. punctatus, exposed independently to non-lethal doses of these toxicants for 28 days. It is suggested that hepatic MT serves as a metal-sequestering protein and is involved in the detoxication of metals only and ensures protection from toxic chemicals in ambience.