Effectiveness of Azadirachta indica (neem) mouthrinse in plaque and gingivitis control: a systematic review.

OBJECTIVES: The aim of this systematic review was to evaluate the effectiveness of Azadirachta indica (neem)-based herbal mouthrinse in improving plaque control and gingival health. METHODS: Literature search was accomplished using electronic databases (PubMed, Cochrane Central Register of Controlled Trials and EMBASE) and manual searching, up to February 2015, for randomized controlled trials (RCTs) presenting clinical data for efficacy of neem mouthrinses when used alone or as an adjunct to mechanical oral hygiene as compared to chlorhexidine mouthrinses for controlling plaque and gingival inflammation in patients with gingivitis. RESULTS: Of the total 206 articles searched, three randomized controlled trials evaluating neem-based herbal mouthrinses were included. Due to marked heterogeneity observed in study characteristics, meta-analysis was not performed. These studies reported that neem mouthrinse was as effective as chlorhexidine mouthrinse when used as an adjunct to toothbrushing in reducing plaque and gingival inflammation in gingivitis patients. However, the quality of reporting and evidence along with methods of studies was generally flawed with unclear risk of bias. CONCLUSION: Despite the promising results shown in existing randomized controlled trials, the evidence concerning the clinical use of neem mouthrinses is lacking and needs further reinforcement with high-quality randomized controlled trials based on the reporting guidelines of herbal CONSORT statement.

Aloe vera herbal dentifrices for plaque and gingivitis control: a systematic review.

OBJECTIVES: To evaluate the effectiveness of aloe vera containing herbal dentifrices in improving plaque control and gingival health. METHODS: A manual and electronic literature (MEDLINE and Cochrane Central Register of Controlled Trials) search was performed up to July 2012, for randomized controlled trials presenting clinical, microbiological, immunological, and patient-centered data for the efficacy of aloe vera herbal dentifrices for controlling plaque and gingival inflammation in patients with gingivitis. RESULTS: From 79 titles and abstracts, eight full-text articles were screened and finally two randomized controlled trials were selected. These randomized controlled trials reported that aloe vera dentifrices were similar in efficacy to control dentifrices in effectively reducing plaque and gingival inflammation in gingivitis patients based on the assessment of clinical, microbiological, and patient-centered treatment outcomes. However, many important details (composition and characteristics of aloe vera and control dentifrices along with appropriate randomization, blinding, and outcomes assessed) were lacking in these trials, and therefore, the quality of reporting and methods was generally flawed with high risk of bias. CONCLUSION: Even though there are some promising results, the clinical effectiveness of aloe vera herbal dentifrices is not sufficiently defined at present and warrants further investigations based on reporting guidelines of herbal CONSORT statement.

Methodological issues in randomized trials assessing probiotics for periodontal treatment.

BACKGROUND AND OBJECTIVE: Probiotics traditionally used in medicine field are now being used in an attempt to control and treat periodontal disease. However, the trials used to analyze the effects of probiotics have been subject to methodological criticism. The aim of this review was to assess the methodological deficiencies in randomized controlled trials evaluating the efficacy and safety of oral administration of probiotics for the treatment of periodontal disease. MATERIAL AND METHODS: A manual and electronic literature search (of MEDLINE and The Cochrane Library) was made, to March 2011, for randomized controlled trials presenting clinical, microbiological, immunological and patient-centered data for the efficacy of probiotics compared with a placebo/standard periodontal therapy for the treatment of periodontal disease. RESULTS: The literature search yielded only four randomized double-blind, placebo-controlled studies that evaluated the efficacy of probiotics (using Lactobacillus reuteri and Lactobacillus salivarius probiotic strains) in patients with gingivitis. The studies were too methodologically flawed (of mediocre quality) with a high risk of bias for any meaningful conclusions to be reached. These studies lacked adequate descriptions of appropriate randomization, allocation concealment, blinding, formulation and dosage of probiotic and placebo, extent and severity of periodontal disease in patient populations, patient-centered outcomes, results data and potential confounding factors. CONCLUSION: The existing randomized controlled trials have important methodological limitations; consequently, there is insufficient evidence to support the efficacy of probiotics in treating periodontal disease. More rigorous scientific research, in accordance with existing guidelines and research recommendations of the present review, is required to examine the safety and efficacy of probiotics before they are embraced in periodontal therapy.

Management of gingival inflammation in orthodontic patients with ozonated water irrigation--a pilot study.

OBJECTIVE: Ozonated water irrigation has recently been tried for its antimicrobial and anti-inflammatory effects in treatment of periodontitis. During orthodontic treatment, gingival inflammation occurs along with increased lactate dehydrogenase (LDH) enzyme levels in gingival crevicular fluid (GCF). Thus, the aim of this pilot study was to evaluate the clinical effects of a single subgingival irrigation with ozonated water on gingival inflammation in orthodontic patients and also to correlate the clinical effects with LDH enzyme activity in GCF. METHODS: Fifteen systemically healthy orthodontic patients (seven men and eight women, mean age 17.3 years) with full-mouth brackets were included in this prospective, cross-sectional, clinical and laboratory investigation. Clinical parameters, LDH enzyme activity and GCF volume were measured at baseline (0 day) followed by subgingival irrigation with 0.01 mg l(-1) ozonated water. These parameters were again assessed on 14th and 28th day. RESULTS: There was significant (P < 0.05) reduction in values of clinical parameters, GCF LDH activity and GCF volume after subgingival irrigation with ozonated water. Also, a significant correlation (r = 0.50, P = 0.01) was observed only between the post-treatment changes of plaque index and LDH values, among the clinical parameters assessed. CONCLUSIONS: A single subgingival irrigation of 0.01 mg l(-1) ozonated water can effectively reduce the gingival inflammation in orthodontic patients, which is also reflected in the reduction of LDH enzyme levels. However, further randomized controlled trials are required to validate the use of ozone irrigation in orthodontic patients for plaque control measures.

Unsuspected intestinal mucormycosis in a neonate presenting as necrotizing enterocolitis (NEC).

Mucormycosis of the gut in neonates is rare, difficult to recognize and hence usually fatal. These cases are usually diagnosed initially as necrotizing enterocolitis (NEC), which leads to a delay in specific treatment. We present a case of neonatal gastrointestinal tract (GIT) mucormycosis in a 2-day-old infant diagnosed following laparotomy and resection for presumptive NEC, together with a review of cases of GIT mucormycosis in newborn babies in the literature.

Aromatic DNA adducts in adjacent tissues of breast cancer patients: clues to breast cancer etiology.

The etiology of the majority of human breast cancers is unknown. Environmental factors have long been suspected to play a role, but no specific causative agent has been identified. If the hypothesis that environmental carcinogen exposure contributes to human breast cancer is true, carcinogen-DNA adducts would be expected to be present in human breast tissues. To address this possibility, aromatic DNA adducts were measured in 87 surgical specimens of normal human breast tissues from 87 breast cancer patients undergoing mastectomy using the nuclease P1-enhanced version of the 32P postlabeling assay. Breast tissue samples from 29 noncancer patients undergoing reduction mammoplasty served as controls. Whereas aromatic DNA adducts were detected in all tissue samples examined, the total adduct levels in cancer patients were significantly higher than that in noncancer controls [mean +/- SEM, 97.4 +/- 23.4/10(9) nucleotides (range, 3.8-1737.1) versus 18.1 +/- 11.6/10(9) nucleotides (range, 5.6-56.7), respectively; P < 0.01, t test and Mann-Whitney test]. This difference was not affected by the age distribution of the two groups. The typical smoking-related DNA adduct pattern (i.e., a diagonal radioactive zone) was observed in 29 of 87 tissues (17 of 17 current smokers, 5 of 8 former smokers, 4 of 52 nonsmokers, and 3 of 10 patients with unknown smoking status) and in 2 of 10 control tissues. It was of interest that a benzo(a)pyrene (BP)-like DNA adduct was observed in 36 normal adjacent breast tissues (41%), 27 of which were from nonsmokers. Levels of this BP-like adduct were extremely high (> 100/10(9) nucleotides) in 5 patients (4 nonsmokers and 1 smoker) and moderately high (> 10/10(9) nucleotides) in 13 other patients (8 nonsmokers and 5 smokers). One patient exhibited this adduct at a level of 1500/10(9) nucleotides, which is comparable to the highest level of total adducts reported in human tissues related to carcinogen exposure (e.g., cigarette smoking). In contrast, this adduct was absent (< 1/10(9) nucleotides) in all of the control tissues. Cochromatography and rechromatography analysis of DNA samples from human breast tissues and from MCF-7 cells treated with BP revealed that this adduct could be generated by BP exposure but is not the major BP 7,8-diol-9,10-epoxide-deoxyguanine adduct detected previously in animal tissues and human mammary epithelial cells. These findings support the hypothesis that environmental carcinogen exposure, in addition to cigarette smoking, may be associated with the etiology of human breast cancer.

Sialyl-Tn antigen expression occurs early during human mammary carcinogenesis and is associated with high nuclear grade and aneuploidy.

Sialyl-Tn (STn) antigen represents an aberrant glycosylation product of cell surface mucin in adenocarcinomas. We studied its expression in 40 breast carcinomas (35 of which included in situ carcinomas) by performing immunostaining with B72.3 monoclonal antibody. STn expression was observed in 50% of cases and was equally frequent in in situ and in invasive carcinomas. Positive STn staining significantly correlated with high nuclear grade (P = 0.001), aneuploidy (P < 0.001) and high S-phase fraction (P = 0.02). No correlation was observed between STn staining and age, menopausal status, presence of invasive component, or hormone receptor positivity. STn staining may provide an objective marker of dedifferentiation of breast tumors and should be investigated further for its prognostic value in breast cancers and as a biomarker of malignant transformation of breast epithelium.

Phase I clinical and pharmacological study of suppression of human antimouse antibody response to monoclonal antibody L6 by deoxyspergualin.

Development of human antimouse antibody (HAMA) is a major limiting factor in the application of murine mAb for clinical use. A novel immunomodulatory drug, deoxyspergualin (DSG), has shown potential to suppress antimouse antibody response in preclinical model systems. We conducted a Phase I trial to determine the effect of DSG on HAMA response to murine mAb L6 administered to patients with advanced cancers (in previous trials, this antibody elicited HAMA in two-thirds of the treated patients). L6 mAb was administered at a fixed dose of 200 mg/m2 on days 1-5. DSG was administered at doses of 50 mg/m2 [dose level (dl) 1] or 150 mg/m2 (dls II and III) on days 1-7. Treatment courses were repeated every 6 weeks (dls I and II) or every 3 weeks (dl III). HAMAs were quantitated by a commercially available ELISA assay (ImmuSTRIP; anti-isotypic antibodies) and a radiometric assay (antiisotypic and anti-idiotypic antibodies). Pharmacokinetics of L6 and DSG was also studied in all consenting patients. Among 24 evaluable patients, 2 patients developed detectable HAMAs using the ELISA (one each at dls I and II) after a median follow-up of 122 days (P = 0.0001 as compared to historical controls). Even in the two patients who developed HAMA, the HAMA levels were quite low (160 and 181 ng/ml; historical experience, 70-38,744 ng/ml). The radiometric assay detected anti-L6 antibodies in 13 patients (4, 6, and 3 at dls I-III, respectively) after a median of 82 days. The median highest anti-L6 antibody level was 129 ng/ml (range, 21-2150). The highest anti-L6 antibody level at dl III was only 44 ng/ml. The results suggest suppression of anti-idiotypic response also. No clinical antitumor activity was observed, and no significant changes in T4/T8 subsets or immunoglobulins occurred (suggesting a lack of generalized immunosuppression). We conclude that DSG can suppress HAMA response to L6. A starting dose of 150 mg/m2/day is recommended for Phase II trials to confirm this observation.

Progressive decrease in nuclear retinoic acid receptor beta messenger RNA level during breast carcinogenesis.

Some of the nuclear retinoic acid receptors (RARs) alpha, beta, and gamma and retinoid X receptors (RXRs) alpha, beta, and gamma are thought to mediate the effects of retinoids on cell growth, differentiation, and apoptosis and thereby prevent breast carcinogenesis. We analyzed the expression of mRNAs for the three RARs and RXR-alpha in histological sections of specimens from 70 breast cancer patients, which included adjacent normal tissue, ductal carcinoma in situ, and invasive cancer, using in situ hybridization. RARs alpha, beta, and gamma and RXR-alpha were expressed in 98.1, 98.0, 93.0, and 100% of the adjacent normal tissues. Significant decreases in the number of cases expressing RAR-beta were observed among ductal carcinoma in situ (83.1%) and invasive carcinomas (51.6%), especially among the poorly differentiated cases (77.4 and 35.7 %, respectively). No relationship was found between the expression of estrogen receptor and RAR-beta. These results implicate decreases in RAR-beta expression in breast cancer development and suggest that they are independent of estrogen receptor status.

Phase I study of a third-generation selective estrogen receptor modulator, LY353381.HCL, in metastatic breast cancer.

PURPOSE: We conducted this phase I trial to determine the safety and toxicity profile of LY353381.HCl-a novel, potent, third-generation selective estrogen receptor modulator (SERM)-because this benzothiophene derivative demonstrated an SERM profile in preclinical studies. PATIENTS AND METHODS: We studied 32 patients with recurrent or metastatic breast cancer. Patients were treated in four cohorts with oral daily doses of 10, 20, 50, and 100 mg. Pharmacokinetic sampling was performed during the first 72 hours following the first dose on day 1 and during the 24 hours after the day 57 dose. Eligibility criteria included Eastern Cooperative Oncology Group performance status of 0 to 2; no significant major organ dysfunction; and at least 3 weeks elapsed since most recent hormonal therapy, chemotherapy, and estrogen replacement therapy. RESULTS: The median patient age was 56 years (range, 30 years to 76 years). The median number of prior chemotherapies for metastatic disease was one (range, zero to four), while the median number of prior hormone regimens for metastatic disease was two (range, zero to five). Receptor status was estrogen receptor (ER) positive and progesterone receptor (PR) positive, 19 patients; ER positive and PR negative, eight patients; ER positive and PR unknown, two patients; and ER and PR unknown, three patients. Dose-limiting toxicity was not observed. Treatment was well tolerated with mild to moderate hot flashes in 18 of 32 patients (56%) at all dose levels. Transvaginal ultrasound performed at baseline and after 12 weeks of treatment showed no endometrial thickening. Of the 32 patients evaluable for response, six patients had stable disease for at least 6 months with a median duration of 7.7 months (range, 6.2 months to 33.8 months). The pharmacokinetics of LY353381.HCl were generally linear with respect to time and studied dose range. CONCLUSION: As predicted in preclinical testing, daily oral LY353381.HCl is safe, is well tolerated at all tested dose levels, and may be clinically beneficial in patients with extensively pretreated metastatic breast cancer. Further studies with LY353381 to evaluate the efficacy in patients with or without prior exposure to tamoxifen and fewer overall prior regimens are under way.

Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy.

PURPOSE: To assess patient and tumor characteristics associated with a complete pathologic response (pCR) in both the breast and axillary lymph node specimens and the outcome of patients found to have a pCR after neoadjuvant chemotherapy for locally advanced breast cancer (LABC). PATIENTS AND METHODS: Three hundred seventy-two LABC patients received treatment in two prospective neoadjuvant trials using four cycles of doxorubicin-containing chemotherapy. Patients had a total mastectomy with axillary dissection or segmental mastectomy and axillary dissection followed by four or more cycles of additional chemotherapy. Patients then received irradiation treatment of the chest-wall or breast and regional lymphatics. Median follow-up was 58 months (range, 8 to 99 months). RESULTS: The initial nodal status, age, and stage distribution of patients with a pCR were not significantly different from those of patients with less than a pCR (P>.05). Patients with a pCR had initial tumors that were more likely to be estrogen receptor (ER)-negative (P<.01), and anaplastic (P = .01) but of smaller size (P<.01) than those of patients with less than a pCR. Upon multivariate analysis, the effects of ER status and nuclear grade were independent of initial tumor size. Sixteen percent of the patients in this study (n = 60) had a pathologic complete primary tumor response. Twelve percent of patients (n = 43) had no microscopic evidence of invasive cancer in their breast and axillary specimens. A pathologic complete primary tumor response was predictive of a complete axillary lymph node response (P<.01 ). The 5-year overall and disease-free survival rates were significantly higher in the group who had a pCR (89% and 87%, respectively) than in the group who had less than a pCR (64% and 58%, respectively; P<.01). CONCLUSION: Neoadjuvant chemotherapy has the capacity to completely clear the breast and axillary lymph nodes of invasive tumor before surgery. Patients with LABC who have a pCR in the breast and axillary nodes have a significantly improved disease-free survival rate. However, a pCR does not entirely eliminate recurrence. Further efforts should focus on elucidating the molecular mechanisms associated with this response.

Appearance of acute leukemia-associated P190BCR-ABL in chronic myelogenous leukemia may correlate with disease progression.

The Philadelphia translocation in chronic myelogenous leukemia (CML) results in the production of a 210 kD BCR-ABL protein. In contrast, in 50% of Philadelphia-positive acute leukemias, the translocation results in the production of a 190 kD BCR-ABL protein. To investigate the hypothesis that the production of P190 may be associated with the progression from chronic phase to blast crisis in CML, we used polymerase chain reaction to analyze blood from 37 patients with accelerated phase/blast crisis CML for the transcripts coding for the P210BCR-ABL and P190BCR-ABL. The mRNA encoding for P210 was detected in all patients. In three patients, mRNA encoding both P210 and P190 was present. In two of these three patients, samples were available from the time of initial diagnosis. Analysis of these samples did not reveal any transcripts for P190. We conclude that in some patients the appearance of P190BCR-ABL may correlate with transformation to a more aggressive, terminal phase of CML.

Minimal residual disease in interferon-treated chronic myelogenous leukemia: results and pitfalls of analysis based on polymerase chain reaction.

Therapy with interferon-alpha results in complete cytogenetic remission in 15-20% of patients with chronic myelogenous leukemia. Even during prolonged clinical follow-up, most of these patients do not relapse. However, because of the limited sensitivity of cytogenetic techniques (approximately 5%) and Southern blots (approximately 1%), it is uncertain whether the residual malignant clone becomes extinct or persists below the limit of detection in these patients. We used polymerase chain reaction to amplify the chimeric BCR-ABL transcripts in 18 patients with chronic myelogenous leukemia who became Ph1 chromosome negative while receiving treatment with interferon-alpha, either alone or in combination with interferon-gamma. At the time of study, these patients had been Ph1-negative for a median of 22+ months. Fifteen patients were positive for residual BCR-ABL transcripts. No residual BCR-ABL message was detected on analysis of multiple serial samples in three patients. In order to confirm these results, the samples from these three patients, along with positive and negative controls, were analyzed by two independent laboratories in a blinded fashion. In the first laboratory, RNA specimens from all three patients were considered negative using chemiluminescent acidinium-ester-labeled probes. In the second laboratory, samples from all three patients were also negative by conventional polymerase chain reaction (PCR). However, when a second round of amplification was carried out on the amplified samples using a different combination of primers, samples from two of the three patients were positive. The results confirm the presence of a small proportion of BCR-ABL-positive cells in the majority of patients who are in complete remission and highlight some of the potential problems of PCR-based analysis. There is a need to standardize PCR methodology and potential confounding factors need to be addressed before PCR can be generally applied to analysis of minimal residual disease in CML. The implications of BCR-ABL positivity for these patients are discussed.

Phase II clinical and pharmacological study of pirarubicin in combination with 5-fluorouracil and cyclophosphamide in metastatic breast cancer.

Doxorubicin containing combination chemotherapy regimens are widely used for treatment of breast and other cancers. However, these regimens are associated with significant toxicities including myocardial dysfunction and alopecia. Analogues of doxorubicin are being developed to reduce these side effects. We conducted a Phase II trial of an anthracycline analogue, pirarubicin, administered in combination with 5-fluorouracil and cyclophosphamide every 3 weeks, as front-line chemotherapy in women with metastatic breast cancer. Patients who had received prior anthracycline therapy were excluded. The chemotherapy doses were as follows: 5-fluorouracil (500 mg/m2 on days 1 and 8), pirarubicin (50 mg/m2 on day 1), and cyclophosphamide (500 mg/m2 on day 1). Among 40 evaluable patients treated on this protocol, a major response (partial or complete remission) was observed in 26 patients (response rate, 62%; 95% confidence interval, 46-77). The median response duration was 8 months, and median survival was 16 months. Grade III/IV myelosuppression occurred in 81% of the courses. The median cumulative pirarubicin dose was 410 (range, 90-870) mg/m2. A significant decrease in left ventricular ejection fraction occurred in 12 patients (at a median cumulative pirarubicin dose of 460 mg/m2) and led to congestive heart failure in 4 of these patients (cumulative pirarubicin doses of 500, 520, 590, and 730 mg/m2, respectively). Eleven patients underwent endomyocardial biopsy, either because they experienced a drop in left ventricular ejection fraction or because they had received a cumulative pirarubicin dose of 600 mg/m2 and were still responding to the treatment. Of these, only one biopsy was found to be more than grade 1.0 (in an individual who had received a cumulative dose of 705 mg/m2). Severe alopecia occurred in two-thirds of the patients. Pharmacokinetic studies revealed a triphasic elimination of pirarubicin with alpha, beta and gamma half-lives of 0.12, 1.44, and 33.9 h, respectively. Total clearance of drug was 4.2 liters.1 h/kg while the cumulative 24-h urinary excretion was less than 10% of the administered dose. The activity of the combination appears to be similar to doxorubicin-containing regimens, while the incidence of alopecia appears to be lower than the historical experience with doxorubicin. However, cardiotoxicity remains a significant problem.