Restricted mouth opening and its definitive management: A literature review

This review was intended to discuss the various possible modifications suggested in the literature for prosthetic steps and surgical corrective procedures in nonresponding or complicated cases during rehabilitation of patients with restricted mouth opening. Material and Methods: Medline, PubMed, and Google were searched electronically for articles using keywords: microstomia and treatment options for restricted mouth opening. The various articles on prosthodontic rehabilitation in microstomia were segregated. From these, various modifications in the prosthetic steps were reviewed. Results: Oral hygiene maintenance is difficult for patient either due to limited access or due to associated lack of manual dexterity, so dental decay and periodontal problems are more extensive in such patients; hence, tooth loss is a common finding. All prosthetic procedures require wide mouth opening to carry out various steps, starting from tray placement during impression making to the final prosthesis insertion, especially removable prosthesis. Various prosthetic modifications given by authors are included in this review for each step in prosthodontic management. A total of eight stock tray designs, 12 custom tray designs, and 17 removable prosthesis designs are discussed along with fixed (either tooth-supported or implant-supported) and maxillofacial prosthesis. However, some patients require surgical intervention also for the correction of microstomia either for function or for esthetic purpose before prosthetic rehabilitation and are also enumerated here. Conclusion: Among all prosthetic restorative options, removable prosthesis is most difficult for dentist to fabricate as conventional methods are either very difficult or impossible to apply. To get a more accurate final prosthesis, we need to modify these steps according to the existing case. Several modifications available are discussed here which can help while managing these patients.

Leprosy - evolution of the path to eradication.

Leprosy is among the world’s oldest and most dreaded diseases and it has been synonymous with stigma and discrimination due to the hideous deformities it produced, mystery around its aetiology and transmission and lack of any effective remedy till recently. Leprosy control started with the use of chaulmoogra oil and for the last three decades, multi drug therapy (MDT) has been our main tool against leprosy. In the last two decades, the reported global prevalence of active leprosy infection has dropped by almost 90 per cent by the combined efforts of the World Health Organization (WHO), local governments, health professionals, and non-governmental organizations (NGOs), however, a parallel drop in the incidence or new case detection rate (NCDR) has not occurred. From 1994 through 2011, more than 100,000 new cases are being detected annually, of whom maximum case load is from India. There is need for research on tools for early diagnosis, short and effective treatment, and prevention of deformities and disabilities. Evaluating the role of immunotherapy and immunoprophylaxis will also lead us to better understanding of their mode of action. Further molecular analysis of Mycobacterium leprae genome may provide the requisite basis for all this. The current reality is that there is a need to sustain and provide quality leprosy services to all persons through general health services, including good referral system. All these provisions in the integrated health care approach will go a long way in further reducing the stigma. Efforts need to be made to reduce deformity through early detection, self care, physiotherapy and reconstructive surgery and developing sound surveillance systems. With all the remarkable achievements in the fight against leprosy, the stage is now set for the final assault. It is hoped that with the efforts of all the stake holders and strong political will, the disease will be eradicated in the near future.

Sexually transmitted diseases in children in India.

Sexually transmitted diseases (STDs) in children are not uncommon in India, though systematic epidemiological studies to determine the exact prevalence are not available. STDs in children can be acquired via sexual route or, uncommonly, via non-sexual route such as accidental inoculation by a diseased individual. Neonatal infections are almost always acquired intrauterine or during delivery. Voluntary indulgence in sexual activity is also an important factor in acquisition of STDs in childhood. Sexual abuse and sex trafficking remain the important problems in India. Surveys indicate that nearly half of the children are sexually abused. Most at risk children are street-based, homeless or those living in or near brothels. Last two decades have shown an increase in the prevalence of STDs in children, though most of the data is from northern part of the country and from major hospitals. However, due to better availability of antenatal care to majority of women, cases of congenital syphilis have declined consistently over the past two-three decades. Other bacterial STDs are also on decline. On the other hand, viral STDs such as genital herpes and anogenital warts are increasing. This reflects trends of STDs in the adult population. Concomitant HIV infection is uncommon in children. Comprehensive sex education, stringent laws to prevent sex trafficking and child sexual abuse, and antenatal screening of all the women can reduce the prevalence of STDs in children.

Direct immunofluorescence of skin biopsy: Perspective of an immunopathologist.

Background: By direct immunofluorescence (DIF), presence of immune complexes in the skin biopsy at various locations such as the dermo-epidermal junction, dermal blood vessels, etc. help to arrive at a diagnosis. Aims: (1) To study the role of DIF in confirmation or exclusion of diseases involving skin vis-à-vis histopathology and clinical diagnosis, (2) to describe the annual spectrum of dermatologic conditions that present to a tertiary referral center and require DIF examination of skin biopsy for confirmation of diagnosis. Methods: A total of 267 biopsies received over a period of 16 months in the Department of Immunopathology were analyzed along with clinical and histopathological details and the correlation between them was studied. Results: DIF was positive in 204 skin biopsies. Of these, 127 biopsies showed good clinico-immuno-histopathological correlation. In 10 cases, only DIF could clinch the diagnosis. In another nine cases, immune deposits were noted, which were unexpected in light of clinical and histopathological diagnosis. The most common skin involvement was seen in vasculitides. DIF was, however, non-contributory in lesions like erythema multiformè, post Kala-azar dermal leishmaniasis, sarcoidosis, lupus vulgaris, pyoderma gangrenosum and prurigo nodularis. Conclusion: The DIF of skin in conjunction with histopathology gives the best diagnostic yield. It is invaluable in confirming the diagnosis of small vessel vasculitides and bullous lesions of skin and can be used as an additional tool to pinpoint the diagnosis of systemic and localized autoimmune diseases involving the skin.

Comparative study of calcipotriol (0.005%) ointment and tazarotene (0.05% and 0.1%) gel in the treatment of stable plaque psoriasis.

BACKGROUND: Topical therapies are the first line of treatment for patients with stable plaque psoriasis affecting a limited body surface area. Though in use for more than a decade, we could not find any reports of studies directly comparing calcipotriol and tazarotene. AIM: To evaluate the comparative efficacy and tolerability of calcipotriol and tazarotene in the treatment of stable plaque psoriasis. METHODS: This was a prospective, right-left side intra-individual parallel 8-week study using calcipotriol 0.005% ointment applied twice daily (right side) versus tazarotene (left side) randomized to either 0.05% (group I) or 0.1% gel (group II) once daily in two groups, each of 10 patients. Efficacy was determined by the assessment of target psoriatic lesions under evaluation by using the severity scale (0-3) of erythema, scaling, and infiltration (ESI score). Evaluation was done at baseline (0 week), 4 weeks, and 8 weeks of treatment. At the end of 8 weeks, patients with more than 75% reduction in ESI score were considered to have marked improvement; 51% to 75%, moderate improvement; 26% to 50%, minimal improvement; and less than 25%, non-responders. RESULTS: Seventeen patients (9 in group I, 8 in group II) completed the study. In group I, reduction in ESI score was significantly more at both 4 and 8 weeks on sides treated with calcipotriol, producing moderate-to-marked improvement (P<0.05). In group II, improvement was comparable in lesions treated with either calcipotriol or tazarotene (0.1%) at the end of 4 and 8 weeks. Adverse effects noted were mild--in the form of burning, pruritus, and irritation--and were observed more often in the lesions treated with tazarotene as compared to those in the lesions treated with calcipotriol, but the difference was not statistically significant. However, none of the patients discontinued the therapy because of adverse events. CONCLUSION: Topical calcipotriol 0.005% ointment is more effective than tazarotene 0.05% gel; however, its efficacy is comparable to tazarotene 0.1% gel in the treatment of stable plaque psoriasis.

A mixed longitudinal study of physical growth in children with atopic dermatitis.

BACKGROUND: Atopic dermatitis is a chronic, relapsing disorder associated with significant morbidity. Growth retardation is known to occur in children affected with atopic dermatitis. However, there is not enough Indian data for this disorder. AIMS: We conducted a longitudinal study to look for the effect of atopic dermatitis on growth attainment of Indian preschool children. METHODS: The growth patterns of 62 children, aged 3-5 years and suffering from atopic dermatitis were studied in terms of body weight, height and head circumference. Sixty-eight normal healthy children matched for age, sex and socioeconomic status were taken as controls. Every child was followed up at intervals of three months following a mixed longitudinal study design for the duration of one year. Severity of the disease was determined by the scoring atopic dermatitis (SCORAD) index. RESULTS: Growth velocities were lower in patients than in controls. Mean changes in body weight of patients of both sexes showed close similarity to controls. Mean values for height and head circumference were found to be significantly lower in girls than in the girls of the control group at majority of the age levels. In contrast, in boys, these values for the patients remained comparable or higher than in the boys of the control group at some of the ages. Girls had comparatively more severe disease than boys and they had lower values than boys for all the growth parameters assessed. CONCLUSION: Growth retardation was observed among children with a more severe form of the disease. Height of the affected children was compromised mostly, though a tendency for catch-up growth was observed. Severe forms of atopic dermatitis may impair a child's linear growth temporarily.

Emergence of ciprofloxacin resistant Neisseria gonorrhoeae in north India.

BACKGROUND AND OBJECTIVES: Though quinolones have been recommended as a single dose treatment for uncomplicated gonorrhoea, there have been reports of treatment failure with fluoroquinolones. In this study we determined the antimicrobial susceptibility levels of consecutive isolates of Neisseria gonorrhoeae to examine the emergence of ciprofloxacin resistance N. gonorrhoeae. METHODS: Minimum inhibitory concentration (MIC) of ciprofloxacin and other drugs (penicillin, tetracycline, ciprofloxacin and ceftriaxone) was determined by agar dilution method. MIC was interpreted according to the NCCLS guidelines. beta lactamase production was detected by iodometric method and chromogenic cephalosporin method using nitrocefin disc. RESULTS: A total of 45 consecutive isolates of N. gonorrhoeae were obtained from patients with suspected acute gonococcal uretheritis. Of the 45 isolates, 35 (77.7%) were resistant to ciprofloxacin, 16 (35.5%) showed MIC value greater than 8 microg/ml. All isolates were sensitive to ceftriaxone while 21 isolates (46.6%) were resistant to penicillin and 23 (51%) to tetracycline. Ten isolates (22%) were found to be beta-lactamase producers. INTERPRETATION AND CONCLUSION: Ciprofloxacin resistant N. gonorrhoeae is on the rise in and around Chandigarh (north India). Thus, periodic surveillance of susceptibility levels of N. gonorrhoeae is essential to prevent the dissemination of drug resistant strains in the community.

Study of desmoglein 1 and 3 antibody levels in relation to disease severity in Indian patients with pemphigus.

OBJECTIVES: To conduct a cross-sectional study to compare Dsg1 and Dsg3 antibody levels independently with severity of disease activity in pemphigus vulgaris (PV) and pemphigus foliaceus (PF). METHODS: Blood samples from 44 patients with pemphigus (PV-38, PF-6) were analyzed using ELISA. The severity of skin and mucosal disease was graded using a score from 0 to 3. RESULTS: A statistically significant correlation between increase in Dsg 3 antibody titres with severity of oral involvement and Dsg 1 titres with severity of skin involvement was found in both PV and PF patients (p < 0.01). However, we were unable to demonstrate a relationship between increased titres of Dsg1 and Dsg 3 antibodies with oral and skin involvement respectively. CONCLUSION: This study suggests that the severity of skin and oral disease in pemphigus is determined by the quantities of Dsg1 and Dsg3 antibodies respectively.

Bipolar aphthosis presenting as mutilating genital ulcers in women.

Three women with large, mutilating genital ulcers of long duration, destroying almost the lower half of the external genitalia, are reported. They had a history of recurrent oral ulcers as well. All patients had been diagnosed as having 'genital ulcer syndrome' in the past and had been treated with antimicrobials. Histopathology of the biopsy from the margin of the ulcer revealed features of leukocytoclastic vasculitis. Considering the history, clinical features and histology, a diagnosis of bipolar aphthosis was made in all patients. All patients responded well to immunosuppressive therapy. The cases are reported because of the presence of genital ulcers of an unusually large size, mutilating character and their close similarity to genital ulcers due to sexually transmitted diseases, especially genital herpes and donovanosis.

Clostridium difficile toxin assay in psoriatic patients.

Chemotherapy-induced pseudomembranous colitis is most commonly associated with methotrexate and 5-fluorouracil. Methotrexate and mesalazine have also been used for the treatment of psoriasis but the effect of these therapies on the Clostridium difficile carriage in the stool of psoriatic patients has not been studied. Our aim was to detect the presence of C. difficile toxin in patients with psoriasis hospitalized for systemic therapy and in those receiving methotrexate and mesalazine. A total of 58 patients with psoriasis were divided into three groups: group A comprised 30 patients admitted with psoriasis involving >30% body surface area, group B1 comprised 15, psoriatic patients receiving methotrexate (0.3-0.4 mg/kg/week), group B2 included 6 patients receiving mesalazine (50-60 mg/kg/day) while group C comprised of 7 patients (5 on methotrexate, 2 on mesalazine) in whom stool samples were taken twice. Among patients in groups B1 and B2, stool samples were taken after at least 4 weeks of therapy. Detection of C. difficile toxin in stool samples was done using the latex agglutination method. Out of the 58 patients 47 were males and 11 were females. The mean age of the patients was 45+/-2.5 years and the duration of the disease was 3+/-0.9 years. Positive C. difficile toxin was found in a total of 19 patients in all three groups (5 patients in group A, 9 in group B1, 2 in group B2 and 3 in group C). Three patients complained of slight abdominal discomfort and increased frequency of stool, of whom 2 had toxin positive in low titres. The rest of the 17 patients who were positive for C. difficile toxin were asymptomatic. There is a obvious rise in the rate of GIT carriage of C. difficile to a variable degree in patients on methotrexate and mesalazine. However, no clear correlation of the gastrointestinal symptoms with either the presence of toxin or its titre could be established.

Leprosy and herpes zoster; an association or dissociation?

Nerve involvement is common to the pathogenesis of both leprosy and herpes zoster. We report two cases of borderline leprosy in which the skin lesions characteristically spared the healed zoster scar. Possible mechanisms and relationship are discussed.

Atopy and alopecia areata in North Indians.

The study was undertaken with the aim of evaluating the effect of associated atopy on severity and age at onset of alopecia areata in north Indians. Presence of atopy was elicited by detailed history, examination and intracutaneous tests. Chi square test was carried out to evaluate statistical significance. One hundred patients (76 males and 24 females) with alopecia areata were evaluated. Historical evidence of atopy was present in 50 including patients alone (23), patients and first degree relatives (11) and first degree relatives alone (16). Intracutaneous tests were positive in 23 out of 50 patients tested randomly. There was a trend towards increasing frequency of severe alopecia as evidence of atopy became stronger e.g. both patient and first degree relatives with atopy or positive intracutaneous test but the results did not attain statistical significance. Similarly the age at onset and duration of alopecia areata was not significantly related to the presence of atopy. It is concluded that in north Indians with alopecia areata, the presence of atopy is not significantly associated with severe alopecia or onset at younger age.