Acute Acalculous Cholecystitis Due to Covid-19: A Case Report

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh human coronavirus, was discovered in Wuhan, Hubei province, China. Since its first documentation in January 2020, the virus has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19) [1]. The common presentation includes fever, myalgia as well as respiratory symptoms such as dry cough, dyspnea and anosmia [2]. Besides pulmonary involvement, SARS-CoV-2 may affect other organs such as the liver, inducing occasionally acute hepatitis and late cholestasis [3]. Rarely, it has been reported to cause acalculous cholecystitis. Several mechanisms are considered to be involved in gallbladder injury in COVID-19 patients. We report here a rare case of acute acalculous cholecystitis in a non-ICU setting COVID-19 patient.

Case Presentation

Figure 1: Chest CT scan showing typical findings of COVID-19 pneumonia affecting 35% of lung parenchyma.

A 52-year-old healthy man, with no past medical history, presented to the emergency department with the chief complaint of fever, myalgia and dry cough evolving for three days. Clinically, he was awake and conscious, with a temperature at 38,3°, blood pressure at 12/07cm Hg, heart rate at 90/min, respiratory rate of 24 breaths/min and O2 saturation at 91 %. Nasopharyngeal RT-PCR was positive for SARS-CoV-2 infection. Laboratory studies showed a normal white blood cell count of 3.64 × 109 /L (normal range, 3.50– 9.50 × 109 /L), elevated blood levels for C-reactive protein (46.7 mg/L: normal range, 0–10 mg/L) and normal kidney and liver tests. The patient was transferred to COVID-19 unit. Chest computed tomography showed typical findings of COVID-19 pneumonia, affecting 35% of lung parenchyma (Figure 1). He was treated by low flow oxygen therapy (3 to 6L) maintaining oxygen saturation more than 93%, methylprednisolone, enoxaparine and vitamins. During his hospital stay, his clinical condition progressively improved. But after seven days, he developed progressive onset of rightsided hypochondrial pain. Physical examination found abdominal distension with right hypochondrium tenderness. Laboratory tests showed that inflammation markers had markedly increased with white blood cell count and C-Reactive protein at 16.97 × 109 /L and 155 mg/L respectively. Ultrasound and computed tomography of the abdomen revealed a severe gall bladder distention with thickened wall and minimal surrounding pericholecystic fluid. No gallstones were identified, and the extrahepatic bile ducts were normal (Figure 2). These findings were consistent with acute acalculous cholecystitis (figure). IV antibiotics were initiated but there was no clinical improvement. After four days, he became hypotensive and tachycardic at 120 beats/min. Emergency surgery was decided. Laparotomy was preferred over laparoscopy to limit aerosolisation. Intraoperative exploration revealed a markedly distended gallbladder with thickened and gangrenous wall. Cholecystectomy was hardly completed because of the severe inflammation of cystic pedicle (Figure 3). Histological analysis showed thickened gallbladder wall with edema and hemorrhage on gross examination. There were no gallstones. Microscopic examination showed fibroinflammatory infiltration with endoluminal obliteration of vessels, ischemic necrosis, venous congestion, edema and hemorrhagic infarction. The post-operative course was uneventful. Abdominal pain was significantly resolved, and vital signs were within normal range with oxygen saturation at 98% on room air. On the 5th post-operative day nasopharyngeal RT-PCR was performed and became negative to SARS-CoV-2. The patient was discharged from the hospital on post-operative day 6 with oral antibiotic, enoxaparine and vitamin supplements. A follow-up examination was done two weeks after surgery and was without abnormalities.

Figure 2: Abdominal CT scan showing severe gall bladder distention with thickened wall.

Figure 3: Cholecystectomy specimen showing gangrenous cholecystitis.

Discussion

AAC is an uncommon condition characterized by inflammation of the gallbladder in the absence of gallstones. It is an insidious clinical condition which typically occurs in critically ill patients, especially related to trauma, surgery, mechanical ventilation, severe burns, total parenteral nutrition, and/or prolonged fasting [4]. Its pathogenesis is thought to be due to gallbladder stasis secondary to lack of gallbladder stimulation, leading to the build-up of intraluminal pressure, which results in inflammation and necrosis of the gallbladder wall. On the other hand, this static condition promotes bacterial colonization of the gallbladder particularly by enteric pathogens such as Escherichia coli, Klebsiella, Bacteroides, Proteus, Pseudomonas, and Enterococcus faecalis [5]. Since the presentation may be insidious and patients often lack right upper quadrant tenderness, clinical diagnosis is challenging [6]. Since late December 2019, the emergence of coronavirus disease 2019 (COVID-19), caused by the novel SARS-CoV-2, has led within a few months to a major global health and economic crisis [7]. It primarily affects the respiratory system, inducing dry cough, dyspnea and anosmia, associated with systemic symptoms like fever and myalgia [2]. Non-specific gastrointestinal symptoms are also seen such as diarrhea and abdominal pain [8]. Although COVID-19 infection mainly affects the lung, other organs such as the liver may be affected, with frequent onset of late cholestasis. However, gallbladder involvement with acalculous cholecystitis is extremely rare. To our knowledge, only 10 cases were reported in the medical literature, since the pandemic declaration. It remains unclear whether AAC is a direct manifestation of the SARS-CoV2 or a consequence of prolonged illness [9]. While most of these cases were described in critically ill patients with long ICU stays, we report the third case of AAC on a healthy patient with mild COVID-19 pneumonia, who did not develop acute respiratory distress syndrome. Alhassan, et al. [10] also reported a recent case of a middle-aged healthy women who developed AAC during her hospital stay for a mild COVID-19 pneumonia.

It was managed by broad spectrum antibiotics with good outcome. It is well known that SARS-CoV2 have a tropism not only to the lungs but also to the liver and the gallbladder. The intracellular entry of the virus occurs through interaction with the angiotensin-converting enzyme 2 receptor (ACE2), which expresses in relatively high amounts in lungs, vascular endothelium and gallbladder [11,12]. Therefore, patients with SARS-CoV-2 infection may be at increased risk from direct viral effects on the vascular endothelium and infection to the biliary tissue [13]. Recently, a case report has described an AAC in an 84-year-old COVID-19 patient, who underwent laparoscopic cholecystectomy. On histological analysis, quantitative reverse transcriptase PCR revealed the presence of SARS-CoV-2 in all 3 sampled regions of the gallbladder wall. This viral RNA detection in the gallbladder indicates direct vesicular involvement [14]. Otherwise, inflammatory cytokine storm generated by the excessive immune response could also be one of the key factors in hepatobiliary injury [12]. Interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), which plasma levels are high in severe inflammatory response, may activate the coagulation cascade, explaining the presence of thrombosed vessels in the gallbladder and the occurrence of ischemic cholecystitis [11,15]. SARS-CoV-2 infection induces inflammation of the vascular endothelium, thereby causing vascular dysfunction, especially in capillaries. Subsequently, microvascular dysfunction leads to a hypercoagulable state, tissue edema, and organ ischemia [12,16,17]. All these evidence support that SARS-CoV-2 may directly or indirectly cause acute cholecystitis.

Conclusion

By reviewing the recent literature, we noticed that the potential mechanisms of COVID-19-associated acalculous cholecystitis in non-ICU setting patients may include the direct effects of viral infection, inflammatory storm and endotheliitis. COVID-19 is proving to have multiorgan involvement during its disease course. Through our case, we aim to highlight the importance of early detection and prompt management of biliary complications such as acute acalculous cholecystitis. As the pandemic continues to spread, further data are necessary to accurately assess the physiopathogenesis of hepatobiliary injury.

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Actinic Neuralgia: Combined Approach to the Trigeminal Nerve

Introduction

Trismus and unusual left facial pain was presented by a 69 year old male patient three months after radiotherapy for a resected metastatic Clear Cell Renal Cell Carcinoma (CCrCC) located in the left infratemporal fossa (IFT). After clinical treatment failure, he was treated with V2 and V3 external ablation and endonasal endoscopic anesthetic infiltration of the sphenopalatine ganglion.

Case Report

A 69-year-old male patient with a previous CCrCC presented a suspicious left IFT lesion in his Positron Emission Tomography with 18F-fluorodeoxyglucose (PET 18F-FDG) follow up, later confirmed with a Magnetic Resonance Imaging (MRI). It was indicated surgery and systemic therapy with sunitinib, axinitib and immunotherapy. He underwent a naso endoscopic surgical resection of the macroscopic lesion in the left IFT, which was confirmed by histopathological and immunohistochemistry studies to be a metastasis of the CCrCC primary tumor. In the first month of follow up, when additional radiotherapy was initiated, he started developing an unusual left facial pain and trismus. Continuous IFT debridements became necessary because of tissue necrosis and Pseudomona aeruginosa infection, for which clinical treatment was promptly initiated. He was treated with ciprofloxacin, nevertheless the facial pain got progressively worse as the radiotherapy carried on. He was diagnosed with actinic myopathy of the masticatory muscles and actinic trigeminal neuralgia (sphenopalatine ganglion, V2 and V3) due to muscle and maxilar and mandibular trigeminal sheath modifications found in the new MRI. Multiples lines of clinical therapy were attempted with dexmedetomidine hydrochloride EV, morphine EV, oral pregabalin and oral baclophen. Since there was no improvement, it was tried a sphenopalatine ganglion transmucosal block but this attempt was unsuccessful as well. Reaching three months of the pain’s onset, he was admitted to the hospital because of failing to control the pain. After a multidisciplinary discussion round with the oncology and pain medicine teams, it was decided to conduct a combined approach: an ablation of the second and third branches of the trigeminal nerve and afterwards a nasoendoscopic infiltration of the sphenopalatine ganglion with 2ml of ropivacain 0.2% and 4mg of dexamethasone. His previously 10 graded (visual analog scale) facial pain, was no longer present immediately after the surgery and he no longer needed any opioids (Figures 1 & 2).

Figure 1:

A. Preop PET.

B. Preop MRI

C. Interoperative endoscopic view of the left tumor with a 30 degree endoscope.

D. IFT three months after radiotherapy onset.

Figure 2:

A. Intraoperative CT showing the ablation needle positioned in V2.

B. Intraoperative CT revealing the ablation needle positioned in V3.

Discussion

Pain management in oncologic patients is certainly a demanding challenge. These patients usually undergo radiotherapy, which can lead to actinic trigeminal neuralgia, because of inflammation of neural tissue, as presented by this patient. This pain can occur not only after radiotherapy, but because of the infiltrative processes of the tumor itself as well. Because of the path that the fifth cranial nerve does, the etiology is likely related to the topography an ENT surgeon would assess, like the V2 and V3 branches in the infra temporal fossa or maybe deeper in the cerebellopontine angle, as a reported case of a trigeminal neuralgia secondary to a clival osteoma compressing the Meckel’s cave. There are countless ways of treating this entity, nevertheless, after clinical failure they can be quite invasive. They are divided into destructive and nondestructive surgical approaches. The first one includes posterior fossa surgeries, trigeminal ganglion surgeries, peripheral nerve rhizotomy, percutaneous glycerol injection and cryotherapy. The latter has two options: microvascular decompression (preferred treatment when well indicated - with an identified vascular loop) and percutaneous needle-ballon micro compression. When referring to non-destructive surgical approaches, there are two reports of minimally invasive procedures performed - both of them endoscopic transoral. In one of them, the trigeminal nerve was completely transected and in the other one it was ablated. Here, we present an option to this non-destructive surgical approaches: an external radio frequency ablation of V2 and V3 and right afterwards an anesthetic infiltration of the sphenopalatine ganglion localized in the IFT. Both procedures shall be performed under general anesthesia [1-5].

Conclusion

Combined approach of external V2 and V3 ablation and nasoendoscopic anesthetic infiltration showed being an effective and precise method of approaching the trigeminal branches for pain control, independent of its cause. It’s an interesting option to be performed in cases of recurrent trigeminal neuralgia. It’s essential to keep in mind the possibility of actinic neuralgia in postradiotherapy patients and multidisciplinary treatment is crucial to offer patients more treatment options.

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Metabolic Syndrome and Longevity: A Framework of Situation

Editorial

Dietary intake, physical activity, and waste elimination choreograph anabolic and catabolic processes that govern development, maturity, and aging in the human superorganism (which includes the host and its microbiome). Metabolism research is experiencing a renaissance after years of being eclipsed by advancements in cellular and molecular biology. Metabolites are becoming increasingly important in all biological processes, including physiological and pathological aging. Several organ metabolic features have been linked to lifespan in recent crossspecies research [1]. Several studies have found a relationship between sphingomyelin levels and longevity [2]. On the other hand, triacylglycerols with polyunsaturated fatty acid (PUFA) side chains and inflammatory by-products are inversely related to longevity [3]. Sphingomyelin levels in the blood and PUFA-containing triacylglycerol levels in the blood have both been linked to female familial lifespan in humans [2]. Longevity is negatively proportional to hepatic levels of enzyme cofactors involved in amino acid metabolism as well as hepatic concentrations of tryptophan breakdown products across mammalian species. Reducing dietary amino acids, notably tryptophan and methionine, has been shown in animal experiments to extend lifespan [4]. As a result, long-lived mammals may consume less energy per day per unit of body mass (mass-specific basal metabolism).

Using proxies like telomere length, gene methylation (which would reflect a “epigenetic clock”), and transcriptional fingerprints (which would demonstrate “transcriptomic aging”), some studies have attempted to determine human biological age [5]. It has also been investigated to assess metabolic features associated with aging. Researchers developed a “metabolic age score” founded on Nuclear Magnetic Resonance methods as a consequence of this finding, that could indicate longevity regardless of the physical maturity or other risk factors [6]. The blood metabolome and lipidome can regularly detect age-related changes and some early indications of age-related illnesses in people [7]. Many human metabolic gene variations have been linked to living to be 100 years old, including those in forkhead box O3 (FOXO3) and other PI3K/ AKT1 signaling genes [8]. Male children of centenarian families have lower abdominal visceral fat, suggesting that a healthy metabolic profile is related to family longevity [9]. Many genetic flaws that cause rapid aging in humans, on the other hand, are linked to metabolic difficulties. Cutis laxa (proline biosynthesis defects), Ehlers-Danlos syndrome (proteoglycan synthesis defects), Lenz- Majewski hyperostotic dwarfism (phosphatidylserine synthesis defects), SHORT syndrome (PIK3R1 hypomorphic mutations), and progressive external ophtalmoplegia (mitochondrial DNA instability) are all examples of these disorders [10]. Even though the bulk of genetically characterized progeroid illnesses are caused by mutations in genes that preserve genomic integrity and hence damage metabolism secondarily, these examples highlight the possible significance of metabolic deficits in aging [11].

As people age, maintaining cellular and organismal metabolic balance becomes more difficult, favoring a metabolic imbalance that self-amplifies and eventually manifests clinically [12]. As a consequence, all of the foregoing anti-aging treatments could be paired with metabolic restructuring, which improves

(1) Food efficiency and

(2) Stress resistance [13].

There are certain commonalities in metabolic reprogramming, despite the fact that it can be very wide and hence difficult to treat pharmacologically. Signal-transduction cascades and metabolic circuitries that remodel as humans age may work in the context of a small number of modules that shift nutrients and other resources from anabolism to non-toxic catabolism, preserving homeostasis [14]. A notable example is the longevity-extending advantages of various techniques that inhibit “insulin and IGF1 signaling” (IIS) or activate autophagy [15,16]. When considering aging and longevity in the context of a systemic rewiring of intermediate metabolism, a number of cautions should be carefully considered [17]. To begin with, many of the studies described above were done on C. elegans or D. melanogaster and have yet to be confirmed in mammals [18]. Second, because there are no well-defined biological biomarkers of aging, determining the short- and long-term impacts of metabolic therapy on the aging process is difficult [19]. Third, none of the longevity-prolonging medicines discussed above has been proved to prevent the development or progression of age-related disorders in humans [17]. We are sure that combining aging and metabolism research will reveal new insights into the aging process, assisting in the development of therapeutically useful healthspan and lifespan extension medicines [20]. In this environment, organizations such as the National Institute on Aging Interventions Testing Program (NIA-ITP), which is attempting to standardize the experimental models and procedures used to research longevity around the world, are likely to play a vital role [21].

Although there is little doubt that a combination of regular exercise and a healthy diet can delay the onset and progression of all indicators of aging, our current understanding of metabolic changes that can improve elderly health and hence extend longevity is still in its infancy. Dietary advice is difficult to come by, and specialized advice from a nutritionist may be advantageous in some circumstances. However, we believe that extending foodfree intervals, reducing overall caloric and animal protein intake, and moving to a Mediterranean diet rich in fibers and complex carbohydrates, when paired with regular physical activity, could have considerable anti-aging effects [22,23]. The worldwide trend toward a westernized lifestyle is introducing new health hazards that must be addressed through public awareness efforts. Positive affect and subjective well-being are surprisingly connected to positive neuroendocrine, cardiovascular, and inflammatory indices [24], implying a biological foundation for the long-suspected link between happiness and health [25]. As a result, policies that promote and democratize high-level education across socioeconomic strata, as well as policies that prioritize peaceful cooperation over vicious competition among individuals, may promote healthy aging and thus comprise the “ultimate preventative medicine”.

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Oral Health Knowledge, Attitude, Practices and Utilization of Dental Services Amongst Automobile Technicians in Benin City

Introduction

Oral health is a key indicator of overall health, well-being and quality of life [1]. Oral diseases cover a broad range of diseases and conditions including dental caries, periodontal (gum) disease, tooth loss, oral cancer, oral manifestations of HIV infection, oro-dental trauma, noma and birth defects such as cleft lip and palate [2]. According to the report of the World Health Organization (WHO) on oral disease in 2021 and the Global Burden of Disease report in 2017, it revealed that an estimated 3.5 billion people globally are affected by oral diseases [2]. Additionally, it is estimated that 2.3 billion people suffer from caries of permanent teeth and more than 530 million children suffer from caries of primary teeth [3]. In most low- and middle-income countries including Nigeria, with an adjustment in living conditions and growing urbanization, the prevalence of oral diseases continues to be on the rise [4]. This increase in oral diseases have primarily been linked to inadequate exposure to fluoride (in the water supply and oral hygiene products such as toothpaste) as well as underutilization of oral health care services in the community [5,6].

It has clearly been established that oral diseases and conditions are preventable and treatable. The growing incidence of preventable oral conditions ranging from dental caries and its sequelae to more sinister conditions like oral cancers have raised the stakes amongst public health practitioners with the glaring need for adequate public enlightenment geared towards all sects, groups and facets of society. This campaign must be targeted at entrenching the most basic of oral health practices such as regular brushing, flossing, proper care and handling of personal dental devices, care in the use of potentially hazardous substances like tobacco and alcohol which has been revealed to contribute to oral health conditions, and regular planned visits to the dental clinics; in the minds and psyche of the average citizen as this has been proven to be the most effective preventive measure against oral diseases [7,8]. Unfortunately, previous studies show that Nigerians do not routinely visit the dental clinic and have poor knowledge and attitude towards utilization of dental services [9]. This worrisome trend has also been highlighted in studies amongst different groups especially in the southwestern part of Nigeria [6,8]. However, there is a paucity of research report on the degree of oral health awareness and utilization of dental services in the south- south of Nigeria even amongst different groups. Though a reported study in Benin city revealed a low level of oral health awareness and utilization of dental facilities [8].

In this light, it is clear that there is need for further study on oral health knowledge, attitude, practice and utilization of dental services amongst the population and different groups in the southsouth Nigeria. Therefore, the present study sought to examine oral health knowledge, attitude, practices and utilization of dental services amongst automobile technicians in Benin city. Automobile technicians (which include motor mechanics, panel beaters, battery chargers, automobile electricians) form a unique group of semi –skilled labor that possess skill sets that have become ever more essential in our contemporary society due to the increased use of automobiles. In the Nigerian context, most of the automobile technology outfits are operated with manual instruments and equipment leading to frequent work-related oral habits. Going forward, most of the automobile mechanics are of low economic and educational background and usually undergo informal training, they therefore can be delineated into commissioned and apprentice. Though there is currently no census on the population of automobile technicians in Benin city; their ubiquitous spread amongst most neighborhoods in Benin city makes them an everpresent group with unique characteristics provides a unique sample population for this study.

Methodology

Research Design

This study adopted the survey research design wherebythe entire population of the study were sampled through the administration of the questionnaire to the selected research participants of the total population. This design was considered appropriate because it can easily be used to reach a large population very cheaply.

Population of the Study and Sample Size

This study included one hundred and fifty (150) automobile technicians geographically dispersed as follows; Oredo local government covering thirteen (13) automobile workshops, Egor local government covering ten (10) mechanic workshops, and Ikpoba-Okha local government covering fifteen (15) automobile workshops all in Benin City. All the respondents were requested to answer a self-administered questionnaire. The questionnaire included 22 items in three sections. The first section was about demographical data. The second section assessed oral health knowledge, and the third section evaluated the practice of oral health preventive measures.

DMFT

The DMFT score of the samples were determined based on the results of clinical examination and calculation of the number of decayed (D), filled (F), and missed (M) teeth due to caries. The data were collected by questioners through observation and direct examination of the samples’ teeth using mirror number 4 and a medisporex catheter. During the examination, the subjects under examination and the researcher sat close to the window to perform the examination under the maximum natural light. After examining each patient, the results were recorded in the questionnaire.

Method of Data Analysis

The study data were analyzed using Statistical Package for the Social Sciences version 22. Descriptive statistical analysis was carried out. Analysis of Variance (ANOVA) was used to determine the mean and standard variation between variables, and a p-value of less than 0.05 was considered statistically significant. Results are depicted in the form of tables and charts.

Results

The result of this study as presented in Figure 1 revealed that from the sample population of 150, the age was found to be distributed as follows; greater than 40 year of age (>40) were dominant with 39.60%, age 35-39 was found to be 26.17% age 30-34 (23.49%), age 25-29 (7.38%) and the least age for the participants was found to be in the group categorized as <18 with 0.67%. The result on gender distribution and educational qualification of the participants revealed that most of the participants were male with 97.16% and a few of the participants were female with a percentage distribution of 2.87% (Figure 2) from a sample size of one hundred and fifty. The education qualification of the participants as revealed in Figure 3 demonstrated that a large proportion of the participants holds a secondary school certificate (60.67%) as the highest educational qualification. (34%) of the participants holds first school leaving certificate as the highest educational qualification and the 5.33% had no formal educational training.

Figure 1: Showing age distribution of the participants.

The result on the distribution of automobile technicians and years of practice revealed that, from a sample size of 150 participants; 55.78% were mechanics, 17.69% panel beaters, 13.61% electrician, and 4.76% vulcanizer (Figure 4). Result on the years of practice (Figure 5) revealed that a greater number of the participants had above ten years (>10) of practice with 89.58%, 8.33% of the participants had 6-10 years of practice and a few had had 1-5 years of practice with 2.08%. Participant’s level of awareness on oral diseases were also examined. The result as presented in Table 1 showed various responses. The result of the responses on do you know that oral diseases can be prevented revealed that 86% of the participants from a population of 150 participants reported with a yes (86%) and 14% of the participants reported with a No. As per Do you know that oral disease can be treated, 88.6% reported with a Yes, and 11.4% reported with a No. concerning the question, have you ever had toothache, 34.9% (Yes) and 65.1% No. as per have you heard of dental caries, 81.9% (Yes) and 18.1% (No).

Figure 2: Showing gender distribution of the participants.

Figure 3: Showing educational qualification of the participants.

Figure 4: Showing occupation of the participants.

Figure 5: Showing years of practice of the participants.

Table 1: Showing level of awareness on oral health.

Table 2: Showing oral health practice of amongst automobile technicians in Benin city.

Table 3: Showing utilization of dental services amongst automobile technicians in Benin city.

Finally, the participants were questioned to know if they have ever heard of oral cancer, the result revealed that 68.2% of the participants did not know about oral cancer while 31.1% demonstrated awareness of oral cancer. The result presented in Table 2 on oral health practice amongst automobile technicians in Benin city, revealed the following; 75.3% reported that the brush only once in a day while 24.7% reported brushing twice a day; as per the response to the question what type of brush do you use, 49.7% reported that the make use of hard brush, 22.1% makes use of soft brush, 23.5% (medium) and 4% of the participants were not sure of the type of brush in use; in response to the question how often do you change your brush, a large number of the participants (53.1%) reported that the only change their brush only when it becomes bad, 3.4% reported once a year and only 12.7% reported that the change their brushes once in three months. Finally, the participants were asked how they remove things in between their teeth, and large number of the participants (82%) reported the use of toothpick, and a few others (9.3%) reported the use of broomstick (Table 3).

The utilization of dental services amongst automobile technicians in Benin city was examined. The result revealed that 80.4% of the participants reported that have not visited a dentist and only 19.6% from a pool of 150 participants reported that they have visited a dentist. Furthermore, for those who reported visiting a dentist, they were examined to know what the reason was for visiting a dentist, 82.1% (toothache), 10.7% (clean the mouth), and 3.6% visited for advice. Lastly, a large proportion (94%) of the participants reported that they would recommend a dental visit to anyone. The mean (SD) values of DT, MT, and FT indices in the participants were 0.13±0.473, 0.16±0.386, and 0.04±0.19 respectively. The mean (SD) value of total DMFT index was 0.31±0.71 in all the participants. DMFT index was associated with years of practice and age. The participants with an increased year of practice (>10) significantly p<0.05 had increased of DMFT as well participants with older age (>40) in comparisons with other variables (Table 4).

Table 4: Mean number of decayed, missing, and filled (D, M, and F) teeth and DMFT index by the demographic variables of respondents.

Note: D: Decayed teeth, M: Missing teeth, F: Filled teeth, DMFT: DMFT index, M: Mean, SD: Standard Deviation and ** significantly different.

Discussion

Oral diseases are reported to be one of the most common diseases affecting humans and despite its recorded high social and economic burdens, oral diseases still receive little attention in many countries around the world and also remains neglected by the international health [10]. Going forward, Oral health considered as a state of being free from oral diseases including chronic orofacial pain, oral cancer, oral infection, periodontal (gum) disease, tooth decay, tooth loss, and other diseases that limit an individual’s capacity in biting, chewing, smiling, and speaking, as well as psychosocial well-being [11,10]. A body of scientific evidence have demonstrated that oral diseases are becoming increasingly prevalent in low- and middleincome countries [12,13], and health education is widely accepted as a suitable approach for oral disease prevention [11]. In the of this, the present study assessed oral health knowledge, attitude, practices and utilization of dental services amongst automobile technicians in Benin city.

The result on sociodemographic information revealed that a greater proportion of the participants were above forty years of age (>40), were male, had secondary certificate/training as the highest educational qualification, had above 10years (>10) of practice and the automobile technicians who participated in the study were distributed in an increasing numerical order as follows; mechanic, panel beater, electrician, spray painter and the vulcanizer with the lowest participation. Oral health knowledge of the participants was assessed and the result (Table 1) revealed that the participants demonstrated adequate knowledge on the prevention and treatment of oral diseases as well as knowledge about dental caries. however, it was observed that 68% of the participants had no knowledge about oral cancer which perhaps could be attributed to their educational qualification. The adequate knowledge demonstrated by the participants corroborates the study of Ehizele and Ofili [14], conducted in same geographic location as the present study although the target population was primary school teacher.

Toothbrush and toothpaste are commonly used as aids for cleaning the mouth amongst Nigerian adults as was observed in the study of [15]. Conversely, the study of Taiwo, et al. [16] reported that amongst other groups of Nigerians, quite a sizable number of the participants used chewing sticks alone as a tooth cleaning aid [16]. In the present study, all the study participants reported using toothbrush and toothpaste for cleaning their mouth and therefore corroborates the study of Ephraim-Emmanuel, et al. [15] on toothbrush and toothpaste being the commonly used aids for cleaning the mouth amongst Nigerian adults. Furthermore, the study examined some variables to assess oral health practice amongst automobile technicians in Benin City and the result revealed that 75% of the participants brushes once a day, 49.7% makes use of hard brush, 53.1% only change their brush when it becomes bad and 82% remove things in between their teeth with toothpick. The present result had a similar pattern of mouth cleaning, change of brush, and remover of things between teeth with toothpick with the study of Akinyamoju, et al. [17] among traders in Ibadan [17] and some adults in Bayelsa state [15]. To prevent oral health problems, it is recommended that adults should brush and floss their teeth at least once a day and have a regular oral health checkup [18].

Good oral health practice consists of the continuous implementation of two sets of behavior: utilization of dental services (regular dental checkup, oral health promotion, and professionally applied preventive means) and self-care habits (good oral hygiene, restriction of sugar intake, and application of fluoride products) [11,19]. The study also examined the utilization of dental services amongst automobile technicians in Benin city. The study revealed that 80.4% of the participants have never visited a dental hospital and among from the 29% of the participants who reported have to visited a dentist, 82.1% was a due to a condition (toothache). This demonstrated an inadequate utilization of dental services among the study participants and negates a good oral health practice. Regardless of the inadequate utilization of dental services, the participants reported that they would recommend a dental visit which is indicative of willingness improve their oral health. Therefore, the need for an improved sensitization and education on the status of good oral health practices.

Despite the great emphasis of world health organization on oral health, it is still one of the public health problems, even in developed countries, and the problem is even more remarkable in developing countries [20]. For over 70 years, the Decayed, Missing and Filled Teeth (DMFT) index has been globally used as the most important index for assessing the status of oral and dental health [21,20]. This index determines the number of decayed teeth, the number of treated teeth, and the number of teeth missed due to decay [22]. This index is used to evaluate and monitor oral health and therefore the present also examined the DMFT of the participants. The result revealed that the mean (SD) values of DT, MT, and FT indices of the participants were 0.13±0.473, 0.16±0.386, and 0.04±0.19 respectively. The mean (SD) value of total DMFT index was 0.31±0.71 in all the participants. DMFT index was associated with years of practice and age. The participants with an increased year of practice (>10) significantly p<0.05 had increased of DMFT as well participants with older age (>40) in comparisons with other variables (Table 4) [23].

Conclusion

Oral diseases are a neglected area of international health, despite their high social and economic costs. They can and do negatively impact quality of life for many populations worldwide. Assessment of oral health knowledge of the participants revealed that the participants demonstrated adequate knowledge on the prevention and treatment of oral diseases as well as knowledge about dental caries. however, it was observed that 68% of the participants had no knowledge about oral cancer which perhaps could be attributed to their educational qualification. The study observed an adequate oral health practice amongst the participants; however, an inadequate utilization of dental services was also observed. DMFT index was found to be associated with years of practice and age. Therefore, the need for an improved sensitization and education on the status of good oral health practices.

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The Flourishing Miasma-Molluscum Contagiosum

Editorial

Figure 1: Molluscum contagiosum demonstrating a centric, waxy core pervaded with virions confined to superficial stratified squamous epithelial layer [1].

Molluscum contagiosum or ‘water warts’ emerges as an extremely contagious, cutaneous viral infection engendered by molluscum contagiosum virus of poxvirus family. Molluscum contagiosum virus is confined to superficial cutaneous layers wherein centroidal, waxy core is permeated by the virus [1,2]. Onset of lesions occurs in around seven weeks following viral exposure. Mean duration of an outbreak of lesions appears at 6 months to five years wherein immunosuppressed individuals demonstrate a prolonged duration [1,2]. Molluscum contagiosum virus disseminates through direct or sexual contact, with contact sports, contact with infected fomites, autoinoculation with scratching or picking the lesions or sharing of contaminated objects as towels. Self-inoculation within diverse region of the body is common in children and widespread, clustered lesions may be discerned [1,2]. Factors contributing towards emergence of molluscum contagiosum are atopic dermatitis, immunodeficiency or crowded living area with inadequate sanitation. Re-infection following a singular infection may ensue [1,2]. Appropriate discernment of the condition is contingent to classical appearance of lesions subject to confirmation by cogent histological examination [1,2]. Commonly discerned within the face, neck, axilla, torso, extremities, abdominal region or genital region, no area of disease emergence is exempt. The condition is frequently discerned in children between one-year to10 years. Typically, lesions in adults appear within the genital region [1,2]. Commonly, irritated, pruritic, non-painful, singular or clustered, miniature, elevated, pink nodules are observed. Molluscum contagiosum exemplifies flesh colored, dome shaped, pearly lesions with a centric punctum and magnitude varying from one millimeter to 5 millimeters. Upon microscopy, molluscum contagiosum characteristically demonstrates molluscum bodies or Henderson-Petersen bodies confined to superficial epidermal layer, superimposing upon the stratum Basale Figures 1 & 2. Cells imbued with abundant, enlarged, granular, eosinophilic cytoplasmic inclusion bodies or accumulated virions with eccentric, peripherally displaced, miniature, compressed nuclei are delineated [1,2].

Circumvention of disease may be obtained with appropriate hygiene and restricted sharing of personal items [3,4]. Spontaneous resolution of lesions in the absence of scarring may occur within a year. Thus, a wait and watch policy may be beneficially adopted. Picking or scratching of lesions may augment viral dissemination, induce bacterial infection, engender scarring or contribute to occurrence of eczema circumscribing the lesions [3,4]. Although treatment is unnecessary, lesions can be exterminated for cosmetic concerns or preventing disease dissemination [3,4]. Eradication of lesions can be accomplished with scraping intrinsic segment of the lesion, a maneuver which may induce scarring [3,4]. Oral agents such as cantharidin or cimetidine within the Paediatric population appear efficacious in expunging molluscum contagiosum. Topical podophyllotoxin or tretinoin can engender disease resolution [3,4]. Mild instances can be treated with salicylic acid which decimates duration of infection [3,4]. Imiquimod is an immunotherapy which can be suitably adopted to treat lesions of molluscum [3,4]. Surgical procedures as cryosurgery employing liquid nitrogen to freeze the lesions or lesion curettage appear optimal. Laser therapy with pulsed dye laser can be advantageously adopted to exterminate lesions of molluscum contagiosum [3,4]. Majority of lesions of molluscum contagiosum resolve spontaneously within nine months to two years. With perpetual cutaneous evolution, possible transmission of infection to family members or associated individuals may ensue. However, following competent eradication spontaneous reoccurrence is unperceived [3,4].

Figure 2: Molluscum contagiosum delineating abundant, eosinophilic, intra-cytoplasmic viral inclusion bodies with an eccentric, miniature nucleus and circumscribing stratified squamous epithelial layer [2].

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