a) A 41-year-old woman who had been using denture cream (2 tubes per week) for 5.5 years, presented with a 3.5-year history of numbness and weakness of the arms and legs, progressing to wheelchair dependence. She also experienced urinary incontinence and mild cognitive decline. Examination showed distal greater than proximal weakness, extensor plantar responses, decreased perception of pinprick to the hips, and decreased vibratory sensation and proprioception to the ankles. Laboratory analysis revealed copper deficiency (serum copper less than 0.1 mcg/mL; normal 0.75 to 1.45), hypoceruloplasminemia (serum ceruloplasmin 0.6 mg/dL; normal range 22.9 to 43.1), and elevated zinc concentration (serum zinc 2 mcg/mL; normal 0.66 to 1.1). Following copper supplementation for 5 days, her symptoms improved gradually. Six weeks later, her zinc and copper concentrations were 1.38 mcg/mL and 3.39 mcg/mL, respectively (Nations et al, 2008).
b) A 42-year-old woman who had been using denture cream (3 tubes per week) for many years presented with a 7-month history of asymmetric hand weakness, hand numbness, and poor balance. Examination showed severe distal upper extremity weakness and atrophy, distal greater than proximal weakness of the lower extremities, hyperreflexia, extensor plantar responses, and decreased pinprick sensation in the hands. An MRI of the brain revealed confluent bifrontal subcortical hyperintense abnormalities on T2 and diffusion-weighted images. Nerve conduction study and EMG revealed an axonal motor neuropathy with active denervation in distal muscles. Laboratory analysis showed hypocupremia (serum copper 0.18 mcg/mL; normal 0.75 to 1.45), hypoceruloplasminemia (serum ceruloplasmin 3 mg/dL; normal range 22.9 to 43.1), and elevated zinc concentration (serum zinc 1.36 mcg/mL; normal 0.66 to 1.1). Following copper supplementation, her symptoms improved gradually. Six months later, her copper and zinc concentrations were 0.86 mcg/mL and 0.98 mcg/mL, respectively (Nations et al, 2008).
c) CASE REPORT: A 50-year-old man with a 4-year history of unsteadiness presented with an ataxic gait, a positive Romberg sign, distal wasting, limbs weakness, impaired coordination, and arms pseudoathetosis. Laboratory results revealed a normochromic, normocytic anemia, leukopenia, neutropenia, and a low vitamin B12 (172 ng/L). He was treated with IM cobalamin injections and his serum vitamin B12 concentration increased to 683 ng/L, but no clinical improvement was observed. At this time, laboratory analysis revealed an undetectable ceruloplasmin (less than 0.085 g/L), a very low serum copper (1.1 mcmol/L), and increased serum zinc (38.2 mcmol/L). It was later found that for 3 to 4 years he had been using approximately 2 to 3 tubes (40 g each) of denture fixative Poligrip Ultra (zinc content: 38 mg of zinc/gram) each week instead of every 6 weeks for an ill-fitting dentures. Within 3 months of copper therapy, his bone marrow suppression resolved; however, his clinical neurological features did not improve (Barton et al, 2011).
d) CASE REPORT: A 36-year-old woman with a medical history of recurrent urinary tract infections, renal colic and stones, pancreatitis, gallstones, GERD, gastric ulcer, irritable bowel syndrome, and dental abscesses requiring a full mouth extraction, presented 5 years later with bone marrow failure (anemia, leukopenia, and neutropenia). She was diagnosed with myelodysplastic syndrome after a bone marrow biopsy. Despite supportive therapy, including growth factor support injections, no major improvement was observed. At this time, she developed atypical pneumonia and was treated with linezolid. She later developed painful muscle spasms, paresthesias of all extremities, ataxia, and areflexia. MRI revealed anular tears and protrusions with stenosis at multiple levels. As she was waiting for a bone marrow transplant, she saw an attorney-generated, television advertisements about zinc-containing denture adhesives causing anemias and paresthesias. She admitted in using denture adhesives up to 6 times daily for 2 years. At this time, laboratory results revealed serum copper concentrations of 11 mcg/dL (normal, 70 to 155), zinc 141 mcg/dL (normal, 70 to 150), and ceruloplasmin 3.1 mg/dL (normal, 17.9 to 53.3). Following treatment with copper supplementation for 3 months, her blood count and copper and zinc concentrations normalized. However, she continued to experience muscle cramps and paresthesia (Crown & May, 2012).
e) CASE REPORT: A 63-year-old man who was using zinc-based denture adhesives for years developed copper deficiency, myelodysplastic syndrome, and severe sensorimotor polyneuropathy. He had a 2-year history of sciatica and low back pain and presented with fatigue, lower extremity edema and bilaterally symmetric distal numbness and tingling in all extremities. MRI of thoracolumbosacral spine revealed canal stenosis at L4/5 and L5/S1 and extensive homogeneous marrow signal abnormality. He also had moderate anemia and neutropenic leukopenia. Three months after presentation, he presented with dyspnea, dry cough, constipation, and ascending numbness and weakness of all extremities. He was diagnosed with myelodysplastic syndrome after a bone marrow examination. Despite supportive care, he presented a month later in a wheelchair with worsening numbness, weakness, ataxia, and back pain. Despite supportive therapy, his condition continued to worsen. After severe serum copper deficiency was identified, it was found that he had been using denture adhesives for years (peak, 45 g weekly or 200 mg daily zinc intake). He was treated with copper supplementation (3 mg elemental copper daily) which improved his hematologic indices; however, his sensorimotor neurologic abnormalities did not improve. He died of aspiration from copper deficiency-induced myelopathy several months after the initial presentation (Afrin, 2010).

a) Howell et al (1992), analyzed reports concerning 361 patients with corrosive esophageal injury published in the English language literature since 1956 (10 retrospective and 3 prospective studies). No patients with first degree burns developed strictures. Of 228 patients with second or third degree burns treated with corticosteroids and antibiotics, 54 (24%) developed strictures. Of 25 patients with similar burn severity treated without steroids or antibiotics, 13 (52%) developed strictures (Howell et al, 1992).
b) Another meta-analysis of 10 studies found that in patients with second degree esophageal burns from caustics, the overall rate of stricture formation was 14.8% in patients who received corticosteroids compared with 36% in patients who did not receive corticosteroids (LoVecchio et al, 1996).
c) Another study combined results of 10 papers evaluating therapy for corrosive esophageal injury in humans published between January 1991 and June 2004. There were a total of 572 patients, all patients received corticosteroids in 6 studies, in 2 studies no patients received steroids, and in 2 studies, treatment with and without corticosteroids was compared. Of 109 patients with grade 2 esophageal burns who were treated with corticosteroids, 15 (13.8%) developed strictures, compared with 2 of 32 (6.3%) patients with second degree burns who did not receive steroids (Pelclova & Navratil, 2005).

a) These 60 children were among 131 patients who were managed and followed-up for ingestion of caustic material from 1971 through 1988; 88% of them were between 1 and 3 years old (Anderson et al, 1990).
b) All patients underwent rigid esophagoscopy after being randomized to receive either no steroids or a course consisting initially of intravenous prednisolone (2 milligrams/kilogram per day) followed by 2.5 milligrams/kilogram/day of oral prednisone for a total of 3 weeks prior to tapering and discontinuation (Anderson et al, 1990).
c) Six (19%), 15 (48%), and 10 (32%) of those in the treatment group had first, second and third degree esophageal burns, respectively. In contrast, 13 (45%), 5 (17%), and 11 (38%) of the control group had the same levels of injury (Anderson et al, 1990).
d) Ten (32%) of those receiving steroids and 11 (38%) of the control group developed strictures. Four (13%) of those receiving steroids and 7 (24%) of the control group required esophageal replacement. All but 1 of the 21 children who developed strictures had severe circumferential burns on initial esophagoscopy (Anderson et al, 1990).
e) Because of the small numbers of patients in this study, it lacked the power to reliably detect meaningful differences in outcome between the treatment groups (Anderson et al, 1990).

a) The use of corticosteroids in the treatment of caustic ingestion in humans has been associated with gastric perforation (Cleveland et al, 1963) and fatal pulmonary embolism (Aceto et al, 1970).