M. Pharm. Dissertation Protoco Submitted to the Ra!i" #an$hi Uni"ersit% o& Heath Sciences' (arnata)a Ban*aore. By Mr. VI+A, V PA-AR B. Pharm.
Under the Guidance of Dr. C.C. PATIL M.Pharm, ph.D Pro&essor . Hea$ DEPARTMENT OF PHARMACEUTICS B L D E A/S COLLE#E OF PHARMAC, BI+APUR0123456 754607548 Ra!i" #an$hi Uni"ersit% o& Heath Sciences' (arnata)a Ban*aore. ANNE9URE II PROFORMA FOR RE#ISTRATION OF SUB+ECTS FOR DISSERTATION
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Name of candidate and address (n B!oc" #etters) Mr. VI+A,.V.PA-AR AT0MA#AR-ADI POST0CHANDAPURI TAL0 MALSHIRAS DIST0 SOLAPUR0846 645 $)
Name of the nstitute B.L.D.E.A/S COLLE#E OF PHARMAC,' BI+APUR0123 456 %) &ourse of study and sub'ect( M. PHARM IN PHARMACEUTICS. )) Date of admission of course( 7:04707547 *) +it!e of the topic; , <FORMULATION AND EVALUATION OF MUCOADHESIVE BUCCAL TABLETS OF ONDANSETRON HCL=. -) Brief .esume of this intended /or" ;0 3.4 Need for the study Encos>re0I 3.7 .e0ie/ of #iterature Encos>re0II 3.6 1b'ecti0es of study Encos>re0III $ 2) Materia!s and Methods ;0 2.1 Source of data Encos>re0IV 2.$ Method of co!!ection of data (nc!udin3 samp!in3 procedure, if any) Encos>re0IV 2.% Does the study re4uire any in0esti3ation or inter0entions to be conducted on patients of humans or anima!s5 f so, p!ease describe brief!y. 000NO,,,, 2.) 6as ethica! c!earance been obtained from your institution in case of 2.%5 000NOT APPLICABLE,,,,
7) #ist of .eferences Encos>re0V
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Si3nature of the candidate
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.emar"s of the Guide
Encos>re0VI 11) Name and desi3nation of (in b!oc" !etters) 11.1 Guide
11.$ Si3nature
Dr. CHANDRASHE(AR.C. PATIL Pro&essor . Hea$' De?t. o& Pharmace>tics B.L.D.E.A/S COLLE#E OF PHARMAC,' BI+APUR0123456. 11.% &o,Guide (if any) ,,,,,,,,,,,, % 11.) Si3nature ,,,,,,,,,,,, 11.* 6ead of Department 11.- Si3nature 0000000000000 1$)
1$.1 .emar"s of the &hairman and Principa!
1$.$ Si3nature This st>$% Can @e carrie$ o>t in o>r a@orator% Encos>re0I ) 3A Brie& res>me o& the inten$e$ Bor). 3.4A Nee$ &or the st>$%; 0 Bucca! de!i0ery of dru3s pro0ides an attracti0e a!ternati0e to the ora! route of dru3 administration, particu!ar!y in o0ercomin3 the disad0anta3es associated /ith the !ater mode of dosin3. Moreo0er, the ora! ca0ity is easi!y accessib!e for se!f medication and can be prompt!y terminated in case of to:icity 'ust by remo0in3 the dosa3e form from bucca! ca0ity. t is a!so possib!e to administer dru3 to patients /ho cannot be dosed ora!!y 0ia this route. 1 ;mon3 the 0arious transmucosa! routes, bucca! mucosa has e:ce!!ent accessibi!ity, an e:panse of smooth musc!e and re!ati0e!y immobi!e mucosa, hence suitab!e for administration of retenti0e dosa3e form. +echnica!!y, an idea! bucca! adhesi0e system must ha0e the fo!!o/in3 properties( (1) maintains its position in the mouth for a fe/ hours, ($) re!eases the dru3 in a contro!!ed fashion, and (%) pro0ides dru3 re!ease in a unidirectiona! /ay to/ard the mucosa. $ +hree different cate3ories of dru3 de!i0ery fa!! /ithin the ora! ca0ity( sub!in3ua!, bucca!, and !oca!. +he sub!in3ua! mucosa is re!ati0e!y permeab!e, 3i0in3 rapid absorption and acceptab!e bioa0ai!abi!ities of many dru3s, and is con0enient, accessib!e, and 3enera!!y /e!! accepted. % +he dru3 direct!y reaches to the systemic circu!ation throu3h the interna! 'u3u!ar 0ein and bypasses the dru3s from the hepatic first pass metabo!ism, /hich !eads to hi3h bioa0ai!abi!ity. +he other ad0anta3es of bucca! dru3 de!i0ery inc!ude( !o/ en<ymatic acti0ity, suitab!e for dru3s or e:cipients that mi!d!y and re0ersib!y dama3e or irritate the mucosa, pain!ess dru3 administration, easy dru3 /ithdra/a!, possib!e to inc!ude the permeation. ) +herefore, the ora! mucosa may be potentia! site for contro!!ed or sustained dru3 de!i0ery. +he permeabi!ity of the ora! mucosa is !o/= hence, the ora! mucosa cou!d be uti!i<ed to potent dru3s /hich are re4uired in sma!! doses. * n this study, ondansetron 6&! (1DN) /as se!ected as a mode! dru3= it is a se!ecti0e serotonin *,6+% receptor b!oc"in3 a3ent. - t is a potent antiemetic dru3 used in the treatment of chemotherapy or radiotherapy induced emesis and a!so used in the ear!y * onset of a!coho!ism. ;!thou3h, it is /e!! absorbed in the 3astrointestina! tract= 1DN under3oes first pass,metabo!ism resu!tin3 in !o/ bioa0ai!abi!ity. +he !o/ dose ()m3) and ma:imum !i"e (7m3) and !o/ mo!ecu!ar /ei3ht (%-*.7- Da) ma"e it as a suitab!e candidate for bucca! de!i0ery. t has been c!assified as B&S &!ass dru3 o/in3 to its !o/ permeabi!ity and hi3h so!ubi!ity. +herefore, it /as e:co3itated to use permeation enhancer in de!i0erin3 1DN throu3h bucca! mucosa. 2
t is effecti0e in the treatment of nausea and 0omitin3, t has a ha!f,!ife %,* h and ora! bioa0ai!abi!ity is > -9 ?. 1D6 sho/s promisin3 pharmaco"inetics and physicochemica! properties hence this dru3 /as se!ected as mode! dru3s for this in0esti3ation. 7 - Encos>re0II 3.7A Re"ieB o& iterat>re; 0 1) #>$a a$it%a et al., ha0e de0e!oped and e0a!uate contro!!ed re!ease mucoadhesi0e bucca! tab!ets of #isinopri!. a dru3 /ide!y used in the treatment of hypertension. 6o/e0er, its e:tensi0e first pass metabo!ism resu!ts in poor bioa0ai!abi!ity. +he ob'ecti0e of present research /or" is to desi3n and e0a!uate the contro!!ed re!ease of mucoadhesi0e bucca! tab!ets of #isinopri! /ith a 3oa! to increase the bioa0ai!abi!ity, reduce dosin3 fre4uency and impro0e patient comp!iance. +he tab!ets /ere prepared usin3 &arbopo!8%), 6ydro:y propy! methy! ce!!u!ose (6PM&), hydro:y ethy! ce!!u!ose (6@&) as mucoadhesi0e po!ymers. ;na!ysis of #isinopri!e is done by UA 0isib!e spectrophometer usin3 /a0e!en3th $19nm. .esu!ts of in-vitro s/e!!in3 study indicate that the +ota! si: different formu!ations (B1 to B-) of #isinopri! bucca! tab!ets /ere prepared by direct compression techni4ues usin3 0arious proportions of po!ymers and e:cipients. n order to se!ect the best formu!ations, 0arious e0a!uation parameters /ere chec"ed and sub'ected to in-vitro disso!ution studies and their re!ease profi!es. 8 2) Sat%a@rata Bhan!a
et al., ha0e prepared and e0a!uate of mucoadhesi0e bucca! tab!ets of +imo!o! ma!eate. +he best in-vitro dru3 re!ease profi!e /as achie0ed /ith the formu!ation B* /hich contains the dru3, &arbopo! 8%)p and 6PM& C)M in the ratio of 1($.*(19. +he in vitro re!ease of +imo!o! ma!eate /as performed under sin" conditions (Phosphate buffer P6(-.7, %2D9.*E&, rpm *9) usin3 USP, FFA disso!ution apparatus type . +he formu!ation B*, containin3 19 m3 of +imo!o! ma!eate e:hibited 2 h sustained dru3 re!ease i.e. 87.17 ? /ith desired therapeutic concentration. +he samp!es /ere fi!tered throu3h Ghitman fi!ter paper No.)9 and ana!y<ed for +imo!o! after appropriate di!ution by UA spectrophotometer at $8- nm. +he in-vitro re!ease "inetics studies re0ea! that a!! formu!ations fits /e!! /ith <ero order "inetics fo!!o/ed by Corsmeyer,Peppas, first order and then 6i3uchiHs mode! and the mechanism of dru3 re!ease is non, Bic"ian diffusion. B+. studies sho/ed no e0idence on interactions bet/een dru3, po!ymers, and e:cipients..n conc!usion, the resu!ts indicated that the prepared 2 sustained,re!ease tab!ets of +M cou!d perform therapeutica!!y better than con0entiona! tab!ets /ith impro0ed efficacy and better patient comp!iance. 19 3) # C)inci et al., ha0e de0e!oped a bucca! bioadhesi0e nicotine tab!et formu!ation for smo"in3 cessation. &arbomer (&arbopo!I82)P NB) (&P) and a!3inic acid sodium sa!t (Na;!3) /ere used as bioadhesi0e po!ymers in combination /ith hydro:ypropy! methy!ce!!u!ose (6PM&) at different ratios. Ma3nesium carbonate /as incorporated into the formu!ations as a p6 increasin3 a3ent. ; decrease in p6 of the disso!ution medium to acidic 0a!ues /as a0oided by incorporation of ma3nesium hydro:ide into the formu!ations. +he de0e!oped formu!ations re!eased N6+ for 7 h period, and remained intact e:cept for the formu!ation containin3 &P( 6PM& at $9(79 ratios. +ab!ets /ere prepared by direct compression of the mi:ture of 6PM& either /ith &P or Na;!3 at different ratios. +he re!ease of N6+ from tab!ets /as studied usin3 modified Bran< diffusion ce!!s. +he samp!es /ere fi!tered and assayed for N6+ at $*8 nm usin3 a UA 1-9; Shimad<u spectrophotometer. t /as sho/n that /ith the de0e!oped formu!ations, the N6+ re!ease and bioadhesion properties of bucca! tab!ets can be contro!!ed by chan3in3 the po!ymer type and concentration. 11 4) Ca>m R et al., ha0e formu!ated ora! contro!!ed re!ease matri: tab!ets of #osartan potassium. Bi!ayer nicotine mucoadhesi0e tab!ets /ere prepared and e0a!uated to determine the suitabi!ity of the formu!ation as a nicotine rep!acement product to aid in smo"in3 cessation. ; ran3e of formu!ations containin3 9J*9? /// &arbopo! 8%)I and 9J*9? /// hydro:ypropy!ce!!u!ose (6P&) /ere prepared and tested for adhesi0e properties and dru3 re!ease. Mucoadhesion /as assessed usin3 bo0ine bucca! mucosa. Pea" detachment force of the tab!ets /as found to reach a ma:imum at $9? /// &arbopo! 8%)I, /hi!st /or" of adhesion continued to increase /ith &arbopo! 8%)I concentration. 6P& concentrations of $9J%9? /// /ere found to pro0ide nicotine hydro3en tartrate (N6+) re!ease approachin3 <ero order "inetics o0er a ) h test period. ; combination of $9? /// &arbopo! 8%)I and $9? /// 6P& /as thus found to pro0ide suitab!e adhesion and contro!!ed dru3 re!ease. +he eff!uent from the ce!!s /as co!!ected o0er a ) h period and assayed for nicotine at certain time inter0a!s usin3 U.A. detection at $*8 nm. In- 7 vitro nicotine re!ease Disso!ution testin3 /as initia!!y carried out to in0esti3ate the effect of 6P& on N6+ re!ease. +he rate of N6+ re!ease from the &.#Hs and bi!ayer tab!ets /as in0esti3ated usin3 USP (FF) apparatus A. t has been proposed that mucoadhesion occurs in three sta3es (Duchene et a!., 1877). +he first sta3e in0o!0es the formation of an intimate contact bet/een the mucoadhesi0e and the mucus. Second!y, the mucoadhesi0e macromo!ecu!es s/e!! and interpenetrate /ith the mucus macromo!ecu!es, becomin3 physica!!y entan3!ed. +hird!y, these mo!ecu!es interact /ith each other 0ia secondary, non, co0a!ent bonds such as hydro3en bonds. 1$ 5) Paoo #i>nche$ia et al.' ha0e prepared bucca! tab!ets of ch!orhe:idine usin3 dru3,!oaded chitosan microspheres. +his in0esti3ation dea!s /ith the de0e!opment of bucca! formu!ations (tab!ets) based on chitosan microspheres containin3 ch!orhe:idine diacetate. +he micropartic!es /ere prepared by a spray,dryin3 techni4ue, their morpho!o3ica! characteristics /ere studied by scannin3 e!ectron microscopy and the in 0itro re!ease beha0iour /as in0esti3ated in p6 2.9 USP buffer. &h!orhe:idine in the chitosan microspheres disso!0es more 4uic"!y in 0itro than does ch!orhe:idine po/der. +he anti,microbia! acti0ity of the micropartic!es /as in0esti3ated as minimum inhibitory concentration, minimum bacteria! concentration and "i!!in3 time. +he !oadin3 of ch!orhe:idine into chitosan is ab!e to maintain or impro0e the anti,microbia! acti0ity of the dru3. +he impro0ement is particu!ar!y hi3h a3ainst Candida albicans. +his is important for a formu!ation /hose potentia! use is a3ainst bucca! infections. Dru3,empty micropartic!es ha0e an anti,microbia! acti0ity due to the po!ymer itse!f. Bucca! tab!ets /ere prepared by direct compression of the micropartic!es /ith mannito! a!one or /ith sodium a!3inate. ;fter their in-vivo administration the determination of ch!orhe:idine in sa!i0a sho/ed the capacity of these formu!ations to 3i0e a pro!on3ed re!ease of the dru3 in the bucca! ca0ity. 1% 6) Ahma$ Mahmoo$ M>mtaD et al., ha0e de0e!oped bioadhesi0e bucca! tab!ets containin3 triamcino!one acetonide in hea!thy 0o!unteers. Bioadhesi0e bucca! tab!ets prepared from different ratios of po!y (acry!ic acid,$,*,dimethy!,!,*, he:adiene) (P;D6) and hydro:ypropy!methy!ce!!u!ose (6PM&) /ith and /ithout 8 triamcino!onc acctonidc (+;;) has been in0esti3ated in the bucca! ca0ities of hea!thy human 0o!unteers. +he inc!usion of hi3her percenta3es of 6PM& pro0ides more pro!on3ed re!ease of dru3 throu3h its properties of 3e!!in3 and s!o/ disso!ution. 6o/e0er, adhesion of the tab!et is reduced in the e:cessi0e f!o/ of sa!i0a and there is a!so a tendency for the tab!et to be dis!od3ed from the mucosa. +he tab!et /ith a P;D6K6PM& ratio of *9(*9 seems to pro0ide a suitab!e compromise for 3ood bioadhesion and pro!on3ed re!ease of dru3. +he triamcino!one acetonide concentration /as determined by a UA spectrophotometer (6itachi, Mode! $999U, and Lapan) at $)9.7 nm. Sho/s that tab!et hydrates and s/e!!s immediate!y and disinte3ration occurs /ithin %9 min /hich reaches the ma:imum at 1.9 h. +he re!ati0e!y !ar3e fa!! in /et /ei3ht after 1.* h is probab!y due to difficu!ty in remo0in3 a!! the s/e!!ed P;D6 partic!es from the mucosa. 1) 7) Ra!esh (hanna MA et al., ha0e prepared Preparation bioerodib!e bucca! tab!ets containin3 c!otrima<o!e. Buccoadhesi0e erodib!e tab!ets for !oca! de!i0ery of c!otrima<o!e (&#+) to the ora! ca0ity /ere de0e!oped usin3 different bio,adhesi0e po!ymers a!on3 /ith so!ub!e e:cipients !i"e mannito! and po!yethy!ene 3!yco!, -999. ;n apparatus simu!atin3 the in-vivo conditions of the mouth /as desi3ned in order to assess in-vitro, the bio,adhesi0e performance and re!ease characteristics of these tab!ets. +he in-vitro adhesion time and re!ease characteristics /ere found to be a function of the type of po!ymer and a!so the tota! composition of the tab!ets. n 0i0o e0a!uation of p!acebo tab!ets in hea!thy human 0o!unteers indicated a !inear and positi0e corre!ation bet/een the in-vitro and in-vivo adhesion time. 1* Encos>re0III 19 3.6A O@!ecti"es o& the st>$%; 0 +he present study is p!anned /ith the fo!!o/in3 ob'ecti0es; 0 1) +o prepare standard ca!ibration cur0e of 1ndansetron 6c!. $) +o prepare mucoadhesi0e bucca! tab!ets by /et 3ranu!ation method usin3 po!ymer !i"es, 1) Natura! po!ymer, chitosan, Sodi.;!3inate etc. and Semi, Synthetic po!ymers, 6PM&, @& etc %) Dru3, e:cipients compatibi!ity study by B+. Spectroscopy. )) +o perform e0a!uation parameter !i"es 1. ;ppearance, thic"ness, hardness, /ei3ht 0ariation, friabi!ity test. $. Determination of s/e!!in3. %. Surface p6 study. ). Bioadhesion. *. .esistance time -. In-vitro disso!ution study usin3 USP FF (@!ectro !ap, +D+ 9-p) ana!ysed them by usin3 UA,Spectrometer (pharmaspec 1299, Shimad<u, Lapan). 2. Stabi!ity testin3. 7. In-vitro permeation studies of the optimi<ed formu!ations. Encos>re0IV 11 7) Materials and Methods: - :.4A So>rce o& $ata; 0 Primar% $ata; 0 +his data /i!! be co!!ected by conductin3 !aboratory e:periments and recordin3 the obser0ation. Secon$ar% $ata; 0 +his /i!! be co!!ected from 0arious 'ourna!s and te:tboo"s. :.7A Metho$ o& coection o& $ata; 0 +he study is p!anned to co!!ect the data from the !aboratory,based e:periments, /hich inc!ude the fo!!o/in3( 1) Preparation of 1ndansetron hc! tab!ets by usin3 different po!ymers by /et 3ranu!ation method. $) &ompatibi!ity study of dru3 /ith 0arious po!ymers /i!! be carried out by usin3 B+,.,7)99 S Shimad<u, Lapan. %) @0a!uation parameter such as, appearance, thic"ness, hardness, /ei3ht 0ariation test, friabi!ity test, dru3 content uniformity, bioadhesion, in,vitro disso!ution studies, s/e!!in3 inde:, in-vitro resistance time. )) In-vitro permeation studies /i!! be carried out for the optimi<ed formu!ation. *) +he stabi!ity studies of the formu!ation /i!! be carried out as per &6 3uide!ines and data /i!! be co!!ected. ENCLOSURE0V
1$ List o& re&erences; 0 1. Mada0 Deepa" .+, ;yyappan S, hanmu3am C, Sundaramoorthy and +. Aetriche!0an. De0e!opment and in-vitro @0a!uation of Buccoadhesi0e Metoc!opramide 6ydroch!oride +ab!et Bormu!ations. nternationa! 'ourna! of pharmatech .esearch coden , $911= %(*1-,*$*. 2. Prasanth Aasantha Ais/anadhan, ;nand Pado!e, ;bin ;braham and Sam +homarayi! Mathe/. Bucca! +ab!ets of #isinopri! by Direct &ompression Method for Bucca! Dru3 De!i0ery. nternationa! research Lourna! of Pharmaceutica!s, $91$= $(%9,%7. 3. Pate! CA, Pate! ND, Dodiya 6D, She!at PC. Bucca! Bioadhesi0e Dru3 De!i0ery System. ;n 10er0ie/. nternationa! Lourna! of Pharmaceutica! and Bio!o3ica! ;rchi0es, $911= $($)( -99,-98. 4. C Na3a .a'u, S Ae!muru3an, B Deepi"a , Sundar Ainushitha . Bormu!ation and in0itro e0a!ution of bucca! tab!et of Metopro!o! tartrate. nternationa! Lourna! of pharmacy and Pharmaceutica! science, $911= %( $%8,$)-. 5. S/amy PA, Cina3i MB, Biradar SS, Gada SN and Shi!pa 6. Bormu!ation Desi3n and @0a!uation of Bi!ayer Bucca! +ab!ets of Granisetron 6ydroch!oride. ndian Lourna! of Pharmaceutica! @ducation and .esearch, $911= $)$,$)2. 6. Upendra na3aich , Aandana chaudhary
, .oopa "ar"i
, ;"ash yada0
, Pra0een Sharma
. Bormu!ation of medicated che/in3 3um of ondansetron hydroch!oride and its pharmaco"inetic e0a!uations. nternationa! Lourna! of Pharmaceutica! science and research, $919= 1($)( %$,)9. 7. M Pra0een Cumar, M .a'endra Prasad, M Pramod and A Prabha"ar .eddy. @ffect of permeation enhancer on e:,0i0o permeation of 1ndansetron hc! bucca! tab!ets. nternationa! Lourna! of Pharmaceutica! science and research, $911= $ (11)( $7)1,$7)*. 8. Syed ;me<uddin ;<har, Putta .a'esh Cumar, Ai0e" Sood and Somashe"ar Shya!e. Studies on direct!y compressed ondansetron hydroch!oride mucoadhesi0e bucca! tab!ets. Lourna! of app!ied pharmaceutica! science, $91$= $ (*)( 199,19*. 9. Guda ;ditya, Ganesh Cumar Gudas
, Manasa Bin3i
, Suba! Debnath
, AA .a'esham
. Desi3n and @0a!uation of &ontro!!ed .e!ease Mucoadhesi0e Bucca! +ab!ets of #isinopri!. nternationa! Lourna! of current Pharmaceutica! research, $919 = $ ()) ( $),$2. 1% 10. Satyabrata Bhan'a
, P @!!aiah
, Su'it Cumar Martha
, Pratit Canchan Sahu
, Sandip Prasad +i/ari
, Bibhuti Bhusan Pani3rahi
, Deba'yoti Das
. Bormu!ation and in vitro e0a!uation of mucoadhesi0e bucca! tab!ets of +imo!o! ma!eate. nternationa! Lourna! of Pharmaceutics and Medica! .esearch, $919= 1())( 1$8,1%). 11. G N"inci, S Sene!, & G Gi!son , M Sumnua. De0e!opment of a bucca! bioadhesi0e nicotine tab!et formu!ation for smo"in3 cessation. nternationa! Lourna! of Pharmaceutics, $99)= 12%,127. 12. &a!um . Par", Da!e # Munday. De0e!opment and e0a!uation of a biphasic bucca! adhesi0e tab!et for nicotine rep!acement therapy. nternationa! Lourna! of Pharmaceutics, $99$= $1*,$$-. 13. Pao!o Giunchedi, &!audia Lu!iano, @!isabetta Ga0ini
, Massimo &ossu
, Mi!ena Sorrenti
. @uropen Lourna! of Pharmaceutics and Biopharmaceutics, $99$= $%%, $%8. 14. ;hmad Mahmood Mumta<, 6un3,Sen3 &hOn3 . @0a!uation of bioadhesi0e bucca! tab!ets containin3 triamcino!one acetonide in hea!thy 0o!unteers. nternationa! Lourna! of Pharmaceutica! Science, 188*= $)8,$*). 15. .a'esh Channa, SP ;3ar/a!, ;!"a ;hu'a. Preparation and e0a!uation of bioerodib!e bucca! tab!ets containin3 c!otrima<o!e. nternationa! Lourna! of Pharmaceutics, 188-= -2,2%. ENCLOSURE0VI 45A Remar)s o& the #>i$e +he present /or" is aimed to de0e!op and e0a!uate the Bucca! tab!et of 1ndansetron 6&!. 1ndansetron 6&! is a /ide!y used as anti emetic dru3. +he dru3 has a shorter bio!o3ica! ha!f,!ife of about %,* hrs and its bioa0ai!abi!ity is on!y -9?. Sustained 1) re!eased tab!et possib!y impro0e ora! bioa0ai!abi!ity of 1ndansetron 6&!. +he proposed study can be carried out in the !aboratory.
International Journal of Oral Science (2013) 5, 21–25: Characterization of oral bacterial diversity of irradiated patients by high-throughput sequencing
Propolis Can Potentialise The Anti-Adhesion Activity of Proanthocyanidins On Uropathogenic Escherichia Coli in The Prevention of Recurrent Urinary Tract Infections