Category: Top to Toe

INTERVIEW LIM TECK CHOON

Dr Johnson Ng Wei Siang ENT/Head & Neck Surgeon

 

Nose cancer comes to the forefront of Malaysians’ minds when Datuk Lee Chong Wei revealed that he was diagnosed with this cancer last year.

This month, HealthToday catches up with an ENT/head and neck surgeon to take a closer look into a common nose cancer, nasopharyngeal carcinoma, and how it affects Malaysians, particularly the Chinese community.

HT: It is said that nasopharyngeal carcinoma (NPC) is difficult to detect. Why is that so?

Nasopharyngeal carcinoma is a cancer that arises from the region of the nasopharynx, which is in the upper area of the throat that lies behind the nose and just below the base of skull.

Cancers arising from the region of nasopharynx are difficult to detect for a few known reasons. One is that it arises from a site that is inaccessible and obscured from sight. Secondly,its early growth can be completely asymptomatic, or its early symptoms can be very non-specific and mild that many do not seek medical attention earlier on.

Another major contribution to its usually late detection lies with the lack of awareness of this potentially life-threatening disease among the general public and some of our healthcare providers. The recent unfortunate high-profile event that happened to our national shuttler has seen some sudden spike in awareness as well as change in attitude among the general public on this disease.

CANCERS ARISING FROM THE REGION OF NASOPHARYNX ARE DIFFICULT TO DETECT FOR A FEW KNOWN REASONS.

HT: What are the symptoms of NPC?

The symptoms of NPC can be more easily understood if it’s classified into localised, regional or distant symptoms.

In the earlier phase of cancer growth, it could cause progressive nose block usually on one side, nosebleed or blood stained nasal discharge and sputum. As our ear is connected to our nasopharynx via the Eustachian tube, ear symptoms are also early signs of potential disease. Similar to having ear symptoms such as ear pain, ear block sensation, reduced hearing and ringing sound in the ear during a bout of bad flu, a growing tumour in the region of nasopharynx will also produce similar symptoms.

As the tumour grows further, it will erode and invade its nearby structures. It can extend forward into the orbit (eye) or upwards into the base of skull to involve the important cranial nerves in our head and neck region. These nerves control movements of our eye, sensation on our face, movements of our vocal folds, tongue etc.

The region of the nasopharynx is also rich in lymphatic drainage. Hence, it is very common that regional presentation with a neck swelling is commonly the earliest symptoms that many patients seek medical attention for prior to diagnosis. Our body lymphatic system works like a filter against infection or cancer cells. Unlike infection where the lymph node swelling is usually painful and resolves after the infection settles, cancer in the lymph node is usually painless and progressively increases in size over time.

Distant symptoms of NPC are late symptoms of disease due to the cancer spread elsewhere in the body including the brain, lungs, liver and bone. Seizures, difficulty breathing, jaundice, and bone pain are some of such symptoms.

Finally, there are also generalised symptoms of any cancer including significant unexplained weight loss and loss of appetite.

HT: What is the prevalence and incidence of NPC in Malaysia? At what age is NPC commonly detected?

The prevalence of NPC varies worldwide. It is a predominant disease especially among the ethnic Chinese. Globally its incidence is only less than 1-in-100,000. However, in endemic areas including some parts of Southern China and Hong Kong, its incidence rises to over 20 per 100,000 population.

In Malaysia, according to the Ministry of Health Cancer Registry 2007-2011, NPC is ranked the fifth most common cancer overall in Malaysia accounting for about 5% of all cancers registered. However, it is the third most common cancer among the males coming in only after colorectal and lung cancer with an incidence rate of 6.4-in-100,000 male population. Its calculated lifetime risk for NPC in Malaysia is 1-in-143 for all males and 1-in-417 for all females which translates to male to female ratio of 3:1.

Among the different ethnic groups in Malaysia, NPC is most common among the ethnic Chinese (49%) followed by the natives of Sabah and Sarawak (28%) and Malay (22%). In Sarawak, NPC among Bidayuh accounts for 48.4% of its cases.

The most common age group at presentation is 40-60 years old. However, NPC may occur even in the younger age group where its risk among the male starts increasing from 25 years. The youngest case of NPC was diagnosed at 6 years of age.

HT: What are the possible causes of NPC?

At present, there is no direct genetic mutation that could be linked to NPC. However, we are 3-8 times more likely to develop NPC in our lifetime if we have a positive first-degree relative with NPC.

In terms of lifestyle, smoking and eating salted fish has been shown to be major risk contributors to develop NPC.

Epstein-Barr virus (EBV) infection has also been strongly linked to NPC. It is  a member of the human herpesvirus family and it causes one of the most common human virus infections worldwide. Infection spreads via the saliva of the infected person and the virus persists and remains dormant in the body after infection. Currently, EBV antibodies are used as a screening tool for high-risk individuals for NPC.

HT: What are the standard treatments for NPC?

For newly diagnosed NPC, primary treatment would involve some form of radiotherapy usually in combination with chemotherapy unless the disease is in its very early stages.

The newer generation of radiotherapy, intensity modulated radiotherapy(IMRT), has greatly improved treatment outcomes for NPC while reducing its side effects.

For local recurrent cases (the cancer coming back at or near the same place as the original tumour), advancements in radiotherapy delivery with options of image-guided radiotherapy and CyberKnife® are now available.Surgery excising the nasopharynx (nasopharyngectomy) may also be considered.

For regional recurrence (the tumour has grown into lymph nodes and/or surrounding tissue near the original tumour location) or residual disease in the neck, surgery involving some forms of neck dissection is currently the recommended treatment of choice.

HT: What are the common complications caused by NPC?

As the disease progresses, one of the most debilitating complications arises when the disease invades the base of skull to involve the important cranial nerves in the head and neck region. It can cause blindness, affect the eye movement causing a squint and double vision, numbness over the face, voice change, choking episodes and difficulty swallowing. It can also cause intense headache from the raised pressure within the skull vault.

Distant spread to brain, lungs and bone can cause seizures, difficulty breathing and intense back pain. NPC like any other cancers can be life threatening if not detected early.

Complications from treatment process are due to the side effects of the radiotherapy and chemotherapy. Radiotherapy side effects include excessive dry mouth, oral ulcers, dental caries, osteoradionecrosis and skin burns while chemotherapy can cause toxicity to the ears, heart or kidneys. 

PATIENTS WITH NON- RESOLVING NECK SWELLING, EAR OR NASAL SYMPTOMS SHOULD SEEK MEDICAL ATTENTION EARLY SO AS NOT TO MISS AN EARLY CANCER.

HT: At which stage of NPC will patients have the best chances of survival when treated?

The survival of NPC is markedly improved in the early stages of disease. Cancer outcome is usually measured based on overall 5-year survival.

In stage 1 disease, the 5-year survival is about 90%. Although its outcome is only measured up to 5 years, many patients do remain cured and survive many years beyond. For stage 2 and 3 disease, the 5-year survival drops to 60-70% while for stage IV disease it is less than 40% without distant spread and 0% with distant spread.

Unfortunately, only 10% of cases present with stage 1 disease while over 60% presenting in the later stages of stage 3 and 4 disease. The lack of awareness among the general public and some healthcare providers remain the main stumbling block that prevents early diagnosis of the disease. Patients with non-resolving neck swelling, ear or nasal symptoms should seek medical attention early so as not to miss an early cancer. HT

If you like this article, do subscribe here. 

Words Lim Teck Choon

When most people think about the immune system, they envision white blood cells rushing in the bloodstream to eliminate potentially harmful foreign microorganisms such as bacteria and viruses. Some will also associate lymph nodes with the immune system. There is another often underappreciated component to the immune system: two roundish lumps at the back of the throat known as the tonsils.

ENTirety with

Professor Dato’ Paduka Dr Balwant Singh Gendeh Consultant Ear, Nose & Throat Surgeon Pantai Hospital Kuala Lumpur

The First Line Of Defense Against Infections

The tonsils we commonly think of are called the palatine tonsils. Prof Dr Balwant explains that these are the fleshy tissues located one at each side at the back of our throat or pharynx.

There are also other types of tonsils in our body, all located around the pharynx:

The pharyngeal tonsil, or adenoids, is a mass of tissue located on the roof of the space at the back of the throat (nasopharynx). The adenoids play a role in the immune system during childhood. They shrink as we age and eventually disappear during adulthood.

A pair of tubal tonsils (sometimes called Gerlach’s tonsils) are located on each side of the location where the auditory tube opens into the nasopharynx.

A pair of lingual tonsils are located on the back part of the tongue, one at each side.

These tonsil tissues are arranged to form what is called the Waldeyer’s tonsillar ring. This ring acts as the first ring of defense against infections by microorganisms that find their way in through the nose and mouth.

The tissues in the tonsils are similar to that found in lymph nodes. Like lymph nodes, tonsils can swell in size in the presence of infections.

Hence, our tonsils can serve as an indicator as to whether there is an infection happening in our body. “Tonsils are very necessary for children up to their teenage years,” Prof Dr Balwant reiterates. Hence, the current recommendation among many healthcare professionals these days is to keep the tonsils for as long as possible.

However, swollen tonsils due to infection can also be a painful bother. This condition, called tonsillitis, is ironically the main reason why many people had their tonsils removed in the past – a classic case of shooting the messenger for the bad news!

Heinrich Wilhelm Gottfried von Waldeyer-Hartz was an early 20th century anatomist and lecturer from Germany. He was the first person to detail the structure and function of lymphatic tissue in the neck and throat region, hence the naming of the tonsillar ring after him.

Tonsillitis: The Good & The Pain

Each time we breathe and eat, we are also inviting all kinds of microorganisms into our body. Some bacteria and viruses may be harmful, and often, because the throat is their first “pit stop”, that region becomes infected.

During an infection by bacteria or viruses, the tonsils sometimes become swollen, with white spots often seen on them. This condition is called tonsillitis, and the swollen tonsils are often accompanied by sore throat and fever.

6 Facts about Tonsillitis

1. It can happen at any age, but it commonly affects children from preschool (kindergarten) to mid-teens.

This is because tonsillitis is contagious, and children are frequently exposed to the bacteria and viruses responsible for tonsillitis while playing and mingling with one another at school. The frequent contact is also the reason why children may also experience recurrent tonsillitis.

However, Prof Dr Balwant advises adults who experience recurrent tonsillitis, especially those 30 years old and above, to visit an ENT specialist – the recurrent tonsillitis may be a sign of a more serious problem that needs medical attention.

2. The symptoms of mild tonsillitis – pain, swollen tonsils, fever – usually resolve themselves within a week or so.

However, some viruses and bacteria may cause more serious problems if left to their own devices. For example, the Streptococcus family of bacteria can give rise to strep throat once they infect the tonsils. If left untreated, there is a chance that the infection can advance to affect the blood and the urinary tract.

Therefore, it is advisable to consult a doctor if the tonsillitis is persistent despite us having received treatment over a period of time.

3. Other reasons to see an ENT specialist:

• The tonsils have swollen to an extent that we experience breathing or swallowing difficulties.
• There are swollen lymph nodes at the sides of our neck.
• Tonsillitis is usually accompanied by high fever (over 39ºC).

4. Mild tonsillitis can be treated with antibiotics (if it is caused by bacteria) and plenty of rest.

Prof Dr Balwant also recommends drinking plenty of fluids and gargling with salt water. Lozenges and warm tea mixed with honey can be helpful in providing relief. The doctor may also prescribe pain relief medications if the pain is especially bothersome.

5. While healthcare professionals recommend keeping the tonsils, surgical removal or tonsillectomy is sometimes necessary.

It may be the ideal solution for people who experience persistent, long-term tonsillitis or frequently recurrent tonsillitis. It is also recommended when other conventional treatments do not work.

6. Tonsillectomy may also be necessary if the infection has spread deeper into surrounding throat tissue. This condition, called tonsillar cellulitis, will lead to pus formation in the affected areas. When this occurs, the ENT surgeon will attempt to drain the pus while prescribing antibiotics if bacteria is responsible for the infection. If these efforts fail to yield the desired results, Prof Dr Balwant points out that the infected tonsils may need to be removed at a later date.

Other Tonsil Troubles

Stones In The Tonsils?

The surface of our tonsils isn’t smooth. In fact, there are various crevice-like pockets called crypts. According to Prof Dr Balwant, when bacteria, dead cells, mucus and other substances become trapped in these crypts, they can form soft aggregates that may eventually harden to become tonsil stones.

Symptoms. It is possible for some people to have tonsil stones without realizing this, as these stones may be small and do not cause any discomfort. If the stones grow to larger sizes, however, they may cause the tonsils to swell and give rise to bad breath, discomfort and issues associated with enlarged tonsils (such as difficulties in breathing and swallowing). Ear pain and ongoing cough may also be seen in some people. 

Treatment. Prof Dr Balwant reveals that for smaller tonsil stones, gargling with salt water after every meal may help to dislodge these stones and to reduce bad breath. Antibiotics may be prescribed when necessary to reduce the number of bacteria in the tonsils that contribute to stone formation. For more severe cases, the ENT specialist can remove the stones using a technique called cryptolysis. If all else fails to yield the desired result, tonsillectomy may be necessary.

Tonsil Cancer

Cancer can also develop in the tonsils. Like most cancers, we have not identified the precise causes, but it has been linked to smoking and the human papilloma virus (HPV). People who smoke or have HPV infection tend to have a higher risk of developing tonsil cancer. It can occur at any age, but the risk also increases with age.

Prof Dr Balwant adds that when cancer develops, usually only one tonsil is involved.

HPV is most commonly transmitted through oral, vaginal and anal intercourse, and people infected with HPV may not show any symptoms. Fortunately, HPV vaccines are available to protect against infection by the virus.

Symptoms. The early symptoms of tonsil cancer may be mistaken as those for strep throat, hence it may be worth visiting an ENT specialist when someone 30 years old and above has persistent, non-healing sore throat.

Other symptoms can include:

• One tonsil noticeably larger than the other
• Difficulties and/or pain when chewing, swallowing and speaking
• Blood in the saliva
• Swelling in the neck
• Severe ear pain
• Unintentional weight loss

Treatment. Early stage cancer treatment includes surgical removal of the affected tonsil followed by radiation therapy to kill any remaining cancer cells present in the region. For more advanced cancer, chemotherapy will also be included as part of the treatment regime, and more advanced surgery may also be necessary. Like most cancers, better treatment outcome is more likely if the cancer is detected at an early stage. HT

If you like this article, do subscribe here. 

WORDS Hannah May-Lee Wong

Dr Lau Lake Koon Implant & Aesthetic Dentist

 

World Oral Health Day falls on March 20^th every year. The global awareness day highlights the importance of keeping good oral hygiene and reminds us that oral health comprises a big part of every individual’s wellbeing. Yearly, the World Dental Federation (FDI) focuses on a specific theme and this year, it’s “Say Ahh: Act on Mouth Health”. The campaign aims to encourage everyone to walk the talk, and actively take measures to improve their oral health.

Anyone remember the Academy Award winning movie Cast Away (2000) starring Tom Hanks? It talks about a FedEx employee who was on-board a plane that crashed into the sea. Although he survived, he was “cast away” to an uninhabited island. Before he got on the ill-fated plane, he was suffering a bad toothache and kept putting off going to the dentist to get it checked. As a result, he was left on an island with no dentist and was forced to extract his tooth himself (ouch!). Let’s not be that character. We don’t have to wait for a toothache to pay our dentists a visit. Beyond that, we should also diligently care for our teeth and encourage our children to do the same.

This World Oral Health Day, HealthToday chats with friendly local dentist, Dr Lau Lake Koon, as he graciously answers a series of frequently asked questions:

We’re curious to know, how would you as a dentist define good oral health?

The human mouth, just like the gut and other parts of the body, contains good and bad bacteria. A balance of these good and bad bacteria maintains healthy functioning of the body. Good oral health to me is defined by maintaining an optimum number of good bacteria against bad bacteria in the mouth. This can only be attained through practicing good oral hygiene, having a healthy diet and having a healthy body.

Your dentist, through your regular check-ups, should be able to identify any dental issues that may exist, treat them and educate you on how to care for your teeth. That said, it is important that you as a patient consistently practice good oral hygiene and carry out whatever that was prescribed to you by your dentist. Frequent visits to the dentist will catch existing problems in the early stages. This is a good thing because as the saying goes, prevention is better than cure.

We often hear dental experts telling us we don’t brush our teeth long enough for us to get a good clean. How long should we brush our teeth for, and how often?

Brushing your teeth, the proper way for approximately two minutes each time should be enough to keep the teeth clean. There are many ways of brushing your teeth and your dentist will show you what’s best for you. Generally, I recommend brushing with the Bass technique, which includes brushing under the gumline with the toothbrush at a 45-degree tilt.¹ That said, I rarely advise my patients to brush for longer. In fact, the more common problems I see daily arise from:

1. Not flossing
2. Not brushing at night before sleeping
3. Not brushing correctly

It is during our sleep that our mouths have a warm, stable environment that goes uninterrupted for hours. This kind of environment is most suitable for bacterial growth. If there are food debris and bacteria in the mouth, bacteria will grow exponentially. This can increase the risk of developing cavities and the formation of tartar (plaque that stays and hardens on your teeth) which leads to gum disease.²

The most important advice I give to patients is to brush their teeth at night, right before sleeping. It’s a simple procedure that will go a long way in keeping teeth healthy. It is recommended to brush twice a day: in the morning and at night before sleeping.

Are electric toothbrushes better than normal toothbrushes?

With the advent of stronger formulated toothpaste brands, more awareness on oral care, better oral care techniques and better designed toothbrushes, it is not necessary to use an electric toothbrush.

In my practice, there are two extreme groups of patients:

The first group consists of those who do not take care of their teeth at all and require lots of education to change their habits. In these cases, I would need to resolve all their dental issues, restore dental functioning and aesthetic, and rehabilitate the patient, for them to take care of their teeth effectively in the future. This group would benefit from using an electric toothbrush.

The second group consists of those who are experts in their oral care regime. They use the latest electric toothbrushes despite not really needing them. In some cases, the over-brushing can cause the tooth enamel (the hard, outer layer of the teeth) to be worn out and cause sensitive teeth. These people should stop using electric toothbrushes.

In summary, electric toothbrushes should be reserved for those who are unable to care for their teeth (for example, those with Parkinson’s disease or are handicapped), those with very bad dental conditions or those who have severe stains from smoking or drinking tea, coffee or wine. In most cases, a normal toothbrush is more than enough to keep your teeth clean. It is important to check with your dentist what’s most suitable for you.

How often should we pay our dentists a visit?

It is recommended that a person with no outstanding dental issues visits the dentist every 6 months.

Cavities and gum disease are quite common among us. What causes them and how do we prevent them?

Cavities are mostly caused by taking sweet food or drinks. But one must understand, it is the frequency or exposure time to the sweet items, and not the amount consumed, that causes cavities.

For example, a person who drinks two cups of coffee in 15 minutes every morning will have much less incidences of dental caries (tooth decay) compared to a person who drinks one cup of coffee over a four-hour period every morning.

Gum disease is caused by a gradual build-up of plaque and tartar on the tooth surfaces. If these are left long enough, it causes gum infection. Gum bleeding is a sign of gum infection. This is also the main cause of gum recession and shaky teeth in one’s old age.

Why do some people have sensitive teeth and what are the best ways of dealing with it?

Besides over-brushing with an electric toothbrush or using overly strong formulated toothpaste, gum recession (from gum disease) and cavities can also cause sensitivity. The best thing to do is to make an appointment for a dental check-up as soon as possible.

Let’s talk about teeth whitening. Do whitening toothpastes work? What is the most effective way of whitening our teeth to look good?

Whitening toothpaste is an example of stronger formulated toothpaste brands. They contain higher levels of abrasive particles. They are more effective in removing stains and debris on the teeth. However, on a clean tooth surface, whitening toothpastes will not make teeth get whiter. On a stained and dirty tooth, whitening toothpastes will be more effective in removing the stains, thus the teeth look cleaner — NOT whiter.

Professional whitening done by dentists use approved chemicals with or without laser and they do not cause long-term side effects. These whiten the teeth beyond their original colour.

What can we do to avoid bad breath?

Most bad breath is caused by ineffective brushing techniques, not flossing, not brushing the tongue and indigestion issues. If the mouth still harbours large numbers of bacteria or rotting foodstuff, it will smell.

How about food? Is staying away from sugary food really the key to having good teeth?

Everything is about moderation. As I tell my patients, you must enjoy your life! But how you enjoy your cup of coffee or wine is important. Finish your coffee within 20 mins to reduce exposure time. Try to limit yourselves to a max of 2 sweet drinks a day, preferably during meal times so that your teeth can recover in-between meals. After a night of having wine, remember to brush your teeth before sleeping — don’t let the strong wine stains linger and bind onto the teeth surfaces. Overall, if you take care of your teeth, you can enjoy them for a much longer time.

How about caring for children’s teeth? Is it different from an adult’s oral hygiene routine?

It is important to instil good oral hygiene habits from young. I often start coaching parents about oral care for children, even before the baby is born. My advice:

After birth: It is important to gently wipe your baby’s gums with a clean wet cloth after every milk feeding.

6 months: The first front teeth will appear when the baby is approximately 6 months old. You should continue wiping with a clean wet cloth until the age of 1 to 1.5 years old. Make sure your children understand that they must have their teeth cleaned by their parents before sleeping every night and upon waking up every morning.

1.5 to 2 years old: Parents can start using small baby toothbrushes to brush their children’s teeth. Parents should brush for their children first, then let their children practice brushing after. This should go on until the child is 7 years of age. After that, continuous supervision should be sufficient. Non-fluoride toothpaste brands should be used until the child does not swallow toothpaste anymore (usually by 7 years of age). Parents should bring their children for dental check-ups every six months, as there are many changes happening in a growing child’s teeth.

References:

1. https://www.colgate.com/en-us/oral-health/basics/brushing-and-flossing/3-tooth-brushing-techniques-that-get-the-job-done
2. https://www.webmd.com/oral-health/guide/tartar-dental-calculus-overview#1

If you like this article, do subscribe here. 

WORDS PANK JIT SIN

Hi there. It’s me. Your friendly neighbourhood health writer. World Asthma Day is around the corner and there are important things you need to be reminded about it.

 

1. Asthma is a chronic disease. It affects your airways leading to the lungs. While you may have heard of someone growing out of asthma, the truth is their airways have broadened or their symptoms lessened.
2. Asthma can strike at any age. Just because you didn’t have asthma as a child, it doesn’t mean you’re scot-free. In fact, older people who develop asthma may have a difficult journey in getting diagnosed, as it is similar in symptoms to diseases such as emphysema and heart disease.
3. My kid will never be a competitive sportsperson! Well, you’re wrong. Proper management of symptoms will allow a child to lead a normal life and this includes being competitive in sports and even going on to achieve greatness. David Beckham (the world-famous footballer), Jackie Joyner Kersee (the Olympian) and Kashyap Parupalli (an elite Indian badminton player) all achieved greatness in spite of asthma.
4. Steroids in the inhalers will cause problems in my kids when they grow up. The misinformation about steroids in inhalers have been going on for generations. It needs to stop. The amount of steroid in each puff is miniscule. The steroids used in asthma inhalers are very safe and have a very low risk of side effects even over many years of use.
5. Not everyone experiences the same symptoms. Symptoms may differ from person to person. Because of this, treatment for every asthma sufferer is also different. Some may need larger doses of inhalers; some may even need to take oral steroids to bring their airway inflammation under control. The key message here is—please visit your doctor regularly for checkups and maintenance.

Every year, the worldwide authority in asthma management decides on a theme and helps empower organizers around the world to undertake their own World Asthma Day event. The body is known as Global Initiative for Asthma or GINA. GINA collects scientific information from existing research and updates the guidelines on asthma treatment periodically.

This year’s theme is ‘STOP for Asthma,’ with STOP being the acronym for Symptom evaluation; Test response, Observe and assess and Proceed to adjust treatment. The acronym is for doctors to quickly recall the steps to undertake each time they see patients with asthma. It is also helpful for persons with asthma to know the basic steps in managing and modifying their treatment each time they go for a follow up with their doctor.

Remember, asthma doesn’t need to be problematic and does not translate to a poorer quality of life. All you need to do is get it under control. The sky is still the limit! HT

If you like this article, do subscribe here. 

WORDS MAK WEN YAO

On every first Tuesday of May, health advocacy groups and educators from around the globe celebrate World Asthma Day where they strive to improve awareness of the airway disease. As asthma continues to burden both the patients and the health system, it is high time for us to further understand what asthma really is, and what we can do to minimise its impact.

UNDERSTANDING WHAT ASTHMA REALLY IS

Asthma is a chronic condition where the airways become inflamed and stimulated to produce excessive sticky mucus. The bronchial tubes of an asthmatic patient, or the air passageway that connects the windpipe to the lungs, will become narrow as the muscles surrounding them constrict in response to the noxious external stimuli. As these tubes struggle to remain open, the patient’s ability to breathe also becomes compromised. 

An asthma attack is frequently described as having to struggle to draw a full breath, often accompanied by coughing, wheezing, and an overall tightness across the chest. When the airway becomes constricted and obstructed by thick mucus, the patient has to spend every ounce of energy just to draw in enough oxygen to make it to  the next breath. This could be a harrowing experience to patients and uninformed family members. Some patients say, “It’s like drowning in air.”

However, people with asthma may experience the disease in other ways. The condition is largely dependent upon the types of the trigger and other aggravating factors. A mild attack could last only minutes and resolve spontaneously without any treatment, while severe attacks could span hours and may require hospitalisation.

Asthma is a non-communicable disease that is common among children but can affect adults as well. According to the National Health and Morbidity Survey in 2011, more than 1-in-20 Malaysians self-reported that they suffered from asthma (6.4%). In addition, many patients or family members are not fully aware of the disease symptoms or the appropriate management of the condition. The head of the Ministry of Health’s Pulmonology Services, Dr Jamalul Azizi Abdul Rahaman, once said that out of 2 million patients with asthma, only 6% were well controlled. “There is low awareness of the disease, leading to poor compliance,” said Dr Jamalul Azizi.

COMMON CAUSES OF ASTHMA ATTACK

1. POLLUTION                        
2. PETS                         
3. DUST               
4. CHEMICALS                
5. MOLD

Although we have yet to completely understand the fundamental causes of asthma, we now know that the exposure to certain environmental particles or inhaled substances could cause an asthma attack.

Research has revealed a delicate interplay between the physical and psychological components of an asthmatic patient. Available scientific evidence points to a relationship between heightened emotional arousal, such as extreme anger or fear, and dyspnoea—difficulties in breathing—in asthmatic patients.

 Certain household medicines could trigger an attack as well. Aspirin and a group of painkillers known as the non-steroidal anti-inflammatory drugs (NSAIDs) may cause symptoms in certain patient populations. NSAIDs such as ibuprofen or naproxen are thought to increase the production of some pro-inflammatory chemicals in our body that can cause asthma attacks.

It is important to understand that asthma may not always manifest in the same way. Each individual may respond differently even if they were exposed to the same aggravating factor. It would be essential to understand how the body reacts when exposed to a potential allergen and take the appropriate steps as recommended by the doctor.

ASTHMA TREATMENT AND CARE

While there is currently no cure for asthma, the condition can be well controlled if managed appropriately. Advances in medical care allow asthma medicine to be directly administered into the lungs,thus bypassing many unwanted side effects associated with systemic treatment method. The inhaler is, by far, the most extensively used option, but certain patients may have to use a nebuliser (a machine that helps one breathe in the medicine as a mist through a mask or a mouthpiece) or depend on oral medicine as an add-on treatment to the inhaler.

The array of treatment options and medical devices can be confusing. It is important to discuss any treatment option with your doctor and pharmacist in order to gain the best benefits and avoid any asthma emergency.

There are generally two types of asthma treatment:

1. The quick reliever

• functions as the rescue medicine to rapidly relax muscles around the airway during an asthma attack.
• relieves symptoms of breathlessness and helps the patients to regain control of their breathing.

For example, short-acting beta- agonists.

2. Long-term controller medicine

•  functions to prevent asthma attacks.
• reduces inflammation of the airway, making it less likely for allergens to trigger an attack.
• may be given in a combination of inhaled and oral medicine.

For example, long- acting beta-agonists that relax the airway muscles and corticosteroids that reduce airway inflammation and swelling.

USEFUL TIPS

Are you using your inhaler properly?

1. Always shake the inhaler canister before use. This action will mix the active drug well with the propellant to deliver the right dose into the lungs.
2. Your lips should form a tight seal around the inhaler to ensure the dose reaches its target.
3. Time your breathing appropriately while using the inhaler. Breathe out completely and take a deep breath while pressing the canister.
4. Hold your breath for around 10 seconds with your lips closed and then breathe out slowly after a puff is delivered to allow for the medicine to exert its effect.
5. If your doctor prescribed a second puff, wait for about 1 minute. Then, repeat the steps 1-4. HT

If you like this article, do subscribe here. 

Words Lim Teck Choon 

ENTirety with Professor Dato’ Paduka Dr Balwant Singh Gendeh Consultant Ear, Nose & Throat Surgeon Pantai Hospital Kuala Lumpur

 

Unlike our eyes, our ears do not have any protective lids to keep things from finding their way inside. Perhaps unsurprisingly, ear discomfort is common among those who spend a considerable amount of time in water. We have terms such as ‘surfer’s ear’, which describes a condition in which lumpy bony growth forms in the ear canal due to prolonged irritation from cold and wet conditions. More common, though is ‘swimmer’s ear’, which describes ear discomfort such as pain, redness and swelling.

Swimmer’s ear is commonly attributed to water finding itself into the ear, but the actual cause is infection. The medical term for swimmer’s ear is otitis externa, and it can happen to anyone, not just swimmers.

Let’s find out more about otitis externa this month with Professor Dato’ Paduka Dr Balwant Singh Gendeh.

WHEN OUR EAR CANAL HAS UNINVITED GUESTS

Otitis externa is an infection in the ear canal. Bacteria such as Staphylococcus aureus are the most common unwanted guests that trigger this infection, but it is also possible for fungi (such as Candida albicans) to trigger an infection.

Such infection commonly affects swimmers and other people whose ears are in contact with water for a simple reason: the water that gets into the ear creates a moist environment that encourages the unwanted guests in the ear canal to increase in numbers large enough to cause an infection.

However, Prof Dr Balwant points out that otitis externa is not just a swimmer’s problem. Anyone can be affected by it, so long as certain conditions are present for the unwanted guests to thrive in the ear canal.

“IF WE MAKE IT A HABIT TO REMOVE EARWAX TOO OFTEN, WE ARE MAKING OUR EAR CANAL MORE VULNERABLE TO UNWANTED GUESTS.”

A suitable environment. Our ear canal is dark and warm, which makes it a great place for many bacteria and fungi to move in and live. These guests feed on the dead skin, secretions and various other substances trapped among the fine hairs in the ear canal.

Moisture. Even if we don’t swim regularly, our unwanted guests rarely worry about being deprived of moisture. This is because we live in a tropical climate, where it is humid all year long!

WAIT, SO OUR EARS ARE ALWAYS VULNERABLE TO THESE UNWANTED GUESTS?

Not always. As Prof Dr Balwant points out, our ear has its own defense mechanism – our earwax. Earwax, or cerumen, is secreted in the ear canal and it is an acidic substance containing enzymes that inhibit the growth of bacteria and fungi. It also traps and removes debris and other substances that nourish these unwanted guests.

However, this is not a fool-proof mechanism. Excessive moisture spilling into the ear canal can dislodge the cerumen coating the ear canal. If we make it a habit to remove earwax too often, we are also making our ear canal more vulnerable to these unwanted guests.

1. Therefore, we should always dry our ears as much as possible after a bath, a swim or a hot sweaty day.
2. Also, we should only clean our ear canal once in about every three weeks.
3. We should also avoid inserting our fingers or foreign objects into our ear canals.

WHAT HAPPENS AFTER THE UNWANTED GUESTS MOVE IN?

Prof Dr Balwant points out that so long as our unwanted guests are living happily in our ear canal, there is a risk of infection. This is because the skin lining the ear canal  is very thin, unlike the skin lining elsewhere. Hence, it can be damaged easily due to frequent ear picking resulting in recurrent ear infection.

When there is a tear in the skin, the unwanted guests can move inside. This will trigger our immune system to react and get rid of these guests, resulting in the inflammation seen in otitis externa. The thinness of the ear canal lining and the ease in which it becomes damaged can cause recurrent infection.

LET’S HEAR MORE ABOUT THE SIGNS & TREATMENT OF OTITIS EXTERNA

WHAT ARE THE SYMPTOMS?

• Ear discomfort (otalgia), such as itchiness, ‘fullness’ inside the ear due to swelling, and pain that radiates to the face, neck and side of the head.
• Ear discharge (otorrhoea).
• Some hearing loss (usually temporary).

ARE THERE ANY LONG-TERM COMPLICATIONS?

If not treated properly, the infection can spread over time into surrounding tissues and even nearby bones. Increasingly severe hearing loss may also result.

These complications will require more complex treatments, possibly even surgery.

HOW IS OTITIS EXTERNA TREATED?

Prof Dr Balwant explains that most mild cases can be successfully treated using appropriate topical medications (such as eardrops, ointments or creams). If we are unsure as to what to do, we can seek advice from a general practitioner.

If still no improvements are seen, or if the symptoms are severe, it may be time to visit an ENT specialist.

HOW CAN THE ENT SPECIALIST HELP?

To properly clean the ear canal. The ear canal of someone with otitis externa is often clogged with earwax, debris and various secretions. (In fact, long standing impacted wax is one of the common causes of otitis externa!).

The ENT specialist will perform a procedure called ‘ear toilet’ or rarely  ‘flushing’.  Guided by direct visualization from a device called the otoscope, the specialist will use a medical device to create a gentle suction in order to clean the ear canal. If the debris and  secretions are thick and hard to dislodge through suction alone, the ENT specialist can use antibiotic or hydrogen peroxide droplets to soften them first.

To inspect the eardrum. Our eardrum allows us to hear. It is also a thin piece of tissue. During an infection, the weakened eardrum is especially vulnerable to damage.

The ENT specialist will inspect the eardrum to ensure that it is in good shape. If the eardrum is damaged, the use of water and other fluids (such as eardrops) will be avoided, as doing so may cause damage to other ear structures normally protected behind an intact eardrum.

Damaged eardrum can usually heal on its own after a few months, although sometimes surgery may be necessary. Treatment is determined on a case-by-case basis, so our ENT specialist may advise us on our options after performing an examination.

To determine the nature of the uninvited guests in our ear canal. Oral or topical antibiotics can help with getting rid of bacteria, but they do not work on fungi and viruses. Therefore, determining the type of the microorganisms that are giving us so much problem will allow the ENT specialist to prescribe the best treatment option.

What If Otitis Externa Keeps Coming Back?

Some people may experience long-term infection called chronic otitis externa. It’s more common among people with existing chronic skin- related diseases, such as eczema and psoriasis, as well as people with diabetes or conditions that affect the ability of their immune system to fight infections properly. People with chronic otitis externa should consult an ENT specialist for a proper treatment plan tailored for their conditions instead of self- medicating. HT

If you like this article, do subscribe here. 

WORDS PANK JIT SIN Almost everyone has a handy bottle of hand sanitizer in their pocket or handbag. These sanitizing products are either gel or liquid based and use alcohol as their main antibacterial and antiviral agent. Some have added chemicals like triclosan and triclocarban. The US Food and Drug Administration (FDA) recently banned the addition of triclosan in soaps and other sanitizing products such as hospital cleaning agents. They didn’t want bacteria to develop resistance to the chemical and render it ineffective in disinfecting hospitals and healthcare settings. HealthToday takes a closer look at triclosan in sanitizers to see how they affect our health. What doesn’t kill you As the saying goes, what doesn’t kill you makes you stronger. The same holds true for bacteria and viruses. At the top of the list is the risk of antimicrobial resistance to products containing triclosan. Hospitals and clinics use disinfecting products containing active ingredients like triclosan and possibly other antiseptics under the assumption these chemicals will kill all germs. If we were to use sanitizers containing the same germicides, the germs will slowly get used to the chemicals and develop resistance. A Canadian study in 2011 found that healthcare workers who used hand sanitizers were significantly more likely to fall ill compared to their colleagues who preferred to use soap and water. It looks like food Sanitizers have caused accidental poisoning of children. Some parents can be overzealous in keeping their children’s hands clean using sanitizers. Children like to put their hands in their mouths, and this will introduce alcohol and other additives found in hand sanitizers into their digestive system. Worse still, some sanitizers are attractive to young children who may drink it and suffer alcohol poisoning, which can lead to low blood sugar, coma and seizures. It can mess with your hormones Triclosan exposure has been associated with changes in thyroid gland, which produces hormones that regulate various body functions, and testosterone levels. It also increases oestrogen sensitivity of cells, thereby potentially speeding up puberty in girls and may have negative effect on boys. The evidence comes from studies on rats which involve oestrogen receptors. People also have oestrogen receptors so triclosan probably has similar effects on them. It can mess with your immune system Triclosan has been associated with an increased likelihood of developing allergies in a US study. While triclosan looks to be the major bad guy found in sanitizers, the US FDA also banned 28 other ingredients including, benzethonium chloride, chloroxylenol, chlorhexidine gluconate, and many more. In essence, FDA is telling users to stick to regular soap and water for their cleaning needs. Soap is a surfactant, which means it makes the surface slippery and prevents things from sticking to it. Lathering our hands with soap dislodges small particles and rinsing with water effectively washes them away, leaving our hands clean.   If you like this article, do subscribe here.

WORDS ABRAHAM MATHEW SAJI

Our liver is one of the major internal organs of our body that works nonstop to purify our blood as well as to produce and store essential micronutrients that are required by our body. When the liver is infected or sore, it fails to perform its functions and this results in the signs and symptoms manifested by hepatitis. The word hepatitis is a combination of hēpar or hēpat, which means liver in ancient Greek, and itis (the Greek word for inflammation). Thus, hepatitis simply means inflammation of the liver.

1. What Are The Causes Of Hepatitis?

Inflammation of the liver can be caused by various conditions, illnesses, some foods and drinks, certain medications and also viruses. Speaking about viruses, virus types A, B, C, D, E, F and G have been reported to cause infectious hepatitis. With medical advances and our quest for knowledge, the alphabetical list will only get longer. The most common are hepatitis A virus (HAV), hepatitis B virus (HBV) and hepatitis C virus (HCV). Of these, HBV and HCV can cause chronic hepatitis that can lead to conditions of liver cirrhosis and also liver cancer if left untreated.

Hepatitis A infections are often mild and can be treated easily compared to the others. Upon treatment and recovery, patients get immune to the virus. There is also a safe and effective vaccine available. This type is more common in places with poor hygiene and sanitation conditions.

Hepatitis B and hepatitis C infections can be caused by one or more of the following:

• Sharing needle with infected person
• Having unprotected sex with infected person
• Sharing personal items like toothbrush and razor blade with infected person
• Receiving a blood transfusion from an infected person
• Having a tattoo created using an unsterile or infected needl
• Bitten by an infected person
• Through lactation from an infected mother
• When the virus enter through a break in the skin.

Both HBV and HCV infections are treatable, depending on the severity of the infection. There is a safe and effective vaccine available to protect us from HBV. However, there is no vaccine yet against HCV. Ongoing research and medical advances may result in more effective prevention and treatment options soon.

2. What Are The Symptoms Of Hepatitis?

From the time when a person is infected with the virus to the development of symptoms is known as the incubation period. Each type of virus has varying incubation periods eg, 15–45 days for HAV, 45–160 days for HBV and 14–180 days for HCV. At the initial stages—also referred to as acute phase—some of the common symptoms are:

• mild-to-moderate fever
• loss of appetite
• fatigue muscle and joint aches
• nausea
• vomiting
• diarrhoea
• abdominal pain
• weight loss.

Symptoms of chronic hepatitis

 When the acute phase is left untreated, the disease progresses to the long-term (chronic) phase with the following symptoms:

• moderate-to-high fever
• jaundice
• abdominal swelling
• swelling of lower extremities of the body
• yellowness of skin, eyes and tongue (jaundice)
• blood in vomit or faeces
• itchy skin
• dark urine
• hives
• liver cirrhosis
• increase in liver enzymes and tumour markers
• liver cancer.

3. How Is Hepatitis Diagnosed?

As the symptoms of most infectious hepatitis are common, the diagnosis of the type and degree of infection can be done by thorough laboratory investigations like:

• Pathological blood tests that can detect the levels of enzymes, proteins and antibodies
• Pathological nucleic acid tests that can confirm the type of virus and its numbers
• Scans that can detect inflammation and any damage to surface of the liver
• Paracentesis, where a sample of the abdominal fluid is extracted and tested
• Liver biopsy that can detect cancer and extent of liver damage
• Elastography that measures stiffness of the liver
• Liver function tests that can help to identify liver disease.

4. What Are The Treatment Options For Hepatitis?

There is a wide array of treatment options available today and will depend on factors like:

• Type of infection
• Degree of infection
• Age and other underlying conditions of the person.

The treatment dose and duration may also be prolonged based on any or more of the above factors. Advances in research have seen treatment options moving from chemical-based medications to biotechnological interventions like monoclonal antibodies.

5. How Can We Prevent Hepatitis?

As the old adage goes, “An ounce of prevention is better than a pound of cure.” Some of the steps we can take to prevent being infected by hepatitis viruses are:

• Avoid injecting illegal substances into our body
• Avoid sharing of needles, toothbrushes, razors and other personal care items
• Practice safe sex
• Seek and share information with partner about any infection
• Wash hands properly with soap and water after using the toilet
• Consume safe drinking water
• Eat clean and fresh foods
• Ensure needles used in body piercing or tattoo have been sterilized
• Avoid or drink moderate amounts of alcohol
• Consult doctor for vaccination against HAV and HBV.

6. Love your Liver!

Here are some key steps we can take to ensure our liver stays healthy:

• Eat healthy and balanced meals
• Eat small portions of meals that can be easily digested
• Exercise regularly
• Maintain a healthy weight
• Avoid or drink moderate amounts of alcohol
• Consult doctor to ensure the medications we take don’t harm our liver
• Consult doctor before taking supplements

7. Is Recovery Possible?

Complete recovery from infectious hepatitis can be considered when:

• The causative virus has been completely removed from the bloodstream and liver
• Antibodies have been detected in the blood pointing to immunity
• The associated symptoms, which occurred during the infectious state have improved.

8. What Is The Situation In Malaysia?

In 2017, there was an estimated 1 million people who were chronically infected with HBV and an approximate 800,000 were positive for antibody to HCV. An effective nationwide vaccine coverage and the availability of affordable and effective treatment, which has been made possible by the Ministry of Health have been the reasons for these numbers being under control. Based on the newborn vaccination schedule, every newborn would have been immunized against HBV by the age of 6 months, with progressive doses at 1, 2 and 6 months. HT

If you like this article, do subscribe here. 

Dr Andrew Chan Kieng Hock

Consultant Oral Surgeon Private Dental practice

Klang, Selangor.

Wisdom tooth surgery is one of the most common minor oral surgical procedures performed in the dental clinic setting by a dentist, often under local anaesthesia (LA). But some complex and challenging cases are best undertaken by a trained consultant oral surgeon or an oral and maxillofacial surgeon, to minimize post-operative side- effects. Dr Andrew Chan Kieng Hock explains the finer points of wisdom tooth surgery and how to survive it with as little discomfort as possible.

Figure 1: Panoramic radiograph showing impacted lower left wisdom tooth.

Photos by Dr Andrew Chan Kieng Hock

Figure 2: Clinical view of the partially impacted tooth.

To Remove Or To Retain?

Usually, a wisdom tooth—or better known as a third molar— erupts in the oral cavity between the ages of 18 and 25 years. However, it is not uncommon for a wisdom tooth to emerge at a later date in some people. As a matter of fact, this tooth is the last molar and the final adult tooth to erupt. Most people will feel some form of discomfort, pain, swelling, or even fever during the phase of eruption.

The accurate definition of an impacted tooth means a failure to completely erupt into a normal functional chewing position due to insufficient space (limited jaw arch); an obstruction by another tooth; an abnormal development of a tooth position (ectopic position); and sometimes, but very rarely, due to a tooth being fused (ankylosed) with the alveolar bone.

A tooth is said to be completely impacted if it is entirely covered by the gum and/or the alveolar bone in the jaw hence rendering it clinically invisible. A partially impacted tooth is clinically visible but has failed to reach the functional chewing position.

Some studies among adults show that the prevalence of one or more impacted wisdom teeth is around 25% to 73%. The reason for the huge difference is mainly due to the fact that some dentists in certain countries believe strongly in prophylactic or preventive removal of asymptomatic wisdom tooth while dentists from other countries don’t. There are obvious differences in the consensus among dental practitioners from country to country. To overcome the differences, several established dental bodies and healthcare policymakers have produced certain guidelines and best clinical practice which are regularly updated to help surgeons make a more sound and objective decision in the management of impacted wisdom tooth. One such guideline is by the UK National Institute for Health and Care Excellence (NICE).

In this article, some of the more common reasons for surgical removal of impacted wisdom tooth and its associated side- effects are discussed.

Figure 3: Panoramic radiograph showing right lower wisdom tooth associated with dentigerous cyst.

Indications To Remove A Wisdom Tooth

There are various valid reasons to remove an impacted wisdom tooth before it develops harmful side-effects. Each tooth and each individual’s circumstances are unique. Therefore, the decision to remove must be solely based on careful risk-benefit assessment.

If a tooth is at high risk of developing a disease, the decision to remove it is justifiable. On the other hand, removing a healthy tooth is unjustifiable.

The following summarizes the most common indications for removal:

• Unrestorable dental decay due to area of food and plaque stagnation between the wisdom tooth and the adjacent molar.
• Non-treatable pulpal/ periapical infection
• Infection under the gum flap of the tooth (pericoronitis). Cited as the most frequent reason for removal of impacted wisdom tooth but only after the second or subsequent episodes unless the first attack is very severe. Occasionally, the surgeon may decide to just excise the gum flap (operculectomy) using a blade or a laser to facilitate the tooth eruption. However, the risk of recurrence is always a possibility.
• Widespread inflammation of soft tissue (cellulitis); collection of pus (abscess); and bone infection (osteomyelitis), all of which are usually due to untreated pericoronitis.
• Braces (orthodontic) considerations whereby, wisdom teeth must be removed for proper retraction and alignment of the upper and lower teeth. However, there is little evidence at the moment to support the removal of wisdom teeth solely to prevent crowding of front teeth.
• Prophylactic removal due to specific and serious medical and surgical conditions such as abnormal heart valves which are prone to infective endocarditis, organ transplants, hip and joint replacement implants; chemotherapy, and radiotherapy.
• To facilitate tooth restoration including dental prosthesis. For example, an impacted wisdom tooth under an existing denture.
• Internal/external tooth resorption including the adjacent tooth.
• Tooth in the line of fracture which will hinder the management and healing process.
• Fractured wisdom tooth.
• Cyst/tumour development such as dentigerous cyst and ameloblastoma.
• Tooth hindering reconstruction jaw surgery.Tooth involved in the zone/ field of radiation or tumour resection.
• Tooth used to act as a suitable donor for intentional tooth transplantation.

If surgical intervention is not warranted, a constant periodic monitoring every 6 to 12 months by clinical or radiograph examination is essential because of the future changes in position and/or pathology. The relative risk of retaining an impacted wisdom tooth must be discussed thoroughly with all patients concerned.

In some rare  instances, the person’s occupation or circumstances may necessitate them to be away from accessing dental healthcare facility. For instance, soldiers, navy personnel, astronauts, oil and gas explorers, or even overseas students. In such instances, the decision to remove the wisdom tooth earlier than later is justifiable.

Another pertinent issue is regarding the removal of opposing or contralateral tooth. It is generally agreed that if the offending tooth is associated with the criteria, removal is warranted.

Figure 4: Surgical removal of both the upper and lower wisdom teeth.

Wisdom Tooth Surgery: What To Expect?

The surgical procedure is usually straightforward for simple cases and has a minimum potential risk and morbidity when performed by a competent surgeon using sound surgical technique. The surgeon will take appropriate medical and dental history; clinical examination, and a diagnostic radiograph before the onset of the surgery. The imaging is required to identify clearly the position of the tooth and the proximity of nearby vital structures such as the inferior alveolar nerve in relation to the wisdom tooth.

In a dental clinic setting, the procedure is most often performed under local anaesthesia or supplemented by intravenous (IV) sedation. Sometimes, it can also be performed under general anaesthesia (GA) in a hospital setting, if need be, in such cases as removal of all four wisdom teeth concurrently, or if the tooth is associated with cyst/ tumour management.

Appropriate post-operative painkillers, antibiotics, and anti-swelling medications are normally prescribed after the surgery. It is important to maintain good oral hygiene besides taking all the necessary medications throughout the healing process.

The recovery of wisdom tooth surgery, under proper care, is usually uneventful with some swelling, pain, discomfort and limitation of mouth opening. All these symptoms will resolve within a week or so. But unfavourable surgical outcomes is inevitable in some rare complex cases which include prolonged bleeding or swelling; prolonged pain, development of dry-socket (alveolar osteitis); severe lockjaw (trismus); local and/or systemic infection; osteomyelitis, violation of vital nerve structures which causes temporary or permanent numbness (paraesthesia); jaw fracture, and creation of sinus communication (oroantral fistula).

In conclusion, the verdict to remove or retain a wisdom tooth can be a daunting task to many people, and present challenges even to a practising dentist. As discussed, there are numerous factors influencing the risk and benefits in the management of wisdom tooth. Therefore, a comprehensive pre-surgical and diagnostic assessment is crucial in making the final decision after taking into consideration all the specific circumstances and the needs of each individual. A careful and competent practitioner would always keep in mind that there is no ‘one-size- fits-all’ remedy and each case should be assessed separately and carefully. HT

If you like this article, do subscribe here.