Category: Top to Toe

Dr Andrew Chan Kieng Hock

Consultant Oral Surgeon

Private Dental practice Klang, Selangor.

Our oral cavity is part and parcel of our body. So, there is undeniably an inter- relationship between oral disease and systemic disease where oral infections such as gum disease is linked to certain medical conditions such as heart disease, diabetes and pregnancy. There is, in fact, a large body of evidence of such an association, especially in the last 2 decades or so. Dr Andrew Chan Kieng Hock discusses the impact of gum disease on certain medical conditions.

Gum disease, a common oral disease

Gum disease is a common oral disease, which leads to tooth loss in adults worldwide. Accord- ing to the National Oral Health Survey of Adults (NOHSA) 2010 conducted by the Oral Health Division of Ministry of Health Malaysia, the prevalence of gum disease for all levels of severity was approximately 94% in den- tate group (>15 years old) and approximately 18% for severe periodontal disease (deep pocket ≥6 mm).1

There are two major types of gum disease, namely gingivitis and periodontitis. In the case of gin- givitis, the inflammatory disease is confined to the surrounding gum tissues without affecting the connective tissue attachment. But periodontitis is more severe and characterized by destruction of the underlying tooth-supporting structures such as the periodontal ligament, the alveolar bone and the cementum. It is important to note that not all cases of gingivitis will ultimately progress to peri- odontitis if patients receive timely effective treatment.

Early warning signs and symptoms of gum disease are:

1. Bleeding gums while brushing, flossing or eating.
2. Red and swollen gums.
3. Persistent bad breath.
4. Receding gums and tooth sensitivity.*
5. Loose teeth or separating teeth.
6. Pus between the gums and teeth
7. Sores in the mouth.*

The Link To Heart Disease

Cardiovascular disease is the number one cause of death in Malaysia.2 Well-known risk factors include obesity, smoking, hypertension,hypercholesterolaemia, diabetes, unhealthy diet, and sedentary lifestyle.

New revelation from many scientific studies have concluded that patients with gum disease or periodontal disease are two to three times more at risk of getting heart attack, stroke and other cardiovascular complications.³

There are more than 500 species of bacteria residing inside our mouth in the form of biofilm and plaque (sticky deposit). Several studies have indicated the significant presence of periodontal pathogens eg, Prevotella intermedia, Fusobacterium nucleatum, Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans using polymerase chain reaction (PCR) technique from samples of atheromatous plaque of human subjects.⁴

The microorganisms enter the bloodstream, move into the systemic circulation and settle on the endothelial linings of blood vessels including the coronary arteries. Inflammatory response then is triggered followed by formation of atheromatous/ fatty plaque, thickening of the blood vessel walls, narrowing of the lumen, and decreasing normal blood flow. All these events— gradually but surely—will result in blood clot, complete obstruction of blood flow and ruptured plaque which is then clinically diagnosed as heart attack or stroke.

Besides, numerous experimental data from human and animal models strongly support the association between gum disease and heart disease via the bacterial- host inflammatory mechanism or pathway. Therefore, the control of periodontal infections is important in reducing the overall inflammatory response in our body, and hence reducing the overall risk of cardiovascular complications.

The Link To Diabetes

Currently, Malaysia has 3.6 million people diagnosed with diabetes. And this figure is set to go up to 7 million by the year 2025, equivalent to a prevalence of 31.3% of adults aged 18 and above.5 Diabetes and gum disease have a mutual negative impact against each other according to numerous scientific studies. Diabetes increases the prevalence and severity of periodontal disease. Similarly, aggressive periodontal disease also increases the severity and complications of diabetes by increasing the insulin resistance in the body. This is especially true in type 2 diabetes patients who already have underlying insulin resistance.

The large majority of bacteria associated with gum disease are gram negative bacteria, which produce highly potent endotoxins. Endotoxins readily circulate in the bloodstream triggering the inflammatory response, and thus increase the levels of harmful inflammatory serum makers such as C-reactive Protein (CRP), interleukin-6 (IL-6), prostaglandin E (PGE) and fibrinogen. Subjects with healthy gums have very low levels of these inflammatory markers in the body.

Insulin resistance is recognized as a chronic inflammatory state, thus is made worse by inflammation arising from gum disease. This explains why case-control studies by several investigators have revealed that type 2 diabetes subjects who manage to control their gum disease not only have lower levels of inflammatory markers but also better control of their glucose levels.

Other well-established risk factors, which we must bear in mind are obesity, poor diet and lack of physical exercise. A good understanding of these knowledge will assist healthcare providers and their patients in the holistic management of diabetes.

The Link To Pregnancy

Worldwide, there has been a steady decline in infant mortality and morbidity due to better healthcare system. But the prevalence of preterm labour (gestational period <37 weeks) and low birth weight babies (<2.5 kg) remain high, and are associated with perinatal death and long-term defects. Conventionally, expecting mothers who are at high risk are those aged below 18, with a history of drug and alcohol abuse, smokers, experience stress, and have certain genetic disorders.

A pertinent risk factor that was discovered not too long ago is periodontal disease. Several investigators in this field have indicated that the relative risk for preterm birth and/or low birth weight among mothers with advanced gum disease was four to seven times higher than mothers with healthy gums after adjusting for age, race, smoking, and socioeconomic status.6 As discussed earlier, gum disease triggers an increased level of inflammatory markers in our body including prostaglandin E mediator (PGE). PGE causes early uterine contractions in expecting mothers, hence the preterm delivery of small infants.

So, what’s the conclusion?

Gum disease is a bacterial infection, which is both treatable and preventable. Bacteria and their byproducts can travel easily into a person’s systemic bloodstream via inflamed gum tissues. This triggers an inflammatory response in our body which have adverse impact on our general health with the outcomes including heart disease, diabetes and pregnancy complications. Therefore, the importance of early and effective management of oral infections— particularly gum disease—cannot be overemphasized.

Physicians and dentists should play the important role of informing their patients the interlink between oral disease and systemic disease (Figure 1), and must advise patients to seek regular dental treatment in view of the evidence. The strong case presented here is a point made for the adage: prevention is always better than cure. HT

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WORDS RACHEL SOON

“I couldn’t feel the burn!!!” Peripheral neuropathy’s silent decay 

What happens when our sense of touch misfires? What happens when your fingertips feel the pricking of invisible needles, or can’t feel the heat from an open flame? This month, HealthToday consults physician and neurologist Dr Hiew Fu Liong on the stealthy onset of peripheral neuropathy and why it often goes unnoticed, especially among diabetics and the elderly.

A tired man settles into his favourite chair at home, rubbing his feet. These days they always get numb towards the evening. Poor circulation, he thinks, but that’s just part of getting older. On the table is a basin of steaming water prepared by his wife, and he gratefully puts it on the floor and sticks his feet in to soak. He lies back in his chair, eyes closed and relaxing.

Ten minutes later,  his wife comes in and gasps, staring at his feet. Horrified, she exclaims: “That water was just boiled! It hasn’t cooled yet!” The man finds himself rushed to the hospital with second- and third-degree burns. He can see the skin peeling from his feet, but he feels nothing at all.

WHAT IS PERIPHERAL NEUROPATHY?

Peripheral neuropathy is a condition where our nerve cells are damaged in a way that interrupts or changes the messages being sent between our brain and spinal cord (known as the central nervous system, or CNS) and the rest of our body.

We can think of our body as having a phone network. Whenever we interact with the world around us with any part of our body—through sight, sound, touch, smell, or taste— electrical signals are sparked and sent through a network of fibres, called nerves, to the CNS, which helps read those signals and send new ones back. This network goes all the way to the outermost (peripheral) parts of our body and is known as the peripheral nervous system (PNS).

How do our nerves carry these electrical signals? Like phone or power cables, nerves are long and thin cells, which consist of layers of protective insulation (a myelin sheath), wrapped around a delicate electrical conductor (an axon).

If both the myelin sheath and the axon are intact, signals can travel between the CNS and the PNS as they’re meant to be. However, if either the sheath or axon are damaged, these signals may be incomplete, changed, or even fail to reach the CNS.

This disrupted signalling can cause us to feel sensations that have no physical cause. Alternately, it can also cause us to feel no sensations even when something should be triggering them. It can also cause problems with movement if the parts of the PNS leading into our muscles can’t receive signals from the CNS, which tell them how to move.

Consider two persons having a phone conversation. If the line is good, they can hear every word the other person says. However, if the line is damaged somewhere along the way, they might miss parts of the conversation, or be disconnected halfway through.

WHAT ARE THE SIGNS OF PERIPHERAL NEUROPATHY?

The trouble with peripheral neuropathy is how different the symptoms (see inset box) can be from one person to another, as well as how gradually the symptoms develop. It can go unrecognized or uninvestigated for years because early signs are usually dismissed as a natural part of ageing or other conditions.

Symptoms to look out for:

• Tingling, burning, shooting, stabbing, and/or “electric shock”-like sensations
• Numbness
• Extreme sensitivity to touch
• Tachycardia (accelerated heartbeat even when resting)
• Muscle weakness
• Dizziness
• Sweating
• Acute discomfort in the extremities (hands, feet).

Peripheral neuropathy can lack symptoms entirely during its early stages. It’s estimated that up to 50% of people with diabetes and peripheral neuropathy don’t have symptoms.

At a later stage, it can result in numbness so severe that sufferers fail to notice injuries on their limbs, especially their feet. On the other hand, some experience hypersensitivity to a degree where they are unable to feel a breeze without feeling pain.’

The most commonly affected areas are the hands and feet, but other areas of the body can also be affected.

WHAT CAUSES PERIPHERAL NEUROPATHY? WHO’S AT RISK?

More than 20% of people with peripheral neuropathy develop the condition for no apparent reason. The rest can be due to one or more of the following sources of nerve damage:

• Complications from another disease. Globally, diabetes is the most common cause of peripheral neuropathy; it’s responsible for an estimated 35% of all cases. Cancer, infections and inflammatory diseases are also known causes.
• Ageing, with an estimated 8.1% of people aged 40 to 49 years, and 34.7% of those aged above 80 years affected.
• Exposure to environmental toxins, such as cigarette smoke and excessive alcohol.
• Nutritional deficiency. A lack of essential nutrients, especially vitamins B1, B6 and B12, is known to impair nerve recovery.
• Genetic conditions, such as mutations inherited from one’s parents or a spontaneous mutation occurring during one’s lifetime.
• Side effects from certain medications, which may directly or indirectly affect the nerves.
• Repetitive or prolonged nerve pressure from activities such as typing, cooking, or prolonged sitting. Carpal tunnel syndrome is a form of peripheral neuropathy.
• Physical injury such as trauma from motor accidents, falls, or sports.

As a result, groups of people at higher risk of developing peripheral neuropathy include the elderly (over 60 years), those with diabetes, smokers, heavy drinkers, vegetarians and others on exclusionary diets, the malnourished, patients with renal impairment, and those with impaired gastrointestinal functions due to disease, medication, or recent surgeries.

WHAT CAN BE DONE ABOUT IT?

Early diagnosis is crucial. If treatment starts early enough, many cases of peripheral neuropathy can be prevented, reversed or at least controlled before nerve damage reaches a point of no return. A doctor can examine a patient by testing what sensations they feel from gentle pressure by small tools, such as tuning forks, cotton, pin, and/or a biothesiometer.

Physicians may use validated questionnaires (eg, DN4 or painDETECT), which provide a set of questions that can be scored to see if a patient might need follow- up with a specialist. The specialist can do a nerve conduction study to directly check for signs of nerve damage.

Treatment focuses on regenerating the nerves, addressing the reasons behind the ongoing nerve damage, as well as alleviating symptoms.

B vitamins at medical-grade doses (higher than those in food supplements) may help damaged nerves regenerate, particularly in patients with nutritional deficiencies due to age, lifestyle, and/or certain medications.

Some patients may need antidepressants or anticonvulsants to control neuropathic pain. Physiotherapy and rehabilitation can help restore muscle and nerve function. Adjustments to existing medications and lifestyle behaviours may also be required, but only after the risks and benefits have been assessed by a doctor.

There’s evidence that acupuncture can help relieve symptoms, but look out for a certified acupuncturist, as needles can cause further nerve damage or infection, if not properly handled.

To date, there is no single effective treatment for peripheral neuropathy, but a  combination of pharmacological and non- pharmacological treatments can collectively contribute to easing symptoms and stopping—or even curing—the disease, as long as the signs are caught in time. HT

HOME RELIEF

If you or someone in your home has confirmed peripheral neuropathy, here are some recommended steps to take at home to relieve symptoms. However, these measures should only complement, but not replace, treatment by a trained medical professional.

• Always check hands and feet for any injuries or ulcers, especially if diabetes is also involved.
• Keep warm as symptoms usually worsen at night or with cooler temperatures.
• Wear gloves to sleep or reduce air-conditioning use.
• Gloves and long sleeves also help protect the skin for those who are touch sensitive.
• Keep affected areas out of the direct path of air-conditioning eg, while driving.
• Certain ointments such as capsaicin gels can provide pain relief when rubbed into affected areas.

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WORDS HANNAH MAY-LEE WONG

A psychiatrist and mindfulness-based therapist expands on the topic of anxiety, a crippling yet common mental health issue. He also explains how Acceptance and Commitment Therapy (ACT) can work as a treatment option for those with anxiety disorder.

How would you define anxiety disorder?
Anxiety symptoms are part and parcel of life. For example, it’s normal to feel anxious when you have a deadline for an assignment approaching. Having anxiety disorder on the other hand, means to have anxiety symptoms (fears, worries, and psychosomatic symptoms) that are more intense and frequent, to the extent that it interferes with a person’s daily activities such as job performance, school work, and relationships.

What are the more common causes of anxiety disorder?
The common mental disorders under the anxiety category that I encounter in my adult psychiatric clinic are: panic disorder, agoraphobia, generalized anxiety disorder, and social anxiety disorder. It’s also common for anxiety to occur with depression. The causes of these are multifactorial— it could be biological (caused by hormonal disorders such as thyroid problems, or stress from a physical illness like cancer); psychological (such as traumatic childhood experiences, stressful life events like unemployment, etc.); environmental (natural disasters, haze), or social (political instability such as riots or demonstrations that are prolonged).

Can anxiety disorder run in the family?
If yes, does this mean that there is a genetic component to the disorder? Yes, that’s one of the biological causes of anxiety disorder. I have a strong family history of anxiety disorders. I know the condition inside out. The genetic risk factor partly contributes to my particular interest in anxiety education and treatment.

When should someone with a possible anxiety disorder see a mental health professional?
Someone with a possible anxiety disorder should see a health professional when:

• It interferes with his or her daily activity at school, work, or home.
• He or she makes excessive or unnecessary visits to doctors due to psychosomatic symptoms (a physical illness or other bodily conditions caused or aggravated by a mental factor) or is frequently absent from work due to poor physical health.
• The anxiety leads to depression symptoms such as: loss of interest in daily activities; feeling hopeless or helpless; experiencing changes in sleep, appetite, or weight patterns; having irrational guilt, anger or irritability; or having suicidal thoughts.
• Loved ones can’t tolerate the negativity of the person with anxiety disorder, giving rise to interpersonal challenges eg, marital and parenting issues.
• A person copes with anxiety using unhealthy or harmful methods eg, excessive alcohol consumption, illicit drug abuse, self-harm, or binge eating.

What could happen if the disorder is not properly controlled or treated?
The following complications could occur:

• The affected person could continue to have frequent psychosomatic complaints which could lead to excessive use of medical services—these people tend to “doctor shop”. Due to their weakened immunity, they are also more prone to getting various physical illnesses.
• The person could develop other anxiety disorders (eg, generalized anxiety disorder combined with panic attacks and social anxiety), depression, or suicidal thoughts.
• The person could also turn to alcohol or substance abuse. It can also lead to behavioural addictions like gambling, pornography, or computer gaming addictions.

What is Acceptance and Commitment Therapy(ACT)?
Acceptance and Commitment Therapy (ACT, typically pronounced as the word ‘act’) is an action-oriented and scientifically supported approach to psychotherapy for conditions such as anxiety disorders, major depressive disorder, and substance-use disorders.

Please tell us more about ACT.
ACT teaches various mindfulness and acceptance-based skills (such as present moment awareness, thought defusion, emotional acceptance, and observing mind) in therapy sessions. These methods are intended to help people befriend anxiety symptoms rather than fight or feel bad about them. ACT also uses a set of exercises that help patients identify and commit to their meaningful goals and values in life.

What is the goal of ACT?
To act towards our value-based goals. In ACT, we don’t aim to get rid of anxiety symptoms (such as panic attacks); it’s to embrace anxiety and move towards meaningful goals in life.

Aside from ACT, what other common therapies are recommended for anxiety disorders?

• Cognitive Behavioural Therapy (CBT) eg, challenging thoughts, exposure therapy, and social skills training.
• Antidepressant and anti-anxiety medications may be prescribed by a qualified doctor.
• Relaxation training eg, progressive muscle relaxation, pleasant imagery, and deep breathing. • Emotional Freedom Technique (EFT).
• Eye Movement Desensitization and Reprocessing (EMDR).
• Exercise, meditation, hypnosis, and prayer.

Can one’s anxiety disorder truly go away?
It’s normal to have some anxiety in daily life. It’s also not uncommon that anxiety disorder does not truly go away. Therefore, the aim of ACT is not to eliminate anxiety. It’s to learn to cope with anxiety and move on with life to achieve what is meaningful to us.

What is your advice to people who decide to self-diagnose and “DIY” their own ACT using information found online or in a book?
If it works well for you, good; if not, get guidance from a mental health professional who is familiar with ACT. There is no one-sizefits-all or best treatment plan. Most importantly, do not give up; explore with a therapist on methods or combinations of treatments that suit you. HT

WORDS HANNAH MAY-LEE WONG

It’s certainly no fun when it seems only pimples have got your back. Want to get rid of them? Take the advice of a dermatologist.

Having acne can really ruin one’s confidence and having them on your back is no less embarrassing. Back acne or ‘bacne’ is particularly frustrating as they appear in places that are hard to reach. Thankfully, according to consultant dermatologist Dr Ch’ng Chin Chwen, there are things you can do to alleviate back acne. In this article, Dr Ch’ng debunks some common myths about back acne and gives us helpful dermatologist-approved tips on how to get rid of them the right way.

What causes back acne and why do only some of us get them?
Acne, no matter which part of the body it appears in, is mostly triggered by genetic and hormonal factors. There is some recent evidence pointing to high sugar foods and milk/dairy products as key contributing factors to acne breakouts as well.

A variety of medications are known to be associated with acne breakouts. These include oral corticosteroids, hormones (such as anabolic steroids, certain contraceptive pills, and testosterone), certain antiepileptic medications, antibiotics or antidepressants, and some chemotherapeutic medications.

Why is the skin on our back particularly prone to acne?
This area has more sebaceous glands. The formation of acne on our skin involves sebaceous glands, which are more abundant over our face, upper chest and back. Areas without sebaceous glands don’t develop acne (for example, the palms).

What worsens back acne?

• Using harsh skin care items like antibacterial soaps, astringents and abrasive scrubs can disrupt the skin’s natural protection layer, irritate the skin, and worsen acne. Hence, excessive washing, scrubbing or use of drying skin care products can also exacerbate back acne.
• Use of oily/thick textured skin care products that clog the pores can worsen back acne. For people with acne-prone skin, it’s best to stick to oil-free or non-comedogenic skin care products.
• Back acne may be more common in our country because of our hot and humid weather. Sweating, wearing thick or tight clothing, or working in an oily environment can clog pores and worsen back acne.
• Stress has long been known to be a contributing factor to acne breakouts.

What should we do to get clear skin on our backs? Any medication or topical treatment options available?

• Avoid trigger factors as mentioned earlier in this article.
• Practice good skin care habits: no excessive washing/ cleansing, diligently use sun protection, avoid hot and humid places, shower immediately after sweating, wear loose and airy clothing made of cotton, and regularly moisturize your skin.
• Topical acne medicines (similar to those that treat facial acne) are available in most pharmacies. Perhaps look for products that can cover large surface areas easily, such as products specifically formulated for body acne or spray-on products.
• Your dermatologist may prescribe oral medicines such as antibiotics, spironolactone, and isotretinoin to treat your acne.
• Light and laser treatments provided by your dermatologist may also help treat back acne. Do you recommend those with back acne to use a loofah/ back scrubber? Gentle scrubs can help clear clogged pores, but harsh scrubs can disrupt skin barrier and cause more inflammation—the balance may be difficult to strike. If you want to use loofah, use it softly, and remember to wash and dry the loofah properly after each use for hygiene reasons.

It’s easier to opt for a chemical exfoliator rather than physical scrubs for a gentler effect. Use products with AHA (alpha hydroxy acid), BHA (beta hydroxy acid) or salicylic acid. Note that salicylic acid is stronger and may not be suitable for those with dry skin to use regularly.

Are those ‘special acne body wash’ the best option for those with back acne?
Yes. Body washes that contain AHA, BHA or salicylic acid may help with back acne.

When should we see a dermatologist?
If you have tried changing your diet, lifestyle, skin care products, and have regularly used over-the-counter acne gels but still have uncontrolled acne, you should see your dermatologist.

It’s hard to care for our backs as some areas are hard to reach. Are there any products that can help us solve this problem?
Some products come in a spray form for difficult-to-reach areas. HT

WORDS LIM TECK CHOON

#1 Obstructive sleep apnoea (OSA) is NOT a snoring problem.
Like its name would suggest, OSA is a condition in which there is an obstruction in your airway that interrupts your breathing while you are asleep. Possible obstructions include tonsils and adenoids in children or muscles at the back of the throat that can become too relaxed during sleep, narrowing the airway as a result.

When you have OSA, your body interrupts your sleep to get you to breathe each time oxygen levels fall below normal. As a result, you never truly reach deep sleep, and you wake up still feeling very tired.

Snoring is one possible sign of someone with OSA, but someone who snores may not necessarily have OSA.

OSA can also be ‘silent’—the person with OSA may not snore at all. Dr Mangayarkarasi shares that people with ‘silent’ OSA often have high blood pressure because of their condition; often their OSA is detected only after the doctor begins investigating the cause of their high blood pressure.

#2 OSA is linked to many serious issues and poor quality of life.
Additionally, lack of proper sleep can lead to daytime sleepiness, which in turn puts you at risk of reduced workplace productivity and/or academic performance as well as accidents. Accidentally falling asleep while driving due to OSA is a main cause of road accidents.

#3 Among children, hyperactivity may be a symptom of OSA.
Studies found that children with OSA are more likely to have problems paying attention or concentrating, and they also tend to develop attention deficit hyperactivity disorder (ADHD). As a result, their academic performance will suffer, and they will also have behavioural problems.

Children with OSA are also at increased risk of health problems listed in the previous point.

#4 OSA can be managed for better daily sleep and quality of life.
There is no cure for OSA. Dr Mangayarkarasi points out that, fortunately, it can be managed using continuous positive airway pressure (CPAP) therapy.

If you have OSA, your doctor may advise you to use a CPAP device each time you sleep. You need to wear a sleep mask attached to the device via a rubber tube, and once you’ve switched on the machine and go to sleep, the device will continuously deliver air via a steady, constant pressure. That way, your body will never be deprived of oxygen and you can achieve true sleep.

What about surgery? While surgery to widen the airway is certainly possible, Dr Mangayarkarasi reveals that among adults, this option is considered only after CPAP therapy fails to yield the desired positive results. This is because there is still a high possibility of someone developing OSA again some time in the future after a surgery.

For children with OSA, however, surgery is often the first option. Such surgery typically involves the removal of the tonsils to make more room in the airway.

#5 CPAP therapy is more convenient than before.
Don’t be put off by the above photo— that’s a typical image associated with the use of a CPAP device, but it’s an old school one!

These days, the device is smaller, lighter, and sleeker, thanks to improved technology. There are even portable versions that will be most suitable for people who travel often,and these portable versions may even come with slots to charge your mobile phone! Furthermore, the rubber tubes are thinner, longer, and more flexible to allow for more mobility, while the masks are also smaller and more comfortable to wear.

Aren’t CPAP devices expensive?
They do cost quite a bit, but in Malaysia, you can withdraw from your EPF funds to purchase the device. Furthermore, you may be able to pay in installments. Some government hospitals may offer CPAP devices at a subsidized cost as well. Therefore, don’t immediately assume that you cannot afford a CPAP device.Talk to your ENT specialist—they can advise you on how you can best afford CPAP therapy within your budget. HT