Keep your teeth intact even as you age
Dr H.S. Chawla

MOST of us tend to nibble something or the other every now and then, alone or in company, due to a variety of reasons. However, we do not realise that whenever we eat any sugary substance in any form and quantity, it accelerates the formation of acids in the mouth. This happens because the bacteria there react very aggressively to sugar. Being microscopic in size, these bacteria do not require large amounts of food to produce acid. Repeated attacks of such acids on teeth lead to the formation of cavities.

It has been proved beyond doubt that the body’s defence mechanism — in this case, saliva — is capable of protecting the teeth and repairing the damage done by acid attacks on an average three times a day. More than three such attacks result in a microscopic pit on tooth enamel, and more attacks lead to visible cavities. Thus, it is safe to conclude that a decrease in the general production of saliva leads to a reduced amount of protection against cavities.

This is precisely what happens as we age. From the dental health point of view, some of the important physiological changes that occur in our body are (i) a decrease in the production of saliva, which contains a number of digestive enzymes and other protective components like immunoglobulin — IgA and IgG, — (ii) physiological gum recession, and (iii) laxity of tonus of oral musculature.

Physiological gum recession increases the space in-between the teeth (inter-dental), resulting in large food lodgment areas. The decrease in the tonus of the oral muscles leads to late clearance of food particles from the oral cavity. These factors are devastating for dental health. The occurrence of root caries at gum levels in a large number of teeth at old age is very common.

Is it possible to have the teeth in perfect health in old age? The answer is a resounding “Yes”! Your teeth can serve you for all your life. Dental diseases are, to a very large extent, preventable. All that is required are these simple precautions that will protect the teeth as you age:

(i) Clean your teeth with brush, floss/interdental brush.

(ii) Use fluoridated tooth paste.

(iii) Do not eat sugary items in any form more than three times a day. The total frequency of intake of food in a day, howsoever small in quantity, should also not be more than five times a day.

There is common belief that sweet things will not harm teeth if one brushes immediately after eating. This is not so. The cavities are produced by bacteria, and we cannot eliminate them altogether. Some quantity of bacteria will always be present in different nooks and corners of the mouth. Sugar taken in any form and quantity at any time will produce acid resulting in damage to the teeth.

Inter-meal sugary snacks are more harmful than the ones taken at meal times. The sticky sugary items are more harmful than the non-sticky ones. Here is good news for cheese eaters. Ending your food with a piece of cheese is known to prevent demineralisation of teeth.

With growing age, our immunity in general goes down, thus increasing the importance and requirements of proper brushing. Stress should be given to the physical cleaning of teeth, spending more time and effort using soft toothbrush and fluoride toothpaste, interdental brush and flossing.

Here is a clever tip to keep teeth young as we age:

Brush thoroughly well before a meal with fluoride tooth paste. By brushing just prior to a meal, the number of bacteria in the mouth is significantly reduced. As such, the amount of resultant acid production and other toxins is less. Secondly, fluoride toothpaste prevents dental caries.

For getting the desired benefits as one ages, the time required for brushing is around 5-7 minutes: dry brush first, without tooth paste, and as the mouth becomes filled with spit, it can be spat out; this is continued. This way the bacteria are dislodged slowly and thrown out of the mouth along with each spit. After the dry brushing, apply tooth paste and the brush again for about 30 to 40 seconds. One can also use the toothpaste twice to get a good effect. It is like greasy hands get cleaner after second scrub with soap.

You can have perfect teeth even at late old age if you (i) consume sweet substances not more than three times a day; (ii) limit to five the total number of times you eat food in a day; (iii) spend 5-7 minutes on an average on brushing; and (iv) use fluoride toothpaste.

The writer is Professor, Oral Health Sciences Centre, PGI, Chandigarh.

Piles, fissure, fistula no longer incurable
Dr Pankaj Garg

Troublesome diseases like piles, fissure and fistula are often considered as a taboo and people shy away from discussing them in the open. Most people think that these diseases are incurable. The reality, however, is that the latest developments in proctology have made these disorders curable with minimally invasive methods.

In the initial stages, the options are a high-fibre diet, banding (a rubber band is inserted on the neck of piles), cryotherapy (use of liquid nitrogen to freeze the piles), bipolar coagulation (bipolar electrotherapy is used to coagulate the piles), sclerothrapy (an injection is applied at the base of the piles which causes sclerosis {thrombosis/clotting} of veins), infra-red coagulation or laser (a photo coagulator is used to focus infra-red light which spot welds the piles) and haemorrhoidolysis (galvanic waves are applied directly to the piles which produce a chemical reaction and shrink and dissolve the piles). These modalities do not help much in the higher stages of the disease.

Advanced stages: Open or conventional/traditional surgery results into a wound in the lower anal canal, which takes a lot of time to heal. Since the lower part of the anal canal is highly sensitive to pain, the patient experiences agonising pain for four-five post-operative days.

Doppler haemorrhoidal arterial ligation — Under doppler (ultrasound) guidance, a needle and a thread is passed beneath the artery, and a knot is externally tied, to stop the blood flow to the haemorrhoid region.

Stapler technique -- This operation is done in the upper anal canal which is insensitive to pain. A disposable stapler device is used to obliterate the blood supply to the piles and remove the excess which corrects the mucosal prolapse and restores the haemorrhoidal tissue back to its original anatomical position.

The last two procedures don’t create any wound and the patient is pain-free right after the operation.

Anal fissure: Anal fissure is a tear in the anus causing a painful linear ulcer at the margin of the anus. It may cause itching, pain or bleeding. At least 50 per cent of fissures heal by themselves. Initially, sitting in plain warm water, a high-fibre diet and an anaesthetic ointment is helpful.

Nitroglycerin ointment relaxes anal sphincter and results in fissure healing in more than 80 per cent of the patients. The principal sideeffect is headache in 20-40 per cent cases.

Botulinum injection given locally relaxes the anal sphincter and healing occurs in about 60 per cent patients.

If medical treatment fails to give relief, then surgery is indicated. Anal dilatation has fallen out of favour due to high incidence of anal incontinence (loss of control over gas or liquids) after the procedure.

Lateral internal sphincterotomy -- A small cut is made in the portion of the anal muscle. This relaxes the sphincter muscle and helps in healing.

Anal fistula: Anal fistula is an abnormal passage (communication) between the interior of the anal canal or rectum and the skin surface. An anal fistula usually lasts until it is surgically removed. The methods available are fistulutomy, seton (thread) treatment, advancement flap, fibrin glue and anal fistula plug.

Anal fistula plug is a highly sophisticated absorbable material which is placed and anchored in the fistula tract. Apart from having better success rates than glue, it has all the advantages of the fibrin glue (non-invasive, little pain, early recovery, less morbidity, and can be used again after a failure with no risk of incontinence). Its biggest advantage is that it can be used safely in high and complex fistulas.

The writer is a senior consultant surgeon, Fortis, Mohali.

Jaw injuries can lead to disability
Dr Ravinder Chadha

THE temporomandibular joint (TMJ) or the jaw joint is located in front of and below the ears. Like other joints this is also supported by muscles and ligaments and innervated by nerves. This joint has a ball and socket arrangement like the shoulder and hip joints, but unlike them it dislocates and is more prone to injury during accidents. Most joint injury cases are temporary and resolve in short periods. This is usually done conservatively, but in some cases it may become chronic and debilitating.

The causes: during an accident there is a sudden impact on the head leading to tearing of the muscles and ligaments causing pain and swelling. This can also happen with a sudden blow to the jaw during brawls or while playing football, hockey, etc.

Individuals in the habit of clenching or grinding teeth (while in sleep).

In cases of severe malocclusion of teeth.

While eating hard crunchy foods requiring excessive chewing vis-à-vis nuts can injure the joint.

Prolonged episodes of mouth being kept open during dental jobs or an examination of the throat as in laryngoscopy.

The symptoms: Jaw discomfort and soreness. Locking of the jaw — Normally fully open mouth should admit first two knuckles between incisors.

Clicking/ popping of the jaw.

Clenching/ grinding of the teeth.

Pain at the temples or back of the head which may radiate to neck, shoulders, etc.

Treatment

This should be undertaken promptly once the diagnosis has been made; otherwise surgery can be the only option. Usually, the conservative treatment entails:

• Ice pack and moist heat applications which relieve pain.
• In cases of malocclusion, special bite appliance is fitted in the upper or lower teeth. This helps taking off the pressure on the joint and the muscle.
• Eat soft foods. Avoid hard nuts/other foods which require excessive chewing, clenching, grinding, etc. This relieves inflammation.
• Relaxation techniques and stress management.

Certain exercises also help:

• Curl the tongue upwards, the tip touching the roof of the mouth, slowly opening and closing the mouth.
• Opening the mouth against the resistance of the hand (this is done by placing the elbow on the table with the chin in a hand) for 10 seconds. Repeat this 5-6 times.
• Yawning is a good exercise as it stretches the muscles supporting the joint.