A Family Doctor's Tale - CATARACT

DOC I HAVE A CATARACT

Every one will have cataract sooner or later because the eye's  natural lens degenerates over time. I have a patient who is a avid golfer who develop a cataract on his left eye due due to exposure to the sun. Any way he asks me to send him to an eye specialist for removal after I confirm that it was ripe for removal.
His operation was a big success and he was very happy with result so much so that he wanted the eye surgeon to remove the normal right lens for him so that he does need to wear spectacles.
 The eye surgeon was reluctant but go along with his wishes after he signed that he will take all the responsibility. Unfortunately the right lens could be removed totally because it was still stuck to the tissue behind the lens. He had to resort to another eye specialist to remove the lens from the back of the eye. That costs him another $9000 for the operation. He finally got his wish for not wearing spectacles.

A cataract is a clouding of the eye's natural transparent lens, which helps us to focus on the objects we see.
The lens is mostly made of water and protein.
Due to age, some of the protein may clump together and start to cloud a small area of the lens. This is a cataract, and over time, it may grow larger and cloud more of the lens, making it harder to see.


Cataracts ( A Simple Guide to Cataract)are classified as one of three types:
1.A nuclear cataract is most commonly seen as it forms.
This cataract forms in the nucleus, the center of the lens, and is due to natural aging changes.


2.A cortical cataract, which forms in the outer lens cortex, gradually extends its spokes from the outside of the lens to the center. Many diabetics develop cortical cataracts.


3.A subcapsular cataract begins at the back of the lens. People with diabetes, high farsightedness, retinitis pigmentosa or those taking high doses of steroids may develop a subcapsular cataract.


A cataract begins slowly and at first has little effect on your vision.
There may some blurring of vision .
Light from the sun or a lamp may seem too bright or glaring.
Colors may not appear as bright as they once did.


The eye's lens changes as we age, forming cataracts.
1. exposure to ultraviolet light may be a cause of cataract development, so eye specialist recommend wearing sunglasses and a wide-brimmed hat.


2.Other types of radiation such as from TV or PC monitors may also be causes.
Airline pilots may be exposed to cosmic radiation.


3.People with diabetes are at risk for developing a cataract.
The same goes for users of steroids and diuretics.


4.Other risk factors include cigarette smoke, air pollution and heavy alcohol consumption


Symptomatic treatment:
When symptoms begin to appear, you may be able to improve your vision for a while using new glasses, strong bifocals, magnification, appropriate lighting or other visual aids.

Some eye care practitioners believe that a diet high in antioxidants, such as beta-carotene (vitamin A), selenium and vitamins C may slow down cataract development.


Eye drops such as Catalin and Quinax has been prescribed to slow down the development of cataract.


Surgical treatment:
An intraocular lens (IOL) is implanted in the eye in place of the patient's clouded natural lens.
During surgery, the surgeon will remove your clouded lens, and in most cases replace it with a clear, plastic intraocular lens (IOL).


Cataract surgery is very successful in restoring vision.

I have a Malay patient who have advanced cataracts in both eyes. However I persuaded him he will refused any operation and rather depend on his grandchildren to bring him to the clinic because of his poor eyesight. One day he had a fall and landed in hospital. There the eye surgeon was able to convince him to have an operation.After the operation he could see perfectly and was so pleased that he came to tell me about it.


The most important prevention for cataracts is to avoid direct sun rays and other forms of radiation from TV or PC monitors, polluted air and smoking.

A Family Doctor's Tale - CORNEAL ULCERS

DOC I HAVE A CORNEAL ULCER

Corneal ulcers are more common than most people thought. Damage to the cornea may be due to injury or scratches from contact lens. Infection is another cause.
Last year one of my patient developed herpes zoster (shingles) of the right upper forehead. 
Unfortunately the herpes infection also affect her eyesight from a corneal ulcer and opacity from the infection.
No eye drops could help the opacity from the corneal ulcer. She now has partial loss of vision from the opacity of her corneal ulcer.

Corneal ulcer ( A Simple Guide to Corneal Ulcers) is a inflammatory disease of the surface of the cornea which causes local destruction of the superficial layer of the cornea resulting in ulcers.


Corneal ulcers can be infectious(due to infection) or non infectious(due to damage)


Corneal ulcers may be present more frequently in patients with:
Vitamin A deficiency
autoimmune disease
neurological disorders like facial palsy


The causes of Corneal ulcers can divided into 2 type:
Infections:
1. Bacterial infection such as Streptococci, Staphylococci, pneumococci, pseudomonas


2. Viral infections such as herpes simplex( A Simple Guide to Herpes), herpes zoster( A Simple Guide to Shingles),


3. Fungal infection


Non-infection:
1.Injury due to hard contact lens, abrasions from trauma, accidental scratch


2.autoimmune disease


3.Systemic disease


Symptoms varies from mild to severe:

1.Severe pain in the eye or around the eye and eyebrow especially with infectious causes. 
Non-infectious causes may not give rise to pain.


2.Red eye - increased blood flow through inflamed eye shows up the blood vessels


3.Tearing -excess tears from inflammation


4.Discharge -may be pus discharge from eyes especially in the morning


5.Light sensitivity - sensitive to bright lights


Signs:

1.White spot on the cornea, that depending on the severity of the ulcer, may not be visible with the naked eye


2.increased dilated blood vessels present due to inflammation


The presence of a corneal ulcer can be seen using a slit lamp microscope.

Sometimes a dye fluorescein may be dropped into the eye making it more visible and easier to detect.


If the patient is suspected to have infection(pus discharge from the eyes), a tissue culture of the corneal cells(gently scraped from the ulcer) may be necessary to determine the type of micro-organism infecting the eye.


The complication is always the risk of :

1.Severe infection of the eye especially with pseudomonas infection causing infection of the anterior chamber of the eye and then spreading to the rest of eye resulting in loss of an eye.


2.Scarring of the corneal ulcer resulting in partial loss of vision


Treatment depends on the type of corneal ulcer:

Infection:
1.Bacterial infection requires more intense treatment with oral antibiotics and antibiotic eye drops given every 15 minutes


2.Viral infections are usually treated with acyclovir tablets orally and acyclovir eye cream


3.Fungal infections are less common but are usually treated with antifungal medicine and eye drops.


In all infection cases, corticosteroid medications are not given.
Painkillers such as paracetamol can be given for pain


Non-infection:
1.Corticosteroid eye drops are usually given to reduce the inflammation


2.Antibiotic are also given to prevent infections of the ulcer.


In all cases the eye should be covered with eye pad until the epithelium of the ulcer heals about 10-14 days.


The prognosis depends on the severity of the disease


Most cases can be healed if detected early.


There may be minimum scarring of the cornea with possible loss of some vision.


Rarely the eye may be lost if there is severe infection and no treatment.

Prevention of corneal ulcers are:
1.nutritious diet with vitamin supplements can strengthen the body resistance against illness.


2.Avoid the use of infected contact lens lotion


3.Soft lens are more prone to eye infection. Always wash the hands before using any contact lens.


4. Avoid rubbing the eyes with dirty hands or tissues


4. A healthy lifestyle with less stress and mild exercise is always good for the body.

A Family Doctor's Tale - ENTROPION

DOC I HAVE ENTROPION

Recently I have a elderly female patient who complained of pain in her left eye due to pricking sensation in conjunctiva(the white part of the eye). What has happened is that the eyelashes on the lower eyelid has become pointed inwards towards the eye. It is usually due to the inversion of the lower eyelid which cause the eyelashes to point inwards and cause pain or irritation of the eye.
My own mother also suffered from this condition about 20 years ago. Many times she had her lower eyelashes removed by laser. She also had operation to tighten the lower eyelid muscle to evert the lower eyelids. Regrowth of the eyelashes is fairly common. Tightening of the eyelid muscle last longer before the muscle become loose again.


Entropion ( A Simple Guide to Entropion) is an inversion(rolling inwards) of the eyelid usually in a elderly person.


Entropion is more common in women than in men.


The causes of Entropion can divided into 2 type:


Spasm of Orbicularis muscle:

1. Degeneration of the peripheral connective tissue of the eye


2. Occurs in old age


3. Occurs also after removal of eyeball


4. Primarily affects the lower eyelid.


Cicatricial:

1. Scarring  of the eyelid muscle to connective tissue as a result of injury,  trauma, burns


2.retraction of the connective tissue of eyelid from infections such as trachoma, chronic infections


3.Congenital disease


4. May affect either upper or lower eyelid


Symptoms varies from mild to severe due to rubbing of eyelashes against the cornea or conjunctiva:

1.Irritation of the conjunctiva


2.Conjunctival congestion - increased blood flow through irritated eye shows up the blood vessels


3.Tearing -excess tears from irritation


Signs:

1.Erosions, opacities and vasculisation of the cornea


2.increased dilated blood vessels of conjunctiva present due to irritation


3.The presence of inward turning eyelids and eyelashes


The presence of inward direction of the eyelashes and eyelid can be seen more accurately using a slit lamp microscope.

Some of the complications from entropion are:
1.Recurrent corneal ulcers


2.Recurent irritation and conjunctivitis of eyes.


3.Severe infection of the eye - rare


Treatment depends on the type of Entropion:


1.Conservative - Eversion of eyelid especially lower eyelid with adhesive plaster or tape for temporary relief together with lubricating eyedrops


2.Surgery - 
a.Removal of inturning eyelashes using laser
        
b.Operation to tighten the eyelid muscle:

Quickert procedure: 2 to 3 strategically placed stitches are used under local anesthesia to evert the eyelid.
Recurrence is common.
This is useful for patients who are not suitable for surgery


Repair of inverted eyelid: is done by incision above and below the eyelids and removal of connective tissue or scarred tissue and tightening of the eyelid muscle.
This is usually done on an outpatient basis and under local anesthesia.

Post operatively the wounds are protected by antibiotic creams and dressings.
Healing usually occurs within 1 week.


Antibiotics are also given for any infections of the conjunctiva and cornea.


The prognosis is usually good.


Recurrence is rare but do occur especially due to weakening of eye muscles from age.

A Family Doctor's Tale - BLEPHARITIS

DOC I HAVE BLEPHARITIS

Some morning you get up from your night sleep and find your eyelids stuck with some gluey mucus and you force your eyes open to find your eyes blurry because there is a sticky mucus discharge on your eyelashes.

This is infection of your eyelids or blepharitis.

Blepharitis ( A Simple Guide to Blepharitis) is a disease which causes inflammation and infection of the margins of the eyelids.


Bacterial Infections:
----------------------------

1.Gram positive bacteria such as Streptococcus and Staphylococcus are common


2.Gram negative bacteria such as Klebsiella, E.coli, Pseudomonas,


Parasitic Infections:
----------------------------

Deodex folliculorum rare cause


Non-infectious:
--------------------

blocked oil glands of eyelashes


Squamous:
--------------

typically scales on lashes- usually non-infectious


Ulcerative:
----------------

yellow crusts on eyelids which causes small bleeding ulcers when removed -usually due to infections.


Symptoms:

1.Irritation and discomfort of eyelids


2.tearing of eyes


3.photophobia (fear of bright lights and sunlight)


4.Yellow discharge or crusts on eyelashes


Signs:

1.White scales on eyelashes in squamous blepharitis


2.yellow crusts on eyelashes in infectious blepharitis


3.small bleeding ulcers on eyelids where crusts have dropped.


4.Conjunctivitis


5.Culture and sensitivity to antibiotics of the discharge from eyedlids


Complications of Blepharitis may result in:
1.Stye or chalazion of eyelid


2.Conjunctivitis


3.Scarring of eyelids


Treatment of Blepharitis depends on the type of Blepharitis:
Squamous Blepharitis
-----------------------------

1.Treat underlying cause such as seborrhoeic dermatitis


2.Application of antiseptic or antibiotic cream to eyelashes


Ulcerative Blepharitis
----------------------------

1.Rest in dark room


2.Painkiller for pain


3.Removal of crusts and diseased eyelashes by washing warm water or saline


4.Strong antibiotic eye drops and cream applied to eyelashes:
a.cephalosporin, penicillin, ampicillin, tetracycline, for most streptococci, staphalococci, hemophilus bacteria


b.cephalosporins, gentamycin for pseudomonas


5.Treat associated conjunctivitis


Squamous Blepharitis
-----------------------------
Treatment by removal of the scales is generally good.


May vary with response to underlying cause.


Recurrence is common.


Ulcerative Blepharitis
-----------------------------
Most cases recovered well.


Rarely there may serious complications such as
loss of eyelashes,
scarring of eyelashes
conjunctival ulcers


Prevention of Blepharitis is by:
1.Avoid rubbing of eyes with dirty hands


2.Good hand hygiene


3.Healthy lifestyle with balance diet and adequate sleep.


4.Reducing watching of TV and computer monitors


5.Regular eye checkups

A Family Doctor's Tale - PTERYGIUM

DOC I HAVE A PTERYGIUM

A pterygium is actually a small fleshy growth at the corners of the conjunctiva(white part)of the eye. Many patients think it is cancerous or a large blood clot and may request its removal.
Removal is usually unnecessary unless the growth is covering the cornea(black part) of the eye and affecting the vision.

Pterygium( A Simple Guide to Pterygium) is a fleshy tissue that grows in on the inner corner of the eye towards the pupil.
It may appear on the outer corner.
It is usually triangular in shape.


Pterygium is more common in people who spend time outdoors than indoor


The exact cause of Pterygium is not well known.
1. Long-term exposure to sunlight, especially ultraviolet (UV) rays

2.chronic eye irritation 

3. dusty conditions 

4. dry eye may contribute to pterygium as well.


Symptoms varies from mild to severe:

1.discomfort in the eye


2.Conjunctival congestion


3.Tearing -excess tears from irritation


Signs:

1.fleshy growth on the conjunctiva on inner side of eye growing towards pupils


2.increased dilated blood vessels in the fleshy growth


The fleshy growth on the conjunctiva on inner corner of eye may grow towards the pupils and cause:
1.Partial blindness if the pterygium covers the cornea


2.Recurrent irritation and conjunctivitis of eyes.


3.Severe infection of the eye - rare


Treatment depends on the severity of the pterygium:

1.Mild:
Eye drops with anticongestion and anti-inflammatory properties may shrink the blood vessels which provide nourishment for the growth of the pterygium.


2.Severe:
Once the pterygium reaches the cornea and may cover the cornea, surgical resection of the pterygium may be necessary otherwise the eye sight may be affected.

Surgical resection may also be done if the pterygium is unsightly.


The prognosis is usually good.


Recurrence is rare but do occur due to regrowth of the blood vessel supplying the pterygium. 
This occurs more in younger people.


Prevention of growth of pterygium is by:

Wearing UV protective sunglasses


Avoiding dry and dusty conditions


Using artificial tear eye drops to prevent eye dryness

A Family Doctor's Tale - STYE AND CHALAZION

DOC I HAVE A SWELLING IN MY EYELID

A Stye ( A Simple Guide to Stye) is an infected gland at the edge of the eyelid.


A stye develops when a gland supplying wax to eyelash at the edge of the eyelid becomes infected. 

A stye can grow on the inside or outside of the lid.
Styes are not harmful to vision, and they can occur at any age.


A stye starts with pain, redness, tenderness and swelling in the area of the eye gland  of the eyelid. 

Then a small pimple appears. 

Sometimes just the immediate area is swollen; 
other times the entire eyelid swells. 

There may be frequent watering in the affected eye, a feeling like something is in the eye or increased light sensitivity.


Staphylococcal bacteria is often found in the nose, and it's easily transferred to the eye by rubbing first your nose, then your eye.


Treatment for Stye
Most styes heal within a few days on their own. 

You can apply hot compresses for 10 to 15 minutes, three or four times a day over the course of several days.

This will relieve the pain and bring the stye to a head, much like a pimple. 

The stye ruptures and drains, then heals.


If you have frequent styes, your eye doctor may prescribe an antibiotic ointment to kill the bacteria causing the stye.


Styes formed inside the eyelid either disappear completely or (rarely) rupture on their own, and they can become more serious. 

These styes may need to be opened and drained by your family doctor.


In my family practice I must have done at least a hundred incision and drainage of the stye.
Many are repeated operations. Once beaten not twice shy.
Many of the stye are due to dirty hands or dirty contact lenses which cause infection of the wax gland of eyelashes. 
Most of the patients are female. 
Because of the pain and the ugly appearance of their eyelid, the patient would rather have it removed than to wait until it burst. 
Even though I jokingly that the patient will be an one eyed jack for 1 day wearing an eye pad to absorb the pus and blood, the patient will still ask for the operation. 
After cleaning the eye with antibiotic drops, local anesthetic is infiltrated around the stye usually from inside the eyelid( less chance of scar formation) and the abscess forming the stye is incised and drained of the pus and dirty blood. 
Once the pus is removed the eyelid is cleansed again with antibiotic eye drops and antibiotic ointment is applied into the wound. 
An eye pad is applied to the eye and plastered on.
The next day the eye pad is removed with all the pus and blood and surprisingly the swelling has gone down.
The patient is then given antibiotic eye drops to clean the eye and eye ointment to apply to the eye lid every night. 
There will be no wearing of contact lenses for at least 1 week.


 Chalazion:
is another type of eyelid swelling which is further in the eyelid than a stye which is at the eyelash area.

Often mistaken for a stye,  a chalazion is an enlarged, blocked oil gland in the inner lining of the eyelid. 

A chalazion mimics a stye for the first few days, then turns into a painless hard, round bump later on. 

Most chalazion develops further from the eyelid edge than stye.


Although the same treatment speeds the healing of a chalazion, the bump may linger for one to several months. 
If the chalazion remains after several months, your eye doctor may drain it  to facilitate healing.

The same operation is done for the chalazion except the incision is done further into the eyelid. 
For the upper eyelid the eyelid may have to be inverted for the operation to be done.

A Family Doctor's Tale - CONJUNCTIVITIS

DOC I HAVE A RED EYE

Red Eyes or Conjunctivitis is a very common disease in a family clinic. The main complaint will be a red teary and painful eye. Very often conjunctivitis may occur as an epidemic where many people get the infection at the same time.

Conjunctivitis ( A Simple Guide to Conjunctivitis) is an inflammation of the conjunctiva(the white of the eye and inner lining of eyelids). 

It is one of the most common and treatable eye infections in children and adults.



Conjunctivitis can be caused by: 
1.virus or bacteria
2.irritating substances (shampoos, dirt, smoke, and especially pool chlorine)
3.allergens (substances that cause allergies).


Conjunctivitis caused by bacteria, viruses can spread easily from person to person, but is not a serious health risk if diagnosed promptly.


Common symptoms are:
1.Redness in the white of the eye or inner eyelid

2.tears overflowing

3.yellow discharge that crusts over the eyelashes, especially after sleep. Other discharge from your eye may be green .

4.Pain in the eye

5.Itchy eyes (especially in conjunctivitis caused by allergies)

6.Burning eyes (especially in conjunctivitis caused by chemicals and irritants)

7.Blurred vision

8.sensitivity to light



Bacterial or viral Conjunctivitis can also be spread through hand contact when rubbing the eyes or touching contact lenses after touching infected skin. So proper hand hygiene is important.


Being around a person who has conjunctivitis and wearing contact lenses may increase your risk of getting conjunctivitis, but the outcome is usually very good with treatment.


Treatment of Conjunctivitis:
1.Infections:
Conjunctivitis caused by bacteria is treated with antibiotics.
The antibiotic can be given as eye drops, ointments, or pills.
Eye drops or ointments may need to be applied to the inside of the eyelid three to four times a day for five to seven days.


No Medicine can treat conjunctivitis caused by a virus.
This type of conjunctivitis often results from a common cold( A Simple Guide to Common Cold).
You may, however, help relieve symptoms by applying a cold compress.


2.Irritating substance:
For this type of conjunctivitis, use warm water for five minutes to wash the irritating substance from the eye.


3.Allergies:
Allergy-associated conjunctivitis is treated with antihistamines or when the allergen is determined and removed.


Other measures for treating your eyes:
1.Protect your eyes from dirt and other irritating substances.

2.Do not use contact lenses, if you wear them.

3.Place cold compresses on your eyes.

4.Wash your face and eyelids with mild soap or baby shampoo and rinse with water to remove irritating substances.

5.Do not rub your eyes with hands that are not washed.

6. Do not use the same bottle of drops in the other eye if it is not infected.


Prevention of further infections:
1.Do not touch or rub the infected eye(s).


2.Wash your hands often with soap and warm water.


3.Wash any discharge from your eyes twice a day using a fresh cotton ball or paper towel. Afterward discard the cotton ball and wash your hands with soap and warm water.


4.Wash your bed linens, pillowcases, and towels in hot water and detergent.


5.Avoid wearing eye makeup.
Don’t share eye makeup with anyone else.


6.Do not wear another person’s contact lens.


7.Wear glasses instead of contact lenses.
Throw away disposable lenses or be sure to clean extended wear lenses and all eye wear cases.


8.Avoid sharing common articles such as unwashed towels, cups, and glasses.


9.Wash your hands after applying the eye drops or ointment to your eye or your child’s eye.


10.Do not use eye drops in a non-infected eye that were used for an infected one.

A Family Doctor's Tale - STOMATITIS

DOC I HAVE STOMATITIS

Again this topic may come under the conditions seen by dental surgeons or ENT surgeons but it is frequently seen by family doctors. An infected mouth occurs usually due to poor oral hygiene, infections, smoking, medications and lack of vitamins especially the vitamin B group.

Stomatitis is inflammation of the mouth


There are many many disorders which can cause Stomatitis:
1.Bacteria, viruses, fungal 

2.avitaminosis especially vitamin B


3.leukemia( A Simple Guide to Blood Cancer), agranulocytosis 

4.Dental problems,poor fitting denture, poor dental hygiene

5.smoking

6.medicines: phenytoin, iodides, barbiturates


Stomatitis usually appear on the inner surface of the cheeks and lips, tongue, soft palate, and the base of the gums. 

They may begin with a tingling or burning sensation, followed by a red hyperemia of the inside of the lining of the cheek, gums or tongues.

The inflamed surfaces may develop into mouth ulcers( A Simple Guide to Mouth Ulcers)
Occasionally, a severe occurrence may be accompanied by fever, lymphadenopathy(enlarged lymph nodes) and lethargy.
Most mouth ulcers are not infectious.

Oral mucosal smears may be necessary to determine those with bacterial or fungal infections.


The exact treatment will depend on the cause of the Stomatitis. Sometimes all that is required is to remove the cause of the Stomatitis such as an ill fitting denture.


The following measures may help to reduce pain from Stomatitis:
Proper oral hygiene:
---------------------------
1.keep your mouth clean at all times,

2.avoid foods that are spicy, acidic, salty or particularly hot or cold, which can make the symptoms worse,

3.eat a healthy diet that includes fresh fruit and vegetables,

4.gargle with warm salt water or use a diluted chlorhexidine mouthwash once a day to help reduce the length of time the ulcers last.
5.sprays and rinses are also available for pain relief.

Medical treatment:
-------------------------
The main treatment of the Stomatitis is application of topical corticosteroids (Kenalog in orabase or Oracorte E), or other soothing preparations. 

Where bacteria are present the appropriate antibiotic will treat the Stomatitis. 
Antifungal agents are used to treat fungal infection.

Vitamin B are important in patients with deficiency of the vitamins.

Treatment of underlying conditions:
----------------------------------------------
Treatment of systemic condition causing the Stomatitis such as leukemia


1.Good oral hygiene may help in the prevention of some types of mouth ulcers or complications from mouth ulcers.
This includes brushing the teeth at least twice per day, flossing at least daily, and going for regular dental checkup and cleaning.

2.Live a healthy lifestyle by making sure you eat a balanced diet, take regular exercise and learn to manage stress.

3.Most importantly do not SMOKE.

A Family Doctor's Tale - GLOSSITIS

DOC I HAVE GLOSSITIS

Again this topic may come under the conditions seen by dental surgeons or ENT surgeons but it is frequently seen by family doctors. A swollen painful tongue occurs as a result of food or chemicals irritating the tongue.

Glossitis is an acute or chronic inflammatory disease of the tongue which can cause swelling of the tongue and change of color of the tongue.


The finger like papilla on the surface of the tongue may be lost as a result leading to a smooth tongue.



Bacterial Infections:
----------------------------

1.Gram positive bacteria such as Streptococcus and Staphphylococcus may be painful and lead to upper respiratory tract infection


2.Gram negative bacteria such as Klebsiella, E.coli, Pseudomonas, Mycobacteria(including tuberculosis), Legionaire's Disease,chlamydia ( A Simple Guide to Chlamydia)


Viral infections:
------------------

Herpes simplex ( A Simple Guide to Herpes)


Non-infectious:
----------------

1.Dryness of the mouth and low saliva in the mouth may allow bacteria to grow more readily.


2.Local dental abnormalities, rough edges of teeth ,ill fitting dental appliances, or other trauma to the tongue


3.Tongue Piercings


4.irritants such as tobacco, alcohol, hot foods, and spicy food.


5.Sensitivity to toothpaste, mouthwash, breath fresheners,and dental material


6.Allergies to dyes in candy or preservatives in food.


7.Drug induced such as anticholinergics (cause dryness of mouth), certain blood-pressure medications (ACE inhibitors).


8.Mouth breathing


Systemic diseases:
------------------------
A painful tongue may be due to several underlying serious medical conditions:

1.iron deficiency anemia, pernicious anemia and other B-vitamin deficiencies


2.Skin diseases such as oral lichen planus( A Simple Guide to Lichen Planus), erythema multiforme, aphthous ulcer, pemphigus vulgaris,


3.Systemic diseases such as syphilis, and others.


Occasionally, glossitis can be inherited.


Symptoms:

1.Swelling of the tongue


2.Tongue color changes often dark red


3.Pale if caused by anemia.


4.Fiery red if due to vitamin B deficiency


5.Sore and tender tongue


6.Smooth tongue


7.Aphthous ulcers ( A Simple Guide to Mouth Ulcers) of the tongue


8. Swollen tongue resulting in difficulty with chewing, swallowing, or speaking.


This may require emergency treatment especially if breathing is compromised.


Complications may occur such as :
1.difficulty in breathing and swallowing


2.cervical lympadenosis (enlarged lymph nodes of the neck)


3.upper respiratory tract infection



The goal of treatment is to reduce inflammation and swelling.

1.Good oral hygiene


2.Attend to dental problems


3.Antibiotics and antifungal treatment depending on the organism found


4.Corticosteroids may be given to reduce inflammation


5.For mild cases, topical applications of steroid mouth rinses or creams that is not swallowed are used


6.Underlying causes such as Anemia (A Simple Guide to Anemia)and nutritional deficiencies must be treated, often by dietary changes or other supplements


7.Avoid irritants (such as hot or spicy foods, alcohol, and tobacco) to minimize the discomfort.


8.hospitalization may be required if unless tongue swelling is severe.



Prognosis is usually very good.


Recurrences are common


Prevention is by:
1.Avoid smoking


2.Healthy lifestyle with balanced diet and exercise.


3.Regular cleaning of gums and teeth by brushing and flossing


4.Gargling of mouth after meals


5.Regular dental checkups

A Family Doctor's Tale - GINGIVITIS

DOC I HAVE GUM INFECTION

Gum infection are seen very commonly in a family doctor clinic even though it is under the domain of dental surgeons. Sometimes it is because of poorly constructed dentures or dentures which has become loose or too tight. There is usually pain and swelling of the gum. Many patients prefer to seek the help of family doctors than the dental surgeons because of their trust in family doctors and the higher cost of dental surgeons.

Gingivitis is an acute disease which causes inflammation and infection of the gum with redness, swelling and bleeding.


Bacterial Infections:
----------------------------

1.Gram positive bacteria such as Streptococcus and Staphphylococcus may be painful and lead to upper respiratory tract infection


2.Gram negative bacteria such as Klebsiella, E.coli, Pseudomonas, Mycobacteria(including tuberculosis), Legionaire's Disease, chlamydia( A Simple Guide to Chlamydia)


Non-infectious:
------------------

1.malocclusion

2.food impaction

3.dental calculus

4.dental procedures

5.exposure to heavy metals

6.long term phenytoin treatment

7.Oral contraceptive pills


Systemic diseases:
--------------------

1.diabetes mellitus ( A Simple Guide to Diabetes)


2.leukemia ( A Simple Guide to Blood Cancer)


3.Debilitating diseases

4.autoimmune diseases


Symptoms:

1.Painful gum


2.Red swollen inflamed gum


3.bleeding in between the gum


4.Fever may be present


Signs:


1.Red swollen inflamed gum around neck of teeth


2.Swelling of papilla between teeth


3.Gum boils or abscess in the gum


4.Gum ulcers

5.Gum swab for bacteria and antibiotic sensitivity


6.X-rays of teeth may show tooth decay and infection


Complications of gum infection may cause:
1.damage to root canals


2.cavity in the teeth


3.upper respiratory tract infection


Treatment of the gum infection includes:

1.Rest and fluids


2.Painkiller for pain


3.Antibiotics depending on the organism found:

a.cephalosporin, penicillin, ampicillin, tetracycline, for most streptococci, staphalococci, hemophilus


b.cephalosporins, gentamycin for pseudomonas


Very often the right antibiotic given to the patient will clear the gum infection but if the underlying cause such as poorly constructed dentures and poor oral hygiene is not treated then recurrence of the gum infection will recur.


4.Oral application of oral antibiotic cream


Prognosis is usually very good.


Surgery for abscess and other gum or tooth problem very rarely needed.


Prevention of gum diseases are:
1.Avoid smoking


2.Healthy lifestyle with balanced diet and exercise.


3.Regular cleaning of gum and teeth by brushing and flossing


4.Gargling of mouth after meals


5.Regular dental checkup

A Family Doctor's Tale - LARYNGITIS

DOC I HAVE A HOARSE VOICE

Have you ever times when your voice was so hoarse and soft that your friends or family cannot even hear you or thought you were mumbling to yourself. These are all signs of laryngitis. Teachers and lecturers are most prone to get it.
 
Laryngitis ( A Simple Guide to Laryngitis) is the inflammation of the mucous membranes of the laryngx (Vocal box) which produces the sound of the voice.


Laryngitis is caused by
1.bacterial or viral infections of the larynx.
2.excessive use of voice
3.inhalation of irritants such as cigarette smoke


Laryngitis is also associated with
1.bronchitis
2.pneumonia
3.whooping cough
4.diphtheria


Laryngitis produces mild but uncomfortable symptoms:


1.hoarseness of voice
2.loss of voice
3.pain on speaking
4.Tiredness
5.Fever of low grade rarely


The most important indications of Laryngitis are:
1.Symptoms of hoarseness or loss of voice

2.Physical examination of the throat may showed the presence of redness and swelling of the vocal cords with some pus discharge. The movement of the vocal cords may be impeded.
Sometimes nodules may be found on the vocal cords due to excessive usage of voice.


To confirm the diagnosis:
1.nasal and throat swabs to determine the type of infection

2.Xray of the chest and neck to determine any pressure of other organs pressing on the larynx

3.A biopsy of the nodules on the vocal cords if present to exclude malignancy


In order to recover from Laryngitis, the patient should:
1.Rest the voice. A rested patient will recover faster.


2.Adequate warm Fluids helps to keep the mucus membranes moist


3.Steam inhalations may help


4.Antibiotics if there is suspicion of bacterial infection.

5.Gargles and decongestants may help to soothe the throat and vocal cords


6.Avoid smoking.talking


Acute laryngitis usually clears up within 10 days.

Very rarely chronic laryngitis may cause hoarseness of voice for months or years.

A Family Doctor's Tale - TONSILLITIS

DOC I HAVE PAINFUL SWELLINGS IN MY THROAT

When I was working in the ENT Department of the Singapore General Hospital, there were at least 10 cases of patients every day with enlarged painful swellings in their throats. 
These are infected tonsils and the bad breath emitted by the patient can be terrible.
Some of the patients could not even swallow their saliva.


Tonsillitis is inflammation (swelling) of the tonsils.
The tonsils are actually lymph nodes in the back of the mouth and top of the throat. They normally help to filter out bacteria and other microorganisms to prevent infection in the body.


They may become so overwhelmed by bacterial or viral infection that they swell and become inflamed, causing tonsillitis.(A Simple Guide to Tonsillitis)


The infection may also be present in the throat and surrounding areas, causing pharyngitis. The inflammation may involve other areas of the back of the throat including the adenoids ( A Simple Guide to Adenoiditis) and the lingual tonsils (areas of tonsil tissue at the back of the tongue).


Viral or bacterial infections and low immunity factors lead to tonsillitis and its complications.


The herpes simplex virus, Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis.
Bacteria cause 15-30 percent of pharyngotonsillitis cases.
Streptococcus pyogenes is the most common bacteria causing acute Tonsillitis


Tonsillitis most often occurs in children but rarely occurs in children younger than two years.
Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years.
Viral tonsillitis is more common in younger children. 

A peritonsillar abscess is usually found in young adults but can occur occasionally in children.



There are several variations of tonsillitis:
1.acute
2.recurrent
3.chronic tonsillitis and
4.peritonsillar abscess.



The type of tonsillitis determines what symptoms will occur.



Acute tonsillitis:
----------------------
Patients complains of:
1.Ear pain
2.Fever, chills
3.Headache
4.Sore throat which is severe and lasts longer than 48 hours
5.Tenderness of the jaw and throat
6.Voice changes, loss of voice
7.Foul breath, dysphagia (difficulty swallowing),
8.Odynophagia (painful swallowing), and tender cervical lymph nodes.
9.Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea.
( A Simple Guide to Obstructive Sleep Apnea)
10.Lethargy and malaise are common. 

These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.



Recurrent tonsillitis: 
---------------------------
This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.



Chronic tonsillitis: 
--------------------------
Patients usually have:
1.Chronic sore throat, foul breath,
2.Enlarged tonsils, and
3.Persistently tender cervical nodes.



Peritonsillar abscess: 
-----------------------------
Patients often have:
1.Severe throat pain, fever,
2.Drooling,
3.Foul breath,
4.Trismus (difficulty opening the mouth), and
5.Muffled voice quality (as if talking with a hot potato in his or her mouth).



I will usually look in the mouth and throat for signs of: 1.enlarged, visible tonsils that are usually reddened and may have white spots (pus) on them.


2.enlarged and tender lymph nodes of the jaw and neck.


3.Fever and chills.


4.Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement.


5.neck and jaw stiffness (often found in acute tonsillitis).


6.Signs of dehydration (found by examination of skin and mucosa).


7.Palatal petechiae (pinpoint bleeding spots on the soft palate).


8.Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists.


A culture of the tonsils may show bacterial infection. 
A culture for the streptococcus bacteria (strep) may be taken using a throat swab because it is the most common and most dangerous form of tonsillitis.


If the cause of the tonsillitis is bacteria such as strep, antibiotics are given to cure the infection.
The antibiotics may need to be taken for 10 days by mouth.
They must not be stopped just because the discomfort stops, or the infection will NOT be cured.


2.Rest to allow the body to heal.

3. Fluids especially warm (not hot), bland fluids or very cold fluids may soothe the throat.
Gargle with warm salt water or suck on lozenges (containing benzocaine or similar ingredients) to reduce pain.

4.Fluid replacement and pain control are important. 

5.Hospitalization may be required in severe cases, particularly when there is airway obstruction. 

When the condition is chronic or recurrent, a surgical procedure to remove the tonsils (tonsillectomy) is often recommended.



Tonsillitis symptoms usually lessen in 2 or 3 days after treatment starts.
The infection usually is cured by then, but may require more than one course of antibiotics. 

A tonsillectomy may be recommended if tonsillitis is severe, recurrent, or does not respond to antibiotics.


Complications of untreated strep tonsillitis may be severe:


1.Rheumatic fever and subsequent cardiovascular disorders 

2.Post-streptococcal glomerulonephritis followed by kidney failure


2.Dehydration from difficulty swallowing fluids


3.Blocked airway from enlarged tonsils


4.Peritonsillar abscess or abscess in other parts of the throat causing difficulty in swallowing. An operation is usually done to release the pus in the abscess.

A Family Doctor's Tale - MOUTH ULCERS

DOC I HAVE A MOUTH ULCER

I think every one of us have a mouth ulcer at one time or other either through cracked lips from cold weather or more frequently from biting the tongue or scraping the tooth against the lining of the cheek.

Mouth ulcers (A Simple Guide to Mouth Ulcers)are painful open sores or lesions in the mouth.
They may appear red or yellow in color.

 Mouth ulcers occur either singly or in clusters, causing a lot of discomfort or pain. They  usually heal within 7 to 10 days.


There are many many disorders which can cause mouth ulcers:
1. canker sore (aphthous ulcer),
2.leukoplakia, (a disease with depigmentated skin)
3.gingivostomatitis,( A Simple Guide to Gingivitis), (A Simple Guide to Stomatitis)
4.oral cancer,
5.oral lichen planus (A Simple Guide to Lichen Planus)
6.oral thrush.


Oral thrush is very common in babies. It appear as a white patch on the lining of the cheek. The way to tell an oral thrush lesion from a milk curd is to wipe it with a cotton bud. The milk curd will wipe off but not the oral thrush. Treatment is usually with antifungal lotion.

7.Hand mouth and foot disease(A Simple Guide to Hand Mouth Foot Disease)

Hand mouth and foot disease  in children will present with multiple mouth ulcers. It can be very painful for the child who will  usually lose appetite.

The most common mouth ulcer is Aphthous ulcer.
 It is an open sore in the mouth, which appears as a painful white or yellow ulcer surrounded by a bright red area.


Mouth ulcers may occur at any age, but usually first appear between the ages of 10 and 40.
Women are more prone than men. 

The cause is unknown.
There may be an inherited tendency or an immune system link.
Mouth injury such as dental procedures or aggressive tooth cleaning my cause mouth ulcers.
They may occur at the site of a bite when the tongue or cheek is bitten.
They can also triggered by stress, dietary deficiencies (especially iron, folic acid, or vitamin B12), menstrual periods, hormonal changes, food allergies, and similar situations.


There are different types of mouth ulcers.
1.A single mouth ulcer is usually caused by damage to the mouth, like biting the cheek, or damage to the gum with a toothbrush or a sharp tooth or filling. 
They usually go away once the source of the problem is treated.

2.A recurrent ulcer is one that comes and goes, sometimes every few weeks.


Minor ulcers are the most common.
They usually appear inside the cheeks, on the lips, tongue, and gum.
Most of these ulcers are small, round and can sometimes come in clusters(four to six) at any one time.

Large ulcers are more severe, have an irregular border, and can last for 5-10 weeks. 
They usually appear near the tonsils and can be very painful, especially when swallowing.   
You usually only get one at a time.

 Very rarely,some patients have up to 100 very small painful ulcers (herpetiform type), which last for one to two weeks.


Ulcers are very common. About 20% of the population have recurrent mouth ulcers at some time in their lives. 
Often they begin in childhood or adolescence. 
Most people grow out of them by their late twenties.


Mouth ulcers usually appear on the inner surface of the cheeks and lips, tongue, soft palate, and the base of the gums.
They may begin with a tingling or burning sensation, followed by a red spot or bump that ulcerates.
Pain spontaneously decreases in 7 to 10 days, with complete healing in 1 to 3 weeks.

Occasionally, a severe occurrence may be accompanied by fever or lethargy. 
Recurrence is common and may continue for years.
Most mouth ulcers are not infectious.


Treatment of Mouth Ulcers
The exact treatment will depend on the cause of the ulcer. Sometimes all that is required is to remove the cause of the ulcer, such as a sharp tooth.


The following measures may help to reduce pain from mouth ulcers:
keep your mouth clean at all times,
avoid foods that are spicy, acidic, salty or particularly hot or cold, which can make the symptoms worse,
eat a healthy diet that includes fresh fruit and vegetables,
gargle with warm salt water,
use a diluted chlorhexidine mouthwash once a day to help reduce the length of time the ulcers last.
sprays and rinses are also available for pain relief.

Medical treatment:
The main treatment of the mouth ulcer is application of topical corticosteroids (Kenalog in orabase or Oracort E), or other soothing preparations.
Dry the area first with a cotton wool bud and then use a wet finger or the back of a spoon to put the cream on the sore area. You can use it up to four times a day after meals. However, it is most effective to use this cream late at night as it stays there for longer.


Preventing mouth ulcers
Good oral hygiene may help in the prevention of some types of mouth ulcers or complications from mouth ulcers.
This includes brushing the teeth with a soft toothbrush at least twice per day, flossing at least daily, and going for regular dental checkup and cleaning.

Try to avoid getting run down by making sure you eat a balanced diet, take regular exercise and learn to manage stress.