In developed countries, diabetic retinopathy (DR) is one of the most horrible complications of diabetes and leading cause of blindness. A diabetic is 25 times more at risk of becoming blind.

High blood sugar levels damage the intricate blood vessels in the retina- the light sensitive tissue responsible for sight. Consequently, blindness ensues.

In Singapore, 8.2 percent of adults are diabetics.  A study involving 13,296 adult diabetics were evaluated by retinal photography. The findings showed that 21.8 percent have DR while 10.8 percent are in the early stages of DR.

Non-proliferative DR

DR starts as tiny bulges (microaneurysms) that develop in the retinal blood vessels. An obstruction of blood flow ensues and fluid and blood leaks. When your eye doctor examines your retina, white patches (cotton wool spots) are seen. This is the non-proliferative stage. Most of the time, you’ll not notice anything wrong with your eyes unless it is accompanied by diabetic maculopathy.

Proliferative DR

To compensate for the obstruction and decreased blood flow new blood vessels would grow (neovascualrization). But they grow abnormally

These new blood vessels bleed easily. When they bleed into the clear gel of your eyes it blocks your line of vision resulting into distorted images.  Leaking blood vessels repair themselves growing scar tissue. When the scar tissue contracts it pulls off the retina from the eye wall causing blindness. Also, if new blood vessels become too plenty they can obstruct outflow of fluid from the eye and pressure develops (neovascular glaucoma) complicating the condition and contributes to blindness.

Symptoms of DR

Symptoms of DR include floating spots, dark streaks or haze that blocks vision, blurring or distorted vision, increased sensitivity to glare, poor night vision and blindness.

Risk Factors for DR

74% of diabetics develop DR and is more common among diabetics who had the disease for more than 10 years with uncontrolled blood sugar levels.

Risk factors for developing DR  include skyrocketing blood sugar levels, long duration of diabetes, hypertension, high cholesterol levels, smoking and gestational diabetes (diabetes during pregnancy).

Diagnosing Diabetic Retinopathy

Upon diagnosis of type 2 diabetes an eye assessment should be done then annually thereafter. Children with type 1 diabetes should be screened three to five years after the initial diagnosis and then every year thereafter.

Regular retinal examinations and serial photography are essential procedures since they monitor changes in the retina.

Diagnostic procedures include optical coherence tomography (OCT) which detects retinal swelling. Fundus fluorescein angiography identifies leaking and growing vessels and bleeding in the retina.

Reducing DR risks

Good blood sugar control – HbA1C should be within 6.5-7.5 percent – reduces risk by 76% and slows progression by 54%. Good control of concomitant hypertension with blood pressure lower than 130/80 can lower your risk together with normal blood lipid levels.

Lifestyle modifications can significantly help. Eat a balanced diet of more veggies and fiber-rich foods. Exercise regularly, avoid smoking and go easy on alcohol.

Radiosurgery utilizes high energy beams to hamper the DNA of the tumour cells which makes the cells to arrest multiplying. A high radiation dose is delivered with precision in Stereotactic radiosurgery in a single treatment. It is performed as a day surgery procedure.

The different technologies for performing radiosurgery are The LINAC (X-knife system, BrainLab system, etc.) which utilizes a Linear Accelerator to perform radiosurgery.

Fractionated stereotactic radiosurgery (SRT)

In cases where the volume of the tumour is large then, the radiation dose is to be divided and a small fraction of the total dose is to be administered daily over several weeks. In case teh dose is given in a single treatment then, it can be quite damaging to the surrounding healthy brain tissue. Side effects to the surrounding normal brain are reduced. SRT is a safer alternative to high dose single session stereotactic radiosurgery. The Gamma-knife technology is not capable of doing the SRT.

In case the treatment is successful then, on repeating the MRI, the tumour may have reduced in size, disappeared or remained the same in size. When there is no increase in size it indicates that the tumour is not growing and the cells are not diving and are inactive. The status of the tumour can be regularly monitored by conducting MRIs of the brain with gadolinium.

Side-effects of radiosurgery

Radiation necrosis may occur. The effects of radiation necrosis may remain permanent in some cases.

Latest methods of radiosurgery: micro-multileaf collimator

Micro-Multi Leaf Collimator Radiosurgery or Micro-(MLC) Radiosurgery is the latest form of radiosurgery that is presently available in Singapore. Micro-Multi Leaf Collimator Radiosurgery utilizes a complicated computer controlled system to best suit the high energy X-rays from the LINAC to the 3D shape of the tumour. In combination with fractionation, this method has the potential of reducing the side effects while still maintaining the possibility of good results.

To offer better results, new imaging modalities such as PET can be combined with MRI and CT. Technique such as Intensity Modulation (IMRT and IMRS) can enhance results and further lower risks.

Such combination methods are more superior as compared to older methods such as the Gamma-knife. There is no requirement of any head pin or screw fixation in fractionated Micro-(MLC) Radiosurgery. This offers increased patient comfort and lower pain. Apart from that larger volumes of the tumour can be more readily treated as compared to the Gamma-knife method.

Nasal allergies

The immune system is accountable for shielding the body against harmful germs, compounds and cells. The immune cells are mobilised whenever any germs enters the body, the immune system mounts a response to fight it. In an allergic reaction, the immune system incorrectly recognizes a harmless substance as harmful and mounts a response which is not required. This reaction which takes place in the nose is known as nasal allergy or allergic rhinitis.

Causes

These injurious substances are known as allergens. Most allergens are inhaled while some are ingested through the food. Few of the common allergens are house dust mites, pollen, animal dander and fungi. Common causes in children are enlarged tonsils and adenoids and obesity.

Symptoms

Few of the symptoms of nasal allergies are – Nasal congestion or blocked nose, itchy nose and eyes, post-nasal drip, runny nose, sneezing, loss of smell, and mouth breathing.

Symptoms may vary from mild and infrequent – to – severe and occurring daily. Symptoms in children may differ from adults. They may sweat during sleep, breathe through mouth or have restless sleep. The learning ability of the child may be affected.

In case symptoms such as recurrent bleeding, coloured mucus, a blocked nose without other nasal symptoms are present then, the patient must immediately consult an Ear-Nose- Throat (ENT) specialist.

Diagnosis

It is made on clinical grounds. Allergy tests such as skin prick test or a blood test can help to recognize the allergens. In few cases a computed tomography scan may be required to exclude other nasal conditions.

Treatment

There are several treatment options available. Patient education is essential as this condition is chronic and patient involvement is vital for good control. The symptoms can be reduced by Environmental control of allergens. Oral medications – pills and syrups – or nasal sprays can be used to provide symptom relief. Nasal steroid sprays are safe and helpful in controlling the allergic reaction and are generally the first line medication. Surgery is indicated in cases which fail to respond to treatment with medications.

Cure

Allergy improves as one gets older. Immunotherapy is an alternative, which involves the introduction of allergens into the body at controlled doses. They are started at a very low dose and gradually they are increased so that the body builds tolerance towards the allergen. Immunotherapy can be administered in weekly injections or daily oral sublingual instillations.

According to the American Cancer Society, worldwide breast cancer is the most common cause of cancer in women. It is expected that 1.3 million women worldwide will be diagnosed with the disease. Additionally, breast cancer is the second leading cause of cancer deaths in women and 465,000 women will succumb to the disease. It is not surprising that in Singapore breast cancer is the most common cancer in women resulting to deaths. However, the good news is, as statistics show, there is a decreasing trend of deaths from breast cancer due to improved screening procedures and treatment.

Screening is a procedure to discover signs of cancer before a person experiences symptoms. Breast cancer can be detected usually at a very early stage- the stage where it can be promptly excised and given a total cure.  If cancer is discovered when symptoms and signs appear, the cancer may have grown larger and metastasized with a very poor outcome.

If you’ll see your family physician, he or she will conduct a clinical breast exam. A skilled and trained health provider conducts a thorough breast exam. He or she feels every area of your breasts including that area under your axillae or armpits. If you’re highly suspicious of a malignancy, he or she might do some diagnostic test such as an excision biopsy and/or refers you to a breast surgeon.

Experts agree that the most reliable early screening method is through mammography that can detect small malignancies. This diagnostic procedure dramatically improves the chances of survival by as much as 20-39 percent according to clinical trials in 50-74 year old women and 17 percent in 40-49 year old women. Most women can avail of mammography easily.

Mammography is actually an x-ray of your breast, if abnormalities are detected on a screening mammography, you’ll be further recommended for diagnostic mammography.

You can prepare yourself for this procedure by knowing what it is. A mammogram is an image of your breasts. To take that image your breasts are compresses between two firm surfaces to spread the tissues. Then an x-ray takes an image for a doctor to analyze and detect abnormalities. This procedure is sometimes painful and uncomfortable for women.

A less uncomfortable method is digital mammography. It is a highly refined diagnostic procedure for detection of breast cancer at its very early stages. It employs computer imaging and has lesser pain during the procedure as compared to the conventional mammography.

In Singapore, highly specialized clinics are available to conduct this life saving procedure. The frequency of mammography would depend upon your risk and age. Usually, for screening purposes the procedure is done every 3 years.

Rather than wait for breast cancer symptoms and to reduce your risk of dying from breast cancer – go for that mammogram!

Below are mentioned few different methods which enhance the breast -

Autologous Fat Transfer to augment the breasts

In this method the breast is enhanced by using the patient’s own fat. The breasts that are enhanced are natural in shape and normal. The fat is carefully extracted via a non traumatic method like waterjet, washed, filtered and then it is injected again into the suitable anatomical planes. To attain one size bigger the patient may probably have to undergo the procedure more than once and must also have adequate amount of fat store for the plastic surgeon to harvest it.

Anatomical cohesive gel implant

Currently, this is the most popular type of breast enhancement. This kind of implant fails to leak even when cut through and it offers the patient with the best natural shape. There are several companies which offer a “life warranty” on their product. This procedure needs excellent surgical skills and expertise in properly placing the well selected implant. There will be a presence of a slight incisional scar. The success of this implant is dependent on selecting of the size and proper planning of the procedure.

Some temporary methods

Artificial materials such as macrolane, hyacorbs, etc are utilized to enhance the size of breasts. These methods are temporary and shall last for approximately a year. Approximately 100 ml of these materials are injected into the breasts, and as these materials are biologically degradable, the body shall eliminate them within a year, requiring replacement. The cost of the material is high and the procedure is accompanied with pain and with some possible complications. Some sensitive patients may develop reactions to the material used.

Liquid silicone prosthesis

In this method when the external coverings deteriorate, they seep or leak. The prosthesis requires to be replaced after 10 years.

Others

Injection of semi-permanent fillers, liquid silicone or other permanent materials should not be considered due to immense unfavourable results.

Conclusion

The ideal method of breast enhancement should be the one which is natural and preferably the one which utilizes one’s own tissue. Presently the best alternative is the anatomical cohesive gel prosthesis which offers a natural shape.

The intraocular lens implanted in the eye which permits vision at one distance – far, near or intermediate is known as monofocal implant. Generally, the monofocal implant is selected by the patient. There are several patients, who are in their 50s and above, generally suffer from presbyopia – inability to see near as a result of age or “Lao Hua Yan” – and have being habituated to using reading glasses. There is availability of several more options and comprehending them is essential.

Monovision

In monovision, patients undergo cataract extraction and have monofocal implants. The affected eye is fitted with an intraocular lens which permits clear distant vision. The non- affected eye is fitted with a monofocal intraocular lens so that after the operation, the eye is slightly myopic which permits near vision. Hence, initially it is important to judge which the dominant eye is. Patients option for this alternative need to know that the distant vision for the non-dominant eye shall be compromised for vision at closer distances. Patients requiring clear vision for distance in both the eyes should not select this alternative.

Even though, it is seen that monovision remains a well-liked alternative as there is freedom from spectacles. The compromise in distant vision in the non-dominant eye can be reverted with spectacles or contact lenses.

Multifocal implants

The patient can see clearly both, for far and near. Both the eyes of the patient need to be fitted with the multifocal implant. The disadvantage is that this lens cannot be used in night time as the pupils get more relaxed and dilated resulting in glare and halos vision.

Toric lenses

Toric contact lenses are known to rectify astigmatism. Toric lenses have to be dialled into position as per the axis of astigmatism. These lenses fail to give rise to any haloes or flare.

M

teeth enamel, improving the brightness and colour of the teeth. The two most effective teeth whitening methods recommended by dentists is the in-office whitening procedure, such as BriteSmile, or the customised take home whitening kit. Teeth whitening with BriteSmile treatment can erase years of yellowing as well as harsh staining from coffee, cigarettes, and red wine in the time it takes to get a haircut, a manicure or lunch. In fact, clinical studies prove that this In-office treatment resulted in an average improvement of 6-9 shades, in about one hour.

The BriteSmile Whitening Gel

The BriteSmile light is used in combination with a patented whitening gel, which has been optimised for patient safety and maximum results. A specially designed lamp that shines a gentle, blue light on your teeth, works in tandem with a proprietary whitening gel to accelerate the whitening process. This light has been clinically proven safe for tooth enamel as well as skin, gums, and other soft tissues. It emits virtually

BriteSmile Technology

The BriteSmile Whitening System

BriteSmile has revolutionised tooth whitening with state-of-the-art technology that is safe and effective. While other whitening gels contain as much as 35-50 percent hydrogen peroxide, BriteSmile’s proprietary gel contains only 15 percent peroxide and is buffered at a nearneutral pH value that is compatible with tooth enamel. The gel also contains other ingredients such as glycerinand highly purified water to prevent tooth dehydration and to further ensure safety. The gel is specifically engineered to respond to the blue wavelengths of the light system. When the light

illuminates the gel, it activates and safely accelerates the whitening process, achieving amazing results in just one hour. Clinical testing has proven that the teeth whitening procedure is safe. Safety studies conducted at the University of Medicine and Dentistry of New Jersey found conclusively that BriteSmile whitening resulted in no structural change in teeth; no adverse impacts on fillings and no softening of tooth enamel. These study results were confirmed by senior researchers at

New York University. The pH balanced proprietary gel is not harmful to the gums and because it is not ingested, the gel does not carry many other risks or side-effects of other options in the marketplace.

Dr Tay is the Director of The Implant and Oral Surgery Centre with over 10 years of clinical experience. She is a fully qualified specialist registered with the Singapore Dental Council and is on the Academy of Medicine, Singapore Roll of Specialists. She holds a position at the National University of Singapore as an Adjunct Lecturer and is also Visiting Consultant to Raffles Hospital. Dr Tay lectures extensively on the topic of dental implantology and  has published in international journals. She has also co-authored a book “A Patient’s Guide to Dental Implants”. Her expertise includes full mouth reconstruction with dental implants and smile makeovers. Dr Tay has been granted operating privileges at major private hospitals in Singapore including Gleneagles Hospital, Mount Elizabeth Hospital and Raffles Hospital. Dr Tay currently practices at Camden Medical Centre.

For more information, please visit www.iosc.com.sg

The most common type of endodontic surgery is an apicoectomy. In this procedure your surgeon removes a small portion of the root of the tooth and the infected area around the root close to the bone. He may then place a filling in the root area that he removed and stitch up the incision made in your gums. The bone around the affected area will eventually heal in fill it in. Other types of endodontic surgery include repairing a damaged root, removal of an affected root or roots, and dividing a tooth in half in an effort to save it. An intentional replantation is performed on a tooth that is removed and then treated and replanted back into your jaw. These are examples of some of the procedures an endodontic surgeon can use to save your teeth. Each case is treated individually and your treatment may vary.

Your surgeon will usually perform procedures under local anaesthetic although if the surgery is extensive, a general anaesthetic may be used. You can usually resume normal activates and in some cases be able to drive yourself home after endodontic surgery. Most endodontic surgery is covered by insurance and recovery time is short. Your endodontic surgeon will consult with you before the decision for surgery is made. Many times the alternative to surgery is complete removal of the tooth or teeth. If this is the case you may receive an implant or partial dentures to replace the extracted tooth. Endodontic surgery can help to save a tooth that has been damaged or infected. Your endodontic surgeon will determine which procedure is your best option and give his recommendations accordingly.

Dr Johnathan Wee is a dental specialist in endodontics with the Singapore Dental Council(SDC). His key interest areas in endodontics include management of dental trauma, evolving techniques in endodontic retreatment and post endodontic restorative outcomes.  Presently, Dr Wee divides his time between his clinical practice, academia, lecturing and attending endodontic conferences around the world in his continual journey to be a better endodontist for his patients.

Copyright © 2010. Advent Endodontics Inc. All Rights Reserved.
Dr Johnathan Wee, Clinical Director

It is important to understand the construction of a tooth to know why a cracked tooth may cause pain and discomfort. Inside teeth is living tissue called pulp that contains nerves and blood vessels. The dentin surrounds the pulp and this is surrounded by the enamel, the hard part of your tooth that you see. When the enamel cracks, either above the surface of the gums or below, any movement in the tooth from chewing or grinding your teeth irritates the pulp. As the crack gets worse the pulp is continually irritated and may become sensitive to temperature. If the tooth is not repaired the pulp may eventually become infected and spread to the gums, jaw and other areas of the mouth. When this happens your dentist may have no choice but to pull the affected tooth.

The method your dentist uses to correct a crack in your tooth depends on the type of crack it has. A craze is a crack that affects only the outer layer, the enamel, and this type of crack is normally left untreated unless the craze in on a tooth that causes concern for your appearance. In this case your dentist may apply a crown or a cap for cosmetic reasons. A fractured cusp affects the surface of your tooth and is common in molars. Your dentist may apply a crown or remove the affect portion of your tooth and then apply a crown to replace it. Rarely does a fractured cusp require a root canal since it does not usually affect the pulp.

Teeth may become cracked above the gum line or below. If the tooth is not completely split by the crack your dentist may feel a root canal is your best treatment option. A root canal removes the affected pulp and then a crown is applied to the tooth to prevent further cracking. If your tooth is split completely by a crack, a root canal and a crown or complete removal may be your treatment options. While a cracked tooth will not heal, your dentist does have treatments and procedures to help save your tooth and prevent further damage.

Dr Johnathan Wee is a dental specialist in endodontics with the Singapore Dental Council(SDC). His key interest areas in endodontics include management of dental trauma, evolving techniques in endodontic retreatment and post endodontic restorative outcomes.  Presently, Dr Wee divides his time between his clinical practice, academia, lecturing and attending endodontic conferences around the world in his continual journey to be a better endodontist for his patients.

Copyright © 2010. Advent Endodontics Inc. All Rights Reserved.
Dr Johnathan Wee, Clinical Director

Treatment depends on the type, location and severity of each injury. The nature of the injury, the length of time from injury to treatment, the care of the tooth taken after the injury and the body’s response, all these factors affect the long-term health of the tooth. Root resorption can be prevented by timely treatment especially in cases of dislodged or knocked-out teeth. Any dental injury, even if it appears to be mild may immediately require examination by a dentist or an endodontist. At times, the adjacent teeth may suffer from an additional, unnoticed injury which shall be noticed only by a thorough dental exam. Some of the traumatic dental injuries are Chipped or Fractured Teeth; Dislogded (Luxated) Teeth; Knocked-Out (Avulsed) Teeth and Root Fracture.

Chipped or Fractured Teeth

Chipped or Fractured Teeth can be repaired either by

• Reattaching the broken piece.
• By placing a tooth-colored filling.
• Placing an artificial crown or “cap” to restore the tooth.
• Root canal treatment.
• Extraction.

Dislogded (Luxated) Teeth

Treatment of Dislogded (Luxated) Teeth involves –

• Repositioning and stabilizing the tooth.
• Root canal treatment.
• Medication such as calcium hydroxide may be put inside the tooth.

Knocked-Out (Avulsed) Teeth

The knocked out tooth should be handled very gently, avoiding touching the root surface itself. Avoid the use of soap or any other cleaning agent, and never scrape or brush the tooth. If possible, the tooth should be placed back into its socket as soon as possible. The dentist shall place a stabilizing splint for a few weeks. The chances of saving the tooth shall depend upon the length of time the tooth was out of the mouth and the way the tooth was stored before reaching the dentist.

Dr Johnathan Wee is a dental specialist in endodontics with the Singapore Dental Council(SDC). His key interest areas in endodontics include management of dental trauma, evolving techniques in endodontic retreatment and post endodontic restorative outcomes.  Presently, Dr Wee divides his time between his clinical practice, academia, lecturing and attending endodontic conferences around the world in his continual journey to be a better endodontist for his patients.

Copyright © 2010. Advent Endodontics Inc. All Rights Reserved.
Dr Johnathan Wee, Clinical Director