Keep Those Teeth Clean or else...

Several years ago I saw a patient in the hospital for bacterial endocarditis. Bacterial endocarditis is an infection of the heart lining or valves. It is a very serious condition requiring intravenous antibiotics for at least one month. The patient was a young male with a relatively unremarkable medical history. Upon examination, he was found to have multiple dental cavities with gingivitis. Poor dentition is a cause for infective endocarditis! Then, several months ago, I was involved in a young female who was admitted due to strokes from endocarditis. After an extensive evaluation, it was presumed that the infection was from her oral cavity.

Infective or bacterial endocarditis affects about 29,000 individuals yearly. Individuals with heart conditions such as prosthetic valves, history of rheumatic carditis, congenital disease, or Marfans syndrome are at risk. The source of infection may come from IV drug use, dental procedures, GI procedures, urinary and prostatic procedures, skin infections, colon cancer, cardiac surgery, or respiratory infections. The bacteria enters the bloodstream and settles onto the heart. A vegetation or infective mass develops on the valve resulting in a cascade of signs and symptoms such as fever, rash, joint pain, fatigue, cough, weight loss, skin lesions, trouble breathing, etc...

One important preventative task is to keep those teeth clean. Routine brushing, flossing, and dental visits will keep the bacteria from developing and seeding into the body.

Antibiotics during dental procedures may be used to prevent endocarditis in high risk individuals. A single dose of Amoxicillin or Clindamycin is typically given one hour prior to the procedure. Guidelines suggest antibiotic prophylaxis in treatments involving gingival or tooth root manipulation.

The following conditions should receive antibiotics:
1. People with artificial heart valves
2. Certain congenital heart disease conditions
3. Previous history of endocarditis
4. Cardiac transplant

Mitral valve prolapse is not an indication for antibiotics.

Practice good oral hygiene and keep brushing those teeth!
For more information, talk to your health care professional and dentist. Thanks!

Male Breast Cancer

A pleasant 60 year old obese male presented to my office with complaints of a left breast lump for the past several months. He described it as tender and firm. There was no redness or pus. It was near his nipple area. He has no family history of breast cancer. His medical history was unremarkable. He does have a 30 year history of tobacco use. Upon examination, a 2 cm mass was palpated and minimally tender. He was sent for a diagnostic mammogram and ultrasound. The results came back highly suspicious for tumor and he was promptly referred to surgery for biopsy. His results are pending.

Male breast cancer is rare. About 1% of breast cancers occur in men. About 2000 men were diagnosed with breast cancer in 2008 with approximately 400 deaths. Typically, male breast cancer occurs between the ages of 60 and 70 with the median age being 67.

Risk factors include:
1. Age
2. Obesity
3. Heavy alcohol use
4. Liver disease
5. Hormone usage
6. Klinefelter Syndrome (chromosomal disorder)
7. Strong family history of breast cancer
8. Radiation exposure
9. High estrogen levels (from obesity, alcohol, hormone use, etc...)

Signs and symptoms include:
1. Lump
2. Nipple pain
3. Nipple discharge
4. Enlarged lymph nodes under the armpit
5. Changes to the breast skin such as redness, dimples, scaling...
6. Nipple soreness
7. Nipple inversion

Diagnosis is made by mammogram, ultrasound, and biopsy.
The most common type of male breast cancer is infiltrating ductal carcinoma.

Treatment depends on the staging/severity. It may consist of mastectomy, chemotherapy, radiation, and/or hormone therapy.

Male breast cancer is very similar to female breast cancer. Prognosis and remission rates are virtually identical and is based on the staging and extent of the cancer.

Two ways to prevent this rare disease is to maintain a healthy weight and to drink alcohol in moderation.

Talk to your health care professional for more information.

Thank you and have a nice day.

Fluoride in Children

Fluoride plays an essential role in dental health. Fluoride helps prevent tooth decay by stopping the acid from bacteria to erode enamel and by strengthening the enamel. It can also assist in reversing early tooth decay by remineralization. Since the addition of fluoride in the water system, tooth decay has been reduced by about 30%. Unfortunately, over 25% of toddlers still present with one or more cavities.

Water fluoridation became national policy in 1951. About 60% of the United States population receives fluoridated water. If you are unsure about your town's water system, contact the local health department. Below is the dosing for fluoride depending on the fluoridation of the town water.

Dosing Schedule for Children for Dental Caries prevention
Ages 3 months to 3 years old
1.Local Water Fluoride <0.3 ppm: Fluoride 0.25 mg daily
2.Local Water Fluoride 0.3-0.7 ppm: No Fluoride Supplement Necessary
3.Local Water Fluoride >0.7 ppm: No Fluoride Supplement Necessary

Ages 3 to 6 years old
1.Local Water Fluoride <0.3 ppm: Fluoride 0.50 mg daily
2.Local Water Fluoride 0.3-0.7 ppm: Fluoride 0.25 mg daily
3.Local Water Fluoride >0.7 ppm: No Fluoride Supplement Necessary

Ages 6 to 16 years old
1.Local Water Fluoride <0.3 ppm: Fluoride 1.00 mg daily
2.Local Water Fluoride 0.3-0.7 ppm: Fluoride 0.50 mg daily
3.Local Water Fluoride >0.7 ppm: No Fluoride Supplement Necessary

Fluoride supplements are typically prescribed. It comes in liquid and chewable tablet forms and may be combined with a multi-vitamin. Supplementation may begin at six months of age. As children get older, fluoride toothpastes are used to prevent tooth decay.

Children two years of age and younger should not use fluoride toothpaste but instead use a training toothpaste like Orajel Toddler. Children over two years of age should use an ADA approved fluoride toothpaste but with assistance from a parent. Kids should be taught not to swallow and use a "pea-size" amount. Also, children under six years of age should not use fluoride mouth rinses.

Excessive fluoride intake can cause a condition called enamel fluorosis (discoloration of the permanent teeth). Talk to your health care professional for more information.

Finally, dental visits should begin within six months of the first tooth or at one year of age.

Hope this was informative!

Folic Acid and Pregnancy

Throughout residency and in practice, I have seen many pregnant women. One of the most important pieces of advice I provide is the need to take a prenatal vitamin, more importantly, folic acid.

Folic acid is a B9 vitamin, essential in cellular production and division. It is found in green leafy vegetables, orange juice, dry beans, spinach, bananas, peanuts, enriched whole grain foods, and kale. The recommended daily allowance is 400 micrograms/day. Folic acid can help prevent coronary heart disease, anemia, and, in babies, neural tube defects.

Neural tube defect is a condition when the baby sustains a birth defect where there is incomplete development of the brain and spinal cord. Examples include spina bifida, anencephaly, and encephalocele. Typically, these defects occur in the first month of pregnancy, when the mother is unaware of her pregnancy. Folic acid can reduce the incidence of neural tube defects by up to 70%. Unfortunately, about 3000 babies are born each year with a neural tube defect.

The recommended dose for women who are pregnant or are expecting to be pregnant is 400 micrograms per day. Adequate folic acid intake should begin for all women who are of child-bearing age. It is wise to start a prenatal vitamin one month prior to conception to help ensure fetal nerve and brain development. One study indicated that three out of four women did not take their vitamin at least four times a week in the month before they became pregnant.

Folic acid can also reduce the possibility of cleft palates, preeclampsia, premature birth, congenital heart defects, and miscarriage.

There are special circumstances when more folic acid supplementation is required. Examples include previous child with a neural tube defect, family history of neural tube defects, personal history of diabetes, seizure disorder, or rheumatoid arthritis.

Folic acid supplementation does not stop at the birth. During breast feeding, the recommended amount is 500 mcg daily.

Typically prenatal vitamins contain 400mcg of folic acid. Most multivitamins also contain 400mcg. Check the label and verify that it has 100% of the RDA (recommended daily allowance).

Talk to your health care professional for more information. Thank you and have a nice day.

The Importance of Fiber

Fiber is an essential component in a healthy diet. There are numerous benefits in eating an adequate amount of fiber. Unfortunately, many Americans do not meet the recommended goals.

Fiber is a type of carbohydrate that can not be digested. It passes through the body without being metabolized but it participates in many roles to maintain health.

There are two main types of fiber:
Insoluble-Fiber that does not dissolve in water and thus can help with constipation.
Soluble- Fiber that can dissolve in water and forms a gel like substance. This helps with cholesterol and sugar control.

The recommended amount is based on age, gender, and caloric needs but on average one should consume about 25 grams a day of dietary fiber from food. The average American consumes about 5-15 grams per day.

The benefits of fiber include:
1. Improves bowel health and aids in constipation
2. Lowers risk of heart disease
3. Decreases risk for diabetes and helps stabilizes blood sugar
4. Reduces risk for diverticular disease
5. Helps reduce bad cholesterol levels
6. Helps with weight loss
7. Lowers risk for hemorrhoids
8. Helps with irritable bowel syndrome
9. Reduces chances of gallstones and kidney stones

Sources of fiber include whole grain foods, legumes, nuts, fruits, and vegetables.

Here are some tips about adding fiber to your diet:
1. Add color to your plate (green leafy vegetables, red apples, brown rice, etc).
2. Instead of "white" foods, go with colorful foods...brown rice instead of white, sweet potatoes instead of white potatoes, whole grain pasta instead of white pasta.
3. Add fresh or frozen vegetables to soups, casseroles, pasta dishes.
4. Eat more beans, legumes, peas, lentils...refried bean nachos!!!
5. Drink water to also avoid constipation and to help the beneficial effects of fiber
6. Snack on dried fruit, fresh fruits, veggie sticks, nuts, popcorn, whole grain crackers instead of chips.
7. Substitute white flour with whole grain flour...great for pancakes.
8. Choose whole grain cereals.
9. Read food labels.
10. Add fiber gradually to your diet.
11. Add a spoonful of flaxseed to your food.

Here are some examples of foods with their fiber counts:
2 slices of whole-wheat bread = 4 grams of fiber
1 cup of cooked brown rice = 4 grams
Reduced-Fat Triscuit crackers = 3 grams
¾ cup cooked oatmeal = 3 grams
1 cup of canned minestrone soup = about 5 grams
1/2 cup vegetarian or fat-free refried beans = about 6 grams
1/4 cup kidney beans, added to a green salad = 3 grams
1 large apple = 4 grams of fiber
1 banana = 3 grams
1 cup strawberries = 4 grams
1 cup cooked broccoli = 4.5 grams
1 cup raw carrots = 4 grams
1 sweet potato = 4 grams
1 cup cauliflower, cooked = 3 grams
2 cups raw spinach leaves = 3 grams

Talk to your health care professional about dietary fiber. In some cases, patients may need fiber supplements such as Metamucil or Benefiber

Thank you and drive carefully!

Eye Floaters

34 year old male presented to my office with complaints of seeing spots and transient blurry vision. He stated it began about a week ago after recovering from a cold. He describes the spots as bright "sperm-like" things. The blurry vision occurred when he was reading a book. He could not read the preceding word when focusing on a specific word but after a few minutes, the vision cleared. He also complained of a mild frontal headache. In the office, he continued to see the bright spots, but otherwise felt well. His blood pressure was excellent and his physical exam was unremarkable. He was sent to the eye doctor with the presumed diagnosis of visual floaters. The diagnosis was confirmed after the retinal examination.

Visual floaters (entopsias) are common, typically after the age of thirty five. They are from pieces of the vitreous gel in the eye that float and drift aimlessly in the eye ball. They can be described as spots, specks, cobwebs, light-flashes, strings, or clouds in the visual field. Floaters are more evident on a white or bright background. They may interfere with vision depending on the location but they are constantly moving and eventually settles to the floor of the eye.

Risk factors include older age, near-sightedness, Diabetes, sarcoidosis, syphilis, history of retinal disease, or previous cataract surgery.

Floaters are typically not a major problem. They tend to be an annoyance. An ophthalmologic examination is recommended to assess the retina. Medical concerns include retinal detachment (emergency), diabetic retinopathy, vitreous detachment (severe), bleeding in the eye, and infection.

If there is a sudden onset of floaters or if there are flashing lights with the floaters, contact the eye physician immediately. Also, if there seems to be a shade coming down the visual field, contact the eye specialist immediately. These are signs of a retinal detachment.

Floaters tend to dissipate with time. The brain also adapts to the presence of floaters and they become less annoying. There is no safe proven method to eliminate floaters. Surgical intervention may be utilized in very severe cases. Talk to you health care professional for more information.

Thank you.

Bad Things Can Happen to Healthy People

I recently took care of a young patient who was diagnosed with a large neck mass that was compressing his windpipe and carotid and jugular vessels. He was diagnosed with tongue cancer years ago with a recurrence in 2008. He underwent surgery, radiation, and chemotherapy but unfortunately the neck mass developed. He fought hard. His family provided extraordinary support. However, there was nothing medically that could be performed to cure his cancer.

Reviewing his case, I expected to find the cause of the tongue cancer. I expected to see a tobacco history but he never smoked. He had no significant history of alcohol, drug, or tobacco use including chew tobacco. We looked at environmental and work exposures but found no association. He worked in HVAC. Bad things can happen to healthy people.

In medicine, we assess risk factors, find causes, and prevent potential severe medical conditions. We advise people to stop smoking to reduce the chance of heart disease. We encourage exercise and healthy diets to reduce the obesity epidemic. We vaccinate children to prevent Polio, Measles, Mumps, etc...We advise colonoscopies, pap smears, mammograms to prevent cancer. However, as in life, the unexplainable does occur in medicine.

One of the most frustrating aspects in medicine is when bad things happen to healthy people. This young man had no risk factors for tongue cancer yet he was diagnosed at around thirty years of age. The median age for tongue cancer is sixty. Risk factors include tobacco use, alcohol, HPV, and age. The incidence is about three per 100,000 per year (rare). We can only blame a faulty gene. The thought is always what could we have done to prevent this but unfortunately the answer is nothing.

Does this case reduce the importance of preventative medicine and risk factor stratification? No. It makes me appreciate how delicate and precious human life is and to be more cognizant about medical "zebras" and rarities. It makes preventative medicine more important so people can live life to its fullest. Therefore, eat healthy, drink in moderation, avoid drugs, do not smoke, exercise, and laugh. And if something bad does happen, understand that there is always a silver lining somewhere in the clouds, whether it be improving a physician's skill, bringing a family together, or making people appreciate their own lives.

Also, pray for the citizens of Haiti. It is a devastating situation and I wish to all my colleagues who are going to Haiti a safe journey.

Thank you.

Please Stop Smoking!

The past several months I have had a run on severe tobacco related illnesses. Smoking is very detrimental to the vital organs but yet about 46 million adults smoke in the United States. Here are several patient cases...

50 year old male presented to me with complaints of chest pain and shortness of breath. He smokes 2 packs a day for 30 years. He has a history of high blood pressure but was not taking his medication due to cost (but yet could afford his 2 pack a day habit). He was sent to the ER and was found to have a myocardial infarction (heart attack). He underwent cardiac stenting and is now on multiple medications to prevent another heart attack.

70+ year old female presented to the office with chest pain and back pain. She smoked a pack a day for over forty years. A chest xray was done and a mass was found. After further diagnostics, she was diagnosed with lung cancer and the tumor had wrapped around her heart. Surgery could not be performed. Palliative therapy was done and she passed away.

A young twenty-something adult came to me with complaints of exertional shortness of breath. He was hospitalized for pneumonia several months ago. He continues to wheeze and utilizes two inhalers to stabilize his breathing. The patient began smoking when he was eight and continues despite repeated counselling to quit. He is a laborer but now has difficulty with exertional work. His quality of life is poor and he has difficulty keeping up with his young son.

A 60+ year old male saw me in the office with flu-like symptoms. He had trouble breathing, fever of 104, fatigue, and muscle aches for several days. Supportive care was advised with follow up. Several days later, his relative called and said he was confused. He was admitted to the hospital and diagnosed with pneumonia. Despite aggressive antibiotics, steroids, and oxygen support, he decompensated within 24 hours and was intubated (tube placed into his lungs). Upon further investigation, he had smoked 1 and a half pack a day since childhood and his lungs were in poor shape. Due to his smoking history, he developed COPD (chronic obstructive pulmonary disease) which made him very susceptible for respiratory infections and failure. He is recovering.

A 60+ year old female presented to the office with an oral gum lesion for several weeks. It was a raised mass with ulcerations on her lower gum line. She has poor dentition. She had smoked for many years. The patient was reluctant to go to the specialist but eventually listended to my advice. The biopsy revealed squamous cell carcinoma (cancer) and a total excision was performed. This scare resulted in her quitting tobacco.

This is just a sample of cases I see that are tobacco related problems. Smoking can contribute to many health problems such as COPD, lung cancer, heart disease, oral cancers, asthma, strokes, heart attacks, emphysema, pancreatic cancer, bladder cancer, high blood pressure, cervical cancer, peripheral vascular disease, pneumonia, kidney cancer, impotence, psychological disorders, fetal problems, etc....

Help is out there. Call your health care professional to help quit this deadly habit!

Acute Sinusitis

In recent months, I have seen many complaints of sinus infections. The typical patient will come to the office and complain of facial pain around the cheeks with a fever and nasal drainage. Acute sinusitis is a very common illness in the primary care setting, accounting for about 16 million office visits per year.

Acute sinusitis is inflammation of the sinuses or cavities around the nasal passages. Sinuses are air chambers that make mucus to clear particles and organisms in the air. Cilia, or tiny hairs, clears out the mucus from the sinuses and helps it drain through the nasal canals. The swelling from sinusitis interferes with drainage and mucus builds up in the cavities. The mucus then becomes a breeding ground for infection.

The most commonly affected area in adults is the maxillary sinus. In children, it is the ethmoid sinus.

The causes of sinusitis include:

1. Viral (Rhinovirua, Influenza, Adenovirus, Parainfluenza)

2. Bacteria (Streptococcus, Haemophillus, Moraxella)

3. Fungal (Aspergillus, Mucormycosis) in immunocompromised patients (Diabetics, HIV, cancer patients)

Risk factors include:

1. Allergies

2. Nasal passage abnormalities (deviated septum, polyps)

3. Trauma

4. Dental infections

5. Recurrent upper respiratory infections

6. Nasal dryness

7. Inhaled irritants (tobacco smoke)

8. Immune disorder

9. Inflammatory disorder

10. Hormones

Signs and symptoms (up to 4 weeks) include:

1. Pain/pressure in the cheeks, between the eyes, forehead, or nose (worse when leaning forward)

2. Upper teeth pain

3. Headache

4. Fever

5. Bad breath

6. Nasal drainage (yellow/green)

7. Trouble breathing through the nose

8. Reduced ability to taste or smell

9. Cough at night

10. Nausea

11. Fatigue

12. "Double sickening" (Patient begins with a cold, gets better, then gets worse again)

Treatment includes:

1. Saline nasal spray (Ayr or Ocean spray)

2. Short term decongestant (Sudafed)

3. Anti-inflammatory (ibuprofen)

4. Fluids

5. Rest

6. Moist heat on the sinuses (warm compresses)

7. Humidifier

8. Avoid anti-histamines

If the symptoms do not improve after several days, contact your health care professional.

Typically viral sinus infections will improve after 5-7 days. Acute bacterial sinus infections usually require antibiotics.

If the symptoms do not improve after sufficient treatments, diagnostic imaging such as a CT may be taken to confirm diagnosis. Specialist referral to an ENT usually are reserved to persistent sinusitis, mental status changes, severe facial or dental pain, severe swelling or redness around the eyes, visual complaints, high fever, and sinusitis refractory to medical management.

Major complications are extremely rare.

Contact your health care professional for more information.

Thank you and have a nice day.

Tobacco Cessation

The new year always brings resolutions such as weight loss, exercising, improving relationships, etc. Another very common one is tobacco cessation or trying to quit smoking. Here are some strategies to help with this difficult yet attainable resolution.

1. Go cold turkey if possible. It can be done, especially in cases where an individual smokes less than a pack a day.
2. You need to really want it!!! Daily commitment is a requirement when trying to quit.
3. Set a quit date. Make it a meaningful date such as a wedding anniversary, birthday, or holiday.
4. Take advantage of counselling programs to keep motivated. It can range from phone sessions to group meetings.
5. Understand the positives when quitting such as improved breathing, lower risk for heart disease, whiter teeth, better breath, lower risk for lung cancer, more available money, etc...
6. Utilize social support from friends and family members. If other people smoke, make it a group goal and support one another.
7. Remove cigarettes, ash trays, other related items to reduce the urges.
8. Avoid or change habits that trigger tobacco use (i.e. alcoholic drink at a bar).
9. Avoid smoking environments and eat at non-smoking restaurants.
10. Reward yourself in successful weekly or monthly intervals.
11. Do it for the children...second hand smoke increases asthma attacks, allergies, ear infections, sinus infections, etc.
12. Talk to your physician about medications such as Chantix, bupropion, or nortriptyline, especially if smoking more than one pack a day.
13. Utilize nicotine replacement supplements to help with the cravings and withdrawal symptoms such as the gum, patch, nasal spray, lozenge, or inhaler.
14. Do not let smokers smoke in your house or car.
15. Exercise and eat healthy to keep your weight stable.
16. Chew gum, eat carrot sticks or pretzels, suck on lollipops, to keep your mouth busy.
17. Try alternative therapies such as hypnosis, acupuncture, or acupressure.
18. It is OK to "slip." Try again and get back on track.
19. Stop the excuses.
20. It is all about "one day at a time."
21. Try Quit Meters (available online) to keep track of your success
22. Find a healthy passion to replace smoking such as leading a tobacco cessation group.
23. NEVER GIVE UP!!!
24. Talk to your health care professional...use them as a resource.

Check out the QuitNow website or call 1-800-QuitNow (free service)
Thank you and have a Great New Year!!!