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Diffuse Oesophageal Spasm (DES)

Management Team

Diffuse Oesophageal Spasm (DES)

Overview

DES is characterised by uncoordinated, often very strong, and irregular oesophageal contractions. These spasms can result in substantial chest pain and dysphagia (difficulty swallowing).

The cause of DES is unclear, but the following may play a role in its occurrence:

  • Neuromuscular dysfunction:
    • Impaired inhibitory neurotransmission: Normally, the oesophagus uses excitatory as well as inhibitory neurotransmitters to regulate smooth muscle contraction. In DES, there may be reduced or absent inhibitory signals from the nerves that control digestion and related processes (enteric system), leading to simultaneous uncoordinated contractions of the oesophageal muscles.
    • Disrupted smooth muscle function: The smooth muscle in the oesophagus may respond abnormally to neural signals, causing spasms or contractions that are out of sync with normal peristalsis.
  • Gastroesophageal reflux disease (GERD)
  • Hypersensitivity to acid
  • Psychological stress
  • Oesophageal inflammation
  • Genetic factors
  • Ageing
  • Oesophageal structural abnormalities

  • Chest pain (which may mimic heart attack symptoms)
  • Dysphagia (difficulty swallowing)
  • Regurgitation (this is less common than in other oesophageal motility disorders)

  • Oesophageal manometry: This test is used to diagnose DES based on the measurement of uncoordinated contractions.
  • Barium swallow: A barium swallow may reveal a "corkscrew" pattern in the oesophagus.

  • Medications:
    • Calcium channel blockers or nitrates: These are used to relax the oesophageal smooth muscles and reduce the spasms.
    • Prokinetic agents and antidepressants: These are used for nerve modulation.
  • Botulinum toxin (Botox): In refractory (nonresponding) cases, Botox injections may be considered to reduce spasms by inhibiting the release of acetylcholine, which is known to induce smooth muscle contraction.
  • Surgery: This is used in severe cases.
    • Esophagectomy (removal of all or parts of the oesophagus)
    • Myotomy (cutting of muscles in the oesophagus)
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Dental Plaque

Management Team

Dental Plaque

Overview

Dental plaque is a sticky colourless film containing bacteria, saliva, and leftover food particles; constant plaque formation on the teeth is normal. However, regular non-removal of plaque can lead to the hardening of the dental plaque, forming tartar, which is the leading cause of gum disease. As tartar cannot be removed by brushing and flossing, tooth cleaning by a dental professional is required.

Initially, tartar appears off-white or yellow; later, it takes on the colour of the food or substances being consumed. Certain activities, including the consumption of tea, coffee, red wine, and chocolates, chewing tobacco, and smoking, cause the tartar to appear darker.

When bacteria in the oral cavity mouth interact with starchy or sugar-rich foods, such as chocolates, bread, pasta, fruits, milk, soft drinks, or juices, they release acids for metabolising the carbohydrates in these foodstuffs. Failing to brush teeth or delays in brushing teeth after the consumption of such foods can cause the combination of bacterial cells and acids and carbohydrates to accumulate; the resulting deposits appear as a sticky, colourless film, which is termed plaque.

The common symptoms of dental plaque formation include:

  • Fuzzy sensations on the teeth
  • Red, swollen gums
  • Bleeding gums, especially after brushing
  • Halitosis (bad breath) that does not go away

Severe dental plaque and tartar formation can lead to:

  • cavity formation
  • tooth infection and loss
  • gingivitis and other types of gum diseases

If the teeth appear or feel fuzzy, it is likely that plaque formation has occurred. For the maintenance of dental hygiene, scheduling an appointment with a dentist, who will examine the gums and teeth and prescribe appropriate treatments (if needed), is recommended.

Regular visits to the dentist for teeth cleaning are also recommended. While some people need to undergo tooth cleaning once every 6 months, in cases where plaque formation is severe, more frequent visits may be required. Dentists often recommend the type of cleaning schedule that best suits the patient’s needs.

Dentists use specialised instruments for the removal of plaque and tartar. The following treatments may also be recommended:

  • Application of dental sealants to prevent further plaque formation.
  • Fluoride-based treatments to inhibit the growth of plaque-causing bacteria and reduce the risk of tooth decay.
  • Application of prescribed toothpaste or antibacterial mouthwash.
  • Treatments to prevent dry mouth and increase saliva production.
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Diastema

Management Team

Diastema

Overview

Diastema refers to the presence of an unusual gap between teeth, most commonly occurring between the front two teeth. Diastema affects both children and adults; however, gaps between the milk teeth of children are normal and usually close once their permanent (adult) teeth erupt.

Diastema is reported to be hereditary; several people are genetically prone to this condition. Sometimes, family history serves as a risk factor for this condition. The other causes of diastema are as follows:

  • Missing teeth or reduced tooth size
  • Oversized frenum (the connective tissue band that connects the gums and lips).
  • In some cases, an abnormal swallow reflex has been linked to the development of diastema. Under normal circumstances, while swallowing, the tongue presses against the roof of the mouth. However, repeated pressure resulting from the tongue being pressed against the front teeth may result in the gradual formation of a gap between teeth.
  • In some people, advanced gum disease causes the formation of gaps between the teeth. In such cases, the infection in the gums erodes the bone underneath, thus loosening the teeth and eventually, causing the formation of a gap.

Patients with the aforementioned conditions are at a risk for developing diastema.

A gap between the teeth is the only sign of diastema, provided the teeth and gums are healthy. If the gap is caused by a gum disease, patients may notice inflammation, redness, pain, or other gum disease-specific symptoms. Given that diastema does negatively impact the oral health, it is not a matter of concern, unless it is a consequence of gum disease. Plenty of corrective cosmetic treatments are available for patients that prefer to close the gaps between their teeth.

Diastema is often diagnosed by dentists during a routine dental exam, without the need for further testing.

Patients that are bothered by gaps between their teeth are advised to schedule a dental consultation. Dentists discuss the treatment options with the patients in detail. Nonetheless, an increasing gap between teeth would require prompt action.

There are several methods to correct and/or treat diastema. The cause and nature of diastema (whether it is a result of gum disease or merely of cosmetic concern) determines the course of treatment.

  • Cosmetic treatments for diastema: Several cosmetic dental treatments are available for patients with otherwise healthy teeth simply wish to close the gaps:
    • Dental bonding: To conceal the gaps, the dentist will apply a tooth-coloured composite resin onto the tooth/teeth. Thereafter, to ensure that the teeth have a natural look/appearance, they are shaped and polished.
    • Application of porcelain veneers: Custom-made ceramic shells (veneers), when attached (often permanently) onto the front teeth, close the gaps between the teeth, offering a more uniform look.
    • Application of braces: If the gaps are large, the teeth may need to be physically moved together via the use of orthodontic treatments, i.e., clear orthodontic aligners or braces. In mild cases, diastema can usually be fixed without braces.
    • Frenectomy: The presence of an oversized/thick oral frenum causes the teeth to be pushed apart, resulting in the formation of a gap. A frenectomy serves to either remove or loosen the frenum. In many cases, frenectomy is performed along with other cosmetic procedures, such as veneer application or dental bonding.
    • Application of dental bridges: Dental bridges are often recommended by dentists if a missing tooth is the cause of diastema; the bridges serve to replace the tooth. To place a bridge, the presence of two healthy teeth on either side of the gap is necessary; these teeth are altered to serve as anchors that hold the bridge in place.
    • Application of dental implants: Similar to a dental bridge, an implant serves as a replacement for a missing tooth. However, the application of a dental implant does not necessitate the reshaping of the neighbouring teeth. Implant application involves the placement of a threaded titanium post to replace a missing tooth root; once the tissues around the implant heal, a dental crown is fixed to close the gaps between the teeth.
  • Gum disease treatment for diastema: If gum disease is cause of diastema, the dentist would need to first perform periodontal treatment to eliminate the harmful bacteria. After the infection is treated, patients can choose to get rid of the gap between the teeth using one or more of the aforementioned cosmetic treatments. Common methods for gum treatments include the following:
    • Teeth cleaning: For cases for mild gum disease, deep dental cleaning, i.e., scaling and root planing, is recommended by dental experts. This process is similar to a regular cleaning procedure; however, during deep cleaning, the gums will be numbed to provide relief from pain or discomfort while the dentist attempts to clear the bacteria present in the deeper crevices under the gums.
    • Gingival flap surgery: For cases of moderate to advanced gum disease, gum surgery may be needed. During this procedure, an incision is created along the gum line, so that the gums may be moved back temporarily and the tooth roots are visible. After the roots are thoroughly cleaned, the gums are repositioned and sutured back into place. If bone loss is observed around a tooth, a dental bone graft may also be used to aid the regeneration of bone tissues.
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Developmental Dysplasia of the Hip

Management Team

Developmental Dysplasia of the Hip

Overview

Developmental dysplasia of the hip (DDH) refers to the abnormal development of the hip joint. It involves a spectrum of conditions, ranging from mild instability to complete dislocation. DDH can affect one or both hips and is more common in women.

  • Unequal leg length in newborns and infants.
  • Asymmetry of the thighs or gluteal folds and abnormal movements of the hip joint.
  • In children of walking age, pain on the affected side, limping while walking, and reduced movements of the hip joint.

  • Females are more affected than males.
  • The first-born female child is commonly affected.
  • Genetics or family history.
  • Breech position (feet coming out first instead of head) of the foetus during pregnancy and brain injury during or before birth (cerebral palsy).

  • Physical examination of the child by performing tests, such as the Barlow test (to assess whether the hip can be dislocated and can come out from the socket) and Ortolani test (to assess whether the hip can be reduced back after dislocating it), the gait pattern at the walking age, and examination of the spine and knee joints.
  • Ultrasonography is the preferred test in children under 6 months of age.
  • Pelvic radiography (X-ray) is preferred in children above 6 months of age.

Non-surgical treatment

This is the initial choice of management, especially in the early stages of the disease. Treatment approaches include:

  • Bracing (Pavlik harness) in children aged below 6 months to keep the hip joint reduced.
  • Hip spica cast, which is a form of plaster applied around the hips, pelvis, and occasionally the knees to keep the hips in a reduced position.

Surgical treatment

Surgery is considered for irreducible hip dislocation or in cases of late presentation. Procedures include:

  • Open reduction of the hip followed by a cast.
  • Osteotomy by creating a fracture surgically in the pelvis, hips, or both, followed by hip reduction and fixation using plates and screws.
  • Hip replacement is occasionally recommended only for adults who have had dislocation for a prolonged duration.
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Degenerative Spine Diseases

Management Team

Degenerative Spine Diseases

Overview

Degenerative spine disease refers to a group of conditions wherein changes in the spine occur due to ageing, wear and tear, or injury. It primarily affects the intervertebral discs, vertebrae, and associated structures, leading to pain, stiffness, and potentially neurological symptoms.

  • Intermittent or persistent pain in the neck and back, which may radiate to one or both lower limbs. The pain can be localised to a particular region (front or back of thigh/legs).
  • Stiffness in the back.
  • Occasionally, weakness of the legs or bowel and bladder involvement may occur if the compression is severe.

  • Physical examination of the spine to assess if there is any structural deformity, and evaluation of the range of motion, reflexes, and muscle strength.
  • Radiography (X-ray) to assess the vertebral bodies, disc space, bony spurs, and spinal alignment.
  • Magnetic resonance imaging (MRI) to identify nerve and spinal cord compression and assess soft tissue.

Non-surgical treatment

Conservative non-surgical treatment methods include:

  • Physical therapy with strengthening exercises, stretching, and posture correction.
  • Medication to relieve pain and muscle spasms.
  • Activity modification.
  • Interventions, such as epidural steroid injection, facet joint injection, and nerve root injection.

Surgical treatment

  • Decompression through laminectomy.
  • Discectomy with or without spinal fusion.

These are decided by the treating surgeon based on the patient’s condition.

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de Quervain’s Tenosynovitis

Management Team

de Quervain’s Tenosynovitis

Overview

De Quervain’s tenosynovitis is an inflammatory condition that affects the tendon sheath at the base of the wrist, restricting the movement of the thumb.

  • Pain at the base of the thumb that sometimes radiates to the forearm or the elbow.
  • Occasional swelling or redness of the wrist.

  • Wrist overuse-led injury.
  • Women are more commonly affected than men.
  • Middle age (40–59 years).
  • Pregnancy and breastfeeding.
  • Rheumatoid arthritis, diabetes, and thyroid disorders.

  • Physical examination for assessing the pain and certain tests, such as asking the patient to make a fist with the thumbs inside and bending it towards the little finger.
  • Ultrasonography to confirm the diagnosis.
  • Magnetic resonance imaging is rarely required.

Non-surgical treatment

The primary aim of the non-surgical treatment is to alleviate pain. These treatment methods include:

  • Anti-inflammatory medication during the initial phase of the condition.
  • Splints to reduce inflammation by resting the affected area (keeping the thumb in an upright position).
  • Applying ice packs to the affected area.
  • Lifestyle modifications.
  • Steroid injections (a maximum of 1–2 injections) to help reduce the symptoms by approximately 50%–80%.

Surgical treatment

  • Surgery is recommended for patients in whom non-surgical treatment options have failed.
  • The minimally invasive surgery can be performed under local or a short general anaesthesia and involves a small 1–2 inch incision at the base of the thumb to release the thickened tendon sheath and relieve the symptoms.
  • Post-surgery care:
  • A pressure dressing is usually applied for 2 weeks following which the sutures are removed.
  • Physical therapy is usually initiated after suture removal and involves mobilisation and strengthening exercises.
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