GP Buzz June-September 2013 by PEARL PEARL

A PUBLICATION FOR

PRIMARY CARE PHYSICIANS

MCI (P) 097/03/2013

June-september 2013

Work Your

Stress Away

What else is there for Erectile Dysfunction? The Journey to a

Brighter Smile

Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit www.ttsh.com.sg/gp/.

Bioabsorbable Coronary Sten ts

contents

editor’s note

06 in every issue

Where Are You On The Wellness Continuum?

030 editor’s note 040 in the news

The GP BUZZ editorial team: Jessie Tay Lee Wei Kit Celine Ong

260 fitness 290 special recipes

ADVISORY PANEL: Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Mr Joe Hau

in this issue 06 Now You See It, Now You Don’t

GP Buzz is a magazine by Tan Tock Seng Hospital, designed by

12 Work Your Stress Away... We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg.

15 After The Magic Pill, What Else Is There For Erectile Dysfunction?

20 The Journey To A Brighter Smile 24 Fad Diets: How Effective Are They For Weight Loss?

t is said that wellness exists on a continuum. It is different and distinct to every individual.

To many, it is not just one thing but involving interconnected elements that can range from the spiritual, body and mind. It is not only how much you weigh, your cholesterol level but also how well you manage stress. The road to achieving wellness is a choice and it may begin with the consciousness to build a healthy lifestyle which could range from dietary planning to engagement in physical activities. In this ‘Wellness and Health’ issue of GP BUZZ, we aim to look at the heart, mind, oral aesthetics and even sexual well-being of an individual. The cover story showcases bioabsorbable coronary stents, one of the latest advancements in the field of angioplasty. We cast the spotlight on psychological and emotional wellbeing with tips on how to work your

stress away. Treatment options for erectile dysfunction, a common issue facing men, are also detailed in this edition of GP BUZZ. Let’s not forget the importance of oral health, the key to a great smile for that added esteem boost. We debunk the myth of fad diets for healthier and wiser dietary choices. Specially for this issue, we bring you a special three-course herbal menu customised in consultation with Ms Dora Ng, Principal Acupuncturist of Tan Tock Seng Hospital’s (TTSH’s) Complementary Integrative Medicine Clinic and with the chefs from the Hospitality & General Services team. Finally, we get physical with a series of pilates exercises which are used by TTSH Physiotherapists for patients to tone up their abdominal muscles, manage their back pain, strengthen and improve the stabilisation of their back. Now, where are you on the wellness continuum? The GP BUZZ Editorial Team

June - september 2013

in the news

an Tock Seng Hospital’s (TTSH’s) Clinic 2B (non-subsidised) offers one-stop dietetics service.

Launched in October 2012, patients can now be referred by their doctors to an in-clinic Dietitian to obtain pre- and post-surgery nutritional advice. Currently, this service is available for Urology patients every Tuesday to address general healthy eating matters.

IN-CLINIC DIETETICS SERVICE

In each session, TTSH’s Dietitian conducts a detailed nutrition assessment to determine the patient’s nutritional risk and status. This involves gathering information including anthropometry (e.g. height, weight, weight changes), biochemistry data, clinical signs, dietary history (e.g. diet recalls, food frequency information, eating patterns). The Dietitian will educate and advise the patient on dietary or nutrition plans based on the patients’ nutritional requirements.

First in Healthcare Prof Philip Choo, CEO of TTSH, receiving the award from Mr Kulshaan Singh, Managing Director, Aon Hewitt South East Asia and Ms Tan Su-Lin, Vice-President, CATS Classified, Singapore Press Holdings.

n the recent Aon Hewitt Best Employers 2013 study, Tan Tock Seng Hospital (TTSH) was recognised as one of the Best Employers in Singapore.

The Aon Hewitt Best Employers study is a regional research study to identify best employer organisations in each of the nine participating countries in Asia Pacific region. The study aims to identify a list of Best Employers in Asia and their unique people practices,

and provide insights on how organisations can create a competitive advantage through people. One of the nine organisations recognised as Best Employers in Singapore and the first healthcare organisation in Singapore to clinch the award, TTSH was deemed to have demonstrated high levels of employee engagement, compelling employer branding, effective leadership and a high performance culture.

CME Schedule June - September 2013 Lunch Symposium on Common Joint Conditions for GPs CME POINTS

1 CME point*

GP Forum – Updates on Prostate and urinary diseases CME POINTS

To be confirmed

DATE

06 July 2013

DATE

21 September 2013

TIME

1.00pm - 2.30pm

TIME

1.00pm - 4.30pm

VENUE

REGISTRATION DETAILS

Conference Room 1 & 2, Tan Tock Seng Hospital Cheryl Chee Contact: 6357 3242 Email: cheryl_pl_chee@ttsh.com.sg

VENUE

REGISTRATION DETAILS

Court Yard 1 & 2, Basement 1, Oasia Hotel, Sinaran Drive Hilary Chua Contact: 6357 3197 Email: hilary_xm_chua@ttsh.com.sg

* Subject to the approval of Singapore Medical Council. For an updated listing of CME and event schedule, please visit http://www.ttsh.com.sg/gp/. Information is correct at the time of publishing.

cover story

Now You See It,

Now you

Don’t Bioabsorbable Coronary Stents – A New Frontier in Treating Heart Disease

Scan this QR code to read the article online.

Blocked heart arteries, also known as coronary artery disease, is a major problem in Asia and leads to symptoms of a heart attack and angina. Coronary angioplasty and stenting is a widely accepted procedure to effectively treat these blockages and involves the implantation of a permanent metallic tube called a stent in the artery which props the vessel open. A new generation of bioabsorbable stents is now available which disappears after two years, leaving the vessel in its restored natural state. This ‘vascular reparative therapy’ represents a new advancement in cardiology.

cover story

Past CAD Invasive Treatments A quick recap of how the invasive treatment of CAD has evolved over the last several decades is worthwhile.

oronary artery disease (CAD) is rampant in Asia. CAD leads to limited blood flow to the heart culminating in, at its worst, a heart attack in which a portion of the heart muscle permanently dies, but also symptoms of angina which can range from mild to limiting chest pain or shortness of breath on exertion. A combination of increasing affluence leading to unhealthy dietary habits along with a general ageing of our population has made CAD a widely prevalent disease that affects not only longevity but also quality of life and productivity. Coronary angioplasty and stenting are widely accepted procedures to effectively treat blockages in the coronary arteries. This article will highlight a recent advancement in the field and focus on the newest generation of biodegradable coronary stents.

About 50 years ago Surgeons performed the first coronary artery bypass graft surgery in which veins from the leg were harvested and implanted in order to ‘bypass’ blockages in the patient’s own native arteries. This revolutionised the treatment of heart disease but the extensiveness of the operation and risks (particularly for stroke or paralysis) was a physical as well as psychological barrier for many patients.

About 20 years ago The procedure was modified with the implantation of metallic stents after balloon angioplasty at the site of the blockage, yielding much lower restenosis rates. These stents are metal tubes that look quite similar to the spring of a ball-point pen and act like a metal scaffold that props the artery open thereby preventing the artery from collapsing back on itself. Stents reduced the need for emergency surgery to less than 1% and although elastic recoil of the artery was eliminated by the scaffolding effect, the stent itself incited new tissue growth that resulted in re-narrowing of the vessel and a restenosis rate of about 15-20%. Thus, while procedural safety improved markedly, there remained a one-in-five chance of the blockage recurring.

About 30 years ago Coronary angioplasty came into existence in which, under local anesthesia, a thin plastic tube called a ‘catheter’ was introduced via the femoral artery in the groin and advanced to the heart. Through this catheter, a small balloon was introduced into the artery and the blockage point was opened up by inflating the balloon. The catheter was then removed and the patient went home a few days later with a small nick in the groin instead of a huge incision in the middle of the patient’s chest. However, balloon angioplasty patients suffered from a 5% risk of emergency bypass surgery due to complications and a 30-50% risk of recurrence, termed ‘restenosis’. Restenosis results in the shrinking back of balloonstretched artery at the site of the blockage, somewhat like an elastic band slowly recoiling.

Early 2000s Coronary procedures moved from the groin to a more elegant approach via the radial artery in the wrist. Introduced in the mid-1990s, the radial approach is now the de facto standard-of-care and offers lower complication rates than a groin procedure. At the same time, the next iteration of these stents came in the form of ‘drug-coated’ devices which slowly eluted a special drug that reduced the restenosis rate to less than 10%. Although these drug-eluting stents represent a marked improvement over the previous generation of stents and have an excellent long-term safety record, concerns about leaving a permanent implant have remained – both in the minds of cardiologists as well as patients. The stent, a permanent irritant in the vessel, is always at risk of suddenly clotting (causing a heart attack) and requires prolonged use of blood thinners.

cover story

“Studies with the leading bioabsorbable stent have shown that indeed, the stent is largely gone by two years and the vessel is restored to its original healthy functional state…” Stents Renewed This brings us to the most recent and exciting development in the field of angioplasty – the bioabsorbable stent. The basic concept behind having a temporary scaffold in place is quite simple. Studies show that after balloon dilatation of a blockage you really need a stent to prop up the artery for 3-4 months after which the artery gets ‘set’ in its new, expanded shape. Therefore, if the stent could disappear after ‘doing its job’, the patient benefits from the implant and from not having a permanent presence in the artery. If this stent can elute the same drug as metallic drug-eluting stents, tissue regrowth and restenosis is prevented. Initial versions of bioabsorbable stents were made of magnesium which degraded very quickly, within a month or two and this rapid disappearance of the scaffold

resulted in the blockage recurring in a large fraction of the patient’s heart due to recoil of the artery. Another version of the bioabsorbable stent used poly-L-lactic acid (PLLA), a polymer similar in consistency to plastic. PLLA has a long history of safe use in medical implants (e.g. orthopedic screws, pins, soft tissue implants) and degrades into lactic acid which is then broken down by the body into water and carbon dioxide. This stent had a much slower degradation profile (12-24 months) and hence the scaffolding was retained for the critical first few months after stent implantation. The only problem was that the stent incited a similar tissue reaction as the bare metal stents leading to restenosis.

A four-year follow-up of the current stent demonstrates excellent results with very low restenosis rates and no signs of a ‘late catch-up’ in terms of problems. The need for long-term blood thinners is significantly less. Furthermore, the bioabsorbable stent is substantially easier to image using non-invasive techniques like cardiac CT as compared to their metallic counterparts, an important and welcome benefit.

Drawbacks of Bioabsorbable Stent While the bioabsorbable stent represents an important advancement in stent technology, at present there are a few limitations.

The next logical step was to impregnate the PLLA with the same drug that drug-eluting metallic stents use and the most recent generation of bioabsorbable stent is exactly that – a drug-eluting PLLA stent that combines the best of all worlds – a temporary scaffold that elutes a drug, expands the artery and then disappears. Studies with the leading bioabsorbable stent have shown that indeed, the stent is largely gone by two years and the vessel is restored to its original healthy functional state, giving rise to the term ‘vascular reparative therapy’ for the current generation bioabsorbable stents.

First, the stent has largely been tested in relatively simpler coronary lesions; more complicated blockages may not be suited to receive this stent and, hence, not everyone is a candidate. Second, the stent is not as easily deliverable to the blockage as the metallic stents are – it is a bit more bulky and sometimes that may make getting the stent down the coronary artery a challenge particularly if the artery has a very curved course. Third, these stents are substantially more expensive than the metallic drug-eluting stents; this becomes particularly important if a patient requires multiple stents.

Finally, the long-term follow up is limited to 4-5 years. While we don’t know how these patients will behave years down the line, if the earlier studies with PLLA stents are any indication, there is no suggestion that these stents have any long-term adverse effects. Bioabsorbable stents represent a new way forward and ‘vascular reparative therapy’ may indeed be the future. Patients should consider a bioabsorbable stent as an option preferably via the radial (wrist) approach. Patients should have an open discussion about the pros and cons with their physicians prior to undergoing coronary procedures.

Dr Fahim H. Jafary Dr Fahim H. Jafary is a Senior Consultant in the Department of Cardiology at Tan Tock Seng Hospital. He is a graduate of the Aga Khan University Medical College in Karachi. He was trained in Internal Medicine at the University of Texas Health Sciences Center in Houston and Cardiology at Tufts Medical Center in Boston. Dr Jafary is certified in Cardiology & Interventional Cardiology by the American Board of Internal Medicine, and Nuclear Cardiology & Cardiovascular CT by the Certification Boards of Nuclear Cardiology and Cardiovascular CT. Dr Jafary has been performing coronary angioplasty and stenting for close to 15 years.

Biodegradable Stent

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WORK YOUR STRESS AWAY… Work stresses are present and can lead to burnout if they are not properly managed. Stress management strategies are available for a healthier you – physically, psychologically and emotionally.

Scan this QR code to read the article online.

‘W

ork stress’ is something that we experience commonly in the work place. With the constant threat of a possible economic crisis looming before us, there is always the pressure for us to improve our work performance and increase our productivity. Work stress often occurs when our capabilities or needs do not meet the requirements of our jobs. This could arise from a number of sources such as work overload, time pressure to meet datelines, not liking the job and having to deal with difficult people at work.

While some stress may be good in motivating us to perform better at our jobs and to increase our productivity, prolonged or excessive exposure to stress can lead to burnout. Burnout is the state of physical, psychological and emotional exhaustion which leaves you feeling overwhelmed or hopeless. When this happens, your productivity is reduced. Effective management of personal and work stress can allow you to exert a positive influence over those around you and also prevent you from being affected by the negativity from others.

Here are some tips to help you reduce work stress:

Tip 1: Recognise the different manifestations of work stress and how it impact on us physically, psychologically as well as emotionally. •

Physical impact: - Breathlessness - Fatigue - Headaches / Migraines - Insomnia - Loss of appetite - Numbness - Problems in digestion - Reduced immunity - Tensed muscles

•

Emotional impact: - Anxiety - Apathy - Depression - Frustration / Irritability - Restlessness

•

Psychological impact: - Difficulty concentrating - Diminished interest at work - Loss of confidence - Negativity - Poor judgment - Worrying - Increase drinking or smoking to cope at work - Social withdrawal

Effective management of personal and work stress can allow you to exert a positive influence over those around you...

Tip 2: Identify your sources of work stress. Work stress can come from one source or many sources. In order to deal with our stressors, we need to first know what is stressing us. Below are some examples of sources of work stress: • • • • •

Work conflicts Work overload Information gaps Blocked career Meaningless job

Tip 3: Manage your stressors. • Resolve your conflicts at work. If you feel that you have been unfairly treated at work, consider expressing your grievances in an assertive, nonaggressive manner instead of suffering in silence.

When you are faced with problems dealing with a difficult superior or co-worker, do bear in mind that we can only be in control of our own feelings and reactions, and not the behaviours of others.

• Manage your time effectively. In order to achieve work–life balance, you require good time management skills.

First, make a plan. Create a list where you identify important tasks that you need complete within the day, including leisure activity.

Next, work out your priorities by determining what is most urgent or most important to you. Always target the difficult tasks at a time when you feel most energetic (such as in the morning) and leave the simpler tasks for later.

Procrastination is often the main cause for our lack of time. Hence, self-discipline is very important.

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• Positively reframe your negative thoughts. Many of us experience recurring self-defeating thoughts when we feel stressed. These thoughts often tell us that we are ‘stupid’, ‘incompetent’ or ‘unable to cope’. Dwelling in these negative thoughts can deflate our morale and we become less motivated in our jobs. Therefore, it is important for us to reframe these thoughts in a more positive light.

Consider what you would say to a friend who is having these thoughts. You will probably say something encouraging such as ‘Making one mistake does not mean that you are a failure.’ In the same way, we need to encourage ourselves and not beat ourselves up when we feel defeated.

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Tip 4: Learn to relax. Remember the saying, ‘All work and no play makes Jack a dull boy’? It is important for us to engage in pleasurable activities in order to relax. • • • •

Have enough sleep Eat healthily Exercise Confide in your spouse, a family member or close friend. Do not bottle up your feelings • Schedule ‘me’ time. Set aside time to engage in your hobby or favourite activities such as playing music, watching a movie or going for massages • Go for a vacation

• Consider enhancing your skills and knowledge. The work environment is constantly changing rapidly due to advancing technology. Therefore, it is important that we upgrade our skills and fill up any knowledge gap in order to maintain our competitiveness. We are happy workers when we feel competent in our work. • Inject new meaning into your job. Do you find your job meaningful? If no, perhaps it is now time for you to consider other job options.

Ask yourself what is meaningful to you. Being able to help the less fortunate? Working with the elderly, maybe? Or, you may even consider expanding your current portfolio or develop your skills in another area.

• Seek professional help. Many a times, we keep things to ourselves to avoid burdening our loved ones with our problems. Therefore, it is sometimes advisable to seek professional help by consulting with a psychologist to help you manage your stressors.

There are a variety of treatment methods for Erectile Dysfunction (ED), a common condition afflicting men today. Read on to understand the modes of treatment and effectiveness of each of the treatment options.

Remember, work stress can lead to adverse impact on our physical, psychological and emotional health if it is not managed properly. So work, work, work those stresses away!

Dr Jaswyn Chin Dr Jaswyn Chin is a Clinical Psychologist from the Psychological Services Department in Tan Tock Seng Hospital. She is a registered Psychologist with the Singapore Psychological Society and conducts stress management talks for organisations on a regular basis.

After the magic pill, what else is there for Erectile Dysfunction? Scan this QR code to read the article online.

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Urology specialist clinic who has already tried one or more types of the pills mentioned earlier, and the response was not ideal. In that situation, are there other modes of treatment available and how effective can they be, when the pills have failed?

Pills

Penile Injections

These pills are collectively known as phosphodiesterase-5 inhibitors (PDE5Is) and they are usually prescribed on an on-demand regime, that is, as and when the patient wants to have sexual intercourse.

Penile injections have been available even before the advent of PDE5Is, and they are a good alternative to the pills.

This article will address these issues and I hope it will encourage men with this problem to look further for more effective treatment.

The pill has to be taken at least 30-45 minutes prior for it to be effective, and stimulation will be required to kick-start the effect. For some people, the need for planning and scheduling can be counterproductive and it can take the joy of sex away.

Sexual Counseling & Therapy Majority of cases of ED are caused by both medical and psychological factors such as anxiety, depression, sexual naiveness etc. If present, treatment should be multipronged, involving both the doctor and the sexual therapist.

rectile Dysfunction (ED) is a very common condition that afflicts men of all ages. It is present, in varying severity, in about 30% to more than 50% of men above the age of 40 years.

Viagra, Levitra and Cialis, which are pills prescribed for ED, more men and their partners have a greater awareness of this issue, and a larger number of them are coming forth to seek treatment.

With the widespread advertisement and marketing by the makers of

It is not uncommon nowadays to see a patient with ED in the

The doctor will perform the medical evaluation and initiate treatment, while the sexual therapist will supplement by providing sexual counselling and techniques to overcome the psychological and behavioural issues. Both of these services are now available in Tan Tock Seng Hospital (TTSH).

To overcome this, there is a new method of treatment where a smaller dose of Cialis, 5 mg, is taken on a daily basis. This allows for a constant presence of the drug within the blood stream so that erection and sex can be more spontaneous. The common side-effects experienced include facial flushing, headache and muscular ache while the more serious adverse effects such as giddiness and chest pain are rare. These PDE5Is cannot be taken together with nitrates.

The injectable drug commonly used in Singapore is Alprostadil, and there are Papaverine and Phentolamine as well. These drugs can be used singly or in combination, on an on-demand regime. The needle used is very short and narrow, and the injection is performed at the shaft of the penis into the cavernosal tissue. The drug usually takes about 15-30 minutes to work, and sexual stimulation is preferred to initiate the effect. The pain experienced is quite mild and the side-effects, such as bleeding, penile pain, prolonged erection etc. are uncommon. These drugs work via a different pathway from the PDE5Is, and they can be effective even though the response to the pills has been poor. They should not be given to patients with a history of

prolonged erection, or bleeding tendency due to medications, coagulopathy and other causes.

Vacuum Erection Device The penile vacuum device can effect an erection by placing it over the penis and activating a graduated pump to gently create a vacuum within the device, thereby drawing in blood to fill the distensible cavernosal tissue. A medical grade silicon band is then placed at the base of the penis to maintain the erection for the duration of the sexual intercourse, and it should not be left there for more than 30 minutes. With some practice, it is a fairly easy to use appliance that does not rely on the effect of a drug. Needless to say, the man or his partner must have the dexterity to manipulate the device and the silicon band. It should be avoided in men who have bleeding tendencies. The adverse events due to the device is uncommon. They include bruising or bleeding beneath the skin due to excessive negative pressure

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Reservoir (shown inflated & deflated)

Cylinder inflated creates erect penis

Cylinder deflated in flaccid penis

Momentary Squeeze (MS) Pump

Picture Courtesy of Amercian Medical Systems, Inc.

Inflatable Penile Implant

generated, a slightly cooler penis which may be unpleasant for the partner, and prolonged erection.

Penile Implants

the ability to achieve orgasm and ejaculation remain the same after the surgery. There are two types of penile implants – malleable and inflatable.

Should all else fail, penile prosthesis surgery is an alternative worth considering. Again, an erection is effected by mechanical means and is not reliant on the effect of a drug. The sensation and

The malleable penile implant, as the name suggests, can be bent and it can be straightened. The implant is surgically inserted into the penis in a simple and short

operation. The resultant outcome is a constantly erected penis that can be straightened for sexual intercourse, or it can be bent and tucked away in the trousers at other times. The inflatable type of penile implant is also surgically inserted and it consists of three components – the cylinders

which are inserted into the penis, the saline reservoir which is placed in the retropubic space and the pump which is placed within the scrotum for easy access. To achieve an erection, the man just has to locate and repeatedly squeeze the pump in the scrotum to cycle the saline from the reservoir into the penile cylinders, thereby inflating them. After the sexual intercourse, he then squeezes the deflation button in the pump to release the saline back to the reservoir and thereby deflating the cylinders. The surgery is slightly more complex and it takes a longer time to perform as compared to the malleable implant. The patient usually stays for a night and he goes home the next day with the implant deflated. He can start cycling the implant two weeks after surgery and start using the implant after six weeks. These implants can be left within the body permanently. The two key complications following implant surgery are infection and mechanical failure. The

incidences are in the region of about 2% and 5% respectively. Should either of these occur, the implant can be easily changed. They do come with warranty.

Low Testosterone State Blood testosterone level should preferably be checked in men with ED, especially if they have concomitant lack of libido. This test should be performed in the morning between 7am and 11am, as there is a diurnal variation of the serum testosterone level. Should the level be low, that is less than 8 nmol/L, testosterone replacement therapy can be offered. In summary, the treatment of ED goes beyond just pills. At times, a combined approach incorporating sexual therapy and testosterone replacement therapy can yield better outcomes. Should these measures fail, there are other effective alternatives such as penile injections, vacuum erection device and penile prosthesis surgery. These options should be actively discussed with patients so that they do not lose hope when the pills fail them.

Dr Simon Chong Dr Simon Chong is a Consultant in the Department of Urology at the Tan Tock Seng Hospital (TTSH). He obtained his basic medical degree at the Queen’s University of Belfast in UK, and went on to obtain his MRCS and MMed in Surgery before completing his urology training. His subspecialty interest is in Male Sexual Dysfunction/Andrology and Male Infertility. He did his subspecialty training with Dr David Ralph in the University College Hospital and the London Clinic in Harley Street, and his team in the Institute of Urology in London, UK where he learnt procedures such as penile prosthesis implantation, various surgical techniques for Peyronie’s disease, phalloplasty and organpreserving procedures for penile cancer. He is actively involved in Men’s Health and Andrology in Singapore where he has organised and lectured in GP and public forums. He is also a Clinical Senior Lecturer of the Yong Loo Lin School of Medicine of NUS, and Programme Director of the Urology Residency Programme in TTSH.

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ral health encompasses the daily care and maintenance of the oral tissues. This comprises two components: the hard tissues and soft tissues. Teeth and bone make up the hard tissue component, while the lips, cheeks, gums and tongue make up the soft tissue component. Teeth are made up of three main layers: enamel, dentine and pulp (Figure 1).

Infected Pulp

INITIAL FINDINGS Abscess

Figure 2 – Tooth with caries extending to the pulp.

Enamel Dentin Pulp Chamber

The Journey to a Brighter Smile Scan this QR code to read the article online.

Oral health plays a vital role in the overall well-being of a person. Many people may have the misconception that all forms of dental treatment are painful and will tend to neglect their oral health. With new approaches to dental treatment and multidisciplinary care, dental treatment has transformed the perception of many patients as the whole experience can be made more comfortable and pleasant. Read on to find out more about a patient’s oral health journey.

Root Canal

Figure 1 – Tooth with three layers.

Without proper care and maintenance, oral neglect can lead to a myriad of problems such as tooth decay and gum disease. A root canal infection will occur if tooth decay progresses to the pulp chamber and swellings can develop with abscess formation (Figure 2).

She had been reluctant to seek dental treatment earlier as she had an innate fear of the dentist from her primary school days. She had overcome her fear for the initial visit with the encouragement of her sister, who had also undergone treatment with Dr Vivien several years earlier.

Tooth decay can be prevented by reducing the frequency of sugar intake while proper tooth brushing technique with a daily flossing regimen may prevent gum inflammation called gingivitis. Individuals with increased risk of dental decay may supplement their daily oral hygiene routine with the use of fluoride mouth rinses.

FEARFUL NO MORE Ms Elaine Ou was first presented to the Tan Tock Seng Hospital (TTSH) Dental Clinic in early 2009 with the hope of realigning her teeth prior to her wedding day. She had been referred to Dr Vivien Tan Hui Ling, the Head and Senior Consultant of Dental Clinic by her family members.

Elaine had scheduled a wedding photo shoot in July 2009 prior to her wedding day, which was to be held in January 2010. She was found to have several teeth with prior root canal treatment and dental fillings. Dr Vivien sought to understand Elaine’s hopes and expectations by the end of the dental treatment course. Relevant radiographs were obtained and diagnostic casts were prepared. The treatment options available were discussed with Elaine to provide her with a better understanding of the commitment required for treatment to proceed. Although the timeline was challenging, both Elaine and Dr Vivien decided to embark upon the proposed plan.

DECISION-MAKING Circumstances were compounded by the fact that Elaine was at a higher risk of developing dental caries.

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An atypical extraction scheme was decided upon whereby her grossly decayed upper left canine tooth was removed as very little tooth structure was remaining for the tooth to function even with prosthetic restoration. Three other premolar teeth and her wisdom teeth were also removed under general anaesthesia. Concurrent removal of the teeth under general anaesthesia expedited the commencement of braces without compromising Elaine’s comfort levels.

CLINICAL COURSE The molars were banded and activation began. Elaine was compliant with her six-weekly reviews as her wedding day drew closer. On 8 January 2010, the eve of Elaine’s wedding, she had the orthodontic brackets removed and tooth-coloured composite resin restorations placed on her upper front teeth to achieve desired aesthetics for her special day. The bride was, without a doubt, the most beautiful person at the wedding.

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Elaine had returned on 22 January 2010, after her honeymoon, to have her orthodontic brackets replaced and treatment continued. Upon completion of her braces treatment in April 2011, Elaine had further tooth-coloured composite resin restorations placed before commencing on definitive crowns on her upper teeth.

Dr Tan Hui Ling, Vivien Dr Vivien Tan Hui Ling is the Head and Senior Consultant of the Dental Clinic in Tan Tock Seng Hospital. She graduated from the University of Singapore in 1980 and obtained her Masters in Dental Surgery (Oral Surgery) from the National University of Singapore in 1984. She embarked on further specialisation in Orthodontics from the Oregon Science Health Sciences University in 1986. She was awarded the Health Manpower Development Plan fellowship to the University of North Carolina, Chapel Hill in 1991 to subspecialise in the management of dentofacial and craniofacial deformities. Since then, she has been practicing orthodontics exclusively for the past 27 years. Her current interest has been centred on adult orthodontics especially in the field of corrective jaw surgery.

Dr Ang Kok Yang, the dental officer in-charge of Elaine’s case together with Dr Vivien, had prepared five upper teeth to receive crowns to provide adequate protection against fracture during function. Retainers were subsequently fabricated to hold the teeth in their new positions. Elaine’s new smile had warmed many hearts at the end of treatment. Her whole outlook on dentistry had been changed for the better. When she returned for an annual review in December 2012, she had progressed to the next stage in life: motherhood. The arrival of her little bundle of joy, a new baby girl, made her smile even wider than ever. This time, she no longer dreads her dental visits.

Dr Yap Wai Yan Dr Yap Wai Yan is the Senior Dental Associate at the Dental Clinic in Tan Tock Seng Hospital (TTSH). She received her Bachelor of Dental Surgery from the National University of Singapore in 2002. She has had work experiences from Alexandra Hospital and Jurong Medical Centre. Her current practice in General Dentistry here allows her to increase her scope in patient management with a multidisciplinary approach. Elaine Ou in her annual review session with Dr Vivien Tan.

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ad diets commonly refers to idiosyncratic diets and eating patterns that provide shortterm weight loss, with little or no emphasis on long-term weight management. These diets usually enjoy temporary popularity.*

how effective are they for weight loss? What are you looking for in an effective weight loss programme? If you are looking for a quick fix rather than a gradual and sustainable weight loss, you may be falling into the trap of fad diets. Fad diets promise quick fix and promote ‘magic’ foods. Some diets have rigid rules that focus on weight loss. Claims of the effectiveness of such diets are based mostly on single studies or testimonials only.

Fad diets usually have catchy names that focus on single nutrients. Examples of fad diets include the South Beach Diet, Zone Diet, Dr Atkins’s New Diet Revolution, Cabbage Soup Diet, Grapefruit Diet, The Good Carbohydrate Revolution, Paleo Diet, to name a few. While the South Beach Diet draws attention for its switch from ‘bad’ fats to ‘good’ fats, the Zone Diet encourages the consumption of calories from carbohydrate, protein and fat in a balanced ratio. The Atkins’s Diet has been made popular for its limited carbohydrate intake that has reportedly resulted in significant weight loss for its dieters.

How it works Anyone hoping to achieve quick weight loss usually looks to fad diets as miracle eating programmes. These diets are usually made popular by testimonials by its dieters, who generally make claims of the diet’s success in weight loss. Fad diets often omit certain foods or entire foods groups from its menu. Though fast and significant weight loss can be achieved if you follow these diets religiously, the results are usually temporary. Losing excessive amount of weight in a short period of time is usually the result of water weight loss instead

of fat loss. Thus, this is not permanent.

The Pitfalls How long can one stay on such a rigid diet? Being on such a diet requires a great level of motivation and self determination from the dieter. Once positive results of weight loss are achieved, the dieter often forgoes the diet plan and falls back into old eating habits, hence regaining the lost weight if not more. Inappropriate dieting can also lead to nutrient deficiencies, constipation, dehydration, fatigue and result in low mood as well. Fad diets put the pressure on the dieter to make choices guided by the diet plan. At times, the diet can be excessively restrictive. For example, the Cabbage Soup Diet limits intake to a large amounts of cabbage soup over seven days.

• Eating two servings of fruits and two servings of vegetables daily • Avoiding empty calories such as sweetened beverages, sweets, etc. • Watching your food portion sizes • Practising mindful eating and exercise • Incorporating regular physical activity into your daily life A balanced, healthy diet allows you to enjoy a variety of foods in moderation whilst controlling your calories intake. Incorporating exercise as part of your everyday routine helps burns calories and contributes to weight reduction. Thus, the best diet is simply a lifestyle that includes food you enjoy, exercise and healthy habits.

Healthier Strategies for Weight Loss Instead of getting yourself disappointed by the non-sustainable results, adopt healthier weight loss approaches. Start by devoting yourself to a healthier lifestyle that includes eating a balanced and healthy diet. Exercise is still the best approach to gradually shed off the extra pounds and maintain your desired weight. Some strategies for weight loss include: • Eating a variety of foods • Minimising the intake of saturated and trans fats

Ms Kavita Ms Kavita is the Senior Dietitian in the Nutrition & Dietetics Department of Tan Tock Seng Hospital. She completed her Bachelor Degree in Nutrition and Dietetics from the University of Newcastle, Australia in 2005. Kavita specialises in the nutritional consultation of gastrointestinal and weight management patients.

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* Source: Wikipedia http://en.wikipedia.org/wiki/Food_faddism

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Fitness

Pilates: Targeting the ‘Core’ issue Scan this QR code to read the article online.

Basic Pilates Mat Exercises for Beginners

ore, also known as the centre or ‘powerhouse’ of the body, is where Joseph Pilates, the founder of Pilates exercises, placed his main focus when he developed his method of exercises in the 1940s.

1. Hundreds 1

Pilates exercises, when done correctly, will recruit the deep core muscles such as transversus abdominus, diaphragm, pelvic floor muscles and multifidus; align, stabilise and protect the spine from injury. In addition, Joseph designed his exercises holistically by including simultaneous involvement of both leg and arm movements for ease in transference to functional activities. Apart from the ‘core’, pilates also places emphasis on precision, flow, control, concentration and proper breathing during the exercise with ultimate aim to achieve good posture and movement without thinking.

Begin with lying in supine, knees bent and hands on the side.

People of any age or level can benefit from pilates. Therefore, it is common to see pilates being incorporated in rehabilitation regime to treat patients with low back pain due to conditions such as degenerative changes in the spine, slipped discs and spinal instability. Pilates exercises can be performed either with equipment such as the reformer (picture on the left) or on the mat. The benefit of using a reformer is that it is able to alter the level of difficulty of a movement based on the resistance of the springs. In Tan Tock Seng Hospital, physiotherapists with clinical pilates training will incorporate suitable pilates exercises for the patient to tone up their abdominal muscles, manage their back pain, strengthen and improve their back. Some studies have shown that when pilates exercises are practiced over a period of time, it is able to reduce frequency, duration and intensity of low back pain.

2. Knee to Chest

Begin with four-point kneeling, hands and knees on the mat. Hands and knees should be shoulder and hip width apart respectively. Maintain a slight curve in the lower back.

Inhale and slowly lift your head and shoulders off the floor and try to reach your fingers towards your feet while keeping the hands a few inches above the mat. Keep your chin close towards your chest to prevent neck strain. Exhale and return back to resting position. Repeat three sets of 10 repetitions or up to point of fatigue.

Inhale and slowly straighten one leg back while balancing on both hands and opposite knee. Exhale and draw the leg back while still maintaining the curve in the lower back. Repeat three sets of 10 repetitions or up to point of fatigue.

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special recipes

Basic Pilates Mat Exercises for Beginners 3. Single Leg Kick 1

4. Clams 1

Begin with lying in prone, forehead resting on hands and legs together flat on the mat.

2 Begin with lying on the side, knees bent and feet placed together inline with the torso.

Inhale and bend one knee towards the buttock until the foot points towards the ceiling.

Lift the thigh 3 inches off the mat while keeping the knee bent.

Herbal Recipes for Wellness

Inhale and lift the knee on the top while keeping your feet together at all times. Make sure that your torso is straight and not rotated backwards as you lift your knee.

Exhale and return to resting position. Repeat three sets of 10 repetitions or up to point of fatigue.

Chinese herbs are not only used in enhancing the flavour of the dish but they could also possess properties to improve overall health and may at times aid healing.

Exhale and straighten the knee with the thigh still lifted.

Lower the leg down on the mat once the knee is fully straightened. Repeat three sets of 10 repetitions or up to point of fatigue.

he use of chinese herbs for cooking exists since ancient times.

Ms Vernetta Wong Vernetta Wong is the Senior Physiotherapist and a certified clinical pilates instructor in the Physiotherapy Department of Tan Tock Seng Hospital. She had completed her Master of Musculoskeletal Physiotherapy in University of Queensland, Australia in 2012. Her area of interest is neck and back conditions and she works closely with this group of patients.

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In this special edition of ‘Healthy Recipes’, we bring you three herbal recipes created with both Codonopsis Pilosula Root (Dang Shen 党参) and Angelica Sinensis Root (Dang Gui 当归).

Codonopsis Pilosula or Dang Shen is a perennial flowering plant native to northeast Asia and Korea. Its root is widely used as an ingredient in Chinese cuisine to make nutritional herbal soup as well as a tonic beverage when used on its own. Its health benefits are similar to that of Ginseng. It is sold at a more affordable price, thus it is also known as the ‘poor man’s Ginseng’.

special recipes

HERBAL AGAR AGAR (Serving: 32 pieces) Ingredients

Dang Shen is commonly used in Traditional Chinese Medicine (TCM) to correct ‘Qi’ (气) deficiency and improve blood circulation to revitalise the body.

Dang Shen 15gm Dang Gui Slices 15gm Red Dates 15gm Wolfberry 15gm

Method

1. Add water and the herbs (i.e. dang shen, dang gui, red dates and wolfberry) into a pot. 2. Steam the herbal mixture for 3 hours. 3. When it is ready, set aside the herbal stock by straining the mixture. 4. Add the herbal stock, sweetener, agar agar powder in a pot and bring to boil. 5. Pour the mixture into the agar agar mould and add in the wolfberry and longan. 6. Let it set and it is ready to be served chilled.

Dang Shen also possesses other health benefits such as: • Stimulates appetite • Improves blood circulation • Stimulates the central nervous system and increases endurance • Boosts immunity by increasing white blood cells, activating macrophages and other key components of the immune system • Treatment of chronic upper respiratory tract infection • Reduces fatigue and increases white blood count in patients who are undergoing chemotherapy However, if Dang Shen is used excessively, it may interfere with blood clotting and is best to be avoided prior to surgery. Angelica Sinensis or Dang Gui is a perennial fragrant plant of the Apiaceae family which is indigenous to China. The stem can grow to three metres tall and has a purplish hue.

Low Calorie Sweetener 15gm (e.g. Equal™) Agar Agar Powder 10g Longan 1 can Water 1 litre

HERBAL CHICKEN SOUP (Serving: 300ml x 6 bowls)

Its root is widely used in TCM to treat gynaecological symptoms, giving rise to its reputation as ‘female Ginseng’.

Dang Gui possesses other health benefits such as: • Relieves constipation • Helps correct mild cases of anaemia • Counters chronic fatigue syndrome

Dang Shen 30gm Dang Gui Slices 15gm Red Dates 15gm Wolfberry 15gm

Skinless Boneless 45gm Chicken Legs Salt 2.5gm Water 2 litres

Method

1. Bring a pot of water to boil. 2. Add in the chicken and poach for 10 mins. 3. After 10 mins remove the chicken and set aside. 4. Take a pot, add in the 2 litres of water, chicken and the herbs (i.e. dang shen, dang gui, red dates and wolfberry). 5. Steam the chicken and herbal mixture for 3 hours. 6. When it is ready, add in salt for flavour. 7. Scoop and serve.

Dang Gui is also found to have oestrogen-like property that nourishes the uterus and helps regulate female hormones. It is one of the essential herbal items often prescribed by TCM physicians to treat pre-menstrual as well as menopausal symptoms.

HERBAL TEA (Serving: 220ml x 23 cups) Ingredients

Dang Shen Dang Gui Slices Red Dates Ms Dora Ng Ms Dora Ng is the Principal Acupuncturist of the Complementary Integrative Medicine (CIM) Clinic of Tan Tock Seng Hospital (TTSH). She is a Registered Traditional Chinese Medicine (TCM) Physician with the TCM Practitioners Board, Singapore. She has special interest in the treatment of chronic pain and TCM-based dietary counselling.

Method

Herbal Agar Agar (32 pieces)

Ingredients Calories (kcal) Carbohydrate (g) Protein (g) Total fat (g) Saturated fat (g) Cholesterol (mg) Dietary fibre (g) Sodium (mg)

30gm 15gm 30gm

Wolfberry 30gm Honey 300gm Water 5 litres

1. Add water and all the herbs (i.e. dang shen, dang gui, red dates and wolfberry) into a pot. 2. Steam the herbal mixture for 3 hours. 3. When it is ready, remove or strain the herbs. 4. Add honey and let it boil. 5. Ready to be served hot or chilled.

Per serving

8.9 2.1 <0.1 0 0 0 <0.1 0.9

Herbal Chicken Soup (300ml x 6 bowls)

Ingredients

Ingredients Dishes prepared by the Hospitality & General Services, Tan Tock Seng Hospital.

Nutritional Information

Per serving

Calories (kcal) Carbohydrate (g) Protein (g) Total fat (g) Saturated fat (g) Cholesterol (mg) Dietary fibre (g) Sodium (mg)

9.0 0 1.5 0.3 <0.1 6.2 0 170

Herbal Tea

(220ml x 23 cups)

Ingredients

Per serving

Calories (kcal) Carbohydrate (g) Protein (g) Total fat (g) Saturated fat (g) Cholesterol (mg) Dietary fibre (g) Sodium (mg)

40.4 10.6 <0.1 0 0 0 0 1.8

Recipes were designed by Ms Dora Ng from CIM Clinic and chefs from the Hospitality & General Services, Tan Tock Seng Hospital. Nutritional information provided by the Nutrition & Dietetics Department of Tan Tock Seng Hospital. Photo Courtesy of Mr Henry Lim, Photographer, Tan Tock Seng Hospital.

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