Bad Breath---causes and solutions

Almost everyone has had (or knows someone who has) bad breath. Termed "halitosis" in medical jargon, bad breath has a number of identifiable and often correctable causes. Unfortunately, the flavored gums, mints, and mouthwashes available in the local pharmacy provide only temporary improvement and do not generally address the underlying cause.  Let's look at some of these causes and possible solutions.

What causes bad breath? ---Most often, the odor is caused by the decay of food particles and bacteria that produce a sulfur-containing compound.

What are the leading causes of bad breath?

1. Dental disease --- Poor dental hygiene frequently leads to the production of plaque, a sticky film that attaches to teeth.   Plaque contains millions of odor-producing bacteria and contributes to the development of dental cavities and gum disease.
     
2. Odor-producing food---Onions, garlic, certain spices are common culprits. In addition to the unpleasant odors from the mouth, they can also have a "double whammy" effect after eating.  Once absorbed into the blood stream, these odors can enter the lungs and be released through breathing.
    
3. Infection---Several sources of infection affecting the nasal passages and throat can be responsible for bad breath. These include sinus infections, tonsillitis, and gingivitis (gum) disease. With sinus infections, there may be a foul-smelling post-nasal drainage responsible for breath odor.  Tonsils have numerous crevices or pits that can trap mucous, bacteria and other debris.  This trapped material can solidify into foul smelling "stones".   Infection of the gums (gingivitis) is caused by odor-producing bacteria.
      
4. Dry mouth ---A major role of saliva is to clear food particles and bacteria from the mouth. When this function is diminished, odor-producing bacteria can proliferate. Reasons for having too little saliva range from mouth breathing, to certain medications (e.g. antihistamines), to an autoimmune disease called Sjogren's syndrome. "Morning breath" is thought to result from dry mouth after sleeping with the mouth open.
    
5. Gastroesophageal reflux--- With gastroesophageal reflux (GERD) stomach acids travels back up the swallowing tube (esophagus) and into the throat and mouth. Symptoms of GERD include heart burn and regurgitation of food or sour liquid into the mouth.
     
6. Using tobacco products---Dipping snuff, chewing tobacco or smoking cigarettes can leave an unpleasant odor in the mouth.  Additionally, use of these products may contribute to the development of gum disease.

What can be done to prevent bad breath?
When bad breath has an identifiable cause underlying its development, addressing the specific condition should result in improvement.   Avoidance of foods with strong odor and stopping smoking are two steps that can be taken to address these "self-induced" causes.  Treatment of sinusitis may involve the use of antibiotics, corticosteroids or decongestants. Tonsillar stones can be prevented by regular gargling with salt water or the use of a water flosser to remove the debris before they have the opportunity to harden.  Regular dental hygiene is the key measure in preventing periodontal disease like gingivitis. Established gum disease may require specialized dental care.

When dry mouth is the cause of bad breath, management can range from drinking more fluids to medications to increase saliva production. In someone with adequate saliva production, taking in extra fluids or sucking on sugarless candy may be enough.  Sjogren's syndrome is associated with inadequate saliva production and may require treatment with an artificial saliva preparation (e.g. Biotene) or an oral medication (e.g. Evoxac) to increase saliva production. Management of GERD can involve the use of antacids, acid blockers, and life-style measures such as avoidance of spicy foods and elevation of the head of the bed.

When there is no underlying condition leading to bad breath, prevention hinges on practicing good dental hygiene.  Most dental authorities recommend brushing teeth twice daily, with careful attention to the gum line as well as all tooth surfaces.  In addition, flossing at least once a day will help to prevent plaque formation.  Since the surface of the tongue can also harbor odor-producing bacteria, brushing the tongue or using a tongue "scraper", a plastic tool that scrapes away bacteria that builds on the tongue, can help. In addition to personal dental hygiene, seeing a dentist periodically for teeth cleaning is also a good practice to adopt.

Sources for article:
What is Halitosis? from the Academy of General Dentistry.
Halitosis from Family Doctor. org

Uterine Fibroids, Part 2 - Management Options

Last week we learned about a very common gynecological problem, uterine fibroids, and the symptoms that they can produce.  In the past, many women with large or highly symptomatic fibroids opted to undergo surgical removal of the uterus (hysterectomy).  While removal of the uterus does provide definitive treatment for symptomatic fibroids there are a number of reasons why this might not be the best treatment option.
   
Today, there are a number of ways of treating uterine fibroids with management being highly individualized.  There is no "one size fits all" when it comes to specific treatment measures.  Some of the issues taken into consideration when establishing a treatment plan include:

• The size and/or number of tumors present
• The symptoms that the fibroids are causing---bleeding, pain, complaints related to bowel or bladder function, etc.
• The desire to maintain fertility
• The age of the woman and proximity to menopause
• Secondary problems such as anemia due heavy menstrual bleeding or other pelvic pathology

When asymptomatic.   "Watchful waiting" is usually the best option for managing fibroids that are discovered coincidentally or those that are not producing symptoms.  This means allowing time to pass before intervening, while at the same time monitoring for signs or symptoms of worsening. Fibroids typically grow slowly, are rarely associated with cancer, and in most cases do not interfere with pregnancy.  This approach is particularly appropriate for fibroids detected in women approaching menopause since they tend to shrink once estrogen levels drop.

Medical options for heavy bleeding.   Heavy menstrual periods or spotting between periods are common complaints in women with fibroids. The blood loss can be significant enough to lead to an abnormal red blood cell count (anemia).  There are several non-surgical approaches to address heavy bleeding although these generally have no effect on the fibroid itself. Also, symptoms can return once treatment is stopped.

1. Birth control pills----The hormones in birth control pills thin the inner lining of the uterus (endometrium) that is normally shed during the menstrual period. This will have no effect on the fibroid itself but often reduces menstrual blood flow and intermenstrual spotting.
    
2. Hormone therapy with gonadotropin releasing hormone (GnRH) agonist---- Usually delivered via injections, this type of treatment effectively shuts down estrogen production and menstrual periods.  The idea is that without estrogen stimulation, fibroids should regress in size.  Unfortunately, the same issues related with normal menopause---thinning of the bones, hot flushes, headaches, depression, loss of libido, night sweats, etc.----can be expected with this form of treatment. Lupron is the trade name for the best known GnRH agonist medication. While GnRH agonists will often shrink fibroids, they typically grow back once the medication is stopped.
    
3. Progesterone-releasing intrauterine device (IUD)---Usually used for contraception, this type of IUD has also been approved by the Food and Drug Administration (FDA) for treatment of heavy menstrual bleeding. The hormone in the IUD works to thin the endometrium leading to lighter or absent menstrual periods. 

Surgical removal of individual fibroids --- Myomectomy is a surgical procedure done to remove fibroids while leaving the rest of the uterus intact. "Myo" means muscle, which is the primary component of fibroids; "ectomy" means surgical removal. It is most appropriate for women who want to maintain their fertility or who do not want to undergo hysterectomy.  For fibroids within the wall of the uterus, the procedure can be done through a standard abdominal incision or with a laparoscope. In the laparoscopic procedure, a small tube fitted with a camera and surgical instruments are inserted into the abdomen through small incisions to perform the procedure. A third approach used with fibroids on the inner lining of the uterus is called hysteroscopic myomectomy.   In this procedure, a viewing instrument called a hysteroscope is inserted into the uterus through the vagina and surgical instruments attached to the hysteroscope remove the fibroids.

Uterine artery embolization (UAE) --- This minimally invasive procedure is performed by a radiologist rather than by a surgeon. During the procedure, a catheter is inserted into an artery in the groin and directed to the blood vessels supplying the fibroid. Once its location is confirmed, small plastic or gelatin particles are injected through the catheter in order to cut off blood flow to the fibroid.  Lacking blood supply, the fibroid effectively "dies" and it shrinks in size. Studies have shown an average of 50% reduction in the size of the fibroid with 90% of women achieving satisfactory results.

Hysterectomy remains an option---This surgical procedure to remove fibroids along with the uterus remains an appropriate treatment option in many cases. This is particularly true in the case of extremely large or multiple fibroids that could not be addressed via a less invasive approach.  Most women will be candidates for vaginal or laparoscopic hysterectomy, which generally has fewer complications and faster recovery time than the standard abdominal approach.  Some gynecologic surgeons advocate a "supracervical" procedure that conserves the cervix, fallopian tube and ovaries.

Newer treatments --- Recently developed treatments that are currently being performed at selected centers in the U.S. include MRI guided Ultrasound Surgery and Radiofrequency Ablation.   MRI-guided Ultrasound is a non-invasive, outpatient procedure which uses high doses of focused ultrasound waves to shrink fibroids. Radiofrequency ablation involves inserting a catheter via a laparoscope and into the fibroid itself.  Both of these treatments use heat to effectively "kill" the cells comprising the fibroid without affecting surrounding tissue.

Sources for article:
Uterine fibroids from Mayo Clinic
Fibroid Tumors: What Every Woman Must Know from WebMD
Myomectomy from Mayo Clinic
Uterine artery embolization from Medline Plus
Laparoscopic Radiofrequency Ablation Treats Uterine Fibroids from the University of California San Francisco Medical Center

Uterine Fibroids, Part 1-A surprisingly common problem

Uterine fibroids, also known as leiomyomas or simply "myomas", are non-cancerous tumors that grow in, on, or outside of the wall of the uterus.   In a study involving U.S. women between the age of 35 and 49 years of age, it was found that 60% of African-American women and 40% of Caucasian women had evidence of this benign tumor. The prevalence of fibroids increased to over 80% in African-American women and 70% in Caucasian women by the time they were 50.

Fibroids can range in size from smaller than a pea to larger than a grapefruit.   Often, there will be more than one present.  Fibroids are most common during a woman's reproductive years as their growth is affected by the presence of hormones, both estrogen and progesterone. After menopause, when estrogen levels decline, fibroids usually shrink in size.

Many women are unaware they have fibroids because they often cause no symptoms.  These are usually discovered during a routine pelvic exam or after performing an ultrasound of the uterus for some other reason. Approximately 20-25% of women who have fibroids will have symptoms which are based primarily on the size or location of the tumors.  The most common symptoms caused by fibroids are:

• Heavy, painful, and often prolonged menstrual periods
• Spotting between periods
• Chronic pelvic pain
• Abdominal fullness
• Constipation or frequent urination due to pressure on the bowel or bladder
• Painful intercourse
• Lower back pain

In severe cases, uterine fibroids can produce problems with fertility, premature labor, or repeated miscarriages.

Should an asymptomatic uterine mass be detected on routine examination, or if a woman presents with symptoms or physical findings consistent with fibroids, an ultrasound of the pelvic region is typically performed. In most cases, the sound wave test is adequate to establish the size, number, and location(s) of the tumor(s) and to establish a treatment plan. In  some cases, more in-depth imaging studies such as magnetic resonance imaging (MRI) or x-rays of the pelvis following injection of dye into the uterine cavity and fallopian tubes (hysterosalpingogram) may be required.

In the past, many women with large or highly symptomatic fibroids opted to undergo surgical removal of the uterus (hysterectomy).  Once the uterus is removed, however, a woman can no longer have children.  Additionally, hysterectomies were often accompanied by removal of the ovaries ("total hysterectomy"), producing a "surgical menopause".  While removal of the uterus does provide definitive treatment for symptomatic fibroids there are now a number of other treatment options for treating fibroids.  In next week's Health Tips we'll look at a number of medical as well as surgical options for removing fibroids or addressing the symptoms that they produce.

Sources for article:
Uterine fibroids from Mayo Clinic
Uterine fibroids from MedLine Plus

Help for excessive sweating

Sweating is a physiologic process whose primary purpose is to help with regulation of body temperature. People normally sweat more profusely when it's hot outside or when exercising. People also sweat more in response to situations that make them nervous, angry, embarrassed, or afraid. In an estimated 2 to 3% of Americans, however, sweating can be so excessive that it disrupts normal activities. Sweating of this severity is known as hyperhidrosis. Hyperhidrosis may be present if you have any of the following:

• Excessive sweating of the soles and palms that causes clammy hands and unpleasant foot odor.
   
• Profuse sweating that soaks through clothing
   
• Sweating that results in a skin problem such as a fungal rash or prickly heat
   
• Sweating that occurs at night or when the ambient temperature is normal

What causes excessive sweating? Hyperhidrosis can be primary or secondary. Primary hyperhidrosis is the most common type. It most often affects people who are otherwise healthy with excessive sweating involving the feet, hands, head, and underarms. Secondary hyperhidrosis has an underlying cause, such as hormonal changes (e.g. menopause), anxiety, an overactive thyroid gland, excessive caffeine consumption, certain medications, and with some types of infection and cancer.

What can be done for hyperhidrosis?  When hyperhidrosis is secondary to some other problem, the most effective treatment is to address the underlying cause. For example, if an overactive thyroid is responsible, addressing this condition should take care of the problem. In instances where there is no known cause, treatment usually follows a stepwise progression:

1. Over-the-counter (OTC) antiperspirants.  These are usually tried first since they are readily available and fairly inexpensive. Most antiperspirants have an aluminum-based compound as their main ingredient, which works at the level of the sweat glands to decrease sweat production. This distinguishes antiperspirants from deodorants that merely block odor.
    
2. Prescription antiperspirants. When an OTC antiperspirant is insufficient, use of a prescription antiperspirant may be considered. These also contain aluminum compounds, but at a higher concentration than the OTC products. Xerac and Drysol (aluminum chloride hexahydrate) are two of the most common prescription antiperspirants. These products are most appropriately used to prevent underarm sweating. Since they can be irritating and staining to clothing, they are typically applied before bedtime. After several nights of use, the prescription antiperspirant is then applied only once or twice weekly to maintain the effect.
    
3. Iontophoresis. This treatment is best applied to hyperhidrosis affecting the hands and/or feet.  It involves the use of a device that passes electricity through the skin while the affected appendages are immersed in water.  While its mechanism of action is unclear, it has been used successfully for years. The procedure is painless, and typically takes anywhere from 10 to 20 minutes.
    
4. Botox (botulinum toxin). Botox has been approved by the FDA for use in excessive underarm sweating. It works by blocking the nerves that trigger the sweat glands.  Treatment involves the delivery of multiple injections, usually performed by a Dermatologist, into the armpit which can provide up to 6 months of benefit.  As expected, the treatment can be uncomfortable, but side effects are uncommon.
    
5. Oral medications. The most commonly used medications for managing hyperhidrosis are anticholinergics. Robinul (glycopyrrolate) is one of the most commonly prescribed of these.  In addition to dry mouth, these medications can cause a number of side effects including constipation, blurry vision, urinary retention, loss of taste, dizziness and confusion. Other classes of medications occasionally used include beta blockers (e.g. propranolol) and benzodiazepines (e.g. Valium). These medications work primarily by "blocking" the physical manifestations of anxiety.
    
6. Surgery. Surgery is the treatment of last resort and is only considered in cases of severe hyperhidrosis when other treatments haven't worked. The two primary surgical options are 1) removal of the sweat glands themselves or 2) sympathectomy, a procedure in which the nerves that activate sweat glands are destroyed.  

Are self-care measures helpful for excessive sweating?  There are a number of things that you can do to reduce sweating and associated body odor. The first is to bathe daily with an antibacterial soap. Be sure to dry yourself completely after bathing, since odor-causing bacteria thrive in a moist environment. Antiperspirants are most effective when applied near bedtime when sweating is minimal. Whenever possible, wear natural fabrics, such as cotton, wool or silk. These help to allow the skin to breathe. When exercising, one of the newer wicking fabrics will help to move moisture away from the skin.  Wear shoes that are made of breathable material, such as leather, and socks made from cotton or wool that will absorb moisture. For many people, it is best to avoid certain foods or drinks, such as alcohol, spicy foods and caffeine, since these can contribute to sweating. If your sweating is precipitated by anxiety or stress, engaging in relaxation exercises may be helpful.

Sources for article:
Hyperhidrosis from the American Academy of Dermatology
What's in Your Antiperspirant? from WebMD
Medications from the International Hyperhidrosis Society

Macular Degeneration

The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain. The macula is a portion of the retina which provides the detailed, central vision needed for activities such as reading and driving.  Macular degeneration is the breakdown of this small, but highly important, area of the retina.  The most common cause for this is aging, thus the name, age-related macular degeneration (AMD).  AMD is estimated to affect approximately 2 million Americans with most cases occurring over the age of 70.
   

Two types of AMD are recognized, dry and wet. Dry AMD (also known as non-neovascular) constitutes around 85% of the cases. It is characterized by yellow deposits in the retina called drusen. Dry AMD usually progresses slowly as the light-sensitive cells in the macula break down. Wet, or vascular AMD, is a more severe form of the disease that starts off as dry AMD. The name "wet" comes from the fluid that leaks from abnormal blood vessels growing beneath the macula. The leakage of blood and fluid beneath the macula can cause rapid and permanent loss of vision.

 What are the symptoms of AMD? The predominant symptoms of AMD are somewhat different depending on whether it is wet or dry.  Initially, with dry AMD, words on a page may appear blurry.  As it progresses, dry AMD causes loss of central vision in the affected eye.  Dry AMD generally affects both eyes, but the rate of progression may vary between eyes.  In wet AMD, an early symptom is that straight lines appear wavy.  This can progress fairly quickly to the development of dark gray spots or blank spots in the visual field.

Who is at risk for developing AMD?  Most AMD develops in those over the age of 60 with up to 30% of people over the age of 75 having some degree of AMD.  Due to their longer life expectancy, women are more likely to develop this disease. Other risk factors include smoking, obesity, high blood pressure, elevated cholesterol, and a family history of AMD.

How is AMD diagnosed? An evaluation by an Ophthalmologist is warranted should visual symptoms (blurry words, central blind spot, etc.) suggestive of AMD occur. A dilated eye exam may demonstrate drusen or abnormalities of the macula. If wet AMD is suspected, a fluorescein angiogram is usually performed.  In this test, a special dye is injected into the arm and pictures are taken of the retina as the dye passes through its blood vessels.  A second scanning procedure known as optical coherence tomography may also be used to make high-resolution images of the retina to look for abnormal blood vessels.

Is there a treatment for AMD?  AMD cannot be cured, but there are measures that can help preserve vision.  For wet AMD, laser surgery, photodynamic therapy, and injections into the eye (anti-VEGF therapy) may be used to destroy the leaky blood vessels growing beneath the macula.  No specific treatment is recommended for early stage, dry AMD, although regular examinations are necessary to monitor for progression to intermediate dry AMD or to wet AMD.  It is recommended that someone with early AMD use a tool known as the Amsler grid to monitor for progression of AMD.  When looking at the center dot on the Amsler grid, the normally straight lines may appear wavy with worsening of the disease. For those with intermediate or advanced AMD, the National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants (vitamin C, vitamin E, beta-carotene) and zinc significantly slowed further progression of AMD and its associated vision loss.

Can AMD be prevented?  AMD cannot be prevented but certain life-style measures that may help to lower the risk of developing the disease. These include eating a healthy diet, not smoking, maintaining normal blood pressure and keeping one's weight at an ideal level. There is also some evidence that avoidance of excessive exposure to sunlight by wearing a hat or sunglasses may help to reduce the risk of developing AMD.

Sources for article: 

Facts About Age-Related Macular Degeneration from the National Eye Institute
Age Related Macular Degeneration from the American Academy of Ophthalmology