HYPERDONTIA (SUPERNUMERARY/EXTRA TEETH): Excess teeth in the mouth

OVERVIEW

 Hyperdontia is an oral condition characterized by an excess of teeth and the additional teeth are referred to as Supernumerary teeth or Extra teeth. They are mostly permanent teeth and commonly erupts in the upper jaw. Causes include: Continuous growth of the dental lamina, heredity and underlying conditions such as Gardner's syndrome. Extraction/removal is the only treatment.

Notice the 2 extra teeth at the back of the incisors. These type of extra teeth are
called MESIODENS

The standard number of primary (milk or temporary) teeth is 20, while the standard number of permanent teeth is 32. Primary teeth are the first set of teeth that erupt in a person's mouth by the age of 36months. At 12years of age, the primary teeth starts to get replaced by the permanent teeth. At age 21, permanent teeth are fully erupted.

When a person develops more than 20 primary teeth or more than 32 permanent teeth, the person is said to have Hyperdontia, and the additional teeth are referred to as Supernumerary teeth or extra teeth.

Supernumerary teeth can erupt among the primary or permanent and in any part of the dental arch (or jaws), but the most common are permanent and occur in the upper jaw among the front teeth. After this position, it is next common behind the wisdom* teeth

*Wisdom teeth are the 3rd and final set of molars that most people get in their late teens or early twenties

Supernumerary teeth occurrence is the same for primary teeth in both males and females. But for permanent teeth, it occurs twice as common in males compared to females

CAUSES

• Overactivity or continuous growth of the Dental Lamina: This is the tissue that forms teeth. It is a zone of cells that initiates the formation of the tooth germ which forms the teeth
  
• Hereditary: The disorder can also be inherited
  
• Underlying conditions: Two major conditions that causes the eruption of ST are: Gardners's syndrome and Cleidocranial Dysplasia. if this is the case, the ST are usually multiple

Extra teeth growing around the molar teeth. This type is called Paramolar
because it is supplemental. Notice that it caused misalignment of the molars

CLASSIFICATION

Supernumerary teeth are classified based on their location and morphology (i.e. what they look like or shape)

BASED ON SHAPE

1. Mesiodens: If it is located among the front teeth
   
2. Paramolar: If it is located around the normal molar teeth
   
3. Distodens or Distomolar: If it is located behind the wisdom teeth

BASED ON MORPHOLOGY

1. Supplemental tooth: If it is shaped normally like the other teeth where it is found
   
2. Rudimentary tooth: If it is not shaped like a normal tooth. Rudimentary teeth are then classified based on what they look like
   
   
   • Conical Rudimentary tooth: If it looks small, triangularly or peg-shaped. It occurs commonly among the front teeth
   • Tuberculate Rudimentary tooth: If it is barrell-shaped
   • Molariform Rudimentary tooth: look similar to premolar or molar teeth but enough to be called a supplemental teeth

PROBLEMS ASSOCIATED WITH SUPERNUMERARY OR EXTRA TEETH

The presence extra teeth may cause the following problems

• Cosmetic and aesthetic problems: Extra teeth causes the mouth to look crowded, unsightly and misalignment of dentition. In most cases, the hinders the person from having a beautiful smile
• Delayed eruption or maleruption (abnormal eruption) of adjacent teeth: Extra teeth can also prevent the normal eruption of adjacent teeth
• It may also lead to the re-absorption of the roots of adjacent teeth

TREATMENT

Removal or extraction of extra teeth is the only currently known treatment. However, it should be done only when they pose the problems mentioned above

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NOCTURNAL ENURESIS: PRIMARY NOCTURNAL ENURESIS AND SECONDARY NOCTURNAL ENURESIS; CAUSES; TREATMENT AND MANAGEMENT; BEDWETTING ALARM

OVERVIEW

Nocturnal Enuresis is the involuntary release of urine while asleep at night after the age at which it is supposed to have stopped and bladder control occurred. It is also known as Night-time Urinary Incontinence or Night-time bedwetting, and people who bedwet are referred to as Enuretics or Bedwetters.

There are 2 types of Nocturnal Bedwetting:

• Primary Nocturnal Enuresis (PNE)
• Secondary Nocturnal Enuresis (SNE)

PRIMARY NOCTURNAL ENURESIS (PNE)

This is when a child has not yet had a prolonged period of not bedwetting. Here, the bedwetting occurs from infancy. It is the most common type of bedwetting among children and is viewed as a delay in maturation of the nervous system.
According to the National Sleep Foundation, between 13-20% of 5-year-old children, 10% of 7-year-olds, and 5% of 10-year-old children still wet the bed. Even at age of 16, 1% of boys and girls bedwets about once or twice in 3months

CAUSES 

Notable causes of PNE include:

1.     Genetics: PNE is strongly linked to genetic make-up. Children whose parents were not bedwetters have only a 15% chance of bedwetting. But when one or both parents were bedwetters, the chances jump to 44% and 77% respectively

2.     Inability to recognize the sensation of a full bladder during sleep: This is usually due to an immature nervous system

3.     Inability to hold urine for the entire night: This may be due to a small bladder. Also, studies have shown that bedwetters have an increased bladder tone (unintentional contraction of the muscles of the bladder) which functionally decreases bladder capacity

4.     Production of a large amount of urine during sleep: This is usually due to insufficient production of the *Anti-diuretic Hormone (ADH)*. During sleep, the body increases the level of ADH to signal the kidney to produce less urine. When this doesn’t happen, bedwetting may result

*ADH (Vasopressin): This is a hormone that helps the body retain water. It is released when the body is dehydrated or in low activity causing the kidney to conserve water.*

5.     Poor/Unhealthy daytime toilet habits: Many children habitually ignore the urge to urinate and put off urinating as long as they possibly can. Parents are familiar with the “potty dance” characterized by leg crossing, face straining, squatting and groin holding that children use to hold back urine

SECONDARY NOCTURNAL ENURESIS:

This is when a child or adult bedwets again after being dry for a period of at least 6months. It is mostly a sign of an underlying medical or emotional problem. 

CAUSES

Notable causes of SNE include:

• Urinary tract infection: A urinary tract infection can make it difficult to control urination. Signs and symptoms may include daytime bedwetting, frequent urination, bloody urine and pain during urination.

• Diabetes: People with type I diabetes have a high level of sugar (glucose) in the their blood. Consequently, the body increases urine output. Frequent urination is a common symptom of diabetes.

• Structural or anatomical abnormality/Neurological problems: An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence or other urinary problems that could show up as bedwetting.

• Emotional problems/Stress: This may include parent conflict or divorce, arrival of a new baby, moving to a new town, sleeping away from home, starting a new school, or loss of a loved one or pet. Children who are being physically or sexually abused sometimes begin bedwetting.

• Chronic constipation : When the bowels are not regularly and adequately emptied, it puts pressure on the bladder

• Sleep apnea: Sometimes, bed-wetting could be a sign of Obstructive Sleep Apnea (OSA), a condition in which breathing is interrupted during sleep

• Excessive fluid intake.

TREATMENT AND MANAGEMENT

NOTE: Most of the measures discussed here is best for tackling PNE. SNE is best approached by treating the underlying medical condition

Most times, children outgrow bedwetting on their own. If there is a family history of bedwetting, the child will probably stop bedwetting around the same time the parent(s) stopped bedwetting. So, a wait-and-see approach is usually recommended until the child is at least 6 or 7years old

However, treatment is recommended when the child is especially bothered or embarrassed by the condition.

Treatment and management procedures include:

• Using bedwetting alarms: These are small battery-operated devices connected to a moisture sensitive pad on the child’s night wear. When the pad senses wetness, the alarm goes off! Ideally, bedwetting alarms sounds just as the child begins to urinate – in time to help the child wake, stop the urine flow, and get to the toilet to expel it. But if the child sleeps deeply, another person may need to listen for the alarm.
  Bedwetting alarms are highly effective, carry a low risk of relapse or side effects and may provide a better long-term solution

• Using absorbent underwears/underpants: These help reduce embarrassment for bedwetters and make cleanup easier. They are known as “training pants” or “diapers” when used for younger children  and as “absorbent underwear” or “incontinence briefs” when marketed for older children and adults. They are ideal for bedwetters wishing to spend night-outs or go camping

• Using waterproof mattress pads: This also ease the cleanup of bedwetting episodes. But, they only protect the mattress while the sheets, clothes and even a sleeping partner may be soiled
• Others: 
  • Reassuring the child that bedwetting is a normal part of development and that he/she will eventually outgrow it
  • Limiting the amount of fluids the child drinks right before bed
  • Making sure the child urinates before going to bed
  • Avoiding caffeine, which can act as a diuretic (a substance that promotes the production of urine), especially in the evening
  • Waking the child to urinate during the night, before the time that he/she would usually wet the bed

• Medications: As a last resort (because of their accompanying side effects), medications may be prescribed by a doctor to treat bedwetting.
  
  These medications and their aims include:
  
  • Slowing night-time urine production: Drugs such as Desmopressin acetate (DDAVP) – the synthetic replacement for ADH – causes the body to make less urine at night. It can cause seizures especially when the child has a headache, has vomited or feel nauseous, or drinks a lot of water with it.
  • Calming the bladder: Antichorlinergic drugs like Oxybutynin or Hyoscyamine helps reduce bladder contractions, consequently increasing its capacity. Side effects may include dry mouth facial flushing 
  • Changing the sleeping and waking patterns of a child: Anti-drepressant drugs such as imipramine or amitrityline treat bedwetting by changing a child’s sleeping and waking pattern. Side effects include mood changes and sleep problems

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HIRSUTISM (UNWANTED AND EXCESSIVE HAIRINESS IN WOMEN): CAUSES; SIGNS AND SYMPTOMS; AND TREATMENT

OVERVIEW

Hirsutism is a condition in which unwanted and excessive hairs develop in women just the way it does in men. Women with this condition have coarse, pigmented hairs (i.e. hair with the same colour as scalp hair) in areas where they are supposed to grow fine hairs or no hair at all. These areas include the chin, above the lips, chest, back, abdomen, sideburn area, around the nipples and even on the buttocks. Causes of Hirsutism include: Polystic Ovary Syndrome (PCOS), Cushing's syndrome, Congenital Adrenal Hyperplasia, tumours in the ovaries or adrenal glands, certain medications and obesity. Treatment of Hirsutism include: using medications and hair removal procedures

Hirsutism: Unwanted hairs on the chin

Women with this condition are said to be Hirsute

DO YOU STILL WEAR THOSE TIGHT-FITTING SHOES? SEE WHAT THEY CAN DO YOUR TOE-NAILS

CAUSES

Hirsutism can be caused by either an increased level of the male sex hormones (androgens) or an oversensitivity of the hair follicles to them. Normally, when women reaches puberty, their ovaries (the pair of reproductive organs that produce eggs and sex hormones in females) begin to produce both the female sex hormones (oestrogen and progesterone) and androgens (testosterone, dihydrotestosterone). The male hormones stimulate hair growth (in areas such as the armpits and pubic region), increase in size and intensify the growth and pigmentation of hair. However, the level of androgens is lower compared to the female hormones. That is the balance!

But in hirsute women, the level of androgens become much higher.

Other significant courses of hirsutism are

1. Polycystic Ovary Syndrome (PCOS): This is a condition in which women have a number of small cysts (fluid-filled sacs) around the edge of their ovaries. It is a common cause of Hirsutism and results from imbalances in the sex hormones. In addition to hirsutism, women with PCOS often have acne, balding near the front of the head, menstrual irregularities, infertility, obesity, diabetes and high cholesterol levels
2. Cushing's syndrome: This occurs when the body is exposed to high levels of the hormone, Cortisol. This may be due to prolonged usage of medications such as prednisone. It can also develop when the adrenal glands make too much cortisol.
3. Congenital Adrenal Hyperplasia: This is an inherited disorder where people lack the enzyme, 21-alpha-hydroxylase, that the adrenal glands need to make their hormones (cortisol and aldosterone). While this is happening, the body produces more androgens, causing the male characteristics to appear early, inappropriately or abnormally.
4. Tumours in the ovaries or adrenal glands: In rare cases, an androgen-secreting tumour forms in the ovaries or adrenal glands. This can cause Hirsutism
5. Medications: Some medications can induce Hirsutism. A classic example is Danazol, a drug used to treat women with endometriosis. Others include: phenytoin, epanutin, cyclosporin and minoxdil
6. Insulin resistance
7. Obesity

In rare cases, a woman with hirsutism will have normal levels of androgens and the specific cause of the unwanted hair growth can not be identified. This is known as Idiopathic Hirsutism

Hirsutism: Unwanted and excess hairs on the chest and nipples of women

THE HAMSTER FACE DISEASE

SIGNS AND SYMPTOMS

Apart from hirsutism, this high level causes other signs and symptoms (medically known as Virilization*) such as the following to manifest

• Deepening of voice
• Balding
• Oily skin
• Acne
• Decrease in breast size
• Enlargement of the clitoris
• Increase in muscle mass

*Virilization: This is a term used in medicine and biology which refers to the biological development of differences in sex/gender, i.e. changes that make a male body different from a female body. Androgens are solely responsible for virilization*

TREATMENT

The treatment of hirsutism requires patience because hair follicles have a life cycle of 6months. So it may take several months before significant difference in hair growth can be seen.

1. Hair removal procedures
   
   
   • Electrolysis: This involves inserting a tiny needle into each hair follicle. A pulse of current is then emitted through the needle to destroy the follicles. Electrolysis is best suited for treatment of small areas, although larger areas may be treated with multiple sessions overtime. It is safe and effective, but can be painful and often expensive
   • Laser hair removal: This procedure involves using a concentrated beam of light (laser) to generate heat inside the hair follicles, destroying their ability to produce hairs. it is expensive, effective, faster and less painful than electrolysis. However, there may be some skin redness and swelling after the procedure. It also carries a risk of burns and skin discoloration.
     
2. Medication
   
   
   • Birth control pills/oral contraceptives: Birth control pills or other hormonal contraceptives which contain the hormones oestrogen and progestin treat hirsutism by lowering the levels of androgens. They are usually the first choice for the treatment of hitsutism and the improvement it presents is usually high in most women
   • Anti-androgens: These medications act by directly decreasing androgen production, reducing its effects on the hair follicles or blocking it from attaching to their receptors in the body. However, anti-androgens can cause birth defects, so an effective form of birth control should be strictly used by sexually active women who take them to prevent them from getting pregnant. Examples of anti-androgens are spironolactone, finasteride and cyproterone acetate
   • Topical creams: This involves the use of prescribed and nedicated creams specifically for excessive facial hairs in women. They are applied directly to the areas of excessive hair growth to slow their growth. However, they do not remove hairs permanently and once their usage is discontinued, the hairs return. Example of a topical cream that improves hirsutism is Eflornithine hydrochloride (Vaniqua)
   For women who are obese, losing weight may reduce androgen levels and improve Hirsutism
    

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CATARACTS (CLOUDY EYE):CAUSES, RISK FACTORS, SIGNS AND SYMPTOMS, TREATMENT USING SURGERY

OVERVIEW

Cataracts is a disease in which the clear lens of the eye becomes cloudy or opaque, causing a blurry vision. It is the most common cause of vision loss as we grow older. it also occurs in babies when they are born or shortly after birth, this is known as Congenital cataracts. Causes and risk factors of cataracts include: Age, blunt trauma/injury, skin diseases, hereditary/genetic makeup, smoking/drinking, certain drugs and radiation. The major signs and symptoms of cataracts are: blurred or dim vision, fading or yellowing of colours, seeing "halos" around lights etc. The ONLY treatment of Cataracts is surgery to remove the affected lens and replace it with an artificial lens known as the Intraocular lens (IOL)

HALITOSIS: THAT EMBARRASSING PROBLEM THAT MAKES EVERYONE WANT TO KEEP THEIR DISTANCE!

HOW WE SEE/WHAT HAPPENS DURING CATARACT

The lens is an important part of the eye that is usually transparent and clear. Its major function is to focus light rays from objects entering the eye onto the retina* so as to form an image. These light rays chemically react with the cells of the retina. The chemical reaction, in turn, causes electrical responses which is carried to the brain through the optic nerve*. The brain then interprets what we see as vision.

*Retina: a layer of light sensitive cells at the back of the eye*
*Optic nerve: the nerve found in the eye, directly involved with vision*

In a normal eye, since the lens is clear and transparent, it is able to focus light rays on the retina well enough for a sharp image to be formed. But if the lens is cloudy because of a cataract, light rays does not pass through easily and adequately, as a result the image formed on the retina will be blurry and the vision, in turn, will be blurry

For people with cataracts, their vision is similar to looking through a cloudy water or a dirty window.

Cataracts is not contagious and does not cause the eye to shed tears abnormally. It is neither painful nor make the eye itchy or red. It is also NOT a growth or tumour in the eye. Cataracts is the most common cause of vision loss as we age. Both men and women are affected equally. Cataracts may develop in only one eye , but it usually develops in both eyes. When it does, the cataract in one eye may be more severe than the other

What happens during cataracts

HEARTBURN: WHEN WHAT STAYS DOWN COMES UP!

CAUSES AND RISK FACTORS

These include

1. Age: Age is the common cause and factor that places us all at risk of developing cataracts - since we will all grow old someday. As we age, the lenses in our eyes become less flexible, less transparent and thicker. Age-related changes cause tissues that makes up the lens to break down and clump together, clouding small areas within the lens. As the cataract continues to develop, the clouding becomes denser and involves a greater part of the lens
   
2. Blunt Trauma/Injury: This refers to a physical injury caused to a part of the body due to impact or a force and not by penetration. For example, hitting one's chest on the steering during a car accident will cause a blunt injury. This is different from when a bullet or knife penetrates the body. Blunt trauma or injury such as that sustained from a punch to the eye during a fight causes the lens fibres to swell, thicken and whiten. The swelling normally resolves with time but the white colour may remain. In severe blunt trauma, the capsule that envelops the lens may become damaged, allowing water from other parts of the eye to rapidly enter the lens causing it to swell and whiten. Cataract dues to injury may occur immediately after the injury or some weeks to years afterward. Also, when it appears, it may not increase in size or be progressive
   
3. Hereditary/Genetic make-up
   
4. Skin diseases: The skin and the lens are very much related (in fact, they have the same embryological origin), and as such can be affected by similar diseases. Skin diseases such as dermatitis, eczema, ichthyosis and pemphigus may occasionally cause cataracts to develop
   
5. Smoking/Drinking alcohol: Cigarette smoking has been shown to cause a two-fold increase in risk of developing cataracts. However, the relationship between alcohol and cataract is yet to be fully established
   
6. Certain drugs: some drugs such as corticosteroids (e.g. Prednisolone) can induce cataract development
   
7. Radiation: Exposure to radioactive rays such as Ultraviolet light, microwaves and X-rays can have negative effects on the lens, causing cataracts

 Cataracts also occur in babies when they are born or shortly after birth. This is known as Congenital Cataracts and may be the result of the mother having contracted an infection during pregnancy. Older babies and children can also have cataracts. This is referred to as developmental, infantile or juvenile cataracts. These kinds of cataracts may also be due to certain conditions, such as myotonic dystrophy, galactosemia, Lowe's syndrome or rubella. Congenital cataracts don't always affect vision, but if they do, they are can be removed soon after detection.

The characteristic blurring vision associated with cataracts

MIGRAINE: THE ONE-SIDED HEADACHE

SIGNS AND SYMPTOMS

NOTE: The signs and symptoms given here are those of cataracts caused by age

Cataracts develop very slowly, so most people do not even know that they have them. Long distance vision is more severely affected at first. People with cataracts may have the following signs and symptoms

• Clouded, misty, blurred or dim vision]
• Vision may be stained with small spots or dots
• Increasing difficulty with vision at night or when the lights are dim
• Fading or yellowing of colours
• Seeing "halos" around lights
• Sensitivity to light and glare
• Double vision in one eye (this is rare though)
• Glasses need to be changed more frequently
• Eventually, wearing glasses becomes less effective

Cataracts do not usually cause any change in the appearance of the eye. Any discomforts, such as irritation, aching, itching or redness are most likely caused by some other eye disorder.

Cataracts are not hazardous to the sufferer's health, or the health of the eye, it affects ONLY the lens. But if the cataract becomes hypermature (i.e. completely white), the sufferer may experience inflammation, headache and some pain. Hypermature cataracts need to be removed as soon as possible

TREATMENT

Surgery to remove the cataracts is the ONLY effective treatment. And it is advised when the cataracts has become severe, hindering everyday life. Surgery is recommended when the person:

• Is having trouble looking after him/herself or someone else
• Finds it difficult to drive
• Has problems leaving the house
• Finds it difficult to see or recognize people's faces
• Has problems doing his/her job
• Cannot read properly
• Can no longer watch television properly

Surgery basically involves removing the clouded lens and replacing it with a clear artificial lens implant known as Intraocular Lens (IOL). This artificial lens is positioned in the same place as the natural lens and it becomes a permanent part of the eye

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HALITOSIS ALSO KNOWN AS BAD BREATH OR SMELLY MOUTH: CAUSES, SELF-DIAGNOSIS, TREATMENT, MANAGEMENT AND FRESH BREATH TIPS

OVERVIEW

Halitosis, also known as bad breath or smelly mouth, is a condition in which unpleasant, offensive, and smelling odours are exhaled or released during breathing or talking. It is a very common problem that can affect anyone at any age. Causes of halitosis include: eating strongly scented food; poor oral hygiene; lifestyle such as smoking, drinking and chewing tobacco products; oral health problems such as periodontitis, dry mouth, dental caries etc and even non-oral diseases such as diabetes, acid reflux, liver or kidney problems etc. You can check if you have halitosis by exhaling into your cupped palm and smelling the air, licking the back of your palm and smelling the result, or asking a trusted friend to smell your breath

Halitosis

CAUSES

The NUMEROUS causes of bad breath have been summarized into 3 main causes

1. THE KIND OF FOOD WE EAT

Normally, after food has been chewed in the mouth, digested in the intestines, and absorbed in the bloodstream, they are finally carried to the lungs where the scent of the food is given off in your breath. So when we eat certain foods with strong scents such as onions, garlic, spices etc, the scents of these foods tend to stick to our breath for a long time.

2.    2. POOR ORAL HYGIENE

This is the major cause of bad breath

After eating, food particles normally stick to the corners of our mouths, crevices of our teeth, and even on our tongue. Ideally, it is advised that you brush and floss your teeth after each meal so as to remove them. This is because these food particles acts as substrates for the growth and blossoming of bacteria which, in turn, releases gases that comes out of the mouth as offensive odour. If these bacteria are still left to themselves, they could form plaques which irritate the gums and eventually form plaque filled pockets between the teeth and gums leading to gum disease (Periodontitis)

Also, excessive drinking, smoking, and chewing of tobacco based products can also cause bad breath, discolouration of the teeth and even irritate the gums

3.     3. OTHER ORAL HEALTH PROBLEMS

Persistent bad breath could also be an indication of underlying oral diseases. Some of these diseases are:

• Gum disease: This disease is also known as Periodontitis, and is the result of plaque building up in the teeth. If left unattended to, this disease can damage the gums and even eat into the jawbone. Bad breath could be an indication of an impending gum disease.
  
• Dry mouth: This condition is medically known as Xerostomia. Saliva is needed to moisten and cleanse the mouth by neutralizing acids produced by plaque and washing away the dead cells that accumulate on the tongue, gums and cheeks. If not removed, these cells decompose and can cause bad breath. Dry mouth may be caused by salivary gland problems, side effects of various medication or continuous breathing through mouth.

·        Other oral and non-oral diseases that may cause bad breath are yeast infections of the mouth, dental caries, respiratory tract infections, Pneumonia or bronchitis, sinusitis, diabetes, chronic acid reflux, and liver or kidney problems.

SELF-DIAGNOSIS

You can self-diagnose yourself to know if you have Halitosis. This can be done by:

• Cup your palm over your mouth, exhale and immediately inhale the exhaled air. The major demerit of this method is that most times you actually perceive the smell of your palm. 

• Lick the back of your palm, allow the saliva to dry and smell the result. This method often leads to over-estimation 

• Lightly scrape the back of the tongue with a plastic disposable spoon and smell the dried residue 

• Ask a trusted adult family member or close friend to smell your breathe. This is the most effective because the person can help you decipher the kind of smell, its possible cause and whether it is coming from the mouth or nose.

TREATMENT AND MANAGEMENT

Treatment/management of bad breathes and fresh breath tips are as follows:

• Avoid eating high scented foods in its raw form. Its best you cook them, so as to reduce their scent
  
• Chewing gum (this measure is only temporary). In cases of dry mouth, chewing sugar free gums can help stimulate the flow of saliva
  
• Treat any underlying oral diseases
  
• Reduce the intake of sugary food and drink as these can increase the amount of bacteria in your mouth
  
• Low consumption of tobacco-based products and alcohol
  
• Maintaining proper oral hygiene: This involves taking steps to greatly reduce the accumulation of dirt and bacteria in the mouth and on the teeth. They are:
  • Use a soft, suitable toothbrush and a toothpaste containing fluoride 
  • Replace your toothbrush at most every 3months 
  • Brush all areas of your teeth, paying attention to where your teeth meet the gums 
  • Clean the tongue adequately, especially the interior part 
  • If possible and convenient, brush your teeth after each meal 
  • Use anti-bacterial or anti-odour mouthwash to gargle the mouth. This should not replace brushing, but can be included as part of your daily routine. Besides, its effect is short-lived

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