Thursday, September 23, 2010

5.(15-17) Osteoporosis/Dentistry/Footcare

Physician's Notebooks 5  -  See Homepage

Chapters 15 to 17 - Osteoporosis, Foot Care and Dentistry in Scroll Down Order and note the descending order tables of contents of each chapter.

Suffix: -penia means lack of as ostopenia, lack of bone, or sarcopenia, lack of muscle.
      Chapter 15  Preventing Osteoporosis. Update 09 December 2018
Osteoporosis (OP) means
Protecting against osteoporosis fractures -The 5 Rights
Right Nutrition
Right Physical Activity
Right Avoidance
Right Monitoring
Estrogen Replacement & Other Preventives

Osteoporosis (OP) means weakening of your bones due to decrease in bone density from loss of calcium (Ca) to the extent that fractures occur during normal activity or minor bump. The worst fracture is in a hip while walking or standing. By extreme old age 1/3rd of women and 1/6th of men will have fractured a hip; often it means invalidism or death. So avoiding it ought to be on everyone’s healthy longevity list.
   Osteoporosis, a lifetime process from birth, is worse in women, mildly progresses to age 50 and speeds with menopause and in men after age 60. It has no symptom until the lowering density of bone goes below the fracture threshold. Then bones start to break.
Osteomalacia is a weakening of bone matrix support due to vitamin D deficiency or renal phosphorus-losing disease and results in the rubbery bone rickets, in children who do not have sunlight and eat poorly. The blood tests for Ca and P are low and the Parathyroid hormone is high. In osteoporosis, all 3 tests can be normal.
Osteoporosis is worst if thin when young, and fat when old, and it is increased by drinking alcohol, smoking, or inactivity. The key to slowing OP is being alert to it early and removing, reducing or compensating its causes and risks. At age 86 I have headed off its worst effects by right nutrition, right physical activity, right avoidance, right monitoring and right preventives.
   Osteoporosis is a series of time bombs. During your first 50 years, your bones slowly lose density without your being aware. Then, one un-fine day, out on a stroll and Bang! – A broken hip! Or catch flu and cough, and Wham! – Several cracked ribs! Or slip on stairs and Alikazam! – A broken wrist!
Right Nutrition
Build up and conserve Calcium in bone especially in your first 20 years. (A parental responsibility) If you succeed, the worry is less. High early calcium level in bone will keep it stronger to resist fracture even after years of loss. Good calcium intake comes from milk fortified with vitamin D that improves calcium intestinal absorption and bone incorporation. After age 30, especially if one has high cholesterol or high Blood Pressure, be sure to use milk with low-fat, low-sodium. Another food source of Ca is bone from eating small fish like sardine or the shell encasing shrimp.
   On body weight, I mentioned increased risk of OP for those who are thin while young and fat later. But I do not like to promote overweight. It makes worse risks than OP. Older person may go to BMI as low as 19 so long as good calcium and normal vitamin D intake. Low healthy body weight lowers risk of fracture from standing-up, from bump and from fall.

Right Physical Activity
Cultivate walking; it is the best exercise against OP. Jogging damages bone and joint and over-strains muscle and you may suffer falls. Avoid heavy-exertion exercise and sports after age 40. With particular physical activity like stairs walking up and down, use side hand-hold to prevent stumble or fall. Do not dive into swimming pool, do not jump up and down or jump from any height, and do not engage in physical contact or running sports. And arising from floor bed, use your hands on a chair to take stress off the hips. And get rid of motor vehicle after age 60.
Right Avoidance
Alcohol, tobacco, aspirin and NSAID meds, the thyroid and cortisone-like hormones, anticonvulsants, cyclosporine and other chemotherapy for cancer may increase calcium loss. I am not advising never to take these. Just be aware and compensate by being sure to also take maximal calcium in food and pill. Too much time in chair or bed and excessive x-rays favor fractures. In particular case, a risk factor may be unavoidable; still, knowing of having the risk factor should make you more careful in activity where risk exists.
   Fall and trauma to bones are particular risks as we age. Even sneezing and coughing can cause rib and vertebral fracture so if you want to cough or sneeze, or blow nose, sit down, keep mouth open to dissipate internal body pressure and breathe out of mouth as you sneeze. Falls to the side risk hip fracture so hold on to support if there is risk of (or while) falling. And be alert to footwear and floor unstable for standing or walking. (No high-heel, no pointy front of shoe; no slippery, wet, hard floor; very good against falls is Japanese tatami floor)

Right Monitoring
should be basis of prevention. A test I used is heel scan DX-2000, results shown in following graphs.
Bone density from x-ray of heel bone. These from me at age 71 on your left and age 73 on right. Lower horizontal numbers are my ages in decade. Vertical numbers on left side are bone density index in gram/square cm. Note the 3 parallel downward curving lines of graph. Central line is average normal bone density index for age, and upper and lower lines are 2 standard deviations plus and from it. Black dot on left graph is my test at age 71 showing nearly normal bone density for my age then. On right graph you see the dot showing my bone density at age 73 and it shows bone density 0.747 g/square cm, a significant drop into the yellow increasing risk level toward the pink fracture danger level, warning me to check my calcium and vitamin D. The bone density test is simple, inexpensive and a good screen but one gets small dose of x-ray. A first baseline test should be done at age 55-60. If on normal curve, it may be done once every 5 yrs. If low, it indicates osteoporosis and risk of OP fracture, and metabolic internist or orthopedist should be consulted to start preventive measure.
At age 78, the just-above x-ray bone density graph (me) was obtained. A different color code is used from the first two, but the lowest pink region is same in all three graphs - the region of high risk for osteoporosis fractures. The top green region in this recent graph is the same as the top light blue region in the older two above it - the region of lowest risk for fracture. This age-78 x-ray bone density was taken after 5 years of three 500 gram calcium carbonate tablets and 0.250 microgram 3 caps vitamin D daily and you should note the black dot, which means my bone density at age 78, sitting just inside the color of normality and compare it to age 73 when it was entering the fracture area. Here we see the effect of calcium and vitamin D daily in reversing osteoporosis. (By 2017 at age 84, a 4th and 5th bone density test showed no osteoporosis and now I take 1 calcium and 1 vitamin D pill a day)
          First, follow the Right Activities - nutrition, physical, avoidance and monitoring. Then get blood tests once a year: serum Ca2+, inorganic phosphorus (IP), parathyroid hormone (PTH), vitamin D (25 OH vit. D), alkaline phosphatase (AP) and serum magnesium (Mg2+). Any abnormality that includes a low Ca2+, a low vitamin D or a high PTH calls for a bone density test. If bone density does not show progression toward risk of fracture, just rely on calcium in the diet. I took calcium carbonate 500 mg and vit D (D3, 7 OH cholecalciferol) 0.25 microgram (10 IU) with each meal until the bone density and blood test signs of osteoporosis reversed. Calcium and vitamin D may cause hard stool constipation solved by routine digital stool removal and may elevate plasma Ca2+ that should be monitored by blood testing.
   Estrogen Replacement & Other Preventives: (Interested reader should click) 
 Estrogen Replacement is controversial but preventive of OP in women. Other preventives such as Fosamax and like meds are not worth the risks and do not give better results than Ca and vit. D.
Chapter 16. Foot Care (The following descending column gives the headings in order of appearance in text)
My aging feet
The best foot bath
Pay attention to your footwear
Special problems - diabetes, overweight, hypertension
Infections between toes, mostly fungal (eg, athlete's feet)
Fractures of the feet
Heel fracture
My aging feet: Being age 86, I have had my own foot woes. Once you reach age 70, the feet are a source of falls that fracture hip, leg and foot bones, that make you bed-ridden and that torment and, finally, kill you by infected foot ulcers.
The best foot bath is pleasantly hot (temp 43C) water and additions suggested by your podiatrist. If you are bothered by just about any foot problem, a daily pleasantly hot bath will improve it. Do not trim your nails; have it done by your podiatrist only. Similarly for callus or corns; by podiatrist only. If problem like painful fissures, click 
Pay attention to your footwear: The safest walking shoe should be lightweight, not bulky, have no hard or sharp ridges on the upper rims, have good friction soles with a slightly up-curve front tip, and fit your feet but not too snugly. I have found these specs best satisfied by the inexpensive, thinly gum-soled, cloth shoe, often blue color and usually made in China.
  Special problems - diabetes, overweight, hypertension, smoking all risk foot ulcers that become infected and kill. Never, never check a bath's temperature by dipping a toe in. It is the cause of many lost toes and lost lives too.
Infections between toes, mostly fungal (eg, athlete's feet) bother almost everybody. Prevention is: 1) Do not go barefoot or use cross-worn socks, slippers, shoes over your bare feet; 2) Keep your feet dry (Particularly between toes) and cool (Use very thin or no socks when appropriate), and treat any cut or trauma even the slightest with immediate antiseptic and band aid). Athlete's feet  gives the typical symptom of itching between toes. The itching can be immediately relieved by rubbing-in a corticosteroid ointment (One dose usually enough). Definitive treatment of Athlete's foot or other fungal skin problem is Lamisil 250 mg  twice a day for one month. (But be sure to have a dermatologist do a microscopic check for fungus before starting Lamisil.)
Heel bone (Calcaneus) Fractures: In old, bad days this use to be called Lover's Fracture because it was commonly seen in lovers, always the male type, desperately escaping from husbands or boyfriends of their lovers by jumping from dangerous heights. Today, any fall - not enough to kill but enough to fracture) and landing on the heel(s) causes it. Easily diagnosed by the heel pain often with Mondor sign, a black and blue swelling extending from heel into sole of foot. If the x-rays show no displacements - simple compression fracture - treatment is 6 to 8 weeks on non weight bearing but is there is displacement, operative repair and fixation with wire is best.
17. Your Teeth and the Best Dentistry (Below, the descending column of headings in the order they appear in this chapter. Use search & find or scroll if you wish to go right to them)
Now at age 86
Finding a Good Dental Office
Dental x-ray minimizing policy
 Cleaning Your Teeth
Dental Caries (Cavities)
The biggest mistakes I made
over-vigorous brushing pushes mouth bacteria into blood
Best eating when you don't have teeth to chew

Now at age 86, missing my natural full set of uppers and barely tolerating the removable ones, I wish I had heeded this advice: Do everything you can to preserve all your teeth into old age: rinse mouth after sweets, use tooth brush bristles to remove in-between food, avoid dangerous chewings (hard candies, nuts jujubes), fluoridate either by direct treatment or public water, and, most of all, pay very strong attention to following this advice plus six-monthly dental visit to remove tartar.
Start by finding a good dental office, preferably for life. On principle, I prefer a University-HMO Dental Service or Clinic because the profit motive is minimal due to the dentists being on salary. Also there are uniform standards and least possibility of abuse.
  If you choose a private dentist, beware of newspaper or magazine advertisement – it suggests commercial motive and you want to avoid that. Find out what anesthesia and analgesia (pain relief) is offered. Any dentist that offers to make you unconscious, tranquil by drug or gives gas anesthesia like nitrous oxide is a hazard.
  A dental xray-minimizing policy should be part of your choosing a dental facility. It means asking your dentist at the time when he proposes to x-ray you: "Why is it necessary?" Routine x-ray on each visit is a no go. Dental x-rays should be done on your complaint of tooth or gum pain that suggests dental caries or lesions that might be revealed by the x-ray, or after your dentist examines your teeth and determines a need for the x-ray, which he should be able to explain briefly and simply to your satisfaction. Also be sure your dentist has latest (within last few years) x-ray machine and observes all safeguards. A dentist who holds a dental film in your mouth with his hand while he takes x-ray shows a careless attitude.
Pregnancy: I do not advise taking fluoride pill to protect coming baby from dental caries. Fluoride in water and tooth paste is good.
Immediately from birth a program to limit excess sweets and carbohydrate and always follow with good mouthwash should be thought over and put into effect.
Children: As soon as a child can be taught it, a regular tooth brushing should be introduced in a fun way but never forced. Use pleasant color brush and nice tasting tooth paste. Parent should brush together with the child after every eating. Also add the habit of following all eats and drinks with water in mouth and swallowed.
  Concerning child dentistry, be sure to find a dentist who is strong in preventive dentistry. Do not allow a child to be put to sleep or medically tranquilized or given gas. It may take training to get young child to accept local anesthesia. Be patient and loving. Have your child watch when dentist gives you local anesthesia and show your child you do not mind.
  “Straightening” of teeth and other cosmetic dentistry should only be done after independent 2nd opinion and not rushed into. There are appropriate ages that expert cosmetic dentists know after permanent teeth are in place.
  Cleaning Your Teeth: As an adult you want to combine regular brushing and avoiding both toothpick or flossing in favor of using good toothbrush bristle to get in between teeth. The bristle can replace toothpick or flossing and is safer. Use after-eating or mouth-rinse. Avoid sticky candies. Be very careful eating hard nuts or chewing bones. Be alert to early feeling twinges of possible dental caries. Removal of dental plaque at 6-month interval is wise.  
Dental Caries (Cavities) are destructive areas in the tooth enamel and pulp caused by bacteria growing on pieces of food that get shoved tightly between teeth during eating and are not removed by toothbrush. An acidic, sweet mouth environment favors dental caries. Prevention is: to correctly use toothbrush bristles and get food specks out from between teeth, to do good mouth rinse with alkaline antibacterial mouthwash (baking soda 1 tablespoon to a quart), and to go once every 6 months for dental cleaning by your dentist. A bad mouth odor may be sign of dental caries.
  I find that the biggest mistakes I made in care of my teeth were biting on the wrong things that dislodged dental covers (inlay). Once a nurse I knew gave me a Jujube (a semi-soft jelly candy) that was hard enough and sticky enough to dislodge an expensive gold molar which cost a lot to replace. Another time I was preparing lunch and trying to open a plastic encased fast food salad. Its opening seemed stuck so impatiently I used my front tooth bite and “Whoops!” out came another inlay. Do not use your teeth for anything but normal chewing and, even there, be careful with hard sticky foods or chicken bones or nuts. 
Be gentle with your toothbrush-use because over-vigorous brushing pushes mouth bacteria into your blood. Consult your dentist for tooth pain, for sensitivity or for excess tooth move-ability. And if you have a history of heart disease, precede your visit to dentist with taking antibiotic Augmentin (Assuming you have no known allergies to penicillin and clavulinic acid) on empty stomach with glass water, within 1 hour before the visit; then, just before going into dentist chair, clean mouth with good antibacterial mouthwash to prevent seeding your blood with mouth bacteria and getting infection on a heart valve. If you have the allergies, consult your physician for alternative antibiotic.
 Best eating when you don't have teeth to chew : Here the problems are chewing hard pieces and chewing poorly digestible pieces. First, as much as possible scissors the larger pieces into more smaller pieces to make them more digestible. Second, choose prepared foods that are already softened. E.g., soft white bread sandwiches, meatloaf with or without spaghetti, soft soups like clam chowder etc.

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