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Tooth loss, more reasons to take care of your gums




Red, puffy and bleeding gums is a common complaint from patients visiting the dentist. Gums should never bleed even when you brush or use dental floss. If your gums bleed even sometimes, something is wrong. Gums should never be red or swollen.

World Health Organization sources have indicated that a significant proportion of adult populations suffer from some form of periodontal disease, or more commonly known as “gum disease”, and it has even overtaken dental caries as the main cause of tooth loss.

More than 60% of adults in Malaysia tend to suffer from some form of periodontal disease. It is also the main cause of tooth loss amongst our adult population. Oral health professionals in Malaysia are now spending more time treating this disease than before.

The modern era is characterised by longevity and better health, but unfortunately, many adults continue to suffer from periodontal disease, leading to early loss of teeth, and jeopardizing quality of life.

Every day, a sticky, almost invisible film forms on tooth surfaces, which is derived from salivary glycoproteins. If not removed by proper oral hygiene, it matures into what is called plaque, (also called plaque biofilm or oral biofilm), and this biofilm is the primary aetiology of periodontal disease.

If you do not remove this plaque biofilm, it will be contaminated by bacteria, which are found in abundance in the oral cavity. It is said that there are more than 650 species of bacteria present in our mouths, and some of these bacteria can lead to periodontal disease if it multiplies outside the normal range.

Plaque biofilm can be seen particularly at the gingival margins. The bacteria within the plaque biofilm produces toxins that make the gums red, swollen and bleed easily.

This inflammation is the start of periodontal disease.

The toxins produced by the bacterial plaque biofilm not only cause inflammation of the gingival tissue, but also cause destruction of the alveolar bone, which holds the root of our teeth.

When sufficient bone has been lost, the tooth loosens. Finally, when deprived of most of the periodontal ligament and supporting bone, the tooth becomes so loose that it either falls off or has be extracted.

Our immune system, which has a role in targeting the bacteria within the plaque biofilm, can also contribute to the destruction of the tooth-supporting tissue, which will eventually lead to tooth loss.

There are several local and systemic contributing factors that can lead to the initiation and progression of the disease.

Symptoms of gum disease are bleeding gums, migration of teeth, receding gums, mouth malodour (halitosis), taste disturbances and tooth loss as the disease progresses.

Signs of gum disease include inflamed gingiva (gums) and the space between the neck of the tooth and soft tissue known as sulcus becoming deeper, resulting in a term called periodontal pocketing (which harbours multiple anaerobic bacteria causing the destruction of the supporting structures).

There will be radiographic changes indicating the destruction of alveolar bone.

Periodontal disease in the early stages, only involving the supra gingival area, is called chronic gingivitis, and when it proceeds to the roots of teeth via periodontal pocketing, and affects the supporting structures of teeth like the periodontal ligament and alveolar bone, it is called chronic periodontitis.

Gingivitis is reversible if early treatment is sought, but periodontitis is irreversible, and treatment only prevents more damage.

It is unfortunate that what is lost due to the disease (especially bone) is hard to gain back, even with sophisticated dental treatments.

No early signs

In its early stages, periodontal disease is almost painless, and this will prevent many individuals from seeking dental help and intervention.

You may not notice the gradual onset of puffiness of your gingiva or pay attention to occasional bleeding when brushing.

Four out of five teenagers and adults have some form of periodontal disease, and most do not even know it.

That is why people lose more teeth from periodontal disease than from all other reasons combined.

But the good news is that most periodontal disease can be prevented, or treated in its early stages.

Most people have varying resistance to the disease at different times in their lives. For example, a person’s immune system may be normal for years, and then when immunity diminishes, it can cause the “resting” periodontal disease to flare up.

No one knows why our resistance to the disease varies.

Periodontal disease can have an active phase where the disease progresses rapidly, and a “quiet phase” where the disease practically “hibernates” for a certain period of time.

Some experts feel that the immune system of the host plays a major role in these cyclic changes in the progression of the disease.

Periodontal disease and

systemic disorders

Ongoing research and scientific papers over the last decade have linked periodontal disease to systemic conditions like diabetes mellitus, atherosclerosis, cardiovascular diseases, strokes, osteoarthritis, respiratory tract and lung infections, obesity and renal disorders.

These conditions are considered as systemic host-mediating factors that can contribute to the progression of periodontal disease.

Research has now shown that diabetics are more susceptible to gum disease, and gum disease in turn has been implicated in poor glycaemic control in these individuals.

Even some cancers are linked to periodontal disease, and recently, Alzheimer’s disease has also been mentioned.

The exact mechanism whereby this association occurs is still being debated, but it has been suggested that the by-products of periodontal pathogens and the host immune response to this bacterial infection may play a contributory role.

Research and clinical trials conducted at Universiti Malaya’s Faculty of Dentistry on the association of periodontal disease and systemic conditions like diabetes and obesity have shown that there is a link. More research is being carried out to determine this link.

Findings from such research will make the prevention and management of periodontal disease even more important for our patients.

Management of periodontal disease

Periodontal disease is very unpredictable. We think that the disease is caused by a group of bacteria present in our mouth and not by any one particular microorganism.

Thus, it is difficult to develop a vaccine for the disease as several species of microorganisms may be involved in the initiation and progression of the disease.

The main clinical periodontal parameters that dentists assess are the plaque and bleeding scores, and periodontal pocket depths, before we can embark on any non-surgical or surgical interventions.

This will give us information on the stage of disease progression. Radiographic evaluation of the hard structures can also be done to evaluate, among other findings, the alveolar bone levels.

The management of periodontal disease will consist of removing the bacterial plaque biofilm from the mouth, along with any deposits in the supra-gingival and sub-gingival parts of the teeth, and making the roots of the teeth as clean as possible by a procedure known as scaling and root planning/debridement.

Scaling and root planning/debridement aims to reduce the bacterial load in the mouth by removing deposits that are contaminated by bacteria.

Local contributing factors like overhanging restorations, ill-fitting prosthesis, carious lesions and malocclusion can act as traps for bacterial plaque biofilm and have to be addressed.

The bacterial plaque biofilm can become calcified (if not removed regularly) into hardened calculus (tartar). Calculus can also harbour plaque biofim due to its rough surface, and its removal has to be done professionally because of its tenacity.

The systemic host-mediating factors may require referral to our medical colleagues, if the patient is not under medical care.

To maintain this lowered level of bacterial load, it is imperative that patients practise proper oral hygiene. Oral hygiene education has now become an important and integral aspect of periodontal therapy, and should be reinforced at every visit and review.

Mouth rinses like chlorhexidine, which have antibacterial effects, can be used as an adjunct to mechanical oral hygiene methods like tooth brushing and flossing.

These mouth rinses are especially useful in individuals with poor manual dexterity, such as patients who have had a stroke.

It is also useful in patients who have undergone periodontal and maxillofacial surgery to look after their oral hygiene during the post-surgical phase.

I would advocate antimicrobial mouth rinses for any individual who has issues maintaining their mechanical plaque control.

The prevention of periodontal disease is literally in our hands, and together with oral health professionals, we can try and identify the disease early and prevent it from causing damage to tooth-supporting tissue, thus, preventing tooth loss and improving our quality of life.

We should make regular visits to the dentist and we should treat oral health as an important aspect of our lives. (The Star/ANN)

Prof Dr Dasan Swaminathan is a specialist periodontist. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice.

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Why Small Farms will be the backbone of food security



The ecological axiom that: ‘Energy flow through a system tends to organise and simplify that system’, is abundantly clear in agriculture. As farms moved from small interdependent units, bounded by fences and hedgerows, to large cropping fields to accommodate machine management, we lose the biodiversity that once existed on that landscape and the biomass that provided the Ecosystem Services. This sacrifice was rationalised through the invocation of economic profit. The economic ‘profit’ gained by subsidies on fossil fuel and uncontrolled extraction from the Global Commons. The ‘development’ of agriculture has become a race to control the commodity market. The farmer ceased to be a feature of the farm. In a telling statement, the farmers of Sri Lanka sent the following statement to the CGIAR in 1998 :

‘We, the farmers of Sri Lanka would like to further thank the CGIAR, for taking an interest in us. We believe that we speak for all of our brothers and sisters the world over when we identify ourselves as a community who are integrally tied to the success of ensuring global food security. In fact it is our community who have contributed to the possibility of food security in every country since mankind evolved from a hunter-gather existence. We have watched for many years, as the progression of experts, scientists and development agents passed through our communities with some or another facet of the modern scientific world. We confess that at the start we were unsophisticated in matters of the outside world and welcomed this input. We followed advice and we planted as we were instructed. The result was a loss of the varieties of seeds that we carried with us through history, often spanning three or more millennia. The result was the complete dependence of high input crops that robbed us of crop independence. In addition, we farmers producers of food, respected for our ability to feed populations, were turned into the poisoners of land and living things, including fellow human beings. The result in Sri Lanka is that we suffer from social and cultural dislocation and suffer the highest pesticide- related death toll on the planet. Was this the legacy that you the agricultural scientists wanted to bring to us ? We think not. We think that you had good motives and intentions, but left things in the hands of narrowly educated, insensitive people.’

The diverse farm had to yield to production monoculture, which was made possible through the burning of fossil fuels. Ironically the burning of fossil fuels is the major reason for the current destabilised climate and threat to agriculture. One consequence of climate change is the predicted rise in global temperatures. If ambient temperatures exceed 40 degrees , which has become the reality in many places even today, food production will be compromised. All the food we eat originates with plants and plants produce using photosynthesis. Photosynthesis, or the capture of solar energy by plants, is done with chlorophyll, the thing that makes plants green and chlorophyll begins to break down after 40 degrees. Landscapes whose summer temperatures go beyond this limit will have smaller and smaller crops as the temperatures increase. The only solution to this oncoming crisis, is to begin introducing trees at strategic points on the landscape.

Trees and all other forms of vegetation cool the environment around them through the transpiration process, which takes place in the leaves. The water absorbed by the roots is sent up to the leaves which release it as vapor, cooling the air around it. Measurements on trees done by research institutions worldwide, indicate that an average large tree produces the cooling equivalent of eight room sized air conditioners running for 10 hours, a cooling yield 0f 1,250,000 Bthu per day. Plantations of trees have been recoded to have daytime temperatures at least 3 degrees below the ambient. This is an important aspect of Ecosystem Services that needs to be considered for adaptive agriculture.

Small farms which produce food with low external energy and maintain high biomass and biodiversity, are the models of food production that can face the climate compromised future before us. Capital, resource and energy expensive agricultural systems could fail in a high temperature future and threaten global food security, we need options. One would be to encourage a consumption and distribution system that facilitates small farmers to enter the market. Another would be to realise the value of the ecosystem services of a farm and develop systems to measure and reward. We are all aware of the future before us. Now is not the time to stand blinking like a deer facing the headlights.

But placing trees in and around cropping areas becomes a problem in large cropping fields designed to accommodate machine management. The management of such trees and hedgerows requires needs that cannot be provided without human management. Agricultural landscapes will need management that will be adaptive to the changing climate. An example would be; small interdependent units bounded by fences and that increase biodiversity and the biomass while providing Ecosystem Services.

Investment in food security, should take climate change seriously. All new agricultural projects should address the heat thresholds of the planned crops. The Sri Lankan country statement at COP 21 stated that :

“We are aware that the optimum operating temperature of chlorophyll is at 37 deg C. In a warming world where temperatures will soar well above that, food production will be severely impacted.”

And that :

“We are aware that the critical Ecosystem services such as; production of Oxygen, sequestering of Carbon, water cycling and ambient cooling is carried out by the photosynthetic component of biomass. This is being lost at an exponential rate, due to the fact that these Ecosystem Services have not been valued, nor economically recognised.”

These statements cry out for the recognition of the role that small farms will have to play in the future. In a temperature compromised future, small farms with high standing biomass, through their cooler temperatures will continue to produce food in heat stressed periods. If such Ecosystem Services can be given a value, it will strengthen the economy of small farms and ensure local, sustainable food production into the future.

Small farms which produce food with low external energy and maintain high biomass and biodiversity, are the models of food production that can face the climate compromised future before us. Capital, resource and energy expensive agricultural systems could fail in a high temperature future and threaten global food security, we need options. One would be to encourage a consumption and distribution system that facilitates small farmers to enter the market. Another would be to realize the value of the ecosystem services of a farm and develop systems to measure and reward. We are all aware of the future before us. Now is not the time to stand blinking like a deer in sheadlights.

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Encouraging signs, indeed!



Derek and Manilal

Local entertainers can now breathe a sigh of relief…as the showbiz scene is showing signs of improving

Yes, it’s good to see Manilal Perera, the legendary singer, and Derek Wikramanayake, teaming up, as a duo, to oblige music lovers…during this pandemic era.

They will be seen in action, every Friday, at the Irish Pub, and on Sundays at the Cinnamon Grand Lobby.

The Irish Pub scene will be from 7.00 pm onwards, while at the Cinnamon Grand Lobby, action will also be from 7.00 pm onwards.

On November 1st, they are scheduled to do the roof top (25th floor) of the Movenpik hotel, in Colpetty, and, thereafter, at the same venue, every Saturday evening.

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Constructive dialogue beyond international community



by Jehan Perera

Even as the country appears to be getting embroiled in more and more conflict, internally, where dialogue has broken down or not taken place at all, there has been the appearance of success, internationally. President Gotabaya Rajapaksa will be leading a delegation this week to Scotland to attend the UN Climate Change Conference (COP26). Both the President, at the UN General Assembly in New York, and Foreign Minister Prof G L Peiris, at the UN Human Rights Council, in Geneva seem to have made positive impacts on their audiences and, especially amongst the diplomatic community, with speeches that gave importance to national reconciliation, based on dialogue and international norms.

In a recent interview to the media Prof Peiris affirmed the value of dialogue in rebuilding international relations that have soured. He said, “The core message is that we believe in engagement at all times. There may be areas of disagreement from time to time. That is natural in bilateral relations, but our effort should always be to ascertain the areas of consensus and agreement. There are always areas where we could collaborate to the mutual advantage of both countries. And even if there are reservations with regard to particular methods, there are still abundant opportunities that are available for the enhancement of trade relations for investment opportunities, tourism, all of this. And I think this is succeeding because we are establishing a rapport and there is reciprocity. Countries are reaching out to us.”

Prof Peiris also said that upon his return from London, the President would engage in talks locally with opposition parties, the TNA and NGOs. He spoke positively about this dialogue, saying “The NGOs can certainly make a contribution. We like to benefit from their ideas. We will speak to opposition political parties. President Gotabaya Rajapaksa is going to meet the Tamil National Alliance on his return from COP26, which we will attend at the invitation of the British Prime Minister. So be it the NGO community or the foreign diaspora or the parliamentary opposition in Sri Lanka. We want to engage with all of them and that is very much the way forward”


The concept of a whole-of-government approach is indicative of a more cohesive approach to governance by government ministries, the public administration and state apparatus in general to deal with problems. It suggests that the government should not be acting in one way with the international community and another way with the national community when it seeks to resolve problems. It is consistency that builds trust and the international community will trust the government to the extent that the national community trusts it. Dialogue may slow down decision making at a time when the country is facing major problems and is in a hurry to overcome them. However, the failure to engage in dialogue can cause further delays due to misunderstanding and a refusal to cooperate by those who are being sidelined.

There are signs of fragmentation within the government as a result of failure to dialogue within it. A senior minister, Susil Premajayantha, has been openly critical of the ongoing constitutional reform process. He has compared it to the past process undertaken by the previous government in which there was consultations at multiple levels. There is a need to change the present constitutional framework which is overly centralised and unsuitable to a multi ethnic, multi religious and plural society. More than four decades have passed since the present constitution was enacted. But the two major attempts that were made in the period 1997-2000 and again in 2016-2019 failed.

President Rajapaksa, who has confidence in his ability to stick to his goals despite all obstacles, has announced that a new constitution will be in place next year. The President is well situated to obtain success in his endeavours but he needs to be take the rest of his government along with him. Apart from being determined to achieve his goals, the President has won the trust of most people, and continues to have it, though it is getting eroded by the multiple problems that are facing the country and not seeing a resolution. The teachers’ strike, which is affecting hundreds of thousands of schoolchildren, is now in its fourth month, with no sign of resolution. The crisis over the halting of the import of chemical fertiliser is undermining the position of farmers and consumers at the present time.


An immediate cause for the complaints against the government is the lack of dialogue and consultation on all the burning issues that confront the country. This problem is accentuated by the appointment of persons with military experience to decision-making positions. The ethos of the military is to take decisions fast and to issue orders which have to be carried out by subordinates. The President’s early assertion that his spoken words should be taken as written circulars reflects this ethos. However, democratic governance is about getting the views of the people who are not subordinates but equals. When Minister Premajayantha lamented that he did not know about the direction of constitutional change, he was not alone as neither does the general public or academicians which is evidenced by the complete absence of discussion on the subject in the mass media.

The past two attempts at constitutional reform focused on the resolution of the ethnic conflict and assuaging the discontent of the ethnic and religious minorities. The constitutional change of 1997-2000 was for the purpose of providing a political solution that could end the war. The constitutional change of 2016-19 was to ensure that a war should not happen again. Constitutional reform is important to people as they believe that it will impact on how they are governed, their place within society and their equality as citizens. The ethnic and religious minorities will tend to prefer decentralised government as it will give them more power in those parts of the country in which they are predominant. On the other hand, that very fact can cause apprehension in the minds of the ethnic and religious majority that their place in the country will be undermined.

Unless the general public is brought aboard on the issue of constitutional change, it is unlikely they will support it. We all need to know what the main purpose of the proposed constitutional reform is. If the confidence of the different ethnic and religious communities is not obtained, the political support for constitutional change will also not be forthcoming as politicians tend to stand for causes that win them votes. Minister Premajayantha has usefully lit an early warning light when he said that politicians are not like lamp posts to agree to anything that the government puts before them. Even though the government has a 2/3 majority, this cannot be taken for granted. There needs to be buy in for constitutional reform from elected politicians and the general public, both from the majority community and minorities, if President Rajapaksa is to succeed where previous leaders failed.

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