Dental Reflections 011

now for a little ramble on everybody's favourite dental hard tissue lesion, the non-carious cervical lesion!

scourge of all honest dentists, NCCLs of varying shapes and sizes can be found in just about every mouth. NCCLs as a lesion also have various aetiologies and thus serve as diagnostic indicators for complex problems in the mouth. a lesion is after all part of a complete disease process...

the NCCL can be generated by factitious means (overbrushing) as well as from occlusal overloading (bruxism), while their appearance can be modified by acid erosion. the key is to be able to identify each possible cause, and to link them up into a total treatment plan.

the NCCL of overbrushing is by far the most common type of NCCL. sheer chronic traumatic brushing force will over time cause gingival recession. the denuded root surface is then worn away by the same chronic brushing force, creating smooth-surfaced depressions in the root dentine. enamel may also be lost due to an undermining effect, but will have a smooth surface.

the NCCL of bruxism is a rarer lesion. current theories point to loss of the enamel and later dentine at the CEJ region due to flexion of the tooth under parafunctional loads. the lesion will have a well-defined wedge shape, and the coronal margin at the enamel will have a sharp edge. this lesion, seen early enough, will actually be bounded by enamel, unlike the overbrushing NCCL which begins in dentine. later lesions will, due to increase in size in an apical direction, have their gingival margins in dentine, but will once again have the classic sharp edge to the enamel border.

Acid erosion modifies the shape of the NCCL by eating away at its borders. the coronal edge is more affected, possibly due to the higher mineral content of the enamel. the effect is a dramatically wide lesion with reference to its coronal-apical dimensions, with an enamel involvement often 3mm or more in height. the surface is smooth and gives the restorative dentist headaches in trying to figure out how to place a bevel for his composite.

in the whole scheme of things, aetiology will lead to diagnosis, diagnosis will lead to treatment planning, and then on into review and a re-planning if necessary. it goes without saying that all 3 conditions identified should be dealt with.

overbrushing can be dealt with, first by education and then by devising a monitoring system. education for me would consist of actually getting the patient to stick out his hand so you can demonstrate on his skin/thumbnail what adequate brushing pressure truly means. once the patient has been told about soft toothbrushes, he is also informed that he can self-monitor; he will still be overbrushing if his toothbrushes spoil rapidly or his new restorations have been rubbed away by his brushing. this also incentivises the patient by empowering him to take care of his own condition.

bruxism is of course a much more tricky proposition to deal with. splints and such are by no means simple things to manage, and given the complex, multifactorical nature of the bruxism syndrome, referral is always a viable option.

acid erosion will require a careful review of dietary intake. acid erosion from dietary sources tends to lead to NCCL aggravation, whereas acid reflux from GERD or bulimia will lead to erosion of the palatal surfaces of the teeth, especially the upper anteriors and first premolars, and the 2 problems could of course also come superimposed. it is also a given that what the dentist considers acidic and detrimental to dental health a patient may consider a normal part of his diet, for example an orange every day as an afternoon snack or grapefruit juice with the breakfast. modifying of behaviour as opposed to banning may be more effective in the long run, as a patient may be more willing to listen if you tell him to rinse with water and apply Recaldent as opposed to being faced with a bleak future containing no lime juice after his lunches.

once the aetiologic cause has been at least initially addressed, the dentist can consider the question of restoration. i personally take a conservative approach to restoring the NCCL. if the lesion's cause has been dealt with, they will of course not get deeper, and restoration becomes option if the lesion does not trouble the patient aesthetically or via sensitivity.

most of us have been at least cursorily trained to deal with NCCL lesions using direct restorative materials, including the whole tooth-coloured restorative spectrum of composite resins and glass ionomer resins. other options, although now out of vogue, include amalgam and direct gold. a further consideration of an indirect restoration, for example CAD-CAM ceramics or even an indirect composite resin, were mooted over dinner with some friends but i have yet to try these or even heard of these being issued to a patient as of yet.

direct restoration of the NCCL faces a few challenges. the first is crevicular fluid, possibly compounded by blood in the case of the gingivitis patient. the second is aesthetic considerations with colour and contour, having to match the colour of both the coronal enamel as well as the root dentine. the last are the mechanical and chemical challenges faced by the restoration with respect to the aetiologic factors which created the NCCL in the first place.

crevicular fluid, flowing freely from the sulcus of an inflamed patient, is the bane of the restorative dentist. either the material must be able to handle the presence of fluid and its challenges to the material as well as its bond to tooth structure, or the dentist must be able to practically, if not absolutely, eliminate the crevicular fluid. for the first option, glass ionomer is the usual favourite option. while the material handles crevicular fluid a whole lot better than its other tooth-coloured alternatives, bathing it in crevicular ooze or blood is an invitation to failure. it may in fact be best to scale the patient, institute OHI and chemical adjunctives such as antibacterial mouthwash, and return to the problem in a few weeks when the gingiva is more willing to behave. this is cold comfort for the dentist faced with impatient patients or long intra-visit times which he can do nothing about. a second option mentioned by a colleague was an on-the-spot laser gingivectomy; laser ablation of inflamed and overhanging tissue, with its attendant cauterisation, would help greatly in terms of relative isolation of the lesion.

how does one choose shade for an NCCL? match to the coronal enamel, match to the root dentine, choose a happy medium, do a 2-colour build-up? there is no safe answer for this, as every aesthetic situation varies. this will become a major pitfall if root dentine colour varies greatly from coronal enamel colour, especially if there is exposed root on adjacent teeth which is not to be restored. long bevels on the coronal enamel are a great help when trying to achieve a colour match in an unfavourable situation, or if the edge of the NCCL has been back-stained by dietary content, when using a composite resin; the opacity of glass ionomer generally provides much more colour masking at the risk of an opaque and obvious restoration if colour match is sub-optimal. contour is also critical; a flat restoration is un-natural and may trap food. over-contoured restorations, on the other hand, will stick out and look 'pregnant' and unaesthetic. adequate contour helps to hide the restoration as well as provide a more 'self-cleansing' shape that will aid hygiene. good fine diamonds are critical for this.

finally, not every material is suitable to every NCCL. glass ionomer beats composite resin flat in terms of flex resistance, which will be critical in the stress-fracture NCCL of the bruxer. conversely, in acid environment or when faced with mechanical trauma from overbrushing, composite resins will perform better. when conditions with varying requirements coexist ot create an NCCL of multifactorial aetiology, simplify your problem by eliminating one cause first and restoring in a manner to suit the more intractable problem.

once the NCCLs have been restored, the dentist must be able to evaluate success. the restoration now becomes a diagnostic indicator of the success in eliminating aetiology. if, despite your best efforts in restoring, you notice the restorations disappearing in months, obviously something is wrong. perhaps your overbrusher has not taken your OHI to heart. perhaps your bruxer hates his splint. perhaps your dietary acid patient has fallen back on his usual comfort food without the hygiene behaviour modifications that you prescribed for him. in such a situation, reevaluate the causes, your aetiological control measures, and then re-restore the patient so that your monitoring devices are back in place!

The Little Flowers By The Roadside

i think that as a nation, we don't stop and stare often enough. there are times when we rush through life and fail to see the gradual changes around us. the blooming of the wild orchids in the trees on the way to the bus stop. the lizard scurrying on its way to the next tree. the pigeon squashed on the street. the neighbourhood kids who have grown up and gone to university. the way the wanton mee uncle flicks his scoop. sometimes one need to find time in the whole rush of life to breathe a bit.

here's a little poem:

"What is this life if, full of care,
We have no time to stand and stare.
No time to stand beneath the boughs
And stare as long as sheep or cows.
No time to see, when woods we pass,
Where squirrels hide their nuts in grass.
No time to see, in broad daylight,
Streams full of stars, like skies at night.
No time to turn at Beauty's glance,
And watch her feet, how they can dance.
No time to wait till her mouth can
Enrich that smile her eyes began.
A poor life this is if, full of care,
We have no time to stand and stare."

W.H. Davies

*note: this whole entry does not apply to accidents on expressways! please drive on!*

Quando, Quando, Quando, Quandary

its kind of surreal when bits of your ancient past show up in unexpected ways in the present. today a patient came in for 6/12 carrying a book by Benoit Mandelbrot. i never actually knew that he was doing stuff on markets, although his chaos theory expertise makes so much sense given the unpredictability of stock markets. and if Mandelbrot-sama is writing on such a topic, it makes it more than obvious that market behaviour will truly be impossible to predict with any accuracy over any significant stretch of time...

*for those of you i lost along the way, here!*

http://en.wikipedia.org/wiki/Benoit_mandelbrot

http://en.wikipedia.org/wiki/Mandelbrot_set

Dental Reflections 010

the fine art of examining a scientific paper was emphasised to us during an excellent paper review yesterday. the topic of the OS Journal Club session was guided bone regeneration and membranes, focussing on the PhD paper of a particular oral surgeon in his quest to understand the importance of membranes in guided bone regeneration. one of the salient points brought up was that the PhD student's research was done on rats, whereby he had to hack up a whole bunch of rat mandibles. time consuming surgery for sure, especially in such a tiny, fiddly, smelly animal model. his conclusion was that for block grafts, at least, while the placement of membranes did not give a significantly better result in terms of graft outcome, the smaller confidence intervals for the membrane group once he plotted his stats indicated that he would still like to put in his Gore-Tex for his grafts.

this was picked up on by members of the floor; Gore-Tex has its own little problems. while much more able to hold its shape that the equivalent collagen membrane, once a Gore-Tex membrane gets exposed infection (and loss of the whole chunk of graft) happens very rapidly. post-op infections seem to correlate to size; the bigger the graft area, the bigger the Gore-Tex, the larger the area of flap which will not benefit from vascularisation of the graft region (due to the interposed Gore-Tex barrier) and hence the higher the chance of failure. this was practically eliminated in the 5mm diameter defect and graft sites in the rats. the differing immune and wound healing physiologies were also mentioned as significant, with a pithy quote from Prof Henk Tideman to sum it all up. questioning the over-reliance on animal experimental models, he said

'...you can put poop in a dog and it will still heal'

indeed...

The Old Man And The Sashimi

food review! the eatery du jour is Wasabi-Tei, a little (and i do mean little) japanese diner on the 5th floor of Far East Plaza. once again a surprise find from HungryGoWhere.com, we decided to head over to get some japanese food for comfort purposes.

Wasabi-Tei has a reputation for being run by a tyrant of a chef, who has a peculiar way of taking orders, but who creates amazing food which generates quite a crush of people. with this in mind, we arrived about 15min before opening time (1715hrs) and were first at the head of a queue which slighly overflowed the eatery's roughly 20-seat capacity by the time the doors opened. the excess people were left quietly sitting outside.

layout of the eatery corresponds to that of your average sushi shop. the chef's main work area is in the centre of the floor, with a bench all round. once customers are seated he is effectively locked in, much like an Elizabethan thrust-type stage. from here he and his wife command the floor. orders of food are taken first, from left to right, then drink orders. there is a strict rule of ordering everything at first instance, else a fee of 20% of cost is levied on the 2nd order. drinks are factored into a $2 'occupancy' charge, unless you want booze. Ocha is of course free-flow, and very hot.

a standard-issue starter of stewed chicken and wakame was plonked down in front of the whole eatery. while some food reviewers were over the moon with the starter, i found it pleasant enough but nothing to write home or scream oiishi about. a rather homely flavour which relaxes you as opposed to a knock-your-socks-off overture kind of starter.

next up was an Una-maki. here our opinions divided. the una-maki was cut in to 4 big, chunky sections with the unagi spilling out the terminal ends for visual effect, then piled on a small dish with a bit of pickled ginger and wasabi before special-secret-keroppi sauce was dribbled on (for those who understand the reference, a pat on the head for you!). i liked it. big-ass pieces of unagi, soft and tender with a sauce to modulate the potentially overpowering fishyness that unagi occasionally suffers from. minus points for incompletely slicing the nori between my pieces, requiring me to tear my makizushi apart. a ruptured maki is a tragedy... PJ found the sauce too sweet, and was not terribly impressed with the way he plonked the unagi pieces on the dish before getting the rice ready for rolling.

next up was a teriyaki salmon set. a slab of salmon, accompanied with shredded cabbage and salad dressing, pickled cucumber and a good old bowl of miso soup on the side. huge serving. and i say it again, it was big! i liked the done-ness of the salmon, altho the skin was a bit charred, resulting in PJ removing it from circulation.

the last item ordered was a Gyu-jyu. beef on rice in a laquered square box. honestly, while the beef-and-garlic concept was a good change from the usual beef-and-sauce type of gyu-don/jyu thingy, it was a little bit on the stringy side. anathema to she-of-the-active-ortho. i got a glimpse of the chirashi-don as i was eating this. similar box, intimidating mound of fish. i so want that the next time i go.

and so... in summary:

Jon - yesyesyes! want sushi in servings big enough to hurt when thrown! wantwantwant! surly service and small seats are a small price to pay!

PJ - nothing to write home about

Changin' - Stephanie

Senseless

there are times when the impetus to put finger to keyboard just strikes, inexhorable and irresistable. sometimes this is in the face of great tragedy. other times great joy. other times the understated simplicity of a flower in bloom or the smile on a patient's face will create the stirring in ones heart to write. and for me, it was rediscovering a Koda Kumi song on JPopAsia.com...

people ask me why i listen to music in a language i don't understand. it's usually surprising enough for them when they find out my preferred channel is 93.3, and when they find out it's because im actually hoping for the occasional JPop song to hit the airwaves, the mystery deepens.

my greatest moments in music have been as a musician. i believe in the power of the melody, the communion of the chord progression, the rage of the rhythm. to me, what are words next to the sheer depth of emotion that music, unfettered by the speech of man, can evoke? an encumberment at best. listen to Holst's Planets and Rach II. words? words fail us, as they often do in everyday usage. best to sit back and let the music hit you, soak deep into your being and speak directly to your spirit.

and that is why i like JPop. the chords speak to me too. they call out to me in ways the white man's songs, or that crap which people term as R&B, never will. the melodies speak of a world of ways strange and familiar, and its rhythms seem to lift my feet forward.

JPop. it just is.

Moon Crying - Koda Kumi

3

its really been 3 years! 5 of knowing her, 3 of love, and many more to come. despite all the difficulties i have grown to love her more and more, her little idiosyncrasies and peculiarities adding charm and humanity to a wonderful person.

and with that background, here's a food review for the anniversary dinner!

Dozo is located in Valley Point Shopping Centre, away from the orchard crowd somewhere in the River Valley area. i got to know about it from the ever-useful hungrygowhere.com portal, where it had garnered 16 straight positive reviews on the strength of its service.

they really weren't kidding. my reservation was for 6.30 but by 5.30 me and PJ were already starving, so we toddled down from Orchard after doing some essential shopping. arriving 15min early, we inquired as to whether we could occupy early. the staffer immediately ushered us in. the restaurant's culture is one whereby all the waiters and waitresses are warm, friendly and joke with the guests, be in when introducing menu items or serving the food. they also aim to give best service. when i made the booking, the person taking the call asked if it was a special occasion. the resulting exchange of information yielded a little cake with a candle on the house. high marks for service, these guys are deliberately aiming to deliver.

the dinner (which is after all the point of the whole exercise, ja?) is organised as a set menu costing $58+++ for a dinner or $38+++ for lunch, sans the starter. diners get to choose the appetiser (starter is fixed), soup, entree, main, dessert and drink. the menu choices are also rotated every 3 months to keep things new and exciting.

the starter dish was 3 very small, chic-looking bite-sized things which were honestly very tasty but i'm not quite sure what they were. i do recall a grilled scallop with a sprig of asparagus and what seemed to be foie gras on a piece of toast.

for appetisers, i had escargot and PJ had her a foie gras chawanmushi. the escargot was acceptable, i guess. the concept was to subvert the usual garlic butter paradigm by making it a teensy bit like an oyster mornay, ie drowning it in cheese. i like cheese more than i like oysters, to be honest. more cheese for the escargots would have been nice. PJ's chawanmushi was a source of unexpected amusement. it actually, in all honesty, smelled like wet dog. not unpleasantly so, it was more like a small happy dog which had been caught in the rain while on walkies rather than a Hound of the Baskervilles type of smell, but still wet dog. and it tasted like... chawanmushi with bird liver in it. tasty, but nothing to make faces like a japanese food vlog.

soup was a cream of mushroom with black truffles and a seafood bisque. i dont know whether its my philistine tastes, but the seafood didnt quite agree with me. too much of the crustacean-type umami, and perhaps a little too much grog thrown into the soup stock. more cream might have modulated the flavour well. the mushroom was however good. coarse-blend mushroom bits for extra goodness. not quite sure why truffles are so hyped tho...

next up was a beef carpaccio for me and a crab salad for PJ. the carpaccio was a bigger hit with me than it was for her. the external surface of the beef appeared to have been lightly cooked before being thinly sliced and went well with the flaked parmesan and crepe. i think i would actually have been pretty happy to eat something like that (in 3x the quantity) for a light lunch. the crab salad was however a bit of a hassle; while the claw had been cracked and a section removed for access, it still required some dissection.

i had the beef steak for a main. consisting of medium-rare sliced beef on a very very hot granite stone, this seemed to be the best item of the night. one could cook each individual slice to preference on the hot stone, protected by a leaf, and few things make me happier than beef. Peijun's cod was decent enough, but by this time she was beginning to feel stuffed, and eating the cod became a bit more of an exercise. the pairing of cod with some filo pastry did assist in lightening the usually heavy flavour of the fish.

dessert was a hot chocolate cake with ice cream, and a green tea creme brulee. both competent, but nothing to write home about. and of course, the surprise little cake to end the evening!

so to sum up, excellent service, okay food. nice ambience, although going early means its quite quiet. it seems more like a girls night out kind of place, where the waiters can be cheeky and the small serves will fill up petite young ladies...

Lion - May'n, Megumi Nakajima

The Fine Art Of Annoying Your Dental Practitioner

or: how to piss me off.

its actually quite strange how patients can find new and inventive ways to piss off the dentist. its not the cleverest thing to do really, to antagonise the person who will be placing sharp objects into your head in an effort to fix things gone wrong in your mouth.

1) say the word 'cheap' more than 2 times in 20min
-yes, i really do like being reminded of how amazingly low i charge in the government service, and how good that makes me feel about the quality of work vs its monetary value
1a) say the word 'expensive' more than 2 times in 20min when i try to refer you, or in reference to the last dentist you saw
-see above

2) address your dentist as 'Mr' instead of 'Dr'
-especially when i specifically introduce myself as Dr Ee. are you deaf, rude or inattentive? we've been 'Dr' since the 1980s in these parts, mind...

3) inordinate squeamishness towards dental treatment
-grow up. please. the days of low-TLC dentistry ended with the last generation. we treat patients well... until they anger us.

4) strange noises during treatment
-some describe the noises as sounding constipated. some describe them as tortured. i really don't want to hear things when im trying to deliver an injection, clear your decay or clean the crud out of your gums.

5) keeping quiet during treatment and then filing complaints with the Clinic Exec after
-why not just tell me before i do things and save us the trouble? if you don't want something, opening your mouth and keeping still is in fact implied consent. so yes, please... don't be an idiot.

6) show a lack of attentiveness when the dentist explains treatment/brushing technique
-these days we work on a basis of information and trust. you must must must must understand what it is that we do. we are only legally empowered to advise, not to dictate. for goodness sake, pay bloody attention when i talk to you. and 'you decide lah' is not an acceptable answer, it reeks of a lack of responsibility.

7) knock on the dentist's door or barge in demanding to be seen when it isn't your turn
-if you can't do this in an ATM queue when drawing money or at HDB HQ when applying for a flat, what makes you think it's acceptable here? and do you really want to piss off the person who will be putting sharp objects into your mouth?

8) act as if subsidised dental treatment is a birthright and not a privilege
-really, if you can wear good clothes, nice shoes and a decent watch and carry a leather wallet with money in it and a credit card and yet complain that $60 2 times a year for scaling in the private is too expensive, what are you actually telling me? thats less than 50 cents a day across the year, for your information...
8a) act as if getting fast appointments is a birthright and not a privelege
-yes, we really are booked up for 3 months solid. welcome to government service! no amount of whining or threatening the Clinic Exec will change this fact, or our desire to honour the appointments of those who came before you.

so yes, 8 ways to piss of your dentist. this is of course not exhaustive. feel free to drop me suggestions so that i may add to this list.

Dental Reflections 009

so heres one which is a teensy bit off the clinical and more into the philosophical.

what exactly is the relationship of the practitioner to the patient? what is it that patients expect from us, and we from them?

this was sparked after lunchtime discussions with Boss K about our ever-beloved FON patients and their weird ways. the main point here being, why in the world would a patient want to kick up a big fuss and aggravate the very people who they expect to treat their illnesses? we've all seen them in various forms wherever we practise... the Geylang Door-Knockers, the people who get the NDC patient-service 'bomb-squad' down on practically every visit, the nasty parents at HPB. and yet, these people come back again and again and again to our clinics despite having made their unhappiness very unclear. lets be honest; we're not the only dental practice in town. there is an abundance of dental treatment available to the population, from the back-lorongs of Geylang to the high towers of Orchard Road. some even go across the causeway on occasion. but yet the problematic people still return like homing pigeons. is it the excellent (for its cost) service we provide? the ability to break a young ego and spoil his day? or is it the fact that we're inexpensive?

i think that something should be done about this. we should be able to perform our services, get thanked for it at the end of the day and not have to worry about verbal abuse or getting stalked or complaints being forwarded to the boss for doing treatment in a manner consistent with modern standard of care. we should not have to have patients complain about rising costs of dental work when they live in condominiums and have nice watches and gold jewellery. we should not have people barge into our rooms demanding to be seen as walk-ins for loose teeth when the periodontal damage was already done 10 years ago. and we most certainly should be appreciated for heroically scaling the severe periodontitis cases instead of getting scolded or complained about because they feel sensitive when their great walls are being broken down. we should be allowed to blacklist nasty patients from our clinics, and to share this information with the other polyclinics if necessary. people who abuse us and want to play the system for all its worth do not deserve to benefit from healthcare in the public sector; their selfish interference in fact decreases efficiency and drives up running costs. i already suspect that healthcare bleeds a huge chunk out of the government budget. people should pay for their dental work so that more money can be turned to education and general medicine for the terminally ill.

and as an aside, i hate it when people call my treatment cheap. it makes me feel cheap. i do the best work humanly possible under the conditions. but the public thinks dental work is like buying refrigerators or cars; compare the price tag and buy something cheap. how clean they end up after a scaling is not important so long as it's 'gentle'. they'll never see the subgingival wall, anyway, and all that matters to them is that the black spots have been removed...

Cast Iron

i think i must be getting a touch of the emo, if things like this can hit me harder than they should. after 2 weeks of faithful support, hearing unsavoury and inaccurate things about myself is a slap in the face. but then again, what's there to expect. i went to do a dirty job, to be the enforcer/bad cop/hatchetman that noone was willing or wanted to do. what more can one expect than misinformation and malice?

the news came to me as such: a certain classmate of mine was conversing with a junior on All Night Long. and in the course of discourse with this year 2 she was told by said junior that there was this year 5 called Jon who kept coming down every night, and made the juniors sing and sing and sing the anthem until 11pm.

[rant] half-truths are the nastiest lies. yes, i was there every night. i think that the year 2s in general deserve some support. its not like the old days when things were convenient to make visits, now that they've been plonked in the parking lot far away from a faculty which, due to the unthinking and misguided actions of a few successive years of infantile iconoclasts, has been unable to show the level of support that they could in the old days. now, only a few seniors pop by for fly-bys and don't really stay to get to know the new colleagues-in-the-making. frankly, its easier to talk to the year 2s than the year 1s, which is what i've mostly been doing. the Ballman, FOC head, various dance ICs... either getting to know them a little bit better, or even in one case having a deep discussion that i think did both our souls some good. but to imply that to kick the asses of dysphonic juniors was my only activity or reason for coming boggles the mind. its tiring, dammit! its tiring to show up every night without rest, to stay back and talk to people and find out how they're doing and craft words of encouragement for each and every one of them personally. i could well have not given a rat's posterior about orientation. lets face it, who does these days? who cares about the company of dirty children playing at construction worker in the parking lot far away from one's immediate area? the sponsors for sure, and they have every right to be there. but respect also those who give, not of money but their time. by not understanding the heart of the people who show up for you, you spit on their charity, the precious time which they have given which you cannot return to them. and in so doing, you show your lack of manners. it is this same paradigm shift in attitude which drives your seniors away from visiting you, it reeks of a foul egotism which cannot be allowed so early in your career.

by exaggeration, you also show either a poor memory or a lack of integrity. i did not make them sing every night, although the singing was... *searches for a kind word* sub-par. i wish i could have done so, but it was not meant to be. and to say that i held them back from going home on time, up until 11pm every night? you bare-faced liar! they were dispersed far and wide before eleven, possibly an good half hour earlier on most nights, and i only pushed the song, what, 3 of the 8 nights before All Night Long. glue for sticking bits onto the float must have addled your brain...

and finally, i'm a Year 6, you fool. remember that. [/rant]

and to end with a little quote, here's something i found while reading a bit of fiction...

'Not all of me is dust. Within my song, safe from the worm, my spirit will survive'
- Alexander Pushkin

what kind of song, what kind of legacy will i leave? hopefully one that resounds richer and louder than that which that damn fool of a junior dares to think of me...

Dental Reflections 008

seems like i've been doing a lot of big-ass CRs here. the irony being of course the absence of such basics as primer and B-shades... have kinda developed a technique for doing massive CR direct inlay-onlay work to restore occlusal surfaces or even VD...

1) caries free and any cavity prep necessary or possible. in the absence of decent dentine bonding systems, fling Vitrebond with abandon at all visible dentine.

2) place matrix system of choice (or lack of choice *coughcough*) and get 3/4 of the occlusal height needed. cure, check for clearance

3) vaseline the opposing tooth

4) re-etch the tooth if needed. splooge a generous dollop of CR onto the tooth, shape it roughly to look sort of like a tooth.

5) bite and grind! beware the patient with weird bite/posturing.

6) cure. check occlusion. curse under your breath if the patient has only just revealed said wierd bite.

Dental Reflections 007

been a couple of things ive wanted to write about but never got round to, so here i am with an urge to write and some time to kill!

1) the nefedipine hyperplasia patient

uncle Carranza tells me that a good 1 in 5 of these patients will have some form of gingival hyperplasia. at the least, this makes SAP into a messy affair as they will bleed like animals in a slaughterhouse. at worst... a week or 2 ago, i saw a patient who had nifedipine hyperplasia superimposed on severe generalised chronic periodontitis. his papillae were swollen to the point where they were actually touching his CEJ. in 20min i could only root plane half his mouth...

considering that the hyperplasia is actually a fibrotic overgrowth of tissue that will not go away by itself even after OH improves or nefedipine is substituted (the only improvement being reduction in oedema) there really should be a lot of business for gingivoplasty via either the gingivectomy or modified Widman technique...

2) the periodontal abscess patient

with no Graceys, can there be adequate debridement? since im not exactly equipped with the funkiest of root planing ultrasonics, it usually means some form of hand-instrumented root planing will be needed. and when the fall-back is a set of single-ended 2L+2R... gyaaaa!

Conquering New Territory

Queenstown. not exactly terribly awe-inspiring when one rolls the name around the inside of ones head. but here i am. the sun is shining wanly through my room window and the nurse has gone on tea-break. and i think i'm pretty happy, all things considered.

of course, it stands to reason that i miss my old place. the availability of company is a greatly important thing. and the availability of a PA machine as well... it really is turning out that our work is being hindered by the simple inability to do PAs. not to say that diagnoses of simple conditions are impossible, but when one wants to advise on prognoses of teeth with either cuspal coverage or perio issues...

on the bright side, the scalers rock. the machines are just 6 months old, and both an inbuild chair unit and a trolley-mounted cheong-Cavitron are available for me to rape calculus at my leisure. you have to love it when the Cavitron-clone has a Turbo button, the usage of which will make patients shriek with sensitivity! rocking!

Triangler - Gabriela Robin

Dental Reflections 006

how many factors can you think of that will mess with good matrix band placement and hence hinder the interproximal contour of a Class II restoration? here's a short and by no means exhaustive list...

1) insufficient tooth structure to band securely and still touch the adjacent tooth/teeth
2) weird concavities in the root surface that prevent the band from adapting well despite attempts at wedging
3) unusual coronal morphology/the cusp of Carabelli
4) long-standing cavitation into which the abutting tooth has drifted
5) a diastema whereby even furious burnishing will not stretch the band far enough to allow a contour that prevents food trapping

and how to overcome them?
1) euuhhh... work in CR. freehand yourself some buccal and mesial structure, then band from there.
2) with crappy wooden wedges, not a lot a man can do. prepare to stuff a fine diamond or an EVA into the interprox region...
3) this is actually, strangely enough, not too bad if you work in CR. you can shape the tooth bit by bit and respect the original structure. if you work in amalgam... fat hope
4) enamel mod *hack up coughcough* the offending neighbour!
5) this is counterintuitive... leave the gap big enough so that any food which makes its way in comes out easily. and teach the patient the joys of the interprox brush.

Prisoner of Love - Utada Hikaru

Under A Warm Sky

just when i was least expecting it, an email plopped itself into my mailbox, and now i know that i have my marching orders. to Queenstown it is then. i guess this isnt the place to dissect exactly why i've been sent there, but i dont feel too much of a wrench. after all,
1) am i not the most junior employee, and a maggot amongst the maggots? if i got everything i wanted and word was sweet and easy, it would be called fantasy and not a job.
2) wherever i go, God has a plan.

went to Cedele with Peijun for lunch. now, i think my views on priorities in food are well known. flavour and quantity are the 2 pillars of a good meal, in my opinion. secondary considerations include service, ambience (whereby i mean good seats and lighting and decent music) and costing. Cedele was established on the principles of providing alternative food choices. to whit, they concoct egg-free desserts and gluten-free mains. all very noble, of course, but how does it all match up? after all, the proof of the pudding is in the eating...

Cedele did not get off to a good start with its surly front-door dude. but we persevered (on the uncomfortable front-door purgatory seats, no less) and were rewarded with a table near the window. within a few seconds it became apparent that the outlet (apparently the Wheelock branch is newly opened) was having staffing problems. a full house, and many staff running around like headless (but stylish, mind) chickens, bussing tables, pouring water and doing every damn thing but actually taking orders. finally a nice young man *yay* came to our aid and took the orders for our mains, as well as our drink orders. while our mains did arrive, the drink orders fell through the cracks. i mean... one warm water and one iced water, and a reminder is needed? severe work flow problems. and down to the mains...

Peijun ordered what basically amounted to a mushroom and bacon fettucine carbonara. i felt adventurous and had some fusion-sounding thing that basically said steak and pasta. firstly there really wasn't much to say about Peijun's food. it was competent but... meh. if you can screw up a pasta with cream and cheese and bacon in it, you should be hung from the nearest crossbeam available. my food... was weird. firstly, if the menu promises medium-rare pieces of beef, i most certainly do not expect the pieces well-done in the style of a boot sole. and squeezing lime juice on it most certainly does not help things. damn tree hugger chefs. disappointment was written on my face, enough for my dearest lunch partner to see.

so after that fiasco we had a quick look over the dessert menu. they were offering a free scoop of icecream for orders totalling over $25 *handily achieved*. the Honey Nut was rather good, a base flavour of vanilla given life by a hint of honey and some nice bits of nuts. we also ordered a Cranberry Scone, enticed by the purported hot scones and cranberry jam. alas, this was not to be. half an hour of waiting later, we politely called for the bill and cancelled the scones. not 2 minutes later, the prodigal scones finally arrived. we stuck our ground and the scones were taken away and we caught a glimpse of them being binned... *tragedy in freefall*

so yeah... Cedele. not going back there in hopes of a good square meal. this is the kind of place girl gangs go to gossip over cakes and coffee. lime my beef steak? *unmentionable* you!

Back Again

so i return to stick my head into the grind once again. i really hope that all i've gained over the week will not fade from me as sunsets collect. its been a rare and precious experience, something to be treasured for a lifetime.

so there i was, a new church camp looming on the horizon. school had precluded any attempts at attending for the last four years, and i was really wondering what this camp would turn out to be like. it didnt help expectations to have, as its theme and song, 'A Passion for Thee'. i have to confess, i truly cannot stand that song. hearing makes me feel as if heat-plasticised treacle is being poured into my head via a hole trephined by a squad of upset monkeys. nothing to do with the words, guys, its the tune and chord work. if the tune gives me the musical equivalent of an MSG headache, i will have trouble liking it. but that's just me...

getting there and starting to do stuff, this camp exceeded all expectations. it was good to be playing again. even despite all the difficulties of an ad-hoc gang of noisemakers which were often-times difficult to round up. i was also blessed to have as a discussion group a fellowship of people who could open and talk about the things of life. it wouldn't have been the same without them. people to laugh with, cry with, and do nonsense with. valuable beyond belief.

at this point i'd also like to make a shout-out to Debbie and Norman, Tapir-boy and Angel-girl, dynamic duo, partners-in-crime and life and soul of our gang. they've been a literal blessing to ACTS (and i say blessing because every other word is inadequate) and the camp really wouldn't have been the same without them.

and finally i'd like to remember the camp speaker. Pastor Richards delivered the Word simply and truly. i just wish more people could have had the chance to hear him *brandishes sermon VCDs* best. camp. messages. ever.

back into the real world, i'll be waiting to see what's on my plate for monday. going to be reorganising my life a bit to give me more prayer and bible time. hope that all i've seen and heard doesn't get swept away in the rush of life...

Heart of Worship - Matt Redman

Dental Reflections 005

amongst my experiences in NDC i can now add the WWF Pulpect. i have performed WWF SAP before, whereby when i really need to get a patient cleaned up in a hurry (think pack-a-day smoker, never been cleaned in his life and radiotherapy looming in a month) i will head-lock the patient in the crook of my left arm and get the job done. not my favourite maneuvre, but i do seem to be using it a lot more than i would like to have to. but today, i had to use the same headlock to do a pulpectomy...

pt was scheduled for CAP #47(d).

hx of an impacted #48, causing the caries for which i was scheduled to spend a leisurely hour digging out. NRMH, NKDA

and so there i was, with the patient in the chair. EPT -ve but cold ++ve, non-lingering. this was probably a sign of trouble to come, but as i was checking the tooth over it didn't seem terribly out of the ordinary. 2 carts into the IDN and some initial caries free later, i was greeted by the sight of a mass of hyperplastic, hyperaemic strawberry-red tissue bursting out of the distal cavity. and IDN be buggered, it was sensitive to manipulation.

one quick scream to Dr Lui and some prodding later, and it seemed that my only option would be for the patient to grin and bear it while de-roofing the pulp chamber to allow for a good intrapulpal. the sheer irony of of hyperplastic pulp is that the tissue that you want desperately to anaesthetise is blocking the line of sight for you to get your needle into position to do the intrapulpal. damn. and so i had to headlock the patient and rip a diamond bur across the occlusal, and then stuff in a big-head round bur to slash out the pulp from the chamber, all the while apologising profusely and sweating in the deficient air-conditioning. to compound matters, when i sent the patient in for a PA to make sure i was digging in the right direction, and not to china, the radio auntie didn't have the faintest idea how to handle a PA for a patient with dam on! gwaaaaaaaaargh... ended up grabbing an EndoRay from Dr Kuah and aiming it meself.

upon returning from the PA queue, the pulp stumps were still gushing fantastic amounts of blood (hyperaemia ftl) and so another shoutout to Dr Lui later i was witnessing my first live demo in the use of Ledermix. Dr Lui qualified that Ledermix is not a good thing to use in infected cases in general, but due to the sheer amount of inflammation in this case, closing up after splorking Ledermix onto the pulp stumps would prove helpful and allow me to finish up the case in 1-2 weeks with much less bleeding.

hope it all works out...

Dental Reflections 004 and some spleen

so there i was, with an upset patient in my chair...

pt c/o swelling R face for 7/7:
on 290408 i did a PSA block for cons purposes. after that the patient noted swelling and ecchymosis.

o/e: R lower cheek area presented with ecchymosis, tender on palpation of the bruised region. posterior to the ecchymosis was a region of inflamed skin. pt reported using a muscle ointment on the bruise to cope with the pain. no abnormalities intraorally; buccal sulcus normal. adjacent teeth nttp/pp and vital except for the one with the prior RCT. stetson's duct was patent, with clear fluid expressed.

everything basically pointed towards me having nicked a vessel or something. blood then tracked down the fascia and pooled in the lower end of the buccal space. so what's to be done? AB cover and review, plus some Piriton for the skin irritation that seemed to be connected to usage of an oil of wintergreen-containing ointment. pretty standard stuff, management is basically to make sure that the dead space is taken care of using antibiotics to minimise risk of ending up with a cellulitis.

now at this point the blog will leave didactics and move into full-blown rant mode...

for this patient there is also an incidental finding of acute malignant shit-for-brains. the patient was remarkably ungracious about the whole incident. yes, youre upset because you have a big-ass bruise on your face. yes, you acknowledge it's your bloody fault that when i bent over backwards to give you a fast review you didnt show up because you thought it was getting better, and couldnt be arsed to come down and grace my chair with your presence. but for goodness sake, checking you up one more time costs money too! x-rays don't come free! and medications certainly don't come free either. if you don't want to eat medications and still want to be seen, what do you want me to do? we already bent over backwards to waive all the clinical stuff and x-ray fees, now be a good hippopotamus and eat your medication! no point coming up with stupid excuses about 'i fear medications' (this doesn't translate well from the mandarin) or 'antihistamines make me sleepy'. how do you expect things to happen if you don't eat medications? and when you casually mention the fact that a dentist in your church told you it was just a nicked vessel and not to worry, it identifies you as a person of the book and destroys testimony, not to mention the snide remarks about God blessing you with a haematoma. shit for brains! truly shit for brains...

and i have to review her again on thursday. i am so looking forward to this...

Dental Reflections 003 + some other stuff

when a patient has hope, he always does better than the patient who doesnt have hope. the patient who believes what you say and acts on it will also perform better in the long run.

so what do you do with the patient who
1) has a Hx of NPC with all the problems of
1a) xerostomia
1b) a 1 3/4 finger opening of DOOOOOOM!
2) doesnt use his F- gel
3) is still ACTIVELY SMOKING ~20/day?

doing his CAPs felt like an exercise in self-punishment. there was smoker's breath, exposed dentine blackened, not by foodstuff and caries, but by the assortment of noxious chemicals from the ciggies, bad-ass caries (ever seen distal upper 7 look as if a rat has chewed it?). amazing. hope my little preventive talk got into his thick head...

Kenneth managed to get me hooked on another anime series. Macross Frontier tells the story of a colony fleet, its inhabitants, a group of civilian military contractors who defend said fleet and in particular one particular, well, for want of a better description, reluctant bishonen. i think my general tastes in anime tend towards exploding things and series which have fun and don't take themselves too seriously, notable exceptions being Monster and Gunslinger Girl. this series kinda fits the mould, and they know that they have rabid fanboys amongst the viewers! expect frog abuse, micronisation errors and the ever-loved Macross Missile Massacre(tm) a-plenty!

My Boyfriend's A Pilot - Ling Minmei

Dental Reflections 002

got to review a case today after a pulpect, thought this one was worth writing up.

pt walk-in c/o lingering sensitivity on #12

o/e: #12 barrel morphology, AR (o) intact (and yes the barrel was that big), nttp/pp and perio normal but lingering to cold, EPT positive

dx: #12 irreversible pulpitis, normal periapex

so there i was with a pulpect of a #12 in a tooth with an old AR which i suspected to be a dens invaginatus. hacking out the AR yielded.... no pulp chamber or canal. gentle exploration at the base of the invagination yielded nothing either. and so, one consult later, my answer appeared in front of me... the canal, by very very careful staring at the PA, was in fact mesial to the dens invaggie chamber, and had i gone on a quixotic dig-to-china spree on the base of the chamber i may well have done a mid-root perf. heng ah!

lesson learned... in the dens invaginatus the pulp chamber proper may not lie in the middle of the tooth!

Dental Reflections 001

what i learned this week:

1) fear is a very powerful motivator and must be managed well. or else patients will go and do stupid things and make stupid choices.

2) the people who have dental anxiety tend to have heightened gag reflexes and strong circumoral and tongue muscle tone. truly trouble never comes singly.

3) never underestimate the trouble in matrix banding a lone-standing tooth and trying to get good contour from the outset. it's not going to happen.

4) the person who smokes a pack a day is smoking just over $10 bucks of noxious chemicals every day. this means that the SAP visit he claims is too expensive could be afforded by, oh, say, stopping smoking for 5 or 6 days. the single unit chrome partial by not smoking for, oh, 2 months. and then imagine the patient who smokes 2 packs a day...

4a) truly, smoking is a great social evil that keeps the poor poorer. and yet it is a self-inflicted poverty that strikes in 2 phases; the first when the person spends his hard-earned Yusof Ishaks on smokes, and second when he lands his posterior on the NCC treatment list...

Luminosity Is Levity/ And Levity, Luminosity

its been a very long time since i put finger to keyboard for this blog. far too long. but i guess after recent turns of events one should take the time to put ones mind to the written word as an exercise in focus. sorry boss; there ain't not patients present on worklist or in-tray...

it finally happened on sunday. ibu myra decided to postpone the orthognathics for PJ because of a persistent, nasty, phlegmy URTI. in a dispassionate way, one could well reflect that it was for the best. who wants to do elective ops on a patient who isn't ASA 1? and in a way that allows one to be gripped in emotion, this has been something that she's quite literally been waiting for; and end point to her ortho tx. and this has taken four whole years, probably twice the duration of your average pt. but all in, long term management of a disappointment situation must be one whereby disappointment gives way to acceptance and a willingness to move forward. failure to recognise a closed door and an acceptance of a new path will only need to unhappiness and depression.

so what's my take on the whole thing?

- the good Lord closes doors according to his will and timing, and it is definitely not in the christian's best interests to either whine at the door which he closes, or to try to breach the door.

- at the same time, the door which he will surely open instead of the closed door will be a door that will prove beneficial compared to the closed door.

- true peace comes from acceptance of guidance when one's will is subordinate to, and guided by, the divine hand.

so yeah... time to apply leave for the 12th of may!

a second thing ive been wanting to do is start a series of blog entries on what i've learnt at work so far. i'd hate to forget any of the lessons that i've learnt while i've been here, and there are so many of them...

as a closing note, watch Bamboo Blade. a recent work of anime, this short series focusses on a high school kendo club and its members. and thats probably all i can say without blowing the plot, after all its classic slice-of-life genre stuff. the brilliance lies in how this series has fun, advances plot and yet doesn't take itself too seriously. there's emotional development, yet not too treacly and emo, great shinai-work, and they even created a whole faux Super Sentai show for the lead character to idolise! enough blurb! get thee to Veoh!

Star Rise - Bamboo Blade Seiyuu

And Now, For Your Entertainment And Vilification Pleasure...

this over the class mailing list: a debate in the country-over-the-bridge re implants. anyone who's known me for a while is probably familiar with my opinion of the state of politics there. sadly, showboating and unsubstantiated rhetoric seems to extend to the helathcare sector as well. on with the show:

*****

Wednesday February 13, 2008

Dental visits a pain in the pocket

ACCORDING to statistics, about 10% of people who are 55 years and older will begin to lose their teeth. Whatever the cause attributed to each individual, age is the single biggest factor. Because of our ageing population, the number of people who would become edentulous would be a substantial number. The market is huge.
Many old folks are at the mercy of dental surgeons, especially the ones who now describe themselves as implantologists.
Many of them wear doctor’s coats, carry stethoscopes and insist on being called doctors. They charge by the tooth for every implant. Current prices range from RM7,000 to RM9,000 for the implantation of a tooth. This does not include the cost of the replacement parts, surgery, X-rays, etc.
Hence, for about four to five teeth to be implanted in the average elderly person, the price can come up to RM45,000. This is more than the cost of a complex angioplasty, bypass operation, or a hip replacement.
There seems to be no regulation to control these prices. It is a free market, with dentists, specialists, as well as GPs competing and charging whatever the market can take.
Most older people are poor and have to depend on their relatives. And few family members want to pay these exorbitant charges.
Government specialists, curiously, do not provide teeth implants for most of these unfortunate victims. If they do, it is to learn the technique before leaving government service.
While the cost of private medical care is now regulated and there are guidelines provided by the MMA, implantology is a wide open field with no control. Even the Malaysian Dental council has not tried to exert any control.
The patients who cannot afford implants are given cheap dentures or a mix of implant and a bridge (if they can afford the latter).
Having watched the implantation procedure, I think this is really a simple procedure, most of the time done under direct vision. There are no special tools required.
Most surgically trained medical GPs should be able to learn this procedure very quickly. There will, of course, be some difficult cases which can be left to the specialists.
Dental surgeons, whether specialists or GPs, work in a very narrow field of the human body. From experience, I have learnt that they know little or nothing about the wider spectrum of medicine.
The number of antibiotics they are familiar with is very few.They ask for a history of diseases that the patient may have but do not know how to assess how bad these diseases are or how they should be treated.
They have no idea about emergencies that may occur with surgery or with drugs.
They do not know anything about cardiopulmonary resuscitation.
Because of these weaknesses, I would suggest the following remedial actions:
> The Malaysian Dental Council should investigate and control prices in this dog-eat-dog business. They must impose some discipline to care for poor old people.
> The dental surgeon who calls himself an implantologist should give a written bill to the patient before he starts treatment. He should list all his immediate charges as well as charges for subsequent visits.
> It should be possible to train technicians to do single implants. These technicians should be licensed and also given guidelines on charges. Prices would come down in a free market once you increase the supply.
> Medical emergencies during a dental implant are rare but can happen. Hence it should be mandated that an anaesthetist should be on standby during any implant or surgical procedure done by a dentist.
> The dentist should buy and place in his clinic emergency equipment. This would include a defibrillator, a heart monitor, a pulse oxymetre and an ECG machine.
> The implantologist should be certified, which means going before a panel of peers who will verify if he has the knowledge and skills to perform large volume implantation.

MEDICAL DOCTOR,
Kuala Lumpur.

*

Thursday February 14, 2008

Get your facts right, doc

MEDICAL Doctor in his letter “Dental visits a pain in the pocket” (The Star, Feb 13) does not even know the duties of a dental surgeon and a dental technician.A dental surgeon graduates with a “Bachelor of Dental Surgery” degree and is conferred with the title Doctor while a dental student studies anatomy, physiology, biochemistry, dental materials, pathology, microbiology, pharmacology, medicine, surgery and all other dental subjects in a dental college.The RM7,000 to RM9,000 fee is still cheap for a single dental implant. The cost to set up a dental surgery with implantology varies from RM500,000 to RM1mil or more. The material costs and laboratory charges are equally high.The procedure for doing a dental implant is not simple. It is a high precision procedure and needs lots of training before the dental surgeon can provide such treatment. It is not just a case of cut and fix.All dental surgeons providing dental implant treatment have undergone intensive training and attended courses and meetings like the latest Osstem Meeting 2007 at KLCC on Nov 25 last year.

Here are my replies to some of the suggestions raised in the letter:

> The Malaysian Dental Council together with the Health Ministry have set the range of dental charges for basic dental treatment under the Private Healthcare Facilities and Services Act. Dental specialist charges have not as yet been imposed.

> All dental surgeons providing dental implants and any other dental treatment quote the treatment charges prior to starting the treatment and patients are forewarned of any other charges that may occur during the procedure should any deviation of treatment arise.

> Technicians are not surgeons. They only fabricate the implants, crowns, bridges, dentures and splints in their laboratories.

> All dental surgeons doing dental implants are fully aware of any medical emergencies that may arise and are well prepared for it. So far, not a single emergency has occurred for a dental surgeon to require a defibrillator, a heart monitor, a pulse oxymeter or an ECG machine.

> Should such a need arise, the dental surgeon will either call for medical help or take the patient himself to the nearest medical centre.

> A dental surgeon providing dental implant treatment has attended courses and is proficient in his expertise. Not all dental surgeons provide dental implant treatment.Medical Doctor should get his facts correct before alarming the public unnecessarily. If you cannot afford an expensive car, you should buy a cheaper car according to your budget.The Malaysian dental surgeons are doing a very good service to the public.

DR JASPALL SINGH,

Vice-President, Malaysian Private Dental Practitioners Association,

Kuala Lumpur.

*

Saturday February 16, 2008

What a dentist can do only a dentist can do

I REFER to the letter ‘Dental visits a pain in the pocket’ (The Star, Feb 13). The dental treatment charges in Malaysia are well regulated by the Medical Practice Division, of the Health Ministry under the Private HealthCare Facilities and Services Act 1998 (Act 586).This act is well supported by Malaysian Private Dental Practitioners’ Association and Malaysian Dental Association.Dental practitioners’ in the private sector whether they are GPs or Specialists are well trained in this aspect and are supposed to adhere and practise dentistry according to these guidelines.The healthcare clients (new terminology for patients) have their own rights. Under the Act, they have all the rights to know about the charges and treatment procedures.If they do not feel satisfied with the dentist, there is the “Grievances Mechanism” in clinics to address the issue under the Act.The writer also said that the dental surgeons were not well versed in drugs.The second year of dental course covers pharmacology.In fact, dental surgeons can treat Upper Respiratory Tract Infection (sore throat) that is a common disease treated by medical practitioners.The third year covers subjects of general surgery and general medicine.The syllabus clearly shows that dental surgeons are on par with their medical counterparts.Another accusation by the writer is that implantologists are not well trained and medical GPs can place implants.This is a joke!My sincere advice to him is, please look at your backyard.There are a lot of illegal and incompetent medical practitioners. Try to rectify that.We have our own professional body to regulate competency.In conclusion, I feel the writer was wrong in all his statements and figures.He was too emotional in expressing his opinion and created an increase in dental phobia among dental patients.One important phenomenon that everyone must realise is that: “What a dentist can do only a dentist can do.”

Dr NEDUNCHELIAN VENGU,

President, Malaysian Private Dental Practitioners’ Association.

*

Monday February 18, 2008Cheaper to do dental implants here AS A practising oral implantologist, I read with alarm and concern the polemic “Dental visits a pain in the pocket” (The Star, Feb 13).
To clarify matters and to set the record straight, I would like to address certain inaccuracies that were unfortunately passed off as facts:
> To qualify as an oral implantologist requires vigorous practical and theoretical grounding on par with medical doctors: a five-year basic degree in addition to a further two to four years of specialisation.
During the course of the training, many modules are identical to those undertaken by medical students, including management of medical emergencies and performance of cardio-pulmonary resuscitation (CPR).
> The current prices of implants in Malaysia range from RM5,000 to RM9,000, which is substantially lower than those in other countries. For example, implants in Singapore easily cost in excess of S$6,000 (RM13,662); in the UK, more than £2,500 (RM15,788); in the US, more than US$2,500 (RM8,050).
In fact, many foreign patients of mine have performed multiple dental implants in Malaysia specifically due to the equivalent level of professional competence but at a fraction of the price back home.
> Implants are not necessarily the final word in tooth restoration (even though the procedure ranks as the best among the options available in terms of comfort, function and aesthetics).
In the interest of cost, cheaper options such as dentures and bridges are available. On this note, no right-minded dental practitioner will force a patient to have implants done if affordability is an issue.
> The Malaysian Dental Association does provide a list of recommended fees for dental implants. However, as the writer pointed out, it is a free market; therefore each patient has the right to find the practitioner that he is most comfortable with.
> Government specialists have been providing dental implant services for some time now at lower rates compared with private fees. The writer seems to be ignorant of this fact.
> The implantation procedure is not as simple, nor as straightforward, as claimed by the writer.
As stated in the foregoing points, an oral implantologist has to undergo lengthy clinical and hands-on training to become an expert in the field.
There are many serious complications and adverse effects that can arise should the procedure be done incorrectly: for example in the case of guided bone regeneration procedure, sinus lift and bone harvesting.
I hope I have clarified some of the misconceptions that the writer has generated in his letter.
AN ORAL IMPLANTOLOGIST,
Petaling Jaya, Selangor.

*

> Sunday February 24, 2008>

> Dental implants have the best bite

> THE ideal standard of care for replacing teeth is not a denture or even a bridge anymore, but dental implants. >

> Dental implants are now used to replace missing teeth, stabilise loose dentures, straighten teeth and rehabilitate patients who have lost parts of their jaw and face due to cancer or accidents.

> We refer to the letter “Dental visits a pain in the pocket” (The Star, Feb 13) and wish to express our sadness over the misconceptions of a colleague whose profession we highly respect and admire.

> Dentists or dental surgeons are part and parcel of the healthcare providing medical profession and work hand in hand for the betterment of our patients.

> We do empathise with his concern for the older members of the population who due to inadequate dental care in the past now require dental implants.

> However, the main cause of teeth loss in older people is not aging as stated by medical doctor, but gum disease.

> This means that a healthy adult who takes proper care of their teeth and gums will enjoy a full set of teeth for life.

> Hardly 10% of dentists practice implantology and also because implants are all imported and costly, the cost of providing the service is still relatively expensive.

> Research and development of dental implantology took a lot of time, effort and expenditure on the part of university researchers and implant manufacturers.

> The cost of training is still very high because it involves highly trained lecturers, logistics and material costs.

> Implantology is not as simple as it looks.

> Such treatment can range between simple to highly complex procedures that involve bone grafting, gum grafting, specialised imaging, detailed planning and a thorough understanding of occlusion which may take years of experience to understand and successfully manage.

> Special dedicated tools, equipment and materials are needed in implantology.

> Dental implantology usually does not incur any more trauma than an ordinary extraction of a tooth, and therefore does not require any extra safety measures that are not already in place in all dental clinics.

> Dental implants have helped countless people around the world to enjoy their food again. They are the best replacement for lost teeth.

> Though expensive currently, the price will keep coming down due to free market forces.

> Like in all professions, some dentists charge more and some less. Find one you can afford.

> After all, dentists here in Malaysia are highly trained and yet are still among the most affordable in the world.

> The cost for dental implants in Malaysia is one of the lowest in Asean.

> This has led many from overseas like Australia, Europe, America and Japan coming to Malaysia to enjoy the benefits of dental implantology at international standards and yet at half the price or less in their home countries.

> Dental implantology has placed Malaysia on the map as a major destination for health tourism in this region.

> DR FIRDAUS HANAPIAH & DR CHOW KAI FOO,

> President and Honorary Secretary,

> Malaysian Oral Implant Association (MOIA).

*

*had enough? more to come*

*

Saturday February 23, 2008

Implants cost too much

I REFER to the letter Cheaper to do dental implants here in The Star, Feb 18. Implants in Malaysia costs between RM5,000 and RM9,000. Let us say it is RM7,000 on the average, which is the equivalent to 7,000 cups of coffee or three months' pay of a government medical officer’s salary here.
In Britain, it is £2,500 which is about 1,500 cups of coffee there or less than a month's salary of a government medical officer.
In the United States, it is US$2,500, which is about 1000 cups of coffee there or much less than a month's salary of a government medical officer. In Singapore, it is S$6,000, which is about 2000 cups of coffee there or less than a month's salary of government medical officer.
A baby delivery by Caeserean section here - which includes general anaesthesia and few days stay in a private hospital - would cost less than a tooth implant in Malaysia.
So dental implants here are among the most expensive in the world.
Suggesting other alternatives like dentures and bridges is like telling a patient with a bone fracture not to have nailing and plating and just to have plaster casts, as it will heal anyway.
Just as there is government control over food items and other products, there must be a price control over dental procedures. Dental health must be available and affordable to the rakyat of Malaysia.
As can be seen from above, a reasonable charge for an implant would be around 1,500 cups of coffee or RM1,500 by comparing the different prices of several countries. A root canal should not cost more than RM300 and crowns not more than RM300.
Technicians here should be taught to perform implants as there are other more difficult procedures that are also done by technicians. For example, there are midwives doing a good job with examinations, investigations and the delivery of babies.
Ultrasound and echo (for heart patients) are done by technicians, medical assistants are doing examinations, investigatings and treating patients while dental nurses are doing fillings and extractions. In addition, anaesthetic assistants are giving general anaethesia in rural areas.
Medical doctors should be taught to do implants as they have basically learnt all that the dentists have learned such as oral anatomy, physiology, pathology, bone regeneration, bone harvesting etc.
In my rural posting I was taught to extract teeth and do fillings. Implants have now become a common part of dental procedures, just as root canal treatment.
If there is a shortage of oral implantologists then we should recruit medical doctors. I am sure doctors here will fulfil their Hippocratic Oath to serve the public.
Dentists are also bound by Hippocratic oath to serve the public.
*
ANOTHER DOCTOR,
Kuala Lumpur.

Monday February 25, 2008Dental implants an expert’s job WE REFER to the ongoing discussion on dental, medical and healthcare costs in Malaysia. In Implants cost too much (The Star, Feb 23) oral implants were likened to treatment for bone fractures.
Comparing the cost of dental implants to the local price of a cup of coffee does not make sense. This is because a major cost of a dental implant is the cost of the imported prosthesis itself.
More than just the cost of materials, oral implantology is a multi-stage multi-disciplinary treatment procedure. The surgical component (i.e. the placement of the implant within the bone) is performed by the implantologist/ oral surgeon.
In fact, we invite interested medical surgeons to equip themselves with the proper training and accreditation that enable them to perform this surgical procedure.
The demand for oral implants is far higher than what dentists in this country can cope with. Having well-trained medical surgeons to help out in the surgical process will be a welcome bonus.
The next step involves designing an artificial tooth over the implant. When a patient requests an implant, this tooth component is the one he or she will see and use every day.
Therefore, this stage is best carried out by a dentist properly trained in treatment planning, dental occlusion, function and aesthetics.
Based on the dentist’s exact specifications and detailed instructions, the prosthesis (tooth) is custom-made in the laboratory by a dental technician. Finally, this prosthesis is precisely attached to the implant.
Function and cosmetics are examined clinically. This multi-stage, multi-disciplinary approach is important to ensure that each stage is done by an expert in that field, to ascertain the best possible treatment outcome.
The dental implant of today is by no means the ultimate replacement for missing teeth. Further research and development (R&D) is required.
Currently, essential/basic dental treatment like extraction, pain relief, fillings, scaling, and infection management are already affordably priced. These procedures are cheaper than most medical surgical treatment.
We are working towards a time when dental implants are no longer an optional luxury but a common affordable treatment alternative, just as cars were once exclusive to the rich but are now commonplace.
We can achieve all this and more only with the understanding and cooperation of our medical colleagues and the public.
Who knows, with support from all parties and sufficient funds for R&D, the option of replacing a missing tooth with a new one grown from stem cells may soon be available.

DR FOO CHI CHEAN, President – Malaysian Academy of Cosmetic Dentistry.
DR MELISSA FOO SUYIN, Oral & Maxillofacial Surgery Department, Hospital Sungai Buloh.

*****

really, to sum up, it does look like a bad case of doctors with itchy backsides and a poor understanding of what other people do. it doesn't mean that a well-rehearsed procedure is effortless just because it looks to be so. also, healthcare should be based on needs, not wants.

Now I Know

i finally understand the fuss about tuna-based sushi. this is a bit of an overdue blog, but anyway me and PJ went out over last weekend to celebrate her birthday. it involved going for a play and then a good dinner.

Chesty Nutty Bang Bang: The Hairspray of the Phoenix was quite literally 2+ hours of cheap shots. very good ones too, mind. the comedy crew opened up mercilessly spoofing the now-infamous MDA rap (youtube for it, you lazy buggers!), followed by skewering such subjects as Ribena ads, Beauty World, Heroes, 881... excellent. you have not lived until you have heard people sing Umbrella in hokkien. catch the next one when they get back on the stage! also ran into Lor, long-unseen JC class rep. good catchin up w her, wonder when our gang will next assemble...

the evening's laughter was followed up by a meal at Sushi Yoshida. we always passed by the place on the walk from Cine to PJ's place, and saw head chef Yoshida-san standing with the valet parking dude of the bar next door watching the world pass by every time. this reached the point where we dubbed the place 'Valet Sushi'. original plan was to check out a restaurant up the hill for dinner, but a great urging for a dinner of the raw fish variety struck PJ. i thought to myself, what the heck? expensive raw fish, here we come!

Sushi Yoshida is located in a small corner next to Bar Stop on Devonshire Rd, they possess a common entrance so dont walk past wondering where it is. ambience is cosy, slightly darkish in terms of lighting for my taste but alright otherwise. serving staff are generally friendly but still rough around the edges. the sushi, however, is excellent. this will be remembered as the place where i had my first Chu Toro Nigiri. its not just any old Magurozushi, mind you. a completely different animal, and another excellent proof that without fat of some kind food has less flavour. it tasted like fish in a good way, darker than salmon. it literally made me wish i had another hundred bucks to splurge on O-Toro. i must admit PJ was less blown away than i was, but now if i can get good tuna cuts i'll get some over the more generic local favourite salmon. in japan noone eats shake-sashimi anyhow...

Umbrella - Mandy Moore

O Muse! Sing in me, and through me tell the story...

after having discovered the wonders of the disc borrowing service at Gramophone, there are a couple of movies that we've watched that warrant a mention. in particular, go check out 'O Brother, Where Art Thou?' by the Coen brothers. in terms of comedy, this is one fun movie! 3 men escape from a chain gang to go get some treasure, and the rest would be spoiling the movie i guess. definitely worth the rental fee!

I Am The Man Of Constant Sorrow - The Soggy Bottom Boys

How To Fly A Kite

or... the life of a DO after 4 and a half working days. seems as if the old saying about sheer boredom punctuated by moments of abject terror really is true. i've had irritating pulpectomies, angry patients, and a panic-attack-in-the-chair from a heart patient. ive scaled, root planed, done TDs, CRs ARs, and too much GIC to count. but i still need to be faster. and learn how not to irritate the consultants. bleah.