Coming home soon

I have been in Philadelphia for nearly a month now, attending the continuing dental education course in endodontics at the Penn Dental School, University of Pennsylvania. Dentists from all parts of the world come to this ivy league university to update knowledge on the current concepts and techniques in endodontics. Really thankful to have reliable staff and fellow colleagues as temporary doctors to be in my practice while I am away. I'm almost done packing to go home now but not looking forward to my 24 hour flight...

The above radiograph showed a lower right second molar which seemed unrestorable, with a perapical lesion. Bacteria in the root canal system was eradicated during the root canal treatment to a level that allow healing of the periapical lesion and the tooth remained in function to date.

US is great but home is still the best!

Dental Therapists, anyone?

Remember how nervous you were during primary school when dental nurses came into your classroom, hoping that your name would not be in their list? Guess what? they will be back in your life, not in schools but probably in your private dental practices. According to the soon to be approved Dental Act 2012, dental therapists will be allowed to treat patients less than 18 years old under the supervision of a dentist, in private general dental practices. Who are these dental therapists?  Just a new label on dental nurses that spilled over from the public sector.

Read the link below:
http://ohd.moh.gov.my/modules/xt_conteudo/index.php?id=99

Dental nurse training was established in 1948 to overcome shortage of dentists then. We definitely have enough dentists now, considering there are already fourteen dental schools in Malaysia to date. The Dental Training College in Penang is the only college that supplies these dental nurses to the public sector, however, the supply for these nurses has exceeded its demand.

So, the next time you step into your dental office, the person who will be fixing your teeth may not be a dentist, who has spent at least four years in his or her life receiving proper training in dentistry. I have nothing against dental therapists as long as they practice within their scope. In fact, they complement the work of dentists. Once the law has passed, the standard of private dental care may deteriorate if it is not regulated properly. Who will check whether dental therapists are treating teenagers and children and not adults in private clinics? And how are dentists going to supervise the work of these therapists? Will patients be informed that  they are treated by therapists or will they just assumed that they are under the care of a dentist until something goes wrong? If there is a demand for dental therapists in private dental healthcare, will there be more of them being trained in future?

I'll leave it to you to ponder.

Five year-old root canal

Did this root canal in the year 2007 and the tooth is still surviving and serving its function in the oral cavity. Tooth 46 was presented with a buccal sinus and radiolucency at the furcation at the time root canal treatment was initiated. There was a lateral canal at the furcation, as the portal of exit. The review radiograph taken five years later showed complete healing, with trabecular bone reformation. 

Dental care services at government clinics

A pretty twenty-something year old lady from a town in Perak came all the way to me to have a root canal done on her lower wisdom tooth. I was saddened when I discovered that the adjacent lower first and second molars had already been extracted at her young age. Apparently she couldn't get root canal treatment in her home town and extraction was her only option when she visited the dental clinic there. She managed to google me in her attempt to save her third molar.

That got me thinking about the kind of dental treatment Malaysians receive out of Kuala Lumpur. The fact is there hasn't been any improvement in our national dental healthcare for the past twenty or more years. Our government dental clinics have been doing simple fillings and extractions only, all these years. One can never get a root canal done there, and even if this treatment modality is available in some main Klinik Kesihatan Gigi, the waiting list is so long that the patient might as well extract the tooth. Our new dental graduates are subjected to compulsory government services for three years. They were taught how to carry out root canal treatment in dental schools, then why is the service not provided in government dental clinics? In my understanding, these government clinics are poorly equipped with the gadgets and tools necessary to carry out root canal treatment. No budget apparently, wonder where all the taxpayers' money go?

How many twenty-something year old Malaysians can afford a RM7000 implant to replace an extracted tooth? Instead of focusing on implementation of the national health insurance 1Care, our Ministry of Health should seriously look into improving dental services in the public sector.

Soo Dental Surgery family is expanding

Yes, family of Soo Dental Surgery is expanding. For starters, Asma, my staff is expecting and she will be on maternity leave at the end of this year. Congrats Asma! The new face at our clinic is Norhayati, or Yati, our new dental nurse, who just joined us this week and is already adapting well. Not forgetting our gorgeous visiting orthodontist, Dr Indah Yuri, who comes in alternate Saturdays to take care of patients who need braces here and also Dr Darren, who helps me with dental surgeries from time to time.

I think we make a great team here :)

Obsessed with Length

Length determination is a crucial process during root canal treatment because it decides where canal cleaning and shaping ends. Ideally, canal preparation should terminate at the apical constriction, which is the narrowest point of the canal. The apical constriction is usually 0.5mm from the root apex. Clinically, canal length determination can be achieved with an apex locator and reconfirmed radiographically with measured files in canals. A non-vital infected canal harbors millions of microorganisms. Hence, a canal that is prepared short, even by 1mm, will leave behind microorganisms located in the untouched part of the canal, leading to root canal failure. If the working length is too long, there will be a loss of apical stop, causing overextension of root canal filling and micro leakage.

Horizontal root fracture

Root canal treatment on a traumatized 11, with a fractured crown. It was left opened for drainage by the referring dentist for a few days until the patient was due to see me. A horizontal root fracture at the apical third of the root was suspected.

I strongly opposed to this practice of open drainage, which is unscientific and unjustifiable. It is against the objectives of RCT, where asepsis and removal of microorganisms from the root canal system is the key to successful treatment of apical periodontitis. Once the tooth is left opened, more microbes, species and substrate will gain entry to the canal system and periradicular areas.

Since the tooth was left opened for a few days already, I had no choice but to do the RCT. According to Andreason, the apical fragment of the fractured root is usually vital and RCT is only performed up to the coronal fragment. In this case, since there is minimal displacement of the apical root fragment , RCT was carried out to the full root length. A thorough cleaning and shaping, and irrigating with NaOCl eliminated microbes that had entered the RCS and subsequently, the canal was medicated with CaOH for two weeks. During obturation, sealer escaped between the fracture and peri radicular radiolucency was observed associated with the fracture. An apical surgery to remove the fractured tip would be indicated if no resolution occurred at the periradicular area.

Luckily, the peri radicular lesion disappeared, as shown on the review pa radiograph after one year, indicating hard tissue repair around the fracture line, and the tooth is symptom free. Outcome of horizontal root fractures are generally favorable.

Wisdom Trouble

I did root canal treatment on three lower second molars for three patients today and these three teeth have one thing in common; damaged/decayed lower second molar caused by the lower wisdom teeth.

The wisdom tooth only appears in a person's mouth between the age of 18 to 20 – the age which marks the arrival of adulthood and gives rise to an additional wisdom! However, some wisdom teeth are impacted due to limited space in the dental arch and the impaction causes problems like gum infection due to food impaction and decay on the adjacent second molar appears to be a more serious problem.

The recommended treatment in these cases is to remove the impacted wisdom tooth to eliminate food impaction problem so that the patient can clean effectively and to conserve the lower second molar which is a functional tooth. Most lower second molars in these cases have large decay and usually a root canal treatment is needed.

Yee Sang Dinner 2012

The Chinese New Year Reunion Dinner for my staff at Soo Dental Surgery this year was held at the Yuan Zuan Chinese Restaurant, One World Hotel. The restaurant captain was nice enough to give us a private room with a Monet-like painting. It was attended by my nurses, Banun and Asma and their respective families, and friends, Dalia and hubby and Shiamala.

It was a sumptuous nine-course meal, beginning with delicious fruit yee sang. The roast chicken was rather small but we had giant-size fish and prawns. Din, Dalia's husband commented intelligently that all seafood served has to be super-big because it is the year of the water dragon! The prawns were everyone's favorite and the meal was completed with chilled date dessert and deep fried 'nian gou'.