The Public Servant

Kami sedia membantu

We are here to help

That was the slogan reiterated again and again by the Ministry of Health. We are expected to project altruism and willingness to serve the public, and expect nothing in return. As trained practitioners, we need not be told to do so, it has been ingrained in us since university.

It’s been more than 1 year since I joined civil service. I’ve enjoyed it at times, and reaped the benefits of being a civil servant (25 days of leave, not requiring to work weekends etc).

Your mileage may vary: every clinic/hospital has different staff and mentality. Public hospitals, in fact, are some of the best places. They employ the best and most motivated staff. They have a culture of excellence and quality control by specialists. They have state-of-the-art technology and facilities. The specialists generally have an air of quiet confidence and exert their supremacy through medical knowledge.

On the other hand, primary dental care clinics are overloaded with patients and paperwork. There is poor infrastructure, leaky roofs, fused bulbs and poor maintenance.

Oh and speaking of maintenance, most medical equipment in the ministry is serviced by Quantum Medical Solutions (QMS). There is a movement now to investigate the legitimacy of their tender to a contract of 13 years. Even staff in my clinic are claiming that QMS is a shady organisation used to siphon public money into pockets of the elite. Here’s an excerpt from change.org, I’ll leave it up to you to decide.

Quantum Medical Solutions also known as QMS, have been awarded a Tender of 13 years to supply and service the equipment of 2830 clinics over 10 states in Malaysia, where 1809 are Government Medical clinics and 1021 Government Dental Clinics.

I believe many healthcare professionals who has worked, managed or experienced the services rendered from QMS is not as promised.

Very frequently there seem to be a shortage or absence of equipment in clinics of desperate needs which are not met and thus service are interrupted/halted indefinitely. Whereas wastage of resources in purchasing items, equipments with exceptionally high value and not required are provided in what they term as “GAP LIST” under the MEET program which are not reviewed.

Kami sedia membantu. How to membantu when the facilities are in a sorry state?

My clinic in Gombak is a tiny clinic, but that’s not the problem. We have 2 dental chairs – one functioning, one broken. The broken one is used for extractions and checkups. The functioning one is for fillings and scaling. We don’t have a lab – so we don’t do dentures. X-ray machine is frequently broken, so we can’t do root canal treatments. These things are commissioned to be serviced by QMS, and time and time again after each repair it breaks down the next day. I can vouch firsthand for the petition above. It frustrates me and everyone else around me. But as civil servants, what can we do? Ideally, I hire an independent contractor to fix these things, and I can fire them if the quality is not what was expected. But I’m not in charge, nor are my bosses, we rely on funding from the bigwigs above and if nothing is changed, our clinic will remain 3rd world.

I’ve looked around and noticed that, as a consequence of poor infrastructure, the kami sedia membantu spirit has died away. Absolute altruism descended into relative nonchalance. The thing about practising in public sector is that many perceive treatment and advice to be relatively inconsequential. Patients generally are from the B40 segment of society and will adhere to what practitioners say. This is what’s called paternalism. In my years of training in the UK, paternalistic behaviour was frowned upon and could result in lawsuits.

That brings me to my last point: I’m not progressing my career here.

Day in day out, I feel sad, short-changed because I cannot offer my patients the care they deserve. My treatment options are limited to fillings, extractions and scaling. This is what’s called symptomatic treatment. I can’t do root canal treatments, crowns, dentures and more exciting stuff. Heck I can’t even take an X-ray to properly diagnose and treat.

The truth is this: this place is stifling my career growth as a dentist. As much as I am committed to altruism, to help the people of the world, I cannot continue to sit here and do nothing. I was told my wiser brother: “altruism [without adequate resources] is low-impact, more like grassroots activism.”

So I’ve decided to resign from the government and continue to pursue my career as a private dentist. With the civil service already so overstaffed and  many more fresh grad dentists waiting patiently for their posting opportunity, I thought it might be a win-win for me to free myself of taxpayers’ burden as well as a vacancy for a fresh grad. By joining the private sector, I bear the hope that with better resources, I can give back to society by providing real solutions.

BDS!

About one month ago I ended my time at university. Five years of blood, sweat and tears culminated in that moment, for I have finally graduated!

The moments at the graduation ceremony were indeed glorious. There were fancy costumes to wear, elaborate rituals to uphold and a Hippocratic oath to read out. Everyone was grinning, laughing, congratulating, hugging & shaking hands. People came with their families, whose parents were so proud and probably happier than their children. But deep down, we all knew that the graduation is just a ceremony, and that the real nail-biter was results day. I’ll spend more time talking about that instead.

I was in a restaurant in downtown Belfast with a few friends having lunch, knowing that it’s results day so we could either celebrate or cry together. It’s 2017 and we’re in the age of push-notifications. A beep on my phone and I got an email titled EXAMINATION RESULTS. Immediately my pulse raced and I quickly fumbled my fingers over to the mobile web browser to log into the university’s student portal. When I found out, I let out a huge sigh of relief. No screaming or cheering, some joy, but mostly relief. It was finally over!

Photo credits: Yi Lin T Photography

So here I am, with a Bachelor of Dental Surgery. Here’s to a beginning of a dental career that I’m so very excited to embark on. I’m ready to contribute to society.

Finally,

Dr Fong Wenkai
BDS (Belfast)

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P.S. I’ve returned home to Malaysia for good! Currently waiting for a government placement. Will soon blog about the process of applying (as of 2017) and my experience with it.

A Sensitive Issue (Pt 2)

With the basic knowledge of the biology of dental sensitivity, this next part will be quite easy to piece together the puzzle.

WHAT CAUSES SENSITIVITY?

Listing down things like this is part & parcel of studying dentistry. I noticed that almost all of lectures comprise of lists and lists of things i.e signs & symptoms, risk factors, clinical features etc. Since joining dental school my train of thought has always been in lists rather than in paragraphic words or in images.

Anyway, all the things below have one thing in common, that is exposed dentine.

Image source: Sensodyne

1) Gum recession – gum diseases (gingivitis and periodontitis) cause the gum level to recede or inflame, exposing the root surface dentine.

2) Tooth decay – caries can cause cavitation and bore a hole in your tooth down through the enamel into dentine, once again exposing dentine.

3) Cracked tooth or leakage in filling – these are similar as they create a communication directly into the dentine from the outside world, causing fluid pressure changes etc.

4) Tooth whitening – bleaching products contain hydrogen peroxide as an active ingredient with a possible side effect of sensitivity. Take caution before getting your teeth whitened!

5) Toothbrush abrasion – intense brushing with a hard toothbrush can rub away enamel especially at the gum margins, exposing dentine. Use a soft/medium toothbrush and use circular motions as if you are massaging the gums.

6) Acid erosion – either extensive extrinsic (from acidic food and drinks such as soft drinks and orange juice) or intrinsic (from gastric reflux) causes. Can cause slow wearing away of enamel thus leading to exposed dentine.

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READ THE INGREDIENTS!

Now, toothpaste manufacturers like to throw at you terms like Novamin, Pro-Argin, Pro-Relief, Pro-Expert. But what do they mean?

This part is going to be handy. I’m going to tell you some neat tips to guide you to buy what’s suitable to treat dental sensitivity.

Potassium nitrate

Image source: Colgate

Colgate has this product called Sensitive with Sensifoam – containing this special ingredient called potassium nitrate (KNO3).  Potassium salts act by diffusion along the dentinal tubules and decreasing the excitability of the intradental nerve fibers by blocking the generation of action potential. Also, toothpastes containing potassium nitrate and fluorides have been shown to reduce post-bleaching sensitivity. [1]

Besides Colgate, a number of other manufacturers do make toothpastes containing potassium nitrate, look out for those!

Strontium chloride

 Image source: Sensodyne

The original Sensodyne made by GlaxoSmithKline was first marketed in 1961 as a desensitising toothpaste with strontium chloride. Today, Sensodyne is synonymous with tooth sensitivity, and is well-known among people with sensitive teeth. SrCl2 forms a barrier and blocks the openings of dentinal tubules, thus not allowing fluid movement within the tubules.

Arginine + calcium carbonate

This is one of  the ingredients marketed by Colgate as “Pro-Argin” and “Pro-Relief” products. It serves the same function of strontium chloride, plugging dentinal tubule openings. Arginine and calcium carbonate work together to accelerate the natural mechanisms of occlusion to deposit a dentine-like mineral, containing calcium and phosphate, within the dentinal tubules and in a protective layer on the dentine surface. [2]

Stannous fluoride

 Image source: Oral-B

Most toothpastes that contain fluoride come in the form of sodium fluoride and sodium monofluorophosphate. Stannous fluoride, for you chemistry nerds, is tin (II) fluoride (SnF2). Oral-B’s Pro-Expert line is one of the toothpastes containing this version of fluoride.

Stannous fluoride acts in a similar fashion as that of sodium fluoride, i.e. formation of calcium fluoride precipitates inside tubules. Also, some studies have shown that stannous fluoride itself can form insoluble precipitates over the exposed dentine. [1]

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FYI I’m not endorsing any particular brand nor am I paid (I wished I was!) by these companies to talk about their products. Which is why I included a pictured example of one of each brand’s products!

If you do have sensitivity, I suggest you read the ingredients list, and armed with the knowledge I have given you, make an informed decision. One man’s meat might be another man’s poison, so you may have to try different products till you find one that works for you!

There is a lot of research pouring into exploring dental sensitivity. New products come and go all the time. Who knows, in the future, we might a complete cure for sensitivity?

References

[1] Dentin hypersensitivity: Recent trends in management

[2] How dental products containing 8% arginine and calcium carbonate work to deliver effective relief of sensitive teeth

A Sensitive Issue (Pt 1)

Sensitive teeth are common, really common. Sensing that this is a profitable industry, big pharmaceutical companies like Colgate, Sensodyne (GSK) and Oral-B bombard you with information about sensitivity and how their products can help with it. Now, take a step back and put your thinking caps on. These pharmaceutical companies sometimes manipulate information just to market their products a lot better. Trust me, you may not have sensitive teeth, but after seeing a Sensodyne product packaging and how well it’s made to fix sensitivity, you may think you have sensitive teeth too. That’s how good their marketing is!

I am here to write the unadulterated truth regarding sensitive teeth. I’m gonna delve into the detailed biology of it, what causes it and how you can read product packaging better. This is not coming from a pharmaceutical salesperson, this is coming from a young dental student eager to help everyone out there!

Due to the extent of the content I intend to write in this article, this post will be the first in a two-part series on dental sensitivity.

THE BIOLOGY

Now, you may recall that I blogged about anatomy of a tooth, I am going to build on that. The most important bit of information that you need to know is the presence of dentinal tubules in your dentine. The picture below illustrates that perfectly.

Image source

Enamel is the hardest substance in the human body and is a non-living, mineralised hard tissue. So it’s basically a rock.

Dentine, on the other hand, is vital tissue. It is a living, breathing segment of the tooth and dentinal tubules are part of that vitality. These microscopic tubes connect the outermost surface of the dentine to the pulp where the nerve lives. You see where this is going?

In sensitive teeth, dentine becomes exposed, i.e. no enamel protection or gum coverage. There is a direct link between the tubules and the outside world, connecting straight to the pulp. It’s almost as if your nerve is exposed itself, yikes!

Brännström’s Hydrodynamic Theory

This theory answers why cold & hot drinks trigger intense pain in sensitive teeth.

Dentinal tubules are filled with fluids, and lined by cells called odontoblasts on the inner surface of the dentine, surrounding the pulp. When you drink cold & hot drinks, it triggers changes in fluid pressure and movement in the dentinal tubules. These in turn trigger the odontoblasts, activating pain receptors within the pulp and sending these signals to the pain.

So this is how dental sensitivity works. The key concept here really is the exposed dentine, dentinal tubules and the hydrodynamic fluid changes within these tubules. Now, take a moment be in awe of the intricate details of this biological design. This is why I love biology so much.

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I do realise that people have relatively short attention spans these days, so this is the end of part 1 on dental sensitivity. Stay tuned for part 2, where I will talk about the causes of dental sensitivity, and the practical part of choosing the right toothpaste!

My Thoughts About Grinding

These are my teeth. My teeth have been flattened after of years of grinding teeth in my sleep. I never realised this until a friend of mine pointed this out to me back during my A-levels days.

“Hey!” he said, “why are your canines flat?”

I have a condition known technically as bruxism. And I am not the only one. It’s a very common condition and we as dental students are gaining awareness of it as we see more and more cases of bruxism.

Bruxism – clenching and grinding of teeth

The grinding mostly happens at night when one is unconscious. It is often a tapping/chomping movement and a side-to-side sliding movement. Clenching happens in the day, and also not within conscious control. Only when pointed out do people realise that they’ve been clenching. Clenching is common when one is anxious or stressed, but constant clenching is a sign of bruxism.

People who have bruxism often have sore muscles around the mouth (muscles of mastication – the muscles that help you chew your food) especially the masseter muscle at the sides of the lower jaw. This can lead to an enlargement of this muscle caused by intense “workouts” every night so bruxers have large squarish faces. Some patients even have headache caused by soreness of the temporalis muscle (it can be felt if you place your hand on your temples and clench). I was told by a lecturer that night-grinding can often involve strength of muscle movements that are beyond normal conscious control.

Most dentists are able to detect bruxism by looking at one’s teeth. We call it tooth wear, or more specifically, attrition. Teeth like mine are prominent signs of severe bruxism but most people have milder versions.

Why does bruxism happen?

Actually, to this day, nobody knows.

Some people have proposed theories such as stress. Here’s the reasoning: if we clench when we’re stressed, so we should grind when asleep because of stress too! It is quite true that in today’s urban lifestyle with economic recession, job insecurities and household debt, people are more stressed than ever before.

Me personally? I don’t think I am that stressed up all the time. I do however get stressed up when exams are upon me or when I’m nervous. And if I were chronically stressed I would have had anxiety problems and depression which would pose a larger problem than having flat teeth!

Okay so to the title of this blog post: my thoughts about bruxism. I feel that since muscle motor control is handled by the brain, it occurs to me that there has to be something wrong in the motor centres of the brain that is causing bruxism.

Take epilepsy for example: people who suffer from epilepsy get seizures and convulsions due to abnormal electrical discharges in the brain. Part of a tonic-clonic seizure is the uncontrolled biting/chewing. Convulsing patients often bite their own tongue and it is wise to not put anything into the mouth of a convulsing patient, as they might bite off the object or even your finger! [1] Tongue biting is also used as a diagnosis of an epileptic seizure. [2]

DISCLAIMER NOTICE: These are only my thoughts about the subject. Nothing I say here can be taken as fact. So don’t quote me on this! We have to wait until scientists figure it out.

My theory is this: tongue-biting in a seizure may be similar to bruxism. It involves the involuntary unconscious contraction of the muscles of mastication. What if bruxism is like a “mini seizure” (partial seizure?) caused by abnormal electrical brain activity? I do agree that stress may contribute to the abnormality of brain activity – like how during a stressful exam season, we so often have nightmares about doing badly. If stress is able to cause our brain to make nightmares, it can definitely lead to further brain disorders like electrical discharges.

Don’t worry, fellow bruxers. This is only my theory. You have no brain disorders and neither have I. Let’s just hope that further research into brain wave activity by neuroscientists can clear this up soon enough and determine the true underlying physiology of bruxism. I will blog about the treatment methods for bruxism some time in the future – it’s surprisingly interesting!

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References

[1] http://www.webmd.com/epilepsy/what-to-do-during-a-seizure

[2] http://www.ncbi.nlm.nih.gov/pubmed/7487261