Friday, July 31, 2009

What's should I do ? If my patient wants high quality, look nature, prefect BUT very cheap.

It happens often enough in any dental practice. A patient walks in to have a new denture done. He tells you all the horrible things the old denture is doing to him. He wants those things rectified. You faithfully design a different denture that addresses all his concerns.

Patient’s Denture Wish List
1. Teeth that look new
2. Teeth that look real
3. Whiter teeth
4. Teeth with more bite
5. Sexier teeth

When the new denture is ready, the patient, spits it out, can’t tolerate for one second and start comparing the “merits” of old denture with the demerits of what you’re just done. It doesn’t matter if you pull out that wish list written in the patient’s own handwriting and signed against “sexier teeth”. They think the new teeth you’re giving them just ain’t sexy.

Most dentists will reel from the shock of seeing a happy, enthusiastic patient walk in for the first visit, only to be entertaining a critical and uncooperative one at the end. Can these cases be spotted at the beginning and weeded out before taking the case? I find it difficult. During initial examination, the dentist may be able to establish how the patient felt and what the patient wanted at that point in time. They may feel that their old denture had teeth which were too short. They wanted longer teeth, bigger teeth, whiter teeth… Even if the dentist could read their minds at that point in time, he would have seen that they wanted longer teeth. But once the longer teeth are issued, they begin to sound funny, feel funny and chew funny, they may decide to take issue with their new dentures in the most unexpected ways, saying that it’s uncomfortable, unstable and just not right.

The vast majority of dentures do require some adjustment before issue. Nothing is perfect - especially a set of new dentures to which the patient is not accustomed. In the vast majority of cases, patients are satisfied after adjustments are made. If the new dentures are significantly longer, larger or thicker than the old ones, then a period of adaptation (with 100% patient participation and cooperation) is required. Only in rare cases are redoing the denture necessary. If the patient is agreeable to a redo of the denture, this time without such a great departure from their old set of dentures, then, an amicable conclusion is still possible. And it usually ends up amicably. Even if the patient is unwilling to bear the cost of the redo, the dentist would still be in the position to end off with a satisfied patient - something more important to the dentist than making a profit out of every single case.

Just for the sake of job satisfaction, many dentists are willing to redo dentures. But not all patients allow the willing dentist to redo. What if the patient declares that he has lost all confidence in the dentist even before wearing the denture for any reasonable length of time (less than an hour)? He is not asking for a redo. He is asking for a refund.

Reading their minds now, the dentist may see a totally different patient from the very nice and accommodating one on the initial visit. So mind reading doesn’t help. What might help, is a third eye that can look into the future and predict trouble and unpleasant responses from initially nice and friendly patients. How I wish I can do that.

Thursday, July 30, 2009

Speeding Up Our Life Cycle

Are you one of those parents who always need to be around when your child is doing his/her homework? I may not remember much of my primary school curriculum, but I’m sure I didn’t do algebra at Primary 1!

Ali has 3 marbles more than Tom who has 1 marble more than Jerry. If Jerry has 2 marbles, how many marbles do Tom and Ali have?


Let Jerry have j marbles
Tom has j+1 marbles
Ali has 3+j+1 marbles
Given that j=2
Therefore Tom has 2+1=3 marbles
Ali has 3+2+1=6 marbles
Well, at least that was the way I was taught to do this sort of “problem sums”. I don’t know how smart other people and their kids are. But I certainly wouldn’t have a clue as to how many marbles Ali and Tom have when I was in Primary 1. And I don’t expect my 6-year-old son to be able to do that. To me, this is probably Primary 4 work. Why are they teaching it at Primary 1 now? A chill runs down my spine when I imagine what they might teach in Primary 2, 3, 4, 5, 6.

If you think that’s not bad enough, have you heard of the Primary 2 kids who had to write book reviews as homework? Almost every child would seem to have read a book that no child would find interesting. Almost every child would get an A for their insightful review copied from My son would probably get an F because instead of a book review, I’d be the only parent who would write an essay on how stupid the whole exercise is.

We are a nation obsessed with upgrading, efficiency and bang for buck. That’s not a bad thing - provided we don’t let things get out of hand. Compared to my son and other kids in school today, I went through primary school at a very comfortable pace. It’s not just about enjoying childhood. It’s also about being true to yourself. So what if my homework was never flawless? At least I understood most of it and did it myself. So what if my projects were made out of cheap cardboard and coloured paper? At least my parents didn’t have to scrimp on the next meal to get materials that would make my project look as professional as the others.

If learning is forever, why rush into it? More importantly, how much does a Primary 1 kid really need to know at Primary 1? Are the schools really in such need to show that they are improving and reaching ever higher standards? What simpler way to show “improvement” than bringing Primary 2 work to Primary 1.

Wow. That’s an impressive improvement. What do we do next year? Let’s bring the Primary 3 work to Primary 1. Wow!

The end point? There is no end point in theory, but for practical reasons, most people would stop at an MBA or a PhD. And my friend who holds an MBA (and a very expensive one too) just got retrenched for the nth time. He has been switching careers, attending diploma courses to help him remain employable. After multiple humbling career switches with equally humbling salaries, he still ended up retrenched. It’s quite baffling that with so much more experience, he is worth much less than he was young. He’s finally considering becoming a tour guide - a job done very well by another friend of mine who only finished his O Levels.

Is it because this friend of mine didn’t learn about how many marbles Ali has when he was in Primary 1? Would our kids not fall into the same predicament when they hit 40 because the education system they are under is now an improved one that will make sure you won’t wash toilets or drive taxis if you have an MBA?

I’m glad that I can sometimes decide my own worth. My years of experience are tangible and worth something in the field of dentistry. While I can still hold handpieces and scalpel blades steady, I don’t have to retrain and acquire new skills in a food court or toilet to remain employable. Not so for many friends my age. Many of them have reached their “employ by …” age. Like the primary school system, everything is being sped up in Singapore. We can’t wait to graduate. We can’t wait for the IRs to be built. We can’t wait for the next rally at the stock market.

So why not attain O Level knowledge by Primary 6. Retire to wash toilets by 40 (already happening). Draw CPF at 90. No, this is one thing which will only be slowed down. Happy speeding on the other lanes.


Crown Lengthening Case

Smiles are not just affected by tooth positions. They are also affected by gum levels. Gum surgery can correct gum levels.

Her main concern is her crooked teeth. To fix that properly, it would be good to first correct her gum level. The gum level ought to be where it's indicated by the black dots.

The gums are peeled back to expose bone.

The gum level around the 2 "sunken" teeth has been brought up. The next step is to change the positions of the teeth.

It's a week after gum surgery, our patient is back for her crown preparations. Her canines have been root canal treated. We ground them down to gum level, then placed fibre posts inside the canals.

The crowns of the canines are rebuilt from scratch to conform with the crown positions we want.

The rest of the teeth are carefully prepared to conform with the final tooth positions we want.

The prepared teeth are protected with temporary plastic crowns. We will wait for the gum level (after surgery) to stabilise before we take impressions for the final e-max crowns. So far, we have already successfully realigned the patient's teeth.

Case completed.

Sunday, July 26, 2009

Horsing Around

Oh no! I had a drop too much of Knock Out Beer and I’m dreaming again. I bought a horse in Australia (the girl is part of the package). I wanted to keep it as a pet. Then I found out that it was used for racing (the girl was the jockey). So I sold the horse …

Yao mo gao chor ah?

If I find out that a horse has been used for racing, then all the more I should keep it in my own stable, my own ranch (with a decent room for the girl) and not sell it. But then, this was just a dream and dreams don’t have to make cents … I mean sense.

And I also dreamt that I spent millions upon millions of other people’s money to build a titanium building. Then angry mob came to tear down the building, melted down the titanium and the expensive metal was turned into thousands of dental implants for edentulous patients who would otherwise not be able to afford it.

More Knock Out Beer. And another dream. This time, I dreamt I was CEO designate for some company running a sovereign wealth fund. I panicked. I didn’t know anything about managing SWFs. The job was killing me. I was losing billions and people were staring, pointing fingers at me. I had to find a replacement, a scapegoat if you will.

I found him. But the guy was too smart to be a scapegoat. He soon realised that like Obama, he’ll be inheriting a disaster in the making. He quits over “strategic differences”. Whatever that means. It’s just a dream. I’d better go back to work and stop horsing around.

Monday, July 20, 2009

Going for wisdom tooth surgery.

Pre-operative instructions for patients undergoing surgery.
1. Have a good meal a least 4 hours before surgery. Comsume only water after that.
2. Make sure all the medications you are taking are made known to the surgical team.
3. Avoid supplements like ginseng and gingko biloba for at least 4 days before surgery. Consult TCM practitioner if in doubt.
4. Do not smoke.
5. Maintain good oral hygiene.
6. Have an adult to accompany you home after the surgery if you are to be sedated.

Post - operative care for patients who have just undergone surgery.
1. Bite as hard as you can on the gauze provided when the surgical site is still numb.
2. Be careful not to bite your lip before anaesthesia wears out. Ulcers may occur due to stretching or accidental biting.
3. Swallow overflowing saliva. Do not keep rinsing your mouth. If you need to spit, do so very gently.
4. Avoid drinking through a straw.
5. Do not blow your nose. Sniff if there is mucus. Pinch your nose when sneezing.
6. Do not consume hot drinks, alcohol or coffee for the first 48 hours.
7. Do not smoke.
8. Apply cold compress on the cheek or lip over the surgical site during the first 24 to 48 hours.
9. Stop cold compress and rinse your mouth with warm salt water after 48 hours. Maintain good oral hygiene.
10. Avoid food that requires chewing for at least 3 days.
11. Avoid physical exertion for at least 5 days after surger.
12. Follow all instructions on medication.
13. Panax notoginseng promotes healing. Consult your TCM practitioner for a suitable formula.
14. Call the clinic immediately if "sand" leaks out from the would.

Sunday, July 19, 2009

Teeth Whitening FAQs.

Q: Why bleach my teeth?
A: It's mainly for cosmetic reasons. Whiter teeth look cleaner, healthier and younger. In the reel and real world, cosmetic reasons can make a world of difference. The cast from the TV series Baywatch had their teeth bleached. The wannabes below obviously had no tooth whitening budget.

Q: Can all teeth be bleached?
A: Crowns and fillings do not bleach. Brown or grey teeth are much harder to bleach than yellowish teeth. Make sure that your teeth have a uniform colour and not a patchy appearance.

Q: Do you do laser whitening?
A: No, we do not do laser whitening. Our system is chemically activated and works just as well. Laser whitening will cost about $1200. This is because the dentist needs to rent the machine and buy the bleaching gel from the same company. The high advertising costs must also be paid for. For laser whitening, the total cost to the dentist can be as high as $900 per patient. The bulk of what you pay for goes to the supplier.

Q: How quickly can I see results with the take home kit?
A: Results are noticeable after an hour's application. It takes about 4 days of continuous wear (1 hour 2 times a day) to reach maximal results.

Q: What sort of results can I expect?
A: You will never get chalky white teeth. Going two shades whiter is a reasonable expectation. Results do vary and satisfaction cannot be guaranteed as some teeth may not bleach well in spite of our best efforts.

Q: Can everyone go for bleaching?
A: Bleaching is not recommended for pregnant women.

Q: What are the side effects?
A: Sore gums and sensitive teeth are common side effects. However, it's often temporary. See your dentist if it gets uncomfortable.

Q: How long does it last?
A: Re-treatment may be required every 1-2 years or so. It depends on your diet and how well you maintain your teeth. Coloured drinks and some herbs will cause staining very quickly.

Tuesday, July 14, 2009

Cost of one plate of Char Kway Teow

Somebody suggested that we can consider reintroducing non-air-con buses. Unthinkable? Not so. The only problem is, our public transport system does not always let the market decide. Peanuts can tip the balance. Let me illustrate.

Just yesterday, at some old coffeeshop at Hougang, I decided to have an unhealthy char kway teow for lunch. The last time I ate at the stall, the char kway teow was priced at $2 and $3. Obviously, the $3 plate had a larger serving of noodles and cockles. And to make myself feel less guilty about eating such an unhealthy dish, I would always order the $2 plate. The $3 serving was almost 2 times larger. Apparently, the $3 plate was not very popular.

A surprise awaited me at the stall when I went there yesterday. There was no more $2 char kway teow. Instead, it was either $2.50 or $3. Yep, I fell for the trap. $2 is now $2.50. $3 is still $3. Which one would I order? $3 of course. The hawker may not have really increased the price of his $3 char kway teow. However, by increasing the price of his $2 char kway teow by 50 cents, thus closing the gap between “regular” and “large” to only 50 cents, he has definitely increased the demand for the $3 “large” plate. How ingenious.

Now we go back to the topic of non-air-con buses. Will there be any takers? I’m sure there will be. Some old folks, some foreign workers, backpackers etc. But what about the fare? How much less than the air-con buses? Half the price? Wait a minute. The public buses in Singapore don’t have windows that can open. They can’t just use the vehicles whose air-cons are not working to run the non-air-con services. They’ll have to buy new buses or import old buses from neighbouring countries. Either way, it means spending money which in turn means that the fares can’t be too low. Being unprofitable is a death sentence in Singapore, even though some companies that are far from unprofitable continue to squeeze their customers who have little or no choice. If there is little difference between fares charged for air-con and non-air-con buses, which type will our wise consumers go for?

Monday, July 13, 2009

Cost of tooth bonding

When a painted wall in your home becomes indelibly stained, what do you do? Yes, you'd paint it. If you decide to make the wall less stainable and easier to clean, you could also bond ceramic tiles to it.

In dentistry, bonding is the method by which a dentist adds a tooth coloured material to the surfaces of your teeth to mask underlying discolouration, cavities, gaps or undesirable contours or alignment. Like the wall in your home, there are 2 methods of bonding, namely direct and indirect bonding.

Direct Bonding

We have upgraded to a new cordless LED curing light (left). The light is cool, it's more powerful in terms of pure light intensity and does the job in half the time that older machines take. The older halogen light unit (right) is cumbersome and heat-generating.



The tooth or teeth to be treated are first trimmed to reduce or roughen the surfaces that are to be bonded.

Next, chemicals are applied to the surfaces of the teeth to improve the grip in much the same way you would apply paint primers. Then, a composite material of the desired colour is applied to the surface of the tooth and allowed to harden. The results are faster and more dramatic than bleaching. You can theoretically "paint" your teeth as white as you want.

For shape or alignment correction, the dentist will add material to the tooth to thicken it in some areas. By selectively thickening certain parts of a tooth that are slightly out of place, the treated tooth can be made to flush with the other teeth. In a similar way, teeth can be slightly enlarged by adding material to close gaps between them. Putting on braces may be the ideal treatment for crooked teeth, but bonding yields immediate results and costs much less.

One limitation to bonding is that you can only add but not subtract. To correct the positions of teeth that are too bulging, you'll have see an orthodontist. Another setback is the strength and durability of composites. These materials seldom last more than 5 years. You are likely to need repairs and patch up every few years.

Cost Estimation
Tooth coloured fillings/bonding S$100-S$200

Friday, July 10, 2009

Could you remember me "doctor" ?

Everyone who can read this must remember the time of film cameras, negatives and 3R prints that could cost 40 cents each. You had to bring your roll of film to the studio for processing and wait a week. Then, as more and more people could aford cameras, tiny photo-developing booths/kiosks took over the job of the studios. Processing could take just one day, then 20 minutes. I remember getting receipts from these booths that said: “Goods not collected within 6 months will be discarded”. Which is fair, considering the lack of space in the tiny little booth.

Many people don’t realise that dental clinics have their fair share of “trash” in the form of plaster models. Once the dentures, crowns or bridges are completed, these models are practically useless. The more patients we see, the faster they pile up. If we were to keep all these models from day 1, we would need to rent a warehouse to store them.

So what happens to dentures that are not collected? We call up the patient to remind them. But we can’t keep reminding them, can we? Of course not. We have better things to do. But what if the patient turns up 2 years after the denture was first made expects to collect it? You may have guessed it by now, we had one like that just a week ago.

If I were in that patient’s shoes, I would feel nervous, apologetic with only the faintest hope that the dentures will still be around. But as you may have guessed it again, this patient was angry and demanding. Insisting denture or refund of deposit. But what do people understand by deposit? Isn’t it something to protect the business in case the patient/customer abscorns, abandons treatment or dies halfway? Unfortunately, many seemingly educated Singaporeans refuse to acknowledge the fact that they have been irresponsible. They cannot blame the clinic for discarding their uncollected dentures and forfeiting the deposit.

“But I have already paid! But I have already paid!”

“We reminded you to collect your dentures. You didn’t respond”

“I was busy what”

How to make them understand? Perhaps they do understand. Could it be that just because they didn’t need or want the new denture back then and suddenly decided 2 years later that they wanted it? Yes. They could make the denture first, pay only half the fees as deposit and then collect their dentures when they are “ready”.

Isn’t it amazing the kind of service some of our patients expect us to provide? How do we manage this sort of cases? Charge them for storage?

Wednesday, July 8, 2009

Instant Orthodontic

What do brides to be and air stewardesses have in common? They have no time to put on braces before that last interview with the airline management or the appointment with the photographer. Since 2003, our clinic has been helping many hopeful air stewardesses pass that last interview and take off on a high flying career with "instant orthdontics". We have also helped many brides and bridegrooms to be to get their smiles ready for the camera.

There is actually no such thing as "instant orthodontics"
. In fact, we don't do orthodontics at our clinic. The illusion of instant orthodontics is created by a technique which involves elective root canal treatment and the crowning for crooked teeth with full ceramic crowns. In some cases, additional procedures like gum surgery may be required.

Case: Hopeful Air Stewardess

This is a classic case that brought our humble practice in the Hougang heartlands into the recommendation list of an airline's management. The patient is a young and attractive teacher on her way to a new career as an air stewardess (or cabin attendant if you want to be PC). Below is a plaster model of her teeth before treatment.

From the inside, we can see that her two central incisors are protruding forward. The incisor on the right side was even rotated. Her lateral incisors were also sunken relative to the rest of her teeth. It's our duty to inform her that the ideal treatment for her case is orthodontics. She would have to extract a couple of teeth, put on braces for 2 to 3 years. She rejected the option because as an air stewardess, she would not be allowed to put on braces. She also needed to look good in time for her final interview.

I took impressions of her mouth and studied her case closely. The twisted right central incisor was marked (x) for elective root canal treatment. I would have to break off the crown and then rebuild it from scratch. The two lateral incisors only needed to be "thickened up" with crowns to put their outer surfaces in alignment. The tilted canine on the right side could be set straight also by covering it with a crown.

Below is what we call a diagnostic wax-up. It's similar to a mock up of the final result we can get. It's done by adding wax to recontour the original study model. Of course, the twisted crown was broken off on the model and reset in a new position. In this wax-up, I included the canine on the left. The patient decided to do just 5 Empress® crowns from her right canine to the left lateral incisor.

I performed the root canal treatment as planned and then cut the crowns accordingly. The impressions were sent to the lab and in a week, they were ready for cementation. The plaster models below was taken from the patient after the crowns were cemented. Note that we managed to completely realign 5 of her teeth by crowning. Root canal was only required for one tooth.

It should be noted that "instant orthodontics" is a compromised and less than ideal solution. Vital teeth which have been crowned in this case may require root canal and quite a bit of follow up treatment in future.

Cost Estimation
The above case would cost about S$4200 today

Case: Anxious Bride To Be

This young lady has canines that are protruding, lateral incisors with too much gum covering and tilted backwards. Straighten her teeth and make her gum level even? This bride to be became anxious and excited after she saw our website and realised that something can actually done to change her smile before she and her hubby go before the camera.

We first performed gum surgery on her 2 lateral incisors to even out her gum line before we even attempt to bring her lateral incisors forward. We can see from this picture on top that her two canines are bulging out.

The next step is to perform elective root canal treatment to remove the nerves inside her canines. The two protruding teeth were cut off at the top, glass fibre posts were cemented in the root canal spaces and built up.

All 6 of her front teeth have been prepared for crowning. However, her gums have not healed from the surgery yet. That's why we've decided to place temporary plastic crowns for her.

Here she is with her temporary crowns. They don't look very natural, but the straightening effect is already there.

Two months after the surgery, we took impressions for her final crowns. 6 emax crowns were then cemented. She's ready to go before the camera.

Cost Estimation

This case will add S$6000 to the wedding budget.

Medisave Approved @ My Dental Clinic

My dental clinic medisave is approved , you can use your Medisave for part of surgical fees like dental implants, wisdom teeth surgery, Surgical excision of soft tissue tumour and Root Canal Surgery.

Medisave audits have been driving many dental clinics crazy. Almost no clinic can escape without refunding money due to "overclaiming". It has been and will always be our clinic's policy to help our patients claim the maximum amount that MOH and CPF Board allow. We are not in the position to dictate or even advise our patients on what to do with their own money.

On the other hand, organisations which regulate the use of Medisave funds have the duty of protecting our patients' Medisave reserves. The maximum claimable amounts stipulated by MOH are not meant to cover 100% of the bill. As private practitioners, however, we always try our best to charge and claim in a way that results in no cash payment on the part of our patients. Nevertheless, this is not always possible. MOH has very rigid guidelines on the maximum claimable amount for a particular type of wisdom tooth condition. At the MOH side, the evaluation is based purely in x-rays.

Below is a detailed explanation on how much is claimable:

1. Single Wisdom Tooth Surgery (from $450 - $800)

If your wisdom tooth looks like this on the x-ray, we will be able to claim up to $800 for the surgery. Most of the surgery $600 is well within our charges for this surgery. If you present at our clinic for the removal of this tooth, we will take no cash from you.

If your wisdom tooth looks like this on the x-ray, we will only be able to claim up to $200 for the surgery. If you present at our clinic to remove this tooth, we may not be able to charge within the limit. Figure on paying about $200 in cash.
If your wisdom tooth looks like this, we will not be able to claim anything for you regardless of how difficult the extraction is. Sorry, we don't make the rules.

Surgical excision of 2-3 wisdom teeth (Max $1000)

If you are taking out 2 or 3 wisdom teeth at the same time and at least one of them looks like the second x-ray on top, you can claim a maximum of $1000. This may not cover you fully when all 3 extractions are difficult. You may need to fork out $200-$300.

Surgical excision of 2-3 wisdom teeth (Max $1200)

If you are taking out 2 or 3 wisdom teeth at the same time and at least one of them looks like the first x-ray on top, you can claim a maximum of $1200. This is within the range of our charges. You will not need to fork out cash even if both lower teeth require surgery.

Surgical excision of 4 or more roots/wisdom teeth (Max $1400)

If you are taking out all 4 of your wisdom teeth where at least one of them looks like the second x-ray, you can claim a maximum of $1400. If the upper teeth are simple extractions, $1400 will be well within our charges for the entire treatment. You will not need to fork out any money.

Surgical excision of 4 or more roots/wisdom teeth (Max $1600)

If you are taking out all 4 of your wisdom teeth where at least one of them looks like the first x-ray, you can claim a maximum of $1600. $1600 should cover everything. You will not need to fork out any money.

2. Surgical excision of soft tissue tumour ($200)

3. Drainage of Pus ($150-$200)

4. Root Canal Surgery (surgical removal of root tip after failure of root canal treatment) ($800)

5. Implant Surgery excluding crown $900 to $1500 claimable

6. Biopsy ($200)

Sunday, July 5, 2009

Amalgam Fillings VS. Composite Fillings

Amalgam Fillings

Believe it or not, the amalgam filling has a more than 150 - year proven track re c o rd. It is still one of the most reliable, predictable and safe materials with which to fill a cavity.

Composite Fillings

Studies over the past thirty years have shown composite resin to be a safe restorative material. There is no scientific evidence that composites cause adverse health effects in the general population.

Wednesday, July 1, 2009

How to get my working place?

Getting here: Coming out from Orchard MRT, head for the Wisma Atria exit. As you exit the station, you'll see the passage to Wisma Atria on your right, a Seven Eleven store and with DBS Autobank on your left. Go through the underpass (on the left) until you see an Orchard Road exit on your right. Go up that escalator and walk past Tangs towards Lucky Plaza. From the trademark bubble lift overlooking Orchard Road, go up to the 5th level. You enter a maze of carpeted corridors. Just turn right after you have come out of the lift and you'll see us.

Rainy day tip: Coming out from the MRT station, go for the Wisma Atria exit, walk straight through Wisma Atria until you reach the end of the building with a passageway leading to Takashimaya. Once you're inside Takashimaya, exit left where a Levis store and BritishIndia outlet are. You'll see an underpass. Descend into this underpass, walk to the other end and you'll find yourself in the basement of Lucky Plaza.