Thursday, August 27, 2009

Cosmetic Dentists

The strangest patients I’ve met are those think that I should give them a discount for insulting me. Do people not realise that if they want a discount, they should at least say something nice to the one who is in the position to give them a discount? Flattery may not work all the time, but being nice is the necessary first step to getting a discount.

My friend recently posted me a YouTube video. I realised that there are good places where one can get very cheap dental treatment. Perhaps that’s where I should refer some of my troublesome patients.

Many companies that provide services have taglines. Some are catchy pieces of advice like:

“Don’t leave home without it”

“Just do it”.

Some are boasts like

“The ultimate driving machine”
“The happiest place on earth”
“The world’s favourite airline”

Others are promises, pledges or guarantees if you will.

“Melts in your mouth, not in your hands”

“When it absolutely, positively has to be there overnight”

The problem with such promises is that it’s not always easy to live up to them. For the cosmetic dentist who dares to call himself a cosmetic dentist, patients can expect miracles. Take the example of lady who walked into my clinic recently. She had a terrible looking bridge. I’m always happy to see such cases because it’s so easy to make an improvement.

Not so in this case. After numerous waxups and trials of provisional bridges, she was still not satisfied. She started pointing out ways in which her new bridge differed from her old, ugly bridge as if she was suddenly missing the ugly old bridge. Nightmare. Numerous things to change, numerous times, they were changed back because the changes asked for were just not right. It’s too late to re-access the psychological profile of the patient and the patient, from her point of view, must be wondering if I’m really good enough dedicate myself to cosmetic dentistry. Why do other cases look so perfect in other people’s mouths but not in hers? Shouldn’t I be treating my patient’s equally?

In despair, I sought help from a great man. In a recent speech he made, I learned something important. Cosmetic dentistry is an aspiration and not an ideology. It’s going to take decades or even centuries to reach such goals. Equal treatment for all cases is false and flawed, and completely untrue.

Some people may not believe that these words came from a great man, but what are great words but words that cannot be challenged. Obviously, I lack such greatness and must therefore continue adjusting that stupid bridge.

Monday, August 24, 2009

Dental Implants

Dentistry is no longer a sunset profession. Every couple of years, something truly new or even revolutionary emerges in the field of implant dentistry. More and more, these replacement teeth are becoming as good as the real thing. In fact, they are getting better than the real thing. Even though implants are vulnerable to gum problems, they are even more firmly anchored in bone than natural teeth and your implants will never require any root canal treatment as they have no pulpal liabilities.

In the more developed countries, patients have sued their dentists for not offering implants as an alternative. Indeed, implants can be superior to other forms of treatment like dentures and bridges. The failure to offer and suggest implants is seen as a disservice to the patient. Yes, we do get patients asking about implants every now and then. However, it’s going to take quite a while before the general population in Singapore learns that implants are not just a more expensive treatment option pushed by dentists for economic reasons only.

At the other end of the spectrum, are patients or even dentists who are “advertisement-educated”. Information they received is often biased or hyped. This may result in problems for both patients and dentists. It’s a long learning curve for dentists and patients alike. Experience and scepticism make all the difference.

Tuesday, August 18, 2009

Root Canal Amnesia

In the heartlands where price sensitivity is highest, root canal treatment is probably the most common necessary treatment that is rejected by the patient because of cost factors. For someone with no income, paying $300-$1000 for root canal can be difficult. It’s OK if the patient is willing to extract the tooth. Problems arise when the patient insists on keeping the tooth but is only willing to pay for a filling, thinking that root canal is only indicated as an excuse for the dentist to charge more.

This puts everyone in a no-win situation. Many heartland dentists reluctantly fill up teeth which should be endodontically treated first. When there is no pain, the patient assures the dentist that he is OK with a temporary filling and will do something about it later. When the patient gets pain afterwards, they forget all about the filling being temporary and they having been advised to do root canal previously.

Wednesday, August 5, 2009

IV Sedation

Outpatient Intravenous Sedation.

No Hospitalisation. Sleep Through Your Surgery, Wake Up, Walk Home

S$600 per hour (includes cost of drugs and anaesthetist charges)

After 17 years in private practice, I have met numerous patients who tell me they have "dental phobia". In reality, most people do not have a genuine phobia for dental treatment. By "dental phobia", they usually mean that they just want to be pampered.

Well, whether it's true dental phobia or patients just want to be pampered, we can reduce anxiety with intravenous sedation. If you wish to be pampered and have no "budget problems", we recommend IV sedation for wisdom tooth surgery, implant surgery and even difficult extractions. "Intravenous" means that the drug is injected into a vein, usually in the back of the hand. After the needle is inserted, a plastic tubing is left in place for continuous infusion into the vein. The tube stays in place throughout the procedure.

The patient's pulse and oxygen levels are measured using a pulse oximeter. This gadget clips onto a finger and measures the pulse and oxygen saturation of the blood. It will warn the dentist and anaesthetist if your oxygen level is low. To be kiasu, we would give our patients supplemental oxygen through a nasal cannula throughout the procedure. The device also comes with a cuff around the arm to measure blood pressure at regular intervals.

What drugs are used?

The most commonly used drugs for IV sedation are benzodiazepines. These are sedative drugs sometimes prescribed as sleeping pills. Examples include Dormicum. Someone who has been consuming sleeping pills regularly for years may not react well to benzodiazepines. The patient may be "knocked out" when the drug is administered in a bolus but effects of sedation are gradually lost as the operation progresses.

Propofol is usually preferred for a deep and a consistent level of sedation throughout the operation. The advantage of Propofol is in its rapid recovery time of less than 5 minutes. Because of the short duration of its action, the drug must be continuously administered. We do this by pumping Propofol using an electric infusion pump. The dose rate is set by the anaesthetist.

What about safety?

IV sedation is very safe when carried out by an anaesthetist. Statistically speaking, the mortality rate is literally 1:1 million. In contrast, the mortality rate for general anaesthesia (GA) is 1:598,000.

However, contraindications include pregnancy, known allergy to the drugs used, alcohol intoxication, CNS depression and some instances of glaucoma. Cautions include psychosis, impaired lung or kidney or liver function, and advanced age (above 70). Heart disease is generally not a contraindication.

What are the advantages of IV sedation?

* IV sedation tends to be the method of choice if you don't want to be aware of the procedure - you "don't want to know". The alternative in the US is oral sedation using Halcion, but oral sedation is not as reliably effective as IV sedation.

* The onset of action is very rapid, and drug dosage and level of sedation can be tailored to meet the individual's needs. This is a huge advantage compared to oral sedation, where the effects can be very unreliable. IV sedation, on the other hand, is both highly effective and higly reliable.

* The maximum level of sedation which can be reached with IV is deeper than with oral or inhalation sedation.

* The drugs produce amnesia for the procedure. The patient forgets the trauma of the operation even though he/she may not be unconscious.

* The effects of intubation and nausea from GA are not found in sedation. No fasting and long preparations are required before the operation.

Are there any disadvantages?

* You need to bear with the initial discomfort of having a needle inserted into your hand.

* It is possible to experience complications at the site where the needle entered, for example haematoma (a localised swelling filled with blood).

* Patients may become dependent on IV sedation such that they want IV sedation even for non-invasive procedures like fillings.

* Recovery from IV administered drugs is not complete at the end of dental treatment. You may need to be escorted by someone who can take care of you.

After IV Sedation:

(1) Have a companion (sorry, we don't provide) take you home and rest for the remainder of the day.

(2) Have an adult stay with you until you're fully alert.

(3) Don't perform any strenuous or hazardous activities and don't drive a motor vehicle for the rest of the day.

(4) Don't eat a heavy meal immediately. If you're hungry, eat something light, e.g. porridge or bread.

(5) If you experience giddiness, lie down for a while or have a glass of isotonic drink.

(6) Don't drink alcohol for the rest of the day.

(7) Take medications as directed by your dentist.

(8) If you have any unusual problems, call your dentist.