Beware of Guns.

Ever since I moved and start living in Betong, I have been actively reading articles online regarding dentistry and anything that has to do with it, which is surprisingly good since I have always pushed myself for so many times to be constantly updated with the latest knowledge and development in dentistry.

So recently, as I was browsing through Google to find an article about painless dental visit, I stumbled upon an article, a published letter to the Editor of The Star on February 2008 regarding dental visits in Malaysia. So here is how the letter goes;

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.

My first few words that came out after reading this was: Shame on you medical doctor! Obviously he knows nothing what a dentist can do. Clearly he knows nothing about general health. I was to a certain extent angry initially. But I seek to understand and acknowledge his needs to be emotional about the costly dental treatments. If I could write a personal letter back to this medical doctor, I would not explain or educate him a single thing about dentistry. With his appalling judgment about dentists, it is such a disgrace to have a colleague in the health sector with an attitude and mindset like this. I don’t intend on being emotional and biased. So, to other medical doctors out there, to friends, and colleagues, here is my respond on this atrocious accusation.

First and foremost, I would like readers to know that I have made a meticulous exploration on the latest development, guidelines and knowledge on topic above mentioned prior to making my comments and response.

It is true that edentulous people are becoming a substantial number. According to NOHSA 2000, more than one third of population in 65-74 years of age was edentulous; almost half of population was edentulous by the age of 75. From that, more than ¼ of population wore prostheses, removable or fixed, or both. Female population was in higher proportion than male, and the urban and rural population was equally same. With that being said, there is no need for discrimination of pooper population having no better teeth replacement, such as implants. People pay for what they can afford regardless of how they want the otherwise. That is just how life is. No poor people who work manual labor obtaining 50cents per hour dream of ever owning a brand new Honda City. While on the other hand, a medical doctor is able to afford that. Even though it is likely that they want a more luxurious sporty BMW M3 series instead. Point is, change only what you can, accept what you can’t!

In his emotional letter, he accused that dentists insist on being called doctors and wear doctor’s coats carrying stethoscopes and that we know little or nothing about the wider spectrum of medicine. Doctors make people healthier. When people get sick, or in pain, doctors figure out why, do tests to see what is wrong, and give them medicine and other kinds of treatment. Dentists are equally doctors; doctors of dental medicine, specializing in the region of head and neck. During undergrad, we were taught of all basic medical sciences, from anatomy to physiology, pharmacology and more. There is a need for dentists to know all that because the mouth has a connection to the guts through the esophagus, and to the lungs through the trachea. Whatever that is in the oral cavity has the likelihood of transferring to the whole gastrointestinal system. And subconsciously, people are at risk of inhaling bacteria into their lungs and that can bring to diseases if the bad things pass through. The neck connects the head to the body. Blood vessels in the head and neck drains directly to the heart. No dental patients coming in to dental clinic leaving their body and limbs at the medical clinic. Isn’t that common sense already? One a medical doctor should have known.

In addition, dentists are at a closer contact with patients because commonly, dentists treat diseases in their mouth, a very narrow part of the human body but the number one home of bacteria. Dentists wore white coats to protect themselves from this infectious air spray during treatment. With regards to carrying stethoscopes, dentists, usually those oral surgery specialists, they are usually involved in surgeries in the OTs, repairing clefts, fixing fractured facial skeleton, marsupalizing large cysts, sectioning bony tumors and reconstructing the face. And all these surgeries usually require an anesthetist and long hours in the OTs. It is the surgeon’s responsibility to ensure that the patient’s vital status is in good stable condition, hence the need to carry the stethoscopes. One is considered malpractice if did not ensure stable vital status. One is not proudly carrying stethoscope for the sake of respect.

With regards to implants, this particular treatment modality is well known to be expensive, not because a private general dentist blindly charges patients. 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.  It is the nature of implantology itself. This treatment of replacing lost tooth is a new development founded early 20^th century but first successful implant dated end of the 1970s. Implants are expensive because of its technique sensitive to create a biological integration between metal and bone. Plus, titanium is the only metal that can produce integration between bone and implant. Therefore, the type of metal itself is already super expensive. Even then, the cost for dental implants in Malaysia is one of the lowest in Asean.

Implants in the government service are available but limited to specialists only. Even then, these treatments are still as expensive as private clinics. “Medical doctor” also stated that the implantation procedure is an easy procedure done under direct vision. Yes, looking at it in youtube looks easy. Something even a technician can do. Seeing is easier than done. Please Wikipedia this: dental technician. They are a member of the dental team who upon prescription from a dental clinician constructs custom made restorative and dental appliances in the lab. Work of place: lab. They do not have direct communication nor deals directly with patients. They deal with dental materials in the lab, constructing prosthesis. They are not trained to treat diseases in the mouth. Implants are not simply done by GPs. A certificate of Implantology is required for the practice. There are many factors to be considered in implants, the art and science of it. An oral surgeon has to undergo lengthy clinical and hands-on training to become an expert in the field. There are existing ethical bodies to regulate this practice and dentist’s competency.

With that being said, 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 realize is that: “What a dentist can do only a dentist can do.”