LESSONS LEARNT FROM TODAY'S CLASS

Well, let's look at what I have learn on one fine Thursday afternoon.

THE TOPIC OF TODAY is "FACIAL INJURY and MOTOR VEHICLES ACCIDENT (MVA)"

MVA is so common in Malaysia because of the rate and number of road traffic accidents in Malaysia is on an alarming high. Dozens fatality occur each day and it makes it to around 7000 each year. Press those throttle speed and move your car to above 110 kmph, but be aware, that even at modest speed of 60 can kill you once an impact occurs.

Much said, MVA, along with assaults and domestic violences, are one of the three most common attributors for facial injury (or maxillofacial trauma). Maxillofacial trauma involves fracture of bony structure of the face bone, bleeding into the tissue and may eventually lead to less commonly severe life-threatening conditions. From the aspect of MVA, my lecturer suddenly talks about the differences in local and imported car. He reasoned that types of car can influence the type of severity in injury and prognosis.

Imported cars - with the names like Mercedes, Honda, Toyota and so on has flourished in our streets for ages. The same goes with our national cars of Proton and Perodua. Automobile industry in Malaysia is still relatively new and any high technology engineering incorporation will takes time. Its been 3 decades but the impact of such booming industry was so imminent. In general perception, a middle class will buy a local product while the rich can go with an AP (Approved Permit) and to grab one of those fancy imported car.

Now for comparison, let us look at a Mercedes 230C and a Proton Perdana...some of those popular classy sedan vehicle of all time among the Malaysian. Mercedes 230C can be bought at a price of exceeding RM 350k while a Proton Perdana costs around RM 100k. Now as a Malaysian with an ordinary salary of RM 3k per month, which one would you buy? It is easy to say that one will pick the Proton Perdana for its cheaper price tag.

Well, let us go deeper.

• In Malaysia, the local automative industry was well-protected by imposing strict and higher sales and import duty on the imported cars. 200% import duty and you will get a Mercedes 230C at a price of RM 350k, whereas the real price for it is USD 40k or about RM 150k.
• In overseas, people usually do not buy cars, either first or second hand via bank loans. They usually buy their cars via direct full cash payment. However in Malaysia, loans are available everywhere and it makes any Tom, Dick and Harry can own a car. Now the problem of finance and debts, Malaysia has a high amount of car-loan debt in the world!!
• There is some question why AP is such an issue. You can freely imports a car. Not surprisingly, some civil servant can even afford such a car. I wonder where they get their finance to support their ambition. Corruption or ah long?
• The imposing of seemingly unfair price over the same types of sedan has created an unfair environment of both cars to compete in the market. with the consumer power with an average incomes, it seems that as easily predicted, one will prefer Perdana over a Mercedes because it is cheaper. With such, the local car manufacturer will have an upper hand of advantage with more sales and profit compared to the imported one. Thus, the market value becomes uncompetitive for the locals.
• Local cars are not that local anyway. Technology from overseas, components from overseas but been assembled locally. That is what defines it as a local made car?
• Due to lack in competition, one can easily sees a decrease in quality making of the subsequent batches of car. Proton over the years, have trouble in producing such a good-quality car. In its earliest years, a Proton Saga is like a Mitsubishi engine contained in an aluminum body work! Because of the quality issues, safety issues will arise.
• To proof this, I have an experience when I was in my brother-in-law's car few years back - his 90's batch of Proton Saga. Upon the traffic light, the Proton Saga slowed down as the light had already turn red. Out of nowhere...."Boom", and looking at the front mirror, a Mercedes at the back with its handsome driver on his mobile phone on one hand and a document on one hand (I wonder how he drive) hit the bumper of our car. It seems like he was not able to stop his car in time because he is apparently busy. Now, with such a light impact, guess which car suffered more damage?
• Another proof of safety concern, there was a test in the past where we have an experiment to see at which car can brakes into zero in the shortest time. Again, a Proton model with a Toyota model. Not surprisingly, Toyota can brakes into zero in a shorter time than a Proton, enough for it to stop and to avoid an experimental cone located 200 metre from its starting point.
• Now for most of us, a car can be troublesome, besides of its price and difficulty to endure a city traffic jam. The option is a motorcycle. Now, you do not need to be a genius to figure out how dangerous this vehicle with no surrounding barrier to protect you from a direct impact in an accident. You can easily fly a few dozens metre once get bumped over by a car.
• In a car accident, you either survive with minimal injury, or get killed...less likely a severe injury.
• In a motorcycle accident, you either survive with very bad injury or an instant kill.
• Not surprisingly, with the fact that a low quality cheaper cars and million of motorcyclists roaming on the streets across the country, now you know why MVA is so common.

Was it hard to figure it out!! Once my lecturer touched on this, it becomes clearer to me now!!

WHY QUIT SMOKING NOW?

Smoking is a pleasure for some people and for others it is a symbol of elegant, coolness and so on. However, many realize the dangers behind smoking, yet, the number of smokers continue to rise every year. It is estimate that 1 in 5 of us smokes. When 28 million Malaysian are been used as a data, now you got 5.6 million smokers in Malaysia alone; while it reaches more than 1.4 billion worldwide.

Once you light up a cigarette, the heat helps to release thousands of chemical compounds in the list of name such as carbon monoxide, hydrogen cyanide, nicotine, tar, at least 43 carcinogens and numerous mutagens. Carcinogens are agents that induce the process of cancer in our body and mutagens are agents that induce mutation of genes in the body.

Nicotine is found naturally in tobacco leaves as an alkaloid that used widely as an insecticide in the past. With low concentration in a stick of cigarette, it reaches the brain in within 10 seconds and full body after 15 seconds upon inhalation. Nicotine raises the blood pressure, heart rate and increase alertness and relaxation. However, once the nicotine level dropped, smokers will take another stick to hit the desire, thus the need for maintaining the kicking level causes addiction.

Tar in the cigarette similar from those used to pave the road! Tar tends to accumulate on the branchial tubes leading to the lungs and burn the tiny hairlike projection of cilia that trap harmful particles before they enter the lungs. Thus, the chances of getting lung cancer is high.

Carbon monoxide is a poisonous gas that quickly absorbed into the blood to reduce oxygen capacity. Therefore, smoker has to exert more physical effort to attain a task than non-smoker, causing heart to work harder. The gas also causes vision impair, impairing perception of time and coordination.

So, why not stop smoking? Over the years of research, many points out the great benefits from smoking cessation. In dentistry, we also deal with cases that need smoking cessation in the clinic. Below are the good effects of quitting your cigarette packs.

WITHIN THE PERIOD OF STOP SMOKING

20 minutes Blood pressure, pulse rate and temperature of hands and feet return to normal.

8 hours Nicotine level is now fallen to only 6.25% of normal peak during smoking.

12 hours Blood oxygen level returns to normal.

24 hours Anxieties peak but should normalize within 2 weeks - this is the most critical part, where success depends on this 2 weeks period.

48 hours Damaged nerve endings start to regrow while your smell and taste return to normal; anger and irritability peaks.

72 hours Breathing becomes easier and lungs functional abilities increase with 100% nicotine-free and almost 90% of its by products should have been passed down via urine; symptoms of chemical withdrawal syndrome like restlessness peak.

10 to 14 days Recovery is likely where addiction no longer in place; blood circulation to gum and teeth normalize.

2 weeks to 3 months The risk for heart attack starts to drop and lungs functional begins to improve.

3 weeks to 3 months Blood circulation improves substantially and any chronic cough would have disappear.

1 to 9 months No more fatigue and shortness of breath; cilia have regrow to help to keep your lungs clean and reducing risk of lung infection.

1 year Risk of coronary heart disease dropped to half of a smoker.

1 to 5 years Risk of stroke declined to half of a non-smoker.

10 years Risk of lung cancer declined by half of an average smoker

15 years Risk of coronary heart disease is now that of a person who never smoked.


SO STOP SMOKING NOW. IT'S NEVER BEEN TOO LATE.

Source: http://whyquit.com/whyquit/A_Benefits_Time_Table.html, http://en.wikipedia.org/wiki/Nicotine,

DENTINAL HYPERSENSITIVITY

You are enjoying a craftly delicious ice cream that you have just bought from the store. It looks so tasty and tempting, yet you want to savour the moment first. Then, you took the first bite. Alas! A sudden short and sharp pain struck your teeth and you feel irritated by it. Fortunately, the pain did not last long. Now, you take the second bite. Ouch!! The cycle repeats again.

The scenario is so obvious as many may have know that you possibly know what is wrong with that. In general, this condition is known as teeth sensitivity. In more scientific approach, this condition is called dentinal hypersensitivity.

Dentinal hypersensitivity is a short, sharp pain upon stimulation of cold or hot food and environment. It has several degree of pain which may range in between irritation all the way to shooting pain, depending on individuals. This condition affects most on young adults around the age of 20 to 40, with more on female. It affects roughly a third of all adults in Malaysia.

There are many possible causes for this condition. The most popular acceptance is that the dentine area of the tooth, which located inner of the outer layer enamel. Once the dentine has been exposed to the oral environment, there are direct connection between the nerves inside the pulp and the surrounding. Next, you must have a trigger. Most commonly hot, cold, sour and sugarly food; air pressure and physical biting force can cause the condition.

According to the famous Brannstrom's hydrodynamic theory, dentine area is not solid in composition, rather it contains numerous tunnels that connect right into the pulp nerves. These tunnels or also known as dentinal tubules contains liquid that travel into the nerve receptor. Once food or stimuli acts on the tooth surface, there will be disturbance on the liquid, a hydrodynamic flow and disturbance will trigger the nerves in it. Therefore you have pain.

The other causes can be due to excessive force inserted on the teeth when brushing. Brushing too hard can cause not only gum bleeding, but also erosion of the tooth surface. Decaying teeth (caries) or any root tooth expose can lead to the condition.

There are many ways to treat this condition, where most popularly, any dentist will recommend you Sensodyne. [visit the web here]

In the market there are various types of Sensodyne toothpaste that will do different actions to stop different cases. The most common product is in fact the SENSODYNE ORIGINAL. It was the first ever Sensodyne product, helps to seal a layer of protection against pain from hypersensitivity. It contains strontium chloride which helps to seal off the tubules, thus relief the symptoms better. It is used daily for teeth and gum health maintenance It also has potassium nitrate that helps to desensitize the nerve ending.

What I Got From This Week

This morning (on 08/01/09), I was in this cold-refrigerator-room. Well - not really, but that is what Dewan Kuliah 4 (DK 4 in short) is always been referred as. DK 4 is a super-duper cold lecture hall in my campus, as if it gives you some kind of cold environment, similar as if like you are studying in England. Anyway, back to the business on what I learnt on this week.

One: I found out that one of my lecturer have read my blog before and I'm wondering on what occasion was that. She is an expert in endodontics. She was mentioning something about this website called Nicenet, a website dedicated to encourage more interaction and intellectual discussion between students and teachers, regardless of age, level and background. Suddenly she looked straight at me and said, "Yeah you as well, I have been to your website (meaning this blog) before. So how long have you been writing it?" I was startled but I was still able to give a simple answer, "Since two years". Then the other eyes inside the hall were either staring at me as well or giving me some surprise look. You see, since I started this blog, I have never introduce, advertise or promoting it within my fellow course-mates.

Two: I found out that been a dentist is not human enough. While pointing out the lecture slides that discussing on how to take a proper history on a patient, she also said,"You guys as a future dentist should be more 'human'." This is not the first time I heard of such statement. All these while, dentist is not been like a normal person when they try to communicate or examine their patient which indicated that we are not so 'human' at all! Taking history from a patient may seems troublesome but that is how we derive a proper diagnosis, treatment and prognosis. History taking requires a substantial amount of knowledge, good communication and examination.

"You should be like Sherlock Holmes or just nice to be like the CSI," she added later. It is true, the concept of investigation and examination are important in dentistry as an overall. Sometimes we do misdiagnosed a certain disease or condition because of lack of information, improper technique and so on. This does not only applied to myself but also to others. Been a human does not made you perfect. Sometimes we do made mistakes but all of these are part of our life. Therefore, I believe in that we should prepare ourselves even in what ever we do. But in a nutshell, does been a dentist seems 'inhuman' enough?

On the next day, I have a clinical session. 

Three: I came across a patient with tooth crack syndrome. She complaint of the tooth (47 - Lower right second molar) been in pain while biting but relief after release the biting. Therefore, she felt very uncomfortable when eating. There is a large tooth-coloured (composite) filling on that tooth that is large and extended from a side to another (Mesi0-occluso-distal) restoration. My partner and I conducted a few examination over her problematic tooth.

First, a radiographic features a widening of PDL area with no signs of caries and dislodged previous restoration seen. Following pulp sensibility testing reveals the tooth is still on vital with delayed exaggerated response to electrical pulp test, suggesting a dying pulpal tissue. Last but not least, we applied a blue-coloured dye called Canal Blue which detects the crack line on the tooth.

Treating a cracked tooth is not simple. The list of treatment options are as follows - crown, root canal treatment or removed the tooth. But we just leave her tooth untreated since she does not have much time and seldom came for an appointment. She also refused a molar band around the tooth to protect the tooth from further cracking. What I learned from this case? Simple, people will never visit a dentist if he or she feels nothing wrong about it, at least YET!!

In next post, I would like to discuss a matter that one of my reader did complaint about her difficulties she had when she done a dental treatment under my junior last time. Well, another classic example of tales from people undergoing dental treatment!!

A Day In Paeds Clinic

Today is 23th December...meaning the clock is ticking even closer to the Christmas day itself. It is only 2 days left on the calender, yet the mood for some holiday season had already begun since like last Friday. Today I have a great time in the children dental clinic since today it is my turn to be there and I have an appointment with one of my children. Due to medical and legal etiquette, I will not post or upload any pictures of the clinic itself here. Just let the words tell it all.

I have an scheduled appointment with one of my patient today. His father brought him a bit late than usual and requested me to deal with their son's carious teeth. Since this is my first time encountering him, I was surprised that the child had some sort of genetic disorder disease. No matter what the child had, it was my responsible to treat his case too.

I never heard of the disease and it did nothing to ring any of my bells because simply because I never learn it before. The child is 6 years-old, a happy-go-lucky boy but unfortunately suffered from a rare genetic disorder called Noonan Syndrome. This disease is not fatal and does not possesses any harm to the child himself. during the treatment, he seems to be not in any state of anxiety but as time goes by he get a bit tired and irritated, as in all case of children that attends the dental clinic.

I managed his carious front tooth for about half an hour and then before he left, I gave him some cookies and water for him and his siblings. Watching them left, I felt the warmness in their family. Although they may not be celebrating Christmas because they are Indian Muslim, I still think of how appropriate the timing for me to post this up. A family warmness during hard time or great time were shared among all others.

I may not be able to go back during this Christmas but I do hope those who are able to do so to really use the time to reflect on the year that we have just been through. 2008 is raising its curtain soon. So what have your year been? Good or bad are just part of it. Lets look forward for a brand new year.

Today I learnt a few thing:

1) The warmness family relation is what it matters - it doesn't matter if one of them are less unfortunate than the others, the essential part is the familyhood itself. A family endures good and bad time together.

2) Noonan Syndrome is a relatively common genetic disorder which affects every 1 in 1000 to 2500 live births. It is regarded as a male version of Turner syndrome. he principal features include congenital heart malformation, short stature, learning problems, indentation of the chest, impaired blood clotting, and a characteristic configuration of facial features of webbed neck, wide spaced eye and low set ear. These kids are not asked to born in such a way...I really pity them!!

OUCH!! IT'S AN ULCER!!

Ouch!! It's an ulcer on my mouth!!

Ever wonder why on Earth there are always been ulcer here and there on your mouth? Ulcer as defined as the loss of epithelium (skin cells outermost layer) integrity, continuity and thickness, is one of the most annoying things any patient can complained to a dentist. I'm sure you still remember that toothache (pain) as I featured before is quite a common complaint. (Lost? Click here and here)

Scary, annoying but true, ulcer in mouth caused by many reasons. Oral ulcer also known as canker sores in some dictionary. If you are having lichen planus, anemia, immune defect, some hand-foot-and-mouth disease or simply you accidently bite on any part of your mouth (trauma), you are likely to develop ulcer in your mouth. There are a lot more reasons that can cause it, too many that deriving a diagnosis based on causes can be difficult.

Most commonly, ulcers in mouth can be due to these several diagnosis in general:

(1) Traumatic ulcer
As the name suggests, it is caused by accidental biting on any parts of you mouth, let says your tongue or maybe due to eating hot stuff and you get your tongue burned. Usually it heals in within 10 days. You know how to get it heal by yourself - Bonjela!!

(2) Recurrent aphthous ulcer or RAU in short
This is way too common. The annoying thing is that in this features, the ulcer tends to recur again and again, although not on same site all the time, but the recurrence can give a bad experience. Ulcers are painful, no doubt! Therefore pain can persists long enough and may disturbs patient's daily routine.

It doesn't have imminent causes, but likely due to stress, hypersensitivity, autoimmune, hormonal changes and etc. This ulcers can manifest in three forms: minor (small) in a few numbers, major (big) that most likely to be single sore or herpetic (smaller but can fused to become one). Depending on types of RAU, healing can take longer than normal traumatic ulcers.

Treatment of ulcers can be done in many regiments. Steroids, antiseptic mouthwash or antibiotic mouthwash, or even local anaethestic can work to relieve the pain and other symptoms..

And last but not least, some studies say that you can ry to prevent mouth ulcer by taking these food: orange, lime, tomato, nuts, barley, soy and vinegar. Yes, kind of true.

Know Your Common Toothache!! (Part 2)

Our lesson regarding toothache covered the most commonly caries and pulp infection on the first part. This week, I see another three patients complaining the main problem of pain from tooth. The previous sentence means nothing but to tell you that toothache is somehow annoying and very common occur. So beware if the signs of toothache arise suddenly or may slowly creeping in, as it may indicates some problems over your tooth.

Remember this?

Here are the common cause of toothache:

• Dental caries or cavity
• Infected dental pulp that required some form of root canal treatment or extraction (removal)
• Gum disease
• Emergence of wisdom tooth
• Cracked tooth
• Jaw disease
• Exposed root of tooth
• Dry socket following removal of tooth

This part we will look at the causes from the bold one above - Gum disease and emergence of wisdom tooth.

GUM DISEASE

Gum disease in the mild to moderate condition is known as gingivitis. Gingivitis is the inflammation or swelling that occurs around your gum which primary induced by dental plaque. Commonly people with gingivitis will complained of swelling gum, mouth sores or ulcers, severe oral odour, painless gum except when pressure is applied and, bleeding gum occurs easily especially when brushing and flossing. Gingivitis is a preventable disease and curable as well. To prevent gingivitis, make proper oral hygiene that includes toothbrushing and flossing daily. Mouthwash is optional, usually using (saline) salt water or chlorhexidine. If gingivitis is not treated, it can progress to cause periodontitis, a even more severe form of gum disease.

EMERGENCE of WISDOM TOOTH

Wisdom tooth or third molar is not actually wisdom. As wisdom it maybe, as painful it will be to endure the process of it to come out. The reason behind the pain is that it is the last to erupt, having relatively inadequate space to squeeze itself out from the jaw and may have many problems in terms of positioning.

Because of these, the third molar especially the lower one will always cause impaction on the adjacent tooth. Impaction can be classified into mesioangular, distoangular, vertical or horizontal.
Diagnosis depends on the way the position of the third molar, for example...the radiograph below, it looks like the third molar is in a horizontal position in relative to all the teeth. Thus, it is known as horizontal impaction of third molar.

Another problem arise with regards of the wisdom tooth is pain due to failure to erupt completely through the gum bed and the gum at the back of the wisdom tooth extends over the biting surface, forming a soft tissue flap around the tooth called an operculum. Teeth covered by an operculum can be difficult to clean in which allow accumulation of debris which may cause pericoronitis, a common infection problem in young adults with partial impaction.

In removing the wisdom tooth, there are guidelines in which we can determine in which condition we can or we cannot remove the impacted wisdom tooth. The list is in here. So the preferable treatment for this condition is to remove it but the patient should always be aware of the possible complications due to the treatment.

Know Your Common Toothache!! (Part 1)

Toothache can be a very annoying experience and sensation that ones can get. Unfortunately, everyday in my clinic I always see many cases of patient coming into the dental clinic to seek for dental treatment to relieve their toothache. In some stage of our life, toothache may occur due to certain conditions pretty much related to our teeth or general health, where they can be avoided.

Simply looking at its meaning, toothache or also known as odontalgia is the pain of the tooth and around it. As annoying as it is, we should know a little bit regarding its causes, so that you will know what to expect and how to deal about it. For the first part, we will look at the pain due to caries and infected pulp.

Here are the common cause of toothache:

• Dental caries or cavity
• Infected dental pulp that required some form of root canal treatment or extraction (removal)
• Gum disease
• Emergence of wisdom tooth
• Cracked tooth
• Jaw disease
• Exposed root of tooth
• Dry socket following removal of tooth

Dental caries and infected dental pulp are two very common condition. I see it everyday. Some other form of toothache are also caused heart disease (heart attack, chest pain)

CARIES or CAVITY

Dental caries is a very common mouth disease that affected over 90% of the adults worldwide. Dental caries involved damaging the tooth structures that may resulting holes on the tooth. The damage occurs first at outer hard layer called enamel, which then goes into dentin and cementum.

If left untreated, the cavity which mainly contain bacteria will continue to destroy more tooth structures until when it reach the dentin. The dentin consists of tubules that connect deep into the pulp. The tubule is sort of like a tunnel and when the cavity passes through it into the pulp, where the nerves are, the nerve inside the pulp will inflammed or swollen to cause pain. As for this, i recommend you to get it treated by removing the infected caries and placing some filling material to fill the tooth.

INFECTED DENTAL PULP

When the dental pulp is affected usually due to caries process, the pulp will undergoes changes into inflammatory (swelling) status accompanied with pain. The pain is usual because the inflamed pulp cause increase in pressure and the surrounding tissue. The pain can spread to adjacent tooth, thus we may feel pain but confused to pin point the exact pain location. This is called pulpitis.

Pulpitis can be divided into two condition - reversible pulpitis and irreversible pulpitis.

When I get reversible pulpitis?

• When you have sharp and transient pain but does not disturb your sleep
• Pain occurs with taking cold, sweet or sour food
• Caries or cavitated tooth
• Upon examination, the dentist will notice that your infected tooth is not tender to percussion (when the dentist lightly knocking your tooth), respond to cold and hot test, respond to tooth vitality (still alive) and no tooth mobility (loosening)

How we deal it? Simple, we relieve pain with prescribing medication, remove the caries and do pulp capping...we seal the pulp basically.

When I get irreversible pulpitis?

• When you have sharp, throbbing and lingering pain that truly disturbs your sleep
• Pain occurs spontaneously but get worsen with hot, sweet and sour food - some get comfort from taking cold food
• Upon examination, the dentist will notice that your infected tooth may or may not have localized swelling, not respond well to cold and hot test, not respond to tooth vitality (stage of dying tooth)
• and no tooth mobility

How we deal it? Because the tooth is in dying stage, it should be manage accordingly. Pain control, do root canal treatment or optionally extraction (removal). Do forge out more money for the former option and do prepare to lost a tooth for the latter option.

That's all for now...next time...the series will continue with toothache from other causes....