Quality & Affordable Dentistry in Malaysia

Anxiety and Pain Control in a dental clinic in Selangor, Malaysia

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Dentists are also better trained in psychology, human relations, pharmacology, pain control, and patient management. We also have many new and sophisticated modalities from equipment and materials to drugs and hypnosis.
Dentists are also better trained in psychology, human relations, pharmacology, pain control, and patient management. We also have many new and sophisticated modalities from equipment and materials to drugs and hypnosis.

Oh why, oh why, did the profession we choose have to be labeled with the reputation for being the most dreaded physically painful ordeal known to man? The jokes and cartoons abound, and some parents and others use going to the dentist as threats to their loved ones. Old fashioned dentistry does have a long and well-documented history of pain and other horror stories. Less known, however, is dentistry’s significant contribution to general anaesthesia, and pain and anxiety control. It is my intent in this article to not dwell on movies such as Little Shop of Horrors, The Dentist, and the like, or any of the other assorted negatives, but rather to show what we have done and are doing to make the patient’s dental experience quite a pleasant one.

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General Anaesthesia History in Selangor, Malaysia

Today, general anaesthesia is as common as surgery and extremely safe. As we all know, it is used most often in hospitals, but it is also used by oral surgeons in the surgery suites of their offices and in like facilities of cosmetic/plastic surgeons. But, in general and specialty dentistry, other than oral surgery, it is needed, requested, and used less and less. Why? The public is better educated and informed, and it is a rational public that makes up the majority of our patients. Dentists are also better trained in psychology, human relations, pharmacology, pain control, and patient management. We also have many new and sophisticated modalities from equipment and materials to drugs and hypnosis. We will delve deeper into these issues throughout the remainder of this chapter.

An Informed Malaysian Public in Selangor, Malaysia

Modern dentistry has been around for some 150 years. With the opening of the Baltimore College of Dental Surgeons in the mid-1800s. a new age was born. No longer did we have to go to physicians and even barbers to receive dental treatment. From that time, dentistry has become an exact science, coupled with artful eyes and hands. The public today knows that dentists and dentistry have acquired an enormous amount of credibility, and this is reflected in polls which evaluate the history, integrity, and respectability of the various learned professions. Much has been written in various magazines and newspapers, especially those publications which deal with prevention, health, glamour, and beauty. The desire to be healthy and look our best has captured the world, especially Malaysia. With our desires firmly in place, we look for answers from some of these same publications, television segments, dialogue with friends and family, and from our dentists themselves. As dentists, we feel proud to share the information that we have about those fears, because we are so confident of our ability to control them. I can personally cite many cases where my patients were so nervous at the initial examination that they could hardly speak coherently. By the third or fourth treatment appointment, after having been shown that contemporary dentistry was not going to hurt them, they became relaxed. Many have fallen asleep during treatment, some with absolutely no medication, local anaesthesia, or nitrous oxide (gas). They had simply become believers, never again to lapse into their former phobias.

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Completely open and meaningful conversations at consultation appointments, before any dentistry is attempted, can and usually does allay the many concerns of the fearful patient. Thus, many childhood experiences with “bad dentists” can be explained and understood.

Contrasts can be drawn between then and now and patients can easily see the differences in dentists, staff, facilities, and equipment. I’m not saying that most dentists of yesteryear were pain mongers, but a few were insensitive; and it only takes one if he was your dentist. Most dentists then, as today, were serious students of their profession, but our knowledge and technology simply had not progressed to today’s sophisticated standards.

Malaysian Dentists’ Training in Selangor, Malaysia

Malaysia Dentists today are trained differently, starting all the way back to dental university, and more than ever, great emphasis is placed on psychology and human behaviour. It is, of course, widely recognised that it is essential to be a competent and skilled technician, but that alone is not enough.

Patient management is paramount and many courses on the subject are incorporated into the typical dental school curriculum. Post-graduate courses typically offer courses from intravenous sedation (IV) to hypnosis. The in between courses include oral sedation, the regularly used local anaesthesia, and even neurolinguistic programming. We attend conferences all over the world for specific course disciplines to learn the fundamentals and the scientific foundation that make them work. We then learn the practical applications, and finally, before returning home to our practices, we quite often have a hands-on opportunity to use those techniques under close instructor supervision. As you can see, this is quite an advancement from the days of merely asking our patients to “open wide and sit still.”

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Treatment Modalities in Selangor, Malaysia

Over the years, we have discovered that one of the greatest barriers to dental treatment is the fear of pain and discomfort; we have made careers of assuring our clients a happy, safe, and pain-free environment. Below is an outline of the current methods used to insure that all patients have comfortable dental visits:

I. PRE-TREATMENT

• If you have any sort of heart condition, a history of rheumatic fever, prolapse valve, joint or other replacement, you will be pre-medicated with an appropriate antibiotic. Let your dentist know if any such condition exists.

• Patients too anxious about treatment can be provided with very effective tranquillisers that will help them follow through with their needed treatment.

• For individuals who are super-sensitive to dental procedures, appropriate analgesia (pain killers) can be administered to ensure no discomfort during this treatment.

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II. DURING TREATMENT

After being properly prepared using the protocol described above, patients may be administered the following, if appropriate:

• Nitrous Oxide (laughing gas). Only upon request or if your dentist finds it desirable for you.

• Topical Anesthesia (an ointment applied to the area that is about to receive the dental injection). This makes the area less susceptible to dental pain from the injection.

• Local Anesthesia. This is the “novocaine” that will be injected at the site where the topical anaesthesia is used. (Today novocaine is rarely, if ever, used. We now use primicaine, carbocaine, and several other newer generations of highly effective local anaesthetics.)

• Tender Loving Care (TLC). A well-trained staff will always be there to help alleviate all of your anxieties, fears and trepidations. They want you to have a pain-free, anxiety-free, and actually enjoyable dental experience.

• High-Tech Revolution. Many dentists have or will soon have newly developed and highly successful and proven high-tech equipment that will make many procedures even easier, faster, and totally pain-free-even without injections. Two of these gems are:

1. Micro-Abrasive Cavity Preparation Systems: This technology works on the principle of pressurised air, directing very small aluminium oxide particles into the decayed area of a tooth and removing the carious lesion. In over 90% of the cases treated by this method to date, no needle or anaesthesia was necessary or used; and in all cases, there was no noise, no drill, and no pain. Exciting!!!

2. Electro-Anesthesia: This system connects the patient via electrodes to electro-anaesthesia equipment. (Cedeta is the brand name of one of these devices.)The patient controls the amount of electric current required to gain the necessary anesthetic effect. Reports show this to be completely effective in over 50% of the cases where applied. Again, no needles are required.

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III. AFTER TREATMENT

• Antibiotics (to control infection): These are continued or prescribed when indicated.

• Pain Killers: If there is any chance at all that patients might experience any post-operative pain, they will be prescribed the appropriate analgesia. This works, by far, the best before the anaesthesia wears off.

• Anti-Inflammatories: If the possibility of swelling (a rare occurrence indeed) is diagnosed, patients can be provided an anti-inflammatory medication to help control it.

• Occasionally, when procedures dictate that swelling will follow, you are asked to apply ice to the affected area for a few hours, so the swelling will be minimised.

In summary, these ever-evolving new technologies really do work and are virtually safe when administered properly and with the practitioner’s vigilance. Dental patients can indeed be worry-free about anxiety and pain and, after a few visits, may actually look forward to future visits. It’s been a long hard road to get to where we are today, but the future looks even better.

The Exam, Treatment Planning, and Treatment Conference Process in Selangor, Malaysia

You have finally decided it is time to institute a dental program for yourself or your loved ones. You have selected a dentist that you think will meet your requirements. You believe that once your treatment is completed and you are personally instructed in home care, that your fear of infection, dental pain, and anxiety are, at least, temporarily alleviated.

You made an appointment a week ago and now you are actually walking in the door of a dental office. Just opening the door causes a sweat to break out on your forehead and chin. Your mind is confused and frayed, but you pull yourself together enough to report to the receptionist and introduce yourself. In all probability, she is friendly and sincere, and conveys a feeling of relative tranquility to you. You rapidly connect and you begin to feel comfortable. She hands you some forms and questionnaires to fill out and explains what the day’s exam will be like.

Now you are really feeling at home and since she has told you that no treatment, needles, drills, or pain will be forthcoming today, you are really trusting her. Wishful thinking perhaps, but still, that is the feeling that comes through.

You are seated comfortably, filling out your forms. Perhaps your new friend has served you a beverage and you are beginning to feel more like you are at a boutique than a dental office. After you complete the paperwork, you have a short interview with her. She reviews your health history and past dental experiences, and goes over financial and insurance information with you. Now, you are so relaxed and comfortable that you can hardly wait to see if the rest of the visit is going to continue as non-threatening and pleasant. Well, it does. She brings in the dentist to greet and meet you and her warm, broad smile engages you with a genuineness you thought came only from the clergy. You exchange niceties as you get to know each other a bit. Then, she also reviews your health history, paying particular attention to any abnormalities, allergies, or medications you may be taking. And, if you have had a history of any serious ailments, she will query you further so she can be sure to institute the necessary precautions at your future treatment. Next, she will focus on your dental history and ask you what specific concerns you may have and how she can address your individual needs. After you both feel you are communicating well and are able to understand what you want and what she has to offer, you will both walk into the exam room.

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The Dental Examination in Selangor, Malaysia

There, a comprehensive oral exam will take place. First, the outer surfaces of the face will be observed for any abnormalities, especially any suspicious looking lesions that might be skin cancer, such as basal cell carcinoma. If any, the doctor will dictate these to the dental assistant to make the appropriate notes on your dental health chart. Next, she will palpate aggressively the areas under your lower jaw bones, with her gloved hands to see if there are any abnormal lumps, bumps, or growths. She will then move to the areas just in front of the ears and ask you to open and close a couple of times. She is feeling for any abnormal movements, clicks, or snaps and observing if there is a direction to either side when your opening occurs. She will then ask you if you notice any clicking, snapping, popping, or noise when you open and close, and also whether you have any history of chronic headaches. These are all indications of temporomandibular joint dysfunction (TMD). Again, the dental assistant makes the appropriate remarks in the dental chart.

At last, it’s time to open your mouth and have her look inside.The inside of the lips and cheeks are closely examined as is the roof of the mouth, both the hard and soft palate. The tongue on all of its surfaces, the floor of the mouth, and the anterior (front) and lateral tonsiler pillars also are observed. These are the areas just in front of and to the outer sides of the tonsils. She will have you stick your tongue out and say “ahhhh!” This allows a good look at the tonsils themselves and the entrance into the throat. While a dentist’s providence is from the vermillion boarder of the lips (the thin-line junction between the outer, more textured and thicker, skin-like portion of the lips and the inner, thinner, smoother, pinker portion) to the tonsils, we still need to examine these extreme positions. 

The reason is that we must be ever vigilant so that we can refer problems to our physician and specialist colleagues. And, of course, if we find areas of concern in any of the dental areas just mentioned, we, as general dentists, will most likely refer the patient to an oral surgeon or oral pathologist for further evaluation and study.

Next, she is going to closely examine your occlusion the way your bottom teeth fit and interdigitate with your top ones). She will classify your dental occlusion as a I, I, or III. This means that if you are a class I, you are dentally normal. If a class II, your lower teeth set back from your upper teeth relatively too far. And the opposite is true for a class III, where the lower teeth protrude forward too far. There is a second I, IL, and III classification that relates to the skull or the skeletal occlusion. Rather than these relative positions for the teeth, they are related to the relative positions of the lower jaw and the upper jaw. This can be determined with extra-oral (outside the mouth) full skull lateral radiographs known as a “cephelogram” and their subsequent pencil tracings, highlighting anatomical land marks and analysing various planes and angles. This technology is most often used while diagnosing orthodontic problems and solutions. While considering your occlusal classification, she will also observe whether you have any wear facets (small or larger areas of the teeth that have been worn down, probably by tooth grinding). If so, she will be considering if this is related to your occlusal classification or any malfunction of the previously evaluated temporomandibular joint (TMJ).

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Ah ha! She is going to look at your teeth now. Well, almost, but there is one more thing to do and that is a thorough periodontal evaluation. This begins with a general overall observation of the gingival tissue (gums). She classifies the colour and the texture of the gums. They should be a pinkish colour, not red and not orange. People of colour may have more melanin pigmentation in the gums to various degrees. The texture should be stippled, like the appearance of the surface of an orange peel. The areas in between the teeth should be small triangular extensions of the gum around the teeth. She will probe the gums with a thin, rounded instrument called a “periodontal probe.” The portion going into the crevice between the gum and the tooth is marked in one millimetre increments to give the dentist an accurate measurement. It is placed parallel to the long axis of the tooth and generally moved inward until it stops at the point where the gingiva is attached to the tooth. This distance is generally one to two millimetres under the visible gumline in a healthy mouth. If the distance is found to be two to three millimetres, a conservative treatment will be considered. Three and one-half to five millimetres will require more aggressive, but probably non-invasive, treatment; cases of more than five millimetres may require surgery. Also, upon probing a healthy mouth, we will not find any bleeding points or puss areas. Just remember, as gross as it sounds, people with even moderate periodontal disease have blood and puss in their mouths all the time.

If your gums are fairly well infected and at risk, she may do a complete periodontal probing and charting right now at this first appointment. This requires 192 areas if you have a full complement of teeth, including wisdom teeth. Six areas on each tooth are measured, three on the lingual surface and three on the facial surfaces. (See figures 6.a through 6.f.)

Now, finally, it’s time to look at your teeth. She will go through your entire dentition, tooth by tooth, and call out to the assistant who is charting everything graphically on your record. First, she is calling out existing conditions, such as fillings, crowns, bridges, root canals, and the like. The second time through, she calls out treatment necessary, such as broken fillings that need to be repaired, cracked teeth, decayed teeth, and teeth to be replaced. If a tooth looks suspicious as to its vitality or if it is super-sensitive, she may test it with a pulp tester to get an idea of its relative vitality. Some dentists test all the teeth with a vitalometer (pulp tester).

Photographs, both extra-oral and intra-oral, may be taken next. This is usually done with a 35mm camera which enlarges the size of the teeth significantly (1:2 and 1:3). This aids the dentist in the diagnosis but, more importantly, helps the patient see and understand his problems at the next appointment, the treatment conference. If the office has an intra-oral video camera, that will probably be used instead, as hard copies can be done on the spot. 

Diagnostic casts (study models) often are made at this point. Impressions are taken of each of your dental arches, then plaster or a harder artificial stone is poured into these negative re-creations of your dental arches to make models simulating the positive dental arches. These are later separated from the impressions, trimmed, cleaned up, and used as still another aid in diagnosis and patient education. They are particularly valuable in cases with missing teeth and malocclusions. They are always taken as part of the permanent record in orthodontic cases.

Now, let’s see what still remains to be done. How about radiographs (x-rays)? You will have either a full series of intra-oral radiographs which usually number 14 (figure 6.k). In many cases today, you will have an extra-oral panorex (OPG)  taken instead. In either case, you will have an additional set of four intra-oral bite-wings (figure 6.m). These are what show areas of decay and defects between teeth, where they meet one another.

The advantage of periapicals over a panorex is usually one of clarity, especially when evaluating periodontal disease and lesions or pathology at the ends of the tooth roots. These usually take the form of periapical abscesses or cysts.

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On the other hand, the panorex-type (OPG) shows all the anatomy in wider detail and helps evaluate risks and landmarks, such as the maxillary sinus and mandibular canal. This can have serious implications when evaluating the removal of third molars (wisdom teeth) or the potential for placing successful implants.

This, in all likelihood, completes your initial comprehensive oral exam. You will be reappointed for your treatment-planning conference. In the meantime, your new doctor and her staff will be preparing all your materials gathered today, so she can study and evaluate these to prepare a successful treatment plan for you.

Treatment Planning in Selangor, Malaysia

The staff and doctor have quite a bit of work to do now that the information has been gathered and the patient is gone. The staff will develop and mount the radiographs. The film will be processed if taken by a 35mm camera. The impressions will be converted into models and all charts, records, graphics, models, radiographs, and photographs will be placed on the dentist’s desk for evaluation and treatment planning. There are complete dental text books written on this subject alone, so I will not be presumptive enough to present this one short passage as an authoritative study. But, in a nutshell, what most dentists attempt to do is to establish a treatment plan that will work for you. Most of us are very serious about our career and our patients. We are also sensitive to criticism and rejection and so sometimes a complete treatment plan may be omitted because we don’t like to hear “no.” But, we do have an ethical and moral obligation to provide you with enough information and options so you can intelligently decide which of the various alternatives are best for you. We call this, “informed consent,” and it is important that we inform you of the alternatives with all of their advantages and downsides before you give us your consent to proceed.

The one point I want to emphasise is that it is a fine line between under treatment and over treatment, but most of us try our level best to find that level of optimal health, function, comfort, dental longevity, and aesthetics. It is important to most of us to do all of that and still not perform unneeded procedures.

We must, at the very least, help our patients to rid themselves of all disease and infections of the mouth. This includes all decay, whether new or under old restorations. It includes getting rid of infection in and around the teeth, such as periodontal abscesses and cysts; and it includes getting rid of infections around wisdom teeth and often the wisdom teeth themselves. Also, it means freeing the gingiva of all inflammation and infection. If the bone is affected with infection, that too must be treated. If economics make this task very difficult, we still need to get rid of all the decay, even if we must place temporary restorations for awhile.

The less advanced gingival and periodontal problems can be handled by conservative, less expensive techniques; but the final responsibility for this will be with the patient. His home care commitment is what is really going to count in the long run. If he has moderate to severe periodontal disease and there is no financial way that he can obtain the necessary treatment, the dentist will consider referring him to a dental school, other teaching institution, or a welfare clinic.

We have just discussed the basics, but the treatment planning will also include the ideal dentistry that can be provided. What are the best restorations for each situation? Should orthodontics (straightening the teeth) be done before restoring the dentition? Is TMJ therapy indicated? How about opening the bite? Are there any other aesthetic considerations? In short, what can I, as a dentist, do to help this patient to the optimum?

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After all these things have been considered, it is probably best to have alternative treatment plans available. None of them should diminish quality in any way. It’s best if each can be built upon in the future without having to do anything over that which has already been treated. We, sometimes, call this “phase treatment.” An example of this would be the financially challenged patient just referred to. We would eliminate all decay and defective fillings and place temporary restorations. We might extract any infected teeth and cleanse the socket areas. We could refer the patient to a teaching institution to handle his periodontal problems. Then, we would place him on a three-month recall system to carefully monitor his progress and compliance. A second phase could include converting his temporary fillings to permanent ones. Then, a third phase might be orthodontic treatment, followed by phase four to replace all the missing teeth. And finally, a fifth and final phase might be placing porcelain laminate veneers on the facial surfaces of all the teeth that show when he smiles his biggest grin. In this way, a patient’s dental health is never compromised. Rather, each and every phase is built upon to enhance the previous one at the patient’s rate and comfort zone. This is non-threatening and allows the patient to plan and goal set for his future dental health and aesthetics.

The dentist has now considered all these interrelating scenarios and has written up the treatment plan or alternative treatment plans including phases. It’s now time for you to come back to the dental clinic so the dentist can share this information with you and you can then intelligently decide on your own course of action.

You arrive for your scheduled planning conference. You may have a special confidant with you -a spouse, parent, offspring, or friend. They may be more objective and help you to understand your alternatives. In addition, they will be hearing all about it firsthand and with all of the visual aids present.

The dentist, one of his assistants, you, and hopefully your closest other will be seated in a conference-style room. Your radiographs will be mounted and on a view box with back lighting. Your diagnostic models and photographs will be laid out in front of you and, of course, the dentist will have your dental record, complete with charts, graphics, and a treatment plan in front of him. The dental assistant’s job will be to take further notes and, if appropriate, offer the patient further assurances from her experiences that the treatment will be comfortable and pain-free. Your friend will just be there to support you, but will be welcomed to ask questions and enter into the discussion. Now it’s time for the dentist to outline for you your existing conditions. He will explain this in terms that you can easily understand

He may have pictures or models of actual restorations that are similar to those that are proposed for you. He probably will tell you that you can proceed at your own pace and comfort level. If you want cosmetic dentistry after all disease is climinated and you don’t need any lengthy orthodontics or bite-changing procedures, he may tell you he can do it in a matter of days or weeks. But, if the more lengthy procedures are necessary, it may take months or even a couple of years. Still, you are in control of the expediency desired. The dentist’s only limitations are those imposed by necessary longer procedures.

Once you understand your alternatives and make your choices, the doctor will formulate a treatment schedule that contains the length of time for each appointment, amount of time between appointments, and what the appointment is for. He will hand this schedule to the dental assistant or patient coordinator and she will then get you on the dentist’s schedule according to your availability.

You will have discussed fees with the patient coordinator or clinic manager prior to making your final decision. All that is left now is for you and her to finalise financial arrangements that you both can live with.

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If pre-medication is necessary, a prescription will be written and given to you. You will be given very specific instructions and asked to follow them to the letter. I hope, by this time, you feel confidence in your decision and your new dental home. The treatment ahead should go quite smoothly and you will reap many rewards as each step or phase is accomplished. These will come in the form of mental assuredness, emotional tranquility, physical comfort and health, and improvement in self-esteem and self-confidence. Congratulations! You are on your way!

Mesial lingual, surface.
Mesial lingual, surface.
Mid-lingual surface.
Mid-lingual surface.
Distal lingual surface.
Middle facial surface.
Middle facial surface.
Mesial facial surface.
Mesial facial surface.
Distal facial surface.
Distal facial surface.
Photograph from intra-oral camera.
Photograph from intra-oral camera.
The impression.
The impression.
Pouring plaster into the impression.
Pouring plaster into the impression.
The finished models.
The finished models.

Full-mouth series of intra-oral radiographs.
Full-mouth series of intra-oral radiographs.
Extra-oral panorex radiograph. (OPG)
Extra-oral panorex radiograph. (OPG)
Bite-wing radiographs.
Bite-wing radiographs.
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