Countdown to my overseas lecture

Countdown to my 1st overseas lecture. Literally via the causeway over the sea of Johor Straits into Johor.

I will be talking about Functional Posterior Composite: Updates on adhesive and layering and Anterior Esthetics Design.

The 2nd lecture will be an interesting one. Digital Smile Design is gaining popularity and I am glad to be exposed to it early in my career. During the lecture, I will sharing with the participants my experience in smile makeover with ceramic veneers and laser gum contouring. My pet topic has always been on management of gummy smile and I will definitely be covering how I combine digital technology with laser gum contouring and botulinum toxin.

To share the stage with Dr Dominic Leung, a very experienced and respected dentist (graduated in 1975), I must say the honour is mine to be invited to Esthetics Dentistry 1.0

Sharing 2 slides from the lecture as a prelude to what to expect during the lecture on 25th November 2017.

Composite lecture and workshop

Concluded my lecture and workshop with Dentsply Sirona on 12 Oct through a clinician's perspective.

During the lecture, the participants were introduced to the fundamental of restoring a good posterior composite. Topics on preventing post-operative sensitivity and tips to a lasting restoration were covered as well.

During hands on, participants had the chance to try bilaminate layering technique for Class II composite.

Can we prevent crooked teeth?

For the longest of time, dentists' approach to crooked teeth is to straighten them. A commonly heard statement is that 4 teeth will be removed before putting on braces to straighten them. And that was exactly my experience when I was a teenager.

After becoming a dentist, I thought about how I can PREVENT my patients and my children from going through similar fate. How can they have a set of straight teeth with a nice smile without removing any healthy tooth?

My son is now 2 years old and bottle feeding has made him susceptible to crooked teeth. In fact he is showing signs of teeth crowding. What are the causes of him having crooked teeth? Is it because he has larger teeth or is his jaw not developing well enough?

“Functional dental growth” explains the situation he is in. Bottle feeding is preventing his jaw from developing to its full potential and his teeth are pushed into an awkward position. The position of the tongue and facial muscles are of paramount to the development of the jaw and positions of the teeth. The tongue and facial muscles sandwich the teeth in the middle. If there are unfavourable forces from these soft tissue structure (sucking of bottle), the upper teeth will be pushed inwards and jaw development will be impeded, resulting in crowding.

In an ideal situation, everyone should breathe through the nose and nasal breathing will result in an expansive force on the upper jaw.[1]  Secondly, the tongue should naturally rest on the palate (roof of the mouth) and not floor of the mouth. Correct positioning of the tongue will help to react against the inwards pressure from the cheek muscle (buccinator). Lastly, the lips should be closed together (competent) to have a favourable inwards pressure on the front teeth to prevent them from protruding forward. With favourable forces, the jaw will develop normally and crooked teeth can be prevented. The ideal position of the tongue and lips are prevented with habits like tongue sucking, mouth breathing, bottle feeding or use of most pacifier.

How does the tongue move differently during breastfeeding & bottle feeding? Breastfeeding requires the child to position his/her tongue towards the palate by pushing the nipple onto the palate to obtain the milk. Bottle feeding often result in the child positioning his/her tongue onto the floor of the mouth to create space for the bottle teat. With bottle feeding, the child will use an inwards pressure from cheek muscle to obtain the milk instead of the tongue. While it is easy to expect every mum to breastfeed her children, in reality it may not be a straightforward choice for mothers. In some cases, the child’s tongue is tied to the floor of the mouth, preventing it from touching the palate.

Instead of using a milk bottle to sooth, a good alternative is Dentistar range of products. Dentistar pacifier is designed by a German dentist and it allows the tongue to touch the palate when the pacifier is in the mouth. My twin babies are using Dentistar Singapore to sooth, to allow their teeth to grow into their natural positions.

In addition, some children are not able to breathe through their nose due to airway inflammation, allergic rhinitis, asthma, swollen adenoids and tonsils. [2] This will result in the child adapting to breathe through his/her mouth, causing the cheek muscle to exert an inwards pressure and tongue to position at floor of the mouth.

Looking beyond crooked teeth, the improper development of the jaws may lead to sleep apnea [3]. Sleep apnea in children is linked to ADHD [4] and in adults it is linked to high blood pressure and heart failure [5].

In the past, crooked teeth are often managed when all the permanent teeth are out. The understanding of functional dental growth allows us to take precaution at a younger age while the jaw is still developing, in the hope to prevent the need for extraction for braces at an older age.

“Functional dental growth” does not explain how we can prevent all forms of teeth and jaw alignment issue. Some cases of alignment are skeletal (jaw bone problem) or genetic in nature which we may not be able to prevent fully at this stage. However, with our knowledge and resources now, we can prevent some causes of crooked teeth, namely from our modern lifestyle and hopefully prevent future generation from having their teeth taken out to create a nicer smile.

 

 

 


Resources

1- Gungor, Ahmet Yalcin, and Hakan Turkkahraman. “Effects of airway problems in maxillary growth: a review”Eur K Dent 3.3 (2009): 250-4
2 - Small, Peter, and Harold Kim. “Allergic rhinitis.” Allergy, Asthma & Clinical Immunology 7.1 (2011): S3
3 - http://www.aafp.org/afp/1999/1115/p2279.html
4 - Youssef NA, Ege M, Angly SS, Strauss JL, Marx CE. “Is obstructive sleep apnea associated with ADHD?” Ann Clin Psychiatry. 2011 Aug; 23(3):213-24.
5 - Jean Louis, Girardin, et al, “Obstructive sleep apnea and cardiovascular disease: role of the metabolic syndrome and its components.” J Clin Sleep Med 4.3 (2008): 261-72

Invitation to Dentsply Sirona Restorative Forum

Thankful for an invitation from Denstply Sirona Restorative to their Restorative Forum in Konstanz, Germany. This is an interesting aspect for my continuous education and unlike previous education where it was only on the technique to achieve better dentistry, the spotlight of the forum   is on the in depth explanation of their material. The forum has allowed deeper understanding on the innovative R&D and unique products from Denstply Sirona. The hands on training on the 3rd day at University of Zurich strengthen the confidence in their product.

I am a big user for their composite material (Ceram.X SphereTEC) and has documented most of my composite cases with this material. The reason behind my choice for this material is the SpehereTEC technology that allow better physical properties and not compromising on the aesthetic outcome of the restoration.

For the patient, we normally use composite as a material to restore or build back the missing portion of the tooth (most often due to decay). Hence it is important for the material to be compatible to the body, good physical properties to withstand the loading from the daily chewing and look natural in the mouth. Video link here.

In the small group of about 18 dentists worldwide with 6 from Asia, most of them are researchers or lecturers in school, so it was interesting experience for me to have in depth discussion about the material with them. One of the participant is the author of a dental material textbook and leading name in field of Dental Material.

 

Hipster guide to Dental care

The time has come when whitening toothpaste and fluoride mouthwash are too mainstream, you are seeking for dental care that is more alternative, less mainstream. You are looking for something more hipster, more you.

Baking Soda
Baking soda in geek language is sodium bicarbonate, which is a form of weak alkali powder. Some have advocated using it to remove stain and whiten teeth due to its mildly abrasive properties. It may be able to remove the stain due to its abrasive properties but wouldnt be able to break down the internal stain that whitening gel removes.

The hispter will use it for another purpose. They will use it to help prevent decay! Hipster or not, all of us want to prevent decay and to some of us a visit to the dentist maybe dreadful. Baking soda with its alkali properties can help to buffer our mouth from the decay causing acid.

Mixing a teaspoon of baking soda with tap water and using it to rinse can help to prevent decay.

Do note, it does not replace good brushing and flossing and should only be used as a supplement to them and not a replacement to good brushing and flossing. Old school brushing and flossing are still essential to prevent decay.

2. Coconut oil
The hipster oil, coconut oil has gained much traction to the hispter community. As a result, its price has also increased many folds.

Coconut oil is used as a mouthwash and and a teaspoon of it is placed is mouth and using the swishing motion, the coconut oil is pulled through the teeth and the mechanical action is claimed to be able to “pull” the bacteria out from the gum and teeth surface. The process is continued for 20minutes before spitting out the coconut oil.

The concept is similar to using a commercial mouthwash, but substituting with a hipster mineral oil. Mouthwash and coconut oil pulling can again be a supplement but good old brushing and flossing are still essential to prevent decay and gum disease.

3. Hydrogen peroxide
Hydrogen peroxide is the “bad boy” of dentistry. Its bad name is from the fact that it is used as the active ingredient in teeth whitening. Some articles have claimed that hydrogen peroxide damaging the enamel and causing sensitivity. It is true that high concentration and misappropriate handling can cause teeth sensitivity and may damage the gum and lip. Hence, most health authourity rule by law that only registered dentists are allowed to handle hydrogen peroxide gel of more than 0.1% concentration on patients.

Apart from using for teeth whitening, hydrogen peroxide is used as a mild antiseptic. Technically hydrogen peroxide can be used to disinfect the mouth but it needs to be used with great cautious as it can cause injury to the mouth if it is too concentrated. Remember most health authourity ban non dentists from using hydrogen peroxide of more than 0.1% for use in the mouth.

Many techniques can be found online where hydrogen peroxide is used to kill bacteria in the mouth. Hydrogen peroxide is like Mr Hyde and Dr Jekyll, good at killing bacteria but can cause damage if used inappropriately.

6 monthly dental check up. A myth or science?

Have you tried googling how often should you visit the dentist? The answer on Google varies. The most common answer is that you should visit your dentist every 6 months.

Many dentists would admit 6 months was not a number postulated from clinical studies or researches but one of historical convenience.

6 monthly dental check up does make sense because for the average person that’s the time taken for teeth eating bacteria (streptococcus mutans) and jaw bone eating bacteria (A. actinomycetemcomitans, P. gingivalis, P. intermedia etc) to create nuisance in the mouth. During the check up, we will be checking the teeth for decay, leakage around existing restorations or crack lines and gum for gum inflammation.

Dental check up is similar to the concept of sending a car for regular servicing. Some parts of the automobile would show signs of wear and tear and most often the car is still functional despite the wear and tear. There are some occasions when the severe wear and tear could compromise the safety of the driver and passengers, so it is still a good practice to send your car for regular servicing. Of course, there are people who have never send their automobile to any forms of servicing for years and have not experienced any functional issue… yet.

In our dental clinic, during the check up we will update you the condition of your teeth and gum and the general health of the oral cavity. More often than not, most of us will have areas that we are not brushing well enough and certain areas where we may need to keep a watchful eye to prevent losing the tooth and this is also the time we will inform you and share tips on how to clean those individual blindspots.

Most often, during the visit we will be doing the routine scaling and polishing (cleaning) to remove plaque that contain teeth eating and jaw bone eating bacteria and also calculus (hardened plaque) that requires removal with a special machine (ultrasonic scaler) and remove unsightly stains.

At some circumstances, we may need to see you more often or less often. Patients with very poor oral hygiene or having high risk factors may be required to be seen 3-4 monthly or patients with very good oral hygiene and low risk factors can be seen 9-12 monthly. Ironic is that most of the low risk patients with good oral hygiene will still prefer to be seen every 6 monthly to ensure everything is in tip top conditions.