MDAApr-Jun 2017

A p u b l i c a t i o n o f M a l a y s i a n D e n t a l A s s o c i a t i o n

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Management of ComplicatedCrown Fracture in Immature Permanent Tooth

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Occlusion, Do IReally Bother?

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World Oral Health Day2017 Malaysia

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Dr Wong Foot Meowshares thoughts on theevolution of MDA.

HOLDINGTHE REINS,TWICE

April-June 2017

EditorDr Mas Suryalis AhmadEditor-in-Chief, MDA NewsHonorary Publication SecretaryMalaysian Dental Association 2016/2017.

Contributing writersDr Chow Kai FooDr Leong Kei JoeDr Nur A’thirah ZulkiflyDr Jayaseel RamachandranDr Eileen KohDr Malcolm R Edwards Dr Norashikin Abu BakarDr Jeannette Wong Xue Ying

Ex-officioDr John Ting Sii Ong

TreasurerDr Koh Mei Yen, Eileen

Advertisement LiaisonDr Wong Chin Mee, AngieDr Ng Su Chin, JanicePuan Razana Abdul Karim

MALAYSIAN DENTAL ASSOCIATIONMalaysian Dental AssociationD-5-1, Pusat Komersial Parklane,Jalan SS7/26, Kelana Jaya,47301 Petaling Jaya, Selangor.

Tel: 603-7887 6760 603-7887 6762Fax: 603-7887 6764E-mail: mdaassoca@mda.org.my mdentalassoc@gmail.comWebsite: www.mda.org.my

Conceptualised & Produced byPaul & Marigold (DeCalais Sdn Bhd)G-1-1 Plaza Damas,60, Jalan Sri Hartamas 1,Sri Hartamas, 50480 Kuala Lumpur

Tel: 603-6206 3497Fax: 603-6201 0756Email: arvind@paulandmarigold.comWebsite: www.paulandmarigold.com

Note:Views expressed are not necessarily those of The Malaysian Dental Association. The Malaysian Dental Association takes no responsibility for the consequences of any action taken based on any information published in MDA News and neither shall it be held liable for any product or service advertised in the same. No part of this publication may be reproduced without the permission of the publisher.

Messagefrom the EditorDr Mas Suryalis AhmadIt’s the time of the year again for the Annual General Meeting of the Malaysian Dental Association. This year, the event will be held for the very first time at Wisma MDA Kelana Jaya, with an opening CPD talk by our distinguished speaker, Prof Dr David Ngeow Wei Cheong.

I would like to take this opportunity to thank everyone for their guidance throughout my term as the Honorary Publication Secretary, and I apologise for all my shortcomings. I have learnt a lot, especially from Prof Dr Ngeow and Dr Leong Kei Joe, who have always been there to point me in the right direction.

Also, many thanks to the MDA Council members 2016/2017, especially Dr Chow Kai Foo, Dr Ng Woan Tyng, Dr Eileen Koh, Dr Siow Ang Yen and Dr Angie Wong for their support, dedication and great teamwork.

My sincere acknowledgements also go to the Northern, Southern and Eastern Zone committee members, as well as other members of the Council, I am truly honoured to have shared this journey with all of you.

Being part of the MDA Council has opened up so many doors. I met respectable members of the dental fraternity, established professional network and developed new friendships.

This has been a truly rewarding experience and I thank the Association for giving me the opportunity to play my humble role in the Association.

To our members, thank you very much for your continuous support for MDA. I welcome the new members to our Association, and I wish all the best to the new line-up of MDA Council.

MDA News welcomes submission of scientific articles to be featured in our upcoming issues. Please forward your articles to: massuryalis@gmail.com

24 Holding The Reins, Twice

31 Occlusion, Do I Really Need to Bother?

34 Management of Complicated Crown Fracture in Immature Permanent Tooth

InsideFeature

Activities

13 7th Borneo Dental Congress & Trade Exhibition/8th MDA Eastern Zone AGM

15 MDA & CPR Committee Activities 2016/2017

16 Northern Zone Activities January-May 2017

19 World Oral Health Day 2017 Malaysia

April-June 2017

5Message from the President

Dr Chow Kai FooBDS; FDSRCS; AM(Mal)President Malaysian Dental Association 5th June 2017

MALAYSIAN DENTAL ASSOCIATION

Dear esteemed MDA members,

Greetings and best wishes to each of you. May you be greatly blessed with good success in your endeavours and challenges.

“Infinite striving to be the best is man’s duty. It is its own reward.” – Mahatma Gandhi

We live in an intensely beautiful universe on a deeply troubled planet. Man’s ability to harness power and direct it determines the type of civilisation achieved. For thousands of years man was basically confined to using muscle power from humans and animals.

Muscle power to steam power to oil power to nuclear power to flowing waters, solar, wind, waves. When man learnt to move massively from muscle power to other sources of power and direct them intelligently, human increase of knowledge and travel erupted. In the past civilisations developed in isolation.

Today, civilisations are tied and connected to each other due to an unprecedented explosion of communications technology and increasing ability to harness and direct power precisely and intelligently.

Are we evolving into a more and more intelligent being or are we actually already built with infinite potential let loose into an almost infinite universe to explore and discover for ourselves meaning and purpose? Whatever it is let us find common ground to work towards, especially in our profession of dentistry.

Back to teeth... we are in a world full of stupendous living things. There are fish that have teeth that are all canines with two hinges in their jaws and there are fish that have human-like teeth.

Search for images of the goliath tiger fish and pacu fish from the Amazon and see them for yourselves. The goliath tiger fish teeth are all beautifully curved canines attached to upper and lower jaws that are both hinged. You can imagine the biting power.

MDA News

6The pacu fish is related to the piranha and have human-like chompers, unlike us do not need dentists because their teeth are continually being replaced throughout life.

The Deputy Health Minister Datuk Datuk Seri Dr Hilmy Yahya has announced to the press general dental practitioners can continue to perform specialist procedures as long as they do not claim to be dental specialists.

It also goes without saying general dental practitioners must use this freedom responsibly to persevere in continuing professional education and maintain their skills and knowledge on the cutting edge of dentistry or at least to the level of expertise at which they want to practice responsibly.

As my presidential term draws to an end, let me recount some of the issues highlighted during this roller coaster term:

• Freedomofpracticewithcorrespondingresponsibility. The MDA has advocated strongly that the qualified dentist is professionally able to self regulate and is already credentialed to carry out any kind of dental practice as per FDI policy guidelines. It is helpful to note that the FDI aka World Dental Federation representing up to 200 nations around the world in their policy statement on Basic Dental Education states by consensus, “The primary aim of dental education is to ensure that competent dentists are capable of critical thinking, possess the necessary clinical skills and the willingness for lifelong learning. The new dentist should be able to carry out any kind of dental practice without harm to patients using modern, appropriate, effective and currently accepted methods of treatment.”

• Dentistsshouldbeactivelyinvolvedinreducing and ultimately eliminating excessive sugar consumption both for themselves, families and patients. Sugar not only causes dental caries but is the main cause of obesity which is tied closely to diabetes which impacts adversely the diseases of the mouth and body. The MDA Ops Sifar Gula, by raising public awareness of the deleterious effects of excessive sugar consumption may have reduced it a little and may have saved

thousands of teeth, not to say reduce some obesity, gives us a small feel of how powerful such an activity can have.

• Thedentistisaphysicianwhohappenstospecialise in the mouth and surrounding structures. This is an important mindset to develop and maintain so that we do not see the teeth only and fail to see the powerful healthy effect that a gleaming set of fully functioning lasting teeth can have on the whole human being.

• AlltheactivitiesandplansoftheMDAshouldbe tied to our prime directive, “To promote the art and science of dentistry for the benefit of the public.” This is our primary objective and will keep and maintain us as an outward looking organisation that seeks to serve the public and paradoxically ourselves.

My deepest appreciation and thanks to the MDA Council 2016-2017, the staff of the MDA headquarters, affiliates and members for all the support and encouragement and yes, the occasional head-up meted out.

Serving Together With You

Sugar not only causes dental caries but is the main cause

of obesity, which is tied closely to

diabetes.

April-June 2017

7T

he clause, “A practitioner whose name does not appear in the Specialist Division of the Dental Register shall not practice as a dental specialist in that specialty.” has proven to be controversial and led the profession on a merry-go-round.

The Malaysian Dental Association (MDA) since 2012 was given the impression it meant what it said, which was a dentist who was not a duly recognised dental specialist should not use the title of specialist and that it will not limit the practice of dentistry by dentists only.

However, it was not as simple as that. Since then, there have been several meetings and correspondences with the Oral Health Division, Malaysian Dental Council, Health Minister, and even the Attorney-General regarding the matter.

This has greatly tested our stamina and legal understanding of the clause, almost turning some of us into etymologists like in a Dan Brown novel. The purpose is to ensure dentists, both non-specialists and specialists, will not be limited in the practice of dentistry unduly. I have endeavoured to give a concise report on the events that unfolded.

8 October 2012In a meeting with the then Health Minister Datuk Seri Liow Tiong Lai, he emphasised his overall sentiment and spirit on enabling the profession to practice freely and responsibly with as few constraints as possible.

The clause on privileging and penalty were removed. It was agreed that under the section, “Practitioners Practicing as Dental Specialists”, only the following clause will be maintained:

“A practitioner whose name does not appear in the Specialist Division of the Dental Register shall not practise as a dental specialist in that specialty.”

2013 to 2015It was brought to our attention the legal interpretation of the clause might mean a non-specialist might not be able to do any dental procedure that was deemed as under the province of a dental specialist.

This clause might also meant a dental specialist could only perform procedures deemed under his particular specialty. There was a move to reinstate a privileging/credentialing clause as an “escape clause” to enable non-specialists to carry out certain specialist procedures.

The Long Journey

Odyssey of the controversial clauses on “Practitioners Practicing as Dental Specialists” in the New Dental Bill that will be tabled in Parliament.

Dr Chow Kai FooPresident Malaysian Dental Association

MDA News

8be achieved. We note there is no intention to restrict dentists from practising any particular field of dentistry that is within his/her competence. Based on the extensive discussions, we agreed on the following edit of the clause in the dental bill:

“In relation to the Specialist Division of the Dental Register, a practitioner may practice in any particular field of dentistry, provided he has the knowledge and skill to do so.”

This new edit was also not accepted.

20 March 2017With the impending tabling of the new dental bill in the current Parliament sitting, an urgent briefing and dialogue with Dr Monerasinghe was called. All MDA members were invited to come. Held at the MDA headquarters, briefing and dialogue were heated at times and inconclusive.

There was a meeting between the Deputy Health Minister, MDA President and Dr Firdaus, President of the Islamic Dental Association of Malaysia at the Parliament house. The Deputy Health Minister listened patiently and graciously requested for a written appeal from the MDA.

It was then decided an emergency MDA Council Meeting should be called as soon as possible with MDA members to build a consensus appeal to the Health Minister.

2 April 2017The MDA Emergency Council Meeting was held in the MDA HQ. Clause 1 is similar to one in the Medical Act and the powers that be insisted the new dental bill should maintain it, in line with the Medical Act. After lengthy deliberations, a consensus was reached.

6 November 2016There was great concern among the profession when a workshop was organised by the Health Ministry to list the “specialist procedures”. Based on this development and the impending tabling of the dental bill in the upcoming parliamentary seating, the MDA EOGM Resolution passed unanimously:

“That the house calls for the withdrawal of the new Dental Bill 2016 for review by all stakeholders with the intention to strike out any clause that limits the practice of dentistry by dentists.”

The intent of the resolution was so dentists, both non-specialists and specialists, will not be limited in the practice of dentistry.

15 November 2016 The Registrar of the MDA and her officers met with representatives of the dental profession. During the meeting, the representatives of the Malaysian Dental Council, MDA, Malaysian Private Dental Practitioners’ Association and the Islamic Dental Association of Malaysia unanimously agreed to remove the abovementioned clause. It was agreed that it would be replaced with the following:

(1) A practitioner whose name does not appear in the Specialist Division of the Dental Register shall not:

(a) practice dentistry under the style or title of a specialist, or under any name, title, addition or description implying that he is a specialist.

(b) advertise or hold himself out as a specialist.

(2) The Specialist Division does not restrict the right of any practitioner to practice in any particular field of dentistry or the right of any specialist to practice in other fields of dentistry.

7 February 2017The new dental bill was not tabled in Parliament still. It was informed to us by Dr Elise Monerasinghe of the Oral Health Division that the Attorney-General’s Chambers had not accepted the clauses that were agreed upon.

Based on this, the MDA representatives in another meeting on the above date with the Registrar of the Malaysian Dental Council Dr Noor Aliyah Ismail came to another agreementt.

We agreed the safety and welfare of the public is of utmost importance while considering the interests of the profession, and a happy respectful balance should

The following letter was sent to the Health Minister, Deputy Health Minister and

the President of the Malaysian Dental

Council.

April-June 2017

9YAB Datuk Seri Dr S. Subramaniam (Menteri Kesihatan Malaysia)

YB Datuk Seri Hilmy (Timbalan Menteri Kesihatan Malaysia)

Datuk Seri Noor Hisham (Presiden Majlis Pergigian Malaysia)

Dear Datuk Seri,

Request to amend one clause in the new dental bill

1. Warmest greetings and regards from the Malaysian Dental Association (MDA). We are acutely aware of how busy you are over many matters of importance and especially in the matter of the tabling of the new dental bill in Parliament. Please bear with us as we wish to raise up a matter of enormous concern to a majority of the dental profession whom we represent on one clause in the dental bill. Our members are from the universities, armed forces, public and private sector.

2. The interpretation of the clause seems to imply that a general dental practitioner will not be able to carry out certain dental procedures. The MDA Council in an emergency meeting on this matter and after lengthy deliberation wish to propose the amendment of the following clause for your kind consideration:

Practitioners practising as dental specialists“A practitioner whose name does not appear in the Specialist Division of the Dental Register shall not practise as a dental specialist in that specialty.”

To:

“A practitioner whose name does not appear in the Specialist Division of the Dental Register shall not practise dentistry under the title of a specialist in that specialty.”

3. This clause by itself without any additional clause will give due recognition to specialists, yet at the same time both specialists and non-specialists will not be limited in the practice of dentistry unduly.

Thus the professional ability of general dentists to practice dentistry as they deem fit will be respected and protected. The MDA feels that we should not embark on an exercise to define what specialist procedures are and are not because dentistry is so integrated in such a tiny structure that it is quite impossible to draw clear lines and is practically unenforceable.

Furthermore such a clause that limits the freedom of practice of dentistry by the general dentist will reduce the accessibility of many dental procedures to the general public especially in the rural areas, result in monopolies and drive up prices for the rakyat.

On behalf of the Council and members of the MDA.

Looking forward to your kind consideration and consent.

Yours sincerely, Dr Chow Kai Foo President Malaysian Dental Association 10 April 2017 Note: This letter was accompanied with supporting documents.

With this move we earnestly hoped the minister will hearken to our appeal to give due recognition to specialists and yet at the same time both specialists and non-specialists will not be limited in the practice of dentistry.

MDA News

10

18 April 2017The Health Ministry legal advisor, under instruction from the Deputy Health Minister, called to inform the MDA President that the clause has been edited to make it clear it just means no one can claim to be a dental specialist unless registered as one. Dentists can continue to practice as before. Also there will be no credentialing clause. A written reply was not possible because of official confidentiality reasons.

As a result of the many appeals and objections by the MDA backed by all our esteemed members, affiliates and interested parties, there was quite a lot of support for there being no undue limitation of the practice of dentistry by dentists.

It was mentioned dentists have already been doing all the procedures all this time and should not be suddenly restricted. We are thankful for the positive response to the concerns of the dental profession with regard to the new dental bill and and we look forward

to a new era of forward development of our beloved profession in our mission to promote the art and science of dentistry for the benefit of the public.

Please remember with freedom comes responsibility and the more freedom we want, the more responsible we must become.

We heartily thank everyone involved for this positive outcome. The esteemed members of the MDA, affiliates, MDA Committee on the Dental Bill, stakeholders and various associations and individuals all deserve mention. Meanwhile let us continue to observe this matter closely.

It is not over until it is over.

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MDA News

12Selamat Hari Raya!

Greetings to my dear fellow colleagues from all parts of Malaysia. By the time this print reaches your hands, our Muslim colleagues will be celebrating the festive season of Hari Raya.

Furthermore, our Annual General Meeting would have also concluded and this will mark the change of a new council for the association. It has indeed been a very fruitful year, albeit the many challenges and responsibilities faced by the association.

Truly, all the achievements would not have been possible without a fully united and committed council, not to mention your understanding and support as members to the association. As the saying goes, one can move fast when one is alone, but together, we can move further.

I wish to congratulate Dr Mas Suryalis on her portfolio as the Editor-in-chief of MDA News, who has not only contributed selflessly for the smooth edition of all the four issues throughout her tenure but has also make substantial contribution, despite her busy schedule, to the Malaysian Dental Journal, as the new Editor-in-chief.

As you would have notice that from this year, the association is going even Greener. Our annual reports are readily downloadable from our website via the MDA login. In my opinion, this move will also encourage our members to make full use of the MDA members section to retrieve information such as CPD-points accumulation, membership payment history, and previous CPD activities.

If you have forgotten your ID and password, please feel free to call up our secretariat for assistance. In fact, the association has made immense effort to uplift the website, and I strongly urge all of you to visit it regularly.

On the administrative tasks, the council has come together for seven council meetings, held at different zones, and the 8th council meeting is already in planned, scheduled on 17 June 2017.

Message from the Honorary General Secretary

Dr Leong Kei JoeHonorary General Secretary

MALAYSIAN DENTAL ASSOCIATION

April-June 2017

13

Apart from this, our President was also engaged in numerous governmental meetings and attended invitations to local and overseas scientific meetings. Of these, the recent international meet as at the Asia Pacific Dental Congress 2017, 22-25 May 2017, at Macau. Our delegation from MDA was involved not only in the congress proper but also in attending business meetings (APDF).

On the local front and as the Publication and Promotion Chairman of the Malaysian – International Dental Exhibition and Conference 2017, I wish to inform all members that registration for this event is still open and I urge all members to come in to support this event as a big family of the dental fraternity.

Education is never cheap and knowledge is priceless. It is indeed an event not to be missed and the scientific programme has been well tailored for all.

Before I pen off for the last time as the Honorary General Secretary of MDA, I wish to take this opportunity to thank all the council members for having the trust in me to serve the association under this portfolio. Last but not least, my heartiest congratulations to new line up of council members for 2017/2018.

Yours sincerely, Dr Leong Kei Joe

MDA News

147th Borneo Dental Congress & Trade Exhibition/8th MDA Eastern Zone AGM

Report prepared by:Dr Nur A’thirah Zulkifly Secretary 7th BDC 2017

The 7th Borneo Dental Congress and Trade Exhibition (BDC) cum 8th MDA Eastern Zone Annual General Meeting were held at Sutera Pacific Hotel, Kota Kinabalu from 17 to 19 March 2017.

This year’s event was themed

“Optimising Today’s Dentistryfor Tomorrow” and the congress has offered a platform for knowledge exchange, discussion and also networking among delegates from Sabah, Sarawak, West Malaysia, Brunei, Singapore and Australia.

There were 427 participants at the 7th BDC, and this marked the highest participation since the first BDC in 2011.

A total of 208 dentists and 136 dental auxiliaries registered for the event, exceeding the expected turnout. The 7th BDC was officiated by Datuk Seri Panglima Haji Masidi Manjun, who is Sabah’s Tourism, Culture and Environment Minister.

This year, the organising committee incorporated a corporate social responsibility project. A dental check-up session was held for the orphans of Rumah Anak Kesayangan Sembulan on the morning of 18 March before the opening ceremony.

Volunteers from Klinik Pergigian Luyang were engaged to carry out dental screening in the Mobile Community Transformation Centre, Klinik Pergigian Bergerak. This project was supported by the Deputy Director of Dental Health Services Sabah. The MDA Eastern Zone also donated RM1,000 to the orphanage.

April-June 2017

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In his speech, he showed support to organisations such as the MDA Eastern Zone which could contribute to the betterment of Sabah and its society. MDA President Dr Chow Kai Foo, MDA Council members, MDA Northern, Southern and Eastern Zone committee members and congress delegates enjoyed the dinner thoroughly.

The 8th MDA Eastern Zone AGM was held on the afternoon of 19 March. The newly elected office bearers for the year 2017/2018 are:

Chairman: Dr James Chhoa Jau Min

Secretary: Dr Sim Wen Sann

Treasurer: Dr Cindy Chong Ei Yen

Excos: Dr Alex Lo Shen En

Dr Chen Yu Nieng

Dr Jane Lau Ning Shing

Dr Ignatius Niap Tat Yuen

Dr Lynn Ko Wei Linn

Advisors: Dr James Chu Kok Weng

Dr Haji Abdul Rashid Hassan

Internal Auditor: Dr Philomena Sonia Jane Pang

The congress ended with a closing lecture on the evening of 19 March and a lucky draw session. The BDC was a success, with a history made for MDA Eastern Zone once again.

The congress provided an all-rounded experience with a good combination of trade exhibition, scientific conference, hands-on workshop and also community service for the local dental fraternity.

The knowledge, insights and networking gained by this congress is important to keep all delegates up-to-date with the latest innovation in dental sciences and to continue to explore beyond the boundaries of conventional dentistry for the benefit of the people.

The pre-congress four concurrent workshops were on 17 March. Dr RL Halili Castillo from Philippines shared her knowledge and experience in two workshops – “A quick gap: Bridging the gap in the minimally invasive way” and “How to create high quality aesthetic composite restorations in simple steps”.

We also had the opportunity to learn from Dr Alex Chan from Hong Kong through the workshop “Advance in Endodontics – TF – Adaptive System”. Meanwhile, Dr David Cox from Australia shared his knowledge on “Laser Dentistry – All you wanted to know about Diode Dental Laser, but were afraid to ask”.

The trade exhibition was launched with a ribbon-cutting ceremony. There were 33 booths, with approximately 66 traders. It showcased the latest in dental equipment and materials from across the globe. It was very well-received by the dental fraternity.

Besides the scientific programme and trade exhibition, the BDC had also added fun and laughter to the congress with a beachside party themed “Aloha Sabah”. This was the first time the BDC had an outdoor informal dinner.

Guests were entertained with a fire-eater show and other interesting and fun games. It was officiated by Chief Minister of Sabah, represented by Assistant Minister to the Chief Minister, Dato Ir Edward Yong Oui Fah.

MDA News

16MDA CPD & CPR Committee Activities 2016/2017

Report prepared by:Dr Jayaseel Ramachandran

2016

28-31 JulyMDA Malaysia International Dental Exhibition and Conference (MIDEC) 2016

21 AugustNorthern Zone’s one-day Basic Life Support and Automated External Defibrillator course

14-16 Oct 15th Penang Dental Congress

18 Nov MDA Universiti Sains Malaysia talk at USM Kubang Kerian

25&27 OctDPL lecture in Kuala Lumpur (25 October 2016) and Penang (27 October 2016) by Dr Stephen Henderson and Dr Jane Merivale.

11 Dec

The 1st MDA Cardiopulmonary Resuscitation and AED course conducted at Wisma MDA Kelana Jaya by Prof Dr Rashidi Ahmad from Universiti Malaya Medical Centre, and supported by Schiller

April-June 2017

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13-15 Jan24th MDA Scientific Convention and Trade Exhibition (SCATE) 2017 at Putra World Trade Centre

17-19 MarEastern Zone 7th Borneo Dental Congress and 8th Eastern Zone AGM at Hotel Pacific Sutera, Kota Kinabalu, Sabah

2017

17 Jan Op Sifar Gula

11 MarMDA Southern Zone Annual General Meeting 2017 in Johor Bahru

12 Mar MDA Northern Zone AGM 2017 in Penang

7 May The 2nd MDA CPR and AED course at Wisma MDA

27-30 July MDA MIDEC 2017 at Kuala Lumpur Convention Centre

19 MarMDA WOHD (World Oral Health Day) 2017 at Perdana Park, Tanjung Ara, Sabah

MDA News

18Northern Zone Activities January-May 2017

Report written by:Dr Jeannette Wong Xue Ying

Oral Health Awareness Campaign 2017

The MDA Northern Zone was invited to attend the annual Oral Health Awareness Campaign organised by AIMST Dental Students’ Association. The campaign was held from 3 to 5 March 2017 at Amanjaya Mall, Sungai Petani, Kedah.

The aim of this campaign was to create awareness among the community in Sungai Petani, Kedah of oral health and its importance as well as to provide screening and early detection for the community for prevention of oral diseases.

As with the years that came before, MDA Northern Zone has continued to lend support to this campaign by sponsoring RM2,000 this year. It was an honour to be a part of a campaign that serves the local community as well as supports a dental faculty in the northern region.

April-June 2017

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MDA Northern Zone AGM/CPD programmeThe MDA Northern Zone AGM/CPD programme was held on the 12 March 2017 at Olive Tree Hotel, Penang. The event started at 8.30am and concluded at 5pm.

A total of 64 participants attended the scientific programme, with 56 of them attended the AGM.

MDA Northern Zone was privileged to have invited Dr Leong Kei Joe, a specialist in Paediatric Dentistry and Dr Dasera Raj, a specialist in Special Needs Dentistry to give lectures during the event.

Dr Leong, who is currently the Head of the Paediatric Dentistry Department at Queen Elizabeth Hospital and Sabah Women and Child Hospital, Kota Kinabalu, gave lectures on “Common oral-dental pathology and anomalies in children” and “non-pharmacological behaviour management techniques”.

Dr Dasera, who is the Head of Department for Special Needs Dentistry at Seberang Jaya Hospital, gave an introduction to Special Needs Dentistry and also talked about the basic behavioural guidance strategies for patients with special needs.

The AGM saw the annual zone report and financial report for 2016 being passed, and the new office bearers for the term 2017/18 elected. The following are the incoming zone office bearers of 2017/18:

Chairman: Dr Tan Sock Hooi

Secretary: Dr Jeannette Wong Xue-Ying

Treasurer: Dr Tan Hooi Shan

Committee members: Dr Ang Lai Choon

Dr Teh Yik Pin

Dr Gan Peijun

Dr Choo Wan Ling

Dr Tay Hui Wen

Auditor: Dr Lim Eng Hin

The outgoing MDA Northern Zone chairman Dr Lim Chiew Wooi thanked the committee members and MDA Northern Zone members for their support. He had a great time serving MDA Northern Zone and wished the incoming committee all the best.

Dr Tan Sock Hooi then thanked the members for electing her as the chairman for the term 2017/18. She looked forward to serving MDA Northern Zone together with the incoming committee, and hoped members would continue to support the programs organised by MDA.

MDA News

20

Ipoh CPD ProgrammeMDA Northern Zone’s Ipoh CPD programme was held on the 14 May 2017 at MH Hotel, Ipoh. The event started at 8.30am and ended at 4pm with a total of 56 participants.

This year’s Ipoh CPD programme covered a variety of topics, which were presented by oral maxillofacial surgeon Dr Lee Chee Wei, periodontist Dr Swee Wen Yeng and endodontist Dr Siew Kai Ling.

Dr Lee, who is based in Kuala Lumpur Hospital, started the programme with his topics on sleep apnea and management of surgical complications.

This was followed by Dr Swee from Sungai Petani,Kedah who shared current trends in periodontics.

Dr Siew, who works in a private practice in Kuala Lumpur, discussed about endodontic perforation and its management.

April-June 2017

21World Oral Health Day 2017 Malaysia

Report written by:Dr Eileen Koh Organising Chairperson WOHD 2017

On 19 March 2017, the Malaysian Dental Association together with Oral Health Division (OHD) of the Health Ministry, Dental Services Division of Malaysian Armed Forces, and Dental Deans’ Council of Malaysia partnered together to arrange a list of activities for the

World Oral Health Day (WOHD) 2017 celebration in Malaysia.

The national launching of WOHD 2017 was officiated by Datuk Ir Edward Yong Oui Fah, Assistant Minister in Sabah Chief Minister’s Department, representing the Chief Minister of Sabah, Datuk Seri Panglima Musa Haji Aman at Perdana Park, Tanjung Aru, Kota Kinabalu, Sabah.

The arrival of guest of honor, Yang Berhormat Datuk Ir Edward Yong Oui Fah, Assistant Minister in Sabah Chief Minister’s Department.

GOH “watered” the rafflesia (launching gimmick) and WOHD plaque raised up from the center of rafflesia.

Emcee of WOHD event: Mr Abu Bakar Ellah

The theme for this year is “LiveMouth Smart”.

MDA News

22

The activities booth.

Tooth Fairy Mascot at the Perdana Park.Mascot at the Perdana Park.The exhibition booth.

April-June 2017

23

This was the first time WOHD Malaysia is celebrated in Sabah. We hoped to create an unprecedented awareness among Malaysian public, especially those residing in Sabah, Sarawak and Labuan, of the importance of oral health to overall health.

The range of programmes conducted include distribution of public education flyers and brochures, display of informative placards at Perdana Park, health and dental exhibitions (11 booths), puppet shows (nine booths), and various children educational activities (tooth origami challenge, colouring activities and many more).

The exhibition booth.

Presentation of the WOHD Plaque to MDA President.

The activities booth.

MDA News

24

We provided free dental check-up service for the public in two new mobile dental buses. Free gifts were distributed to the visitors. A photo booth corner was set-up to allow the visitors and guests to take photos and share it on social media.

Besides that, the WOHD organising committees worked hard in promoting the celebration beforehand through press media, radio stations and TV stations. We also had a Facebook page (@wohd2017malaysia) as a promotion platform to emphasise on the importance of oral health and to share its activities. Smile competition and dental student video competition were carried out too.

Free dental check-up service provided to the public.

Registered yourself at WOHD counter for goodies redemption.

Air-conditioned, well equipped mobile dental bus.

Tarian Kontemporari Tradisional Sabah by school children from SK Tanjung Aru II, Kota Kinabalu.

April-June 2017

25

In conjunction with the WOHD 2017, the OHD took the opportunity to launch their two mobile dental buses with ribbon cutting ceremony and zumba dance. Throughout the day, we managed to attract 1,000 people to participate in the event.

Dancers in Traditional Costumes

Visitors taking photo with props at WOHD Photo Booth.Launching of two brand new mobile dental buses in conjunction of WOHD 2017.

Dancers in traditional costumes.

Warm up with Zumba before the WOHD walkabout.

MDA News

26Holding the Reins, Twice

MDA veteran and successful dentist Dr Wong Foot Meow was the association’s president in 1997 and 2007. He shares thoughts on the evolution of MDA, and industry challenges then and now.

Interviewee: Dr Wong Foot Meow

Interviewed by: Khaw Chia Hui

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27

What was the impetus to run for the MDA presidency in 1997 and again in 2007? Allow me to digress a little. History creates a bridge between the past and the present so significant and insignificant events do not slip out of the mind. We learn from history and avoid the same mistakes.

Not many can remember the Malayan Dental Association was formed some 89 years ago on 2 September 1938. The Malayan Dental Association underwent a metamorphosis and became the Malaysian Dental Association (MDA) on 24 March 1967. Since those days, it has been said many a time that selfless service and sacrifice to the profession and country shall be the cardinal cornerstone of the MDA Presidency.

My first stint as President in 1997 was straightforward and a natural progression when I became a Council Member in 1989. Over an eight-year period, I acquainted myself with the various personalities, learnt the ropes and working mechanics of the Association.

It was the time when MDA was consolidating and starting to take off. The association was exceedingly fortunate in those days to have a good mix of strong, dedicated leaders and personalities of various ages such as Drs Lim Chee Shin, Yim Khai Kee, Ratnanesan A, Pathmanathan, Mohamed Yunus Mohamed, Hashim Yaacob, Mej Gen Mohamed Termidzi, Paul Lee, Low Teong, and Ishak Abdul Razak, to mention a few.

The presidential contest in 1996 was a three cornered contest. I campaigned on the platform of three promises:

We met Dr Wong at his private practice in Jalan Medan Tuanku in the heart of old Kuala Lumpur, not far from his family home. With hard work and good hands, he secured a scholarship from the Armed Forces to pursue dentistry, which also made him the first in his family to earn a degree.

Upon graduation, he served as an army dentist for more than 14 years. In it here, he learnt important lessons on discipline, being thorough, a sense of responsibility, among others. He carried these values with him when he started his own clinic almost 29 years ago.

It is a testament of his reputation that his clinic remains popular even after all these years. Although he admitted to not being particularly IT savvy, he is adamant that dentistry is a technical vocation where it treads the fine line between skill and art.

We learn from history and avoid the same mistakes.

MDA News

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a. That an important feature should I be elected, shall be the development and fostering of close cooperation between the various arms of the dental profession in particular the public, private sector, Armed Forces and academia. This rapport and close cooperation is necessary for the formulation and development of policies affecting the profession, oral health of the community and in Continuing Education Programmes;

b. At that time I was very supportive of Dr Ratnanesan’s success in bringing the 89th FDI World Dental Congress to Malaysia in 2001 and pledged to harness the MDA towards that end; and

c. That the MDA Council shall seriously look into the mechanics of acquiring an MDA House. Two of the objectives were achieved and the seeds of Wisma MDA as it stands today was planted those many years ago.

I again returned as President for the 2006/07 term after some encouragement from many senior members of the Association. It was a time of change and the MDA Council felt the Association and dental profession were ready to move forward to the next level of performance excellence, this included consolidating measures to improve the outlook, membership and administration of the MDA.

Having help to set the groundwork during my earlier Presidency in 1996/97, when subcommittees in administration, continuing dental education, dental product endorsement, insurance, publications were fine-tuned by Council to propel the MDA forward, I thought it opportune to return to see through to fruition the solid groundwork we had put down over the last 10 years.

Among the key issues were the just implemented Private Healthcare Facilities and Services Act (1988) and Regulations (2006). Under the 1988 Act, all private dental clinics were compelled to register with the Health Ministry by October 2006.

Also in the mix were

• illegaldentistry,

• patients’complaintsandlitigationconcerns,

• theimplementationoftheCPDpointsystemlinked to the Annual Practicing Certificate,

• MalaysianDentalManpowerDevelopmentand

• dentalinflation.

I would say that the years commencing 2007 was the starting of a glorious period for the MDA. All the issues were complicated but over time, with the input of successive MDA councils, diplomacy, negotiations, common sense and persistence won the day and saw many of the issues slowly resolved satisfactorily the results of which is evident today, for the benefit of the membership. Accordingly, from that time onwards, the issues slowly evolved and crystallised into the following:

• myCPDforonlinemonitoringoftheContinuing Professional Development System to plan, record, and track CPD activities and credit points. MDA wisely went into CPD in a big way before any other profession including lawyers and engineers and our Members are deservedly reaping the rewards today;

• NationalOralHealthPlan(2011-2020);

• NationalHealthcareFinancingPlan;

• DentalTourismasanadjuncttoHealthTourism; and

• AdvertisingBoardforIssuesofAdvertising.

Nevertheless, the dental world is constantly changing and things are still evolving. As some old issues are resolved, new ones arise e.g. the Moratorium by the governing bodies on dental education in 2013, Goods and Service Tax implemented in 2015, etc.

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Please share some of the milestones you were involved in during those times? a. Increase in membership. In 1990, the MDA

membership stood at 1,126 and had only 10 subcommittees. We worked hard to increase the MDA membership and by 2007, there were 2,500 members served by 25 Committees (not including the MDA Northern and Southern Zones). The issues confronting the MDA at the turn of this century were not earth-shaking but were nevertheless important for the steady growth and relevance of the MDA.

b. Positive resolution. We negotiated carefully many items and policies current at that point in time such as:

• ImplementationofthePrivateHealthcareFacilities and Services Act (1998) and Regulations (2006). The MDA with the assistance of the Dental Division Ministry of Health slowly eased the private sector seamlessly into this game changer.

• OralHealthCareCampaigns.MDAisalways on the forefront of increasing awareness of oral healthcare via yearly oral health care month and various oral health care campaigns.

• EffectiveDentalManpower.MDAwasalways one of the earliest to promote “Workshops on Dental Manpower Training in Malaysia” as well trained dental professionals can only be assets for the country.

• ITandmultimediawasstartingtomakeits presence felt. MDA Council embraced IT and electronic data processing, as it was the way forward.

• Others:Precursorsofmanyofpresentday issues were deliberated upon and these include the CPE Programme and CPD points, Patients Complaints Bureau Committee, Wisma MDA, Dental Tourism and cooperation with Dental Division in arresting illegal dentistry.

By 2007, the membership had grown, the finances were consolidated and improved, and the expectations of discerning MDA members ever more demanding. MDA presidents may come and go but we all contribute over time and I would say my contribution significantly served as signposting and building blocks on the various issues listed above, which helped, make the MDA what it is today.

In 2007there were

approximately

2,500 dentists

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How would you say times have changed in the 10-year period?Dentistry is like a sleeping giant. There was only one dental school in Malaysia until 1997 but five new dental schools (one public and four private) have since been established since 1998.

In 2007 there were approximately 2,500 dentists, with a ratio of one dentist for every 10,000 people. At that time we have a sizeable private sector and the usual public dental service. Things then inexorably changed:

a. Governmental regulations relating to healthcare and minimum standards have become more stringent. The Health Ministry is also enforcing the rules more strictly and frequently.

b. Increasing responsibilities. The public is becoming more educated and well informed. They now have access to more dental information and the dental profession also innovated and improved to change with the times to continue making dentistry a premier vocation

c. Staying connected. MDA also forged ahead with continued cooperation, trust and teamwork in the Council. Running an organisation successfully is not easy and requires a lot of hard work and dedication by each and every member of the team. The MDA realised the importance of electing the right Council members, and this includes the zone leadership who support the various Zones of the MDA. Bringing all these components closer together were two (2) important international events. The MDA hosted the 16th APDC/APRO Congress in April 1993 and in 1997 organized the 4th FDI/MDA Scientific Convention plus the historic 54th MDA AGM /BSGDS (British Society of General Dental Practitioners’) Scientific Convention.

d. The age of technology: Even in those days, multimedia was starting to become the buzzword. The most significant trend is the continuation in digitalisation of the dental industry. Nowadays we are enamoured with the concept of digital impressions, 3-D intraoral

scanners, CAD/CAM units, digital radiography, 3D printers, smart hand pieces, HD cameras, dental diagnostic detection devices, and intelligent electronic dental equipment sterilizers, compressors and lights.

There have also been downsides to modernisation of the profession:

a. Keeping updated: MDA was computerised way before the advent of Personal Data Protection Act 2012 and the usual issues of hackers, copyrights and illegal downloading. MDA followed the formal path and managed our accounts and records fairly uneventfully.

b. Information ethics: Advertisement and use of social media is also now viewed from an ethical perspective. In Malaysia, there is now the Malaysia Competition Act that disallows Fee schedule displays. In addition, dentists are governed by Advertising Guidelines for Healthcare Facilities and Services (Private Hospitals, Clinics, Radiological Clinics and Medical Laboratories) 2010. We have to innovate with the times.

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Are the industry challenges similar or vastly different in 2017?Current dental literature has outlined many issues but in the Malaysian context, we may be faced with the following challenges:

a. Dental patients are becoming more selective, today’s consumers are more discerning and many now need convincing due to rising costs.

b. Increasing digitalising of dentistry. Dental technology advances are helping to reduce failures by minimizing material failure. In addition, cutting edge technologies now allow clinicians to move towards ‘precision dentistry,’ which will create a more predictable and satisfactory dental result with minimal complications. Whilst the practice of dentistry is now more precise, it has also become time consuming and terribly expensive. However never be a blind follower of any trend without good evidence-based science to support change in your practice. Digital X-rays, web sites, electronic dental records will come to the fore but incorporate prudently.

c. The significant gender shift in Malaysian dentists with more female dentists and increasing tendency of younger dentists to target and recommend up expensive market dentistry to their patients.

d. The need for niche dentistry. To excel, we need to be proficient in any area of expertise.

e. The rise of group practices. This is a given and be prepared for it.

f. Dental protection. Other than Dental Protection Limited, other local companies are entering the market.

g. Dental health insurance plans. I do not think that it will take off in Malaysia but you never know.

Are there any areas you feel MDA should address now?I am not a statistician and do not have any Malaysian dental figures to quote offhand but current international dental publications indicate that there are five important trends. I am sure the MDA think tank committee would have considered the following in detail.

a. The advent of Gen-Y now entering the market, the change in demographics, age and diversity of patients as the world becomes more globalised and the Malaysian population’s requirements.

b. Change in mindset, the current generation now prefers “teeth for life” with extraction as the last resort.

c. Trends in disease patterns. Lifestyle medical issues will impact on the practice of dentistry so we have to be prepared.

d. Diversity among dental practices: Currently, the Ministry recognises only seven specialties i.e. oral surgery, orthodontics, paediatric dentistry, periodontology, oral medicine/oral pathology, dental public health, and restorative dentistry. In the private sector, dentists tend to focus

MDA News

32on high end dentistry including dental implants, aesthetic dentistry, restorative dentistry and orthodontics.

e. Increased specialisation and cutting edge technology – whether there is a need for more oversight or even regulations on minimum standards with the increasing use of technology to maintain a high standard of quality within the profession.

What are your expectations of MDA in the near future?The current leadership is doing extremely well. The MDA Annual Report in 2015 stated MDA has 26 sub committees serving 5,353 members, owns a brand new building.

The annual convention turnover is nearly RM4 million with an accumulated fund of approximately RM9.5 million as at December 2014. This when compared to the MDA in 1990 with 10 subcommittees serving a membership of 1,126 with an accumulated fund of RM270,000 in December 1989.

I think we are heading in the right direction. The future of dentistry is bright. I must congratulate and commend what the MDA is doing presently. They have the correct people to spearhead the initiatives with the correct policies and set the standards of practice to bring confidence and trust to the Malaysian dental profession, members and dental trade for a win-win scenario. It is my hope for the MDA to maintain its momentum and continue growing exponentially to showcase Malaysian dentistry to greater heights.

The MDA should support the authorities that have put into place a good comprehensive program to maintain high dental standards in the training and practice of dentistry. However, the MDA must also always be innovative and on the alert to safeguard the wellbeing and welfare of the dental profession.

The MDA Strategic Plan/Think Tank Subcommittee should be visionary and now look into current issues of the day, e.g. the future of group practices; the case for international standards dental hospitals in

Malaysia; ethical issues and intra dental issues like establishing bridges for newer members to more experienced colleagues, cross referrals and mentor discussions; state of art facilities and how to get more members on the cutting edge of dentistry either through CDE or formal teaching programmes, employment opportunities and post-graduate training.

You have run a successful private practice for nearly three decades. What are the challenges of keeping a thriving practice in this new age?Patient satisfaction is the key to a successful dental practice. As a solo dental surgeon I need to do the common things uncommonly well. There is a maxim in dentistry that states, “the best dentistry that lasts is the one that is done extremely well the first time”.

Other pearls of wisdom I learnt still hold true today:

a. Plan to succeed. You should have a progressive strategy to reach whatever target you have set for yourself.

b. Establish achievable goals. Have a long-term plan but customise it to your strong points, analyse and adjust to augment your ability over time.

c. Reinvest in your practice. Facilities, equipment and technology upgrades are mandatory.

d. Reinvest in yourself and your staff. Continuing education to stay as one of the best in the business

e. Run a unique practice. To become a leading trademark oral health care provider, make your practice unique. Whether you offer routine dental service or emphasise a certain specialty, you must acquire the power to attract and retain a high percentage of patients. Such satisfied patients will in turn refer their friends and family. Once you reach critical mass, you have to ensure that you maintain your usual good standards and consistency to retain your regular patients.

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What are your thoughts on the profession currently?The first thing we were told upon entering dental school in the early days was that the dental profession is one of the nation’s critical professions and has a definite role, its own place and part to play in our country. The standards were high. We were trained to always do our best and be competent at whatever we do.

That grounding and guiding principle gave us a good start in our approach to dentistry and life. I have been a dental surgeon for a good 40 years now and therefore in a privileged position to come up with some observations.

a. The field of dentistry is always dynamic and constantly evolving. In the early days, even in the administration of the MDA, senior MDA members must remain valued, give appropriate input, and not overstay their welcome. The younger and more talented ones were always

given the opportunity to do their part. To improve themselves, dentists in general should read widely, not just dental literature but in other related fields as well. We must also be well versed with medical co-morbidities. This will have serious implications in the practice of dentistry in the future.

b. Economic squeeze: Many of the current trends point to a more competitive dental marketplace in the future. Some of these trends in the Malaysian scenario will include:

• Workforce:Acombinationofanincreasingnumber of dental graduates with senior dentists still in the workforce. Things will become very competitive.

• Dentaleconomics:Thereisthisscenariointhe West where there is stagnation in the growth in spending for dental services, with a shift in attending government clinics. This means that the cost of dental services will rise, and dentists’ incomes may not be able to keep pace with inflation.

• Dentalpractice:Iftheeconomyremainsas it is, there will be a shift in the types of dental services provided toward routine and preventative care, with a decline in the frequency of high end dentistry

c. Impact of dental and information technology: The key phrases nowadays are: “Change is inevitable and times change.” These adages became common because they are true. While change is inevitable, it is also the driving factor in the dental industry. So far it has been positive and has been the catalyst for new dental procedures, materials, products, and services that have improved patient care and that will provide major paradigms shifts in what dentists can do and what end results the patients’ can expect.

d. Dentists should have a passion for dentistry and compassion for others at the same time. Monetary reward is not everything and we should be considerate of our patient’s situation.

e. Most dentists should endeavour to have another set of dental skills in addition to bread and butter dentistry to make you more marketable. I would encourage dentists to take courses in certain dental sub-specialities to enhance their skills and clinical acumen to serve their patients better.

Patient satisfaction

is the key to a successful

dentalpractice.

MDA News

34Occlusion, Do I Really Need to Bother?

Article written by:Dr Malcolm R Edwards BDS, MScD, FDSRCSEng, DRDRCSEdin, MRDRCSEdin, FDSRCSEdin, FHEA Dr Edwards is a Consultant in Restorative Dentistry at the University of Central Lancashire (UCLAN) in Preston, United Kingdom. He is also the Director of Postgraduate Dental Studies, and coordinates all MSc courses at UCLAN. He runs workshops and lectures throughout the UK and across South East Asia on many topics in Restorative Dentistry.

I am often asked this question, and some dentists manage to avoid any serious involvement with occlusion and are quite happy to continue in this happy state of ignorance.

It is, however, a risky strategy if we are planning on providing anything other than simple fillings and single units, and even then we can get caught out if we have not even had a critical look at the existing occlusion prior to treating the patient.

My approach to occlusion is quite simple, stability is the keyword. We do not do anything which will promote instability, our work should maintain, and where possible, improve stability in the patient’s occlusion.

Dr Malcolm Harris

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For a majority of the patients, we will still be able to adopt a conformative approach, but we will be confident in our decisions because we have had a detailed look at the occlusion and its influence on our proposed treatment.

For some patients, as a result of our occlusal examination, we may want to explore the option of changing the bite, whether it be an alteration to the guidance or even increasing the vertical dimension.

These proposed changes can be tried out on the mounted models, and a risk/benefit assessment performed. Does the benefit of any such alterations to the patient’s existing occlusion outweigh any risks involved?

If so, we can discuss these with the patient. Such proposed changes can be carried out on the model, either by the addition of wax, or by modification to the teeth.

A discussion of occlusion with dentists often brings about drooping of the eyelids and a nodding of heads, particularly if it takes place after a large lunch. It is, however, not a complex subject, and aside from easily acquired knowledge, dentists only need to have mastered three clinical skills.

Firstly, the ability to take an accurate impression, and this is one we should already have acquired. Secondly, to be able to use a facebow, and finally, the ability to be able to find and record centric relation.

Armed with these skills, and some awareness of the features that promote stability in an occlusion, we are well placed to take on more complex cases, and provide patients with restorations in the sure and certain knowledge that we are promoting stability in their occlusion, and that this will add to the longevity of our work.

Despite popular belief, the study of occlusion is not one of the dark arts, it is interesting, challenging, and can even be fun.

Centric relation – what is it, and how do I find and record it?In the first article, I described the three skills we need to master to enable us to examine the occlusion of a patient, and design our restorations to maintain or improve occlusal stability. Of these, (taking accurate impressions, facebow and centric relation records) the one that most dentists struggle with is finding and recording centric relation.

How do we know whether we are achieving these ideals? The first thing we should do, for all of our patients, is carry out a simple occlusal examination. This will involve nothing more than a quick assessment of the stability of centric occlusion, a look at lateral excursions for tooth contacts on the working, and non working sides, tooth contacts in protrusion, and finally the slide from centric relation to centric occlusion.

Having carried out this quick, chairside assessment we are in a position to decide whether or not any of the restorations we are proposing could have a destabilising influence on the existing occlusion. In the majority of cases we will be fine to carry on without any further occlusal concerns, confident because we have had a look at the present scheme.

However, in some cases it might be that a tooth we are planning to restore plays an important role in guidance, or is an interference. In such cases we may well need to modify our preparation to allow for this, or select a more appropriate material for our restorations, or even adjust the contact. A more detailed look at the occlusion now becomes necessary.

For these cases, we will need to take some impressions for accurate study models, and get them mounted on a semi adjustable articulator. This will enable us to carry out a more thorough examination of the occlusion and tooth contacts in function.

The study of occlusion is

not one of the dark arts, it

is interesting, challenging, and can even

be fun.

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What is it?The first thing to say about centric relation (CR) is that it is a relationship between the upper and lower jaws. It has nothing to do with the teeth, and is therefore unaffected by tooth wear, the loss of some teeth, or the presence of dental restorations.

Centric occlusion (CO), on the other hand, is affected by a change in tooth or restoration contour, or indeed the loss of a tooth. This makes CR a position that is independent of the teeth, and therefore a reference point to which we can return at any time.

There are a number of techniques that we can use to find centric relation on our patients, the one I will describe is one I have found works well for most patients, most of the time.

Finding CR is much easier when the patient is co-operative, and so it is important to explain to the patient what we are going to do, and why we are doing it. I usually explain to the patient that when they bite together, it is their teeth that will determine how their jaws ultimately close, and that clearly this has changed over time.

I then go on to explain that because of these changes, the jaws may now be closing into a position that is not in harmony with the position that the jaw joints would like the jaws to close into, and so we are going to find the position that the jaw joints would like to close in to, were it not for the teeth.

I usually finish by advising the patient that when they close their teeth together from CR they will not meet in their usual way, and that it is likely they will experience an initial point of contact at

the back on one side. The patient now knows what to expect, and will be anticipating a different contact when their teeth meet.

Finding CRLie the patient flat back in the chair, it will be easier to find CR with the patient in this position.

Sit comfortably so that your forearms, when parallel to the floor are at the same level as the patients face.

Place your hands on the patients mandible as shown, your little fingers should be positioned at the angle of the mandible, your thumbs ideally intra orally on the attached gingivae, and your other fingers on the lower border of the mandible.

Force is applied in two directions, firstly you support and lift the mandible posteriorly, and secondly you apply a gentle force backwards with your thumbs. If you just push backwards the natural reaction of the patient is to push against you, and they will try to protrude their mandible.

We want the patient to relax their jaw and allow us to feel the rotation of the mandible as we open and close their mouth. It is this rotation that tells us that the condyles are located in the glenoid fossa and that the patient is on their terminal arc of closure.

When we close the patient’s teeth together they will experience that single point of contact (usually) and we can further enlist the patients support by asking them to identify the location of this contact, and to remember it for us. They should close onto this contact in a reproducible manner if we have the jaws in centric relation.

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It is helpful if your nurse then supports the wafer, as shown in the picture, and is careful to make sure that their fingers are not interfering with the jaw closing. This allows the dentist to regain their bi-manual support of the lower jaw, and guide the mandible as we did when finding CR.

It is important to watch the jaw close and the teeth approach the opposing jaw, remember we only need sufficient contacts to locate the wafer, if the patient bites through the wafer we must start again with a new wafer.

When we think we have sufficient indentations in the wax, we tell the patient to stop closing, and chill the wax with air from the three-in-one syringe before asking the patient to open in order that we can remove the wafer and place it into some cold water.

In order to verify the accuracy of the model and the wafer, we can now carefully offer up the wafer to the upper and lower casts in turn to check that it fits accurately against the occlusal surfaces.

If it does not fit accurately, we will need to repeat the wafer recording as it may have distorted. If the second wafer does not fit either, we must assume that despite our best efforts, the study cast is not accurate and take another impression.

What next?We now have what should be a set of accurate study casts, and a wax wafer centric relation record. With the use of a facebow transfer the models can be mounted onto a semi adjustable articulator, and this will allow us to gain a complete understanding of the patient’s occlusion.

It also provides us with the opportunity to trial any modifications to the patient’s occlusion to assess the possible benefits of such adjustments, have a diagnostic wax up that will be functional as well as aesthetic, and enable us to design restorations that will at least maintain occlusal stability if not improve it.

Remember, not every patient will require mounted study models, but if we don’t examine the occlusion of every patient we will not be able to identify those patients where it is necessary if we are to provide functional, and long lasting restorations.

Recording CRAt this point, we should be fairly confident that we have found CR, and our next objective is to record it. The important issues here are that we must record the position without any tooth contact, and that we must use a recording medium that will not flex or distort.

As can be seen in the pictures, I use a brittle, beauty wax, which I have warmed in water, and folded into a double thickness wafer. This is trimmed to fit the upper model and can be tried into the patient’s mouth to verify the fit.

This then goes into a water bath, the water should be just about bearable for your hands, if it is too hot the wax wafer will completely melt. Whilst this is softening, it is the opportunity to explain to the patient what it is that we are going to do, find CR again, and then place a cotton wool roll behind their upper incisors to prevent them from closing back into CO.

Once the wafer has softened, it is removed from the water bath, the cotton wool roll is removed as the patient opens their mouth, and the wafer if gently fitted to the upper arch. We need indentations that allow for accurate location of the wafer on the model, but no areas of perforation through the wax.

MDA News

38Management of Complicated Crown Fracture in Immature Permanent Tooth

Report prepared by:Dr Norashikin Abu Bakar DDS (USM), DClinDent PaedDent (UKM).Lecturer in Paediatric Dentistry,Faculty of Dentistry,Universiti Teknologi MARA

Crown fracture is the most common dental injury in the permanent dentition, with the maxillary central incisors being the most frequently affected teeth. Nevertheless, a study by Tovo et al (2004) reported only 20% of children

with crown fracture sought treatment immediately after injury. Pain, hypersensitivity and swelling were sighted as the main reasons for seeking dental treatment.

A delay in treating traumatically exposed pulp tooth may permit ingrowth of bacteria or diffusion of bacterial toxins into the pulp, resulting in pulpal inflammation and compromised pulpal healing. Severity of injury and the stage of root development are strong predictors of pulpal healing outcome.

What is the challenge?Immature permanent teeth have short roots, wide apices, as well as a thin and relatively weak dentinal wall. Thus, the loss of tooth vitality before its maturity may leave the tooth vulnerable to fracture, with possibility of an unfavourable crown root fracture.

In addition, necrotic immature teeth are challenging to treat endodontically. Performing chemochemical debridement and achieving good apical seal using conventional endodontic treatment method may be difficult in these teeth.

Therefore, every effort should be made to preserve the vitality of the pulp so that root development will continue in a traumatised immature permanent tooth.

Figure 1: Immature teeth 11 & 21 with wide apex and thin dentinal wall.

Figure 2: Immature tooth 11 presented with chronic apical periodontitis following 5 months after dental trauma.

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How to manage?The treatment approaches for traumatically exposed pulp in immature permanent teeth include:

1. Direct pulp capping

2. Partial pulpotomy/Cvek pulpotomy

3. Apexification with calcium hydroxide

4. Apical barrier technique

5. Regenerative endodontic

Both direct pulp capping and partial pulpotomy are aimed at preserving pulp vitality, thus facilitating continuity of root development in immature permanent teeth.

Traditionally, apexification with calcium hydroxide is the treatment of choice for necrotic immature teeth. This method is undertaken to induce the formation of calcified apical barrier, which would later facilitate the obturation procedure.

However, apexification may have several disadvantages, including long duration of treatment that requires multiple visits, as well as an increased risk of root fracture. The increased risk of root fracture is related to root dentine brittleness, which results from long-term presence of calcium hydroxide inside the root canal.

Apical barrier technique was introduced as an alternative treatment to apexification with calcium hydroxide. A barrier material (for example, MTA) is placed at the apex to achieve apical barrier for conventional root canal treatment.

Recently, a biologically based treatment called regenerative endodontic was introduced. The ideal goal of this treatment is to prepare the spaces inside the root canal with an environment that promotes repopulation of progenitor stem cells, regeneration of pulp tissue and continuation of root development. Several case reports have demonstrated successful clinical and radiographic outcomes for this treatment option in necrotic immature teeth.

Material of choice1. Calcium hydroxide

2. Mineral Trioxide Aggregate (MTA)

3. Biodentine

MTA and Biodentine are the materials of choice for management of complicated fracture in immature permanent teeth because of its superior physical properties over calcium hydroxide.

Both MTA and Biodentine have:

• goodsealingability

• biocompatibility

• hardtissueinductionpotential

• hydrophilicproperty

However, MTA and Biodentine are expensive. There is also a potential for discolouration, especially with MTA. Perhaps, these disadvantages may have made calcium hydroxide to remain as a popular material of choice for many clinicians.

Conclusion Timely management and an appropriate treatment plan are important factors that would determine the prognosis of an immature tooth with a complicated crown fracture.

Referencesi. Güngör, H.C., 2014. Management of crown

related fractures in children: an update review. Dental Traumatology, 30(2), pp.88-99.

ii. De Castro, M.A.M., Poi, W.R., De Castro, J.C.M., Panzarini, S.R., Sonoda, C.K., Trevisan, C.L. and Luvizuto, E.R., 2010. Crown and crown-root fractures: an evaluation of the treatment plans for management proposed by 154 specialists in restorative dentistry. Dental Traumatology, 26(3), pp.236-242.

iii. Flores, M.T., Andersson, L., Andreasen, J.O., Bakland, L.K., Malmgren, B., Barnett, F., Bourguignon, C., DiAngelis, A., Hicks, L., Sigurdsson, A. and Trope, M., 2007. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental traumatology, 23(2), pp.66-71.

iv. www.iadt-dentaltrauma.org