Dentistry’s Descent

A short while ago, I posted something on Facebook that sparked the curiosity of many of my closer friends.

Yes, I’ve been in the profession for 30 years and boredom set in since the very start! Believe it or not, I was already talking about retirement (from the profession) and migrating (voting with my feet) 15 years ago. While I’ve gone back to pursue my passion in the arts, dentistry is still bringing home the bacon. If I ever have to quit any time soon, it would most likely be because it fails to bring home the bacon.

The cataclysmic changes I was talking about was reported by the Online Citizen a month later. It has to do with a new policy which restricts the practice of dental GPs. They would not be allowed to carry out complex dental procedures without first acquiring a Certificate of Competency (COC)

I’ll come back to COC later. First, some background and history of dentistry in Singapore that I have managed to live through.

Sunset Profession

In my book Dental Phobia, I painted the alamak patient as one who would refer to the neighbourhood dentist as Pull Teeth One. Indeed, to most heartlanders born in the 1950s or earlier, dentistry is little more than filling teeth, pulling out teeth and making plastic teeth. In spite of the lack of glamour and prestige, many retired dentists who once had lines as long as Toto queues managed to make their fortunes just providing these relatively simple services. If they had wanted their children to follow in their footsteps, the younger generation will need to swim against some very hostile currents engulfing the profession today. Suffice to say that unless they somehow have the same Toto-like queues that their predecessors once had (extremely unlikely in today’s competitive environment), they may not even survive, let alone thrive and make their fortunes.

When I first graduated in 1988, dentistry was decidedly a sunset profession. Crowns and bridges were considered extremely high end procedures and root canals occurred as frequently as condemned criminals getting a presidential pardon. My starting pay was not as “upper middle class” as I had wanted it to be, but the cost of living was low then and I managed to get by.

Into the 1990s, many patients started asking for tooth-cloured fillings – which were invented in 1962. These materials evolved rapidly and by the 1990s, had become a lot more reliable since my student days. But Singapore tends to be a little behind time due to the low priority placed on good dentition. Full ceramic Dicor crowns (which were more aesthetic than porcelain fused to metal crowns) were already around since the 1950s and Empress crowns were already available since 1980. They did not become popular in Singapore until the turn of the century circa 2000.

But as millennials grew into image-conscious, blogging teens, orthodontics turned into a virtual necessity for kids with malocclusion. More and more dentists started doing it. Even as the tussle between Taiwanese serials and Korean dramas was still ongoing and K-pop was still in its infancy, costly European implants with limited user support became drowned under the tide of cheap and good Korean products with excellent after sales service provided by smiling, bowing Korean staff.

On top of that, Medisave could be used to make partial payment for some surgical procedures. Tooth replacement with implants, root canal surgery, wisdom tooth surgery became a bit more affordable for all. Extractions were feared, not for the pain, but the loss. Endodontics (root canal) became commonplace – with that came crowns, metal-free restorations, cosmetic gum surgery, flexible dentures. More and more people wanted to save their teeth. More and more asked for implants to replace their missing teeth. More and more did ceramic crowns and veneers for their front teeth. More and more whitened and straightened their teeth, or even go through extreme makeovers for that winning smile. The scope of practice for the dental GP swelled and so did our population. Dentistry in Singapore was no longer behind time.

The Sun Rises

New technology and innovations always excite Singaporeans and rising from the ashes, dentistry became a sunrise profession. All of a sudden, dentists started attending continuing education courses, not just to earn continuing education points (they need 70 points in a 2-year period) by sleeping through irrelevant lectures but actually acquiring new skills and adopting new technologies. I have personally witnessed many young and even not so young dentists getting energised into bringing their practices to the next level. Many who are not specialists have trained themselves to provide complex, high value cases for considerably lower fees. Consequently, demand for sophisticated dentistry went up. In my opinion, that was the golden decade (2000-2010) for the profession in Singapore. Never mind the alamak patients. The internet provided an almost endless stream of curious and interested inquirers. Dentistry regained its status as a promising career and a glamorous one at that. Straight A students started pounding the doors to be enrolled in the Faculty. The barrier to entry was raised accordingly. GPs who had upgraded themselves became decidedly upper middle class.

But it ought to be noted that the concept of the super GP is not new. Quite a number of dental GPs currently in their 70s were already doing braces, wisdom tooth surgeries, precision dentures and even implants during their heydays. It was during this golden decade, with the increase in opportunities to learn, share and advertise skills that super GPs flourished.

With so much potential within the profession, it’s difficult for venture capitalists not to take notice. As money started pouring in and a few blue eyed boys were identified as potential CEOs, some dental clinics started to transform, branching out into every nook and cranny of our tiny little island. An Indian professor once gave a talk at one of our continuing education lectures. He said that the ratio of dentist to population was still not ideal. He felt that we didn’t have enough dentists and ought to produce more until we attained a healthy ratio like that in Australia.

Our professor seemed to have forgotten that our geography here is very different from that in Australia. If you don’t want to see Dentist A in Australia, Dentists B could be 2-hours’ drive away. In Singapore, there are scores of dental clinics between 2 MRT stations. How difficult is it to obtain treatment if one really needs it? Then, he also talked about our aging population and why we need more dentists. I wish he had attended a conference on geriatric dentistry here. The room was barely 25% full whereas at a conference on aesthetic dentistry, there’s only standing room available. It’s obviously not simple arithmetic at work here.

After one company went public, a dozen or so wannabes started rooting for a ride on the IPO bandwagon. On a street with only two blocks of flats with two rows of shops on the ground floor, there were 3 dental clinics and only 2 medical clinics. Things have gone totally irrational. A patient recently remarked to me that he sees more dental clinics than coffee shops and that’s not an exaggeration. At one of the clinics where I work, there are two other dental clinics within 20m and another 4 within 300m, another 2 within 500m.

The CEOs of these rapidly multiplying practices were not only desperate for dentists to man their new branches but they lose sleep while closely monitoring “sales figures”. The problem of manpower is not too difficult to overcome. Foreign dentists or dentists who graduated from certain foreign universities are allowed to work in Singapore. Meanwhile the Faculty of Dentistry at NUS has almost doubled its intake of dental students since my time. Only about 30+ of us graduated back then. Today, almost 80 are expected to graduate every year!

The arithmetic is simple. If you set up 100 clinics, you “need” 100 dentists. The manpower issue is by no means an insurmountable issue. As in any other industry, you could either employ foreign graduates or wait for NUS to churn them out or do both. The problem of sales target is a lot trickier and it’s not difficult to figure out why. Are there enough patients and indications to feed these high maintenance clinics equipped with high tech equipment on hefty leases? Can the trees keep branching out without looking back on whether there’s enough earth to support it? What happens when there are too many dentists and too few patients? Will dental treatment become cheaper as dentists undercut one another? Will dentistry still be practised as ethically as before?

In 2013, the Chinese authorities decided to introduce a cooling measure for their overheating property market. Couples who sold a second property had to pay hefty taxes for the sale. What did the Chinese couples in Shanghai do? The selling couples teamed up with the buying couples and both couples got divorced. The ex-husband in the selling couple would keep the property. Money from the buying couple was given to the ex-wife in the selling couple so it didn’t look like a sales transaction. The ex-wife from the buying couple then married the ex-husband from the selling couple! They then got divorced with the ex-wife from the original buying couple keeping the property. When everything was back in place and the property transferred, the two couples got together again. No taxes paid. Shanghai saw 30 divorces a day when this game was ongoing.

While Singaporeans are way less crafty and unscrupulous, dentists are pretty smart people – until they get caught. Be prepared for lots of juicy scandals. The golden decade is pretty much over.

The COC

Dentistry depends a lot on skill and skills take time to develop. Nobody is skillful when he first graduates. I would have gone crazy if my boss set a quota for me when I first started private practice. In a way, many young graduates today are not so lucky. And the character of the whole industry has also been totally transformed. This is the age of dental empires. Your friendly neighbourhood dentist is fast going extinct. With cookie cutters on steroids, new clinics are sprouting up everywhere with emphasis placed almost entirely on branding and not the practitioner. They don’t even put the practitioner(s)’ names out there anymore. As a result, practitioners no longer have any sense of belonging to the practices. The practices milk them and they in turn milk patients and get out, either to another practice or another country. The only real winner here is the dental empire. I will come to the aftermath of this carnage in a moment.

The author doing his first sinus lift (under supervision) in 2008

I’ve heard about the COC way back in early April and I’d wanted to refrain from commenting until the thing goes public. And would you believe it, some commercial entity has already prepared itself for it long before the rest of us have any inkling of this shocking development. TOC reported that “The Singapore dental fraternity is up in arms over the possibility of a conflict of interest in relation to the introduction of certificate of competencies (COC) and restriction framework for dentists who are general practitioners.”

The latest development involves a complaint being made to the CPIB and I shall not comment on whether the complainants have a case until investigations have concluded. Suffice to say that there are too many coincidences. It’s sad that some of my colleagues had to resort to reporting criminal activity to get this problem solved, but then again, is there any other way?

Now, what is the COC and why do the authorities think that it should be implemented? The COC is a scheme that follows a recent proposal by the Ministry of Health (MOH) and the Singapore Dental Council (SDC) — which is the profession’s self-regulatory body — that could require dentists in general practice to undergo more training for procedures such as wisdom teeth surgery and implants before they are certified “competent”.

For the record, there is already a COC in force for facial aesthetics (Botox and filler injections). Of course, we’ve never learned that in dental school, so it’s only fair that we must attend a course (with a written test at the end) and pass it before we can perform the procedure. However, I remember I only had to take a one-day course to obtain my COC for that. Even though the 1-day course is officially recognised, I felt it was really inadequate. I learned much more from a voluntary programme with a lot of hands-on practice on volunteers in Taiwan.

The obvious irrationality here is, you can be a total newbie in the field of facial aesthetics and you just need one day’s course to get a COC. You can have decades of experiences removing wisdom teeth and sinking implants. You still need a COC to certify your competence.

Explaining the purpose of the COC, the Ministry of Health (MOH) and the Singapore Dental Council (SDC) said in a joint statement that the moves are meant to allow “dentists to be further trained in these specific dental procedures and to be able to practice safely and competently without having to undergo specialist training. Both the MOH and SDC added that the decision on certification is backed by international benchmarks, patient concerns and complaints.

The author doing his first sinus lift (under supervision) in 2008

Let’s say you want to “further train” a dentist to do a complex root canal. Will this “further training” exceed the length of training that the dentist had in dental school? If not, then is this just a formality? If not, does it then mean that the curriculum for the procedure of root canal in NUS is somehow inadequate? Does it mean that foreign degrees that are recognised by the ministry are inadequate and they are just beginning to realise that?

There are some very senior super GPs out there who have done literally thousands of wisdom tooth surgeries and implants. That is competency. Do they need to attend courses to be certified for basic competency in procedures which they have been doing expertly for decades?

Coincidentally (or so it seemed), local dental group Q&M dental group stated in an interview with ST on 2 May that it was setting up a private dental college in Singapore by the middle of this year. The college wouldn’t provide degrees but would provide “courses” for graduate students. How superior are these “courses” (days?weeks?months?) compared to those which our GPs have been attending? What value do they add to their decades of experience?

The company running the college, Q & M College of Dentistry Pte Ltd, has already been incorporated in December last year (long before we knew anything about the COC). Coincidentally again, the Aoxin Q&M dental group limited, a subsidiary company which is also registered in Singapore lists Professor Chew Chong Lin as an independent director. My colleagues who made the complaint to CPIB has an issue with this arrangement as Professor Chew Chong Lin is also the President of the Singapore Dental Council since 2009. SDC is the self-regulatory body for the dental professions constituted under the Dental Registration Act (Chapter 76).

This is an important milestone. For the longest time, the regulatory body for dentists has been throwing rules, guidelines and regulations at us. The so called “self-regulation” is quite a misnomer. In spite of the elected members of the council, the cue always appears to come from the Ministry and not from the general body of dentists. Besides that, the council in both SDA and SDC are dominated by Q&M dentists. For the first time in our history, dentists who have been under the thumb of the council are calling out on a possible major transgression.

Other colleagues talked about a “slippery slope”. What are we slipping into? Certification for dental assistants before they are allowed to assist? Which company is going to manage this certification process? Your guess is probably the same as mine. It of course does not mean that inhouse, informally trained assistants are less competent. It’s going to be a question of who is approved and what is recognised.

The Public

When news of the COC first emerged, the response from the public was quite predictable. Folks who had bad experiences with treatment outcomes flooded Facebook with comments supporting it. If these comments were to be taken seriously, then there should be no argument as to whether there ought to be a COC. The impulsive commenters may not be aware that with the COC in place, they may have to go to a specialist to get their wisdom tooth removed or their implant placed. They may not think twice about supporting it until they need to pay for it. By then, it’s already too late.

So do the specialists have any cause for celebration? Maybe, maybe not. The biggest losers are the super GPs whose numbers have grown steadily throughout the golden decade. If there are hundreds of disciplines and procedures they need to obtain COCs for, it could take years before they are certified “competent” in all these procedures.

This is what will happen to my surgical kits after COC

What about the public? Why do people complain? Many dentists who have been practising successfully for 40 years had all the complaints they ever received made within the last 10 years. Why no complaints before that? Because they suddenly became lousy dentists in the last 10 years? Or is it because patients have become more knowledgeable and demanding? Has it also become a lot easier to complain? Just a click of the mouse. Assuming that these complaints are justified and treatment outcomes could have been better, why did such problems arise? Why are so many inexperienced dentists attempting risky procedures which are beyond them? Why are they cutting costs with incompatible third party implant components? Could it be because they have committed themselves to a massive implant package and suppliers are chasing them for payment? Could it be because the staff are not paid, the leasing company is hounding them and the landlord sends another reminder? Could it be because they have a “sales target” and the CEO of their dental empire is breathing down their necks?

If I were a patient and I need to have my wisdom teeth removed, would I go to a dentist with a good track record or would I go to a newbie with a COC. It’s a no-brainer for me, but the scheme should make sense as long as there are enough unthinking people around.

Treating these problems with COC is like treating cancer with antibiotics. The root of the problem is that we have too many dentists and dental clinics. Way too many. Only some of us are doing well. The rest are struggling and forced to do things they shouldn’t do. The numbers are unreal and should not have been allowed to build up in the first place. And the biggest irony is that in spite of the numbers, the public is not going to be served any faster or better because so many super GPs are going to get their hands tied. And that’s after beefing up the supply of dentists to a “healthier” level. It’s a joke, except that it’s not funny. The bubble is set to burst and the empires are striking out at the small fries who have been minding their own business. Make no mistake, we are at (or perhaps even gone past) the peak of a dental bull run and the only way to go is down. It ain’t going to be a pretty picture down there.

The Outcome

Nobody can be sure what the outcome is. One part of me wants things to go back to the status quo, let me practise the way I’m used to for another 10 years or so before I quit for good. Another part of me is hoping that a tsunami would sweep through the dental landscape, flattening out all the cookie cutter practices and restore the old school of solo and small group practices (not more than 6 branches) where patients identify with their friendly neighbourhood dentists and not some brand.

Unfortunately, neither of these outcomes are likely, given the interests of corporations and the numbers they show. Couple that with a ministry that knows better than the rest of us and you have a perfect recipe for a humble pie that we will all be forced to eat. To endure the humiliation/inconvenience and settle for much less than what I deserve? Or to quit and move on to something else?


Dental Phobia by Chan Joon Yee

Regression With Technology

For a country that fiercely defends its independence when criticised about press freedom and human rights, we are virtually led by the nose when it comes to following cool innovations from Western countries. Just like in Singapore, the folks who implement these policies over in the US have little idea of the challenges on the ground.

The usual narrative is that this is something that will help us keep up, failing which we would fall behind the rest of the world. Sometimes, it’s better to fall behind than to march along with the other children as they follow the pied piper of Hamelin.


Dental Phobia by Chan Joon Yee

When Doctors Get Desperate

Toni Bark is a forceful promoter of ice-cold dips in lakes and other dubious “alternative cures” like homeopathy. On her website, she claims to practise “Disease Reversal, Holistic, and Functional Medicine”. A bestselling author, popular speaker and a powerful crusader on social media, she has also made a vocation out of speaking against vaccines and how they harm our children. You would think that she must be some self-taught guru with no substance beyond her gift of the gab. Except that Dr Toni Bark is a qualified paediatrician.

Dr Toni Bark MD

Yes, she sees (or appears to see) little or no threat from measles and other illnesses that had killed many children in the past. At the same time, she makes many parents think that there are safe “natural cures” for these conditions. Instead of managing common paediatric conditions in a clinical practice, she focuses on “illnesses” caused by vaccines and insists that vaccines are the cause for autism in the face of overwhelming evidence to the contrary. As a layman, she could have been dismissed as some snake oil salesman, by Dr Bark testifies in courts as an expert witness!

There is always a supply of conspiracy theorists ready to lap up whatever sensational cover ups that the activists have exposed. Dr Spark claims that 70% of the reports on the safety of vaccines in mainstream media are paid for by the big pharmaceutical companies (Big Pharma). Followers and believers of the anti-vaccination movement come in all shapes and sizes. From Jews to Muslims, school dropouts to university professors, homeless folks to those who live in mansions – there is no typical profile for the average “anti-vaxxer”, as they are commonly referred to. Throw in a few celebrity “influencers” and you’ll have an unstoppable anti-vaxxer movement.

However, if you were to study these anti-vaxxer websites, a predictable pattern is observed. There is usually very little scientific data or statistics – just moving, even tear-jerking stories. While most rational people will not accept these stories as representative of the mean, some people just fall for it. Knowingly or otherwise, the cult leaders capitalise on the people’s mistrust in the government (and who can blame them after the fake news about WMD in Iraq that cost Americans thousands of lives and $2.4 trillion) and manipulate that mistrust so that they can even make the most far-fetched conspiracy theory believable. Sadly, the writing is on the wall. Truth is losing ground. The more the authorities try to beat them down with statistics, the more the cult would try to rebel against the system and recruit new members.

All cults come with leaders and for someone as intelligent and well-trained as Dr Toni Bark, it’s hard to see her as a follower even though the anti-vaxxer movement may not have started with her. Whatever her motives, it is likely that she became much better known after she spoke out so vehemently against vaccines, especially when she travels the country to give fiery speeches and riveting talks against the establishment in contrast with the usual stuff that most unassuming paediatricians talk about. She wouldn’t have generated any buzz. She wouldn’t have become famous if she had worked as a regular doctor. By going against all that and practising quakery, her patient load increased rather than decreased.

Vaccination

“The anti-vaccine lobby has grown from a fringe movement in the late ’90s, early 2000s to this massive media empire that has now hundreds of websites, amplified on social media. They have political action committees now, it’s become politicized,” said Peter Jay Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and the director of the Texas Children’s Center for Vaccine Development. “This was never a problem up until a few years ago, but now it’s become this huge issue.”

Yes, it’s now so huge that it has become political. It is believed that Donald Trump scored quite a number of points by pointing out that vaccines could be a cause for autism. Like Dr Bark, Senator Rand Paul is also a doctor and an ophthalmologist to boot. He too seemed to have gained quite a few supporters by suggesting that vaccination should not be compulsory. A 2015 Pew Research Poll concluded that 68 percent of U.S. adults say childhood vaccinations should be required, but 30 percent say parents should be able to decide.

The movement is bearing a toxic fruit. In 2018, 349 individual cases of measles were confirmed in 26 states and the District of Columbia. This is second to 667 cases reported in 2014. Measles was supposed to have been eliminated in the US in 2000 but most recently from January 1 to April 4, 2019, 465 individual cases of measles have been confirmed in 19 states! Will it hit a new high?

Meanwhile, the anti-vaxxers continue their crusade to leave more children unprotected. Are they simply ignorant, misled, or do they have a more devious motive – like some vegan guru who doesn’t practise what she preaches?

We all know that politicians are in a breed of their own and their stand can shift with the movement of public sentiment. But It would not just be an irony but an utter insult to the medical profession if doctors who are not doing well practising medicine somehow manage to earn a fortune by going against it.


Dental Phobia by Chan Joon Yee

You Can’t Please Everybody

True story. Tim was gym owner who was all stressed out even though he was doing a booming business. After numerous ranting sessions with friends and family, he began to rationalise his position. He realised that over 90% of his customers were satisfied with the service and amenities he provided. Less than 10% were habitually complaining, threatening and making all sorts of demands.

Tim had been reading books by business gurus who said that he must hold his customers as a bucket would hold water. Once there’s a leak, his business will bleed. It all sounds very nice and logical, but the reality is something that the guru had not grasped. Tim decided that he would just refund the membership fee to that measly 10% and focus on that 90%.

The guru was wrong. He did earn a little less money, but his business did not bleed. Most importantly, Tim’s sleep and appetite improved. His regained his health and he was even beginning to enjoy his work.



Dental Phobia by Chan Joon Yee

New Experiences by Old Dentists

Sometimes, even after 30 years in practice, dentists still get new experiences; cases they have not seen before, patients they have yet to encounter.

How often do patients sympathise with their dentists? Not very often. They don’t feel bad when they keep exhaling through their mouths, fogging dentist’s mirror. They may not even try to keep their mouths open for a long procedure. They think it’s the dentist’s problem when they can’t open their mouths.

On a few rare occasions, they say “sorry”. But when a difficult patient (who claims to have a phobia for dentists) says “poor thing” when she sees the dentist struggling, it brings a strange feeling to the poor dentist. Is she being apologetic? Is she mocking? Something to chew on.


Dental Phobia by Chan Joon Yee

How Deep Are Your Pockets?

Madam Wang Xiaopu is an investor from China. Convinced that Singapore’s medical aesthetics industry is a gold mine, she signed a contract to buy over 20,000 shares in a company holding a chain of aesthetic clinics for $32.5 million. She was informed by Dr Goh, a major shareholder in the company, that the clinics have a pre-tax profit of $10 million in 2012, and its pre-tax profit was also growing at a rate of more than 30 per cent a year. The chain, which originally had 14 branches, is now facing insolvency, rendering Madam Wang’s shares worthless.

Madam Wang is just one of many faceless (clueless) foreign investors wooed into the seemingly lucrative local healthcare industry. With millions injected into their war chests, the aggressive clinic management teams spawn dozens of branches, quickly saturating the small local market and creating the illusion of insufficient manpower. I’ve already written about the apparent shortage of dentists which is not due to dentists unable to meet the demand of patients but rather them not meeting the demand from the sheer number of “shell” clinics built. And the drying wells are seen everywhere. Small clinics which used to be doing very well have deregistered themselves from GST. Some have seen a 30-50% drop in revenue. On the ground, clinicians bonded to “high performance” practices are struggling to hit targets and this sometimes results in overwork, over-treatment or even cases of fraudulent claims of which we have seen and will see a lot in the coming months and years.

It is unfortunate that most of those in the know hesitate to comment on this issue before the profession/industry reached this state. They are reticent for a variety of reasons. Some keep quiet because they are in the game themselves. Some are afraid of saying the “wrong” thing. Some simply just don’t want to get “marked”. Why speak out when they are still earning a comfortable income? A doctor who commented on my Facebook posting on this subject quickly changed his mind and removed his comments. That’s how fearful Singaporeans are, even when they need to sound the alarm for a house on fire. Instead of voicing out their concerns, some quietly crawl through loopholes to sustain their income. But for how long can all this last without blowing up in our faces?

As Singapore opens its doors to high net worth new citizens, it’s worthwhile to keep an eye on the industries they invest in. What is the demand for high value medical services which are readily available for a lower price tag and with fewer restrictions/regulations in the region? When profits and ROIs fall far short of investor expectations, the scene will turn really ugly.


Dental Phobia by Chan Joon Yee

No Dental Stem Cell Banking

Recently, the governing body for dentists in Singapore sent out a circular reminding dental practitioners that they are not allowed to carry out any activity relating to the harvesting of dental pulp tissues and DPSCs (dental pulp stem cells).

The reason behind this prohibition is that “dental pulp tissue and dental pulp stem cells currently (bolding mine) lack clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions.”

Strata Insurance Brokers

Before I go further, I must declare that I have absolutely no interest whatsoever in harvesting dental pulp tissue and neither do I encourage patients to spend money paying for a service which is unlikely to be put to good use in the near future. Sounds a bit like insurance? Well, that’s almost exactly what it is. So if there is currently no evidence that you’re having cancer or kidney failure, why buy a crisis cover? The majority of people who buy insurance will not gain from it, but they buy a policy in case of untoward circumstances because having no evidence of cancer of kidney failure currently does not mean that you won’t get any evidence of cancer or kidney failure in future.

Now let’s take a look at dental stem cells. What are they?

Wikipedia:

Dental pulp stem cells (DPSCs) are stem cells present in the dental pulp, the soft living tissue within teeth. They are multipotent, so they have the potential to differentiate into a variety of cell types. Other sources of dental stem cells are the dental follicle and the developed periodontal ligament.

Why are stem cells such cool stuff? They are like promising recruits in the army. When a battalion of commandos gets wiped out, you can train them to replace the commandos. When an artillery battery gets wiped out, you can train them to be artillery men. These cells give hope for patients who need organ transplants because theoretically (and sometimes in the laboratory), stem cells can be cultivated to produce various kinds of living tissues. However, not all stem cells have the same potential.

When we talk about stem cell potency, there are several levels to consider. A unipotent stem cell refers to a cell that can differentiate along only one lineage. Of all the stem cells, a unipotent stem cell has the lowest differentiation potential. This means that the cell has the capacity to differentiate into only one type of cell or tissue. Unipotent cells are found in the skin. You can technically grow new skin using these stem cells. However, patients who need skin grafts often need them urgently and there is currently no technique that yields quick and consistent results.

Image from page 55 of "Cunningham's Text-book of anatomy" (1914)

Stem cells can also be pluripotent. As far as embryonic origins go, there are only 3 categories of tissues in our body. Depending on its origin, a pluripotent stem cell can differentiate into one of 3 tissue categories. An ectodermal stem cell can grow into ectodermal tissue (skin, nerves). An endodermal stem cell can grow into endodermal tissue (lung, gut lining) and a mesodermal stem cell can grow into mesodermal tissue (muscle, bone, blood, urogenital).

Dental stem cells are multipotent and there is already quite a bit of literature on it. Multipotency describes progenitor cells which have the gene activation potential to differentiate into discrete cell types. They can theoretically be induced to grow into different types of cells (independent of embryonic origin) as in blood, brain and bone. Multipotent cells have been found in cord blood, adipose (fat) tissue, cardiac (heart) cells, bone marrow, and the mesenchymal stem cells (MSCs) which are found in our wisdom teeth. Seeing the huge potential of an insurance concept, businesses have pounced on the opportunity to sell pricey storage facilities for cord blood and even extracted wisdom teeth as they are the most readily available sources of multipotent stem cells.

Dental Stem Cells: Regenerative Potential Free Download

Right there at the top of cell potency, totipotency represents the cell with the greatest differentiation potential, being able to differentiate into any type of tissue. Totipotent stem cells are only found in an embryo that is a few hours old – before it grows 3 layers. You can theoretically grow an entire organism or organ with a totipotent stem cell, but obviously, you would need to sacrifice a living organism in the process. Ethical issues get in the way, but it gets more interesting.

Induced pluripotent stem cells, commonly abbreviated as iPS cells or iPSCs, are a type of pluripotent stem cell artificially derived from a non-pluripotent cell, typically an adult somatic cell, by inducing a “forced” expression of certain genes and transcription factors. By 2007 scientists have successfully produced human iPSCs derived from human dermal fibroblasts which are not even stem cells. The feat earned Shinya Yamanaka and John Gurdon the Nobel Prize in Physiology or Medicine 2012. This discovery raised a question. Why do we need to store or harvest stem cells at all if they could be made from an ordinary cell?

But let’s not get carried away and drift into the realm of science fiction. Stem cell technology is still in its infancy and the American FDA does not approve any of the stem cell therapies out there. Some are even considered dangerous. Nevertheless, clinics there are already using stem cells to treat problems ranging from arthritis and torn tendons to paralysis and stroke. These patients are willing to take the risk even though researchers say that there’s (currently) no evidence that the treatments work or are even safe.

What do we do to such experimental therapies? We certainly should not encourage them, but the practically harmless process of harvesting cord blood or dental stem cells should both count only as insurance policies. In the case of cord blood, there is only one chance at birth. For teeth, there are more opportunities, though the process is a little more invasive. What will the outcome be? Will we be able to grow new livers and kidneys from teeth? Will induced pluripotency render cord blood and dental tissue banking obsolete? Or will all this research finally lead us to a dead end?

Hundreds of healthy teeth are extracted in Singapore every day to make way for tooth movements and alignment. What’s wrong with banking these teeth? Those who opt for the service are merely placing their bets on the future. Why should they be dictated by the “lack of clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions”? Pessimistic and cynical as I am, I believe that the final outcome of a dead end to all this research is most unlikely.


Dental Phobia by Chan Joon Yee

Just Pay More Lor

Mr Khaw Boon Wan

Transport Minister Khaw Boon Wan said in Parliament on Mar 7 2018 that while Singapore’s transport fares are currently “affordable”, the Government also needs to ensure the “sustainability” of the transport network.

“We must be careful that (fares) are not priced too cheaply, as maintaining a “high-quality” transport system requires resources,” he said. “Cheap fares are popular, but they are not sustainable.”

The current formula is “inadequate”, he said, and the Public Transport Council (PTC) is reviewing it to take into account “total costs”.

“I am confident that they can work out a fair and sustainable arrangement. Please support the PTC when they make their recommendations,” Mr Khaw said.

And not too surprisingly, the PTC had this to say:

“A widening gap between cost and fares is not sustainable for any public transport network.”

While PTC said it was too early to commit on whether this new component would mean a fare hike at the next review in the third quarter of this year, it pointed to the need to keep the system sustainable.

An interesting coincidence perhaps, but what does the PTC actually do or claim to do? Let’s take a closer look at info extracted from their website.

As the Public Transport Council (PTC), we regulate public transport fares and ticket payment services. We also advise the Minister for Transport on public transport matters. Established in 1987 under the Public Transport Council Act (Cap 259B), we operate within the ambit of the Public Transport Council Act and in accordance with overarching public transport policies.

We strive to bring about a quality and affordable public transport system for the people of Singapore. We also work closely with the public transport industry players and public agencies like the Land Transport Authority (LTA).

Key Function and Objectives

Our key statutory powers include:

Regulating bus and train fares (taxi fare has been deregulated since 1 September 1998);
Promoting and facilitating the integration of bus and train fares for efficient public passenger transport services and facilities;
Regulating ticket payment services for buses and trains;
Regulating penalty fees to deter fare evasion;
Gathering public feedback on any matter relating to bus, train and taxi services in Singapore, through surveys and other methods; and
Advising the Minister for Transport on public transport matters.

PTC’s Council Members are appointed on the basis of their competency, good public standing and wealth of experience, especially their ability to contribute effectively to PTC’s deliberation on public transport issues. The Council Members are chosen from a wide spectrum of society including:

Professional services
Business
Academic institutions
Labour unions
Grassroots organisations

The composition of the Council is made up of a broad and diverse representation from society, which includes academia, labour union, industry and the people sector. This facilitates a wide representation of views from the public. The Council currently comprises 17 members and many of them are regular users of public transport.

chauffeur

So Council members in the PTC are chosen for their competence, good public standing and “wealth of experience”. If you’re talking about “competence” and “good public standing”, then that should rule out an undistinguished guy like me. But I’m not sure what kind of experience they’re looking for. You see, I have taken the MRT on its test run in 1987 and I’ve been taking it almost on a daily basis ever since, enjoying the speed and comfort, showing it off to friends from overseas till the early 2000s. Then, things changed. The passenger load grew at a frightening rate. There was crowding on the platforms, squeezing in the trains. Our once proud and efficient MRT was no longer as reliable and comfortable as it used to be. Then came the frequent breakdowns, delays, death on the rails, tunnel flooding incident and train collision. Does that count as “experience”? More importantly, do the chosen council members have the experiences of watching our MRT deteriorate to its current state? How justified is an increase in fares?

Dentist.

Then on 18th May 2018, Mr Khaw said something even more outrageous and mind-boggling.

“The Public Transport Council (PTC) had mulled over including rail reliability into the formula for calculating public transport fares, but ultimately decided against it. This was partly because reducing fares in the face of an unreliable rail system would mean withdrawing resources from the operators when they, in fact, need to inject more funds to fix the system. When a system is very unreliable, in fact, that is the time to pump in more resources. And because of that, you punish them through reduced fares; you are withdrawing resources from the operators and you’ll be doing exactly the opposite, the wrong thing.”

Yao mo gao chor ah? Since this is newagedentists.com and I’m promoting my book, Dental Phobia, I should come up with an appropriate analogy.

Once upon a time, there was a dentist by the name of Dr Poh Chwee Kee. He had just taken over a thriving dental practice from a retiring senior. He was glad that there was still a lot of materials left behind, so without bothering to order new materials, he used what was available. Then, his patients started coming back to him, complaining of fillings that fell out. Dr Poh Chwee Kee checked his instruments and his filling materials and discovered that the filling materials handed over to him had all been contaminated. He called the supplier and fresh stocks of filling materials would cost him a bomb.

So Dr Poh Chwee Kee informed the patients affected by the contaminated filling material that he would replace their fillings for a higher fee than they had paid for the old fillings that had failed. He explained that maintaining a “high-quality” dental practice requires resources. His profit had fallen 68%.

“Just pay me more lor. Cheap fees and free re-treatment for failed cases are popular, but they are not sustainable.”

Is it his patients’ fault that this problem had occurred? Why should they be made to pay to fix a problem that ought not be there in the first place? Not surprisingly, Dr Poh lost all his patients in no time. Why? Because it’s the service provider’s responsibility to provide a reasonable standard of service. If he fails to do so, he must rectify the problem at his own expense. How can he ask people to pay him more to fix the problem after he has failed to deliver?

The logic is the same, but the situation is very different. Dr Poh did not have the backing of a council that happens to agree with him most if not all the time. He also did not have a monopoly of dental services in his town. For those who do, karma may strike in an unexpected place.


Dental Phobia by Chan Joon Yee

A Nose Job Gone Wrong?


Dental Phobia by Chan Joon Yee

Boosting Outbound Medical Tourism

My friend – let’s call him C, had a problem. Actually it’s not really his problem, but his teenage daughter got pregnant – which kind of made it his predicament since he is a highly respected person with a solid reputation in his community. C’s daughter ended up flying off to a European country for an abortion cum holiday before returning to Singapore to attend school. The reason C took the trouble to do that had something to do with this piece of news.

The finer details are still being finalised, but the new Healthcare Services Bill is intended to better “safeguard the safety and well-being of patients” in the changing healthcare environment while enabling the development of new and innovative services that benefit patients. It is also supposed to strengthen governance and regulatory clarity for better continuity of care to patients. It is further assumed that HCS Bill – and the National Electronic Health Record (NEHR) that it mandates – address wider issues of “patient welfare”.

The obvious advantage of this system is that inaccurate or incomplete medical history will be a thing of the past. An unconscious patient brought into A&E will have all his drug allergies and current medical condition clearly displayed for the convenience of the attending physician – assuming he is correctly identified. The core data accessible to future attending physicians include 1) Patient Profile; 2) Events; 3) Diagnosis; 4) Operating Theatre Notes/Procedures/Treatments; 5) Discharge Summary; 6) Medications; 7) Laboratory Reports; 8) Radiology Reports; 9) Immunisation; and 10) Allergies.

The scheme will be implemented in 3 phases. By December 2020, all private medical and dental clinics must comply. Below are some answers to FAQ provided by MOH.

1. Who will be able to access my health records?

Only doctors who are caring for you will be able to access your records.

2. What kind of health information will be captured in the NEHR?

It will include your diagnosis, medications, allergies, and vaccination records. In addition, the system will capture operating theatre notes and procedures, as well as laboratory and radiology reports. It will not, however, include doctors’ personal case notes of each consultation. Yes, every liposuction and fat transfer to the butt that you had will be made known to the doctor giving you a flu shot in the arm.

3. Can my insurance company or employer look up my records through the company doctors?

If anyone wants to look up your records for purposes other than caring for your health, they will have to get explicit consent from you.

4. What if I don’t want anybody to look up my health records?

You can opt out of the NEHR. When you do so, your medical records will still be uploaded into the system, although doctors or other healthcare professionals will not be able to access them. The authorities have said that this will not change for now, although they are open to feedback on the issue.

5. Will all my old health records be uploaded into the NEHR system?

No, there will be no backdating of old health records. And of course, for some procedures, you don’t need to see the medical records to know that they have been performed.

6. What cybersecurity measures will be taken to make sure that all this sensitive information will be protected?

The authorities have said they will take measures similar to what the Inland Revenue Authority of Singapore uses to protect its tax database from hackers and other cybersecurity threats.

My friend C has many friends and colleagues who are doctors. We may assume that every one of them is professional in his/her approach, but we also happen to be one of the most judgemental societies in the world. Will C’s friends and colleagues not look at C’s daughter differently if they know that she had an abortion in her teens? Just look at the way we dis-incentivise single parenthood. I would think that “Victorian” is already a very kind word to use for the total lack of graciousness, compassion and flexibility in granting a faultless child his citizenship.

I seriously think that we need to fix such social stigmas and narrow-mindedness before we even think of implementing something as progressive as the NEHR. But given all the “safeguards” mentioned, does C have any reason to worry that the record of his teenage daughter’s abortion is going to follow her for life, visible to every future doctor that she sees? Maybe not, but would you take the risk if you were in C’s shoes? Wouldn’t it be safer to be totally off the record here? What all this point to, besides better continuity of care to patients as purported, is a boost to outbound medical tourism for procedures ranging from abortion to plastic surgery or treatment for psychiatric conditions and sexually transmitted diseases. The Bill works perfectly for a bunch of hogs, but fails miserably to take human weaknesses and social stigmas into consideration.

Sexually transmitted disease word cloud

There is another issue. The elephant in the room, is that doctors will have to spend a good amount of money just plugging into the NEHR. Clinics whose patients don’t mind the tattered cushions in the waiting area and mouldy walls in the toilet must now fork out money for a business broadband account. It’s no longer optional.

Entering data also takes up time. All this will add to the administrative workload of doctors who are supposed to be clinicians. 30-year-old clinics which have not gone digital estimate that they need to fork out almost $17,000 for software/hardware and put in many hours of familiarisation trials to get started. All this will inevitably translate into higher medical costs. Another boost for outbound medical tourism.

Meanwhile, the policymakers who sit in trendy offices and hold trendy meetings (courtesy of our compliant taxpayers) go about their daily chore of generating more and more work for people whose response can only fall between voluntary acceptance or involuntary compliance.


Dental Phobia by Chan Joon Yee

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