MonthMay 2019

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

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