The Official Newsletter of the UWI Dental Students Association
August 2008 Issue 3
Radiographic Investigation: Interview with
Dr. K. Pillai Third Year Dentistry: What to expect now that you’ve arrived! Introducing the language of Botswana
SETSWANA 101
The Fill In
Issue 3 August 2008
FIRST VISIT It seems as if time just keeps flying by as we now present our final issue of the Fill In. Don’t be startled just yet; it’s the final issue for this academic year. School activity has just about come to a pause for most clinical students as the month of August marks that supposed period of calm known as a holiday. We here at the Fill In may not fully appreciate that concept as much work has to be done for our next issue. We are happy to see that slowly but surely, our publication is making its way to more and more people everyday. This is something we continuously wish to emphasize: pass it on! The more, the merrier! Speaking of which, we soon hope to establish a Dental Students Editorial team, whose sole purpose will be the management of this very newsletter. All of you out there with some skill, please don’t hesitate to volunteer your help. We expect the number of people contributing to increase as the clinical students return to school. In this issue, we feature an interview with the arduous, dedicated Dr. Kamala Pillai. Most of us know her from her radiology clinic sessions, and clinic consultations. The 2008 graduating class was the first to include students from Botswana. In an attempt to bring us closer to our Batswana (not Botswanian!) classmates, this issue provides an introduction to their language, Setswana. We also bring to the new third year students a section on what to expect having finished the insanity that was last semester. All clinicians, clinical students and those soon-to-be clinical students should take particular note of the detailed article presented on the importance of a proper first visit assessment. As always, we welcome your input and express our gratitude to all those who have contributed to this venture thus far. Once again, don’t forget to forward this to as many people as you can and remember to check out our website for the latest updates. TFI
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The Scene •
Now available are our official UWI DSA polos! That’s right, now you can show some school pride with these comfortable shirts bearing an embroidered Dental Students Association logo. They’re available in black and white for men and women. Contact any member of the executive to secure yours!
•
The DSA Executive recently attended a meeting with the dean, the director of the school, the polyclinic co-ordinator and the Guild president. Among the issues raised were problems being faced on clinic as well as throughout the school. Several solutions to these problems were put forward by the DSA. We were also informed that many of the issues raised were in the process of being addressed, and that some would even soon be rectified. •
As compensation for time being lost due to the malfunctioning air conditioning system, we were able to negotiate optional use of clinic for final year students during the month of August. (All clinical students usually have August as a holiday). The initiative was spearheaded by the final year class rep, Nalini Mungal, who has also proposed that optional Thursday afternoon sessions also be made available. Approval for these sessions is still pending. •
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The current dispensary request forms have been around for quite some time and since students are now required to purchase their own instruments, many of the listed items have since become irrelevant. The DSA recently submitted a proposed revision of the request form, which includes the most commonly used instruments/materials grouped according to procedure type. The form is aimed towards increasing efficiency in acquiring the necessary items, and was received by the polyclinic coordinator with great approval.
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Meet the Staff
Dr. Kamala Pillai "I have seen it all, you cannot trick me!" These are the famous words of the ever-keen Dr. Kamala Pillai. For some of us, it may seem as though she has eyes in the back of her head, and often she herself hints at the possibility, as there is no other explanation for some of the things she sees! Dr Kamala Pillai joined the faculty in 2000 and is a senior lecturer at the University of the West Indies, School of Dentistry, in Oral Medicine and Radiology. After qualifying with a BDS in 1964, Dr Pillai has travelled extensively within India to various dental schools. She has held the title of Professor since 1976 in India and abroad and in some cases visiting professor since that time. This founding member, and past president of the Indian Dental Association, Manipal branch, has over 35 dental related publications to her name in addition to being named "Best Teacher" from Jordan University of Science and technology in 1991. Dr. Pillai's career has led her from India to Libya, Jordan, Canada and of course Trinidad. Despite being busy writing a book on Oral Radiology (we are trying very hard to get a sneak peak!), Dr Pillai is still able to lecture full time, and always makes herself available for one on one consultations with students. Some may call her a workaholic but we call her dedicated! In this final FILL-IN issue of the academic year, we present 24 questions with Dr. Kamala Pillai.
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24 Questions with Dr. Pillai 1) What is your greatest joy? My children and grand children. Also as a teacher for 41 years, I feel happy to see my former students doing very well and reaching a high position in their profession 2) What is your secret fear? Fear of the unknown 3) What is the best advice you have ever received, and from whom? “You may extract thousands of teeth as a routine, but who will appreciate it? You publish one paper in a widely read international journal, your colleagues will recognize and appreciate you.” This advice and encouragement was given by Dr. Sunder J.Vazirani, former Director of College of Dental surgery KMC, Manipal, India. 4) Most embarrassing moment? Coming out of a top restaurant in Cairo, Egypt, after a dinner party and a friend pointing out the napkin dangling around my waist. Are you taking it home? A souvenir? 5) What is the happiest moment you can remember? Birth of my first grand child 6) What do you consider your greatest achievement? (Being) well-educated (trained in the UK and USA), successful and having well-settled children 7) Any interests other than dentistry? Gardening, cooking, home making and listening to Malayalam (south Indian) music 8 )If you could do something other than dentistry, what would it be?
9) What is something people don’t know about you? I was a member of the medical college volley ball and hockey team. I was also Professor of oral medicine and radiology from 1976 to 2000 in India and abroad, guided postgraduate students for MDS degree. Also , my temperament. 10) What’s your favorite food? Fish baked in banana leaf and chicken 69, Kerala style 11) Favorite alcoholic).
drinks?
(alcoholic/non
Coconut water 12) People you admire and why? Dr. Geoffrey Howe, the British professor and Dean, faculty of Dentistry, Jordan University of Science and Technology, Jordan for his ability to recognize and appreciate talents and strength of his colleagues; Bill Gates for revolutionizing the IT industry, King Hussein of Jordan for statesmanship and progressive strategies. 13) What were your initial impressions of Trinidad & Tobago when you arrived. Have they changed? The country looked like my home state of Kerala with coconut trees all over the place and a similar climate, but the first shock came soon. My car was stolen the very next day it was bought that lead to fear and psychological trauma. The situation has not changed much.
General medicine
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14) What influenced your decision to enter the field of dentistry, and futhermore Radiology and Oral Medicine? I have been observing as a high school student, how successful the few dentists I knew were. I was, at that time, fascinated by the detective capability of radiographs. 15) Where is the one place you would like to visit? Alaska
Issue 3 August 2008 21) What are your fondest memories as a lecturer? Meeting former graduates who were “all praise” for the information and advice they received from me. Someone recognizing your hard work! 22). What are your fondest memories as a student? Receiving invaluable advise and mentorship from my teachers and the love and affection from classmates, some of whom are still in frequent contact even after 44 years
16) Biggest pet peeve? Unreasonable, unwarranted delay in getting urgent things done 17) Favorite movie? Aradhana, the Hindi movie and Sound of Music 18) What do you do to unwind? Chat with my grand children. Gardening 19) If you win the lottery tomorrow, what would you do with the money? No luck so far! If a miracle happens, I would use it to support an orphanage and home for the destitute.
23) What is the one thing in your life you would like to accomplish in the future? Writing books in areas of my specialty, using vast collection of photographs & radiographs of rare cases and lecture materials prepared carefully over 40 years and constantly updated 24) Is their anything in your life you would like to do over, if you could? I am quite happy with what I have achieved so far. However, I would have liked to work in a well-established teaching and research institution and publish hundreds of research papers worthy of reference by future dentists.
20).You have been teaching for many years. In that time, what is the funniest or strangest thing that a student has done during a lecture?
-Dinesh Martin
Passing a bangle from one student to another and to the entire class until the one who started was caught.
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Setswana 101 ‐Mahilo K. Mahilo Setswana, is an African language written in the Latin Alphabet. It is the national and most commonly spoken language in Botswana and internationally, is spoken by over 4 million. Due to historical ties, it is also spoken in some southern African countries like South Africa. Other spoken languages in Botswana are Kalanga, Seyei, Seherero and other different dialects of Setswana. People from Botswana are Batswana (singular Motswana). Let us learn some basic Setswana greetings. 1.Formal greetings
PRONUNCIATION TIPS Dr. M: Dumela, Rra/Mma (Hello, Sir/Madam). Dr. K: Dumelang.(Greetings to you too) • The g is pronounced voiceless velar fricative (similar to an “h”) at the Dr.M: O tsogile jang? (Are you well? {How are you beginning of a word eg. Gaone. If in the this morning?}) middle of word, more of a silent Dr K: Ke tsogile sentle, Rra/Mma. Wena, o tsogile • The th is pronounced as an aspirated jang? (I'm well, Sir/Madam. How are you?)
plosive (similar to a silent “h”).The same aspiration rule is true for all other consonants used in combination with h (e.g., ph, etc.)
(Replace tsogile with tlhotse for afternoon greetings.) •
2. Informal greetings
The combination tl is said as seen, with each letter being pronounced
Le kae? – (How are you? ) Re teng, rra/mma – (We're well, Sir/Madam. {Ke teng, rra/mma for I am well.} ) 3. Casual talk: O a re eng? (pronounced 'wah‐reng') – (Wassup? ) 4. Useful expressional phrases: Ke a leboga, rra/mma. – (Thank you, Sir/Madam) Ke itumetse, rra/mma. – (Thanks, Sir/Madam) Leina la me ke _______. – (My name is _____. ) Leina la gago ke mang? – (What is your name?) Ke tshwerwe ke tlala. – (I'm hungry) Ke tshwerwe ke lenyora. – (I'm thirsty) Ke rata ___. – (I like ____.) Ga ke rate___. – ( I don't like ___. ) 6
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Ke batla ___. – (I want ___.) Ga ke batle ____ ‐ ( I do not want ____ ) A re tsamaye! –( Let's go!) Kokelo‐ (Clinic) Ke nako mang?‐ (What is the time?) Ke kopa thuso.‐ (Can you please help me.) A o ya ko ____? – (Are you going to _____?) ____ ke eng ka Setswana? – (What is _____ in Setswana?) 5. Farewells: Robala sentle – (Sleep well) Boroko! – (Good night) Tsamaya sentle – (Go well {said to the person/group leaving}) Sala sentle – (Stay well {said to the person/group staying})
What did the dentist find at the North Pole?
A Molar Bear!!
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Student Perspectives Year 3: A time to relax? Dinesh Martin Congratulations! You’ve made it to third year and now it’s time to get on to the real stuff, experimenting, I mean working on patients. Sorry to burst your bubble, but your first dental patients will not be seen until January. Trust me though, the first semester is not a waste. Semester 1 There are several courses that will run throughout this semester. They include Periodontics, Orthodontics, Endodontics, Prosthodontics, Paediatric Dentistry and General Medicine. All of the courses will be conducted at the School of Dentistry, with the exception of the General Medicine course which runs from 8am to 12pm every Wednesday at the San Fernando General Hospital. Periodontics There are no surprises here as this course continues from second year. Periodontics isn't just the technique of tooth brushing (quick, name 3!), but also involves the tooth-supporting tissues, the microorganisms involved in the diseases which affect them and of course, treatment. Teeth don’t just ‘fall out’, (unless you get hit in the jaw) and hopefully by the time this course is complete you will be better able to arrest disease in your patient, and maybe even yourself! Remember, if you don’t pay attention to periodontal health, you will find yourself needing a prosthodontist!.
Orthodontics All your ladies with long nails, (and you guys too) time to get them cut! This course involves the bending of steel (no supermen, very thin stainless steel wire), and if you’re not careful the sharp ends of the wire will leave an unwanted mark. The orthodontic course is pretty short and straightforward. Mr. Paul Seerattan takes you through some basic theory about removable appliances (e.g. retainers). He will also demonstrate how the wires are bent into the distinct intricate shapes required to actually make them work! More importantly, he will show you how to avoid injuring yourself while doing it (remember those nails!). Trust me, your fingers will hurt, some may even bleed (as I learnt the hard way), and some of you might get a few grey hairs. Several of those shapes are pretty weird, but it beats doing the Head and Neck anatomy final I’m sure! Have no fear, the first couple of times are hard, but you’ll get the hang of it. Practice! Practice! Practice! After that, you may even find yourself making other random designs with your newfound skill!
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Some may ask what the point of a future dentist learning this is. It’s really for you to have an understanding of the theory and being able to differentiate a good appliance from a bad one. Before it sounds like all fun and games, you should know that there is in fact a practical and written exam (nothing too deadly, don’t worry) at the end of the course. Endodontics You have no doubt, heard of the dreaded root canal. As second year is finally over, you should have an understanding of pulpal tissue (assuming of course that you remembered from oral bio), so you're already on your way. Endo will basically teach you how to manage a patient when the pulp story ends badly. The course is an intricate mix of theory and practical, and you might find yourself lost many times, but it’ll all come together in time. The endodontic course will probably be one of the more enjoyable phantom head lab courses, except for the constant running downstairs to take radiographs (but we’ll let you find out about that on your own). Study hard, there is one spotter (be sure to learn the names of your instruments), and a written exam or two. Prosthodontics If you don’t know by now what prosthodontics means, then you have qualified to redo second year. The course will comprise mostly theory, with a few practical sessions. You may not appreciate it at the time, but when you’re face with your first denture patient on clinic, you will not regret having attended these lectures! There is no assessment for this course, but try to attend for your own sake. Paediatric Dentistry. You may not have considered this, but the management of a child is going to differ greatly to that of an adult. Having almost been made deaf by eardrum shattering screams of a peado patient recently, I was especially thankful for the lectures on behaviour management that are part of this course. In addition, an introduction to pulp treatment in the paediatric patient (many new dental materials will be introduced) will be given. If you thought working on a phantom head was hard, try fitting your hands in the mouth of an anxious child, amidst his parents threatening him with no Playstation for the rest of the week. Treating a paediatric patient will undoubtedly be one of the hardest skills to acquire on the clinic, especially if they refuse to cooperate. Learn all you can from this course, it will save you a lot of money on hair dye (or maybe even implants) The most significant part of the third year is the clinical portion where you begin seeing dental patients. Treating patients on the clinic is an entirely different experience from that to which you’ve been previously exposed. You are meeting new people; some may be friendly and others just intimidating. Relieving pain, giving someone a new smile, and the general feeling that you helped someone can be quite rewarding. However, you should bear in mind that these things can only be done if you have the knowledge, understanding and physical skill to do so. Remember this: lectures and labs form the foundation for all that you’ll be doing on clinic and eventually in your practice, so their importance cannot be emphasized enough!
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Honestly, third year wasn’t that much of a “breeze”, but the first semester was probably the easiest so far. This is relative of course! Keep your head in the books because from here there’s no turning back. Keep working at it and never hesitate to ask any one of us in the higher years for tips and advice. Best of luck to you!!
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Exam Tips The contents of the following review article will be of tremendous relevance to all clinical students. Give a detailed account of the information that you obtain from your patients at their first appointment. INTRODUCTION The first appointment with a patient is the most critical of all encounters between the patient and practitioner. It is at this visit that the foundation for the future interaction between both is laid. This appointment begins the instant the practitioner sees the patient. Careful observation of the patient should begin at this point. An understanding of the patient’s main concern should be gained as well as their expectations from treatment. A thorough medical, social and dental history, as well as a clinical exam complete with radiographs and special tests will serve to provide a complete picture, thus enabling the practitioner to develop a holistic plan of treatment which can then be discussed with the patient. Patients who are often fearful can at this time be placed at ease and become more receptive to the idea of dental treatment or may indeed be totally turned off from dentistry. If the first visit is the laying of the foundation for this relationship, then the information gathered at this point is the cornerstone. During the initial observation of the patient any physical characteristics which may be manifestations of underlying medical problems should be noted and discussed with the patient during the course of the visit. The patient’s demographic data should be recorded. Their primary concern as well as a history of this complaint should be ascertained. In the case of discomfort or pain, site, radiation to surrounding areas, duration of an average episode, as well as aggravating and relieving factors along with any accompanying symptoms should be determined. >
prescribed or home remedies – should also be noted.
Any use of medications -
This process provides a list of provisional
differential diagnosis even before a thorough history and clinical exam are done.
>
In many third world societies, like the Trinidadian society, the use of many home therapies such as cotton soaked
with rum, kerosene or clove oil placed over the offending tooth, or whole cloves and crushed aspirin in the tooth are not unheard of. The frequency of use of such home therapies is associated with a lack of dental public health awareness and as such this subject warrants some research.
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HISTORY TAKING MEDICAL AND DRUG HISTORY Irrespective of any other history, a complete medical history should be taken (Kidd and Smith 1996) to ensure that the dentist does not endanger the patient during further examination and treatment and vice – versa. It should be concise and systematically applied to ensure that maximum information is obtained (Scully and Cawson 1998). Many systems exist that act as an aide-memoiré ensuring that a comprehensive medical history can be quickly taken. Table 1 below illustrates one such example and the significance of each question.
TABLE 1 SHOWING ROUTINE QUESTIONS FOR A MEDICAL HISTORY AND REASONS FOR EACH QUESTION
REASON
ANAEMIA
Impaired Oxygen carrying capacity affects decision for G.A.
BLEEDING DISORDERS
Affects decision to perform surgery of extractions
CARDIO RESPIRATORY DISORDER
Asthma Or M.I. affects peri-operative precautions etc.
DRUG TREATMENT; ALLERGIES
ENDOCRINE DISEASE
FITS AND FAINTS
GASTROINTESTINAL DISORDER
HOSPITAL VISITS
Affects procedures done or medication prescribed e.g. Penicillin Affects patient overall health and recovery & metabolism of medication. Medications affect oral tissues; affects peri-operative precautions Oral presentations exist and risk of vomiting affects G.A. Idea of response to anaesthetic or underlying medical condition
INFECTIONS
Communicable diseases, HIV status.
JAUNDICE OR LIVER DISORDER
Possible indicator of Hepatitis
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KIDNEY DISORDER
Impairment of Drug Excretion
PREGNANCY
Time of Tx affected. Use of Teratogenic drugs contraindicated
RADIATION
Tx. For or history of Cancer.
ADAPTED FROM SCULLY AND CAWSON - MEDICAL PROBLEMS IN DENTISTRY An accompanying drug history for each medical problem present will also ensure that in the advent that medication needs to be prescribed, harmful drug interactions are avoided. In addition many drugs have an effect on the oral tissues (Abdollahi and Radfar 2003). †
SOCIAL HISTORY Along with this comprehensive understanding of the Medical and Drug history of the patient it is also important to understand the patient’s social background. The patient’s occupation may give clues as to their level of compliance dental awareness and ability to comprehend medical terms thus enabling the practitioner to use appropriate language or simplify complex terms. It may also give clues as to the conditions under which the patient operates e.g. high stress levels may lead to bruxing and occlusal problems, or work in a chemical or industrial environment with abrasive particles may result in tooth wear. It may also give an idea as to how possible it is for the patient to afford treatment and as such aid the practitioner in selecting appropriate treatment options.
DENTAL HISTORY During the conversation with the patient information should also be gained about the patients past dental history. This enables the practitioner to gauge the patient’s attitude towards dental care as well as tailor the visits to the patient’s particular circumstance. For example patients who exhibit fear may be gradually conditioned to accept treatment in a relaxed and comfortable manner while others may best be treated under sedation. It may also provide invaluable clues as to the nature of the presenting complaint.
†
Nifedipine and other Calcium Channel blockers may cause Gingival Hyperplasia with prolonged use as in Epileptics.
Tetracycline use by pregnant women may cause intrinsic staining of teeth of the foetus. There is ongoing debate whether Oral Contraceptives may be counteracted by some antibiotics (Archer and Archer 2002), which may lead to unexpected pregnancies and medico legal complications if patients are not informed of this fact.
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EXAMINATION EXTRA ORAL AND INTRA ORAL EXAMINATION Upon completion of the history taking portion of the visit, the practitioner then proceeds to examine the patient. Thorough extra oral and intra oral examinations are done. Table 2 lists the major areas examined.
TABLE 2 SHOWING AREAS EXAMINED DURING EXTRA ORAL AND INTRA ORAL EXAMINATION. EXTRA ORAL FACIAL TISSUES, SWELLING, ASYMMETRY FACIAL NERVES LYMPH NODES TMJ INTRA ORAL SOFT TISSUES LIPS MUCOSA FLOOR OF MOUTH SALIVARY GLANDS THROAT TONGUE GINGIVAE
Subsequent to this a record or charting is done of the teeth. Presence and absence of teeth, presence of carious lesions, and restorative status including use of prosthetic devices are all noted. Notes can also be made on findings of significance such as staining, presence of supernumeraries, wear facets or
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fractures. Signs of occlusal discrepancies and habits such as bruxism, clenching and nail biting can also be recorded. A Basic Periodontal Exam (BPE) or CPITN may also be applied using the WHO probe (Ainamo et al 1987).
RADIOGRAPHIC EXAMINATION Left and Right bitewing radiographs are taken to determine the presence and extent of interproximal lesions. Periapical radiographs may also be taken if necessary to determine the periodontal status of teeth and supplement the endodontic examination. These may also aid in determining the nature of suspected intra or extra oral pathology (e.g. osteomyelitis, condensing osteitis, or carcinoma.) Indications for extra oral radiographs may also be evaluated and appropriate referrals made.
SPECIAL TESTS Special tests may also be done to provide additional information about the status of individual teeth and aid in arriving at a definitive diagnosis. Some of these are outlined in Table 3 along with the conditions in which they are useful.
TABLE 3 SPECIAL TESTS AND THE CONDITIONS IN WHICH THEY ARE USEFUL TEST
CONDITION
Lateral percussion
Periodontitis
Probing of gingival sulcus
Periodontitis
Bone sounding
Periodontitis
Mobility
Perio-Endo Conditions or Fractures
Vertical percussion
Endodontic Conditions
Vitality testing – electronic, thermal,
Endodontic Conditions
mechanical
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Palpation
Endodontic Conditions
Use of anaesthesia
Localization of pain
Tooth sleuth
Fractures
Auscultation
TMJ Disorders
DIAGNOSIS AND TREATMENT PLAN DISCUSSION At this juncture the practitioner may choose to analyse the information collected and present it in a manner in which the patient understands. Patient questions and concerns are also addressed. An ideal treatment plan along with alternatives is formulated and discussed with the patient. Some may choose to take impressions and occlusal records for study casts and diagnostic wax-ups if advanced restorative work is needed.
CONCLUSION Although the entire process of the initial visit as described here may take some time, it is my belief that thorough history taking and examination coupled with an understanding of the patient’s expectations can lead to formulating a plan which is acceptable to both patient and practitioner. Any deviations from this plan will be understood and more easily acceptable to the patient. Taking this time would also begin the process of building a solid relationship between patient and practitioner leading to a feeling of being part of the team working for the holistic care and benefit to the patient. References 1.
Kidd and Smith, 1996, Pickard’s Manual Of Operative Dentistry Seventh Edition, Oxford University Press.
2.
Scully and Cawson, 1998, Medical Problems in Dentistry Fourth Edition, Wright.
3.
Abdollahi M, Radfar M. A Review of Drug-Induced Oral Reactions. Journal of Contemporary Dental Practice
4.
Johanna S. M. Archer MD, David F. Archer MD, Oral contraceptive efficacy and antibiotic interaction: A myth
2003 February; (4)1:010-031.
debunked, Journal of the American Academy of Dermatology 46, 6 , June 2002, 917-923. 5.
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Cutress TW, Ainamo J, Sardo-Infirri J. International Dental Journal. 1987 Dec; 37(4):222-33.
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Featured Article In this section we continue where we left off on last month’s issue: part 3 of the article on Complete Dentures by Prof McCord. Please note that in order to access this article, you may be required to register a FREE account at the website.
Predefinitive treatment: rehabilitation prostheses J F McCord & A A Grant In this part, we will discuss: • • •
Common soft tissue conditions Common hard tissue conditions Rehabilitation devices.
Abstract This article deals with the treatment of common conditions affecting the denture supporting tissues. Several preliminary (non-definitive) treatment options are presented along with a brief account of their rationale. Full text: http://www.nature.com/bdj/journal/v188/n8/full/4800500a.html PDF: http://www.nature.com/bdj/journal/v188/n8/pdf/4800500a.pdf
-Taken from http://www.nature.com/bdj/journal/v188/n8/abs/4800500a.html
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Please feel free to submit any questions, articles and comments to the editors at thefillin@gmail.com. We welcome your suggestions and contributions. Tell us what you would like to see in this newsletter!! Please visit our website for the latest updates, as well as every copy of The Fill In
www.uwidsa.org The UWI Dental Students Association can be contacted at
uwidsa@yahoo.com. Lookout for our next issue!
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