Tuesday, February 19, 2008

Dental Implants - Letters in The Star

On February 13, 2008 The Star published a Letter to the Editor by MEDICAL DOCTOR that contained many misconceptions about dental implants. This letter and the responses it had evoked are reproduced below so that the public can be corrected of any misconceptions and have a more accurate picture of dental implants.
~ Azlan Adnan
Wednesday February 13, 2008

Dental visits a pain in the pocket

ACCORDING to statistics, about 10% of people who are 55 years and older will begin to lose their teeth. Whatever the cause attributed to each individual, age is the single biggest factor.

Because of our ageing population, the number of people who would become edentulous would be a substantial number. The market is huge.

Many old folks are at the mercy of dental surgeons, especially the ones who now describe themselves as implantologists.

Many of them wear doctor’s coats, carry stethoscopes and insist on being called doctors. They charge by the tooth for every implant. Current prices range from RM7,000 to RM9,000 for the implantation of a tooth. This does not include the cost of the replacement parts, surgery, X-rays, etc.

Hence, for about four to five teeth to be implanted in the average elderly person, the price can come up to RM45,000. This is more than the cost of a complex angioplasty, bypass operation, or a hip replacement.

There seems to be no regulation to control these prices. It is a free market, with dentists, specialists, as well as GPs competing and charging whatever the market can take.

Most older people are poor and have to depend on their relatives. And few family members want to pay these exorbitant charges.

Government specialists, curiously, do not provide teeth implants for most of these unfortunate victims. If they do, it is to learn the technique before leaving government service.

While the cost of private medical care is now regulated and there are guidelines provided by the MMA, implantology is a wide open field with no control. Even the Malaysian Dental council has not tried to exert any control.

The patients who cannot afford implants are given cheap dentures or a mix of implant and a bridge (if they can afford the latter).

Having watched the implantation procedure, I think this is really a simple procedure, most of the time done under direct vision. There are no special tools required.

Most surgically trained medical GPs should be able to learn this procedure very quickly. There will, of course, be some difficult cases which can be left to the specialists.

Dental surgeons, whether specialists or GPs, work in a very narrow field of the human body. From experience, I have learnt that they know little or nothing about the wider spectrum of medicine.

The number of antibiotics they are familiar with is very few. They ask for a history of diseases that the patient may have but do not know how to assess how bad these diseases are or how they should be treated.

They have no idea about emergencies that may occur with surgery or with drugs.

They do not know anything about cardiopulmonary resuscitation.

Because of these weaknesses, I would suggest the following remedial actions:

> The Malaysian Dental Council should investigate and control prices in this dog-eat-dog business. They must impose some discipline to care for poor old people.

> The dental surgeon who calls himself an implantologist should give a written bill to the patient before he starts treatment. He should list all his immediate charges as well as charges for subsequent visits.

> It should be possible to train technicians to do single implants. These technicians should be licensed and also given guidelines on charges. Prices would come down in a free market once you increase the supply.

> Medical emergencies during a dental implant are rare but can happen. Hence it should be mandated that an anaesthetist should be on standby during any implant or surgical procedure done by a dentist.

> The dentist should buy and place in his clinic emergency equipment. This would include a defibrillator, a heart monitor, a pulse oxymetre and an ECG machine.

> The implantologist should be certified, which means going before a panel of peers who will verify if he has the knowledge and skills to perform large volume implantation.

Kuala Lumpur.


Thursday February 14, 2008

Get your facts right, doc

MEDICAL Doctor in his letter “Dental visits a pain in the pocket” (The Star, Feb 13) does not even know the duties of a dental surgeon and a dental technician.

A dental surgeon graduates with a “Bachelor of Dental Surgery” degree and is conferred with the title Doctor while a dental student studies anatomy, physiology, biochemistry, dental materials, pathology, microbiology, pharmacology, medicine, surgery and all other dental subjects in a dental college.

The RM7,000 to RM9,000 fee is still cheap for a single dental implant. The cost to set up a dental surgery with implantology varies from RM500,000 to RM1mil or more. The material costs and laboratory charges are equally high.

The procedure for doing a dental implant is not simple. It is a high precision procedure and needs lots of training before the dental surgeon can provide such treatment. It is not just a case of cut and fix.

All dental surgeons providing dental implant treatment have undergone intensive training and attended courses and meetings like the latest Osstem Meeting 2007 at KLCC on Nov 25 last year.

Here are my replies to some of the suggestions raised in the letter:

> The Malaysian Dental Council together with the Health Ministry have set the range of dental charges for basic dental treatment under the Private Healthcare Facilities and Services Act. Dental specialist charges have not as yet been imposed.

> All dental surgeons providing dental implants and any other dental treatment quote the treatment charges prior to starting the treatment and patients are forewarned of any other charges that may occur during the procedure should any deviation of treatment arise.

> Technicians are not surgeons. They only fabricate the implants, crowns, bridges, dentures and splints in their laboratories.

> All dental surgeons doing dental implants are fully aware of any medical emergencies that may arise and are well prepared for it. So far, not a single emergency has occurred for a dental surgeon to require a defibrillator, a heart monitor, a pulse oxymeter or an ECG machine.

> Should such a need arise, the dental surgeon will either call for medical help or take the patient himself to the nearest medical centre.

> A dental surgeon providing dental implant treatment has attended courses and is proficient in his expertise. Not all dental surgeons provide dental implant treatment.

Medical Doctor should get his facts correct before alarming the public unnecessarily. If you cannot afford an expensive car, you should buy a cheaper car according to your budget.

The Malaysian dental surgeons are doing a very good service to the public.

Malaysian Private Dental Practitioners Association,
Kuala Lumpur.


Saturday February 16, 2008

What a dentist can do only a dentist can do

I REFER to the letter ‘Dental visits a pain in the pocket’ (The Star, Feb 13). The dental treatment charges in Malaysia are well regulated by the Medical Practice Division, of the Health Ministry under the Private HealthCare Facilities and Services Act 1998 (Act 586).

This act is well supported by Malaysian Private Dental Practitioners’ Association and Malaysian Dental Association.

Dental practitioners’ in the private sector whether they are GPs or Specialists are well trained in this aspect and are supposed to adhere and practise dentistry according to these guidelines.

The healthcare clients (new terminology for patients) have their own rights. Under the Act, they have all the rights to know about the charges and treatment procedures.

If they do not feel satisfied with the dentist, there is the “Grievances Mechanism” in clinics to address the issue under the Act.

The writer also said that the dental surgeons were not well versed in drugs.

The second year of dental course covers pharmacology.

In fact, dental surgeons can treat Upper Respiratory Tract Infection (sore throat) that is a common disease treated by medical practitioners.

The third year covers subjects of general surgery and general medicine.

The syllabus clearly shows that dental surgeons are on par with their medical counterparts.

Another accusation by the writer is that implantologists are not well trained and medical GPs can place implants.

This is a joke!

My sincere advice to him is, please look at your backyard.

There are a lot of illegal and incompetent medical practitioners. Try to rectify that.

We have our own professional body to regulate competency.

In conclusion, I feel the writer was wrong in all his statements and figures.

He was too emotional in expressing his opinion and created an increase in dental phobia among dental patients.

One important phenomenon that everyone must realise is that: “What a dentist can do only a dentist can do.”

Malaysian Private Dental Practitioners’ Association.


Monday February 18, 2008

Cheaper to do dental implants here

AS A practising oral implantologist, I read with alarm and concern the polemic “Dental visits a pain in the pocket” (The Star, Feb 13).

To clarify matters and to set the record straight, I would like to address certain inaccuracies that were unfortunately passed off as facts:

> To qualify as an oral implantologist requires vigorous practical and theoretical grounding on par with medical doctors: a five-year basic degree in addition to a further two to four years of specialisation.

During the course of the training, many modules are identical to those undertaken by medical students, including management of medical emergencies and performance of cardio-pulmonary resuscitation (CPR).

> The current prices of implants in Malaysia range from RM5,000 to RM9,000, which is substantially lower than those in other countries. For example, implants in Singapore easily cost in excess of S$6,000 (RM13,662); in the UK, more than £2,500 (RM15,788); in the US, more than US$2,500 (RM8,050).

In fact, many foreign patients of mine have performed multiple dental implants in Malaysia specifically due to the equivalent level of professional competence but at a fraction of the price back home.

> Implants are not necessarily the final word in tooth restoration (even though the procedure ranks as the best among the options available in terms of comfort, function and aesthetics).

In the interest of cost, cheaper options such as dentures and bridges are available. On this note, no right-minded dental practitioner will force a patient to have implants done if affordability is an issue.

> The Malaysian Dental Association does provide a list of recommended fees for dental implants. However, as the writer pointed out, it is a free market; therefore each patient has the right to find the practitioner that he is most comfortable with.

> Government specialists have been providing dental implant services for some time now at lower rates compared with private fees. The writer seems to be ignorant of this fact.

> The implantation procedure is not as simple, nor as straightforward, as claimed by the writer.

As stated in the foregoing points, an oral implantologist has to undergo lengthy clinical and hands-on training to become an expert in the field.

There are many serious complications and adverse effects that can arise should the procedure be done incorrectly: for example in the case of guided bone regeneration procedure, sinus lift and bone harvesting.

I hope I have clarified some of the misconceptions that the writer has generated in his letter.

Petaling Jaya, Selangor.


Implants cost too much

I REFER to the letter Cheaper to do dental implants here in The Star, Feb 18. Implants in Malaysia costs between RM5,000 and RM9,000. Let us say it is RM7,000 on the average, which is the equivalent to 7,000 cups of coffee or three months' pay of a government medical officer’s salary here.

In Britain, it is £2,500 which is about 1,500 cups of coffee there or less than a month's salary of a government medical officer.

In the United States, it is US$2,500, which is about 1000 cups of coffee there or much less than a month's salary of a government medical officer. In Singapore, it is S$6,000, which is about 2000 cups of coffee there or less than a month's salary of government medical officer.

A baby delivery by Caesarean section here - which includes general anaesthesia and few days stay in a private hospital - would cost less than a tooth implant in Malaysia.

So dental implants here are among the most expensive in the world.

Suggesting other alternatives like dentures and bridges is like telling a patient with a bone fracture not to have nailing and plating and just to have plaster casts, as it will heal anyway.

Just as there is government control over food items and other products, there must be a price control over dental procedures. Dental health must be available and affordable to the rakyat of Malaysia.

As can be seen from above, a reasonable charge for an implant would be around 1,500 cups of coffee or RM1,500 by comparing the different prices of several countries. A root canal should not cost more than RM300 and crowns not more than RM300.

Technicians here should be taught to perform implants as there are other more difficult procedures that are also done by technicians. For example, there are midwives doing a good job with examinations, investigations and the delivery of babies.

Ultrasound and echo (for heart patients) are done by technicians, medical assistants are doing examinations, investigations and treating patients while dental nurses are doing fillings and extractions. In addition, anaesthetic assistants are giving general anaesthesia in rural areas.

Medical doctors should be taught to do implants as they have basically learnt all that the dentists have learned such as oral anatomy, physiology, pathology, bone regeneration, bone harvesting etc.

In my rural posting I was taught to extract teeth and do fillings. Implants have now become a common part of dental procedures, just as root canal treatment.

If there is a shortage of oral implantologists then we should recruit medical doctors. I am sure doctors here will fulfil their Hippocratic Oath to serve the public.

Dentists are also bound by Hippocratic oath to serve the public.

Kuala Lumpur


Dental implants have the best bite

THE ideal standard of care for replacing teeth is not a denture or even a bridge anymore, but dental implants.

Dental implants are now used to replace missing teeth, stabilise loose dentures, straighten teeth and rehabilitate patients who have lost parts of their jaw and face due to cancer or accidents.

We refer to the letter “Dental visits a pain in the pocket” (The Star, Feb 13) and wish to express our sadness over the misconceptions of a colleague whose profession we highly respect and admire.

Dentists or dental surgeons are part and parcel of the healthcare providing medical profession and work hand in hand for the betterment of our patients.

We do empathise with his concern for the older members of the population who due to inadequate dental care in the past now require dental implants.

However, the main cause of teeth loss in older people is not aging as stated by medical doctor, but gum disease.

This means that a healthy adult who takes proper care of their teeth and gums will enjoy a full set of teeth for life.

Hardly 10% of dentists practice implantology and also because implants are all imported and costly, the cost of providing the service is still relatively expensive.

Research and development of dental implantology took a lot of time, effort and expenditure on the part of university researchers and implant manufacturers.

The cost of training is still very high because it involves highly trained lecturers, logistics and material costs.

Implantology is not as simple as it looks.

Such treatment can range between simple to highly complex procedures that involve bone grafting, gum grafting, specialised imaging, detailed planning and a thorough understanding of occlusion which may take years of experience to understand and successfully manage.

Special dedicated tools, equipment and materials are needed in implantology.

Dental implantology usually does not incur any more trauma than an ordinary extraction of a tooth, and therefore does not require any extra safety measures that are not already in place in all dental clinics.

Dental implants have helped countless people around the world to enjoy their food again. They are the best replacement for lost teeth.

Though expensive currently, the price will keep coming down due to free market forces.

Like in all professions, some dentists charge more and some less. Find one you can afford.

After all, dentists here in Malaysia are highly trained and yet are still among the most affordable in the world.

The cost for dental implants in Malaysia is one of the lowest in Asean.

This has led many from overseas like Australia, Europe, America and Japan coming to Malaysia to enjoy the benefits of dental implantology at international standards and yet at half the price or less in their home countries.

Dental implantology has placed Malaysia on the map as a major destination for health tourism in this region.

President and Honorary Secretary,
Malaysian Oral Implant Association (MOIA)
Affiliate of the Malaysian Dental Association


Dental implants an expert’s job

WE REFER to the ongoing discussion on dental, medical and healthcare costs in Malaysia. In Implants cost too much (The Star, Feb 23) oral implants were likened to treatment for bone fractures.

Comparing the cost of dental implants to the local price of a cup of coffee does not make sense. This is because a major cost of a dental implant is the cost of the imported prosthesis itself.

More than just the cost of materials, oral implantology is a multi-stage multi-disciplinary treatment procedure. The surgical component (i.e. the placement of the implant within the bone) is performed by the implantologist/oral surgeon.

In fact, we invite interested medical surgeons to equip themselves with the proper training and accreditation that enable them to perform this surgical procedure.

The demand for oral implants is far higher than what dentists in this country can cope with. Having well-trained medical surgeons to help out in the surgical process will be a welcome bonus.

The next step involves designing an artificial tooth over the implant. When a patient requests an implant, this tooth component is the one he or she will see and use every day.

Therefore, this stage is best carried out by a dentist properly trained in treatment planning, dental occlusion, function and aesthetics.

Based on the dentist’s exact specifications and detailed instructions, the prosthesis (tooth) is custom-made in the laboratory by a dental technician. Finally, this prosthesis is precisely attached to the implant.

Function and cosmetics are examined clinically. This multi-stage, multi-disciplinary approach is important to ensure that each stage is done by an expert in that field, to ascertain the best possible treatment outcome.

The dental implant of today is by no means the ultimate replacement for missing teeth. Further research and development (R&D) is required.

Currently, essential/basic dental treatment like extraction, pain relief, fillings, scaling, and infection management are already affordably priced. These procedures are cheaper than most medical surgical treatment.

We are working towards a time when dental implants are no longer an optional luxury but a common affordable treatment alternative, just as cars were once exclusive to the rich but are now commonplace.

We can achieve all this and more only with the understanding and cooperation of our medical colleagues and the public.

Who knows, with support from all parties and sufficient funds for R&D, the option of replacing a missing tooth with a new one grown from stem cells may soon be available.

President – Malaysian Academy of Cosmetic Dentistry.

Oral & Maxillofacial Surgery Department, Hospital Sungai Buloh.


Monday March 3, 2008
Why dental implants are costly

I WRITE in response to opinions expressed on dental implants in letters to The Star on Feb 13 and Feb 23.

I wish to inform the concerned persons that the practice of dental implant placement is a recognised procedure carried out by dental practitioners (dental surgeons) who have undergone the required training.

It is worthy to note that dental implants are fabricated abroad and imported and thus remain costly and the procedural cost of implants may vary from practitioner to practitioner in the private sector.

Government dental specialist clinics provide implants as well, but case selection often favours functional purposes.

Should there be any dissatisfaction over treatment provided by dental practitioners, complaints can be channelled to the Malaysian Dental Council, which regulates the profession.

In addition, the Malaysian Dental Association and its affiliate bodies are dental bodies which are also able to address issues related to dentistry.

Senior Director of Oral Health

Ministry of Health Malaysia

and Registrar, Malaysian Dental Council

1 comment:

Ian Furst said...

From the Canadian perspective: We have many of the same debates here. Fee's do have a signficiant impact on treatment acceptance -- one only needs to look at the population penetrance of implants were dentistry is socialized (appx 90-120/10,000) vs where it's private (15-30/10,000). From the dentists point of view however, it is the hidden time required that requires higher fees since there are longer consultations, lower acceptance and longer follow-up with the expectation that they will last 10-20 years. www.waittimes.blogspot.com