Dr. Fadzlinda Baharin
‘First of all, could you please begin by sharing about your journey of pursuing dentistry and how you ended up as a lecturer, here in USM?’
Regarding the introduction of me and dentistry, it started a long time ago during my childhood. I was unhappy with my teeth because I felt my teeth were different from other people. Now I know it was actually an anterior crossbite.
But the impact of having that crooked teeth, I can still remember how unattractive I was during that time. I started thinking like, I do not like my teeth and I want it to be fixed.
So to cut the story short, I had four premolars out and I was treated by an amazing orthodontist at that time. I was really inspired by her. Even though the treatment was long - orthodontic treatment takes about two and a half years, but I just loved coming back to the clinic to see her because apart from the treatment, she gave advice on SPM because I was a student at that time. She gave advice on examinations, about life and attitude. And she was super excited when she knew that I enrolled in dentistry.
I joined dentistry in PPSG, School of Dental Sciences, USM. I think being an undergraduate at that time, that was the best time of my life. During undergraduate’s time, that is when the self-discovery happens. When you are an undergraduate, you mingle with your friends, talk to your lecturers and during your clinical years you start to treat patients. That is when you learn how to build relationships, I would say. During the clinical years, when you start to treat patients, that is when your empathy and your communication skills bloom.
Regarding how I ended being a lecturer over here, I think I have a natural leaning towards teaching. Both my parents are teachers – were teachers: they are retired teachers now and my late grandfather was a teacher as well. They were passionate and really enjoyed their job as a teacher. I really admire and respect that in that sense. When I graduated, I worked as a temporary secondary school teacher as well and I taught Physics. I still have those secondary school children in my Facebook friend list. They call me Cikgu, you know? So I think that is a very good reminder of what I am doing now: to teach, to share and to disseminate the knowledge.
‘Well Dr, paediatric dentistry is one of the many specialities in dentistry. Could you tell us why you chose to pursue this speciality and what is the most fulfilling part of being a paediatric dentist?’
In simple words, I just love children. They are adorable. I do not have the magic to make children behave better on a dental chair. But I think I have the capability of being, or say, composed when they are at their worst behaviour. I think I have this passion to deal with them. I think why I chose paediatric dentistry was when I did my undergraduate in USM last time. During that time, USM was a new school so the curriculum was structured such that dental students need to enrol in the medical curriculum 100% - Year 1 to Year 3. So, we had to go to the same classes and would sit the same exams. If you did not pass the exam, the same thing, you had to repeat the year. It was tough because on top of that, we had our dental classes in between. To say that with such training, I am now familiar with medical problems, the medical terminologies, the diseases – its aetiology, pathophysiology and general management. In our population, we have these sick children, special needs children and children that need to stay in the hospital. So if I work as a paediatric dentist, I have the chance to play a role to help these children to improve their oral health so that they can have a better quality of life. That is why I joined paediatric dentistry. This is because it is so fascinating, and basically as a paediatric dentist, you do every single thing. I mean, there is the whole dentistry in it, it is just the patients are children.
Yeah and treating children is amazing. It is always interesting. You would learn a lot from your child patient.
‘So Dr, you also completed your postgraduate studies at King’s College London. Do enlighten us about your dental school experience in the United Kingdom and the challenges you faced while studying there.’
I had my MSc in Paediatric Dentistry from King’s College London, United Kingdom. The training took 2 years to complete. I believe the stress is all the same, whether it is local or abroad: the stress of studying, even undergraduates. The feeling of being a student, being assessed. It is just the same – the feeling of overwhelmed by being a student.
Being abroad means that you go out of your comfort zone. You are away from your family and you have to live in a different culture with different food. Food is everything, I am so Asian when it comes to food. I eat nasi lemak a lot. Things like that, okay? So for me, personally, it is a culture shock for me there, like “You had salad for your lunch?” No, I can’t! What I am trying to say is it is a different way of life that you need to cope while doing your postgraduate studies.
But the advantage of doing your postgraduate overseas or abroad is even though it is a different culture, but you are learning as well and it is an eye-opening experience. You have the opportunity to meet significant people in dentistry in person.
When I was in the UK last time, Professor Hosey was my teacher - if you know, the paediatric dentistry textbook by Welbury and Hosey. These people are significant people in the world of paediatric dentistry or dentistry and then I had the chance to attend lectures from the late Professor Anderson. Professor Anderson wrote a lot of papers, guidelines and books in dental traumatology. Meeting these people just inspires you. You sort of get first-hand information from them. It motivates you to be a better clinician all the time.
Not so much on fancy procedures meaning to say like: “What fancy procedures did you learn over there?”. It is more or less the same if you train locally. It is just that you get the opportunity to observe and to see how people abroad or internationally work. So, I think it is a really good experience and I do advise and recommend those students who want to go abroad to do their postgraduate studies. It will be a very valuable experience for you and I would say, maybe it is a once-in-a-lifetime opportunity. You do not go to the UK every week. I don’t know, maybe you go to the UK for shopping, London every year. But yeah, for me, it is a once-in-a-lifetime opportunity to go there.
‘So Dr, let’s move on to the present. You have various areas of research interest and Hall’s technique is one of them. Could you please briefly explain its usage and relevance in dentistry, and also what sparked your interest in it?’
Thank you. Hall’s technique, I love it, right. I really love it. I hope all the undergraduate students, please read, learn and understand this technique so that you can perform independently and confidently when you work later on. Because Hall’s technique is super easy, alright? I can assure you.
Hall’s technique is actually a biological approach for caries management in children. We do Hall’s technique in primary molars, not permanent molars. Well, I don’t know. Research and studies are going on, maybe we can do it in permanent, but not now, the evidence now all supports Hall’s technique in primary molar.
What do we mean by “biological approach”? Conventionally or traditionally, what I learned during my undergraduate time, when we do caries removal, we must make sure that you achieve a caries-free stage. You get your high-speed diamond bur for access cavity and then when you want to remove caries, you change it to a slow handpiece with stainless steel round bur. You remove caries and have to make sure it is caries-free.
What does it mean by “caries-free”? You take your explorer and then try to sort of like scratch the floor or the wall. If you can hear the screeching sound, then it is caries-free. That is how conservatively or how traditionally we do.
But now, the evidence shows that you do not have to do that. In fact, if you keep on removing caries, there is a risk of pulpal exposure. Once the pulp is exposed, you have to do the necessary steps such as proceeding to pulp therapy.
Now with Hall’s technique, what they prove from the technique is even though you do not remove the caries – that means the softened dentine is still in the cavity, but if you cap it with a stainless steel crown straight away, it will prevent all the nutrient, oxygen from getting in the cavity and feed the cariogenic bacteria. There is no source for the bacteria to survive. In simple words, the bacteria just dies and the caries process stops. Basically, it skips the step of caries removal.
But it is not a straightforward technique, okay? It is not a quick fix. “Oh I remember, Dr Linda mentioned Hall’s technique. Let’s take a stainless steel crown and just pop down the crown on this tooth.” You must know the science behind it. Before you do that, you must have a bitewing radiograph just to make sure the caries does not invade in the pulp chamber or there is no radicular radiolucency. You must make sure of that and one of it is by taking a radiograph. Apart from that, you have to do your clinical examination, palpation. Is the tooth tender to percussion? If clear, then you can do Hall’s technique. If there is tenderness to percussion or presence of an abscess, a little bit of mobility, the patient complained of throbbing pain for weeks, then you cannot do Hall’s technique. You have to do pulp therapy - maybe pulpotomy or pulpectomy, depending on the case.
So, Hall’s technique is not a straightforward case – you must rule out many things. There is a list of it. If everything is alright, then yes, please do Hall’s technique because it is so simple. You do not need any local anaesthesia. You do not need caries removal. If there is natural space, you can straight away pop down the crown. But if there is no natural space between the teeth, you can put ortho-separator mesial and distal of the tooth, then leave it for about 5 days. When the patient comes back to see you, you remove the ortho-separator and the space is created. Select the correct size of the stainless steel crown. Put luting cement then just pop down.
Evidence shows an excellent success rate, meaning to say, the tooth stays in the arch without sign and symptom for 5 years. It is a good success rate for a primary tooth because primary teeth will shed and be replaced by permanent teeth.
Looking at how simple it is, yes please, you can do it. If you work in private practice, you can do it. If you work in the Ministry of Health also, definitely you can do it, as long as you know what the indications and contraindications are.
‘So Dr, in September recently, you also had a sharing session on KelantanFM, focusing on the topic of dental trauma among young patients. So what roles do parents or teachers play in such situations where a child has a broken tooth and how should they handle it?’
If any of you watched the session with KelantanFM, as I mentioned during that session, children, they just do not sit still. They move a lot. You cannot expect a child to sit and remain silent. They will jump, they will run, they will get into a fight. So, there is a high possibility that they get dental trauma. Not many teachers or parents know the importance of getting immediate treatment. Maybe they think: “Oh, it’s just teeth”. You know, no broken nose, no broken hand so “We can go to see your dentist whenever I’m free”.
What we want to emphasize is that there are certain categories or classification of dental trauma you need to manage immediately because it dictates the success rate. The longer you wait, there is an increased risk of pulp necrosis, for example.
Well, maybe at the early stage, it hurts a little bit so the child does not complain. Mum says “Wait, I’ll bring you next week, maybe”. So by next week or next 2 weeks, there is an abscess already. We have to do complete root canal treatment, for example. If let’s say Mum brings the child earlier, potentially we can save the tooth by doing Cvek pulpotomy: just shave a little bit of the pulp and put some medicament and restore the tooth with composite.
They (parents) do not know about this - the impact of delayed treatment on them. It is just teeth – you just fix it. It makes a difference, especially in avulsion cases. That is what I really emphasize on. In fact, in one of my studies, I assessed the teacher’s knowledge, awareness, attitude towards the avulsion cases. Unfortunately, not many know how to manage avulsion.
They did not know how and they did not have the courage to re-implant the tooth. Of course, I do understand, alright? Even my dear undergraduate final year dental students, they might not be able to re-implant independently, right? So, I do understand in that sense. It’s okay if they do not have the courage to re-implant the tooth, but we should educate these school teachers to put the tooth in the appropriate medium of storage and bring it to the dental clinic as soon as possible so the dentist can re-implant the tooth as soon as possible. This is because the longer you wait, the lower the success rate, meaning to say, there will be more complications later on, such as ankylosis and resorption.
It is important for them to know certain dental injuries which need immediate management and I think it is our job as a dentist to tell them because no one will tell them about this. That is why I try to reach the community by giving advice through the radio. Reaching the community needs a constant effort, not one-off - no one will ever listen. So, I need my dear dental students as well, when you work later on, you will give talks to the community and go to schools. Please disseminate the knowledge, share the knowledge with the people so that they know how to deal with it when it actually happens in real life.
‘What kind of medium of storage do you recommend to store the fractured tooth?’
We just do not want to keep it dry. We can store it in milk. If you do not have any medium, you can get a cup and ask the child to spit in the cup, so you can put that fragment in the cup. There are a number of recommended media but the most suitable (practical) is actually milk. But sometimes, you do not have milk in hand. So, my personal advice would be: the simplest way is just to get a container and ask the child to spit into the container so the container contains his own saliva. Then you can put the tooth in the container and bring it to the dental clinic.
The dentist will assess the situation. If it is too long, the dentist might want to clean the surface beforehand or do RCT – extirpate the pulp before implant. There are a number of ways to do it. So, the dentist would assess the lesion but bring the tooth, the child to the dental clinic as soon as possible.
So, I think the most applicable and realistic is the child’s own saliva.
Tap water, no. It is easy to get but no, because it is just going to do more harm than good. So I would not recommend tap water. Instead, just use the patient’s saliva. Ask the patient to spit into that container, put the tooth in and then bring it to the dental clinic. I think that is the most realistic, practical and safest way of doing it.
‘Dental anxiety has always been a thorny issue and a child’s first visit to the dentist is usually the “make-it-or-break-it” factor. So, from your own personal experience as a paediatric dentist, could you share with us some useful tips in ensuring a pleasant dental experience for young patients and in making brushing a much more enjoyable activity?’
Regarding pleasant experiences, WE have to be pleasant. Be a pleasant dentist, alright? Make sure your dental team is pleasant as well, your dental setting is pleasant as well. It is easier said than done, right? If this is the child’s first dental visit, check their chief complaint first: Is it just a check-up?
But most of the time, these children come with complaints of pain or dental abscess, because unfortunately, our people, they only come when they have a problem, right? When they come in, they are stressed already. That is the normal or common situation.
As a dentist, you assess the condition first: is it an emergency that needs immediate treatment? Or perhaps you can sort of provide temporary filling and buy time. In paediatric dentistry, one of the philosophies is actually to instil a positive attitude towards oral health in these children. In simple words, we as a dentist, we must make sure the child is happy and they want to come back and see you again. Do not let the child patient leave the clinic crying. I do understand your undergraduate requirements, yes. But you know, in the long run, we do not want these children to associate dental visits with something negative or an unpleasant experience. We want these children to grow up with an attitude: I want to come back to see this dentist, maybe just for a routine dental checkup. As a paediatric dentist, it is important for me to make these children happy. But at the same time, as a clinician, I need to assess the condition of the children’s oral health.
If no emergency, what I normally do is only to assess the child’s behaviour during that first visit. I want to know my patient more because that would sort of dictate my treatment plan. The more you know your patient, I think the easier the process would be. That is why I would say, you need to love the children first. If you hate seeing them, then I do not think you can have the strength to withstand the stress of dealing with these little patients.
‘Do you mind sharing some tips in ensuring brushing to be a much more enjoyable activity for children?’
The guideline says we must brush our teeth twice per day: morning and before bedtime and to use fluoride toothpaste not less than 1000 ppm fluoride. Even though they are children, they need to use adult toothpaste. That is sort of the advice you give to the parents. But you will not be surprised if parents complain to you that it is so difficult to get their child to brush their teeth. Brushing is a must to avoid dental care, whether you like it or you do not like it. It is a must because the lack of toothbrushing would increase the risk of getting caries. It is a well-known fact, supported by very good studies.
I do understand the frustration among the parents. It is like a constant “war” for some of them to get their children to brush their teeth. Brushing is actually like any other personal hygiene routine. We take showers, we trim our nails, we shave, we put shampoo, we wear clean clothes. All these make us more comfortable and more presentable. As for children, they do not know about brushing unless someone introduced the activity to them and I would say that parents should do that. The parents should be responsible from the very early, meaning to say from the newborn stage. The preventive advice that we give to parents is actually to start cleaning your baby’s gum pad with a cloth every time after they finish feeding. If you do it daily from the start, you clean your baby’s gum pad every time you finish feeding, the baby sort of recognises the activity. When the child grows a little bit older, let’s say 2 or 3 years old, the child would have a complete set of primary teeth. The child remembers Dad brushes his teeth every day. If that happened, I suppose there should be no “war” when it comes to brushing.
The “war” happened because brushing is alien to them. Let’s say the child is 5 years old. Mum never introduced any sort of cleaning of the mouth before and all of a sudden at the age of 5, Mum buys a toothbrush and a toothpaste. I do not like the taste of the toothpaste: it is spicy. It is actually minty, but they describe it as spicy and they do not like it. Then Mum said “I don’t care, you will get worms in your mouth”. She grabs the child and brush. And the child sees Mum so angry and the child would associate brushing with “Mum gets angry”. So, the child associates brushing with a negative event or experience. Over the years, the child will brush only when Mum is around; when Mum is not around or when Mum is not looking, the child will not brush. So the habit is not there.
That is why I would advise students to give practical advice to parents. The brushing habits start from very early: from the newborn stage. And it is always Mum or Dad – it is always parents and that is why in the guidelines, it mentioned “supervised brushing” until the age of 7 or 8. It is said in the guidelines until the age of 7, Mum or Dad need to be there in person or they should brush the child’s teeth because it needs to be supervised brushing. This is because till the age of 7 or 8, we believe the child has not developed the manual dexterity. The way they hold the toothbrush, move the toothbrush around and inside the mouth might not be effective or inefficient. So perhaps it is not clean enough to remove the plaque.
‘So, here comes the last question. In this new era of digital dentistry, what qualities should dental students or young dentists possess, in your opinion, to remain competent and also, what is the one piece of advice you would like to offer to them?’
From my understanding, meaning to say that the technologies are taking place. So we are using less human touch. During this COVID-19 pandemic especially, we will see this happening now.
Even though we are moving towards a digital era, we cannot deny the importance of human qualities in ourselves. Even though we get this information from online resources and technologies are determining how we perform things, still, there are certain procedures or certain things that technologies cannot do, right?
You are going to be a dentist, all of us are clinicians. To date, we have not invented any robots to perform dental procedures. Even if we have robots one day, I am not sure how far it can replace the job we are doing now because true human interaction is a complex thing. What differentiates you and technology or you and “robots” is your empathy. That is my single advice to all of you. We should cultivate the empathy skills in ourselves. It is the human touch. Only you can recognise your patient’s feelings, only you can read or anticipate your patient’s behaviour. If a patient comes in and I see their facial expression looks very unprepared and upset, as a paediatric dentist, I will unlikely do invasive treatment if there is no need to do so. A dental extraction is only done if the patient gives the best cooperation because I am going to give local anaesthesia and carry out extraction. If the patient does not allow that, those things are not going to happen. Maybe I will give the patient a general anaesthesia. So, I have the ability to decide what and what.
I do not think, to date, there are any technologies that can replace that: the decision-making, the ability to show empathy. So, my advice to all young graduate students is: as a human and as a dentist, I think we should learn to improve our empathy, our ability to understand others, your lecturers, your colleagues, your patients. Please participate in the discussion, meaning to say, speak up whatever on your mind and be a team player.
I think the challenge now, especially with this pandemic season when everything is at home and isolated, we tend to lose human interaction. Of course, you can keep in touch with this virtual online meeting and all but it is still different, right? Unlike previously, where you can be in a group doing activities, studying together. I think it is a new thing for all of us. The new norm which I am scared of might affect the personal or interpersonal skills and the empathy quality in all of you. Even though we can learn many things from the Internet, virtual classes and all that, your practical and clinical sessions with patients still need to be done under supervision. I hope that clinical sessions would be resumed one day and you can continue your clinical session and from there, we will together sharpen the communication skill, the empathy skill and how you treat your patient as a human being.