Prof. Dr. Eswara Uma
“First off, could you give us a brief introduction of your background and how you come about choosing paediatric dentistry as your area of expertise?”
I hail from a place called Vizag which is in the southern state of Andhra Pradesh and it is known for its beaches and also for its strategic location as far as Indian defence is concerned. However, I grew up in the North of India in a place called Chandigarh, which is about 250 km from the National Capital of New Delhi. When the time came for me to pursue my higher education, I actually wanted to do medicine. But in India, in order to get into any professional courses, especially medicine or dentistry or engineering, and that too in public universities, we are supposed to write the entrance exams.There are a limited number of seats and I was offered a seat in dentistry.
In my family, we were clueless about dentistry other than knowing that dentistry is something to do with pulling out people's teeth. However, my parents and my uncle advised me to take a jump in it and make a career out of it for myself. I took their advice. I had to move away from my house and I joined a public university in Hyderabad. I was there for 5 years and I made great friends.
Once I finished, I had to move back to be with my parents because I was also offered a junior residentship in a Premier Institute of India, which is,Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh. However, my friends stayed back because they were preparing for their postgraduate entrance exam. Since I had already cleared one exam, I was very confident of myself. And when the time came for the entrance exam, my friends cleared, I did not clear the exam. That was the rudest shock of my life. So, I took a year's break and studied all over again because preparing for a competitive exam is a different ballgame. Meanwhile, the Army Dental Corps in India were recruiting dentists. I applied and I got selected. I was all set to join the army dental corps till I wrote my next entrance exam.
While I was doing my junior residentship, they announced there was one postgraduate seat open in Paediatric dentistry in PGIMER. I told myself, “what are the odds of getting it? You didn't get through in an exam where there were so many seats and here, only one seat is open, there's no way you're going to get it.” So, I didn't even apply.
Then a very good friend of mine asked me about the entrance exam and she found out that I didn’t apply. So, she literally dragged me to register for the exam on the very last day before the closing day. And I wrote the exam and forgot about it.
It was the same friend who called and told me that I got the seat. I was shocked. I said to myself, “Okay, this is an opportunity which has been given to you, grab it with both your hands and just make something out of it for yourself.”
It was a lot of hard work, sweat, tears, but I have no regrets whatsoever, and looking back, I'm so indebted to my friend who made me fill up the form that day. So, if you ask me, how did I end up being in paediatric dentistry? I have one word and that is serendipity.
“Being a paediatric dentist could be a bittersweet experience. On one hand, it may be fun working with children, but on the other hand, it may be challenging to have them comply with the treatment. In general, children are afraid of the dentist. What are the notable challenges that you face, and how do you overcome them?”
If I say treating children is so easy, I will not be doing justice at all, because even today, there are times when I do feel a bit nervous. I'm not worried about their behaviour but what concerns me is the fact that because of their behaviour, will it affect the treatment outcomes which I'm planning for that particular child? So, having said that, when you try to help them, you may end up feeling nervous that you may hurt them.
However, we need to remember that we are all humans. When we see somebody crying, the first thing that happens is we let our defences down and we start worrying “Oh, why is this person crying? Did I hurt them in any way?”. So, what you need to think is, “why is this kid crying?” Because that is where the answer lies, that will help you in treating these children. I know the procedures which are going to cause pain to the child and the procedures which are not going to cause any pain to the child. I know how to manage if a child is in fear. All I need to do is to find out, “Why are you scared?” And the answer helps 9 out of 10 times.
The second aspect is, I always keep in mind that most or 50% of the children are fuss-free, easy to manage, they just walk in and get all their treatment done. Then come the 30% of the children who might be potentially cooperative. At the moment, they're anxious and scared. But then, depending on how I interact with them and how I make them feel comfortable, they have the potential to become cooperative. Then I have 15% of the children who do not have the ability to cooperate, no matter what. Because of their age, like a two-year-old baby, I cannot talk to them, the baby cannot express. The same way goes to a child with special needs and for them, we have different strategies to manage this group.
Now that leaves me with 5% of children, which means 1 in 20 children who really show disruptive behaviour. In order to manage these children, I need explicit consent from the parents. Especially in today's world, where we have hyper-parenting and helicopter parents. I need to be really careful in terms of how I manage these children. If the parent does not agree with my strategies, I just hang on. I tell the parents to seek a second opinion.
The third thing is patience. I need to show empathy towards them and most importantly, depending on the age of the child, I try to go down to the level of intellect of the child and I take them along with me. It becomes easier for me when I understand the temperament of the child. So, I like observing the child. For me, the first visit of the child is very crucial. I spend nearly 40 to 45 minutes in the first visit of the child, letting the child get familiar with me and vice versa. I use the most common “tell-show-do” technique where I explain to the child what I am going to do. So, I can say that it is actually very easy to treat children if you remember these few things.
“Prof, you have a good deal of experience in treating children with special healthcare needs. Do share with us a few stories regarding your experience and how different it is to treat these special children, in terms of facilities and procedures?”
I have treated a number of children with special healthcare needs,so in terms of special facilities required, it depends on the special needs of that particular patient. Let me share an example - We had a child who was around 12 years of age, had a global delay of development and the child wouldn't let the dentist examine the mouth. So, the mother came to Melaka Manipal Medical College and said, "I have taken my child to many places and my child does not cooperate and they have told that the child has to be treated under general anaesthesia and I don’t want my child to be treated under general anesthesia.” So, I said, "Okay, we will have a look and try. You please sit in the chair and take the child in your lap. Even though the kid is big to sit in the lap, never mind, the child is going to feel very comfortable." To the mother’s surprise, the child allowed herself to be examined by the students. After that day, the kid was comfortable during the subsequent visits and would sit by herself. The only condition the child had was, it would be the same students treating her, nobody else, not even me, she wouldn't allow me to touch her. So, I would just stand and watch. In that way, we could manage the patient on the chair itself.
On the other hand, back in India, I had another twelve-year-old child who was severely autistic along with a history of seizures and many other medical issues. This child needed multiple extractions and the child also had a mesiodens. The mother tried sitting on the chair with the child in the lap but the child would not cooperate. I had to explain to the mother that we have to treat her child under general anaesthesia as multiple extractions were involved and the parent agreed.
It varies from case to case. But yes, there are many cases where managing on the chair may not be easy. You may need the help of treating them under general anaesthesia and the operation theatre (OT).
There are 30% of my cases for which I need the help of general anaesthesia where I treat the child when the child is not moving, I can complete the full mouth rehabilitation. Then the child comes for regular follow-ups in the chair. It becomes much easier that way.
There are many people who have mobile anaesthetic units in their operatory. I personally prefer to be in a hospital setting because all kinds of backup are there. In case of any emergency, there is an ICU. Things can happen which you do not anticipate. You have a backup in the hospital and you can manage it.
“It is an amazing feat that you have hospital-based experience working in India and the UAE. Could you kindly share with us your experience working in these two countries, and how different it is, compared to Malaysia’s modus operandi?“
I worked in the UAE for about 3 years and most of my career has been in India. I worked with very fantastic chairs and fantastic equipment and materials. And I've also worked in places where things were not so fantastic. But what I have realised is, I am only as good as my team. I may be very knowledgeable and skillful, but if my support is not on the same page as me, my work is not good at all.
Let me explain, I might do restorative work on a child, so I have to be quick. My dental operatory assistant is the one who will be mixing the material. If my material is not properly mixed and I place it, the restoration may fail. So, I cannot blame my assistant who did not mix it properly. It's teamwork. So, it's my responsibility.
Whichever place I have worked, I worked with fantastic teams, whether it was Dubai or back in India. In India, I made friends with a lot of anaesthetists and I did a lot of multidisciplinary work with paediatricians, haematologists, dermatologists, ENT specialists and there is a lot of learning in both ways. I learned a lot from them about their speciality and they learned a lot about dentistry.
So everywhere, it's the same, but what matters is teamwork. And that's what leads to having a sense of fulfillment in our work.
“Now let's talk about an organisation that serves a good cause. You are a fellow of the foundation in advancement of International Medical Education and Research (FAIMER). What are your roles and responsibility as a member? And what are some of the work the foundation has carried out to achieve its vision?”
FAIMER of which I'm a fellow, is basically set up to improve the healthcare system by empowering the medical education. For example, I'm a trained clinician, I know about research, how to treat patients but when it comes to academics, I am not so well-trained in student assessment or teaching-learning activities. By being a fellow of FAIMER, it has empowered me in getting to know newer teaching-learning methods; what are the ways to make the classes more interesting, how to have new methods of assessment, how to make it more tangible, and also make it more fair across the board for all the students.
So that students don't feel that there is some kind of bias. There's a lot of research which we do and basically, the end goal is to make the students, the future professionals, their education more enriching. When the student graduates, he knows all the things which he is supposed to know because at the end of it if the student knows everything, it is the community, which is going to benefit.
I'm the chairperson for the soft skills committee in the college and one of the outcomes for the new dental graduates is that they practice ethically and professionally, they exhibit professionalism. We conduct assessment of professionalism for our students in year 4 and year 5. In year 3, we give them orientation about what is professionalism; what is expected of them, what they should do, what they should not do. Then we assess them and the students are given feedback from their friends, faculty, the dental support staff, the office, and also from themselves. Finally, we tell them about the areas that they are good in and also the areas in which they can probably improve. We give them constructive feedback, which possibly will help them in the future. So that there are no problems later in life because today, things are always taken out of context.
In developed countries, they already have their structured health professional’s education. We have a lot of graduates from developing countries going into the developed countries and they have to match their standards. So, these kids back in the developing countries need to be trained. So, it doesn't make a difference where you study.
“Prof Uma. You have been working in this field for about 20 good years. You've seen a lot of things, right. In your opinion, how has the paediatric dentistry evolved throughout the years?”
If I say anything about paediatric dentistry, it will sound as if I'm trying to sell but that's not it. The point is we tend to do everything of dentistry in paediatric dentistry; I can do endodontics for the child, I can do prosthodontics, orthodontics, surgical procedures. If you ask how paediatric dentistry has evolved, paediatric dentistry has evolved as much as dentistry has evolved itself.
How so? For example, you have rotary endodontics, we do rotary endodontics in primary teeth, nowadays we do Zirconia crowns in permanent teeth, we have zirconia crowns for children as well. We do interceptive orthodontics and preventive orthodontics.
The only thing which we do not do is implants. There is a restriction because of the age, the child's growth is not completed. There are still situations in children where they say implants can be given like a child with Ectodermal Dysplasia or a child with multiple missing teeth, where people have tried. It is not accepted but people are still looking at it. Other than implantology, we do everything else. So everything goes, we grow along with the best of dentistry.
“What advice would you like to deliver to dental students, especially those who aspire to further their studies in paediatric dentistry?”
First of all, congratulations on choosing paediatric dentistry as your next step because as I just said, the scope is huge. I have seen many of our students who after graduating, come back and say that there is so much to do! Sometimes, there are situations where we feel overwhelmed by the child's behaviour but most of all, there is so much we can do. Whether you want to go into academics or you want to go into private practice, the scope is huge.
The only limiting factor could be that 30% of your patients who you may not be able to treat in the chair or in your operatory, you will need to be associated with a hospital. Hence, you need admission rights to admit your patients.
Other than that, the sky's the limit. Traumatology is one more thing that one can look at. So, if you want to pursue paediatric dentistry, good decision. My best wishes and of course, there is a lot of hard work and that goes without saying because postgraduation is all about being on call because of emergency situations like trauma. You have your lectures, seminars, clinical work, and research work. You will wish that they were more than 24 hours in a day. But then, at the end of it, it will be worth it, believe me. You will feel very satisfied. In fact, today, I prefer treating children rather than adults because I feel very comfortable working with children.