Our State of being
OPENN WIDE
December 2017 Volume 7 issue 2
Our State of Being
The frigid weather has finally settled into our lives here in Philadelphia, and while some of us welcome it with open arms, many of us choose instead to huddle inside the walls of Penn, hibernating with our study guides and feeding the flaming hearth that is dental school with endless treatment plans. Regardless, whatever your predilection for weather, let Penn ASDA warm your cockles with our winter newsletter, a little bit of entertaining reading material in these winter times. "Our State of Being" refers not only to the seemingly ever-present reminder to take care of your health while in dental school, but also to the essence of who we are in the now. In our last newsletter, changes were abound. There was a new curriculum, new construction, new administration, new licensure exams, etc. Such changes are still ongoing, so we thought it wise to take a breath, take stock of the students amongst us, and see how we all have been doing as a collective. This newsletter features information on Penn's general state of wellness, perceptions of stress, our cultural diversity, and more. Please take a moment to familiarize yourself with some of our members who have come from near and far, as well as treat yourself to a little reading time. Happy Holidays, Your Penn ASDA CE Team
Table of Contents
Photography Contributors Matthew Casey Stephanie Chen (page 3) Deanna Pandolfo (cover)
Our State of Being 3 Kelly Chuang The State of Wellness 4 Katherine Hilton Canine Crunchies 8 Alexis Pawlak Fatima Naqvi Joanie Jean The PASS Process 11 Kathleen Mascardo From Whence We Came 17 William Manorlorakis Culture Shock 22 Mateo Nelson Silver Diamine Fluoride 24 Tim T. Wang
General statements about stress Medical students have demonstrated higher levels of stress, anxiety, and depression than age-matched peers, with female students ranking higher psychological distress than male students (1). Burnout Burnout is common during medical school with as many as at least 50% of medical students experiencing burnout at some point during their medical education (2). Risk factors for increased stress Several professional and personal characteristics including impulsivity, lack of mentorship, evening shifts, lack of faculty support, and cynical residents may increase risk of developing stress and burnout (2). One cohort study of Canadian dental students conducted by Stewart and colleagues highlighted the increased tendency towards increased psychological manifestations of stress and decreased positive coping strategies such as drawing away from social support (3). In a study of Canadian dental students conducted by Dahan and colleagues, three types of students were identified based on stress level: relaxed, moderately stressed, and highly stressed (4). Relaxed students often exhibited positive coping skills such as a wide network of family, friends, and faculty to rely on, healthy relationships with mentors, exercise and extracurricular activities (4). Moderately stressed students accepted the stress as a part of the dental educational experience and took advantage of stress as a stimulus to enhance academic performance (4). However, of these types, the group of most concern was the one featuring highly stressed students (4). These students not only exhibited poor coping skills such as avoidance, worrying, or complaining, but they also exhibited difficulty adjusting to the intense curriculum and heavy workload, preserve quality of life, difficult interpersonal relationships with faculty, and fear of failure (4). Often their physical, social, and mental health was affected by this stress (4). Impact on future practice and mental health Even more worrisome, this stress and burnout may not be limited to medical school, but may affect the student’s future practice and professional career both during and after residency (2). Additionally, burnout has been related to suicidal ideation and psychiatric disorders (2). Wellness, one study proposes, is a central part of the medical curriculum as it can impact a physician’s ability to care for and empathize with their patients, maintain longevity in their careers, and improve their quality of life (2). Student thoughts One study, conducted at Case Western Reserve University, evaluated medical students’ thoughts on the importance of wellness and integration into the medical school curriculum. In this study, it was found that the medical students found wellness to be an important for their future careers and that wellness activities had helped to alleviate the overwhelming nature of their heavy course-load. Structuring wellness into an elective course relieved any guilt about taking the time to conduct wellness (5). Additionally, they found speaking with classmates to be helpful as a coping mechanism to deal with stress (5). What to do about it After concluding their data collection, one group of researchers suggested several tactics to improve dental education including establishing appropriate expectations for personal and academic performance in dental school early on during dental school orientation, specifically the promotion of discussion of self-efficacy and self-concept, academic identity which may come into question as the students face the challenges of dental school and the importance of establishing a collaborative class attitude over a competitive one (3). Additionally, they promoted problem-focused coping skills and student empowerment so as to open communication in the academic setting to reduce resentment, stress, and helplessness amongst dental students experiencing this severe stress (3). Several studies proposed not only helping these students to develop better coping mechanisms to deal with the stress, but also to reduce stress in the first place (4, 6). A study reviewing the available literature on stress management in dental education identified two strategies that appear to reduce stress: 1) increasing positive stress coping mechanisms and 2) decreasing sources of stress (6).The first tactic involves such interventions as breathing techniques while the second reduced the academic stressors by decreasing exams and requirements or directly addressed students’ underlying fear of failure (6). In a study done by Shankarapillai, a randomized controlled trial was done to test the effects of active intervention versus didactic intervention on the outcome of stress prior to the students’ first periodontal surgery (7). In this study the active intervention involved a 60-minute yoga session whereas the didactic intervention featured a stress reduction lecture (7). Students in the active intervention group exhibited statistically significant reduction in anxiety both during and post-procedure (7). Several other studies featured stress-reduction interventions featuring yoga, walking and moving meditation, body scan, guided imagery, and breath awareness (2,8). Additional interventions including cognitive behavioral therapy, structured mentorship programs, peer-validation, and meditation, among others would ideally be built into the curriculum (2). Further studies Current available studies on wellness and burnout often suffer from response bias, use self-report to gather data, feature small sample sizes, and/or fail to thoroughly evaluate causality; additional information is necessary to address these issues (2,6). Further studies are needed to evaluate the factors contributing to stress, depression, and burnout among dental and other health professional students. A Look at Stress and Wellness at PDM In an informal GAD-7 survey completed by dental students at Penn Dental Medicine, the most common responses ranked on the lower-anxiety end of the answer spectrum. The most common reported answer to the GAD-7 questions was “some days” and the second most commonly reported answer was “not at all” resulting in a cumulative score of 5 (mild anxiety) (10). Since the clinical threshold for additional testing and evaluation of anxiety is at least 10, it is important to understand that our students scored well below this marker (10). While this trend falls lower than may be expected based on the literature studying anxiety among medical and allied health students, it is important to remember that the GAD-7 can be used to screen not only for generalized anxiety, but also post-traumatic stress disorder, social anxiety disorder, and panic disorder (11). With this in mind, I would like to highlight the two answers of the GAD-7 that indicate increased stress, but may not point to one of these other disorders: “Feeling nervous, anxious or on edge?” and “Worrying too much about different things?” Both of these questions elicited a significant number of answers in the “more than half the days” or “nearly every day” category to describe the last week alone. This indicates that there is still a substantial amount of anxiety experienced throughout the week of a Penn Dental student. In an informal survey of Penn Dental Medicine students, the three most common de-stressing activities include watching TV or Netflix, talking to a friend/family member, and exercise. Secondarily, additional de-stressing activities include meditation/prayer and of the “other” category, the most common responses included alcohol or food. While these reflect both healthy and unhealthy coping mechanisms as outlined in the studies featured in this article, it is crucial to bring attention to the fact that there are various opportunities available here at Penn Dental to improve wellness and overall health. The Molar Yogis, Penn Dental Happiness Project, Mindfulness at Penn, and the new wellness selective offer various sitting and moving meditations and information on additional stress reduction techniques throughout the year. Further, CAPS is available at the dental school for students seeking one-on-one or group support. Finally, I would stress the need for collaboration and camaraderie within and between graduating classes. At Penn Dental, as with any professional curriculum, the course load and scheduling can prove to be a challenging adjustment, accompanied by life's many unexpected challenges —cars break down, apartments need repair, the weather suddenly turns frigid, rough days in clinic when a procedure goes awry. Life and practice can be difficult and we need to rely on each other both as peers in school and as future colleagues to succeed. If you haven’t already - it is time to make wellness a priority and to seek out strong support networks, destress according to your own interests and energies, and to tackle each new challenge knowing that failing isn’t the end of the world, that you are only human, and that you have people here to help you through each day. Citations: 1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-73. 2. Ishak W, Nikravesh R, Lederer S, et al. Burnout in medical students: a systematic review. Clin Teach. 2013;10(4):242-5. 3. Stewart DW, de Vries J, Singer DL, et al. Canadian dental students’ perceptions of their learning environment and psychological functioning over time. J Dent Educ. 2006;70(9):972-81. 4. Dahan H, Bedos C. A typology of dental students according to their experience of stress: a qualitative study. J Dent Educ. 2010;74(2):95-103. 5. Lee J, Graham AV. Students’ perception of medical school stress and their evaluation of a wellness elective. Med Educ. 2001;35(7):652-9. 6. Alzahem AM, Van der Molen HT, Alaujan AH, et al. Stress management in dental students: a systematic review. Adv Med Educ Pract. 2014;5:167-76. 7. Shankarapillai R, Nair MA, George R. The effect of yoga in stress reduction for dental students performing their first periodontal surgery: a randomized controlled study. Int J Yoga. 2012;5(1):48-51. 8. Rosenzweig S, Reibel DK, Greeson JM, et al. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88-92. 9. Patient Platform Limited. Generalized anxiety disorder assessment (GAD-7). Available at: https://patient.info/doctor/generalised-anxiety- disorder- assessment-gad- 7. Accessed November 14, 2017. 10. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7. 11. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity and detection. Ann Intern Med. 2007;146(5):317-25.
Katherine Hilton, Class of 2021, provides an overview on student stress and reports on survey data regarding student happiness here at Penn
Students participate in yoga during ASDA Wellness Week
The State of Wellness
Diagram from Spitzer et al 2006
Image from Fatima Navqi
Avocado and Chickpea Toast with Pomegranate
Shrimp and vegetable Fettuccine Alfredo
Image from Alexis Pawlak
by Fatima Naqvi Servings: 4-6 Total Time: 30 mins Ingredients: 1-2 tablespoon Olive oil 1 cup red, yellow, and green bell peppers (chopped) 1-2 tablespoon Green onion (chopped) 1-2 Garlic clove (minced) 1 lb Fettuccine pasta 1/2 lb broccoli floret (chopped) 1 lb large shrimp (cleaned and cooked) 1 cup Alfredo sauce Directions: In a pan, heat oil to medium heat. Sauté onion, garlic, and bell peppers and reduce the heat to medium low to sweat the onions, bell peppers, and garlic until tender. Then, place in a large serving bowl. In a large pot of boiling salted water, cook pasta per directions. Add broccoli to boiling water for last 3-5 minutes. Drain and place pasta and broccoli into the serving bowl. Add shrimp to warm mixture, and toss all ingredients together. Top with Alfredo Sauce.
by Alexis Pawlak Servings: 1 Total Time: 5 mins Ingredients: 1/2 Avocado 1/4 cup Canned Chickpeas, rinsed and drained 1 tsp Olive oil 2 Slices 100% whole-wheat bread, lightly toasted 1/4 cup Pomegranate seeds Directions: In a bowel, mash avocado, chickpeas, yogurt, lime juice, and oil. Season with salt and pepper. Spread avocado-chickpea mixture over toast. Top with pomegranate seeds.
Canine Crunchies
Need a quick pick-me-up or some ideas for meal prep? Penn ASDA has you covered! Some of our students share their recipes.
The PASS process is a murky mystery to many domestic dental students here at Penn. To help address this issue, Kathleen Mascardo (Class of 2019) interviews some of the international students at Penn undergoing this rigorous journey.
Sweet Potato and Beef Chili
Images from Joanie Jean
For over 30 years, Penn Dental Medicine has provided leading dental education for internationally-trained dentists seeking practice licensure in the United States. Every year, 30 to 35 people are meticulously selected from nearly 1,000 applicants for the 2.5-year Program for Advanced Standing Students (PASS) at Penn. These international dentists join 2nd year predoctoral students in their second semester, experiencing full integration into Penn’s regular DMD class. This integration is unique and different from many other dental schools in the United States. In a way, Penn Dental has created a study in anthropology through the integration of PASS into the pre-doctoral class and in so doing, directly addressed a controversial need. In today’s political and social climate, it has become even more imperative that we constantly start dialogues and open doors for communication, healing, and understanding. Only in breaking down cultural barriers within our own backyard can we grasp a deeper understanding of our patients and of the world in general. Notwithstanding PDM’s full class integration, little is known about PASS students to the greater dental community at large. Although integrated into one class, a glaring dichotomy has always existed between PASS students and the rest of the Penn student population. More than cultural differences, it seems that the rigors and perplexities of dental school have everyone running with a constant sense of urgency at “getting things done,” to the point where we often fail to take advantage of the rich, cultural experience that Penn’s multiethnic community has to offer. It is important to note that the steady increase in PASS applicants every year is a direct reflection of the rapidly increasing immigration and diversification of the US population. As future dentists, we will have a more diverse patient pool than ever before. What better way to practice multicultural discourse than in our very own backyard? To get the ball rolling, we are interviewing five PASS students from the Class of 2019 for this issue of Penn ASDA. These are their stories, in their own words and with their own voice.
The PASS Process
by Joanie Jean Servings: 4 Total Time: 45 mins Ingredients: 1 lb Lean ground beef 1/2 tsp Salt 1/2 tsp Black pepper 3 Cloves minced garlic 1 Diced red onion 1 lb sweet potato, peeled and cubed 2 tsp Coriander 1 1/2 tsp cumin 1/2 tsp Paprika 1/4 tsp Chili powder 1 tablespoon Olive oil 1 Can diced tomatoes, drained 2 1/4 cup Chicken stock Directions: Season ground beef with salt and pepper. Mix together the garlic, onions, and sweet potatoes. In another small bowl, mix together the coriander, cumin, paprika, and chili powder. In a large, heavy-bottom pot, heat oil until hot. Add the garlic, onions, and salt to the pot and saute until softened. Next, add in the ground beef with half the spices and diced tomatoes. Brown and break up with a spoon. Drain the grease. Last add in the potatoes, chicken stock and remainder of spices. Bring to a boil, then lower to a simmer. Cook covered another 15 minutes or until sweet potatoes are softened. Serve!
Chandani Acharya Nepal Tell us a little bit about yourself. I was born and raised in Nepal. I completed dental school there. After graduation, I worked as a general dentist for 2 years and moved to USA. I’m married and a mother to an 18-month old baby girl. How does it feel to essentially “start over?” It feels great and awesome. I feel like I am re-inventing myself with more knowledge, strength, and encouragement than I had before. ' How is dentistry (in general) different in your home country than in the United States? People in Nepal are less aware of oral health as compared to people in [the] USA. [Nepalese] people do not have dental insurance and prefer to pay out of pocket for treatments. There is not much use of [the] latest dental technology [but] it is starting to change gradually. What are you most proud of about your home country? The world’s highest peak, Mount Everest, and birthplace of Lord Buddha are in Nepal. What is your favorite dish from your home country? “Momo” is a type of dumpling which is made from dough usually filled with minced chicken, pork, and also vegetables. It is steamed and served with [a] special kind of tomato sauce. The dish is a must-try food item of Nepalese cuisine. What is your favorite childhood memory? Exploring the paddy fields and streams behind our countryside home with my cousins during summer breaks in school. We would try to fish in streams and if we found one, we would keep it as a pet. What do you miss most about your home country? Family, of course. Thank God for WiFi, Skype, and Whatsapp! Now that you are in the PASS program, what has been your greatest challenge? Balancing my family and personal life with academic, clinical, and volunteering demands of dental school. What do you like most about being a student at Penn Dental Medicine? As a student, it feels great to be part of an Ivy League school. I like the way how PDM trains dental student[s] from diverse culture[s]; providing excellent knowledge, skills, and values to become qualified dentist[s] in [the] USA. What is your favorite quote or what is the best piece of advice you’ve ever received? “The less you respond to negative people, the more peaceful your life will become.”
Image from Chandani Acharya
Image from Gina Askander
Gina Genevia Askander Iraq Tell us a little bit about yourself. I’m half Armenian, born in France, and raised in Iraq. Iraq is Ancient Mesopotamia where [the] first written language was developed. Mesopotamians invented the wheel. What made you decide to pursue dentistry in the United States? We immigrated to the USA after the loss of my oldest sister (my second mom) amid the violence in my country. I love working as a dentist and there is no other job out there [to] satisfy me like Dentistry. So it was only logical to get my dental license in my new home (USA). Which dental school did you go to in your home country and how is it different to PDM? I graduated from Al-Mustansiriya University College of Dentistry. Ways of teaching are very different. Exams were rarely MCQs, [but rather] mostly descriptive. PDM provides [the] best of the new dental materials out there. What is your favorite dish from your home country? My favorite dish is called “Doma.” It contains grape leaves, onion shells, tomato shells, and zucchini shells stuffed with rice, meat, parsley, diced onions, and diced tomato. I highly recommend this dish. Now that you are in the PASS program, what has been your greatest challenge? Living away from my family. What do you like most about being a student at Penn Dental Medicine? I like the commitment of the faculty and staff to their students. Students matter. [Teachers] are there to help us through our struggles and challenges. What is your favorite quote or what is the best piece of advice you’ve ever received? “Do not stress too much. Enjoy and have fun.”
Tetiana Marchenko Bass Ukraine Tell us a little bit about yourself. Curious about life, very adventurous, and creative – that’s what my husband answered when I asked him. I feel like I’m always seeking something new – knowledge, skills, and places. Talking about Ukraine, I have nothing to say except that it is a beautiful country with great people. People who have faith, courage, and thousands of years of heritage (literally!) that is passed from generation to generation. It’s the land of open hearts and beautiful nature. How does it feel to essentially “start over?” Honestly, I don’t know. I’m not starting over, but continuing to get better. I think of this situation as taking several steps back in order to leap forward. Of course it was a strange feeling going back to dental assisting after having assistants of your own, but after a brief adjustment period, I found this experience mostly fun and useful. Which dental school did you go to in your home country and how is it different to PDM? I am a proud graduate of Kharkiv National Medical University. I also finished my post-diploma education in the same school. PDM gives students a lot more opportunities and time to develop practical skills, so transition to actual patient care is a lot smoother. I also admire [that] PDM is [on the] cutting edge of dental science. What are you most proud of about your home country? Despite the long history of oppression, [Ukraine] was able to retain its culture, language, and freedom-loving spirit. For centuries, we were not allowed to speak [our] Ukrainian language, celebrate our holidays, and at times even to practice our religion. Now that Ukraine is finally free, it is amazing to see that the younger generation has fully embraced our culture that was carefully preserved for many generations. What is your favorite dish from your home country? I think all Ukrainians will answer the same – Borscht! This is [a] red soup which include[s] a lot of beets, carrots, cabbage, and potatoes. You can make it with any kind of meat or even without it; but my absolute favorite is one with pork ribs in it. With black bread, salo, and sour cream – yummy! If you wanna try it, ask any Ukrainian girl, [because we all learned] how to [cook it] since we were 10! What is your favorite childhood memory? Definitely my grandparents’ house! Ripe grapes and raspberries, shining sun, grandma’s flowers, sounds of a distant train whistle, and a big family gathering around the table for dinner. Their house still smells like [my] childhood every time I visit. What do you miss most about your home country? Most of all, I miss my two “F”s – Family and Friends. It’s sad to miss majority of celebrations – someone’s wedding, birthday, christening, etc. Of course, everyone [is] sending me pictures, but I wish I could be there in person. What do you like most about being a student at Penn Dental Medicine? That I am surrounded by people who are much better than I am – smarter, more talented, hard workers, kinder, full of positivity. It inspires me to work non-stop, shaping myself into a better professional and a human being. What is your favorite quote or what is the best piece of advice you’ve ever received? “The beauty will the save the world,” by Fyodor Dostoevsky. The author’s opinion [about] beauty has nothing to do with someone’s physical appearance, but [rather] the inner beauty of someone’s heart. Things like kindness, dignity, empathy, and sincerity. And our world needs this beauty indeed.
Image from Tejasi Avasare
Image from Tetiana Marchenko
Tejasi Avasare India Tell us a little bit about yourself I hail from the Republic of India – a country known for illustrious history, culture of peace, and harmony. I am a worshipper of Art and Science; hence I belong to the field of Dentistry. What made you decide to pursue Dentistry in the United States? The US offers global platform for professional growth. When the opportunity to pursue Masters at an esteemed university in the US came along, my thoughts were magnetized with a picture of [a] bright career path ahead of me, and within seconds I had made my decision to pursue a dental career in the US. Which dental school did you go to in your home country and how is it different to PDM? I attended Pravara Rural Dental College affiliated with Maharashtra University of Health Sciences. Our basic sciences lectures were taught alongside medical students. We had long and short essay type questions for exams and our exams were conducted annually at the same time for approximately two- to three- thousand dental students across the entire state of Maharashtra. How is Dentistry (in general) different in your home country than in the United States? Limited infrastructure and access to technology makes Indian dentistry less regulated. Fee-for-service and lack of third party involvement makes it a free market and brings with it all of its pros and cons. It is definitely more efficient in terms of time and money for the patient as compared to Dentistry in the US. There is less oral health awareness and rural Dentistry in India predominantly consist of extractions and complete/partial dentures. What are you most proud of about your home country? I’m proud of my country’s long and rich history. Science and philosophy [are the foundations] of Indian society and many of our traditions and customs have deeper roots in scientific reasoning. [It is] the birthplace of many religions and for centuries together, [we have all] cohabited with peace, love, and respect in spite of differences in beliefs. What do you miss most about your home country? The aroma of the soil when the first drop of rainy season hits the ground, majestic mountains and delicate waterfalls, calling of Indian Black Cuckoo from mango orchards, lilting notes of my mother tongue and her dialects, big families and even bigger festivals, sumptuous cooking of my mom, warmth of granny’s blanket... Now that you are in the PASS program, what has been your greatest challenge? Effective time management, learning to be a multitasker, getting used to the technology and electronic health records system, and speed tracking to get assimilated in the culture of PDM.
Image from Hattanas Kumchai
Hattanas Kumchai Thailand Tell us a little bit about yourself. I finished dental school in Thailand in 2010. Then I spent 5 years in Boston studying Prosthodontics (Residency and DScD degree). Now I join PASS program at Penn for a US dental degree. What made you decide to pursue Dentistry in the United States? There are vast opportunities available in the US. Education is top-notch. Dentistry is a very strong profession here. How does it feel to essentially “start over?” To me it is not really “start[ing] over” because this is only 2.5 years compared to 6 years of my previous dental school in Thailand. Going back to fundamentals is never a bad thing. How is Dentistry (in general) different in your home country than in the United States? Dentistry in [the] US seems to be influenced [by the] business side more than in my home country. There is also more focus on esthetics here. What do you miss most about your home country? I miss [the] food and people there. Now that you are in the PASS program, what has been your greatest challenge? My challenge is to have a good balance between school and family. I have 2 kids and spending time with them is one of my [priorities besides] studying.
William Manolarakis, Class of 2021, interviews fellow first-year classmates, showcasing Penn Dental's diversity
Julian Johnson Sierra Leone When did you move to the United States? I moved to the United States in 2008 from Sierra Leone. What inspired you to study dentistry at Penn Dental? My decision to study dentistry was driven by my desire to use my knowledge and skills to improve oral health in Sierra Leone and other underserved areas. I chose to study dentistry at Penn Dental because Penn is one of the best research institutions in the United States, and they provide the opportunity for students to actively be involved in research during dental school. The didactic curriculum is structured in a way to facilitate adequate clinical experience and research knowledge during the course of the program. What are some cultural differences between Philadelphia and your native country that you have encountered so far? In general, Sierra Leoneans are polite and manner-conscious, which means strangers randomly say hello on the street. It is like a social norm to politely greet people. In a small city or town, it is common for neighbors to show up at your house uninvited. Additionally, the weather is tropical in Sierra Leone and is mostly hot all year round, with two there being two seasons: rainy and dry. How do you feel that your future approach to patient care has been shaped by your upbringing? I have developed a caring relationship based upon my experience interacting with people from different cultural backgrounds. This experience, in addition to my upbringing, will foster a platform for effective patient care. Do you have any general plans yet for your career after graduation from Penn Dental Medicine? I have a few plans in mind, but my main goal is to find ways to improve oral health in Sierra Leone and underserved areas. Shivali Patel Zimbabwe When did you move to the United States? I was born in Canton, Michigan and moved to Harare, Zimbabwe at the age of four. I lived there until the completion of high school and I moved back to Michigan to begin university in 2013. What inspired you to study dentistry at Penn Dental? Studying dentistry at Penn Dental Medicine would allow me to serve and work with a diverse population and many underserved communities that lack access to affordable dental care. This is something that is very important to me, as I grew up in a country where many communities lacked access to affordable dental care. What are some cultural differences between Philadelphia and your native country that you have encountered so far? I have noticed people in Philadelphia to be very friendly and informal in their speech and dress and more direct whereas in Zimbabwe there is much more formality. How do you feel that your future approach to patient care has been shaped by your upbringing? My different experiences, both in the United States and Zimbabwe, have given me a unique perspective of the dental field in two very different cultural settings. Having lived in two different cultures, has better equipped me to be adaptable,and to assimilate and relate to patients of varying backgrounds. Do you have any general plans yet for your career after graduation from Penn Dental Medicine? At this point, I am undecided. I am trying to keep my options open to a specialty that interests me.
Images from Julian Johnson
From Whence We Came
Images from Shivali Patel
Images from Ashley Roberts
Ashley Roberts Barbados When did you move to the United States? I moved to the United States from Barbados in August 2013 to attend the University of Pennsylvania,where I got my B.A. in Chemistry. I had visited the United States before but this was the first time that I would be living here for a prolonged period of time away from home. What inspired you to study dentistry at Penn Dental? As an undergraduate and a member of the Penn Pre-Dental Association, I got the opportunity to participate in an oral literacy demand study conducted principally by a group of dental students at PDM. As a research assistant, I gained more insight into the everyday operations of the school and the level of care that PDM provides and I became more interested in attending as a dental student. What are some cultural differences between Philadelphia and your native country that you have encountered so far? There are many! However, being in a city environment itself completely contrasts with the Bajan (Barbadian) lifestyle. From the words we use, to how and when we say them to how we pronounce them, the list is endless, but one of the major differences that I have had to adjust to is the food. Not that I don’t love the range of cuisines here in Philly but sometimes I still crave a Bajan Sunday Lunch, fishcakes, macaroni pie or flying fish. How do you feel that your future approach to patient care has been shaped by your upbringing? Growing up around my family business started by my grandparents (sixty years ago this year) has taught me a lot about being empathetic with others, which I think is a huge part of patient care. My number one goal is to be able to provide top-notch service but at the same time never forgetting the individual needs of each patient. Do you have any general plans yet for your career after graduation from Penn Dental Medicine? At the moment, I want to specialize, but I am not sure as yet where life will lead me in terms of going back home or staying here, but I know that Penn Dental Medicine will equip me with endless opportunities. Evelyn Spencer Australia When did you move to the United States? I moved to the U.S. in the fall of 2014 after graduating from the University of Sydney in Australia. What inspired you to study dentistry at Penn Dental? My interest in dentistry began during my undergraduate study, as I worked as a dental assistant. When I graduated with my degree in Medical Science, I realized that while I still wanted to go to dental school, I was greatly interested in research. Australia has incredible dental schools, but I was greatly drawn to the amazing research-oriented dental schools in the US. I participated in research for a year at Penn Dental during my Post-Bac program and decided it was exactly what I was looking for. What are some cultural differences between Philadelphia and your native country that you have encountered so far? Cheese Whiz!!! I will never again question the rationale behind neon-orange cheese-flavored goop, especially in the context of cheese steaks! How do you feel that your future approach to patient care has been shaped by your upbringing? My approach to patient care has definitely been strongly influenced by my upbringing in Australia, where we have a unique health care system. This has instilled a strong belief that patients all deserve the same right and access to a fundamental standard of care and should be treated equally with respect. Additionally, the Australian government began funding a dental scheme several years ago providing free basic dental care and prophylactic treatments for children between the ages of 2-17,which I personally saw in effect as a dental assistant. Seeing how this positively impacted families that would not have gone to the dentist without this program impressed the importance of taking the time as a dental professional for proper patient education, instilling the importance of oral hygiene and setting up good habits for the rest of their lives. Do you have any general plans yet for your career after graduation from Penn Dental Medicine? Having just started my D1 year, I don't yet have any specific plans after graduation. I definitely would like to pursue further education and continue with research. I look forward to sticking around the US for a little while yet! Nessim Temstet France When did you move to the United States? I moved to the United States in 2013, right after receiving my French Baccalaureate at the age of 18. It was really hard at first to leave Paris for New York City, but I was motivated to discover and take part of a complete new world! What inspired you to study dentistry at Penn Dental? As far as I can remember, I always aspired to becoming a dentist. However, I became familiarized with Penn Dental Medicine right before deciding to go to the United States for College. I remember asking my advisor which dental school was the most knowledgeable for its excellency and training, and she naturally responded UPenn. Being an international student, I knew that this was going to be a difficult journey, but I was excited and motivated to take on this challenge and to prove myself I was able to do it. What are some cultural differences between Philadelphia and your native country that you have encountered so far? There are so many differences between Philadelphia and Paris. Mostly, people seem to be friendlier and more open-minded here in PA. I appreciate the fact that I can interact with peers and faculties from various backgrounds, cultures and religions. Also, I realized that people in the United States in general tend to be very proud of the college institution they attend and represent its values and colors, which is not the mentality in France. How do you feel that your future approach to patient care has been shaped by your upbringing? Coming from France, a country having a socialized health care system, I hope that I will be able to handle the various issues that health care professionals are and will be facing in the coming years. I will do my best to practice patient-centered dentistry regardless of my patients’ origins or social status. I would also love to help patients speaking a different language to receive appropriate treatment. Do you have any general plans yet for your career after graduation from Penn Dental Medicine? I have not yet made my mind on a particular career path after graduation from Penn Dental. One thing is certain though, I am really proud to be part of a dental school that is trying to grow students' interests into various directions. For now, I am looking forward to applying to a Master's Program at Penn, which I hope to do while completing my DMD degree.
Images from Evelyn Spencer
Images from Nessim Temstet
Images from Mateo Nelson
Those of us brought up in the Hawaiian culture are educated in‘ike ‘aina–knowledge from/of the land–which in turn influences and informs how we experience our world. For instance, with 150 or so words for rain, the fundamental relationship we have with nature is easily construed through ‘Olelo Hawai’i (Hawaiian language). There’s the windless rain, kuaua, that we wait for when it’s time to plant ‘uala (sweet potato); the hukihe’enehu on the Big Island that prompts fishermen to raise their nets to catch nehu fish; or if we see fortuitous anuenue (rainbow), we call it uapoko. Then, there’s Philly rain. Searching through this extensive lexicon of precipitation, I find nothing quite familiar. The rain here is kind of relentless–like a guest who’s long overstayed their welcome –certainly nothing like the gentle paki’oki’o that comes and goes in Manoa Valley, where I’m from. Indeed, I would say East Coast weather has probably been the most dramatic change from home. In fact, it snowed the day before my interview at Penn. It wasn’t my first time seeing snow, as I’ve experienced blizzards on Mauna Kea (white mountain) on the Big Island. It was, however, my first time slipping and falling in it while wearing a suit! Still acclimating and getting my bearings around the historic City of Brotherly Love, I can appreciate William Penn’s vision and legacy of a simple grid plan. Navigation is so simple. Back home, as always, nature shapes and leads the way. It’s just easier to tell someone, “Gomauka (mountainside),” ormakai (oceanside). Either of those landmarks will likely be your background or foreground, since modern development emerged out of the ahupua’a system in which land was divided in wedges originating from mountaintops and fanning out along streams to the shoreline. While the concrete jungle of Philadelphia is not exactly teeming with wildlife, “jungle” does sound oddly appropriate considering how numerous and aggressive the mosquitoes are here! First of all, coming from the tropics, where we do constant battle with “B52” cockroaches and giant centipedes; I was looking forward to a pest-free life. On the contrary, I found myself seeking asylum indoors. Thankfully, squirrels are a redeeming distraction, and my phone’s become a live Crittercam for the local Penn population. To me, they’re like nature’s Comedy Central when you tune into their nutty antics. As for what I’m accustomed to in Hawaii, being the planet’s most isolated landmass, we find more exotic flora and fauna–95% of which is endemic. Sadly, we also have one of the highest extinction rates. Still, you may surf over giant palaoa (humpback whales); get nudged by curious honu (sea turtle); or be transfixed by the distinct red comb of an ‘alae ‘ula, the endangered wetland bird from whom Maui stole fire. Many of these creatures are considered ‘aumakua, or ancestral spirits, so when you’re here look for ho’ailona (signs) and discuss kauna (hidden meaning) with the locals, who are quite fluent in the language of magical realism. Meanwhile in Philly, I’ve been brushing up on my urban lingo (I’ve heard “jawn” and “drawlin’”) and learning how to pronounce Schuykill in a way that doesn’t rhyme with gooey. At the same time, I’m becoming especially reaquainted with the term “pregame” after every exam it seems–so almost every week. Admittedly I’ve been struggling with culture shock, but there’s also a silver lining: a vibrant culinary scene (no more spam musubis), Dunkin’ Donuts, beer gardens, colonial architecture, East Coast accents, and the occasional two-and-a-half hour bus ride to NYC. Already my new PDM and PsiO ‘ohanahas peaked my interest in seeing a hockey game for the first time and trying scrapple–a possible addition to my love for all things made with spam. It still feels weird to put on a tie or touch a human skull. When iwi (bones) are uncovered in Hawaii, it instantly halts construction because they are considered vessels of mana (inner power), so to touch human remains is strongly kapu (forbidden). In spite of the vast differences culturally, I’m aware and appreciative of PDM’s efforts to promote diversity and inclusion.Yet, the competitive undercurrent and demands of dental school can be isolating, and thus, stirs a sense of feeling stranded on yet another island. Nonetheless, I’m grateful to be here and hope to feel differently over the course of the next four years. Aloha mai kakou!
Culture Shock
by Mateo Nelson Class of 2021
Silver diamine fluoride: A potential paradigm shift for treating caries
Silver nitrate did not follow the same fate overseas. In fact, SDF (a combination of silver nitrate and fluoride) was created in Japan by Dr. Mizuho Nishino as part of her doctoral thesis published in 1969. [10] Consequently, SDF has been routinely used in Japan for arresting caries since 1970.
Tim T. Wang Class of 2021
In July 2016, the New York Times highlighted Silver Diamine Fluoride (SDF) as an alternative treatment for dental caries that could be non-invasive and cost-effective.[1]The article helped to reignite the discussion surrounding a century-old method that has been almost forgotten about in the United States. While additional studies are needed to develop evidence-based protocols for widespread usage, SDF has the potential to change the model of how caries are treated in American dentistry. How It Works SDF is a colorless liquid that can be topically applied on dried carious lesions to arrest dental decay in both permanent and primary teeth. SDF is composed of about 25% silver and 5% fluoride[2]. The silver kills the caries-causing bacteria by breaking through the bacterial cell wall and disrupting bacterial respiration and DNA replication[3]. The fluoride, like in current fluoride varnishes, promotes enamel remineralization. In combination, SDF can treat caries by degrading the responsible bacteria and surrounding matrix metalloproteinases that contribute to breakdown of dentin.[4]Moreover, SDF can decrease dental hypersensitivity. While SDF is currently being used in several other countries, it is used sparingly in the United States. The Food and Drug Administration originally cleared SDF as a safe method to treat hypersensitive teeth in 2014. However, dentists have since started using it off-label as a non-invasive way to treat tooth decay. In January 2016, Oregon approved Medicaid funds to pay for SDF treatments, becoming the first state to do so.[5]Since then, a growing number of states have started to include SDF coverage in their Medicaid programs.[6] Moreover, over half of American dental schools have incorporated SDF into their curriculum, particularly for training pediatric dentists. Historical Background The use of silver nitrate, a main component of SDF, to arrest caries in the United States was recorded as early as in the 1800s. [7] Dr. Percy Howe slightly modified silver nitrate by adding ammonia, which improved the compound’s stability and antimicrobial effectiveness. From 1917 to 1950, Dr. Howe popularized the usage of silver nitrate as a routine treatment for caries, a method that became colloquially known as Howe’s Solution. However, a perfect storm during the 1950s left silver nitrate out of the cariology paradigm. First, silver nitrate lost its champion when Dr. Howe passed away around 1950. During this time, the dental field made several technological advances in restorative capabilities (e.g. local anesthesia, composite fillings), which allayed the urgency for a non-invasive caries treatment. The subsequent rise in cosmetic dentistry shunned silver nitrate because it stained carious lesions black (see Drawbacks of SDF). In addition, the water fluoridation movement had just taken off around the country, which became the gold standard for caries prevention. [8,9] Silver nitrate, as a result, was mostly forgotten about in the United States until a group of American dentists brought it back into the cariology conversation in the last few years. Benefits of SDF While SDF has yet to gain widespread usage in America, it is quickly garnering the attention of oral health professionals across the country. In fact, the American Academy of Pediatric Dentistry (AAPD) recently published a study that supported the usage of SDF for children and adolescents. [11] The main benefits of SDF include increasing access to care, shifting from invasive to non-invasive treatment, and eliminating carious bacteria more comprehensively. SDF lowers the cost of treating caries because only a few drops are needed to kill the carious bacteria and promote remineralization. While severely decayed teeth will still require restorations, SDF reduces the need for surgical dentistry in many less severe cases and offers solutions at a fraction of the cost. The New York Times reported that a particular pediatric cavity cost $151 to drill but only $25 for SDF application. [12] SDF therefore would increase access to care in low income populations. SDF would also expand access to caries treatment in underserved populations. Older adults who struggle to transport themselves to the dental office can have early lesions arrested via SDF application. Likewise, it is more practical and efficient for dentists in rural and understaffed areas to supervise the application of SDF compared to a surgical procedure. In addition, SDF is a non-invasive method to treat caries. Topical application lowers the need for anesthesia and surgical work. The reduction in the risk and trauma of anesthesia in itself would be particularly beneficial for kids and older adults. Finally, unlike traditional surgical dentistry which removes decayed tooth structure, SDF targets and kills the responsible bacteria via silver ions’ antimicrobial property. As such, repeat applications of SDF would ensure more complete removal of caries-causing bacteria than drilling and filling. Drawbacks of SDF While there are many potential benefits of SDF, it also comes with several drawbacks. The most prominent is in the realm of aesthetics: SDF permanently stains carious lesions black. This makes SDF difficult to use as a standalone agent for carious anterior teeth. In today’s society, a person’s smile can have profound professional and personal impacts that range from business opportunities to self-confidence. Dental aesthetics has direct implications on an individual’s quality of life, so SDF may not be a preferred solution for every patient. There are also limitations on cases where SDF can be used. The ADA state that patients with mouth sores and silver allergies cannot use the treatment. Patients have also reported that SDF has an unpleasant metallic taste. [13] Case Study In 2014, dentists from Hong Kong published a case report showing the successful arrest of rampant dental caries using SDF. [14] A teenage Chinese boy was suffering from chronic oral graft versus host disease, which led to the rampant caries. The teeth were hypersensitive and severely decayed (panel A). After plaque removal, the patient received three doses of SDF (38%) over four weeks. After this period, the teeth were no longer hypersensitive, the caries were arrested, and gingival health improved. The carious lesions were stained black (panel B). SDF stabilization of the patient’s oral condition allowed subsequent cosmetic dental restorations (panel C). This case illustrates an exciting example of combining SDF with restorative dentistry to treat patients more effectively. Outlook SDF research in the United States has increased exponentially over the last few years. These studies add to the existing literature, most of which have been completed in other countries. A recent Nature review article summarized that “high quality randomised controlled trials are needed to fully clarify [SDF’s] role in the prevention and management of childhood caries.”[15] However, the ADA also reported last year that there are multiple ongoing clinical trials for SDF, and thus there should be results forthcoming.[16] SDF is a fascinating new (old) discovery in dentistry. The wide range of SDF benefits include expanding access to care, reducing invasive procedures, enhancing preventative dental care, and many more. While SDF may not be suitable for every case, it provides an exciting new tool for dentists to fight tooth decay. As such, while it is necessary to exercise caution towards SDF, it is definitely an agent worth learning about and keeping in mind going forward. Citations [1] Saint Louis C. A Cavity-Fighting Liquid Lets Kids Avoid Dentists' Drills. The New York Times. Published July 11, 2016. Accessed December 10, 2017. [2] Silver Diamine Fluoride in Caries Management. ADA Science in the News. Published July 12, 2016. Accessed December 10, 2017. [3] Clement JL, Jarrett PS. Antibacterial Silver. Met Based Drugs. 1994; 1(5-6): 467–482. [4] Maragliano-Muniz P, Nový B. The dos and don'ts of silver diamine fluoride. Dentistry IQ. http://www.dentistryiq.com/articles/2016/07/the-dos- and-don- ts-of- silver-diamine- fluoride.html. Published July 26, 2016. Accessed December 10, 2017. [5] Saint Louis [6] Pediatric Oral Health Research & Policy Center. Are your kids covered? Medicaid coverage for the essential oral health benefits. http://www.aapd.org/assets/1/7/AreYourKidsCoveredfinal.pdf. Accessed December 10, 2017. [7] Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc 2016;44(1): 16-28. [8] Over 70 Years of Community Water Fluoridation. Centers for Disease Control and Prevention. https://www.cdc.gov/fluoridation/basics/70-years.htm. Published February 17, 2017. Accessed December 10, 2017. [9] Horst et al., 2016 [10] Nishino M. Studies on the topical application of ammoniacal silver fluoride for the arrest of dental caries. Osaka Daigaku Shigaku Zasshi (Journal of Osaka University Dental Society). 1969 Jun; 14(1):1–14. (article in Japanese) [11] Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Recommendations: Clinical Practice Guidelines. 2017;39(6):146-155. [12] Saint Louis, 2016 [13] ADA, 2016 [14] Chu C, Lee AH, Zheng L, Mei ML, Chan GC. Arresting rampant dental caries with silver diamine fluoride in a young teenager suffering from chronic oral graft versus host disease post- bone marrow transplantation: a case report. BMC Res Notes. 2014; 7: 3. [15] Richards D. The effectiveness of silver diamine fluoride in arresting caries. Evid Based Dent. 2017 Oct 27;18(3):70. [16] ADA, 2016
C
B
A
Images from Chu et al 2014
pennasda.org
Penn ASDA Chief Editor Kelly Chuang Contributing Editors Elizabeth Bailey Anjali Bhatia Jasmine Faldu Katherine Hilton Emily Huang William Manolorakis Kathleen Mascardo Fatima Naqvi Tim T. Wang
pennasda.ce@gmail.com
Copyright Penn ASDA 2017
